For women particularly the emotional context and the relationship between the partners are the most important factors in sexual pleasure and satisfaction. Women have numerous emotional challenges to deal with, such as the menstrual cycle, pregnancy and childbirth, and the demands of raising a family. The impact of these on both the emotional climate and the sexual relationship is almost inevitable. The following outlines the categories of women’s sexual problems as they commonly occur.

Problems with Desire and Arousal

Recent studies have identified that desire and arousal are inextricably intertwined much of the time, and the bodily changes of arousal, such as vaginal lubrication and pelvic engorgement, are often unnoticed by the woman. This confirms what many women know, that they do not feel the need to initiate sexual activity, but can enjoy it when it happens. The level of feelings of desire varies through the menstrual cycle and over the life cycle. When a woman or her partner perceives a change in her level of sexual desire or arousal as a problem, then it may require attention. For some women it is “just how it is� and they are quite philosophical about it, but the partner may be pressurizing her to change. Discrepancy in desire levels between partners can lead to much anguish, with the woman often labelled as ‘the problem’, whether her desire is the higher or the lower!

Problems with orgasm

Some women develop orgasmic ability over time, and with experimentation, others, about 10%, do not experience orgasm at all. A woman may be anorgasmic, or pre-orgasmic, in which case she would believe she has never experienced an orgasm or climax, or she may have ceased being orgasmic for a number of reasons, medical illness amongst them. Male partners are often more troubled by a lack of orgasm than the woman herself, drawing parallels between male and female sexualities. A man may see it as a failure or lack of prowess on his behalf, whilst the woman is satisfied with sex as it is. Reduction in the intensity of orgasm is common during and after the menopause.

Aversion, Phobia, “ Sexual Anorexia�

These three presentations of sexual avoidance may occur at any time in life, but are more common in younger women. Strong feelings of revulsion at the prospect of sexual activity are typical of sexual aversion, and may result from early childhood events or later problems, frequently with the theme of disgust, humiliation and shame.
Sexual phobia, or fear of sexual contact is a common response to earlier trauma, abuse or violation.
The sexual anorexic may feel willing and wanting to be sexual but cannot allow herself to proceed when in the sexual encounter. She may have low self esteem, and family of origin issues are likely antecedents.
In all three presentations, the woman may be puzzled at her reactions, and go to great lengths to avoid being in sexual situations. Some are able to overcome their reluctance from time to time, usually with the help of alcohol and other drugs. All may have family of origin and relationship disturbances underlying the sexual symptom, likely to require counselling or therapy.

Painful Sex

Pain occurring in the absence of any infection or inflammation, may indicate that there is insufficient vaginal lubrication, or incomplete arousal, so that the inner part of the vagina does not expand to make space for penetration. There are lubricants and topical hormone treatments available for this, if indicated. Alternatively, vulvodynia could be present, causing exquisite pain to the touch, and this would require gyneacological assessment, and possibly medication. In some circumstances, counselling or therapy is indicated.

Vaginismus

This is painful involuntary spasm of the muscles round the entrance to the vagina, rendering penetration either very painful or impossible. It is usually caused by fear of the pain of penetration, and responds well to a combined physical/psychological intervention. this might include the use of vaginal trainers. When it occurs in later life, the dynamics of the relationship and the woman’s psychological state are likely to need very thorough assessment. A deteriorating marital relationship may be manifested by this condition.