Original Research

International Journal of Impotence Research (2004) 16, 130–134. doi:10.1038/sj.ijir.3901179 Published online 12 February 2004

Cost implications of sexual dysfunction: the female picture

D Goldmeier1, F Malik2, R Phillips3 and J Green1

  1. 1St Mary's Hospital, London, UK
  2. 2M Pharmacia, Ltd, High Wycombe, UK
  3. 3The Goffin Consultancy, Kent, UK

Correspondence: D Goldmeier, Jane Wadsworth Sexual Function Clinic, Jefferiss Wing, St Marys Hospital, Praed Street, London, W2 1NY, UK. E mail: david.goldmeier@st-marys.nhs.uk

Received 23 December 2002; Revised 19 March 2003; Accepted 31 March 2003; Published online 12 February 2004.

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Abstract

This study examined the clinical workload, outcome and direct costs of managing women with sexual dysfunction in an NHS clinic in the UK. A retrospective analysis of a 3-month period showed that of 47 referrals to the clinic, 38 undertook treatment. The therapists' assessments suggested that over 80% of patients improved on treatment. The average cost per patient was £472 (compared to £335 per annum for erectile dysfunction, which included physician's and drug costs). The average cost by type of practitioner was £278 (psychologist), £322 (physician), £532 (physician and psychologist) and £597 (sex therapist). Patients required between 1 and 51 treatment sessions, which were mainly restricted to psychological therapy. Female sexual dysfunction (FSD) represents a significant economic burden to the NHS. Further research on the potential role and cost effectiveness of pharmacological agents for FSD is warranted.

Keywords:

psychological analysis of female sexual dysfunction

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Introduction

Female sexual dysfunction (FSD) is an age-related, multifactorial and highly prevalent syndrome affecting 20–50% of women.1,2,3,4 Four general categories of FSD have been identified: hypoactive sexual desire disorder, sexual arousal disorder, female orgasmic disorder and sexual pain disorders as well as vaginismus.5

The prevalence of FSD is estimated to be higher than male sexual dysfunction. The US National Health and Social Life Survey of 3000 men and women found that 43% of women reported sexual dysfunction compared to 31% in men.6 However, previous work suggests that FSD remains an underdiagnosed and undertreated problem.7 There may be a number of reasons for this, which include reluctance of women to come forward for treatment as well as the current lack of simple and effective pharmacological agents to treat FSD. In contrast, the management of male sexual dysfunction receives a high level of interest due in part to the availability of effective pharmacological treatments (eg sildenafil, alprostadil and apomorphine). This study was conducted to review the clinical workload and management of patients attending the sexual function clinic at St Mary's Hospital specifically because of FSD problems. To our knowledge, this type of study has not previously been reported in the literature.

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Methodology

A clinical audit (retrospective analysis) of patients attending the Jane Wadsworth Clinic was conducted. Ethics approval was not required as clinical audits are encouraged as a method of monitoring and improving the routine management of patients at St Mary's Hospital. This study was conducted from the perspective of the NHS Trust (St Mary's Hospital).

All FSD patients attending the Jane Wadsworth sexual function clinic from May to July 2002 were included in this study. This sample of patients consisted of new patients referred from other areas of the NHS in addition to 'walk-in' patients at the clinic and patients attending for the management of their FSD. Patients' records were reviewed from first presentation at the clinic to end of August 2002 or completion of therapy, if sooner.

Data were obtained on patients' age, specific type of dysfunction, type of therapy sessions, duration and number of sessions. Direct medical costs were calculated and included practitioner time, laboratory investigations, referral to other health-care workers and any pharmacological agents prescribed. These data were obtained from patient records at St Mary's. Additional resources used outside the clinic were tabulated as appropriate and are termed 'ancillary management'. All cost data were obtained from St Mary's hospital (accounting department). Personnel costs were estimated based on a full-time equivalent direct salary cost to the NHS. These were estimated at £43.96 per hour for physicians, £21.98 per hour for psychologists and £33.33 per hour for sex therapists. Costs for other health-care workers, laboratory costs and pharmacological agents prescribed were also obtained from St Mary's hospital and calculated accordingly.

Treatment success was assessed by the treating practitioner using a five-point Likert scale (much improved, improved, same, worse or much worse). Where therapy was ongoing, practitioners were asked to estimate the projected outcome together with the additional number of therapy sessions necessary to complete therapy. As this was a retrospective study, we have no data on either the patient's assessment of their response to treatment or that of their partners.

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Results

A total of 47 women aged between 20 and 55 y with sexual dysfunction were referred to the Jane Wadsworth clinic (see Figure 1).

Figure 1.
Figure 1 - Unfortunately we are unable to provide accessible alternative text for this. If you require assistance to access this image, please contact help@nature.com or the author

Patients' age at presentation.

Full figure and legend (59K)

Patients were seen either by individual practitioners, that is, psychologists, sex therapists, physicians or by physicians and psychologists working together in 'conjoint clinics'.

Patients were assigned to the practitioners according to the type of diagnosis and availability of practitioners. Generally, the more complex cases were assigned to conjoint clinics and the relatively easy cases to sex therapists. Once patients were assigned to a practitioner, all subsequent therapy sessions took place with the same practitioner. Therapy sessions varied according to the type of practitioner, illustrated in Table 1.


In the sample of 47 patients, 18 (38%) were booked for a conjoint clinic, 16 (34%) patients were booked to see a psychologist, 10 (21%) to see a sex therapist and the remaining three (6%) to see a physician. However, two patients were referred to other specialists and a further seven did not attend their therapy sessions.

Of the 38 patients who attended therapy sessions, 31 (82%) had a diagnosis for one type of FSD; the remaining seven (18%) patients were diagnosed with more than one type of FSD. The distribution of these diagnoses is shown in Figure 2.

Figure 2.
Figure 2 - Unfortunately we are unable to provide accessible alternative text for this. If you require assistance to access this image, please contact help@nature.com or the author

Diagnoses—all patients.

Full figure and legend (57K)

Figure 3 illustrates the distribution of the number of therapy sessions attended by patients (n=38). There is a wide variation in the number of therapy sessions, which range between 1 session (two patients) and 51 sessions (one patient). In all, 25 patients (66%) had between 1 and 10 sessions and the remaining 13 (34%) received between 11 and 51 sessions.

Figure 3.
Figure 3 - Unfortunately we are unable to provide accessible alternative text for this. If you require assistance to access this image, please contact help@nature.com or the author

Number of therapy sessions.

Full figure and legend (58K)

Patient outcome was evaluable in 19 patients who had completed therapy and estimated for 13 patients with incomplete therapy. Patient outcome could not be evaluated in six (16%) patients, six (16%) patients' outcome remained the same, 18 (47%) were improved and eight (21%) were much improved (Figure 4).

Figure 4.
Figure 4 - Unfortunately we are unable to provide accessible alternative text for this. If you require assistance to access this image, please contact help@nature.com or the author

Clinical outcome in sample of 38 patients.

Full figure and legend (37K)

In patients with an evaluable outcome, the success rates defined as patients who improved or were much improved at the end of their therapy (n=32) is illustrated in Table 2. Physicians had the highest success rate at 100%, followed by conjoint clinic (83%), sex therapist (75%) and psychologists (67%).


The cost of managing 38 FSD patients at the Jane Wadsworth clinic is estimated at £17 952 with an average cost per patient of £472 (see Table 3). The total and average costs varied according to the type of practitioner. The average costs per patient by type of practitioner were £597 (sex therapist), £532 (conjoint), £322 (physician) and £278 (psychologist).


In this sample, 11 (29%) received medical treatment considered ancillary to their FSD. All patients were seen either by a physician or jointly with a psychologist. Details of ancillary management of the 11 patients, together with the estimated cost per patient are shown in Table 4. The additional costs for the ancillary management of FSD range between £60 and £1057.


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Discussion

The total number of women with sexual dysfunction treated at the Jane Wadsworth clinic is small, 47 during the 3-month period reviewed or an estimated 152 patients annually. Two patients were referred to other specialists, as their primary diagnosis was not FSD. In addition, seven patients did not attend their therapy sessions. This may be due to long waiting times (often 6 months in our clinic and up to a year in others) for the initial appointment. Thus a total of only 38 patients could be included in the analyses.

Of the 38 patients who did attend therapy sessions, 31 (82%) patients were diagnosed with one subtype of FSD and the remaining seven (18%) patients had two or more subtypes of FSD. A wide variation in the number of therapy sessions required to complete treatment was observed, ranging between 1 and 51 sessions. Patient outcome improved in 24 (68%) of patients, six (16%) remained the same and six (16%) were unevaluable.

A wide variation in practitioner success rates was observed; physicians had the highest success rate at 100%, followed by conjoint clinic (83%), sex therapist (75%) and psychologists (67%). However, this analysis did not attempt to adjust for any potential bias in the allocation of patients to type of practitioners. Indeed, the more difficult cases are more likely to be allocated to conjoint clinics and the relatively easy cases managed by the sex therapists. The remaining patients were allocated according to the availability of practitioners and the need to reduce waiting lists.

The average cost per patient is approximately £472. The costs of managing FSD patients vary according to the type of practitioners ranging from £278 per patient for psychologist to £597 per patient for sex therapists. Based on a sample of 800 men, the direct medical cost of treating male sexual dysfunction patients at our clinic is about £335 per annum. This includes physician time plus the annual costs of sildenafil (100 mg taken once weekly).

The literature demonstrates that male sexual dysfunction significantly impairs quality of life and that treatment with drugs such as sildenafil is indeed cost effective.8 Furthermore, the cost effectiveness of sildenafil compares favourably with that of accepted therapies for other medical conditions.9

The current management of FSD is largely limited to cognitive behaviour and other forms of nonpharmacological therapy, and this is reflected in the wide variety of practitioners who undertake it in our clinic. Treatment length and success rates for psychotherapy in FSD are very similar to rates observed in men with ED prior to the introduction of intracorporeal injections and other pharmacological treatments such as sildenafil.10 Psychological therapy may produce lasting beneficial effects with limited or infrequent follow-up therapy required.

There are, however, a number of current pharmacological therapies that may be useful for women with FSD. The media have repeatedly suggested that the 'little blue pill' will soon be available for women with FSD. Recent studies suggest that pharmacological therapy may indeed increase subjective parameters in women with arousal and/or desire problems who were postmenopausal or posthysterectomy (but not oestrogen or androgen deficient),11 or who were taking SSRI antidepressants.12 More surprising is the subjective improvement noted on high-dose local alprostadil application in women with arousal difficulties.13 Androgen replacement therapy probably has a place in women who have a truly low testosterone level and also low sexual desire. Guidelines for such therapies have been discussed elsewhere.14,15,16 There is little doubt that novel pharmacological agents that effectively and safely increase sexual desire and arousal would be of benefit to both patients and practitioners.

In other behavioural problems, group therapy has been shown to be cost effective.17 In a recent study, group therapy has been shown to yield successful outcomes in women with FSD18 and indeed may be more cost-effective than individual therapy. However, group therapy in patients with sexual dysfunction may be difficult to implement due to the sensitive nature of this condition.

Female sexual desire and arousal are responses that are context related unlike stimulus-related desire and arousal in men. Thus female sexual function and FSD should not be equated with male sexual function, because that would ignore major components of women's sexual satisfaction, which include affection, communication, respect and the ability to be vulnerable.19,20 Treatment for FSD we believe should always include sexual, relationship, psychological and pharmacotherapy, if available and appropriate, within the context of the patient's socioeconomic and cultural background.

The majority of patients in this study attended the clinic with their partners. Other researchers have shown that the principal predictor for completion of treatment in women with low sexual desire is the male partner's attendance and motivation.21

In our study, few women with genital pain syndromes presented because such patients were referred to a number of other in-house specialist clinics other than our own. Vulval pain is seen in 13% women who come to our walk in clinics for screening for sexually transmitted diseases and vulvar vestibulitis in 5%.22 Pain control of vulvar vestibulitis in many patients responds to vestibulectomy, antidepressants or gabapentin.23,24,25 However, sex therapy and biofeedback are necessary for the patients to again have enjoyable and satisfactory intercourse.26

There is clear evidence in the literature to demonstrate that FSD is a significant health problem for patients and their partners, and yet women may not come forward to present their FSD. A study undertaken at our unit, however, showed that of such women 60% would want treatment of their FSD.7 However, the waiting lists to see specialists are often extensive with many patients having to wait at least 6 months before seeing a consultant. The introduction of effective pharmacological and other treatments has the potential to reduce waiting lists significantly. Patients may require fewer therapy sessions and therefore practitioners' time could be made available to manage patients currently on waiting lists.

This is the first study to comprehensively review the current management of FSD in the UK. This study demonstrates nonpharmacological therapy for FSD is both challenging and costly to the NHS. Pharmacological therapy in men has been shown to be cost effective and the potential cost effectiveness of pharmacological treatment for FSD should be explored.

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