Berek and Novak's Gynecology 15th Ed.

11 Sexuality, Sexual Dysfunction, and Sexual Assault

Rosemary Basson

David A. Baram

• Most young men and young women have multiple serial sexual partners but use condoms inconsistently, thereby exposing themselves to sexually transmitted diseases (STDs) and unintended pregnancies.

• Sexual response reflects the fundamental interplay between the mind and body: psychological, interpersonal, cultural, environmental, and biological (hormonal, vascular, muscular, neurological) factors interact and modulate sexual experi- ence.

• Factors that can affect sexual response include mood, relationship duration and quality, age and stage in life, past sexual experiences—wanted, coercive, or abusive—personal psychological factors stemming from relationships in childhood with parental figures, previous losses and traumas, and ways of coping with emotions, current and past illness, and use of medication, alcohol, and illicit drugs.

• Physical, emotional, and economic stressors of pregnancy may negatively affect emotional and sexual intimacy.

• Sexual value systems, folklore, religious beliefs, physical changes, and medical restrictions influence sexual attitudes and behavior during pregnancy and postpartum.

• Despite the importance of issues relating to sexuality, many women find it difficult to talk to their physicians about sexual concerns, and many physicians are uncomfortable discussing sexual issues with their patients.

• Asking about sexual concerns gives physicians an opportunity to educate patients about the risk of STDs, encourage safer sex practices, evaluate the need for contraception, dispel sexual misconceptions, and identify sexual dysfunction.

• Many of the sexual problems couples encounter result from a deficit of knowledge or experience, sexual misconceptions, or inability of the couple to communicate about their sexual preferences.

• Sexual problems are common. Vaginismus is an involuntary reflex precipitated by real or imagined attempts at vaginal entry. Dyspareunia may affect two-thirds of women during their lifetime. Vestibulodynia, the most common type of dyspareunia, has a prevalence of 15%.

• Sexual assault of children and adult women has reached epidemic proportions in the United States and is the fastest growing, most frequently committed, and most underreported crime. The terms sexual abuse survivorand assault survivor are preferable to victim.

• Childhood sexual abuse has a profound and potentially lifelong effect on the survivor. Although most cases of childhood sexual abuse are not reported by the survivor or her family, it is estimated that as many as one-third of adult women were sexually abused as children.

• Women who were sexually abused as children or sexually assaulted as adults often experience sexual dysfunction and difficulty with intimate relationships and parenting.

• The National Women’s Study revealed that 13%, or one of eight adult women, are survivors of at least one completed rape during their lifetime.

Most women feel that sexuality is an important part of their lives even when chronic illness is present. Providing patients with information about normal sexual changes that occur with puberty, pregnancy and postpartum, menopause, and older age is part of routine obstetric and gynecologic care.

Sexual dysfunction can arise from gynecologic diseases such as endometriosis, procedures such as those associated with infertility, and treatments such as pelvic radiation, bilateral salpingo-oophorectomy, and use of aromatase inhibitors or gonadotropin-releasing hormone (GnRH) antagonists. Sexual abuse can have long-lasting effects on sexuality and other psychophysiological aspects of a patient’s life. Women seen in gynecology clinics may have comorbid illnesses that interrupt their sexual function. Inquiry about sexual concerns and explanation of the implications of a disease and its treatment are integral components of gynecologic care.

Sexuality

The spectrum of normal sexual response varies from one woman to another and throughout a woman’s lifetime (1–3). Physicians should be aware of their patients' sexual values, attitudes about specific practices, and concerns about their sexuality. Maintaining open communication with patients about their sexuality allows the physician to counsel them about sexual issues and problems and other aspects of their reproductive health.

Sexual Activity

Sexual activity among adolescents in the United States increased during the past 20 years (3). The average age for first intercourse for both men and women is 16 years. By 19 years of age, as many as three-quarters of women have had intercourse. Most young men and young women have multiple serial sexual partners but use condoms inconsistently, thereby exposing themselves to sexually transmitted diseases (STDs) and unintended pregnancies. A recent study of North American women, using a large and diverse community-based sample, shows that of the 3,205 women aged 30 to 79 years almost one-half were not sexually active in the previous 4 weeks, with 52% of those citing lack of interest and 61% citing lack of partner as the major reasons. Of those who were sexually active recently, 13.7% noted sexual problems and dissatisfaction with their overall sexual lives (4).

Genital Anatomy

For most women, their clitoral tissue is the most sexually sensitive part of their anatomy, and its stimulation produces the most intense sexual feelings and the most intense orgasms. Many women first need to experience both nonphysical and nongenital physical stimulation before clitoral stimulation can be enjoyed. In the absence of arousal, direct clitoral stimulation can be unpleasant and be perceived as too intense and even painful. Immunohistologic studies identified neurotransmitters thought to be associated with sensation concentrated right under the epithelium of the glans clitoris (5). Clitoral tissue extends far beyond the visible portion when the clitoral hood is retracted. It includes the clitoral head, shaft, rami running along the pubic arch, periurethral tissue in front of the anterior vaginal wall, and the bulbar tissue under the superficial perineal muscles surrounding the anterior distal vagina. Other sexually sensitive areas include the nipples, breasts, labia, much of the skin generally, and to some extent, the vagina. Although the lower third of the vagina is responsive to touch, the upper two-thirds is sensitive primarily to pressure. The rich supply of nerves in the fascia anterior to the upper vagina (Halban’s fascia) and the proximity of the clitoral type of spongy tissue around the urethra anterior to the vagina contribute to the pleasurable sensations of intercourse. Many women experience orgasm more easily from direct clitoral touch, possibly provided at the same time as intercourse.

Figure 11.1 The blended sex response cycle showing the many reasons/incentives for initiating/accepting sexual activity.

There is speculation about the existence of a “G-spot,” named after Ernest Gräfenberg, who first described it in 1944 (5). This area of the vagina, located anteriorly midway between the symphysis pubis and cervix, is thought to be exquisitely sensitive to deep pressure. Stimulation of this area associated with orgasm and loss of fluid was not scientifically proven to be anything other than dilute urine. Women who are normally continent often leak urine at orgasm; this is not abnormal and does not require medical intervention.

Sexual Response Cycle

Sexual response reflects the fundamental interplay between the mind and body: psychological, interpersonal, cultural, environmental, and biological (hormonal, vascular, muscular, neurological) factors interact and modulate sexual experience. The initial phase of the sexual response cycle may be one of desire, but more often women, particularly those in long-term relationships, are motivated by factors other than sexual desire (3). Women initiate or consent to sex for many reasons, including a wish to increase emotional intimacy with their partners. By directing her attention to sexual stimulation, a woman’s subjective sexual arousal/pleasure/excitement triggers sexual desire. Desire and arousal coexist and compound each other (Fig. 11.1). Sexual satisfaction (with one, many, or no orgasms) can be achieved if a woman can stay focused, her pleasure continues, the duration of the stimulation is sufficiently long, and there is no negative outcome (e.g., pain or partner dysfunction). The response is circular, with phases overlapping and in variable order (e.g., desire may follow arousal, and higher arousal may follow the first orgasm). Desire, once triggered, increases the motivation to respond to sexual stimuli and to agree to or ask for more intensely erotic forms of stimulation. Any initial spontaneous desire will augment the response. This circular type of cycle can be experienced a number of times on any one occasion of sexual interaction. This motivation/incentives module reflecting the importance of the mind’s appraisal of sexual stimuli is supported by empirical research (6--7).

Physiology

Desire and Arousability

Sexual desire provides one of many motivations to be sexual. Feelings of desire may be triggered by both internal (e.g., fantasies, memories, feelings of arousal) and external (e.g., an interested and interesting partner). Sexual cues are dependent on adequate neuroendocrine function. Multiple neurotransmitters, peptides, and hormones modulate desire and subjective arousal (9). Substances that promote sexual response include norepinephrine, dopamine, oxytocin, melatonin, and serotonin acting on some receptors. Prolactin, serotonin acting on other receptors, endocannabinoids, opioids, and γ-aminobutyric acid inhibit sexual response. These peptides and neurotransmitters are themselves modulated by sex hormones that direct the synthesis of enzymes involved in the production of neurotransmitters and the synthesis of their receptors. Biological factors do not act independently from environmental factors, a finding in human and animal models. Dopamine and progesterone, acting on receptors in the hypothalamus, facilitate sexual behavior in female rats that underwent oophorectomy and received estrogen. The presence of a male animal in an adjacent cage can cause an identical change in sexual behavior (10). Likewise, the ability to be aroused and intensity of response can be increased in some women by giving them a modest dose of testosterone, by administering bupropion (dopaminergic), or by a change of partner (11–13). Even in rodents, complex networks exist whereby the female assesses the context of potential sexual activity and relates it to past experience and expectation of reward (14). In women, sexual interest is influenced by their psychological mindset, beliefs and values, expectations, sexual orientation, preferences, and the presence of a safe and erotic environmental setting. Empirical research confirms that an experimentally induced happy or sad mood can impact subjective sexual arousal (but not objective vaginal congestion as measured by a vaginal photoplethysmograph, a tamponlike photoelectric device placed in the vagina) while the woman views an erotic video, with subjects reporting significantly less subjective arousal and marginally significant fewer genital sensations when a negative mood was induced prior to viewing an erotic film clip (15). Moreover, other research concludes that cognitive factors (i.e., lack of erotic thoughts and being distracted or concerned about sexual behavior) were the best predictors of sexual desire: other dimensions including relationship factors, psychopathology, and medical problems appeared to have an indirect impact on sexual desire with the cognitive factors acting as the mediators (16). Sexual desire, interest, and arousability are most strongly influenced by mental health and feelings for the partner, both generally and specifically, at the time of sexual interaction (4,13,17,18). Sexual desire is strongly influenced by fatigue; as a result, sex late at night is not usually attractive to a busy woman. Similarly, chronic illness typically reduces desire and arousability (19).

Sexual Arousal

Recent brain imaging reflects the complexity of sexual arousal, confirming that multiple areas of the brain are involved in sexual response. Brain imaging of healthy people during visual sexual stimulation identifies a model of sexual arousal involving complex brain circuitry, including cortical, limbic, and paralimbic areas known to be involved in cognition, motivation, and emotions linked to changes within the autonomic nervous system (20). Specific inhibitory regions deactivate these sexual responses (21). As demonstrated in this ongoing research, none of this is particularly simple. In a small study, sexually functional surgically menopausal women receiving no hormonal therapy viewed erotic videos during functional magnetic resonance imaging. The women failed to show the brain activation typical of premenopausal women and also typical of themselves when they were treated with both testosterone and estrogen, and yet, they reported sexual arousal from the erotic videos without, and with, hormonal supplementation (22).

Accompanying the subjective excitement and erotic feelings of arousal are a number of physical changes. These changes include genital swelling; increased vaginal lubrication; engorgement of the breasts and nipple erection; increases in skin sensitivity to sexual stimulation; changes in heart rate, blood pressure, muscle tone, breathing, body temperature; mottling of the skin; and a “sex flush” of vasodilatation over the chest, breasts, and face. With sexual stimulation, brain activity in the hypothalamus and other areas influencing the genital response are activated, triggering the autonomic nervous system to allow increased blood flow to the vagina. Vasodilatation of the arterioles in the submucosal vaginal plexus increases transudation of interstitial fluid, which moves from capillaries between the epithelial intercellular spaces and into the vaginal lumen. Simultaneously, the autonomic nervous system allows relaxation of the smooth muscle cells surrounding blood spaces (sinusoids) in the extensive clitoral tissue and labia, causing clitoral swelling and vasodilatation in the labia. Recent immunohistologic studies indicate nerves containing nitric oxide are present in the genital skin covering the clitoris and labia (5).

With arousal, the vagina lengthens, distends, and dilates, and the uterus elevates out of the pelvis. With increased sexual stimulation, vasocongestion reaches a maximum intensity. Genitally, the labia become more swollen and darker red and the lower third of the vagina swells and thickens to form an “orgasmic platform.” The clitoris becomes more swollen and elevates to a position near the symphysis pubis, and the uterus elevates fully out of the pelvis. The breasts become more engorged, the skin more mottled, and the nipples more erect.

The neurobiology of arousal is incompletely understood but the genital vasocongestive responses appear to be highly automated, occurring within seconds of an erotic stimulus (23). Parasympathetic nerves release nitric oxide and vasoactive intestinal polypeptide (VIP), mediating vasodilatation (24,25). Acetylcholine (ACh) blocks noradrenergic vasoconstrictive mechanisms and promotes nitric oxide release from endothelium. The parasympathetic and sympathetic nervous systems and the somatic system function less independently than was previously believed. Communication was identified between the cavernous nerves to the clitoris, containing nitric oxide, and the distal portion of the (somatic) dorsal nerve of the clitoris from the pudendal nerve (5). The pelvic sympathetic nerves primarily release (vasoconstrictive) noradrenaline and adenosine triphosphate, but some release ACh, nitric oxide, and VIP. Nitric oxide is thought to be the major neurotransmitter involved in vulvar engorgement (5,25). In the vagina, VIP, nitric oxide, and other unidentified neurotransmitters are involved (25).

Even in women without any sexual dysfunction, there is highly variable correlation between the degree of subjective sexual excitement and the increase in congestion around the vagina (23,26). This poor correlation was shown repeatedly over the past 30 years based on psychophysiologic studies using the vaginal photoplethysmograph. Congestion in response to a sexual video is reduced in women with disruption of the autonomic nerve supplying the vulva and vagina (e.g., from nonnerve-sparing radical hysterectomy). Otherwise healthy women experiencing chronic lack of arousal (including lack of subjective excitement and lack of any awareness of genital congestion) show increases in vaginal congestion from erotic stimuli that are similar those in control women (23,26). With the so-called cervico-motor reflex, cervical touch (in the laboratory with a balloon-tipped catheter to replicate penile pressure) leads to a reduction in pressure in the upper portion of the vagina and an increase in pressure in the middle and lower portions. Simultaneously, an increase in electromyographic activity in the levator ani and puborectalis muscles was recorded. It is thought that during intercourse penile thrusting on the cervix might cause contraction of the pelvic muscles to facilitate “ballooning” of the upper vagina, perhaps to facilitate pooling of semen. The same muscle contraction constricts the lower vagina, which may afford increased stimulation of the partner’s penis, thereby maintaining rigidity (27).

A further reflex demonstrated in laboratory studies shows reduced uterine tone in response to mechanical or electrical stimulation of the glans of the clitoris. Background activity of the uterine muscle was abolished by clitoral stimulation if either the glans clitoris or the uterus was anesthetized. Uterine pressure declined on clitoral stimulation. This reflex may underlie the known increase in size and the elevation of the uterus with sexual arousal (28).

Orgasm

Orgasms is a brain event, typically triggered by genital stimulation that can occur during sleep or from stimulation of other body parts including the breast and nipple or by fantasy, occasionally by medication, and in spinal cord injured women by vibrostimulation of the cervix. In able-body women, it involves a myotonic response of smooth and striated muscle associated with feelings of sudden release of the sexual tension built up during arousal. It is described as the most intensely pleasurable of the sexual sensations. Reflex rhythmic contractions (3–20 0.8/sec) of the muscles surrounding the vagina and anus occur. Some women may subjectively perceive uterine contractions during orgasm and some may report a difference in their perception of orgasm after hysterectomy, but this is not objectively documented. An objective quantitative measure was established that shows strong correspondence with the subjective experience of orgasm. Analysis of rectal pressure data while volunteers imitated orgasm, tried to achieve orgasm and failed, or experienced orgasm showed a significant and important difference in this analysis between orgasm and both control tasks (29).

Brain imaging studies of women during orgasm showed brain activations and deactivations similar but not identical to those found in men (30). There is profound deactivation in the anterior part of the orbitofrontal cortex (OFC). This area is thought to be involved in urge suppression and behavioral release. This area is activated when experiences are particularly hedonic, with further activation increasing satiation and deactivated with feelings of satiety. The medial OFC is part of the neuronal network underlying self-monitoring and is connected to the amygdala. The latter is deactivated during the genital stimulation and arousal and remains deactivated during orgasm. Deactivation of this network is associated with a more carefree state of mind. The subjective description of orgasm is very much in keeping with this depiction (31).

The majority of women most easily experience orgasm from direct clitoral stimulation. More direct contact with the clitoris is possible from contact of pubis to pubis after the man has ejaculated and penile size is reduced, if the man maintains contact. The bodies are more closely approximated and the woman can move her pelvis on his at a rate that is most conducive to her orgasm. Breast stimulation, kissing, and clitoral stimulation during intercourse are other commons means of experiencing orgasm. Women are potentially multiorgasmic, capable of experiencing a number of orgasms close together during one sex response cycle and of resuming sexual activity without any refractory period.

Resolution

Following the sudden release of sexual tension brought about by orgasm, women experience a feeling of relaxation and well-being. The gradual lessening of pelvic engorgement contrasts with the quicker loss of penile firmness in men. Nongenital changes that took place during arousal are reversed, and the body can return to a resting state after some 5 to 10 minutes. With further stimulation, the response can resume before or after this resting state is reached. As depicted in Figure 11.1, the cycle of response can be experienced a number of times during any given sexual encounter. Women who enjoy arousal without orgasm and without any sense that orgasm is very close but frustratingly absent report a similar sense of well-being and relaxation.

Factors Affecting Sexual Response

Numerous factors can affect sexual response (13,19,32–34). These factors include mood; age; relationship duration and quality; personal psychological factors stemming from relationships in childhood with parental figures; previous losses, traumas, and ways of coping with emotions; illness; and use of medication, alcohol, and illicit drugs.

Mental Health

Studies find that mental health has the strongest links to women’s sexual function (4,17,35,36). Lack of mental well-being, even if it does not meet the criteria of a clinical diagnosis of mental disorder, is strongly linked to women’s symptoms of low desire (37). One study of women, where a diagnosis of clinical depression was excluded, showed a strong association between decreased sexual interest and self-reporting of negative emotional and psychological feelings, including low self-esteem, feelings of insecurity, and lost femininity (18). Impaired sexual desire is noted in most studies of women with depression, even before the administration of antidepressants with sexually negative side effects (35). Paradoxically, depressed women may masturbate more frequently than women who are not depressed, despite an increased prevalence of dyspareunia and difficulties with arousal and orgasm in partnered sex (38). Self-stimulation may cause calmness, relaxation, and improved sleep and in women is often not a consequence of sexual urge or desire.

Aging

The degree to which aging itself, the marked changes in ovarian function associated with menopause, and the marked reduction of adrenal production of prohormones (importantly dehydroepiandrosterone [DHEA]) that can become estrogen and testosterone may affect women’s sexual response was addressed in large population studies. Some studies showned little increase in sexual problems with age, whereas in others almost 40% of the sample reported reductions in responsiveness and an increased desire for nongenital sexual expression (13,39,40). In one study, the prevalence of reduced desire increased significantly as a function of both menopause status and age, from 22% in the premenopausal group to 32% in the postmenopausal group (41). Low levels of desire were strongly associated with other sexual problems, including difficulties with arousal and orgasm. One large cohort of women studied over 10 years from peri- to postmenopause showed a decline in desire and responsiveness as a function of both age and menopause (42). The independent effect of menopause was indirect. The number of menopausal symptoms experienced influenced well-being, which in turn affected sexual responsiveness and sexual desire and interest.

Many studies of sexuality and aging show that older women report less distress about lack of desire when compared with younger women (17,18,43). In a nonclinical study of 102 women, the determinants of sexual satisfaction in those younger than 45 years of age were compared with those of women older than 45 years of age (18). There was no difference in sexual satisfaction achieved either by intercourse or noncoital sexual activities. Older women reported lower frequency of orgasm and different ratings on certain dimensions of sexual satisfaction. For the older women, the dominant qualities important to their satisfaction were those related to an emotional sense of calm and to factors such as feeling secure with their partner, whereas for younger women the subjective physical experience was more important.

Despite reports of reduced sexual interest and desire by some older women, most retain some interest and maintain the potential for sexual pleasure for their entire lives. In older women, a strong predictor of continued sexual interest is sexual behavior and enjoyment at an earlier age. A discrepancy between sexual interest and actual sexual activity occurs in many cases because an adequate partner is no longer available. In other instances, the cessation of sexual activity with age is more an expression of emotional problems resulting from lack of tenderness, communication, and attraction.

In addition to partner availability, an older woman’s sexuality is influenced by her partner’s general and sexual health and the relationship itself, which will determine how well the couple can adapt to changes in their sexual function as they age (17,44,45). Although some older women may retain negative societal attitudes toward sex that it is not “natural” (i.e., not focused intercourse), studies show a shift from intercourse to nonpenetrative sex and to a variety of activities that involve affection, romance, affectionate physical intimacy, and companionship (46). For some older women, it is clear that the setting, whether a nursing home or a grown-up child’s home, strongly influences the opportunity for sexual expression.

If intercourse is perceived as a necessary component of sexual activity with a partner, some older women will lose motivation and interest as a result of discomfort and dyspareunia associated with lack of estrogen.Although the increase in vaginal congestion in response to visual sexual stimulation is similar in women with and without estrogen, baseline vaginal blood flow is lower in estrogen-deficient women (23). Thus, the increase in lubrication may be insufficient. There may be loss of elasticity and thinning of the vaginal epithelium, which becomes vulnerable to damage from intercourse. Estrogen depletion predisposes women to vulvar vaginitis and urinary tract infections, both of which contribute to dyspareunia and reduce sexual self-image. Women who remain sexually active, alone or with a partner, may have less vulvar and vaginal atrophy than sexually inactive women but may still be symptomatic (47).

Adrenal production of testosterone precursors gradually decreases with age, beginning in the late 30s. Large epidemiological studies have not shown serum levels of testosterone to correlate with women’s sexual function (48,49). Available assays were not sufficiently sensitive in the female range of serum testosterone to detect particularly low levels. When mass spectroscopy was used: serum testosterone levels were similar in 121 women carefully assessed and diagnosed with disorders of low desire and arousability to levels in 125 women similarly carefully assessed but to exclude any sexual dysfunction (50). A second difficulty, over and beyond the unreliable assays for serum testosterone, was the fact that intercellular production of testosterone in peripheral tissues (from adrenal and ovarian) precursor hormones—DHEA, DHEA sulfate (DHEAS), and androstenedione (A₄)—previously could not be measured. Total testosterone activity (ovarian and peripherally produced “intracrine production”) has been measured using mass spectrometry assays for androgen metabolites, most notably androsterone glucuronide (ADT-G). There appears to be a wide range of ADT-G among women of any given age, and levels decrease with age. Importantly there were no group differences in ADT-G between 121 women carefully diagnosed with desire and arousal disorders and 124 sexually healthy controls (50).

Illnesses that accompany aging may have an impact on sexual dysfunction. The association is weaker than that between male erectile dysfunction and hypertension, hyperlipidemia, diabetes, and coronary artery disease. Depression is the major factor influencing sexual function in women with chronic illness including end-stage renal disease (51), multiple sclerosis (52), or diabetes (53). Some sexual activities (e.g., intercourse) or responses (e.g., orgasmic intensity) may be limited by arthritic, cardiac, or respiratory disorders.

Personality Factors

Studies show that, compared with functional women, those who have concerns about low levels of desire and arousability are characterized as having vulnerable self-esteem, high levels of anxiety and guilt, negative body image, introversion, and somatization (18). The clinical impression of women with orgasmic disorder is that many are extremely uncomfortable in conditions in which they are not in control of circumstances or their bodily reactions. For many women with vaginismus, there is a phobic quality to the fear of vaginal penetration. Many women with provoked vestibulodynia show a marked fear of negative evaluation by others, ultra conscientiousness, and self-criticism, as well as an increase in somatization and anxiety (54).

Relationships

Most women who report loss of desire and arousability to physicians indicate that their partnerships are stable and satisfactory. An environment free of conflict, abuse, and the threat of separation or divorce is insufficient to nurture a woman’s sexual desire. Commonly, the woman reports that her partner is not emotionally intimate with her—not willing to reveal his (or her) feelings, fears, and hopes. Additionally, the woman’s need for eroticism and variety of sexual stimulation may not be met. These women frequently classify their relationship as being that of “very good friends.” Such a context is insufficiently sexual for nurturing or triggering a woman’s sexual desire. Change of partner is shown to be a major factor in increasing women’s desire and responsiveness, and there is a lessening of innate desire with the duration of a relationship (13,34). The woman’s feelings for her partner is one of the major determinants of lack of distress about sex; similarly, the woman’s feelings for her partner, or a change of partner, were major determinants of a woman’s desire (13,17,55).

Sexual Dysfunction in the Partner

Multiple aspects of a woman’s circumstances can influence her sexual function, and one of the most important aspects is sexual dysfunction in a male partner (56). Successful treatment of a male partner’s erectile dysfunction can result in reversal of the woman’s sexual problems, including difficulties with sexual arousal, lubrication, orgasm satisfaction, and pain (45).

Infertility

Infertility evaluation and assisted reproductive techniques can have negative effects on a woman’s body image and feelings of sexual self-worth. Infertility may cause her to feel hopeless and sexually undesirable. The loss of sexual spontaneity resulting from the goal-oriented approach to sex while trying to conceive with scheduled intercourse (coinciding with ovulation naturally or after hormonal stimulation) may lead to sexual dysfunction and is considered a major problem for many women (57). Erectile dysfunction may be a consequence, compounding the couple’s fertility difficulties and the woman’s sexual satisfaction (58). The stress of testing and waiting for results may disrupt emotional intimacy, causing further damage to sexual function. These changes do not always reverse with a successful pregnancy. Often there are unresolved feelings of guilt over personal responsibility for the infertility and feelings of resentment of the multiple procedures required for women compared with one semen analysis for men.

Drugs

Prescription and nonprescription medications, including alcohol and illicit drugs, can alter the normal sexual response (Table 11.1). Adjustments in dosage or formulation of medication may be required. Theoretically, pharmacologic agents might improve or reverse the loss of arousal, desire, and orgasm commonly associated with serotonergic antidepressants (SSRIs). A Cochrane review could make no recommendations for women but did note that bupropion may be effective based on the results of one of two randomized controlled trials (43,59). In highly selective women on SSRIs, sildenafil may reverse orgasmic dysfunction (60).

Table 11.1 Medications Affecting Sexual Response

Drugs with potential negative sexual effects

• Antihypertensives: β-blockers, thiazides • Antidepressants: serotonergic antidepressants • Lithium • Antipsychotics • Antihistamines • Narcotics • Benzodiazepines • Oral contraceptives and oral estrogen therapy • Gonadotropin-releasing hormone (GnRH) agonists • Spironolactone • Cocaine • Alcohol • Anticonvulsants

Drugs that appear to be potentially prosexual

• Danazol • Levadopa • Amphetamines • Bupropion

Table 11.2 Sex and Chronic Illness

• Biological disruption of the sexual response, e.g., multiple sclerosis damaging pelvic autonomic nerves • Negative psychological consequences of the illness affecting sexual response, e.g., feeling sexually unattractive as a result of disfigurement from surgery, medication, stomas • Increased fatigue • Chronic pain • Incontinence or stomas reducing sexual self-confidence • Accompanying depressive illness • Treatment of chronic illness, e.g., chemotherapy-inducing ovarian failure • Limited mobility, e.g., arthritis precluding intercourse, Parkinson’s disease precluding masturbation • Cardiac or respiratory compromise such that orgasm or movements of intercourse cause angina or intense dyspnea

Chronic Illness

Chronic illness and living with a cancer diagnosis can affect sexual function in a number of ways (Table 11.2) (20).

Chronic Pelvic Inflammatory Disease and Endometriosis

Chronic dyspareunia, remitting temporarily or not at all with surgical or medical therapy, typically is associated with loss of sexual motivation or interest. Although definitive therapy is the overall goal, encouragement of nonpenetrative sex is very important for preservation of the woman’s sexual enjoyment, sexual self-esteem, and relationship. GnRH therapy producing a temporary medical menopause can add further difficulties with reduced arousability and vaginal discomfort from the low estrogen state.

Polycystic Ovarian Syndrome

There is no evidence that the higher androgen levels associated with polycystic ovarian syndrome (PCOS) afford protection from low sexual desire or low sexual arousability. Some but not all studies of women with PCOS report reduced sexual satisfaction compared to controls. The limited data suggest that lower satisfaction is related to obesity and cosmetic androgen-related effects of hirsutism and acne. One small case study showed desire to increase in six women with antiandrogen treatment and to decrease in 13 women (61). Metformin may improve sexual function in women with PCOS (62).

Recurrent Herpes

Fear of spreading an STD may reduce sexual motivation and arousability. Clear guidance regarding safer sexual practices is needed, along with a discussion of the causes of the woman’s lowered sexual motivation. A recognized difficulty with recurrent herpes is viral shedding despite lack of skin lesions and uncertainty whether long-term antiviral therapy prevents shedding.

Lichen Sclerosis

Tethering of the clitoral hood, which occurs with lichen sclerosis, may cause pain with clitoral stimulation. When this skin disorder involves the introitus, it may cause dyspareunia or prevent entry of penis, dildo, or fingers. Reduced sexual sensitivity of the involved vulvar skin is a common complaint. Topical corticosteroid administration is the primary treatment, although topical testosterone cream may be beneficial when loss of sexual sensitivity occurs.

Breast Cancer

Sexual dysfunction following breast cancer treatment is likely to persist more than 1 year after diagnosis of breast cancer (63). Chemotherapy appears to be responsible for most of the resulting sexual difficulties, including loss of desire, subjective arousal, vaginal dryness, and dyspareunia (64). A small study of women with past breast cancer and complex endocrine status resulting from ongoing antiestrogen therapy found that, whereas relationship factors predicted desire, history of chemotherapy predicted disorders of arousal lubrication, orgasm, and dyspareunia but there was no connection between sexual function and androgen levels including androgen metabolites (65). A model for predicting sexual interest, function, and satisfaction after breast cancer has evolved from two large independent groups of breast cancer survivors (64). The most important predictors of sexual health were absence of vaginal dryness, presence of emotional well-being, positive body image, better quality of relationship, and lack of partner sexual problems. A temporary “medical menopause” from adjuvant GnRH agonist treatment is associated with reversible sexual dysfunction (66). Use of tamoxifen does not consistently alter sexual function, but use of aromatase inhibitors is often associated with severe dyspareunia from the profoundly estrogen-depleted state (67,68).

The optimal management of ongoing dyspareunia from the estrogen deficient state, especially when the woman is on aromatase inhibitors, is unclear. Zero systemic absorption of estrogen from vaginally administered preparations is the goal, and formulations are under investigation for efficacy at lower dosages than are currently available. Some oncologists will permit the use of local estrogen via a Silastic ring that does cause brief, but detectable (although not to premenopausal estrogen levels), systemic absorption. For most of the 3 months that the ring is in place systemic absorption is not detectable. Vaginal moisturizers can allow some benefit but do not restore the full elasticity.

Fertility preservation is considered along with the overall treatment plan for younger women, and a number of options are emerging. One is to delay treatment to undergo a cycle of hormone stimulation and oocyte retrieval, providing the growth of the tumor is not expected to be promoted by exogenous estrogen. Other techniques can avoid exposure to exogenous hormones by retrieving ovarian tissue and either aspirating the oocytes or reserving ovarian tissue strips and then using cryopreservation. An even newer technique called in follicle maturation involves obtaining immature follicles from the cryopreserved ovarian tissue, maturing them in vitro, to be followed by in vitro fertilization procedures (20).

Diabetes

The majority of studies clearly identified a strong link between sexual dysfunction and comorbid depression but not with diabetic controls, duration of diabetes, or its complications. Data are limited in quality given that many studies do not clarify estrogen status, different assessments of sexual function are used, and many publications study only the women who do not remain sexually active—those who simply do not have a partner or may have discontinued activity as a result of severe dysfunction (69). Prevalence of low sexual desire is found to be similar in women with and without diabetes, whereas difficulties with lubrication are approximately two times more common in women with diabetes. Some but not all studies show increased prevalence of dyspareunia, orgasmic difficulties, and sexual dissatisfaction (70). A large study involving women enrolled in the long-term Epidemiology of Diabetes Interventions and Complications (EDIC) study neither compared patients with control women nor inquired about dysfunction in those who were not sexually active. Nevertheless, dysfunction was present in 35% of the active women with low desire, and more than half had problems with orgasm arousal and lubrication. In multivariate analysis, only depression and marital status predicted sexual dysfunction (69).

Hysterectomy

Simple Hysterectomy

Despite speculation that there might be different sexual outcomes depending on whether hysterectomy was vaginal, subtotal, or total abdominal, this difference is not supported by study (71,72). In a large prospective observational study of 413 women undergoing three different types of hysterectomy (vaginal, supracervical, and total abdominal hysterectomy), sexual pleasure improved in most women, independent of the type of hysterectomy (72). The prevalence of one or more bothersome sexual problems 6 months after vaginal, supracervical, and total abdominal hysterectomy was 43%, 41%, and 39%, respectively. The results of another prospective trial of 158 women randomized to total abdominal hysterectomy and 161 to supracervical abdominal hysterectomy showed no difference in sexual outcomes (71). A retrospective study of 108 women undergoing classic intrafascial supracervical hysterectomy and 125 undergoing total hysterectomy did not find any sexual benefits of classic intrafascial supracervical hysterectomy over total hysterectomy (73). There was no difference between groups in time from surgery to first intercourse, change in libido, sexual frequency, or frequency or degree of orgasm.Overall, two-thirds of the women in the study experienced either no change or an improvement in sexual function, regardless of which procedure was performed. Both this study and a study comparing total laparoscopic hysterectomy with laparoscopically assisted vaginal hysterectomy found similar effects on sexual function (74).

Radical Hysterectomy

Techniques were developed to avoid the portions of the inferior hypogastric plexus in the cardinal and broad ligaments, and preliminary studies suggest minimal reduction of vaginal congestion in response to sexual stimulation in a laboratory setting (75). Only one of two small clinical studies confirmed preservation of sexual function (76,77).

Cancer of the Cervix

Sexual symptoms encountered in women with cancer of the cervix include reduced vaginal lubrication secondary to surgical menopause, radiation damage, and/or interruption of the autonomic nerves. A study conducted in Croatia showed the importance of fear of dyspareunia. Of 210 women treated with combinations of surgery, radiation, and chemotherapy, 50% reported a marked fear of pain. Only six patients identified actual dyspareunia and only three patients found penetration impossible (78).

There is marked synergy between cancer of the cervix and sexual abuse as a cause of sexual dysfunction (79). An absence of sexual satisfaction was reported by 20% of women with neither abuse nor cancer of the cervix, by 31% of women who were sexually abused and did not have cancer of the cervix, by 28% of women with cancer of the cervix and who were not abused, but by 45% of women with a history of both abuse and cancer of the cervix. The lack of sexual satisfaction resulted in a decrease in well-being in 18% of women with neither a history of abuse nor cancer of the cervix, 39% of women who were abused and did not have cancer of the cervix, 23% of women with cancer of the cervix who were not abused, and in 44% of women with a history of both abuse and cancer of the cervix. Dyspareunia was extremely rare in women without cancer of the cervix, but it was reported by 12% of those with cancer of the cervix and by 30% of those with cancer of the cervix and past sexual abuse.

Pregnancy

Physical, emotional, and economic stressors of pregnancy may negatively affect emotional and sexual intimacy. Sexual value systems, folklore, religious beliefs, physical changes, and medical restrictions influence sexual attitudes and behavior during pregnancy and postpartum. In the absence of preterm labor, antepartum bleeding, or an incompetent cervix, there is no evidence that sexual activity, orgasm, or intercourse increases the risk of pregnancy complications. Normal changes that occur with sexual activity during pregnancy include increased breast tenderness, increased sensitivity to uterine contractions with orgasm, general discomfort, less mobility, and fatigue. Sexual satisfaction in pregnancy is closely related to feeling happy about the pregnancy, continuing to feel attractive, and understanding that in a healthy pregnancy sexual activity and orgasm do not harm the fetus.

Toward the end of the third trimester the need for closeness, emotional support, and nurturing may be far greater than any desire for orgasms or intercourse. Nevertheless, a study noted that 39% of 188 women reported being engaged in intercourse during their birth week (80). Difficulties may arise from the partner’s reaction to the woman’s pregnancy, the physical changes of pregnancy, lack of information regarding sex and pregnancy, and lack of direction from the physician when complications arise. A general lessening of sexual desire in both pregnancy and the postpartum period is common and considered normal. A prospective analysis of sexual function of 40 healthy pregnant women showed a reduction in desire and in all aspects of sexual response beginning in the first trimester, changing little in the second, and reducing further in the third trimester (81). Couples should be encouraged to continue their usual patterns of lovemaking during pregnancy if they are emotionally and physically comfortable and there are no contraindications to either orgasm or intercourse.

Postpartum

The ongoing vaginal bleeding and discharge, perineal discomfort, hemorrhoids, sore breasts, and decreased vaginal lubrication associated with nursing, compounded by fatigue from disturbed nights, all contribute to decreased motivation for sexual activity. Further complicating factors include fear of waking the baby, a decreased sense of attractiveness, change of body image, or mood change. Many couples resume sexual activity and include intercourse by 6 to 8 weeks postpartum, but some couples wait as long as a year before resuming their prepregnancy level of sexual intimacy. Typically women who nurse report less sexual activity and less sexual satisfaction than those who bottle feed. The effect of the mode of delivery on sexual function is still unclear. Two studies showed operative vaginal delivery confered the highest risk of dysfunction (82,83).

Physicians can provide considerable help to patients and their partners by acknowledging and discussing the normal fluctuations in sexual desire and frequency of sexual activity during and after pregnancy.

Assessment of Sexual Problems

Despite the importance of issues relating to sexuality, many women find it difficult to talk to their physicians about sexual concerns and many physicians are uncomfortable discussing sexual issues with their patients. In one survey, 71% of adults said they thought their doctor would dismiss any concerns about sexual problems they might introduce, and 68% said they were afraid that discussing sexuality would embarrass their physician (84). Through the use of a structured questionnaire and review of the records of 1,065 women who consecutively attended 37 family practices in areas of high, medium, and low socioeconomic status, 40% of women had at least one form of sexual dysfunction according to diagnostic criteria of the International Statistical Classification of Disease (ICD-10). Only 4% had a prior entry in their medical record relating to sexual problems (85).

There are numerous reasons physicians are reluctant to discuss issues relating to sexuality with their patients. Anxiety about physicians' perceived inability to treat sexual problems, unwillingness to spend the time required to accurately assess sexual concerns, personal discomfort when discussing sexual matters with patients and distress arising from their patients' history of sexual-related violence are all potential barriers. Not asking about sexual function suggests to patients that sexuality is not important and should not to be discussed. Moreover, many gynecological interventions and a number of gynecological conditions interrupt sexual function, necessitating the inclusion of sexual health in gynecological assessment. Asking about sexual concerns gives physicians an opportunity to educate patients about the risk of STDs, encourage safer sex practices, evaluate the need for contraception, dispel sexual misconceptions, and identify sexual dysfunction. Many sexual concerns can be resolved by providing factual information and reassurance. Management of sexual dysfunction requires appropriate biopsychosocial assessment and intervention. Even when patients currently have no sexual problems, when gynecologists routinely inquire about sexual health, they can teach that future sexual issues can be addressed in a professional, confidential, and nonjudgmental setting.

Interviewing Techniques

To be sufficiently comfortable to establish rapport and trust with patients, physicians need to be familiar with the components of a sensitive, detailed, sexual assessment and the general principles of management of dysfunction. Good listening skills and attention to nonverbal cues are helpful. The use of straightforward language that patients can understand and acknowledge, and the recognition that many people find it difficult to discuss these sensitive, intimate, and extremely common issues are necessary.

Figure 11.2 Algorithm for screening sexual dysfunction.

A few open-ended questions can initiate the subject of sexual function (Fig. 11.2). Sexual inquiry is part of the medical history taken during a routine gynecologic assessment. There is evidence that an introductory sentence would greatly increase the chance a woman will identify her sexual problem. Listed in Table 11.3 are some examples of screening questions related to particular obstetric–gynecologic circumstances.

Optimally, the detailed assessment is obtained from both partners. Questions can be directed to the couple or the individual partners, depending on the circumstances (Table 11.4). When dyspareunia is present, detailed questioning is necessary (Table 11.5).

Table 11.3 Screening for Sexual Problems

Situation in which Screening
Question Is Necessary	Suggested Screening Question
Before surgery or instituting medication or hormone therapy	Your surgery or medication is not expected to interfere with your sexual function. I need to check, though, whether you have any difficulties now with sexual desire, arousal, or enjoyment; or is there any pain?
Routine antenatal visit	Women’s sexual needs can change during pregnancy. Do you have any problems or questions now? There is no evidence that intercourse or orgasm leads to miscarriage. Of course, any bleeding or spotting will require checking and postponing sexual activity until we have evaluated you. Many women find fatigue and/or nausea reduce their sexual life in the first 3 months, but usually things get back to normal for the middle 3 months and sometimes right up to term.
Complicated antenatal visit	These complications may well have already caused you to stop being sexual. Specifically, you should not (have intercourse/have orgasms).
After one or more miscarriages	Some women temporarily lose desire for sex after a miscarriage—this is quite normal. Many couples concentrate on affectionate touching while they both grieve about what has happened. Do allow yourselves some time. If any sexual problems persist, we can address them.
Infertility	All this testing and timed intercourse and disappointment, plus the financial burdens that are coming up, can be very stressful on your sex life. Try to have times when you and your partner are sexual just for pleasure and intimacy’s sake—not when you are trying to conceive. Do you have any problems now?
Postpartum	It may be some weeks or months before you have the energy to be sexual, especially if your sleep is really interrupted. This is normal. If problems persist, or if you have pain, this can be addressed. Do you have any questions right now?
Perimenopause or postmenopause	We know many women have very rewarding sex after menopause—more time, more privacy. If you find the opposite or you begin to have pain or difficulty getting aroused, these things can be addressed. Do you have any concerns now?
Woman who is depressed	I know you are depressed right now, but our studies tell us that sex is still important for many women who are depressed. We also know that some of the medications we prescribe interfere with sexual enjoyment. Do you have any problems right now?
Chronic illness	Arthritis/multiple sclerosis can interfere with a woman’s sex life. Are you having any problems?
Potential damaging surgery	Obviously the focus right now is to remove your cancer entirely when we do your surgery. The nerves and blood vessels that allow sexual sensations and lubrication may be temporarily and sometimes permanently damaged. If when you have recovered you notice any sexual problems that persist, they can be addressed. Do you have any sexual concerns now?
Bilateral oophorectomy	Your surgery will remove a major source of estrogen and approximately one half of the testosterone your body has been making. Testosterone will still be made by adrenal glands (small glands on top of the kidneys), and some of this gets converted into estrogen. Many women find that these reduced amounts of sex hormones are quite sufficient for sexual enjoyment, but others do not. Any sexual problems that do occur almost certainly can be addressed. Do you have any problems now?

Table 11.4 Biopsychosocial Assessment of Sexual Dysfunction

Sexual problem in patient’s own words	Clarify further with direct questions; give options rather than leading questions.
Duration, consistency, priority	Duration of problems? Are problems present in all situations? If more than one problem, which is most troubling?
Context of sexual problems	Emotional intimacy with partner, activity/behavior just before sexual activity, privacy, safety, birth control, risk of sexually transmitted disease, usefulness of sexual stimulation, sexual skills of partner, sexual communication, time of day
Rest of each partner’s sexual response	Check this currently and before the onset of the sexual problems—sexual motivation, subjective arousal, enjoyment, orgasm, pain, and erection and ejaculation in male partner
Reaction of each partner to sexual problems	How each has reacted emotionally, sexually, and behaviorally
Previous help	Compliance with recommendations and effectiveness
Reason for presenting now	What has precipitated this request for help
Assessment of Each Partner Alone
Partner’s own assessment of the situation	Sometimes it is easier to acknowledge symptoms, e.g., total lack of desire, in the partner’s absence
Sex response with self-stimulation	Also ask about sexual thoughts and fantasies
Past sexual experiencesa	Positive, negative aspects
Developmental historya	Relationships to others in the home while growing up, losses, traumas, how they coped. To whom (if anyone) was this person close? Who showed them affection, love, respect? Clarify if some of these themes are playing out now in the current sexual relationship.
Ask about sexual, emotional, and physical abusea	Explain abuse questions are routine and do not necessarily imply causation of the problems.
aThese items of the single patient interview may sometimes be omitted (e.g., for a recent problem after decades of healthy sexual function).

Table 11.5 Assessment of Dyspareunia: By History

• Ask if vaginal entry is possible at all (i.e., with finger, penis, dildo, speculum, tampon) • Ask if sexual arousal is experienced when intercourse is attempted and as it progresses • Ask exactly when the pain is experienced:   —With partial entry of the penis/ dildo   —With attempted full entry of penile head   —With deep thrusting   —With penile movement   —With the man’s ejaculation   —With the woman’s subsequent urination   —For hours or minutes after intercourse attempts   Ask if on some occasions there is less/no pain, and if so, what is different

Physical Examination

Routine pelvic examination is an essential component of general medical care; this is not the case with women who seek care for sexual concerns. Given the prevalence of negative past sexual experiences, including abuse, a pelvic examination should be performed only in the presence of a definite indication, and the procedure should be clearly explained to the patient (Table 11.6). Management of dyspareunia mandates careful vulvar, vaginal, and pelvic examination. A physical examination can confirm normal anatomy and the healthy nonaroused state of the genitalia, it does not confirm healthy sexual function. Nevertheless, such an examination can be both instructive and therapeutic.

Diagnostic Criteria

Just as phases of sexual response overlap, types of women’s sexual dysfunctions overlap (18,41). The Second International Consensus on Sexual Dysfunctions in Men and Women provides evidence-based recommendations for the diagnosis of sexual dysfunction and encompasses the proposed revisions to the American Psychiatric Association’s Diagnostic and Statistical Manual, Fourth Text Revised (DSM-IV-TR) definitions of women’s sexual dysfunction (86,87) (Table 11.7).

The official revisions—DSM-V—are due in 2012. Interim publications advocate that desire and arousal disorders are merged (88,89). Increasing evidence indicates that desire ahead of and at the outset of sexual engagement, although probably welcomed by both partners, is not mandatory for women’s sexual enjoyment and satisfaction (3). It is the inability to trigger desire and arousal during sexual engagement, and an initial absence of desire, that constitutes disorder. Therefore, merging sexual and desire difficulties into one disorder appears logical.

Each disorder is then further classified by the following descriptors:

1. Lifelong or acquired

2. Generalized or situational

3. The degree of distress—mild, moderate, or marked

4. Presence of contextual factors

  A. Past factors from developmental history affecting psychosexual development

  B. Present contextual factors—interpersonal, environmental, societal, and cultural

  C. Medical factors

Table 11.6 Physical Examination for Sexual Dysfunction

General examination	Signs of systemic disease leading to low energy, low desire, low arousability, e.g., anemia, bradycardia and slow relaxing reflexes of hypothyroidism. Signs of connective tissue disease, such as scleroderma or Sjögren's, which are associated with vaginal dryness. Disabilities that might preclude movements involved in caressing a partner, self-stimulation, intercourse. Disfigurements/presence of stomas; catheters that may decrease sexual self-confidence, leading to low desire; low arousability.
External genitalia	Sparsity of pubic hair, suggesting low adrenal androgens. Vulval skin disorders, including lichen sclerosis, which may cause soreness with sexual stimulation (e.g., when it involves the clitoral hood). Cracks/fissures in the interlabial folds suggestive of chronic candidiasis. Labial abnormalities that may cause embarrassment/sexual hesitancy (e.g., particularly long labia or asymmetry).
Introitus	Vulval disease involving introitus (e.g., lichen sclerosis). Recurrent splitting of the posterior fourchette manifest as just visible white lines perpendicular to fourchette edge. Abnormalities of the hymen (e.g., hymenal band across the introitus). Adhesions of the labia minora. Swellings in the area of the major vestibular glands. Allodynia (pain sensation from touch stimulus) of the crease between the outer hymenal edge and the inner edge of the labia minora +/− allodynia of the Skene’s duct openings (all typical of provoked vestibulodynia). Presence of cystocele, rectocele, or prolapse interfering with the woman’s sexual self-image. Inability to tighten and relax perivaginal muscles (often associated with hypertonicity of pelvic muscles and midvaginal dyspareunia). Abnormal vaginal discharge associated with burning dyspareunia.
Internal examination	Pelvic muscle tone. Presence of tenderness or trigger points on palpating deep levator ani as a result of underlying hypertonicity.
Full bimanual examination	Presence of nodules and/or tenderness in the cul-de-sac or vaginal fornix, or along uterosacral ligaments. Retroverted fixed uterus as causes of deep dyspareunia. Tenderness palpating posterior bladder wall from anterior vaginal wall suggestive of bladder pathology.

Table 11.7 Revised DSM-IV Definitions of Women’s Sexual Dysfunction

Diagnosis	Definition	Comments
Sexual desire/interest disorder	Absent or diminished feelings of sexual interest or desire, absent sexual thoughts or fantasies and a lack of responsive desire. Motivations (here defined as reasons/incentives) for attempting to become sexually aroused are scarce or absent. The lack of interest is beyond a normative lessening with life cycle and relationship duration.	Minimal spontaneous sexual thinking or desiring of sex ahead of sexual experiences does not necessarily constitute disorder. Additional lack of responsive desire is integral to the diagnosis.
Combined sexual arousal disorder	Absent or markedly reduced feelings of sexual arousal (sexual excitement and sexual pleasure) from any type of stimulation and absent or impaired genital sexual arousal (vulval swelling and lubrication).	There is minimal sexual excitement (subjective arousal) from any type of stimulation—erotic material, stimulating the partner, genital and nongenital stimulation. There is no awareness of the reflexive genital vasocongestion.
Subjective sexual arousal disorder	Absent or markedly reduced feelings of sexual arousal (sexual excitement and sexual pleasure) from any type of stimulation. Vaginal lubrication and other signs of physical response still occur.	Despite lack of sexual excitement/ subjective arousal, lubrication is noted by the woman or partner. Intercourse is comfortable without use of external lubricant.
Genital arousal disorder	Absent or impaired genital sexual arousal–minimal vulval swelling or vaginal lubrication from any type of sexual stimulation and reduced sexual sensations from caressing genitalia. Subjective sexual excitement still occurs from nongenital sexual stimuli.	Subjective arousal (sexual excitement) from nongenital stimuli (erotica, stimulating the partner, receiving breast stimulation, kissing) is key to this diagnosis. Early studies indicate reduced vasocongestion in some but not all cases. Loss of sexual sensitivity of physiologically congested tissues accounts for others.
Orgasmic disorder	Despite the self-report of high sexual arousal/excitement, there is either lack of orgasm, markedly diminished intensity of orgasmic sensations, or marked delay of orgasm from any kind of stimulation.	Women with arousal disorders frequently do not experience orgasm. Their correct diagnosis is one of an arousal disorder.
Vaginismus	Persistent or recurrent difficulties of the women to allow vaginal entry of a penis, finger, or any object despite the woman’s expressed wish to do so. There is often (phobic) avoidance and anticipation/fear/experience of pain, along with variable and involuntary pelvic muscle contraction. Structural or other physical abnormalities must be ruled out/addressed.	Confirmation of this diagnosis is not possible until there has been therapy sufficient to allow a careful introital and vaginal examination. It is a presumptive diagnosis initially.
Dyspareunia	Persistent or recurrent pain with attempted or complete vaginal entry and or penile vaginal intercourse	There are many causes, including localized provoked vestibulodynia (vulvar vestibulitis syndrome) and vulvar atrophy from estrogen deficiency.
From Basson R, Wierman M, van Lankveld J, et al. Summary on the recommendations on sexual dysfunction in women. J Sex Med 2010;7:314–326, with permission.

Management of Sexual Dysfunction

Many of the sexual problems couples encounter result from a deficit of knowledge or experience, sexual misconceptions, or inability of the couple to communicate about their sexual preferences.Brief counseling and education by the obstetrician–gynecologist regarding the circular sex response cycle can identify the areas where sexual dysfunction can occur.

The PLISSIT Model

Gynecologists may sometimes need to provide detailed management for certain conditions (e.g., for the chronic dyspareunia of provoked vestibulodynia [PVD]), frequently the first two levels of a model, known by its acronym as PLISSIT, are sufficient to address women’s sexual problems. The model is as follows:

1. Permission. The concept of permission is the validation of the patient’s concerns and confirmation that the gynecologist’s office is an appropriate setting to address them.

2. Limited Information. The patient is provided with information about sexual physiology and behavior so misunderstandings, myths, lack of knowledge, and inadequate sexual skills can be addressed.

3. Specific Suggestions. This stage may involve altering the problematic sexual context, reeducating patients about specific attitudes and practices, advising different forms of sexual stimulation, screening for mental health issues, identifying interpersonal issues and prescribing hormones and medications.

4. Referral for Intensive Therapy. Examples where this step may be necessary include (i) intrapsychological issues stemming from childhood that impair women’s ability to be aroused and experience sexual pleasure and satisfaction including past traumas and abuse, (ii) for couples who need more specialized help in sexual communication, and (iii) for male sexual dysfunctions.

As an example of a PLISSIT approach, a woman with chronic dyspareunia from PVD is first given validation of her pain and is provided with the information that PVD is common and many women find that the pain precludes intercourse. The patient and her partner are encouraged to focus on nonpenetrative aspects of lovemaking. The next level is the provision of limited information about chronic pain mechanisms, the role of psychological stress, and genetic and possible immune factors. Specific suggestions could include ongoing encouragement to remove intercourse as one of the ways the couple interact sexually, explanation of basic cognitive behavioral therapy (CBT) concepts and/or referral to psychologist or counselor for the same, prescription of medications for chronic pain, prophylaxis for overgrowth of candidiasis when this is relevant, and referral to a pelvic muscle physiotherapist. Referral for intensive therapy may be indicated for further pain management, including learning the skills of mindfulness, further exploration of CBT, for couple counseling if the relationship cannot cope with the stress, or occasionally, to a gynecologist specializing in vulvar surgery if vestibulectomy is considered.

Figure 11.3 Breaks in the circular sex response cycle subsequent to infertility testing.

Sexual Dysfunction

The larger surveys find approximately 10% of women report ongoing sexual dysfunction that is particularly upsetting, while a further 20% report sexual problems that are less distressing (4,90). Comorbidity of low desire and subjective arousal along with infrequent or absent orgasm is the most common presentation (18,91). Postmenopausal vaginal dryness and associated dyspareunia affects some 15% to 30% of women with marked cultural differences to the extent that this leads to bothersome sexual difficulties (92). Lack of lubrication and associated dyspareunia is reported by 5% to 25% of younger women with marked cultural differences leading to resulting sexual distress (92). Introital dyspareunia from PVD, the most common cause of dyspareunia in premenopausal women, is thought to affect some 15% of women (93). Isolated lack of orgasm despite high arousal is of unknown prevalence because studies generally include women with low arousal alongside their lack of orgasm.

Management of Sexual Desire and Arousal Disorders

Construction of the woman’s sex response cycle showing the various breaks can be highly therapeutic for the woman and her partner. For example, Figure 11.3 shows the various breaks subsequent to infertility testing. The couple learns that it is “normal” for the woman to have low motivation to be sexual when emotional intimacy has suffered. If the issues distancing the couple cannot be addressed in the gynecologist’s office (i.e., they extend over and beyond the common reactions to infertility testing and procedures), referral to a relationship counselor may be necessary. The gynecologist can address the sexual context and the type of stimulation that is provided. Often sex has become “mechanical”—intercourse focused to achieve conception. Most women need more nonphysical stimulation, more nongenital physical stimulation, and more nonpenetrative genital sexual stimulation, and this can be stressed. Privacy issues, time of day, and emotional closeness at the time of lovemaking can all be discussed. Factors personal to the woman that may be impairing her ability to be aroused, such as low sexual self-image and distractions, can be identified. Referral for CBT may be necessary when low self-image appears ingrained and stems from developmental factors. Biological factors influencing arousability, including fatigue, medication effect, and depression, may be involved. Fears regarding outcome, such as lack of adequate birth control or partner dysfunction, can be identified. Inquiring about the patient’s thoughts at the time of potential lovemaking can be helpful. Some women admit to evoking negative thoughts or allowing spontaneously emerging negative thoughts to intrude when there is a sexual opportunity. Guilt about sex and about women having sexual pleasure may be present. If the woman is a new mother, she may feel on one level that sex now is “wrong.” Experiences of assisted reproduction technique or delivery may lead to the woman feeling loss of control; this in turn may lead to a need to regain control in all aspects of her life, which may suppress her sexual feelings. CBT and mindfulness therapies are recommended (94).

Randomized controlled trials of transdermal testosterone for medically and psychiatrically healthy postmenopausal women with low sexual desire were published. Four involved surgically menopausal estrogenized women (95–98). Transdermal testosterone (300 μg) daily significantly increased the frequency of sexually satisfying events (p = .049) compared to placebo. At baseline, these studies showed that the recruited women reported two to three sexually satisfying experiences per month, and these increased to approximately five per month with active drug (300 μg of testosterone), and to four per month with placebo. Using a validated unpublished questionnaire, scores in the desire and arousal scales were significantly increased by active drug in the first three studies (for desire: p = .05 in the first study and .006 in the second, .001 in the third). The fourth smaller study of prescribed transdermal estrogenrecruiting women showed significant increase in desire and response scales, but not in the numbers of sexually satisfying events (98). Results from one study of 549 naturally menopausal women receiving oral estrogen and transdermal testosterone were similar (99).

Two studies of transdermal testosterone to estrogen-deficient women showed benefit (100,101). A previous small study showed minimal or no benefit from transdermal testosterone in estrogen-deficient women with past history of cancer (102).

There was minimal benefit from transdermal testosterone when given to premenopausal women in another study of 261 premenopausal women recruited on the basis of loss of their former sexual satisfaction (103).

The criteria for recruitment are a major drawback of the testosterone patch trials. It is not certain that the recruited women had any sexual disorder: the focus consistently was on the frequency of satisfying events in women able to have such experiences—some 50% (98). The participants did not have consistent difficulties or dysfunctions, pointing against a biological cause or need for a biological remedy and pointing toward psychological, relationship, or contextual factors, which are inherently variable. As noted, there was improvement in the secondary end points of desire and response subscales in the (unpublished) validated questionnaires used in all the trials. Increasing the degree of pleasure and arousal currently experienced may not necessarily imply that absent pleasure and absent arousal would be remedied.

Long-term safety issues include those of the combination of testosterone and estrogen and concerns about estrogen itself. Beginning systemic estrogen some 10 years postmenopause is known to increase cardiovascular risk: aromatization of exogenous testosterone to estrogen is likely. For postmenopausal women not receiving estrogen, long-term sequelae of creating a distinctly nonphysiological profile of the testosterone:estrogen ratio are completely unknown. Endogenously high testosterone along with obesity in older women is associated with insulin resistance and increased cardiovascular morbidity (104).

Genital Arousal Disorder

There are no approved medications for treating desire and arousal disorders in women. Approval was sought from the U.S. Food and Drug Administration (FDA) for transdermal testosterone but not granted because of theoretical risks to breast tissue and cardiovascular health with only modest benefit. Approval for phosphodiesterase inhibitors was not sought—the larger studies show no benefit of placebo for women’s sexual dysfunction. Off-label use of sildenafil when genital congestion is likely to be impaired by an underlying illness such as diabetes, multiple sclerosis, or spinal cord injury showed some modest benefit to lubrication in small studies (33).

Orgasmic Dysfunction

Lifelong orgasmic disorder is more common than acquired loss of orgasm. Some women acquire orgasmic dysfunction in association with relationship problems, depression, substance abuse, medication (especially use of SSRIs), or chronic illness (e.g., multiple sclerosis). Aside from those using SSRIs, most women who experience lack of orgasm are found on careful questioning to have only modest degrees of subjective excitement. Sometimes women respond to reassurance that most couples do not experience orgasm simultaneously, that most women experience orgasm far more easily from direct clitoral stimulation, and that this does not constitute dysfunction.

Common causes of lack of orgasm include obsessive self-observation and monitoring during the arousal phase, sometimes accompanied by anxiety and distracting negative and self-defeating thoughts. The woman may be so intent on monitoring her own and her partner’s response and concerned about “failing” that she is unable to allow her natural reflexes to take over and trigger an orgasm. Lack of orgasm may be related to negative feelings toward sexuality, low self-esteem, poor body image, a history of sexual abuse, and fear of losing control, and ineffective sexual technique. The only evidenced-based therapy is encouragement of self-stimulation, accompanied by erotic fantasy, so-called directed masturbation. Several excellent self-help books are available to help women become orgasmic through self-stimulation (105). A vibrator may be helpful if the plateau of high arousal is reached but there is still no orgasmic release. When the woman has experienced orgasm with self-stimulation with or without the use of a vibrator, she may or may not be able to teach the technique to her partner. Issues of trust may surface, and more intense psychological help may be needed. To counter the orgasmic delay or absence induced by SSRIs, highly selected women benefited from the prophylactic use of sildenafil (61).

Sexual Pain Disorders

Vaginismus

Vaginismus is an involuntary reflexive contraction of pelvic muscle precipitated by real or imagined attempts at vaginal entry. Often other muscles tighten including thighs, abdomen, buttocks, and even jaw, fists, and other muscle groups. It may be generalized—the woman is unable to place anything in her vagina, even her own finger or a tampon—or it may be situational, in which case she can use a tampon and can tolerate a pelvic examination but cannot have intercourse. Couples frequently cope with this difficulty for many years before they seek help and then do so in order to begin a family. Often there are no obvious circumstances predisposing to vaginismus, such as an unpleasant past sexual experience or trauma, sexual abuse, or a painful first pelvic examination. Higher rates of psychopathology were found with regards to agoraphobia without panic disorder and obsessive-compulsive disorder. Some studies showed that women with vaginismus have higher scores on neuroticism, depression, state anxiety, phobic anxiety, social phobia, somatization, and hostility. They were shown to have increased catastrophic thinking compared to those women without dyspareunia and those with other forms of pain (e.g., PVD). Women with vaginismus had higher propensity for disgust (55). Despite the theories, there is no scientific evidence that vaginismus is secondary to religious orthodoxy, negative sexual upbringing, or concerns about sexual orientation. Women with vaginismus typically have an extreme fear of vaginal entry and misconceptions about their anatomy and the size of their vagina. They fear that harm will come from something the size of a penis entering the vagina, and similarly they fear that they would be damaged by vaginal delivery.

Although the term “vaginismus” is often loosely used to refer to reflex tightening secondary to dyspareunia (e.g., from PVD or vaginal atrophy), strictly speaking, the term should only be used when no such pathology is present. Thus, the diagnosis of vaginismus is provisional until a very careful introital and vaginal examination can be done. This is not possible until the woman learns to be able to abduct her thighs, open the labia with her fingers or permit the examiner to do so, and to tolerate introital touch. The therapy for vaginismus must begin before the diagnosis is confirmed:

1. Encourage the couple to engage in sexual activities that exclude any attempt at intercourse. They may need to have “dates” and deliberately provide sexual contexts.

2. Explain to the patient the reflex contraction of pelvic muscles around the vagina to touch, especially when touch was associated only with negative emotions and physical pain. These women rarely use tampons and avoid the introitus and vagina in sexual play and have not experienced any neutral or positive sensations from this area of their bodies.

3. Institute self-touch on a daily basis for a few minutes as close to the vaginal opening as possible. This may be done while the woman is in the bathtub or relaxing by herself on the bed. This is not sexual, and at first it will be highly anxiety provoking. Providing she does this daily, the anxiety will quickly decrease.

4. Suggest adding visual imagery to the previous exercise so that she imagines being able to have a limited vaginal examination, sitting up on the examination couch at about a 70-degree angle to, with the aid of a mirror, view the vaginal opening and separate her labia, and be in control of what happens.

5. As soon as she is ready, perform the partial vulvovaginal examination as in step 4. If possible, encourage her to touch the vagina, moving her finger past the hymen, possibly afterward doing the same with the physician’s gloved finger.

6. Once the vagina is adequately examined, prescribe a series of vaginal inserts of gradually increasing diameter. When symptoms suggestive of PVD are present—especially burning with semen ejaculation, dysuria, or vulvodynia after intercourse attempts—she should use only the smallest insert before a repeat examination takes place.

7. When it is necessary to exclude PVD, repeat the examination with the woman checking for allodynia with a cotton swab. Sometimes the physician can do this; it depends entirely on the amount of anxiety and apprehension the woman retains. The number of false-positive findings for allodynia can be limited if the patient touches the rim of the vaginal opening. Provoked vestibulodynia or other gynecologic findings should be treated.

8. Once the patient is able to use larger inserts, the following steps can be undertaken:

  a. Encourage the woman to allow her partner to assist her in placing the insert in her vagina.

  b. Encourage the couple during their sexual times to briefly use the insert—to prove to her that the insert will still go in when her body is physiologically aroused.

  c. Once she has used the insert on a number of occasions during sexual play, encourage her to follow it immediately with insertion of her partner’s penis. It is usually preferable for the woman to hold her partner’s penis in the same position she used with the insert and to insert the penis herself. He must allow his pelvis to move forward with gentle pressure as she tries to insert it. The use of external lubrication is advised in these first attempts at penile entry.

Phosphodiesterase type 5 inhibitors may be used to treat temporary situational partner erectile dysfunction that occurs at the crucial moment when the woman is finally able to accommodate her partner’s penis.

Figure 11.4 Schematic of proposed pathophysiological mechanisms underlying the chronic pain of vulvar vestibulitis syndrome and therapeutic interventions. WBC, white blood cells.

Dyspareunia

Dyspareunia, one of the most common types of sexual dysfunction seen by gynecologists, affects some two-thirds of women during their lifetime. Both psychological and physical factors are involved—the mind being able to powerfully modulate both immune and neurological systems, causing objective changes in the latter. The gynecologist’s assessment of dyspareunia needs to be holistic: biological, psychological, and sexual (Fig. 11.4).

There are three aspects to the management of dyspareunia:

1. Assisting the couple to have rewarding sexual intimacy even if intercourse initially is precluded

2. Identifying the psychological issues contributing to and arising from the chronic pain

3. Treating, whenever possible, the underlying pathophysiology that triggered the chronic pain circuits

It is helpful to clarify that the popular depiction of sex as foreplay followed by “real sex” (i.e., intercourse) is not the reality for many sexually satisfied couples. The couple can be encouraged to consider the many varieties of human sexual interaction and ways of giving and receiving genital and nongenital sexual pleasure. It is important for the couple to see removal of intercourse from the menu of sexual activity as an opportunity for more exploration and creativity, and not as a loss. Inclusion of the partner in the assessment and evaluation of chronic dyspareunia allows his feelings to be addressed and his compliance with nonpenetrative sex encouraged. The couple rendered emotionally distant because of chronic dyspareunia may find it difficult to adapt to alternative forms of lovemaking.

Provoked Vestibulodynia

PVD is defined as pain on vestibular touch (from tampon, examining finger, penis, tight seam on clothing, etc.) where physical findings are limited to variable (possibly absent) vestibular erythema and the presence of allodynia (feeling a burning pain from the touch stimulus) on localized areas around the outer edge of the hymen and inner edge of the labia minora where the two meet. The whole introital circumference may be affected: typically the lower part (lower horseshoe or 4 to 8 o'clock location) is involved along with the areas immediately around the openings of Skene’s ducts. Typically pelvic muscle tone is heightened. This is the most common cause of dyspareunia seen in clinics, with at least 50% of women reporting lifelong symptoms and others acquiring them after possibly multiple occasions of painless intercourse. PVD is considered a chronic pain syndrome, with features suggesting both central and peripheral sensitization within the nervous system. This means that there are physical changes within the nervous system that perpetuate the pain cycles, and these can be targeted both by medications (chronic pain drugs) and mind skills including CBT and mindfulness. The cause of the sensitization within the nervous system is not established with certainty, but internal stress appears to be a likely cause. Women with PVD report higher levels of perfectionism, reward dependency, fear of negative evaluation, and harm avoidance, higher levels of trait anxiety, and shyness (55). Higher rates of depression and anxiety disorders are found in women with PVD compared to controls. Women with PVD have more catastrophic thoughts about intercourse pain and the negative consequences on the partner and durability of the relationship than women with other types of dyspareunia (55). There is evidence of hypervigilance for pain. Many women with PVD have other pain syndromes such as irritable bowel syndrome, temporomandibular joint pain, interstitial cystitis, dysmenorrhea, and, especially for midaged women, fibromyalgia (55).

The management of PVD includes psychological methods to address the chronic internal stress and possibly adjunctive medications, simultaneously or subsequently. The psychological methods include CBT and mindfulness. Particular attention is paid to the catastrophic thinking. Giving the woman as much information as appropriate on the mechanisms of chronic pain allows her to see the role of the emotions experienced alongside the physical sensation of pain. Realizing that her thoughts can alter her emotions moves her onto understanding how cognitive therapy will change her pain intensity. Mindfulness has been used for 3,500 years for ameliorating chronic pain but only recently in Western medicine. Given its use in other pain conditions, it was added to the holistic treatment of PVD (106). Chronic pain medications include tricyclic antidepressants and antiseizure drugs. Applications of local anesthetics and or local anti-inflammatories such as sodium cromoglycate can be used. Topical steroids need to be avoided because initial benefit moves onto worsening of the presumed neurogenic inflammation. Evidence-based guidelines suggesting which medical treatment to choose are lacking. A typical outcome of the psychological therapy is that pain intensity and distress lessen sufficiently to allow the woman who regains her sexual confidence with nonpenetrative sex sometimes to begin to include intercourse. Prior to doing so she might use topical local anesthetic on residual areas of allodynia. Her expectation of less pain combines with her expectation of reward to reduce the intensity of the dyspareunia. The local anesthetic may contribute to a positive experience.

Introital pain may be caused by conditions other than PVD. The differential diagnosis includes recurrent tears of the posterior fourchette, which may be treated with the topical application of estrogen or testosterone and, if necessary, a perineorrhaphy. Other diagnoses are congenital abnormalities, including a hymenal ring that is rigid, scar tissue (e.g., from episiotomy repairs), a vaginal septum, and, much more commonly, vaginitis or vulvitis, sometimes resulting from the use of over-the-counter vaginal sprays and douches. One important common cause of dyspareunia is friction from inadequate genital sexual arousal. Estrogen deficiency with inadequate lubrication, progressing to loss of elasticity and thinning of the epithelium from vaginal atrophy, is another common cause. This condition is easily treated with local estrogen therapy. Deep dyspareunia resulting from pelvic disease, including endometriosis, is managed by treatment of the underlying conditions.

Sexual Dysfunction Midlife and Later

Because sexual dysfunction in older women can be related to a variety of factors, broad-spectrum treatment approaches are needed in which individual, interpersonal, and sexual aspects can be addressed simultaneously. The following steps in therapy are recommended:

• To encourage the woman to take responsibility for discovering what provides sexual pleasure and arousal and to learn to guide her partner toward stimuli and contexts (surroundings and time of day) that are pleasurable to her now, as they may be different and more complicated than when she was a younger woman and possibly her relationship was relatively new.

• To assist her to understand that a more rewarding outcome will increase her sexual motivation. Factors relating to the couple’s sexual style and even sexual dysfunction in the partner may need to be addressed.

• To counsel her that women can begin rewarding sexual experiences in the absence of desire, which can be reassuring and therapeutic.

• To acknowledge that resentment, frustration, and disappointment toward her partner will very likely preclude arousal and pleasure: the couple may benefit from referral for relationship counseling.

• To advise that deep-seated psychological distress from factors in her development or current refractory mood disorders may require referral to a psychologist or a psychiatrist.

Practical suggestions for aging patients might include taking a warm bath before lovemaking to loosen stiff joints, making love in the morning when the couple is less fatigued, or having neither intercourse nor orgasm as a necessary goal. Local estrogen supplementation can alleviate vaginal dryness, urinary tract symptoms, and dyspareunia, restoring vaginal cell health, decreasing pH, and increasing vulvar and vaginal blood flow.The aging couple can be encouraged to use low-key, more prolonged sexual stimulation because the rate of sexual response is slower.

To relieve sexual symptoms of dyspareunia and lower sexual self-image from estrogen deficiency–associated vaginal dryness and recurrent urinary tract infections, topical vaginal estrogen is recommended. There is some evidence topical therapy may be more effective for sexual symptoms than systemic, and when systemic estrogen is used for nonsexual reasons, additional topical vaginal estrogen may still be required (107).

Ultra low-dose estrogen from a Silastic ring or vaginal cream or vaginal pill is an emerging therapy, to avoid the (albeit) small systemic absorption from current formulations of ring (releasing 7.5 μg estradioldaily) or estradioltablets (containing 25 μg estradiol daily). These ultra low-dose formulations may prove appropriate for women with past history of breast cancer. Every woman with such history currently is treated individually by her oncologist, taking into account her sexual symptoms, the importance to her of penetrative sex, as well as her particular tumor endocrinology.

Investigational local vaginal DHEA may benefit vulvar vaginal atrophy, in the absence of systemic absorption of either DHEA or the intracellularly produced estrogen or testosterone. Early research shows a generalized sexual benefit in terms of coital comfort, ease of orgasm, and sexual motivation (108).

Female Genital Mutilation

Increasing numbers of women who underwent female genital mutilation or female genital cutting (FGC) need gynecologic care in Western counties. This ancient tradition from at least 200 B.C. has cultural rather than religious origins and is not restricted to any particular ethnic group or religious sect. Type I FGC involves removing part or all of the clitoris and prepuce, Type II is an excision of part or all of the clitoris and the labia minora with or without excision of the labia majora, Type III is known as infibulation and is the most extreme form, involving narrowing the vaginal orifice and creating a covering of the adjoined labia minora and or labia majora with or without including the clitoris. There are other “lesser” procedures often noted as Type IV, such as pricking of the female genitalia for nonmedical reasons. Although some 85% of FGC are Types I and II and 15% are Type III, recent immigration and refugee resettlement from countries where Type III predominates, including Somalia, resulted in many more women with Type III FGC in North America and Europe.

Sound data are lacking on psychosexual outcome. The taboos against discussing sexual displeasure or pain from FGC limit data collection. Despite this, there is evidence that FGC may not destroy sexual function and prevent enjoyment in all women (109). FGC invariably damages many neural networks associated with the vulvar and perineal areas, potentially altering genital sensation. Neuroplasticity within the brain and spinal cord is thought to account for the fact that some, perhaps even the majority, of women have sexual response, sometimes including that from genital stimulation and other times from stimulation of breasts or other areas of the body.

Results of studies of dyspareunia are somewhat conflicting, some suggesting it is only temporary after first intercourse during the initial period of marriage and after reinfibulation (110). Some studies that noted increased prevalence of dysmenorrhea, vaginal dryness, lack of sexual desire, difficulty reaching orgasm, as compared to noncircumcised women, failed to find increased incidence of dyspareunia.

Surgery is recommended for women with Type III FGC complications such as dysmenorrhea, a desired vaginal birth that would not be possible without surgery, apareunia, dyspareunia, or difficulty voiding. The defibulation should be preformed after counseling regarding risks and benefits, the former including bleeding infections, preterm labor if the woman is already pregnant, and scar formation. The benefits include lower risk of chronic urinary and vaginal infections, voiding difficulties, dysmenorrhea, dyspareunia, and intrapartum complications. Regional or general anesthesia is required, as local anesthesia may allow the sensation of touch to trigger flashbacks to the original traumatic procedure. The surgical technique of defibulation was detailed and summarized (111).

It is apparent to people helping women who underwent FGC that culture plays a very important role in their sexual health. It is imperative that the specific needs of the individual woman with FGC are understood in order to help her. Care should be given in a nonjudgmental manner that encourages trust and open discussion. Her own cultural significance of the FGC should be explored and often an interpreter is necessary to really understand her situation.

Sexual Assault

Sexual assault of children and adult women has reached epidemic proportions in the United States and is the fastest growing, most frequently committed, and most underreported crime (112–114). Sexual assault is a crime of violence, conquest, control, and aggression, not passion, and encompasses a continuum of sexual activity that ranges from sexual coercion to contact abuse (unwanted kissing, touching, or fondling) to forcible rape. The terms sexual abuse survivor and assault survivor are preferable to victim.

In a survey of female family practice patients, 47% reported some type of contact sexual victimization during their lifetime; 25% reported attempted rape, and 13% had been forcibly raped, many as children (115). Among battered women, approximately 68% experience marital rape as an element of their repetitive abuse (116). Uninvited sexual attention in the workplace is reported by 50% of women in the United States (117). Spousal rape is reported infrequently because of fear of retribution and economic dependency (118). Obstetrician–gynecologists should routinely inquire about a history of childhood sexual abuse or adult sexual assault. These experiences are common and often have a lasting and profound effect on a woman’s mental and sexual function as well as her general health and well-being.

Childhood Sexual Abuse

Childhood sexual abuse has a profound and potentially lifelong effect on the survivor. Although most cases of childhood sexual abuse are not reported by the survivor or her family, it is estimated that as many as one-third of adult women were sexually abused as children. Childhood sexual abuse is often accompanied by another type of household dysfunction, such as physical abuse, violence against other family members, or substance abuse by parental figures (114). Younger children are more often exposed to genital fondling or noncontact abuse (exhibitionism, forced observation of masturbation, or posing in child pornography), and children older than 10 years of age are more likely to be forced to have intercourse or oral sex (119). As children age, they are more likely to experience sexual abuse outside the home and more likely to be victimized by strangers. As adolescents, women survivors of childhood sexual abuse are at risk for early unplanned pregnancy, STDs, prostitution, further sexual abuse (revictimization), antisocial behavior, running away from home, lying, stealing, eating disorders and obesity, and multiple somatic symptoms (120). These women are more likely to engage in health risk behaviors such as smoking, substance abuse, and early sexual activity with multiple partners (121). They may be less likely to use contraception (122). Survivors often avoid pelvic examinations and are less likely to have Papanicolaou (Pap) tests because of the association between vaginal examinations and pain (125). They often receive inadequate prenatal care and are more likely than women who were not abused to experience suicidal ideation and depression during their pregnancies and to deliver smaller and less mature babies (114).

Obstetrician–gynecologists can assist their sexual assault patients by validating their feelings and concerns and giving them control over their examination. It is important to ask the patient for permission to perform the examination, give her the opportunity to have an advocate in the room with her, and let her know that she has the right to stop the examination at any time (114).

Survivors may be unable to trust or establish rapport with adults. Some women blame themselves for the abuse and come to believe that they are not entitled to assistance from others. Thus, they risk continuing to enter abusive relationships. Women survivors of childhood sexual abuse often develop feelings of powerlessness and helplessness and may become chronically depressed. They experience a high incidence of self-destructive behavior, including suicide and deliberate self-harm, such as cutting or burning themselves (114,124,125). The most extreme mental health symptoms in assault survivors are associated with the onset of abuse at an early age, frequent abuse over a long period, use of force, or abuse by a parent or other trusted individual. Survivors are at risk for becoming victimized again later in life (126). Of women who report being abused as children, 50% are abused again as adults. Women who are sexually abused as children carry the effects of abuse into adulthood. As adults, they have the same level of physical symptoms and psychological distress as women who do not report childhood sexual abuse but are currently experiencing sexual or physical abuse (127).

Women who were sexually abused as children or sexually assaulted as adults often experience sexual dysfunction and difficulty with intimate relationships and parenting (128). Chronic sexual concerns may include fear of intimate relationships, lack of sexual enjoyment, difficulty with desire and arousal, and anorgasmia. Compared with women who were not sexually assaulted, they are more likely to experience depression, suicide attempts, chronic anxiety, anger, substance abuse problems, dissociative personality disorder, borderline personality disorder, fatigue, low self-esteem, feelings of guilt and self-blame, and sleep disturbance (127,129–131). They often experience social isolation, phobias, feelings of vulnerability, fear, humiliation, grief, and loss of control (132,133). Survivors of sexual assault represent a disproportionate number of patients with chronic headaches, fibromyalgia, and chronic pelvic pain (they have a lower pain threshold) and are more likely to have somatic symptoms that do not respond to routine medical treatment (130,134). Women with common gynecologic symptoms, such as dysmenorrhea, menorrhagia, and sexual dysfunction, are much more likely to have a history of sexual assault (135). If they were forced to perform oral sex, they may have a dental phobia and avoid preventive dental care.

Survivors may develop posttraumatic stress disorder (PTSD), in which characteristic symptoms are exhibited following a psychologically traumatic event outside of normal human experience.Symptoms of PTSD include blunting of affect, denial of symptoms, intrusive reexperiencing of the incident, avoidance of stimuli associated with the assault, and intense psychological distress and agitation in response to reminders of the event (112,124). Women affected by PTSD are more likely to commit suicide. The cognitive sequelae include flashbacks, nightmares, disturbances in perception, memory loss, and dissociative experiences (136). These women may not be able to tolerate pelvic examinations and may avoid seeking routine gynecologic care because these examinations may remind them of the sexual abuse they experienced as children. They are more likely to use the medical care system for nongynecologic concerns (137). Women with PTSD are at greater risk for being overweight and having gastrointestinal disturbances (121).

Rape

Although the legal definition of sexual assault may vary from state to state, most definitions of rape include the following elements:

1. The use of physical force, deception, intimidation, or the threat of bodily harm

2. Lack of consent or inability to give consent because the survivor is very young or very old, impaired by alcohol or drug use, unconsciousness, or mentally or physically impaired

3. Oral, vaginal, or rectal penetration with a penis, finger, or object

The National Women’s Study provides the best statistics available about the incidence of forcible rape in the United States (132). This study revealed that 13%, or one of eight adult women, are survivors of at least one completed rape during their lifetime. Of the women they surveyed, 0.7% were raped during the past year, equaling an estimated 683,000 adult women who were raped during a 12-month period. Of the women surveyed, 39% were raped more than once. Most rapes occurred during childhood and adolescence; 29% of all forcible rapes occurred when the survivor was younger than 11 years of age, and 32% occurred between the ages of 11 and 17 years. “Rape in America is a tragedy of youth” (132). Twenty-two percent of rapes occurred between the ages of 18 and 24 years, 7% between the ages of 25 and 29 years, and only 6% occurred when the survivor was older than 30 years of age. Although women of all ages and cultures are vulnerable to sexual assault, prisoners, adolescents, drug users, the elderly, those who experienced sexual assault as children, women in abusive relationships, and women with emotional and physical disabilities are at most risk (138–140).

There are many myths about rape. Perhaps the most common myth is that women are raped by strangers. Only about 20% to 25% of women are raped by someone they do not know. Most women are raped by a relative or acquaintance (9% by husbands or ex-husbands, 11% by fathers or stepfathers, 10% by boyfriends or ex-boyfriends, 16% by other relatives, and 29% by other nonrelatives)(132). Acquaintance rape may seem to be less traumatic than stranger rape, but survivors of acquaintance rape often take longer to recover. Another common misconception about rape is that most survivors sustain serious physical or life-threatening injury. Sixty percent of rape survivors report some physical injury. General body injury is more than twice as common as genital and anal injury (141). Serious injury is rare, occurring 4% of the time, although almost half of the rape survivors report being fearful of serious injury or death during the assault (132). The most common genital injuries from a sexual assault are vaginal lacerations resulting in bleeding and pain. Intraperitoneal extension of a vaginal laceration or damage to the anal mucosa is rare (142). Common nongenital injuries in survivors include cuts, bruises, scratches, broken bones and teeth, and knife or gunshot wounds (143). About 0.1% of sexual assaults result in death. Common causes of death during a sexual assault include mechanical asphyxiation, trauma, lacerations, drowning, and gunshot wounds (142).

There are at least four types of rapists (144):

1. Opportunist rapists (30%) exhibit no anger toward the women they assault and usually use little or no force. These rapes are impulsive and may occur in the context of an existing relationship (date or acquaintance rape). The highest incidence of acquaintance rape is among women in the 12th grade of high school or in the first year of college (145). Approximately one half of female college students report that they were date raped. Many of these women may have been unable to give consent because they were impaired by alcohol or so-called date rape drugs (Rohypnol or other benzodiazepines, ketamine, or gamma-hydroxy butyrate [GHB]). Date rape may have even greater psychological consequences than rape by a stranger because it involves a violation of trust (142).

2. Anger rapists (40%) usually batter the survivor and use more physical force than is necessary to overpower her. This type of sexual assault is episodic, impulsive, and spontaneous. An anger rapist often physically assaults his victim, sexually assaults her, and forces her to perform degrading acts. The rapist is angry or depressed and is often seeking retribution—for perceived wrongs or injustices he imagines were done to him by others, especially women. He may victimize the very young or the very old.

3. Power rapists (25%) do not intend to physically harm their victim but rather to possess or control her to gain sexual gratification. A power rapist may use force or the threat of force to overcome his victim. These assaults are premeditated and repetitive, and they may increase in aggression over time. The rapist is usually anxious and may give orders to his victim, ask her personal questions, or inquire about her response during the assault. This assault may occur over an extended period while the victim is held captive. These rapists are insecure about their virility and are trying to compensate for their feelings of inadequacy and low self-esteem.

4. Sadistic rapists (5%) become sexually excited by inflicting pain on their victim. These rapists may have a thought disorder and often exhibit other forms of psychopathology. This type of assault is calculated and planned. The victim is often a stranger. The rape may involve bondage, torture, or bizarre acts and may occur over an extended period of time. The victim often suffers both genital and nongenital injuries and may be murdered or mutilated. Other rapists may act out of impulse, as when they encounter a victim during the course of another crime such as burglary. Some rapists believe they are entitled to their victim, as in acquaintance rape or father–daughter incest (116). A consistent finding among all types of rapists is a lack of empathy for the survivor.

Even when sexual assaults are reported (only 16% of rapes are reported to the police), few rapists are arrested, and even fewer are brought to trial and convicted. Less than 1% of rapists serve a prison term (144,146). Successful prosecution of rapists is often dependent on the extent of the survivor’s injuries and the completion of a detailed forensic examination (147). Many women do not report the assault to the police because they are concerned about their name being disclosed by the news media, they fear retaliation from the perpetrator, are afraid they will not be believed, or do not trust the judicial process (148). Assault is more likely to be repeated if survivors in abusive relationships do not seek medical care, report the incident to police, or seek an order of protection (116).

Only 26% of rape survivors seek medical attention after an assault (116). Women are more likely to immediately seek treatment after sexual assault if weapons were involved, serious physical injury occurred, or physical coercion or confinement was used in the assault (149). Many rape survivors do not inform their physicians about the assault and may never volunteer information about the assault unless they are directly asked. When obtaining a medical history, physicians should routinely ask, “Has anyone ever forced you to have sexual relations?”

Effects of Rape

Following sexual assault, women have many concerns, including pregnancy, STDs (including human immunodeficiency virus [HIV] infection), being blamed for the assault, having their name made public, and having their family and friends find out about the assault. The initial reactions to sexual assault may be shock, numbness, withdrawal, and possibly denial. It is difficult to predict how an assaulted individual will react. Despite their recent trauma, women presenting for medical care may appear calm and detached (147).

Table 11.8 Prophylactic Medications Following Sexual Assault

Gonorrhea	Ceftriaxone 125 mg IM or Ciprofloxacin 500 mg PO or Spectinomycin 2 g IM
Chlamydia	Azithromycin 1 g PO or Doxycycline 100 mg PO bid × 7 days or Erythromycin 500 mg PO qid × 7 days
Trichomoniasis and bacterial vaginosis	Metronidazole 2 g PO
Hepatitis B	Vaccine 1.0 mL IM. Repeat in 1 and 6 months.
Tetanus (if indicated)	Td 0.5 mL IM
HIV	Zidovudine 300 mg and Lamivudine 150 mg (Combivir) PO bid for 28 days. Addition of protease inhibitor should be considered for high-risk exposures.
Pregnancy	Plan B (levonorgestrel 0.75 mg) 2 tablets immediately or
	Ovral 2 tablets immediately, repeat in 12 hours or
	35 μg combination birth control pill, 4 tablets immediately, repeat in 12 hours or
	Mifepristone 10 mg as a single dose or
	Placement of a copper IUD
IM, intramuscularly; PO, by mouth; bid, twice a day; qid, four times a day; Td, tetanus and diphtheria; IUD, intrauterine device.

The rape trauma syndrome is a constellation of physical and psychological symptoms, including fear, helplessness, disbelief, shock, guilt, humiliation, embarrassment, anger, and self-blame. The acute, or disorganization, phase of the syndrome lasts from days to weeks. Survivors may experience intrusive memories of the assault, blunting of affect, and hypersensitivity to environmental stimuli. They are anxious, do not feel safe, have difficulty sleeping and eating, and experience nightmares and a variety of somatic symptoms (116,150,151). They may fear that their assailant will return to retaliate or rape them again.

In the weeks to months following the sexual assault, survivors often return to normal activities and routines. They may appear to have dealt successfully with the assault, but they may be repressing strong feelings of anger, fear, guilt, and embarrassment. In the months following the assault, survivors begin the process of integration and resolution. During this phase, they begin to accept the assault as part of their life experience, and somatic and emotional symptoms may decrease progressively in severity. However, the sequelae of rape are often persistent and long lasting (124). Over the long term, survivors may have difficulty with work and with family relationships. Disruption of existing relationships is not uncommon. Nearly half of the survivors lose their jobs or are forced to quit in the year following the rape, and half change their place of residency (133).

Examination

The responsibilities of physicians providing immediate treatment for sexual assault survivors are listed in Table 11.8. Many health care facilities have trained sexual assault nurse evaluators (SANE). Because of the legal ramifications, consent must be obtained from the patient before obtaining the history, performing the physical examination, and collecting forensic evidence. Documentation of the handling of specimens is especially important, and the chain of evidence for collected material must be carefully maintained. Everyone who handles the evidence must sign for it and hand it directly to the next person in the chain. The chain of evidence extends from the examiner, to the police detective, to the crime laboratory, and finally to the courtroom.

The patient should be interviewed in a quiet and supportive environment by an examiner who is objective and nonjudgmental. Support personnel and patient advocates, such as family, friends, or, if available, a counselor from a rape crisis service, should be encouraged to accompany the patient. It is important not to leave the survivor alone and to give her as much control as possible over the examination. To provide useful forensic information, the examination should be performed as soon as possible after the incident occurred. Providers in all 50 states are required to report all cases of suspected or known childhood sexual abuse to appropriate authorities.

The history should include the following information:

1. A general medical history and a gynecologic history must be obtained, including last menstrual period; prior pregnancies; past gynecologic infections; tetanus immune status; history of liver disease, thrombosis, or hypertension (possible contraindications to emergency contraception with estrogens); contraceptive use; prior sexual assault; and last consensual intercourse before the assault.

2. It is important to ascertain whether the survivor bathed, douched, used a tampon, urinated, defecated, used an enema, brushed her teeth or used mouthwash, or changed her clothes after the assault. These activities can impair the collection of forensic evidence.

3. A detailed description of the sexual assault should be obtained, including the place, time, and date of the assault; number and appearance of assailants; use of drugs or alcohol in relation to the assault; loss of consciousness; use of weapons, threats, and restraints; and any physical injuries that may have occurred.

4. A detailed description of the type of sexual contact must be obtained, including whether vaginal, oral, or anal contact or penetration occurred; insertion of a foreign object with a description of the object; whether the assailant used a condom; and whether there were other possible sites of ejaculation or oral contact, such as the hands, clothes, breasts, or hair of the survivor. Saliva, respiratory spray, or semen recovered from these sites could yield DNA from the assailant.

5. The emotional state of the survivor should be observed and recorded.

The physical examination serves to detect, evaluate, and treat all injuries and to collect forensic evidence (152). It is important, when examining survivors, to pay close attention to detail. Examiners should wear powderless gloves at all times in order to prevent contamination of the evidence with their own DNA.

The survivor should undress while standing on clean examination table paper to catch any hair or fibers falling from her clothing. All of her clothing should be placed by the survivor (to avoid DNA contamination from the examiner) in individually labeled paper bags, sealed, and given to the proper authorities. Wet or damp clothing should be air dried before packaging in paper bags because DNA evidence degrades quickly if it is moist (139). During the physical examination, the degree of injury to the survivor should be assessed, and any injuries should be documented for use as evidence. The nature, size, and location of all injuries should be carefully documented, using photographs or body charts (traumagram) if possible. Ultraviolet photography may enable the examiner to record injuries not seen with standard photographic equipment, such as bite marks, stains, blood, or weapon imprints. Nongenital injuries occur in 20% to 50% of all rapes, so it important to carefully examine the entire body (152,153).

The most common injuries are bruises and abrasions of the head, neck, and arms, and genital injuries accompanied by bleeding and pain (150). Hair and skin should be examined for dirt, foreign material, dried blood, and dried semen (152). Ruptured blood vessels in the retina may be the result of trauma from choking. If oral penetration has taken place, injuries of the mouth and pharynx may occur (154). Injury to the oral cavity, including a torn frenulum, broken teeth, trauma to the uvula, and injuries of the hard and soft palate, are related to forced fellatio. Evidence of trauma is more likely when the assault has occurred out of doors or is perpetrated by a stranger (155). The most common genital findings are erythema and small tears of the vulva, perineum, and introitus. Genital trauma is more common in postmenopausal women. A Foley catheter, placed in the distal vaginal vault and then inflated, allows for full visualization of hymenal injuries (138). There may be bleeding, mucosal tears, erythema, or a hematoma noted around the rectum if penetration occurred. Identification of small lacerations of the genitalia or rectum may be aided by colposcopy or by staining with toluidine blue, which has an affinity for the nuclei of exposed submucosal cells and will make the injuries stand out (153,154,156). Toluidine blue should be applied before the speculum examination, as insertion of the speculum itself can cause small lacerations and false-positive results. Toluidine blue is spermicidal and should not be applied until all forensic evidence is collected (156). Bite marks are not uncommon and frequently are found on the breasts or genitalia. Impressions and photographs of bite marks can be made and used to help identify the assailant. Foreign bodies may be found in the vagina, rectum, or urethra.

Samples should be obtained from any sites of contact (vagina, rectum, or mouth) and tested for gonorrhea and chlamydia. A vaginal wet prep examination should be performed for evidence of trichomonas. A urine or serum pregnancy test should be performed, and baseline testing for syphilis, hepatitis B (surface antigen and immunoglobulin M antibodies to hepatitis B core antigen), and HIV. Urine and blood samples should be collected to screen for the presence of any date rape drugs.

Evidence must be properly collected for legal purposes according to the following procedures:

1. Examination of the patient with a Wood light may help identify semen, which will fluoresce blue-green to orange. Areas of fluorescence should be swabbed with a cotton-tipped applicator moistened with sterile water, then air dried and submitted as evidence. Swabs of the skin, vagina, mouth, breasts, and rectum may be obtained to test for the presence of sperm or semen. In general, use a dry swab to obtain evidence from wet areas, and a wet swab to obtain evidence from dry areas.

2. A Pap test may be useful to document the presence of sperm.

3. A sample of the vaginal secretions should be obtained for examination for motile sperm, semen, or pathogens. Motile sperm in the vagina indicate ejaculation occurred within 6 hours. Nonmotile sperm can be found in the cervical mucus for as long as 1 week after ejaculation. If ejaculation occurred in the mouth, seminal fluid may be rapidly destroyed by salivary enzymes (142). If the survivor reports an anal assault, specimens can be obtained by washing the rectal vault with 10 mL of normal saline injected with a red rubber catheter. Allow the saline to stand for several minutes, then aspirate the rectal fluid and submit as evidence.

4. Vaginal secretions should be collected for DNA fingerprinting and to test for the presence of seminal contents, including acid phosphatase, p30 protein (specific to the prostate), seminal vesicle-specific antigen, and ABO antigens (151).

5. The survivor’s pubic hair should be combed over a sheet of paper in an attempt to obtain pubic hair from the assailant. Both the comb and the pubic hair should be submitted as evidence. If the pubic hair is matted, it should be clipped, not pulled, and submitted.

6. Fingernail scrapings from the survivor should be collected using an orangestick and evaluated for evidence of trace fibers or the assailant’s blood, hair, or skin. Use a wet swab to obtain evidence for DNA fingerprinting from between the survivor’s fingers.

7. Saliva should be collected from the survivor to document whether she is a secretor of major blood group antigens (80% of the population are secretors). If the patient is not a secretor and blood group antigens are found in vaginal washings, the antigens are probably from the semen of the assailant (151).

8. Respiratory spray from where the assailant placed his face and breathed on the survivor may be collected from her breasts, shoulders, face, or neck. Collect the sample with a moist swab and submit for DNA analysis.

Treatment

Treatment of sexual assault survivors should be directed to prevention of possible pregnancy and provision of prophylactic treatment for STDs (Table 11.8). About 5% of fertile rape survivors become pregnant as a result of the rape. All sexual assault survivors of reproductive age should be offered emergency contraception (157). If the survivor desires emergency contraception, a preexisting pregnancy can usually be ruled out by performing a sensitive human chorionic gonadotropin assay. Pregnancy prophylaxis can be provided by several different regimens (158–160).

1. Administration of one tablet containing 0.75 mg of levonorgestrel followed by a second tablet 12 hours later (Plan B). A single 1.5-mg dose of levonorgestrel is just as effective as the two-dose regimen and is the preferred method of emergency contraception (159). Levonorgestrel is available by prescription for women younger than 17 years, and available over the counter for women 17 years and older. Levonorgestrel is more effective than any other emergency contraception method and has the fewest side effects (160)

2. Immediate administration of two tablets of a combination oral contraceptive (each containing 50 μg of ethinyl estradiol and 0.5 mg norgestrel, such as Ovral birth control pills) followed by two more tablets 12 hours later (Yuzpe regimen)

3. Four tablets of a combination birth control pill containing 35 μg of ethinyl estradiol and a progesterone followed by four more tablets 12 hours later

4. Mifepristone as a single 10 mg dose (161)

5. Placement of a copper-containing intrauterine device

These regimens are highly effective if administered within 120 hours after the sexual assault (159,162). The sooner the medications are taken, the more effective they are. Most regimens have a failure (pregnancy) rate of about 1.5%. Emergency contraception failure poses little teratogenic risk if the pregnancy continues (163). Some patients experience nausea and vomiting when given emergency contraception containing estrogen, which can be controlled with an antiemetic agent such as promethazine (12.5 mg every 4–6 hours) or ondansetron (4 mg every 6 hours). Emergency contraception should be repeated if vomiting occurs within 2 hours of taking the initial dose. Most women who take emergency contraception usually experience their next menstrual period within 3 days of the expected date. Women using mifepristone for emergency contraception may experience delayed onset of the subsequent menstrual period (161). Emergency contraception may delay but not prevent ovulation; for this reason, patients receiving emergency contraception should be encouraged to use contraception if further coital episodes occur during the cycle.

The risk of acquiring an STD from a rape is difficult to assess because the prevalence of preexisting STDs is high (43%) in rape survivors (164–166). The risk is estimated as follows: gonorrhea, 6% to 12%; trichomonas, 12%; chlamydia, 2% to 12%; syphilis, 5%.

1. Because it is difficult to differentiate between a preexisting STD and a newly contracted one attributable to a sexual assault, prophylaxis should be offered to all survivors. This is especially important because most sexual assault patients do not return for follow-up appointments (151). Prophylaxis should cover infections with Neisseria gonorrhoeae, Chlamydia trachomatis, trichomonas, bacterial vaginosis, incubating syphilis, and HIV. Recommendations include (165,167):

  a. Ceftriaxone, 125 mg intramuscularly for the treatment of gonorrhea (if the patient is allergic to cephalosporins, spectinomycin, 2 g intramuscularly, or ciprofloxacin, 500 mg orally, may be used), PLUS:

  b. A single dose of 1 g of azithromycin orally or 100 mg of doxycycline orally twice a day for 7 days for treatment of chlamydia (if the patient is pregnant at the time of the assault, erythromycin 500 mg orally four times a day for 7 days may be substituted for doxycycline), PLUS:

  c. A single dose of 2 g of metronidazole orally for the treatment of trichomoniasis and/or bacterial vaginosis

2. Hepatitis B vaccination should be offered if the sexual assault survivor has experienced vaginal, oral, or anal penetration. Hepatitis B is 20 times more infectious than HIV during intercourse(114). Vaccination is recommended at the time of the initial evaluation. Subsequent doses are provided 1 month and 6 months after the first dose is administered. It is not necessary to treat the patient with hepatitis B immune globulin (167). Vaccination is not necessary if the patient has documented hepatitis B immunity.

3. Tetanus prophylaxis (0.5 mL intramuscularly) should be administered for deep tissue wounds or for bite wounds.

4. Conversion of HIV through sexual assault, although reported, is low and similar to conversion from occupational exposure (0.1% to 0.3% per episode) (168). The probability of transmission depends on the type of assault, presence of trauma and bleeding, site of ejaculation, HIV viral load in the ejaculate, presence of a concomitant STD or ulcerative lesions in the assailant or survivor, and the community prevalence of HIV/acquired immune deficiency syndrome (153,168). The risk of HIV transmission may be greater in children because of the thinness of the vaginal epithelium. Factors to consider when discussing HIV postexposure prophylaxis with patients include the likelihood of exposure to the virus, the risks and benefits of treatment, the toxicity of routine antiretroviral prophylaxis, the interval between the sexual assault and the initiation of therapy, and the patient’s desire to be treated. All survivors of unprotected vaginal or anal sexual assault presenting within 72 hours should be offered HIV prophylaxis unless the assailant is known and tests negative with rapid HIV testing (169). Treatment should be initiated as soon as possible. The usual regimen is Combivir or its equivalent (300 mg zidovudine [AZT] and 150 mg lamivudine [3TC]) administered twice daily for 4 weeks). Administration of a protease inhibitor (nelfinavir, five 250 mg tablets twice a day for 28 days) should be considered for high-risk exposures, such as when the assailant is known to be HIV infected. Providers should also consider consulting an HIV specialist or calling the National Clinicians' Post-Exposure Prophylaxis Hotline. Side effects of HIV prophylaxis include nausea, malaise, headache, and anorexia. About 33% of survivors who elect to take antiviral medication discontinue therapy prematurely (168). Patients should be aware that the efficacy of prophylactic treatment for HIV after sexual assault is unknown, and they will have to be carefully monitored if they initiate treatment with antiretroviral medication.

5. Bite wounds can be treated with amoxicillin/clavulanate (Augmentin) 875 mg twice a day for 3 days.

6. If prophylactic treatment for gonorrhea, chlamydia, trichomonas, and bacterial vaginosis is not given, the survivor should return in 2 weeks for repeat testing for STDs and pregnancy. If the initial serologic test results were negative, repeat serologic tests for syphilis, hepatitis B, and HIV should be performed at 6, 12, and 24 weeks after the assault.

7. Ongoing supportive counseling for the patient should be arranged, and the patient should be referred to a sexual assault center or a therapist who specializes in the treatment of sexual assault survivors. A number of excellent resources are available for providers caring for women who were sexually assaulted (170). These include a policy statement on treatment of sexual assault survivors from the American Academy of Family Physicians and a national protocol for sexual assault medical forensic evaluations from the U.S. Department of Justice.

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