Markus Wiegel

The Female Sexual Function Index (FSFI): Cross-Validation and Development of Clinical Cutoff Scores

The Female Sexual Function Index (FSFI) is a brief, multidimensional scale for assessing sexual function in women. The scale has received initial psychometric evaluation, including studies of reliability, convergent validity, and discriminant validity (Meston, 2003; Rosen et al., 2000). The present study was designed to cross-validate the FSFI in several samples of women with mixed sexual dysfunctions (N = 568) and to develop diagnostic cut-off scores for potential classification of womens sexual dysfunction. Some of these samples were drawn from our previous validation studies (N = 414), and some were added for purposes of the present study (N = 154). The combined data set consisted of multiple samples of women with sexual dysfunction diagnoses (N = 307), including female sexual arousal disorder (FSAD), hypoactive sexual desire disorder (HSDD), female sexual orgasm disorder (FSOD), dyspareunia/vaginismus (pain), and multiple sexual dysfunctions, in addition to a large sample of nondysfunctional controls (n = 261). We conducted analyses on the individual and combined samples, including replicating the original factor structure using principal components analysis with varimax rotation. We assessed Cronbachs alpha (internal reliability) and interdomain correlations and tested discriminant validity by means of a MANOVA (multivariate analysis of variance; dysfunction diagnosis x FSFI domain), with Bonferroni-corrected post hoc comparisons. We developed diagnostic cut off scores by means of standard receiver operating characteristics–curves and the CART (Classification and Regression Trees) procedure. Principal components analysis replicated the original five-factor structure, including desire/arousal, lubrication, orgasm, pain, and satisfaction. We found the internal reliability for the total FSFI and six domain scores to be good to excellent, with Cronbach alphas > 0.9 for the combined sample and above 0.8 for the sexually dysfunctional and nondysfunctional samples, independently. Discriminant validity testing confirmed the ability of both total and domain scores to differentiate between functional and nondysfunctional women. On the basis of sensitivity and specificity analyses and the CART procedure, we found an FSFI total score of 26.55 to be the optimal cut score for differentiating women with and without sexual dysfunction. On the basis of this cut-off, we found 70.7% of women with sexual dysfunction and 88.1% of the sexually functional women in the cross-validation sample to be correctly classified. Addition of the lubrication score in the model resulted in slightly improved specificity (from .707 to .772) at a slight cost of sensitivity (from .881 to .854) for identifying women without sexual dysfunction. We discuss the results in terms of potential strengths and weaknesses of the FSFI, as well in terms of further clinical and research implications.

Sexual Desire and the Female Sexual Function Index (FSFI): A Sexual Desire Cutpoint for Clinical Interpretation of the FSFI in Women with and without Hypoactive Sexual Desire Disorder

INTRODUCTION A validated cutpoint for the total Female Sexual Function Index scale score exists to classify women with and without sexual dysfunction. However, there is no sexual desire (SD) domain-specific cutpoint for assessing the presence of diminished desire in women with or without a sexual desire problem. AIMS This article defines and validates a specific cutpoint on the SD domain for differentiating women with and without hypoactive sexual desire disorder (HSDD). METHODS Eight datasets (618 women) were included in the development dataset. Four independent datasets (892 women) were used in the validation portion of the study. MAIN OUTCOME MEASURES Diagnosis of HSDD was clinician-derived. Receiver-operator characteristic (ROC) curves were used to develop the cutpoint, which was confirmed in the validation dataset. RESULTS The use of a diagnostic cutpoint for classifying women with SD scores of 5 or less on the SD domain as having HSDD and those with SD scores of 6 or more as not having HSDD maximized diagnostic sensitivity and specificity. In the development sample, the sensitivity and specificity for predicting HSDD (with or without other conditions) were 75% and 84%, respectively, and the corresponding sensitivity and specificity in the validation sample were 92% and 89%, respectively. CONCLUSIONS These analyses support the diagnostic accuracy of the SD domain for use in future observational studies and clinical trials of HSDD.

ORIGINAL RESEARCH—EDUCATION: Sexual Communication Skills in Residency Training: The Robert Wood Johnson Model

Few medical schools or residency programs offer adequate training in sexual medicine. Using the experience gained in our long-standing program in human sexuality for medical students, we have pilot tested a half-day intensive workshop curriculum for residents that focuses on sexual communication skills and management of sexual problems. Unlike our medical school program, this residency course was offered on an elective, one-day basis. The current report describes the successful implementation of our pilot program with 46 medical residents from subspecialty and primary care residency programs. Before the workshop, 22 (48%) residents indicated that they were uncomfortable with open discussion of sexual issues and would not feel comfortable in addressing the topic with their patients. A number of factors were identified as barriers to communication, including lack of time, inadequate training, and personal discomfort. After the workshop, the participants rated themselves as more comfortable with the topic and as more likely to address sexual issues with their patients. The participants evaluated the workshop positively overall and responded well to the interactive format and audience-response components. Most of the participants showed interest and willingness to participate in further training in sexual medicine skills. Our program offers a model for training of residents in communication skills and management of sexual problems. The difficulties in implementation and overcoming institutional barriers to curriculum reform are addressed.

Psychotherapeutic interventions for treating female sexual dysfunction.

Abstract. A review of the current approach to the assessment and treatment of female sexual disorders from a sex therapy perspective is described. The importance of a comprehensive evaluation of both the woman and her partner, prior to formalizing a treatment plan, is stressed. Certain interventions are common in the treatment of all female sexual difficulties, for example, education and information about female sexuality generally, communication training, non-demand pleasuring, and permission to engage in self-pleasuring. Specific interventions are also described for such issues as past sexual or physical trauma. The overall goal of treatment is increased pleasure and satisfaction, rather than perfect genital response. Finally, the factors associated with treatment success are noted along with the observation that these factors are the same factors that contribute to a successful outcome in any psychotherapeutic endeavor.

Determinants of sexual arousal and the accuracy of its self‐estimation in sexually functional males

Men with and without sexual dysfunction present with varying patterns of agreement between subjective estimates of sexual arousal and more objective psychophysiological measures of the same construct. This relative accuracy seems to be associated with sexual function, with men who have sexual dysfunction presenting less accurate estimations (mostly reporting below measured arousal levels). The purpose of this study is to clarify the processes underlying sexual arousal and the accuracy of its self‐estimation. We looked at potential predictors of sexual arousal (subjective and physiological) and accuracy in estimating objective sexual arousal in a sample of 60 sexually functional males. Predictors included pre‐existing sexual attitudes (erotophobia), both trait and state positive and negative affect, self‐focused attention, and interoceptive awareness. Results indicate that this sexually functional sample generally reported below their own erection level. Interestingly, trait negative affect was associated with somewhat lower levels of subjective arousal and higher levels of physiological arousal. On the other hand, state positive affect facilitated both subjective and objective arousal and increased somewhat the accuracy of estimates of erectile responding. Pre‐existing sexual attitudes as well as variations in self‐focused attention and interoceptive awareness evidenced little effect on sexual arousal or the accuracy of its estimation.

Attributions for sexual situations in men with and without erectile disorder: evidence from a sex-specific attributional style measure.

This study investigated the attributional styles of men with and without sexual dysfunction for both positive and negative sexual and general events using a sex-specific version of the Attributional Style Questionnaire (Sex-ASQ), and ascertained the preliminary psychometric properties of the measure. The Sex-ASQ was created by embedding 8 hypothetical sexual events (4 positive, 4 negative) among the original 12 events in the Attributional Style Questionnaire (ASQ; C. Peterson, A. Semmel, C. von Baeyer, L. Y. Abramson, G. I. Metalsky, & M. E. Seligman, 1982). The Sex-ASQ was completed by 21 men with a principal DSM-IV diagnosis of Male Erectile Disorder (MED) and 32 male control participants. The psychometrics of the Sex-ASQ were satisfactory, but with the positive sexual event scales found to be less stable and internally consistent than the negative sexual event scales. Reasons for modest reliability of the positive event scales are discussed in terms of the original ASQ. As expected, men with MED did not differ significantly from men without sexual dysfunction in their causal attributions for general events, indicating that both groups exhibited an optimistic attributional style in general. Also as predicted, men with MED made more internal and stable causal attributions for negative sexual events than men without sexual dysfunction, and also rated negative sexual events as more important. For positive sexual events, the 2 groups did not differ in attributional style, with both groups making more external/unstable/specific causal attributions than for positive general events. Differences between explanatory style for sexual versus nonsexual events found in both sexually functional and dysfunctional men lend support for explanatory style models that propose both cross-situational consistency and situational specificity.