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

Jessica Murtagh, CNM, MSN, RN

Womens 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 decient 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 womans 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. Womens 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;55:438446 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 womens 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 womens health care. Womens 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, womens experiences of prenatal care vary from those feeling satised 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.3,59,13,14 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 ofce visits.57 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 condence to handle sexual health difculties, 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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about sexual activity to their providers rst.8 In addition, of those who never conversed with their providers about sexual activity in pregnancy, 76% felt that it was a topic that should have been addressed.8 The failure to communicate about sexual health with female patients could have negative physical, emotional, and psychosocial outcomes.9 Sexual health involves a plethora of factors. According to the World Health Organization (WHO), sexual health includes physical, mental, emotional, and social well-being in all sexual behaviors and beliefs.10 Sexual health is not merely the absence of disease and dysfunction, but an overall balanced sense of the sexual self. Current knowledge about female sexual function and dysfunction also demonstrates these as multifactorial processes in the spectrum of sexual health.11 Pregnancy is a particularly sensitive time to consider sexual health, sexual function, and sexual dysfunction.12 FEMALE SEXUAL FUNCTION Female sexual function is not easily dened, as there is not a singular response from women but instead a wide variety of what can be considered normal. The role of psychologic, social, personal, cultural, and biologic factors are critical in the consideration of female sexual function, and there is a lack of agreement over which factor is more inuential.11 Biologic aspects, including vascular, neurologic, and structural components, are yet to be fully understood.15 Furthermore, cultural beliefs can limit what research can be performed on female sexual function and what actually gets spoken about in everyday life. For example, sexual activity may be considered forbidden or taboo during menstruation and pregnancy.11,16 Such cultural constraints can hinder women from discussing sexual concerns with professionals and can limit sexual freedom and gratication.11 Even if the biologic and anatomic structures and functions of women and their sex drives become better understood, subjective experiences commonly remain a private matter. The current understanding of female sexual function has evolved over time from epidemiologic, laboratory, and scientic models. The rst formal investigation in the United States of female sexual behavior was started by Kinsey17 in the 1950s; his research helped open the doors to more scientically driven explorations.17 These investigations resulted in the physiologic linear four-stage model developed by Masters and Johnson in the 1960s, Kaplans three-stage sexual response model in the 1970s, a circular model by Whipple and Brash-McGreer in the 1990s, and most recently Bassons intimacy-based cyclical

Jessica Murtagh, CNM, MSN, RN, 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, Chicago, IL.

model.1821 The objective of these explorations and models was to determine the normal sexual response in women by considering arousal, orgasm, resolution, and later, more psychosocial and emotional elements, such as sexual desire and satisfaction.11 The earlier models focused more on the physiologic processes and did not include the emotional, mental, and social variables that greatly impact female sexual function. In 2003, Bancroft et al.22 published the results of a survey of a national sample of 987 heterosexual women 20 to 65 years of age. 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.22 In a cross-sectional study using an Internet-based survey of 350 homosexual women with an average age of 35.5 years, sexual functioning was again most correlated to relationship characteristics and psychologic features.23 Both of these studies highlight the significance of incorporating the whole of the personand not just the physicalin understanding female sexual function. 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.11,16 The cyclical model shows many points of entrance into the female sexual response cycle that often overlap. A woman may have a personal motivating factor to initiate or agree to sexual activity, or may have spontaneous desire that is then reinforced by sexual stimuli, biologic responses, and psychologic perspectives.24 Of signicance in the cyclical model is that desire is not always rst before arousal or the sole reasoning for engaging in sexual activity.25 Further into the cycle, subjective arousal occurs, which can lead to more desire followed by sexual satisfaction experienced as orgasm or nonphysical rewards.24 Greater subjective arousal contributes to a womans responsiveness to sexual stimuli, which furthers arousal and/or orgasm, continuing possibly many times over with even greater intensity each time. Positive sexual experiences facilitate the sexual response cycle and enable a state of sexual neutrality to move into sexual motivation, desire, arousal, and satisfaction.24 The context in which sexual behavior occurs for women helps determine whether a woman will seek out sexual activity, be receptive to it, and/or be subjectively satised. The womans relationship with her partner, herself, and past sexual experiences affect where in the sexual response cycle the woman may fall and function.24 Engaging in sexual activities does not have to directly result in orgasm, but instead may help to satisfy other particular physical, spiritual, social, and emotional needs. A woman may engage in sexual activity for stress relief, to feel closer to her partner, to be in a position of power, or to boost her self-esteem.24 A womans sexual functioning is therefore not linear. The cyclical model is useful for clinicians because it helps depict the multifaceted sexual functioning
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with chronic medical conditions or side effects of certain medications.29 Sexual dysfunctions may endure throughout the lifespan or be temporary, general or situation specic, and physiologic and/or psychologic in origin.26 The categories and denitions of female sexual dysfunction have been expanded over the past decade to incorporate the full spectrum of female sexual response, including more subjective measures (Table 1).21,30 These expanded denitions are now considered the standard in the diagnosis of female sexual dysfunction instead of the DSM-IVTR classications, because they are more appropriate to the current understanding of the female sexual response cycle.21,30 Denitions of Common Female Sexual Dysfunction Sexual Desire/Interest Disorder
Figure 1. Modied model of Bassons21 female sexual response cycle.

of women and also shows areas where there may be a problem that impacts sexual function. FEMALE SEXUAL DYSFUNCTION Female sexual dysfunction is dened as any problem that may be encountered in the sexual response cycle that deviates from a womans normal range of functioning.26 Dening female sexual dysfunction is not as absolute for women because of the qualitative nature of female sexual function. What may be abnormal for one woman may not be abnormal for another woman.24 Sexual dysfunction falls on a continuum with female sexual disorder. In sexual dysfunction, there is an interruption in normal sexual functioning at one or several points in the sexual response cycle. In comparison, a sexual disorder consists of both the sexual dysfunction element in addition to persistent distress.27 An abnormality in ones sex life can exist but may not warrant further evaluation unless the woman experiences a certain degree of anguish over it.27 When investigating female sexual function versus dysfunction and disorder, 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.28 The distress must be experienced by the woman herself, and that which bothers her partner alone is not then a sexual dysfunction of the woman but rather of her partner.25 Female sexual dysfunction and disorder must be discussed in the context of each individual womans life, culture, social climate, experiences, relationship, and health in order to tease out the distress element.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, arousal, and orgasm. Primary dysfunctions correspond with the traditional linear sexual response model, whereas secondary dysfunctions are associated
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The latest denition of sexual dysfunction secondary to lack of desire is called sexual desire/interest disorder, which refers to a lack of desire or interest in sex before the sexual encounter and also a lack of desire during sex. Desire that occurs during sex is called responsive desire. This clarication 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; dysfunction occurs when there is a total lack of desire even during act.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.24 A woman with adequate lubrication but no subjective awareness of that arousal is classied separately than one with subjective feelings of arousal but no physical signs of vasocongestion or lubrication. In women with persistent genital arousal disorder, physical symptoms are present, but are often not linked to subjective desires, and can interfere with every day functioning.24 Dyspareunia If there is pain related to a lack of arousal, this is not considered an arousal disorder but instead is classied as dyspareunia.24 Dyspareunia is any pain experienced during vaginal penetration or intercourse. Approximately 8% to 22% of women are affected by dyspareunia at one time or another.31 Several dyspareunia syndromes exist, and a careful, detailed history and physical evaluation of each patient is critical to gain insight into cause and treatment options (Table 2).31 Because dyspareunia is common, sexual health histories should include one or two questions about pain encountered during sexual encounters.
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Table 1. Expanded Denitions of Female Sexual Dysfunction

Sexual desire/interest disorder Absent or diminished feelings of sexual interest or desire, absent thoughts or fantasies, and a lack of responsive desire; lack of motivations for attempting to become sexually aroused; 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; vaginal lubrication or other signs of a physical response may still occur Complaints of impaired genital sexual arousal; self-report may include minimal vulvar swelling or vaginal lubrication from any type of sexual stimulation and reduced sexual sensations from caressing genitalia; 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; the lack of subjective arousal distinguishes this from genital arousal disorder Spontaneous, intrusive, and unwanted genital arousal that occurs in the absence of sexual interest and desire; 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, markedly diminished intensity of orgasmic sensations, or marked delay of orgasm from any kind of stimulation Persistent or recurrent pain with attempted or completed vaginal entry and/or penilevaginal intercourse Persistent or recurrent difculties of the woman to allow vaginal entry of the penis, a nger, or any object, despite the womans 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 Womans orgasmic disorder Dyspareunia Vaginismus Sexual aversion disorder
Source: Basson et al.29

Female Orgasmic Disorder In women experiencing arousal issues and/or dyspareunia, reaching orgasm becomes another complication. Female orgasmic disorder is diagnosed when a woman does not experience orgasm. However, if the lack of orgasm is related to problems with arousal, then the diagnosis centers around the arousal disorder rst.24 Addressing the arousal disorder will often correct the inability to orgasm. Cognitive behavioral therapy has been found to be effective for women who have a primary diagnosis of anorgasmia. Pharmacologic agents that induce female orgasm have yet to be found and approved for widespread use.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. Although menopause may seem like a direct risk for sexual dysfunction, there has not been a study with statistically signicant results documenting a universal decline in sexual function in menopausal and postmenopausal women.24 Chronic medical conditions, such as diabetes, hypertension, overactive bladder, multiple sclerosis, spinal cord injury, and major depressive disorder, can contribute to female sexual dysfunction. Gynecologic and obstetric conditions, such as endometriosis, broids, infections, various prolapses, nonnerve sparing hysterecJournal of Midwifery & Womens Health  www.jmwh.org

tomy, and previous episiotomy or operative delivery are also associated with sexual dysfunction.27 Medications that block adrenergic receptors, dopamine, and those that have anticholinergic or sedative effects can also be problematic.27 Oral contraceptives are another medication group that have been thought to affect sexual function, but the majority of evidence reveals that only a small minority of women actually experience such a side effect.27 Other nonphysical risk factors include tobacco, alcohol, and drug use, obesity, poverty, education level, negative past sexual experiences, and substandard relationships.25 Environment and choice of partner alone can be major factors in female sexual functioning and dysfunction.24 Prevalence of Female Sexual Dysfunction Sexual dysfunction in the reproductive years is more prevalent than one would suspect. In a review of the literature published between 1950 and 2008 that evaluated women between 18 and 50 years of age, sexual disinterest was the most common sexual complaint.33 In a study of 3589 women in the United States and Europe, 20% to 30% of women in the United States who were 20 to 59 years of age reported low sexual desire.33 In this population, 15% to 19% of the women surveyed in the United States qualied for hypoactive sexual desire disorder when low sexual desire and distress were evaluated together.33 Overall, a total of 11 studies conrmed that a lack of sexual interest
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Table 2. Dyspareunia Syndromes

Dyspareunia without organic pathology Vaginismus Diminished sexual response Menopause Levator spasm Sjogren syndrome Diabetes Systemic inammatory/ 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, standard denitions of sexual dysfunction disorders, and uniform recall timeframes, prevalence estimates would be more consistent and reliable.34 SEXUAL FUNCTION IN PREGNANCY Many pregnant women believe that sexual function diminishes over the course of pregnancy, typically because of practical concerns. The rst trimester of pregnancy is often a time when libido decreases because of fatigue, emotional lability, nausea, sore breasts, and heightened anxieties or fears about miscarriage.16 During the second trimester, women are said to feel more erotic and energetic, with an increase in libido as physical discomforts subside, vaginal lubrication increases, and previous apprehensions diminish.16 Women may want to engage in sexual activity frequently and because of increased genital blood ow may end up reaching orgasm for the rst time, multiple times, and/or easier than before they were pregnant.16 By the third trimester, physical aches and obstacles can again become overwhelming, making traditional sexual acts more difcult and less frequent.8,16 Sexual needs of the pregnant woman and her partner can be met in a variety of ways. Several positions, such as side by side, woman on top, and hands and knees can be more comfortable during pregnancy.16 In addition to vaginal intercourse, sexual activity in pregnancy can include masturbation, massage, oral sex, foreplay, mutual caressing, kissing, fantasy, the use of sex toys, and cuddling.8,16 In a cross-sectional study of 141 pregnant women by Bartellas et al.,8 71% of the respondents who completed the questionnaires reported a decrease in sexual frequency during pregnancy compared to prepregnancy activities. The third trimester of pregnancy appears to mark a particular period in which sexual behaviors become the most infrequent. During the rst trimester, 96% of pregnant women engaged in vaginal intercourse, whereas only 67% did so by the third trimester.8 Aslan et al.35 surveyed 40 healthy pregnant women using the Female Sexual Function Index (FSFI) questionnaire. Participants completed the questionnaire one time per trimester during their pregnancies. The frequency of intercourse attempts over a 4-week period went from a mean of 6.9 times in the rst trimester to a mean of 2.5 times in the third trimester.35 Conversely, DeJudicibus et al.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, with a signicant decline in the third trimester. Gokyildiz et al.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, all of whom were experiencing a normal pregnancy. Before becoming pregnant, 84.7% of women had intercourse one to four times per
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Dyspareunia related to medical illness

Dyspareunia related to specic gynecologic pain syndromes

Dyspareunia related to surrounding organ systems

Dyspareunia related to postoperative changes

Source: Steege and Zolnoun.31

was found to be the most frequent complaint of young women.33 The actual prevalence of all types of female sexual dysfunction is unclear because the research methods, measurements, and tools used to evaluate these conditions differ. One survey of 356 Australian women 20 to 70 years of age found less desire, arousal, 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.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, whereas adding the sexual distress measure resulted in lower estimates of the incidence of desire, arousal, and orgasm disorders.34 If researchers in this eld were to use the same instruments, such as the Sexual Function Questionnaire and
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week, which decreased to 70% in the rst, 61.3% in the second, and 32% in the third trimesters, respectively.37 Fatigue is a major predictor of sexual frequency during pregnancy.12,37 Other commonly cited reasons for lessening sexual activity include decreased sexual desire, libido, interest and satisfaction, and an increase in pain.12,3538 In the study by Gokyildiz et al.,36 79.3% of women partici pants were satised with their sexual lives before pregnancy, which decreased to 56%, 42.7%, and 20% in the rst, second, and third trimesters, respectively. According to Erol et al.,38 a lack of libido or desire in 92.6% of the participants was the second most common sexual dysfunction cited during pregnancy. Fear of Harming the Fetus Fears of harming the fetus or inducing preterm labor are other contributors to the decline in sexual activity. 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.8,37 In a cross-sectional study of 190 women with a mean age of 26.7 years, a structured questionnaire that inquired about perceptions and beliefs of sexual intercourse before and during pregnancy found that 43.7% felt that sexual intercourse during pregnancy could cause problems like preterm labor, damage to the baby, and bleeding.39 In the Bartellas et al.8 survey of a mixture of 141 primigravid and multigravid women, the number of women who were afraid of causing preterm labor grew with each trimester, from 9% of women in the rst trimester, to 21% in the second trimester, and to 49% by the third trimester. Sexual activity was shown to decrease in proportion to the increase in women fearful of causing preterm labor. However, the literature does not support an association between sexual intercourse and increased risk of preterm labor and delivery. Yost et al.40 evaluated the effect of coitus on preterm birth in a population of women (n = 165) who had a previous preterm delivery, 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 = .35). This difference was not statistically signicant. The author concluded that there is not enough evidence to suggest abstaining from sexual intercourse in order to avoid preterm birth.40 Fok et al.13 surveyed 298 pregnant Chinese women through self-administered questionnaires investigating sexual experience during pregnancy. The majority of women and their partners (82.9% and 84.9%, respectively) expressed concerns about the effects of sexual intercourse on the pregnancy and baby. The most common concerns were bleeding (n = 222; 74.8%), labor (n = 180; 60.7%), infection (n = 180; 60.7%), rupture of membranes (n = 161; 54%), and damage to the fetus (n = 214;
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71.8%). Despite these fears, only bleeding and pain after sexual intercourse during pregnancy were observed and occurred in less than 12% of the women surveyed.13 In an otherwise normal pregnancy, 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.16 Female Sexual Function Index The studies that have investigated sexual function during pregnancy have some limitations. The study populations are small, homogeneous, lack randomization, and are often retrospective. Although the results of these studies are largely similar, differing measures and methods make it difcult to aggregate this data. One proposal to help quantify this research is the use of the FSFI questionnaire. The FSFI has been validated and shown to be a reliable measure of female sexual function via 19 questions that assess desire, arousal, lubrication, orgasm, satisfaction, and pain domains.41 It was designed to be a tool to measure female sexual function for women of all ages, both pre- and postmenopause.41 This tool was used in the studies by Aslan et al.35 and Erol et al.,38 which allows for quantied results about female sexual function and dysfunction during pregnancy. However, the FSFI was not originally drafted to measure female sexual function specically in pregnancy. Future research needs to be performed to develop a measurement tool to investigate female sexual function during pregnancy that includes physical, emotional, and sociocultural variables. CLINICAL IMPLICATIONS Female sexual function and dysfunction in nonpregnant and pregnant populations are areas of interest for womens health care providers. A collective understanding of how sexual function affects a womans life can contribute to more comprehensive, holistic care. Time for addressing sexual health concerns is often not built into routine ofce visits, and if a sexual history is obtained, it is usually for a more narrow and specic purpose. The Sexual History A sexual history is a basic component of the health history obtained at the outset of all primary health services, including prenatal care. Given the frequent incidence of sexual dysfunction in women, particularly during pregnancy, a few basic questions and techniques can be used to facilitate sexual health discussions. From these discussions, several methods exist to then evaluate sexual functioning. The Permission, Limited Information, Specic Suggestions, Intensive Therapy (PLISSIT) model is one technique that has been proposed for addressing sexual health concerns. This model was developed in 1976 by Annon and has been used as a framework in many clinical
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settings.42 It provides a foundation for health care workers to identify health issues, make suggestions and appropriate interventions, and refer when necessary.43 Alteneder et al.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, intrapartum, and postpartum periods. However, in todays fast-paced medical environment, the PLISSIT model may be too time-consuming and outdated as a sexual health assessment. Another algorithm (Ask, Legitimize, Limitations, Open, Work [ALLOW]) has been formulated to help assess and manage sexual dysfunction in both men and women.44 Like PLISSIT, the ALLOW algorithm is a step-by-step method used to inquire about sexual function, guide discussion, and decide on treatment options. The provider can determine how comfortable they may be in treating sexual dysfunction versus referring to a specialist once the limitations level is reached. Together, the provider and patient can make a plan.44 The ALLOW method is more succinct than PLISSIT and is an acceptable and helpful method to guide an evaluation of sexual health. In general, when obtaining a sexual history, there should be a comfortable and trusting environment between the patient and practitioner.5 The more at ease the practitioner appears, the more likely the patient will give a complete sexual health history. Normalizing sexual health discussions and maintaining a nonjudgmental stance improves patient disclosure.5 Particularly for homosexual women, who can be fearful of coming out to practitioners, health care providers who are sincere and direct about sexual orientation and specic sexual needs greatly improve patient satisfaction and outcomes.14 Patients may disclose personal and sometimes traumatic experiences during sexual health discussions, and providers must be prepared to handle this information. Rape, domestic violence, and childhood sexual abuse are all serious life events that have signicant effects on ones sexual function and emotional, physical, and mental health.45,46 The sexual history can be brief or extensive, depending on the nature of the visit. 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, mental health conditions, medications that may impact sexual functioning, history of sexually transmitted infections, dyspareunia, and relationship status.5,6,9 Open-ended questions can help the conversation ow forward.9 If a brief assessment is all that time allows for, there are a few key questions to ask (Table 3).5 These questions are concise, gender neutral, and allow for an adequate sexual health assessment. Depending upon what issues are mentioned, referral to a specialist or a follow-up appointment particularly devoted to sexual functioning can be made.5
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Table 3. Key Questions to Ask During a Sexual Health History

Are you currently sexually active? If so, with men, women, or both? Do you have any concerns or difculties with sexual intercourse?
Source: Kingsberg.5

In addition to the sexual history, a physical examination, including a pelvic examination, may be included if it is clinically warranted. Laboratory studies may also be performed to check levels of estrogen, testosterone, prolactin, and thyrotropin. However, often little is gained from both the physical examination and laboratory results, and a sexual history remains the most informative.47 Routine clinicianpatient interviews and history gathering cannot be replaced even by the best scales, instruments, and questionnaires or patient-reported outcomes when evaluating and discussing female sexual function and sexual dysfunction.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, what the best method is for doing so, and what populations of women are at particular risk for sexual dysfunction. 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 scientic research. If hormones, neurobiologic chemicals, and genes can be isolated and their role in female sexual dysfunction determined, more treatment options could become available for women of all ages.27,49 There are currently no sanctioned medications to treat female sexual dysfunction, because hormone and neurotransmitter therapies have fallen short and have not been proven safe nor efcacious in clinical trials.25,29,47 Despite the popularity of male enhancement products to treat male-related sexual dysfunctions, no such miracle products work for women.47 This again cites the need for more medical research, long-term clinical drug trials, and treatment options for female sexual function and dysfunction. Although there may not be a simple solution to female sexual function, there is evidence to support the use of cognitive behavioral therapies, sex therapy, and shortterm psychotherapy. The goals of these therapies vary, but mostly focus on identifying problematic thoughts or behaviors that contribute to sexual dysfunction, improving communication and closeness in relationships, enhancing erotic stimulation and satisfaction, and addressing personal mental health concerns, such as low self-esteem or past abuse.47 Treatment courses rely upon information gleaned in clinical interviews with all female patients. By opening the dialogue about sexual function and
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dysfunction, more insight can be gained about the many elements that affect womens 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. CONCLUSION Female sexuality is a complex topic as evidenced by the assortment of research done from biologic, psychologic, and sociocultural paradigms. Sexual function during pregnancy is an area that has not been the subject of a great deal of research. Moreover, discussions of female sexual functionespecially during pregnancyappear to be infrequent in the clinical setting. This leaves women turning to friends, books, or the media for information, and perpetuates the air of mystery around female sexual function, dysfunction, and sexual expectations during pregnancy. Prenatal care visits provide opportunities to initiate discussions about sexuality during pregnancy. Ideally, conversations surrounding sexual health should happen on a regular basis during primary care visits both before and after pregnancy. Counseling about sexual health should not only highlight potential problems and difculties, but also the opportunity to improve self-worth and interpersonal relationships. Women should be encouraged to have an open and honest conversation with their partners and also with their health care providers about their sexual needs, expectations, and obstacles. Female sexual functioning in and out of pregnancy is a worthwhile clinical subject and can be instrumental for boosting patient satisfaction and welfare.

health among unmarried middle-aged and older women. J Gen Intern Med 2009;24:5116. 8. Bartellas E, Crane JM, Daley M, Bennett KA, Hutchens D. Sexuality and sexual activity in pregnancy. BJOG 2000;107:9648. 9. Peck SA. The importance of the sexual health history in the primary care setting. J Obstet Gynecol Neonatal Nurs 2001; 30:26974. 10. World Health Organization. Dening sexual health: Report of a technical consultation on sexual health, January 2831, 2002. Geneva, Switzerland: World Health Organization, 2006:135. 11. Rosen RC, Barsky JL. Normal sexual response in women. Obstet Gynecol Clin North Am 2006;33:51526. 12. DeJudicibus MA, McCabe MP. Psychological factors and the sexuality of pregnant and postpartum women. J Sex Res 2002; 39:94103. 13. Fok WY, Chan LY, Yuen PM. Sexual behavior and activity in Chinese pregnant women. Acta Obstet Gynecol Scand 2005; 84:9348. 14. McManus AJ, Hunter LP, Renn H. Lesbian experiences and needs during childbirth: Guidance for health care providers. J Obstet Gynecol Neonatal Nurs 2006;35:1323. 15. Munarriz R, Kim NN, Goldstein I, Traish AM. Biology of female sexual function. Urol Clin North Am 2002;29:68593. 16. Kitzinger S. Womans experience of sex. London, UK: Dorling Kindersley Limited, 1983. 17. Kinsey AC, Pomeroy WB, Martin CE. Sexual behavior in the human female. Philadelphia: WB Saunders, 1953. 18. Masters WH, Johnson VE. Human sexual response. Boston: Little, Brown, 1966. 19. Kaplan HS. Disorders of sexual desire and other new concepts and techniques in sex therapy. New York: Brunner/Hazel Publications, 1979. 20. Whipple B, Brash-McGreer K. Management of female sexual dysfunction. In: Sipski ML, Alexander CJ, editors. Sexual function in people with disability and chronic illness. Gaithersburg, MD: Aspen Publishers, 1997. 21. Basson R. Womens sexual dysfunction: Revised and expanded denitions. CMAJ 2005;172:132733. 22. Bancroft J, Loftus J, Long JS. Distress about sex: A national survey of women in heterosexual relationships. Arch Sex Behav 2003;32:193208. 23. Tracy JK, Junginger J. Correlates of lesbian sexual functioning. J Womens Health (Larchmt) 2007;16:499509. 24. Basson R. Womens sexual function and dysfunction: Current uncertainties, future directions. Int J Impot Res 2008; 20:46678. 25. Kammerer-Doak D, Rogers RG. Female sexual function and dysfunction. Obstet Gynecol Clin North Am 2008; 35:16983. 26. Sobczak JA. Female sexual dysfunction: Knowledge development and practice implications. Perspect Psychiatr Care 2009; 45:16172.

REFERENCES
1. Laumann EO, Paik A, Rosen RC. Sexual dysfunction in the United States: Prevalence and predictors. JAMA 1999; 281:53744. Erratum in JAMA 1999;281:1174. 2. Hamilton BE, Martin JA, Ventura SJ. Births: Preliminary data for 2007. Natl Vital Stat Rep 2009;57:123. 3. von Sydow K. Sexuality during pregnancy and after childbirth: A metacontent analysis of 59 studies. J Psychosom Res 1999;47:2749. 4. Novick G. Womens experience of prenatal care: An integrative review. J Midwifery Womens Health 2009;54:22637. 5. Kingsberg SA. Taking a sexual history. Obstet Gynecol Clin North Am 2006;33:53547. 6. Kingsberg SA, Janata JW. Female sexual disorders: Assessment, diagnosis, and treatment. Urol Clin North Am 2007; 34:497506. 7. Politi MC, Clark MA, Armstrong G, McGarry KA, Sciamanna CN. Patient-provider communication about sexual

Journal of Midwifery & Womens Health  www.jmwh.org

445

27. Clayton AH. Epidemiology and neurobiology of female sexual dysfunction. J Sex Med 2007;4(Suppl 4):2608. 28. Domoney C. Sexual function in women: What is normal? Int Urogynecol J Pelvic Floor Dysfunct 2009;20(Suppl 1):S917. 29. American Psychiatric Association. Diagnostic and statistical manual of mental disorders, text revision, 4th ed. Washington, DC: American Psychiatric Association, 2000. 30. Basson R, Althof S, Davis S, Fugl-Meyer K, Goldstein I, Leiblum S, et al. Summary of the recommendations on sexual dysfunctions in women. J Sex Med 2004;1:2434. 31. Steege JF, Zolnoun DA. Evaluation and treatment of dyspareunia. Obstet Gynecol 2009;113:112436. 32. Meston CM, Hull E, Levin RJ, Sipski M. Disorders of orgasm in women. J Sex Med 2004;1:668. 33. Stuckey BG. Female sexual function and dysfunction in the reproductive years: The inuence of endogenous and exogenous sex hormones. J Sex Med 2008;5:228290. 34. Hayes RD, Dennerstein L, Bennett CM, Fairley CK. What is the true prevalence of female sexual dysfunctions and does the way we assess these conditions have an impact? J Sex Med 2008; 5:77787. 35. Aslan G, Aslan D, Kizilyar A, Ispahi C, Esen A. A prospective analysis of sexual functions during pregnancy. Int J Impot Res 2005; 17:1547. 36. Gokyildiz S, Beji NK. The effects of pregnancy on sexual life. J Sex Marital Ther 2005;31:20115. 37. Trutnovsky G, Haas J, Lang U, Petru E. Womens perception of sexuality during pregnancy and after birth. Aust N Z J Obstet Gynaecol 2006;46:2827. 38. Erol B, Sanli O, Korkmaz D, Seyhan A, Akman T, Kadioglu A. A cross-sectional study of female sexual function and dysfunction during pregnancy. J Sex Med 2007; 4:13817.

39. Khamis MA, Mustafa MF, Mohamed SN, Toson MM. Inuence of gestational period on sexual behavior. J Egypt Public Health Assoc 2007;82:6590. 40. Yost NP, Owen J, Berghella V, Thom E, Swain M, Dildy GA 3rd, et al. Effect of coitus on recurrent preterm birth. Obstet Gynecol 2006;107:7937. 41. Rosen R, Brown C, Heiman J, Leiblum S, Meston C, Shabsigh R, et al. The Female Sexual Function Index (FSFI): A multidimensional self-report instrument for the assessment of female sexual function. J Sex Marital Ther 2000;26:191208. 42. Annon JS. The PLISSIT model: A proposed conceptual scheme for the behavioral treatment of sexual problems. J Sex Educ Ther 1976;2:115. 43. Alteneder RR, Hartzell D. Addressing couples sexuality concerns during the childbearing period: Use of the PLISSIT model. J Obstet Gynecol Neonatal Nurs 1997;26:6518. 44. Hatzichristou D, Rosen RC, Broderick G, Clayton A, Cuzin B, Derogatis L, et al. Clinical evaluation and management strategy for sexual dysfunction in men and women. J Sex Med 2004;1:4957. 45. Seng JS, Petersen BA. Incorporating routine screening for history of childhood sexual abuse into well-woman and maternity care. J Nurse Midwifery 1995;40:2630. 46. McAllister M. Domestic violence: A life-span approach to assessment and intervention. Lippincotts Prim Care Pract 2000;4:17489. 47. Basson R. Clinical practice. Sexual desire and arousal disorders in women. N Engl J Med 2006;354:1497506. 48. Kingsberg S, Althof SE. Evaluation and treatment of female sexual disorders. Int Urogynecol J Pelvic Floor Dysfunct 2009; 20(Suppl 1):S3343. 49. Burri AV, Cherkas LM, Spector TD. The genetics and epidemiology of female sexual dysfunction: A review. J Sex Med 2009; 6:64657.

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