Psychological and interpersonal dimensions of sexual function and dysfunction.

INTRODUCTION: There are limited outcome data on the etiology and efficacy of psychological interventions for male and female sexual dysfunction as well as the role of innovative combined treatment paradigms. AIM: This study aimed to highlight the salient psychological and interpersonal issues contributing to sexual health and dysfunction, to offer an etiological model for understanding the evolution and maintenance of sexual symptoms, and to offer recommendations for clinical management and research. METHODS: This study reviewed the current literature on the psychological and interpersonal issues contributing to male and female sexual dysfunction. MAIN OUTCOME MEASURE: This study provides expert opinion based on a comprehensive review of the medical and psychological literature, widespread internal committee discussion, public presentation, and debate. RESULTS: Medical and psychological therapies for sexual dysfunctions should address the intricate biopsychosocial influences of the patient, the partner, and the couple. The biopsychosocial model provides an integrated paradigm for understanding and treating sexual dysfunction. CONCLUSIONS: There is need for collaboration between healthcare practitioners from different disciplines in the evaluation, treatment, and education issues surrounding sexual dysfunction. In many cases, neither psychotherapy alone nor medical intervention alone is sufficient for the lasting resolution of sexual problems. The assessment of male, female, and couples' sexual dysfunction should ideally include inquiry about predisposing, precipitating, maintaining, and contextual factors. Research is needed to identify efficacious combined and/or integrated treatments for sexual dysfunction.

Vaginal dryness: a comparison of prevalence and interventions in 11 countries.

INTRODUCTION: There is limited research comparing cross-cultural differences in women's experiences of vaginal dryness. AIM: To examine international differences in the prevalence of vaginal dryness, the degree to which it is experienced as problematic or bothersome, the use of lubricants to alleviate it, and women's discussion of this problem with physicians. MAIN OUTCOME MEASURES: Questionnaire measuring the level of vaginal dryness and degree to which it is perceived as bothersome. METHODS: The Global Survey of Sexual Attitudes and Practices was administered to 6,725 women from 11 countries: UK, Germany, Japan, Australia, Canada, Spain, Italy, Mexico, Argentina, Brazil and Thailand. RESULTS: Prevalence of self-reported vaginal dryness varied from a minimum of 5.8% in Italy to a maximum of 19.7% in Brazil. The proportion of women with self-reported vaginal dryness who found it very bothersome varied as well (e.g., 5.6% UK, 26.4% Germany). Pain during intercourse ranged from a reported low of 3.6% in Australia to 18.6% in Brazil. Older women (50-65 years) as compared with younger women (18-34 years) reported significantly more vaginal dryness in the UK, Australia, Canada, Italy, Spain, Argentina, and Thailand (P values <0.02). The majority of women under 50 attributed vaginal dryness to inadequate sexual arousal while women over 50 believed it was because of aging or menopause. Cross-culturally, women differed substantially in the likelihood of discussing their sexual life/concerns with a physician. CONCLUSION: Women from different countries differ substantially in their experiences, concerns, and reports of vaginal dryness/sexual pain, as well as their familiarity with personal lubricants as a treatment. Researchers should assess the prevalence and degree of the bother of vaginal dryness in order to make international comparisons of the burden of this condition.

FSFI scores of women with persistent genital arousal disorder compared with published scores of women with female sexual arousal disorder and healthy controls.

INTRODUCTION: Although persistent genital arousal disorder (PGAD) has been mistaken for hypersexuality, there is no research documenting the sexual functioning of PGAD women to support or refute such an assumption. AIM: To compare the Female Sexual Function Index (FSFI) scores of PGAD women to that of women diagnosed with female sexual arousal syndrome (FSAD) and healthy controls. METHODS: The FSFI scores of heterosexual women who met all five features qualifying for a diagnosis of PGAD (N = 172) on an online questionnaire were compared with previously published FSFI scores of women diagnosed with FSAD (N = 128) and healthy controls (N = 131). MAIN OUTCOME MEASURE: Total and subscale scores on the FSFI. RESULTS: On every subscale of the FSFI with the exception of desire, the PGAD women obtained scores between that of the FSAD and the healthy control group. The FSAD women displayed the greatest problems in desire, arousal, lubrication, orgasm, and pain while women with PGAD reported somewhat more desire than the control group but did not meet the cutoff score for sexual dysfunction. PGAD women are more similar to the normal control group than women with FSAD. CONCLUSIONS: There is no evidence to support the belief that women who meet criteria for a diagnosis of PGAD are "hypersexual." In fact, their overall sexual functioning falls within the normal range and is significantly better than that of women diagnosed with FSAD.

To BATHE or not to BATHE: patient satisfaction with visits to their family physician.

BACKGROUND: BATHE is an acronym for Background, Affect, Trouble, Handling, and Empathy and refers to specific questions or comments incorporated into a standard medical interview. The BATHE technique was developed as a rapid psychosocial intervention for the assessment of psychological factors that may contribute to patients' physical complaints. The present research was designed to determine whether the use of BATHE significantly increased patient satisfaction during a visit to a family physician. METHODS: Four family physicians in a busy urban family practice center were involved in the study. Two physicians were instructed to use the BATHE protocols until data had been collected from 10 patients and then to proceed in their usual fashion with their next 10 patients. The other two physicians conducted their interview as usual with their first 10 patients and then used BATHE with the following 10 patients. All patients were asked to complete a satisfaction survey following their consultation. RESULTS: BATHEd patients responded with significantly higher ratings for 8 of the 11 satisfaction measures, including those related to information provided, perception of physician concern, and likelihood of recommending the physician to others. CONCLUSIONS: The results of this pilot study support the use of BATHE with primary care patients, as it increases patient satisfaction, possibly by helping patients sense that their physician is sympathetic and concerned.

Persistent genital arousal disorder in women: case reports of association with anti-depressant usage and withdrawal.

Little is known with certitude about the triggers of persistent genital arousal disorder (PGAD) in women, although there appears to be certain common features of the disorder. Women complain of unbidden feelings of genital arousal that are qualitatively different from sexual arousal that is preceded by sexual desire/and or subjective arousal. The majority of women find PGAD distressing and report only brief relief with orgasm. In this article, we describe five women who believe they developed PGAD either after withdrawing from selective serotonin reuptake inhibitor (SSRI) anti-depressants or while using them. We discuss these sexual symptoms in relation to what is already known about prolonged SSRI withdrawal syndromes and the possible etiologies of these conditions. While not a common cause of PGAD, it is possible that use of, and withdrawal from, pharmacological agents contributes to the development of PGAD.

Normal and persistent genital arousal in women: new perspectives.

Interest in women's sexual functioning has increased in recent years although the primary emphasis has been on deficits in both genital and subjective sexual response. Female sexual psychophysiology research suggests that women are capable of greater sexual responsiveness than previously thought and can experience genital response in the absence of a subjective experience of sexual arousal. Women who report relatively persistent genital arousal, both with and without accompanying distress, provide case examples of the potential for dissociation between genital and psychological sexual response. In this article, we provide case illustrations of women reporting unprovoked genital arousal both with and without distress and suggest that what appears to be spontaneous genital arousal in some women may be the result of either subconscious processing of sexual stimuli in the environment - stimuli that are either consciously unacceptable or not noticed. Finally, we suggest that there may exist three types of genital arousal in women: 1) spontaneous sensations of genital arousal that are appraised as mildly pleasurable; 2) persistent feelings of genital arousal that are experienced as mildly distracting but not especially unwelcome or bothersome; and 3) continuous, intense, and persistent genital arousal that is extremely distracting, distressing, and worrisome. A variety of psychological, pharmacological, vascular, and neurological factors may account for these differences in women's genital arousal responsiveness. However, a full understanding of the range and variation in women's sexual experience remains to be elucidated.

Social concerns of women undergoing infertility treatment.

OBJECTIVE: Our study was undertaken to determine [1] what women are disclosing to their employer with regard to their infertility, [2] what demographic characteristics are associated with women who are more likely to disclose, and [3] if there is an association between disclosure and lowering one's stress. We hypothesize that, in certain women, disclosure may lower stress, and therefore increase success rate of in vitro fertilization. DESIGN: Cross-sectional questionnaire. SETTING: University Infertility Treatment Center. PATIENT(S): We handed out a questionnaire to patients being evaluated and treated for infertility over a 6-month period. A total of 267 questionnaires were handed out and all were collected. MAIN OUTCOME MEASURE(S): We collected demographic data as well as information regarding privacy, disclosure, and stress. We then compared women who disclose to their employer that they are being seen by an infertility specialist to those women who do not disclose. We also measured stress and determined if higher stress level was associated with disclosure or nondisclosure. RESULT(S): Most women who did disclose did so because they needed a reason to leave work for frequent doctor visits. Among women who did not disclose, the main reason for nondisclosure was to protect their privacy. Women with a high school education were more likely to disclose compared with those with a college and postgraduate education. African American/Caribbean American women were least likely to disclose. Those who were out of work more often because of their infertility were more likely to disclose. There was not an association with disclosure and decreasing stress level. CONCLUSION(S): Women who did or did not disclose their infertility status to their employer were different with regard to level of education, race/ethnicity, and number of visits per month to the doctor. The decision to disclose does not seem to have a significant impact on stress.

Relationship between hypoactive sexual desire disorder and aging.

OBJECTIVE: Explore the association between Hypoactive Sexual Desire Disorder (HSDD) and aging. The American Foundation of Urologic Disease and the American Psychiatric Association stipulate that HSDD is only diagnosed when both low sexual desire and sexually related personal distress are present. DESIGN: Community-based, cross-sectional study. SETTING: Europe (UK, Germany, France, Italy) and the USA. PATIENT(S): Women aged 20-70 in sexual relationships participating in the Women's International Study of Health and Sexuality (n=1998 Europe, n=1591 USA). INTERVENTION(S): No interventions were administered. MAIN OUTCOME MEASURES: Self-administered questionnaire that included two validated instruments: Profile of Female Sexual Function(c) measured sexual desire; Personal Distress Scale(c) measured sexual distress. Women with low desire and distress were considered to have HSDD. RESULTS: The proportion of European women with low desire increased from 11% amongst women aged 20-29 years to 53% amongst women aged 60-70 years. The proportion of American women with low desire displayed a trend towards an increase with age. In the 20-29 year age group 65% of European women and 67% of American women with low sexual desire were distressed by it. This decreased to 22% and 37%, respectively, in the 60-70 year age group. In Europe and the USA the prevalence of HSDD in the population did not change significantly with age (6-13% in Europe, 12-19% in the USA). CONCLUSIONS: The proportion of women with low desire increased with age while the proportion of women distressed about their low desire decreased with age. Consequently, the prevalence of HSDD remained essentially constant with age. This may explain why no association between HSDD and age is often reported in the literature.

Vulvodynia: a state-of-the-art consensus on definitions, diagnosis and management.

Vulvodynia is a chronic pain syndrome affecting up to 18% of the female population. Despite its high prevalence and associated distress, the etiology, diagnosis and clinical management of the disorder have not been clearly delineated. This "white paper" describes the findings and recommendations of a consensus conference panel based on a comprehensive review of the published literature on vulvodynia in addition to expert presentations on research findings and clinical management approaches. The consensus panel also identified key topics and issues forfurther research, including the role of inflammatory mechanisms and genetic factors and psychosexual contributors.

Hypoactive sexual desire disorder in postmenopausal women: US results from the Women's International Study of Health and Sexuality (WISHeS).

OBJECTIVE: To determine the prevalence of hypoactive sexual desire disorder (HSDD) among US women by reproductive status and age and to explore the correlates of sexually related distress. DESIGN: The Women's International Study on Health and Sexuality questionnaire was mailed to a national sample of US women in 2000. The survey included validated questionnaires: the Short Form-36, which measures overall health status; the Profile of Female Sexual Function, which assesses sexual desire; and the Personal Distress Scale, which measures distress caused by low desire. Four groups of women were studied: surgically postmenopausal, aged 20 to 49 years and 50 to 70 years; premenopausal, aged 20 to 49 years; and naturally postmenopausal, aged 50 to 70 years. Clinically derived cutoff Profile of Female Sexual Function and Personal Distress Scale scores were used to classify women with HSDD and determine its prevalence. The relations between sexual desire and frequency of sexual activity or relationship satisfaction were assessed. Overall health status of HSDD women and women with normal desire were compared. RESULTS: The prevalence of HSDD ranged from 9% in naturally postmenopausal women to 26% in younger surgically postmenopausal women. The prevalence of HSDD was significantly greater among surgically postmenopausal women, aged 20 to 49 years, than premenopausal women of similar age, whereas there were no significant differences in the prevalence between surgically postmenopausal women, aged 50 to 70 years, and naturally postmenopausal women. For many women, HSDD was associated with emotional and psychological distress as well as significantly lower sexual and partner satisfaction. HSDD was also associated with significant decrements in general health status, including aspects of mental and physical health. CONCLUSIONS: HSDD is prevalent among women at all reproductive stages, with younger surgically postmenopausal women at greater risk, and is associated with a less active sex life and decreased sexual and relationship satisfaction.

Persistent genital arousal in women -- a new syndrome entity.

The persistent sexual arousal syndrome (PSAS) is a newly described entity where women become involuntarily aroused genitally for extended periods in time in the absence of sexual desire. Genital vasoengorgement and oedema have been observed. These women are found to be usually very distressed. The cause of the syndrome in the majority of cases is unknown, although a number of women report symptoms after withdrawal from selective serotonin reuptake inhibitors (SSRI) antidepressants. There is no specific therapy at present, although electroconvulsive therapy (ECT) has resulted in clinical improvement in cases where there was concomitant severe depression.

Chronic vulvar and other gynecologic pain: prevalence and characteristics in a self-reported survey.

OBJECTIVE: To characterize and assess the prevalence of chronic gynecologic pain and, more specifically, chronic vulvar pain. STUDY DESIGN: A questionnaire was mailed to women aged 18-80 years who were ambulatory patients at an academic multidisciplinary practice. Quality of life, health history, obstetric and gynecologic history, and pain symptoms were assessed. RESULTS: Of the 4,872 surveys mailed to deliverable addresses, 36.8% were returned. The population was primarily Caucasian (83%), with an average age of 50.2 years. Approximately 4% of respondents reported a history of vulvar pain in the 6 months preceding the survey, and 17% reported other types of chronic gynecologic pain. Women reporting vulvar and nonvulvar pain were 2 times as likely as asymptomatic women to report a history of depression and vaginal infections, a poorer quality of life (p < 0.001) and greater stress. Dyspareunia and pain with daily activities were reported more frequently by women with vulvar pain than by women with non-vulvar gynecologic pain. CONCLUSION: The prevalence of vulvar pain in this study was lower than previously reported. Chronic gynecologic pain, and vulvar pain in particular, affects quality of life on both intimate and social levels. Self-reported stress and vaginal infections were the strongest correlates of chronic vulvar pain.

Bupropion improves sexual functioning in depressed minority women: an open-label switch study.

Minority women often have a unique set of beliefs and expectations about medical treatment. At this time, there is a dearth of research looking at how depressed minority women respond to pharmacological interventions for the sexual concomitants of depression. This was the first study to examine the impact of a medication switch, from a selective serotonin reuptake inhibitor to bupropion SR, on the sexual functioning of depressed minority women. Eighteen minority women (5 Hispanic, 10 African American, 2 Asian American, and 1 Native American), who were experiencing poor tolerability and/or lack of efficacy on an adequate trial of a selective serotonin reuptake inhibitor for depression, along with low sexual desire, were enrolled in this prospective open-label study. The selective serotonin reuptake inhibitor and bupropion SR were cross-tapered with a target dose of 150 to 300 mg of bupropion SR. The patients were followed for 10 weeks, and measures of sexual functioning and depression (Hamilton Rating Scale for Depression) were administered in an academic medical setting. Data were collected from July 2003 to December 2004. In the group as a whole, there were significant improvements in desire (F1,17 = 34.86, P < 0.001), arousal (F1,17 = 25.99, P < 0.001), and orgasm (F1,17 = 20.16, P < 0.001), on the Changes in Sexual Functioning Questionnaire. African-American women demonstrated the greatest improvement in depression (F1,16 = 9.55, P = 0.006), desire (F1,16 = 8.62, P = 0.01), and arousal (F1,16 = 8.83, P = 0.009) after the medication switch. Overall, this intervention appeared to be an effective treatment of low sexual desire in a diverse group of depressed minority women. The majority of women successfully completed the trial and planned to continue using bupropion SR after their participation in the study.

Depression and sexual functioning in minority women: current status and future directions.

Despite the increasing number of non-Caucasians in the United States, the overwhelming majority of research into both depression and sexuality has been conducted with European-American (Caucasian) samples. Sexual dysfunction and depression often co-occur, impacting relationship satisfaction, quality of life, and treatment adherence. These issues may be particularly salient for African-American, Hispanic, and Asian-American women, yet this area of research has been relatively unexplored. Cultural factors may shape women's response to sexual dysfunction, resulting from the depression itself as well as antidepressant medication. Further research emphasizing gender and culture is needed to elucidate the prevalence, impact, and treatment of sexual dysfunction in specific groups of depressed minority women.

Biological and psychosocial pathophysiology of female sexual dysfunction during the menopausal transition.

INTRODUCTION: Although increasing age is a primary determinant of reduced sexual function in older women, hormonal changes may be significant contributors to female (and couples') sexual dysfunction. AIM: To analyze the most relevant biological, psychosexual, and/or contextual factors that influence changes in women's sexuality during and after menopause. METHODS: A Postmenopausal FSD Roundtable consisting of multidisciplinary international experts was convened to review specific issues related to postmenopausal women and sexual dysfunction. MAIN OUTCOME MEASURE: Expert opinion was based on a review of evidence-based medical literature, presentation, and internal discussion. RESULTS: Menopause is associated with physiological and psychological changes that influence sexuality: the primary biological change is a decrease in circulating estrogen levels. Estrogen deficiency initially accounts for irregular menstruation and diminished vaginal lubrication. Continual estrogen loss is associated with changes in the vascular, muscular, and urogenital systems, and also alterations in mood, sleep, and cognitive functioning, influencing sexual function both directly and indirectly. The age-dependent decline in testosterone and androgen function, starting in the early 20s, may precipitate or exacerbate aspects of female sexual dysfunction; these effects are most pronounced following bilateral ovariectomy and consequent loss of 50% or more total testosterone. The contribution of progestogens to sexual health and variability in the effects of specific progestogens are being increasingly appreciated. Comorbidities, influenced by loss of sexual hormones, between mood and desire disorders and urogenital and sexual pain disorders are common and remain frequently overlooked in clinical practice. Physical and psychosexual changes may contribute to lower self-esteem, and diminished sexual responsiveness and sexual desire. Nonhormonal factors that affect sexuality are health status and current medication use, changes in or dissatisfaction with partner, partner's health and/or sexual problems, and socioeconomic status. CONCLUSION: Determination of the best way to provide optimal management of sexual dysfunction associated with menopause requires additional controlled studies.

Psychological and interpersonal dimensions of sexual function and dysfunction.

INTRODUCTION: There are limited outcome data on the efficacy of psychological interventions for male and female sexual dysfunction and the role of innovative combined treatment paradigms. AIM: To highlight the salient psychological and interpersonal issues contributing to sexual health and dysfunction; to offer a four-tiered paradigm for understanding the evolution and maintenance of sexual symptoms; and to offer recommendations for clinical management and research. METHODS: An International Consultation assembled over 200 multidisciplinary experts from 60 countries into 17 committees. The recommendations of committee members represent state-of-the-art knowledge and opinions of experts from five continents were developed in a process over a 2-year period. Concerning the Psychological and Interpersonal Committee of Sexual Function and Dysfunction, there were nine experts from five countries. MAIN OUTCOME MEASURE: Expert opinion was based on grading of evidence-based medical literature, widespread internal committee discussion, public presentation, and debate. RESULTS: Medical and psychological therapies for sexual dysfunctions should address the intricate biopsychosocial influences of the patient, the partner, and the couple. The biopsychosocial model provides a compelling reason for skepticism that any single intervention (i.e., a phosphodiesterase type 5 inhibitor, supraphysiological doses of a hormone, processing of childhood victimization, marital therapy, pharmacotherapy of depression, etc.) will be sufficient for most patients or couples experiencing sexual dysfunction. CONCLUSIONS: There is need for collaboration between healthcare practitioners from different disciplines in evaluation, treatment, and education issues surrounding sexual dysfunction. In many cases, neither psychotherapy alone nor medical intervention alone is sufficient for the lasting resolution of sexual problems. Assessment of male, female, and couples' sexual dysfunction should ideally include inquiry about: predisposing, precipitating, maintaining, and contextual factors. Treatment of lifelong and/or chronic dysfunction will be different from acquired or recent dysfunction. Research is needed to identify efficacious combined and/or integrated treatments for sexual dysfunction.

The impact of hormones on menopausal sexuality: a literature review.

Menopause is associated with physiological and psychological changes that influence sexuality. During menopause, the primary biological change is a decrease in circulating estrogen levels. Estrogen deficiency initially accounts for altered bleeding and diminished vaginal lubrication. Continual estrogen loss often leads to numerous signs and symptoms, including changes in the vascular and urogenital systems. Alterations in mood, sleep, and cognitive functioning are common as well. These changes may contribute to lower self-esteem, poorer self-image, and diminished sexual responsiveness and sexual desire. Other important nonhormonal factors that affect sexuality are health status and current medications, changes in or dissatisfaction with the partner relationship, social status, and cultural attitudes toward older women. The problems in sexual functioning related to estrogen deficiency can be treated with hormone therapy that includes estrogens alone and estrogens combined with androgens. Vaginal lubricants and moisturizers also may be useful in ameliorating postmenopausal sexual complaints. This article reviews the literature on the impact of menopausal estrogen loss on sexuality and on the effect of hormone therapy on sexual function during menopause.

Arousal disorders in women: complaints and complexities.

Female sexual arousal disorders constitute a varied spectrum of difficulties, ranging from the total absence of genital or subjective pleasurable arousal to feelings of persistent genital arousal in the absence of sexual desire. Arousal disorders can be associated with physical factors (eg, vaginal dryness) or psychological factors (eg, anxiety, distraction), or a combination of both. The most common complaint is the absence of subjective sexual excitement or pleasure despite adequate physical arousal (eg, lubrication). Pharmacological and physical treatments include the use of oestrogen, lubricants and vibrators. There may be a place for drugs that increase vasocongestion and vasodilation. Psychological therapy addresses inhibitions, and interpersonal and motivational factors.