The Working Group on A New View of Women’s Sexual Problems offers clinicians a compelling alternative to physiologically based, performance driven models of women’s sexuality derived largely from ahistorical, decontextualized views of women’s sexuality. The Working Group points out that the existing system of categorization of women’s sexual difficulties, canonized in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, erases the relational context of sexuality and fails to acknowledge important differences among women that affect women’s sexual functioning. In contrast, the model proposed by this working group of feminist theorists is multi-dimensional, complex, and clearly contextual. This model functions as a springboard for clinicians and educators seeking a new conceptual platform for expanding their interventions to women seeking to understand their own sexual functioning better. I wish to focus on the implications of this model for opening more comprehensive discussions addressing sexually transmitted diseases and the impact these diseases have on women’s sexual attitudes, behavior, functioning and relational choices.
Sexually transmitted diseases (STDs) and their impact on women’s sexual functioning have generated minimal empirical interest or investigation beyond the large number of studies examining AIDS-related risk and prevention behaviors. AIDS is a critical health issue affecting women’s sexuality; however, it is only one of numerous sexually transmitted diseases that cause physical, emotional, and psychological problems for girls and women. Millions of women are affected in acute and chronic ways by the vast array of curable and medically manageable, but incurable, STDs prevalent in the United States and other countries. Although most of these diseases are not life-threatening, many women are directly affected by these STDs in physically and emotionally devastating ways.
The American Psychiatric Association’s Diagnostic and Statistical Manual (DSM-IV) acknowledges that sexual disorders may be due to a general medical condition, substance abuse, or psychological factors, or to a combination of these, but gives virtually no recognition to the role STDs may play in disorders of desire, vaginismus, or sexual aversion disorders. The DSM-IV does not address the issue of STDs directly, but an acknowledgement of the existence of sexually transmitted diseases affecting women’s functioning can be inferred from the text describing the “sexual pain disorders,” such as dyspareunia (pain with intercourse), in which physiological causes for sexual pain are to be “ruled out” before assigning a diagnosis. The classification “Sexual dysfunction due to a general medical condition” refers to vaginal infections as one category of general medical conditions that can cause disorders of arousal, orgasm, or pain syndromes, but does not acknowledge the psychological impact that STDs or the fear of contracting STDs might have on an individual.
In contrast, the Working Group’s paper acknowledges sexually transmitted diseases as both direct and indirect causes of women’s sexual suffering. Under the category, “Sexual problems due to socio-cultural, political, or economic factors,” STDs are named as one of several reasons for some women’s anxiety about sex. These authors posit that inadequate access to information and services for STD prevention and treatment, as well as the absence or inadequacy of information and services about contraception, abortion and other matters pertaining to sexuality, can have a direct negative impact on women’s sexual functioning. The second category “Sexual problems relating to partner and relationship” mentions “inhibitions in arousal or spontaneity due to partner’s health status or sexual problems,” which could include a partner’s sexual health problems, such as having frequently recurring herpes outbreaks, a positive HIV status, hepatitis, or other STD-related health difficulties. The third category of women’s sexual problems, “Sexual problems due to psychological factors” clearly mentions the potential for “sexual inhibition due to fear of sexual acts or of their possible consequences,” including pain during intercourse and the risk of contracting a sexually transmitted disease. Finally, the fourth category, “Sexual problems due to medical factors,” refers to the presence of pain or lack of physical response during sexual activity that can occur despite the presence of a supportive and safe interpersonal situation when medical conditions, including STDs or the side effects of medical treatments, interfere with sexual pleasure and functioning.
This explicit acknowledgment of the multiple roles that sexually transmitted diseases play in the development and continuation of women’s sexual difficulties is extremely important and has implications for educators and clinicians committed to increasing women’s sexual pleasure and self-empowerment. This working document develops a conceptual framework that permits us to expand our understanding of the role STDs play in inhibiting women’s sexual self-esteem and self-expression. This “new view” of women’s sexual problems can become a springboard for the work of educators and practitioners working with female clients on their sexual difficulties.
Effects of STDs on Women’s Sexual Functioning: Beyond Prevention
Prevention has been the primary focus of most sex education regarding sexually transmitted diseases. A second aim of STD-related education, particularly that directed at high school age girls, appears to be to use the fear of STDs to discourage girls and young women from engaging in sexual behavior and to encourage the practice of sexual abstinence. Some educational material, particularly information presented in the brochures on specific STDs available in health clinics and physician offices, focuses on how medically to prevent transmission of recurring and chronic STDs, such as HIV, venereal warts, herpes, or hepatitis, to one’s sexual partner and encourages communication with partners about STD status before engaging in sexual activity.
What, then, do we offer to women who are already actively dealing with the emotional and physical challenges of having one or more STDs and to women who are dealing with partners who have STDs. Education about prevention is very important, but is not adequate to address these women’s needs. The issues involved are numerous and include the following:
- We need to assist women to develop comfort with asking a new or potential male or female partner specific questions about his or her prior exposure to STDs and teach women strategies for assessing their relative level of risk from exposure to chronic, viral STDs or STDs that may be asymptomatic in a partner. A primary concern for women who may be carriers of a viral STD is the fear of acquiring another, different STD through exposure to a partner.
- We need to provide education and effective intervention to women whose levels of sexual self-esteem and relational trust have been damaged due to having contracted a curable or chronic sexually transmitted disease to assist them in integrating this new element into their sexual identity in a way that does not lead to either denial (and associated risk behavior with a new partner) or to self-rejection and resignation to a life without sexual involvement and pleasure.
- Women who have partners that suffer from recurring outbreaks of a viral STD, such as venereal warts and herpes, or neurological pain disorders, such as vulvodynia, that cause pain with sexual activity or penetration, need to be helped to separate fear from fact and to determine a personal range of safe and pleasurable sexual behaviors; behaviors that allow for sexual satisfaction of both partners while decreasing the risk of exposure to their partner’s disease. Such women could also benefit from coaching in ways to deal with a partner’s STD that protects the woman without eroding their partner’s sexual self-esteem or healthy sense of sexual self-expression.
- Many women suffering from STDs lack access to adequate information about allopathic and complementary treatments that might assist them in reducing the physical or psychological burden on or interference level with their sexual lives. Although we certainly hope that most women have access to well-trained, sensitive medical providers who are up-to-date in their medical knowledge about STD treatment, in actuality, many women need to be encouraged to be proactive, participatory consumers of health care services. We can encourage women to be assertive with their providers about their questions, needs, and concerns related to having an STD, and train them in the skills they need to communicate their concerns effectively to their health care provider. Women also need to be taught that it is acceptable to seek a second opinion, even a third opinion, if their condition fails to improve or if their practitioner seems disrespectful, disinterested, or unknowledgeable.
- Educators and counselors need to have a keen awareness of the role that fear of contracting another STD might have on a woman’s sense of sexual well-being and be alert to relationship and intimacy avoidance patterns that might have their root in the feelings of discomfort and dis-ease that many women experience once they have acquired an STD, particularly if the circumstances of acquiring the STD involved a dishonest or unscrupulous partner.
- Finally, these issues also affect the thinking and decision-making of women who may be considering, or be asked by a partner to consider having more than one lover simultaneously. The choice to be polyamorous, either as a single person or through involvement in a negotiated, ethical, responsible, non-monogamous relationship has significant implications for managing the risks associated with STDs.
Extending our Vision
As indicated earlier, prevention has been the primary focus of most sex education regarding sexually transmitted diseases. The document, “The New View of Women’s Sexual Problems” extends our thinking about the ways in which either the threat or the actuality of having an STD can affect women’s sexual functioning, satisfaction, and decision-making. Educators and clinicians can effectively utilize the ideas contained in the “New View” document to become more conscious and effective in helping women retain and nurture positive sexual self-esteem and a sense of sexual safety in the face of the challenges sexually transmitted diseases pose to our sexual health and happiness.
(Revised Draft: 2/22/2000)
Abstract
BEYOND STD PREVENTION:
IMPLICATIONS OF THE NEW VIEW OF WOMEN’S SEXUAL PROBLEMS
Beth A. Firestein
The new view of women’s sexual problems proposed by this working group provides educators and clinicians with a multi-dimensional, context-sensitive framework for understanding sexually transmitted diseases and STD prevention. Sexually transmitted diseases function as both direct and indirect causes of women’s sexual suffering. This article discusses both common and less frequently recognized issues concerning STDs and their impact on women’s sexual functioning and psychological well-being. The summary focuses on implications for educators and clinicians committed to increasing women’s sexual pleasure and self-empowerment.
Key words:
STD prevention, women, sexuality, sexual problems, sexually transmitted disease, HIV/AIDS