G43. Human Sexuality

I. Definition and Classification

Core Concepts

• Human sexuality: biological, psychological, interpersonal and sociocultural aspects of sexual life.
• Main domains: biological sex, gender identity/expression, sexual orientation, sexual behavior and relationships.
• Clinical approach: respectful, nonjudgmental, medically accurate and individualized.
• Biological sex: chromosomes, gonads, hormones, internal reproductive organs and external genitalia.
• Gender identity/expression: internal sense of gender and external presentation.
• Sexual orientation: pattern of sexual/romantic/emotional attraction.
• Sexual behavior: actual sexual practices; may not perfectly match identity or orientation labels.

Sexual Orientation

• Heterosexual: attraction to another sex/gender.
• Homosexual / lesbian / gay: attraction to same sex/gender.
• Bisexual: attraction to more than one sex/gender.
• Asexual: little or no sexual attraction.
• Transgender: gender identity, not sexual orientation.

II. Sexuality Through the Female Life Course

Puberty and Reproductive Age

• Puberty: pulsatile GnRH activation → FSH/LH → ovarian estrogen → secondary sexual characteristics and reproductive maturation.
• Adolescence/reproductive age: orientation, gender identity and sexual behavior may become clearer; desire varies by person and context.
• Influences: hormones, mood, stress, relationship, health and medications.

Pregnancy and Postpartum

• Uncomplicated pregnancy: sexual activity/intercourse is generally safe.
• Restriction may be needed with bleeding, placenta previa, ruptured membranes, preterm labor risk or individualized contraindication.
• Pregnancy/postpartum influences: nausea, fatigue, body image, fear, perineal pain, mood, sleep deprivation and breastfeeding.
• Lactation: prolactin ↑ → GnRH ↓ → estrogen ↓ → dryness, reduced lubrication, dyspareunia in some women.

Menopause

• Estrogen deficiency may cause genitourinary syndrome of menopause: dryness, burning/irritation, reduced lubrication, atrophy, dyspareunia and urinary symptoms.
• Sexual function is also affected by relationship, health, psychological factors and medications.

III. Female Sexual Response and Dysfunction

Sexual Response

1. Desire: interest/motivation for sexual activity.
2. Arousal: genital vasocongestion, lubrication, clitoral engorgement.
3. Orgasm: subjective pleasure + rhythmic pelvic/perineal muscle contractions.
4. Resolution: return toward baseline.

Female Sexual Dysfunction: Practical Groups

• Sexual interest/arousal disorder: reduced desire, interest, arousal or pleasure with distress.
• Orgasmic disorder: delayed, infrequent or absent orgasm with distress.
• Genito-pelvic pain/penetration disorder: dyspareunia, penetration difficulty, pelvic floor spasm/fear/anxiety.
• Diagnosis requires clinically significant distress and biopsychosocial assessment.

Causes

• Biological: GSM/menopause, vulvovaginal disease, endometriosis, chronic pelvic pain, endocrine disease, neurologic/systemic disease.
• Medication-related: SSRIs, some antihypertensives, centrally acting drugs, excess alcohol.
• Psychological: depression, anxiety, stress, trauma, body-image concerns.
• Interpersonal/social: relationship conflict, poor communication, cultural/religious pressure, sexual violence.
• Principle: female sexual dysfunction is often multifactorial.

IV. Clinical Assessment and Management

Assessment

• Clarify concern, onset, duration, severity, distress and pattern: lifelong/acquired, generalized/situational.
• Review relationship factors, contraception, pregnancy/postpartum status, menopause, medications, chronic disease and mental health.
• Ask about pain, bleeding, discharge, dryness, trauma and safety/violence when relevant.
• Pelvic exam if pain, bleeding, vulvovaginal symptoms, suspected infection, atrophy or anatomical pathology.

Management

• Treat the cause; there is no single treatment for all sexual dysfunction.
• Education/reassurance; address relationship and psychological factors; counseling/sex therapy when appropriate.
• Review and adjust causative medications if possible.
• Treat gynecologic disease, infection, endometriosis, pelvic pain or endocrine disorder.
• Dryness/GSM: lubricants, moisturizers, local vaginal estrogen or other local therapy when appropriate.
• Pelvic floor physiotherapy: useful for many pain/penetration disorders.