The Use of the Sexual Function Questionnaire as a Screening Tool for Women with Sexual Dysfunction

AIM

To determine if the validated Sexual Function Questionnaire (SFQ), developed to assess efficacy in female sexual dysfunction (FSD) clinical trials, may also have utility in identifying target populations for such studies.

METHODS

Data from five clinical trials and two general population surveys were used to analyze the utility of the SFQ as a tool to discriminate between the presence of specific components of FSD (i.e., hypoactive sexual desire disorder, female sexual arousal disorder, female orgasmic disorder, and dyspareunia).

RESULTS

Sensitivity/specificity analysis and logistic regression analysis, using data from all five clinical studies and the general population surveys, confirmed that the SFQ domains have utility in detecting the presence of specific components of FSD and provide scores indicative of the presence of a specific sexual disorder.

CONCLUSIONS

The SFQ is a valuable new tool for detecting the presence of FSD and identifying the specific components of sexual functions affected (desire, arousal, orgasm, or dyspareunia).

Evaluation of the role of pudendal nerve integrity in female sexual function using noninvasive techniques

OBJECTIVE

Using quantitative sensory testing and a validated questionnaire, we investigated the role of pudendal nerve integrity in sexual function among women.

STUDY DESIGN

Participants completed the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire (PISQ). Vibratory and pressure thresholds were measured at the S2 dermatome reflecting pudendal nerve distribution.

RESULTS

A total of 56 women enrolled; 29 (51.8%) were asymptomatic and 27 (48.2%) had 1 or more forms of female sexual dysfunction (total sexual dysfunction) including: desire disorder 16.1%, arousal disorder 26.8%, orgasmic disorder 25%, and pain disorder 12.5%. Age, parity, menopausal status, and body mass index were similar between groups. PISQ scores were lower in symptomatic subjects compared with controls (P < .001). Decreased tactile sensation was found at the clitoris for women with total sexual dysfunction, desire disorder, and arousal disorder. Women with arousal disorder also had decreased tactile sensation at the perineum.

CONCLUSION

Pudendal nerve integrity may play a role in female sexual dysfunction.

Practice patterns of physician members of the American Urogynecologic Society regarding female sexual dysfunction: results of a national survey

The purpose of the study was to evaluate practice patterns of members of the American Urogynecologic Society (AUGS) with respect to female sexual dysfunction (FSD). A brief self-administered survey of 20 questions was mailed to 966 physician members of the AUGS in the United States of America and Canada; 471 surveys were returned (49% response rate). The majority of responders see urogynecology (19%) or urogynecology and general gynecology patients (43%). Sixty-eight percent of physicians were familiar with questionnaires to assess FSD; however, only 13% said they use these for screening purposes. Most said they believed screening for FSD was somewhat (47%) or very important (42%). Despite having these beliefs, only 22% of the responding physicians stated they always screen for FSD, while 55% do so most of the time and 23% admitted they never or rarely screen. Similar results were obtained regarding screening following urogynecologic surgery. Several barriers to screening for FSD existed, the most common being lack of time. The majority of respondents (69%) underestimated the prevalence of FSD in their patient population. Finally, although more than half of responders had received post-residency training in urogynecology (59%), 50% of them stated the training with respect to FSD was unsatisfactory, while only 10% were satisfied. Overall, many urogynecologists do not consistently screen for FSD, underestimate its prevalence, and feel they received unsatisfactory training.

Tactile sensitivity in women with sexual arousal disorder

Evidence suggests that tactile sensitivity may differ between women with sexual arousal difficulties and women with normal sexual functioning. Tactile sensitivity was examined on the distal portion of the dominant hand index finger and on the lower lip in women with female sexual arousal disorder (FSAD) (n = 17) and in normally functioning women (n = 17). The two groups did not differ significantly in age, length of current relationship or on measures of sexual experience and sexual desire. Hierarchical binary logistic regression indicated that finger threshold was significantly associated with FSAD women versus control women, and hierarchical linear regression indicated that finger threshold was associated with severity of arousal dysfunction. Logistic regression showed that 76.5% of participants were correctly classified and 23.5% were incorrectly classified using tactile sensation as a predictor variable. Possible underlying mechanisms and clinical implications are discussed.

Low sexual desire in midlife and older women: personality factors, psychosocial development, present sexuality

OBJECTIVE

Recent population-based surveys indicate that the prevalence of sexual dysfunction, particularly low sexual desire and arousal disorders, is increasing with age. However, there seems to be greater variability of the sexual experience and functioning in midlife and older women, suggesting a higher dependence on basic conditions like general well-being, physical and mental health, quality of relationship, and life situation.

DESIGN

A series of studies was conducted in the authors' Female Sexual Dysfunction research group to assess differences in (1) determinants of sexual satisfaction, (2) personality factors, and (3) present sexuality between younger and older women in both patient and nonpatient populations.

RESULTS

The results of these studies highlight that in comparison with functional women, patients with hypoactive sexual desire are generally characterized by a vulnerable self-system with several rather inadequate self-regulatory mechanisms. The results of the brief sexual function questionnaire indicate that the present sexuality of women seeking professional help for low sexual desire is significantly different from the sexuality of a control group of nonpatients. These between-group effects proved to be far more important than any age effects within both groups and showed that all domains of sexuality were negatively affected and overshadowed by the sexual dysfunction.

CONCLUSIONS

These results are supportive of the growing evidence against a simple model of midlife sexuality that depicts women as victims of their bodily and hormonal changes. Instead, life stressors, contextual factors, past sexuality, and mental health problems are more significant predictors of midlife women's sexual interest than menopause status itself. Evaluation and treatment approaches require consideration of the full range of contextual factors, including relationship quality, personality factors, past experience, and mental and physical health.

Female Sexual Dysfunction: Principles of Diagnosis and Therapy

Female sexual dysfunction is a common health problem, affecting approximately 43% of women. Female sexual dysfunction is defined as disorders of libido, arousal, orgasm, and sexual pain that lead to personal distress or interpersonal difficulties. It is frequently multifactorial in etiology, with physiological and psychologic roots. Approaching female sexual dysfunction involves an open discussion with the patient, followed by a thorough physical examination and laboratory testing. Therapy consists of patient and partner education, behavior modification, and may include individualized pharmacotherapy. Ultimately, as awareness and research in the field grows, it is hoped that a better understanding of the physiology and pharmacology of the female sexual response will be achieved.

Outcome measurement in female sexual dysfunction clinical trials: review and recommendations

Defining and measuring Female Sexual Dysfunction (FSD) is a complex and challenging task. Several factors have confounded the theory and measurement of FSD including: the use of an inappropriate male paradigm; difficulty in capturing the complexity of women's sexual response; an evolving but presently untested nosology; and the relative independence between subjective and objective aspects of women's sexual response. Each of these factors have contributed to the difficulty in developing meaningful and valid endpoints for clinical trials. The Food and Drug Administration's (FDA) 2000 draft guidance document for female sexual dysfunction clinical trials recommended the use of daily diary measures as primary and self-administered questionnaires (SAQs) as secondary endpoints. Event logs or diary measures may be adequate for assessing aspects of male sexual performance (e.g., erectile function), or in other therapeutic areas with discrete and readily observable endpoints (e.g., incontinence). However, psychometric theory suggests that for female sexual dysfunction clinical trials, SAQ instruments may provide more sensitive and reliable measures of outcome. We offer an alternative set of recommendations in the hope that the FDA will reconsider its position and to serve as potential guidelines for non-industry sponsored research on female sexuality as well. First, we propose that SAQs be elevated from their current status as secondary endpoints to be considered as potential primary endpoints in clinical trials of FSD. Second, we recommend that depending on the trial design and intervention under study, either an SAQ or diary measure (typically one or the other, and not both), might serve as a primary endpoint in a clinical trial. Third, SAQs and diaries should be employed, analyzed and interpreted in their particular areas of strength. Diaries are most useful for enumerating events and/or counting frequencies. SAQs are superior at gathering subjective data related to women's sexual function. Fourth, we believe there is a theoretical basis for considering SAQs to be superior measurement tools compared to diaries in assessing sexual dysfunction in women. At present, however there is insufficient objective data to fully support this opinion. Conversely, we do not anticipate either theoretical or objective evidence to support the alternative hypothesis (that diaries are superior to SAQs). If this proves to be correct in the future, diary measures may no longer be considered as primary endpoints for FSD clinical trials. Finally, we recommend that the FDA and/or other regulatory agencies reconsider the emphasis given to the number of successful or satisfactory sexual events over time as primary endpoints because they do not definitively demonstrate whether there has or has not been any improvement in the FSD endpoint under study (e.g., sexual desire). Successful and satisfactory encounters represent an amalgam of subjective assessments that are too far removed from the essential FSD component.

Male sexual dysfunction and quality of life in schizophrenia

OBJECTIVE

To describe the prevalence and clinical correlates of sexual dysfunction in a sample of adult male outpatients with schizophrenia treated with olanzapine, risperidone, quetiapine, or haloperidol, focusing on associations between sexual dysfunction and patient-perceived quality of life.

METHOD

Sexual dysfunction was assessed in 139 outpatients with DSM-IV schizophrenia who were receiving olanzapine, risperidone, quetiapine, or haloperidol, but no other medications associated with sexual side effects. Structured assessments were made of psychiatric symptoms, quality of life, and relationships.

RESULTS

Sexual dysfunction occurred in 45.3% of patients. Patients with and without sexual dysfunction did not significantly differ with respect to severity of psychiatric symptoms. However, as compared with patients without sexual dysfunction, patients with sexual dysfunction reported significantly lower ratings on global quality of life (t = 2.4, df = 136, p = .02) and the level of enjoyment in their life (t = 2.5, df = 136, p = .01). Patients with sexual dysfunction were significantly less likely than those without sexual dysfunction to report having a romantic partner (17.5% vs. 43.4%; chi(2) = 10.7, df = 1, p = .001), though they were not significantly less likely to report difficulty making friends (27.0% vs. 32.9%; chi(2) = 0.57, df = 1, p = .45). Among patients with romantic partners, those with sexual dysfunction reported significantly poorer quality of their relationships (t = 2.3, df = 42, p = .02) and were less likely to talk to their partner about their illness (t = 2.0, df = 42, p = .047).

CONCLUSIONS

Sexual dysfunction is common in men with schizophrenia who are treated with olanzapine, risperidone, quetiapine, or haloperidol and is associated with diminished quality of life, decreased occurrence of romantic relationships, and reduced intimacy when relationships are established. High prevalence and substantial interference with quality of life combine to make sexual dysfunction an important area for clinical assessment and appropriate intervention in the community management of schizophrenia.

Psycho-biological correlates of rapid ejaculation in patients attending an andrologic unit for sexual dysfunctions

INTRODUCTION AND OBJECTIVES

Rapid ejaculation (RE) is the most common sexual dysfunction in males. The aim of the present study is to determine the contribution of intrapsychic, organic and relational factors to the pathogenesis of RE and the relationship between RE and erectile dysfunction (ED) in a sample of patients attending for the first time to an Outpatient Clinic for sexual dysfunction.

METHODS

We studied a consecutive series of 755 patients using Structured Interview on Erectile Dysfunction (SIEDY), a brief, recently validated, multidimensional instrument specifically designed by our group for the study of pathogenetic factors of ED. RE was defined as ejaculation within 1 minute of vaginal intromission and its severity was categorized on a 4-point scale using a standard question. A complete physical examination and a series of biochemical, hormonal, psychometric, penile vascular and rigidometric evaluations were performed.

RESULTS

Twenty-eight percent (n = 214) of patients attending to our sexology clinic reported RE of any degree. Patients reporting RE were younger (48.5 +/- 12.6 vs. 52.9 +/- 12.9 years old for RE and not RE respectively; p < 0.0001) and showed a higher prevalence of anxiety symptoms when compared to the rest of the sample. Among organic factors subjects with RE showed a higher prevalence of hyperthyroidism and significantly lower fasting plasma glucose (94 [87-110] and 98 [89-113] mg/dl for RE and non-RE respectively; p < 0.01). No difference among groups was observed for other hormones or clinical, biochemical and instrumental parameters. Finally RE patients showed a higher prevalence of partial erection sufficient for penetration when compared to the rest of the sample. Similar differences were observed between patients with and without RE when those without ED were excluded from the analysis.

CONCLUSION

Our data suggest a minor involvement of organic factors to the pathogenesis of ED in patients with concomitant RE. On the other hand, in our sample, patients complaining about RE are younger, healthier than the rest of the sample and are characterized by high degree of anxiety symptoms and hyperthyroidism.

Female sexual dysfunction: the important points to remember

Media exposure regarding male sexual dysfunction and the growing number of viable treatment alternatives for erectile dysfunction has resulted in increasing numbers of men seeking clinical appointments and treatment for the condition, which has previously been considered taboo. Because these problems usually arise within the context of relationships, some investigators have alluded to increased rates of sexual dysfunction among the partners of these men. Also, since general practitioners, gynaecologists, geriatrists, and urologists are also seeing female patients for evaluation of various types of dysfunction, certain groups of these women with underlying chronic conditions have been noted to have high rates of concomitant sexual dysfunction. Physicians who have good rapport with these patients are in a privileged position to help with these intimate problems, which are often difficult for patients to discuss. Therefore, it is of extreme importance that these professionals become knowledgeable about and comfortable with the initial evaluation and possible treatment of female sexual dysfunction.

[Female sexual dysfunction]

Female sexual dysfunction (FSD) is a disorder with relatively high incidence in the community. Its incidence in age-dependent and it can significantly limit the quality of life of women concerned. Dysfunction, as a multicausal and multidimensional problem, it comprises biological, psychological and interpersonal factors. Disorders are listed according to a sexual desire, arousal, experiencing an orgasm and pain incidence. Authors summarized data on incidence, diagnosis and therapy of this disorder.

Incidence of sexual side effects in refractory depression during treatment with citalopram or paroxetine

OBJECTIVE

The incidence of sexual dysfunction due to antidepressant drugs reported in pre-marketing clinical efficacy trials is often several times lower than in subsequent clinical experiences and independent reports. Although it is commonly believed that the reason for this discrepancy is that the nonleading questions employed in conventional clinical trials underestimate sexual dysfunction while the direct questioning used in independent trials provides more accurate data, few studies have actually compared these 2 methods.

METHOD

In this study, 119 patients with a DSM-IV-defined major depressive episode (82 women and 37 men) who had been treated with but not responded to a selective serotonin reuptake inhibitor (SSRI; either citalopram or paroxetine) were assessed regarding sexual functioning by means of open-ended questions and direct questioning at baseline (after SSRI treatment only) and after 4 weeks of SSRI treatment plus buspirone or placebo.

RESULTS

More patients reported sexual dysfunction in response to direct questioning (41%) as compared with spontaneous report (6%) (p < .001). Sexual dysfunction correlated with the duration of the depressive episode, but not with age, dose of SSRI, plasma level of SSRI, duration of SSRI treatment, or any measurement of depression. No statistically significant differences regarding the incidence of sexual dysfunction were found between the citalopram and the paroxetine groups.

CONCLUSION

Open-ended questions are an insufficient tool to estimate sexual dysfunction, and premarketing clinical trials should therefore include basic explicit assessments. The failure to find a correlation between treatment duration and sexual dysfunction adds to the notion that sexual side effects due to SSRIs do not abate over time.

The female sexual function index (FSFI): cross-validation and development of clinical cutoff scores

The Female Sexual Function Index (FSFI) is a brief multidimensional scale for assessing sexual function in women. The scale has received initial psychometric evaluation, including studies of reliability, convergent validity, and discriminant validity (Meston, 2003; Rosen et al., 2000). The present study was designed to crossvalidate the FSFI in several samples of women with mixed sexual dysfunctions (N = 568) and to develop diagnostic cut-off scores for potential classification of women's sexual dysfunction. Some of these samples were drawn from our previous validation studies (N = 414), and some were added for purposes of the present study (N = 154). The combined data set consisted of multiple samples of women with sexual dysfunction diagnoses (N = 307), including female sexual arousal disorder (FSAD), hypoactive sexual desire disorder (HSDD), female sexual orgasm disorder (FSOD), dyspareunia/vaginismus (pain), and multiple sexual dysfunctions, in addition to a large sample of nondysfunctional controls (n = 261). We conducted analyses on the individual and combined samples, including replicating the original factor structure using principal components analysis with varimax rotation. We assessed Cronbach's alpha (internal reliability) and interdomain correlations and tested discriminant validity by means of a MANOVA (multivariate analysis of variance; dysfunction diagnosis x FSFI domain), with Bonferroni-corrected post hoc comparisons. We developed diagnostic cut off scores by means of standard receiver operating characteristics-curves and the CART (Classification and Regression Trees) procedure. Principal components analysis replicated the original five-factor structure, including desire/arousal, lubrication, orgasm, pain, and satisfaction. We found the internal reliability for the total FSFI and six domain scores to be good to excellent, with Cronbach alpha's >0.9 for the combined sample and above 0.8 for the sexually dysfunctional and nondysfunctional samples, independently. Discriminant validity testing confirmed the ability of both total and domain scores to differentiate between functional and nondysfunctional women. On the basis of sensitivity and specificity analyses and the CART procedure, we found an FSFI total score of 26.55 to be the optimal cut score for differentiating women with and without sexual dysfunction. On the basis of this cut-off we found 70.7% of women with sexual dysfunction and 88.1% of the sexually functional women in the cross-validation sample to be correctly classified. Addition of the lubrication score in the model resulted in slightly improved specificity (from .707 to .772) at a slight cost of sensitivity (from .881 to .854) for identifying women without sexual dysfunction. We discuss the results in terms of potential strengths and weaknesses of the FSFI, as well in terms of further clinical and research implications.

Scale for Quality of Sexual Function (QSF) as an Outcome Measure for Both Genders?

BACKGROUND

For years, there has been interest in sexual dysfunction and its impact on quality of life but usually focused on one gender. Therapeutic options that became available raised the interest to evaluate effects on the other partner but there is no standardized instrument applicable for both genders. This paper reports first data regarding the development of a new general "Quality of Sexual Function" (QSF) scale.

METHODS

The raw scale was based on our own gender-specific scales and the pertinent literature. The scale was applied in over 700 persons of a cross-sectional survey in Germany. Factorial analyses were performed to describe the internal structure (domains) of the scale and for item reduction. Internal consistency reliability and some aspects of validity were analyzed with the same community sample preliminary reference values determined.

RESULTS

The scale consists of 32 specific items and eight general questions. Four dimensions were identified: "psycho-somatic quality of life,""sexual activity,""sexual (dys)function-self-reflection," and "sexual (dys)function-partner's view." The internal consistency reliability coefficients of the total scale and the subscales were good as were the total-domain correlations. Content validity was promising.

CONCLUSION

This self-administrable 40-item QSF scale can measure and compare quality of sexual function for both genders. The scale was well accepted by the respondents. It is easy to answer and the evaluation is simple. Only a few results of reliability and validity have been established in this early stage of the development of the new instrument. Further research is needed to complete many missing aspects of reliability and the construct validity, particular its sensitivity to treatment effects.

[Sexuality in the aged]

The demographic development in the western industrial societies makes the quality of life of older people a very important issue. Leading a satisfying sexual life is part of this. The picture of older people as asexual humans can no longer be maintained. Recent studies show that the fundamental psychosociological need for acceptance, tenderness, warmness and security does not disappear with age. Sexual activity in the age primarily depends on the existence of a partnership. Sexual dysfunctions in aging result from physical, psychological, and partner-related changes, as well as lifestyles. This has to be considered in diagnosis and treatment. Principally, there is no difference between the treatment of older and younger sexual partners