Richard Balon1 and Terri L. Woodard2
(1)
Department of Psychiatry, Tolan Park Building 3rd floor, 3901 Chrysler Service Dr., Detroit, MI 48201, USA
(2)
Department of Gynecologic Oncology and Reproductive Medicine, MD Anderson, Houston, TX, USA
Richard Balon
Email: rbalon@wayne.edu
Keywords
Female sexual dysfunction diagnosisDiagnostic criteriaFSIADFODGPPPDClinical interviewLaboratory assessment of FSDPsychometric assessment of FSD
19.1 Introduction
Diagnosis is important for many reasons. It helps clinicians name what they observe and communicate their observations with others. The process of generating a differential diagnosis also allows them to sharpen their observations and to be able to describe and classify them more precisely. Diagnosis also helps patients: first, they may feel more assured when the clinician is able to name their malady, which increases their confidence that the provider understands and knows what he/she is doing, and, second, it enables them to seek and acquire more information about their condition themselves. Last but not least, diagnosis is the starting point and cornerstone of the treatment process.
So, what is a diagnosis? It is a short “scientific” description for taxonomic classification and/or process of deciding the nature of a diseased condition by examination of symptoms. It can also be described as a careful examination and analysis of facts in an attempt to understand and explain something or a decision made based on such observation. In psychiatry and in many other medical specialties, diagnosis is derived from a composition of symptoms (or signs) that delineate a disorder (which implies disordered function), rather than a disease of known etiology.
Diagnosis should strive for a high degree of validity and reliability. Robins and Guze [1] outlined a method for achieving validity in psychiatric illness that consists of five phases : (1) clinical description, (2) laboratory study, (3) exclusion of other disorders, (4) follow-up study, and (5) family study. Others [2, 3] added further criteria, such as physical and neurological factors discussed by Feighner [2] and antecedent validators (familial aggregation, premorbid personality, precipitating factors), concurrent validators (e.g., psychological testing), and predictive validators (diagnostic consistency over time, rates of relapse and recovery, and response to treatment) proposed by Kendler [3]. The issue of reliability has been addressed during the creation of Diagnostic and Statistical Manual of Mental Disorders, Third Edition [4], and diagnostic interviews based on the criteria published in this manual. Most of the diagnoses listed in DSM-III were found to be fairly reliable in studies using structured interviews and other approaches.
There are various classification systems for diseases and disorders; however, two of the systems most commonly used to diagnose and classify sexual dysfunctions are the International Classification of Diseases and Related Health Problems (ICD) and the Diagnostic and Statistical Manual of Mental Disorders (DSM) . The ICD is published by the World Health Organization (WHO) and is the global health information standard for mortality and morbidity statistics as well as the diagnostic classification standard for all clinical and research purposes (ICD information sheet). Its Tenth Revision (ICD-10) is currently in use; however, the ICD-11 is anticipated to be finalized and released in 2017. The DSM is published by the American Psychiatric Association and was developed to provide standard criteria for the classification of mental disorders. Its Fifth Edition (DSM-5) was published in 2013 and contained extensive revisions [5].
The ICD-10 classifies sexual dysfunction based on the sexual response cycle, similar to the previous edition of the DSM (DSM-IV) [6]. However, the ICD-10 places emphasis on sexual dysfunction not being caused by an organic disorder or disease, while the DSM-IV had provisions for sexual dysfunction due to a general medical condition and substance-induced sexual dysfunction. ICD-10 diagnoses that are specifically applicable to the area of female sexual dysfunction (FSD) are listed in Table 19.1.
Table 19.1
ICD-10 classification of sexual dysfunction
|
Lack or loss of sexual desire (frigidity and hypoactive sexual desire disorder) |
|
Sexual aversion and lack of sexual enjoyment (sexual anhedonia) |
|
Failure of genital response (female sexual arousal disorder) |
|
Orgasmic dysfunction (inhibited orgasm in female, psychogenic anorgasmy) |
|
Nonorganic vaginismus (psychogenic vaginismus) |
|
Nonorganic dyspareunia (psychogenic dyspareunia) |
|
Excessive sexual drive (nymphomania) |
|
Other sexual dysfunction not caused by organic disorder or diseases |
|
Unspecified sexual dysfunction not causes by organic disorder or disease |
ICD International classification of diseases and related health problems
The intent of the newly revised DSM-5 was to refocus on the validity of diagnosis in all areas, including sexual dysfunctions. One major paradigm change was that the linear sexual response cycle was abandoned as a guiding concept in diagnosing sexual dysfunctions, based on research that questions the validity of the linear model of sexual response in women [7, 8]. The diagnoses of sexual dysfunctions in the DSM-5 are now listed alphabetically instead of according to the phase of sexual response cycle. In addition, gender-specific diagnoses were added, duration of dysfunction for at least 6 months became a required criterion, and two new female sexual dysfunction diagnoses—Female Sexual Interest/Arousal Disorder (FSIAD) and Genito-Pelvic Pain/Penetration Disorder (GPPPD) —were created through the merging of the former DSM-IV diagnoses of Female Hypoactive Sexual Desire Disorder with Female Sexual Arousal Disorder and Dyspareunia with Vaginismus, respectively. Sexual Aversion Disorder was discarded, because of a lack of empirical support for the diagnosis. The diagnosis of sexual dysfunction due to a general medical was also discarded. DSM-5 diagnoses applicable to the area of female sexual dysfunction are listed in Table 19.2. In addition, Table 19.3 compares the DSM-IV and DSM-5 symptomatology/changes of female gender-specific diagnoses.
Table 19.2
DSM-5 classification of female sexual dysfunction
|
Female orgasmic disorder (FOD) |
|
Female sexual interest/arousal disorder |
|
Genito-pelvic pain/penetration disorder |
|
Substance/medication-induced sexual dysfunction (in women) |
|
Other specified sexual dysfunction |
|
Unspecified sexual dysfunction |
DSM Diagnostic and statistical manual of mental disorders
Table 19.3
Comparison of DSM-IV and DSM-5 criterion A (symptomatology) of gender-specific female sexual dysfunctions
|
DSM-IV diagnosis |
DSM-IV criterion A |
DSM-5 diagnosis |
DSM-5 criterion A |
|
Hypoactive sexual desire disorder (both male and female) |
Persistently or recurrently deficient (or absent) sexual fantasies and desire for sexual activity. The judgment of deficiency or absence is made by the clinician, taking into account factors that affect sexual functioning such as age and the context of person’s life |
Female sexual interest/arousal disorder |
Lack of or significantly reduced sexual interest/arousal, as manifested by at least three of the following: 1. Absent/reduced interest in sexual activity 2. Absent/reduced sexual/erotic thoughts or fantasies 3. No/reduced initiation of sexual activity and typically unreceptive to a partner’s attempts to initiate 4. Absent/reduced sexual excitement/pleasure during sexual activity in almost all or all (approximately 75–100 %) sexual encounters (in identified situational contexts, or, if generalized, in all contexts) 5. Absent/reduced sexual interest/arousal in response to any internal or external sexual/erotic cues (e.g., written, verbal, visual) 6. Absent/reduced genital or nongenital sensations during sexual activity in almost all or all (approximately 75–100 %) sexual encounters (in identified situational contexts or, if generalized, in all contexts) |
|
Female sexual arousal disorder |
Persistent or recurrent inability to attain, or maintain until completion of the sexual activity, and adequate lubrication-swelling response to sexual excitement |
||
|
Female orgasmic disorder |
Persistent or recurrent delay in, or absence of, orgasm following a normal sexual excitement phase. Women exhibit wide variability in the type or intensity of stimulation that triggers orgasm. The diagnosis of female orgasmic disorder should be based on the clinician’s judgment that the woman’s orgasmic capacity is less than would be reasonable for her age, sexual experience, and the adequacy of sexual stimulation she receives |
Female orgasmic disorder |
Presence of either of the following symptoms and experienced on almost all or all (approximately 75–100 %) sexual encounters (in identified situational contexts or, if generalized, in all contexts) 1. Marked delay in, marked infrequency of, or absence of orgasm 2. Markedly reduced intensity of orgasmic sensations |
|
Dyspareunia |
Recurrent or persistent genital pain associated with sexual intercourse in either male or female |
Genito-pelvic pain/penetration disorder |
Persistent or recurrent difficulties with one (or more) of the following: 1. Vaginal penetration during intercourse 2. Marked vulvovaginal or pelvic pain during vaginal intercourse or penetration attempts 3. Marked fear or anxiety about vulvovaginal or pelvic pain in anticipation of, during, or as a result of vaginal penetration 4. Marked tensing or tightening of the pelvic floor muscles during attempted vaginal penetration |
|
Vaginismus |
Recurrent or persistent involuntary spasm of the musculature of the outer third of the vagina that interferes with sexual intercourse |
||
|
Sexual aversion disorder |
Persistent or recurrent extreme aversion to, and avoidance of, all (or almost all) genital sexual contact with a sexual partner |
DSM Diagnostic and statistical manual of mental disorders
Only time and more research will reveal whether the changes introduced in the DSM-5 are progressive, meaningful, and clinically relevant. It is noteworthy that even with the newly sparked interest in the validity of diagnosis of sexual dysfunction, none of the diagnostic systems adhere to the principles outlined by Robins and Guze [3], Feighner [4], and Kendler [5]. Some of the new changes in the DSM-5 have been vigorously criticized as confusing and have not been accepted by all experts [9]. In fact, there are some who have questioned the true existence of female sexual dysfunction disorders and feel that women’s sexual concerns have been excessively medicalized, partially due to pressure from the pharmaceutical industry.
It is essential to distinguish between relatively more common “sexual problems” and true diagnosable sexual dysfunction disorders. Sexual problems are transient disturbances or disruptions in sexual functioning which may arise due to temporary stressors, relationship problems, and/or other conditions that have a short duration (less than 6 months). We will focus on the diagnosis of female sexual dysfunction disorders using the DSM-5 criteria as a descriptive framework for describing and assessing FSD.
19.2 Female Sexual Dysfunction in the DSM-5
The three female gender-specific DSM-5 [5] sexual dysfunction diagnoses—FSIAD, FOD and GPPPD—have their specific symptomatologies summarized in Criterion A of each diagnosis and share the same three criteria B, C, and D (see Table 19.4). For all three diagnoses, it should be specified whether the distress over the symptoms is mild, moderate, or severe and whether the dysfunction is lifelong (ever since the woman became sexually active) or acquired (the dysfunction started after a period of relatively normal sexual functioning).
Table 19.4
DSM-5 criterions B, C, and D
|
Criteria B |
Persisted for a minimum duration of approximately 6 months |
|
Criteria C |
Symptoms in criterion A cause clinically significant distress in the individual (based on the clinician’s judgment) |
|
Criteria D |
Should not be better explained by a nonsexual mental disorder or as a consequence of severe relationship distress (e.g., partner violence) or other significant stressor and is not attributable to the effects of a substance/medication or another medical condition |
DSM Diagnostic and statistical manual of mental disorders
The DSM-5 recognizes that ‘sexual response has a requisite biological underpinning, yet is usually experienced in an intrapersonal, interpersonal, and cultural context.’ Thus, sexual function involves a complex interaction among biological, sociocultural, and psychological factors. Accordingly, the DSM-5 recommends that a number of associated features “be considered during the assessment of sexual dysfunction, given that they may be relevant to etiology and/or treatment and that they may contribute, to varying degrees, across individuals:
(1)
(2)
(3)
(4)
(5)
In many clinical contexts, the precise etiology of a sexual problem is uncertain. However, a sexual dysfunction diagnosis requires ruling out problems that are better explained by a nonsexual mental disorder, the effect of a substance, or a medical condition or by severe relationship distress, partner violence, or other stressors [5, p. 423]. The DSM-5 also specifically states that if the sexual dysfunction is attributable to another medical condition, the individual does not receive a psychiatric diagnosis; yet it stops short of proposing that sexual dysfunction disorders be categorized as exclusively psychiatric diagnoses.
In spite of the complexity of female sexual dysfunction disorders, the descriptive framework is a concept that can be useful to psychiatry as well as other related disciplines where women often present with sexual health concerns, such as obstetrics and gynecology and urology. Using this framework, a provider can assess symptoms and identify possible etiologic factors.
19.2.1 Specific FSD Diagnoses
19.2.1.1 Female Orgasmic Disorder
The diagnosis of female orgasmic disorder (FOD) requires the presence of (1) a marked delay in, marked infrequency of, or absence of orgasm and/or (2) a markedly reduced intensity of orgasmic sensations. These symptoms should be experienced on all or almost all (approximately 75–100 %) occasions of sexual activity. FOD specifiers should identify whether the dysfunction is generalized (occurs under all circumstances) or situational (i.e., only with certain types of stimulation, situations or partners). It should also be specified if a woman has never experienced an orgasm under any situation.
19.2.1.2 Female Sexual Interest/Arousal Disorder
The diagnosis of Female Sexual Interest/Arousal Disorder (FSIAD) is characterized by a lack of or significantly reduced sexual interest/arousal. It must be manifested by at least three of the following (in any combination): (1) absent/reduced interest in sexual activity, (2) absent/reduced sexual/erotic thoughts or fantasies, (3) no or reduced initiation of sexual activity and being unreceptive to a partner’s attempts to initiate sex, (4) absent or reduced sexual excitement/pleasure during sex in all or almost all (approximately 75–100 %) of sexual encounters, (5) absent or reduced sexual interest/arousal in response to any internal or external sexual/erotic cues (e.g., verbal, visual), and (6) absent or reduced genital or nongenital sensations during sexual activity in almost all or all (approximately 75–100 %) of sexual encounters.
FSIAD replaces the diagnoses of Hypoactive Sexual Desire Disorder and Female Sexual Arousal Disorder as defined in the DSM-IV. These two diagnoses were combined based on data suggesting that desire and arousal are not separate entities and that women do not reliably distinguish between desire and arousal. However, many critics have argued that the new diagnostic criteria exclude a significant number of women with low desire and arousal. While there is general agreement that considerable overlap exists when comparing symptoms between these two constructs, differences between the tails of the normal distribution curve describing those with FSIAD would also be clearly evident.
Unlike Female Sexual Arousal Disorder as defined in the DSM-IV [6], a lack of adequate swelling-lubrication response is no longer specifically required, but it is subsumed under (6)—absent or reduced genital sensations. The change is based on data that physiological measures of genital response do not differentiate women who report sexual arousal concerns from those who do not; therefore, the DSM-5 states that the “self-report of reduced or absent genital or nongenital sensations is sufficient” [5, p. 434]. FSIAD specifiers should identify whether the dysfunction is generalized or situational.
19.2.2 Genito-Pelvic Pain/Penetration Disorder
The diagnosis of Genito-Pelvic Pain/Penetration Disorder (GPPPD) requires persistent or recurrent difficulties with one or more of (1) vaginal penetration during intercourse; (2) marked vulvovaginal or pelvic pain during intercourse or penetration attempts; (3) marked fear of anxiety about vulvovaginal or pelvic pain in anticipation of, during, or as a result of vaginal penetration; and (4) marked tensing or tightening of the pelvic floor muscles during attempted vaginal penetration.
GPPPD replaces the diagnoses of dyspareunia and vaginismus from the DSM-IV, based on research that suggests that the two conditions have a great degree of overlap and cannot be reliably differentiated.
19.2.3 Substance/Medication-Induced Sexual Dysfunction
A non-gender-specific FSD diagnosis of Substance/Medication-Induced Sexual Dysfunction requires presence of significant disturbance in sexual function with the evidence (based on history, physical examination, or laboratory findings) that the dysfunction developed during or soon after substance intoxication or withdrawal or after exposure to a medication and that the involved substance or medication is capable of producing the dysfunction. The dysfunction should not occur during delirium. It should be specified whether the onset was during intoxication, during withdrawal, or after medication use and whether the distress is mild, moderate, or severe.
19.3 Factors Contributing to FSD
There are numerous “etiological” factors that may contribute to FSD, and all should be considered during diagnosis. There are normative changes in sexual functioning that occur in women during menopause, pregnancy, parturition, and breastfeeding that may lead to the development of a sexual dysfunction [10]. Factors such as age, lower levels of education, lower socioeconomic class, poor physical and emotional health, and a history of sexual abuse have all been associated with FSD. Several recent review articles [11–14] reviewed possible biologic factors underlying sexual dysfunction (psychological and relational factors have been discussed previously):
(a)
(b)
(c)
(d)
(e)
(f)
(g)
19.4 Establishing the Diagnosis of FSD
There are significant barriers to the identification and diagnosis of FSD. As Jha and Thakar [11] point out, women do not always directly voice complaints of sexual dysfunction, but may present with more covert symptoms such as pelvic pain, distress about menses, general dissatisfaction with a contraceptive precaution, or distaste for genital area or for sexual activity at the time of genital examination. Physicians and others may be reluctant to discuss sexual activity and sexual history for various reasons (lack of training, lack of practice, being embarrassed or fearing that patient may be embarrassed, male gender, and others [11]). Nevertheless, evaluation of sexual functioning should be part of any comprehensive evaluation by any healthcare professional regardless of profession of origin.
Proper evaluation [15, 16] of sexual function/dysfunction consists of several components, as indicated:
(1)
(2)
(3)
(4)
The clinical interview is the primary and most important source of information, and a variety of methods have been described elsewhere [17]. Derogatis and Balon [16] proposed a matrix of three sequential levels: Level 1 determines why the patient is seeing the clinician and what has prompted the visit and clarifies whether the patient currently has or has previously complained of sexual dysfunction. Her partner’s input can be quite helpful at this level. Level 2 focuses on the character and nature of the patient’s sexual dysfunction (FOD, FSIAD, GPPPD). If the woman complains of more than one dysfunction, effort should be made to identify which is the primary one. It also should be determined whether the dysfunction is transient, fluctuating, permanent, generalized, or situational. At this level, one may use the diagnostic algorithm based on DSM-5 outlined by Latif and Diamond [13]. This algorithm progresses from asking the patient about sexual interest to questions about sexual arousal, orgasm, and sexual pain. Level 3 seeks to establish the etiology of the patient’s sexual dysfunction (e.g., atherosclerosis, depression, endometriosis, infection, marital discord).
Questions about sexual functioning should be direct and specific. Vague questioning such as “How is your sex life?” should be avoided, as it may generate ambiguous answers such as “OK.” The interview should be semi structured, yet tailored to the individual patient. The questions should be asked in a respectful yet serious manner [16]. One may use questions modeled on the DSM-5 criteria of FSDs to arrive to a preliminary diagnosis of a specific FSD.
The history should include a sexual history (including details about first sexual experimentation, intercourse, masturbation), reproductive history, status of current sexual relationship, sociocultural and personal beliefs about sexuality, and history of sexual trauma [13]. A detailed medical and surgical history as well as information about substance abuse (including smoking) and medications (including over the counter, herbal, and contraceptives [13]) should be elicited.
The clinical interview should be followed by a complete physical examination which includes a pelvic examination [13]. The pelvic examination is especially important for women with possible GPPPD. There are several physiologic measures of sexual function that could potentially help determine organic factors underlying the diagnosis of sexual dysfunction [13]. These include vaginal photoplethysmography (a measure of genital blood flow) and measurements of vaginal lubrication, volume, pressure, and compliance [13]. There are many other tests and measures that could be used (e.g., measuring the bulbocavernosus reflex, electromyograms of pelvic muscle floors, electrovaginograms), but most of these methods are “invasive, poorly defined, and lack standardization, validity, and reliability” and thus have little value in establishing a diagnosis [13]. Currently, such testing cannot be routinely recommended and should be reserved for use in investigational protocols.
Laboratory tests should be ordered based on clinical information and suspicion of underlying pathology. Laboratory tests are rarely definitive in determining the etiology of FSD, but they may help rule out biological factors and conditions [16]. Diagnostic testing that may be considered includes plasma estradiol, total testosterone, free testosterone, sex hormone-binding globulin, thyroid-stimulating hormone, and prolactin. Other assays such as a lipid profile, dehydroepiandrosterone, glycosylated hemoglobin A1C, thyroid panel, luteinizing hormone, follicle-stimulating hormone, and complete blood count may be warranted based on clinical findings.
There are a number of validated questionnaires and scales that are available for psychometric assessment of various aspects of female sexual functioning. These include the Derogatis Interview for Sexual Functioning (DSIF/DSIF-SR) [18], which has gender-specific versions; the Female Sexual Function Index [19]; the Profile of Female Sexual Functioning (PFSF) [20], which also has a brief form (B-PFSF) [21]; the Sexual Function Questionnaire [22]; the Sexual Interest and Desire Inventory (SIDI) [23]; the Female Sexual Distress Scale (FSDS) [24]; and the Shor Personal Experience Questionnaire (SPEQ) [25] (see Table 19.5). Their usefulness, validity, and reliability have been summarized by Derogatis [15] and Derogatis and Balon [16]. It is important to emphasize that none of these instruments are diagnostic tools. They should be used as an additional source of information that is integrated with information obtained by the clinical interview, physical examination, and other testing. Giraldi and colleagues [26] note that there is a serious lack of standardized, internationally (culturally) acceptable tools that are truly validated in the general population that can be used to assess FSD in women with or without a partner, independent of the partner’s gender. Nevertheless, Clegg et al. [27] strongly recommend including FSD questionnaires/scales as part of the clinician’s routine encounters with female patients. According to them, these instruments have several important roles, including serving as an assessment tool to detect FSD and diagnose a particular disorder [27, p. 161], identifying and assessing distress and patient satisfaction/problems, and measuring treatment-induced change. However, it is important to note that no specific questionnaire/tool has been developed in response to the new diagnostic concepts introduced in the DSM-5.
Table 19.5
Selected validated questionnaires and scales
|
Instrument |
Domain |
Questions |
Gender |
Interview/Self-report |
|
Derogatis interview for sexual functioning (DISF/DISF-SR) |
Cognition/fantasy, drive/relationship, arousal, behavior/experience, orgasm, total score |
25 |
Female and male |
Both |
|
Profile of female sexual functioning (PFSF) |
Desire, arousal, orgasm, pleasure, concerns, responsiveness, self-image |
37 |
Female |
Self-report |
|
Sexual function questionnaire |
Desire, arousal-sensation, arousal-lubrication, enjoyment, orgasm, dyspareunia, partner relationship, total score |
26 |
Female |
Self-report |
|
Female sexual function index (FSFI) |
Desire, arousal, lubrication, orgasm, satisfaction, pain |
19 |
Female |
Self-report |
|
Sexual interest and desire inventory (SIDI) |
Overall total score |
13 |
Female |
Clinical interview |
|
Female sexual distress scale (FSDS) |
Sexually related personal distress, revised version added desire item |
12 (revised: 13) |
Female |
Self-report |
|
Short personal experience questionnaire (SPEQ) |
Feelings for partner, sexual responsivity, sexual frequency, libido, distress/dyspareunia, partner problems |
9 |
Female |
Self-report |
19.5 Conclusion
The diagnosis of FSD is complex, complicated, and continuously emerging. The new DSM-5 [5] and, hopefully, the next revision of the ICD introduce simpler, though untested classification systems that facilitate valid and reliable diagnosis of female sexual function disorders. At present, data obtained from the clinical interview, physical examination, targeted laboratory testing, and, possibly, psychometric assessment should be used in conjunction with the DSM-5 diagnostic criteria as a descriptive framework to establish diagnosis and etiology, of sexual dysfunction disorders in women.
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