© Springer International Publishing AG 2017
Waguih William IsHak (ed.)The Textbook of Clinical Sexual Medicine10.1007/978-3-319-52539-6_2828. Sex and Sexual Orientation
(1)
Psychotherapy and Psychopathology Research Unit from Research Center on Psychology (CIPsi), School of Psychology, University of Minho, Campus de Gualtar, Braga, 4710-057, Portugal
Keywords
BisexualGayHomosexualityLesbianMSMSexSexual orientationWSWLGBTSexual Orientation
Sexual orientation can be defined as romantic, affective, and/or sexual attraction to same sex, opposite sex, or both. When a person is romantic, affective and/or sexually attracted to same sex they are usually named homosexual, when attracted to opposite sex they are usually classified as heterosexual, and when attracted to both sexes they are named bisexual. Sexual orientation can be addressed through self-identification, according to sexual behaviors or based on sexual fantasies. Commonly, a combination of these criteria was used to define sexual orientation.
Sexual orientation is clearly more complex than a dichotomy between heterosexuality and homosexuality, and can be metaphorically described as the colors of a rainbow [1]. Alfred Kinsey is a well-known sex researcher, who developed the Kinsey Sexual Orientation Scale . Kinsey interviewed more than 18,000 men and women from the USA and collected information about sexual behaviors. During this work, Kinsey and his team found out that individuals self-identified as heterosexuals, for instance, may have in their past had same-sex sexual activity. Therefore, Kinsey proposed a sexual orientation scale from “exclusively heterosexual” to “exclusively homosexual,” with other options in between—“predominantly heterosexual, only incidentally homosexual,” “predominantly heterosexual, but more than incidentally homosexual,” “bisexual —equally heterosexual and homosexual,” “predominantly homosexual, only incidentally heterosexual,” “predominantly homosexual, but more than incidentally heterosexual.”
Although same-sex behavior has been reported in different societies across time, sexual orientation concept is recent, being reported in medical discourse during the nineteenth century. The first reference to “homosexuality ” backs to 1868 [2]. Nevertheless, the first studies conducted raised several empirical questions regarding sample collection and possible outcome generalization. Homosexual samples were collected in clinical contexts; therefore sample bias can be described, with individuals reporting more frequently higher levels of psychological symptoms. Additionally, when comparative studies were conducted, sample size of homosexual was significantly lower compared to heterosexual ones. Another concern was the definition of sexual orientation, where for some studies it was conceptualized based on sexual behaviors, for others based on self-identification, and for others defined by sexual attraction [2].
In 1973, it was proposed at an American Psychiatric Association meeting that homosexuality should no longer constitute a mental illness. Later, in 1974, the American Psychiatric Association members vote for the depathologization [2]. Consequently, the concept of homosexuality has been removed from the DSM-III, but it was replaced by “egodystonic homosexuality.” The “egodystonic homosexuality ” was only retrieved from DSM in 1988. Therefore, between 1973 and 1988, homosexuals who reported personal distress associated to their own sexual orientation were diagnosed with a mental disorder. This diagnosis promotes the discrimination against homosexuals during this decade.
Homosexuality gathers closer attention from social, media, and research fields, when compared to heterosexuality or bisexuality. When a HIV epidemic occurred in the USA, gay men were considered a risk group for HIV and sexually transmitted infections. Homosexuality was associated to a chronic illness with significant and negative impact on lifestyle. In order to overcome that prejudice, epidemiologists, especially those who work in the HIV field, since at least 1990, have started to apply the concept of “men who have sex with men”. The acronyms MSM —“men who have sex with men,” and later WSW —“women who have sex with women” [3]. It also allows conducting studies that transcend the social construction of sexual orientation. Nowadays, the acronyms MSM and WSW are widely spread in the sex research field.
Asexuality
According to Bogaert [4], asexuality is the absence of sexual attraction towards men and/or women, which can be addressed as the “absence of a traditional sexual orientation” ([4], p.279). Although asexuals did not experience sexual attraction, they can get involved in intimate relationships and experience romantic attraction [5]. In a study conducted by Bogaert [4], using a probability sample from the UK, the main findings suggested that only 1.05% of the population referred that they never felt sexual attraction to anyone. Interestingly, according to the author, the rate was similar to rates of same-sex attraction, which gathers much more attention from social, political, religious, or research disciplines. Nevertheless, in the past years, asexuality has received more attention from disciplines such as psychology and sexology [6].
Asexuality definition raises questions regarding clinical diagnose classifications, mainly associated to “personal distress.” Asexuals do not experience sexual aversion; however, they often feel that something is wrong with them, revealing personal distress. Additionally, they also tend to classify less behaviors as sexual, when compared to non-asexuals, which is probably due to lack of associated pleasure experienced [7]. Although asexuality is commonly described as lack of sexual attraction, the definition can also include lack of sexual behavior or self-identification [5]. If self-identification is considered, asexuality can also be conceptualized as a sexual orientation.
Sexual Scripts and Heterosexual Bias
Activists and social media may be responsible for sexual orientation being a core theme nowadays. Several steps forward have been made regarding deconstruction of myths about sexual orientation and sexual minorities. Concerning sexuality and sexual functioning, sex researchers struggle with a major concern: heterosexual bias. Although research about sexuality among gays, lesbians, and bisexuals has increased across the years, the heterosexual script remains. The heterosexual script regulates how a sexual relationship/intercourse should happen; when the heterosexual script is used for a better understanding of sexuality among gays, lesbians, and bisexuals, specific information and details may be lost in the process, forming generalizations without empiric support.
Social interactions can be described and conceptualized according to individual beliefs regarding personal expectations [8]. Therefore, a script is learned through lifetime based in modeling behaviors. If we transfer the social scripts knowledge to sexuality field, there is a propensity for sexual scripts being taught from men to boys, and from women to girls, with men learning to perform perfectly in sexual context, and women learning to be sexually submissive [8]. Sexual scripts constitute universal rules about how we should sexually behave and how we expect others to sexually behave. Gender roles, sex roles, sexual expectations among others constitute sexual scripts [8, 9]. Culturally, individuals are raised in order to establish intimate and romantic relationships with someone from the opposite sex, and not with someone from the same sex. Likely, vaginal intercourse constitutes the major sexual behavior during sexual intercourse, while other sexual behaviors (e.g., oral sex, cuddling) are characterized as preliminary sexual behaviors [8, 9].
Homophobia and Internalized Homophobia
Homophobia can be defined by hostility and explicit prejudice against gays and lesbians. When the concept “homophobia ” is used, we are describing a discriminatory attitude towards gay and lesbian, which implies serious political and social concerns. The concept “homophobia” may be considered inadequate for several reasons. First of all, the suffix “phobia,” in psychology and psychiatry, refers to an irrational fear and a persistent avoidance. For that reason, the word “homonegativity” is preferred to “homophobia.”
Internalized homophobia is defined by negative attitudes developed by homosexuals against themselves. It is considered a major vulnerability factor for health problems in gays and lesbians. Across life span, we are exposed to a heteronormative environment, and therefore some young gays, lesbians, and bisexuals develop feelings of internalized homophobia, characterized by negative attitudes towards their own sexuality. On the other hand, internalized homophobia promotes psychological distress, which impairs other life areas [2]. Internalized homophobia is conceptualized as a component of minority stress, by causing psychological distress associated to being part of a minority group, which is a target to discriminatory actions. Minority stress, is characterized by internalized homophobia, perceived stigma and experiencing discriminatory episodes. Nevertheless, internalized homophobia appears to be the core factor for experiencing psychological distress among sexual minority groups [2, 10, 11, 12]. Negative experiences associated to discriminatory attitudes promote psychological distress and poor psychological adjustment, which may lead to psychological and psychiatric disorders [12].
The American Psychological Association [13] established some guidelines regarding concepts in order to decrease the negative bias against gays, lesbians, and bisexuals. According to American Psychology Association, Division 44, the words “gay” and “lesbian” are preferable to “homosexual,” because homosexuality has been considered a mental illness over decades, and therefore the word is still negatively associated to mental disorders. Additionally, “homosexual” can also be discriminatory for lesbian women once it recurrently used to refer to men, neglecting women [13].
Same-Sex Relationships
Research on same-sex couples is still considered sparse due to several reasons. A major explanation is the fact that same-sex marriage is still illegal in some countries or states in the USA. Therefore, when researchers aim to study same-sex relationships they have to clarify the inclusion criteria for describing a same-sex couple.
Despite of sexual orientation, in intimate and sexual relationships, men tend to appreciate physical appearance and body image, while women value contextual and intimate characteristics. Additionally, in romantic and intimate relationships, affectivity, shared interests, moral and social beliefs are often treasured in an intimate partner. The first longitudinal study with same-sex and opposite-sex couples in civil union was conducted by Balsam et al. [14]. The major finding suggested that same-sex couples reported better dyadic adjustment and less conflict situations when compared to opposite-sex couples. For lesbian couples, sex frequency activity was a major predictor of better and satisfactory relationship, while for gay couples, the length of the relationship was a significant predictor of satisfactory relationships, with longer civil unions being associated to a decrease in dyadic adjustment [14].
Non-monogamy is more common across same-sex relationships, particularly in gay couples. Nevertheless, non-monogamy can be established by mutual agreement and rules can be defined. According to Hoff et al. [15], the reasons why gay men establish rules for non-monogamous relationships are: building trust in their relationship, promote honesty and protect themselves in terms of sexual health. No significant differences have been found regarding relationship satisfaction between monogamous and non-monogamous couples.
Extra-dyadic relationships can occur in both same-sex and heterosexual relationships. Commonly, in heterosexual couples, extra-dyadic relationships occur in secrecy. An interesting characteristic of gay couples is that extra-dyadic relationships can occur with knowledge of both partners and with mutual agreement. Although not well empirically established, extra-dyadic relationships by mutual agreement may promote sexual and relationship satisfaction. When extra-dyadic relationships occur by mutual agreement, we no longer talk about infidelity.
Closed relationships may help prevent transmission of sexual infections, by decreasing sexual risk behavior. So gay couples may agree to allow a third person to be part of their sex lives. Along with the mutual agreement, protective sexual behaviors can be negotiated with all members at the same time.
Sex Roles in Gay and Bisexual Men Relationships
During penetrative sexual behavior , gay and bisexual men engage in sex roles labeled as insertive (“top”), receptive (“bottom”), or versatile. Gay and bisexual men who often engage in anal sex where they penetrate their partners usually label themselves as “top,” gay and bisexual men who often engage in anal sex where they are penetrated by their partners usually label themselves as “bottom,” and gay and bisexual men who engage in both types of anal sex are often labeled as “versatiles.” Although these labels usually refer to anal sex, they can also be used to other sexual activities, such as oral sex or fisting [16]. Sex labels exist to describe and identify gay and bisexual men preferences during penetrative sexual behaviors. Nevertheless, social and cultural associations can be inferred. In some cases, the “top” gay or bisexual men may be considered as more dominant, comparatively to “bottom” gay or bisexual men, who are considered as submissive.
Gender roles and stereotypes associated to masculinity and feminity may have a role on sex labels and sexual behaviors among gay and bisexual men. According to Carballo-Diéguez et al. [17], versatile gay or bisexual men more likely engaged in a “top” sex role when they perceived their partners as less aggressive, with smaller penis, less taller and handsome, and with lighter skin. On the other hand, if they perceived their partners as more aggressive, more handsome, with darker skin, or with larger penis, which is considered as more masculine, they adopt a “bottom” sex role more often [17]. This findings support the idea that gender stereotypes, masculinity and feminity, play a major role in same-sex relationships, specially between two men. Sex roles in same-sex relationships may be dependent on gender representations, with “top” gay or bisexual men being considered more masculine and “bottom” gay or bisexual men being described as more feminine. The main characteristics associated to self-labeling are the physical appearance and penis size, with gay and bisexual men with smaller penis more often label themselves as “bottoms,” because they believe they will not being able to satisfy their partners [16]. When looking for a partner, “top” gay or bisexual men often look for partners with more feminine characteristics, usually associated to “bottom” gay or bisexual men, while “bottom” gay or bisexual men usually look for partners with characteristics often associated to “bottom” gay or bisexual men [17, 18].
Sexual Difficulties
Sexual dysfunctions have been conceptualized by international classification systems according to a heterosexist perspective, which is based on classic models of sexual response (e.g., [18, 19]). Therefore, penile–vaginal penetration continues to play a major role in the definition of sexual difficulties. Nevertheless, along with sexual dysfunctions referred on international classification systems, complaints as “not having a steady sexual partner” or “sexual desire discrepancy” were often referred by gay men and lesbian women as the most frequent sexual problem experienced [20–23]. Therefore, self-perceived sexual difficulties can be distinct from the sexual dysfunctions referred by international classification systems, and should be addressed in clinical context.
Assessing Sexual Difficulties
Regarding measures for assessing both male and female sexual functioning, once again a heterosexist bias can be found. One of the most common self-reported measures for assessing male sexual difficulties is the International Index of Erectile Functioning (IIEF; [24]). The IIEF is a self-reported measure with 15 items assessing five domains: erectile function, orgasmic function, sexual desire, intercourse satisfaction, and overall satisfaction [24]. The IIEF [24] is a very reliable measure for both clinical and research context [25], however it has been developed according to a heterosexual perspective. Therefore, Coyne and her colleagues developed an adapted version of the IIEF for men who have sex with men (IIEF-MSM; [26]). The IIEF-MSM included the five domains assessed by the original IIEF [24], with modified questions, mainly adapted for both receptive and insertive anal intercourse. According to the study conducted by Coyne et al. [26], with a sample of 486 men who have sex with men, HIV-positive, Cronbach’s alpha values were: 0.82 for erectile function; 0.83 for orgasmic function; 0.89 for sexual desire, 0.55 for intercourse satisfaction; and 0.42 for overall satisfaction. Despite of satisfaction questions, the other domains assessed by the IIEF-MSM revealed overall high internal consistency. Regarding satisfaction questions, the authors found out that the frequency of sexual intercourse attempts was not associated with the other items, which can be explained by the HIV status of the sample. Additionally, sexual satisfaction with a regular sexual partner was also unrelated to global sexual satisfaction, possibly due to types of sexual relationships maintained by the men in the sample [26]. The IIEF-MSM has been recently adapted, and research has shown good outcomes [26, 27]. However, anal sex pain is not assessed by the IIEF-MSM [28], and according to several studies it constitutes a major concern among men who have sex with men [29–32].
For women, the Female Sexual Functioning Index (FSFI; [33]) is the most frequent tool for assessing sexual functioning, constituted by 19 items evaluating sexual desire, orgasmic function, sexual arousal, lubrication, sexual satisfaction, and sexual pain. As a reliable measure for self-reported sexual difficulties in women, the FSFI [33] is widely used in both research and clinical context [33, 34]. However, the introduction to the measure states that sexual intercourse is defined as penile penetration of the vagina, which is inadequate for women who have sex with women [35]. Therefore, the psychometric properties of the FSFI were assessed in a sample of 350 lesbian women, with two major adaptations: the sexual intercourse definition was removed, and the period of time was modified from 4 weeks to 6 months. The decision was mainly based on previous studies that argue that lesbian couples engage less frequently in sexual activity [36, 37]. Findings from the study of the psychometric properties of the FSFI in a lesbian women sample showed good outcomes [35]. More specifically, the Cronbach’s alpha values were: 0.84 for satisfaction; 0.89 for sexual desire; 0.93 for sexual arousal and orgasmic function; 0.95 for lubrication; 0.96 for sexual pain [35].
Prevalence of Male Sexual Difficulties
Although prevalence of sexual difficulties has been largely studied among heterosexual men, with empirical data being consistent with premature ejaculation as the most frequent complaint in heterosexual men [38–43], little is known regarding prevalence of sexual difficulties among gay and bisexual men.
Empirical studies addressing prevalence of sexual difficulties in gay and bisexual men are fewer compared to studies conducted worldwide with heterosexual samples. Additionally, instruments for assessing sexual functioning were characterized by a heterosexual bias [28], and several methodological limitations were addressed. Duration criterion varies in a range from experiencing once in lifetime to experiencing during 3 months over the last year. Moreover, studies did not consider associated levels of distress. Despite of the methodological limitations, a few studies have focused on assessing prevalence of sexual problems in gay men community. Findings have suggested rates between 75 and 98% of gay men experiencing at least one sexual problem across lifetime. Lower rates were found for current sexual problems, with ranges between 42.5 and 79% [31, 44–47].
One of the first studies that attempted to assessing the prevalence of gay men’ sexual problems found that 97.5% experienced at least one sexual problem across lifetime, and 75% currently had at least one sexual problem [31]. If sexual dysfunctions were considered, frequencies were 92 and 52%, respectively [31]. Regarding lifetime sexual problems, 61% reported receptive painful anal sex, 49% referred lack of sexual desire, 46% experienced difficulties in keeping an erection, 44% had premature ejaculation, 40% experienced difficulties in getting an erection, 39% had orgasmic difficulties, and 14% reported insertive painful anal sex. For current sexual problems, 19% had premature ejaculation, 16% experienced lack of sexual desire, orgasmic difficulties, and receptive painful anal sex, 15% had difficulties in keeping an erection, and 13% in getting an erection, and 3% reported insertive painful anal sex [31].
According to a study conducted in Hong Kong, 49.1% of gay men experienced at least one sexual problem across 3 months in the past year, and 36% felt extremely bothered about that problem [45]. Premature ejaculation was the most frequent sexual problem referred, with a range of 21.8%, followed by lack of sexual desire and absence of sexual pleasure, with a range of 20%, performance anxiety, erectile difficulties, orgasmic difficulties, with ranges of 10.9, 9.4, and 9.1%, respectively, and sexual pain, with a range of 3.6% [45]. On a web-based study conducted by the same authors, with men who have sex with men, findings showed that 42.5% experienced at least one sexual problem over 3 months, in the past year [46]. Findings suggested performance anxiety as the most frequent problem (18.7%), followed by sexual pain and absence of sexual pleasure (13.8%), premature ejaculation (10.8%), lack of sexual desire (8.3%), erectile difficulties (6.3%), and orgasmic difficulties (5.6%). Overall, aging was associated to erectile difficulties and fewer sexual desire problems. Also, men aged 25–34 years reported more frequently sexual pain [46].
In a study conducted in Australia, Mao et al. [48] assessed gay men’s sexual problems that occurred at least over a month during the last year. Contrary to what was expected, aging was not associated to any sexual problem, while being HIV-positive was positively associated to sexual problems. Regarding frequency rates, 40.0–59.0% reported lack of sexual desire, 38.5–51.6% experienced erectile difficulties, 41.5–47.0% had performance anxiety, 25.5–31.8% revealed absence of sexual pleasure, 21.8–31.3% had orgasmic difficulties, 16.6–20.7% had premature ejaculation, and 6.5–7.8% experienced sexual pain [48].
Previous findings suggested that current sexual problems were less frequent then lifetime sexual problems . According to a study conducted by Seibel et al. [47], 75% of men who have sex with men attending a workshop about sexual health experienced at least one sexual problem across lifetime, while 65.1% had at least one sexual problem currently. Current sexual problems were defined as being experienced recurrently and persistently over the past year, and being associated to distress and life interference. Results suggested that erectile difficulties were experienced by 38.4% as a current sexual problem, and by 40% as a lifetime sexual problem. For orgasmic difficulties percentages were 32.7 and 43.3, lack of sexual desire was experienced by 26.4 and 34.3%, premature ejaculation occurred in 19.3 and 30.2%, and sexual pain was reported by 2.2 and 5.7% as a current and a lifetime sexual problem, respectively [47].
Recently, Hirshfield et al. [44] conducted a web-based study with men who have sex with men , with 89% identifying themselves as gay men, 10% as bisexuals, and 1% as heterosexuals. Sexual problems were assessed by asking the participants if they experienced a list of symptoms (low sexual desire, erectile difficulties, premature ejaculation, difficulties in reaching orgasm, sexual pain, absence of sexual pleasure, and performance anxiety), at a given time, over the past year. Results indicated that 57% experienced lack of sexual desire, 45% erectile difficulties, 44% performance anxiety, 37% absence of sexual pleasure, 36% orgasmic difficulties, 34% premature ejaculation, and 14% sexual pain. Younger men who have sex with men reported more problems related to sexual desire, premature ejaculation, absence of sexual pleasure and sexual pain [44].
More recently, a study conducted in Portugal indicated anal sex pain was the most frequent sexual difficulty in gay men, followed by lack of sexual desire, retarded and premature ejaculation, and erectile difficulties [49]. When associated levels of distress were considered, anal sex pain remains as the most frequent sexual complaint, followed by lack of sexual desire, retarded ejaculation, erectile difficulties, and premature ejaculation. Moreover, significant differences in prevalence were found when levels of personal distress were considered, with gay men reporting significantly less sexual difficulties when associated distress was assessed [49].
According to a recent study conducted in Croatia, regarding prevalence of sexual difficulties among gay and bisexual men, findings suggested that 60.2% reported at least on sexual difficulty in the previous year, and 52.3% reported at least one sexual dysfunction [50]. The most frequent sexual difficulty was lack of sexual interest, followed by felling anxiety before having sex, erectile difficulties, premature ejaculation, absence of sexual pleasure, and retarded ejaculation. The sexual difficulties with more associated distress were erectile difficulties, performance anxiety and retarded ejaculation [50].
Overall, lifetime sexual problems suggested receptive anal sex pain , lack of sexual desire and erectile difficulties as the most frequent sexual problems [31, 47]. For current sexual problems findings were contradictory, and some studies suggested lack of sexual desire as the most frequent sexual problem [44, 48], while others indicated premature ejaculation [31, 45], erectile difficulties [47], and sexual pain [46] as the most frequent sexual problem.
Concerning sociodemographic predictors of sexual problems in gay men, studies indicated that older gay men reported fewer sexual problems compared to younger men, with exception for erectile difficulties [44, 48, 51]. Contrary to erectile difficulties, highly reported by older gay men, sexual pain was extremely common among younger gay men [46].
Premature ejaculation as a clinical condition refers to latency time about ejaculation after vaginal penetration. Therefore, it is not possible to establish this clinical diagnosis in gay men [52]. Additionally, vaginal intercourse is very common among heterosexual couples, while gay couples reported other sexual behaviors, namely masturbation, oral and anal sex. Therefore, it is important to understand how this difference among sexual behavior affects the ejaculatory function. According to Jern et al. [52], sexual orientation does not seem to have a significant effect on delayed or premature ejaculation. Moreover, a previous study has found no differences between gay men and heterosexuals regarding premature ejaculation [53].
Sexual Difficulties and HIV Status
The treatment for HIV , including antiretroviral therapy may be associated with increased risk of sexual dysfunction in men [54, 55]. Additionally, HIV-positive gay men presenting significantly more complaints related to sexual functioning compared to HIV-negative men [27, 48]. More specifically, HIV-positive gay men reported more complaints about lack of sexual desire and erectile difficulties compared to HIV-negative [55–58]. However, it is not possible to infer whether these difficulties are associated directly to the clinical condition or to other factors, including the use of condoms or regarding the fear of contracting HIV [56]. Furthermore, clinical depression is more common in HIV-positive individuals [55]. Therefore, other psychosocial factors should mediate the relationship between HIV status and sexual problems. HIV-positive gay men state that psychological factors and side effects from HIV treatments can promote sexual problems [55, 57].
Sexual Difficulties and Sex Roles
Gay men who engage in anal sex can adopt three distinctive roles: “top”; “bottom”; or “versatile” [59–62]. Gay men who usually penetrate their partners and engage in penetrative behavior are considered “top,” while gay men who frequently are penetrated by their partners and engage in receptive behavior are labeled as “bottom.” Finally, gay men who involved in the two previous described behaviors are labeled as “versatile.” “Tops” more frequently prefer engage in a sexual relationship where they were dominant and in control, tend to select partners that worship their bodies during sexual intercourse, and partners with a more female body; while “bottoms” prefer a submissive sexual relationship [59]. Also, empirical data suggested that self-sex labels regarding gay men were good predictors of sexual behavior [61]. Consequently, a new complaint associated to painful receptive anal sex, known as anodyspareunia , should be considered [29–32].
Rosser et al. [31] studied sexual problems experienced by gay men and found out that about 61% reported painful anal sex. Given this remarkable result, they decided to assess severity and frequency of anal sex pain, and main results suggested that 63% of gay men reported occasional pain, with mild to moderate severity, and 12% experienced persistent pain with extreme severity [32]. The main factors associated to painful anal sex were lubrication, followed by psychological factors such as anxiety, previous stimulation, penis size and confidence level of sexual arousal [32]. Therefore, the authors proposed a new sexual dysfunction- “anodyspareunia”—characterized by recurrent or persistent sexual pain felt during receptive anal sex. More recently, Damon and Rosser [29] conducted a study where they studied painful anal sex using a behavioral criterion and a clinical criterion. On one hand, the behavioral criterion was based on frequency and severity of pain. On the other hand, the clinical criterion was based on: (1) if experienced sexual pain very often, (2) if experienced distress and/or interpersonal difficulties due to pain and, finally, (3) if no sexual pain experienced was due to an involuntary spasm of the anus muscle, lack of adequate lubrication, use of drugs/medication, or medical condition. Overall, the results indicated that 14% of the sample met criteria for behavioral painful anal sex and 10% met the clinical criteria. More specifically, 21% of the sample reported that their pain occurred across lifetime, and about 60% considered the pain as problematic. Regarding the distress associated, 25% of the sample reported extreme levels, and 18% experienced extreme interpersonal difficulties. Consequences were avoidance of anal sex for a period of time (82%) and restriction of anal sex as the penetrating partner (49%). Participants attributed the pain to psychological factors, penis size, to specific anus health problems, and no use of drugs.
Prevalence of Female Sexual Difficulties
Across worldwide, new studies emerge concerning female sexual problems, but very little is known regarding lesbian women sexual problems. Specificities regarding lesbian women’s sexuality should be addressed, such as sexual behaviors, namely tribadism (genital contact), mutual masturbation, oral sex, or finger–vaginal penetration [63]. Nevertheless, both lesbian women and heterosexuals defined vaginal penetration as sexual intercourse [64]. Research regarding lesbian women’s sexuality is mainly focused on frequency of sexual activity, sexual satisfaction, and intimacy [65, 66].
Regardless of lack of empirical data about sexual problems in lesbian women, evidence suggested that, overall, lesbian women reported fewer sexual difficulties when compared to heterosexuals [67–69]. According to a study conducted by Beaber and Werner [67], lesbian women reported better levels of sexual arousal and orgasmic function [67]. Additionally, a negative association was found for heterosexuals regarding sexual functioning and anxiety levels. No significant association was found for lesbian women, which was explained due to their good communication pattern [67]. Likewise, a previous study also suggested that lesbian women reported fewer difficulties in reaching orgasm , when compared to heterosexuals [68]. Despite of methodological limitations, according to Matthews, Hughes and Tartaro [69], in a study assessing sexual problems with a dichotomy scale “yes or no”, sexual dysfunction index was calculated by the presence of two or more sexual difficulties. Findings suggested a lower sexual dysfunction index for lesbian women. More specifically, heterosexuals had more complaints associated to sexual pain, while lesbian women referred more difficulties in reaching orgasm [69]. No significant differences were found for sexual activity frequency [69, 70].
According to Lau, Kim, and Tsui [45], in a study with women who engage in same-sex relationships, over the last year, 75.6% reported at least one sexual problem, and about 45% felt extremely bothered about that sexual difficulty. Lubrication difficulties were the most frequent sexual concern (39.3%), followed by lower sexual desire (30.7%) and absence of sexual pleasure (30.3%), difficulties in reaching orgasm (24.7%), sexual pain (23.6%), and performance anxiety (16.9%). Also, lubrication difficulties increase with aging [45]. Regarding self-reported sexual problems, according to a study conducted by Meana, Rakipi, Weeks, and Lykins [71], 28% of lesbian women reported difficulties in reaching orgasm, 15% experienced arousal difficulties, and 12% referred lack of sexual desire. Findings from a web-based study with women who have sex with women (74.5% were lesbian women and 17.5% self-defined themselves as bisexuals) indicated that 24.8% of the sample scored for high risk for sexual dysfunction [72].
Studies concerning the role of associated levels of distress of sexual problems were also scarce with lesbian women. Nevertheless, associated levels of distress were a crucial variable concerning sexual dysfunctions. According to Burri et al. [66], when distress levels were controlled, 9.9% of non-heterosexual women reported lack of sexual desire, 8.4% experienced difficulties in reaching orgasm, 6.5 and 6.4% referred arousal and lubrication difficulties, respectively, and 5.9% reported sexual pain.
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