Female sexual response depicting three different women or one woman at different times.
A baseline desire was believed to be necessary prior to initiation of excitement. The process of desire is not well understood but apparently involves both neurotransmitters such as dopamine as well as sex hormones.[6]
Excitement or arousal is characterized by vascular changes and autonomic sensations of excitement influenced by the noradrenergic system. The clitoris engorges, increasing exposure and sensitivity, and blood flow increases to the vulva and vagina, increasing lubrication from transudate.[6] Transitory feelings of intense pleasure occur with accompanying contractions of the muscles of the pelvic floor and release of endogenous opioids, serotonin, prolactin, and oxytocin characterize orgasm.[6]
Plateau is a heightened state of arousal below the threshold for the reflex of orgasm. It may persist until resolution, be returned to after orgasm before resolution, or be returned to multiple times after multiple orgasms.
Resolution is the period after orgasm or plateau with an accompanying increase in serotonin and a decrease in dopamine.[6]
Traditionally, a woman was believed to progress sequentially through these phases. Deviations, such as a lack of progression to orgasm or orgasm without excitement was presumed dysfunctional.
This model is not inaccurate in depicting the phases that can be a part of sexual response. There may, however, be overlap of the stages and varying sequence which could give the appearance of dysfunction. With more recent categorization, the conceptualization of the female sexual response has been expanded to recognize this process as a cycle rather than linear. The model of sexual response was modified to integrate subjective arousal, satisfaction without orgasm, a baseline of neutral desire, and acquisition of nonsexual rewards (emotional intimacy, well-being) which then feed future arousal and motivation to begin the cycle again, more accurately reflecting the non-linear nature of female sexual response.[7]
This nonlinear model reflects the World Health Organization’s definition of sexual health which states it “includes physical, mental, emotional, and social well being in all sexual behaviors and beliefs.”[8] This implies that irrespective of classification system, the patient’s unique sexual response and activity is not a dysfunction if it causes her no distress.
According to Basson and the efforts of the International Committee of the American Foundation of Urological Disease and the Second International Consensus of Sexual Medicine, a newer revision of the major categories of sexual dysfunction (yet to be validated) would include:[8]
Subjective sexual arousal disorder – feelings of excitement and pleasure from stimulation are absent or diminished despite a physical response.
Genital arousal disorder – minimal vulvar swelling or lubrication results from stimulation but subjective excitement may still be present.
Combined sexual arousal disorder – both of the preceding disorders are present concurrently.
Sexual desire/interest disorder – feelings of desire, fantasies, and responsiveness are absent or diminished.
Persistent sexual arousal disorder – genital arousal is spontaneous, unsolicited and sexual desire may or may not be present; it is unrelieved by orgasm.
Orgasmic disorder – orgasm from any kind of stimulation is absent despite arousal.
Vaginismus – involuntary contractions of the pelvic floor muscles prevent or make difficult the entry of a penis, finger, or any object into the patient’s vagina despite desire.
Dyspareunia – persistent or recurrent pain with attempted or deep vaginal entry.
These definitions address the fact that a women’s sexuality is susceptible to context. Although they still reflect the phases of sexual response, they clarify that these phases are likely to overlap. They also present a shift in focus from initial desire and note that desire can be triggered by arousal instead of vice versa, rather than considering this sequence dysfunctional. This system also divorces the ideas of subjective sexual arousal and objective arousal of the genitalia.[8] This more granular approach to the classifications may assist the clinician in fully understanding the patient’s problem and forming a more complete treatment plan.
The potential causes for sexual dysfunction are broad and varied (Table 24-1). Regardless of the underlying cause of the distress, the clinician must perform a thorough exploration of the patient’s history, with specific focus on the sexual history, and also seek out a broad range of psychological and physical findings that could be responsible for the dysfunction. Although the dysfunction may be the problem itself and disrupt other areas of the patient’s life, it can also be a symptom of another underlying medical or psychological disorder or even such a disorder’s treatment such as a medication side effect. If so, the clinician should seek to address not only the sexual dysfunction itself, but the underlying cause.
Medical conditions
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Medications
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Physical factors
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Psychological factors and interpersonal relationship disorders
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Trauma
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Scope
More than 40% of women have a sexually related complaint.[9, 10] However, this encompasses all women with any complaint that does not necessarily meet criteria of a disorder or dysfunction in that the complaints are not distressing or negatively impacting interpersonal relationships. Using stricter criteria, several population surveys have found the prevalence rates to range approximately 3%–12% for the different types of dysfunction, age and sexual orientation.[10–12]
The prevalence of sexual disorders varies with age as different factors (situational, medication use, disease history) come into play. Hypoactive sexual desire disorder is the most common female sexual disorder in the United States with estimates ranging from 7.4% to 12.3%.[10] Dyspareunia and vaginismus are also common though the reported rates vary widely.[6] Female sexual arousal disorder is less common, with a national survey putting the prevalence at 3.3%–6.0%. Orgasmic disorder is less common at 3.4%–5.8%.[10]
History
Screening questionnaire
A preprinted questionnaire administered prior to the encounter may be helpful in initiating conversations regarding sexual health. The simplest would include questions that are derived from or based on the Brief Sexual Symptoms Checklist for Women, soliciting information in a non-threatening and straightforward way. The clinician is free to create one to suit the unique needs of the clinical environment (Figure 24-2).[13]
If the screening questionnaire is positive for a sexual problem and the visit was not originally scheduled to address sexual issues, a separate visit may be necessary to fully elucidate the history and extent of the problem.
Environment
The clinician must not fail to meet the patient’s need by appearing uncomfortable addressing sexuality or holding biases that could lead to a lack of exploration of sexual history. Patients desire a welcoming environment with knowledgeable providers that provide personable relationships.[14] Sexual history taking can, however, be uncomfortable for both the clinician and the patient, so rapport and an empathic attitude are paramount.
It is important for the clinician to enter the encounter with no preconceived notions of the patient’s sexual orientation. After eliciting a positive answer that the patient is sexual active, a simple follow-up question such as, “with men, women, or both?” portrays the clinician as nonjudgmental, normalizing, and validating the context of the patient’s particular situation.
Approach
There are various models to structure the approach to the patient with a sexual complaint including the ALLOW and PLISSIT models (Figures 24-3 and 24-4).
Sub-specialization in sexuality is not required to address patient complaints adequately. Even if the clinician only makes it through the first three steps of the ALLOW model and refers the patient, it could be said that “ALL” has been done for the patient.[15]
The PLISSIT model also has room for referral for problems beyond the clinician’s scope in the “Intensive Therapy” element of the algorithm.
Either model effectively has the clinician normalizing the discussion, legitimizing the complaint with recognition of its importance to the patient, and focusing on either referring the patient for specialist care or planning on methods of management together.
Patient perception
Asking the patient what she believes the problem to be is often helpful, particularly with psychosocial issues. A dysfunctional thought process may be revealed that would otherwise not be treated if merely the end physical symptoms were addressed. For example, consider the woman with a sexual encounter prematurely postpartum and resultant episiotomy breakdown. Avoidance of sex due to fear of pain and potential disruption of the old wound may lead to decreased desire. If this “hypoactive desire disorder” were addressed traditionally without acknowledging the fears of the sex act itself with education regarding healing and wound integrity, the problem would be unlikely to resolve. Similarly, a patient’s fears of infection or pregnancy may motivate aversive behaviors that could be perceived as a lack of desire.
This direct line of questioning may also elicit detail that screening questionnaires lack. A frank answer detailing abuse or a loss of self-esteem or attraction due to weight gain could aid the clinician in a more timely diagnosis and treatment plan.
Sexual history
A standard sexual history including age at first coitus, whether the patient is currently sexually active, number of lifetime partners, number of current partner(s), sex of partner(s), sexual practices (oral, anal, vaginal as well as use of lubricants, aids, toys, etc.) and time with current partner should be elicited. If a screening survey is not used, then the sexual history should include asking an open-ended question such as, “Is there any problem with your sexual function that you would like to discuss?” Each positive answer warrants further exploration. For instance, if the patient reports pain with intercourse, it is important to determine under what conditions (position, depth of insertion, movement, etc.).
Previous sexual response/dysfunction history
It is important to assess whether the patient’s problem is recent and acute versus prolonged and chronic. Does it occur only with her current partner or with other partners? If the complaint is anorgasmia, has she ever had an orgasm with self-stimulation or with a different partner? If the concern is dysfunction of desire, is there a history in this in previous relationships? Mapping the patient’s own sexual response patterns aids the clinician in both fully understanding the context of this patient’s problem at this point in her life as well as leading to a more effective plan for management.[7]
In addition to the standard and expanded sexual history, additional historical elements can influence the diagnosis and treatment plan. These include factors that are risks associated with sexual dysfunction as well as potential causes of dysfunction (Table 24-1).
Age
Although sexual desire and activity may decrease with age, to exclude a sexual history in patients over 70 would ignore the potential 22% that report vaginal intercourse in the past year.[16] Masters and Johnson established with their work that there is no apparent absolute age at which sexual activity ceases.[5] The clinician should not assume that sexual identity and activity has become any less important to the patient due to age alone. Instead, realize that it may be an important part of the patient’s life, potentially impacting her ability to maintain healthy interpersonal relationships, self-image, and a sense of self-worth.[17]
Also important in the later years, particularly after natural or surgical menopause, is the known decrease in estrogen and the accompanying decreases in sexual desire as well as vaginal lubrication and atrophy, which may lead to dyspareunia.
Comorbid conditions and relationships
Predictable prognosticators for those with sexual dysfunction include poor general health, low mental health scores or marital difficulties.[3] In fact, a large cross-sectional population survey found the single strongest association with arousal, orgasmic, and enjoyment problems in women was marital difficulties. All women in the survey who reported a sexual problem also showed an association with anxiety and depression.[18] Patients with known depression are much more likely to experience sexual dysfunction.[19]
Although these connections with depression and anxiety may be somewhat expected, assumed positive elements in a patient’s history are also found to correlate with sexual dysfunction. At least among middle-aged and older women, a higher association with sexual dysfunction can be found in those with a college degree or higher as well as those in a significant relationship.[3]
The clinician can easily draw connections between specific medical problems, such as vascular or neurogenic disease that could decrease physiologic response and contribute to a dysfunction in a patient who otherwise would have no lack of desire or ability to orgasm. Pain syndromes or musculoskeletal deformities may contribute to pain and avoidance (Table 24-1). The clinician should review the patient’s medical history in detail to guide both diagnosis and treatment.
The clinician must always keep in mind the possibility that more than one of the sexual dysfunctions may exist, particularly in light of the evolving understanding of the overlap of both the phases and the dysfunctions of sexual response.[20, 7]
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