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Sexual
Health & Intimacy
Female Sexual Dysfunction in Primary Care:
When Is Referral to a Sex Therapist Indicated?
Carole Pasahow, DSW
Until recently, most women who had sexual concerns suffered in
silence. As women's roles have evolved, however, so too have perceptions
about the importance of a fulfilling sexual life. Furthermore,
female sexual dysfunction (FSD) was neglected due to the lack of
appropriate, available treatment compared with male sexual dysfunction.
Today, FSD is recognized as a valid, treatable group of disorders.
As multiple effective therapies for FSD have been developed, coupled
with the pharmaceutical industry's ongoing race to produce agents
to enhance female genital circulation, sexual health has become
an essential component of women's medical care.
WOMEN'S SEXUAL CONCERNS AND THE EXAM
ROOM
More women are now looking to their physicians for advice and guidance
about improving their sexual experiences. However, many physicians
are reluctant to engage in such discussions due to lack of knowledge,
embarrassment, and/or time limitations. As a result, physicians
may fail to address sexual function, and this important element
of the patient's history is left undocumented.1
In such cases, there is the possibility of missing both the physical
and the psychological aspects of sexual complaints. Thus, it is
crucial for physicians to acquire the tools to diagnose and treat
such problems—and to discern when referral to a sex therapist
is indicated.
This article describes brief diagnostic and treatment interventions
that physicians can utilize for FSD. In addition, the basic treatment
approaches used by sex therapists will be discussed, with emphasis
on indications for therapist referral.
DEFINITIONS
Female sexual dysfunction includes disorders of desire, arousal,
and orgasm, as well as dyspareunia and vaginismus. Hypoactive sexual
desire is defined as a persistent lack of desire for sexual activity
and sexual fantasies. Female arousal disorder is a chronic inability
to develop and maintain sexual excitement and genital lubrication.
Orgasm disorder is a persistent delay or absence of orgasm following
normal sexual excitement and stimulation. Finally, sexual pain
disorders include dyspareunia, which is defined as recurrent complaints
of genital pain associated with sexual intercourse. Vaginismus,
a subset of pain disorder, is an involuntary contraction of the
perineal muscles when vaginal penetration is attempted. In order
to satisfy the Diagnostic and Statistical Manual of Mental
Disorders, Fourth Edition criteria for FSD, the sexual problem
must cause marked distress or interpersonal difficulty.2
SEXUAL HISTORY
Physicians can assume a proactive role in evaluating and sometimes
treating these disorders. It is imperative that physicians become
comfortable talking with their patients about these concerns. If
physicians approach this information as a routine aspect of patient
history, patients will be more likely to share their difficulties.3
The sexual history must be incorporated into the busy schedule
of the modern office practice. Certain key questions can help to
target common female sexual complaints, and can be integrated easily
into the medical history (Table).
This will provide the essential information for an initial assessment
of the patient's level of functioning in all phases of the sexual
response cycle.
In addressing these issues, patients with FSD can be identified for
further assessment. The physician should then try to establish onset
(ie, lifelong versus acquired) and, for an acquired complaint, to
ascertain a possible trigger or cause. It is also important to consider
context (ie, generalized versus situational) to evaluate whether
the FSD is limited to certain types of stimulation, situations, or
partners, or is present in all circumstances. Finally, it is necessary
to determine whether the etiology is medical, psychological, or both.
It is particularly important to assess patients with FSD for depression
and anxiety, as these emotional disorders frequently underline or
accompany sexual dysfunction.
BRIEF INTERVENTIONS
All techniques for treating FSD involve patient encouragement and
education about the physical and psychological components of sexual
activity. It is important to recognize that FSD is almost always
inextricably intertwined with "real life" psychosocial
issues. Both patients and partners should be provided with information
about anatomy, sexual function, and the body changes that normally
accompany pregnancy and menopause. The physician should emphasize
how stresses such as work and child care can adversely affect sexual
activity, and explain the importance of relaxation and accommodation
in creating a favorable environment for sexual encounters.
Desire Dysfunction
Patients should be encouraged to make "dates" for sexual
activities. Such planning can help to create sexual anticipation,
which in turn promotes sexual desire.
Arousal Dysfunction
Patients should be advised to try noncoital massage. Sensual massage
without genital stimulation—where one partner provides stimulation
while the other partner receives pleasure and gives feedback as to
what feels good—can give couples a "model" for sexual
activity. These exercises are aimed at promoting relaxation, enhancing
communication, and heightening physical and sexual feelings. Couples
can also use erotic materials such as videos and books to enhance
stimulation and provide distraction from life stresses.3
Orgasmic Dysfunction
Many women complain not necessarily of anorgasmia, but rather that
it takes them too long to reach orgasm—that it seems like too
much work for them and their partners. The physician should explain
the importance of direct clitoral stimulation by the patient or her
partner. This can be provided orally, manually, and/or with a vibrator,
with additional mental stimulation through the use of fantasy and
sexual communication. The patient can also be instructed in the correct
way to perform Kegel exercises, which can be used during intercourse
to enhance orgasm.
Sexual Pain Disorders
Patients with dyspareunia and vaginismus must be evaluated carefully
to eliminate any possible physical causes. After ruling out physical
etiologies, the physician can recommend the use of vaginal lubricants
(eg, Astroglide, Replens) and specific intercourse positions to decrease
friction and minimize deep thrusting. Other helpful suggestions include
using graduated vaginal dilators to desensitize the fear response
to penetration and promote better muscle tone and accommodation;
taking a warm bath before sexual activity; and using topical lidocaine
or nonsteroidal anti-inflammatory drugs before intercourse.4
SEX THERAPY
If patients' sexual problems do not respond to these interventions
and they are motivated to continue working on FSD, referral to a
sex therapist can be helpful. In such cases, the physician and sex
therapist should work together to provide the most effective treatment.
To make an appropriate referral, it is important for physicians to
understand what sex therapy entails. All sex therapies have a common
aim, which is to change self-defeating beliefs and attitudes. This
may involve resolving underlying pathologies, as well as addressing
psychological problems and marital discord.5 The therapist also provides
education, corrects misconceptions, and teaches specific skills to
reduce performance anxiety and enhance pleasure.
Indications for Referral to a Sex Therapist
Longstanding Dysfunction.—Re-gardless of the
etiology, sexual problems that remain uncorrected for a long period
of time often lead to anger, chronic performance anxiety, feelings
of rejection, and sex-avoidance behaviors in both the patient and
her partner.
Multiple Dysfunctions.—Patients often present
with multiple sexual dysfunctions and difficulties in several areas
of the sexual response cycle. This may begin with one type of sexual
disorder that gradually "poisons" all sexual activity over
time, so that it may be difficult to identify the initial cause.
Sexually Aversive Behavior.—The patient finds
sexual contact repugnant, and actively avoids genital contact with
a partner, constituting a phobic disorder.
Psychological Disorder/Marital Conflict.—Often
there are complicating factors that make FSD more difficult to treat,
such as unresolved childhood conflicts resulting in guilt and fear
of losing control during a sexual encounter. Religious prohibitions
about engaging in sexual activity may also interfere with sexual
pleasure. Stress and conflict in the couple's relationship, as well
as depression and anxiety (which may be primary or secondary causes
of FSD), generally require the intervention of a sex therapist.
Current/Past Physical or Sexual Abuse.—In
these cases, there may be mandatory reporting requirements, with
intervention by social services and law enforcement. A sex therapist
can help to provide psychological support, as well as work with the
patient over the long term to resolve fears arising from sexual violence.4
Desire Dysfunctions.—These problems may be
difficult to treat in the context of a busy office practice, and
can represent a wide range of difficulties. When the etiology is
physical—eg, lack of desire can be traced to the use of birth
control medications, hormonal changes, antidepressants, antihypertensives,
or heart medications—the disorder is readily amenable to treatment
by a physician. Frequently, however, desire disorders have an underlying
psychological and/or marital component that requires considerable
time to evaluate and treat. Discrepancies in sexual desire and frequency
of sexual activity between partners can also benefit from intervention
by a sex therapist.
Lack of Response to Physician Intervention.4—Patients
who report no improvement in FSD after three or four physician visits
should be referred to a sex therapist for more comprehensive evaluation
and treatment.
q
If the physician determines that a sex therapist is required to treat
a patient's sexual difficulties, the next step is to find a qualified
professional. If the physician's health network does not include
a therapist, the American Association of Sex Educators, Counselors,
and Therapists can provide names of professionals in a given geographic
area. This organization certifies sex therapists, and can be contacted
by telephone at 804-644-3288 or via the Internet at http://www.aasect.org.
CONCLUSION
In light of the changes in the US health care system, ob/gyns and
primary care physicians must be prepared to evaluate and treat FSD.
This involves implementing strategies to obtain an adequate sexual
history as part of the overall medical history, to assess for physical
and psychological etiologies, to provide basic interventions, and
to make referrals to a sex therapist when required. In many instances,
patients' sexual complaints comprise both physical and psychological
components. For these cases, the physician and sex therapist can
work in tandem to ensure the best possible outcome.
Patient Information
Pasahow, C. Sexy Encounters: 21 Days of Provocative Passion Fixes. Avon,
Mass: Adams Media Corporation, 2003. Web site: www.passion-fix.com.
Carole
Pasahow, DSW, is a private practitioner in Fair Lawn, NJ. She
may be contacted at cpasahow@yahoo.com.
References
- Krychman
M, Shulman L. Sexual dysfunction: current issues. The
Female Patient. 2001;26(11):4-7.
- Diagnostic and
Statistical Manual of Mental Disorders, ed IV. Washington,
DC: The American
Psychiatric Association; 1994:493 -518.
- Pasahow, C. Sexy
Encounters: 21 Days of Provocative Passion Fixes. Avon,
Mass: Adams Media Corporation, 2003.
- Phillips N. Female
sexual dysfunction: evaluation and treatment. Am Fam
Physician. 2000;62(1):127-136.
- Foley S, Kope S,
Sugrue D. Sex Matters for Women. New York: The Guilford Press;
2002:318.
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