Abstract
Good sexual functioning is a part of overall well-being. Assessment of sexual functioning should be part of any complete psychosomatic assessment. The cornerstone of this assessment is a comprehensive clinical interview of the patient, with, if possible, collateral information obtained from the partner or another clinician. In addition, comprehensive assessment of sexual function should include a physical examination with a special focus on sexual function, laboratory testing and possibly other specialized testing and, in some cases, psychometric assessment. The results of a thorough assessment may serve as a basis for considering possible etiology(ies) of sexual dysfunction, coexisting comorbidities and as a starting point of managing sexual dysfunction.
There are several reasons for addressing psychosomatic assessment of sexual function/ dysfunction in this volume. First, this volume focuses on psychosomatic assessment. Lipowski [1] defined ‘psychosomatic’ as ‘referring or related to the inseparability and interdependence of psychological and biologic (physiologic, somatic) aspects of human kind’. Balon [2] has argued that sexual function and dysfunction ‘with its complex regulation, involving the central nervous system, peripheral nervous system, various hormones, as well as psychological factors, including relationship, the stage of a person's development and life circumstances, seems to be a prime example of the interdependence of psychosocial and biologic/physiologic factors’. Sexual function/ dysfunction seems to almost perfectly fit into the biopsychosocial model of illness. It could be also argued that the sexual function/dysfunction area is quintessentially psychosomatic. Second, Fava and Sonino [3] and Lipowski [4] postulated that psychosomatic medicine may be defined as a comprehensive, interdisciplinary framework. Human sexuality, sexual function and dysfunction have become the focus of many disciplines - psychiatry, psychology, sexology, obstetrics and gynecology, endocrinology, urology and others. Actually, it seems that a new interdisciplinary field of sexual medicine is gradually emerging. Third, parts of this volume discuss psychological well-being and lifestyle. As Stevenson and Elliott [5] emphasized, ‘Sexuality is not a lifestyle issue; it is a quality-of-life issue. The psychiatrist's goal is to maintain, restore, or improve a patient's quality of life, and sexual function should be a routine part of that clinical service mandate’. Fourth, as Swartzendruber and Zenilman [6] stated while proposing a national strategy to improve sexual health, ‘Sexual health is an integrated care-delivery and prevention concept that recognizes sexual expression as normative and encompasses preventive and treatment services throughout the life span’. Interestingly, in spite of all arguments that human sexuality and its impairments should clearly be one of its primary areas, psychosomatic medicine does not pay much attention to human sexuality. An example is a recently published well-written introductory book to psychosomatic medicine by Amos and Robinson [7] - it mentions ‘sexual disorders’ only in one place, in relationship to the psychiatric aspects of Parkinson's disease. Research in various areas of sexuality is currently done by either psychologists or urologists or gynecologists. The annual meetings of the American Psychiatric Association have almost nothing presented in this area. Human sexuality, as pointed out by Wylie and Weerakoon [8], has limited representation in undergraduate and postgraduate health training programs, and training in the area of human sexuality is frequently non-standardized and inadequate [9‒11]. The reasons for the psychiatry's and psychosomatic medicine's lack of attention to this important part of well-being and overall functioning are not totally clear. Maybe it is the perpetual stigma of sex, or the heavy emphasis on biology compared to psychology in this area lately, or the lack of solid evidence of the efficacy of psychological interventions for sexual dysfunctions, or the lack of reimbursement for psychological treatments, or the lack of research in this area in general (including imperfect diagnostic criteria), or the conservative politics, or probably all of the above and more. However, the large evidence of the connection of sexual functioning and mental and somatic illness, and of the importance of good sexual functioning for overall well-being underscore the need for psychosomatic medicine's need to reintegrate sexual function/dysfunction into its framework. Incorporating an assessment of sexual function into a regular comprehensive psychosomatic assessment should be the first step in this process.
General Issues
Considering the framework of psychosomatic medicine, impairment of sexual function may occur: (1) as a primary sexual dysfunction in an otherwise healthy individual, or coexisting with other illness, either mental or physical; (2) connected to or intertwined with another mental or physical illness (or both), either as a sequel of another illness, or triggering an impairment or disorder. Impairment of sexual functioning may, in these interactions, either worsen the primary illness or be without any effect on it. Sexual dysfunction could, actually, at times, be a marker or predictor of another disease (e.g. erectile dysfunction may be the first sign of cardiovascular disease or diabetes mellitus). In addition, impairment of sexual functioning may occur due to medication for either mental or physical illness, or both. Impairment of sexual functioning due to mental and physical illness and due to medications and drugs of abuse has been summarized in numerous publications lately [e.g. 5, 12-16].
Thus, psychosomatic assessment of sexual function/dysfunction should focus on determining whether the impairment is a primary dysfunction, or whether there is a connection to another mental or physical illness, or to its treatment(s), or a connection to substance abuse; what the connection exactly is and what the possible consequences or impact of the dysfunction are. Psychosomatic assessment of sexual functioning should include all possible avenues such as using physical examination, laboratory testing and possibly various scales and other specialized tests, but one needs to realize that the cornerstone of a good psychosomatic assessment is a comprehensive clinical or medical interview. Two recent chapters [17, 18] reviewed clinical and research evaluation of sexual functioning. The following text draws from these chapters and from the vast body of literature on sexual medicine and psychosomatic medicine to propose a comprehensive psychosomatic assessment of sexual function/ dysfunction applicable to clinical practice of psychosomatic medicine.
Psychosomatic Assessment of Sexual Functioning
Psychosomatic assessment of sexual functioning, as proposed here, should include the following components:
Comprehensive clinical interview of the patient. Obtaining collateral information from the partner or another clinician is desirable, though not always possible.
Physical examination with a special focus on sexual function.
Laboratory tests and possibly other specialized testing (e.g. neurological evaluation, penile plethysmography).
Psychometric assessment.
Including all four components of the assessment would be ideal, but clearly it is not always possible or useful (e.g. see the discussion of psychometric assessment below).
Comprehensive Clinical Interview of the Patient
A clinical interview focused on sexual functioning and its relationship to ‘psyche and soma’ could be either part of a general evaluation (including the evaluation of patient well-being and/or lifestyle), or an evaluation of a specific illness with possible associated sexual dysfunction or a question about sexual dysfunction only. The interviewing clinician should be clear about the focus of the assessment. Frequently, the focus is clarified up front by the question(s) posed by the referring clinician or by the patient him/herself. Thus, reviewing the chart, referring physician's note, previously filled-out questionnaire or any other materials should be done, if possible, prior to any interview. This pre-interview review should focus not only on sexual functioning, but also on other illnesses that may impact sexual functioning (almost all), the scope of functional impairment in other areas by any illness, and laboratory test results (see below). While the information obtained through this review provides one with guidance and is frequently invaluable, one should realize that not everything could be accepted at its face value for various reasons (cultural and religious issues, personal issues such as shyness, macho attitude or narcissism) and thus should be continuously probed, compared and viewed in a wider clinical and/or psychological context.
Traditional model of female sexual response cycle demonstrating all phases (females may achieve more than one orgasm per sexual response cycle, males achieve one orgasm per cycle).
It is important to note that while mental status examination is frequently the crucial or core part of the interview during the usual consultation-liaison or psychosomatic medicine consultation, the ‘present illness’ description and history are much more important than mental status examination during the psychosomatic assessment of sexual function. Questioning about sexual function/dysfunction should be very specific: general, nonspecific questions like ‘How is your sex life?’ call for general, nonspecific answers, such as ‘OK’. All parts of sexual response cycle should be probed by questioning (for illustration of sexual response cycle see fig. 1). Some examples of the specificity of questioning are [ 18]:
General: How often do you have sex? Who initiates sex, you or your partner? Do you masturbate?
In relationship to another illness/medication: Have you been more tired/exhausted when having sex lately? Has the frequency/desire/enjoyment/erection-arousal/orgasm changed since you started this medication? Are you afraid of having sex since you had a heart attack? Has the sensation in your genitalia changed lately?
About sexual desire/libido: Do you think about sex often? Do you feel like having sex often? Have there been any changes in your desire to have sex?
About arousal: Do you get easily aroused by your partner? Do you get wet easily (women)? Are you getting hard enough during intercourse (men)? Do you have erections when you wake up?
About orgasm: Do you have any difficulty reaching orgasm? Do you reach orgasm at all?
The interview should be conducted in a serious manner, the interviewer should be comfortable with asking questions about sexual functioning and should acknowledge that the patient may not be comfortable with all questions. The conduct of the interview should be semistructured, starting with open-ended questions and moving gradually, based on the obtained information, to more closed-ended questions. It may be useful to discuss possible connections between certain illnesses and impairment of sexual functioning, as it may help the patient to become more open in discussing his/ her sexuality. Like in other areas of assessment, nothing should be assumed.
During the interview, the clinician may use two guiding principles. We describe the first one as a matrix for the interview with a focus on sexual dysfunction (the following is adapted from reference [18], p 31). The interview could be conceptualized as a matrix of three sequential levels of questioning with the following goals:
Level 1. Determine why the patient is seeing the clinician and what has prompted the visit or evaluation. Clarify whether sexual dysfunction is part of the overall complaint. Clarify whether the patient is currently complaining or has previously complained of impairment of sexual functioning. Partner questioning could be quite helpful at this level (difference of opinion as to whether sexual problem exists and in what context it occurs).
Level 2. Determine the patient's sexual dysfunction(s) (e.g. hypoactive sexual desire disorder, erectile disorder). If the patient has more than one dysfunction, determine whether one could be identified as the primary one (e.g. man with erectile dysfunction develops subsequent ejaculation problems). It should be ascertained whether the dysfunction is transient, fluctuating or permanent. Attempt to determine whether the temporary characterization of the dysfunction (transient etc.) is influenced by comorbid condition(s) such as cardiovascular or endocrine disease, depression or anxiety. Realize that primary anorgasmia, or organic versus psychological etiology of erectile dysfunction could be, at times, differentiated by temporal history, partner variables (erectile problem with one person and not another) or masturbatory function.
Level 3. Seek information about the possible etiology of sexual dysfunction (e.g. atherosclerosis, marital discord). An assessment of the distress associated with/due to sexual dysfunction could be done at this level, too. Partner involvement could be also helpful at this level.
The second interviewing guiding principle is intertwined with level 3 above and could be summarized in the word ‘biopsychosocial’. This guiding principle is as important in the area of sexual functioning as it is important in the rest of psychosomatic medicine. The etiology of sexual dysfunction could be biological (e.g. atherosclerosis; diabetes mellitus; hypothyroidism; urologic diseases; gynecological problems; medications), psychological (mental disorders such as anxiety disorders, depression, schizophrenia; stress; sexual abuse), or interpersonal/relational (childrearing demands; cultural differences; extramarital affair; marital discord; religious conflict), or multi-factorial, involving two or all three possible areas of etiology (one could argue that for instance substance abuse-associated sexual dysfunctions have biopsychological roots or biopsychosocial roots). In addition, various etiologies could be connected one to another and one could influence the other (e.g. depressed patient's sexual desire could be low due to depression and could get even lower due to antidepressant medication, and all that could lead to marital discord that could, in a vicious circle, lower the desire even more). Thus, it is imperative that the clinicians probe all areas of possible etiology (biopsychosocial) and does not necessarily remain complacent by identifying just one.
The basic elements of comprehensive psychosomatic assessment interview should include (adapted from Derogatis and Balon [18]):
(1) Personal and general data; (2) Reason for consultation/evaluation; (3) Chief compliant in the patient's own words; (4) Information about general mental and physical illness, including review of systems (one could include pertinent laboratory test results, if available); (5) Clarification/delineation of possible sexual dysfunction; (6) Description of the patient's sexual fantasies and/or dreams; (7) Interpersonal issues; (8) Developmental issues; (9) Cultural, moral, religious and social issues pertinent to the patient's sexual functioning; (10) Partner interview whenever possible; (11) General assessment of the patient's sexual well-being. It is important that the interviewer actively searches for connections between illnesses, various functional impairments and sexual dysfunction(s), that he/she looks for pathophysiological links suggested by Fava and Sonino [19]. Complaints of erectile dysfunction in an older male should trigger questions and testing for possible atherosclerosis or diabetes mellitus. Complaints of lower sexual desire and fatigue should initiate questioning about depression and about symptoms of hypothyroidism.
Physical Examination with a Special Focus on Sexual Function
Physical examination is a very important part of a comprehensive psychosomatic assessment of sexual function. It should be performed only by a trained physician or nurse practitioner after the review of systems is obtained. Frequently, the results of physical examination done by the referring physician could be used, but should not be necessarily relied upon. It is possible that the referring physician was focused on a different medical problem and did not pay special attention to sexual organs. It may be desirable to have the physical evaluation of genitalia and/or pelvic examination done by a specialist, e.g. a gynecologist for women and an urologist for men. This specialized examination should focus on any anatomical changes (e.g. cryptorchism, varicocele) or signs of infection or pain. In such cases, specific questions to the examining physician should be posed. In cases of suspected underlying illness/condition, an examination by another specialist may be required, e.g. a neurologist in cases of erectile dysfunction due to diabetic neuropathy or spinal cord injury, or an endocrinologist in cases of diabetes mellitus, hypothyroidism, prolactinoma and others.
Laboratory Tests and Possibly Other Specialized Testing
Laboratory tests may play a role in determining the underlying biological factors in the etiology of sexual dysfunction or in ruling out possible underlying biological etiology. Examples include determining testosterone level in a young male with low sexual desire (possible hypogonadism), fasting glucose in an older male with erectile dysfunction (possible diabetic neuropathy), prolactin level in a male patient with gradual decrease in sexual desire, erectile dysfunction, headaches, infertility or a female patient with gradual decrease of sexual desire, breast pain, menstrual disturbance (possible prolactinoma).
Recommended laboratory tests for patients with possible sexual dysfunction include total testosterone level, free testosterone level, thyroid-stimulating hormone, prolactin, sex hormone-binding globulin and plasma estradiol. Hopefully, some optional tests, such a complete blood count, fasting glucose, glycosylated hemoglobin A1C, thyroid panel and lipid profile would be available upon referral. If not, they could be ordered based on the clinician's suspicion of the underlying pathophysiology. Further optional laboratory tests include various hormone levels, such as dihydroepiandrosterone, luteinizing hormone, and follicle-stimulating hormone.
In the past, various specialized tests for evaluating the vascular component of penile functioning were done. Those included, for instance, phalloplethysmography, Doppler sonography, dynamic cavernosometry and evaluations of nocturnal penile tumescence. Since the arrival of phosphodiesterase-5 inhibitors, the use of these tests decreased and is done by specialists only. The RigiScan for evaluation of nocturnal penile tumescence has some clinical utility as being helpful in ruling out an organic etiology of erectile dysfunction or, for the patient, ‘confirming’ the psychological cause(s) of his erectile problems.
As impairment of sexual functioning could be connected to various systems (CNS, endocrine, cardiovascular), consultations/specialist evaluations (e.g. neurological, endocrinological) may be required to complete the psychosomatic assessment.
Psychometric Assessment
Psychometric assessment may provide additional, though not crucial information for the overall psychosomatic assessment of sexual functioning. At the present time, there are no structured diagnostic interviews, such as the Structured Clinical Interview for DSM-IV, or diagnostic scales available in the area of human sexuality. There are many sexual functioning assessment scales available, although not all of them have been properly validated. These scales (and a few structured or semistructured interviews) usually evaluate a certain area of sexual functioning (erectile functioning, female sexual functioning). The majority of these instruments are self-reported inventories [17] and were developed for clinical trials (more of them in the area of female sexual functioning).
Psychometric assessment could still be helpful in several areas: (a) it could help to clarify the symptomatology of sexual dysfunction, especially if the clinician discusses the individual scale items rating with the patient; (b) it may provide some quantification of sexual function/dysfunction; (c) it could serve as an organized and possibly quantifiable way of communication among clinicians, (d) it provides a clearer documentation of changes in sexual functioning (e.g. improvement during treatment) if done serially, and (e) it provides an organized, fairly structured documentation of symptomatology.
Some of the most frequently used measures of sexual functioning include:
Arizona Sexual Experience Scale (ASEX) [20]. A brief self-reported inventory (5 items) for rapid assessment of sexual functioning during administration of psychotropic drugs. It has been used mostly in clinical trials. The validation has no minimal, and there are no published norms.
Brief Male Sexual Function Inventory (BMSFI) [21]. An 11-item self-reported screening inventory assessing current sexual functioning in men.
Center for Marital and Sexual Health Sexual Functioning Questionnaire (CMSH-SFQ) [22]. A 21-item self-report inventory to assess sexual functioning in four instances: male patient, partner, baseline, follow-up.
The Changes in Sexual Functioning Questionnaire (CSFQ) [23]. A 36-item structured interview assessing changes in sexual functioning associated with mental illness and with psychotropic medications (two versions: female - 35 items, male - 36 items). This questionnaire fits well within the principles of clinimetrics. A self-report version is also available.
The Derogatis Interview for Sexual Functioning (DISF) [24]. A 25-item semi-structured interview evaluating the quality of sexual functioning and matching the self-reported version (DISF-SR); it has a male and a female version. This instrument is available in 12 languages.
The Female Sexual Distress Scale (FSDS) [25]. A 12-item self-reported inventory to measure and quantify sexually related personal distress.
The Female Sexual Functioning Index (FSFI) [26]. A 19-item self-reported inventory measuring the quality of female sexual functioning and profile core aspects of female sexual functioning.
Golombok Rust Inventory of Sexual Satisfaction (GRISS) [27]. A 28-item self-report inventory to assess the quality of a heterosexual relationship and both partners’ sexual functioning. Six subscales of this instrument actually target domains specific to
DSM-IV sexual dysfunctions (female and male avoidance, female anorgasmia, vaginismus, premature ejaculation and male impotence).
The Index of Premature Ejaculation (IPE) [28]. A 10-item self-reported inventory focused on subjective aspects of premature ejaculation.
The International Index of Erectile Function (IIEF) [29]. A 15-item self-reported inventory devised to provide information about erectile function and capacity, widely used in clinical trials, used by various disciplines. This instrument is considered a gold standard in the area of erectile functioning instruments.
The Profile of Female Sexual Function (PFSF) [30]. A 37-item multi-domain inventory with focus on female sexual functioning, especially low sexual desire, devised for clinical trials by pharmaceutical industry.
The Sexual Function Questionnaire (SFQ) [31]. A 26-item self-reported inventory evaluating all aspects of the female sexual response cycle and dyspareunia.
This list does not include any measures of paraphilias or gender identity disorder, as these scales should be used in a very specialized assessment after these disorders are suspected. Most of these scales are not properly validated and are not very useful outside of the research setting. Clinicians should select one or two scales to become familiar with for their clinical practice. They should be aware of scales’ area of use or indication and limitations. The Brief Male Sexual Function Inventory, Changes in Sexual Functioning Questionnaire, DISF, Female Sexual Functioning Index and the Golombok Rust Inventory of Sexual Satisfaction would be probably the most useful ‘general’ scales; some other scales may be used in more specific clinical situations (e.g. The Index of Premature Ejaculation, The International Index of Erectile Function).
Conclusion
Synthesis of the data obtained from some or all parts of the psychosomatic assessment (clinical interview, physical examination, laboratory testing, psychometric assessment) should be helpful in analysis, similar to the two-level functional analysis proposed by Emmelkamp [32]: macroanalysis, i.e. establishing links among coexisting symptoms, syndromes or diseases to determine which problem should be treated first, taking into account patients’ priorities, and microanalysis, i.e. a careful analysis of all symptoms. Psychosomatic assessment of sexual functioning should definitely be a part of any general comprehensive psychosomatic assessment. The clinician should be probing all possible etiologies (bio-psycho-social!) and a possible relationship to any comorbid illness, stress or psychological problem. The questioning should be very specific and nothing should be assumed. Last but not least, clinicians should remember that good sexual functioning is a part of overall well-being. Thus, its assessment and management of its impairment should always be included in the overall management plan.
