Medical personnel and para-professionals of both sexes were invited to attend an unusual, day-long seminar on â€œFemale Sexuality: A New Perspective With a Multidisciplinary Lookâ€ in Jerusalem recently but the audience consisted of about 60 women and one man. After the sole male noted to his chagrin that he was the only person in the hall with XY chromosomes, he quickly slipped out and never returned. Would there have been a men-only audience if the symposium had been dedicated to male sexuality? Of course not! Thus it seems there is a gamut of psychological and communications obstacles when it comes to dealing with women's sexual problems; these have to be dealt with if sexual problems can be adequately treated by the medical community. The seminar, organized by the non-profit Counseling Center for Women (www.ccw.org.il) and the Jerusalem Forum for Women's Sexuality, was a start in the right direction. Hosted by the Hadassah School of Nursing in Ein Kerem, the event was attended by a wide range of women professionals, including doctors, nurses, physiotherapists, social workers and sex therapists. Native English speakers were predominant, which is no surprise, because feminism originated mostly in the US, but there was also an unexpectedly large number of religious Jews who might be expected to think that talk about sex should be confined to the bedroom. There are a lot of women out there with sexual problems an estimated 30 to 50 percent of them, according to the speakers. The difficulties include fear of sex, pain during sex, involuntary vaginismus that prevents intercourse, vulvar vestibulitis infections, lack of sexual desire and/or orgasm, side effects of medications that affect sexuality, psychological trauma from rape or other abuse, sexually transmitted diseases, stresses in relationships, poor body image, past emotional trauma and menopausal problems. How common they are among Israelis has apparently not been documented scientifically, but in Britain, at least, a just-released national survey of sexual attitudes and lifestyles offers some clues. The survey results, published in the journal Sexually Transmitted Infections, found that married women are more likely to have sexual difficulties than either single women or married men. The study, led by sexual health researchers at University College in London, surveyed 11,000 men and women between the ages of 16 and 44 about their sex lives. They found that women were significantly more likely than men to say that they had experienced a short- or longer-term problem with their sex lives. Married women were significantly more likely to report a problem with their sex lives than single women, as were mothers with young children at home. The British survey found that the quality of one's first sexual experience was regarded by both men and women as important, with those reporting a poor first experience more likely to say they had subsequent problems. Men and women who felt they could not talk to their partner about sex were twice as likely to report problems with their sex lives. The authors of an accompanying editorial commented: â€œDespite its prevalence, sexual dysfunction is often endured in silence.â€ Previous foreign studies suggest that as many as 54% of women and 35% of men have sexual problems, but fewer than 11% of men and 21% of women seek help. Many family doctors here are untrained to identify and treat sexual problems due to lack of time for patients and inadequate training in medical schools, said Dr. Diana Flescher, an internal medicine and women's health specialist who spoke at the Jerusalem symposium. With health funds usually limiting their doctors to seeing most patients for only a few minutes of consultation, there was little time for primary physicians who have the closest and year-round relationships with their patients to investigate whether complaints about various physical symptoms in fact resulted from emotional trauma or interpersonal and sexual relationships. Many send women who do complain about pain in sexual relations, for example, to gynecologists instead of dealing with these matters themselves, Flescher said. She added that the doctor's reactions to problems could depend on whether he (or she) was trained in the Freudian school of thought (â€œIt's all in your head, dear!â€), the endocrinology era (â€œIt's your hormones, dear!â€) or the modern bio-psychosocial school of thought that looks at many possible factors and their interaction. Many doctors who do try to treat a woman's sexual problems may ignore the possibility that they are caused by the sexual dysfunction of her partner, who may suffer from depression or systemic disorders, Flescher suggested. Is the partner addicted to pornography on the Internet? Is he a substance abuser? Is the patient angry at him because he is cheating on her? Or is the patient, in fact, a lesbian with a female partner? A doctor's own personal religious, cultural or ethical views may also prejudice the way the problem is treated. Diagnosing and treating problems relating to sexuality should be an integral part of the family practitioner's job, and they should not automatically have to refer all of them to a gynecologist, endocrinologist, surgeon, physiotherapist, psychologist or psychiatrist, she continued. Sexual problems affect all segments of the population, said Moriah Shlomot of the CCW. Founded in 1988, the voluntary organization offers the services of some 25 clinical psychologists and social workers who use an array of therapeutic techniques and approaches to sexual and physical violence, stress, women's life-cycle events, eating disorders, body image and relationships. â€œAll women, whatever their educational and income level, deserve help to live a full life,â€ she said. Michal Schonbrun of the Jerusalem Forum for Women's Sexuality told the participants that sexual health must be regarded as an integral part of human health. â€œOur forum consists of 16 members from different professions, all women although maybe we will eventually expand to include men who are aged 35 to over 80. Three years ago we began to meet every month to discuss cases we deal with and bring in experts. Even after all this time, we continue to learn new things.â€ Several speakers noted that with the development and widespread marketing of Viagra and other drugs for male sexual dysfunction, pharmaceutical companies joined a mad rush to produce such a pill for women's sexual problems. Women's sexual problems have been â€œmedicalized,â€ and treating them is harder than treating the male kind. Many misconceptions resulted from the still-strong influence of US gynecologist Dr. William H. Masters and his psychologist wife, Virginia E. Johnson, who widely publicized their research on human sexual response and the diagnosis and treatment of sexual disorders and dysfunctions. Studying couples in the lab who by their openness could hardly be typical of people with sexual inhibitions they documented (among other things) the physiological nature of female sexual arousal and orgasm. Masters and Johnson also claimed that male and female sexual response were similar physiologically, but they ignored all the emotional, social, cultural, economic and even political influences on their relationships. The 1994 edition of the Diagnostic and Statistical Manual of Disorders of the American Psychiatric Association, which is considered the â€œbibleâ€ of psychiatrists and psychologists, accepted the Masters and Johnson concept of sexual problems being physiologically based. As a result, women's sexuality is still widely regarded solely as a mechanical phenomenon, the speakers stressed, discounting â€œthe culture of intimacyâ€ and the â€œeffects of the relationshipâ€ that have major roles in sexual problems. Anna Wruble-Woloski, a veteran nurse with a doctorate in education who specializes in treating female sexual problems, said that the new perspective on women's sexuality recognizes the fact that many women lack the terminology the actual words to describe their problems. They may know very little about their biology and what they look like â€œdown there,â€ suffer from anxiety or shame due to lack of sex education, and also have inadequate access to information, means of contraception, protection from sexually transmitted diseases and help against violence, Rubel explained. â€œHaving love and romance can affect the immune system, even the body's ability to cope with the flu, so it's medical negligence if medical professionals don't help people achieve the sexual health that they want.â€ Clinical psychologist Marsha Levin Shviro noted that stereotypes such as men always wanting sex and women always willing to have sex in order to get warmth and romance were outdated; she herself encountered many male patients who were not (or no longer) interested and women who were very keen on it. Guidelines for taking a sexual history that includes 26 detailed questions were presented by Tali Rosenbaum, a physiotherapist who spends much of her time treating women for dyspareunia (pain during sex) and those unable to have sex at all. She explained that this can result from muscle contractions, atrophy, prolapse of the vaginal walls and infections, as well as psychological problems. It should be regarded as a pain like any other pain, she insisted, and diagnosis requires taking a detailed sexual history of the patient, listening to the patient and a complete physical examination. Among the possible treatments are behavioral techniques, biofeedback, vaginal exercises at home, massage and the use of medications and ointments. Surgery for congenital defects is the last resort. The growing public discussion in academia, the media and other forums of sexual issues is to be welcomed. Keeping intimate issues locked up in the closet, where they cannot benefit those who are suffering, is not beneficial, and while women should discuss them among themselves, men should also be involved. What a shame that male doctor sneaked out.

Dealing with sexual dysfunction

A Jerusalem symposium addresses women's sexual problems and how to treat them.