For Clinicians

Unsure how to start the conversation? Try one of these open-ended questions or phrases to normalize the discussion and invite your patients to open up about any concerns and/or use one of the validated screening tools in the Clinical Resources section below.

• It is part of my routine to ask about sexual health as part of the well-woman visit. Tell me about any sexual concerns/problems/issues you may be having.
• How do you think this sexual problem may be affecting your relationship or your life in general?
• What distresses you the most about this sexual problem?
• What techniques have you tried to manage the problem so far?
• Do you have any medical conditions that affect your quality of life, including your sexual health?
• What would a successful resolution of your sexual problem(s) look like?
• Tell me about the conversations you have had with your partner so far about this problem.

You can also start with a close-ended question that solicits a direct answer (e.g. Does sex hurt? Are you sexually satisfied?), but be sure to follow it up with another open-ended comment to allow further expansion of the problem (e.g., Tell me more. What do you mean by that?).

Now that you are on the subject of sex, you can ensure a more productive conversation by using one of these models to guide you. Also consider sharing one of the patient handouts linked in the Clinical Resources section below.

The PLISSIT (Permission, Limited Information, Specific Suggestions, Intensive Therapy) model offers the following guidance:

• Ask open-ended questions during routine history to give the patient Permission to talk about her sexual concerns and reassure her that her feelings are normal and acceptable (see examples above). Follow-up on her responses.
• Provide Limited Information, such as:
  1. 1. Education about female pelvic anatomy, the sexual response cycle, or the neurobiological etiology of sexual problems
  2. 2. Discuss changes in sexual function throughout the lifecycle
  3. 3. Explain that sexual interest or desire may not be the first stage in response, and women may not experience orgasm 100% of the time
• Address the most important topics that you can in the limited time you have available; do not feel pressured to cover it all in one visit
• Encourage a follow-up appointment to focus solely on sexual health concerns
• Offer Specific Suggestions and solutions to treat the problem (e.g., use lubricant, over-the-counter moisturizers, or appropriate prescription products; plan date nights and make sexual behavior a priority; improve diet, exercise, and sleep patterns to help overall mood)
• Beyond providing basic information and suggestions, many providers will want to refer a patient, possibly for Intensive Therapy, to qualified sexuality specialists. See the Clinical Resources section below for tools to help you find a sexual health provider or sex therapists in your area.

Recommendations for the clinical evaluation of men and women with sexual dysfunction (Hatzichristou D, Rosen RC, Derogatis LR, Low WY, Meuleman EJH, Sadovsky R, and Symonds T. Recommendations for the clinical evaluation of men and women with sexual dysfunction. J Sex Med 2010;7:337–348.)

The Decreased Sexual Desire Screener (DSDS) is a simple, 5-question, validated screening tool designed to help you assess sexual problems and diagnose generalized, acquired hypoactive sexual desire disorder (HSDD). The first 4 YES/NO questions address the diagnostic criteria for low sexual desire and associated distress. The fifth question (patient circles all factors that may apply) helps rule out other potential medical conditions and other psychiatric problems. (Clayton AH, et al. J Sex Med. 2009;6:730-738). Note: circling any part of number 5 does not preclude HSDD and instead warrants further discussion.

The DSDS includes the following questions:

• In the past, was your level of sexual desire or interest good & satisfying to you?
• Has there been a decrease in your level of sexual desire or interest?
• Are you bothered by the decreased level of sexual desire or interest?
• Would you like your level of sexual desire or interest to increase?
• What factors do you feel may be contributing to your current decrease in sexual desire or interest?
  • An operation, depression, injuries, or other medical condition
  • Medications, drugs, or alcohol you are currently taking
  • Pregnancy, recent childbirth, menopausal symptoms
  • Other sexual issues you may be having (pain, decreased arousal or orgasm)
  • Your partner’s sexual problems
  • Dissatisfaction with your relationship or partner
  • Stress or fatigue
• HerHSDD Decreased Sexual Desire Screener

North American Menopause Society’s (NAMS) MenoNotes

• NAMS Find a Menopause Practitioner
• International Society for the Study of Women’s Sexual Health’s (ISSWSH) Find a Provider
• American Association of Sexuality Educators Counselors & Therapists’ (AASECT) Locate a Professional

• ISSWSH Process of Care for Management of Hypoactive Sexual Desire Disorder in Women
• Implementation of the HSDD Process of Care into Clinical Practice

Female sexual dysfunction (FSD) diagnoses were developed through the American Psychiatric Association and are listed in the Diagnostic and Statistical Manual (DSM). According to the fifth edition, DSM-5, in order to meet diagnostic criteria, a person must experience the female sexual dysfunction condition 75%-100% of the time for at least 6 months and it must result in significant distress. The disorder must not better be explained by a nonsexual mental disorder, a consequence of severe relationship distress such as domestic violence, or other significant stressors. Because DSM-5 has not been universally adopted, DSM-IV diagnoses are also included below.

Providers must translate DSM diagnoses into billable codes using the International Classification of Diseases (ICD). The tenth edition (ICD-10) is currently used and the eleventh edition (ICD-11) will be effective in 2022.

• Omnia Education: Female Sexual Dysfunction
  • Counseling Your Patients About Hypoactive Sexual Desire Disorder and Advances in its Diagnosis and Treatment*
  • Closing the Circle in Hypoactive Sexual Desire Disorder: Communication, Diagnosis, & Treatment*
  • Current and Emerging Approaches to Diagnose and Manage Hypoactive Sexual Desire Disorder
  • Hypoactive Sexual Desire Disorder: New Strategies for Patient Counseling, Diagnosis, and Management*
  • Dyspareunia: Enhancing Diagnosis and Management via Enhanced Patient/Clinician Discussion*
  • Dyspareunia: Best Practices in Counseling, Diagnosis, and Therapy*
  • *Supported by an independent educational grant from AMAG Pharmaceuticals, Inc.
• HerDesire.net: A CME-certified initiative committed to alleviating symptoms of Hypoactive Sexual Desire Disorder through education about screening, diagnosis, treatment and long-term management.*
  • *Supported by an independent educational grant provided by AMAG Pharmaceuticals Inc. and Sprout Pharmaceuticals, Inc.
• NPWH
  • Course on Sexual Health: Intended for NPs, CNMs, and other advance practice clinicians
  • “Treatment of Decreased Sexual Desire in Women”