Psychosexual Evaluation of the Woman With Sexual Complaints

Sexuality MattersPsychosexual Evaluation of theWoman With Sexual ComplaintsLori A. Brotto, PhDMost physicians who provide care for women are familiarwith the possible physical causes of common sexualproblems. However, as such disorders often have psychologicalcomponents or sequelae, these factors must also be assessed.Sexual experiences rarelyoccur in a vacuum. And,although sexuality isan integral componentof quality of life andindividual/relationship satisfaction,1 sexual complaints areextremely difficult to admit andarticulate⎯especially in the kindof detail required for optimalmanagement. The physician mustobtain a complete medical historyand perform thorough physicaland genital examinations, butthis is just the beginning. Becausesexual behavior is inextricablyintertwined with emotional, psychological,and cultural factors,no evaluation is complete withoutconsidering these aspects.Ideally, the woman withsexual complaints should beassessed together with her partner.2 Assessment of the partnercan shed light on the etiology,presentation, and prognosisof sexual complaints, andcan also indicate whether bothmembers of the couple are sufficientlymotivated to work onLori A. Brotto, PhD, is assistant professor,Department of Obstetrics and Gynaecology,University of British Columbia,Vancouver, BC, Canada.the problem. If the clinician isequipped to see both partnersand both are willing, assessmentis best performed over twoseparate sessions (Key Points).To clarify problems ofdesire, arousal, orgasm,and pain, the couplecan be asked to recalla recent sexual episode,and to explain in detailto the clinician whattranspired—includingtheir thoughts, emotions,and behavioral reactions.CONJOINT SESSIONThe goal of the first session is toclarify the sexual problem, assessall aspects of the sexual responsecycle, explore the impact of theproblem on the couple’s sexualand relationship satisfaction, andevaluate the nonsexual dynamicsof their current and past relationship.2 By inviting the woman andher partner to describe the sexualcomplaint in their own wordsthe clinician gains a window intotheir language for discussing sexuality,their level of insight, anda sense of their sexual knowledge.To clarify problems ofdesire, arousal, orgasm, and pain,the couple can be asked to recalla recent sexual episode, and toexplain in detail to the clinicianwhat transpired⎯including theirthoughts, emotions, and behavioralreactions.They should also be askedabout the range of stimuli usedto evoke her sexual arousal, howeffective such stimuli are, andher emotional and sexual reactionsto them. 3 For example, dothey engage in sufficient foreplay(pleasurable activities thatreliably elicit arousal), or dothey bypass all forms of sexualtouching and immediatelyengage in intercourse, resultingin dyspareunia due to insufficientgenital lubrication?The context of the sexual experienceshould also be discussed. 4This consists of both interpersonalfactors (eg, emotionalcloseness, sexual attraction,privacy, safety, contraception,infertility, sexually transmittedinfections [STIs]) and intrapersonalfactors (eg, personal worries,distractions, depression,fatigue). Barriers to arousal mayinvolve the partner⎯eg, lackof attraction, unreliable erections,lack of sexual skill⎯suchthat the clinician may wishThe Female Patient VOL. 32 November 2007

S exuality M attersKey PointsKey Points of the Psychosexual EvaluationConjoint interview• Patient’s description of the problem• Sexual stimuli used to evoke her arousal• Interpersonal/intrapersonal context• Responsive versus spontaneous sexual desire• Sexual experiences despite the current problem• Couple’s sexual and relationship history• Motivation for seeking treatmentIndividual interview(s)• Psychosexual history• Masturbation patterns and frequency• Partner’s sexual response• Interpersonal/intrapersonal context for each partner• Brief psychiatric history, focusing on depression and anxiety• “Family of origin” history• Cognitive myths about sexualityto elicit this information duringan individual interview. 5Because lack of desire is themost common sexual complaintamong women, 6 it is importantto inquire about the woman’s“responsive desire”⎯ie,the patient’s desire to continuesexual activity after arousal isachieved. 4 Spontaneous (nontriggered)desire that may driveher to seek sexual contact canalso be assessed, but she shouldbe reassured that lack of suchdesire does not constitute sexualdysfunction. Recent conceptualizationsof female desiredisorders focus more on “responsive”than on “spontaneous”desire, which may be hormonallydependent and thus morecommon in younger women. 7Understanding this can be normalizingand validating for thepatient, and may be sufficientto resolve her sexual concerns.The clinician should explorewhether the couple still engagesin any type of sexual activity,and which of these activities arepleasurable and satisfying. If acouple has found other modesof experiencing sexual pleasuredespite a sexual problem, thiscan indicate resiliency and willingnessto try alternatives. 2 It canalso give the clinician a senseof their motivation for complyingwith treatment suggestions.Another aspect of the conjointinterview is an assessment ofthe couple’s sexual and relationshiphistory. When and how didthey meet? When did they beginto have sexual contact? Often, awoman with vaginismus may haveoveranticipated “the first time,”leading to physical tension andpsychological anxiety that triggervaginismus. 8 For the couple whoexperienced positive and satisfyingsexual experiences in the past,it is important to focus on exactlywhen things began to “go wrong.”Sometimes life stressors can precipitatesexual complaints⎯eg, a new job, relocating, thearrival of children, busy schedules,caretaking for elders, psychologicaldisturbances. 4The conjoint interview mightend with an inquiry into thecouple’s motivation for seekingtreatment. This can be especiallyinformative if the complainthas existed for some time. Forexample, are relationship deteriorationand the prospect of aseparation motivating the visit?Or is the wish for conceptionor the discovery of an STI thetrigger for seeking treatment?INDIVIDUAL SESSIONIf the woman’s partner is involvedin the assessment, the second sessionwill involve individual evaluationsof each person, followedby a group meeting to integratethe findings, propose treatment,and/or provide information. Ifthe partner is unable/unwilling toparticipate, or if the woman hasno partner, this session can proceedwith the patient alone. Duringthe individual session(s), eachmember of the couple is askedabout their sexual history⎯firstsexual experiences, sexual historyprior to current partner, and anyexperience of unwanted sexualcontact. 4 The individual is alsoasked about past and current masturbationfrequency and motivation.For a woman complaining ofloss of sexual desire, masturbationpatterns can provide insight intoher need for nonpartnered sexualactivity. 9 For the woman with lossof arousal, exploring masturbationand capacity for arousal andorgasm with her alone can clarifythe partner’s contributions to theimpaired sexual response. The Female Patient VOL. 32 November 2007

BrottoThe partner’s sexual responsesare then explored for both membersof the couple. If the patient’spartner is male, his erectile function,orgasmic latency, desire, andsexual satisfaction should be discussed.Research suggests thatthe restoration of erectile functionvia one of the new phosphodiesterase-5inhibitors (sildenafil,tadalafil, vardenafil) can causestrain in a relationship, particularlyif sexual activity nowbecomes intercourse-focused. 10Continuing the assessment ofinterpersonal/intrapersonal context,each member of the coupleshould be asked about their sexualand nonsexual feelings for thepartner. Has one of them keptsecrets that may be contributingto the patient’s sexual complaints?A brief psychiatric history canthen focus on past and presentmood and affect, as well as currentand past psychotropic medications.11 Depression is a commoncomorbidity for all sexual complaints6 and may be assessed witha brief, validated tool (eg, BeckDepression Inventory). Markeddepression or anxiety may requirereferral to a qualified therapist toaddress these disorders prior toinitiating sex therapy. In addition,from an attachment-theory perspective,exploration of the familyhistory (ie, family of origin)can reveal relationships with earlycaregivers, sibling relationships,and earliest sexual teachings. Thismay be a good time to exploreA genital examination of the woman may bewarranted, however, it is not advised to do so in theearly stages of assessment before rapport and anassurance of trust is established.the patient’s cultural and sexualbeliefs to see whether there aremisconceptions⎯eg, only multiorgasmicsex is satisfying; onlyspontaneous sex is pleasurable.A comprehensive assessment ofthe woman’s sexual dysfunctionshould also include a medical history.12 A genital examination ofthe woman may be warranted,however, it is not advised to doso in the early stages of assessmentbefore rapport and an assuranceof trust is established. Forboth the general medical examinationand the specific genitalexamination, if the clinician isa mental health provider, thiswill entail a referral to a gynecologistor a family physician.The individual interviews arethen followed by a reunion of thecouple, where the clinician willattempt to integrate all informationand propose a theory of theproblem’s causes and a treatmentplan. Although these two sessionswill yield a wealth of informationfrom which to establisha management strategy, informationemerging in later sessionsshould be incorporatedto direct ongoing treatment.CONCLUSIONPhysical and genital examinationsare usually essential whenevaluating the patient with sexualcomplaints, but provide only apartial picture. To comprehensivelytreat these women, thephysician must also consider anypsychological contributors and/or consequences, as well as thelarger sociocultural context inwhich these problem occur.REFERENCES1. Defining sexual health. Report of atechnical consultation on sexualhealth. World Health Organization,28-31 January; Geneva,Switzerland; 2002. www.who.int/reproductive-health/publications/sexualhealth/index.html. AccessedSeptember 12, 2007.2. Leiblum SR, Wiegel M. Psychotherapeuticinterventions for treatingfemale sexual dysfunction. World JUrol. 2002;20(2):127-136.3. Rupp HA, Wallen K. Sex differencesin response to visual sexual stimuli:a review. Arch Sex Behav. 2007,August 1; [epub ahead of print].4. Basson R. Women’s sexual dysfunction:revised and expandeddefinitions. CMAJ. 2005;172(10):1327-1333.5. Dennerstein L, Lehert P, GuthrieJR, Berger HG. Modeling women’shealth during the menopausal transition:a longitudinal analysis. Menopause.2007;14(1):53-62.6. Laumann EO, Nicolosi A, GlasserDB, et al. Sexual problems amongwomen and men aged 40-80 y: prevalenceand correlates identified inthe Global Study of Sexual Attitudesand Behaviors. Int J Impot Res.2005;17(1):39-57.7. Basson R, Leiblum S, Brotto L, etal. Definitions of women’s sexualdysfunction reconsidered: advocatingexpansion and revision. J PsychosomObstet Gynaecol. 2003;24(4):221-229.8. Vaginismus. Armenian MedicalNetwork, 2006. www.health.am/sex/more/sexual_pain_disorders_vaginismus/. Accessed September 11,2007.9. Corona G, Petrone L, Mannucci E,et al. The impotent couple: low desire.Int J Androl. 2005;28(suppl 2):46-52.10. Potts A, Gavey N, Grace VM, VaresT. The downside of Viagra: women’sexperiences and concerns. SociolHealth Illn. 2003;25(7):697-719.11. Higgins A. Impact of psychotropicmedication on sexuality: literaturereview. Br J Nurs. 2007;16(9):545-550.12. Basson R, Schultz WW. Sexualsequelae of general medical disorders.Lancet 2007;369:409-424.The Female Patient VOL. 32 November 2007