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Validity of the Decreased Sexual Desire Screener for Diagnosing Hypoactive Sexual Desire Disorder
Journal of Sex & Marital Therapy
Abstract
The Decreased Sexual Desire Screener is a brief diagnostic instrument for generalized acquired Hypoactive Sexual Desire Disorder in women. During the screening visit of 2 clinical trials, the authors assessed sensitivity of the Decreased Sexual Desire Screener in premenopausal women presenting with decreased sexual desire. The authors compared diagnoses of generalized acquired Hypoactive Sexual Desire Disorder made by clinicians who were not trained or specialized in the diagnosis of female sexual dysfunction using the Decreased Sexual Desire Screener with diagnoses made by expert clinicians after an extensive diagnostic interview. The sensitivity of the Decreased Sexual Desire Screener was 0.946 in a North American trial and 0.960 in a European trial.
... 50 The validity of the DSDS was further confirmed in two large clinical trials of flibanserin. 51 In these trials, a comparison of diagnoses by nonexpert clinicians using the DSDS followed by an extensive interview by expert clinicians trained in diagnosis of female sexual disorders showed that the tool has a sensitivity of 0.95-0.96. 51 In the ORCHID trial, which took place across 11 European countries (Austria, Belgium, Czech Republic, France, Germany, Hungary, Italy, The Netherlands, Spain, Sweden, and the United Kingdom), women completed the DSDS in their local language. ...
... 51 In these trials, a comparison of diagnoses by nonexpert clinicians using the DSDS followed by an extensive interview by expert clinicians trained in diagnosis of female sexual disorders showed that the tool has a sensitivity of 0.95-0.96. 51 In the ORCHID trial, which took place across 11 European countries (Austria, Belgium, Czech Republic, France, Germany, Hungary, Italy, The Netherlands, Spain, Sweden, and the United Kingdom), women completed the DSDS in their local language. 52 Therefore, the DSDS is a sensitive, specific, easy-to-use, and brief diagnostic instrument for use by nonexpert clinicians in English and other languages to aid in the diagnosis of generalized acquired HSDD. ...
... 52 Therefore, the DSDS is a sensitive, specific, easy-to-use, and brief diagnostic instrument for use by nonexpert clinicians in English and other languages to aid in the diagnosis of generalized acquired HSDD. 50,51 Sexual Interest and Desire Inventory-Female ...
Screening, diagnosis, and management of hypoactive sexual desire disorder (HSDD) and research into the condition have been challenging due to its biopsychosocial complexity and lack of consensus on relevant measures. Although physician interviews yield much clinically valid information, self-reported questionnaires appear more acceptable to patients and physicians. Consequently, validated patient-reported outcome (PRO) tools are essential for evaluation and management of HSDD, including any therapeutic intervention. The US Food and Drug Administration (FDA) has issued guidance on the use of appropriate endpoints and associated measures for female sexual dysfunction, including HSDD. Although many of the available measures were not designed specifically for HSDD assessment, as per FDA guidelines, most clinical studies have used individual domains or items from established tools, such as the Female Sexual Function Index-desire domain and Item 13 of the revised Female Sexual Distress Scale. For clinical practice, several professional societies recommend the Decreased Sexual Desire Screener and/or a sexual history as tools to diagnose HSDD. This review discusses frequently used PRO tools as well as the newly developed and validated Elements of Desire Questionnaire, which may be appropriate for clinical trials or clinical practice.
... [5][6][7] Although there are many self-evaluation questionnaires, made with the purpose of determining the clinical evaluation of the feminine hypoactive sexual desire disorder, the Decreased Sexual Desire Screener (DSDS) is a validated instrument used by physicians, and which was used in this research. 8,9 The pharmacological treatments for HSDD include homeopathic and hormonal products, phosphodiesterase-5 (PDE-5) inhibitors, psychotropic drugs, etc. [10][11][12] This variety of therapeutic options is because of the poor understanding that we still have over the biology of desire. Bupropion is a reuptake inhibitor of norepinephrine and dopamine approved by the FDA for depression treatment. ...
... The DSDS is a validated instrument to be used by physicians to help in the diagnosis of HSDD. 8,9 Among other advantages, it's brief, it can be used both in premenopausal and postmenopausal women, it's useful for physicians who are not experts in sexual disorders. 8 It's used in a self-administered way and it consists of 5 questions (Table 1). ...
Aim: To compare the effectiveness of bupropion versus buspirone in the treatment of hypoactive sexual desire in women.
Material and methods: Randomized clinical trial with 87 women diagnosed with hypoactive sexual desire, divided in 2 groups. Group A (average age: 47,46±4,83 years) was treated with bupropion (150 mg daily) and Group B (average age: 45,78±5,43 years) with buspirone (20 mg daily), during 6 months. Hypoactive sexual desire was evaluated using the questionnaire “Decreased Sexual Desire Screener”.
Results: Women with hypoactive sexual desire at the beginning of the therapy didn’t have a statistically significant increase in their sexual desire at the end of the study. In the analysis, there weren’t detected statistically significant differences between the groups. Throughout the research, the continuation of the decrease in the sexual desire was statistically significant in both groups.
Conclusion: the treatment with bupropion and buspirone of the hypoactive sexual desire in women, it doesn’t represent an effective therapeutics.
Keywords: coitus, feminine, women, sexuality, pharmacological treatment, hypoactive sexual desire, analysis, psychological, mental and social wellbeing, illness
... One example of this is a condition of reduced interest in and desire for sexual activity, called variously hypoactive sexual desire disorder (HSDD) or female sexual interest and arousal disorder (FSIAD). 15 Regardless of the disorder's label, 15,16 if a woman suffers from prolonged loss of sexual desire that causes her distress and cannot be explained by problematic relationships, stressors, or medical conditions, then it is considered to be a disorder of reward processing for sex, and as such is hypothetically mediated by inefficient information processing in reward circuits. [1][2][3][4][5][6] Disorder of Sexual Interest and Desire, or of Arousal? ...
... 15 Confusion exists because some diagnostic systems now merge disorders of interest and desire in women with disorders of arousal, while other diagnostic systems keep them separate. 15,16 Fortunately, as often occurs when a new therapeutic emerges, things are becoming clearer. It now seems that the primary disorder of loss of sexual interest and desire (not a disorder of arousal or orgasm) can be recognized and treated successfully when it occurs in premenopausal women. ...
Flibanserin is a novel multifunctional serotonin agonist and antagonist (MSAA) that improves sexual functioning in premenopausal women who suffer from reduced sexual interest and desire.
... 43,[73][74][75] Thirteen (43%) studies were given a positive rating for construct validity which is defined by the extent scores of an instrument are associated with other measures consistent with hypotheses about the concepts being measured. 43,[63][64][65][66][67]71,72,78,79,84,85,89 A positive rating for this measurement property indicates "specific hypotheses were formulated and at least 75% of the results are in accordance with these hypotheses". [24][25][26][27] Adequate internal consistency reliability (coefficient alpha ≥ 0.7) was found in 18 (60%) studies. ...
Introduction
Hypoactive Sexual Desire Disorder (HSDD) significantly impacts a woman's daily functioning and well-being (health-related quality of life, HRQoL) and is often undetected by the medical profession and dismissed by society. As a result, the profound and extensive impact of HSDD on the lives of women and their partners is underappreciated.
Objective
This qualitative study was conducted to identify defining symptoms and HRQoL impacts among women with HSDD.
Methods
Six virtual focus groups (90-minutes each) were conducted with 30 adult women to understand HSDD symptoms and HRQoL impacts. Two trained focus group moderators utilized a semi-structured interview guide to capture spontaneous and stated symptoms and impacts. All focus groups were transcribed verbatim, anonymized, coded by two independent researchers using Atlas.ti 9, and then analyzed employing a combination of semi-quantitative and qualitative data analytic methods to evaluate saturation. Elicited content was used to further refine a literature-derived HRQoL conceptual model of HSDD.
Results
A total of 15 pre-menopausal and 15 post-menopausal women participated in the focus groups between October 14 and 21, 2020. Participants reported a total of 10 symptom concepts during the focus group, including loss of spontaneous desire, sexual distress, disinterest in initiating sex, disinterest in engaging in sex, absence of pleasure, little to no sexy feelings, feeling asexual, sexual avolition, vaginal pain, and insomnia. The most frequently reported symptoms were loss of spontaneous desire (n=30, 100%) and sexual distress (n=23, 77%). A total of 41 impact concepts associated with HSDD across 9 domains were reported: partner impact, mental well-being, role functioning, social functioning, familial relationships, appearance, concentration, and overall quality of life and satisfaction with life. Women reported impairment to their mental well-being (n=30, 100%), partner relationship (n=29, 97%), overall quality of life (n=29, 97%), and life satisfaction (n=29, 97%), as well as described feeling stigmatized by healthcare providers, friends, and society as a whole (n=27, 90%). A literature-based conceptual model for HSDD was updated to reflect focus group results.
Conclusions
Women with HSDD report many relevant, important, and meaningful concepts that are inadequately evaluated in research and drug trials. HSDD profoundly and negatively impacts women's HRQoL. Greater awareness of these concepts, and the availability of HRQoL measures that accurately reflect symptoms and impacts are needed to “destigmatize” and improve medical care for women with HSDD.
Disclosure
Any of the authors act as a consultant, employee or shareholder of an industry for: AMAG Pharmaceuticals, Inc., Astellas, Dare, Duchesnay, Ovoca, Field Trip, Palatin Technologies, Pfizer, Materna, Maddora, TherapeuticsMD, Strategic Science Technologies, and Lupin.
... 43,[73][74][75] Thirteen (43%) studies were given a positive rating for construct validity which is defined by the extent scores of an instrument are associated with other measures consistent with hypotheses about the concepts being measured. 43,[63][64][65][66][67]71,72,78,79,84,85,89 A positive rating for this measurement property indicates "specific hypotheses were formulated and at least 75% of the results are in accordance with these hypotheses". [24][25][26][27] Adequate internal consistency reliability (coefficient alpha ≥ 0.7) was found in 18 (60%) studies. ...
Introduction
Hypoactive Sexual Desire Disorder (HSDD) / Female Sexual Interest/Arousal Disorder (FSIAD) impacts health-related quality of life (HRQoL) of women and their partners, yet existing measures fail to adequately capture relevant concepts (ie, what is essential to measure including symptoms/impacts) important to women with HSDD/FSIAD.
Objectives
To identify HRQoL tools used to assess women with HSDD/FSIAD, and to evaluate their psychometric properties (ie, reliability, validity, and responsiveness).
Methods
We conducted searches in PubMed, Embase and PsychINFO from June 5, 1989 to September 30, 2020 for studies in women with HSDD/FSIAD and psychometric analyses (English only). Principles of the Preferred Reporting Items for Systematic reviews and Meta-Analyses, the COnsensus-based Standards for the selection of health Measurement INstruments Risk of Bias Checklist and other psychometric criteria were applied. Based on this search, 56 papers were evaluated including 15 randomized-controlled trials, 11 observational/single arm/open label studies, and 30 psychometric studies.
Results
Of the 18 measures identified, the Female Sexual Function Index (FSFI) and Female Sexual Distress Scale-Revised (FSDS-R) were included in most studies (> 50%). General HRQoL instruments were not used in any of the clinical trials; the SF-12, SF-36 and EQ-5D-5L were reported in two observational studies. No instruments achieved positive quality ratings across all psychometric criteria. The FSFI, FSDS-R, Sexual Event Diary (SED) and the Sexual Desire Relationship Distress Scale (SDRDS), were the only measures to receive a positive rating for content validity.
Conclusion
Reliable and valid HRQoL measures that include sexual desire and distress are needed to provide a more systematic and comprehensive assessment of HRQoL and treatment benefits in women with HSDD/FSIAD. While inferences about HRQoL are limited due to the lack of uniformity in concepts assessed and limited psychometric evaluation of these measures in women with HSDD/FSIAD, opportunities exist for the development of reliable and validated tools that comprehensively measure the most relevant and important concepts in women with HSDD/FSIAD. Lim-Watson MZ, Hays RD, Kingsberg S, et al. A systematic literature review of health-related quality of life measures for women with Hypoactive Sexual Desire Disorder and Female Sexual Interest/Arousal Disorder. Sex Med Rev 2021;XX:XXX–XXX.
... In addition, HCPs can use preformulated questionnaires, such as the decreased sexual desire screener, meant to facilitate the diagnosis of HSDD when clinician-patient time is limited. 58 Clinicians could consider questionnaires before seeing patients in the office to save time; however, follow-up on the questionnaire during in-office, clinician-patient interaction is critical, as not all patients are comfortable with providing written documentation on this sensitive subject. HCPs should also address the most important topics that can be covered in a limited amount of time. ...
Background: Although sexual health can be considered a vital sign for overall health, several barriers prevent women from receiving proper medical counseling, support, and/or care for their sexual health needs and concerns.
Methods: Experts in sexual health compiled research and experience on the impediments to women receiving adequate assessment and treatment for their sexual health. Specific solutions and a roadmap for overcoming such barriers and improving patient–clinician communication are presented.
Results: Social stigma around female sexuality remains in Western culture and as a result, women often avoid and/or are embarrassed to discuss their sexual health with their health care professionals (HCPs). Moreover, midlife women are typically unaware or have misconceptions about conditions that may adversely impact their sexual life, such as genitourinary syndrome of menopause and hypoactive sexual desire disorder. Without understanding there may be underlying medical conditions, there is also a lack of awareness that safe and effective treatments are available. Lack of training, tools, time, and limited treatment options impede HCPs from providing women with necessary sexual health support. Educating women, training HCPs, and providing communication tools to HCPs can facilitate effective dialog between patients and HCPs. More specifically, HCPs can be trained to initiate and maintain a sexual health conversation in a manner that is comfortable for women to convey sexual health needs and concerns, and for HCPs to correctly identify, diagnose, and treat the sexual problems of their female patients.
Conclusions: Solutions exist to address the barriers currently impeding patient–clinician interactions around sexual health.
... 32,33 The DSDS is brief, effective, user-friendly, and self-completed and requires no special training to administer/interpret ( Figure 2). 34,35 The DSDS serves to grant permission and encourage dialogue for screening for HSDD and identification of etiologic factors, obviating potential patient and physician embarrassment. ...
The International Society for the Study of Women's Sexual Health process of care (POC) for management of hypoactive sexual desire disorder (HSDD) algorithm was developed to provide evidence-based guidelines for diagnosis and treatment of HSDD in women by health care professionals. Affecting 10% of adult females, HSDD is associated with negative emotional and psychological states and medical conditions including depression. The algorithm was developed using a modified Delphi method to reach consensus among the 17 international panelists representing multiple disciplines. The POC starts with the health care professional asking about sexual concerns, focusing on issues related to low sexual desire/interest. Diagnosis includes distinguishing between generalized acquired HSDD and other forms of low sexual interest. Biopsychosocial assessment of potentially modifiable factors facilitates initiation of treatment with education, modification of potentially modifiable factors, and, if needed, additional therapeutic intervention: sex therapy, central nervous system agents, and hormonal therapy, guided in part by menopausal status. Sex therapy includes behavior therapy, cognitive behavior therapy, and mindfulness. The only central nervous system agent currently approved by the US Food and Drug Administration (FDA) for HSDD is flibanserin in premenopausal women; use of flibanserin in postmenopausal women with HSDD is supported by data but is not FDA approved. Hormonal therapy includes off-label use of testosterone in postmenopausal women with HSDD, which is supported by data but not FDA approved. The POC incorporates monitoring the progress of therapy. In conclusion, the International Society for the Study of Women's Sexual Health POC for the management of women with HSDD provides a rational, evidence-based guideline for health care professionals to manage patients with appropriate assessments and individualized treatments.
... In today era, where women are at par with men in every sphere of life, distress be it in relation to their professional life or personal life, it does prevail. Hypoactive sexual desire disorder (HSDD) which is characterized by persistent or recurrent deficiency or absence of sexual fantasies and desire for sexual activity is one such disorder which may arise due to personal distress 1 . This entity HSDD includes two further disorders, Female sexual arousal disorder (FSAD) and Female sexual interest arousal disorder (FSIAD) (FDA briefing document). ...
Hypoactive sexual desire disorder (HSDD) is a persistent or recurrent deficiency or absence of sexual desire. It can cause prominent distress and interpersonal difficulty of women. There have been drugs available to treat sexual disorders in men when there is no such drug for women. Nowadays, FDA approved Flibanserin to treat HSDD of premenopausal women. This drug Flibanserin has no novel mechanism of action but the possible mechanism of action is modulating serotonin and dopamine activity in brain parts as balance of these systems is significance for a normal sexual response. Keywords: Hypoactive Sexual Desire Disorder, Premenopausal women, FlibanserinÂ
... The Decreased Sexual Desire Screener (Table 1), a 5-question instrument completed by the patient, was developed and validated for use by clinicians to aid in making the diagnosis of HSDD in premenopausal and postmenopausal women per the DSM-IV-TR and ISSWSH criteria. 2,56,57 Women indicate yes/ no responses to the 5 questions (Table 1). The purpose of questions 1 through 4 is to determine whether there is HSDD. ...
The objective of the International Society for the Study of Women's Sexual Health expert consensus panel was to develop a concise, clinically relevant, evidence-based review of the epidemiology, physiology, pathogenesis, diagnosis, and treatment of hypoactive sexual desire disorder (HSDD), a sexual dysfunction affecting approximately 10% of adult women. Etiologic factors include conditions or drugs that decrease brain dopamine, melanocortin, oxytocin, and norepinephrine levels and augment brain serotonin, endocannabinoid, prolactin, and opioid levels. Symptoms include lack or loss of motivation to participate in sexual activity due to absent or decreased spontaneous desire, sexual desire in response to erotic cues or stimulation, or ability to maintain desire or interest through sexual activity for at least 6 months, with accompanying distress. Treatment follows a biopsychosocial model and is guided by history and assessment of symptoms. Sex therapy has been the standard treatment, although there is a paucity of studies assessing efficacy, except for mindfulness-based cognitive behavior therapy. Bupropion and buspirone may be considered off-label treatments for HSDD, despite limited safety and efficacy data. Menopausal women with HSDD may benefit from off-label testosterone treatment, as evidenced by multiple clinical trials reporting some efficacy and short-term safety. Currently, flibanserin is the only Food and Drug Administration–approved medication to treat premenopausal women with generalized acquired HSDD. Based on existing data, we hypothesize that all these therapies alter central inhibitory and excitatory pathways. In conclusion, HSDD significantly affects quality of life in women and can effectively be managed by health care providers with appropriate assessments and individualized treatments.
... Experiences of the participants in this study showed that women going through menopause have some degree of decreased libido consisted with reports from previous studies [8,[18][19][20][21]. ...
Objective: In the menopausal transition sexual problems are an important issue and one of the most frequently presented health concerns of women attending menopause clinics. This study aimed to explore the ways of managing sexual dysfunctions during the menopausal transition among Iranian women.
Methods: This exploratory qualitative study was conducted in Iran, from May 2013 to April 2015. Twenty-one women in three stages of menopausal transition, aged 42–55 years old, were purposively selected from urban health centers in Mashhad and Gonabad, Iran. Semi-structured in depth interviews were conducted for data collection until data saturation was achieved. All interviews were recorded electronically and transcribed verbatim. Conventional content analysis was used for data analysis using Granehiem and Lundman (2004) recommended method. MAXQDA 2007 software was used for organizing data and managing the process of analysis.
Results: Data analysis demonstrated one overarching theme entitled “Adopting self-sacrifice” consisting of three categories and seven sub-categories. Major categories included: (1) Confronting decline of libido with two subcategories of women’s libido decline and inability to fulfill husbands’ sexual needs, (2) Seeking strategies for coping with two subcategories of looking for experiences of peer menopausal women and choosing how to interact with the husband and (3) Achieving problem solving strategies with three sub categories of obedience in sexual relationships (Tamkin), employing affection based on religious advice, and giving up own right to reach mutual understanding.
Conclusions: The major finding of this study was “Adopting self-sacrifice” in the process of managing sexual dysfunctions during the menopausal transition. The reason for choosing this passive approach by the majority of women has deep roots in their cultural and traditional beliefs.
... One validation study showed strong psychometric properties of this tool in pre-, peri-, and postmenopausal women, and another study found similar strong psychometric properties for premenopausal women presenting with decreased sexual desire. 5,7 The Decreased Sexual Desire Screener should not be used to diagnose or exclude other female sexual disorders, although these frequently coexist with HSDD. This tool has had limited use in clinical or research studies, although it was used extensively in phase III clinical trials of flibanserin. ...
Introduction:
A detailed sexual history is the cornerstone for all sexual problem assessments and sexual dysfunction diagnoses. Diagnostic evaluation is based on an in-depth sexual history, including sexual and gender identity and orientation, sexual activity and function, current level of sexual function, overall health and comorbidities, partner relationship and interpersonal factors, and the role of cultural and personal expectations and attitudes.
Aim:
To propose key steps in the diagnostic evaluation of sexual dysfunctions, with special focus on the use of symptom scales and questionnaires.
Methods:
Critical assessment of the current literature by the International Consultation on Sexual Medicine committee.
Main outcome measures:
A revised algorithm for the management of sexual dysfunctions, level of evidence, and recommendation for scales and questionnaires.
Results:
The International Consultation on Sexual Medicine proposes an updated algorithm for diagnostic evaluation of sexual dysfunction in men and women, with specific recommendations for sexual history taking and diagnostic evaluation. Standardized scales, checklists, and validated questionnaires are additional adjuncts that should be used routinely in sexual problem evaluation. Scales developed for specific patient groups are included. Results of this evaluation are presented with recommendations for clinical and research uses.
Conclusion:
Defined principles, an algorithm and a range of scales may provide coherent and evidence based management for sexual dysfunctions.
... Until recently, primary disorders of interest in and desire for sex have not been well recognized. Confusion exists because some diagnostic systems now merge disorders of interest and desire in women with disorders of arousal, while other diagnostic systems keep them separate [22]. For-tunately, as often occurs when a new therapeutic emerges, things are becoming clearer. ...
Introduction
Flibanserin, is a postsynaptic agonist of serotonin receptor 1A and an antagonist of serotonin receptor 2A, has been shown to increase sexual desire and reduce distress in women with hypoactive sexual desire disorder (HSDD).
Aim
We carried out a systematic review and meta-analysis to assess the efficacy and safety of the drug in women with HSDD.
Methods
A literature review was performed to identify all published randomized double-blind, placebo-controlled trials of flibanserin for the treatment of HSDD. The search included the following databases: MEDLINE, EMBASE, and the Cochrane Controlled Trials Register. The reference lists of the retrieved studies were also investigated.
Main Outcome Measures
Four publications involving a total of 3,414 patients were used in the analysis, including four randomized controlled trials that compared flibanserin with placebo.
Results
For the comparison of flibanserin with placebo, primary efficacy endpoints: satisfying sexual events (the standardized mean difference [SMD] = 0.59, 95% confidence interval [CI] = 0.37–0.80, P < 0.00001); sexual desire score (the SMD = 1.91, 95% CI = 0.21 to 3.60, P = 0.03) and Female Sexual Function Index (FSFI) desire domain score (the SMD = 0.32, 95% CI = 0.19–0.46, P < 0.00001) and key secondary efficacy endpoints: FSFI total score, Female Sexual Distress Scale-Revised (FSDS-R) total score, FSDS-R Item 13 score, Patient's Global Impression of Improvement score and Patient Benefit Evaluation indicated that flibanserin was more effective than the placebo. Safety assessments included the proportion of women who experienced an adverse event (odds ratio = 1.54, 95% CI = 1.34 to 1.76, P < 0.00001), nervous system disorders and fatigue indicated that flibanserin was well tolerated.
Conclusions
This meta-analysis indicates that flibanserin to be an effective and safe treatment for HSDD in women.
... In the larger ROSE trial, of over seven hundred patients [7], the same screener was used and found the overwhelming majority of applicants said "Yes" to all four questions. An even higher percentage, over 90%, said "Yes" to all four questions in a large European Union Phase III trial [8]. When the first three items are endorsed, the fourth item follows. ...
No abstract is available for this article.
... Low sexual desire, as elucidated in this review and emphatically pointed out by researchers such as Miner and colleagues [17], is often untreated due to the embarrassment of clinicians and their patients to introduce the topic within clinical settings. The aforementioned authors encouraged health providers to utilize short, validated questionnaires to assess inhibited sexual desire, including the Decreased Sexual Desire Screener, which can be completed in the waiting room and has a very high reported sensitivity (of 0.946 with a North American sample and of 0.960 with a European sample) [48]. Using such a tool might provide an opener for the discussion of sexual concerns between patients and health care professionals. ...
Sexual desire is a major component of sexuality at any age, and inhibited desire is one of the main sexual dysfunctions reported by older women. Nonetheless, in medical settings, for a variety of reasons discussed herein, its assessment-as well as the assessment of older women's sexual health in general-is typically avoided or conducted by asking a single sex question. In this paper, we have reviewed the literature (most of which is preliminary in nature) regarding the main psychosocial and health factors that could impact older women's sexual desire, as well as potential obstacles to the assessment and treatment of this geriatric sexual issue. It is certainly advisable that medical care providers who are uncomfortable discussing older women's sexual concerns be prepared to make appropriate referrals to clinicians who possess the proper training to accurately assess and treat sexual challenges (and female sexual interest problems in particular) in this neglected patient population.
The purpose of sexual and reproductive healthcare should be the enhancement of personal relationships and a healthy sex life and not merely counselling and care related to procreation or sexually transmitted infections. Providing practical and evidence-based guidance, this textbook follows the curriculum of the joint EBCOG and ESCRH examination in Contraception and Sexual and Reproductive Health . Coverage is comprehensive, allowing readers to gain an in-depth understanding of each topic. Written by trusted experts in the field, topics covered include contraception, infertility and sexual dysfunction, sexual violence and STIs. The text provides advice and practical tips for how to practice patient-centred counselling and shared decision-making. Improving the relationship between the patient and healthcare-provider leads to increased trust, adherence of advice and more satisfactory treatment for the patient.
Background:
Distressing low libido is common among women and has significant negative impacts; mindfulness has shown promise to increase sexual desire in women with low libido, but existing interventions are not tailored to midlife and older women.
Aim:
We adapted a mindfulness intervention to meet the needs of this population and conducted a pilot randomized controlled trial to assess feasibility and acceptability.
Methods:
Women aged ≥45 years with low libido were randomized to the mindfulness intervention or an education group that met over videoconferencing. The intervention included mindfulness instruction and practice, group discussion, and education on sexuality and aging. The education group included general information on menopause and health.
Outcomes:
We defined feasibility by the number of screened women who enrolled and completed their group. We defined acceptability as satisfaction with the group and likelihood of recommending it to another woman with low libido. We assessed sexual function (Female Sexual Function Index) and sexual distress (Female Sexual Distress Scale-Revised) at 6 weeks postconclusion.
Results:
Of 81 women screened, 31 were randomized to mindfulness and 30 to education. Eighteen women in the intervention group and 23 in the control group attended at least 1 session. Time conflict was the main reason for nonattendance. Of the 41 women who started attending groups, 37 (90%) attended at least 5 sessions. In the mindfulness group, 73% of women were very or extremely satisfied. Women in the mindfulness group were more likely to recommend it to another person with low libido as compared with those in the education group (P = .031); 67% said that they would probably or definitely recommend it. There were no significant changes in sexual function in either group (mean Female Sexual Function Index score, 22.6 to 18.6 [P = .101] with mindfulness and 21.2 to 19.7 [P = .537] with education). Women in the mindfulness group had significant improvements in sexual distress (mean Female Sexual Distress Scale-Revised score, 27.1 to 19.7; P = .021) while women in the education group did not (19.0 to 15.8; P = .062).
Clinical implications:
Mindfulness may reduce sexual distress in older women with low libido.
Strengths and limitations:
This is the first trial testing mindfulness for midlife and older women with low libido.
Conclusion:
A virtual mindfulness intervention for midlife and older women with low libido is feasible and acceptable and appears to improve sexual distress as compared with an education control; these findings provide data that can be used to design a larger clinical trial.
Background:
Female sexual dysfunction (FSD) is a significant cause of distress for an estimated 12-24% of women, and over the past 5 decades several questionnaires have been developed for clinical practice.
Aim:
The purpose of this scoping review is to evaluate the ethnic representation of sample populations used in the studies to validate FSD questionnaires.
Methods:
A scoping review was performed using electronic databases, including PubMed and Scopus, to identify FSD questionnaires validated between 1976 and 2021. Weighted averages from the combined ethnicity data were compared to population data from 2019 US census data and 2018 healthcare workforce reports to evaluate epidemiologic diversity. Ethnicity data from each questionnaire were also investigated longitudinally to evaluate trends in representation over the past 50 years.
Outcomes:
Our outcome of interest was comparison of the weighted averages for ethnicity categories from validation populations to the US female general population, US female health care workforce, and US census data.
Results:
48 validation studies were reviewed and showed that the average ethnic representation of the study populations relative to the US general population and US female health care workforce, respectively, was: Caucasian (83.7% vs 62.7% and 68.5%), Black (7.8% vs 13.3% and 8.3%), Hispanic (3.6% vs 16.0% and 9.6%), Native American (0.1% vs 0.8% and 0.3%), Asian (0.6% vs 6.4% and 6.2%), and Other (3.1% vs 0.7% and 1.4%).
Clinical implications:
FSD questionnaires are relied upon in research and clinical settings, so lack of diversity in validation populations could lead to under recognition and undertreatment in ethnic minority women.
Strengths & limitations:
Our results are dependent on the quality of data available from previously published validation studies. We attempted to account for biases in lack of data and size of validation populations by using weighted averages for making comparisons. We chose the US general population and female healthcare workforce for comparison and analyzed validation populations across multiple decades and geographic locations. Many of the validation studies were performed at least 10 years ago and may not reflect the current state of FSD and potential of questionnaire responses of ethnic minority women. This manuscript raises critical awareness regarding the lack of validated instruments for FSD in ethnically diverse women.
Conclusion:
Study populations used to validate FSD questionnaires demonstrate a trend of ethnic minority underrepresentation relative to the US female general and healthcare workforce populations. Battle CR, Rubin RS, Kingsberg SA, et al. Ethnic Minority Representation in Female Sexual Dysfunction Questionnaire Validation: A Scoping Review. J Sex Med 2022;XX:XXX-XXX.
The multidimensionality and interpersonal dimension of human sexuality make the study of female sexual dysfunction (FSD) a challenge. The aspiration to pursue a patient-centered, holistic approach collides with the need to establish commonly accepted diagnostic criteria for different disturbances in sexual functioning, involving one or multiple phases of the sexual response cycle and pain associated with sexual activity. According to recently proposed classifications, which are continuously evolving, the most relevant FSDs include hypoactive sexual desire disorder, female arousal disorder, persistent genital arousal disorder, and female orgasm disorder. The present chapter aims to provide a clinical perspective on these disorders by reviewing the most recent evidence on the pathophysiology, definitions, prevalence, leading etiologies, diagnostic tools, and key therapeutic approaches. Sexual pain-related conditions will be reviewed in another chapter.
It is evident that a gender bias still exists, with prominent biological etiologies of FSDs being neglected and understudied at the expense of psychodynamic and relational determinants. Moreover, classifications should serve to advocate the advancement of our knowledge of female sexual functioning. This process goes through the practical translation of the updated nosology in a language that is intelligible to primary healthcare providers all over the world, and ultimately, to women.
A multitude of biopsychosocial factors influences sexual health at midlife, a common concern in daily practice along with vaginal and pelvic health. HCPs need to be proactive in dealing with possible symptoms because in most cases early management prevent distress and improve quality of life. Female sexual dysfunctions (FSDs) may have a complex etiology but sexual history is not difficult implementing basic knowledge of risk factors and some skills helping women to cope with hormonal and age-related changes.
The present work summarizes key-points to approach sexual symptoms in midlife women, providing principles to diagnose and manage hypoactive sexual desire disorder (HSDD) and genitourinary syndrome of menopause (GSM)/vulvo-vaginal atrophy (VVA), as well as manage contraceptive needs.
We conducted 15 interviews and 3 focus groups (total N = 36) among women 60 and older with low libido to better understand the role that it plays in their lives. Interviews and focus groups were led by facilitators using open-ended questions. A codebook was developed, then codes were assigned to all data. We identified three themes. First, women reported that sex was an important aspect of their lives. Second, women desired to know what was “normal” with regards to sexuality and aging. Third, women were distressed by low libido, concerned that it could have negative effects on romantic relationships and self-image.
Introduction
In 2000, the FDA began issuing advice about treatments for hypoactive sexual desire disorder (HSDD) in women. How its recommendations have evolved has not been reviewed. Its consistent preference for self-rating by patients over evaluation by an examining clinician has not been addressed.
Objectives
Recount the changes in FDA’s proposals about patient-reported outcomes and diagnostics. Compare the value of patient-reported measures and clinical interviews.
Methods
Historical review is based on draft guidances, publications, meetings, and prescribing information.
Results
The FDA has avoided clinician input into diagnosis and evaluation of the severity of HSDD in women. It abandoned its initial (2000) insistence on counts of satisfying sexual events to define efficacy in favor of symptom-related scales to evaluate desire and distress with daily self-ratings. By 2015, the FDA accepted the self-rated Female Sexual Function Index-Desire Domain (FSFI-D) to measure desire and the most relevant item of the Female Sexual Distress Scale-Revised (FSDS-R) to measure distress; retrospection for both is one month. The FDA rejected the one clinician-rated broad measure of HSDD, the Sexual Interest and Desire Inventory (SIDI-F), although well-validated and treatment-sensitive. Since 2005, the FDA has accepted the Decreased Sexual Desire Screener (DSDS) to diagnose HSDD by non-expert clinicians using self-ratings and exploring them in more depth in a clinical interview.
Conclusion
FDA’s decisions on how to measure HSDD in women may have stabilized on accepting 2 co-primary measures: the FSFI-D and the FSDS-R item on bother about low desire, and on accepting the DSDS for diagnosis. FDA’s rejection of clinician ratings of severity through interviews in clinical trials seems unsound because interviews can give broader assessments than (brief) self-ratings, although the agency’s logic was to avoid diagnostic controversies and help avoid overcommercialization. Semistructured clinical interviews for diagnosis (DSDS) and severity-rating (SIDI-F) are well validated and are recommended for clinical practice.
Pyke RE. FDA Decisions on Measures of Hypoactive Sexual Desire Disorder in Women: A History, With Grounds to Consider Clinical Judgment. Sex Med Rev 2021;XX:XXX–XXX.
Introduction:
Sexual problems have significant effects on individual sexual function. The aim of this study was to determine the effect of counseling on sexual function of lactating women with decreased sexual desire.
Methods:
This is a quasi-case research. The sample consisted of 104 lactating mothers with sexual desire disorder from 2 to 6 months after childbirth. Samples were randomly selected and divided into two control and case groups. Data were collected using questionnaires, including the decreased sexual desire scale, sociodemographic characteristics, and midwifery questionnaire, and female sexual function index (FSFI). Sexual function was measured before and 4 weeks after consultation based on the rapport building, exploration, decision making, and implementing the decision (REDI) model. The results were analyzed by using SPSS-24 software and a significant level of <5%.
Results:
The mean age of participants was 30.71 ± 6.23 years and 29.65 ± 5.66 years in the case and control group, respectively (p = 0.380), ∼50% had a diploma degree or more, 100% were living in urban areas, and 95.90% of women were housewives. Both case and control groups were homogeneous in terms of demographic and midwifery variables (p > 0.05). There was a highly significant difference between study and control groups regarding mean FSFI domains except for orgasm, as well as in the total FSFI score 4 weeks after the intervention (p < 0.001). The results of the linear mixed effects model for assessing the trend of mean total FSFI score present that the mean of total FSFI score in the case group was increased 2.26 in comparison with the control group. Estimated slopes for female indicate that the mean of total FSFI score was increased 3.44 for 1 month.
Conclusions:
The results of this study show that supporting lactating women with decreased sexual desire through sexual counseling based on the REDI model can make a significant difference in their sexual function.
Background:
The perimenopause is associated with considerable biopsychosocial changes. The majority of women manage to adjust to these changes and cope well with the shift from reproductive to non-reproductive life. However, some women develop burdensome physical and psychological symptoms during the perimenopause. A strong link between menopausal complaints and depressed mood has been shown in this regard. To date, the decisive factors determining whether a woman will successfully achieve a healthy transition remain unclear. Thus, the purpose of this study is to investigate a range of theory-based markers related to health in perimenopausal women.
Methods:
The Swiss Perimenopause Study comprises a sample of 135 healthy perimenopausal women aged 40-56. A variety of health-related genetic, epigenetic, endocrinological, physiological, and psychosocial markers associated with the menopausal transition are investigated over a period of 13 months.
Discussion:
The Swiss Perimenopause Study will contribute to a better understanding of the biopsychosocial processes associated with the perimenopause, which should help to improve the clinical care of women undergoing the menopausal transition.
Objective:
Low libido is common among women over 60 and negatively impacts well-being and relationship satisfaction. Causes of low libido in this age group are not well understood. We used qualitative methods to explore older women's perceptions of causes of low libido.
Methods:
We conducted 15 individual interviews and 3 focus groups (total N = 36) among sexually active women 60 and older who screened positive for low libido using a validated instrument. Interviews were audio-recorded, transcribed, and coded using a codebook developed by two investigators. Codes were examined, and themes related to causes of low libido emerged.
Results:
Women noted a number of different factors that contributed to low libido. The common factors that women discussed included postmenopausal vaginal symptoms, erectile dysfunction in male partners, fatigue and bodily pain, life stressors, and body image concerns. Women often found ways to adapt to these factors. These adaptations required open communication between partners regarding sex, and some women noted these conversations were difficult or not successful.
Conclusions:
A wide variety of factors contribute to low libido in women over 60, but many of these factors are addressable. Low libido in older women should not be automatically attributed to "normal" aging or to menopause; providers should take an approach to assessment and treatment that addresses biological, interpersonal and social, and psychological factors. : Video Summary: http://links.lww.com/MENO/A499.
Introduction
Hypoactive Sexual Desire Disorder (HSDD) is defined in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Revised (DSM-IV-TR) as persistent deficient sexual fantasies and desire for sexual activity that causes marked distress or interpersonal difficulty. In the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), HSDD has been subsumed by Female Sexual Interest/Arousal Disorder. However, decades of research based on DSM-IV-TR HSDD criteria form the foundation of our understanding of the essential symptom of distressing low sexual desire, its epidemiology, clinical management, and treatment.
Aim
This publication reviews the state of knowledge about HSDD.
Methods
A literature search was performed using terms HSDD and female sexual dysfunction (FSD).
Main Outcome Measures
Physicians acknowledge that FSD is common and distressing; however, they infrequently address it, citing low confidence, time constraints, and lack of treatment as barriers.
Results
HSDD is present in 8.9% of women ages 18 to 44, 12.3% ages 45 to 64, and 7.4% over 65. Although low sexual desire increases with age, distress decreases; so prevalence of HSDD remains relatively constant across age. HSDD is associated with lower health-related quality of life; lower general happiness and satisfaction with partners; and more frequent negative emotional states. HSDD is underdetected and undertreated. Less than half of patients with sexual problems seek help from or initiate discussions with physicians. Patients are inhibited by fear of embarrassing physicians and believe that physicians should initiate discussions. The Decreased Sexual Desire Screener, a tool for detecting and diagnosing HSDD, is validated for use in general practice.
Conclusion
Women can benefit from intervention in primary care, behavioral health and sexual medicine settings. Psychotherapeutic and pharmacological interventions aim to enhance sexual excitatory process and decrease inhibitory processes. Flibanserin, the first centrally acting daily medication for HSDD, was recently approved in the US for premenopausal women.
Female sexual dysfunctions include a group of sexual complaints and disorders affecting women of all ages, and stemming from a heterogeneous array of etiologies and contributing factors. The classification system for sexual dysfunctions in the woman has evolved from a linear categorization of sexual desire, arousal, orgasm, and pain disorders to one that is more complex and overlapping. Personal distress is a key factor in defining a sexual problem as a dysfunction. The recently released Diagnostic and Statistical Manual of Mental Disorders, edition 5, collapses former definitions of female sexual disorders and moves away from the older linear model of diagnostic categories. Physicians should be open to discussing sexual problems with women, and may make use of validated questionnaires in the office setting. Evaluation tools available for assessing sexual function in the woman are in use in the research setting, as are physiological measures of assessment.
Introduction
Combining female sexual desire and arousal disorders is proposed for the Diagnostic and Statistical Manual of Mental Disorders (DSM‐5). Brotto et al. challenged our findings that the proposed criteria could potentially exclude from diagnosis or treatment a large number of women with distressing loss of function or in sexual desire, because (i) our samples were insufficiently severe; (ii) we sought to retain the current diagnostic criteria, whereas they contend that “the bar should be raised”; and (iii) the current sexual function diagnostic criteria are unreliable.
Aim
Here we provide additional data to support our view suggesting that the proposed criteria would potentially exclude large numbers of women from diagnosis or treatment if they have moderate‐to‐marked (rather than severe) hypoactive sexual desire disorder (HSDD), or HSDD with incomplete loss of receptivity.
Methods
In nontreatment validation studies of 481 women in North America and Europe, 231 women diagnosed with HSDD only were compared to women with no female sexual desire.
Main Outcome Measures
Clinicians experienced in sexual medicine determined the severity of HSDD using the standard Clinical Global Impression of Severity. Rating scale data were also used, including the clinician‐rated Sexual Desire and Interest Inventory‐Female and the self‐rated Female Sexual Function Index, Changes in Sexual Functioning Questionnaire, Female Sexual Distress Scale, and an e‐Diary about desire during sexual events.
Results
The severity of the HSDD was rated by clinicians as generally moderate‐to‐marked, not mild. The women with HSDD scored as manifestly sexually dysfunctional and significantly sexually distressed, and reported markedly fewer satisfying sexual events compared to age‐matched, non‐dysfunctional controls, even for those with moderate or milder degrees of severity, providing compelling evidence that our sample of women with HSDD had clinically disordered sexual function. Yet the proposed criteria would apparently allow diagnosis (and therefore treatment) of only severe desire dysfunction.
Conclusion
It would be counterproductive to combine the two disorders, to make individual criteria for the disorders more stringent or to require more such criteria for a diagnosis because such disorders tend to be distinct in presentation, in treatability with currently available therapies, and in logical approaches to be tested to improve therapy. Clayton AH, DeRogatis LR, Rosen RC, and Pyke R. Intended or unintended consequences? The likely implications of raising the bar for sexual dysfunction diagnosis in the proposed DSM‐V revisions: 1. For women with incomplete loss of desire or sexual receptivity. J Sex Med 2012;9:2027–2039.
Female sexual dysfunction is highly prevalent but not well defined or understood. We evaluated and revised existing definitions and classifications of female sexual dysfunction.
An interdisciplinary consensus conference panel consisting of 19 experts in female sexual dysfunction selected from 5 countries was convened by the Sexual Function Health Council of the American Foundation for Urologic Disease. A modified Delphi method was used to develop consensus definitions and classifications, and build on the existing framework of the International Classification of Diseases-10 and DSM-IV: Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association, which were limited to consideration of psychiatric disorders.
Classifications were expanded to include psychogenic and organic causes of desire, arousal, orgasm and sexual pain disorders. An essential element of the new diagnostic system is the "personal distress" criterion. In particular, new definitions of sexual arousal and hypoactive sexual desire disorders were developed, and a new category of noncoital sexual pain disorder was added. In addition, a new subtyping system for clinical diagnosis was devised. Guidelines for clinical end points and outcomes were proposed, and important research goals and priorities were identified.
We recommend use of the new female sexual dysfunction diagnostic and classification system based on physiological as well as psychological pathophysiologies, and a personal distress criterion for most diagnostic categories.
In light of various shortcomings of the traditional nosology of women's sexual disorders for both clinical practice and research, an international multi-disciplinary group has reviewed the evidence for traditional assumptions about women's sexual response. It is apparent that fullfilment of sexual desire is an uncommon reason/incentive for sexual activity for many women and, in fact, sexual desire is frequently experienced only after sexual stimuli have elicited subjective sexual arousal. The latter is often poorly correlated with genital vasocongestion. Complaints of lack of subjective arousal despite apparently normal genital vasocongestion are common. Based on the review of existing evidence-based research, many modifications to the definitions of women's sexual dysfunctions are recommended. There is a new definition of sexual interest/desire disorder, sexual arousal disorders are separated into genital and subjective subtypes and the recently recognized condition of persistent sexual arousal is included. The definition of dyspareunia reflects the possibility of the pain precluding intercourse. The anticipation and fear of pain characteristic of vaginismus is noted while the assumed muscular spasm is omitted given the lack of evidence. Finally, a recommendation is made that all diagnoses be accompanied by descriptors relating to associated contextual factors and to the degree of distress.
Introduction:
Current methods for diagnosing hypoactive sexual desire disorder (HSDD) can be complicated and time-consuming. A previous study reported validity and reliability of a structured diagnostic method created for clinical trials that can be performed in approximately 1 hour.
Methods:
A more succinct tool is needed for incorporation into busy physician practices. Therefore, a brief HSDD screening tool was developed consisting of four self-report questions with an interpretable cut-score and concise confirmatory physician interview.
Main outcome measures:
Accuracy of the HSDD screener cut-score alone, and in combination with physician interview, was then separately evaluated when compared with in-depth interview diagnosis. RESULTS. The results showed good agreement between the two diagnoses (kappa of 0.669 and 0.562 for cut-score alone and cut-score in combination with physician interview, respectively).
Conclusions:
The HSDD screener can reliably detect the likely presence of HSDD in postmenopausal women.
Flibanserin is a 5-HT(1A) agonist/5-HT(2A) antagonist that has been shown to increase sexual desire and reduce distress in premenopausal women with Hypoactive Sexual Desire Disorder (HSDD).
To assess the efficacy and safety of flibanserin over 24 weeks of double-blind treatment vs. placebo in premenopausal women with HSDD who showed a predefined response after 24 weeks of open-label treatment with flibanserin.
Women (N = 738) were treated with open-label, flexible-dose flibanserin (50 mg or 100 mg/day) for 24 weeks. At week 24, women who showed a predefined response, measured using an eDiary, were randomized to 24 weeks of continued flibanserin therapy at optimized dosage (N = 163) or placebo (N = 170). The criteria for entering the double-blind phase were an increase from baseline to weeks 21-24 of ≥2 satisfying sexual events (SSE) and/or ≥4 "desire days." A "desire day" was one in which a woman reported more than "no" desire.
Coprimary endpoints were change from randomization to study end in SSE and desire score. Secondary measures included change in Female Sexual Function Index (FSFI) total and desire domain scores and Female Sexual Distress Scale-Revised (FSDS-R) total and Item 13 scores.
During the open-label period, mean SSE and desire score approximately doubled, and FSFI, FSDS-R total, and Item 13 scores improved. At the end of the double-blind period, flibanserin was superior to placebo in change from randomization in SSE, desire score, FSFI desire domain and total scores, and FSDS-R total and Item 13 scores (P < 0.05, for all). Flibanserin was well tolerated, and withdrawal reactions were not observed.
At the end of the 24-week randomized withdrawal phase of a 48-week trial in premenopausal women with HSDD, flibanserin was superior to placebo on measures of SSE, sexual desire, overall sexual function, and sexual distress. Flibanserin was well tolerated, and no withdrawal reactions were observed following discontinuation.
The Sexual Interest and Desire Inventory-Female (SIDI-F) is a 13-item scale developed as a clinician-administered assessment tool to measure hypoactive sexual desire disorder (HSDD) severity in women.
To estimate the reliability and validity of the SIDI-F as a measure of HSDD severity.
Women, aged 18-65 years, with primary HSDD, Female Sexual Arousal Disorder (FSAD), or no Female Sexual Dysfunction (no FSD) participated in two nontreatment studies (in North America and Europe). On days 0 and 28, subjects were assessed using the SIDI-F, Female Sexual Function Index (FSFI), Changes in Sexual Functioning Questionnaire-Female (CSFQ-F), Locke-Wallace Marital Adjustment Test (MAT) and the Female Sexual Distress Scale (FSDS).
Discriminant validity, convergent validity, divergent validity, test-retest validity, and internal consistency of the SIDI-F.
The North American study enrolled women with HSDD (N = 113), FSAD (N = 49) and no FSD (N = 61); the European study enrolled women with HSDD (N = 130) and no FSD (N = 124). In both studies, mean SIDI-F total score for women with HSDD was lower than for those with no FSD (P < 0.001, for all) demonstrating discriminant validity. Further, mean SIDI-F total score for women with HSDD was lower than for those with FSAD in the North American study (P < 0.001). Convergent validity with the FSFI and CSFQ-F and divergent validity with MAT were demonstrated. Test-retest reliability and internal consistency were high.
The SIDI-F is a valid and reliable measure of HSDD severity in women.
An accurate diagnosis of Hypoactive Sexual Desire Disorder (HSDD) currently relies on a time-consuming interview with an expert clinician. Limited access to such expertise means that many women with HSDD remain undiagnosed. The Decreased Sexual Desire Screener (DSDS) was developed to provide clinicians who are neither trained nor specialized in Female Sexual Dysfunction (FSD) with a brief diagnostic procedure for the diagnosis of generalized acquired HSDD in women.
A prospective non-treatment multicenter study enrolled 263 women at 27 centers in North America in order to test the validity of the DSDS for diagnosing generalized acquired HSDD in women. Subjects completed the DSDS at the screening visit and their answers were reviewed with a clinician who was not an expert in FSD ("non-expert clinician"). Separately and while being unaware of the non-expert clinician's diagnosis, an expert clinician conducted a standard diagnostic interview.
Diagnostic outcomes (generalized acquired HSDD or not) were compared. Primary endpoints included the sensitivity and specificity of the DSDS relative to the standard diagnostic interview. Subject and non-expert clinician debriefing were obtained via a written, structured interview. This ensured that a large sample could be tested under uniform conditions across multiple sites.
Diagnostic assessment by DSDS and standard diagnostic interview were in agreement in 85.2% (224/263) of cases, with the sensitivity and specificity of the DSDS 83.6% and 87.8%, respectively. Debriefing showed that the five DSDS questions were well understood by 85.4% (76/89) of subjects included in the debriefing exercise, while non-expert clinicians considered the DSDS questions adequate to diagnose HSDD in 92.9% (235/253) of cases.
The DSDS is a sensitive and specific brief diagnostic instrument for generalized acquired HSDD in women that is quick and easy to use.
To estimate the prevalence of self-reported sexual problems (any, desire, arousal, and orgasm), the prevalence of problems accompanied by personal distress, and to describe related correlates.
The 31,581 female respondents aged 18 years and older were from 50,002 households sampled from a national research panel representative of U.S. women. Correlates of each distressing sexual problem were evaluated using multiple logistic regression techniques.
The age-adjusted point prevalence of any sexual problem was 43.1% and 22.2% for sexually related personal distress (defined as a score of at least 15 on Female Sexual Distress Scale). Any distressing sexual problem (defined as reporting both a sexual problem and sexually related personal distress, Female Sexual Distress Scale score of at least 15) occurred in 12.0% of respondents and was more common in women aged 45-64 years (14.8%) than in younger (10.8%) or older (8.9%) women. Correlates of distressing sexual problems included poor self-assessed health, low education level, depression, anxiety, thyroid conditions, and urinary incontinence.
The prevalence of distressing sexual problems peaked in middle-aged women and was considerably lower than the prevalence of sexual problems. This underlines the importance of assessing the prevalence of sexually related personal distress in accurately estimating the prevalence of sexual problems that may require clinical intervention.
III.
Female sexual dysfunction (FSD) is a common disorder in postmenopausal women. Currently, there is no clear "gold standard" for the diagnosis of FSD.
The aim of this study was to evaluate the interrater reliability of the Women's Sexual Interest Diagnostic Interview (WSID), a new structured clinical interview designed to diagnose hypoactive sexual desire disorder (HSDD). The reliability of additional interview questions focused on the diagnosis of other types of FSD was also evaluated.
The main outcome measure was the level of agreement in the diagnosis of FSD among clinical experts, between clinical experts and study coordinators, and between clinical experts and patients' self-reported interactive voice response system (IVRS) version of the WSID.
Two versions of WSID were developed based on current diagnostic criteria: a clinician-administered version using a structured interview guide, and a patient self-report version using an IVRS. Three sexual medicine experts developed 20 clinical scenarios portraying cases and noncases of HSDD and other FSD diagnostic subtypes. Ten actresses with experience in standardized patient interviewing rehearsed these scenarios and performed the scripted patient roles in a standardized clinical interview with clinical experts (not the author of the script) and study coordinators, on a one-on-one basis, using the WSID interview format. In addition, all actresses completed the IVRS version of the WSID. Interviews were videotaped and viewed by the expert panel. In each instance, the diagnosis that the interview was scripted to portray was considered as the "gold standard." Kappa (kappa) coefficients were utilized to assess the level of agreement among experts, between study coordinators and the "gold standard", and between the IVRS version of the WSID and the "gold standard".
All experts agreed with the gold standard diagnosis provided by the author of the script (kappa=1.0). Similarly, there was perfect agreement among the experts on the presence of depressive symptomatology (kappa=1.0). On the related diagnoses of arousal disorder, orgasmic disorder, and sexual pain disorder, kappas of 0.894, 0.966, and 0.946 were observed (P<0.0001 for all comparisons). When study coordinator's WSID diagnoses were compared with the "gold standard," kappa for HSDD was 0.851; sensitivity was 0.864, and specificity and positive predictive value (PPV) were 1.00 (P<0.001 for all comparisons). When diagnoses obtained via IVRS interviews were compared with the "gold standard", kappa for HSDD was 0.802, sensitivity was 0.818, and specificity and PPV were 1.00 (P<0.001 for all comparisons).
Agreement as estimated by kappa coefficients was consistently high in both clinician-administered and patient self-reported IVRS versions in the diagnosis of HSDD.
Introduction:
Female sexual dysfunctions (FSDs) are very prevalent, multifaceted problems that continue to be under-recognized and undertreated. Improved recognition and management depend on physicians' inclination and ability to communicate with female patients about their sexual function. Many women hesitate to share sexual complaints due to concerns about physicians' time constraints or their interest in addressing it. Direct questioning by physicians about sexual function is often critical to patients' reporting of sexual concerns.
Aim:
To obtain pilot data on physicians' knowledge, perceptions, and practices regarding FSDs, which may help uncover means of facilitating future dialog between physicians and patients.
Methods:
A self-reply questionnaire was used to survey physicians and other health professionals attending the 2004 annual meetings of four major specialty societies.
Main outcome measures:
Survey questions were included on the prevalence of FSDs; dialog on sexual function/activity; obstacles to appropriate evaluation and management of FSDs; effectiveness of current treatment options; and referral patterns.
Results:
A total of 1,946 attendees completed the survey. Most respondents (60%) estimated that one- to three-quarters of their patients had FSDs. Low sexual desire was the most prevalent FSD observed. A total of 58% of participants reported initiating the first discussion of FSDs in one-quarter or less of patients. Obstacles to discussing sexual health included limited time and training, embarrassment, and absence of effective treatment options. Approximately 60% of participants rated both their knowledge of and comfort level with FSDs as only fair or poor. Eighty-six percent rated current treatment options as fair or poor.
Conclusion:
Healthcare professionals are aware of the high prevalence of FSDs but infrequently initiate a discussion of sexual function with their female patients or conduct a comprehensive evaluation for FSDs. Additional medical education and training are needed to improve the identification and management of FSDs in women.
To develop a screening tool to allow a postmenopausal woman to determine whether to seek evaluation for hypoactive sexual desire disorder (HSDD).
The Brief Profile of Female Sexual Function (B-PFSF) was developed using items from the Profile of Female Sexual Function (PFSF) and the Personal Distress Scale (PDS). Logistic regression analysis was used to select items best able to discriminate between women with HSDD (n = 743) and controls (n = 226) and a screening cut-off score was identified. Cross-validation analyses were conducted using PFSF and PDS responses from an independent group of 147 HSDD women and 104 controls. Forty cognitive interviews were additionally conducted to assess validity of the final tool.
A seven-item instrument was found to provide good discrimination between postmenopausal women with HSDD and controls and to be a reliable and valid tool. Ninety-six percent of women with HSDD and 97% of control women in the independent validation were classified correctly using the identified cut-off score. In the cognitive interviews, all women stated that the questionnaire was easy to complete and covered relevant aspects of sexual function.
The Brief Profile of Female Sexual Function (B-PFSF) is psychometrically valid and appropriate for use as a self-administered screening tool.
Introduction:
The concept of sexually related personal distress is currently central to the diagnosis of all female sexual dysfunctions (FSD). In the current study, we have focused on validating a slightly revised version of the Female Sexual Distress Scale (FSDS), the FSDS-Revised (FSDS-R), to enhance the sensitivity of the instrument with patients suffering from hypoactive sexual desire disorder (HSDD). In addition, we have attempted to extend the validation generalizability of the scale by demonstrating that both instruments possess reliability and discriminative validity in premenopausal women with HSDD.
Aim:
To assess the validity of the revised version of the FSDS, the FSDS-R, for measuring sexual distress in women with HSDD.
Methods:
A prospective methodological study carried out at 27 centers in North America enrolled 296 women aged 18-50 years with HSDD, another female sexual dysfunction (FSD), or no FSD. The subjects completed the FSDS-R at baseline, day 7, and day 28, with a 30-day recall at baseline and with a 7-day recall on days 7 and 28.
Main outcome measures:
Receiver operating characteristic (ROC) analyses of FSDS, FSDS-R, and FSDS-R item 13 were used for the differentiation of HSDD from no FSD, while intraclass correlation coefficient (ICC) was used to estimate test-retest reliability. Cronbach's coefficient alpha was used to measure the internal consistency of the FSDS-R and Pearson's correlation coefficient to assess FSDS, FSDS-R, and FSDS-R item 13 with different recall periods (7 and 30 days).
Results:
Mean total FSDS, FSDS-R, and FSDS-R item 13 scores with either recall period were significantly higher (P < 0.0001) in women with FSD or HSDD than in women with no FSD, showing both tests had discriminant validity. ROC analysis confirmed these findings, while an ICC of >0.74 showed the test-retest reliability of both scales, including FSDS-R item 13 alone, and Cronbach's coefficient alpha of >0.86 confirmed the internal consistency of both tests.
Conclusions:
Consistent with the FSDS, the FSDS-R demonstrated good discriminant validity, high test-retest reliability, and a high degree of internal consistency in measuring sexually related personal distress in women with HSDD. FSDS-R item 13 alone also demonstrated good discriminant validity and test-retest reliability.
Diagnostic and statistical manual of mental disorders
American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.