10. Sexual health

For most people sexuality is an essential aspect of quality of life. Sexuality is a bio-psycho-social phenomenon. All medical, psychological, social and relational events throughout the lifespan may impact sexual functioning and sexual wellbeing. As a result, sexual concerns and sexual dysfunctions are prevalent and often distressing. Usually, patients only present these problems when a health professional proactively enquires about the presence of any sexual difficulties.

According to incentive motivation theories, sexual desire should no longer be regarded as a spontaneous biological drive or ‘libido’ that precedes sexual arousal and that one has or does not have. Rather, desire for sexual activity is the result of competent sexual stimuli that activate the sexual response system, and mediated by the expectation that sex will be rewarding. Biological factors -neurotransmitters and hormones- do not ‘produce’ sexual desire but do determine the sensitivity of the sexual system for sexual stimuli. Based on these changed views, the distinction between arousal and desire has been abandoned in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The new diagnosis ‘female sexual interest/arousal disorder’ should not be made if the sexual difficulties are the result of inadequate sexual stimulation. If a sexual problem is situational, a biomedical cause is most unlikely. Dyspareunia, vulvodynia, and vaginismus are common sexual pain problems in women. Because differentiation between these problems is difficult, in DSM-5 these disorders are merged under the heading of ‘genito-pelvic pain/penetration disorder’. In sexual pain problems, penetration without sufficient lubrication and swelling of the clitoral complex, and insufficient relaxation of the pelvic floor are prevalent precipitating and maintaining factors. In primary dyspareunia, generalized pelvic floor overactivity is related to physical or psychological stressors that were present before sexual debut. In secondary dyspareunia and vulvodynia, pelvic floor overactivity is the consequence of repetitive painful experiences.

Whatever the initial precipitating factor(s) of a sexual dysfunction may be, there are always secondary psychological, relational and contextual maintaining factors that should be explored in the diagnostic and therapeutic process. Treatment of sexual disorders is, by definition, multidimensional, taking into account all possible predisposing, precipitating, maintaining and contextual factors. Therapy may include psycho-education, basic counselling, individual and couple psychosexual behavioural therapy, and hormonal and pharmacological treatment.