Maria Teresa Filocamo and Nadine Di Donato
Abbreviations
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ALLOW BISF-W CSFQ DSFI DSM FSD FSDS FSDS-R FSFI HSDD MFSQ PISQ-12 PLISSIT SFQ SHOW-Q SHOW-Q SIDI-F SQOL-F SSRIs SSS-W WSID-SF |
Ask, Legitimize, Limitations, Open up, Work together Brief Index of Sexual Functioning for Women Changes in Sexual Functioning Questionnaire Derogatis Sexual Functioning Inventory Diagnostic and Statistical Manual of Mental Disorders Female sexual dysfunction Female Sexual Distress Scale-Revised Female Sexual Distress Scale-Revised Female Sexual Function Index Hypoactive sexual desire disorder McCoy Female Sexuality Questionnaire Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire Permission, Limited Information, Specific Suggestions, Intensive Therapy Sexual function questionnaire Sexual Health Outcomes in Women Questionnaire Sexual Health Outcomes in Women Questionnaire Sexual Interest and Desire Inventory-Female Sexual Quality of Life-Female Selective serotonin reuptake inhibitors Sexual Satisfaction Scale for Women Women’s Sexual Interest Diagnostic Interview-Short Form |
Sexuality is a complex process, coordinated by the neurologic, vascular, and endocrine systems.
Sexuality includes family, societal, and religious beliefs and goes sour by aging, health status, and personal experiences. In addition, sexual activity embodies interpersonal relationships; each partner conveys unique attitudes, needs, and responses into the coupling. A breakdown in any of these areas may lead to sexual dysfunction.
Female sexual dysfunction (FSD) is a continuum of psychological and organic disorders focused on sexual desire with interrelated problems of arousal, orgasm, and sexual pain that impairs quality of life for many women [1]. FSD can afflict women of any age, and its severity worsens with the endocrinology of advancing years. Impact is often subtle. FSD may express as apparently unrelated emotional manifestations that could degrade quality of life and family relationships, in social sphere and in the workplace.
Female sexual dysfunction is defined as any problem that may be encountered in the sexual response cycle that deviates from a woman’s normal range of functioning [2]. Defining female sexual dysfunction is not as absolute for women because of the qualitative nature of female sexual function. What may be abnormal for one woman may be normal for another woman [3]. Sexual dysfunction falls on a continuum with female sexual disorder [3].
In sexual dysfunction, there is a break in normal sexual functioning at one or many points in the sexual response cycle. In comparison, a sexual disorder consists of both the sexual dysfunction element in addition to persistent distress [4]. An abnormality in one’s sex life can exist but may not justify further evaluation except when the woman experiences a certain degree of distress over it. When investigating female sexual function versus dysfunction and disorder, distress has to be included and is perhaps the most important variable because of the large range of what can otherwise be normal for women [5]. The distress must be experienced by the woman herself, and that which bothers her partner alone is not then a sexual dysfunction of the woman but rather of her partner [6]. Female sexual dysfunction and disorder must be debated in the context of each individual woman’s life, culture, social, individual experiences, relationship, and health in order to extricate the distress element.
Sexual problems are highly prevalent in women. In the USA, approximately 40 % of women have sexual concerns, and 12 % report distressing sexual problems [7].
Female sexual dysfunction appears in different forms, including lack of sexual desire, impaired arousal, inability to achieve orgasm, or pain with sexual activity.
Female sexual dysfunction can be subdivided into desire, arousal, orgasmic, and sexual pain disorders. Sexual pain disorders include dyspareunia and vaginismus.
The diagnosis of female sexual dysfunction requires the physician to obtain a detailed patient history that defines the dysfunction, identifies causative or confounding medical or gynecologic conditions, and evokes psychosocial informations.
The sexual dysfunction should be defined in terms of onset and duration and situational versus global manifestations. A situational dysfunction occurs with a specific partner, in a certain setting or in a definable circumstance.
The presence of more than one dysfunction should be assessed, because considerable interdependence may exist. A patient complaining about decreased desire might have an orgasmic disorder from insufficient stimulation, with decreased desire developing secondarily as a result of unsatisfying sexual encounters.
4.1 Female Sexual Dysfunction: Revised Classification of Sexual Dysfunction (DSM-V)
The Diagnostic and Statistical Manual of Mental Disorders (DSM) criteria proved to be in a constant of evolution [8]. The first edition of the DSM, in 1952, cataloged 60 categories of abnormal behavior. By 1994, the fourth edition (DSM-IV) listed 297 separate disorders and over 400 specific psychiatric diagnoses [9]. As with other disorders, DSM criteria for sexual dysfunctions reflect the prevailing psychiatric thinking of the time of publication; they have thus evolved throughout the years, reflecting advancements in the understanding of sexual disorders. Diagnostic categories of female sexual interest as described in the DSM-IV 1994 (American Psychiatric Association 1984) were based on the model of human sexual response proposed by Masters and Johnson [10] and further developed by Kaplan [11]. However, recent research has put into question the validity of that model; both the strict distinction between different phases of arousal and the linear model of sexual response were found to inadequately explain sexual behavior, particularly in women [12, 13]. This has in turn led to several proposed changes in sexual dysfunction diagnostic criteria [14]. The DSM-V, published in May of 2013, presents changes in the sexual dysfunction chapter in an attempt to correct, expand, and clarify the different diagnoses and their respective criteria. Although many of the changes are subtle, some are noteworthy: gender-specific sexual dysfunctions were added, and female disorders of desire and arousal were amalgamated into a single diagnosis called “female sexual interest/arousal disorder” [15]. The classification of sexual dysfunctions was simplified. There are now only three female dysfunctions as opposed to five in the DSM-IV. Female hypoactive desire dysfunction and female arousal dysfunction were merged into a single syndrome called sexual interest/arousal disorder. Similarly, the formerly separate dyspareunia and vaginismus are now called genito-pelvic pain/penetration disorder. Female orgasmic disorder remains in place. Unlike its predecessor, the DSM-V includes the requirement of experiencing the disorder 75-100 % of the time to make any diagnosis of sexual disorder, with the notable exception of substance or medication-induced disorders. Moreover, there is now a required minimum duration of approximately 6 months. Finally, in order to make a diagnosis, the disorder must be deemed to have caused significant distress (the DSM-IV requirement of “interpersonal difficulty” was removed). A new group of criteria called “associated features” was also introduced. It is subdivided into five categories: (1) partner factors (e.g., partner sexual problem, partner health status); (2) relationship factors (e.g., poor communication, discrepancies in desire for sexual activity); (3) individual vulnerability factors (e.g., poor body image, history of sexual or emotional abuse), psychiatric comorbidity (e.g., depression, anxiety), or stressors (e.g., job loss, bereavement); (4) cultural or religious factors (e.g., inhibitions related to prohibitions against sexual activity or pleasure, attitudes toward sexuality); and finally (5) medical factors relevant to prognosis, course, or treatment. The criteria of the newly introduced female disorder of sexual interest/arousal are based on those of hypoactive desire disorder. Three out of six criteria are required for diagnosis. As for the diagnosis of female orgasmic disorder, one or both of the following should be present 75-100 % of the time: the absence, infrequency or delay of orgasm, and/or reduced intensity of said orgasm. Regarding the new genito-pelvic pain/penetration disorder, one of the following should occur persistently or recurrently to establish a diagnosis: difficulty in vaginal penetration; marked vulvovaginal or pelvic pain during penetration or attempt at penetration; fear or anxiety about pain in anticipation of, during, or after penetration; and tightening or tensing of pelvic floor muscles during attempted penetration. In conclusion, the DSM-V seeks to remedy some of the inconsistencies of the previous edition. One of the major changes that the DSM-V introduces to the classification of sexual dysfunctions is the merger of sexual disorders of desire and arousal in females. Researchers who advocated this amalgamation [16] based their recommendations on a large body of research suggesting that the separation may have been artificial. Another important change was the fusion of the diagnoses of dyspareunia and vaginismus into a single entry named genito-pelvic pain/penetration disorder. This decision was based on the conclusion that the two disorders could not be reliably differentiated, for two main reasons. Firstly, the diagnostic formulation of vaginismus as “vaginal muscle spasm” was not supported by empirical evidence [17]. Secondly, fear of pain or fear of penetration is commonplace in clinical descriptions of vaginismus [17]. Kaplan even describes it as “phobic avoidance” [11]. Carvalho et al., after testing five alternative models of female sexual function, concluded that the diagnoses vaginismus and dyspareunia overlapped to a great degree [18]. The new edition with the aim to increase the validity and clinical usefulness of DSM introduced also duration and frequency requirements for sexual disorders. All diagnoses except substance- and medication-induced sexual dysfunction now require a minimum duration of approximately 6 months as well as the presence of symptoms 75-100 % of the time. This development corrects what was seen as a flaw in sexual dysfunction diagnostic criteria, especially when compared to other DSM-IV diagnoses which did have duration requirements.
Dyspareunia is defined as recurrent or persistent genital pain associated with sexual intercourse that is not caused exclusively by lack of lubrication or by vaginismus [19]. Diagnosis of dyspareunia is made when the pain causes marked distress or interpersonal difficulty. Dyspareunia can involve pain on entry or deep pain. Painful entry is typically reflective of vulvodynia, inadequate lubrication, or vaginismus. Dyspareunia, which is frequently linked with hypoactive sexual desire disorder (HSDD), has the same situational and psychosocial causes and thus resolves in response to treatment of HSDD. In other cases it is linked with gynecologic disorders, such as endometriosis or vestibulitis, chronic medical conditions, or drugs [20, 21].
4.2 Assessing of Women with Sexual Disorders
Normal versus abnormal sexual functioning in women is poorly understood, although the concept of normal female sexual function continues to develop. A complete history combined with a detailed physical examination is necessary for the evaluation of any women with sexual complaints or concerns. Although laboratory evaluation is rarely helpful in diagnosis or treatment, it may be indicated in women with abnormal physical examination findings or suspected comorbidities. Female sexual dysfunction has been linked to hypertension and its treatment, coronary artery disease, diabetes mellitus, other endocrinological disorders (hyperprolactinemia), and chronic renal failure. The same vascular aberrations that cause erectile dysfunction in men associated with cardiovascular risk factors can cause arousal difficulties in women. Effects of pelvic surgery and hormonal changes associated with menopause are known.
Physicians are often not accustomed with and poorly educated about obtaining a complete sexual history [22] even though this is an important component of primary health care [23]. There are a number of validated self-report and interview-based tools for assessing female sexual dysfunction, but they are mainly used in research settings [24]. The brief sexual symptom checklist is a self-report tool that may be useful in the primary care setting as in addition to a complete sexual history [25]. The checklist includes four basic questions to determine the patient’s satisfaction with her sexual function, details about specific sexual problems, and the willingness of the patient to discuss these problems with the physician [25].
Discussions about sexuality should begin with open-ended questions. If a sexual concern is identified, a detailed history that includes menstrual, obstetric, reproductive, and sexual histories should be done; status of current relationships and sexual activity should be required, so as family and personal beliefs about sexuality, and history of sexual trauma or abuse [25]. Additional elements of the history include medical and surgical history; medication use, including herbal supplements; alcohol, tobacco, and illicit drug use; family history; and birth control method. Several medical conditions and medications are associated with sexual dysfunction.
The Permission, Limited Information, Specific Suggestions, Intensive Therapy (PLISSIT) or Ask, Legitimize, Limitations, Open up, Work together (ALLOW) method can be used to facilitate discussions about sexual concerns and initiation of treatment [25-27] (Table 4.1).
Although physical examination findings are often normal, a complete inspection, including a focused pelvic check, can identify pathology and provide patient education about normal anatomy and reassurance that no abnormality is present. The pelvic examination can detect evidence of low hormone levels, infection, hypo- or hypertonicity of pelvic floor muscles, adhesions, and tenderness. The remaining physical examination focuses on mental status, blood pressure, musculoskeletal, thyroid, breast, and neurologic abnormalities. Abnormal findings are more likely in older women, in women with known gynecologic pathology or chronic systemic disease [28].
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Table 4.1 Models for initiating discussion and treatment of female sexual dysfunction |
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ALLOW |
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Ask the patient about sexual function and activity |
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Legitimize problems, and acknowledge that dysfunction is a clinical issue |
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Identify limitations to the evaluation of sexual dysfunction |
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Open up the discussion, including potential referral |
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Work with the patient to develop goals and a management plan |
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PLISSIT |
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Obtain permission from the patient to discuss sexuality (e.g., “I ask all my patients about their sexuality, is that okay to do with you now?”) |
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Give limited information (e.g., inform the patient about normal sexual functioning) |
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Give specific suggestions about the patient’s particular complaint (e.g., advise the patient to practice self-massage to discover what feels good to her) |
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Consider intensive therapy with a sexual health subspecialist |
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ALLOW Ask, Legitimize, Limitations, Open up, Work together; PLISSIT Permission, Limited Information, Specific Suggestions, Intensive Therapy |
Laboratory evaluation is rarely helpful; however, a focused evaluation is appropriate, particularly if the history or examination suggests a medical condition. Although some experts advocate testing hormone levels in postmenopausal women or in women with decreased desire or arousal, there is no reliable correlation between hormone levels and sexual function [28].
Sexual dysfunction may be the manifestation of psychiatric illness or an adverse effect of psychotropic medication use [29]. If a woman has sexual complaints while taking a psychotropic medication, a detailed history is necessary to identify the etiology [29]. The use of selective serotonin reuptake inhibitors (SSRIs) is a common cause of medication-induced female sexual dysfunction, although all antidepressant classes can cause dysfunction [30]. SSRIs most commonly cause delayed or absent orgasm and decreased libido [30]. The incidence of SSRI-induced sexual dysfunction is estimated to be 30-50 % [31].
4.3 Instrument for the Assessment of Sexual Function
Different types of questionnaires have been used in the last few years to investigate sexual function and dysfunction [21, 32, 33]. Studies of human sexuality are inclined to bias and have varied confounding factors because of the large cultural framework as well as psychosocial factors that distinguish this aspect of human behavior.
Due to its subjective and multifactorial nature and relationship with emotional processes, sexual function needs adequate instruments for assessment, like selfreport questionnaires, investigating different aspects of sexual life with high reliability and validity. Thus, to provide a multidimensional assessment of sexual function, a number of self-administered questionnaires have been developed in the recent past years. Several of these measures have demonstrated adequate psychometric properties, especially test-retest reliability, internal consistency, and discriminant validity. Different types of questionnaires were used to investigate sexual dysfunction of women, such as the Derogatis Sexual Functioning Inventory (DSFI), the sexual function questionnaire (SFQ), the Female Sexual Function Index (FSFI), the Female Sexual Distress Scale-Revised (FSDS-R), and the Sexual Health Outcomes in Women Questionnaire (SHOW-Q).
All these instruments have been developed during the recent past, with the majority having been validated during the past decade. The questionnaires vary mainly in terms of their levels of comprehensiveness; however, all have developed well against established psychometric criteria and have appeared empirical evidence of reliability and validity. A good standardized instrument should evaluate and measure multiple domains, should have internal consistency (a) of at least 0.70 for all domains, and should demonstrate test-retest reliability into an interval of 2-4 weeks of at least 0.50 for items that should display stability over time (Table 4.2).
The Brief Index of Sexual Functioning for Women (BISF-W) was developed in response to the lack of a brief, standardized self-report measure of overall sexual function in women [34]. Previous self-report measures have been either excessively
Table 4.2 Resume questionnaires on sexual function present in scientific literature
|
Inventory |
Published norms |
Interpretive levels |
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BISF-W |
Functional women/surgically menopausal women |
22 questions, seven domains, total score |
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CSFQ |
Depressed/nondepressed women |
5 domains; total score |
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DISF |
Community sample (T scores) |
5 domains; total score |
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FSFI |
FSAD/HSDD/FOD/dyspareunia/functional women |
5 domains; 19 items; total score |
|
SFQ |
Functional/dysfunctional women |
7 domains; 26 item; total score |
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MFSQ * |
Functional/dysfunctional women |
2 domains; 14 items; total score |
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FSDF |
Functional/dysfunctional women |
13 items; total score |
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PISQ-12 |
UI/POP |
12 items; total score |
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SIDI-F |
HSDD/FOD/functional women |
13 items; total score |
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WSID-SF |
HSDD/postmenopausal women |
9 items; total score |
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SQOL-F |
Functional/dysfunctional women, spinal cord-injured women/quality of life |
18 items; total score |
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SSS-W |
Functional/dysfunctional women |
5 domains; total score |
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SHOW-Q |
Functional/dysfunctional women, same-sex relationship |
12 items; total score |
limiting or inappropriate for the use in large-scale clinical trials. The BISF-W consists of 22 items, assessing the major dimensions of sexual desire, arousal, orgasm, and satisfaction [34]. Several items were adapted from the CSFQ, particularly those assessing frequency of sexual behavior, fantasy, masturbation, and sexual preference. Additional items were included to address specific issues supposed to concern women’s sexual functioning and satisfaction, such as body image, partner satisfaction, and sexual anxiety. Several items were designed to evaluate sexual performance difficulties in women, such as diminished arousal or lubrication, pain or tightness during intercourse, and difficulties in reaching orgasm. Items assessing the impact of health problems on sexual functioning are also included [34].
The Changes in Sexual Functioning Questionnaire (CSFQ) was developed with specific versions for females and males to assess sexual functioning in all the domains of the sexual response cycle [35]. It was developed to be used in both clinical and research settings. CSFQ-W is a 35-item instrument identifying five scales of sexual functioning. The original CSFQ items were tested and revised on the basis of conceptual content to ensure that five aspects of sexual functioning (i.e., sexual desire, sexual frequency, sexual satisfaction, sexual arousal, and sexual completion) were evaluated [35]. The CSFQ was used clinically and had the particularity to include a section identifying the sexual pattern of the individual, which permitted information about how much sexual change someone experienced over time [35]. In addition, information on drugs use was collected.
Information about changes could be correlated to the five domains of sexual functioning, so that the clinician could better focus on strategically targeted treatment for the cause of the problem, which could be related to medication, illness, relationship problems, or a combination of difficulties [35]. In addition, the CSFQ addressed the need for an assessment instrument that could differentiate current sexual dysfunction from previous “normal” sexual function and/or lifelong sexual dysfunction [35].
The Derogatis Interview for Sexual Functioning (DISF/DISF-SR) is a coordinated set of brief matched instruments designed to provide an estimate of the quality of an individual’s current sexual functioning [36]. The DISF is semi-structured interview comprised of 25 items and reflects quality of sexual functioning in a multi-domain format. The DISF-SR is a matching self-report inventory designed to achieve the same goal in a patient self-report mode. All instruments in the DISF series are designed to be interpreted at three distinct levels: discrete items, functional domains, and aggregate summary (total) score [36].
DISF items are arranged into five primary domains of sexual functioning: sexual cognition/fantasy, sexual arousal, sexual behavior/experience, sexual orgasm, and sexual drive/relationship. In addition, an aggregate DISF total score is computed which summarizes quality of sexual functioning across the five primary DISF domains [36]. Both the DISF and the DISF-SR take approximately 12-15 min to administer. Internal consistency reliabilities for measures of the DISF-SR are well within acceptable ranges, as are test-retest temporal stability coefficients. The DISF/DISF-SR has demonstrated good discriminative validity and sensitivity to treatment-induced changes and is currently available in 12 foreign languages [36].
Female Sexual Function Index (FSFI) is made up of 19 items encompassing the six domains: desire (items 1-2), arousal (items 3-6), lubrication (items 7-10), orgasm (items 11-13), satisfaction (items 14-16), and pain (items 17-19). The total FSFI score is the sum of all points, and the higher the score, the better the sexuality. Sexual dysfunction was defined as an FSFI score < 26.55, based on the published validation studies [37, 38]. A very good discriminate validity and ability to predict the prevalence of sexual problems have been reported [39, 40].
The sexual function questionnaire (SFQ) is a self-report questionnaire designed to measure female sexual function [41]. It is comprised of 28 items reflecting all aspects of the sexual response cycle—desire, arousal, and orgasm—as well as dyspareunia. Factor analysis produced seven domains of female sexual function: desire, physical arousal-sensation, physical arousal-lubrication, enjoyment, orgasm, dyspareunia, and partner relationship [41]. The item content of the SFQ was reviewed by an external panel of clinicians with expertise in psychology, physiology, gynecology, physical medicine, and the treatment of FSD. Internal consistency of the domains ranged from 0.79 to 0.91 for all domains except partner relationship, which was 0.65, and test-retest reliability is in the acceptable range [41].
The McCoy Female Sexuality Questionnaire (MFSQ) was developed from the questionnaire used in a longitudinal study of the menopausal transition and designed to measure aspects of female sexuality likely to be affected by changing sex hormone levels [42]. The original questionnaire was revised to insure that questions were easy to understand and that labels for the Likert scales described a continuum. The revised MFSQ contains 19 questions, 18 items using 7-point Likert scales with labels at the center and endpoints, and one item requesting a frequency of activity [42]. Seven studies involving both clinical and convenience samples and two with double-blind randomized controlled trials used 7, 9, 10, or 17 MFSQ items and demonstrated acceptable reliability, internal consistency, apparent face, and content validity as well as considerable evidence of construct validity [43]. Results showed selected MFSQ item ratings decreased as women progressed through the menopausal transition, varied positively with endogenous estradiol and androgen levels, were higher in postmenopausal women receiving hormone replacement therapy (HRT), and differentiated between different types of oral contraceptives and the presence or absence of ovaries [44].
The Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ- 12) is a validated and reliable short form that evaluates sexual function in heterosexual women with urinary incontinence and/or pelvic organ prolapse and predicts long-form scores [45]. The PISQ-12 was able to distinguish between women with low or high sexual functioning scores as measured by the SHF-12, a validated sexual function questionnaire that serves as a gold standard. Short forms are useful in the clinical setting because they reduce the time and burden to the patient and provide the clinician with objective means of evaluating functional outcomes of either medical or surgical interventions. In the research setting, a short form is useful when quality-of-life analysis is part of the armamentarium used to evaluate outcomes and compare results [45].
The Sexual Interest and Desire Inventory-Female (SIDI-F) is a clinician- administered instrument that was developed to measure severity and change in response to treatment of HSDD [46]. Seventeen items were included in a preliminary version of the SIDI-F, including 10 items related to desire and seven items related to possible comorbid factors (e.g., other kinds of sexual dysfunction, general relationship satisfaction, mood, and fatigue) [46]. It is a brief, clinician-administered rating scale designed to assess severity of HSDD symptoms in women. Analyses show that majority of the items of the SIDI-F function well in discriminating individual differences in HSDD severity [47]. The validity of the SIDI-F as a measure of HSDD severity was confirmed by a number of observations. Women with a clinical diagnosis of HSDD had significantly lower SIDI-F scores than women not meeting diagnostic criteria for any subtype of female sexual dysfunction and women diagnosed with female orgasmic disorder [48]. There was a high correlation between scores on the SIDI-F and scores on the FSFI and an interactive voice response version of the CSFQ. A cutoff score of 33 was proved to indicate the presence of HSDD [48].
Another questionnaire focused on HSDD is the Women’s Sexual Interest Diagnostic Interview-Short Form (WSID-SF) structured and validated by Derogatis et al. in 2008 to identify hypoactive desire disorders [49]. The authors used this tool on 629 postmenopausal women, and WSID-SF was demonstrated to have good specificity and sensitivity (discriminant validity) in identifying HSDD when compared with FSFI, MFSQ, and FSDS. The intraclass correlation coefficient was 0.80 for women with HSDD and 0.84 for women without HSDD [50].
The Sexual Quality of Life-Female (SQOL-F) questionnaire is a short instrument that specifically assesses the relationship between female sexual dysfunction and quality of life. Symonds and coworkers developed the questionnaire in 2005 [51]. The basis for the generation of the SQOL-F questionnaire was Spitzer’s Quality of Life (QOL) model that involved physical, emotional, psychological, and social components. Validity of the SQOL-F questionnaire first was assessed in the UK and the USA. In the UK setting, studying a sample of 1296 women aged 18-65 years, internal consistency was found to be 0.95, and the questionnaire discriminated well between depressed and not depressed women [51]. In the USA setting, studying three groups of women (women with spinal cord injury, women with sexual dysfunction, and a sample of healthy women), the SQOL-F was lower among women with sexual dysfunction as expected lending support to its discriminate validity. In addition, intraclass correlation coefficient was reported to be 0.85, which showed an appropriate stability for the questionnaire [51].
The Sexual Satisfaction Scale for Women (SSS-W) represents a brief, 30-item, multifaceted measure of women’s sexual satisfaction [52]. It exhibits sound psychometric properties and has a demonstrated ability to discriminate between clinical and nonclinical populations. The final SSS-W consists of five domains (two relational, three personal) of six items each: communication, compatibility, contentment, relational concern, and personal concern. Items in the communication, compatibility, and contentment domains were written to reflect themes relating to sexual satisfaction noted in prior literature. The SSS-W was developed to provide a comprehensive measure of sexual satisfaction and sexual distress that would benefit researchers and clinicians interested in further understanding what constitutes sexual satisfaction in women and how it relates to levels of sexual functioning [52].
The standardized Female Sexual Distress Scale-Revised (FSDS-R) is a screening instrument consisting of 13 items for measuring sexually related personal distress. The fixed choice response format offered the five increments: “never,” “rarely,” “occasionally,” “often,” and “always.” Sexual distress was defined as a FSDS-R score > 11, based on the published validation studies. The higher the score, the greater the distress [53]. A very good discriminate validity and ability to predict the prevalence of sexual problems have been shown for this instrument [54].
Sexual Health Outcomes in Women Questionnaire (SHOW-Q) is formed by 12 items organized conceptually to include 2-3 items per domain: satisfaction with sex, orgasm frequency, sexual desire, and pelvic problem interference with sex. Factor analysis demonstrated a 12-item scale with high internal consistency reliability (Cronbach’s a=0.86) and four reliable subscales (a=0.73 to 0.84). SHOW-Q involves women of diverse sociodemographic and clinical background, including women in same-sex relationships and women who are sexually active without a partner as well as sexually inactive women. SHOW-Q investigates also different aspects of sexual life and pelvic problem interference with sex [55].
Although self-administered questionnaires offer a valid and user-friendly means of assessing sexual function, several limitations should be noted.
First, these measures provide information only on current level of sexual function and cannot substitute for a detailed sexual, psychological, or medical history. Furthermore, the current questionnaires do not provide information on specific background or etiology or the role of comorbid medical or psychiatric conditions. Additionally, some patients may experience discomfort or embarrassment while completing questionnaires or symptom scales or may have difficulty with comprehension. Steps should always be taken to ensure privacy and confidentiality and to assist the patient with comprehension when indicated. Finally, questionnaire or symptom scales should not be used as an alternative to or substitute for direct inquiry or face-to-face clinical interaction with the clinician.
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