Jacques BUVAT, Lille, France
The third Female Sexual Function Forum was again organized in Boston by Dr Irwin Goldstein. It included 9 Grand Master Lectures, 6 Symposia, 20 Podium Presentations. 73 moderated Poster Presentations and 3 Break-out sessions dedicated to discussions of patient management. It was a real success by the number and the enthusiasm of the attendees, the quality of many or the oral presentations, even if a part of the poster presentations were not rigorous enough, and the time allowed for lively discussions. During the business meeting the decision was taken to create a new society exclusively devoted to Female Sexual Function and Dysfunction.
GRAND MASTER LECTURES
John Bancroft reported on a telephone survey of 1030 women organized by the Kinsey Institute about their sexual well being in heterosexual relationship .
The conclusions were that the general well being reflects the sexual well being and subject sexual response. In women interactive aspects are more important than orgasm, and there was racial differences in the parameters evaluated .
The main determinants of sexual well being according to stepwise multiple regression analysis were in order of importance : 1. general well being, 2. subjective sexual experiences, 3. attractiveness of partner, 4. sexual response, 5. frequency of sexual activity with partner, 6. partner sensitivity, 7. subject’s health, 8. partner’s health .
Marcalee Sipski reported on a double-blind crossover study comparing the effects of sildenafil (50mg) to those of a placebo taken one hour before audiovisual erotic stimulation administered alone, then in addition to manual genital self stimulation, in 19 women with spinal cord injury. Results revealed significant increase in subjective arousal with drug alone and drug + sexual stimulation (p < 0001), with a borderline significant effect of drug administration on vaginal pulse amplitude.
This study supports further evaluation of the efficacy of sildenafil in improving sexual responsiveness in women with SCI and other types of neurogenic sexual dysfunctions.
Anne Davis reviewed the literature regarding oral contraceptives and female sexual interest .There are serious limitations in many of the studies. Three of the four available randomized controlled studies show modest decrease in libido associated with combined oral contraceptives .However these results were population dependent and these 3 studies have been conducted in sterilised women, or in women treated for Premenstrual Syndrome. The result could have been different if the pill had been used in a primary contraceptive purpose when taking in account the potential positive effect on libido resulting from an effective contraception .
In addition John Bancroft outlined during the discussion that according to his experience several studies may have been biased by a rapidly occurring drop out of women, due to the mood or libido lowering effects of the combined pill.
George Nurnberg reviewed the literature on the SSRI/antidepressant associated sexual dysfunction with a special attention to women. This drug-induced sexual dysfunction which was a long time under recognized and under reported occurs in 45% to 60% of patients prescribed SSRI’s. Women are overrepresented, more severely affected and respond differently than men. Previous generally inconsistent therapeutic approaches with serotonin antagonist , dopaminergic agonists, alpha adrenergic auto-receptor antagonists stimulants, drug holiday, watchful waiting for tolerance, dose reduction and herbals, as well as substitution by novel non SSRI-antidepressant agents were reviewed. Sildenafil recently emerged as the first agent to demonstrate significant improvement of SSRI-antidepressant associated sexual dysfunction in randomized placebo controlled fashion, initially in men and more recently according to their preliminary experiences, in women, the primary effect in women being on arousal lubrication and not on orgasm or libido. According to the lectures, sildenafil should be considered a first line treatment for this troublesome side effect, and could hence increase the compliance and effectiveness of antidepressant therapy .
Cindy Meston, from the university of Texas, reported on the development and validation of the Female Sexual Function Index (FSFI) a new tool for the study of female sexual arousal disorder .The final version consists of 19 items.
This psychometrically sound questionnaire is easy to administer and has demonstrated ability to differentiate between women with and without sexual arousal disorder .
François Giuliano presented a comprehensive review on the neurophysiology and pharmacology of female sexual response . Few data are available in women and most come from studies in rats where the female sexual behaviour is clearly different from that in humans. He also pointed that in humans, the implication of the central drive differs greatly between the two genders. In men the ability to get and maintain a good erection is sufficient for their feeling of being a performant, and consequently adequate, sexual partner, while in women there is no such physiologic performance and the feeling of sexual arousal results more from cognitive processing of stimulus meaning and content than from peripheral.
R. Basson, from Vancouver, presented a new model of the women’s sexual desire. Rather than suggesting that a kind of sexual hunger necessarily initiates a women’s sexual experiences as in the traditional sex response cycle of Master, Johnson and Kaplan, reflected in DSM-IV dysfunctions, more in line with the new AFUD concept of women having also responsive/receptive desire, an alternative cycle reflects that the woman’s “motor” or force underlying the cycle may be her desire for increased emotional intimacy with her partner. Thus woman’s sexual desire, at least in longer term relationships, may be predominantly an emotional / intimacy based entity .
Its biological underpinnings simply allow sexual repercussions (physical and subjective ) which, in their turn, have powerful emotional meanings, thereby enhancing, or in women with desire problems potentially diminishing, the effectiveness of sexual stimuli that are needed to trigger her inherently responsive desire. On the other hand there is an apparent “spontaneous” sexual desire, or “hunger”, which can influence various parts of the preceding cycle. However it seems that this preceding cycle (emotional intimacyè sexual stimuli è sexual arousal è sexual desire and arousal ) can be repeatedly experienced in a positive healthy manner without the influence of conscious spontaneous “hunger”. This cycle, especially the power behind it, is highly vulnerable, partially accounting for the high frequency of “women’s sexual desire disorder”.
Lastly, Susan S. Allen, director of the division of Reproductive and Urologic Drug products at the Food and Drug Administration, presented an overview of regulatory and drug development issues related fo Female Sexual Dysfunction, and finished her talk with a summary of a recently published Guidance Document related to drug development in this indication.
Female pelvic floor disorders and sexual dysfunction :
Following superbly illustrated talks by Pr Shlomo Raz and Dr Jennifer R. Berman on anatomy, physiology and surgical interventions in Female Sexual Dysfunction related to pelvic floor prolapse, Irv Binik, a professor of physiology at the McGill University of Montreal debated the vaginal /pelvic floor spasm as diagnostic criterion of vaginismus according to the result of an empirical study done in his department. Two gynecologists and two pelvic floor physical therapists examined 29 vaginistic women and two matched control groups of 29 women with vulvar vestibulitis syndrome suffer and 29 women with no penetration or pain problems with intercourse. Women also filled out different questionnaires and underwent vaginal surface EMG testing .Vaginal spasm didn’t characterize women diagnosed with vaginismus by two different psychologists, nor did it differentiate women with vaginismus from matched controls. The reliability of the assessment of spasm within and between professionals was poor. However women with vaginismus demonstrated higher levels of chronic vaginal tension . The degree of interference with intercourse regardless of the presence of spasm differentiated diagnostic groups. Vaginismus seemed more a specific reaction to a generalized pain disorder than a true sexual dysfunction.
Lastly, Alessandra Grazziottin, examined in an elegant and comprehensive overview the interest of pelvic floor rehabilitation in hyper and hypotonic conditions. The association between coïtal anorgasmia and an hypotonic levator ani, a condition generally secondary to vaginal delivery and possibly associated with incontinence, was known since the initial description by Kegel. It is only more recently that the possible implication of an hypertonic levator ani in the etiology or maintenance of sexual pain disorders has been suggested. She proposed treatment guidelines for perineal cinesitherapy and biofeedback treatment, which have the potential to improve the sexual response, besides the improvement of different urologic, gynaecologic and proctologic disorders.
Sexual abuse and sexual function :
Elaine J. Alpert introduced the symposium by reporting on available statistics in the USA . The one year incidence of rape and sexual assault in both genders is of 0,3 % (302,100) over 18, and of 432,100 over 12 , of which only 28 % are reported to police (57% if assailant was a stranger, 18% if the assailant was an intimate partner). The lifetime prevalence is of 18% (one person in 6). This crime is committed primarily by intimate partners (22%), family members (26%), friends and acquaintances (35%), and more rarely by strangers (11%). It is committed primarily against children (54% of the victims are