Sexual desire in Brazilian women: an integrative review of scientific literature

Desejo sexual em mulheres brasileiras: uma revisão integrativa da literatura científica

Abstract

Women’s sexual desire is a recurring subject in gynecology and psychotherapy offices where a relevant and frequent complaint is the lack of sexual desire. This study aimed to carry out an integrative review of the scientific literature published between 2008 and 2018, on the Coordenação de Aperfeiçoamento de Pessoal de Nível Superior, Scientific Eletronic Library Online, Literatura Latino-Americana e do Caribe em Ciências da Saúde platforms on the subject of sexual desire in Brazilian women. Three groups of descriptors were taken into consideration for the searches; the first included “sexual desire” the second, “woman” and the third, “Brazil”. Among the 35 articles selected, data regarding the type of research carried out; the cut-out criterion selected for sample and perspective that were used to comprehend desire were collected. The conclusion is that most articles maintain a biological perspective for understanding desire and point out a gap to be filled by psychology on this matter.

Keywords
Brazil; Libido; Sexual functions disturbances; Women

Resumo

O desejo sexual nas mulheres é tema recorrente nos consultórios de ginecologia e psicoterapia; e a sua falta, uma queixa frequente e relevante. Tendo em vista essa constatação, este trabalho propõe-se a fazer uma revisão integrativa da literatura científica produzida entre 2008 e 2018, nas plataformas Coordenação de Aperfeiçoamento de Pessoal de Nível Superior, Scientific Eletronic Library Online, Literatura Latino-Americana e do Caribe em Ciências da Saúde, sobre o tema do desejo sexual em mulheres brasileiras. Foram utilizados três grupos de descritores para as buscas, o primeiro relacionado é relacionado a “desejo sexual”; o segundo, a “mulher”, “feminino” e “gênero”; e o terceiro, a “Brasil”. Entre os 35 artigos selecionados, foram levantados dados quanto ao tipo de pesquisa realizada, à escolha do critério para recorte da amostra e à perspectiva utilizada para a compreensão do desejo. Conclui-se que a maior parte dos artigos mantém uma perspectiva biológica para compreensão do desejo, e que há uma lacuna a ser ocupada pela psicologia no que concerne a esse assunto.

Palavras-chave
Brasil; Libido; Disfunções sexuais; Mulheres

Sexual desire is a complex phenomenon that comprises different dimensions, such as the biological body, the experience body, emotions, specific cultural framework (including gender, race, social class, education, beliefs, morality, etc.), biographical settings idiosyncratic, the imaginary, and behaviors, among others. Among several sexual desire definitions, we may understand it as a cognitive experience, characterized by thoughts, fantasies, motivations; an emotional entity as sexual interest and desire to have sex; or a behavioral event, such as receptivity or initiation of sexual activity (Brotto & Woo, 2012; Gagnon, 2006; Leiblum, 2012).

Aspects related to women’s sexual desire are a recurring theme in medical and psychology offices, and the lack of sexual desire is a reason for anguish and conflicts in couples. In the world literature, the prevalence of desire disorders varies from 8 to 55%, depending on the population studied (Leiblum, 2012) and, in Brazil, it varies from 11 to 75% (Wolpe et al., 2017); it is four times more common in women than in men (Lara, 2017). Despite being an object of study for decades, it remains a difficult to lead issue (Abdo et al., 2010; Basson, 2000; Cacchioni, 2015; McCool-Myers et al., 2018; Perel, 2017).

The human sexual cycle model was established by Master and Johnson in the 1960s, and modified by Kaplan in 1979, resulting in the phases: desire, arousal, orgasm, and resolution. The physical response during this cycle, and the subjective sensations that accompany it, gave rise to the concept of “sexual function”, and conditions that did not fit this model were considered “sexual dysfunctions”, introduced in the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) from 1980 onwards. These sexual dysfunctions include: “Hypoactive Sexual Desire Disorder” (HSDD) (McHugh, 2016).

In 2000, Rosemary Basson reformulated this theory, arguing that this model would work in a circular fashion and similarly between men and women, only at the beginning of relationships. In long-term relationships, such as those lasting more than one year, it would be the partner’s desire that would stimulate the woman to enter the sexual cycle. Concurrent factors for this return would be linked to intimacy, commitment, tolerance for imperfections in the relationship and the desire to please the partner. It is what is called “responsive desire” (Basson, 2000).

The concept of responsive desire fostered changes in the classification of female sexual dysfunctions in the DSM-V (American Psychiatric Association, 2013), in which HSDD from previous versions was transformed into female sexual interest/arousal disorder. The DSM-V considers that sexual function involves a complex interaction between biological, sociocultural and psychological factors. This broader concept is enhanced by the World Health Organization, for which the focus of sexual health is not on the sexual “function”, a term that can infer sex as a “job” that the organs perform, but whether individuals feel satisfied with their physical, emotional and social experiences in connection with sex (Thomas &Thurston, 2016).

The biologically based view of sexuality, in which desire was traditionally regarded as an instinctive, spontaneous and incessant source of sexual motivation, is thus challenged today. Researchers suggest that relational, cognitive, motivational and evaluative factors preponderantly interfere with sexual demand (Thomas & Thurston, 2016). Therefore, androgen hormones had their importance scrutinized and diminished by the specialized literature, and the attempt to medicalize the decrease in female desire yielded poor results, despite the interest of the pharmaceutical industry in promoting it (Cacchioni, 2015).

It becomes, therefore, essential to look at sexuality from other perspectives than just the biological one. According to Gagnon (2006), sexuality is neither natural nor universal in its form of expression. The social context configures both the experience and the expression of desire, emotions, conduct and bodily practices. For the author, there is a socialization for the beginning of sexual life, through culture, which guides scripts and behaviors considered acceptable for each social group. In a sexist country like Brazil, where gender roles are well defined, the differences in these scripts are evident. Gender thus provides an asymmetry in the relationships between men and women, being an organizer of the way sexual activity unfolds (Rosenkrantz & Mark, 2018; Zanello, 2018).

How has the sexual desire of Brazilian women been investigated? What factors have been identified as relevant? This article aimed to carry out an integrative review on this subject is the literature, published between 2008 and 2018, in the main Brazilian and international scientific platforms.

Method

In order to survey the bibliographic production on the topic “sexual desire in Brazilian women”, an integrative literature review was carried out on the following scientific platforms: Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (Capes, Coordination for the Improvement of Higher Education Personnel) journals portal of Ministry of Education, Lilacs (Latin American and Caribbean Literature on Health Sciences) and SciELO (Scientific Electronic Library Online).

As sexuality is a multidisciplinary matter, we intended to include all national and international scientific papers covering this field of knowledge. These databases were chosen because they cover a large part of qualified national and international journals; they encompass the main publications in the areas of psychology, medicine, collective health, nursing, anthropology and sociology, thus encompassing the largest possible number of relevant publications that had Brazilian women as an investigation sample.

The survey period extended between 2008 and 2018. The search was carried out during the months of August and September 2018, and the articles’ review took place from September to November of the same year. The process was carried out by two people and the consensus criterion was used if the evaluation was initially divergent. The survey took place in three stages.

In the first stage, a search was carried out on the aforementioned platforms, using three groups of descriptors. The first related to “sexual desire” or “libido” (“sexual desire” and “libido”); the second, related to “woman” or “female” or “gender” (“woman”, “women”, “female”, “gender” and the third one related to “Brazil”. Boolean operators OR were used between descriptors of the same group and AND between different groups, as well as truncation (asterisk) for variations of desinences. In Lilacs and SciELO, descriptors in Portuguese and English were used. In Capes, only descriptors in English were used, since this is the default indexing language. The search yielded 6,286 publications, 5,116 of which in the Capes journal portal, 1,119 in the SciELO database and 51 publications in Lilacs. When applying the filters only for peer-reviewed articles; in the areas of psychology, medicine, public health, anthropology and sociology; publication date from 2008 to 2018, 1312 articles were found in Capes, 545 in SciELO and 34 articles in Lilacs, resulting in 1891 potentially relevant references.

The second step was to read the titles and abstracts of those 1891 articles. The following inclusion criteria were applied: article with a sample of Brazilian women, even if it was a mixed sample (Brazilian women + non-Brazilian and/or Brazilian women + Brazilian men), yielding 202 selected articles.

The third stage consisted of reading the 202 selected articles in full. A few of them were excluded, according to the following criteria: (a) literature review (n = 2); (b) questionnaire validation (n = 2); (c) unavailability of the article in its entirety (n = 2); (d) repeated (n = 14) and (e) those that evaluated desire in a very peripheral way, did not problematize or add information on the topic, or even evaluated the sexual function without individualizing the “desire” domain (n = 147). As only two articles addressed the desire, or lack thereof, as the focus of the study, the articles that had the theme as a background were also included. After applying these criteria, the final sample resulted in 35 articles, which constitute the corpus of this review. The staff of the Central Library of the University of Brasília was consulted along all the steps described, and the final result was also submitted to that staff for review. The steps performed are shown in Figure 1.

Figure 1
Systematic review articles selection process

The 35 articles were read and reviewed in detail with regard to the following items: year of publication; gender and investigators theoretical field of activity; type of research and study design; sample selection criteria and perspective to understand women’s desire and what might affect it.

Results and Discussion

The distribution of articles in relation to the year of publication, area of knowledge of the main authors, type of research carried out, instruments and methods used and main focus of the article are shown in Tables 1 to 3. Regarding the gender of the authors and co-authors, 110 of them were women, and 57 were men. This difference shows how the researcher’s gender impacts the choice of the topic to be investigated, and how what is selected to be studied in depth in the scientific community depends on the investigators’ interest and how the topic affects their reality.

Table 1
Distribution of articles by year of publication

Year of publication	Number of published articles
Total	35
2008	3
2009	3
2010	3
2012	1
2013	5
2014	9
2015	5
2016	3
2018	3

Table 2
Field of knowledge of the main authors

Field of knowledge of the main authors	Number
Total	35
Medicine	18
Nursing	9
Physiotherapy	4
Social Sciences	2
Biomedicine	1
Anthropology	1

Table 3
Type of research and method/instrument used

Type of research/Main Instrument/Method		Number	Total
Quantitative
	Female Sexual Function Index	16	23
	Female Sexual Quotient	2
	Pregnancy and Sexual Function Questionnaire	1
	Questionnaire	4
Qualitative
	Open and semi-structured interviews	4	9
	Semi-structured questionnaire	1
	Ethnography	2
	Focus groups	1
	Triangulation of methods (interviews, focus groups, thematic activities)	1
Quantitative/Qualitative
	Female Sexual Function Index + interviews + hormone dosage	1	3
	Watts Sexual Function Questionnaire + questionnaire	1
	Semi-structured interviews and questionnaires	1

Regarding the main authors’ field of knowledge, three were from the area of social sciences and anthropology, and the remaining fields were from the biomedical area. This fact is directly related to the definition of quantitative research as the dominant choice. Nursing was the only field of knowledge among the biological sciences that used the qualitative method in its research. It is noteworthy that no author is from the theoretical field of psychology.

It is also important to highlight that, although the search term was “desire”, the predominance of the articles found was about the “lack of desire”, assessed, in most cases, within the context of sexual dysfunctions, and evaluated mainly by psychometric indices with risk score for sexual dysfunction, preferably the Female Sexual Function Index (FSFI).

The use of this instrument for the evaluation of the desire domain has been criticized by the scientific community, for essentially evaluating the excitatory physical response, and ignoring the pattern of responsive desire, more common in women, as revealed by Basson (2000), and subjective aspects associated with the concept of desire (Forbes et al., 2014).

Among the 35 papers, sexual desire was the main focus in only one of them (Botelho et al., 2015). In 14 articles, the focus was on sexuality, with desire being just one of its aspects (Bevilacqua et al., 2013; Borges & Nakamura, 2009; Camacho et al., 2010; Campaner et al., 2013; Castro, 2009; Feltrin & Velho, 2014; Frazão et al., 2014; Heilborn & Cabral, 2013; Luz et al., 2015; Maluf et al., 2008; Oliveira et al., 2008; Pinho et al., 2018; Santos & Vieira, 2014; Trindade & Ferreira, 2008). In the remaining 20 articles, the main focus was sexual function/dysfunction, with the desire dysfunction being one of the items addressed.

The fact that most of the articles in this review have evaluated desire as a stage of a function to be performed and measured by risk scores, is a good example of the objectification of bodies in our society, where the female body is seen as having a natural way of sex and reproduction function (Martin, 2006). It also demonstrates how sexology in Brazil has followed a predominantly biological trend, in which subjectivity is less considered and hierarchical concepts of gender are justified as “natural” (Russo, 2013).

Among the parameters used for sample selection, 28 articles used biological criteria such as, for example, women with breast cancer or with some other disease, but social criteria, such as the representation of aging was only used in 7 cases.

Considering that sexuality is a complex topic, which involves different factors, the 35 articles were classified in relation to the predominant perspective adopted by the authors in order to understand the desire and its associated aspects. Four categories were listed: if the emphasis given by the author was on the functioning of the biological body, 16 articles were involved; if the emphasis was in cultural norms/social phenomena, there were 10 articles; if in the psychological aspects, 6 articles; or in a systemic way (with two or more interpretive perspectives strongly present), 3 articles. It should be noted that the distribution of the articles in the categories was carried out based on the concept used for the interpretation of the results found, even if the selection of the sample assessed was carried out by other criteria.

It is important to highlight that, even though the sample selection was based on biological criteria, in 11 of these articles, the reading performed was not deterministic; on the contrary, it opened up to the importance of social aspects and their impacts on the reduction of desire. Thus, samples defined based on a biological criterion, such as pregnancy, for example, could have a cultural perspective of interpretation (Camacho et al., 2010; Lima et al., 2013). On the other hand, there is a total absence of samples selected only by psychological criteria, in which the desire was investigated in women without organic changes, body dysfunctions or specific age groups.

The mapping of the 35 articles is shown in the table below. In the “sample selection” field, the samples defined based on social criteria are underlined (Table 4).

Table 4
Classification of articles by interpretive perspective and sample criteria

Interpretive Perspective	What affects desire	Sample cutout	Quantity	Total
Biological	Diseases	Chronic Diseases	3	9
		Neoplasms	4
		Dysfunctions	2
	Reproductive Cycle	Pregnancy	3	4
		Climacteric	1
	Drugs	Reproductive Age	1	3
		Sexual Dysfunction	1
		Menopause	1
Total				16
Social/Cultural	Stigma/Prejudice	Aging	2	6
		Pregnancy	2
		Menopause	1
		HIV/AIDS	1
	Gender	Adolescence	2	4
		Youth	1
		Neoplasm	1
Total				10
Psychological	Body Image and Self-esteem	Neoplasms	2	4
		Renal insufficiency	1
		Obesity	1
	Conjugality	Climacteric	1	2
		Adulthood	1
Total				6
Systemic/Multifactorial	Body-Culture-Psychism	Sexual Dysfunction	1	3
	Culture- Psychism	Incarceration	1
	Body-Psychism	Neoplasm	1
Total				3

Category A: Biological interpretive perspective

In this category, all 16 articles that interpreted desire and its alterations were included, especially from the physical body and its modifications. Three factors stand out as having an impact on sexual desire, listed below by frequency of occurrence: 1) “Diseases” with nine articles; 2) “Reproductive cycle” with four publications; and 3) “Drugs” with three articles.

The diseases that motivated sexuality research were chronic diseases; uterine cervix and breast neoplasms; and urinary and sleep disorders. In women with chronic diseases, fatigue, joint stiffness, chronic pain, vascular changes, medication side effects were some of the factors related to the worsening of sexual interest (Costa et al., 2015; Ferreira et al., 2013; Nascimento et al., 2015).

Among the 4 articles that investigated women with neoplasms, two articles associated breast cancer to sexual dysfunctions (Macedo et al., 2018; Paiva et al., 2016). The reasons listed for the libido reduction were age, vaginal dryness, higher Body Mass Index (BMI), less physical activity, testosterone deficiency and genital atrophy, related to cancer drug treatment. Grion et al. (2016) and Correa et al. (2016) evaluated women with cervical cancer, and identified that concern about the severity of the medical condition, bleeding, vaginal narrowing, pain, genital atrophy, urinary and fecal incontinence, which result from cancer treatment, would cause a deterioration in sexual desire.

Two articles addressed sleep and urinary disorders. Nozoe et al. (2014) assessed 20 mothers caring for children with Duchenne Muscular Dystrophy, relating sexual function and quality of sleep, impaired in these women by the need, on the part of their children, of night care. There was no direct relationship between worse sleep quality and worse desire. This is an apparently incoherent result if we consider sexual desire to be a direct and exclusive result of sleep quality, without considering the psychosocial framework of those involved. The other article assessed urinary incontinent athletes and sexual function. Santos et al. (2018) found a low desire score on the FSFI in 66% of athletes, who were considered dysfunctional. The causes would be the reduction in estrogen secondary to physical activity, common in high performance athletes, which can cause lubrication difficulties.

Still within the “Biological” category, the study of sexuality was related to the stage of the reproductive cycle in four articles, three of them with pregnancy and one with the climacteric. Leite et al. (2009) concluded that a decrease in desire occurs during pregnancy and valued mainly the physical aspects, such as low back pain, postural changes, hormonal changes and fatigue, although they also consider anxiety, fear of the proximity of childbirth and avoidance by the partner. Ribeiro et al. (2014) compared diabetic overweight and not-overweight pregnant women, and concluded that being overweight, in this condition, meant more risk for sexual dysfunction. They related this finding to a higher level of anxiety, depression and less sleep. The third article (Bonfim & Melro, 2014) evaluated the desire relating to the gestational period. In the first trimester, decreased desire was explained by nausea, fatigue, drowsiness and body sensitivity. In the third trimester, body changes, fear and anxiety that precede childbirth were mentioned.

Cabral et al. (2012) assessed the influence of climacteric symptoms on the sexual function of 370 women, and found a relationship between hot flashes, depressed mood and vaginal dryness with a worse risk score for sexual dysfunction.

The effect of drug use was studied in three articles, still within the category “Biological perspective”. In the first one, Strufaldi et al. (2010) compared the effect of oral hormonal contraceptives in different doses, on hormone levels and sexual function of 97 women, evaluated by the FSFI. There was maintenance of desire in the group with the highest dose and even an increase in the group with the lowest dose, which was attributed to the tranquility of using a contraceptive method. Gama et al. (2014) studied the effect of the extract of Tribulus Terrestris in 144 women with a history of sexual dysfunction, through hormonal measurements, FSFI and interviews. There was an increase in the desire scores in the FSFI, although there was a decrease in the level of testosterone. The article did not clarify the relationship between using drugs with improvement in desire. Botelho et al. (2015) investigated the efficacy of transdermal testosterone and estrogen use in 24 peri- and post-menopausal women with loss of libido. They concluded that there was an increase in libido and sexual behavior, but there is no definition of what this sexual behavior would be, nor of how this improvement was estimated.

Of the 35 articles reviewed in the literature on sexual desire in Brazilian women, the category with the highest number, sixteen, was the one that related biological aspects to desire, whether according to a diagnosis of the disease, a period of reproductive life or the effect of medication. This reflects how our society prioritizes the focus on biological factors of female sexuality, to the detriment of psychosocial factors. With the exception of articles that evaluated the effects of medications, the decrease in sexual desire was a constant in all samples surveyed in this category. This finding was prevalent in pregnant, menopausal, cancerous, hypertensive, diabetic, AIDS, insomniac, incontinent and rheumatic women, as well as in healthy women. However, taking into account the results found in the research, relational, self-image, education, cultural and gender factors permeated all of them, strongly influencing them whether positively or negatively. Starting from a physical condition point of view to explain the phenomenon of low desire in women is to miss the point. It is to attribute to the biological, to each body, an individual responsibility that ends up making the role that culture and relationships have on the exercise of sexuality invisible.

Category B: Cultural/social interpretive perspective

In the “cultural/social perspective” category, 10 articles were listed in which the authors seek to understand the change in sexual desire as a function of culture and social aspects, situational or not, associating them to 1) Stigmas / Prejudices”, in six articles; and 2) “Gender”, in 4 articles.

Stigma and prejudice were listed in six articles as influencers of sexual desire, that is, the way in which society’s view of a certain group, or the challenges faced by women belonging to these defined groups, impact sexuality. The samples were chosen using aging, with two publications; pregnancy, with two; menopause, with one and HIV/AIDS, with one paper.

In the group of three articles that cut the sample from aging and menopause, chronological age was not considered, but the social place in which one is placed when at a certain stage of life. Brazilian society is highly stratified in terms of age and the value attributed to different ages, in which the veneration of youth tends to make aging an object of shame, ridicule or disgust, contribute to the assumption that sexuality is no longer part of this phase of life (Goldani, 2010).

In the first study, Bevilacqua et al. (2013) investigated the perception and experience of 29 women from elderly groups about sexuality in old age. Most of them considered sexuality as part of this stage, and others annulled it for religious, moral or psychosocial reasons. The ethnographic study by Feltrin and Velho (2014) compared the meaning attributed to menopause by women and the doctors who treated them. For the majority, menopause represented an accentuation of the dissociation between sex and pleasure, which was already present before, due to lack of sexual education, myths, taboos and the social norm that “right women” cannot express desire. Doctors associated the decrease in desire and pleasure with the decrease in estrogen alone and its physical consequences, ignoring the sociocultural and interpersonal conditions that could interfere in this context. Luz et al. (2015) reviewed the sexual behavior of elderly people from the “Family Health” program. They found that 30% of the mixed sample no longer had sexual desire, and in this group, women represented 80%. After identifying the physical factors that negatively impact the elderly sexuality, such as chronic diseases, erectile dysfunction and climacteric symptoms, the author considers that it is the psychological, social and cultural characteristics that decisively influence sexual function.

Two articles used pregnancy as a sample cutout. Camacho et al. (2010) found varied experiences in relation to sexuality in pregnant women. Some felt an increase in their desire, while others decreased their sexual activity because they felt ambivalence about sex and pregnancy, due to physical or moral violence on the part of the partner. Therefore the factors that influenced most those women’s behavior were the way they saw themselves as a mother and a woman, and the interaction with their partner. Lima et al. (2013) found lack of desire as the most frequent sexual dysfunction before (20.2%) and after pregnancy (51%), in 778 primigravidae, who, being mostly adolescents, linked the exercise of sexuality to guilt, in addition to family conflicts and economic reasons for an unplanned pregnancy in this social group.

Still on stigma/prejudice, Pinho et al. (2018) investigated how the HIV diagnosis impacted sexual desire, which was reduced in more than half of the sample. The tension of negotiating condom use, the fear of infecting the partner, previous experiences of stigmatization, violence by the partner after learning about the HIV diagnosis, were the factors that contributed to this lack of desire.

Among the four articles that interpreted libido from the perspective of gender studies, Borges and Nakamura (2009) studied the social norms surrounding the sexual initiation of students. They pointed out that while women yearned to be respected, valued, restricting the number of dating and sexual partners, resisting the advances of men; it was up to them to insist, based on the belief that male sexual activity was more frequent and intense. They conclude that the learning of sexuality is a process of personal experimentation and impregnation by the sexual culture of the group, through the familiarization of representations, values, gender roles, interaction rituals and practices. Castro (2009) evaluated gender and sexuality in a mixed sample of 16,422 adolescents. Male adolescents are encouraged to start their sexual life earlier, and to see their libido as something uncontrollable; females are encouraged to postpone this beginning, and to associate sexual practice with love. They emphasize that although sexual relations are no longer guided by religious and marriage limits, control of the female body is shifted to emotional sensitivity, remaining at a distance from the erotic field and from sexual desire.

Heilborn and Cabral (2013) investigated the sexual practices of 4,634 young people aged 18 to 24 years. A higher level of education was associated with a greater sexual repertoire, such as oral sex and masturbation, and to a smaller disparity between genders in relation to these practices. Santos and Vieira (2014) evaluated sexual scripts of 36 women with breast cancer. From this survey, it appears that the impact of cancer depended on the interaction of cultural and psychosocial aspects, and on the meaning attributed to sexuality by each script.

Category C: Psychological interpretive perspective

In this category, 6 articles were listed, in which desire or lack thereof was interpreted mainly associated with psychic aspects, highlighting: 1) “Self-esteem/Body Image”, with 4 articles, and 2) “Marriage”, with 2 articles.

Articles that consider self-esteem/body image as a determining factor in desire, encompass investigations with samples designed for women with specific diseases, and associated the results to the impact of diseases on this psychic aspect. Maluf et al. (2008) compared women with breast cancer and benign diseases, concluding that sexual dysfunctions in both groups were related to changes in self-esteem, body image and female self. Bonfim et al. (2014) found an 82% incidence of HSDD in mastectomized women, attributing it especially to the consequences of cancer treatment on self-image and esteem. Frazão et al. (2014) evaluated 24 women with chronic kidney disease, finding sexual dysfunction in all of them, particularly related to low self-esteem resulting from the physical changes of the disease. Carrilho et al. (2015) compared the sexual function of obese women candidates for bariatric surgery to patients with normal BMI and found the same incidence in both groups, stating that sexual dysfunction is more related to body self-image than to BMI per se.

Two articles valued conjugality, in which the relationship with the partner was the condition most linked to female desire. Oliveira et al. (2008) interviewed climacteric women and the quality of the marital relationship determined how the couple adapted to the physical changes that occur in both partners at this stage. Trindade and Ferreira (2008) investigated sexuality of adult women who attended a health center. Their desire for sexual intercourse was primarily due to the partner’s ability (or lack of) in the sexual relationship, approach, quality of the relationship, feelings of anger or resentment, and dysfunctions.

Category D: Systemic/multifactorial interpretive perspective

In this category, three articles were listed, which evaluated sexuality more broadly, without predominance of a biological, social or psychic perspective. The factors influencing sexual desire were divided into: 1) “Body-culture-psychism”, 2) “Society-psychism”, and 3) “Body-psychism”; each with 1 article.

The investigation by Abdo et al. (2010) identified physical, cultural and psychological aspects related to HSDD, ranking those aspects as follows: age over 50 years, married, low educational level, diabetes, cardiovascular disease, breast cancer, post-traumatic stress, medication use and lack of desire from the beginning of sexual life. The factors that were least associated were moderate use of alcohol, having received sexual orientation in childhood and adolescence, previous experience with two or three significant partners in life, better quality of the relationship with the partner and greater sexual repertoire.

Baltieri (2014), valuing culture and the psyche, investigated incarcerated women and sexual dysfunction. Among 80% who scored high for dysfunction, the factors listed were age, total length of imprisonment, and depressive symptoms. The lowest risk was associated to being married, black, having relationships with other prisoners, and receiving conjugal visits in prison.

And, finally, considering the body and the psyche, Campaner et al. (2013), evaluated the psychosocial impact in women of the treatment of genital condyloma and pre-neoplastic lesions of the uterine cervix, sexually transmitted diseases. There was a reduction in sexual desire in 54% of women, caused by the presence of warts and side effects of the treatment; and from the psychic point of view, due to the feelings of fear, shame, pain, anxiety, concern about the possibility of having acquired the disease from the partner’s extramarital relationships.

Final Considerations

Almost all of the 35 articles listed in this review assessed the decrease in sexual drive, failure, the negative, and the intervention indications were only drug-based (Strufaldi et al., 2010; Gama et al., 2014). Few studies offered a perspective of positive aspects, influencing desire (Santos & Vieira, 2014; Camacho et al., 2010; Abdo et al., 2010). The lack of articles evaluating the psychosocial dimension of desire may contribute to the clinician underestimating, ignoring or even avoiding addressing these aspects during the anamnesis of a sexual complaint. Thus, the Brazilian literature has contributed little towards helping the management of lack of desire complaints.

Partner-related conditions appear to be of fundamental importance in women’s desire, as cited in many articles in this review, including quality of communication, adequacy of stimuli, loss of interest resulting from conflicts in other areas, and partner’s own sexual problems (McHugh, 2016.; McCool-Myers et al., 2018). Digging into this issue is imperative in the investigation on female sexual desire.

The socioeconomic level and education were also factors that stood out. The incorporation of cultural capital occurs differently in a society with as much inequality as ours and, as a consequence, the experience of sexuality occurs in different ways among the different social strata, according to the data emerging in this review (Abdo et al., 2010; Bonfim & Melro, 2014; Heilborn & Cabral, 2013; Oliveira et al., 2008; Pinho et al., 2018; Trindade & Ferreira, 2008). These data should be part of the research on sexuality so that the results can be interpreted in the framework of a specific group, considering that the conclusion about a sample may not be extended to all women.

In this survey, only four articles interpreted the data based on gender theories (Borges & Nakamura, 2009; Castro, 2009; Heilborn & Cabral, 2013; Santos & Vieira, 2014) and four others made some considerations taking this factor into account, in a more peripheral form (Feltrin & Velho, 2014; Camacho et al., 2010; Oliveira et al., 2008; Pinho et al., 2018). In the vast majority of studies, this aspect was ignored, which may have contributed to a bias right from the initial research design. It is important to highlight that over the centuries, sexuality has been used by systems of power that regulate its practice, based on the formation of the knowledge to which it refers and on the subjectivation and acts that shape the bodies of subjects (Foucault, 1979). Understanding sexuality as an instrument of these power relations, for example in the configuration of the gender hierarchy is necessary for an approach less centered on the individual, and more focused on cultural changes that result in less stereotyped gender roles. In addition, it is essential that gender studies be part of health professionals training so that they can recognize such gender studies’ influence on sexuality.

The choice of the quantitative method proved to be insufficient in many papers, in which the results were not consistent with the researcher’s hypothesis. This fact may suggest that the subjectivity and complexity of sexuality were underestimated, in an attempt to find a single, isolated factor that could have a direct correlation with women’s sexual desire.

The predominance of studies that evaluated desire from the perspective of the biological body, especially women with diseases or in a certain reproductive stage of life, evidenced the biologization of the focus given to sexuality in Brazilian research. There is a lack of research on women’s sexuality, when not associated to the disease or to a certain hormonal status. Even among the articles that used a culture/society perspective, the age group/life cycle was the main theme, exposing our biological perception of sexuality.

In articles about pregnancy and climacteric, factors that influence desire were cited: the quality of the relationship with the partner and the attention received; the couple’s sexual repertoire; how the woman sees desire and pleasure without a reproductive purpose and the sexual attractiveness of a body outside the slim standards; these aspects are valued differently if the adopted perspective was biological or sociocultural. Although these factors influence desire at any stage of a woman’s life, the investigation of dysfunction in these specific conditions suggests that physical changes determine the decrease in desire, but what is observed is the worsening of a desire that has always been bad. Thus, the problem seems to be in the “woman’s body”, in the “reproductive cycle”, bringing it as a pathologizing event. This biologization leads to the reification and ontologization of the lack of desire, leaving a reduced room to the influence of the partner’s socio-educational and psychological factors and to the traditional gender roles.

Among the limiting factors of this study, it should be mentioned that, despite this investigation being carried out based on the platforms of relevant Brazilian publications and the wide use of descriptors and combinations, it is possible that researched platforms non-indexed articles were not included or that they have other descriptors. Another possible limitation was the inclusion of articles in which desire was not the main focus of the study, a fact that was due to the scarcity of research on the sexual desire of Brazilian women as the main theme.

It is important to emphasize the absence of studies conducted by psychologists that met the inclusion criteria of this review and that indicated psychological causes associated with the change in sexual desire, such as: history of sexual abuse, general personality problems, fears, sexual inhibitions, relational factors. This fact leads to the conclusion that psychology should occupy its space in the study of Brazilian women’s sexuality.

There is a need to carry out further research in the Brazilian cultural context to assess the complexity of the subject and address the multidisciplinarity of the aspects that participate in the construction of female sexual desire, helping in its understanding.

• Article based on the master’s thesis of G. ARAÚJO, entitled “Desejo sexual em mulheres brasileiras: uma perspectiva crítica de gênero”. Universidade de Brasília, 2020.

How to cite this article

• Araújo, G., & Zanello, V. (2022). Sexual desire in Brazilian women: an integrative review of scientific literature. Estudos de Psicologia (Campinas), 39, e210036. https://doi.org/10.1590/1982-0275202239e210036

References

• Abdo, C. H. N., Valadares, A. L. R., Júnior, W. M. O., Scanavino, M. T., & Affif-Abdo, J. (2010). Hypoactive sexual desire disorder in a population-based study of Brazilian women: associated factors classified according to their importance. Menopause, 17(6), 1114-11221.
• American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5 (5th ed.). APA.
• Baltieri, D. B. (2014). Psychosocial pathways to sexual dysfunction among female inmates. Archives of Sexual Behavior, 43, 1105-1114.
• Basson, R. (2000). The female sexual response: A different model. Journal of Sex & Marital Therapy, 26(1), 51-65. https://doi.org/10.1080/009262300278641
  » https://doi.org/10.1080/009262300278641
• Bevilacqua, G., Leite, M. T., Hildebrandt, L. M., & Jahn, A. C. (2013). Sexuality in the perception and experience of elderly women members of a living group. Acta Scientiarum, 35(1), 29-35.
• Bonfim, I. Q. M., & Melro, B. C. F. (2014). Estudo comparativo da função sexual em mulheres durante o período gestacional. UNOPAR Científica Ciências Biológicas e da Saúde, 16(4), 277-282.
• Bonfim, I. Q. M., Batista R. P. S., & Lima, R. M. C. (2014). Avaliação da função sexual em um grupo de mulheres mastectomizadas. Revista Brasileira Promoção Saúde, 27(1), 77-84.
• Borges, A. L. V., & Nakamura, E. (2009). Normas sociais de iniciação sexual entre adolescentes e relações de gênero. Revista Latino-Americana de Enfermagem, 17(1), 94-100.
• Botelho, M. A., Queiroz, D. B., Carvalho, C. F., Freitas, A., Barros, G., Gouvea, J., & Silva, I. (2015). Effects of a transdermal testosterone metered-dose Nano emulsion in peri- and postmenopausal women: a novel protocol for treating low libido. Medical Express, 2(5), M150053. https://doi.org/10.5935/MedicalExpress.2015.05.03
  » https://doi.org/10.5935/MedicalExpress.2015.05.03
• Brotto, L. A., & Woo, J. S. T. (2012). Terapia cognitivo-comportamental e terapia baseada na consciência plena para baixo desejo sexual. In S. R. Leiblum (Ed.), Tratamento dos transtornos do desejo sexual: casos clínicos (pp. 157-171). Artmed.
• Cabral, P. U. L., Canário, A. C. G., Spyrides, H. C., Uchoa, A. A. C., Júnior, J. E., Amaral, R. L. G., & Gonçalves, A. K. S. (2012). Influência dos sintomas climatéricos sobre a função sexual das mulheres da meia idade. Revista Brasileira de Ginecologia e Obstetrícia, 34(7), 29-34.
• Cacchioni, T. (2015). Big pharma, women, and the labour of love University of Toronto Press.
• Camacho, K. G., Vargens, O. M. C., & Progianti, J. M. (2010). Adaptando-se à nova realidade: a mulher grávida e o exercício da sua sexualidade. Revista Enfermagem UERJ, 18(1), 32-37.
• Campaner, A. B., Vespa Júnior, N., Giraldo, P. C., & Passos, M. R. L. (2013). Adverse psychosexual impact related to the treatment of genital warts and cervical intraepithelial neoplasia. Journal of Sexually Transmitted Diseases, 2013, 1-7. https://doi.org/10.1155/2013/264093
  » https://doi.org/10.1155/2013/264093
• Carrilho, P. J., Vivacqua, C. A., Godoy, E. O., Bruni, S. S., Brigido, A. R., Barros, F. C., & Sousa, M. B. (2015). Sexual dysfunction in obese women is more affected by psychological domains than that of non-obese. Revista Brasileira de Ginecologia e Obstetrícia, 37(12), 552-558.
• Castro, M. G. (2009). Famille, genre, génération et sexualité au Brésil. Recherches Féministes, 22, 7-23.
• Correa, C. S. L., Leite, I. S. G., Andrade, A. P. S., Ferreira, A. S. S., Carvalho, S. M., & Guerra, M. R. (2016). Sexual function of women surviving cervical cancer. Archives Gynecology Obstetrics, 293, 1053-1063.
• Costa, T. F., Silva, C. R., Muniz, L. F., & Mota, L. M. H. (2015). Prevalência de disfunção sexual entre pacientes acompanhadas na coorte Brasília de artrite reumatoide inicial. Revista Brasileira de Reumatologia, 55(2), 123-132. https://doi.org/10.1016/j.rbr.2014.10.006
  » https://doi.org/10.1016/j.rbr.2014.10.006
• Feltrin, R. V., & Velho, L. (2014). Sexuality after menopause: ethnographic study in a Brazilian Hospital School. Sexuality Research and Social Policy, 11, 76-87.
• Ferreira, C. F., Mota, L. M. H., Oliveira, A. C. V., Carvalho, J. F., Lima, R. A. C., Simaan, C. K., Rabelo, F. S., Sarmento, J. A., Oliveira, R. B., & Neto, L. L. S. (2013). Frequência de disfunção sexual em mulheres com doença reumática. Revista Brasileira de Reumatologia, 53(1), 25-46.
• Forbes, M. K., Baille, A. J., & Schniering, C. A. (2014). Critical flaws in the female sexual function index and the international index of erectile function. The Journal of Sex Research, 51(5), 485-491.
• Foucault, M. (1979). História da Sexualidade 1: a vontade do saber (4th ed). Paz e Terra.
• Frazão, C. M. F. Q., Bezerra, C. M. B., Paiva, M. G. M. N., & Lira, A. L. B. C. (2014). Alterações no modo autoconceito de mulheres submetidas a hemodiálise: um estudo descritivo. Online Brazilian Journal of Nursing, 13(2), 219-226.
• Gagnon, J. H. (2006). Uma interpretação do desejo: ensaios sobre o estudo da sexualidade Garamond
• Gama, C. R. B., Lasmar, R., Gama, G. F., Abreu, C. S., Nunes, C. P., Geller, M., Oliveira, L., & Santos, A. (2014). Clinical assessment of Tribulus terrestris extract in the treatment of female sexual dysfunction. Clinical Medicine Insights: Women Health, 7, 45-50.
• Goldani, A. M. (2010). Desafios do “preconceito etário” no Brasil. Educação & Sociedade, 31(111), 411-434.
• Grion, R. C., Baccaro L. F., Vaz A. F., Costa-Paiva, L., Code, D. M., & Pinto, A. M. (2016). Sexual function and quality of life in women with cervical cancer before radiotherapy: a pilot study. Archives Gynecology Obstetrics, 293, 879-886.
• Heilborn, M. L., & Cabral, C. S. (2013). Youth, gender and sexual practices in Brazil. Psicologia & Sociedade, 25, 33-43.
• Lara, L. A. S. (2017). Abordagem das disfunções sexuais femininas. In Febrasgo. Tópicos em Saúde Sexual (pp. 7-22). FEBRASGO.
• Leiblum, S. R. (2012). Tratamento dos transtornos do desejo sexual: casos clínicos Artmed.
• Leite, A. P. L., Campos, A. A., Dias, A. R. C., & Souza, E. (2009). Prevalence of sexual dysfunction during pregnancy. Revista da Associação Médica Brasileira, 55(5), 563-568.
• Lima, A. C., Dotto, L. M. G., & Mamede, M. V. (2013). Prevalência de disfunção sexual em primigestas no município de Rio Branco, Acre, Brasil. Cadernos de Saúde Pública, 29(8), 1544-1554.
• Luz, A. C. G., Machado, A. L. G., Felipe, G. F., Teixeira, E. M., Silva, M. J., & Marques, M. B. (2015). Comportamento sexual de idosos assistidos na saúde da família. Journal of Research Fundamental Care Online, 7(2), 2229-2240.
• Macedo, J. B., Brondani, A. S., Costa, G. S., Messias, B. E. S., Nardi, L. L. D., & Braz, M. M. (2018). Occurrence of sexual dysfunctions in mastectomized females with or without breast reconstruction. Acta Scientiarium. Health Sciences, 40, e24544. https://doi.org/10.4025/actascihealthsci.v40i1.34544
  » https://doi.org/10.4025/actascihealthsci.v40i1.34544
• Maluf, M. F. M., Scavino, M. T., Barros, A. C. S. D., Lincon J. M., Duarte, F. S., & Gay, E. A. (2008). O perfil da sexualidade em mulheres com câncer de mama. Revista Brasileira de Mastologia, 18(1) 2-11.
• Martin, E. (2006). A mulher no corpo: uma análise cultural de reprodução (J. Bandeira, Trans.). Garamond. (Original work published 1987).
• McCool-Myers, M., Theurich, M., Zuelke, A., Knuettel, H., & Apfelbacher, H. (2018). Predictors of female sexual dysfunction: a systematic review and qualitative analysis through gender inequality paradigms. BMC Women’s Health, 18, e108. https://doi.org/10.1186/s12905-018-0602-4
  » https://doi.org/10.1186/s12905-018-0602-4
• McHugh, M. C. (2016). What do women want? A new view of women’s sexual problems. Sex Roles, 54, 361-369. http://dx.doi.org/10.1007/s11199-006-9006-2
  » https://doi.org/10.1007/s11199-006-9006-2
• Nascimento, E. R., Maia, A. C. O., Nardi, A. E., & Silva, A. C. (2015). Sexual dysfunction in arterial hypertension women: the role of depression and anxiety. Journal of Affective Disorders, 181, 96-100.
• Nozoe, K. T., Hachul, H., Hirotsu, C., Polesel, D. N., Moreira, G. A., Tufik, S., & Andersen, M. L. (2014). The relationship between sexual function and quality of sleep in caregiving mothers of sons with Duchenne Muscular Dystrophy. Sexual Medicine, 2, 133-140.
• Oliveira, D. M., Jesus, M. C. P., & Merighi, M. A. B. (2008). Climatério e Sexualidade: a compreensão dessa interface por mulheres assistidas em grupo. Texto & Contexto Enfermagem, 17(3), 519-526.
• Paiva, C. E., Rezende, F. F., Paiva, B. S. R., Mauad, E. C., Zuca-Matthes, G., Carneseca, E. C., & Schover, L. R. (2016). Associations of body mass index and physical activity with sexual dysfunction in breast cancer survivors. Archives of Sexual Behavior, 45, 2057-2068.
• Perel, E. (2017). Casos e casos: repensando a infidelidade Objetiva.
• Pinho, A. A., Barbosa, R. M., Brignol, S., Vilela, W., & Monteiro, S. S. (2018). Drivers of sexual inactivity among women living with HIV and AIDS: findings of the GENIH Study em São Paulo, Brazil. Archives of Sexual Behavior, 47, 1983-1993.
• Ribeiro, M. C., Nakamura, M. U., Torloni, M. R., Scanavino, M. T., Scomparini, F. B., & Mattar, R. (2014). Female sexual function of overweight women with gestational diabetes mellitus - a cross-sectional study. Plos One, 9(4), e95094. https://doi.org./10.1371/journal.pone.0095094
  » https://doi.org/10.1371/journal.pone.0095094
• Rosenkrantz, D. E., & Mark, K. P. (2018). The Sociocultural context of sexually diverse women’s sexual desire. Sexuality & Culture, 22, 220-242.
• Russo, J. A. (2013). A terceira onda sexológica: medicina sexual e farmacologização da sexualidade. Sexualidad, Salud y Sociedad, 14, 172-194.
• Santos, D. B., & Vieira, E. M. (2014). Sexual scripts among Brazilian women living with breast cancer. Sexologies, 23, 1-4.
• Santos, K. M., Roza, T., Silva, L. L., Wolpe, R. E., Honório, G. J. S., & Luz, S. C. T. (2018). Female sexual function and urinary incontinence in nulliparous athletes: an exploratory study. Physical Therapy in Sport, 33, 21-26.
• Strufaldi, R., Pompei, L. M., Steinder, M. L., Cunha, E. P., Ferreira, J. A. S., Peixoto, S., & Fernandes, C. E. (2010). Effects of two combined hormonal contraceptives with the same composition and different doses on female sexual function and plasma androgen levels. Contraception, 82, 147-154.
• Thomas, H. N., & Thurston, R. C. (2016). A biopsychosocial approach to women’s sexual function and dysfunction at midlife: a narrative review. Maturitas, 87, 49-60.
• Trindade, W. R., & Ferreira, M. A. (2008). Sexualidade feminina: questões do cotidiano das mulheres. Texto & Contexto Enfermagem, 17(3), 417-426.
• Wolpe, R. E., Zomkowski, K., Silva, F. P., Queiroz, A. P. A., & Sperandio F. F. (2017). Prevalence of female sexual dysfunction in Brazil: a systematic review. European Journal do Obstetrics & Gynecology and Reproductive Biology, 211, 26-32.
• Zanello, V. (2018). Saúde mental, gênero e dispositivos: cultura e processos de subjetivação Appris

Publication Dates

• Publication in this collection
  04 Nov 2022
• Date of issue
  2022

History

• Received
  03 Mar 2021
• Reviewed
  17 Dec 2021
• Accepted
  18 Apr 2022