Newer Challenges in Sexual Health

Abstract

More and more professionals in the field of Sexual Health are encountering problems that do not find a mention in conventional diagnostic manuals. Sexless marriages are one such problem. Its reported incidence varies from 2% to 45% in the age group 18–60 years, depending on the definition used. The figures are higher for the ages of 60 or more. The reasons for the same range from economic development and its ramifications, the monotony of sexual experience, the emergence of the smartphone, and social networking sites, to a possible role of substance use. Artificial intelligence could offer a solution to this vexed problem, although the benefits of anonymous access and a non-judgmental format could actually contribute to increasing the problem.

It is time to go beyond the textbooks, especially regarding Indian sexuality. More and more mental health professionals working in the field of sexual health are called upon to give their expert advice in managing problems that are not mentioned in conventional textbooks or diagnostic manuals. Some examples include the mental health aspects of “sexting” or pornography and the associated unreasonable expectations of the two partners or the problems related to “online sex”, among others.

One such area is the emergence of “sexless marriages.” This entity has been defined in many ways, ranging from “not having sexual contact in the last one month,” to “having sexual intimacy less than 10 times in a year.”^1,2

Although sexual activity is commonly believed to be a key component of emotional well-being, little is known about the factors associated with the absence of sexual activity or its associations with self-reported happiness. ³ Studies suggest that sexless marriages are less happy and less stable than those with sexual activity. ⁴

As regards the prevalence of “sexless marriages,” studies carried out thus far have reported figures ranging from 2% to 45% in the age group 18–60 years.^5,6 The figures are higher in couples aged 60 years or more. In Indian society, it is a common belief that sex is only for procreation, a perception that performing sexual activity after middle age is shameful or morally and spiritually incorrect for one or both partners, to stop sexual intimacy once their kids grow above puberty. These statistics also have another facet. While sexual activity does tend to decline with age, it remains a prevalent behavior. In a survey carried out in the UK, the proportion of men who reported being sexually active was 84.5% in those aged 60–69 years, 59.3% in those aged 70–79 years, and 31.1% in those aged ≥80 years; in women, the respective prevalence was 59.9%, 34.3%, and 14.2%. ⁷ An Indian study reported 27% of couples aged 60 or more, to be sexually active. ⁸ Similar results have been reported in the US population, where 73% of people aged 57–64 years, 53% of those aged 65–74 years, and 26% of those aged 75–85 years surveyed reported being sexually active. ⁹

The reasons for this phenomenon are multiple and merit a closer look. Is it one of the ramifications of the economic development and the resultant lifestyle changes ranging from the long duty hours of both life partners, the accompanying work pressure, and the lack of communication? This question needs to be researched, especially in a rapidly developing country like ours.

The monotony of sexual experience and the absence of novelty factors are other important reasons for declining interest in initiating sexual intimacy. This, in the absence of expert intervention, is bound to contribute to “sexless marriage” in due course of time. There can be other reasons such as the presence of young children in the family, or the presence of one or more elders with disturbed sleep, which can prevent a couple from getting intimate.

The quintessential “smartphone” ever since its invention in 1992 has quietly pervaded our lives in an unprecedented way. Its users have increased from an estimated 34 million in 2010 to 1013 million. Is this device, in some way, responsible for the disappearing sexual activity among married couples? ¹⁰ A review of four studies carried out in this regard found that problematic use of social networking sites (SNS), which is most often associated with problematic use of the smartphone, is correlated with lower sexual arousal, difficulties lubricating, difficulties having orgasms, sexual dissatisfaction, coital pain, and greater sexual distress in women. In men, problematic use of SNS is correlated with lower erectile function, lower desire, intercourse dissatisfaction, overall sexual dissatisfaction, and more difficulties having orgasms. ¹¹ A significant positive correlation was found between screen time and premature ejaculation severity in patients with acquired premature eaculation. ¹² Poor sexual functioning could be the contributing factor in sexless marriages, although systematic studies to find the correlation between the two are needed.

Approximately 5.5% of the global population aged between 15 and 64 years have used drugs at least once in the past year, while 36.3 million people, or 13% of the total number of persons who use drugs, suffer from drug-use disorders. ¹³ Given the association between substance use and sexual dysfunction, besides the socio-occupational dysfunction associated with it, the question of whether substance use is a contributing factor in a sexless marriage needs to be examined. This is an aspect where research needs to be done.

Besides being underreported, this is also an under-researched area, especially in our country. More and more systematic research is bound to shed greater light on the etiological factors and the best approach to address this emerging problem.

With the world on the brink of an artificial intelligence (AI) revolution, does it offer a panacea in “rebooting” sexless marriages? It is an enticing question given the huge amount of interest that is focused on the boundless possibilities that AI could offer. Some researchers have pointed out that an “AI” friend means that you may have a nonjudgmental party who can be a witness to your life and who could be positive and supportive. ¹⁴ This, in fact, points to a scenario where sexless marriages could well be the rule rather than the exception that we seem to believe till now. However, AI could still come up with a solution to this problem beyond our present limits of thinking or the solution could lie in going back to the conventional skill of a mental health professional sitting across the table.

On a larger scale, such topical problems are not just limited to sexual health but are being increasingly reported in other aspects of mental health. The increasing prevalence of relationship problems especially among young adults, and various other presentations that do not fulfill the criteria enlisted in the diagnostic manuals such as Diagnostic and Statistical Manual of Mental Disorders (5th Edition) or the International Classification of Diseases (11th Edition), exemplify this trend.

It is increasingly evident that mental health in general and sexual health is being increasingly talked about in the Indian homes and the onus is on the mental health professionals to rise to the occasion.