Sharon J Parish
Introduction
Sexuality involves the integration of an individual’s intellectual and emotional aspects, personal development, social mores, and biologic function.1 It influences happiness, self-esteem, and interpersonal relationships (see Chapter 17.6 of this book). It may involve intimacy with a partner, masturbation, integration of religious or cultural views, and the definition of one’s sexual identity and orientation.2,3 Sexual expression requires the acquisition of skills that involve the complex integration of emotional and physical behaviors. The human sexual response is multifaceted and therefore is vulnerable to dysfunction (see Chapters 3.1—3.4 and 5.1—5.6). Primary care clinicians are accustomed and ideally situated to deal with such complex issues, and patients hope that their physicians will be able to help.
This chapter will discuss the role of the primary care practitioner in the detection, evaluation, and management of female sexual problems. Internal medicine and family medicine office-based outpatient care of female sexual disorders is explicitly considered. In actual practice, internal medicine subspecialists, gynecologists, urologists, pediatricians, and psychiatrists often manage these problems; and the principles can be applied to these practice settings. We will describe the rationale for screening and a primary care approach to sexual disorders that includes the sexual history, the biopsychosocial model, physical examination, laboratory and diagnostic testing, classification, treatment, and referral.4
Epidemiology in community and clinic populations
Surveys of community samples suggest that sexual problems in women are common (see Chapters 2.1—2.4). In the early 1990s, Spector and Carey concluded that the prevalence of sexual dysfunction was 20-63% in sexually active women of all ages.5 A 1999 analysis by Lauman et al. of a survey of adult sexual behavior at ages 18-59 revealed that 43% of women experience sexual problems that negatively affect their quality of life.6 A comprehensive review of the literature in 2001 by Simons and Carey reported a community prevalence of 7-10% for female orgasmic disorder, and that the current stable prevalence of other female sexual dysfunctions was difficult to estimate because of wide methodological variation of the study designs.7
Moreover, most studies Simons and Carey reviewed did not distinguish between the presence of sexual dysfunction and a meaningful sexual disorder. An example they cited was a large Swedish community study in which the prevalence of the presence of a dysfunction was compared to the prevalence of those who perceived the dysfunction as a problem. For example, only 45% of women with orgasmic disorder saw it as a problem causing psychosocial distress; the 1-year prevalence of anorgasmia was 22%, but the prevalence of orgasmic disorder causing distress was 10%.8
In a review in 2004, Lewis et al. stated that 40-45% of adult women have at least one sexual dysfunction and that low sexual desire increased from 10% before age 50 to 47% at age 74.9 Arousal and lubrication disorders were estimated to be 8-28% and dyspareunia 2-20%. Orgasm dysfunction was present in at least 25% of women of all ages, and vaginismus was reported in 6% of women worldwide.
Simons and Carey’s review reported that prevalence rates in primary care and sexuality clinics were generally higher.7 However, the data had methodological problems and did not apply uniform criteria. Only some studies utilized all of the criteria for sexual disorders used in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV): interpersonal or intrapersonal distress; and the absence of another Axis I disorder, medical condition, or the physiologic effects of a substance.10The DSM-IV system was designed to classify and label psychiatric disorders and has limited applicability in medical settings. In 2000, Basson et al. composed an International Consensus Statement that proposed a new uniform scheme to define female sexual dis- orders.11 This classification system applied to both organic and psychogenic causes of female sexual dysfunction and included the personal distress criterion as an integral component of the definition of a disorder. Although the consensus statement called for research trials to define “clearer specification of clinical endpoints and outcomes”, few subsequent studies, including those reviewed by Lewis et al., have applied this new classification to determine accurate current prevalence rates in clinical populations.9 Moreover, well-validated questionnaires, such as the Female Sexual Function Index, and standard physiologic measures, such as vaginal photoplethysmography, have not been used uniformly in existing studies.12
Although the accuracy of clinical data has limitations, numerous studies have demonstrated that the prevalence of female sexual problems increases with certain medical illnesses and psychosocial factors. Medical and psychologic risk factors and comorbidities include general health status, diabetes melli- tus, cardiovascular disease, genitourinary disease, breast and gynecologic cancer, chronic diseases, and psychiatric condi- tions.11 Sociodemographic factors include low educational attainment, minority status, deterioration in social/economic status, and sexual trauma.6
Screening and detection
Although sexual disorders are common, only 10-20% of affected women spontaneously report these concerns to medical practi- tioners.6 Since clinicians rarely screen for sexual problems, detection rates are low. In an analysis of the detection of sexual dysfunction in an English general practice population, the majority (70%) of the 177 patients surveyed considered sexual issues to be appropriate for the general practitioner to discuss.13 However, physicians recorded sexual problems in only 2% of their notes, despite a survey prevalence of female sexual dysfunction of 42%. Improving screening procedures does improve recognition. In one study in which clinic physicians were trained to take a screening sexual history, 53% of the patients reported a sexual problem.14 Most (91%) of the patients said they considered questions about sexuality to be an appropriate part of the interview. These data demonstrate the high prevalence of sexual problems, improved detection with focused training in history-taking skills, and patients’ acceptance of such discussions.3,4
Although 50% of patients may report sexual problems when asked, not everyone wants treatment. Generally, less than half of women experience personal distress regarding their sexual dysfunction such that it would meet established criteria for a sexual disorder and require clinical intervention.9 The challenge in primary care is to identify existing sexual issues and discern which problems require further assessment and which patients would benefit from addressing problems that would not otherwise be addressed (see Chapter 9.4).
Barriers to addressing sexual problems
Practitioners may be reluctant to discuss sexual issues because of lack of knowledge or skills, discomfort with sexual language, concern over the effect of such a discussion, and fear of opening “Pandora’s box”.15 Both adolescents and adults perceive that physicians are often uncomfortable in discussing sexual issues and lack adequate communication skills to do so effectively.16 An Israeli study examined the attitudes and sexual dysfunction management of179 primary care physicians who attended a family practice and general practice conference.17 While 79% of the respondents thought that the primary care physician should address most sexual problems, 50% or fewer actually treated patients for sexual dysfunction. They perceived that only 12% of their sexual dysfunction patients were female; and the main barriers to treating sexual problems were lack of time (62%) and knowledge (47%).
Physicians may have difficulty in remaining objective and separating their personal beliefs and values from those of their patients.18 They may have limited sexual experience, unresolved issues regarding their own sexuality, or concern about developing sexual feelings toward patients.
Patients fear their doctor will dismiss their sexual concerns or that the topic might embarrass their physician. Consequently, they are often grateful when their practitioner initiates discussions. Patients may be unaware of potential treatments or may be concerned about side effects or adverse outcomes. Gott and Hincliff studied the barriers to older female patients seeking treatment in an English general practice setting.19 The women, of ages 50-92, reported that the most significant barriers were the general practitioner’s attitudes toward later-life sexuality, the attribution of sexual problems to “normal aging”, shame/embarrassment and fear, perceiving sexual problems as “not serious”, and lack of knowledge about available resources.
While physicians and patients should not go beyond their comfort in discussing sexual issues, barriers can be addressed through patient and physician education. While physicians typically do not receive adequate training in sexual medicine and sexual history taking, primary care physicians believe that they should address sexual problems and that they need more training to overcome knowledge deficits.17 Physicians can gain increased comfort and experience in managing sexual problems by incorporating routine sexual health questions into their practice, by sharing cases with colleagues, and by exploring their own attitudes toward sexuality.18
Sexual function and sexual concerns
Patients frequently present questions to their doctors about whether or not their sexual behavior is consistent with sexual dysfunction. Sexuality is subjective, and sexual behavior varies widely. The World Health Organization has proposed definitions of biologic, psychologic, and social components of sexual activity.20 Biologic dimensions include the usual sequence of sexual development and the ability to experience the physical events of the sexual response cycle. Psychologic aspects involve psychosexual maturation and the capacity for intimacy. Social elements relate to societal norms of sexual behavior as they compare with an individual’s sexual expression.4,20
The sexual response cycle (desire, arousal, orgasm, and resolution as a linear model) has been the standard framework for understanding physiologic sexual function (see Chapter 9.1). This approach has been challenged by Tiefer, Basson, and others, who assert that this model assumes that the sexual experiences of men and women are equivalent, when in fact the female sexual response does not always proceed according to the prescribed sequence.4 For example, many women experience desire only after sexual stimulation has led to arousal.21 Moreover, the sexual response cycle model may be too “genitally focused” and limited, defining heterosexual intercourse as the normative sexual experience, when in fact many women experience sexual satisfaction and pleasure through other behaviors.22 Furthermore, women may not see sexuality as a necessary component of satisfying intimate relationships. The sexual response cycle model may not adequately account for the wide spectrum of sexual expression and does not attend to communication and intimacy, both central to female sexual satisfaction. To enhance the quality of sexual discussions with female patients, physicians can learn about and integrate these alternative views of physiologic female sexuality.
Although the classic sexual disorders are prevalent, more commonly seen in primary care are sexual concerns. Women may have questions about their sexual behavior with regard to frequency, techniques to reach orgasm, masturbation, and fantasy. Women may have concerns about communication, disparate attitudes or value systems, sexual orientation, and the role of sexuality in their overall relationship. They may have inadequate knowledge about sexual function regarding developmental issues in adolescence; sexual changes with aging, medical illness, disability, or pharmacologic treatment; and changes with pregnancy, breastfeeding, or infertility.
The generalist can play a key role in sexuality by explaining the medical perspective, providing education, giving permission, and offering reassurance. According to Bullard and Caplan, the most common issues needing clarification are the following.18
Masturbation
From the medical perspective, masturbation is a commonly performed and universal behavior. It is physically safe and can offer individuals practice and sexual self-esteem. It may be problematic if it is associated with excessive guilt or used compulsively to avoid intimacy.
Frequency
There is a wide range of sexual frequency, from monthly to several times daily. Partner disparities in desired frequency may result in interpersonal conflict.
Fantasy
Sexual fantasies are normal as long as they are not associated with disturbing or intrusive thoughts that may indicate deeper psychologic issues.
Clitoral stimulation
Most women need direct stimulation to reach orgasm manually or orally. Approximately one-third of women reach orgasm only through clitoral stimulation, whereas other women require vaginal penetration; and some respond to both forms of stimulation.
Homosexuality
While some women may need support during the “coming out process” (the formation and evolution of sexual identity into a homosexual lifestyle), most lesbian women do not wish to have their sexual orientation questioned or changed. They have similar rates of sexual problems and have comparable sexual concerns. Up to one-fifth of adults, who may not identify themselves as homosexual, have had at least one same-sex encounter.6
Sexual changes with aging
As women age, they may note decreased vaginal muscle tension and expansion, delay in clitoral reaction time, and lack of breast size increase during stimulation. Consequently, they may require more direct genital stimulation and more time for arousal. Estrogen levels decline with menopause, which may be associated with atrophic changes and dyspareunia. Appropriate treatment of this condition often restores sexual function. Although orgasmic capacity is retained with age, there is a decrease in the number and intensity of vaginal contractions. The most important factors for postmenopausal women in maintaining sexual activity are partner availability and the partner’s physical health.23 Many women over age 70 continue to enjoy sexuality; and in response to changes in their sexual physiology, they may become less focused on intercourse and engage in alternate forms of sexual and physical intimacy. The physician can offer information and advice about how to accommodate to these physiologic changes.
Sexual difficulties versus disorders
(see Chapter 2.4)
Sexual concerns may evolve into sexual difficulties or dysfunctions if they result in intrapsychic distress or conflict between partners. In community and primary care samples, sexual difficulties are more common than classic sexual disorders. Frank et al.’s survey (1978) of couples with a high degree of marital satisfaction reported that 63% of the women reported arousal or orgasmic dysfunction and an even higher percentage (77%) reported sexual “difficulties”.24 Survey respondents in an English general practice population reported sexual dysfunction (43%) less frequently than “general sexual dissatisfaction”: 68% of the women reported at least one problem with avoidance, infrequency, and noncommunication.13 The generalist may identify and intervene with sexual difficulties before they amplify into complex disorders.
Organizing a generalist approach to sexual dysfunction
The primary care practitioner can best understand sexual problems by using a model that combines the affected phase(s) of the sexual response cycle; the biologic, psychologic, and social causes; and the predisposing, precipitating, and maintaining factors.25 The three-dimensional model depicted in Fig. 17.1.1 provides a framework for this analysis. The following general considerations may be helpful:
• Psychologic problems can produce sexual dysfunction in the absence of physical disorder.
• Almost all organic problems evoke psychologic reactions, such as performance anxiety and “spectatoring” (obsessive self-observation during sex), which inevitably exacerbate the disorder.
• Sexual function and dysfunction can be a learned phenomenon, subject to behavioral conditioning and learned inhibition.
While specific characteristics may help differentiate organic from psychogenic etiologies, most sexual problems managed by the generalist are multifactorial, especially in older patients with complex medical illness. The best approach is to identify and focus on those causes and factors that are amenable to intervention.
Clinical assessment of female sexual disorders
Detailed discussions of the causes and factors discussed above, sexual history and classification, medical history, physical examination, and physiologic testing are provided in Chapters 9.2-9.5 and 10.1-10.7. Selected highlights of specific recommendations for a practical approach to female sexual disorders in a primary care setting will be presented.
Sexual history taking
The goals of sexual history taking in primary care are listed in Table 17.1.1. While the sexual history can address numerous issues relevant to the female patient, sexual problems are an important and frequently overlooked agenda. A screening sexual problem history aims to detect sexual disorders that cause the patient distress. The sexual history can be incorporated into the medical interview where the clinician finds it appropriate and when the questions arise naturally. Opportunities appear during the urogenital or gynecologic review of systems or the social history, or when discussing a relationship. The clinician can initiate the discussion by asking permission and universalizing the process: “May I ask you some questions that I ask all my patients?” The interviewer can determine whether a patient is in a sexual relationship and ask about the nature of that relationship: “Are you having a meaningful relationship at this time?”; “How is it?”; “Are you sexually involved in this relationship?” Then sexual problem-screening questions might include: “Are you satisfied with your sexual function?” or “How has your illness affected your sexual function?” The clinician can also assess psychologic reactions to medical illnesses that do not have a direct effect on sexual function but do have symbolic implications. For example, after mastectomy, as a result of the perceived disfigurement, women may experience shame or fear of rejection.
Figure 17.1.1. Integrated model of sexual dysfunction. Reproduced with permission from Parish S, Salazar W. Sexual Problems. In FV DeGruy, WP Dickinson, EW Staton, eds. Twenty Common Problems in Behavioral Health. New York: McGraw Hill, 2002:143-172.3
___
Table 17.1.1. Goals of sexual history taking in primary care
Identify any questions or concerns related to sexuality
Identify sexual dysfunction and assess possible organic or psychogenic etiologies
Assess effects of illness, disability, surgery, medication, or substances on sexual function
Assess effects of psychiatric disorders and sociocultural issues on sexual function
Identify and assess the impact of psychologic reactions on sexual function
Identify sexual problems that may be clues to psychosocial problems or organic illness
Identify high-risk sexual behavior requiring education or counseling
Identify sexually transmitted diseases and sexual pain
Assess reproductive concerns, including contraception, infertility, pregnancy, and abortion
Identify and explore the impact of sexual trauma, including molestation, rape, and incest
___
In the sexual problem history, the interviewer can lead a patient through a typical sexual experience, using the sexual response cycle as a guide. Because a dysfunction in one phase can actually result from a dysfunction in another phase (e.g., decreased lubrication may cause pain and lead to decreased sexual desire), a problem should be characterized from its onset as it evolves over time. The interviewer should determine whether the problem occurs in specific situations or is generalized, as well as explore the nonsexual aspects of the relationship, the biopsychosocial context, the influence of cultural or religious mores, and the partner’s sexual function.
Contrary to what is recommended for the general medical interview, it may be useful to model the level of explicitness by starting with a close-ended question instead of open-ended questions. Examples include: “Do you experience any difficulty with lubrication?” or “Have you ever reached orgasm with your partner?” Then one can follow up with an open-ended question such as, “Could you tell me more about that?”
The interviewer should avoid making assumptions about the patient’s sexuality and that the first relationship mentioned is the only one that the patient is having. A patient may be having an affair, and an apparently happily married woman may be having homosexual contacts. The interviewer may include “safety net” questions such as, “Do you have any other questions or concerns about sex?” or “Are there other sexual relationships that I should know about?” 4
The interviewer should use language that is clear, explicit, and mutually understood. The physician should avoid language that is excessively technical or informal, and instead use language that the patient understands and that is comfortable for the interviewer.26
Discussions about sexuality may bring up sensitive issues. The interviewer may uncover issues the patient has never discussed with anyone and which may require specific interventions. For example, a woman may disclose a history of sexual trauma in a very emotional manner, so the clinician needs to be prepared to refer to a qualified resource person who could provide timely and appropriate therapeutic follow-up.3
Clinical evaluation
In analyzing a sexual problem in the primary care setting, the medical history, physical examination, laboratory testing, and physiologic testing will be guided by an understanding of the probable biologic causes and the physiology of the female sexual response. The Female Sexual Function Index is a multidimensional, self-report instrument that has been used to identify and classify the severity of female sexual dysfunctions in research trials (see Chapter 11.2). While validated questionnaires such as the Female Sexual Function Index provide detailed information, they have limited applicability in the clinical setting as routine screening and assessment tools.12 A detailed medical history and general physical examination is recommended for all sexual dysfunctions, with particular attention to the common medical comorbidities, depression, substance use, and side effects of frequently prescribed medications (e.g., selective serotonin reuptake inhibitors, antihypertensive drugs). The genital examination should be targeted to the assessment of specific physical complaints, such as vulvar pain. It can be diagnostic and educational, as, for example, in women with lifelong dyspareunia and difficulty with penetration. A detailed neurogenital and vascular examination may be helpful in women with arousal complaints and suggestive medical or traumatic histories. There are no recommended routine laboratory tests for sexual dysfunctions, especially with those with apparent psychogenic problems. Blood and radiologic testing should be dictated by the clinical suspicion of medical disease, such as lipids or serum glucose, and by gynecologic concerns, such as cervical cultures or pelvic ultrasound. Accurate assays of total testosterone and sex hormone-binding globulin are required with investigational testosterone therapy.27 Physiologic testing (e.g., vaginal photoplethysmography) has been used primarily in research trials and is not used routinely in the primary care evaluation of a sexual problem.
Therapy recommendations
The generalist can effectively diagnose and treat an array of sexual problems. The primary care setting is often the only place where patients can receive treatment, especially in urban or underserved areas. Access to sexual medicine specialists or sex therapists may be limited by geography, cost, language barriers, or managed care restrictions.
Empathic sexual history taking and delineation of problems can be therapeutic. Patients can be coached in enhanced communication. The clinician may suggest that the patient involve her partner. The P-LI-SS-IT model, a widely recognized stepwise approach to sex therapy, provides behavioral and psychologic techniques easily integrated in general practice, as detailed in the following:28
• (P) Permission: patients are given permission to discuss their problems and emotions and to explore new solutions.
• (LI) Limited information: the practitioner may instruct the patient about sexual physiology or suggest educational resources such as literature, videos, and erotica.
• (SS) Specific suggestions might include more tailored approaches designed to improve sexual and emotional communication, such as the sensate focus exercises, which emphasize replacing traditional intercourse with gradual, nondemanding pleasuring techniques; masturbation; Kegel exercises, technical advice regarding sexual positions; and the use of lubricants or dilators.
• (IT) Intensive therapy may involve referral for individual therapy to deal with intrapsychic issues, or couples therapy to improve communication or address conflict.
Treatment and referral for specific sexual disorders
The sexual disorders are categorized by the revised definitions of Basson et al. in Table 17.1.2.27 The recommended primary care intervention and indications for referral are outlined. Referral may involve specialists in urology, gynecology, psychiatry, sex therapy, and pelvic floor physiotherapy.
Table 17.1.2. Sexual dysfunction treatment and referral
|
Sexual disorder* |
Primary care intervention |
Indications for referral to specialist treatment |
|
Sexual desire/interest disorder; Subjective and combined (subjective and genital) Sexual arousal disorder** |
Systemic estrogen/progesterone therapy with attention to risks/benefits; Investigational androgen therapy with attention to potential side effects; Listening exercises to enhance communication: temporary intercourse ban, sensate focus, genital caressing; Kegel exercises; Relaxation techniques; Suggested readings, erotica, and other techniques to enhance sensuality |
Psychiatry referral: Psychogenic lifelong disorder, Complex interpersonal conflict, Psychiatric disorders refractory to primary care treatment (depression, panic disorder), History of sexual trauma |
|
Genital sexual arousal disorder |
Local estrogen therapy; Investigational use of PDE5 inhibitors; Consider clitoral vacuum device; Lubricants (Astroglide, K-Y, Albolene); Zestra (massage oil) |
Gynecology or urology referral: Refractory to estrogen therapy |
|
Orgasmic disorder (psychogenic) |
Lifelong generalized orgasmic disorder: directed masturbation, relaxation techniques if anxiety present; Situational (orgasmic with masturbation, not with partner): focus on trust and safety in relationship, use of vibrators with intercourse, “women on top" position |
Sex therapy referral: Refractory to basic behavioral counseling techniques |
|
Orgasmic disorder (organic or drug induced) |
SSRI-induced anorgasmia: Buproprion, investigational use of PDE5 inhibitor, drug holiday, dose reduction |
Sexual medicine specialist or urology referral: Neurologic condition (multiple sclerosis, spinal cord injury, late diabetes) |
|
Dyspareunia** Vaginismus** |
Treatment of vaginal/cervical infections; Vulvar vestibulitis syndrome (VVS): irritant avoidance, tricyclic antidepressants, anti-convulsants; Adequate stimulation and female control of thrusting with intercourse; Progressive vaginal inserts (finger or dilator) |
Gynecology referral: Complex VVS; Sex and/or pelvic floor physical therapy referral: Lifelong vaginismus refractory to dilator therapy |
*Based on the revised classification of female sexual disorders.27
**Disorders which often present together and have similar treatment considerations.
PDE5: phosphodiesterase type 5; SSRI: selective serotinin reuptake inhibitors.
There are currently no US Food and Drug Administration- approved pharmacotherapies for female sexual dysfunction. However, the generalist may consider investigational uses of prescription medications, such as selective phosphodiesterase type 5 inhibitors and testosterone, or over-the-counter supplements,29 with attention to the considerations regarding these therapies discussed above. The generalist can treat gynecologic conditions, such as atrophic vaginitis, with topical estrogen and address drug side effects, such as with serotonin reuptake inhibitor-induced anorgasmia.
Conclusion
Female sexual concerns and disorders are common, inadequately recognized, and under-treated. Although these disorders may be challenging, a set of clinical skills within the grasp of primary care clinicians can enhance detection and permit successful treatment for many woman. Generalists that naturally and commonly apply a holistic, comprehensive, biopsychosocial approach can make a world of difference by learning how to manage female sexual disorders effectively.
References
1. Klingman EW. Office evaluation of sexual function and complaints. Clin Geriatr Med 1991; 7: 15-36.
2. Parish S, McGinn T. Sexual dysfunction in men and women. In LM Rucker, ed. Essentials of Adult Ambulatory Care. Baltimore: Williams and Wilkins, 1997: 432-41.
3. Parish S, Salazar W. Sexual problems. In FV DeGruy, WP Dickinson, EW Staton, eds. Twenty Common Problems in Behavioral Health. New York: McGraw Hill, 2002: 143-172.
4. Parish S, Salazar W. Sexuality. In J Ryden, PD Blumenthal, eds. Practical Gynecology: A Guide for the Primary Care Physician. Philadelphia: American College of Physicians, 2002: 26-51.
5. Spector IP, Carey MP. Incidence and prevalence of the sexual dysfunctions: a critical review of the empirical literature. Arch Sex Behav 1990; 19: 389-407.
6. Laumann E, Paik A, Rosen RC. Sexual dysfunction in the United States: prevalence and predictors. JAMA 1999; 281: 537-44.
7. Simons JS, Carey MP. Prevalence of sexual dysfunctions: results from a decade of research. AchSxMehûX 2001; 30: 177-219.
8. Fugi-Meyer AR, Sjogren Fugi-Meyer K. Sexual disabilities, problems, and satisfaction in 18-74 year old Swedes. Scand J Sexol 1999: 3: 79-105.
9. Lewis RW, Fugi-Meyer KS, Bosch R et al. Epidemiology/risk factors of sexual dysfunction. J Sex Med 2004; 1: 35-9.
10. Diagnostic and Statistical Manual of Mental Disorders, 4th edn (DSM-IV). Washington, DC: American Psychiatric Association, 1994.
11. Basson R, Berman J, Burnett Aetal. Report of the international consensus development conference on female sexual dysfunction: definitions and classification. J Urol 2000; 163: 888-93.
12. Rosen RC, Brown C, Heiman Jetal. The Female Sexual Function Index (FSFI); a multidimensional self-report instrument for the assessment of female sexual function. J Sex Marital Ther 2000; 26: 191-208.
13. Read S, King M, Watson J. Sexual dysfunction in primary medical care: prevalence, characteristics and detection by the general practitioner. J Public Health Med 1997; 19: 387-91.
14. Ende J, Rockwell S, Galsgow M. The sexual history in general medical practice. Arch Int Med 1984; 144: 558-61.
15. Risen CD. A guide to taking a sexual history. Psychiatr Clin North Am 1995; 18: 39-53.
16. Croft CA, Asmussen L. A developmental approach to sexuality education: implications for medical practice. J Adolesc Health 1993; 14: 109-14.
17. Press Y, Menahem S, Shvartzman P. [Sexual dysfunction - what is the primary physician’s role?] Harefuah 2003; 142: 662-5, 719.
18. Bullard DG, Caplan H. Sexual problems. In MD Feldman, JF Christensen, eds. Behavioral Medicine in Primary Care: A Practical Guide, 2nd edn. Stamford: Lange Medical Books/McGraw-Hill, 2002: 274-92.
19. Gott M, Hincliff S. Barriers to seeking treatment for sexual problems in primary care: a qualitative study with older people. Fam Pract 2003; 20: 690-5.
20. Schover LR, Jensen SB. Sexuality and Chronic Illness. A Comprehensive Approach. New York: Guilford Press, 1998.
21. Basson R. The female sexual response revisited. J Soc Obstet Gynecol Can 2000; 22: 383-7.
22. Tiefer L. Sex Is Not a Natural Act and Other Essays. Boulder: Westview Press, 1995.
23. Greendale GA, Hogan P, Shumaker S. Sexual functioning in postmenopausal women: the postmenopausal estrogen/progestin interventions (PEPI) trial. JW^mniHealth 1996; 5: 445-58.
24. Frank E, Anderson C, Rubenstein D. Frequency of sexual dysfunction in “normal” couples. N Engl J Med 1978; 299: 111-15.
25. Wincze JP, Carey MP. Sexual Dysfunction. A Guide for Assessment and Treatment. New York: Guildford, 1991.
26. Williams S. The sexual history. In A Lipkin, S Putnam, A Lazare, eds. The Medical Interview: Clinical Care, Education, and Research. New York: Springer-Verlag, 1995: 235-50.
27. Basson R, Altholf S, Davis Setal. Summary of the recommendations on sexual dysfunctions in Women. J Sex Med 2004; 1: 24-34.
28. Annon JS. Behavioral Treatment of Sexual Problems: Brief Therapy. Hagerstown: Harper & Row, 1976.
29. Ferguson DM, Steidle CP, Singh GS et al. Randomized placebo- controlled, double-blind, crossover trial of the efficacy and safety of Zestra for women in women with and without female sexual arousal disorder. J Sex Marital Ther 2003; 29(Suppl 1): 33-44.