Michael A Perelman
The etiology of female sexual dysfunction is frequently multidimensional. Health-care professionals treating female sexual dysfunction must consider the psychologic, social, cultural, and behavioral aspects of their patient’s diagnosis and management, as well as organic causes and risk factors. Our current paradigm recognizes the important role of both organic and psychosocial factors in predisposing, precipitating, maintaining, and reversing female sexual dysfunction. Despite the existence of organic pathogenesis, female sexual dysfunction has always had a psychogenic component - even if the female sexual dysfunction was initially the result of constitution, illness, or treatment (see Chapter 17.6 of this book). This chapter highlights a methodology for assessing the psychologic forces which affect a woman’s sex life beyond organic illness and mere performance anxiety. The methodology, referred to as the “Cornell model”, is adapted from the work of Helen S. Kaplan (see Chapter 1.1).1,2 The psychosocial interview can be understood as an interview that provides a broad understanding of the current sexual experience within the context of the woman’s life history. Establishing the “sex status” rapidly identifies the numerous common maintaining causes of sexual dysfunction (e.g., insufficient stimulation, depression) and points toward predisposing and precipitating factors (see Chapters 3.1—3.4 and 11.1-11.5).
The ideal history is an integrated, fluid assessment in which the patient’s response is continually re-evaluated. Assessing response to the initial pharmaceutic and behavioral prescriptions, which functions as a therapeutic probe, is a critical component of the psychosocial evaluation process. The proper evaluation of female sexual dysfunction requires that medical and psychologic concepts and diagnostic procedures be integrated in a comprehensive manner.
The successful treatment of both male and female sexual dysfunctions requires a specific data set that provides answers to three key questions regarding diagnosis, etiology, and treatment:
1. Does the patient really have a sexual disorder and what is the differential diagnosis?
2. What are the underlying organic and/or psychosocial factors?
a. What are the organic factors?
b. What are the “immediate” maintaining psychosocial causes (e.g., current cognitions, emotions, and behaviors)?
c. What are the potential “deeper” psychosocial causes (predisposing, precipitating)?
3. Should the patient be treated or not? Is the severity of the underlying organic and psychosocial factors enough to require direct treatment, or can treatment of these factors be bypassed or concurrent? These decisions are dynamic and should be consistently re-evaluated as treatment proceeds.
The methodology used to answer these questions is a focused history integrating psychosexual and medical factors. This method is a flexible one. For instance, it can be adapted by a primary care physician with only 7 min available or by a sex therapist with 45 min to interview the patient. Once this method is mastered, all necessary data can be captured, even if multiple consultations or a referral is required to facilitate this process. The health-care professionals should obtain the necessary information to answer the above three questions in a manner that does not sabotage the relationship with the patient. First, an attempt should be made to establish what medical, organic, or psychosocial factors require “pretreatment” prior to symptom reversal. Treatment for the female sexual dysfunction should be started as soon as possible, with continuing re-evaluation of the patient’s responses as treatment proceeds. A fuller comprehension of psychosocial issues optimizes patient response and minimizes relapse potential. Since many different professions of origin are involved in the care of women with female sexual dysfunction, this chapter refers to health-care professionals as a generic term for these clinicians.
This history-taking model suggests a rapid assessment of the immediate and remote causes of sexual dysfunction, using a four-phase model of human sexual response (i.e., desire, excitement, orgasm, and resolution) while maintaining rapport with the patient. Keeping this model in mind becomes a useful heuristic device to guide assessment.1 2 3- 6 This model is not necessarily linear and causes could become effects. For example, anorgasmia might diminish desire. However, generally speaking, sexual dysfunctions are disruptions in any of these four phases and/or the sexual pain and muscular disorders. Furthermore, while these dysfunctions can occur independently of each other, they frequently cluster together.
The history is the most important tool to assess the woman’s sexual function. The primary goal of the evaluation session is to obtain the necessary information to help assess the nature of the female sexual dysfunction and to begin developing a treatment plan. However, empathy and rapport with the patient must never be sacrificed in the service of obtaining the critical details. The creation/maintenance of a therapeutic alliance is uppermost. This alliance will be strengthened if the patient is asked direct questions in a comfortable, reassuring, empathic manner. Both patient and clinician will obtain an understanding of the problem and a mutually derived treatment plan. The therapeutic context works best when it is humanistic, emphasizing good communication and mutual respect.
Numerous Continuing Medical Education programs have addressed the problem of encouraging health-care professionals both to initiate and discuss sexual issues by emphasizing the importance of sexual dysfunction as a biologic marker of disease, among other reasons. Health-care professionals must use a direct approach with inquiry initiated in a neutral manner, using nonjudgmental screening questions. Yet, the quest for details must be balanced by a sensitivity to the patient’s anxiety as the information is collected. Changes the patient has experienced in her sexual function and her beliefs as to what the causes of those changes are should be inquired about directly.7,8 Her story should be allowed to unfold in the available time, yet she should be carefully guided with a predetermined list of questions. The health-care professional must be mindful not to interject in the middle of the woman’s explanation of her chief complaint.
While most patients are eager to “tell their story” to an accessible, knowledgeable clinician, others may be ambivalent about discussing details. This anxiety must be appreciated even as the clinician gently proceeds. If needed, the health-care professional can reassure the patient, saying, “I appreciate that discussing these details may be uncomfortable, but understanding them is the way to help you. We can proceed as slowly as you wish.” This usually relaxes the patient and encourages her to continue. Reciprocally, the interviewing must be conducted at the health-care professional’s comfort level. While pursuing an analysis of sexual behavior, it is essential that health-care professionals monitor their own comfort in order to instill the greatest confidence and promote openness on the patient’s part.
The format for both evaluation and treatment can vary, as patients may be single or coupled. Whether single or coupled, most patients visiting a health-care professional will be seen alone. When time permits, for women in a relationship, the health-care professional should encourage partner attendance. However, the issue should not be forced. Treatment format is a psychotherapeutic issue, and rapport should never be sabotaged. While conjoint consultation is a good policy, it is not always the right choice. Health-care professionals should remember that while important information can be obtained from the partner’s perception of the problem, partner cooperation is more important than partner attendance in the evaluation and treatment of sexual dysfunction.9 If the patient wants her “obnoxious, dominating partner” to be present, he should be welcomed, although an individual follow-up with her may be necessary. These are all strategic issues to manage in treatment, although the intricacies are beyond the scope of this chapter.
The psychosocial history captures a pyramid of important pieces of information, beginning with the chief complaint on top and expanding through a relevant developmental historytaking. To any extent possible, both the precipitating and predisposing psychosocial factors should be illuminated. While flushing out a deep understanding of the etiology of a woman’s dysfunction is helpful, understanding the current picture (i.e., maintaining or immediate factors) should be the first priority.
The diagnostic evaluation of female sexual dysfunction focuses on finding potential physical and specific psychosocial factors relating to the disorder. The sexual symptom, the history of the sexual symptom, and the sex status examination must be pursued in detail for all patients during the first meeting. All patients who are being evaluated for sexual difficulties should be briefly screened for psychopathology. However, this does not need to be pursued in depth unless there is evidence of a significant emotional disorder. Additionally, an assessment of the medical status must be conducted or arranged, depending on the health-care professional’s training and competencies. Certain basic information must be obtained from the patient’s history and physical examination, regardless of the specific female sexual dysfunction presented. This exploration will provide a clear understanding and will determine the treatment.
All health-care professionals should have a general understanding of the numerous physiologic and pharmaceutic risk factors that must be assessed when evaluating women complaining of female sexual dysfunction. For instance, they must familiarize themselves with commonly used medications that may cause a central and/or peripheral inhibition of sexual response. Assessment of the medical status must determine whether the patient has an illness or is taking a drug that could be causing the symptom. However, the current chapter presumes the necessary assessment steps and procedures, including the physical examination of the genital and reproductive organs, as well as laboratory tests, have been conducted (see Chapter 9.5). The current chapter will focus on the relevant psychosocial material. However, the health-care professional should not arbitrarily separate the psychosocial/sexual history from the medical history. An integrated medical and sexual history yields a significant amount of information regarding all aspects of a woman’s sexual health and relationships. The health-care professional must identify which variables are most relevant to understanding the etiology of the chief complaint, and focus the interview accordingly.
Identifying the sexual complaint
The health-care professional should obtain a clear and detailed description of the patient’s sexual symptoms, as well as information about the onset and progression of symptoms. The details of the physical and emotional circumstances surrounding the onset of a difficulty are important for the assessment of both physical and psychologic causes. The health-care professional must elicit these details, if not spontaneously offered. Diagnosis will be partially determined by the specific sexual complaint(s). Past and present modifiers should be incorporated, ascertained from key elements obtained from the sex status examination and from reviewing relevant psychosocial and developmental history.9,10
The sexual status examination is the next step in the assessment process. A detailed description of the patient’s current sexual experience and an analysis of her sexual behavior and of the couple’s erotic interaction help rule out organic causes and identify current operating psychosocial antecedents of the disorder. The sexual status examination is the single most important diagnostic tool at the health-care professional’s disposal, and is most consistent with the “review of systems” common to all aspects of medicine.2,9 The interview is rich in detail and clarifies many aspects of the individual’s sexuality. A focused sex status critically assists in understanding and identifying the immediate cause of the sexual dysfunction (i.e., the actual behavior and/or cognition causing or contributing to the sexual disorder). Armed with this information, a diagnosis can be made and a treatment plan formulated. Significantly, the sexual information evoked in history taking will help anticipate noncompliance with medical and surgical interventions. Modifying immediate psychologic factors may result in less medication being needed, regardless of the specific female sexual dysfunction. In general, physicians will intervene with pharmacotherapy and brief sex coaching, which address immediate causes (e.g., insufficient stimulation) directly and intermediate issues (e.g., partner issues) indirectly, and will rarely focus on deeper issues (e.g., sex abuse) (see Chapter 3.4). In fact, when deeper psychosocial issues are the primary obstacles, it is usually time for referral.11
It is particularly useful for the health-care professional, when initiating the discussion of sex with the patient, to obtain a description of a recent experience that incorporates the sexual symptom. One question that will help pin down many of the immediate and remote causes is, “Tell me about your last sexual experience.” Common immediate causes of female sexual dysfunction will be quickly evoked by the patient’s response. There are several frequently identified contributors to female sexual dysfunction, including insufficient stimulation (e.g., lack of adequate friction), lack of subjective feelings of arousal, fatigue, and negative thinking.12
When possible, the health-care professional should ascertain the patient’s thoughts during various types of sexual behavior. The following questions can be helpful: When does antisexual thinking emerge? Is the patient anxious about sexual failure early in the day before sex is even on the horizon? Does she worry that she “is taking too long” while her partner performs cunnilingus? What is the content of her negative thinking? Do her fantasies cause her distress? Is there a fear of negative behavioral consequences, such as urination or flatulence? Is she afraid of what her partner thinks and/or is she judging herself negatively? The mind is capable of derailing normal sexual arousal as well as interfering with the restorative benefit of current and future sexual pharmaceuticals. Understanding cognition can be key to facilitating sexual recovery and satisfaction. Why this person has intrusive thoughts that are of a frequency and intensity that interfere with her sexual function is an issue that generates focus for additional psychosexual history taking.
Which psychosocial factors are currently maintaining the psychic structure that results in the distracted thoughts and implicitly/explicitly reduces sexual arousal? It is interesting to understand what predisposed the patient to have that type of distressing thought and to know her full psychosocial history. However, it is critical to know and understand the current psychosocial obstacles that are maintaining the dysfunctional process.
Health-care professionals should follow up with focused, open-ended questions to obtain a clear picture (e.g., “What is your masturbation technique?”). Inquiries should be made about desire, fantasy, frequency of sex, and effects of drugs and alcohol. Idiosyncratic masturbation may be a hidden cause of female sexual dysfunction.13 The role of masturbation in understanding the pathogenesis of orgasm disorders in particular has not been fully explored. Disparity between the woman’s masturbatory sexual fantasy (whether unconventional or not) and the reality of sex with the partner should be explored. This disparity takes many forms (e.g., body type, orientation, sex activity performed). The health-care professional will become implicitly aware of the patient’s sexual script and expectations, leading to more precise and improved recommendations and management of patient expectations.9,12 For example, a health-care professional could improve outcome by briefly clarifying whether a patient was better off with practicing masturbating or with reintroducing sex with a partner.
Exploring other psychosocial issues
Primary versus secondary
It is not necessary to do an exhaustive sexual and family history for most evaluations. The investigation of these issues should be selective so that the interview does not become unnecessarily lengthy. The patient’s description will probably indicate whether she experiences the difficulty at all times or only under certain circumstances. However, a fluctuating pattern does not necessarily discriminate between psychogenic and organic etiology. In cases of a secondary problem, the clinician will hear of an important change from function to dysfunction. Was the change preceded by or concurrent with major life stress (e.g., change in the structure of the family, loss of a job by herself or a partner)? The patient may guide the health-care professional to the specific cause, or the health-care professional may need to examine the time period of the sexual change for clues to causation. The health-care professional should examine any of the areas known to alter sexual function from the point of view of psychosocial stress, including, but not limited to, health, family, and work.
It is often less important to get a detailed history of earlier developmental issues in cases of secondary sexual dysfunction. Time is more valuably spent exploring the circumstances of life that changed concomitant with the change in sexual function. This hunt for the precipitating factors will likely reveal a pattern within the mindset or experience of the patient which would help explain the shift in sexual function. Sometimes the patient will tell the clinician the cause of change herself. For example, a 35-year-old mother of two might tell the health-care professional, “Sex was great, till I got a venereal disease from my husband’s dalliance with a prostitute on his business trip. Things have never been the same. Every time I start to get excited, I can’t get the image of him with her out of my mind.” This is of course different from the 52-year-old recently menopausal woman who obsesses about lost youth when she notices her diminished lubrication. The guideline is frequently to “interview the crisis”, meaning that the health-care professional should get not only a clear picture of the current situation, but also a full understanding of exactly what occurred and the patient’s response to the change.
In long-standing cases of primary dysfunction, it is more important to look for precipitating causes with an emphasis on what is currently maintaining the dysfunction. For instance, if there was a traumatic or painful first sexual experience, is the woman still afraid that sex will hurt? Is fear causing painful muscular contractions during attempts at coitus? Coital pain for a virginal woman is not uncommon. However, the critical differentiator is the continuation of pain, fear, and their relation to the presenting dysfunction. Greater exploration is warranted, whereas, if later experiences were positive, it would not be necessary to explore “first sex” in great detail. In other words, the health-care professional should identify when the problem began and try to understand its source in a linear, relational manner, rather than assessing all aspects of a person’s sexual history.
Sometimes the patient will provide too much detail on background information which is tangentially relevant, but not primary. In this situation, the health-care professional should gently interrupt, acknowledging the potential importance of the patient’s statement, and move the interview forward. For example, the health-care professional could say, “That’s very interesting, but I wonder if we might postpone those details. I’d like to come back to that, but today I need a broader understanding of your problem.” Alternatively, “That’s helpful, but what happened next?” The goal should be to establish and maintain rapport while gathering the relevant details.
Previous treatment approaches
Depending on the particular patient, the discussion of the last sexual experience and an elaboration of current function will inevitably also evoke information about what previous approaches the patient has attempted. Many women have attempted a variety of treatments for their conditions, including herbal therapies, folk therapies, and professional treatment. The effects of such treatments should be assessed. Additionally, past treatment for psychiatric issues (e.g., depression), early sexual experiences and developmental issues, substance use or abuse, and partner issues may be mentioned by the patient. The health-care professional should decide which material seems most important to understand the sexual disorder’s etiology, following the pattern that emerges naturally from the patient’s description. The following are some helpful ways to examine these other aspects of the psychosocial factors in greater detail, but only the screening elements are required during the first session.
The health-care professional should briefly screen all patients for obvious psychopathology that would significantly interfere with the initiation of treatment for the female sexual dysfunction. Yet, the health-care professional will also want to know whether psychiatric symptoms, if present, are the cause and/or the consequence of the sexual disorder. In addition, it is important for the health-care professional to know whether the patient is receiving appropriate treatment for any psychiatric disorder. The skillful and experienced health-care professional can make judgments about a patient’s or a couple’s psychiatric status by observations of, and interactions with them, by attending to their appearance, speech, and demeanor, by the way they relate to the health-care professional and to each other, and by the feelings they evoke. If any psychiatric issue is severe enough, the health-care professional may decide to refer the patient for psychiatric help prior to initiating treatment for the sexual disorder. Yet, even when a patient and/or her partner seem to be mentally healthy, answers to the following four questions should be obtained:
1. What is her experience with emotional or mental illness?
2. If the patient was in psychotherapy, why was treatment sought and what was learned?
3. Was she ever hospitalized for an emotional or mental disorder?
4. What psychoactive drugs has she taken?2
There is a statistically significant increase in depression for individuals with female sexual dysfunction. If the patient is depressed, the severity of her depression should be clarified. Furthermore, all patients who experience major depression should be queried about suicide risk. Treatment of female sexual dysfunction may improve mild reactive depression, while depressive symptoms might alter response to therapy for female sexual dysfunction.14 A clinician’s history taking must parse out the question of whether the sexual dysfunction is causing depression or whether the depression and its treatment (e.g., selective serotonin reuptake inhibitors) are causing the sexual dysfunction (see Chapters 16.2, 17.2, and 17.3). Besides depression, panic attacks are often associated with sexual complaints, so almost all patients should be asked whether they have any phobias and have ever experienced a panic attack.
A brief review of each partner’s functioning in the work, social, and family areas will also help measure mental and emotional status. If the patient relates in a pleasant, sensitive manner, if her story makes sense, if she enjoys work, if she has friends, and if her answers to the questions about mental health are reassuring, then serious psychopathology can be ruled out. However, if the health-care professional senses that the patient may be suffering from an undiagnosed or unsuspected mental or emotional disorder, further assessment should be arranged.2
When a patient with a variety of psychopathologic states (e.g., stress, phobias, personality disorders) is evaluated for sexual complaints, the health-care professional must consider whether that patient’s emotional conflicts are too severe for a focused treatment of the sexual problem, and whether such treatment should either be safely postponed for another time or occur concurrently with treatment for the emotional distress. In more severe situations, the modal choice is likely to be a simul- tanous initiation of the sexual dysfunction treatment and referral to a mental health practitioner to facilitate patient management. For example, actively psychotic patients are clearly not appropriate candidates for brief treatment, even when they have a real sexual problem. Yet, treatment for a sexual disorder is not contraindicated for many persons with a history of severe psychiatric disturbance who are in a compensated phase of a psychiatric illness. Many such individuals have been successfully treated with sex therapy and have benefited in terms of their overall psychologic well-being. The same will be true for today’s women receiving sexual pharmaceuticals and/or sex therapy. More subtle personality factors, such as fragile selfesteem and fear of being negatively evaluated by others, are frequently prevalent in women with sexual concerns, especially those with low sexual desire. Yet, usually, this would not result in postponing treatment for the sex problem.2
A person who is currently addicted to drugs and/or alcohol is not a suitable candidate for treatment until she has been detoxified and is off the drug. Many mentally retarded individuals, especially those with borderline to moderate impairment, are physically normal and have normal sexual urges. Sexual problems in the mentally retarded tend to involve inappropriate sexual expression and unwanted pregnancy, as well as problems associated with fear of sex and lack of information about sex.2
Family and early psychosexual history
A psychosexual and family history may provide insight into the deeper causes of the patient’s problem and may reveal cultural and/or neurotic origins of the problem. Negative factors from the past might include losses, traumas, negative past sexual relationships, and negative past interpersonal relationships. They may also include cultural and religious restrictions. The healthcare professional should obtain a brief sketch of family background and of sexual development landmarks. Sex pioneer Helen Kaplan asked every patient, “What sort of sexual message did you receive when you were growing up?”2 Possible predisposing factors such as traumatic sexual experiences (e.g., sex abuse, rape) and body image and gender identification issues (initially assessed by asking about response to first menses) should be explicitly ruled out. These avenues should be pursued in depth only if warranted by the manifest emotions and content of the reply to inquiry. The health-care professional should tread doggedly but gingerly, with confidence that rapport will preserve another opportunity.
While sex therapists assess the pattern and quality of the woman’s romantic relationships, health-care professionals typically obtain a brief status of the current relationship. For all women, health-care professionals should assess marital status as well as living and dating arrangements. Contextual factors, including difficulties with the current interpersonal relationship and whether the partner has a sexual dysfunction, should be clarified. The health-care professional may grasp the couple’s interactions from the first interview’s sex status. It remains to be determined whether deeper difficulties in the couple’s relationship determine the patient’s sexual problem.
Previous sexual scripts also need assessment.15 Several questions should be asked, including whether sexual relations were ever good with the current partner, what changed, and what the patient’s view of causation is. Numerous partner-related psychosexual issues may also adversely affect outcome. Reassurance and inquiry (e.g., “No one’s relationship is perfect. What do you argue about?”) can be helpful, as can an evaluation of the degree of acrimony when the patient describes her complaints (e.g., is the anger, resentment, hurt, or sadness a maintaining or precipitating factor, or are the emotions more mild manifestations of the frustrations of daily life?).
For all women, whether or not the problem is partner-specific needs to be determined. If the problem is partner-specific, the health-care professional must ascertain which of several categories are etiologically relevant (e.g., inadequate sexual technique, poor communication, incompatible sexual script or fantasies, no physical attraction). Power struggles, transferences, partner psychopathology, and commitment/intimacy issues are elusive and may have implications for the sexual problem. A woman will often “turn off” if the only time her husband is interested in her feelings is prior to intercourse. Women give multiple reasons for having and wanting sex, with lust being only one of numerous possible emotions present prior to the experience. This is especially important to assess in women with diminished desire. Initially, all that is required is to decide whether the degree of relationship strife is too severe to initiate the female sexual dysfunction treatment. Otherwise, concurrent relationship treatment is provided, or a referral is made and female sexual dysfunction treatment is postponed. However, it will be the bias of many to err on the side of giving the relationship and female sexual dysfunction treatment every possible chance (see Chapters 8.1 and 8.2).
Initial treatment failures should be examined at follow-up. Sometimes the most critical information is made evident by the patient’s reaction to the health-care professional’s first suggestions. The pharmaceutic or behavioral interventions can act as therapeutic probes, illuminating the cause of failure or nonresponse. Retaking a quick “sex status” provides a convenient model for managing follow-up.11 It is also helpful to increase success by scheduling follow-up the first day either a pharmaceutic or behavioral intervention is prescribed. Follow-up is essential to ensuring optimal treatment. Components of follow-up include monitoring side effects, assessing success, and considering whether an alteration in dose or treatment is needed. A continuing dialog with patients is critical to facilitate success and prevent relapse. There are several psychologic issues to consider which evoke noncompliance, including fear of complications; reactions to changes associated with aging; reactions to chronic diseases or injury; changes associated with medications, alcohol, and smoking; and changes associated with life stressors. These are important issues in differentiating treatment nonresponders from “biochemical failures” in order to enhance success rates. Early failures can be reframed into learning experiences and eventual success.9,12,1 18
Partner cooperation must be anticipated before treatment, and follow-up provides opportunity to confirm whether or not such cooperation is present. If cooperation is not present, the recognition of a need for contact with the partner should increase. If the partner’s support for successful resolution of the sexual dysfunction is not present, active steps must be taken to evoke it. Sometimes referral for adjunctive treatment to a sex therapist for the partner may be required.9 It is likely that the more problematic the relationship, the less likely that patient-partner sex education can augment treatment in and of itself. Inevitably, a mental health referral would be required, albeit not necessarily accepted.
Identifying psychologic factors does not necessarily mean that the health-care professional must treat them. Health-care professionals are encouraged to practice at their own comfort level. If not inclined to counsel or if uncomfortable with counseling, the health-care professional may refer or work conjointly with a sex therapist. However, in more complex cases, significant intrapsychic and relationship problems must be investigated by someone.12
Health-care professionals may want to optimize the patient’s response to treatment. In doing so, it is important that health-care professionals do not collude with the patient’s unrealistic expectations. Health-care professionals should be mindful of a patient’s potential idealized notion of her sexual capacity and/or idealization of the treating clinician’s abilities. There are situations when it is appropriate either to make a referral or to decline to treat a patient. Significant, process-based, developmental predisposing factors usually indicate to the need for resolution of psychic wounds prior to the introduction of sexual pharmaceuticals. The more determinants of female sexual dysfunction are driven by developmental processes, the more likely the patient will benefit from sex therapy in addition to pharmacotherapy. There are situations when it is appropriate to postpone treating the patient for the female sexual dysfunction until psychotherapeutic consultation is able to assist the individual in developing a more reality-based view. While this can sometimes be done simultaneously, at other times treatment for female sexual dysfunction must be postponed.
The single patient
The single patient with a psychosexual dysfunction must be assessed in the same manner as if the patient was in a relationship. The patient’s sexual symptom may or may not relate to difficulties in her relationships. Women seeking treatment for primary anorgasmia, and some cases of vaginismus, are suitable for initial intervention for the patient alone. The health-care professional’s time constraints and competencies, along with patient predilections, will determine whether the patient’s single status becomes a therapeutic focus. This issue must be managed with extreme emotional and political sensitivity. Needless to say, sexual orientation issues, for both single and coupled women, require the same if not even greater sensitivity on the health-care professional’s part.
Questionnaires can be used in both training and research. In training, questionnaires provide students with a range of potentially relevant material of interest in the diagnosis and treatment of female sexual dysfunction. In research, questionnaires both allow standardization of diagnostic data collection and provide recognized consistent endpoints. Therefore, the student of female sexual dysfunction treatment and research should have a passing familiarity with commonly used paper-and- pencil tests (for a complete review of this topic, see Chapter 11). Additionally, health-care professionals may choose to use current or future instruments to facilitate history taking. Such instruments must be incorporated in a manner which does not interfere with rapport.
Health-care professionals should make the patient a partner in her care and share conclusions with her. Patients are often anxious and eager to know what is wrong. Interim conclusions should be expressed throughout the interview, especially when they are encouraging. Health-care professionals should make recommendations and/or let the patient know when further evaluation is needed. However, the more complex the sympto- mology and etiology, the more likely additional time is required to make a diagnosis and develop a treatment plan.
Combination treatments for sexual dysfunction, where sex therapy strategies and treatment are integrated with sexual pharmaceuticals, may provide the best solution. There is a synergy to this approach that is not yet supported by empirical evidence, but that is rapidly gaining adherents, who eventually will document its successful benefits. Research on male sexual disorders in the last few years indicates that combination therapy will be the treatment of choice for all sexual dysfunction, as new pharmaceuticals are developed for desire, arousal, and orgasm problems in both men and women.12,19,20 Sexuality is a complex interaction of biology, culture, developmental, and current intra- and inter-personal psychology. A biopsychosocial model of sexual dysfunction provides a compelling argument for integrating sex therapy and sexual pharmaceuticals. Restoration of lasting and satisfying sexual function requires a multidimensional understanding of all of the forces that created the problem, whether a solo physician or multidisciplinary team approach is used. Health-care professionals must carefully evaluate their own competence and interests when considering the treatment of female sexual dysfunction, so that, regardless of the modality used, the patient receives the best care. This sensibility should infuse the perspective on taking a psychosexual history from a woman suffering from female sexual dysfunction.
1. Perelman MA. Commentary: pharmacological agents for ED and the human sexual response cycle. J Sex Marital Ther 1998; 24: 309-12.
2. Kaplan H. The Evaluation of Sexual Disorders: Psychologic and Medical Aspects. New York: Brunner/Mazel, 1995.
3. Perelman MA. The urologist and cognitive behavioral sex therapy. Contemp Urol 1994; 6: 27-33.
4. Perelman M. Letter to the editor: regarding ejaculation: delayed and otherwise. J Androl 2003; 24: 496.
5 Masters WH, Johnson VE. Human Sexual Inadequacy. Boston: Little, Brown, 1970.
6. Kaplan HS, Perelman MA. The physician and the treatment of sexual dysfunction. In G Usdin, J Lewis, eds. Psychiatry in General Medical Practice. New York: McGraw-Hill, 1979.
7. Warnock JK. Assessing FSD: taking the history. Prim Psychiatry 2001; 8: 60-4.
8. Viera AJ. Managing hypoactive sexual desire in women. Med Aspects Hum Sex 2001; 1: 7-13.
9. Perelman MA. Sex coaching for physicians: combination treatment for patient and partner. Int J Impot Res 2003; 15(Suppl 5): S67-S74.
10. Basson R, Burnett A, Derogatis L et al. Report of the international consensus development conference on female sexual dysfunction: definitions and classifications. J Urol 2000; 163: 888-93.
11. Perelman, M. Combination therapy: integration of sex therapy and pharmacotherapy. In R Balon, R Seagraves, eds. Handbook of Sexual Dysfunction. New York: Marcel Dekker, 2005.
12. Perelman M. Sex and fatigue. Contemp Urol 1994; 6: 27-33.
13. Perelman M. Retarded ejaculation. In M O’Leary, ed. Current Sexual Health Reports. Philadelphia: Current Science, 2004.
14. Seidman SN, Roose SP, Menza MA et al. Treatment of erectile dysfunction in men with depressive symptoms: results of a placebo-controlled trial with sildenafil citrate. Am J Psychiatry 2001; 158: 1623-30.
15. Gagnon J, Rosen R, Leiblum S. Cognitive and social science aspects of sexual dysfunction: sexual scripts in therapy. J Sex Marital Ther 1982; 8: 44-56.
16. Althof, SE. New roles for mental health clinicians in the treatment of erectile dysfunction. J Sex Educ Ther 1998; 23: 229-31.
17. McCarthy BW. Integrating Viagra into cognitive-behavioral couple’s sex therapy. J Sex Educ Ther 1998; 23: 302-8.
18. Barada, JA. Successful salvage of sildenafil (Viagra) failures: benefits of patient education and re-challenge with sildenafil. Presented at the 4th Congress of the European Society for Sexual and Impotence Research 2001, Rome, Italy.
19. Perelman MA. FSD partner issues: expanding sex therapy with sildenafil. J Sex Marital Ther 2002; 28: 195-204.
20. Lue TF, Basson R, Rosen R et al. Sexual Medicine: Sexual Dysfunctions in Men and Women. Paris: Health Publications, 2004.