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REVIEW ARTICLE
Female sexuality
T.S. Sathyanarana Rao, Anil Kumar M. Nagaraj1
Department of Psychiatry, JSS Medical College, JSS University, 1Department of Psychiatry, Mysore Medical College and
Research Institute, Mysore, Karnataka, India
ABSTRACT
Sex is a motive force bringing a man and a woman into intimate contact. Sexuality is a central aspect of being human
throughout life and encompasses sex, gender identities and roles, sexual orientation, eroticism, pleasure, intimacy, and
reproduction. Sexuality is experienced and expressed in thoughts, fantasies, desires, beliefs, attitudes, values, behaviors,
practices, roles and relationships. Though generally, women are sexually active during adolescence, they reach their peak
orgasmic frequency in their 30 s, and have a constant level of sexual capacity up to the age of 55 with little evidence that
aging affects it in later life. Desire, arousal, and orgasm are the three principle stages of the sexual response cycle. Each
stage is associated with unique physiological changes. Females are commonly affected by various disorders in relation to
this sexual response cycle. The prevalence is generally as high as 35–40%. There are a wide range of etiological factors
like age, relationship with a partner, psychiatric and medical disorders, psychotropic and other medication. Counseling
to overcome stigma and enhance awareness on sexuality is an essential step in management. There are several effective
psychological and pharmacological therapeutic approaches to treat female sexual disorders. This article is a review of
female sexuality.
DOI:
How to cite this article: Sathyanarana Rao TS, Nagaraj AM. 10.4103/0019-5545.161496
Female sexuality. Indian J Psychiatry 2015;57:296-302.
them are always experienced or expressed. Sexuality is vulva. Contrary to what is depicted in pornography, vaginal
influenced by the interaction of biological, psychological, insertion to reach an orgasm is not common. Some women
social, economic, political, cultural, ethical, legal, historical, can reach orgasm by pressing the breast alone and a few
religious, and spiritual factors.[3] This article is a review of women (2%) by fantasy alone. Some individuals use vibrators
female sexuality. for added enjoyment and variation. By masturbation, many
women need <4 min to reach orgasm.[8]
FEMALE SEXUALITY
THE SEXUAL RESPONSE CYCLE
In the first millennium BC, human cultures clearly experienced
a “axial period” in a striking transformation of human Following the pioneering work of Masters and Kaplan, the
consciousness. The transformation occurred independently sexual response cycle in both sexes is often categorized
in three geographical regions: In China, in India and Persia, as a four‑phase process, desire, excitement, orgasm, and
and in the Eastern Mediterranean, including Israel and resolution.[9]
Greece. In this cultural transformation, a prevailing mythic,
cosmic, ritualistic, collective consciousness embedded in The first stage, sexual desire, consists of the motivational
a tribal matrix with the female in the foreground, slowly or appetitive aspects of sexual response. Sexual urges,
gave birth to a male dominated, rational, analytical, and fantasies, and wishes are included in this phase. The second
individualistic consciousness. This transition in cultural stage, sexual excitement, refers to a subjective feeling of
values began very slowly after the last ice age retreated.[4] sexual pleasure and accompanying physiological changes.
This phase includes penile erection in males and vaginal
In a developing country like India, modern Hindu cultures lubrication in females. Plateauing, sometimes classified
even today contain a general disapproval of the erotic aspect as a separate phase, is a heightened state of excitement
of married life, a disapproval that cannot be disregarded attained with continued stimulation. There is marked
as a mere medieval relic. Many Hindu women, especially sexual tension in this phase, which sets the stage for the
those in the higher castes, do not even have a name for orgasm. The third stage, orgasm or climax is defined as the
their genitals. Though the perception of modern Indian peak of sexual pleasure, with rhythmic contractions of the
women is transforming, many of them still consider the genital musculature in both men and women, associated
sexual activity a duty, an experience to be submitted to, with ejaculation in men. Graph 1 shows three different
often from a fear of abuse.[5] patterns of orgasm in females. Pattern 1 shows multiple
orgasms. Pattern 2 shows arousal that reaches the plateau
According to Sigmund Freud, both sexes seem to pass level without going onto orgasm (note that resolution
through the early phases of libidinal development in the occurs very slowly). Pattern 3 shows several brief drops
same manner. Psychologically, the male‑female difference in the excitement phase followed by an even more rapid
in sexuality starts only during the phallic phase, with resolution phase. This is the final phase, during which a
the appearance of Oedipus complex. However, the general sense of relaxation and well‑being is experienced.
difference becomes most clear only during the genital Then, there is a refractory period in males, which is usually
phase.[6] Though generally, women are sexually active absent in females. Table 1 shows the physical changes in the
during adolescence, they reach their peak orgasmic female during the sexual response cycle.[10]
frequency in their 30 s, and have a constant level of sexual
capacity up to the age of 55 with little evidence that aging
affects it in later life.[7]
range could be that many prevalence studies do not include oriented theorists speculate that this disorder reflects the
dyspareunia within their list of dysfunctions or fail to women’s rejection of the female role or as a resistance against
distinguish it from vaginismus, as dyspareunia is related to a male sexual prerogative. Learning theory understands this
and often coincides with vaginismus. Dyspareunia should dysfunction as a conditioned fear reaction reinforced by the
not be diagnosed when it is primarily due to vaginismus or belief that penetration can only be accomplished with great
lack of lubrication. difficulty and will result in pain and discomfort. A variety
of psychosocial factors may be operative, like religious
Traditionally the etiology of dyspareunia has been divided orthodoxy and regarding sex as dirty and shameful. Fear
into organic and psychological. The organic factors are of pregnancy, disgust regarding genitalia and homosexual
further divided into anatomic, pathologic and iatrogenic. orientation are other causes. The diagnosis is arrived by a
Anatomic factors are congenital factors like agenesis of careful history and unhurried methodical examination.
the vagina and rigid hymen. The pathologic factors include
multiple conditions like vulvar atrophy, cervical erosion, MANAGEMENT
fibroids, ovarian cyst, endometriosis, prolapsed uterus,
tender uterosacral ligaments, tender bladder, squamous Success in treatment depends on accurate diagnosis which in
metaplasia, infections, etc., Iatrogenic factors are usually turn depends on an elaborate sexual history and appropriate
the consequence of a surgical procedure like episiotomy. examination. Biochemical and other investigations also
form an essential part of the evaluation. Serum levels of
The psychoanalytic and learning theories are the two major prolactin, estrogen, progesterone, follicle‑stimulating
psychological theoretical perspectives. The psychoanalytic hormone and luteinizing hormone are most commonly
theory treats dyspareunia as a hysterical or conversion implicated. The doctor‑patient relationship and the patient
symptom symbolizing an unconscious intrapsychic conflict interview are however, the key aspect in management.
and considers dyspareunia to be a result of phobic reactions,
major anxiety conflicts, hostility or aversion to sexuality. FSFI is a questionnaire that can be easily used by health
Learning theory posits that dyspareunia is attributable
professionals to complement the diagnosis and to detect
to lack of or faulty learning which may contribute to a
treatment‑related changes. The FSFI recognizes the need
woman entering sexual relations with a set of negative
for a subjective criterion in defining sexual dysfunction
expectations. Also developmental (attitudes toward
and determines, through the nineteen item answers,
sexuality), traumatic (prior aversive coital experiences) and
five separate domains: (a) Desire/arousal, (b) lubrication,
relational (interpersonal disputes with a partner) factors are
(c) orgasm (d) satisfaction and (e) pain.[18] Another
the other psychological factors.
questionnaire widely used is the sexual history form. This
instrument, through 28 items, evaluates the frequency of
Vaginismus
It is a recurrent or persistent involuntary spasm or constriction sexual activity, desire, arousal, orgasm, pain and overall
of the musculature surrounding the vaginal outlet and sexual satisfaction for women and men.[19]
the outer third of the vagina that interferes with vaginal
penetration. It causes severe personal distress. Women with Apart from these general interventions, sexual health in
this disorder are even unable to insert tampons or permit the elderly women needs specific attention. Due to increase
insertion of a speculum during gynecological examination. in life expectancy and more than one consecutive sexual
However, they can go through all stages of the sexual cycle partner, the couple expect being sexually active even after
including arousal and orgasm. Vaginismus may be complete 65 years of age. However, age decreases the frequency of
or situational. This psychophysiological syndrome may affect genital sexual activity. This issue needs to be addressed.
women of any age and most often afflicts highly educated The clinician should educate that the quality of relationship
women and those in the higher socioeconomic status. Most and an understanding of the physical and psychological
of these cases present as unconsummated marriage. changes due to increasing age play a key role in sexual
satisfaction in old age. Chronic ill health and other
Vaginismus may be due to organic or nonorganic causes. psychosocial situation need to be addressed. Alternatives
Most of the organic causes are lesions of the external techniques are encouraged for better sexual functioning.
genitalia which lead on to vaginismus as a result of natural Vaginal lubrication products are equally essential.[20,21]
protective reflex to pain. Among the frequent organic causes
are hymenal abnormalities, genital herpes, obstetric trauma Managing sexual desire disorders
and atrophic vaginitis. Most commonly, however, no organic Historically, attempts to treat hypoactive sexual desire
causes can be implicated. Vaginismus is hypothesized disorders typically followed the sex therapy prototype
to be the body’s expression of the psychological fear of developed in 1970s. However, recently researches
penetration, hence shares features of a psychosomatic and practitioners have begun to explore concomitant
disorder, phobia, and conversion disorder. Analytically psychotherapies.[22]
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Source of Support: Nil, Conflict of Interest: None declared
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