FEMALE SEXUAL DYSFUNCTION: TAKING THE BULL BY THE HORNS

Sandra* is a 26-year old lady who walked into my office one afternoon for a very interesting conversation. She was a successful career lady in finance, whose star was rising fast in the organization she worked in. She was bubbly and outgoing and conversation with her flowed easily.

However, despite her future looking quite bright, she clearly had a past that was threatening her happiness. You see, Sandra was what one may call a wild card in university. Sandra had grown up privileged as a child, sheltered, with a limited social life. That is, until she got to campus and her life changed.

By the end of her first year of campus had insisted on driving herself and moving out of home to a small apartment near her school. Her parents were happy to grant her the apartment and a small car for convenience. They were happy their daughter was getting independent and provided more than adequately for her upkeep.

Spending time with her new campus friends made Sandra feel like she had missed out on a lot of things as a sheltered child. She was on a roll to catch up. She partied every weekend, explored all the clubs in town that her age-mates frequented and became the life of the party. Her parents had no idea what Sandra was doing with her free time. She made sure of this by spending her weekdays efficiently. She remained top of her class, keeping good grades and never skipping classes.

Though she drank alcohol in plenty and occasionally smoked sheesha, she had the good sense to keep a good distance from recreational drugs. Her Achilles heel however was casual sex. In her first year, she dated a senior student who she thought was in love with her. At the time, she was still living at home and it took a long time to find out that she was just one of the many girls he was seeing. She was heartbroken but because she was never one to wear her heart on her sleeve, she found solace in casual sex.

As she reflects back, Sandra now realizes that she used sex to prove to herself that she was in charge of her heart. She built a wall around her emotions and used sex as a power weapon. Because of her background, she did not lack for anything hence her sexual relations had no monetary attachment. She had sex to control men. She enjoyed waking up in the morning and leaving a hapless man realizing that he did not even have her phone number, long after she was gone.

Sandra ruled the party. She plotted and planned for her prey. She perfected her skills in bed and built a reputation that earned her the nickname Cleopatra. She never dated again. That was, until a year before she came to see me. She had moved on and met a man she was deeply in love with and with whom she had a wonderful relationship. But when he proposed, despite knowing her past, she panicked.

So why was Sandra in my office? Despite the great relationship she enjoyed with her fiancé, their sexual life was a disaster. She was completely unresponsive to him. Her many years of practice came through for her and she would perfectly fake a normal sexual encounter with the aid of lubricants and her man was none the wiser. It broke her heart and she was seeking a remedy.

What Sandra is experiencing is not uncommon but it is not spoken about. Women hardly find the words to ask their gynaecologists about it and many doctors are not trained to effectively deal with female sexual function and dysfunction. In addition, sex is a taboo topic in most communities and has a lot of cultural connotations that make perceptions differ from person to person.

Research shows that female sexual dysfunction exists in about 40% of women in the reproductive age group at any one time, yet even in the developed world, only about 10-15% of them seek help from a doctor. In Kenya the gap is obvious when we begin to see the type of following self-acclaimed sexologists gather purporting to provide help.

It has taken many years of research to understand the female sexual function, initially by Kinsey in the 1950s, leading to the advent of Kaplan's three-stage sexual response model. Later there was the physiologic linear four-stage model by Masters and Johnson in the 1960s, a circular model by Whipple and Brash-McGreer in the 1990s, and eventually the most recent Basson's intimacy-based cyclical model.

These scientific models intend to explain what happens to women during a normal sexual encounter, integrating the physical, spiritual, social, and emotional aspects that contribute to a healthy experience. The key components of the sexual cycle comprise motivation, willingness to become receptive to sexual stimuli, desire, subjective arousal, responsiveness, sexual satisfaction (with or without orgasm), and non-sexual reward (which includes intimacy, well-being and positive self-image).

In the event of absence of any of the above components, it is not automatic that sexual dysfunction is diagnosed. The diagnosis is only valid when the patient is distressed by the said absence. Therefore, a woman who hardly ever orgasms but is not bothered by it is fine. Even the partner’s opinion is not relevant to the diagnosis.

Types of female sexual dysfunction include:

·       Sexual Desire Disorder: lack of interest in sex before and/or during the sexual encounter. It is important to note that a woman’s desire can set in once the encounter is underway, unlike men.

·       Arousal Disorder: lack of physical arousal signs (genital swelling and lubrication) and/or lack of subjective arousal sensations; or on the extreme end, persistent arousal that is unwanted.

·       Dyspareunia: Any pain experienced during vaginal penetration or intercourse. Happens in 8% to 22% of women at one time or another. This may be as a result of genital tract issues that need treatment by the gynaecologist such as endometriosis.

·       Female Orgasmic Disorder: Inability to achieve orgasm where arousal is not an issue.

It is important to note that these disorders may arise from medical complications such as such as obesity, endometriosis, fibroids, infections, genital prolapse, hysterectomy, previous episiotomy or operative delivery. They may also result from prescription drugs such as those used to treat depression like Prozac; or recreational drugs such as alcohol and tobacco. Non-physical causes include poverty, education level, negative past sexual experiences (such as sexual, physical or emotional abuse), and substandard relationships, environment and choice of partner. Most commonly, most women will have multiple causes that need to be addressed wholesomely for restoration of health.

There is no magic bullet to treatment. It starts with women being more forthright and seeking help and gynaecologists being more pro-active in discussing sexual health with their patients without judgement. It is a long process with a multidisciplinary approach that requires patience from both the doctor and the patient and involvement of the partner. Diagnosis of the underlying causes is critical to guiding care.

A quick look around major towns in Kenya that are home to institutions of higher learning will reveal a commensurate growth 24-hour clubs with a wild nightlife, popularly known as the electric avenue. We are spawning hundreds of ‘Sandras’ every year and are not prepared to deal with their future sexual lives. As we raise our voices regarding safe sexual practices, contraceptive access, pre-exposure prophylaxis (PrEP) and post-exposure prophylaxis (PEP), let us not leave behind the long-term impact of youthful pleasures.