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Physical Conditions That Affect Sexual FunctionThere are many conditions and procedures that can affect sexuality and sexual function. Conditions that are a result of a deliberate alteration of sexual anatomy and physiology are briefly outlined here. (Other modules of this course include information on sexual dysfunction and normal changes in sexual response with aging.) Cultural practices and medical procedures that involve a loss of sexual structures can affect self-image, ability to function, and the reactions of other people. The procedures and practices described here are not exhaustive, but they are the ones reproductive health providers are most likely to encounter. 
Male circumcisionMale circumcision—the surgical removal of the skin covering the glans penis (called the foreskin)—is a common practice in the United States and in some other countries, but is less common in most of the world. In different cultures, male circumcision may be practiced for religious reasons or by custom. There is controversy regarding the social and sexual advantages and disadvantages of male circumcision. Few well-conducted studies exist to support a position for or against the practice, but there is some evidence that sensitivity of the glans penis may be reduced with circumcision. The medical benefits of circumcision are debatable, although some studies show lower rates of urinary tract infections among circumcised boys. Some studies have indicated a relationship between circumcision and reduced risk of HIV transmission. A growing body of scientific literature suggests that male circumcision is associated with reduced risk of HIV infection. However, studies have not yet been completed that will determine whether circumcision could be an effective intervention for the reduction of HIV transmission. Clearly, circumcised men are still at risk of HIV transmission and, therefore, condom use should be recommended. Circumcision services should always be offered in the context of informed choice. Female genital cutting (FGC)Female genital cutting (also called female circumcision or female genital mutilation) is the partial or total removal of the external genitalia (e.g., labia majora, labia minora, clitoris). Total removal of the external genitalia, with stitching and narrowing of the vaginal opening, is called infibulation. It is estimated that at least 2 million girls undergo FGC each year in approximately 28 African countries and some communities in the Middle East and Asia. Some girls undergo FGC at infancy, others at between seven and 10 years of age, and others upon marriage into a practicing community or just before or after the birth of a first child. The degree of genital cutting in FGC is more extensive than in male circumcision, and the procedure often results in significant alteration of the genital anatomy and impaired sexual and reproductive functioning. For example, removal of the clitoris (clitoridectomy) may significantly diminish sexual pleasure. Removal of the clitoris, labia majora, and labia minora may leave the woman with little if any sexually sensitive genital tissue. After some forms of FGC, sexual intercourse may not be possible without the gradual and painful dilation of the reduced opening of the vagina. In some cases, surgery may be necessary to open the vagina before intercourse. For women who have experienced genital cutting, first intercourse can be painful, and subsequent sexual activity can continue to be painful. FGC is associated with a high risk of long-term illness or dysfunction and with a risk of death for both girls and women. FGC can cause intense pain, hemorrhage, shock, infection, blocked menses, recurrent urinary tract infections, abscesses, and increased risk of maternal and child morbidity. The procedure itself may facilitate the spread of infection—including HIV infection—if instruments are used and not sterilized before reuse. FGC is valued by those who practice it as a religious requirement. It is considered a necessary rite of passage to womanhood, an assurance of cleanliness or improved marriage prospects, a means of preventing promiscuity and excessive clitoral growth, an enhancement of male sexuality, or a facilitation of childbirth by widening of the birth canal. HysterectomyHysterectomy is the removal of the uterus; removal of the ovaries (oophorectomy) is often performed at the time of uterine removal. Both procedures are major surgery that can have long-term effects on health and sexuality. Removal of the ovaries results in hormonal (estrogen, progesterone, and testosterone) deficiencies, vaginal dryness, and loss of libido. In some studies, between 10% and 46% of women have reported a decreased sexual response following hysterectomy or oophorectomy. Some women report that they experience orgasm differently after hysterectomy, probably because the cervix acts as a trigger point for orgasm. Scar tissue at the top of the vagina or shortening of the vagina may cause painful intercourse. On the other hand, for women who have experienced years of pelvic pain from uterine or ovarian problems, a hysterectomy can greatly enhance the quality of their sexual experience and the overall quality of their life. There is controversy regarding the medical profession’s perception of keeping or removing the ovaries in the absence of disease. Some obstetrician-gynecologists believe that removing the uterus and part of the upper vagina does not interfere with a woman’s ability to have orgasms; others, who believe that total hysterectomy interferes with a woman’s ability to achieve orgasm, may perform supracervical hysterectomy, a method that preserves the upper vagina and cervix, whenever possible. Women who undergo hysterectomy may struggle with physical and emotional pain and bodily changes that influence their sexuality. A woman’s partner may be cautious about resuming sex after the procedure or may have difficulty coping with the bodily changes, thus making it hard for the woman to resume normal sexual relations. In some recent studies, women reported sexual difficulties for more than six months after the procedure, with approximately 15% never resuming sexual intercourse. The most common problem reported by these groups was lack of sexual arousal. MastectomyMastectomy is the removal of the nipple, areola, and breast tissue. There are varying degrees of tissue removal, with radical mastectomy (removal of the chest muscles, lymph nodes under the arm, and additional fat and tissue) being the most extensive. Following mastectomy, adverse effects may include numbness of the skin, scarring, swelling of the arm and hand with the removal of the lymph nodes, and emotional trauma from the organ loss and altered body image. If skin grafting has been performed for reconstruction of the breast, there may be changes in touch and sensation in the breast. For women undergoing chemotherapy or radiation in addition to mastectomy, physical side effects can result in loss of desire, diminished arousal, and weakened orgasm. In addition, loss of hair, weight gain or loss, and changes in skin texture can be as damaging to a woman’s self-esteem as loss of the breast. In cultures where women’s breasts are an important symbol of female sexuality, losing a breast can significantly affect intimate relationships. In studies, some women have reported decreased frequency of intercourse, decreased sexual satisfaction, and difficulty in achieving orgasm as a result of the procedure. Others say that they have experienced no change in sexual function or satisfaction, and some have reported increased sexual satisfaction. Prostate diseaseA number of conditions of the prostate can impact sexual function; these include benign prostatic hyperplasia (BPH), prostate cancer, and prostatitis. BPH is the enlargement of the prostate, usually seen in men over 40 years of age, which causes urinary difficulties. Treatment that involves the use of antiandrogens can reduce sexual drive and cause erectile dysfunction. Studies have shown that surgical procedures may cause erectile dysfunction in a small proportion of men (4–10%) and retrograde ejaculation (ejaculation into the bladder) in a majority (66–75%). Prostate cancer is the most common prostate disease and is the second leading cause of death among men in the United States. Geographic variations exist, with high incidence among African-Americans and Scandinavians, low incidence among Japanese men, wide variation among men of sub-Saharan Africa, and rare incidence among Arabic and North African men. Treatment options for prostate cancer include watchful waiting, surgery, radiation, hormone therapy, cryosurgery, and chemotherapy. Surgery involves prostatectomy (removal of the prostate and some of the tissue around the gland). The effects of this procedure may include impotence (inability to achieve erection) and incontinence (lack of bladder control). With radiation therapy, impotence and urinary incontinence occur slightly less often than after surgery, but damage to the rectum is a potential complication. Hormone therapy inhibits the growth of cancer cells by reducing testosterone, which stimulates their growth. This can be achieved by administering female hormones (estrogen) or removing the testicles—both of which may cause impotence and loss of sexual desire. For men over 70 with less-aggressive tumors, significant coexisting illness, or fear of therapeutic side effects, watchful waiting is the management of choice. Prostatitis is an inflammation of the prostate often caused by bacteria. It can be acute, chronic, or noninfectious. Symptoms include pain in the testes or rectal area, sometimes accompanied by problems with ejaculation, urination, or defecation. Treatment includes the use of antimicrobial and pain-relieving medication. In severe cases, removal of the affected area of the prostate may be required. Prostatitis is not sexually transmissible and may not affect sexual relations.
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