An ideal protocol for the assessment of FSAD should be constructed following theoretical and factual knowledge of the physiological, psychophysiological, and psychological mechanisms involved. The protocol then describes the most parsimonious route from presentation of complaints to effective therapy. Unfortunately, we are at present far from a consensus on the most probable causes of FSAD. Despite this disagreement, at least two diagnostic procedures should be considered. Firstly, assessment of sexual dysfunction in a biopsychosocial context should start with a verification of the chief complaints in a clinical interview. The aim of the clinical interview is to gather information concerning current sexual functioning, onset of the sexual complaint, the context in which the difficulties occur, and psychological issues that may serve as etiological or maintaining factors for the sexal problems, such as depression, anxiety, personality factors, negative self- and body image, and feelings of shame or guilt that may result from religious taboos. Sexual problems are common complications of anxiety disorders and impaired sexual desire, arousal and satisfaction. Laboratory studies suggest potential enhancement of genital arousal by some types of anxiety, but the precise cognitive, affective, or physiological processes by which anxiety and women's sexual function are related have as yet to be identified (50). The ongoing work of Bancroft and Janssen (59) exploring a dual control model of sexual excitation and inhibition in men as well as in women, may clarify any role of anxiety in women's predisposition to sexual inhibition and to sexual excitement. One of the most important but difficult tasks is to assess whether inadequate sexual stimulation is underlying the sexual problems, which requires detailed probing of (variety in) sexual activities, conditions under which sexual activity takes place, prior sexual functioning, and sexual and emotional feelings for the partner. Several studies have shown that negative sexual and emotional feelings for the partner are among the best predictors for sexual problems (16,60). The clinician should always ask if the woman has ever experienced sexual abuse, as this may seriously affect sexual functioning (61). Some women do not feel sufficiently safe during the initial interview to reveal such experiences; nevertheless, it is necessary to inquire about sexual abuse to make clear that traumatic sexual experiences can be discussed. The initial clinical interview should help the clinician in formulating the problem and in deciding what treatment is indicated. An important issue is the agreement between therapist and patient about the formulation of the problem and the nature of the treatment. To reach a decision to accept treatment, the patient needs to be properly informed about what the diagnosis and the treatment involve.
Ideally, in the case of suspected FSAD, the initial interviews is followed by a psychophysiological assessment. In assessment of the physical aspects of sexual arousal, the main question to be answered is whether, with adequate stimulation by means of audiovisual, cognitive (fantasy), and/or vibrotactile stimuli, a lubrication-swelling response is possible. Although psychophysiological testing to date is not a routine assessment, we feel that such a test is crucial in establishing the etiology of FSAD for two reasons. The study that was discussed extensively in the previous paragraph (42) demonstrated how difficult it is to rule out that sexual arousal problems are not caused by a lack of adequate sexual stimulation. Secondly, it showed that impaired genital response cannot be assessed on the basis of an anamnestic interview. Women with sexual arousal disorder may be less aware of their own genital changes, with which they lack adequate proprioceptive feedback that may further increase their arousal. If a genital response is possible, even when other investigations indicate the existence of a variable that might compromise physical responses, an organic contribution to the arousal problem of the individual women is clinically irrelevant. As was shown before, sexual arousal problems in medically healthy women are most likely more often related to inadequate sexual stimulation due to contextual and relational variables than to somatic causes. For estrogen deplete women, care must be taken not to simply facilitate painless intercourse in the nonaroused state with a lubricant but to consider the possibility that estrogen lack has unmasked long-term lack of sexual arousal that is of contextual etiology. Of note, nonresponse in the psychophysiological assessment does not automatically imply organicity. The woman may have been too nervous or distracted for the stimuli to be effective, or the stimuli offered may not have matched her sexual preferences. This problem of suboptimal sensitivity is not unique to this test, many other well established diagnostic tests of this nature have a similar disadvantage (62).
Two other procedures could be used to corroborate findings from the clinical interview and the psychophysiological assessment. The first is the use of self-report measures supplementary to the clinical interview. The Female Sexual Function Index (FSFI) is a brief, multidimensional scale for assessing sexual function in women, and is currently the most often used measure. Recently, diagnostic cutoff scores were developed by means of sophisticated statistical procedures (63). Self-report measures are not very useful for clinical purposes because they lack sensitivity and specificity with regard to causes of the individual patient's dysfunction.
Secondly, a careful focused pelvic exam in medically healthy women may be in order when lack of arousal is accompanied by complaints of pain or vagi-nistic response during sexual activity, or when a psychophysiological assessment has yielded nonresponse. In the latter case, rare diseases such as connective tissue disorder, can be identified. In the former cases the purpose of the exam may be more educational than medical, for instance to observe the consequences of pelvic floor muscle activity (50). An examination that found no abnormalities may also be of therapeutic value. Sometimes a general physical examination, including central nervous system or hormone levels is necessary (64), but in most of the cases only genital examination is required. In women with neurological disease affecting pelvic nerves or with a history of pelvic trauma, a detailed neurological genital exam may be necessary, clarifying light touch, pressure, pain, temperature sensation, anal and vaginal tone, voluntary tightening of anus, and vaginal and bulbocavernosal reflexes (50). The clinician should be aware of the emotional impact of a physical examination and the importance of timing. When a woman is very anxious about being examined it may be appropriate to wait until she feels more secure. In the case of women who are not familiar with self-examination of their genitalia, it is preferable to advice self-examination at home before a doctor carries out an examination. It is recommended that the procedure is explained in detail, what will and what will not take place, and the woman's understanding and consent obtained. It is important to realize that any medical exam is not able to examine function, because the genitalia are examined in a nonaroused state. As such, a medical exam can never replace a psychophysiological assessment.
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