7.1 Female Sexual Function, Sexual Dysfunction & LGBTQ+ Sexual Health
Key Takeaways
Basson's circular model describes responsive desire, in which arousal from context and intimacy can precede desire, a common normal pattern in long-term relationships.
DSM-5-TR female sexual dysfunctions (sexual interest/arousal disorder, orgasmic disorder, and genito-pelvic pain/penetration disorder) require symptoms for at least 6 months with clinically significant distress.
Flibanserin (nightly) and bremelanotide (on demand by injection) are FDA-approved only for premenopausal women with acquired, generalized hypoactive sexual desire disorder.
Lesbian and bisexual women need the same cervical cancer screening as heterosexual women because HPV spreads through skin-to-skin and digital contact.
Transgender women who use estrogen remain at risk for prostate cancer, and breast screening generally begins at 40 after at least 5 years of hormone therapy.
Models of Sexual Response
- Masters and Johnson (linear): Excitement, plateau, orgasm, resolution.
- Kaplan (triphasic): Desire, arousal, orgasm.
- Basson (circular): Many women, especially in long-term relationships, begin from sexual neutrality; willingness and emotional intimacy lead to arousal, and responsive desire follows arousal. Satisfaction depends on emotional and physical outcomes, not only orgasm. Lack of spontaneous desire alone is not a disorder.
Taking an Inclusive Sexual History
- Ask every patient, using gender-neutral language: "Are your partners men, women, both, or people of other genders?" Record sexual orientation and gender identity (SOGI) separately, because orientation does not predict behavior.
- Use the CDC 5 Ps (partners, practices, protection from STIs, past STIs, pregnancy intention) and ask about satisfaction, pain, and concerns.
- PLISSIT model for sexual concerns:
- Permission: invite discussion and normalize concerns.
- Limited Information: education about anatomy, aging, and medication effects.
- Specific Suggestions: lubricants, positions, sensate focus, scheduling.
- Intensive Therapy: referral to sex therapy, pelvic floor physical therapy, or specialists.
DSM-5-TR Female Sexual Dysfunctions
All require symptoms for at least 6 months that cause clinically significant distress and are not better explained by another disorder, relationship distress, or a medication.
| Disorder | Core Features | Common Contributors |
|---|---|---|
| Female sexual interest/arousal disorder | Absent or reduced interest, thoughts, initiation, excitement, or genital sensation | Depression, SSRIs, relationship conflict, fatigue, low estrogen |
| Female orgasmic disorder | Delayed, infrequent, or absent orgasm, or reduced intensity | SSRIs and SNRIs, inadequate stimulation, anxiety |
| Genito-pelvic pain/penetration disorder | Pain with penetration, fear of pain, pelvic floor tightening | Vulvodynia, GSM, vaginismus, endometriosis, trauma history |
The International Society for the Study of Women's Sexual Health still uses hypoactive sexual desire disorder (HSDD), the term in FDA labeling.
Assessment
Review medications (SSRIs, SNRIs, antipsychotics, antiandrogens, opioids, and sometimes hormonal contraception), mood, relationship, trauma history, chronic illness, and menopausal status. Examine for GSM, vulvar dermatoses, vestibular tenderness (cotton-swab test), pelvic floor hypertonicity, and pelvic masses.
Treatment
- Sex therapy, couples therapy, CBT, and mindfulness have the strongest evidence for desire and arousal concerns.
- Medication-induced dysfunction: Lower the dose, switch to bupropion, or add bupropion.
- Dyspareunia from GSM: Lubricants and moisturizers, then low-dose vaginal estrogen, vaginal DHEA (prasterone), or oral ospemifene.
- Genito-pelvic pain: Pelvic floor physical therapy and graduated vaginal dilators; treat any underlying condition.
- Vulvodynia (vulvar pain for at least 3 months without an identifiable cause; provoked vestibulodynia is most common): Remove irritants, use topical lidocaine before intercourse, consider tricyclic antidepressants or gabapentinoids, and refer to pelvic floor physical therapy.
| Drug for HSDD | Use | Key Safety Points |
|---|---|---|
| Flibanserin (Addyi) | 100 mg nightly at bedtime; premenopausal women with acquired, generalized HSDD | Hypotension and syncope; wait at least 2 hours after 1–2 drinks before the dose, or skip it; avoid with moderate or strong CYP3A4 inhibitors; stop if no benefit after 8 weeks |
| Bremelanotide (Vyleesi) | 1.75 mg subcutaneous injection at least 45 minutes before sexual activity; no more than 1 dose per 24 hours or 8 per month | Nausea, transient blood pressure rise, focal hyperpigmentation; avoid with uncontrolled hypertension or cardiovascular disease |
| Testosterone (off-label) | Transdermal therapy for postmenopausal HSDD (Global Consensus, 2019) | No FDA-approved female product in the United States; keep levels in the premenopausal range and monitor for androgenic effects |
Sexual and Reproductive Health for LGBTQ+ Patients
Lesbian, Bisexual, and Queer Women
- Cervical cancer screening follows the same schedule as for any person with a cervix; HPV spreads through skin-to-skin and digital contact, and many have had male partners.
- STI risk is real: BV is common and often concordant between female partners, and trichomoniasis, HSV, and HPV can be transmitted. Test according to reported practices.
- Ask about contraception rather than assuming it is not needed.
- Higher rates of tobacco and alcohol use, obesity, depression, and anxiety, partly from minority stress, call for proactive screening.
- Family building: donor insemination, reciprocal IVF, and the legal steps that protect both parents.
Transgender and Gender-Diverse Patients
- Screen by organ inventory, not by gender marker.
- Transgender men and nonbinary people with a cervix: Cervical screening continues; testosterone is not contraception (see the health equity section).
- Transgender women: Prostate tissue remains, so prostate cancer remains possible (PSA runs lower on estrogen). Breast screening is generally recommended from age 40 after 5 or more years of feminizing hormones (American College of Radiology). Estrogen therapy raises VTE risk, especially with smoking.
- Use the patient's name and pronouns and affirming anatomic terms, and make sure intake forms, restrooms, and records are inclusive.
Sexual Health Across the Life Course
- Pregnancy and postpartum: Intercourse is safe in an uncomplicated pregnancy. After birth, resume when bleeding has slowed and the patient feels ready; lactation lowers estrogen and causes dryness, so recommend lubricants and, if needed, low-dose vaginal estrogen. Address fatigue, body image, and contraception.
- Menopause: Genitourinary syndrome of menopause causes dryness and dyspareunia that worsen without treatment, while desire changes often reflect relationship, mood, and health factors as much as hormones.
- Chronic illness and cancer: Diabetes, multiple sclerosis, pelvic surgery, radiation, and endocrine therapy for breast cancer often affect sexual function. Ask directly, because many patients will not raise the topic first.
A 32-year-old woman reports 9 months of distressing loss of sexual desire that began after she started sertraline for depression, now in remission. She and her partner otherwise have a supportive relationship. What is the most appropriate initial management?
Start flibanserin 100 mg at bedtime while continuing sertraline at the current dose.
Discuss lowering the sertraline dose or switching to or adding bupropion, along with sex therapy.
Prescribe oral conjugated estrogens daily to increase libido and vaginal lubrication.
Reassure her that SSRI-related sexual side effects always resolve within 2 weeks of starting.
A 29-year-old woman with a female partner of 6 years asks whether she still needs cervical cancer screening because she has 'never been with a man.' Her last cytology was at age 25 and was normal. What is the best response?
Screening is unnecessary because HPV is transmitted only through penile-vaginal intercourse.
She should have annual cytology because lesbian women have higher cervical cancer risk.
Screening is needed only if she develops postcoital bleeding.
She follows the same schedule as any person with a cervix, so cytology is due now.
A 28-year-old premenopausal woman with acquired, generalized hypoactive sexual desire disorder chooses flibanserin. She drinks wine with dinner several nights a week. What counseling is required?
Take it at bedtime; after 1–2 drinks, wait at least 2 hours before the dose or skip that night's dose.
Take flibanserin in the morning with breakfast so that alcohol at dinner has no interaction.
Inject it subcutaneously 45 minutes before sexual activity, up to twice daily as needed.
Alcohol is completely safe with flibanserin because the label no longer mentions any interaction.
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