[Men and women--aspects of sexological counseling in the aging]

In our times, sexuality has become an essential part of life for aging people. For the aging, psychosocial and biological changes, as well as increasing morbidity present challenges to a satisfying sexual life. Hence, the demand grows for health-care providers with basic sexological knowledge and counseling abilities. This article discusses relationships between frequent sexual difficulties and aging related organic processes. A therapeutic concept, the "Sexocorporal Approach", is introduced. This approach is based on a model of ongoing sexual development throughout the lifetime enabling adaptation to new life phases and limiting circumstances through sexual learning processes. Aside from pharmacological treatment, the encouragement of sexual learning presents an effective therapeutic approach for practitioners that can be easily learned and applied.

A clinical update on female androgen insufficiency—testosterone testing and treatment in women presenting with low sexual desire

The diagnosis of female androgen deficiency syndrome is suggested by complaints of a diminished sense of well being, persistent unexplained fatigue and decreased sexual desire, sexual receptivity and pleasure in a woman who is oestrogen-replete and in whom no other significant contributing factors can be identified. The diagnosis is supported by the finding of low circulating concentrations of free testosterone. Barriers to its recognition include the non-specificity of the symptoms and methodological problems due to insensitive testosterone assays. Barriers to its treatment include the unavailability of satisfactory forms of testosterone for administration to women and lack of data regarding long-term safety. Although several conditions lead to clear-cut androgen deficiency, such as hypopituitarism, adrenal and ovarian insufficiency, glucocorticoid therapy and use of oral contraceptives and oral oestrogens, it is important for clinicians to recognise that in normal women, androgen levels decline by 50% from the early 20s to the mid 40s, and hence age-related androgen insufficiency may occur in women in their late 30s and 40s, as well as postmenopausally. Satisfactory measurements of free testosterone requires a sensitive and reliable assay for total testosterone, and quantitation of sex hormone binding globulin, from which free testosterone is readily calculated. Adverse effects of testosterone treatment are few if replacement is monitored to achieve physiological circulating testosterone concentrations. Currently, available methods include testosterone implants and testosterone creams, and transdermal patches and sprays are in development.

Reliability and construct validity of the Changes in Sexual Functioning Questionnaire short-form (CSFQ-14)

The Changes in Sexual Functioning Questionnaire (CSFQ) is a 36-item clinical and research instrument identifying five scales of sexual functioning. This study documents the internal consistency and factor structure of a 14-item version of the CSFQ (CSFQ-14), which yields scores for three scales corresponding to the phases of the sexual response cycle (i.e., desire, arousal, and orgasm) as well as the five scales of the original CSFQ. Factor analysis confirms the construct validity of the CSFQ-14 as a global measure of sexual dysfunction. The CSFQ-14 and the individual scales exhibit strong internal reliability.

REVIEWS: Sexual Health Inquiry and Support Is a Primary Care Priority

The World Health Organization defines sexual health as "a state of physical, emotional, mental and sexual well-being related to sexuality." This broad definition goes beyond simply inquiring about sexual dysfunction and ideally fits the model of patient-centered primary care. As we observe that sexual health and physical health are often closely related, discussions about sexual activity can be very revealing. Sexual intimacy appears positively related to loving relationship satisfaction and stability. Sexual problems have a clear negative impact on both the quality of life and emotional state regardless of age. Learning about specific sexual dysfunctions among men can reveal a variety of as-yet-undiagnosed comorbid pathologic conditions such as: (i) depression and other emotional illnesses; (ii) psychosocial stress; (iii) actual cardiovascular disease as well as related risk factors such as hypertension, diabetes, and/or hyperlipidemia; (iv) hyperprolactinemia; and (v) low serum testosterone. Specific sexual dysfunctions among women can reveal pathologic conditions such as: (i) depression and other adverse imitational and psychosocial conditions; (ii) low serum estrogen or testosterone; and/or (iii) vaginal or pelvic disorders. A discussion about sexual health can be accomplished efficiently in a primary care office with the inquiring clinician having the option to deal with any sexual problems and dysfunctions directly, or to refer the patient to an appropriate specialized care source.

Sexuelle Funktionsstörungen aus nervenärztlicher Perspektive

Sexual dysfunctions are widespread and have an enormous effect on quality of life. To understand them, it is necessary to look at both somatic and psychosocial factors, especially those concerning partnership. Psychiatric and neurologic disorders play an important role. Normally, treatment consists of qualified sex counseling and, if necessary, intensive sex therapy. Somatic treatment options exist as well.

The Modified Rush Sexual Inventory: preliminary psychometric findings

Sexual dysfunction associated with psychiatric disorders and the treatment of these disorders can impede a patient's optimal recovery and quality of life. Patients are typically reluctant to report their sexual difficulties. Therefore, self-report measures that comprehensively and concisely assess sexual difficulties are a beneficial contribution to clinical research and practice. The Modified Rush Sexual Inventory (MRSI) not only assesses sexual functioning and satisfaction using a multiple-choice format, but it also includes an introductory section for patients' medical histories and free responses. Though the MRSI has been used in clinical trial research, the reliability and validity of the measure is unknown. This study presents the initial reliability and validity findings of the MRSI.

Diagnosing erectile dysfunction: instruments for endocrine diagnosis

Endocrine factors represent an important and potentially treatable cause of sexual dysfunction. The availability of a correct endocrinological diagnosis allows correct identification of most cases of sexual dysfunction in which the endocrine apparatus is involved. Not only the most frequent causes of endocrine sexual dysfunction, such as hypogonadism and hyperprolactinaemia, but almost all extra-gonadal endocrinopathies (hyper-and hypothyroidism, hyper- and hypocortisolism, steroidal secreting tumours, etc.) may have importance to a greater or lesser extent in sexual function. It is, therefore, necessary that the diagnostic process for sexual dysfunctions of an endocrine nature be as integrated and wide as possible, especially as such pathologies are normally extremely responsive to medical or surgical therapy.

Validation of the McCoy Female Sexuality Questionnaire in an Italian sample

This article presents the result of a study that translated into Italian and validated the McCoy Female Sexuality Questionnaire (MFSQ) on an Italian sample. The questionnaire was first administered to a sample of 240 Italian women (age range, 18-65 years) recruited from a gynecology clinic. A principal component analysis identified 2 factors: sexuality (9 items) and partnership (5 items). Both factors showed an adequate inter-item reliability (Cronbach's alpha of .88 and .75, respectively). The validity of the Italian MFSQ was then tested by administering the questionnaire to a sample of 16 women with sexual dysfunction and 46 control women. Sexual dysfunction diagnoses were assessed through a semi-standardized interview based on the DSM-IV-TR diagnoses for Female Sexual Arousal Disorder, Female Orgasmic Disorder, Dyspareunia, and Hypoactive Sexual Desire Disorder. A discriminant validity test showed significant differences between women with and without female sexual dysfunction. These results indicate that the translated version of the MFSQ is a reliable and valid measure of sexual dysfunction among Italian women. The results also indicated a difference in factor structure between the Italian and the original version of the MFSQ, which warrants further investigation.

[Women's sexual life quality assessment with use of questionnaires in clinical trials--review of accessible tools, their characteristics and comparison of their properties]

AIM

Aim of the study is a review of women's sexual life quality assessment questionnaires available in literature, analysis of their construction, special properties and usability in clinical trials.

MATERIAL AND METHODS

Medline database and accessible literature has been reviewed. Seven questionnaires have been chosen for analysis. Analysis in scope of potential and usability of those questionnaires in clinical tests has been performed.

CONCLUSIONS

Suitability of The Female Sexual Function Index (FSFI) and The Brief Index of Sexual Functioning for Women (BISF-W) have been shown as universal tools for sexual function assessment in clinical trials. They meet current model of women's sexual reaction and criteria of sexual disfunction classification.

[Androgen deficiency in women]

Androgens are defined as the steroids having a binding affinity of the androgen receptor. In the reproduction age a daily production of testosterone is equally divided between the ovaries and adrenal and local tissue conversion of androstenedione and DHEA. After menopause the 80% of testosterone is produced in ovaries, but majority of precursors for peripheral conversion is adrenal origin. Androgen receptors are present throughout in the body; over 200 cellular actions of androgens have been described. Androgenic action is determined by quantitative level of the androgen present in the circulation, its degree of binding to proteins, the degree of interconversion to other androgens and estrogens, and the biological potency and androgen receptor binding affinity of the androgen. The most common clinical symptoms of androgen deficiency are the reduction of sex motivation, sex fantasy, sex enjoyment, sex arousal, vaginal vasocongestion, but also reduction of pubic hair, bone mass, muscle mass, worsening of quality of life (mood, affect, energy), more frequent vasomotors symptoms, insomnia, depression, headache. All these signs and symptoms can be multifactorial. Most common conditions associated with hypoandrogenism in women are hypothalamic-pituitary abnormalities, lack or insufficiency of ovaries, adrenal insufficiency, glucocorticoid therapy, exogenous estrogen administration. Besides the clinical picture the free testosterone measuring is important for diagnosis. The method of choice of this measure is equilibrium dialysis assay. Despite of clinical importance of androgen insufficiency in women, none of methods of androgen substitution is approved by FDA.

Epidemiology of premature ejaculation

PURPOSE OF REVIEW

Accumulating evidence suggests that premature ejaculation is the most common sexual symptom. This review focuses on the epidemiology of premature ejaculation from geographical and medical perspectives.

RECENT FINDINGS

In the past year many articles have been published using the data from the Global Study of Sexual Attitudes and Behaviors, a large survey that investigated various aspects of sex and relationships among 27 500 men and women aged 40-80 years. Despite some methodological bias, discussed herein, a prevalence of more than 21% seems a realistic figure for premature ejaculation.

SUMMARY

Premature ejaculation is the most prevalent sexual dysfunction in every country.

ORIGINAL RESEARCH—WOMEN's SEXUAL DYSFUNCTIONS: The Sexual Interest and Desire Inventory—Female (SIDI‐F): Item Response Analyses of Data from Women Diagnosed with Hypoactive Sexual Desire Disorder

INTRODUCTION

Hypoactive sexual desire disorder (HSDD) is the most common sexual complaint in women. Currently there are no validated instruments for specifically assessing HSDD severity, or change in HSDD severity in response to treatment, in premenopausal women. 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. 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).

AIM

The aim of the study was to use the outcome of item response analyses of blinded data from two randomized, placebo-controlled trials, to assist in the revision of the scale.

METHODS

A nonparametric item response (IRT) model was used to assess the relation between item functioning and HSDD severity on this preliminary version of the SIDI-F.

RESULTS

Results show that the majority of SIDI-F items demonstrated good sensitivity to differences in overall HSDD severity. That is, there was an orderly relation between differences in option selection for an item and differences in overall HSDD severity. The IRT analyses further indicated that revisions were warranted for a number of these items. Five items were not sensitive to differences in HSDD severity and were removed from the scale.

CONCLUSION

The SIDI-F is a brief, clinician-administered rating scale designed to assess severity of HSDD symptoms in women. IRT analyses show that majority of the items of the SIDI-F function well in discriminating individual differences in HSDD severity. A revised 13-item version of the SIDI-F is currently undergoing further validation.

Development of a questionnaire on sexual quality of life in women

The Sexual Quality of Life-Female (SQOL-F) questionnaire has been developed to assess the impact of female sexual dysfunction (FSD) on a woman's sexual quality of life. SQOL-F items were developed through interviews with 82 women. Three data sets from women's health surveys in the United Kingdom and the United States generated data for scale validation. The SQOL-F showed good psychometric properties: convergent validity, discriminant validity, and test-retest reliability. The SQOL-F is a valid instrument for assessing the impact of FSD on quality of life and as an adjunct in evaluating FSD in clinical trials. The SQOL-F sensitivity to changes in sexual function needs confirmation.

Aging and sexual response in the laboratory in patients with erectile dysfunction

Aging places men at increased risk for erectile problems, particularly beginning around their fifties and sixties. Using a psychophysiological assessment procedure that included visual erotic stimulation, vibrotactile stimulation, and intracavernosal injection, this study tested for possible age effects on erectile response and self-reported sexual arousal in a group of men clinically diagnosed with erectile dysfunction. We controlled for three factors of purported importance to erectile functioning: existing comorbidities, use of specific medications, and current tobacco and alcohol use. Results indicated effects from both age and tobacco use on erectile response, although these effects were not uniform across age groups. For example, age had inconsistent effects on erectile response in patients aged 50 to 90 years; tobacco use had its strongest effect on patients under 50 years of age. In general, such covariates were less able to account for variation in erectile response among patients with more-severe ED. Despite these effects, ED men even in the oldest group showed average penile circumference increases of 28 mm under ICI, an erectile response typically sufficient for vaginal intercourse.

Current Perspectives on the Clinical Assessment and Diagnosis of Female Sexual Dysfunction and Clinical Studies of Potential Therapies: A Statement of Concern

INTRODUCTION

The assessment and diagnosis of female sexual dysfunction (FSD) are in a state of transition because of evolving concepts of female sexuality and suggested changes to the FSD diagnostic framework.

AIM

To review the problems with current FSD diagnosis.

METHODS

Multidisciplinary experts from five countries were assembled to convene a "Postmenopausal FSD Roundtable on specific topics related to FSD."

MAIN OUTCOME MEASURE

Expert opinion was based on a review of evidence-based medical literature, presentation, and internal discussion.

RESULTS

Current FSD diagnosis is challenging because of poorly defined distinctions between normal and abnormal, a limited ability to integrate subjective and objective findings and an inability to incorporate contextual factors that play a significant role in sexual behavior. The availability of self-administered questionnaires (SAQs) that assess various domains of female sexual function, as well as those developed specifically for postmenopausal women, suggests that a more structured approach to assessment and diagnosis may be possible. Several SAQs reflecting proposed changes to the FSD diagnostic framework by the American Foundation for Urologic Disease (AFUD), including the Sexual Function Questionnaire (SFQ) and the Female Sexual Distress Scale (FSDS), have been introduced and recently incorporated into a Structured Diagnostic Method (SDM). Recent regulatory decisions and events affecting the development of FSD interventions have highlighted the lack of consensus with regard to clinically meaningful FSD outcomes, as well as shortcomings in a U.S. Food and Drug Administration draft document that provides the primary guidance for conducting FSD clinical studies in the United States.

CONCLUSIONS

Given the high cost and inherent risk of clinical studies, continued development efforts toward FSD therapies are unlikely to proceed in the absence of significant changes in regulatory guidance that reflect the current understanding of FSD and incorporate validated assessment tools.

Confronting the Challenges: Epidemiological Study of Female Sexual Dysfunction and the Menopause

INTRODUCTION

Despite rapid current and anticipated growth in the number of women who will spend a substantial portion of their life span in the postmenopausal period, the nature, incidence, and prevalence of changes in sexual function during and after the menopausal transition remain poorly characterized.

AIM

Challenges inherent in studying the menopausal transition and proposed additions and changes that have emerged from recent consensus conferences on female sexual dysfunction are reviewed.

METHODS

Specific topics related to female sexual dysfunction were presented in a Postmenopausal FSD Roundtable in which multidisciplinary international experts participated.

MAIN OUTCOME MEASURE

Expert opinion was based on a review of evidence-based medical literature, presentation, and internal discussion.

RESULTS

Knowledge concerning sexual function in the menopause is limited, in part, due to the difficulty in designing and conducting studies that adequately address these changes over time, and which also permit the effects of menopause to be distinguished from more general changes associated with aging. Moreover, the study of female sexual function and dysfunction is in the midst of significant transition: a tentative definition of the stages of reproductive aging and menopause has recently been advanced, and a set of comprehensive changes to the diagnostic framework that defines female sexual dysfunction is under review.

CONCLUSIONS

In spite of fast-moving changes in this field of study, it is possible to reach some tentative conclusions about how women's sexual function changes after menopause: postmenopausal women report a relatively high rate of sexual dysfunction (higher than men). There is a marked decline in sexual interest and frequency of sexual activity. This decline can be ameliorated by a number of psychosocial factors, although vaginal dryness and dyspareunia seem to be driven primarily by declining estradiol. The effects of menopause appear to be incremental and additional to those characteristic of aging.

Proposals or Findings for a New Approach about How to Define and Diagnose Premature Ejaculation

PURPOSE

To review and present the proposals or findings for a new approach about how to define and diagnose premature ejaculation (PE).

MATERIALS AND METHODS

Using Medline to search for international peer reviewed manuscripts published from 1996 to 2004 about the definition and diagnosis of PE.

RESULTS

PE, to date, has not a universally agreed definition and diagnostic criterion. Many definitions are partial, subjective and nonspecific. An ideal definition or diagnostic criterion should consist of intravaginal ejaculatory latency time (IELT), the ability to control over ejaculation, the extent of male sexual satisfaction, the extent of female sexual satisfaction, the frequency of female sexual partner reaching orgasm and the extent of psychological and pathological factors. Therefore, the Chinese Index of Premature Ejaculation (CIPE) seems an ideal tool and criterion used to diagnose PE due to including all the elements above. In the majority of cases, PE is the result of a mix of psychogenic, physiological and organic factors. So, besides some routine tests such as urine routine test, endocrine hormone assay, psychosexual counseling, couple evaluation and physical examination, prostate examination, serum leptin assay, semen magnesium assessment and glans hypersensitivity measurement, are suggested to be performed in the diagnosis of PE. Although elucidated by two clinical trials and further confirmed, serum leptin assay seems a promising and objective marker to diagnose PE because it is related to the serotonergic system whose disorder has been confirmed to contribute to the etiology of PE.

CONCLUSION

None of these definitions and diagnoses has been accepted as a universal agreement of PE. CIPE seems an ideal tool and criterion used to diagnose PE and leptin maybe become a promising and objective marker for PE.

Sexual activity and function in postmenopausal women with heart disease

OBJECTIVE

To examine the prevalence and correlates of sexual activity and function in postmenopausal women with heart disease.

METHODS

We included baseline self-reported measures of sexual activity and the sexual problem scale from the Medical Outcomes Study in the Heart and Estrogen/Progestin Replacement Study (HERS), a study of 2,763 postmenopausal women, average age 67 years, with coronary disease and intact uteri. We used multivariable linear and logistic regression to identify independent correlates of sexual activity and dysfunction.

RESULTS

Approximately 39% of the women in HERS were sexually active, and 65% of these reported at least 1 of 5 sexual problems (lack of interest, inability to relax, difficulty in arousal or in orgasm, and discomfort with sex). In multivariable analysis, factors independently associated with being sexually active included younger age, fewer years since menopause, being married, better self-reported health, higher parity, moderate alcohol use, not smoking, lack of chest discomfort, and not being depressed. Among the 1,091 women who were sexually active, lower sexual problem scores were associated with being unmarried, being better educated, having better self-reported health, and having higher body mass index.

CONCLUSION

Many women with heart disease continue to engage in sexual activity into their 70s, and two thirds of these report discomfort and other sexual function problems. Physicians should be aware that postmenopausal patients are sexually active and address the problems these women experience.

LEVEL OF EVIDENCE

II-2.

Measurement of psychosexual differentiation

Since the early 1990s, there has been a surge in interest in the study of infants, children, adolescents, and adults with physical intersex conditions or other congenital conditions that affect, among other things, the configuration of the external genitalia. Regarding psychologic evaluation, an important aspect of both short-term and long-term outcome concerns gender differentiation. This article provides an overview of various measures pertaining to gender identity, gender role, and sexual orientation that have been used in assessment studies of samples of either children and adults with gender identity disorder and/or children and adults with various physical intersex conditions. All of the measures have good psychometric quality although some have been studied more systematically than others. It is hoped that this overview will provide a template for the new generation of studies that are looking at both gender development and sexual orientation in people born with physical intersex conditions.

Evaluation and treatment of unconsummated marriages among Orthodox Jewish couples

Orthodox Judaism expects new brides and grooms to engage in sexual intercourse on the first night of marriage or soon thereafter, despite stringent norms forbidding premarital physical contact. Any delay for more than several weeks in consummating a marriage is seen as problematic and worthy of rabbinic or professional attention. This article examines traditional Jewish sources for this emphasis on marital sexuality, defines the problem of unconsummated marriages, discusses issues pertinent to evaluation, and suggests appropriate treatment strategies. Our focus includes both the Orthodox and Ultra-Orthodox (Haredi) elements of the Jewish community.

A placebo-controlled, randomized, double-blind study of adjunctive bupropion sustained release in the treatment of SSRI-induced sexual dysfunction

BACKGROUND

Sexual side effects are among the common reasons patients discontinue selective serotonin reuptake inhibitors (SSRIs). While many antidotes have been proposed, few have been subjected to double-blind trials. Some evidence has suggested that bupropion may be an effective antidote for SSRI-induced sexual dysfunction. In this double-blind trial, the efficacy of a standard dose of bupropion sustained release (SR) is evaluated in the treatment of SSRI-induced sexual dysfunction.

METHOD

Patients with a history of SSRI-induced sexual side effects were randomly assigned to adjunctive treatment with either bupropion SR 150 mg daily or placebo for 6 weeks. Assessments of sexual function and interest included the Arizona Sexual Experiences Scale (ASEX), Brief Index of Sexual Functioning, and a 10-point visual analogue scale. Efficacy was defined as a 50% improvement on the ASEX at the end of 6 weeks. Data were collected from January 1999 to March 2001.

RESULTS

Forty-one patients entered the study and completed the 6-week trial. No significant differences were seen between placebo and bupropion SR on the ASEX or on any measure of sexual functioning at the end of the trial.

CONCLUSION

A fixed dose of 150 mg/day of bupropion SR taken in the morning does not appear to be effective in the treatment of SSRI-induced sexual dysfunction. Additional trials will be required to define what role, if any, bupropion might have in the treatment of SSRI-induced sexual side effects.

A methodology study to validate a structured diagnostic method used to diagnose female sexual dysfunction and its subtypes in postmenopausal women

The currently accepted gold standard for diagnosis of female sexual dysfunction (FSD) is a nonstandardized interview by a clinician whose field of expertise is FSD. However, the limited number of experts in the field has implications for running efficient large-scale clinical trials. Therefore, we developed a structured diagnostic method (SDM) to enable diagnosis of FSD in postmenopausal women by health care professionals who are not FSD experts. Our study objectives were to evaluate both convergent validity and intrarater reliability of the SDM. The results showed that the method had good convergent validity and excellent intrarater reliability. Thus, we conclude that the SDM can reliably diagnose FSD status and FSD subtypes in postmenopausal women.