For 41-year-old Anjali, sex was never uncomfortable. But many years after giving birth to her two children, she realised that she had never had an orgasm in all that time. What’s more, even that realisation hadn’t come of its own accord. It was only when she was asked about it during a checkup for menstrual difficulties that Anjali sat back long enough to think about it and realise this obvious lack in her sexual experiences.
The solution to Anjali’s condition was all too simple, says Dr Kalaivani Ramalingam, urogynaecologist at Apollo Hospitals, Chennai. “There are two types of orgasms: vaginal and clitoral. And some women simply cannot achieve vaginal orgasm. She just had to be educated about clitoral orgasm and sexual health.”
The lack of even such fundamental knowledge about sexual function and pleasure is indicative of how much difficulty women can undergo when they are living with sexual dysfunction, Dr Kalaivani points out. “Compared to infertility, female sexual dysfunction gets absolutely no attention at all,” she says.
It is no secret that sex still largely remains a taboo topic in polite society in India. For women in particular, the idea of pleasure from sex is rarely talked about. “I think men are a little more forthcoming about it. With women, just the fact that you want to talk about it and seek help means that you're seen in a poorer light. Pleasure is not your prerogative,” observes Dr Kalaivani.
What this often adds up to is a complete lack of awareness about healthy sexual experiences and the commonness of various types of sexual dysfunction.
Vaginismus
Female sexual dysfunction can take many forms, from lack of sexual pleasure to pain to inability to engage in penetrative intercourse. One common condition women struggle with is vaginismus (now grouped into a larger category of conditions called genito-pelvic pain/penetration disorder), where involuntary contractions of the vaginal muscles make penetration difficult and painful, often leading to an aversion to penetrative sex.
Social, psychological, and biological factors can all play a role in causing this condition. “There can be a mental barrier, particularly in conservative societies. Or somebody could have had bad experiences, including being abused,” explains Dr Kalaivani. Anxiety about performance, fears about pregnancy and other consequences, or relationship difficulties can also all contribute to this condition.
On the biological side, infections, various health conditions, menopause, medication side-effects and functional issues such as inadequate lubrication can also contribute to developing this condition. In many cases, this condition can be treated through a combination of physical therapy, mechanical aids like vaginal dilators (plastic tubes used to progressively stretch and relax the vagina), medication and sexual education. One of Dr Kalaivani’s patients, for instance, came to her after two years of inability to have intercourse. “We taught her some relaxation exercises, the use of dilators, and did a lot of hand holding during the process.” Soon the patient was able to enjoy a satisfying sexual relationship with her husband.
Improper sexual organ development
In some cases, the sexual organs may be underdeveloped or may develop with barriers or anomalies. “Some women may have a vaginal block like a membrane, or have a dysfunctional anatomy or improper formation of the vaginal passage,” explains Dr Kalaivani. One 22-year-old woman that she treated, for instance, was referred to her with with severe, painful periods. “She had a physical problem called hematometra, where the menstrual blood collects inside the vagina and there is a very small aperture through which very little blood gets out.” A further workup revealed that the lower portion of the patient’s vagina had not developed, and that she required reconstructive surgery to rectify the problem. In this case, the patient’s condition was diagnosed before she became sexually active. “But if she had been married off in the normal course, she would have presented with sexual dysfunction,” says Dr Kalaivani.
The elusive orgasm
Another set of common conditions that Dr Kalaivani sees is called anorgasmia or orgasm disorders. Much like vaginismus, anorgasmia can result from a range of conditions like illnesses, gynaecological issues, menopause and medicine side-effects, as well as psychological factors such as stress, anxiety, guilt, relationship difficulties and so on.
Patients with these conditions, in particular, may not recognise them because of the lack of emphasis on female sexual pleasure in the first place. Most women are only educated about sex from the perspective of the duty to produce children, and many are raised to think of sex as a necessary but distasteful chore to carry out. In such an atmosphere, the possibility of even raising questions about lack of orgasm doesn’t arise.
Silence and embarrassment
Dr Kalaivani says that she sees at least four or five cases of sexual dysfunctions every month. Yet, significantly, these women rarely come to see her specifically for these reasons.
“Most of the time, they come with some other gynaecological complaints. And when we ask them in due course whether they have any problems with intercourse, there’s often a pregnant pause that tells you there is. And they will often say no, initially,” explains Dr Kalaivani. In Anjali’s case, for instance, it was only when she came in for a follow-up from her first gynaecological checkup several months afterwards that she was finally able to admit the problem.
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Dr Kalaivani Ramalingam, Urogynaecologist at Apollo Hospitals
Many women also arrive at Dr Kalaivani’s office only because they are referred by other specialists. The 22-year-old woman with hematometra, for instance, had come in for a gall bladder problem and was referred to Dr Kalaivani for a consultation before her surgery.
More support and awareness needed
The main difficulty, says Dr Kalaivani, is a lack of sexual education and awareness. “We have this fear that we will be teaching children and young women the wrong things,” she points out. However, it is only with proper sexual education, not just from a dry biological perspective, that women learn to exercise greater autonomy and responsibility over their bodies, to be sure of the kinds of experiences they desire and don’t. When women are empowered with such knowledge, they would also be able to better pinpoint problems of sexual dysfunction instead of suffering in silence.
It’s not just women who need to better understand such situations, adds Dr Kalaivani. Men too, require a better understanding of such problems, so that they can better support their partners in such cases. One of Dr Kalaivani’s patients, for instance, had developed an aversion to sex because her sister had been abused as a child. As her husband felt that this problem had nothing to do with him, he refused to contribute to improving the situation. “Over many sessions, we tried to explain to them that this was something they had to work together towards. But because of the lack of ownership of the problem on the husband’s part, it finally ended in divorce,” rues Dr Kalaivani.
This article has been produced by TNM Brand Studio in association with Apollo Hospitals and not by TNM Editorial.