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Variables Affecting Female Sexual Function

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Sexuality for women extends far beyond the release of neurotransmitters, the influence of sex hormones, and vasocongestion of the genitals. A number of psychological and sociological variables may affect female sexual function, as may the aging process, menopause, the presence of diseases, and the use of certain medications.

Effect of Psychosocial Variables on Female Sexual Response

Among the psychosocial variables, perhaps the most important is the relationship with the sexual partner. John Bancroft, MD, and colleagues at the Kinsey Institute for Research in Sex, Gender, and Reproduction suggest that a reduction in libido or sexual response may actually be an adaptive response to a woman's relationship or life problems (rather than a disorder).(1) According to Basson, emotions and thoughts have a stronger impact on a woman's assessment of whether or not she is aroused than does genital congestion.(2)

Other emotional factors that may have an impact on female sexual functioning are listed in Table 2.


TABLE 2. Psychological Factors Affecting Female Sexual Function
  • Relationship with sexual partner
  • Past negative sexual experiences or sexual abuse
  • Low sexual self-image
  • Poor body image
  • Lack of feeling of safety
  • Negative emotions associated with arousal
  • Stress
  • Fatigue
  • Depression or anxiety disorders

Effects of Aging on Female Sexual Response

Contrary to popular belief, aging does not mean the end of sexual interest, particularly today when many men and women are coupling, uncoupling, and recoupling again, leading to renewed interest in sex due to the novelty of a new sexual partner. Many older women find themselves at a psychologically satisfying sexual peak because of their maturity, knowledge of their body and its workings,

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ability to ask for and accept pleasure, and their greater comfort with themselve.(3)

In the past, much of our information about sexuality at perimenopause and beyond has been based on anecdotal complaints from a small, self-selecting group of symptomatic women who presented to providers.(4,5) Today we have large population-based studies that offer a more accurate picture.(5,7)

Although many studies do show that there is a normative, gradual decline in sexual desire and activity with age, research also indicates that the majority of men and women who are healthy and have partners will remain interested in sex and engage in sexual activity well into midlife, later life, and until the end of life.(5) An informal survey conducted by the consumer magazine More of 1,328 readers of the magazine (which is targeted to women over age 40) bears out this new thinking: 53 percent of women in their 50s said their sex life was more satisfying than it was in their 20s; 45 percent said they use vibrators and sex toys; and 45 percent would like a medication for women that enhances sexual desire and activity.(8)

Several factors appear to affect the ability to continue to be sexually active, most notably the availability of a willing sexual partner and a woman's health status (including the presence of a sexual disorder). The Duke Longitudinal Study of 261 white men and 241 white women between the ages of 46 and 71 found that sexual interest declined significantly among men because they were unable to perform (40 percent).(7,9,10) For women, sexual activity declined because of the death or illness of a spouse (36 percent and 20 percent, respectively), or because the spouse was unable to perform sexually (18 percent). Regression analysis showed that age was the primary factor leading to a reduction in sexual interest, enjoyment, and frequency of intercourse among men, followed by present health. For women, marital status was the primary factor, followed by age and education. Health was not related to sexual functioning in women, and postmenopausal status was identified as a small contributor to lower levels of sexual interest and frequency but not to enjoyment.(3)

A number of changes that occur with aging have effects on sexual response (see Table 3). Despite these changes, most current studies do not show an appreciable rise in sexual problems as women age.(1,2,5,11) For instance, baseline data from the Study of Women's Health Across the Nation (SWAN) suggest that sexual function and practices remain unchanged for premenopausal and perimenopausal women.(6) The study investigated the sexual behavior of 3,262 women without hysterectomy aged 42 to 52 who were not using hormones. Although early perimenopausal women reported more frequent dyspareunia than did premenopausal women, there were no differences between the two groups in regard to sexual desire, satisfaction, arousal, physical pleasure, or the importance of sex. Seventy-nine percent had engaged in sex with a partner within the past 6 months. Seventy-seven percent of the women said that sex was moderately to extremely important to them, although 42 percent reported a desire for sex infrequently (0-2 times per month), prompting the authors to note that a "lack of frequent desire does not appear to preclude emotional satisfaction and physical pleasure with relationships."


TABLE 3. Effects of Aging on Female Sexual Function(3,12,13)
  • Decreased muscle tension may increase time from arousal to orgasm, lessen intensity of orgasm, and lead to a more rapid resolution
  • Distention of the urinary meatus
  • Lack of breast-size increase with stimulation
  • Clitoral shrinkage, decrease in perfusion, diminished engorgement, and delay in clitoral reaction time
  • Decreased vascularization and delayed or absent vaginal lubrication
  • Decreased vaginal elasticity
  • Decreased congestion in outer third of vagina
  • Fewer, occasionally painful, uterine contractions with orgasm
  • Genital atrophy
  • Thinning of vaginal mucosa
  • Increase in vaginal pH
  • Decreased sex drive, erotic response, tactile sensation, capacity for orgasm

John Bancroft, lead author of the 1999-2000 national survey of 987 women that found emotional well-being and the quality of a relationship with a partner had more of an effect on sexuality than aging, suggests that aging affects genital response more in men than women, and sexual interest more in women than men.(1)German researcher Uwe Hartmann, PhD, and colleagues support this view but note that: "there is a greater variability of virtually all sexual parameters with higher age, indicating that the sexuality of midlife and older women, in comparison with that of younger women, is more dependent on basic conditions like general well-being, physical and mental health, quality of relationship, or life situation. It is these factors that determine whether the individual woman can retain her sexual interest and pleasure in sexual activity."(5)

Many researchers suggest that the quality and quantity of sexual activity with aging are also dependent on the quality and quantity of sexual activity during earlier years.(2,5)