"Women trouble"--sexual problems or everyday woes? (Reflections).

How can we define women's sexual problems?

We believe that women may suffer from two types of maladies that alter their sexual perception: sexual problems and sexual dysfunction.

We shall define sexual problems as any situation or issue which affects a woman's sexual well-being and satisfaction and which may or may not require professional intervention.

Sexual dysfunction is a problem that partially or totally limits a woman's sexual encounters, exchanges or satisfaction with her partner.

Treating women in our professional sexology practice has given us the opportunity to re-think the underlying causes of female sexual problems and dysfunctions. It has also led us to consider the reasons for such low demand for the services of sexologists.

The silence with which women treat their sexual concerns points us toward issues of identity and subjectivity. An analysis of such issues will result in different interpretations depending upon the context which serves as point of departure: understanding or lack of understanding between partners or the manner in which female sexuality and subjectivity are constructed and shaped in our culture.

Some of the most significant determining factors include gender, women's subjectivity and daily lives, and emotional bonds.

Gender, Subjectivity and Daily Life

From birth, the process of appropriation of standards, guidelines, values and behaviors is differentiated for men and women. This process is upheld by socially-assigned roles which in turn shape our concepts of what it means to be a man or a woman in our society.

Most of the women who consult us received a sex education that emphasized reproduction. Knowledge transmitted from mother to daughter is related to menstruation and hygiene during menstruation; procreation and methods of avoiding unwanted pregnancies; the use of contraceptives; and, less frequently, the use of condoms. The latter method has taken on a greater importance in recent years due to HIV/AIDS and increased incidence of STDs in women.

Whereas an erotic viewpoint is encouraged in men and they are permitted to practice auto-eroticism from an early age, women are discouraged from the early practice of sexuality and familiarization with their genitals. This encourages women to divorce themselves from their own bodies and from erotic sensations.

Girls are inculcated with messages of modesty, tolerance, acceptance, non-exploration and fear of illness. This makes them feel guilty in the pursuit of pleasure. It is "not nice"--"girls should not be naked," "they shouldn't touch themselves," "don't touch your peepee or you'll get sick." These and other messages shape the images of sexuality which have distanced women from their erotic selves and the experience of sexual pleasure, resulting in the association of erotic sexuality with feelings of guilt and shame.

On the other hand, the very configuration of men's anatomy allows them to be familiar with their genitals and sexual sensations and facilitates their auto-eroticism. For this same reason, early detection of STDs is also easier for men. Women, however, are at a disadvantage, both in learning how to enjoy their bodies as well as in detecting warning signs for possible illnesses (which implies a greater risk to women's health).

The groups of women with whom we work speak of their sexuality in the following terms: "All of the good stuff is for the men, even our bodies." "What I do is I humor him." These ideas reflect a female identity fashioned "for others" and to satisfy others. They "forget" that sexual pleasure is something intimate and personal which requires us to take care of ourselves and make our own decisions.

Issues as different as swapping partners and practices of auto-eroticism both touch on the space of the Self. Thus, we must first know this intimate space to be able to communicate to our sexual partner our needs, likes, preferences and motivations.

The fear of not satisfying a partner or of being naked together, along with the myths associated with orgasm, reveal the marked efficiency with which sexual myths operate and the impact that the socio-cultural construct of the body has upon the images women have of their sexual selves.

The difficulties that women have with their "body image" and in accepting their bodies is at the root of many female sexual problems: "When I go out into the street, I don't look at anyone, I'm so worried about how fat I am." "I don't want to have sex with my partner, I don't want him to see what is happening to my body." "How am I going to accept him if I don't even want to be seen naked?" "Why should I tell him I'm not feeling anything if he's feeling so good." "They never told me what you should feel when you make love."

The above comments reflect a female identity which has been fashioned into a being "of others" that assumes the responsibility of caring "for others," as well as an extreme interpretation of the maternal role. This causes many women to undervalue their sexuality and pleasure in pursuit of strictly reproductive sexuality and tasks related to motherhood.

There is no socially acceptable view of pleasure within the equation of female sexuality = reproductive sexuality. Thus, misinformation and myths of erotic passivity and romantic love are factors which link reproduction and pleasure.

The lack of sexual desire, which limits the frequency of many women's sexual encounters, is accompanied by the acceptance of the sexual behavior desired by their partner, which in turn reinforces the lack of desire. The following cycle ensues: lack of desire-avoidance behavior/acceptance, lack of arousal/anorgasmic, avoidance-lack of desire.

In our experience, this is the most common sexual problem in women. It is interesting to note the link between lack of desire and the overwhelming burden of daily responsibilities, as well as the role which gender plays, in the following comments: "How am I going to feel desire if I spend the whole day working?" "If he wants me, I tell him I have a headache, and that's that." "He always accuses me of not wanting to, but the truth is that, with everything else going on, I can't" "It's easier for him: he doesn't do everything that I do." "After I finish everything I have to do, I fall right asleep."

Women's double, at times triple, workday undoubtedly is responsible for the sexual complaints of many women. They accept their overwork as "natural," and therefore do not see the need to pay attention to, re-focus or re-adjust their daily lives.

In everyday life women and men express their sexuality in unique ways. The multiplicity of socially-assigned roles which women perform wears them down more than men and therefore impacts more heavily upon their comprehensive health.

Emotional Bonds

In our analysis of couple relationships, we have confirmed that there is a displacement of the role of the sexual partner. This role is subsumed within the family context and appears in the form of the caretaking partner, diluting the perception of the couple--characterized by the use of pronouns such as "we" and "us"--as the space of emotional bonds.

There are two important points that we would like to highlight:

1. The quality of the bond between partners.

2. The quality of communication between partners.

In regards to the quality of the bond between partners, we have found a high frequency of:

* The "maternalization" of the relationship.

* The deterioration of emotional/sexual bonds.

* Images of sexuality distorted by social myths which view masculinity and femininity as opposite and/or complementary characteristics, with a hierarchical relationship and exercise of power which affects the exercise of sexuality within the couple.

The maternalization of the relationship refers to the insertion of maternal roles into the couple relationship. In effect, the woman treats her partner as another child, making it difficult to view him/her as a sexual partner, in all that this word implies. In this context, both the style of relationship and the exercise of power within the couple affect the woman's eroticism.

This type of couple is marked by a female identity centered in the care, wishes and acts of the other. The woman's necessities are subordinated, and her boundaries are fixed by the limits set by the partner.

The woman's exaggerated concern for caring for her partner causes symptoms of wear and tear in the emotional bond, which in turn causes misunderstandings when the expectations of each partner are not met. Additionally, the maternal relationship affects sexual satisfaction and the ability to coexist in harmony.

The quality of communication is affected by the different communication styles used by each partner, both in everyday concerns and during intimate moments. Expressive communication, dialogue, the exchange of ideas regarding preferences and sexual fantasies, all promote sexuality within the couple and create a space of intimacy which permits the re-creation of eroticism.

In our experience, the communication styles which predominate within the couple relationship are instrumental. Their contents deal with everyday needs and problems, complaints about responsibility and care of children. In other words, the "we" becomes a depository of all of the problems of daily life. Many of our clients have experienced this weakening of intimacy between partners by the daily concerns of family life.

Giving and taking, in the realm of sexuality, overflows the couple relationship, to emerge in judgments, concepts, images and models which are passed on to children within the contexts of family, community and social life in which each subject operates.

Miscommunication is expressed in suppositions that the other partner knows or should know one's sexual tastes, problems and complaints, and such assumptions create misunderstandings in the couple relationship. Sexuality requires the recreation of intimacy, a gesture that fosters the understanding of and closeness with the other member of the couple. The preparation for sexual exchange must be spoken as a guarantee for women's sexual satisfaction.

Lack of sexual enjoyment and difficulties in communication between partners result in psychological problems, the invasion of the couple's intimacy by everyday concerns and sexual avoidance behaviors, which can have an impact in the many different phases of sexual response.

Everyday life and the multiplicity of roles carried out by women are reflected in the form, mode and content of communication and in the quality of emotional bonds. Women do not communicate their dissatisfaction with their daily lives to their partners but lend their bodies when they are not willing or ready, faking orgasm because they fear loneliness or the loss of economic stability or a home. They continue a sexual relationship even in the absence of desire, to the detriment of their sexual and mental health.

In conclusion, we want to call attention to the importance of sexuality and sexual pleasure as a way of achieving a better quality of life and well-being. We also want to emphasize the need for women to socialize their problems and to learn to say NO when they do not feel ready or willing to share sexually with a partner.

Women's sexuality is affected by the multiple concerns of everyday life, the performance of roles, and the problems which these daily routines and rituals imprint upon a socio-culturally constructed sexual self. The problems of everyday life should be seen as sexual problems; thus, reconstructing sexuality in daily life is one path towards women's sexual enjoyment.

Cuban psychiatrist Ada Alfonso has a master's degree in Human Sexuality and Sex Education, and Cuban psychologist Celia Sarduy, a master's in the Psychology of Health. The authors are the coordinators of the Red de Genero y Salud Colectiva (Gender and Public Health Network) of the Cuban branch of the Asociacion Latinoamericana de Medicina Social (ALAMES, Latin American Association of Social Medicine). They both teach and offer sexology services for women.