KEY POINTS
■ The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision describes sexual dysfunctions as being characterized by disturbances in sexual desire and in the psychophysiologic changes related to the sexual response cycle that cause marked distress and interpersonal difficulty. Thus, the hallmark of female sexual dysfunction (FSD) is a disturbance of sexual functioning that causes personal distress.
■ FSD encompasses four main categories of disorders: decreased sexual desire disorders, female sexual arousal disorder, female orgasmic disorder, and pain disorders.
■ Most epidemiologic studies rarely utilized validated instruments and clinician interview/assessment; therefore, estimated prevalence of FSD varies. Prevalence also varies according to the population being assessed. Although FSDs often coexist, low desire is the most commonly reported dysfunction.
■ PAs should not assume that a patient is sexually active. Therefore, inquiring about general health, sleep patterns, nutrition, and/or psychologic health may help “break the ice” before discussing sexual health.
The increased emphasis on male sexual health over the past decade has resulted in patients' understanding that healthy sexual function
improves self-image and increases their motivation to adopt and maintain a healthier lifestyle. This focus on male sexual function/dysfunction has also increased the demand for clinician and patient education on female sexual dysfunction (FSD). However, a national dialogue with women on sexual health appears to be lacking,1 even though studies show that patients want to discuss this important part of their lives.2 FSD has not been incorporated into most of today's medical and nursing education curricula; therefore, clinicians will rarely initiate a discussion on these topics when seeing a patient in the office and/or clinic.
An analysis of the data from the National Health and Social Life Survey (NHSLS) found that 43% of women had reported one or more sexual problems.3 Women's sexual function is highly contextual; it involves physiologic, psychologic, and relationship factors. Although patients may discuss many different aspects of their sexual lives, the way in which an FSD is described varies. As the number of patient visits to PAs increases, a greater understanding of the types and prevalence of FSD is needed. More importantly, PAs need to equip themselves with the knowledge and skills necessary to initiate a discussion of sexual health as part of routine preventive health care.
CLASSIFICATION OF SEXUAL DISORDERS
The International Statistical Classification of Diseases and Related Health Problems defines sexual dysfunction as the ways in which a person is unable to participate in a sexual relationship as he or she would wish.4 The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) describes sexual dysfunctions as being characterized by disturbances in sexual desire and in the psychophysiologic changes related to the sexual response cycle that cause marked distress and interpersonal difficulty.5 Furthermore, although FSDs often coexist with other medical conditions, the disorder cannot be accounted for by another Axis I disorder (eg, major depressive disorder) nor is it a direct physiologic effect of substance use/abuse (eg, medications, alcohol, or illicit drugs) or a general medical condition (eg, diabetes or hypothyroidism). Thus, the hallmark of FSD is a disturbance of sexual functioning that causes personal distress.5
FSD encompasses four main categories of disorders, with subtypes that further define the nature of the sexual dysfunction.5 The subtypes are based on onset (lifelong versus acquired), context (generalized versus situational), etiologic factors (psychologic factors), and combined factors (psychologic factors plus substance use or a medical condition contribute to the sexual dysfunction but do not account for it). The categories of FSD are decreased sexual desire disorders, female sexual arousal disorder (FSAD), female orgasmic disorder (FOD), and pain disorders.5
Decreased sexual desire disorders This subtype includes hypoactive sexual desire disorder (HSDD) and sexual aversion disorder.5 Sexual fantasies and desire for sexual activity are persistently or recurrently deficient or absent in patients with HSDD. Factors that affect sexual functioning, such as age and the context of the person's life, are considered when determining deficiency or absence. Diagnosis is based on clinician assessment.5
Few studies have assessed the etiology, prevalence, or treatment of sexual aversion disorder. However, it is considered by many experts to be a phobia or anxiety disorder even though its sexual content also classifies it as a sexual disorder.6 Sexual aversion disorder is often associated with a history of sexual trauma, thus patients are usually referred to a sexologist or psychologist for assessement.6