**The Potential Associations of Pornography Use with Sexual Dysfunctions: An Integrative Literature Review of Observational Studies**

#### **Aleksandra Diana Dwulit and Piotr Rzymski \***

Department of Environmental Medicine, Poznan University of Medical Sciences, 60-806 Poznan, Poland **\*** Correspondence: rzymskipiotr@ump.edu.pl; Tel.: +48-61854-7604

Received: 30 May 2019; Accepted: 24 June 2019; Published: 26 June 2019

**Abstract:** This paper reviews the associations between pornography use and sexual dysfunction based on evidence from observational studies. The existing data in this regard mostly derive from cross-sectional investigations and case reports. There is little if no evidence that pornography use may induce delayed ejaculation and erectile dysfunction, although longitudinal studies that control for confounding variables are required for a full assessment. The associations between pornography use and sexual desire may differ between women and men although the existing data is contradictory and causal relationships cannot be established. The strongest evidence is available for the relation of pornography use with decreased sexual satisfaction, although the results of prospective studies are inconsistent. The paper outlines future research prospects beneficial in understanding the nature of associations between pornography use and sexual dysfunctions in men and women.

**Keywords:** pornography; sexual dysfunction; erectile dysfunction; delayed ejaculation; sexual desire; sexual satisfaction

#### **1. Introduction**

The existing literature provides a number of varying descriptions of the term pornography. According to the Final Report of the Attorney General's Commission on Pornography, it can be defined as any material that is predominantly sexually explicit and intended primarily for the purpose of sexual arousal [1]. Currently, pornography represents an important economic venture [2,3]. Its greatest development has occurred along with the emergence of computer technologies and the expansion of the Internet [4,5]. Due to a high sense of anonymity and almost unrestricted access, the Internet has become the most important medium of dissemination of pornographic content (known as online pornography), particularly in the form of images and videos [6,7]. The ease, arousal strength, and diversity with which pornography can be reached online indicates that it may operate as a supernormal stimulus [8].

According to various epidemiological studies, a relatively large number of adults have been exposed to pornography [9–12]. Recent representative surveys demonstrate that in developed countries with unrestricted Internet access, such as the United States and Australia, the majority of men (64–70%) and approx. one quarter/third (23–33%) of women are using pornography [13,14]. However, the number of pornography users is also relatively high in developing countries—recent surveys have shown that over half of students in Ethiopia and Bangladesh have been exposed to it [11,15]. The extensive use of pornography is also supported by data provided by Pornhub, one of the largest online pornographic websites, which clearly indicate that it is primarily men that are associated with content of this type (74%), and that the number of visitors to pornographic sites is growing from year to year (Figure 1). Some men deal with pornography on a regular, daily basis [16]. At the same time, the percentage of women interested in using this type of content is growing [17]. The Pornhub service is

usually visited by young people under the age 34 from the United States, the United Kingdom and India. An emerging and as yet not fully assessed issue is the unintentional contact from advertising or spam e-mail messages both of which may sometimes be difficult to avoid [18].

**Figure 1.** Statistics of pornography use in the period of 2013–2018 according to data shared by Pornhub: (**a**) annual number of visitors to Pornhub, (**b**) visitors to Pornhub by age.

Although interest in pornographic content can be partially considered as a natural element in the development of sexual experience in young people, the multiplicity and diversity of available online pornographic materials as well as the difficulty of restricting access to them lead to a question on the potential effects of pornography consumption. There is a steady increase in number of studies addressing the prevalence, patterns, outcomes, and various other aspects related to pornography use as clearly indicated by a systematic search of English language papers indexed in the PubMed/Medline database—a key term "pornography" yields 142 papers published in the period 1980–1989, 238 papers in 1990–1999, 524 papers in 2000–2009, and as many as 949 papers in 2010–2018. However, despite a continuous interest in the study of various aspects of pornography use, there are number of unresolved issues regarding the nature and magnitude of these effects. For example, some investigations demonstrate that pornography may fit into the addiction framework via mechanisms similar to chemical compounds [19,20] although controversies in this regard exist [21–24]. An addiction to pornography is not recognized in the DSM-5 and ICD-11 classifications (although the latter specifies a diagnostic category of Compulsive Sexual Behavior Disorder under impulse control disorders that may be used to diagnose problematic pornography use), various studies refer to it rather as "self-perceived pornography addiction" [12,16,25–27], and some alternative models based on moral incongruence, compulsivity, or impulsivity were also proposed to describe problematic pornography use [21,28,29]. Whether pornography may be associated with changes in sexual function is also a subject open to wide discussion. However, there are number of recognized risk factors for sexual dysfunction encompassing medical conditions, substance abuse, medication use, as well as cultural and social factors [30] which are difficult to address in studies focusing solely on pornography use. In the general population, the most frequently identified sexual dysfunctions include premature ejaculation and erectile dysfunction in men and desire and arousal dysfunction in women [31], and a number of studies have aimed to evaluate the potential associations between the occurrence of these effects and pornography use. At the same time, the potential effects of pornography use are the subject of a number of nonacademic discussions, and some publicly expressed opinions in this regard appear to be politically and ideologically driven. All in all, this creates a need to critically assess the existing evidence, outline study limitations and shortcomings, and highlight the future research prospects in the field of pornography use and its associations with sexual function.

The aim of this paper was to review the cross-sectional and longitudinal studies as well as case reports on potential associations between the use of pornography and sexual dysfunctions, namely erectile dysfunction, delayed ejaculation, and decrease in sexual desire and sexual satisfaction. These

conditions are among the most often identified sexual dysfunctions in men and women [30–32]. Both quantitative (addressing the frequency of use) and qualitative (addressing the patterns of use) research was taken into account as these two approaches complement each other in understanding the complex nature of factors associated with pornography [33,34]. For this purpose, a systematic search for original research published since 2000 in peer-reviewed journals was performed using the PubMed/Medline and Scopus database, and by hand-searching reference lists from identified papers. The limitations of the conducted studies and future research prospects are also outlined.

#### **2. Delayed Ejaculation**

Delayed ejaculation describes a sexual dysfunction occurring in men, manifested by prolonged time required to ejaculate or complete inability to achieve it. Due to the complexity of psychosexual and psychosocial factors that contribute to its pathogenesis, there are no universal methods of treatment [35]. Its potential causes include, among many, frequent masturbation and the occurrence of significant discrepancies between real sexual intercourse with a partner and sexual fantasy preferred during masturbation [35,36]. Both masturbation and sexual fantasy are often associated with pornography use thus its potential relationship with the onset of delayed ejaculation is hypothetically plausible. A systematic search with key terms "pornography and ejaculation" and "pornography and delayed ejaculation" identified five original papers, including three cross-sectional studies and two case studies.

The first study to address the potential impact of pornography use on ejaculatory dysfunction was conducted on a group of 115 hypersexual, predominantly heterosexual men (mean age 41 years, range 19–76 years) [37]. As reported, a relatively significant percentage of subjects (23.5%; *n* = 27) masturbated chronically (at least 1 h/day or >7 h/week), usually while viewing pornography. In comparison with other subjects, this particular group was characterized by a higher anxiety level and was less likely to establish partner relationships or to persevere in them, even if they were established. These subjects frequently (19/27; 71%) reported some sexual dysfunctions with delayed ejaculation being reported the most often (in over 30% of cases). There are, however, a number of limitations to this study in the context of understanding the potential role of pornography in the occurrence of delayed ejaculation: (1) it only included hypersexual male subjects who represent a group that generally often masturbates and views pornography [38], and it remains unknown how these findings may be representative of the general population; (2) the onset of delayed ejaculation may result exclusively from the frequent masturbation or subjects with delayed ejaculation may tend to masturbate more often—in both cases, pornography use may remain unrelated; (3) it was unestablished whether the pornography use in hypersexual subjects facing delayed ejaculation preceded problems with this sexual dysfunction, therefore its role as a causative factor in delayed ejaculation cannot be established.

Two other cross-sectional studies involving young subjects do not support the potential existence of a relationship between pornography use and delayed ejaculation. The first of them surveyed Italian students attending their final year of high school (*n* = 1492; aged 18–19 years) who frequently admitted to using pornography (78%, including 8% using it on daily basis) and observed that ejaculatory issues were reported in 1% of surveyed, regardless of the frequency of pornography consumption [39]. In the second study, two large-scale samples of heterosexual men (aged 18–40 years) from three European countries, Croatia, Norway, and Portugal (*n* = 3948), were analyzed and, as demonstrated using multivariate logistic regression, no significant association between delayed ejaculation and pornography was detected [40].

In addition to cross-sectional studies, Park et al. [41] and Blair [36] reported cases in which delayed ejaculation appeared in some way to be related to pornography use. The former report described a case of a 20-year-old man with no chronic or mental disorder who used pornography for a long duration at a high frequency (1–2 times/day), gradually reaching for content that deviated progressively further from the standard. He also admitted to using an artificial vagina that supposedly allowed him to reach orgasm much faster. He self-reported the difficulty in maintaining an erection and ejaculating during masturbation and sexual intercourse, which contributed to disturbances in partner relations with his fiancée. As the authors emphasize, despite the fact that the man felt a physical and mental attraction to his partner, he preferred to use a more stimulating erotic toy (artificial vagina). The authors suggest that excessive pornography use could trigger changes in the nervous pathways responsible for sexual desire and erection, as well as changes in the functioning of the reward system, and subsequently caused delayed ejaculation [41]. These suggestions, however, remain purely speculative as no evidence to justify them was provided. As found, the delayed ejaculation was fully resolved after cessation of online pornography use and the quality of partner relationship was improved. However, the use of the artificial vagina was simultaneously discontinued. It therefore remains unestablished whether the delayed ejaculation was in any way related to the use of pornography, the artificial vagina, or both.

The case reported by Blair [36] included a 19-year-old male who could not achieve ejaculation during sexual penetration. The man started using pornographic content at the age of 12; a year later, he used it regularly, and at the age of 15 he began to reach for more and more thematic content (depicting the so-called bondage and acts of domination). Cessation of pornography and advice to avoid masturbation using a firm grip and switch to a more gentle style of penile stimulation were reported to be an effective therapy enabling the subject to achieve orgasm during an intercourse [36]. Therefore, this case also cannot be used as sole evidence for pornography-induced ejaculation impairment as it could just as well result from penile desensitization, a consequence of frequent masturbation. Some studies have reported that masturbation frequency and style, particularly the so-called "idiosyncratic" pattern that due to speed, pressure, and duration is difficult to be replicated by a partner, may be a predisposition for retarded ejaculation [42–44]. Therefore, the extent to which pornography use may contribute to such phenomenon remains unclear.

In summary, there is currently little evidence that an association between pornography use and delayed ejaculation exists and no indication that pornography use can be a cause of this sexual dysfunction. However, the assessment in this regard is only based on cross-sectional studies and case reports. Future research, particularly more extensive cohort studies and case-control observations, is therefore required.

#### **3. Erectile Dysfunction**

Erectile dysfunction is defined as a chronic inability to maintain an erection which prevents the introduction of the penis into the vagina. Its most common causes include age, diabetes, depression, cardiovascular and neurological diseases, selected psychogenic factors (including stress and abuse of psychoactive substances), and using selected pharmaceuticals [45]. Considering that some studies indicated a significant correlation between hypersexuality and problems with erectile function [46], it is plausible that some association in this respect may also exist for pornography use. A systematic search with key terms "pornography and erectile dysfunction", "pornography and erectile function", and "pornography and erection" identified a total of seven papers overall encompassing two case reports [41], six cross-sectional studies [28,39,40,47–49] and one longitudinal study [28].

Two interesting cases were presented by Park et al. [41]. In the first, a 40-year-old man with difficulty in maintaining an erection and achieving orgasm was described. During the period preceding the study he had intensively undertaken masturbation associated with the frequent use of online pornography, which was reported to be associated with an increasing amount of time required to achieve orgasm. He had also begun to view his wife as becoming gradually less sexually attractive. His physical parameters (including state of genitals) were in good condition. The patient was advised that his dysfunctions could have arisen from increased sexual stimulation, frequent masturbation, and change in the stimulation threshold due to exposure to strong pornographic content. The man, however, was unable to refrain from masturbation and watching pornography and did not initiate the treatment [41]. Another case described by the same authors concerns a 24-year-old man who was abusing alcohol and antidepressants, and had attempted suicide. He also reported to using online pornography at a frequency estimated at 5 h daily during the 6 months preceding the treatment. He experienced a weakened sexual interest in his wife, which was manifested by his inability to maintain an

erection and preference to watching pornography, during which he experienced no erection problems. After discontinuing the use of pornography, according to the therapist's recommendation, his erectile dysfunction disappeared [41]. Both of these cases are complicated with confounding variables and no casual relation between pornography use and erectile dysfunction can be seen. In the first, it is not possible to separate the potential effects of frequent pornography use and excessive masturbation, although one should note that these two phenomena can often be highly correlated in men [50]. The second case is complicated by psychiatric history (use of antidepressants and suicide attempt) as well as by the reported alcohol abuse which itself is a common cause of sexual dysfunctions such as erectile retardation [51].

As found in a pilot observational study conducted in 2006 on a small group of young adult men (*n* = 25; mean age 29 years), nearly half of them (*n* = 12) showed no signs of sexual arousal, including erections while watching an erotic film (penile rigidity < 5%; and 0% in eight subjects) [47]. These observations were initially associated with a potentially high level of exposure to pornographic content, lowering the responsiveness to sexual stimuli associated with the presentation of sex in a more standard edition (vanilla sex). In the second stage of the study, a larger number of men were recruited (*n* = 80) and exposed to longer and more diverse erotic films. Nineteen percent of them (*n* = 15) failed to respond sexually. It appeared that the risk of sexual dysfunction increased along with the number of pornographic films that had been viewed by the respondents during the previous year [47]. Another study of a larger range was conducted in 2016 on a group of 434 men (mean age 29.5 years, range 18–72). Using the International Index of Erectile Function questionnaire, the ability to achieve an erection and orgasm, the degree of sexual desire, satisfaction with sexual intercourse, and general sexual satisfaction were evaluated in 276 subjects who had had sexual intercourse during the last month. The study concluded that problematic online sexual behavior (defined as compulsive, persistent, uncontrolled use of pornographic content) was a significant predictor of a low level of erection [49].

In turn, the study surveying Italian high school students (*n* = 1429; age 18–19 years) did not show that erection problems were more frequently admitted by teenagers watching pornography, regardless of the self-reported frequency of its use [39]. A cross-sectional study conducted in two-large scale samples on heterosexual men (aged 18–40 years): the first in 2011 on Croatian, Norwegian, and Portuguese heterosexual men (*n* = 2727) and the second in 2014 on another sample of Croatian men (*n* = 1211) identified a positive relationship between pornography use and erectile dysfunction in the first subset of individuals from Croatia although the effect was small and not confirmed in other groups [40]. Another study reported that instead of erectile dysfunction, pornography use in 280 heterosexual men (mean age 23 years) was positively correlated with sexual arousal which was self-reported when watching visual stimuli in the laboratory [48]. Furthermore, subjects indicating higher pornography consumption also reported a greater desire for solo and partnered sexual behaviors. However, this study had a number of limitations: a high number of monogamous individuals (which may be more sexually exploratory, particularly if young), a rather limited frequency of pornography use in the studied group (individuals were divided into three groups using pornography 0, 1–2, and >2 h per week but the maximum frequency remained unreported), and an unknown period of pornography use in the investigated individuals prior to the study.

The most recent study performed by Grubbs and Gola [28] reported a positive association between self-reported erectile dysfunction and self-reported problematic pornography use but not mere pornography use in a cross-sectional sample of 147 undergraduate men (mean age 20 years) in the United States as well as in a sample of 433 men (mean age 33 years) matched to the demographic norms of this country. The one-year, four-wave longitudinal study that was based on these two samples, completed across all four time points by 117 participants, and with two point-data collected for 278 subjects, also found that baseline pornography use and problematic pornography use was positively associated with prospective erectile dysfunction. However, latent growth modelling indicated that no baseline variables served as predictors of the trajectory of erectile functioning over time. Although these results support the existence of an association between erectile dysfunction and problematic pornography use, they fail to show a causal relationship. It is thus plausible that men with erectile dysfunction may tend to use more pornography, including patterns they self-perceive as problematic [28].

As yet, there is little or no evidence on a causal relationship between erectile dysfunction and frequency of pornography use. It cannot be ruled out that subjects with erectile dysfunction may be more prone to using pornography more frequently. One should note that cross-sectional and longitudinal studies performed so far are solely based on self-reported data introducing a significant limitation. Some research clearly indicates that the prevalence of self-reporting of erectile dysfunction may vary considerably from the prevalence identified by objective methods such as the International Index of Erectile Function to the extent that the former might be unreliable in assessing the real presence of this sexual dysfunction [52]. There is a need for further longitudinal exploration of associations between erectile dysfunction and pornography use that would include individuals of different age and with various baseline pornography use and employ a diverse methodology encompassing physiological measures and partner reports.

#### **4. Changes in Sexual Desire**

From the perspective of biological sciences, the term libido is used to describe sexual desire, a trait controlled by central nervous system associated with the sexual drive and wish to engage in sexual activities [53]. As highlighted, it should not be mistaken for sexual arousal which manifests itself physiologically and may not always be positively correlated with sexual desire [54]. This said, it can be hypothesized whether pornography use increases or decreases libido, and if frequency and duration of pornography consumption may modify such responses. One can also consider different responses in males and females due to varying sex roles and sexually differentiated neural activity in response to sexual stimuli [55]. To explore it, a systematic search for original studies was performed with the key terms "pornography and libido" and "pornography and sexual desire". A total of five papers associated with this subject were identified and included cross-sectional studies [39,40,50,56,57].

Carvalheira, Træen, & Stulhofer [50] analyzed the relationship between masturbation and the use of pornography and sexual desire in a group of European heterosexual men (mean age 40 years, range 21–73) who had reported a problem of reduced sexual desire (*n* = 596). As found, more than half of the studied subjects who had experienced a significant decrease in libido within six months before the examination were involved with pornographic materials at least once a week. The study further found that frequency of masturbation and pornography use are strongly correlated in men with decreased sexual desire. One should note that the cross-sectional nature of this study does not allow any causation between pornography consumption and decreased libido to be established, and that interpretation of the obtained data is also limited by the lack of a control group constituted by men with no sexual dysfunctions. Although it is generally an interesting or even counterintuitive observation that men with an impaired libido may watch more pornography and masturbate often, it is important to highlight that men with lower sexual desire (contrary to women with lower libido) tend to increase the frequency of masturbation in a manner unrelated to pornography consumption [58,59]. Considering the high accessibility of online pornography, it is no surprise that men who tend to masturbate often will also constitute a group using it as sexual stimuli.

Cross-sectional observations in Italian students attending the last year of high school (*n* = 1492, aged 18–19 years) indicated that as many as 78% of them admitted to using pornographic content, with 8% indicating doing so on a daily basis. A decrease in sexual desire was reported by 10% of pornography users, and appeared to increase with the frequency of consumption: among students exposed at least once a week, it accounted for 16%, while in the case of those exposed less often it was 6%; the nonusers did not report it at all [39].

The findings of Carvalheira, Træen, & Stulhofer [50] and Pizzol, Beroldo, & Foresta [39] were not confirmed in a large study encompassing large-scale samples of heterosexual men (aged 18–40 years) from Croatia, Norway, and Portugal (*n* = 3948) and applying multivariate logistic regression [40]. In

turn, a study on women (*n* = 754; aged 18 = 76 years) reported that those involved in a long-term relationship that use pornography more frequently may reveal increased sexual desire towards their partners and report a higher desire for sexual variety [56]. This is a relatively important finding indicating the potential difference in patterns of pornography use between men and women, although one should note that the cross-sectional nature of the study does not imply causation. It remains to be explored whether a pornography-induced increase in libido exists in women or women with higher sexual desire are also more open to watching pornography more frequently. Moreover, the potential role of sexual partner (in terms of sexual desire and satisfaction) and satisfaction from a relationship may represent important factors for inclusion in multivariate analyses conducted in the future. Interestingly, a recent cross-sectional survey of 240 committed heterosexual couples (mean age of males and females 35 and 33 years, respectively) confirmed the positive correlation of pornography use by women with their sexual desire but also found a similar but weaker relation in men [57].

Neurobiological research indicates that the potentially negative effect of long-term pornography use on sexual desire may result from changes in the responsiveness of the reward system to sexual stimuli, preferentially more active as a result of stimuli associated with pornography than with real sexual intercourse [60,61]. However, observational studies do not provide consistent data to support the hypothesis that use of pornography is a causative factor for a decrease in sexual desire and rather provide a contradictory observation as regards the existence and direction of correlations between pornography use and libido. These contradictions may potentially arise from the complex nature of sexual desire in both men and women, which is influenced by a number of biological, psychological, relational, sexual and cultural factors [62,63]. Considering that some studies have reported that subjects with higher sexual boredom and lower libido may tend to masturbate more frequently [50], it is important to elucidate the role the pornography use and pornography-associated masturbation may play in fulfilling the need for sexual gratification. Further cross-sectional studies as well as prospective investigations that control for these factors are greatly required to draw some final conclusions on the relation of pornography use and level of sexual desire.

#### **5. Changes in Sexual Satisfaction**

It could be hypothesized that the frequent exposure to pornography can potentially impact sexual satisfaction. The potential reasons for its decrease may include: (1) a comparison of real partners to idealized acting roles in pornographic films [64,65], (2) disappointment when the actual partner is not interested in recreating the scenes observed in pornographic material, (3) disappointment due to the inability to obtain such a broad spectrum of sexual novelties, with a real partner as presented in pornographic material [66,67] and (4) contact with pornography chosen instead of sexual intercourse with a real partner [68,69].

On the other hand, one could also hypothesize that in some cases, use of pornography may increase sexual satisfaction by providing inspiration for real sex. However, the magnitude of these effects may differ between men and women, and may also be potentially modified by frequency and time of pornography use, as well as type of pornography consumed. Moreover, it may also be hypothesized that shared pornography use in couples may have a positive impact on sexual satisfaction as it could stimulate partners for more sexual exploration during real intercourse [70].

A systematic search with the key term "pornography and sexual satisfaction" identified a total of 23 papers reporting observational studies among which 20 cross-sectional surveys (Table 1) and four prospective investigations were reported [65,71–73].

As found, the associations of pornography use on sexual satisfaction may differ across gender (Table 1). In general, its decrease was more often observed in men than women. Moreover, the frequency of pornography use may also be differentially associated with sexual satisfaction in both genders—in men, its decrease was already reported at a rate of use estimated at a few times per year while in women at a frequency of once a month [74]. As demonstrated in both women and men, age of first exposure may also be associated with decrease in sexual satisfaction, with a two-fold increase in the odds if such exposure occurred ≤ 12 years in reference to individuals exposed for the first time >16 years. Nonreligious individuals and those in a relationship were also found to reveal weaker associations between pornography use and sexual satisfaction [74,75]. Interestingly, one study reported that, in men, the negative association between pornography use and sexual satisfaction appeared to diminish once masturbation frequency was controlled [76]. However, one should note that pornography consumption and masturbation are usually highly associated in men [50]. Altogether, it highlights that the context of pornography use may highly moderate the nature of associated effects and should be taken into account in further assessments. As recently indicated, length of relationship was negatively associated with pornography use in women, thus mitigating its effects on sexual satisfaction [77]. In turn, in newly married couples, pornography use was demonstrated to be negatively correlated with sexual satisfaction [73]. One study demonstrated that the association between pornography use and sexual satisfaction may be differentiated according to the attachment styles of the studied subjects: with no association found in secure individuals (neither anxious nor avoidant), a negative association among preoccupied (high anxiety but low avoidance) and dismissing (low avoidance and high anxiety) subjects and a positive one among fearful persons (simultaneously highly anxious and avoiding) [78]. This puts an association between pornography use and sexual satisfaction in a wider psychological context in which it may arise from early interactions with caregivers that, via internalization of operative cognitive models, guide behavior and cognition, in relation with sexuality in adulthood. This is particularly interesting in the light of the research of Szymanski and Stewart-Richardson [79] who demonstrated that frequency of pornography use as well as problematic pornography use in heterosexual men is related to more avoidant and more anxious attachment styles. The authors hypothesize that these men use pornography as it allows them to experience emotional and/or sexual gratification without having to risk interpersonal rejection or intimacy [79]. Altogether, these findings suggest that the nature of associations between pornography use and sexual satisfaction may depend on various variables encompassing gender, relationship status, cultural/religious factors, and psychological background, and this, in addition to quantitative data, should be taken into account in future studies.

Overall, it appears that individuals, particularly men, who use pornography more often also tend to report lower satisfaction with their sex life. The limitations of cross-sectional studies do not allow us to distinguish whether pornography induces a decrease in sexual satisfaction or whether low sexual satisfaction predicts more frequent pornography consumption, or both. The first longitudinal, three-wave (six months between waves) panel study in this regard conducted on a population of Dutch adolescents (*n* = 1052; aged 13–20 years) revealed that pornography use consistently reduced sexual satisfaction but also that low sexual satisfaction led to increase in pornography use [65]. This highlights that these bidirectional relationships must be taken into account, and that other factors contributing to lower sexual satisfaction (that may potentially include sexual or psychosocial dysfunctions) should be addressed to fully elucidate the reasons for pornography use. Gender was not demonstrated to be a moderator of observed effects in this study. However, another four-wave panel study (six months between waves) which was also conducted on a sample of Dutch adolescents (*n* = 1132; aged 11–18 years) indicated that more frequent pornography use at baseline predicted less sexual satisfaction at the last study point in males, while in females, sexual satisfaction was negatively associated with an increase in pornography use [71]. The findings by Peter & Valkenburg [65] and Doornwaard et al. [71] were not replicated in the other, three-wave longitudinal study (one year between waves) that surveyed 190 newly married heterosexual couples [73]. As demonstrated, the frequency of pornography use in women and men failed to predict changes in sexual satisfaction and pre-existing sexual satisfaction did not predict changes in pornography consumption. More recently, a longitudinal six-wave study (six months between waves) of females (*n* = 775) and males (*n* = 514) aged 15–18 years, also found no significant association between frequency of pornography use and sexual satisfaction, regardless of gender [72]. Further prospective studies will be necessary before any definite conclusions can be drawn.



P—pornography PU—pornography use; PPU—problematic pornography use; SD—standard deviation.

Importantly, the majority of cross-sectional studies summarized in Table 1 only assessed individual pornography use. As shown by Willoughby & Leonhardt [57], shared viewing of pornography in heterosexual couples is correlated with higher sexual satisfaction. As demonstrated, women using pornography may more often experience guilt, disgust, and embarrassment [90], which are rather not experienced when this use is shared with their partners—such a scenario may promote positive sexual interactions in couples. One should note, however, that the findings of Willoughby & Leonhardt [57] are derived from a cross-sectional study and no causality can be established. It can be hypothesized that shared pornography use increases sexual satisfaction in partners or that partners experiencing higher sexual satisfaction may tend to view pornography together more often.

Additionally, interesting associations between pornography use and a partner's sexual satisfaction have been reported. For example, Yucel and Gassanov [91] who surveyed 433 heterosexual married couples observed that a husband's pornography consumption was negatively correlated with his wife's sexual satisfaction while a wife's pornography use was not associated with her husband's satisfaction. In turn, the longitudinal observations made in 190 newlywed couples found that increased sexual satisfaction in men was a predictor of a decline in pornography viewing by their wives [73]. These bivariate associations suggest that gender patterns in pornography consumption in couple relationships may mutually affect sexual satisfaction and may be important to consider in future works on the effects of pornography use on the quality of sex life.

In conclusion, the accumulating evidence from cross-sectional studies supports the hypothesis that pornography use is associated with lower sexual satisfaction. However, the magnitude of this association appears to depend on a number of factors, including gender, relationship status, frequency, duration, and pattern of pornography use, and the age at which pornography use was initiated. One should also note that although much attention is paid to associations with lower sexual satisfaction, some studies not only report no associations of pornography consumption in this regard in large number of surveyed subjects but also indicate that some individuals experience an increase in sexual satisfaction. For example, in a recent cross-sectional study of Polish students who admit to current pornography use, respectively 68% and 7% associated its consumption with no effect and a beneficial effect on sexual satisfaction [12]. Moreover, studies in couples demonstrate that use of pornography may not necessarily be associated with less sexual satisfaction, and that in some cases, a positive correlation can be observed [57]. As already shown in relation to relationship quality, it is highly plausible that the nature of the association between pornography use and sexual satisfaction in individuals in romantic relationships may not only depend solely on the frequency of use but the context in which it is consumed, such as concordance or discrepancy in partners' use, levels of acceptance of pornography use from both partners, known or hidden use, and individual or shared use [70,92]. Moreover, the longitudinal studies conducted so far have failed to fully confirm that pornography use is a causative factor in impaired sexual satisfaction. It remains to be explored whether the potential effect of pornography in this regard can be influenced by: (i) sexual orientation: the majority of studies have focused on heterosexual individuals while homo- and bisexual individuals may even be more frequent pornography users as preliminarily found in men [93], (ii) physical disabilities as they may also influence a baseline sexual satisfaction [94], and (iii) co-occurrence of other sexual dysfunctions, as some authors have indicated that pornography use may be a continuation of pre-existing compulsive sexual behaviors [64,95].

#### **6. Future Research Prospects and Conclusions**

Increasing access to the Internet has opened a completely new chapter for the pornographic industry, simultaneously increasing both the time and strength of exposure to pornographic content, and its potential effects on health. The studies conducted so far indicate a correlational relationship between pornography consumption and selected sexual dysfunctions with the strongest evidence for a decrease in sexual satisfaction. It should be noted that the vast majority of observations are based on cross-sectional studies or case reports and without future research based on extensive case-control

and/or prospective cohort studies, causality cannot be comprehensively assessed. One should also note that assessment of pornography use in studies is mostly based on self-reporting and that objective confirmation of exposure is not possible. Moreover, the presence of sexual dysfunctions such as erectile dysfunction is also often self-reported and creates the risk of their being underestimated; thus, when possible, the use of validated tools is advised. There are number of recognized risk factors for sexual dysfunctions which need to be considered when evaluating the potential effects of pornography use in future studies. The frequency of pornography use may in turn be potentially modulated by various parameters such as gender, cultural/religious factors, relationship status, and psychological background. Further research on associations between pornography consumption and sexual dysfunction should also take these into account. Unlike the effect of psychoactive substances or binge eating, the potential effects of pornography use cannot be recreated using experimental animal models, while the scope of experimental research involving human volunteers is rather limited and can often only be used to assess short-term outcomes. This in turn highlights the need for more, well-designed observational, particularly prospective studies. To provide a broad insight into the potential associations of pornography use with sexual dysfunctions, it would be best for future studies to provide a definition of pornography, specify the type of pornographic content consumed by the studied subjects (e.g., violent, nonviolent, mainstream, and paraphilic), control for the frequency of masturbation, consider the sexual orientation of participants, whether they are in a relationship or not, and if they are what is their relationship satisfaction and whether they consume pornography individually or in a shared manner. The context in which pornography is consumed rather than the mere use may moderate the associated effects, and such context must be taken into account in further assessments. The complexity of factors influencing pornography use and modulating its associated effects, as well as the susceptibility of research models to methodological biases and difficulties in overcoming the limitations of studies strongly justify a need for further investigation on the associations between sexual functionality and pornography consumption, which is particularly important given the high rates of the latter.

**Conflicts of Interest:** The authors declare no conflict of interest.

#### **References**


© 2019 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/).

### *Review* **Hormonal Contraceptives, Female Sexual Dysfunction, and Managing Strategies: A Review**

**Nerea M. Casado-Espada 1, Rubén de Alarcón 1, Javier I. de la Iglesia-Larrad 1, Berta Bote-Bonaechea <sup>1</sup> and Ángel L. Montejo 1,2,\***


Received: 12 May 2019; Accepted: 24 June 2019; Published: 25 June 2019

**Abstract:** In recent decades, hormonal contraceptives (HC) has made a difference in the control of female fertility, taking an unequivocal role in improving contraceptive efficacy. Some side effects of hormonal treatments have been carefully studied. However, the influence of these drugs on female sexual functioning is not so clear, although variations in the plasma levels of sexual hormones could be associated with sexual dysfunction. Permanent hormonal modifications, during menopause or caused by some endocrine pathologies, could be directly related to sexual dysfunction in some cases but not in all of them. HC use seems to be responsible for a decrease of circulating androgen, estradiol, and progesterone levels, as well as for the inhibition of oxytocin functioning. Hormonal contraceptive use could alter women's pair-bonding behavior, reduce neural response to the expectation of erotic stimuli, and increase sexual jealousy. There are contradictory results from different studies regarding the association between sexual dysfunction and hormonal contraceptives, so it could be firmly said that additional research is needed. When contraceptive-related female sexual dysfunction is suspected, the recommended therapy is the discontinuation of contraceptives with consideration of an alternative method, such as levonorgestrel-releasing intrauterine systems, copper intrauterine contraceptives, etonogestrel implants, the permanent sterilization of either partner (when future fertility is not desired), or a contraceptive ring.

**Keywords:** female sexual dysfunction; hormonal contraceptive; libido; desire; sex life; orgasm; vaginal ring; depot medroxyprogesterone acetate

#### **1. Introduction**

In recent decades, hormonal contraception (HC) has made a difference in the control of female fertility, taking an unequivocal role in improving contraceptive efficacy. Moreover, there are numerous studies that state that the use of hormonal contraceptives is very prevalent in the female population of childbearing age [1–8]. In a study carried out by Hall et al. in 2012, it was estimated that 63% of women of reproductive age worldwide who were married or in a relationship were using some type of contraception, with the contraceptive pill as the third most commonly used method (9% of women aged 15–19 years) [3,9]. Combined oral contraception seems to be the most popular form of reversible contraception in Europe and the United States [7,8].

The popularity and widespread use of hormonal contraceptives is partly due to their benefits, such as: (1) Being a highly effective and reversible form of contraception; (2) the woman has control over this method of contraception; (3) the failure rate is less than 1%; and (4) they have a well-established safety profile [1].

However, the use of hormonal contraceptives is relatively recent: In 1956, an oral contraceptive pill (mestranol in combination with norethynodrel) was used for the first time in a clinical trial; a year later, in 1957, the formulation of 150 μg mestranol and 10 mg norethynodrel received approval for the treatment of "female disorders" (menstrual irregularities, etc.) [1]. It was three years later, in 1960, when the Food and Drug Administration (FDA) approved the use of the pill as a contraceptive, containing 75 mestranol and 5 mg norethynodrel [1,10]. At the beginning, oral contraceptives were available only to married women, and, in 1972, the pill also began to be available for single women in all states [1]. Since the approval of the use of the pill in 1960, it has undergone many evolutions in dosage, hormone type, and regimen. It has been used by more than 100 million women worldwide and has the widest geographic distribution of any method of contraception [10].

The use of hormonal contraceptives is widespread, with a significant percentage of healthy population among its users. Some of its side effects are well known, such as the increased prothrombotic and cardiovascular risk (estrogen dependent) [10]. On the other hand, non-contraceptive benefits of hormonal contraceptives, such as as cycle regulation with predictable withdrawal bleeds, decreased menstrual flow, and decreased anemia, have been widely documented [10]. However, the influence of these drugs on female sexual function is not as clear, although it is mentioned in the technical prospects of the contraceptive pills. Additionally, there are very few controlled studies in this field.

Conversely, despite the widespread use of contraceptives in the general population, there are many other drugs that have been widely studied and associated with frequent iatrogenic sexual dysfunction. Antihypertensive drugs, diuretics, and beta-blockers seem to exert a detrimental impact on sexual function [11], as do antipsychotics [12–14], antidepressants [12,13,15], and others. In addition, there are endocrine disorders that are also associated with alterations in sexual function, such as diabetes [16], obesity, and metabolic syndrome [17]. On top of this, sexual dysfunction is a possible symptom associated with other hormonal alterations such as those that take place during menopause [18] or postpartum [19]. There are differences regarding which aspects of sexual function were most affected by menopause. The Massachusetts Women's Health Study, the Melbourne Women's Midlife Health project, the Penn Ovarian Aging Study and the Study of Women's Health Across the Nation (SWAN) are some of the pieces of research that were carried out in this regard. Notably, three out of four of these studies noted declines in sexual desire during the menopause transition [18].

In this review, first of all, detailed information has been included about the hormonal contraceptive methods, focusing on the type of administration, hormonal composition, mechanism of action, and expected effects on hormonal function in women. Second, an approximation is given to the concept and significance of sexual dysfunction, in addition to its prevalence in the female population. These first sections have the objective of contextualizing and favoring the understanding of the next ones; the main aim of this study is to clarify whether there is evidence of the effect of hormonal contraceptives on female sexual function. In this review, we attempt to provide a summary of the existing data about the impact of hormonal contraceptives on sexuality. We differentiate between studies that claim that there are no effects of hormonal contraceptives on sexual function and others that defend that there are. Within the latter, we differentiate between those that show positive and negative effects on female sexual function. Likewise, in this review, some treatment options are proposed according to the studies reviewed.

This review provides a compilation of the existing evidence about the relationship between female sexual function and hormonal contraceptives, in addition to the existing therapeutic management strategies. This is the first review that includes a summary table, which allows the clinician to access to the most relevant information at a glance. Likewise, it is the only study that proposes a therapeutic algorithm for the management of hormonal contraceptives-related sexual dysfunction.

#### **2. Materials and Methods**

The aim of this review is developing, assimilating, and synthesizing the existing evidence about the influence of hormonal contraception on female sexual function. In addition, we intended to identify gaps in knowledge in this field in order to design new studies that may fill those gaps in the future. Our review focuses on the use of hormonal contraceptives in women of childbearing age and on the influence of these drugs on female sexual function [1,2]. In addition, the study reviews the differences in the influence of the HCs on female sexual function (FSF) according to the hormonal composition and the mechanism of action of the different HCs in order to determine which one has the lowest profile of secondary effects in the sexual area. On the other hand, to our knowledge, this is the latest effort to offer an overview of the recommended strategies in cases in which the use of HCs is associated with sexual dysfunction.To achieve this purpose, we performed a scoping review following PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) (Figure 1). In this review, we selected key articles based on hormonal contraception and female sexual function. PubMed and Cochrane were chosen as the main databases used due to the extensive contents of biomedical research they offer, their free access, and their ease of use. Our search term combinations were: "Hormonal contraception" AND "female sexual function" OR "female sexual dysfunction." The filters "publication date: From 2000/01/01 to 2019/01/31" and "review" were applied in the search in order to limit the amount of material available. No language restrictions were applied. Similar and related articles that were considered of special interest for our review were also included, and they were compiled though cross-referencing. Similarly, some relevant clinical practice guidelines were included. The 64 papers that were included were chosen because they fit the topic of the review (presenting information about female sexual dysfunction, hormonal contraception, hormonal variations, and their relationship with female sexual function; directly treating the impact of hormonal contraceptives in female sexual function; or providing relevant information about the management strategies of female sexual dysfunction associated with the use of HCs). We reviewed six prospective observational studies, eight clinical trials, 19 cross-sectional studies, 22 reviews, and nine other works that include consensus and clinical practice guidelines. Most of the studies were carried out in European countries, although there were also studies carried out in the US, Asia, Australia, and South America. The population of the studies reviewed varied between 40 and 18,787, although in the case of clinical trials, the largest population analyzed was 600 subjects.

**Figure 1.** PRISMA flow diagram. (Preferred Reporting Items for Systematic Reviews and Meta-Analyses).

We summarized the findings and best practice recommendations for addressing a woman's contraception and its potential association with sexual function. We excluded those articles that focused on male sexual dysfunction, menopause, and sexual dysfunction related to medical disease, such as oncological pathology. Every attempt was made to combine as much similar data as possible. Institutional review board approval was not needed for this review.

#### **3. Results**

#### *3.1. Hormonal Contraceptives*

The combined oral contraceptive (COC) was first approved in 1960. Since then, it has undergone many evolutions in dosage, hormone type, and regimen. It has been used by more than 100 million women worldwide and has the widest geographic distribution of any method of contraception [10]. In this section, we will provide detailed information about hormonal contraceptives in terms of the existing types, their hormonal composition, their mechanism of action, and the alterations in hormonal function that derive from them.

#### 3.1.1. Types

At present, there are twenty different contraceptive methods approved by the FDA [20], ten of which are female hormonal contraceptive methods: Eight are reversible contraceptive methods, and two are emergency contraceptive methods. In Table 1, we can see the different categories of hormonal contraceptives mentioned.


**Table 1.** Hormonal contraceptives. Route of administration, dosing frequency, mechanism of action, and association with sexual effects.



Reversible contraceptive methods include: Combined hormonal contraceptives (CHCs), progestin-only contraceptives, and intrauterine contraceptives (IUCs). COCs include the "pill" or combined oral contraceptives (COCs), the contraceptive patch, and the vaginal ring. When talking about progestin-only contraceptives, we can differentiate between progestin-only-pills (POPs), depot medroxyprogesterone acetate (DMPA), and the "implant" or single rod etonogestrel subdermal implant. IUCs include copper intrauterine devices (Cu-IUDs) and levonorgestrel-releasing intrauterine systems (LNG-IUS) [10,21,22]. Emergency hormonal contraceptives (ECs) are: Levonorgestrel of 1.5 mg (1 pill) or 0.75 mg (2 pills) and ulipristal acetate [20]. Permanent contraceptive methods that are approved by the FDA are: Sterilization surgery for women, a sterilization implant for women, and sterilization surgery for men [20].

#### 3.1.2. Hormones

The hormonal composition of hormonal contraceptives is based on progestins alone or on a combination of progestogens and estrogens [10,20–24]. Several different progestins are used in combined oral contraceptives (COCs). These progestins may also have estrogenic, antiestrogenic, androgenic, antiandrogenic, or antimineralocorticoid activity [10]. Most progestins are 19-nortestosterone derivatives. Progestins may be classified according to their chemical structure as an estrane (norethindrone, norethindrone acetate, ethynodiol diacetate) or as a gonane (LNG, desogestrel, norgestimate). In general, gonane progestins appear to be more potent than the estrane derivatives (smaller doses can be used), but other differences between the estrane and gonane compounds are difficult to characterize [10]. Table 2 shows the classification of progestogens used in hormonal contraception according to their androgenic potency. Among the contraceptive progestins available in the United States, norgestrel and levonorgestrel are the most androgenic; norethindrone and norethindrone acetate are less androgenic; and desogestrel, etonogestrel, norgestimate, dienogest, and drospirenone are the least androgenic [2]. Newer progestins (norgestimate and desogestrel) have little or no androgenic activity, whereas other progestins (cyproterone acetate, drospirenone, and dienogest) have antiandrogenic activity [10]. The varying progestational "potencies" attributed to different COC preparations are based on pharmacological experimental models. Many variables affect the potency of COCs (including dosage, bioavailability, protein binding, receptor binding affinity, and interindividual variability), making it difficult to extrapolate the results of isolated experiments to provide clinically relevant information in humans. There is no clear clinical or epidemiological evidence that compares the relative potencies of currently available COCs [10]. Systemic progestins may be associated with a loss of sexual desire due to the suppression of ovarian function and endogenous estrogen production [6]. Along the same line of reasoning, in their study about women's self-reported sexual desire across natural cycles, Roney and Simmons observed that levels of salivary progesterone negatively predicted women's sexual desire [25,26]. Furthermore, based on the findings by Grebe et al., effective dosages of progestin should be associated with a stronger positive linkage between women's loyalty/faithfulness to their relationship partners and the frequency with which they engaged in sexual intercourse with their partners [26,27]. However, contraceptive pills with progestogens with antiandrogenic effect do not affect sexual desire, according to some reports [28,29]. In recent studies, drospirenone and dienogest have reported a positive effect on sexual response as well as attraction, desire, satisfaction, and coital frequency [28,30], perhaps due to the ability to reduce the activity of 5-alpha reductase [31].


**Table 2.** Classification of progestogens used in contraception according to their androgenic potency.

With regard to estrogens as hormonal components of hormonal contraceptive methods, three types of estrogens are used in COCs (as it can be seen in Figure 2): Ethinylestradiol (EE), estradiol valerate (E2V), and 17 beta-estradiol (E2). E2V is rapidly metabolized to E2 [10]. Due to its biochemical structure, estradiol has less impact on the synthesis of hepatic proteins than ethinyl estradiol, which is likely to result in a better metabolic and vascular profile [3]. The new formulations of launched COCs have lower doses of estrogen, and EE has been replaced by more "physiological" forms of estrogen, such as 17β-estradiol (E2) or E2-Valerate (E2 V) [32]. There is some evidence to suggest that estrogens play an essential role in female sexuality, and prior research has found that declining sexual functioning in women is most closely related to declining estrogen levels [6,33] Similarly, levels of salivary estradiol positively predicted women's sexual desire, conversely to progesterone [25,26]. Regarding loyalty and faithfulness, dosages of estradiol should predict a weaker positive linkage between women's loyalty/faithfulness to their relationship partners and frequency of sexual intercourse (not including masturbation and sexual fantasies; independently of androgenicity of sexual hormones) [26,27].

**Figure 2.** Types of estrogens used in combined oral contraceptives (COCs).

#### 3.1.3. Mechanism of Action of Hormonal Contraceptives

In Table 1, we can see a summary of the different categories of hormonal contraceptives mentioned with their respective mechanism of action of hormonal contraceptives. The mechanism of action of hormonal contraceptives depends on their hormonal composition and the route of administration.

Combined hormonal contraceptives (CHCs) encompass oral contraceptives (pill), patch, and the vaginal ring. Their mechanism of action is similar.

With regard to combined oral contraceptives (COCs), they have multiple mechanisms of action due to both their estrogenic and progestational components: The suppression of pituitary gonadotropin secretion (inhibiting ovulation), the increase of cervical mucus viscosity (impairing sperm transport), the suppression of the luteinizing hormone (LH), and the impairment of ovulation [10].

The patch is a 20 cm2 square matrix system that delivers 200 mg of norelgestromin (the primary active metabolite of norgestimate) and 35 mg of ethinylestradiol (EE) daily to the systemic circulation. Following the first application of the patch, serum hormone levels increase gradually over the first 48–72 h, reach a plateau, and then remain constant during the remainder of the 21-day period. Compared with COC, plasma hormone levels remain constant, and the peak levels are lower because first-pass hepatic metabolism and gastrointestinal enzyme degradation are avoided. Curiously, although peak levels are lower, the area under the curve, which represents overall EE exposure, is larger. One patch is applied weekly for three consecutive weeks, followed by a one patch-free week. The patch can be placed on one of four sites: The buttocks, upper outer arm, lower abdomen, or upper torso, excluding the breast [10].

The ring releases 15 mg of EE and 120 mg of the progestin etonogestrel (ENG) (the active metabolite of desogestrel) per day, which is absorbed through the vaginal epithelium. Serum hormone levels increase immediately after ring insertion and then decrease slowly over the cycle [10]. The vaginal route is an ideal method of drug administration, and the advantages of this method are well established. By avoiding gastrointestinal absorption and the hepatic first-pass effect, the vaginal administration of contraceptives enables the use of lower hormonal doses and the achievement of steady drug concentrations [34].

There is another group of hormonal contraceptives only composed of progesterone. This group can include the progestin-only pill, depot medroxyprogesterone acetate (DMPA), and the etonogestrel implant. Progestin-only pills (POPs, the "mini-pill") provide reliable, reversible contraception and have very few contraindications. The main mechanism of action is the alteration of the cervical mucus (more viscid, less copious) and the inhibition of sperm penetration. Negative luteinizing hormone (LH) feedback leads to the suppression of ovulation in up to 50% of users. POPs containing desogestrel may inhibit ovulation more consistently [21].

DMPA is administered intramuscularly at three-month intervals (every 12–13 weeks) and is thus considered a long-acting reversible contraceptive (LARC) by some and a short-acting reversible contraceptive (SARC) by others. DMPA works primarily by inhibiting the secretion of pituitary gonadotropins, thereby suppressing ovulation. Women enter a hypoestrogenic state, and their

progesterone is low due to anovulation. DMPA also increases the viscosity of cervical mucus (minor mechanism of action) and induces endometrial atrophy [21].

The single-rod etonogestrel subdermal implant (Implanon/Implanon NXT/Nexplanon) is a LARC. The single-rod implant contains 68 mg of the progestin etonogestrel (ENG) and provides contraception for three years. The ENG implant works primarily by inhibiting ovulation and consistently does so until the beginning of the third year of use. Ovarian activity, including estradiol synthesis, is still present. The ENG implant causes a thickening of the cervical mucus and changes in the endometrial lining [21].

The last group is formed by intrauterine contraceptives (IUCs). This group includes copper intrauterine devices (Cu-IUDs) and levonorgestrel-releasing intrauterine systems (LNG-IUS). Only LNG-IUS are explained in this section, because Cu-IUDs do not have a hormonal component. The chief mechanism of action of all IUCs is the prevention of fertilization; they may also have post-fertilization effects, including the potential inhibition of implantation. The LNG-IUS produce a weak foreign body reaction and endometrial changes that include endometrial decidualization and glandular atrophy. The primary mechanism of action is via changes in the amount and the viscosity of cervical mucus, which acts as a barrier to sperm penetration. Ovulation is likely inhibited in some women, but it is preserved in most study subjects. Endometrial estrogen and progesterone receptors are suppressed, which results in changes in bleeding patterns and may contribute to its contraceptive effect [22].

3.1.4. Hormonal Alterations of Hormonal Contraceptives and Their Influence on Female Sexual Function

In contrast to animal species in which linear relationships exist between hormonal status and sexual behavior, sexuality in the human population is remarkably complex and is not determined so simply by the level of sexual steroids [29].

Hormonal contraceptives (HCs) are responsible for a decrease of circulating androgen levels [1,2,29,35], as well as a decrease of the baseline serum levels of estradiol [6,29,35] and progesterone [35] and the inhibition of oxytocin functioning [35]. However, the concentrations of the follicle-stimulating and luteinizing hormones are similar in freely cycling women and in women using HCs [35]. Decreased circulating androgen levels with oral combined hormonal contraceptive (CHC) use, and its negative effects on sexual life, occur by two mechanisms, as follows: (1) An oral CHC increases sex hormone-binding globulin (SHBG) and decreases free testosterone, and (2) androgen production from the ovary is suppressed with an oral CHC. This antiandrogenic effect may be magnified with an oral CHC containing an antiandrogenic progestin [2]. Thus, all CHCs are antiandrogenic, although some formulations, depending on the specific progestin, are more so than others. The patch and the vaginal ring are more antiandrogenic than the pill [1]. As expected, the baseline serum levels of estradiol and progesterone are significantly higher in freely cycling women than in women using an HC. Nevertheless, the concentrations of the follicle-stimulating and luteinizing hormones are similar in both groups [35]. In respect of oxytocin, its functioning is likely to be altered by this variation in the peripheral estradiol and progesterone levels that were found to be altered in women using HCs, and, therefore, a potential mechanism could be related to the direct binding of progesterone to oxytocin receptors (OXTRs), thereby inhibiting OXTR functioning.

The association between hormones and sexuality is multidimensional, as several hormones are important in the regulation of sexual behavior [29].

Though some evidence shows that testosterone has a role in sexual function for women, these conclusions are derived primarily from studies involving postmenopausal women reporting sexual dysfunction [2]. It has been established that sexual desire, autoeroticism, and sexual fantasies in women depend on androgen levels [29]. However, the relevance of changes in androgen levels for an individual woman is unclear, and some women may be more sensitive to androgen level alteration than others [2]. The review by Casey et al. mentioned that most of the studies showed alterations in SHBG and testosterone levels; however, an overall lack of association was found between CHCs and sexual desire [2]. In other studies, decreased levels of estrogen and testosterone in older women have been associated with decreased libido, sensitivity, and erotic stimuli [29]. In addition, it has been found that patients using birth control pills may present with decreased libido. On the other hand, there are reports that suggest that progestogens with antiandrogenic effects in contraceptive pills do not affect sexual desire [29]. While there is conflicting evidence concerning a link between progestins and libido, there is some evidence to suggest that estrogens play an essential role in female sexuality. In this respect, prior research has found that declining sexual functioning in women is most closely related to declining estrogen levels [6].

Finally, with regard to oxytocin, Scheele et al. [35] describe in their work the possible functional implications of oxytocin in female sexuality and the alterations that occur in women who take hormonal contraceptives. Multiple lines of evidence suggest that the hypothalamic peptide oxytocin (OXT) is a key factor modulating pair-bonding behaviors, which means a strong affinity that develops in humans and some species between a mating couple.

In humans, peripheral OXT concentrations are significantly higher in new lovers compared with singles. Likewise, OXT reduces jealousy ratings and neural responses in an imagery task of sexual partner infidelity. OXT also increases the arousal induced by infant photos in nulliparous women and promotes responsiveness to infant crying and laughter by reducing activation in anxiety-related neural circuits. Moreover, OXT has been found to increase the intensity of orgasm and contentment after copulation. Nevertheless, OXT seems to not have an effect on vital signs. The results of the research by Scheele et al. [35] indicate that endogenous OXT concentrations at baseline positively predicted striatal responses to the romantic partners' faces in all female participants. This mechanism was disturbed in those women using an HC, indicating that the partner-specific modulatory effects of OXT are antagonized by gonadal steroids. HC use alters women's pair-bonding behavior (evident in decreased attractiveness ratings of masculine faces), reduced neural response to the expectation of erotic stimuli (a preference shift towards olfactory cues of genetic similarity), and increased sexual jealousy. Furthermore, women who use an HC while choosing partners are more likely to initiate an eventual separation, and wives who discontinue HC use tend to be less satisfied with marriage if they perceive their husband's face to be less attractive. On the other hand, women prefer masculine faces and exhibit higher levels of intersexual competition related to attractiveness at peak fertility in the menstrual cycle; however, these cyclical shifts were found to be diminished in women using an HC. In conclusion, OXT interacts with the brain reward system to reinforce partner value representations in both sexes, a mechanism which may significantly contribute to stable pair-bonding in humans and appears to be altered in women using an HC.

#### *3.2. Sexual Dysfunction*

To talk about the effects on sexual function, it is first convenient to define the concept of sexual dysfunction, as well as the types of female sexual dysfunction that are currently described. In this section, the methods used and validated to quantify the degree of sexual dysfunction are also briefly discussed. In addition, an estimate of the prevalence of sexual dysfunction in the female population of childbearing age is shown.

According to the DSM-5 (Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition), sexual dysfunctions are a heterogeneous group of disorders that are typically characterized by a clinically significant disturbance in a person's ability to respond sexually or to experience sexual pleasure [18,36]. On the contrary, we would define "sexual health" as a state of physical, emotional, mental, and social well-being related to sexuality; it is not merely the absence of disease, dysfunction, or infirmary. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination, and violence [37].

Therefore, optimal sexual function transcends the simple absence of dysfunction [18]. In this regard too, multiple studies have shown a strong positive association between sexual function and the health-related quality of life [18]. Having said that, it can be gathered that the female sexual function is complex and multifactorial, and it is influenced by many biological, psychological, and environmental factors [2,5,18,29]. Therefore, a complete understanding of women's sexual function requires the individual assessment of these factors. The biopsychosocial approach recognizes that biological, psychological, interpersonal, and sociocultural factors can all affect female sexual function, and these factors interact with each other in a dynamic system over time. Biological factors may include hormonal changes that affect the libido or medical/anatomical problems that affect genital sexual response. Psychological factors include mood symptoms, like depression or anxiety, or negative behaviors such as critical self-monitoring during sexual activity. Some examples of interpersonal factors include general satisfaction in the woman's relationship with her partner, which is closely tied to overall sexual satisfaction, as well as quality of communication in the relationship. Finally, some sociocultural factors to consider include the woman's attitudes about menopause and aging, as well as religious, cultural, and other social values regarding sex [18].

When assessing alterations of sexual function possibly related to hormonal contraceptives, other factors that may also affect it should be taken into account. For example, sex hormones (mainly low levels of estradiol), physical and mental well-being, availability of a partner, feeling for her partner, illness and its treatments, changes in social circumstances, and low socioeconomic status could have an impact on women's desire and sexual responsiveness [5,18]. Therefore, there are several factors that can affect female sexual function which should be explored by health providers for an adequate diagnostic and therapeutic approach to sexual dysfunction. However, there are studies that show in their results that sexual health is not a widely explored area for health providers in general. Mercer et al. showed that only 21% of women with persistent sexual problems discuss it with their healthcare provider [18,38]. Furthermore, a recent survey in the USA reported that the majority of gynecologists routinely ask patients about their sexual activities, but most other areas of patients' sexuality, such as sexual problems, including pleasure and satisfaction, are not routinely discussed [34,39].

Theoretical models of women's sexual response can provide a framework for a better understanding female sexual dysfunction. Three of these models are briefly explained here. First, according to the Masters–Johnson model, sexual response progresses predictably and linearly from excitement to plateau, orgasm, and resolution. The main focus of this model is on the physical response of the genitals. Secondly, Helen Singer Kaplan noted that many individuals had problems with sexual desire, denoting the importance of desire to sexual response. In the 1970s, she modified the Masters–Johnson model to a three-phase model of desire, excitement, and orgasm. Thirdly, in 2000, Rosemary Basson and colleagues proposed an alternative circular model of female sexual response. This model has several distinguishing features. On the one hand, spontaneous desire (or "sexual drive") on the part of the woman is not always the starting point for sexual activity. On the other hand, this model emphasizes that sexual stimuli often precede physical arousal and desire, and sexual arousal and desire often co-occur. Finally, the Basson model acknowledges that both physical and emotional satisfaction are important outcomes of engaging in sexual activity. This physical and emotional satisfaction can lead to higher emotional intimacy, which, in turn, can lead to greater receptivity and seeking out of sexual stimuli—hence, the circular model [18].

There has been debate regarding which model best reflects the experiences of women. In a study of 133 women, most of whom were in their 40s and 50s, women who had Female Sexual Function Index (FSFI) scores falling into the "dysfunctional" range and postmenopausal women were more likely to endorse the Basson model [18,40].

With the concept of sexual dysfunction now developed, we may now discuss the types of sexual dysfunction that are described. Four types of female sexual dysfunction are currently recognized: (1) Female orgasmic disorder, (2) female sexual interest/arousal disorder, (3) genito-pelvic pain/penetration disorder, and (4) substance/medication-induced sexual dysfunction. In order to quantify sexual dysfunction in a fairly objective way, there are two commonly used instruments in sexual function studies: The Female Sexual Function Index (FSFI) and the Female Sexual Distress

Scale-Revised (FSDS-R) [18]. The Female Sexual Function Index (FSFI) is a 19 item scale with six domains: Desire, arousal, lubrication, orgasm, pain, and satisfaction. In this scale, questions are graded on a Likert scale, and domains are weighted and summed to give a total score ranging from 2–36, with a cutoff of less than 26.55 suggesting sexual dysfunction. The FSFI has been validated in multiple languages, across age groups, and for multiple sexual disorders [18,41].

Why is it important to read up on sexual dysfunction? Sexual problems are common, estimated to affect 22–43% of women worldwide [18]. Overall, 27% of all reproductive-age US women (aged 18–44 years) report sexual dysfunction, with low sexual desire being the most common, and 10.8% of these women also experience related distress [2]. The prevalence of sexual dysfunction peaks at midlife, with 14% of women aged 45–64 reporting at least one sexual problem associated with significant distress [18]. The proportion with a notable or severe problem in desire, arousal, activity, or satisfaction ranges from 19–25% [5].

#### *3.3. The E*ff*ects of Hormonal Contraceptives on Sexuality*

This section presents different results found in the literature about the effects of hormonal contraceptives (HCs) on female sexuality (including results that advocate for positive or negative effects or the absence of sexual effects). It also discusses the peculiarities of the different types of HCs on sexuality.

#### 3.3.1. Hormonal Contraceptives Do Not Have Sexual Effects

Some studies have found no change in sexual function with some hormonal contraceptives (HC) [2,3,6,10,42–46]. A recent systematic review of 36 studies involving more than 13,000 women reported no significant changes in sexual desire with the use of oral combined hormonal contraception (CHC) [43]. Another study [47] also reported high satisfaction rates with both LNG-IUS and copper IUC but no difference in sexual function overall or within psychological domains. In another recent study, no association was found between any LARC method and sexual satisfaction scores [48].

On the other hand, Reed et al. explored the relationship between oral contraceptive (OC) use and the risk of developing vulvodynia [49]. Further analysis showed no association between vulvodynia and previous OC use (HR 1.08, 95% CI 0.81–1.43, *p* = 0.60). In a study by Iliadou et al. [50], patients reporting mixed urinary incontinence (MUI) were divided into three groups according to contraceptive use. Of 196 women with MUI, 16 were currently using OC, and 178 reported no current use. Among the 8493 controls, 6321 were not using OC, and 2056 were (*p* < 0.0001). A systematic review of the literature found that sex drive is unaffected in most women taking OC, 3.5% of women taking OC reported a decrease in sexual desire, 12.0% reported an increase, and most of them (84.6%) reported no change [43]. However, the effects of other forms of hormonal contraception on sex drive have not been studied as comprehensively as OC [1].

#### 3.3.2. Hormonal Contraceptives Have Sexual Effects

#### Positive Effects

According to the studies reviewed, hormonal contraceptives have a series of non-contraceptive effects which can influence and improve different areas of female sexual function. Some of these non-contraceptive effects are: Relief of gynecologic pain [1]; improved appearance, self-confidence, and self-esteem [2]; decrease of anxiety and discomfort [2]; loss of fear of having an unwanted pregnancy [6]; more stable levels of hormones throughout the cycle [51]; and less bleeding with the consequent lower risk of anemia [51]. All these effects contribute to the well-being of women and, consequently, to a possible improvement in the female sexual function. Similarly, hormonal contraceptives have described positive effects on some areas of female sexuality. The most frequently affected areas are: Sexual desire, orgasm number and intensity, satisfaction, and arousal. As mentioned, HCs may help to eliminate the fear of pregnancy, presumably providing a more relaxed and enjoyable sexual experience [1]. Similarly, it is reasonable to consider that an improved appearance would promote self-confidence and increase self-esteem, thereby having a positive effect on sexual function [2]. In a comparison between the vaginal ring, an oral CHC containing a third-generation progestin, subdermal contraception, and no hormonal contraception (control group), the three groups using an HC had increased positive indicators of sexual function (sexual interest and fantasies, orgasm number and intensity, and satisfaction) and decreased negative indicators (anxiety and discomfort). The same results were obtained in a comparison between etonogestrel implant and no contraception [2,52]. LNG-IUS have also been positively associated with sexual desire, arousal, orgasm, and overall sexual function compared with no contraception [2,53].

Furthermore, it may be advantageous for women to have more stable levels of hormones throughout the cycle. Because of the monthly fluctuations in estrogens, progesterone and androgens are associated with a range of symptoms, both genital (i.e., vaginal bleeding, heavy menstrual bleeding (HMB), dysmenorrhea, and pelvic pain) and systemic (i.e., depression, fatigue, headache, irritable bowel symptoms (IBS), asthma, and allergy), triggered by a local and systemic rise in inflammatory molecules released by mast cells when estrogen levels drop [51].

#### Negative Effects

To begin with, diminished sexual pleasure experienced by some women who use hormonal contraceptive methods may also be a barrier for their use [54], and this could imply an increase in the woman's vulnerability to unintended pregnancy [54]. Consequently, it is important to keep in mind that hormonal contraceptives could have associated side effects that have an influence on female sexual function. Some of these effects could be: Vaginal dryness [2,10,51], a decrease of lubrication [2,51], and pelvic floor symptoms such as dyspareunia [3,51], urinary incontinence, vestibulodynia, and interstitial cystitis [3]. COCs have been also associated with long- and short-term anatomical changes, such as atrophic vulvovaginitis and a decrease of thickness of the labia minora and vaginal introitus area [1]. Negative effects on some areas of female sexuality have been described with HCs, such as: Decreased sexual desire [2,6,10,54], frequency of intercourse [2,54], arousal [2,54], pleasure [2,54], orgasm [2,54], sexual thoughts [54], interest, and enjoyment [6,54].

In contrast to the above section, Elaut et al. [46] and Li et al. [55] defend in their studies that desire and coital frequency naturally increase around ovulation and premenstrually, and COC-associated ovulation inhibition and cycle regulation may blunt this effect, with the corresponding negative impact on libido [10]. Furthermore, longer durations of oral CHC use and younger ages at initiation have been associated with a higher relative risk of vestibulodynia [2], with the resulting negative impact on female sexual function.

#### 3.3.3. Effects on Sexual Function According to the Type of Hormonal Contraceptive

Combined oral contraceptives are widely studied. Nevertheless, other hormonal contraception methods have fewer studies about their influence on sexual function. In this section, the results obtained from the studies reviewed for each type of hormonal contraceptive will be presented. Table 1 shows a summary of this information.

#### Contraceptive Patch

Concerning patch-related sexual effects, this could be considered the most innocuous CHC. Gracia et al. [56] found that among recent COC users, slight increases in sexual function scores were noted with patch use. However, they concluded that for both products, these changes are not likely to be clinically significant [1,34]. Therefore, it would be advisable to expand the research in this regard.

#### Contraceptive Ring

With regard to ring-related sexual effects, there are mixed results. On the one hand, two studies showed a decrease in sexual function with vaginal ring compared with COCs [56,57], and one study showed similar results but compared with the patch [58]. However, an improvement in sexual function

including sexual desire, fantasies, and satisfaction, accompanied by a reduction of sexual distress, has been described with the vaginal ring [1,2,10,34]. In another study [34], compared with nonusers of hormonal contraception, both vaginal ring and COC users reported significant improvements for anxiousness, sexual pleasure, frequency and intensity of orgasm, satisfaction (all *p* < 0.001), sexual interest, and complicity (*p* < 0.01). However, only women in the vaginal ring group reported a significant increase in sexual fantasies (*p* < 0.001 versus nonusers), while ratings for sexual interest and complicity were significantly higher in ring users versus COC users [34]. As suggested by the researchers, these data indicate that both oral and vaginal contraception seem to improve to some extent the sexual life of women and their partners, whereas the vaginal ring seems to exert a further beneficial effect on the psychological aspects of sexual functioning [59].

Vaginal contraception offers many benefits, including high efficacy, good tolerability, ease of use, once-a-month dosing, and a favorable pharmacokinetic profile, with the added benefits of positive effects on the vaginal microbiome and on sexual parameters [34]. In addition, good cycle control and less fluctuating serum hormonal levels could contribute to the high degree of users' acceptability and satisfaction. Most importantly, a discussion about the vaginal delivery of contraceptive hormones offers the opportunity to stimulate an open dialogue about vaginal functions, thus ultimately contributing to enhancing women's sexual well-being and reproductive health [34]. Consequently, it could be a good hormonal contraceptive option.

#### Depot Medroxyprogesterone Acetate (DMPA)

DMPA is a highly effective method of contraception. It has been used as a contraceptive agent since 1967 by millions of women worldwide, particularly in less developed regions [21]. In respect of DMPA-related sexual effects, there are mixed results. Despite decreased libido being a common complaint among DMPA users and the fact that progestins have been observed to decrease interest in sex [6], positive sexual effects are also described with this method [6,60]—some reviews even reveal that DMPA is unlikely to be associated with sexual function in women [1,2,6]. However, further research would be needed to support these claims.

#### Etonogestrel Implant

Etonogestrel implant-related sexual effects are described as negative effects. It has been associated with a lack of interest in sex, a decreased libido, and a reduced sex drive. In addition, a decreased libido has been observed as a significant cause for implant discontinuation [1,6].

#### Levonorgestrel-Releasing Intrauterine Systems (LNG-IUS)

Intrauterine contraceptives (IUCs) are long-acting reversible contraceptive (LARC) methods that are used by over 150 million women worldwide. IUCs are highly effective methods of contraception that can be used by women of all ages. Rates of IUC use vary throughout the world, from a maximum of 41% in China to a minimum of 0.8% in sub-Saharan Africa [22]. They have generally been associated with positive sexual effects. They have been reported to improve desire, sexual function, and arousal [1,2,60]. Moreover, they seem to improve the health-related quality of life through the improvement of dysmenorrhea and symptoms in patients with endometriosis and adenomyosis, among other things [22].

3.3.4. Other Non-Hormonal Methods of Contraception and Their Effect on Sexual Function

#### Copper Intrauterine Devices (Cu-IUDs)

There has been no evidence to suggest that the copper IUD is associated with an altered libido [6].

#### Vasectomy/Tubal Ligation

As a non-hormonal contraceptive method, the effect of sterilization on sexual function extends beyond a simple hormonal effect into the psychological aspects of permanent pregnancy prevention, whether positive (i.e., relief and comfort in the knowledge that sexual activity will not result in pregnancy) or negative (i.e., regret that pregnancy is no longer possible) [2].

#### Nonuse of Contraception

Female sexual function is complex and multifactorial and is influenced by many biological, psychological, and environmental factors [2,5,18,29]. Therefore, a complete understanding of women's sexual function requires the individual assessment of these factors. Consequently, sexual dysfunction does not have to be associated with hormonal contraception. The use of no contraception was associated with a higher rate of the FSD than the use of either CHCs or nonhormonal methods. Furthermore, lower rates of sexual dysfunction were noted among women using either copper IUC (21%) or a levonorgestrel intrauterine systems (LNG-IUS) (10%) than among women using no contraception (35%). Among other reasons, diminished sexual function perceived to be related to contraception may lead to the nonuse of effective contraception, and, conversely, the nonuse of contraception may in itself be a factor in sexual dysfunction, perhaps owing to concerns about unintended pregnancy [2].

#### 3.3.5. The Sexual Side Effects of Hormonal Contraceptives are not Well Studied

Existing evidence for an association between sexual dysfunction and contraception is inconsistent, and additional research is needed [2]. Findings from studies comparing women using non hormonal contraception with those using hormonal methods have shown mixed results [2]. The sexual side effects of hormonal contraceptives are not well studied, particularly with regard to their impact on libido [1]. Similarly, there is no clear information about the effect of HCs on pelvic symptoms and sexual function, nor on how they affect a woman's quality of life in relation to bowel and bladder symptoms, regardless of period control and menstrual bleeding. Moreover, the association between COC use and the presence of any type of urinary incontinence (UI) is unclear, and results suggest that the effect of current COC use on dyspareunia per se is inconsistent [3].

Healthcare care providers must be aware that hormonal contraceptives can have negative effects on female sexuality so they can counsel and care for their patients appropriately [1]. In order to better evaluate any possible effect on mood or libido, practitioners should assess patients prior to initiation of hormonal contraception to establish their baseline [60]. The lack of consistency in findings highlights the complex and multifactorial nature of female sexual function and focuses on the need for a comprehensive approach to management [2].

#### *3.4. Management Strategies for Sexual Dysfunction Secondary to Hormonal Contraceptives*

This section approaches the therapeutic possibilities for female sexual dysfunction described in the literature. In addition, some keys are given for the management of sexual dysfunction secondary to hormonal contraceptives (Figure 3).

First, when addressing a new sexual complaint, a thorough history using a biopsychosocial approach should be undertaken (Table 3) [18], including an assessment of any current or past psychiatric disorders; medication use and health problems; a history of emotional, physical, or sexual abuse; beliefs and attitudes regarding sex, menopause, and aging; and body image concerns. Particular attention should be paid to symptoms of depression, anxiety, and sleep problems, all of which are common during the menopause transition. Providers should inquire about alcohol or drug use, as substance use disorders are also associated with sexual dysfunction. Any health or sexual problems affecting the woman's sexual partner(s) should also be explored. Providers should inquire about relationship discord or communication issues, and if present, recommend therapy with a certified and specialized therapist [18]. A multidisciplinary approach to the management of female sexual

dysfunction (FSD) is suggested, particularly when multiple contributing or complicating factors are identified, and this may consist of consultations with other professionals, such as a sex therapist, a pelvic floor physical therapist, and a sexual health specialist [2].

**Figure 3.** Management strategies for hormonal contraceptive (HC)-related sexual dysfunction.

**Table 3.** Main data to be collected in the clinical history in case of symptoms of sexual dysfunction.

#### **Information that should be collected in the medical record by health providers in response to a complaint of sexual dysfunction:**


Second, lifestyle counselling should be given by the health providers. General lifestyle counselling that may be useful for all types of female sexual dysfunction include recommending setting aside time for connecting with one's partner, increasing the woman's exposure to sexual stimuli such as erotic literature or films, encouraging the maintenance of a healthy weight, ensuring adequate physical activity and sleep, enhancing skills for coping with stress, and recommending books women can use for self-education (Table 4) [18].

#### **Table 4.** General lifestyle counselling.


When choosing a new hormonal contraception method, health care providers (HCPs) should give information about all available methods in order to make a shared decision [34]. In the Contraceptive CHOICE Project, a prospective cohort study of 10,000 women 14–45 years who want to avoid pregnancy for at least one year and are initiating a new form of reversible contraception, 47% of women who had an interest in a CHC method selected a different method than the one they originally intended to use after receiving counselling about several CHC methods, including the pill, patch, and ring. Awareness of the decision-making factors that affect women's choices regarding methods of contraception may enable HCPs to make more informed recommendations that are targeted to the needs of each of their female patients [4]. The prescription of a contraceptive method is a great opportunity to clarify the multidimensional components of sexual health, including elements of anatomy and physiology of the sexual response [34].

Few clinical remedies or recommendations exist for women experiencing HC-related sexual side effects [54]. Unfortunately, no guidelines exist for the management of sexual dysfunction potentially associated with CHCs in reproductive-age women [2]. As such, when CHC-related female sexual dysfunction is suspected, the recommended therapy is discontinuation of a combined hormonal contraceptive, with consideration of an alternative method of contraception, such as LNG-IUS, a copper IUC, a etonogestrel implant, the permanent sterilization of either partner when future fertility is not desired, or a contraceptive ring (for women who prefer a CHC for cycle control and no contraceptive benefits) [2]. The ring appears to be a reasonable alternative to an oral CHC for women with sexual function concerns. Likewise, LARC methods also appear to be a reasonable alternative [2]. Nevertheless, switching to another combined oral contraceptive may provide some benefit, but there is no clear difference between androgenic or non-androgenic progestins [10]. In addition, the combination of dehydroepiandrosterone (DHEA) and an OC was not associated with improvements in sexual function, and it further negated the benefit of OCs on acne [2]. When COC-related female sexual dysfunction is suspected, another possible option could be to consider formulations with a shorter hormonal free interval (HFI). Formulations with a shorter HFI (24/4 and 26/2) have recently been developed with the aim of offering a reduction in hormone withdrawal-associated symptoms together with a more powerful ovarian suppression. Estradiol valerate/dienogest (E2V/DNG) is administered on a 26/2 regimen and has been shown to offer a high contraceptive efficacy, an improvement in hormone withdrawal-associated symptoms (including but not limited to headache and pelvic pain), and an improvement in sexual function [51,61]. In conclusion, the best contraceptive is one that fulfills women's needs with acceptable side effects and at an affordable price in different settings [32].

Other options to improve HC-related sexual dysfunction could be vaginal lubricants and moisturizers. They are the first-line treatment for vaginal dryness and consequent dyspareunia [2], side effects that are frequently associated with hormonal contraceptives, mainly with combined oral contraceptives. The majority of women participating in a daily study reported positive perceptions of lubricant use, including increased pleasure and comfort [62]. Sharing information on the high frequency of use and positive results experienced across age-groups may be helpful in counseling reproductive-age women about using lubricants [62].

Furthermore, concerning other possible strategies against sexual dysfunction, some studies show positive results on female sexual function with exogenous testosterone [2,18,29], exogenous estrogens [2,6], dehydroepiandrosterone (DHEA) [10,29], tibolone [29], bupropion, and sildenafil [18]. It appears that supraphysiological serum testosterone levels may be necessary to yield any benefit on sexual desire and arousal [18]. The use of compounded testosterone products for transdermal use is on the rise, but these products are not FDA-approved [18], and they can be associated with several side effects. Meanwhile, testosterone therapy in postmenopausal women has been associated with improvements in multiple dimensions of sexual function, including sexual desire, subjective arousal, vaginal blood flow, and frequency of orgasm [2]. Testosterone released from patches has also been described to produce positive effects on mood and sexual behavior and to increase bone mass significantly [63].

With regard to hormonal therapy with exogenous estrogens, results are controversial. On the one hand, exogenous estrogens have been shown to be an effective treatment for low libido and hypoactive sexual desire disorder [6], and, on the other hand, hormone therapy (estrogen with or without progesterone) does not appear to have a significant impact on sexual function, with the exception of vaginal estrogen in women with the genitourinary syndrome of menopause [18]; that is to say, hormonal therapy with estrogen is efficient with regard to genital atrophy, but it is not efficient in regard to sexual desire [29].

Furthermore, although dehydroepiandrosterone (DHEA) supplementation could have positive effects on the female libido [29] by restoring androgen levels in COC users, there is minimal evidence that this correlates with improved sexual functioning [10]. There is also evidence that bupropion and, to a lesser extent, sildenafil, are effective for treating antidepressant-induced sexual dysfunction in women, although some conflicting evidence exists [18].

To conclude, even today, most of the contraceptives available on the market and those currently undergoing research and development interfere with ovulation or follicular development and also affect women's steroid production [32]. This mechanism of action is associated with several side effects, negative sexual effects included, that could be avoided by new contraceptives strategies. For that purpose, research conducted over the past few decades has provided more information on gamete physiology and interaction, offering new opportunities for the development of novel contraceptives that could act by interfering with the process of gamete interaction or with the chemo-attraction or chemo-repulsion of spermatozoa to the fertilization site without affecting the hormonal system [32].

#### **4. Discussion**

As discussed in the review above, hormonal contraception (HC) has made a difference in the control of female fertility since its approval by the FDA almost 60 years ago, and it is also widely used in the female population of child bearing age. Side effects, such as sexual dysfunction, may be sufficient reasons for the discontinuation of this contraceptive method. This represents an increase of the risk of unwanted pregnancy, with the possible worsening of women's wellbeing. However, female sexual function is complex and multifactorial and, despite an association between hormonal contraception and sexual dysfunction having been described in the past, the evidence on that topic is inconsistent.

Sexual problems are common, estimated to affect 22–43% of women worldwide [18], and influencing some types of female sexual dysfunction such as orgasm, sexual interest/arousal, and genito-pelvic pain. As a consequence of the multiple medications on sexual functioning, a specific category has been included in the new American DSM-5 classification system: Substance/ medication-induced sexual dysfunction) [18]. As said above, female sexual function is complex and multifactorial, and a biopsychosocial approach to sexual problems is recommended. It could be said that an HC can influence female sexual function in two different ways. On the one hand, an HC could have a negative influence on sexual function as a biologic factor, because HC use has been associated to hormonal changes. On the other hand, an HC could have a positive influence on sexual function, in psychological terms, since HC use has been associated with an improvement in mood symptoms and self-perception. Different options for hormonal contraception exist. There are three main groups: Combined hormonal contraception (pill, patch and vaginal ring); progestin-only contraceptives (POPs, DMPA, and implant); and intrauterine devices (LNG-IUDs). The hormonal composition of

hormonal contraceptives is based on progestins alone or on a combination of progestogens and estrogens. Apparently, norgestimate and desogestrel, among progestogens, and 17B-estradiol (E2) and E2-valerate (E2V), among estrogens, have a profile less associated with side effects than the others in their respective groups.

The association between hormones and sexuality is multidimensional, as several hormones are important in the regulation of sexual behavior [29]. Hormonal contraceptives (HCs) seem to be responsible for a decrease of circulating androgen levels [1,2,29,35], baseline serum levels of estradiol [6,29,35], and baseline serum levels of progesterone [35], as well as the inhibition of oxytocin functioning [35]. However, the concentrations of the FSH and LH were similar in freely cycling women and in women using an HC [35]. These hormonal alterations can be translated into negative effects on the female sexual function, with reports of a decrease of the libido, increased sexual jealousy, and alterations on women pair-bonding behavior. It has been established that sexual desire, autoeroticism, and sexual fantasies of women depend on androgen levels [29]. However, the relevance of changes in androgen levels for an individual woman is unclear, and some women may be more sensitive to androgen level alteration than others [2]. Furthermore, while there is conflicting information concerning a link between progestins and libido, there is some evidence to suggest that estrogens play an essential role in female sexuality [6]. On the other hand, multiple lines of evidence suggest that the hypothalamic peptide oxytocin (OXT) is a key factor modulating pair-bonding behaviors, and it has been found to increase the intensity of orgasm and satisfaction after copulation. This mechanism was disturbed in those women using an HC, indicating that the partner-specific modulatory effects of OXT are antagonized by gonadal steroids. So, it could be said that HC use alters women's pair-bonding behavior, reduces neural response to the expectation of erotic stimuli, and increases sexual jealousy.

Despite an association between hormonal contraception and sexual function having been described, there are contradictory results between different studies in this respect. Some studies have found no change in sexual function with hormonal contraceptives (HCs) [2,3,6,10,42–46].

According to the studies reviewed, hormonal contraceptives have a series of non-contraceptive effects, which can be related to an improvement on different areas of female sexual function such as sexual desire, orgasm number and intensity, satisfaction, and arousal. All these effects contribute to the well-being of women and, consequently, to a possible improvement in the female sexual function.

By contrast, HCs could be associated with side effects that have an influence on female sexual function. Negative effects on some areas of female sexuality have been described with hormonal contraceptives, such as sexual desire [2,6,10,54], frequency of intercourse [2,54], arousal [2,54], pleasure [2,54], orgasm [2,54], sexual thoughts [54], interest, and enjoyment [6,54].

Combined oral contraceptives are widely studied, and most studies are based on COCs or used them as a comparative method of contraception. Nevertheless, other hormonal contraception methods have fewer studies about their influence on sexual function. There are mixed results with ring- and DMPA-related sexual side effects. The patch could be considered the most innocuous CHC regarding sexual side effects. The implant has been associated with negative sexual effects, such as a lack of interest in sex, a decreased libido, and a reduced sex drive. LNG-IUS have generally been associated with positive sexual effects, so it could be considered the most innocuous HC regarding sexual side effects. However, more studies are needed because of the inconsistency of current available data.

Finally, with regard to treatment options for sexual dysfunction, few clinical remedies or recommendations exist for women experiencing these sexual side effects [54]. Moreover, no clear guidelines exist for the management of sexual dysfunction potentially associated with CHCs in reproductive-age women [2]. First, when addressing a new sexual complaint, a thorough history using a biopsychosocial approach should be undertaken [18]. A multidisciplinary approach to the management of female sexual dysfunction (FSD) is suggested, particularly when multiple contributing or complicating factors are identified, and this may consist of consultations with other professionals, such as a sex therapist, a pelvic floor physical therapist, and a sexual health specialist [2]. Second, lifestyle counselling should be given by the health providers (Figure 3) [18]. When choosing a

new hormonal contraception method, health care providers (HCPs) should give information about all available methods in order to make a shared decision [34]. When CHC-related female sexual dysfunction is suspected, the recommended therapy is the discontinuation of combined hormonal contraceptives with consideration of an alternative method of contraception, such as LNG-IUS, a copper IUC, an etonogestrel implant, the permanent sterilization of either partner when future fertility is not desired, or a contraceptive ring (for women who prefer CHCs for cycle control and non-contraceptive benefits) [2]. The ring appears to be a reasonable alternative to oral CHCs for women with sexual function concerns. Likewise, LARC methods appear to be a reasonable alternative too [2]. Other alternatives could be switching to another combined oral contraceptive [10] or formulations with a shorter hormonal free interval (HFI) [51,61]. Furthermore, with regard to other possible strategies against sexual dysfunction, some studies show positive results on female sexual function with exogenous testosterone [2,18,29], exogenous estrogens [2,6], dehydroepiandrosterone (DHEA) [10,29], tibolone [29], bupropion, and sildenafil [18]. Some alternative options to improve HC-related sexual dysfunction could be vaginal lubricants and moisturizers.

#### **5. Conclusions**

The results of the studies reviewed seem to indicate that hormonal contraception could influence different aspects of female sexual function. However, there are contradictory results between the different studies regarding the association between sexual dysfunction and hormonal contraceptives, so it could be firmly said that additional research is needed.

Meanwhile, it could be said that hormonal contraception has been associated with different alterations in sexual functioning. So, when addressing a new sexual complaint that is time-related with the beginning of hormonal contraception, health care providers should give information about other methods and try to switch them to a method less associated with sexual dysfunction. Vaginal rings and patches are possible options in case of women preferring combined hormonal contraception who report side effects with the pill.

To conclude, a multidisciplinary approach to the management of female sexual dysfunction is mandatory, and health care providers should give lifestyle counselling apart from proposing different treatment options. An adequate relationship with the patient, as well as the routine monitoring of possible sexual dysfunction, are essential in addressing these difficulties. Undoubtedly, the best contraceptive is one that fulfills the women's needs with acceptable side effects and agreed with the prescriber.

**Author Contributions:** Initial manuscripts selection (N.M.C.-E., R.d.A., J.I.d.l.I.-L.), additional review (A.L.M., B.B.-B.), writing of the first manuscript (N.M.C.-E., R.d.A., J.I.d.l.I.-L.) final review of the draft (A.L.M. and B.B.-B.).

**Acknowledgments:** In the name of the authors, we wanted to thank David González-Iglesias, translator of the Official College of Doctors of Salamanca, for his work and dedication.

**Conflicts of Interest:** AL Montejo has received consultancy fees or honoraria/research grants in the last five years from Boehringer Ingelheim, Forum Pharmaceuticals, Rovi, Servier, Lundbeck, Otsuka, Janssen Cilag, Pfizer, Roche, Instituto de Salud Carlos III and Junta de Castilla y León. Berta Bote has received fees to give lectures from Lundbeck and Janssen. Nerea M. Casado-Espada has received an economic award from Janssen in an oral communication contest. None of the other authors declare any conflict of interest.

#### **References**


© 2019 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/).

### *Review* **Uncovering Female Child Sexual Offenders—Needs and Challenges for Practice and Research**

#### **Safiye Tozdan \*, Peer Briken and Arne Dekker**

Institute for Sex Research and Forensic Psychiatry, University Medical Center Hamburg–Eppendorf, 20251 Hamburg, Germany; briken@uke.de (P.B.); dekker@uke.de (A.D.)

**\*** Correspondence: s.tozdan@uke.de

Received: 20 February 2019; Accepted: 21 March 2019; Published: 22 March 2019

**Abstract:** This article provides a short literature overview on female child sexual offenders (FCSO) focusing on the discrepancy between prevalence rates from different sources, characteristics of FCSO and their victims, as well as the societal "culture of denial" surrounding these women. FCSO are a powerful social taboo. Even professionals in the healthcare or justice system were shown to respond inappropriately in cases of child sexual abuse committed by women. As a result, offences of FCSO may be underreported and therefore difficult to research. The lack of scientific data on FSCO lowers the quality of child protection and treatment services. We therefore deem it particularly necessary for professionals in health care to break the social taboo that is FCSO and to further stimulate research on the topic of FCSO. We provide some general implications for professionals in health care systems as well as specific recommendations for researchers. We end with an overall conclusion.

**Keywords:** child sexual abuse; female perpetrator; mother-child incest; gender stereotypes; social taboo

#### **1. Introduction**

#### *1.1. Background*

Stereotypically, child sexual abuse implies the image of a male perpetrator sexually abusing a female child. However, due to an expanding research field since the 1980s [1], it is well established scientific knowledge today, that part of all child sexual offences are committed by women [2–6].

Although research data on female child sexual offenders (abbreviated female child sexual offenders (FCSO) in the following References [1,2,5,7–14]) is available and can be used for reviews and meta-analyses, there is still a noticeable gap of information on what is known about FCSO as opposed to male child sexual offenders [15]. Additionally, most of what is known resulted from studies with only small clinical samples of female offenders registered by the criminal system [16]. Consequently, the assessment and treatment of FCSO is insufficient [2].

Irrespective of the perpetrator's gender, child sexual abuse is an underreported crime [17]. One reason for the low level of knowledge about FCSO could be that FCSO are rarely registered in official statistics and are therefore difficult to reach for clinicians and researchers. One possible explanation for this phenomenon is that child sexual abuse committed by women seems to be a powerful social taboo [18]. Therefore, there is a marked resistance against the disclosure of FCSO [19] even among professionals in the health care and justice system [20]. In order to encourage the disclosure of FCSO, enhance the thematic research, and improve the quality of child protection and prevention, we deem it particularly necessary for clinicians and researchers in the field of sexual health to overcome this taboo.

#### *1.2. Aim*

This article is not a systematic review but is intended to provide a short narrative literature overview on the discrepancy between prevalence rates based on different sources (official reports vs. victimization surveys) and on the adult FCSO's characteristics (e.g., average age, socioeconomic status, mental health issues, victims). Secondly, we focus on FCSO as a social taboo that even percolates the health care and justice system. In order to overcome this social taboo, we provide some general implications for professionals in health care systems. In order to foster research activities on FCSO, we give specific recommendations for researchers in the field of sexual medicine.

#### **2. Method**

We explored the current literature on FCSO and mainly included reviews and studies on FCSO from 2000–2019 examining large and/or representative samples. We focused on data from countries sharing similar cultural and societal backgrounds. We included some additional studies that were published before the year 2000, but had an important impact on this research field and are still frequently cited. We excluded articles in which only juvenile FCSO or general female sexual offenders (with adult victims) were analyzed. Search terms included "female", "woman", or "mother" with "sexual child abuse", "child sexual offending", or "incest" as well as "social taboo" or "gender stereotypes". Searches were performed in PsychInfo, PubMed, KrimDok, and socINDEX. When necessary, additional references were used (e.g., Google).

#### **3. Female Sexual Child Offenders**

#### *3.1. Prevalence of Female Child Sexual Offenders*

Due to different methodologies and samples, prevalence reports of sexual child abuse committed by women vary within the literature. There are two main sources of information for estimating the prevalence of FCSO: Firstly, official reports (i.e., from police or court offices); secondly, victim reports. An overview of the results of different studies and reviews is shown in Tables 1 and 2.


**Table 1.** Prevalence rates (PR) for female child sexual offenders (FCSO) based on official reports.

Studies included all met the definition of child sexual abuse as experiencing vaginal/anal penetration or attempted penetration with fingers, penis, objects and/or oral sex, attempted oral sex, unwanted sexual touching or fondling or any other kind of sexual interaction before the age of 17. <sup>a</sup> Only includes female relatives, no female strangers.



Studies included all met the definition of child sexual abuse as experiencing vaginal/anal penetration or attempted penetration with fingers, penis, objects and/or oral sex, attempted oral sex, unwanted sexually touching or foundling or any other. <sup>a</sup> To our knowledge, the data on ChildLine cited by Roberts [28] have not been published entirely elsewhere. Due to this, it was not possible to specify the sample size by gender. <sup>b</sup> PR specified by gender indicates the proportion of female perpetrators within gender groups. For instance, a PR of 44 for male victims indicates that 44% of all male victims reported a female perpetrator. <sup>c</sup> Only includes female relatives, no female strangers.

The comparison of prevalence rates based on official reports (Table 1) and those based on victimization surveys (Table 2) clearly demonstrate a great gap. Sexual offences against children committed by women appear to be underreported and not prosecuted adequately. Table 2 only includes studies with large sample sizes and/or those examined representative samples published from 2000 and onwards. Taking into account earlier studies on smaller and/or clinical samples, even higher prevalence rates for FCSO with male victims are reported. For instance, Fromuth and Buckhart [32] investigated male students from a midwestern (*n* = 253) and a southwestern (*n* = 329) American university. Thirty-eight males from the midwestern university reported that they were sexually abused as a child and 78% furthermore specified a female perpetrator. Forty-three males from the southwestern university had been sexually abused as children, of whom 78% reported a female perpetrator [32].

#### *3.2. Characteristics of Female Child Sexual Offenders and Their Victims*

Research so far indicates that FCSO are a rather heterogeneous population with different features [5,33–35]. However, some common characteristics of FCSO and their victims were found.

The average age of FCSO seems to range from 26–36 [5]. For instance, Faller [3,36] reported on a sample of 40 FCSO with a mean age of 26.1 years [36] and on another sample of 72 FCSO with a mean age of 28 years [3]; and Nathan and Ward [37] reported on 12 FCSO with a mean age of 30 years. The majority of FCSO in empirical research showed a rather low socioeconomic status [5,12,38] with little vocational qualifications [12,39,40]. According to Berner, Briken, and Hill [41], more than 50% of FCSO had experienced sexual and/or physical abuse themselves [41]. Indeed, many studies demonstrated FCSO as being mentally, sexually, and/or physically abused during childhood [12,38,42–45]. They often show mental health problems, particularly substance abuse [45], personality disorders (passive and/or dependent) with rather low self-esteem [46], and are frequently involved in abusive relationships during adulthood [38,47] or have an absence of intimate relationships [45]. FCSO further appear to be impulsive with low levels of emotional self-regulation [48].

Typically, FSCOs find their victims in their closer social circle [3,16,35,42,49,50]. Often they are their victims' caregivers, i.e., mothers, other relatives, or babysitters [3,16,38]. The prevalence rates shown in Table 2 indicate that FCSO appear to sexual abuse male victims more often than female victims. However, research results so far are not sufficiently reliably to predict who may be

at higher risk to be abused by an adult woman: boys or girls [5]. Victims' age ranges from infants to adolescents [51,52].

#### *3.3. Perception and Handling of Female Child Sexual Offenders*

The discrepancy between official reports and victimization surveys on the prevalence of FCSO clearly demonstrates the under-recognition of women who behave in a sexually abusive manner. Official statistics only reflect those women who have had contact with the criminal justice or social service system. This indicates that reporting FCSO to the police or child welfare agencies seems to be a great obstacle. In fact, from the very beginning of scientific confrontation with FCSO in the 1930 [53], women who sexually abuse children have been a powerful social taboo [18]. Women are usually portrayed as victims and as being passive, innocent, and sexually submissive. Moreover, they are primarily normalized as the gatekeepers of sexuality [18]. In terms of anatomy, some have argued that women are receivers of sexuality which might make it difficult to imagine a woman as someone who sexually abuses others [54]. Instead, women are frequently seen as nurturers and protectors in positions of trust. They are thought of as mothers and those who provide care for others. Women who sexually abuse children undermine such normative labels and challenge traditional gender stereotypes that are firmly established in society [18].

#### 3.3.1. Society

The way in which members of a society perceive and respond to certain events is significantly shaped by medial reports [55]. Research so far has shown that media's representation of sexual offenders is biased [56]. In an analysis of 29 newspaper articles published in Australian dailies, Landor and Eisenchlas [56] showed that male sexual offenders are strongly criticized in media reports, whereas female sexual offenders are usually described in a more sympathetic way. Furthermore, the articles on FCSO usually contain excuses to justify or lessen the seriousness of the women's abusive behavior [56]. Hayes and Baker [18] also analyzed the way in which the media reports on women who sexually abused children. The authors theorized that media reports tend to reinforce traditional gender stereotypes and therefore suppress the development of a public awareness of sexual offences committed by women. Examining 487 media reports from Australia and the United Kingdom, they found that the media mainly presents FCSO as aberrations and pariahs (in terms of outcasts), and thus do not contribute to an atmosphere supporting the safe and timely reporting of offences by victims [18].

Mackelprang and Becker [57] demonstrated that this unequal perception of men and women who sexually offend against children is in fact reflected in societal judgements. The authors asked 432 undergraduate students to judge teacher sexual offence vignettes (e.g., amount of time the offender should be incarcerated) that varied by offender's gender and attractiveness. For all outcome measures reflecting punitive judgements and attitudes towards the offender, female teachers who had had a sexual relationship with a student were evaluated more leniently and judged less punitively than male teachers who did the same. In addition, there has been an even greater tolerance for FCSO when they were described as attractive instead of unattractive. This effect was not observed for the vignettes on male child sexual offenders [57].

#### 3.3.2. Professionals

Professionals in healthcare, criminal justice, and child protection systems were also shown to respond inappropriately in cases of child sexual abuse committed by women [58–62]. For instance, children's disclosure was brushed aside as fantasies [63] or abusive women gained further access to potential victims [64]. In 2010, Mellor and Deering [20] examined professional responses and attitudes toward FCSO. A total of 231 Australian psychiatrists, psychologists, probationary psychologists, and child protection workers were presented with a variation of vignettes describing women and men who had sexually offended against children. Afterwards they completed a questionnaire on their attitudes to women's offending behavior toward children. Compared to male-perpetrated child sexual

abuse, female-perpetrated child sexual abuse was more likely to be rated leniently. This "indicates that a level of professional minimization towards female-perpetrated child sexual abuse exists" [20] (p. 433). Psychotherapists who treat young patients experiencing mother-incest-abuse initially often struggle with the idea of reporting these cases [65]. As Haliburn concluded, the frequency of mental health patients reporting histories of child sexual abuse does not surprise clinicians anymore. However, when the perpetrator is a woman, clinicians' reaction often is "shock and disbelief and a tendency to be dismissive" [65] (p. 423).

#### 3.3.3. Victims and Offenders

As a consequence of FCSO being a social taboo, their victims often have difficulties in recognizing their experiences as sexually abusive [66] and feel intensly confused [67]. It is not unusual that FCSO disguise their abusive behavior as part of childlare activities [67]. This might in part be the reason why in fact even the offenders themselves have difficulties in recognizing their behavior as sexually abusive [68]. FCSO' victims are faced with serious issues regarding the disclosure of their abuse [69], thus hesitating more often to disclose the abuse than victims of male offenders [70]. It is particularly worth mentioning that victims of FCSO in early treatment stages even appear to lie to their therapists about their abuser's sex, claiming that they were perpetrated by a man [71]. These difficulties might be even worse when the female perpetrator is the own mother [72]. Usually shrouded in secrecy, Haliburn [65] called mother–child incest a "double betrayal", since both, the violation of trust as well as the exploitation of the child's affection and dependency needs to take place. Individuals who were sexually abused by their own mother were described as feeling additional shame and stigma [73].

#### **4. Implications**

Based on the outlined research, we propose some general implications for professionals in health care followed by more specific recommendations for researchers in the field of sexual health. As there are many possible clinical and research implications, we do not make any claim to comprehensiveness.

#### *4.1. General Implications*

Offences of FCSO are underreported and therefore FCSO are difficult to study. The resulting knowledge gap about FSCOs reduces the quality of child protection and treatment services. We therefore deem it particularly necessary for health care professionals to overcome the social taboo that is FCSO.

As mentioned, there seems to be a marked resistance in the general public and the health care system to detect FCSO [19]. Historically, the same kind of resistance was documented for the acceptance and awareness of men who sexually abuse children [74]. Thus, in accordance with Mellor and Deering [20], we state that the overall awareness and appropriate attitude towards FCSO have to be improved in health care, criminal justice, and child protection systems. Since a structured training as proposed by Mellor and Deering [20] may strain the organizational capacities of most institutions, we recommend an increased engagement of the issues concerning FCSO in internal conferences and discussions. This may lead to a more open discussion of FCSO among colleagues and therefore to a stronger representation of the issue in the professional's mind. Consequently, this should help to uncover the abusive behavior for both victims and offenders.

As media portrayals of FCSO and their victims are generally inadequate [18], instructions for journalists concerning the appropriate attitude towards FCSO are also deemed necessary.

The tendency to deny and minimize, leads to FCSO being a hidden phenomenon, undeniably difficult to uncover (cf. References [18,75–80]). We therefore advise professionals in both clinical practice and scientific research to consciously challenge and control their own underlying mechanisms of denial when confronted with cases of FCSO.

Since it is assumed that victims of FCSO and even FCSO themselves have difficulties to recognize the women's behavior as sexually abusive [18], we deem an active approach towards FCSO in order to meet their needs is most appropriate. Therefore, we propose education and information within health care, justice, and other systems. For instance, wherever undetected FCSO and/or their victims might occur (e.g., pediatrician practices, youth welfare offices, kindergarten, schools, counselling for victims of sexual offending, women's house), an educational brochure could be distributed to adults. It might briefly and simply inform the reader about the fact that women are also capable of sexually abusing children including contact details for both FCSO and victims. By this, a network including members of different professions within health care, justice, and other systems might be built so that regular communication and information between different systems regarding the issues of FCSO can be established.

Furthermore, we find it important that FCSO are also recognized by the general public, making public outreach necessary. Where great campaigns and activities for public outreach are difficult to implement, we suggest rather simple ways to contribute to public awareness of FCSO. Media reports can be considered to have an impact on social discourses [81] and to play a crucial role in the way society perceives and responds to women who sexually abuse children and therefore undermine traditional gender stereotypes [55]. Professionals in the health care system are sometimes being consulted as experts for child sexual abuse, child sexual offenders, or any other related topic for newspaper articles or television reports. In these situations, we believe in the professional's responsibility to address child sexual abuse by women as an existing problem which can be just as harmful for the victims as child sexual abuse by men can be. In time, the topic may affect and receive more attention in broader circles of the general public and be discussed beyond the professional fields.

#### *4.2. Implications for Researchers*

FCSO are usually only investigated when they are registered in the judicial system (i.e., when they were reported to the police by victims or others). As described earlier, women who sexually offended against children remain undetected very often due to several reasons [70]. We therefore encourage researchers to attempt additional and more active approaches to recruit FCSO for their examinations. For instance, as research results indicate that FCSO are young women between mid-twenties and mid-thirties, online surveys may be an appropriate tool to investigate this population. Online surveys are a highly economic way to reach out for participants who are inhibited due to several barriers such as women who sexually abuse children and furthermore provide a high level of identity protection. Both of which should be helpful when trying to recruit FCSO. Additionally, online surveys are highly suitable to reach women who are at risk to sexually abuse children but did not yet offend against a child. Besides, researchers already investigated female sexual offenders on the internet concluding that they use the internet to connect with like-minded women [82,83].

When creating the survey, we recommend simple language due to the relatively low socioeconomic status of FCSO [5]. As many FCSO reported on being abused in their childhood [41] and having mental health problems, such as depression [84] and alcohol abuse [45], researchers are advised to distribute their study link in internet forums and self-help groups on the internet for victims of child abuse, depressive patients and alcohol abusers.

Additionally, we suggest that researchers should not only include FCSO in their online surveys but also those women who are solely at risk to offend against children and did not yet offend against children. Differentiation between women who have a sexual interest in children can be made, e.g., those who have a pedophilic interest as motive vs. those who have other motives for offending against children or those who are willing to be in treatment vs. those who do not want to be in treatment. These differentiations may lead to different subgroups with varying characteristics implying different research questions and assumptions. This would be in alignment with research on men who are sexually interested in children [85–87].

Finally, if the conditions regarding institutional capacity and financial management are met, qualitative interviews with FCSO or those women who are at risk to sexually offend against children

would be valuable to ascertain more details of FCSO' characteristics, their offence behavior, and their specific underlying mechanisms of denial and minimization.

#### **5. Conclusions**

General public and professionals both reinforce and maintain traditional gender stereotypes which appear to be barriers to the detection of FCSO [80]. The "culture of denial" surrounding women who are sexually offensive [67] conceals their acts as "silent crimes" [88]. It is likely that the diverting prevalence rates based on different sources (official reports vs. victimization surveys) are related to this biased perception and inappropriate handling of FCSO. As a result, FCSO are underreported and difficult to study which leads to insufficient scientific knowledge. The lack of research data on FSCOs lowers the quality of child protection and treatment services. The fact that even professionals in the judicial and health system appear to be part of this collective repression clearly demonstrates that there is a particular responsibility for researchers and clinicians in the field of sexual health to be aware of their own underlying mechanisms and inner processes of denial. It is important to pursue an active approach towards FCSO. Overcoming the social taboo of FCSO is obligatory, especially in the light of the harsh consequences for victims of FCSO [89]. Moving beyond traditional gender stereotypes seems to be necessary to get over the confusion that women considered so far as caregivers, guardians, and defenders (cf. Reference [90]) are able to be just as sexually abusive to children as men.

**Author Contributions:** Conceptualization, S.T., P.B., A.D.; Methodology, S.T., P.B., A.D.; Software, not applicable; Validation, S.T., P.B., A.D.; Formal Analysis, not applicable; Investigation, S.T.; Resources, P.B., A.D.; Data Curation, not applicable; Writing-Original Draft Preparation, S.T.; Writing-Review & Editing, S.T., P.B., A.D.; Visualization, S.T.; Supervision, P.B.; Project Administration, P.B.; Funding Acquisition, P.B., A.D.

**Funding:** Research is funded by the German Federal Ministry of Education and Research (Bundesministerium für Bildung und Forschung, BMBF, 01SR1602).

**Conflicts of Interest:** The authors declare no conflict of interest.

#### **References**


#### *J. Clin. Med.* **2019**, *8*, 401


© 2019 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/).
