When Sandra* joined university, she dated a senior student, whom she thought was in love with her. 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.
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 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 with the realisation 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 26-year-old 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 was 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 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 per cent of women of reproductive age at any one time, yet even in the developed world, only about 10 to 15 per cent 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 attract while purporting to provide help.
It has taken many years of research to understand 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 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.
It is important to note that these disorders may arise from medical complications 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 judgment. 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 in 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.
TYPES OF DYSFUNCTION
Sexual desire disorder: Lack of interest in sex before or during the sexual encounter. Note that a woman’s desire can set in once the encounter is underway, unlike in men.
Arousal disorder: Lack of physical arousal signs (genital swelling and lubrication) 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 per cent to 22 per cent of women at one time or another. This may be as a result of genital tract issues that need treatment.
Female orgasmic disorder: Inability to achieve orgasm where arousal is not an issue.