Lesbians and female sexual dysfunction—
What physicians can learn from lesbian sex
Michele Tartaglia, DO
Katie Riley, CNM, MSN
The objective of this article is to provide a
thorough overview of female sexual dysfunction (FSD) in the lesbian patient and to
illustrate valuable insights that can be gained
from examining certain aspects of lesbian
sexuality that may be beneficial to any
woman. In several studies, for example, lesbians reported greater sexual satisfaction than
did heterosexual women in several studies.
In a 2006 survey, Meana et al1 found that
48% of heterosexual women reported difficulty getting sexually excited compared with
only 15% of lesbians. Coleman et al2 reported that 46% of heterosexual women reported
difficulty reaching orgasm and 15% reported inability to reach orgasm, compared with
28% and 7% of lesbians, respectively.
Factors influencing
sexual satisfaction
This satisfaction gap is likely the result of
specific sexual behaviors rather than sexual orientation. A longer time spent engaged
in sexual activities increases the likelihood
of orgasm for women, irrespective of their
partner’s gender. Women partnered with
women are likely to spend more time in
sexual activities than are women partnered
with men.3 Nichols3 determined those
sexual acts that are most likely to result in
orgasm in women. These behaviors include
kissing, nongenital touching, receptive oral
sex, and digital-vaginal stimulation. Lesbians
are more likely to engage in these behaviors
than are their heterosexual counterparts.2
Of course, nothing about these behaviors is exclusively or expressly lesbian, and
knowledge of these sexual acts may be of
great use for physicians in guiding any
woman who presents with FSD. Examining
the type of stimulation that women are receiving during sexual play is essential.4 We
believe that lesbian sexuality can provide a
guideline for counseling all women—both
lesbian and heterosexual—who experience
sexual difficulties. The following tools and
techniques represent advice that clinicians
can offer to their patients with FSD.
䡲 Increased time spent
on each sexual encounter
Providing advice on this matter may include
discussing slowing the pace of sexual relations with a partner. This discussion should
be approached with great care. The patient
should be advised that achieving this goal
may involve dedicating or scheduling time
for sexual activities and making sure that
these activities take place at a time when both
partners are feeling relaxed and receptive.
䡲 Increased kissing and
nongenital touching
As a relationship matures, couples may
spend less time on these two behaviors,
which are likely to increase intimacy and
set the stage for female orgasm. Physicians
can remind patients about the importance
of these behaviors.
䡲 Nonpenile stimulation
Many women require clitoral stimulation,
either alone or in conjunction with penetration, to experience orgasm. The clinician
may explore the couple’s willingness to practice oral sex and digital- vaginal stimulation.
19
䡲 Self-pleasure
Studies suggest that women who masturbate are more likely than other women to
achieve orgasm during sexual contact with
partners.4 Physicians can assist women by
gently explaining and validating the role of
sexual self-exploration in promoting orgasm.
Beyond recommending specific sexual
techniques, the clinician may be helpful in
broadening patients’ perceptions of what constitutes sexual activity. Many heterosexual
couples define sex as exclusively penilevaginal intercourse. This definition is considered the norm,5 despite evidence that it is not
the most effective way for many women to
achieve orgasm.6 Behaviors that are most likely to result in female orgasm are often labeled
foreplay, a term that suggests that intercourse
is the most important part of sexual contact.3
The norm definition5 is especially problematic for women who do not experience orgasm
solely from penetration.
The clinician may help his or her patient by explaining and normalizing typical
female sexual function. For example, a
woman may believe that something is
wrong with her because she is not able to
have an orgasm with vaginal penetration
alone. Her partner may reinforce this view.
This shared misperception may lead to substantial distress in the relationship. By
reassuring her that many healthy women
require clitoral stimulation in order to experience orgasm, the provider can validate
the patient’s personal sexual response and
direct her to techniques that may result in
greater sexual pleasure.
Although these recommended techniques will not banish all occurrences of
female orgasmic disorder, they represent simple interventions that may shift a couple’s
thinking about sexual satisfaction and how
to achieve it. By broadening the patient’s understanding of sexuality, normalizing her
sexual response where appropriate, and discussing specific sexual techniques, the
physician may be able to help the patient
achieve a greater level of sexual satisfaction.
Sexual dysfunction in
the lesbian population
Although lesbians bring unique relationship issues to the concept of FSD, there is a
tremendous amount of overlap between the
issues underlying FSD in the heterosexual
woman and those underlying FSD in the
homosexual woman. The most common
type of dysfunction in both populations is
hypoactive sexual desire disorder (HSDD),7,8
and the workup and treatment plans for
this dysfunction are identical for all women.
There is also a great deal of overlap in the
underlying causes of HSDD in both populations, including the presence of young
children in the household, hectic work
schedules, depression, and economic stressors. Because these issues are discussed in
depth in other articles in this series of AOA’s
Women and Wellness, the present article
focuses on some of the unique issues found
in lesbian relationships.
20
Internalized homophobia
Although lesbians report greater satisfaction with sex, many studies have shown that
lesbian, gay, and bisexual people report a
higher incidence of sexual dysfunction than
do their straight counterparts.9-11 One theory to explain this high incidence is the
so-called minority stress model, which postulates that as a result of their minority
status, homosexual people experience a
“unique chronic stress.”12 Internalized homophobia, the experience of homophobia
in one’s daily life, and the stress of concealing one’s sexuality or “being in the closet”
can all contribute not only to dysfunction
in one’s sexual life, but also to depression
and anxiety disorders that physicians need
to be sensitive to, as well.
Connectedness:
The ’U-Haul’ phenomenon
There is an old joke among lesbian women:
“What does a lesbian bring on her second
date? A U-Haul truck.” Although the joke
relies on comic exaggeration, it does capture
the rapid, intense bonding experienced in
many lesbian relationships.
This rapid, intense attachment may play
a role in the causes of sexual dysfunction
within lesbian couples. Heiman and
Meston13 reported that the incidence of FSD
increases proportionally with the number of
years in any female relationship. One explanation for this increase could be habituation.
As a couple becomes more comfortable with
one another and they begin to “settle down,”
the initial sexual intensity tends to wane. In
a lesbian couple that settles down by the second date, as the joke goes, this decrease in
sexual activity may occur much earlier than
in a heterosexual relationship.
Lesbian bed death
The belief that lesbian couples have less
frequent sexual encounters has become
colloquialized as lesbian bed death. Iasenza14
has called lesbian bed death the “grand
mommy of all lesbian sex myths” and has
defined it as a notorious dropoff in sexual
activity that occurs about two years into
long-term lesbian relationships.
This decrease in sexual frequency is not
distressing to all lesbian couples, nor does it
occur in all lesbian relationships. The work
of Blumstein and Schwartz15 suggested in
the 1980s that lesbian couples have less sexual contact than other couples. However,
the validity of that assertion has since been
challenged by many authors who have reported evidence that there is, in fact, no
difference in frequency of sexual encounters within heterosexual compared to within
lesbian couples.2,16-19
As previously noted, the quality of sexual encounters tends to be rated as more
satisfying by lesbian women than by heterosexual women. Thus, lesbian bed death
probably should be considered a sexual dysfunction issue only in a couple with
discordant views on the appropriate frequency of sex in a relationship. To assume
that a lesbian couple with relatively few
sexual encounters is dysfunctional is to
stereotype and misdiagnose that couple.
Stereotypes
A great number of stereotypes and generalizations about lesbian women have
permeated the literature on sexual dysfunction. One such antiquated concept
describes the initiation of sexual contact as
being the role of the more “masculine”
partner, and therefore many lesbians avoid
initiation for fear of that label.20 Another
generalization is that heterosexual men are
used to being rejected when making sexual
advances and, thus, tend not to internalize
the rejection, whereas lesbians, when
rejected, believe it is a rejection of them as
an individual. According to this idea, these
feelings of rejection cause the frequency of
sexual activities in the lesbian relationship
to decline.20
Most of these ideas were proposed
more than 20 years ago and are now quite
outdated when one considers the current
social climate for homosexual women.
Nevertheless, such beliefs remain alive
and well in the minds of many practitioners. These stereotypes and inaccurate
assumptions can lead to alienation of the
lesbian patient and improper diagnoses
and treatment plans.
The practitioner must remain openminded about the many types of lesbian
relationships and sexual practices (much as
he or she remains open-minded about various types of heterosexual relationships).
Such an open attitude has been called
21
“cultural humility.”21 A thorough sexual history and an openness to learn more about
your lesbian patients and their unique issues
through the practice of cultural humility will
provide the practitioner with most of the
tools necessary to serve this population.
Cultural humility
As physicians, we are expected to be comfortable addressing sexuality—though, like
most adults in our society, few of us were
raised in a context that encouraged frank
and open discussion of this issue. Most clinical education programs offer only cursory
training in sexuality, and this limited training is often fraught with the biases of a
culture that has a difficult time dealing with
sex. When it comes to tackling sexuality
and sexual dysfunction, our embarrassment,
not to mention the embarrassment of our
patients, can set the stage for awkward
clinical interactions.
Physicians may think of healthy sexual
function as a lower priority than routine
health maintenance, but for our patients
sexuality may have substantial impact on
quality of life. Sexual function may assume
a prominent and sometimes distressing role
in their lives. We may carry the hidden bias
that pleasure is an unimportant and even
selfish goal for our patients. We may also
think of our patients’ sexual function as
“private,” an attitude that would be negligent if applied to other areas of our
22
practice. Even when we want to assist our
patients with issues of sexual function, we
are often at a loss for helpful, evidencebased practices with which to guide them.
All of these factors may lead us to avoid
addressing issues of sexuality in the office
setting, except in terms of pregnancy and
prevention of and treatment for sexually
transmitted infections.22
These difficulties become all the more
exaggerated in interactions with lesbian
patients. Physicians’ discomforts in discussing homosexuality, misconceptions
about the nature of homosexuality and associated behaviors, and personal beliefs
about the morality of homosexuality can
result in awkward clinical interactions and
inappropriate patient care.23
How does the health care provider with
no experience and limited comfort with
lesbian or bisexual patients go about fostering relationships based on cultural
humility? Many of us who received training within the past few decades were likely
educated in the concept of cultural competence, which emphasizes appropriate
cross-cultural interaction through, in part,
increased knowledge of different cultural
practices. Although an understanding of
sexual practices and attitudes among various groups is crucial for the clinician, and
cultural competence represents a valuable
step toward greater inclusiveness and sensitivity, this notion of competence is static.
It implies the possibility of becoming an
expert in other cultures and ignores the
vast and fluid nature of culture itself.
The concept of cultural competence also
ignores the individuality of members of different cultures.
Substituting the provider’s
assumptions about lesbian
and bisexual behaviors for a
rigorous and unbiased history
of the individual lesbian or bisexual patient can lead to
erroneous conclusions about
the patient’s behaviors and
treatment goals.
These problems are
why cultural humility21 may
be a more useful concept than
cultural competence. Rather
than focusing on the clinician as cultural
expert, cultural humility emphasizes humility, flexibility, and respect for the
experience of the individual. As described
by Tervalon and Murray-Garcia,21 culturally humble providers “are ideally flexible
and humble enough to let go of the false
sense of security that stereotyping brings.
They are flexible and humble enough to assess anew the cultural dimensions of the
experiences of each patient.” Furthermore, a
culturally humble provider does not rely
on generic knowledge of an entire group
to substitute for an understanding of the
patient as an individual.21
Achieving this understanding requires
the provider to be proactive in exploring
the unique behaviors and desires of the individual patient and to create a partnership
with the patient based on that understanding. Although this task may initially be
daunting, dedication to developing a culturally humble practice with homosexual
patients will enhance a physician’s entire
practice. By letting go of assumptions and
stereotypes and learning the skills of
cultural humility, we are more likely to
discover important information about all
of our patients—heterosexual and homosexual—which will improve our ability to
provide the highest quality care.
Cultural humility
in clinical practice
Because homophobia is alive and well in
many medical offices, the practice of cultural humility is increasingly important.
A survey of nursing students revealed that
8% to 12% of respondents “despised”
lesbian, gay, and bisexual people, and
40% to 43% believed that patients should
keep their sexuality private.24 Such attitudes
must be addressed and adjusted if our
patients are to receive the quality health
care they deserve.
Making one’s office more welcoming
to lesbian, gay, bisexual, and transgender
(LGBT) patients is much easier than one
might imagine. The Gay and Lesbian
Medical Association has a helpful online
resource of guidelines for care of LGBT
patients.25 Many of these guidelines are
simple to put into practice:25
Waiting Room
Patient Interview
General considerations
䡲 Display brochures that address
same-sex health concerns.
䡲 Display posters that feature
same-sex couples.
䡲 Post a nondiscrimination policy
that addresses sexual orientation
and gender identity.
䡲 Remain gender-neutral when asking
about the patient’s family and relationship.
䡲 Keep an open mind and remain
nonjudgmental throughout the visit.
䡲 Never make assumptions about your
patient’s history or sexual behaviors
from his or her appearance; always ask.
䡲 Remember that many LGBT patients
may have had bad experiences with
health care practitioners. Thus,
be sensitive to their hesitation
to disclose certain information.
䡲 Prepare in advance for interactions
with LGBT patients. It’s important
that you find questions and language
that you are comfortable with
and that you stay well informed
about the unique issues faced by
LGBT patients.
䡲 Advertise your medical services in
LGBT newspapers, magazines, and
newsletters to communicate an open
and welcoming environment to patients
before they even walk through the door.
Intake Forms
䡲 Use the term Relationship status
instead of Marital status.
䡲 Include options such as Partnered
along with Married and Single.
䡲 Add the Transgender option
to the Male and Female boxes.
䡲 Add the option of Both to
the Men and Women options
when asking the patient to describe
sexual partners.
䡲 Although many LGBT patients will not
be “out” to their family or to their coworkers; you are asking them to be “out”
in your office. Doing so will not be easy
for them, and it will require a great deal
of support and discretion on your part.
The purest practice of cultural humility with
your LGBT patients requires that you simply
ask for clarification at any time there is a possibility of miscommunication, such as when
you don’t understand a particular term used
or a sexual practice they may be engaging in.
23
17. Hedblom JH. Dimensions of lesbian sexual
experience. Arch Sex Behav. 1973;2(4):329-341.
18. Jay K, Young A. The Gay Report: Lesbians and
Gay Men Speak Out about Sexual Experiences
and Lifestyles. New York, NY: Summit Books; 1979.
19. Masters WH, Johnson VE.
Homosexuality in Perspective. Boston, MA:
Little, Brown and Company; 1979.
20. Macdonald BJ. Issues in therapy with gay
and lesbian couples. J Sex Marital Ther.
1998;24(3):165-190.
Final note
Remaining open-minded to learning about
LGBT issues from both evidence-based
sources and from LGBT patients themselves
will ensure a quality health care experience
for all.
References
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Michele Tartaglia, DO, CS, is an assistant professor
and residency program director for the Department of
ObGyn at the University of Medicine and Dentistry
of New Jersey School of Osteopathic Medicine.
Dr. Tartaglia is a fellow of the American College
of Osteopathic Obstetricians and Gynecologists.
She can be reached at [email protected].
16. Bressler LC, Lavender AD. Sexual fulfillment
of heterosexual, bisexual, and homosexual women.
In: Kehoe M, ed. Historical, Literary, and Erotic
Aspects of Lesbianism. New York, NY: Hayworth
Press; 1986:109-122.
Katie Riley, CNM, MSN, is a certified nurse-midwife
and an instructor in the Department of ObGyn
at the University of Medicine and Dentistry
of New Jersey School of Osteopathic Medicine.
She can be reached at [email protected].
14. Iasenza S. Beyond “lesbian bed death.”
J Lesbian Stud. 2002;6(1):111-120.