Women's Sexual Function and Dysfunction. Irwin Goldstein MD

Sexual function in women with women: lesbians and lesbian relationships

Margaret Nichols

Introduction

Since the American Psychiatric Association officially declassified homosexuality as a mental illness in 1973, most health-care professionals have gradually accepted the view that being gay or lesbian is a sexual variation rather than a disease.

Many are also recognizing that gay patients often have unique needs and concerns. While most doctors and therapists have at least an occasional homosexual patient, some practitioners find that gays comprise a noticeable portion of their patient load. Gays are concentrated more heavily in urban areas1 and higher educational groups, and lesbian activity is common on college campuses.2 Lesbians are heavy users of mental health services: a national survey of lesbian healthshowed that nearly three-quarters of respondents had at some point been in therapy or counseling, and two-thirds of this lesbian sample preferred female practitioners. So, for example, female gynecologists and sex therapists located near college campuses or in urban settings may find that a significant number of their patients are women who have sex with other women.

This chapter outlines some of the unique features of lesbian sex and lesbian sexual relationships that might concern the health-care professional. The material presented here has been compiled from the relatively meager selection of research oriented toward lesbian sexuality, from the clinical experience of the author and colleagues who work with lesbian clients, and from an Internet-based study of lesbian, bisexual, and heterosexual women’s sexual behavior conducted in 2003-4 at the Institute for Personal Growth, a psychotherapy center in New Jersey serving the gay, lesbian, and bisexual community. The latter data, collected by the author and her colleagues, will be referred to as the Institute for Personal Growth Internet Study results.4

Sensitivity: the “heterosexual assumption”

Before discussing lesbian sexuality, it is worth noting that it is more important for a doctor or therapist to have an open, aware attitude to lesbian patients than to have a wealth of knowledge about sexual minorities. Ryan and Bradford’s lesbian health survey3 established that the single biggest complaint of the respondents was that health and mental health practitioners had an inherent heterosexual bias, an automatic assumption that everyone is “straight”. These assumptions are usually unconscious. For example, when a gynecologist reflexively asks about birth control, when the office intake form asks for “marital status: single/married/divorced/widowed”, when the provider asks “are you sexually active?” and means “are you having heterosexual sexual intercourse”, many lesbians will be offended and/or conclude that the provider is insensitive or prejudiced towards gays. Ryan and Bradford found that as many as 27% of the lesbians interviewed reported that the most common problem with their health-care practitioner was the assumption of being heterosexual. While some women are able to correct the care practitioner and reveal their sexual orientation, others find this assumption to be one more obstacle in their coming- out process. In fact, approximately 17% of the participants reported they would not reveal their sexual orientation to their health-care practitioner even though that information might be critical for treatment. Thus, the “gay-affirmative” health-care professional must approach each female patient as though she may have feelings, history, or current behavior that is homosexual. The provider must demonstrate openness to the possibility of female-female sexual experience in each woman in order to gain the trust of the lesbian patient.

Special features of lesbian sexuality

Identity versus behavior; sexual fluidity

In a culture that stigmatizes same-sex behavior, as ours still does, one would expect the incidence of same-sex attractions to be higher than the incidence of same-sex behavior, and both should be higher than the number of people who self-label as gay. Indeed, every study from Kinsey to the present day has found this. Virtually all studies from the 1950s5 to the presenthave found that the vast majority of self-identified lesbians, 80-90%, have had at least one male sexual partner.

However, the reality is more complicated. Recent evidence suggests that women may be physiologically “wired” for bisexu- ality.7 When presented with lesbian and heterosexual visual erotica, women of all orientations show physiologic arousal to both, whereas men’s arousal is “targeted”: heterosexual men respond to heterosexual erotica and gay men respond to gay male erotica. This confirms what a number of theorists already believe, that women may have a more fluid sexual orientation than men.8-12 Diamond2 found that a significant number of lesbian-identified college women change their self-labeling to bisexual or heterosexual over a 5-year period. Moreover, these women do not “disavow” their former lesbian identity and are open to the possibility of sexual change in their futures.

The Institute for Personal Growth Internet Study reveals an even more complex picture. Of the 231 self-identified lesbians, 75% had had one or more male sex partners, and 63% reported sexual attraction to men; three of them were in relationships with men at the time they completed the survey. Moreover, 52% of the 132 self-identified heterosexual women reported sexual attraction to women, 22% had at least one female sexual partner, and one was currently in a relationship with a woman. If one were to define sexual orientation in terms of capacity for sexual attraction, the majority of these self-labeled lesbian and heterosexual women would technically be bisexual.

However, bisexuality as a personal identity is a relatively new phenomenon, emerging only within the last 20 years.12,13 Women who self-label as bisexual - as opposed to those who simply exhibit bisexual attractions - may be a distinct and unique subgroup within what is now commonly known as the lesbian, bisexual, gay, and transgendered community. The Institute for Personal Growth Internet Study found that the 152 survey respondents who self-labeled as bisexual had some sexual behaviors that set them apart from either lesbian or heterosexual women. Bisexual women masturbated more than (p <0.001), thought about sex more than (p < 0.003), and had nearly twice the number of lifetime sex partners as their gay or straight counterparts (p < 0.02). In addition, they were far more likely to identify also with the “kink” community - women engaging in some form of dominance-submission sex play (p <0.001) - and the ‘polyamory’ community - women with multiple concurrent sexual/ relationship partners (p < 0.001).

In practical terms, it is clear that self-identification is at best an incomplete description of self-orientation, making it imperative that a sexual health practitioner not make any assumptions about the sexual behavior of a client without taking a careful history that includes questions about contact with both men and women regardless of the patient’s expressed identity.

Gender identity and “gender bending”

At the peak of the lesbian feminist movement in the 1970s, it was unacceptable to identify someone as “butch” or “femme”; androgyny was the only “politically correct” choice. However, that has changed dramatically, so much so that female to male transsexuals are much more visible in the lesbian community.14,15 Some of the established professional definitions of transsexualism are being challenged, as more and more women identify themselves as being part of the “transgender continuum”. For example, “trannie boys” are lesbians who take male hormones, may or may not have “top surgery” on their breasts, and retain their female genitalia; “bois” are gay women with completely female bodies who dress and comport themselves like men, use male pronouns to identify themselves, and often appear in public “packing” - wearing a strap-on dildo under their pants. The Internet study allowed women to identify their gender as “female” or “other”. Five per cent of lesbians identified as “other”, while virtually none of the bisexual or heterosexual women did so (p <0.001). Asked to describe “other”, these women used words like “transgendered”, “gender queer”, “butch”, or “ftm (female-to-male)”. We also asked women to identify where they fell on a “butch-femme” continuum, and while 26% of the lesbians labeled themselves “butch”, only a handful of bisexual and heterosexual women did so (p < 0.001).

The phenomenon described above suggests it may be time for a paradigm shift in our concepts of gender identity and sexual orientation. For three decades, both gay rights activists and sexuality experts have encouraged us to think that these two core self-concepts are separate, in part because sexology has long been dominated by the social constructivist view of gender identity. Moreover, we have come to think of “lesbianism” as a uniform sexual orientation, rather than as a label describing a broad range of behaviors and feelings. Increasingly, we are recognizing that there are substantial differences in sexual behavior among self-labeled lesbians: some women have never been attracted to men, others have strong attractions and history of involvement with men. For some, the identity will be constant throughout their lifetime; for others, it may be more fluid. We also notice the lesbian community itself returning to butch-femme dichotomies, but with new twists. Perhaps this means it is time to reconsider a biologic basis, at least for women who label themselves butch or bois, as well as for female-to- male transsexuals, who frequently have identified as lesbian before coming to a “trans” identity. Some studies have shown that girls born with congenital adrenal hyperplasia show more male-typical behavior as children, more dissatisfaction with female sex role assignment, and less heterosexual interest than noncongenital adrenal hyperplasia girls,16 And at least one study of lesbians who identify as “butch” found that “butches” recalled more childhood gender-atypical behavior and had higher waist- to-hip ratios, higher saliva testosterone levels, and less desire to give birth than either “femme” lesbians or heterosexual women.17 The Internet study found self-labeled “butch” women to be less attracted to males (p <0.05) than other lesbians, but with no difference in their number of male partners.

For the health-care provider working with lesbian patients, this implies a need to loosen rigid definitions of gender and to change the currently marked distinction between “transsexuals” and “everybody else”. In the future, the health-care community may be forced to deal with, for example, women who ask their doctors for hormones without desiring full “transition” to the opposite gender; it is not unrealistic to think that even the esteemed Harry Benjamin Standards of Care for transsexuals may need revision.

Sexually transmitted infections

Despite scant research, some of the most consistent findings regarding lesbian sexuality have been in the area of sexually transmitted infections (see Chapter 7.7). Roberts et al.6 reviewed 10 studies, including their own, that all showed lesbians having fewer sexually transmitted infections than bisexual or heterosexual women. In particular, gonorrhea, syphilis, human immunodeficiency virus, and hepatitis B are less common among lesbians, as are abnormal Pap smears. The Institute for Personal Growth Internet Study found significant differences in the total number of lifetime sexually transmitted infections between lesbian, bisexual, and heterosexual women, and a strong correlation (p <0.001) between the total number of sexually transmitted infections and the total number of male sex partners. Looking at individual sexually transmitted infections (Table 8.1.1), we found lower rates for lesbians for each sexually transmitted infection. However, the only significant difference for an individual sexually transmitted infection was for the incidence of abnormal Pap smears: lesbians had the lowest rates, and then bisexuals, and heterosexual women had the most abnormal Pap smears (p <0.01). The data on abnormal Pap smears corroborates the many studies that have shown nuns to have a low incidence of cervical cancer; the differentiating variable probably is the male penis and number of different male partners, not sexual activity alone.

It is important to note that although a number of studies show that lesbians have fewer sexually transmitted infections than heterosexual women, that finding seems to be related to the number of male partners a woman has, and we know from a multitude of sources that most lesbians have had at least one male sex partner. This is yet another reason why there is no substitute for the taking of a detailed sexual history; one cannot rely upon self-identification alone.

The nature of lesbian sexual relationships: “lesbian bed death” and other myths

The “common knowledge” about lesbian relationships

In 1983, the highly regarded book American Couples18 compared heterosexual married, heterosexual cohabitating, gay male, and lesbian relationships, and found lesbian couples to have the least frequent sexual contact. Other work written from a clinical perspective also noted the existence of lesbian couples who had little or no genital contact.19-21 By the end of the 1980s, the term “lesbian bed death” was in common usage in the gay community and eventually became part of a stereotype: the lesbian as a sensual-but-not-sexual woman. Two explanations were often given for this phenomenon; internalized shame associated with homophobia, and the “unmitigated female sexuality” of a two women together (i.e., a union in which both partners had relatively low sex drive, low sexual assertiveness, and a high degree of intimacy).22,23 Both lesbian and gay male relationships are often viewed as being shorter than heterosexual relationships, although Blumberg and Schwartz made it quite clear in their study that longevity was related to legal marital status far more than sexual orientation.18 That is, cohabitating heterosexual couples have relationships as short as gay and lesbian couples, and heterosexual married couples stay together significantly longer than any other type of partnership.

Table 8.1.1. Frequency of sexually transmitted infections (STI)/conditions in lesbian, bisexual, and heterosexual women

Type of STI/condition

Lesbian

°/o“yes"

Bisexual ° “yes"

Hetero ° “yes"

Total Sample ° “yes"

Abnormal Pap smear

13

20

25

18*

Chlamydia

4

8

6

6

Gonorrhea

0

2

1

1

Hepatitis

3

0

2

5

Hepatitis B

6

10

11

9

Herpes

5

11

9

8

HIV

0

0

1

0

Pelvic inflammatory disease

2

2

3

2

Syphilis

0

0

0

0

Vaginitis

5

8

5

6

'Significant at p <0.01; results based on the Personal Growth Internet Study; lesbian women n = 231; bisexual women n = 152; heterosexual women n = 132; % "yes" indicates the percentage of women who responded "yes" to the question, "Have you ever had this condition/infection?"; HIV, human immunodeficiency virus.

In recent years, some sexologists have criticized mainstream sexual theory as being phallocentric and heterosexist.24-26 They have argued against the traditional definition of sex as genital contact directed toward orgasm and suggested an expansion to include mutual, sensual physical contact not focused on orgasm. Others have questioned using sexual frequency as an indicator of sexual health. For example, some studies have shown that lesbians spend more time on the average sexual encounter than do heterosexuals; using the measure of time spent on sex rather than sexual frequency, lesbians might be “healthier” than their straight counterparts.27 Still others28 contend that sex is not necessary for healthy relationship function. In particular, lesbian relationships, which some view as more egalitarian and intimate than the average heterosexual mar- riage,29 may not “need” genital sex for connection - sex may be in effect, “redundant”. From this point of view, sex therapy for a non- genitally sexual lesbian couple might include encouraging them to question why they feel a need to be sexual.

Some lesbian psychotherapists argue that “lesbian bed death” is a myth based on insufficient data. Matthews et al.30 found no differences between the sexual frequency rates of heterosexual and lesbian women, and Iazenza31 found lesbians to be more sexually arousable and more sexually assertive than heterosexual women.

Meanwhile, the lesbian community itself has become more sexual in the last two decades.32,33 Lesbian-owned and -oriented erotica magazines, sex toy stores, and erotic video companies have proliferated. Lesbian clubs like Meow Mix in New York advertise “Pussy Galore” and “I Love Pussy” nights and brag about the “action” in the bathrooms. Lesbian “kink” organizations exist in most major US cities, and polyamory is becoming more common.34

Results of Institute for Personal Growth Internet Study

Data from this study of 231 self-identified lesbians, 152 bisexual women, and 132 heterosexual women were analyzed in two ways: by self-identified orientation and, for women currently in relationships, by whether the participant was involved with a woman or a man. First, like Blumberg and Schwartz,18 we found lesbian relationships to be of shorter duration than heterosexual relationships - 4 years average compared with 8 years (p <0.001), but this difference disappeared when we compared only unmarried women. Among both single and coupled women, lesbians had less sex in the year preceding the survey (p <0.05) but did not differ from heterosexual women in their frequency of masturbation or how often they thought about sex.

Our primary analyses compared women in relationships with other women versus women with men. Overall, women with men had slightly more frequent sex than women with other women (p < 0.05), and this difference was independent of length of time in relationship. The presence of children was not a predictive factor of frequency of sexual activities; there was no difference in the number of children living with women with women versus women with men. Additionally, no difference was observed between the groups in the percentage of women who never had sex, thus casting suspicion on the notion that lesbians are more likely to have nonsexual relationships.

Looking at other aspects of sexuality, the women with women spent more time engaging in sexual activities (p <0.001), had more non-penis-oriented sexual acts as part of their typical repertoire (p < 0.001), and were less likely to have sex because their partner wanted it (p <0.001). Most significantly, women with women were more likely to have orgasms during sex with their partner than were women with men regardless of marital status or length of relationship (p <0.001). The tendency to orgasm during partner sex was not significantly related to the length of time the partners had been together, but was strongly related to the amount of time spent on sex for both women with women and women with men (p <0.001). We found that the typical sex acts associated with orgasm for women (regardless of gender of partner) were kissing (p <0.001), nongenital touching (p <0.006), receiving oral sex (p <0.001), digital-vaginal stimulation (p <0.001), and the use of sex toys (p <0.01). Of these acts, kissing (p <0.001), nongenital touching (p < 0.01), digital-vaginal stimulation (p < 0.001), and use of toys (p <0.001) were more likely to be practiced by women with other women than by women with men.

Lesbian relationships revisited

If we incorporate new information about the lesbian community with the results of more recent research and theory about female sexuality, the picture is more complex than the old stereotype portrays. First, we see increased support for the idea that legal marriage is related to longevity of relationship, for better or worse. Second, while it may be true that women in lesbian relationships have somewhat less sex than their heterosexual counterparts, it is by no means true that the typical lesbian relationship becomes asexual. Women in relationships with other women are less likely to have sex because their partner wants it, which may account for part of the difference in sexual frequency. Furthermore, there is evidence to suggest that lesbian sexuality includes behaviors that are more associated with women’s sexual satisfaction: it lasts longer, is more varied, includes more sex acts likely to lead to orgasm for women, and is in fact more correlated with orgasm. Indeed, if one measured sex not by frequency but, say, by Kinsey’s original standard - sexual contact to the point of orgasm - women with women have more sex than women with men, and are more likely to have sex of their own volition. Assimilating this information can radically change the professional’s paradigm of sexual relationship health. Perhaps we should stop asking so much about sexual frequency, and instead ask more about female orgasm and pleasure, about quality versus quantity.

Lesbian sexual dysfunction

There are few nonclinical data on the nature of lesbian sexual dysfunction compared with those of heterosexual women. Clinical data suggest that sexual desire discrepancy between partners and/or low sexual desire are the most common problems lesbians face, as with heterosexual women.35,36 In the Internet study, participants were given a list of sexual problems (e.g., lack of lubrication, decreased sexual arousal, less desire than partner, more desire than partner, feeling guilty, feeling anxious). An analysis was conducted on self-identified lesbians versus heterosexuals, and a second analysis investigated women with women versus women with men. The results from both analyses showed that lesbians or women with women reported fewer sexual problems than heterosexuals or women with men (p < 0.01, p < 0.001, respectively).

Table 8.1.2 shows percentages of the overall sample of lesbians and heterosexual women as they reported sexual dysfunction, and for which problems there was a significant difference between the two groups. Table 8.1.3 presents the same data broken down for women with women versus women with men. Not surprisingly, lack of interest in sex and/or having less desire than one’s partner were the most frequently reported problems for all women, followed by problems with orgasm, problems experiencing more desire than one’s partner, trouble lubricating, and anxiety about sex. Many of the differences between groups were significant, and only one problem - feeling more desire than one’s partner - was reported more frequently for lesbians/women with women, although not at a statistically significant level.

If lesbians have fewer sexual problems than heterosexual women, and only slightly less sex, how can we account for clinical accounts of “lesbian bed death”? Several possibilities exist. First, it is possible that greater social acceptance of homosexuality over the last two decades has made lesbians feel less internalized shame and homophobia and therefore less self- imposed sexual repression - note that in the Internet sample fewer lesbians than heterosexual women felt guilty about sex. In other words, “lesbian bed death” may have been more common 20 years ago than it is now. Another explanation may lie in the high percentage of lesbians who participate in psychotherapy - clinicians may see a disproportionate number of lesbian couples with sex problems, and lack of interest in sex is by far the most common sexual complaint of all women.

Summary and conclusions

The sexual health professional who works with lesbian clients is rewarded with a broadened and enriched perspective on female sexuality in general. The provider must, as with all minority groups, be sensitive to and respect cultural differences in sexual expression. When one practices within the lesbian community, he or she must be comfortable with patients’ sexual fluidity in both behavior and self-identification, as well as with a broader range of gender identity. Sexually transmitted infections are less common among lesbians, and sexual dysfunction may be less common as well, although lesbians are highly likely to seek counseling when they do have problems.

Table 8.1.2. Frequency of sexual problems in lesbian and heterosexual women

Type of sexual problem

Lesbian ° “yes"

Hetero ° “yes"

Total Sample ° “yes"

Significance level p <

No interest in sex

40

45

42

 

Difficulty/unable to reach orgasm

29

41

33

0.02

Pain with penetration

20

30

23

0.02

Unable to be penetrated

6

5

6

 

Persistent, unwanted arousal

10

17

13

 

Trouble lubricating

13

30

20

0.000

Sex possible, but not pleasurable

19

27

22

 

Guilt about sex

16

24

19

 

Anxiety about sex

29

32

30

 

More desire than partner

36

28

33

 

Less desire than partner

37

46

40

 

Results based on the Institute for Personal Growth Internet Study; lesbian women n = 231; heterosexual women n = 132; bisexual women excluded.

Table 8.1.3. Frequency of sexual problems among women currently in relationships with women versus women in relationships with men

Type of sexual problem

Female-female

°/o“yes"

Female-male ° “yes"

Total Sample ° “yes"

Significance level p <

No interest in sex

39

51

44

0.02

Difficulty/unable to reach orgasm

32

41

36

 

Pain with penetration

22

34

28

0.02

Unable to be penetrated

6

4

5

 

Persistent, unwanted arousal

11

17

14

0.02

Trouble lubricating

18

32

25

0.002

Sex possible, but not pleasurable

20

32

26

0.008

Guilt about sex

18

22

20

 

Anxiety about sex

28

34

31

 

More desire than partner

36

34

35

 

Less desire than partner

39

52

45

0.008

Results based on the Personal Growth Internet Study; women in relationships with women (female-female) n = 205; women in relationship with men (female-male) n = 179.

Most importantly, the sexual behavior of women with other women is different from that of women with men, and probably more consonant with the attainment of female orgasm. Although lesbian couples appear to have sex less frequently than their heterosexual counterparts, they have sex because both partners want to, they spend more time on sex and include more nongenital, non-penis-oriented acts, and their sexual activity more frequently results in orgasm for both partners. Indeed, when questioning not only lesbians but heterosexual women about their sexual practices, it may be useful for the practitioner to focus more closely on female sexual pleasure and to consider quantity of sex less important than quality.

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