Female Sexual Function, Dysfunction, and Pregnancy: Implications for Practice

Jessica Murtagh, CNM, MSN, RN
Women’s sexual function is a complex and dynamic interplay of variables that involve physical, emotional, and psychosocial states. Sexual dysfunction may occur at any level, and diagnosing such issues begins with careful assessment through a sexual health history. However, discussions about female sexual health and function are often deficient in the primary care setting. This article reviews the published research on female sexual function, sexual dysfunction, and sexual function in pregnancy to gain a better understanding of how these aspects of a woman’s life impact the health care services she receives. The evaluation of female sexual function is in need of consistent measurement tools and more dialogue during health care visits. Women’s health care practitioners have an opportunity to advance patient satisfaction and overall health by evaluating and communicating with female patients about their sexual function. J Midwifery Womens Health 2010;55:438–446 Ó 2010 by the American College of Nurse-Midwives. keywords: dyspareunia, female sexual dysfunction, female sexual function, pregnancy, prenatal care, sexual behavior, sexual health, sexual history, sexual intercourse, sexuality

INTRODUCTION Female sexual function, dysfunction, and health during pregnancy are primary topics of concern for women’s health care providers. Although these topics may be regarded independently from one another, each can have a large impact on an individual woman throughout her lifespan. As many as 40% to 45% of women may experience some form of sexual dysfunction in their lifetime.1 Approximately 4 million births occur annually in the United States, with a birth rate currently on the rise.2 Issues focusing on sexual and reproductive health should be a priority for those invested in women’s health care. Women’s sexual function, dysfunction, and sexual functioning in pregnancy are of interest to both patients and providers.3 Prenatal care is one venue where both sexual function and dysfunction can be addressed. According to an integrative literature review of 36 articles published between 1996 and 2007, women’s experiences of prenatal care vary from those feeling satisfied and respected to those feeling rushed, stereotyped, and neglected.4 Women prefer adequate time with their providers, a personable relationship, comprehensive care, and interactive participation in health discussions and decisions.4 Under the aforementioned parameters, sexual health issues could be more easily facilitated and included in routine prenatal and primary care visits. This literature review examines research published primarily after the year 2000 and a few seminal articles that investigated female sexual function, sexual dysfunction, and sexual functioning in pregnancy. The purpose of this article is to explore female sexual function and dysfunction, how they affect women during pregnancy, and present implications for practice.

BACKGROUND Adequate communication about sexual health among women and health care providers is essential and yet is often lacking.3,5–9,13,14 This includes women of all reproductive stages, pregnant and nonpregnant, heterosexual and homosexual, and married and single. The National Health and Social Life Survey (NHSLS), which was conducted in the early 1990s, is the largest sexual survey since the works by Alfred Kinsey in the 1950s. In this survey of 1749 women and 1410 men 18 to 59 years of age, only 10% to 20% of women reported seeking help for sexually related problems.1 Women are not bringing up their concerns to health care providers, and providers are not routinely including sexual health screenings or discussions in their office visits.5–7 Lack of both time during visits and formal preparation for these conversations can hamper providers from carrying out thorough sexual health assessment.5 Providers frequently have a diminished sense of confidence to handle sexual health difficulties, perceive a lack of treatment options, and underestimate how widespread female sexual dysfunction may be.5 A majority of patients report being hesitant or embarrassed to bring up sexual issues and fear judgment from their health care provider.5,7,14 Initiating sexual health screenings and opening a dialogue can be especially useful during prenatal care visits. A metacontent analysis of 59 studies relating to sexuality in pregnancy published between 1960 and 1996 revealed that 68% of primigravid women recalled never having their obstetrician-gynecologist provider discuss sexual matters throughout the duration of pregnancy.3 The 27% of women featured in this review who had received advice said that it was restrictive in nature, in that sexual contact was to be limited to a certain time and amount both before and after birth.3 A cross-sectional study of 141 nulliparous pregnant women with an average age of 27.8 years revealed that 49% of the women had to initiate a discussion
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Address correspondence to Jessica Murtagh, CNM, MSN, RN, Access Community Health Network, 600 West Fulton St., Chicago, IL 60661. E-mail: jessmurtagh@gmail.com

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17 These investigations resulted in the physiologic linear four-stage model developed by Masters and Johnson in the 1960s. and past sexual experiences affect where in the sexual response cycle the woman may fall and function. herself. Bancroft et al. MSN. or to boost her self-esteem.18–21 The objective of these explorations and models was to determine the normal sexual response in women by considering arousal.5 years. For example. continuing possibly many times over with even greater intensity each time. They found that the best predictors of sexual distress were not related to the physiologic sexual response cycle but rather to emotional happiness and partner satisfaction. and social well-being in all sexual behaviors and beliefs.11 Even if the biologic and anatomic structures and functions of women and their sex drives become better understood.23 Both of these studies highlight the significance of incorporating the whole of the person—and not just the physical—in understanding female sexual function. mental. social.16 Such cultural constraints can hinder women from discussing sexual concerns with professionals and can limit sexual freedom and gratification.11 Pregnancy is a particularly sensitive time to consider sexual health. and there is a lack of agreement over which factor is more influential. The role of psychologic.about sexual activity to their providers first.11 The earlier models focused more on the physiologic processes and did not include the emotional. Kaplan’s three-stage sexual response model in the 1970s. neurologic. such as sexual desire and satisfaction. to feel closer to her partner. RN.9 Sexual health involves a plethora of factors. subjective experiences commonly remain a private matter. IL.22 published the results of a survey of a national sample of 987 heterosexual women 20 to 65 years of age. and psychologic perspectives. mental. 76% felt that it was a topic that should have been addressed. arousal. The most recent cyclical model of sexual functioning by Basson21 (Figure 1) acknowledges that women may initiate or be responsive to sexual stimuli not only because of arousal but for many other reasons that may or may not be goal-oriented. model. and sexual dysfunction.22 In a cross-sectional study using an Internet-based survey of 350 homosexual women with an average age of 35.24 Engaging in sexual activities does not have to directly result in orgasm.24 Greater subjective arousal contributes to a woman’s responsiveness to sexual stimuli. biologic responses.25 Further into the cycle. sexual function. emotional. and emotional needs. Chicago. but instead may help to satisfy other particular physical.org . of those who never conversed with their providers about sexual activity in pregnancy.11. A woman may have a personal motivating factor to initiate or agree to sexual activity. The current understanding of female sexual function has evolved over time from epidemiologic. The woman’s relationship with her partner. more psychosocial and emotional elements. and biologic factors are critical in the consideration of female sexual function. and satisfaction. cultural. which furthers arousal and/or orgasm. spiritual. or may have spontaneous desire that is then reinforced by sexual stimuli.jmwh. desire.11 Biologic aspects.10 Sexual health is not merely the absence of disease and dysfunction. social. his research helped open the doors to more scientifically driven explorations. to be in a position of power. and/or be subjectively satisfied.15 Furthermore.24 Of significance in the cyclical model is that desire is not always first before arousal or the sole reasoning for engaging in sexual activity. In 2003. and scientific models. be receptive to it.12 FEMALE SEXUAL FUNCTION Female sexual function is not easily defined.11. sexual functioning was again most correlated to relationship characteristics and psychologic features. Current knowledge about female sexual function and dysfunction also demonstrates these as multifactorial processes in the spectrum of sexual health. Positive sexual experiences facilitate the sexual response cycle and enable a state of sexual neutrality to move into sexual motivation. emotional. According to the World Health Organization (WHO). which can lead to more desire followed by sexual satisfaction experienced as orgasm or nonphysical rewards. A woman may engage in sexual activity for stress relief.16 The cyclical model shows many points of entrance into the female sexual response cycle that often overlap. and psychosocial outcomes. sexual activity may be considered forbidden or taboo during menstruation and pregnancy. graduated from the Yale University School of Nursing nurse-midwifery program in May 2009 and is currently working as a midwife at Access Community Health Network. but an overall balanced sense of the sexual self. sexual health includes physical. orgasm.8 In addition. as there is not a singular response from women but instead a wide variety of what can be considered normal. personal. The cyclical model is useful for clinicians because it helps depict the multifaceted sexual functioning 439 Journal of Midwifery & Women’s Health  www. laboratory.24 A woman’s sexual functioning is therefore not linear.24 The context in which sexual behavior occurs for women helps determine whether a woman will seek out sexual activity. CNM. and most recently Basson’s intimacy-based cyclical Jessica Murtagh. subjective arousal occurs. are yet to be fully understood. including vascular. and later. The first formal investigation in the United States of female sexual behavior was started by Kinsey17 in the 1950s. cultural beliefs can limit what research can be performed on female sexual function and what actually gets spoken about in everyday life. resolution. a circular model by Whipple and Brash-McGreer in the 1990s. and structural components. and social variables that greatly impact female sexual function.8 The failure to communicate about sexual health with female patients could have negative physical.

24 Dyspareunia is any pain experienced during vaginal penetration or intercourse. a sexual disorder consists of both the sexual dysfunction element in addition to persistent distress.27 When investigating female sexual function versus dysfunction and disorder. 5.30 These expanded definitions are now considered the standard in the diagnosis of female sexual dysfunction instead of the DSM-IVTR classifications. Modified model of Basson’s21 female sexual response cycle. whereas secondary dysfunctions are associated 440 The latest definition of sexual dysfunction secondary to lack of desire is called sexual desire/interest disorder. experiences.24 Arousal Disorder Arousal disorders include not only a lack of physical symptoms but the lack of subjective arousal sensations as well as those that experience persistent arousal that is unwanted. In women with persistent genital arousal disorder. including more subjective measures (Table 1). In comparison. Desire that occurs during sex is called responsive desire. What may be abnormal for one woman may not be abnormal for another woman. Volume 55.29 Sexual dysfunctions may endure throughout the lifespan or be temporary. distress has to be included and is perhaps the most important variable because of the large range of what can otherwise be normal for women. and physiologic and/or psychologic in origin. arousal. Primary dysfunctions correspond with the traditional linear sexual response model. and can interfere with every day functioning. This clarification regarding responsive desire is central because the current understanding of the female sexual response cycle shows that desire may or may not be spontaneous before sexual activity. which refers to a lack of desire or interest in sex before the sexual encounter and also a lack of desire during sex. No. because they are more appropriate to the current understanding of the female sexual response cycle.21.25 Female sexual dysfunction and disorder must be discussed in the context of each individual woman’s life. and a careful.30 Definitions of Common Female Sexual Dysfunction Sexual Desire/Interest Disorder Figure 1. relationship. sexual health histories should include one or two questions about pain encountered during sexual encounters. September/October 2010 .26 Defining female sexual dysfunction is not as absolute for women because of the qualitative nature of female sexual function. social climate.31 Because dyspareunia is common. dysfunction occurs when there is a total lack of desire even during act. Approximately 8% to 22% of women are affected by dyspareunia at one time or another.24 The Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) organizes sexual dysfunction according to the traditional linear model of sexual function related to desire. FEMALE SEXUAL DYSFUNCTION Female sexual dysfunction is defined as any problem that may be encountered in the sexual response cycle that deviates from a woman’s normal range of functioning. this is not considered an arousal disorder but instead is classified as dyspareunia. physical symptoms are present. In sexual dysfunction. and health in order to tease out the distress element. and orgasm. and that which bothers her partner alone is not then a sexual dysfunction of the woman but rather of her partner. but are often not linked to subjective desires.27 An abnormality in one’s sex life can exist but may not warrant further evaluation unless the woman experiences a certain degree of anguish over it.21.24 A woman with adequate lubrication but no subjective awareness of that arousal is classified separately than one with subjective feelings of arousal but no physical signs of vasocongestion or lubrication.26 The categories and definitions of female sexual dysfunction have been expanded over the past decade to incorporate the full spectrum of female sexual response.28 The distress must be experienced by the woman herself.24 Dyspareunia If there is pain related to a lack of arousal.24 Sexual dysfunction falls on a continuum with female sexual disorder. there is an interruption in normal sexual functioning at one or several points in the sexual response cycle. detailed history and physical evaluation of each patient is critical to gain insight into cause and treatment options (Table 2).with chronic medical conditions or side effects of certain medications. culture. of women and also shows areas where there may be a problem that impacts sexual function. general or situation specific.31 Several dyspareunia syndromes exist.

27 Oral contraceptives are another medication group that have been thought to affect sexual function.24 Addressing the arousal disorder will often correct the inability to orgasm. dopamine. 15% to 19% of the women surveyed in the United States qualified for hypoactive sexual desire disorder when low sexual desire and distress were evaluated together. self-report may include minimal vulvar swelling or vaginal lubrication from any type of sexual stimulation and reduced sexual sensations from caressing genitalia. a finger. Cognitive behavioral therapy has been found to be effective for women who have a primary diagnosis of anorgasmia. intrusive. fibroids. sexual disinterest was the most common sexual complaint.27 Medications that block adrenergic receptors.33 Overall. such as diabetes. there has not been a study with statistically significant results documenting a universal decline in sexual function in menopausal and postmenopausal women. and those that have anticholinergic or sedative effects can also be problematic.24 Chronic medical conditions. and unwanted genital arousal that occurs in the absence of sexual interest and desire. can contribute to female sexual dysfunction. lack of interest is beyond normative changes associated with lifecycle and relationship duration Absence or markedly diminished feelings of sexual arousal (sexual excitement and sexual pleasure) from any type of sexual stimulation. lack of motivations for attempting to become sexually aroused.32 Factors Associated With an Increased Risk for Sexual Dysfunction There are several correlating factors and conditions that may put some women at an increased risk for sexual dysfunction. obesity. and major depressive disorder. education level. arousal is not relieved by orgasms and may persist for hours or days Self-report of high sexual arousal/excitement but either a lack of orgasm. infections. and drug use. vaginal lubrication or other signs of a physical response may still occur Complaints of impaired genital sexual arousal. and a lack of responsive desire.Table 1. poverty.25 Environment and choice of partner alone can be major factors in female sexual functioning and dysfunction. overactive bladder. markedly diminished intensity of orgasmic sensations. spinal cord injury. a total of 11 studies confirmed that a lack of sexual interest 441 . and previous episiotomy or operative delivery are also associated with sexual dysfunction. but the majority of evidence reveals that only a small minority of women actually experience such a side effect.24 Prevalence of Female Sexual Dysfunction Sexual dysfunction in the reproductive years is more prevalent than one would suspect. Pharmacologic agents that induce female orgasm have yet to be found and approved for widespread use. In a review of the literature published between 1950 and 2008 that evaluated women between 18 and 50 years of age.27 Other nonphysical risk factors include tobacco. various prolapses.33 In this population.jmwh. despite the woman’s desire to participate Extreme anxiety and/or disgust at the anticipation of or attempt to have any sexual activity Subjective arousal disorder Genital sexual arousal disorder Combined genital and subjective arousal disorder Persistent genital arousal disorder Woman’s orgasmic disorder Dyspareunia Vaginismus Sexual aversion disorder Source: Basson et al. subjective sexual excitement still occurs from nongenital stimuli Absent or markedly diminished feelings of sexual arousal (sexual excitement and sexual pleasure) from any type of sexual stimulations and complaints of absent or impaired genital sexual arousal. reaching orgasm becomes another complication. Expanded Definitions of Female Sexual Dysfunction Sexual desire/interest disorder Absent or diminished feelings of sexual interest or desire. Female orgasmic disorder is diagnosed when a woman does not experience orgasm. or any object.org tomy.33 In a study of 3589 women in the United States and Europe. or marked delay of orgasm from any kind of stimulation Persistent or recurrent pain with attempted or completed vaginal entry and/or penile–vaginal intercourse Persistent or recurrent difficulties of the woman to allow vaginal entry of the penis. non–nerve sparing hysterecJournal of Midwifery & Women’s Health  www. and substandard relationships. Although menopause may seem like a direct risk for sexual dysfunction. hypertension. then the diagnosis centers around the arousal disorder first.29 Female Orgasmic Disorder In women experiencing arousal issues and/or dyspareunia. negative past sexual experiences. absent thoughts or fantasies. such as endometriosis. the lack of subjective arousal distinguishes this from genital arousal disorder Spontaneous. multiple sclerosis. 20% to 30% of women in the United States who were 20 to 59 years of age reported low sexual desire. Gynecologic and obstetric conditions. alcohol. if the lack of orgasm is related to problems with arousal. However.

and heightened anxieties or fears about miscarriage. Before becoming pregnant. massage.16 During the second trimester. kissing. emotional lability.8 71% of the respondents who completed the questionnaires reported a decrease in sexual frequency during pregnancy compared to prepregnancy activities. 5. DeJudicibus et al.35 surveyed 40 healthy pregnant women using the Female Sexual Function Index (FSFI) questionnaire.5 times in the third trimester. multiple times.16 Women may want to engage in sexual activity frequently and because of increased genital blood flow may end up reaching orgasm for the first time. foreplay. 96% of pregnant women engaged in vaginal intercourse.34 Changing the recall period from ‘‘within the past month’’ to ‘‘1 month or more in the past year’’ lead to higher estimates of all disorders.16 In addition to vaginal intercourse. and previous apprehensions diminish. and uniform recall timeframes. prevalence estimates would be more consistent and reliable. measurements. arousal. September/October 2010 Dyspareunia related to medical illness Dyspareunia related to specific gynecologic pain syndromes Dyspareunia related to surrounding organ systems Dyspareunia related to postoperative changes Source: Steege and Zolnoun.8.16 In a cross-sectional study of 141 pregnant women by Bartellas et al. woman on top. typically because of practical concerns. oral sex. Gokyildiz ¨ et al. Dyspareunia Syndromes Dyspareunia without organic pathology Vaginismus Diminished sexual response Menopause Levator spasm ¨ Sjogren syndrome Diabetes Systemic inflammatory/ autoimmune diseases Vulvar disease  Lichen planus  Lichen sclerosus  Lichen simplex chronicus  Vulvar vestibular syndrome Vaginal pain  Chronic vaginitis  Adverse effects of oral contraceptives  Levator spasms  Obstetric lacerations Deep dyspareunia  Uterine pain  Adnexal disease  Endometriosis  Pelvic congestion syndrome  Pelvic support Gastrointestinal illness  Crohn disease  Irritable bowel syndrome Bladder disease  Painful bladder syndrome  Interstitial cystitis  Urethral diverticulum Total hysterectomy Pelvic support surgery  Cervicouterine prolapse  Anterior compartment  Posterior compartment the Female Sexual Distress Scale. No.7% of women had intercourse one to four times per Volume 55. whereas adding the sexual distress measure resulted in lower estimates of the incidence of desire. Participants completed the questionnaire one time per trimester during their pregnancies. whereas only 67% did so by the third trimester.34 SEXUAL FUNCTION IN PREGNANCY Many pregnant women believe that sexual function diminishes over the course of pregnancy. standard definitions of sexual dysfunction disorders. During the first trimester. with an increase in libido as physical discomforts subside. mutual caressing. and/or easier than before they were pregnant. physical aches and obstacles can again become overwhelming. sore breasts. One survey of 356 Australian women 20 to 70 years of age found less desire. and orgasm disorders when using an 18-item adapted version of the Sexual Function Questionnaire in combination with the Female Sexual Distress Scale compared to the Sexual Function Questionnaire alone and two groups of questions from Laumann et al.16 By the third trimester.8. with a significant decline in the third trimester.36 used a 63-question face-to-face interview to determine the effects of pregnancy on the sexual life of 150 women at $34 weeks’ gestation.33 The actual prevalence of all types of female sexual dysfunction is unclear because the research methods.9 times in the first trimester to a mean of 2. The frequency of intercourse attempts over a 4-week period went from a mean of 6. such as side by side. 84. making traditional sexual acts more difficult and less frequent. sexual activity in pregnancy can include masturbation. arousal.35 Conversely. and tools used to evaluate these conditions differ.Table 2. women are said to feel more erotic and energetic. such as the Sexual Function Questionnaire and 442 .34 If researchers in this field were to use the same instruments.8 Aslan et al. and cuddling. fantasy. nausea. and hands and knees can be more comfortable during pregnancy. and orgasm disorders. all of whom were experiencing a normal pregnancy. The first trimester of pregnancy is often a time when libido decreases because of fatigue.16 Sexual needs of the pregnant woman and her partner can be met in a variety of ways.31 was found to be the most frequent complaint of young women. vaginal lubrication increases. the use of sex toys. The third trimester of pregnancy appears to mark a particular period in which sexual behaviors become the most infrequent. Several positions.12 used a questionnaire designed to have women recall how frequently they typically had intercourse before pregnancy and then during pregnancy and found an average of once per week before pregnancy and once per month during pregnancy..

a structured questionnaire that inquired about perceptions and beliefs of sexual intercourse before and during pregnancy found that 43. Between 45% and 49% of women and 55% to 62% of their partners reported an overall fear of causing some sort of obstetric complication from engaging in sexual intercourse while pregnant.3% of women partici¨ pants were satisfied with their sexual lives before pregnancy. The majority of women and their partners (82. Although the results of these studies are largely similar.38 which allows for quantified results about female sexual function and dysfunction during pregnancy.8%). rupture of membranes (n = 161. emotional.35–38 In the study by Gokyildiz et al. and are often retrospective. which decreased to 56%.16 Female Sexual Function Index The studies that have investigated sexual function during pregnancy have some limitations. 74. satisfaction. Sexual activity was shown to decrease in proportion to the increase in women fearful of causing preterm labor. damage to the baby. respectively.41 It was designed to be a tool to measure female sexual function for women of all ages. and found that 28% of the women who reported infrequent or no sexual intercourse early in pregnancy had a preterm birth versus 38% of women who engaged in some sexual activity (P = . Despite these fears.38 a lack of libido or desire in 92. it is usually for a more narrow and specific purpose. Intensive Therapy (PLISSIT) model is one technique that has been proposed for addressing sexual health concerns. to 21% in the second trimester. The Permission.9% and 84.7%). From these discussions. and pain domains.12. This difference was not statistically significant.9%.36 79.39 In the Bartellas et al.7%). and damage to the fetus (n = 214. 60. A collective understanding of how sexual function affects a woman’s life can contribute to more comprehensive. 42. holistic care.37 In a cross-sectional study of 190 women with a mean age of 26. However. homogeneous. only bleeding and pain after sexual intercourse during pregnancy were observed and occurred in less than 12% of the women surveyed.7 years. The study populations are small. CLINICAL IMPLICATIONS Female sexual function and dysfunction in nonpregnant and pregnant populations are areas of interest for women’s health care providers. including prenatal care.. Yost et al. Limited Information.37 Fatigue is a major predictor of sexual frequency during pregnancy. Given the frequent incidence of sexual dysfunction in women. 61. 60.8 survey of a mixture of 141 primigravid and multigravid women. libido. and sociocultural variables..40 evaluated the effect of coitus on preterm birth in a population of women (n = 165) who had a previous preterm delivery.7%. from 9% of women in the first trimester. Journal of Midwifery & Women’s Health  www. According to Erol et al. second.37 Other commonly cited reasons for lessening sexual activity include decreased sexual desire.6% of the participants was the second most common sexual dysfunction cited during pregnancy. arousal.40 Fok et al. differing measures and methods make it difficult to aggregate this data. One proposal to help quantify this research is the use of the FSFI questionnaire.13 surveyed 298 pregnant Chinese women through self-administered questionnaires investigating sexual experience during pregnancy.3% in the second. the number of women who were afraid of causing preterm labor grew with each trimester. the literature does not support an association between sexual intercourse and increased risk of preterm labor and delivery.jmwh. The author concluded that there is not enough evidence to suggest abstaining from sexual intercourse in order to avoid preterm birth. labor (n = 180. Fear of Harming the Fetus Fears of harming the fetus or inducing preterm labor are other contributors to the decline in sexual activity. 54%). orgasm. and bleeding.41 This tool was used in the studies by Aslan et al.week. Specific Suggestions. and if a sexual history is obtained. The FSFI has been validated and shown to be a reliable measure of female sexual function via 19 questions that assess desire. lubrication. several methods exist to then evaluate sexual functioning. a few basic questions and techniques can be used to facilitate sexual health discussions. and an increase in pain. the FSFI was not originally drafted to measure female sexual function specifically in pregnancy.8. and to 49% by the third trimester. Time for addressing sexual health concerns is often not built into routine office visits. and 32% in the third trimesters. particularly during pregnancy. The Sexual History A sexual history is a basic component of the health history obtained at the outset of all primary health services.35)..and postmenopause. Future research needs to be performed to develop a measurement tool to investigate female sexual function during pregnancy that includes physical.org 71. However. lack randomization. both pre. The most common concerns were bleeding (n = 222. interest and satisfaction.13 In an otherwise normal pregnancy.8%). respectively.35 and Erol et al. respectively) expressed concerns about the effects of sexual intercourse on the pregnancy and baby. which decreased to 70% in the first.12. infection (n = 180.7% felt that sexual intercourse during pregnancy could cause problems like preterm labor. and third trimesters. there is no conclusive data that indicate that sexual activity should be considered a threat to the fetus or a risk factor for inducing miscarriage or early labor and delivery. This model was developed in 1976 by Annon and has been used as a framework in many clinical 443 . and 20% in the first.

5 These questions are concise. dyspareunia. and treatment options for female sexual function and dysfunction.44 The ALLOW method is more succinct than PLISSIT and is an acceptable and helpful method to guide an evaluation of sexual health. there are a few key questions to ask (Table 3).14 Patients may disclose personal and sometimes traumatic experiences during sexual health discussions. and what populations of women are at particular risk for sexual dysfunction. The goals of these therapies vary. may be included if it is clinically warranted.46 The sexual history can be brief or extensive. Together. improving communication and closeness in relationships. and thyrotropin.25. testosterone. Work [ALLOW]) has been formulated to help assess and manage sexual dysfunction in both men and women. medications that may impact sexual functioning.47 Treatment courses rely upon information gleaned in clinical interviews with all female patients. what the best method is for doing so.49 There are currently no sanctioned medications to treat female sexual dysfunction. in today’s fast-paced medical environment. including a pelvic examination. However. and providers must be prepared to handle this information.5 The more at ease the practitioner appears.9 Open-ended questions can help the conversation flow forward. Laboratory studies may also be performed to check levels of estrogen. a physical examination. and refer when necessary. referral to a specialist or a follow-up appointment particularly devoted to sexual functioning can be made.5 444 Table 3. history of sexually transmitted infections.45. make suggestions and appropriate interventions. more treatment options could become available for women of all ages.6. neurobiologic chemicals. and a sexual history remains the most informative. the ALLOW algorithm is a step-by-step method used to inquire about sexual function.43 Alteneder et al. the provider and patient can make a plan. the PLISSIT model may be too time-consuming and outdated as a sexual health assessment.5 Particularly for homosexual women. By opening the dialogue about sexual function and Volume 55. A sexual history can be included in the review of systems or into the general health history and should include a consideration of complicating chronic health ailments. If hormones. with men. long-term clinical drug trials. The provider can determine how comfortable they may be in treating sexual dysfunction versus referring to a specialist once the ‘‘limitations’’ level is reached. Legitimize. September/October 2010 . Although there may not be a simple solution to female sexual function. guide discussion.44 Like PLISSIT. Open. and childhood sexual abuse are all serious life events that have significant effects on one’s sexual function and emotional. 5. and mental health.48 Future research about female sexual function and dysfunction in general and during pregnancy should be aimed at evaluating whether women are routinely being screened for sexual dysfunction.27.47 Routine clinician–patient interviews and history gathering cannot be replaced even by the best scales. the more likely the patient will give a complete sexual health history.29.settings. Depending upon what issues are mentioned. gender neutral. and relationship status.42 It provides a foundation for health care workers to identify health issues. instruments. and genes can be isolated and their role in female sexual dysfunction determined. Rape.43 proposed the use of the PLISSIT model by nurses working with pregnant women to evaluate and devise interventions regarding sexual needs during the antepartum.5. there is evidence to support the use of cognitive behavioral therapies. or both? Do you have any concerns or difficulties with sexual intercourse? Source: Kingsberg.9 If a brief assessment is all that time allows for. there should be a comfortable and trusting environment between the patient and practitioner. enhancing erotic stimulation and satisfaction. prolactin. depending on the nature of the visit. who can be fearful of coming out to practitioners. sex therapy. domestic violence. Normalizing sexual health discussions and maintaining a nonjudgmental stance improves patient disclosure. physical. such as low self-esteem or past abuse. However. when obtaining a sexual history. No. women. because hormone and neurotransmitter therapies have fallen short and have not been proven safe nor efficacious in clinical trials. health care providers who are sincere and direct about sexual orientation and specific sexual needs greatly improve patient satisfaction and outcomes. and questionnaires or patient-reported outcomes when evaluating and discussing female sexual function and sexual dysfunction. and addressing personal mental health concerns. and postpartum periods. In general. mental health conditions. Investigations into the neurobiologic basis or possible genetic origins of the cause of female sexual dysfunction and options in treatment modalities are the topics of future scientific research. no such miracle products work for women. and decide on treatment options. Another algorithm (Ask.5 In addition to the sexual history. Limitations. but mostly focus on identifying problematic thoughts or behaviors that contribute to sexual dysfunction.47 This again cites the need for more medical research. and shortterm psychotherapy. and allow for an adequate sexual health assessment.47 Despite the popularity of male enhancement products to treat male-related sexual dysfunctions. Key Questions to Ask During a Sexual Health History Are you currently sexually active? If so. intrapartum. often little is gained from both the physical examination and laboratory results.

281:1174. 16. 11. Defining sexual health: Report of a technical consultation on sexual health. Routine sexual health assessment and history gathering help to legitimize discussing female sexual function and can identify possible dysfunctions and disorders and practical treatment solutions all while providing well-rounded patient care. Human sexual response. JAMA 1999. REFERENCES 1. Paik A. Rogers RG. Yuen PM. Woman’s experience of sex. 19. and perpetuates the air of mystery around female sexual function.172:1327–33. more insight can be gained about the many elements that affect women’s sexual health. This leaves women turning to friends. 15. Tracy JK. J Gen Intern Med 2009. Philadelphia: WB Saunders. Laumann EO. Sexual behavior in the human female. Long JS. Perspect Psychiatr Care 2009.33:535–47. 7. psychologic. Fok WY.29:685–93. Johnson VE. and obstacles. Sciamanna CN. 21. Brown. editors. Crane JM.32:193–208. Erratum in JAMA 1999. Martin CE. 14. 4. Peck SA. 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