Sexual Dysfunction in Lesbian Women: A Systematic Review of the Literature

Abstract

Over the past two decades, a growing body of literature has demonstrated the prevalence of sexual dysfunction in heterosexual women. Few, if any, studies have investigated sexual problems specifically in women who identify as lesbian. The aim of this article is to systematically review data on sexual dysfunction in lesbian women. We performed a systematic review of the literature searching MEDLINE via Ovid, EMBASE, PsycINFO, Cochrane Database of Controlled Trials, SCI-EXPANDED, SSCI, CPCI-S, CPCI-SSH, and Web of Science from inception through March 2017. We included all studies assessing sexual dysfunction or sexual problems in lesbian women. Heterosexual, bisexual, and transsexual groups were excluded. Of the 1,822 articles identified, 20 articles met inclusion criteria, 1 of which was a population-based probability study. These studies included 16 cross-sectional studies, 1 case–control study, 1 qualitative interview study, and 1 review of the literature. Sexual dysfunction is prevalent in lesbian women and may differ from sexual dysfunction experienced by heterosexual women. Available data are limited by small convenience samples and varied outcome measures. Current validated surveys may be applicable to this subgroup. There is need for population-based studies with harmonized measures of sexual function to guide an evidence-based approach to sexual dysfunction in lesbian women.

Keywords

sexual dysfunction - sexual problems - lesbian - homosexual

Over the past two decades, a growing body of literature has established the prevalence of sexual dysfunction in women. Although the vast majority of studies about female sexual dysfunction have focused on younger, reproductive age, heterosexual women, studies of female sexual dysfunction have expanded from prevalence estimates in the general population to those including specific patient subgroups such as postpartum women, women with gynecologic cancers, diabetes, HIV, and heart disease.[1] [2] [3] [4] [5] What is not known, however, is whether lesbians experience similar sexual problems as heterosexual women, as this information is seldom elicited in research or clinical contexts. Most studies neglect to ascertain sexual orientation or identity and few have investigated sexual dysfunction specifically in women who identify as lesbian. A recent U.S. population-based survey found that only 29% of U.S. obstetrician-gynecologists routinely inquired about their patient's sexual orientation.[6] Lesbian women also report difficulty disclosing their sexual orientation to their health care providers.[7] Previous high-quality studies have ascertained sexual identity/orientation; however, these studies are limited by small sample sizes of women who report same-sex sexual activities.[8] This study aims to systematically review the current literature on sexual dysfunction in lesbians to identify the prevalence and types of sexual dysfunction experienced by this population.

Methods

Sources

In March 2017, we used three strategies to identify pertinent studies: systematic review of electronic databases, hand-reviewed searches of references of included studies, and discussion with experts in the field to identify relevant new or unpublished data. We searched Ovid MEDLINE, Embase, Web of Science, Cochrane Database of Controlled Trials, and PsycINFO databases from inception to March 6, 2017. We began with the MEDLINE search and translated to the appropriate syntax for each of the other databases, using controlled vocabulary when available. [Appendix A] lists the search strategies for each of the databases.

Appendix A

Ovid MEDLINE
1. ((sex or sexual or libido) adj3 (disorder* or disturb* or function* or impair* or concern* or difficult* or disabilit* or distress or dysphoria or desire or aversion or dysfunct* or satisf* or problem* or symptom* or arousal* or activit*)).tw.
2. exp Dyspareunia/
3. exp Vaginismus/
4. exp Sexual Dysfunctions, Psychological/ or exp Sexual Dysfunction, Physiological/
5. (dyspareunia or vaginismus or hsdd or fsd or bed death or asexual or vaginal discomfort or vagina discomfort or vaginism or frigidity or genitopelvic pain disorder or genitopelvic penetration disorder or female orgasm disorder or arousal disorder or interest disorder or inhibited sexual desire or anorgasmia or vaginal dryness or vagina dryness).tw.
6. exp Homosexuality, Female/
7. exp Sexual Minorities/
8. (lesbian* or gay or homosexual* or same-sex or same sex or lgbt or glbt or glbtq or lgbtq or queer* or non-heterosexual* or sexual minorit*).tw.
9. exp Women/
10. (female or females or women or woman).tw.
11. 1 or 2 or 3 or 4 or 5
12. 6 or 7 or 8
13. 9 or 10
Embase
No. Query Results
#12 #9 AND #10 AND #11 911
#11 'female'/exp OR 'female'/syn 7717420
#10 'homosexual female'/exp OR 'homosexual female'/syn OR 'lesbian*' OR 'gay' OR 'homosexual*' OR 'same-sex' OR 'same sex' OR 'lgbt' OR 'glbt' OR 'glbtq' OR 'lgbtq' OR 'queer*' OR 'non-heterosexual*' OR 'sexual minorit*' 54527
#9 #7 OR #8 112572
#8 'sexual dysfunction'/exp OR 'anorgasmia':ab,ti OR 'dyspareunia':ab,ti OR 'vaginismus':ab,ti OR 'hsdd':ab,ti OR 'fsd':ab,ti OR 'bed death':ab,ti OR 'asexual':ab,ti OR 'vaginal discomfort':ab,ti OR 'vagina discomfort':ab,ti OR 'interest disorder':ab,ti OR 'arousal disorder':ab,ti OR 'female orgasm disorder':ab,ti OR 'geintopelvic pain disorder':ab,ti OR 'genitopelvic penetration disorder':ab,ti OR 'frigidity':ab,ti OR 'vaginism':ab,ti OR 'vaginal dryness':ab,ti OR 'vagina dryness':ab,ti 82216
#7 ((sex OR sexual OR libido OR psychosexual OR hyposexual) NEXT/1 (disorder* OR disturb* OR impair* OR concern* OR difficult* OR disabilit* OR distress OR dysphoria OR desire OR aversion OR dysfunct* OR satisf* OR problem* OR symptom* OR arousal* OR activit*)):ab,ti 39005
#6 #3 AND #4 AND #5 911
#5 'female'/exp OR 'female'/syn 7717420
#4 'homosexual female'/exp OR 'homosexual female'/syn OR 'lesbian*' OR 'gay' OR 'homosexual*' OR 'same-sex' OR 'same sex' OR 'lgbt' OR 'glbt' OR 'glbtq' OR 'lgbtq' OR 'queer*' OR 'non-heterosexual*' OR 'sexual minorit*' 54527
#3 #1 OR #2 112572
#2 'sexual dysfunction'/exp OR 'anorgasmia':ab,ti OR 'dyspareunia':ab,ti OR 'vaginismus':ab,ti OR 'hsdd':ab,ti OR 'fsd':ab,ti OR 'bed death':ab,ti OR 'asexual':ab,ti OR 'vaginal discomfort':ab,ti OR 'vagina discomfort':ab,ti OR 'interest disorder':ab,ti OR 'arousal disorder':ab,ti OR 'female orgasm disorder':ab,ti OR 'geintopelvic pain disorder':ab,ti OR 'genitopelvic penetration disorder':ab,ti OR 'frigidity':ab,ti OR 'vaginism':ab,ti OR 'vaginal dryness':ab,ti OR 'vagina dryness':ab,ti 82216
#1 ((sex OR sexual OR libido OR psychosexual OR hyposexual) NEXT/1 (disorder* OR disturb* OR impair* OR concern* OR difficult* OR disabilit* OR distress OR dysphoria OR desire OR aversion OR dysfunct* OR satisf* OR problem* OR symptom* OR arousal* OR activit*)):ab,ti 39005
PsycINFO
S4 (DE “Human Females” OR “women” OR “woman” OR “female*”) AND (S1 AND S2 AND S3)
S3 DE “Human Females” OR “women” OR “woman” OR “female*”
S2 (DE “Lesbianism”) OR “lesbian*” OR “gay” OR “homosexual*” OR “same-sex” OR “same sex” OR “lgbt” OR “glbt” OR “glbtq” OR “lgbtq” OR “queer*” OR “non-heterosexual*” OR “sex* minorit*”
S1 (“sex* disorder*” OR “sex* disturb*” OR “sex* impair*” OR “sex* concern*” OR “sex* difficult*” OR “sex* disabilit*” OR “sex* symptom*” OR “sex* arous*” OR “sex* activit*” OR “low libido” OR “psychosexual disorder*” OR “psychosexual disturb*” OR “psychosexual impair*” OR “psychosexual concern*” OR “psychosexual difficult*” OR “psychosexual disabilit*” OR “psychosexual symptom*” OR “hyposexual disorder*” OR “hyposexual woman” OR “hyposexual women” OR “hyposexual female*” OR “hypoactive sexual” OR “dyspareunia” OR “vaginismus” OR “HSDD” OR “FSD” OR “bed death” OR “asexual” OR “vagina* discomfort” OR “interest disorder” OR “arousal disorder” OR “female orgasm disorder” OR “anorgasmia” OR “genitopelvic pain disorder” OR “genitopelvic penetration disorder” OR “frigidity” OR “vaginism” OR “vaginal dryness” OR “vagina dryness”) OR (DE “Female Sexual Dysfunction” OR DE “Sexual Function Disturbances” OR DE “Vaginismus” OR DE “Dyspareunia” OR DE “Inhibited Sexual Desire”)
Web of Science
TS = “lesbian*” OR
TS = “gay” OR
TS = “homosexual*” OR
TS = “same-sex” OR
TS = “same sex” OR
TS = “lgbt” OR
TS = “lgbtq” OR
TS = “glbt” OR
TS = “glbtq” OR
TS = “queer*” OR
TS = “non-heterosexual*” OR
TS = “sex* minorit*”
AND
TS = “sex* disorder*” OR
TS = “sex* disturb*” OR
TS = “sex* impair*” OR
TS = “sex* concern*” OR
TS = “sex* difficult*” OR
TS = “sex* disabilit*” OR
TS = “sex* symptom*” OR
TS = “sex* arous*” OR
TS = “sex* activit*” OR
TS = “low libido” OR
TS = “psychosexual disorder*” OR
TS = “psychosexual disturb*” OR
TS = “psychosexual impair*” OR
TS = “psychosexual concern*” OR
TS = “psychosexual difficult*” OR
TS = “psychosexual disabilit*” OR
TS = “psychosexual symptom*” OR
TS = “hyposexual disorder*” OR
TS = “hyposexual woman” OR
TS = “hyposexual women” OR
TS = “hyposexual female*” OR
TS = “hypoactive sexual” OR
TS = “dyspareunia” OR
TS = “vaginismus” OR
TS = “HSDD” OR
TS = “FSD” OR
TS = “bed death” OR
TS = “asexual” OR
TS = “vagina* discomfort” OR
TS = “interest disorder” OR
TS = “arousal disorder” OR
TS = “female orgasm disorder” OR
TS = “anorgasmia” OR
TS = “genitopelvic pain disorder” OR
TS = “genitopelvic penetration disorder” OR
TS = “frigidity” OR
TS = “vaginism” OR
TS = “vaginal dryness” OR
TS = “vagina dryness”
AND
TS = “woman” OR
TS = “women” OR
TS = “female” OR
TS = “females”
CENTRAL
ID Search
#1 MeSH descriptor: [Sexual Dysfunction, Physiological] explode all trees
#2 MeSH descriptor: [Sexual Dysfunctions, Psychological] explode all trees
#3 sex* next disorder* or sex* next disturb* or sex* next impair* or sex* next concern* or sex* next difficult* or sex* next disabilit* or sex* NEXTsymptom* or sex* next arous* or sex* next activit* or “low libido” or psychosexual next disorder* or psychosexual next disturb* or psychosexual next impair* or psychosexual next concern* or psychosexual next difficult* or psychosexual next disabilit* or psychosexual next symptom* or hyposexual next disorder* or “hyposexual woman” or “hyposexual women” or “hyposexual female” or “hyposexual females” or “hypoactive sexual” or “dyspareunia” or “vaginismus” or “HSDD” or “FSD” or “bed death” or “asexual” or “vagina* discomfort” or “interest disorder” or “arousal disorder” or “female orgasm disorder” or “anorgasmia” or “genitopelvic pain disorder” or “genitopelvic penetration disorder” or “frigidity” or “vaginism” or “vaginal dryness” or “vaginal dryness”
#4 MeSH descriptor: [Homosexuality, Female] explode all trees
#5 lesbian* or “gay” or homosexual* or “same-sex” or “same sex” or “lgbt” or “glbt” or “glbtq” or “lgbtq” or “queer*” or “non-heterosexual*” or sex* next minorit*
#6 37-#3
#7 1-#5
#8 #6 and #7
#9 MeSH descriptor: [Women] explode all trees
#10 “women” or “woman” or “female” or “female”
#11 37-#10
#12 #8 and #11

Study Selection

To identify relevant studies, we generated an a priori list of inclusion and exclusion criteria. We included studies of any design that generated primary data on sexual function, dysfunction, or problems in lesbian women. We excluded studies whose participants were identified as bisexual, transsexual, or transgender and those whose manuscripts were not available in English. Our search identified 1,822 articles. Two authors independently reviewed the abstracts for these articles, when available. When abstracts were not available, the authors reviewed all available information provided by the databases. Ultimately, 18 articles met inclusion criteria via systematic review and 1 article by hand review of references in the included studies. Experts who review in the field identified one additional study which was unpublished at the time of our systematic literature search.[9]

Results

The 20 included studies were conducted between 2006 and 2017. The number of published studies on this topic doubled between 2006–2010 and 2011 to present. The studies included 16 cross-sectional survey studies, 1 case–control study, 1 qualitative interview study, and 1 review of the literature. Only one study was a population-based survey.[9] Most studies were cross-sectional internet surveys of small convenience samples with widely varied primary outcomes ([Table 1]). To organize studies according to contemporary diagnoses, we assigned studies to their Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5) diagnosis based on investigated outcomes. In 2013, DSM-5 was published and recategorized sexual dysfunctions ([Table 2]).[10] These DSM-5 changes also combined female hypoactive sexual desire disorder and female sexual arousal disorder into a new category, female sexual interest/desire disorder. Similarly, dyspareunia and vaginismus became one category, genito-pelvic pain/penetration disorder.[10]

Table 1 Major characteristics of studies of sexual dysfunction in lesbian women

Author (year)	Country	Population	Sample size	Study design	Survey instruments	DSM-5 outcome category[a]
Lau et al (2006)	China	Sexually active men and women 18–59 y old	2,130 women (95 WSW)	Cross-sectional telephone survey	None	Female orgasmic disorder Genito-pelvic pain/penetration disorder
Tracy and Junginger (2007)	Australia, United Kingdom, United States	Women who identified as lesbian, 18 y of age or older	350	Cross-sectional internet survey	FSFI	Female orgasmic disorder Female sexual interest/arousal disorder Genito-pelvic pain/penetration disorder
van Rosmalen-Nooijens et al (2008)	Not specified	Women who self-identify as lesbian, with a partner of >6 mo	30	Semistructured interviews	None	None
Beaber and Werner (2009)	Not specified	Women in lesbian relationships and women in heterosexual relationships for >6 mo	42 lesbian women 78 heterosexual women	Cross-sectional internet survey	Multidimensional Anxiety Questionnaire FSFI	Female orgasmic disorder Genito-pelvic pain/penetration disorder
Boehmer et al (2009)	Not specified	Homosexual women with cancer	n/a	Review of the literature	None	Special populations/comorbid medical conditions
Breyer et al (2010)	North America	Medical students	2,276 (64 homosexual females)	Cross-sectional internet survey	FSFI ISL	Female orgasmic disorder Female sexual interest/arousal disorder Genito-pelvic pain/penetration disorder
Burri et al (2012)	Finland	Twin females or female siblings of twins	5,998 (814 with homosexual experience)	Cross-sectional survey	FSFI FSDS DSFI, modified	Female sexual interest/arousal disorder Genito-pelvic pain/penetration disorder
Shindel et al (2012)	International sampling	Women who have sex with women, 18 y of age or older	1,566	Cross-sectional internet survey	FSFI, modified	Lesbian “bed death” and relationship factors
Lacefield et al (2013)	United States	Heterosexual, lesbian, and bisexual female college students	25 heterosexual 25 lesbian 25 bisexual	Cross-sectional questionnaire	Numerous[a]	Psychology and sexual functioning
Boehmer et al (2014)	United States	SMW with breast cancer	85 cases 85 case-matched controls	Case–control	FSFI, modified	Female orgasmic disorder Female sexual interest/arousal disorder Genito-pelvic pain/penetration disorder Lesbian “bed death” and relationship factors
Peixoto and Nobre (2014)	Portugal	Heterosexual and homosexual men and women	192 women (96 lesbian)	Cross-sectional internet questionnaire	Sexual Dysfunctional Beliefs Questionnaire	Psychology and sexual functioning
Blair et al (2015)	United States Canada United Kingdom Australia	Lesbian, bisexual, and heterosexual women 18–45 y of age	839 Heterosexual (42.7%) Bisexual (36.8%) Lesbian (20.5%)	Cross-sectional internet survey	Numerous[b]	Genito-pelvic pain/penetration disorder
Cohen et al (2015)	United States Canada	Women in a same-sex relationship of at least 12 mo	586	Cross-sectional internet survey	Numerous[c]	Lesbian “bed death” and relationship factors
Mark et al (2015)	United States	Men and women of diverse sexual backgrounds	3,569 women lesbian (9.3%)	Cross-sectional internet survey	None	Lesbian “bed death” and relationship factors
Peixoto and Nobre (2015)	Portugal	Lesbians and heterosexual women ages 18–62 y	390 lesbians 1,009 heterosexual women	Cross-sectional internet survey	None	Female orgasmic disorder Female sexual interest/arousal disorder Genito-pelvic pain/penetration disorder
Peixoto and Nobre (2015)	Portugal	Heterosexual and homosexual men and women	168 female participants (84 lesbian and 84 heterosexual)	Cross-sectional internet survey	None	Female orgasmic disorder Genito-pelvic pain/penetration disorder
Peixoto and Nobre (2016)	Portugal	Heterosexual and homosexual men and women	143 women (72 lesbian women and 71 heterosexual women)	Cross-sectional internet survey	None	Psychology and sexual functioning
Peixoto and Nobre (2016)	Portugal	Heterosexual and lesbian women	775 (593 heterosexual and 182 lesbian females)	Cross-sectional internet survey	None	Psychology and sexual functioning
Peixoto and Nobre (2016)	Portugal	Heterosexual and homosexual men and women	985 women (246 lesbian women and 739 heterosexual women)	Cross-sectional internet survey	Numerous[d]	Psychology and sexual functioning
Flynn et al (2017)	United States	Self-identified lesbian, gay, and bisexual adults	2,188 women (1,652 heterosexual, 199 gay or lesbian, 337 bisexual)	Population-based internet survey	PROMIS SexFS	Female orgasmic disorder Genito-pelvic pain/penetration disorder

Abbreviations: DSFI, Derogatis Sexual Functioning Inventory; FSFD, Female Sexual Distress Scale; FSFI, Female Sexual Function Index; ISL, Index of Sex Life; SMW, sexual minority women.

^a Anxiety Subscales of Non-Erotic Cognitive Distraction Questionnaire, Rosenberg Self-Esteem (RSE) Scale, The Eating Disorder Inventory–3, Beck Depression Inventory–II., Heterosexual Attitudes Toward Homosexuality (HATH).

^b Dyadic Trust Scale, Rubin Love Scale, Communication Subscale of Evaluation and Nurturing Relationship Issues, Communication and Happiness Marital Satisfaction Scale.

^c The Global Measure of Relationship Satisfaction, The Global Measure of Sexual Satisfaction, Sexual Esteem Subscale of the Sexuality Scale, Sexual Anxiety Inventory, Automatic Thought Subscale of the Sexual Modes Questionnaire, Dyadic Desire Subscale of the Sexual Desire Inventory, Frequency of Sexual Activities Scale.

^d Questionnaire of Cognitive Schemas Activation in Sexual Context, Sexual Modes Questionnaire—Automatic Thoughts Subscale Positive Affect—Negative Affect Scale, Female Sexual Functioning Index.

Table 2 DSM-5 summary of diagnoses of sexual dysfunctions

Diagnosis	Definition
Female orgasmic disorder	Difficulty experiencing orgasm and/or markedly reduced intensity of orgasmic sensations, almost all the time, in all sexual contexts, for at least 6 months
Female sexual interest/arousal disorder[a]	Lack of or significantly reduced sexual interest/arousal in sexual activity, sexual thoughts/fantasies, sexual initiative/receptiveness to sexual activity with a partner, excitement/pleasure with sexual activity, in response to internal/external stimuli, response to genital/non-genital stimulation, for at least 6 months
Genito-pelvic pain/penetration disorder (GPDD)[b]	Persistent or recurrent difficulties with vaginal penetration during intercourse, vulvovaginal or pelvic pain during penetration or intercourse, fear or anxiety about vulvovaginal/pelvic pain in anticipation of, during, or because of vaginal penetration, marked tensing or tightening of the pelvic floor muscles during attempted vaginal penetration, for at least 6 months
Substance/Medication-induced sexual dysfunction	Disturbance in sexual function with a temporal association of substance intoxication, withdrawal, or exposure to a medication
Other specified and unspecified sexual dysfunctions	Symptoms characteristic of a sexual dysfunction which do not fully meet criteria for a sexual dysfunctions diagnostic class

Note: All the aforementioned diagnoses must cause clinically significant distress in the individual.

^a Combines female hypoactive sexual desire disorder and female sexual arousal disorder.

^b Combines vaginismus and dyspareunia.

In this review, the most studied topic was genito-pelvic pain/penetration disorder (10 studies) followed by female orgasmic disorder (8 studies), and female sexual interest/arousal disorder (5 studies). We identified no studies investigating substance/medication-induced sexual dysfunction. We also identified studies investigating sexual dysfunction in the setting of anxiety, relationship factors, and breast cancer, areas not specifically addressed by DSM-5.[11] [12] [13] Interestingly, some studies described “lesbian bed death,” a decreased frequency of sexual activity over time, experienced by lesbians in long-term relationships. While these categories are not specified by DSM-5, they are likely relevant to our study population.

Female Orgasmic Disorder

The prevalence of female orgasmic disorder in lesbian women is difficult to elucidate, as current studies report a wide range of prevalence estimates. Many of these studies conclude lesbian women experience fewer problems with their ability to reach orgasm than heterosexual women.[9] [14] [15]

Peixoto and Nobre, in a convenience sample cross-sectional survey of Portuguese women, reported lower rates of difficulty achieving orgasm in “lesbian” compared with heterosexual women (14.6 vs. 25.8%).[14] Taking personal distress regarding sexual difficulties into account, the prevalence of orgasm dysfunction decreased (6.7 vs. 11.5%, respectively).[14] Breyer et al demonstrated that women who identified as “homosexual” reported high mean scores for orgasm on the Female Sexual Function Index (FSFI).[15] In a recent population-based U.S. study by Flynn et al, “lesbian” women reported higher orgasm ability compared with heterosexual women as measured on the PROMIS SexFS survey.[9]

Contrary to the aforementioned studies, Lau et al reported a nonsignificant difference of inability to achieve orgasm in a Chinese cross-sectional, convenience sample of “homosexual” compared with heterosexual women (24.7 and 20.4%, respectively).[16] This prevalence estimate was higher than the estimate of Peixoto and Nobre in their Portuguese population. Cultural differences in reporting, variation in sample size, and poor sampling influence the estimates of orgasmic dysfunction in these studies. Peixoto and Nobre adjusted prevalence rates to account for personal distress regarding sexual difficulties and persistence of symptoms over a 6-month period. Lau and colleagues did not. This lack of adjustment may have resulted in overestimation of prevalence of orgasmic disorder in the Chinese population.

Few studies report individual characteristics, as they relate to female orgasmic disorder. For example, previous population-based studies of heterosexual women report age as a correlate of sexual function.[17] [18] Our review yielded conflicting results. Lau et al reported the prevalence of orgasmic dysfunction in a convenience cross-sectional study varied by age group (7.7% in women 18–39 years old and 38.0% in women 40 years old).[16] In contrast, Tracy and Junginger found that orgasm ability was stable across younger and older age groups of adult lesbian women in an international sample.[19] Given a lack of longitudinal data demonstrating changes in sexual function over time, it is possible these differences are related less to age and more to temporal or generational factors. Our findings suggest that age may play a role in female orgasmic dysfunction among lesbian women, though current evidence is inconclusive.

Psychosocial factors may mediate the ability to achieve orgasm. Beaber and Werner investigated the relationship between anxiety and sexual functioning in lesbian and heterosexual women. Lesbian women reported higher levels of orgasm than heterosexual women, comparable to other studies.[11] Among heterosexual women, anxiety was negatively correlated with aspects of sexual functioning, including orgasm. There was no correlation between anxiety and difficulty with orgasm in lesbian women, despite similar levels of anxiety between the two groups. The authors postulate lesbian women may experience anxiety differently than heterosexual women, leading to stressors that do not manifest as sexual problems.[11] In contrast, Tracy and Junginger did find anxiety to be associated with decreased orgasms in lesbian women.[19]

Our review demonstrates lesbian women may suffer with orgasmic dysfunction less often than heterosexual women. We also identified age and anxiety as possible mediators of female orgasmic dysfunction. It is possible that differences in relationship dynamics, body knowledge, and communication exist between lesbian and heterosexual women. These factors may facilitate more frequent attainment of orgasms in lesbians even in the presence of individual anxiety and aging. Given the discrepancies found among identified studies, further research is needed to characterize the true relationship between aging and psychological factors as mediators of sexual functioning in lesbians.

Female Sexual Interest/Arousal Disorder

Several studies investigated sexual interest, desire, and arousal in lesbian women. These studies indicate that lesbians may have lower rates of dysfunction in these areas as compared with heterosexual women.

Peixoto and Nobre, in a convenience sample of Portuguese women, reported lesbian women suffer with lack of sexual desire (21%) and difficulty with arousal (10.3%).[14] Yet, when moderate or extreme personal distress regarding sexual difficulties was considered, lesbian women had lower rates of lack of sexual desire (6.7%) and sexual arousal difficulty (5.6%) as compared with heterosexual women.[14] Two other studies reported similar findings. Breyer et al found higher sexual desire among lesbian women as compared with heterosexual women and Beaber and Werner reported lesbians had higher levels of arousal than heterosexual women.[11] [15] On the other hand, one cross-sectional study of Finnish women with “homosexual” experiences reported homosexual women had significantly lower levels of desire for sexual activity (9.9 vs. 6.9%) and lower rates of sexual satisfaction (17.1 vs. 6.4%), despite higher rates of sexual activity frequency as compared with heterosexual females.[20] After controlling for frequency of sexual activity, however, desire levels were similar.[20] These results seem to suggest that, as with arousal disorders, a minority of lesbians have difficulty with desire and at a lower rate than heterosexual women. This same study also reported “homosexual” women participate in sexual activities significantly more frequently than heterosexual women including kissing, fantasies, masturbation, oral sex, vaginal sex, and anal sex. This may suggest a higher desire for sexual activity and higher arousal secondary to higher frequency of participation in foreplay activities.

When looking at age as related to sexual interest and arousal disorders, Tracy and Junginger, using the FSFI modified for length of time of symptoms (6 months vs. 4 weeks), reported older age (>50 vs. <50 years) was associated with less desire for sexual activity, lower levels of arousal, more problems with lubrication, and lower overall sexual functioning in an international convenience sample of women who identify as lesbian.[19] Age, however, was not a correlate of sexual satisfaction or orgasm. A decrease in interest or desire for sexual activity has also been described in large, population-based studies of aging and menopausal heterosexual women.[8] [17] [18] The similarity in findings may be explained, in part, by the biologic and hormonal changes of menopause, a transition experienced by all women regardless of sexual orientation or practice. Higher quality, population-based studies are needed to determine the extent to which lesbians experience sexual desire and arousal difficulties and whether these differences lead to personal distress or lower sexual satisfaction.

Genito-Pelvic Pain/Penetration Disorder

Many studies demonstrate lesbian women do participate in a variety of sexual activities including vaginal and anal penetrative sex, orogenital sex, masturbation, annilingus, and vibrator use.[15] [20] [21] [22] A cross-sectional study of more than 2,000 lesbian women in the United States and United Kingdom found that 86% of women reported a history of vibrator use and 52.6% of lesbian women reported insertion of a vibrator into their own or their partner's vagina during sexual activity.[22] Another cross-sectional survey reported approximately 70% of lesbian women had engaged in vaginal intercourse and almost 20% had engaged in anal-receptive sex.[16]

Many studies in our review demonstrate that lesbian women, like heterosexual women, do report pain with sexual activity. Some studies report similarities between lesbian and heterosexual women who experience pain during intercourse. Blair et al in a cross-sectional convenience study of women aged 18 to 45 years reported the location of genito-pelvic pain did not differ between heterosexual, bisexual, and lesbian women. Pain inside the vagina was the most commonly reported location, followed by the pelvic/abdominal pain, and pain at the introitus.[23] The most common context for experiencing pain was during vaginal penetration which did not differ by sexual orientation. Furthermore, GPPD was reported to negatively impact a woman's relationship, regardless of sexual orientation.[23]

Interestingly, the degree to which lesbian women experience pain varies in comparison to heterosexual women. Studies examining the frequency of genito-pelvic/penetration disorder show that lesbians report either less[9] [14] [23] or similar pain[9] [16] [20] as compared with heterosexual women. Only one study found that lesbian women reported higher pain scores compared with heterosexual women.[15] These studies are limited by small convenience samples.

The prevalence of reported GPPD in lesbians varies across populations and is estimated to be between 5.9 and 24.2%.[14] [16] [20] [23] Few identified studies account for distress related to GPPD as defined by DSM-5 diagnostic criteria. Peixoto and Nobre in a cross-sectional survey of Portuguese women demonstrated prevalence of reported pain in lesbians decreased from 17.4 to 9.8% after adjusting for personal distress related to these issues as compared with 18.6 to 13.3% in heterosexual women.[14] Similarly, Burri et al reported no statistical significance in the prevalence of reported pain between non-heterosexual and heterosexual women (5.9 vs. 5.7%) when controlling for distress.[20]

Blair et al in a cross-sectional convenience sample found women aged 18 to 45 years who identified as lesbian were less likely than heterosexual women to report genital pain.[23] Similarly, Flynn et al in a population-based cross-sectional survey concluded lesbian women reported lower vaginal discomfort compared with bisexual and heterosexual women.[9] The overall finding that lesbians report less GPPD is unlikely explained only by sexual practices. While it is possible that lesbians with genital pain may avoid penetrative sexual activities, evidence for this is lacking. These findings raise questions regarding how relationship dynamics, body knowledge, and communication between lesbian partners may influence GPPD and its impact on sexual satisfaction and functioning.

To this point, Blair et al also explored the concept of relationship dynamics and sexual pain and found that although lesbians experience genital pain, communication with their partner was associated with the perception of their pain having less of an effect on relationship and sexual functioning.[23] Of note, they found no differences in levels of communication between heterosexual, bisexual, and lesbian women.[23] If lesbian women are not necessarily communicating more, then it may indicate the quality of communication between lesbian women dampens the negative effect of pain on sexual functioning or allows for accommodation in sexual practices. This is an area worthy of further investigation.

Age and anxiety have differing influences on GPPD in lesbians. Two studies suggest older age does not correlate with increased reporting of GPPD as was observed for orgasmic disorder in a cross-sectional surveys of lesbian women in China[16] and Australian, U.S. and UK lesbian women.[19] Beaber et al found anxiety did not correlate with pain in lesbians, whereas it did in heterosexual women.[11]

We identified a growing body of literature regarding GPPD in lesbian women, demonstrating acknowledgment that lesbian women participate in penetrative intercourse and may experience sexual dysfunction because of these activities. However, we identified one study in our review that modified the FSFI by omitting a statement regarding “penile penetration (entry) of the vagina,” stating this was not considered appropriate for a “lesbian” sample.[19] This demonstrates that investigation of GPPD in lesbian women may be missed secondary to a lack of understanding of lesbians' sexual practices despite the fact that many studies in our review identify GPPD as an area of concern for lesbians. It remains uncertain, however, how GPPD affects overall sexual function and satisfaction in lesbian women, as personal distress and duration have not been well elicited in identified studies.

Substance/Medication-Induced Sexual Dysfunction

Substance/medication-induced sexual dysfunction is defined as disturbances in sexual function temporally related to substance intoxication, withdrawal, or exposure to medications.[10] Substance abuse and antidepressant medications have long been associated with sexual dysfunctions including inhibited orgasm and diminished sexual desire and excitement.[24] [25] Previous studies report higher incidences of substance abuse and anxiety/depression among lesbian women.[26] It is unknown whether a correlation exists between higher substance abuse and antidepressant medication use and sexual dysfunction in lesbian women, as our review identified no studies investigating these outcomes.

Psychology and Sexual Functioning

Mental health disorders and psychological domains have been associated with sexual dysfunction in men and women, though mainly studied in heterosexual populations. Our review identified several studies investigating psychological domains and sexual functioning in lesbian women.

Beaber and Werner investigated the relationship between anxiety and sexual functioning in a cross-sectional convenience sample of hetero- and homosexual females. Despite no difference in anxiety levels between the two groups, anxiety was negatively associated with sexual function for heterosexual women but was unrelated to sexual function in homosexual women, suggesting differences in the manifestation of anxiety for hetero- versus homosexual women.[11] Conversely, Tracy and Junginger found psychological symptoms (depression, anxiety, hostility) in lesbian women were associated with sexual dysfunction, including decreased arousal, orgasm, satisfaction, lubrication, and overall sexual functioning.[19]

Two studies investigated cognitive distractions during sexual activity as mediators of sexual functioning. Lacefield et al investigated anxiety in relation to cognitive distractions during sexual activity among a very small convenience sample of heterosexual, lesbian, and bisexual women. They reported lesbians had lower anxiety regarding sexually transmitted disease contraction and had lower scores on emotional and internal anxiety.[27] Another cross-sectional convenience survey study of hetero- and homosexual men and women with distressing sexual symptoms reported significantly more negative automatic thoughts and fewer erotic thoughts during sexual activity, regardless of sexual orientation.[28]

Peixoto and Nobre have published several cross-sectional convenience sample studies in Portuguese women investigating the interaction of psychological domains and sexuality including sexual beliefs, personality traits, and cognitive schemas. One cross-sectional convenience sample study investigated the relationship between sexual beliefs and sexual functioning in homo- and heterosexual men and women. They reported lesbian women scored higher on feelings that sexual desire is sinful.[29] Another similarly designed study investigated the difference of personality traits in hetero- and homosexual men and women with and without sexual problems. They found women with sexual problems (orgasmic difficulties, lack of sexual desire, arousal difficulties, and sexual pain) had higher rates of neuroticism (a personality trait increasing a person's likelihood of moodiness and feelings of anxiety, fear, anger, worry, envy, jealousy, guilt, depressed mood, and loneness) regardless of sexual orientation. Lesbian women also scored higher on conscientiousness (carefulness, vigilance) than heterosexual women, though its effect on sexual functioning remains unknown.[30] Another study found sexual abuse thoughts, failure thoughts, lack of erotic thoughts, and positive affect were found to mediate sexual function in lesbian women.[31]

While inconclusive, these studies suggest that psychological factors can negatively impact sexual functioning in lesbian women. Many of these studies reported no significant difference in outcomes comparing lesbian and heterosexual women. This demonstrates psychological well-being is an important determinant of sexual functioning for all women, regardless of sexual orientation.

Lesbian “Bed Death” and Relationship Factors

Lesbian “bed death” is a term that has been colloquially used to describe a perceived phenomenon of decreased sexual activity in lesbian relationships with no decrease in intimacy over the duration of a relationship.[7] [32] Although not always explicitly defined in the literature as “bed death,” the notion that there is a rapid decline in frequency of sexual activity in lesbian relationships has been reported.[7] One semistructured interview of 30 women who self-identify as lesbian, with a partner of more than 6 months, reported a majority of lesbians experienced “bed death” and felt it was related to decreased sexual initiative and sexual desire.[7]

The concept of lesbian “bed death” is controversial, however, as the current literature may over emphasize the infrequency of sexual activity in long-term lesbian relationships. Cohen in a cross-sectional convenience sample of women in a same-sex relationship of at least 12 months reported that lesbian women engage in frequent sexual activity, report good sexual esteem, and were overall very sexually satisfied.[32] Additionally, the presence of this phenomenon does not seem to always create relationship problems or impact overall sexual functioning, as lesbians who reported they could discuss sexual problems freely with their partners reported higher overall sexual satisfaction despite the presence of “bed death.”[7]

The decline in sexual activity described as “bed death” may be related to relationship factors. Cohen reported 89% of women who had been in a relationship for 1 or 2 years engaged in sex once a week or more. This declined to 73% after being in a relationship for 2 to 10 years and 56% beyond 10 years.[32] Tracy and Junginger suggested relationship duration is associated with less desire for sexual activity and overall decreased sexual functioning.[19] One study reported higher relationship satisfaction was associated with better overall sexual functioning as well as several specific domains of sexual functioning, including increased arousal, less trouble with lubrication, greater pleasure/orgasm, and greater sexual satisfaction.[19] It was not associated with desire for sexual activity. This study supports a hypothesis that the quality of the relationship increases the quality of sexual activity for lesbians, particularly increased arousal with sexual activity. However, as the authors discuss, this was contrasted by the finding that longer relationship duration was associated with an increase in many domains of sexual dysfunction including decreased overall sexual functioning.

In a population-based study by Flynn et al, lesbian women reported less partnered sexual activity in the past 30 days as compared with heterosexual women (47 vs. 56%, respectively) despite reporting similar rates of “single and not dating” relationship status (21 vs. 22%, respectively). Lesbian women also reported higher rates of masturbation than heterosexual women (25 vs. 12%, respectively).[9] These results suggest that “bed death” may be a lesbian-specific phenomenon rather than one that occurs as a result of long-term relationships, regardless of sexual orientation.

It is important to note that distress related to frequency of sexual activity is not included in the DSM-5 diagnoses of sexual dysfunction, though various domains of sexual dysfunction may ultimately impact the frequency of sexual activity. Our review suggests the frequency of sexual activities may correlate with sexual satisfaction and functioning in lesbians. This is an area which warrants further investigation, as it is not currently recognized as a domain of sexual dysfunction by current DSM-5 criteria.

Special Populations and Comorbid Medical Conditions

Studies demonstrate women with medical comorbidities experience increased rates of sexual dysfunction.[1] [2] [4] Our review identified only two studies investigating sexual function in lesbians with medical comorbidities. A review of the literature in 2009 revealed that very few studies have investigated sexual dysfunction in “sexual minority” cancer survivors, despite knowledge that female cancer survivors are at high risk for sexual dysfunction.[12] A case–control study in 2014 by the same author found the risk of sexual dysfunction and overall sexual functioning did not differ significantly between “sexual minority” women, including lesbians, with and without breast cancer. They did report, however, that sexual minority women with breast cancer experienced lower sexual desire and ability to reach orgasm, less sexual frequency, as well as higher rates of sexual pain.[13] We did not identify studies investigating sexual dysfunction in lesbian women who suffer with gynecologic cancer, heart disease, HIV, or other comorbid conditions.

Conclusions

Quality data regarding sexual dysfunction in lesbian women are considerably lacking. We identified only one population-based study investigating sexual dysfunction in lesbian women.[9] Almost all identified studies in our review employed cross-sectional internet surveys of convenience samples, some of which were very small.[11] [27] We also identified an incongruent approach to studying sexual dysfunction in lesbian women. No study used DSM-5 diagnostic criteria to study sexual dysfunction in lesbian women, similar to previous studies of heterosexual women. It would be beneficial for future studies to design outcomes as they are related to current DSM diagnostic criteria including assessing the duration of symptoms or accounting for distress as a marker for diagnosis. It would be beneficial for future research to design outcomes applicable to current clinical diagnoses, as this would improve the translational impact of research in this area.

Our review identifies the need for congruent employment of validated survey instruments for better applicability and understanding of sexual dysfunction in lesbians. Studies varied widely in their outcome measures and survey tools. The most frequently employed survey instrument among studies in our review was the FSFI, used in 7 of 20 identified studies.[11] [13] [15] [19] [20] [28] [33] Other studies employed different survey instruments including the Index of Sex Life, Female Sexual Distress Scale, Derogatis Sexual Functioning Inventory, and various other instruments, including invalidated author-designed survey tools. The FSFI is a 19-item validated questionnaire which identifies areas of sexual dysfunction, including desire/arousal, lubrication, orgasm, satisfaction, and pain/discomfort.[34] It has been employed in many studies of heterosexual women. We believe the FSFI is applicable to lesbian women based on this review with one slight modification. Changing the use of the word “penile” to “penetrative” would allow increased applicability to lesbian women who participate in a variety of penetrative vaginal and anal activities, either with sexual toys or male partners. This would likely allow accurate identification of lesbian women with GPPD.

GPPD was identified as the most investigated type of sexual dysfunction in lesbian women. We demonstrate lesbian women participate in vaginal penetration and suffer with vulvar and vaginal pain during sexual activity, perhaps similarly with heterosexual women. This is an important finding, as misconceptions may exist regarding the frequency with which lesbian women participate in vaginal penetrative sexual activity. Identification of these problems relies on a provider's ability to ask directive questions about a woman's sexual orientation and sexual practices without assumption that lesbians do not participate in certain sexual activities, including having sex with men as reviewed by Stoffel et al in this issue.[35]

We also identified lesbians suffer from dysfunction related to sexual desire and arousal, though they may do so with less frequency than heterosexual women. The reason for this remains unclear, though it may be related to relationship factors. We identified a unique phenomenon referred to as “lesbian death bed,” referring to a decrease in sexual activity over the duration of a relationship. It remains unclear if this decrease causes distress or should be considered a sexual dysfunction in lesbian population, though this phenomenon merits further investigation. Relationship satisfaction and mental health also seem to play an important role in this population and may be interrelated. The biopsychosocial model of health and sexuality has been previously described.[36] Clinical practice should aim to identify relationship stressors and mental health issues in conjunction with sexual dysfunction. This will help guide appropriate referrals to sex and mental health counselors as part of a multidisciplinary approach to the treatment of sexual dysfunction in lesbian women.

Aside from one study investigating sexual function in sexual minority women with breast cancer, we identified no other studies investigating sexual function in women with comorbid medical conditions and substance abuse issues. This is an area of the literature severely lacking, as many studies have described comorbid conditions and substance abuse as correlates of sexual functioning in heterosexual women. Additionally, our review did not identify any studies related to treatment of sexual function in lesbian women. Further studies are necessary, as providers continue to care for an aging population with increasing comorbid conditions.

Our review has limitations. While our search criteria were vast, it is possible some studies were omitted secondary to lack of identifiable keywords or other terminology related to sexual minority population that was not employed by our search. Additionally, while a hand-review search of references of included studies was performed, we did not read all complete manuscripts listed as references in included studies.

To our knowledge, this is the first systematic review of sexual dysfunction in lesbian women. Our review highlights a need for higher quality studies with congruent outcome measurements to help guide an evidence-based approach to sexual dysfunction in lesbian women.

No conflict of interest has been declared by the author(s).

Acknowledgments

The authors acknowledge Patty Smith for her contribution to our literature search.

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