Women's Sexual Function and Dysfunction. Irwin Goldstein MD

Role of the nonphysician health-care clinician

Amy L Gamez

Introduction

It is an exciting and dynamic time, as the specialty of female sexual health is developing into an independent field that can improve the quality of life of our patients. Nonphysician healthcare clinicians play an integral part in an interdisciplinary team in the management of female sexual dysfunction. They can be instrumental in helping patients with female sexual dysfunction confront their sexual health issues, as well as in the planning and carrying out of a successful treatment strategy.

Nonphysician health-care clinicians, including nurse practitioners and physician assistants, can provide a critical part of comprehensive care to the patient with female sexual dysfunction. Among other things, the nurse practitioner and physician assistant are trained to educate patients on sexual health issues, perform health assessments, conduct patient interviews, and take a thorough medical history that incorporates a sexual health history. Evaluation of sexual dysfunction should become a part of the routine history and physical examination. Nonphysician health-care clinicians have the opportunity to address sexual health proactively with female patients, mostly because they are the first clinicians encountered by the patient in a primary care setting. Health-care professionals in endocrinology, urology, gynecology, and family practice settings are in key roles to identify females experiencing sexual dysfunc- tion1 (see Chapters 17.1-17.4 and 17.6).

This chapter will explore how the nonphysician healthcare clinician can assist in the integration of awareness, diagnosis, and treatment of female sexual health issues in the primary care setting. A brief historical perspective will provide the developmental background of sexual health treatment. The next section supplies suggestions on how to create an office environment that is “sexual health friendly”, and guidance to the clinician on how to promote a permissive atmosphere in which patients can effectively communicate their sexual problems. The chapter will then delve into the intricacies of the interaction with the patient, such as taking a sexual health history and breaking the barriers that currently exist, as well as discussing the physical examination and appropriate laboratory testing. Then, suggestions will be provided on how to integrate the evaluation techniques to be utilized. Lastly, this chapter will provide suggestions on how to incorporate treatment-management strategies to help patients in their everyday lives.

Historical perspective

From the start of the twentieth century until the late 1960s, sexual dysfunction had been treated within a psychoanalytic framework.2 Sex therapy, as it is known today, was essentially founded by Masters and Johnson in 1970, whose published report on a “new” approach to sexual problems revolutionized what health professionals saw as the appropriate treatment for such difficulties2 (see Chapters 1.1 and 11.1). This linear model of the sexual response cycle, in contrast to the psychoanalytic practices, focused primarily on the vascular and neurologic changes, which included four stages: (1) excitement; (2) plateau; (3) orgasm; and (4) resolution.3 Subsequently, a biopsychosocial model was presented that combined biologic, psychologic, and sociocultural influences, and interpersonal relationships, and suggested that emotional intimacy, commitment, sharing, and tenderness to another person are often required for a woman to respond to sexual stimuli.3 Based on those models, the criteria of the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV), provide guidance in the diagnosis of female sexual dysfunction; these criteria include the four main categories of sexual desire disorder, sexual arousal disorder, orgasm disorder, and sexual pain disorder.4 The 1999 Consensus Classification System further expanded the DSM-IV criteria to include physical as well as psychologic causes of female sexual dysfunction. Several changes were made in the specific definitions and criteria for each diagnosis, including use of a personal distress criterion for most diagnostic cate- gories5 (see Chapter 9.1).

Recently, with the advent of oral therapies in the treatment of male erectile dysfunction, sexual health issues have become an easier topic to discuss for both men and women (see Chapters 13.1-13.3, 14.1, and 14.2). An increasing number of patients are discussing sexual problems with their health-care providers, requiring the nonphysician health-care clinician to keep abreast of the latest treatment options as well as knowing the available resources. As the field of female sexual dysfunction continues to progress, nonphysician health-care clinicians will have the responsibility of furthering the development of their role in the management of female sexual dysfunction.

Creating an environment that promotes sexual health

Identifying patients with sexual issues

The first step in identifying female patients with sexual health issues is to recognize that this is a common problem. Sexual dysfunction in women is age-related, progressive, and highly prevalent, affecting 30-50% of American women6 (see Chapters 2.1-2.4). Potentially, every other female patient to enter the office could be experiencing some type of sexual dysfunction.

Even after recognition, many patients are reluctant to disclose their sexual problems to their primary care physician and/or endocrinologist, urologist, or gynecologist despite good patient rapport. Usually, patients do not present with female sexual dysfunction symptoms in the primary care setting as they do with other disorders; therefore, it is important to ask appropriate questions to elicit their concerns (see Chapter 17.1).

So, how are we to identify female patients with sexual health issues? Generally, nonphysician health-care clinicians have more time to spend with their patients, enabling them to establish better rapport. In turn, the time spent encourages patients to feel more comfortable in disclosing sensitive issues, particularly those that have to do with sexuality. By our increasing the comfort level through a good patient-clinician relationship, the patient will feel more at ease when asked questions of a sexual nature. However, if the patient is unwilling to bring up the subject on her own, it is essential for the clinician to introduce the subject in a sensitive manner. But what is the right way to “ask the question”? What question will make the patient comfortable? We have certainly learned from approaching men with erectile dysfunction that there is no one correct question for everyone. Questions to consider when introducing sexual health are as follows:

 Are you sexually active?

 Are you experiencing any difficulties with your sex life?

 Are you having any difficulties sexually, such as problems with desire, sexual arousal, or reaching orgasm? (This is more direct and will probably elicit a clarifying question from the patient if she is interested.)

One final suggestion about approaching the subject is to ask questions concerning sexual health on the history intake form. This will let the patient know that her health-care clinician is receptive to sexual health issues as well as to her overall wellbeing.

Creating the environment

A goal of the clinician is to create and promote an environment that is “sex-discussion friendly”. There are several ways to achieve this goal. One way is to encourage the clinician to be aware of exhibiting negative nonverbal cues.

Conducting interviews while standing or making minimal eye contact are prime examples of negative nonverbal cues. Conversely, by sitting down, actively listening, and making good eye contact, the clinician will promote a more comfortable environment for the patient.

Secondly, the office can convey its interest in patients’ sexual health by the availability of patient education materials such as brochures and patient questionnaires. As mentioned earlier, history intake forms provide another vehicle to display the commitment of the office to sexual health care. The inclusion of sexual health concerns on the intake form shows the patient that the clinical staff are interested in all of her medical issues, including those about sex. By implementing these suggestions, an office will go a long way toward creating a more conducive and “friendly” environment for sexual health discussions (see Chapter 11.2).

Establishing the roles in the office

Due to lack of specific academic education, few urologists and gynecologists are skillful in sexual medicine. For this reason, it is crucial for the physician with a surgical background to convey the message that the nonphysician health-care clinician is a valuable resource in the office in regard to sexual health issues. Although the physician has the final responsibility for the patient’s treatment, the nonphysician health-care clinician can assist in providing patient information, diagnosis, treatment, and integration of care so as to provide a comprehensive evaluation of the patient’s sexual health concerns.

Additionally, there must be clear guidelines as to the relationship between the physician and nonphysician health-care clinician regarding care of sexual health patients. Items to clarify include the following: who should conduct the initial interview? When should the sexual health questions be posed, and by whom, the nonphysician health-care clinician, the physician, or both? What treatment protocols are to be used?

Table 17.5.1. Sample questions to elicit sexual health concerns

Do you have any sexual concerns that you would like to discuss

 

today?

Are you experiencing any difficulties with your sex life?

Do you have any difficulty becoming lubricated with sexual

 

intercourse?

Do you have difficulty achieving orgasm?

Do you experience pain with intercourse?

Do you currently suffer from a sexually transmitted disease?

Furthermore, while it is important to create a conducive environment, it is worth ensuring that the office staff are instructed on their respective roles. For nurses, medical assistants, and ancillary staff, it might be as simple as teaching each person to be sensitive to the patients who are being given sexual health brochures or medication samples.

Interaction with the patient

Addressing sexual health history

Once a comfortable environment has been established, it is necessary to incorporate a detailed and thorough sexual health evaluation in addition to the routine history and physical examination. The nonphysician health-care clinician must be open, empathetic, and nonjudgmental during the interview to allow the patient to feel comfortable in disclosing sensitive and private matters. Moreover, the clinician should make a concerted effort to avoid making moral or religious judgments regarding the patient’s behaviors; instead, the clinician should relate the information from a point of view that includes emotional and psychologic health.7

For appropriate evaluation and management, it is important to establish the patient’s sexual orientation early in the interview process. Since gender identity conflicts are often a cause of sexual dysfunction, the mode and type of the questions posed by clinicians should ease patients into openly expressing their concerns.8 Ideally, these patients should be referred to a sex therapist/psychologist for further evaluation.

Regardless of sexual orientation, the patient should be asked questions about sexual activity such as whether or not she is currently sexually active. If so, one should ascertain frequency of intercourse, the number of partners over the past year, and any associated symptoms with sexual activity (e.g., pain, burning, bleeding).

Next, the clinician should evaluate the patient’s scope of sexual dysfunction. For instance, the patient’s concern over sexual desire and how that relates to her partner relationship should be discussed. The assessment should include the patient’s past as well as current information regarding sexual arousal, her ability to achieve orgasm, and any associated pain during sexual intercourse.

Additionally, discussions may involve overall sexual satisfaction. The clinician should determine whether the dysfunction is a lifelong or acquired problem, and whether the dysfunction is generalized or situational.

The variations of questions will differ from practitioner to practitioner, depending on comfort level and experience. Table 17.5.1 lists sample questions.

Sometimes the patient’s own testimonials provide the best insight.8 For example, the patient may disclose relationship problems or possible embarrassments about urinary incontinence during intercourse. Obtaining this information early in the interview may expedite diagnosis, treatment initiation, and/or proper referral to another health-care clinician.

Alternatively, questionnaires may be used prior to the office visit to save time. There are a variety of validated scales, such as the Female Sexual Function Index, that assess the domains of desire, arousal, orgasm, and pain. Another useful instrument is the Female Sexual Distress Scale, which helps to quantify the patient’s level of bother and distress.9,10

Consequently, a sexual history may help to explain the patient’s current health problems, or aid in identifying new health problems such as depression/anxiety, diabetes, or hypertension.

Barriers to discussing sexual health issues

It is important to recognize some of the barriers to discussing sexual health issues by clinicians to illustrate the importance of sexual health evaluation in women. Female sexual dysfunction is a common problem. Although the available literature demonstrates the importance of sexuality to patients, physicians often do not introduce the subject during clinical encounters.11 Patients report that physician discomfort and anticipated non- empathetic response to sexual problems are the primary barriers to discussing sexual health.7 The intent is to treat the whole person. The ability to understand and overcome the barriers will allow clinicians to better identify sexual dysfunction among their female patients.

Many clinicians, due to feelings of embarrassment or unfamiliarity, feel uncomfortable discussing sexual issues with their patients. Clinicians may also worry that their patients will find the questioning offensive. In one study, only 35% of primary care physicians reported that they often or always took a sexual history.7 However, research conducted on healthy women has indicated that they would seek advice from their family physicians if the physicians raised the issue of sexual function rather than the women themselves having to volunteer the information.12

Furthermore, the clinician should practice sexual health interviews on a regular basis in order to become more comfortable in discussing sexual issues with patients. As the level of comfort exhibited by the clinician increases, the expression of patient concerns will be enhanced.

Appropriate timing in discussing sensitive sexual health issues is another element the clinician must consider. The patient may feel uneasy discussing sexual issues while being physically examined and become hesitant in disclosing information. For better results, the comfort level should be established during the interview process.

Another barrier is the perceived lack of time by clinicians during a patient visit. Clinicians worry that asking patients about their sexual issues will take too much time for evaluation and treatment. In actuality, asking about sexual issues may save time, as underlying issues are uncovered. Clinicians can decide to what level they want to delve with each patient and at what point a referral to another health-care clinician is necessary.

An additional obstacle is the reluctance to address sexual function due to the clinician’s lack of expertise. Generally, clinicians do not feel comfortable discussing issues on which they do not have a great deal of knowledge. More often than not, primary care practitioners have received little training on how to assess female sexual function.13 Clinicians can inform themselves about female sexual dysfunction through continuing education programs, attending educational conferences on female sexual health, and reading journal articles, other current research, and other published material. The DSM-IV criteria provide the current diagnostic and classification system for female sexual dysfunction; however, they do not provide a background for understanding the patients’ sexual problems. Clinicians need to address possible contributing factors such as relationship difficulties, and biologic or psychosocial issues. By taking a thorough history, nonphysician health-care clinicians can perform the initial assessment for biologic, psychosocial, interpersonal, and emotional factors that will enable them to recommend the appropriate referral.

Lastly, the clinician may harbor the misconception that female sexual dysfunction requires a more complicated treatment plan. Male sexual dysfunction is perceived to be an uncomplicated diagnosis compared to female sexual dysfunction and easier to treat. Hence, many clinicians avoid the issue of female sexual dysfunction altogether.

Medical history and physical examination

The medical history (see Chapter 9.2) should include focused questions on the patient’s overall health condition. The nonphysician health-care clinician can be instrumental in helping patients to understand how the medical history indicates the etiology of female sexual dysfunction. It is an opportunity for patients to understand that female sexual dysfunction can potentially be a normal consequence of their health issues.

In addition to a thorough sexual health history (see Chapter 9.4) to identify sexual problems, the nonphysician health-care clinician can perform a focused physical examination and laboratory blood tests (see Chapter 9.5). Sexual dysfunction may be symptomatic of organic or psychiatric disorders or a combination of both. Some of the possible risk factors associated with female sexual dysfunction are listed in Table 17.5.2.

The patient’s current medications should be reviewed, including prescription, over-the-counter drugs, and street drugs, as some may contribute to the etiology of a patient’s sexual dysfunction (Table 17.5.3). Additionally, the patient’s current medical therapy can be turned into an opportunity for the nonphysician health-care clinician to educate the patient, and to clarify how some of these medicinal interventions may contribute to sexual health issues.

Table 17.5.2. Risk factors for female sexual dysfunction

 

Cancer

 

Cardiovascular disease

 

Depression/anxiety

 

Endocrine disease

 

Fatigue

 

Genital surgery

 

Genital atrophy

 

Hormonal abnormality

 

Interpersonal relationships

 

Medications

 

Neurologic disease

 

Psychosocial factors

 

Sexual or physical abuse

 

Urogenital disorders

Moreover, the clinician should review the patient’s surgical history, including pelvic surgery, back surgery, and cardiovascular surgery. For example, a hysterectomy may reduce blood flow to the vagina and decrease lubrication. A thorough physical examination should be performed, including a gynecologic examination to assess physiologic etiologies, pain, and trauma. The goal of the examination is detection of disease; however, the examination also provides an opportunity to educate the patient about normal anatomy and sexual function, and to reproduce and localize pain encountered during sexual activity.8 After a comfortable rapport has been established, the clinician can teach the patient during the examination and when appropriate, make use of readily available mirrors, illustrations, and pictures to make the patient feel more comfortable with her own anatomy.

The nonphysician health-care clinician should coordinate with the physician to establish a protocol of laboratory tests to be ordered at the initial evaluation. This initial blood testing may identify an underlying disease such as diabetes or hypercholesterolemia. Treating these organic disorders may improve or reverse the patient’s sexual dysfunction.

Table 17.5.3. Medications associated with female sexual dysfunction

 

Antihistamines

 

Antihypertensives

 

Anticonvulsants

 

Benzodiazepines

 

Diuretics

 

Narcotics

 

Antiandrogens

 

Oral contraceptives

 

Antidepressants

 

Antiestrogens

Incorporating an integrated treatment strategy

Integration and multidisciplinary treatment coordination

In coordinating the sexual health evaluation and interdisciplinary treatment plan, the nonphysician health-care clinician is likely to enhance treatment outcomes through follow-up. Another added benefit is that the nonphysician health-care clinician can collaborate with the clinical staff in determining which treatment options are most appropriate for this list. The responsibilities include maintaining continual communication and synchronizing the interventions proposed by the interdisciplinary team members, such as the endocrinologist, urologist, or gynecologist, as well as a sex therapist, psychologist, or psychiatrist, depending on the resources of the community. One way to implement team communication is through scheduled teleconferences or meetings to discuss patient progress. Integrating each team member’s assessment allows better understanding of the patient’s problem for an optimal treatment plan. The coordination of the services of these specialists is paramount if the goal is to keep patients knowledgeable and interested in addressing their original sexual health issues. The nonphysician health-care clinician can assist in devising a comprehensive treatment plan and determining which treatments the physician deems appropriate to utilize in the armamentarium of the practice.

The nonphysician health-care clinician’s own sexual health education

As previously mentioned, nonphysician health-care clinicians must continue to educate themselves to increase the knowledge base regarding female sexual dysfunction, as this is a rapidly growing field. By making a commitment to self-education, the nonphysician health-care clinician can help to educate other staff members in the office through periodic in-service programs.

Education can be furthered by reading textbooks and journal articles, and attending conferences, such as the annual meeting of the International Society for the Study of Women’s Sexual Health. There is a growing list of national, regional and community-sponsored continuing medical education talks and teleconferences with emphasis on the field of sexual health.

The nonphysician health-care clinician certainly is in a strategic position to educate the patient and office staff about the clinical trials underway on female sexual dysfunction. In order to integrate this additional service into the office, the nonphysician health-care clinician needs to be aware of the research protocols that are available in the office as well as any research opportunities that are available in the community.

How the nonphysician health-care clinician can incorporate patient education into female sexual dysfunction treatment and management

For clinicians to be successful in the treatment of sexual dysfunction, the most crucial aspects of medical care are coordination and implementation.The nonphysician health-care clinician can be instrumental in assisting patients with female sexual dysfunction to confront sexual health issues, and can assist in planning and carrying out a successful treatment strategy. Educating the patient and partner about normal female physiologic response and female pelvic and genital anatomy is often necessary. Additionally, physiologic changes associated with aging, pregnancy, menopause, and vascular dysfunction should be explained. The clear correlation between the patient’s general health and sexual function must be emphasized.14 The nonphysician health-care clinician can play a significant role in informing the female patient about the definition of female sexual dysfunction through handouts and brochures.

Patients may need education on how to modify harmful lifestyle behaviors (i.e., alcoholism, recreational drug use, smoking, sedentary lifestyle, and promiscuity) that could be a factor in their sexual dysfunction. Sexually transmitted disease prevention through education and awareness may be prudent, depending on the patient’s risk factors.

Educating patients on their prescribed sexual health medications and sexual health interventions is very important. Patients often need reinforcement on how and when to take their medications as well as discussion of possible side effects that they may experience that could lead to discontinuation of treatment. Partner education and sexual evaluation are a critical component in the management of female sexual dysfunction.

The nonphysician health-care clinician should be aware of the current literature on female sexual dysfunction to be able to provide patients with information on available treatments.

Expanding the “sexual health friendly” environment beyond the office setting

Once the nonphysician health-care clinician is comfortable with the field, it may be time to expand the area of academic influence. The first step is promoting intraoffice appreciation of the field of sexual medicine. Essentially, this involves teaching the staff to “spread the word” that the health-care team is interested in being attuned to the sexual health needs of female patients. The next step is to consider out-of-the-office medical education. This enables other clinicians and their office staff as well as the general community to become aware of the practice’s special expertise in female sexual dysfunction. With continued knowledge, the nonphysician health-care clinician may eventually consider delivering local talks to other nonphysician health-care clinicians. It is an opportunity to teach and excite them about the field of sexual medicine in the expectation that some may eventually see patients in their own offices.

Conclusion

It is an exciting time in the field of female sexual dysfunction as it ventures to become an independently recognized field in the practice of medicine. The treatment of female sexual dysfunction is progressively evolving, as new approaches and treatment options are discovered through basic and clinical research.

A collaborative approach is ideal in the management of female sexual dysfunction, including both medical and psychosocial evaluation. The nonphysician health-care clinician, as part of the necessarily multidisciplinary team, can play a significant role in the management of the complexity of the female patient with sexual dysfunction. While the physician is ultimately responsible for the patient’s overall management, the nonphysician health-care clinician can assist by performing the initial evaluation, providing patient education, and assisting in the protocol development for the practice/office staff, thus playing an integral role in the management of patients with female sexual dysfunction.

References

1. Keller M. Female sexual dysfunction: definitions, causes, and treatment. Urol Nurs 2002; 22: 237-44, 284.

2. Weiderman MW. The state of theory in sex therapy (the use of theory in research and scholarship on sexuality). J Sex Res 1998; 35: 88-99.

3. Walton B, Thorton T. Female sexual dysfunction. Curr Womens Health Rep 2003; 3: 319-26.

4. Anastasiadis AG, Davis AR, Ghafar MA et al. The epidemiology and definition of female sexual disorders. World J Urol 2002; 20: 74-8.

5. Basson R, Berman J, Burnett A et al. Report of the international consensus development conference on female sexual dysfunction: definitions and classifications. J Urol 2000; 163: 888-93.

6. Berman JR, Bassuk J. Physiology and pathophysiology of female sexual function and dysfunction. World J Urol 2002; 20: 111-18.

7. Nusbaum MR, Hamilton C, Lenahan P. Chronic illness and sexual functioning. Am Fam Physician 2003; 67: 347-54, 357.

8. Nusbaum MR, Hamilton CD. The proactive sexual health history. Am Fam Physician 2002; 66: 1705-12.

9. Rosen R, Brown C, Heiman J et al. 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.

10. Derogatis LR, Rosen R, Leiblum S et al. The female sexual distress scale (FSDS): initial validation of a standardized scale for assessment of sexually related personal distress in women. J Sex Marital Ther 2002; 28: 317-30.

11. Phillips NA. Female sexual dysfunction: evaluation and treatment. Am Fam Physician 2000; 62: 127-36, 141-2.

12. Sarkadi A, Rosenqvist U. Contradictions in the medical encounter: female sexual dysfunction in primary care contacts. Fam Pract 2001; 18: 161-6.

13. Coons HL. Women’s health in primary care: interdisciplinary interventions. FamSystHeolh 2002; 20: 237-51.

14. Lightner DJ. Female sexual dysfunction. Mayo Clin Proc 2002; 77: 698-702.