This POC defines the role of clinicians in addressing FSDs for both core and advanced levels of engagement. Core level skills are proposed as both necessary and sufficient for effective basic management of women with FSD and are designed with the recognition that some patients whose sexual problems are identified will be referred to sexual health experts. Advanced level skills describe professional competencies for clinicians with greater interest in women's sexual health and sexual medicine specialists ( Figure 1 ).

To encourage all practitioners to address sexual function in their patients, it is important to emphasize that even the most basic assessment can be useful and limited to a small number of specific questions with minimal time involvement. Three questions ( Figure 2 ) can suffice for a basic assessment.It is essential to inquire about the gender of partners. It is important not to make assumptions about sexual orientation and behavior, as not all patients identify as heterosexual or engage exclusively in heterosexual sexual behaviors even if they label themselves as such.

Another strategy is to inquire about sexual functioning in the context of a more general discussion about the patient's intimate relationships. A broad open-ended question, such as “How are things going with your partner/spouse?” may elicit a comment about sexual concerns, and this can easily be followed by, “and how are you and your partner doing in terms of your sexual relationship?”

This screening assessment is an effective strategy for addressing sexual concerns and problems and can be used to address any awkward, socially undesirable, or stigmatizing topic.It begins with a universalizing and normalizing ubiquity statement that reassures the patient that sexual concerns are common, normal, and even expected.For example, “Many women who have reached menopause, like you, have concerns about sexual activity.” This normalizing, universalizing statement is followed by a closed-ended question, “Do you?” that acts as a screen. A positive response is then followed by an open-ended invitation, “Please, tell me about it,” to initiate the patient's narrative. Preceding the normalizing statement with a declaration that assessing sexual functioning is an important part of your usual history and physical examination with all your patients can help put patients at ease.

The framework for addressing women's sexual health begins with a mandate to screen for and detect sexual problems and concerns, followed by application of the 4-step model of care discussed later herein, when a sexual problem or concern is detected. The essential precondition for addressing FSD is to detect it. The most fundamental recommendation of this document is simply to ask about sexual satisfaction, concerns, or problems.

Four-Step Model

The 4-step model provides a framework for engaging with the patient. The 4 steps that follow screening and detection are as follows: step 1, elicit the patient's story; step 2, name and (re)frame attention to the sexual concern or problem; step 3, empathic witnessing; and step 4, referral or assessment and treatment.

After a problem is detected, step 1 is to elicit the story of the problem so that it can become the focus of attention (step 2). Empathic witnessing, step 3, reinforces the importance of the problem and validates the patient's efforts to address it. The first 3 steps serve as the foundation for recommending treatment or referral (step 4), which will often be the outcome of core level engagement.

Step 1. Elicit the Story The first step is to elicit a narrative description of the problem and it's affect on the patient's life, emotional state, and relationships. The goal is to help the patient discover and describe her distress, her functional impairment, and the effect the problem is having on her life. Patient-Centered Communication: Open-Ended Questions 37 Fortin A.

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et al. Effect of patient-centered communication training on discussion and detection of nonadherence in glaucoma. The core principles of patient-centered interviewing are to enable the patient to express what is important to her, to recognize her concerns and emotions, and to allow the interviewer to synthesize the biopsychosocial depiction of the patient's problem.Although patients prefer that the clinician bring up the topic, this interviewing style allows the patient to lead parts of the conversation so that her concerns and expectations can be heard.The most fundamental element of patient-centered communication is the use of open-ended questions to elicit the patient's story. Open-Ended Questions in Ask-Tell-Ask Sequences As clinicians elicit the patient's story, they also provide new information. Because clarity regarding the patient's understanding is essential to giving information, it is critical to ask the patient before telling the patient something new. With the first ask of an ask-tell-ask sequence the clinician will learn what the patient knows that is correct, mistaken, and the most useful information the patient can understand. The tell is then purposefully constructed to validate the patient's correct understanding, correct her mistaken beliefs, and add the next piece of information they are ready to hear. After new information is provided, a second ask should be used to learn whether the information had the intended effect and to iteratively continue the ask-tell-ask dialogue. Asking before telling helps the clinician stay on the thread of the patient's narrative and avoid providing information that will be confusing or to which the patient cannot respond. Bringing the “Pain” Into the Room The essential goal of a discussion about a sexual problem is to elicit the patient's story and bring the patient's emotional distress and impact of the dysfunction on the patient's life into the narrative (bringing the “pain” into the room). Normalizing emotional distress and then asking about it, essentially a reapplication of the ubiquity statement process focused on emotional distress, is an effective strategy for accomplishing this. In summary, the purpose of step 1 is for the clinician to expose the problem and elicit the magnitude of distress sufficient to justify declaring the problem worthy of clinical attention.

Step 2. Name and (Re)Frame Attention to the Sexual Problem or Concern Step 2 consists of naming and framing the problem. It does not require a precise or refined diagnosis at this point in the process. The essential task is to name and validate the importance of the sexual problem or concern in whatever form the patient and clinician understand it. The clinician can move on with additional assessment and more specific diagnosis, according to their level of engagement, as described in step 4. Patients may present with a concern that initially seems to be “the problem” but that turns out to be due to or accompanied by another equally or more important problem that they did not initially mention or that became apparent through the process of eliciting the story. This is often the case with sexual problems or concerns. In these circumstances the naming becomes a reframing, which is accomplished with the following generic statement: “It seems to me that in addition to your <initial complaint>, what you've just told me about your <sexual concern or problem> is just as painful, important, and worthy of attention.”

Step 3. Empathic Witnessing A patient-centered interview intrinsically witnesses the patient's story, and just listening is an empathic act. Empathic witnessing by a clinician is powerful and healing, and this effect is amplified when the clinician reflects her or his understanding of the patient's life and efforts in words. The strategy is to commend the patient on her efforts to address and cope with the issues and challenges she has revealed in her story. Empathic witnessing statements may take the following form: I am impressed with how committed you are to addressing <the sexual problem and its effects on your relationship/life> despite how difficult that is. You are <really beginning to take steps/determined> to try and solve <this problem>. Step 3, empathic witnessing, is really the beginning of treatment for many women, as the reflection and understanding it creates begin to solve the problem.

Step 4. Referral or Assessment and Treatment Step 4 offers 2 pathways that can be used singly or in combination. At this point, the clinician may choose to either refer to another clinician or specialist or continue with further assessment and treatment. As busy clinicians know, effective management of any clinical problem takes time. Sexual problems are not unique in this respect, but they do deserve time proportional to the effect that they have on the quality of patients' lives. A clinician should deal with the time required for addressing a sexual problem in the usual fashion by choosing to manage it at that appointment or to validate and schedule a follow-up visit. Whether the clinician manages the sexual problem herself or himself or elects to refer, the skills that follow will help with the execution of efficient history taking and construction of a therapeutic plan. The options in step 4 allow clinicians practicing at different levels of engagement to adjust the intervention to their skills, comfort, and resources.