Female Sexual Function and Dysfunction Elisabetta Costantini Donata Villari Maria Teresa Filocamo Editors 123 Female Sexual Function and Dysfunction Elisabetta Costantini • Donata Villari Maria Teresa Filocamo Editors Female Sexual Function and Dysfunction Editors Elisabetta Costantini Maria Teresa Filocamo Department of Urology SS Annunziata Hospital University of Perugia Savigliano Perugia Italy Italy Donata Villari Department of Urology University of Florence Florence Italy ISBN 978-3-319-41714-1 ISBN 978-3-319-41716-5 (eBook) DOI 10.1007/978-3-319-41716-5 Library of Congress Control Number: 2017932279 © Springer International Publishing Switzerland 2017 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. Printed on acid-free paper This Springer imprint is published by Springer Nature The registered company is Springer International Publishing AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland Foreword I am proud and pleased to present the first edition of this book entitled Female Sexual Dysfunctions. The goal of this book is to disseminate the state-of-the-art, scientific, evidence-based information on the study, diagnosis, and treatment of women’s sexual health concerns. An Eastern myth tells a story about blind men and an elephant, in which a group of blind men touch an elephant to learn about it. Each one feels a different part, but only one part. They then compare notes and realize that they are in complete disagreement. Only when they stop talking and start listening, collaborating, and comparing notes are they able to see the whole elephant. The story teaches us that although one’s sub- jective experience is true, it might not be the complete truth. So is female sexual dys- function (FSD) the sexological elephant? The debate is not new, but opinions remain polarized. A crucial paradigm for understanding the etiology and treatment of sexual problems is to view sexuality and sexual function and dysfunction in a biopsychoso- cial context, meaning that we must recognize that different factors influence a wom- an’s sexual life to get the full picture of her sexuality. The critical voices argue against the existence of female sexual dysfunctions, making accusations of disease-monger- ing and suggesting that the pharmaceutical industry are medicalizing female sexuality and creating a problem that does not exist. However, their opponents argue that real feminism is to give women with distressingly low sexual desire an opportunity to receive medical treatment just as men are able to do. While the debate is going on, 30–50 % of women report low desire and 12 % report that the problem is distressing. Furthermore, the prevalence of low desire increases with age, but the level of distress decreases. For years, only one pharmacotherapeutic treatment—testosterone therapy—has been available for low sexual desire in surgi- cally postmenopausal women. Female sexual dysfunctions have traditionally been treated with sex therapy, relationship therapy, and other psychotherapeutic approaches, which are often good treatments but are not always successful. Pharmacological treat- ments are, therefore, justified—especially if the underlying problem is biological. Very little research has investigated the effect of psychotherapeutic approaches, and discussions of what constitutes good end points when evaluating the effect of treat- ment are lacking. Is the aim to increase sexual activity, to achieve a subjective feeling of increased desire or empowerment, or to gain a deeper understanding of what pro- motes and prevents a good sex life? Many of these soft end points might be important for the woman but are difficult to measure in a clinical trial. v vi Foreword Could we imagine having the same discussion about treating male low desire with testosterone or using phosphodiesterase type 5 (PDE5) inhibitors for erectile dysfunction? What is the difference? Clinical experience with testosterone has shown us that selected women clearly benefit from medical treatment and that some women benefit from flibanserin therapy; however, the existence of a distinct placebo effect in clinical trials strongly indicates the additional importance of psychological factors. However, despite these data, some people argue that women will feel under pressure to seek unwanted medical treatment for their sexual problem, with the implication that men can be trusted to make a rational decision regarding the risk versus reward of receiving treatment, whereas women cannot. Thus, even in the twenty first century, we still approach women’s and men’s sexuality differently. These disparate approaches to male and female sexuality are despite substantial changes in the attitude of Western culture towards female sexuality over the past 150 years. From women’s sexuality being considered something that did not exist or was wrong and immoral if it was expressed, through to the new attitudes that arose during the 1960s to 1970s when women were considered to have the same right to orgasm as men, men and women were claimed to be sexually equal, and women could control pregnancy and their own sexuality. Today’s situation is an increased focus on sexual desire as something expected to be present throughout life, and the concept that sexuality is one of the cornerstones in keeping couples together. The concepts of and attitudes to female sexuality have continuously evolved, much more so than our attitudes towards men’s sexuality, with men being seen as having a strong, stable, and often biologically driven sexuality that is not doubted. Furthermore, the participants are arguing like the blind men from the myth: depending on what specialty, experience, theoretical tradition, and experi- ence we come from, our concepts of female sexuality and dysfunction are disparate, and we interpret the female sexual dysfunction elephant differently. Thus, we miss an important opportunity to see the whole elephant and address all aspects of female sexuality. Such challenges, especially when combined with the disagreement between different academic and clinical opinion leaders—all of whom claim to rep- resent women—are harmful, as we miss the opportunity to embrace and understand all aspects of female sexuality, how it is formed and expressed, how it functions, what is important for the individual woman, and how we can best help women who seek help for a better sexual life. Once again, as we fail to work together, we are repeating the mistakes of the blind men. However, unlike an elephant, female sexual dysfunction is not a well-defined and well-delineated phenomenon, and it is experi- enced differently from one woman to another; in fact each woman perceives herself and her situation individually and should be consulted and treated based on her needs. To provide women with the best possible care, we need more research into all aspects of female sexuality and treatment options, and following the example of the blind men, we must finally start listening, collaborating, and comparing notes. Vincenzo Mirone Italian Society of Urology, Turin, Italy Contents 1 Sociocultural Considerations ................................... 1 Donata Villari 2 Anatomical and Physiological Description of Women’s Sexuality ..... 7 Serena Maruccia and Angela Maurizi 3 Female Sexuality: A State of Mind ............................. 27 Linda Vignozzi 4 Evaluation Systems of Female Sexual Function ................... 33 Maria Teresa Filocamo and Nadine Di Donato 5 Becoming a Woman: When and Why Gender Dysphoria May Challenge the Basic Steps of Women’s Sexual Identity ................................... 47 Alessandra Graziottin 6 Endometriosis and Sexuality .................................. 63 Nadine Di Donato and Renato Seracchioli 7 POP and Impact of Surgery on Female Sexual Life ............... 79 Montserrat Espuña Pons, Franca Natale, and Elisabetta Costantini 8 Urinary Incontinence and Mid-urethral Slings: Which Is the Impact on Female Sexual Life? ..................... 89 Elisabetta Costantini 9 Female Sexual Life During Malignancies ........................ 95 Donata Villari 10 Sexuality in Couples with Reproductive Difficulties .............. 107 Lucia Alves Silva Lara 11 Sexuality After Abuse ....................................... 123 Valeria Dubini 12 Female Sexual Dysfunction in Alcohol and Drug Abuse ........... 135 Marina Ziche vii viii Contents 13 Female Sexual Function During Male Sexual Dysfunction and Vice Versa ............................................. 145 Maria Antonella Bertozzi and Valeria Ales 14 Female Sexuality in Chronic Pelvic Pain ....................... 157 Antonella Giannantoni 15 Female Sexual Function and Neurological Disease . . . . . . . . . . . . . . . 169 Elena Andretta 16 Female Genital Cosmetic Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175 Sushma Srikrishna and Linda Cardozo 17 Role of Physical Therapy in the Treatment of Female Dysfunction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 189 Merete Kolberg Tennfjord, Marie Ellström Engh, and Kari Bø Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 205 Sociocultural Considerations 1 Donata Villari Ἔρoς δ᾽ ἐτίναξέ μoι φρένας, ὠς ἄνεμoς kὰτ ὄρoς δρύσιν ἐμπέτων. Saffo – Ereso – 630 avanti Cristo – Leucade 570 avanti Cristo Eros shakes my mind like a mountain wind falling on oak trees Paul Julius Moebius −1835–1907 Über den phisiologische Schwachsinn des Weibes 1900 Nature holds the maiden in the obscure vision of her instincts. Her repugnance for men, the repulsion that inspires her sensuality, appears to the consciousness of the virgin as absolute, enduring feelings … The better a girl is, the more firmly she is convinced that she has no desire… and that her longings should be turned towards the ideal. “The Mental Inferiority of Woman,” 1900, preface to the third edition . .. yes and how he kissed me under the Moorish wall and I thought well as well him as another and then I asked him with my eyes to ask again yes and then he asked me would I yes to say yes my mountain flower and first I put my arms around him yes and drew him down to me so he could feel my breasts all perfume yes and his heart was going like mad and yes I said yes I will Yes. from Molly Bloom’s monologue in James Joyce, Ulysses – Paris, 1922 Since the 1970s the term “sexual medicine” has become common usage [1]. Interestingly and appropriately enough, the introduction of the 2012 ESSM Syllabus of Sexual Medicine [2] stresses that the use of the term “sexual”, understood, however, simply as an adjective referred to sexual or gender identity, was borrowed from studies of botanical taxonomy at the beginning of the nineteenth century [3]. And even after being transferred to the context of a discipline that analyzes human sexuality, the term was at first employed exclusively in the study of reproduction. The term “sexology” appeared for the first time in Elizabeth Osgood Goodrich Willard’s 1867 work, Sexology as the Philosophy of Life: Implying Social D. Villari Department of Urology, University of Florence, Florence, Italy e-mail: [email protected] © Springer International Publishing Switzerland 2017 1 E. Costantini et al. (eds.), Female Sexual Function and Dysfunction, DOI 10.1007/978-3-319-41716-5_1 2 D. Villari Organization and Government [4]. And the mathematician Karl Pearson, one of the founding fathers of modern statistics and a convinced believer in eugenics, in the 1888 inaugural lecture of the Men and Women’s Club, which he had founded, enti- tled “The Woman’s Question,” stressed the need for a “real science of sexology” [5]. The Italian Paolo Mantegazza (1831–1910), physiologist and pathologist, a visionary writer who was among the first to spread Darwin’s theories in Italy, pub- lished La fisiologia dell’amore (The Physiology of Love) (1873), L’Igiene dell’amore (The Hygiene of Love) (1877), La fisiologia del piacere (The Physiology of Pleasure) (1880), and La fisiologia della donna (The Physiology of Woman) (1893). He dedicated himself to important studies in neurophysiology and pharmacology based on animal models, treating topics absolutely in the vanguard for his time, among which were female sexuality, male and female infertility, masturbation, erec- tile dysfunction, and vaginismus [6]. But it was the dermatologist Iwan Bloch in his 1907 work, Das Sexualleben unserer Zeit in seinen Beziehungen zur modernen Kultur [7], who was the first to stress the importance of a multidisciplinary approach for those who intend to do in- depth studies of the “life of love,” by integrating knowledge from diverse fields such as biology, anthropology, philosophy, psychology, sociology, ethnology, and medicine, a concept that is completely shared nowadays. At the start of the 1900s, this “new science” seemed to be something chaotic and vague. It was in this field that Freud came onto the scene as precursor and interpreter of his times. Still, his theory of female sexuality was strongly conditioned by the ethical principles and the customs of the society of his day, despite the transgressive and groundbreaking questions his theories introduced (we need only think here of childhood sexuality). Freud has no organic theoretical work specifically dedicated to the female psyche in the sexual sphere; what exist are mainly clinical cases or fragmentary theories. By his own admission, the origin and development of female sexuality remained an inextricable enigma, which led him, despite his charisma, to collaborate with con- temporary women analysts [8]. While the myth of Oedipus remains a cornerstone in the psychosexual history of the male individual, it is attributed to the woman in its “reciprocal” form (reverse Oedipus), though with various interpretative complications and a marked asymme- try that led Freud himself to state that at the very best in the female sex “Oedipus” can never be completely overcome. Freud held that the penile substitute, the clitoris, was initially invested with strong focalization and very intense sensations but that afterward, in the so-called genital phase, these sensations were transferred to the vagina, and this represented the achievement of psychosexual maturity. In this way the clitoris was disinvested, losing its importance for orgasm, to the point that con- tinued clitoral orgasm was interpreted as evidence of a neurosis, synonymous with fixations and regression to the pregenital phase. Recent psychophysiological studies disclaim Freud’s theory of female sexuality. Indeed, current analytical interpretation has reappraised and reformulated his hypotheses, with the consequence that the opposition between clitoral and vaginal orgasm is no longer accepted. As we have already noted, an important contribution to the study of female psy- chosexual development has been given by the work of the first women analysts, the