Diagnostic Criteria Just as phases of sexual response overlap, types of women’s sexual dysfunctions overlap (18,41). The Second International Consensus on Sexual Dysfunctions in Men and Women provides evidence-based recommendations for the diagnosis of sexual dysfunction and encompasses the proposed revisions to the American Psychiatric Association’s Diagnostic and Statistical Manual, Fourth Text Revised (DSM-IV-TR) definitions of women’s sexual dysfunction (86,87) (Table 11.7).
The official revisions—DSM-V—are due in 2012. Interim publications advocate that desire and arousal disorders are merged (88,89). Increasing evidence indicates that desire ahead of and at the outset of sexual engagement, although probably welcomed by both partners, is not mandatory for women’s sexual enjoyment and satisfaction (3). It is the inability to trigger desire and arousal during sexual engagement, and an initial absence of desire, that constitutes disorder. Therefore, merging sexual and desire difficulties into one disorder appears logical.
Table 11.3 Screening for Sexual Problems
Each disorder is then further classified by the following descriptors: 1.
2.
3.
The degree of distress—mild, moderate, or marked 4.
Presence of contextual factors
A. Past factors from developmental history affecting psychosexual development
Table 11.4 Biopsychosocial Assessment of Sexual Dysfunction aThese items of the single patient interview may sometimes be omitted (e.g., for a recent problem after decades of healthy sexual function).
B. Present contextual factors—interpersonal, environmental, societal, and cultural
C. Medical factors
Management of Sexual Many of the sexual problems couples encounter result from a deficit of knowledge or
Dysfunction experience, sexual misconceptions, or inability of the couple to communicate about their sexual preferences. Brief counseling and education by the obstetrician–gynecologist regarding the circular sex response cycle can identify the areas where sexual dysfunction can occur.
Table 11.5 Assessment of Dyspareunia: By History
Ask if vaginal entry is possible at all (i.e., with finger, penis, dildo, speculum, tampon)
Ask if sexual arousal is experienced when intercourse is attempted and as it progresses
Ask exactly when the pain is experienced: —With partial entry of the penis/ dildo —With attempted full entry of penile head —With deep thrusting —With penile movement —With the man’s ejaculation —With the woman’s subsequent urination —For hours or minutes after intercourse attempts
Ask if on some occasions there is less/no pain, and if so, what is different
Table 11.6 Physical Examination for Sexual Dysfunction
General examination Signs of systemic disease leading to low energy, low desire, low arousability, e.g., anemia, bradycardia and slow relaxing reﬂexes of hypothyroidism. Signs of connective tissue disease, such as scleroderma or Sj¨ogren’s, which are associated with vaginal dryness. Disabilities that might preclude movements involved in caressing a partner, self-stimulation, intercourse. Disfigurements/presence of stomas; catheters that may decrease sexual self-confidence, leading to low desire; low arousability.
External genitalia Sparsity of pubic hair, suggesting low adrenal androgens. Vulval skin disorders, including lichen sclerosis, which may cause soreness with sexual stimulation (e.g., when it involves the clitoral hood). Cracks/fissures in the interlabial folds suggestive of chronic candidiasis. Labial abnormalities that may cause embarrassment/sexual hesitancy (e.g., particularly long labia or asymmetry).