Sexual medicine


Sexual medicine is a branch of medicine concerning the diagnosis, treatment, and prevention of disorders of sexual function. Examples of disorders treated with sexual medicine are erectile dysfunction, hypogonadism, and prostate cancer. Sexual medicine often uses a multidisciplinary approach involving physicians, mental health professionals, social workers, and sex therapists. Sexual medicine physicians often approach treatment with medicine and surgery, while sex therapists often focus on behavioral treatments.
While literature on the prevalence of sexual dysfunction is very limited especially in women, about 31% of women report at least one sexual dysfunction regardless of age. About 43% of men report at least one sexual dysfunction, and most increase with age except for premature ejaculation.

Scope

Sexual medicine addresses issues of sexual dysfunction, sex education, disorders of sex development, sexually transmitted infections, puberty, and diseases of the reproductive system. The field connects to multiple medical disciplines with varying degrees of overlap including reproductive medicine, urology, psychiatry, genetics, gynaecology, andrology, endocrinology, and primary care.
However, sexual medicine differs from reproductive medicine in that sexual medicine addresses disorders of the sexual organs or psyche as it relates to sexual pleasure, mental health, and well-being, while reproductive medicine addresses disorders of organs that affect reproductive potential.

History

The concept of sexual medicine did not arise in North America until the latter half of the 20th century, specifically around the time of the sexual revolution during the 1960s and 70s where the baby boomer generation had an increase in birth control pill use. Prior to that, open discussion of sex was seen as taboo. Psychoanalytic theories about sexuality, such as those proposed by Sigmund Freud and Helene Deutsch, were considered highly controversial. It was not until the post-World War II baby boom era and the sexual revolution of the 1960s and 1970s that sex, and subsequently sexual disorders, became a more accepted topic of discussion.
In fact, urologists were the first medical specialty to practice sexual medicine. Not only does their practice focus on the urinary tract, there is a large emphasis on male reproductive organs and male fertility. Today, sexual medicine has reached a wider range of medical specialties, as well as psychologits and social workers, to name a few.
What really opened the doors for the societal normalcy of sexual medicine was the Massachusetts Male Aging Study performed in 1994 that clearly defined erectile dysfunction as a condition that affects a large population of American males. It also had reported that, if possible, men would be willing to improve their sexual performance if a medication was deemed to be safe. On March 27, 1998, sildenafil citrate was approved by the Food and Drug Administration for the treatment of erectil ED. The approval of Sildenafil transformed the way America talked about a topic that was once very private before.

Diagnosis

Sexual medicine plays a role in a wide range of medical specialties, from a primary care provider to a sexual health physician to a sexologist. A physician's role in taking a sexual history is vital in diagnosing a patient who presents with a sexual dysfunction.
Unfortunately, there is some anxiety that arises when sex comes up for discussion, especially between a healthcare provider and their patient. It's reported that only 35% of primary care physicians have taken a sexual history and, due to this, there is a gap in acheiving holistic healthcare. Clinicians fear their patients are not willing to share information, but in reality, it may be that the provider is shying away from the discussion. This steering away can be a result of ack of training, lack of structured tools and knowledge to assess a sexual history, and fears of offending the patient. Thus, knowing how to take an objective sexual history can help a clinician narrow down the pathogenesis of their patient's sexual health problem.
Issues related to sexual or reproductive medicine may be inhibited by a reluctance of the patient to disclose intimate or uncomfortable information. Even if such an issue is on the patient's mind, it is important that the physician initiates the subject. Some familiarity with the doctor generally makes it easier for patients to talk about intimate issues such as sexual subjects, but for some patients, a very high degree of familiarity may make the patient reluctant to reveal such intimate issues. When visiting a health provider about sexual issues, having both partners of a couple present is often necessary, and is typically a good thing, but may also prevent the disclosure of certain subjects, and, according to one report, increases the stress level.
Taking a sexual history is an important component of sexual medicine when diagnosing a patient with a sexual dysfunction. A sexual history incorporates social, medical, and surgical patient information, and should touch on all factors that affect an individual's sexuality. Essentially, it is a conversation between a provider and patient geared towards obtaining information a patient's sexual health status. If this is done properly, it will be easier for the physician to address patient concerns on their issues and conditions. Some patients may not be comfortable in sharing information, but it is the role of the physician to create a comfortable and non-judgemental, private environment for their patient to speak openly.

Disorders of sexual function

Sexual dysfunctions are sexual problems that are continuous in a person's life, adding stress and difficulty to personal relationships. Congenital or acquired, these conditions refer to any pathology which interferes with the perception of satisfactory sexual health. Varied conditions include absent sexual organs, hermaphrodite and other genetic malformations, or trauma such as amputation or lacerations.
Examples of conditions which may be treated by specialists in this field include:
Female
Male
Non-exclusive
Once a diagnosis of sexual dysfunction has been made, treatment is often integrative and individualized. Sexual medicine experts aim to discover both the physical and psychologic factors that are the cause of an individual's sexual dysfunction.
Male sexual dysfunction
The most common male sexual dysfunction disorders are erectile dysfunction, low libido, and ejaculatory dysfunction.
Once etiology and cardiovascular risk factors for ED have been identified, lifestyle or non-pharmacological therapy can be initiated to mitigate risk factors. As of 2018, the American Urological Association ED guidelines recommend shared medical decision-making between patient and provider over first-, second-. and third-line therapies. However, phosphodiesterase-5 inhibitors, such as sildenafil and tadalafil, are often recommended due to their favorable efficacy and side effect profile and work by increasing the lifespan of the vasodilator nitric oxide in the corpus cavernosum. Alternative treatments for ED are the use of vacuum-assisted erection devices, intracavernosal injection or intraurethral administration of alprostadil, and surgery if necessary.
Treatment for decreased libido is often directed towards the cause of the low libido. Low levels of hormones such as testosterone, serum prolactin, TSH, and estradiol can be associated with low libido, and thus hormone replacement therapy is often used to restore the levels of these hormones in the body. Low libido can also be secondary to use of medications such as selective serotonin reuptake inhibitors, and so reduction of dose of the SSRI is used to improve libido. Additionally, low libido due to psychological causes is often approached with psychotherapy.
Similarly, treatment of ejaculatory dysfunction such as premature ejaculation is dependent on the etiology. SSRIs, topical anesthetics, and psychotherapy are commonly used to treat premature ejaculation.
Psychiatric Barriers
Sexual disorders are common in individuals with psychiatric disorders. Depression and anxiety disorders are strongly connected with reduced sex drive and a lack of sexual enjoyment. These individuals experience a decreased sexual desire and sexual aversion. Bipolar disorder, schizophrenia, obsessive–compulsive personality disorder, and eating disorders, are all associated with an increased risk of sexual dysfunction and dissatisfaction of sexual activity. Many factors can induce sexual dysfunction in individuals with psychiatric disorders, such as the effects of antipsychotics and antidepressants. Treatment may include switching medications to one with less sexual dysfunction side effects, decreasing the dose of the medication to decrease these side effects, or psychiatric counseling therapy.
Lifestyle Barriers
General health greatly relates to sexual health in both males and females. Sexual medicine specialists take into consideration unhealthy lifestyle habits that may contribute to the sexual quality of life of individuals who are experiencing sexual dysfunction. Obesity, tobacco smoking, alcohol, substance abuse, and chronic stress are all lifestyle factors that may have negative impacts on sexual health and can lead to the development of sexual dysfunctions. Both obesity and tobacco smoking have negative impacts on cardiovascular and metabolic function, which contributes to the development of sexual dysfunctions. Chronic smoking causes erectile dysfunction in men due to a decrease in vasodilation of vascular endothelial tissue. Alcohol dependence can lead to erectile dysfunction in mend and reduced vaginal lubrication in women. Long term substance abuse of multiple recreational drugs, leads to a decrease in sexual desire, inability to achieve orgasm, and a reduction of sexual satisfaction. Chronic stress may potentially contribute to sexual dysfunction, as it can induce high levels of cortisol, which may cause harmful effects in if it remains altered long term. High levels of cortisol have been shown to cause a reduction in gonadic steroids and adrenal androgens. Studies have shown that these steroids and adrenal androgens have effects on genital arousal as well as sexual desire.
Sexual medicine experts are responsible for promoting healthy lifestyle habits to their patients in order to help prevent sexual dissatisfaction. Adoption of healthy lifestyle routines include: avoiding drugs, smoke, and excessive alcohol, as well as incorporating regular physical activity accompanied by a balanced diet and use of stress-management strategies. These habits can be proposed before trying to incorporate pharmacological therapies and/or psychiatric therapies.

Sexual dysfunction in transgender persons

Limited research has been performed on sexual dysfunction in transgender patients, but preliminary research suggests that initiating a sexual relationship is difficult for some transgender patients. One recent study published in the Journal of Sexual Medicine surveyed 518 transgender individuals about sexual dysfunction and disturbances and reported that difficulty initiating sexual encounters and difficulties achieving orgasm were the most prevalent sexual dysfunctions experienced in the study sample.

Challenges in Sexual Medicine

While the awareness of sexual health importance has increased in regards to patients' general health and well-being, there is still a taboo that follows sexual health. The perception of sexual health varies among different cultures, as the notion is tied with many cultural norms, religion, laws, traditions, and many more. Therefore, sexual medicine is a very unique component in the medicinal practice that holds its own pack of challenges. The main obstacle that stands between these discussions have been reported as the lack of education regarding sexual issues in patients. The discussion of sexual health and taking a sexual history faces barriers as physicians infrequently address these topics in visits, and patients are reluctant to discuss openly due to the perception that it is the physician's duty to initiate the topic and fears that the conversation will make the physician uncomfortable.
Another challenge in sexual medicine is that in a standard process of drug discovery and development, human tissue and cells are not used in testing the candidate drug. Instead, animal models are often used to study sexual function, pathophysiology of diseases that cause sexual dysfunction, and new drugs. Pharmacokinetic and pharmacodynamic relationships are studied in animal models to test the safety and efficacy of candidate drugs. With animal models, there is a limitation to understanding sexual dysfunction and sexual medicine, as the results achieved can only mount to predictions.
Identification and treatment of female sexual dysfunctions are also a challenge as women often encounter difficulty within multiple disorders and sexual phases. The various sexual phases that are encompassed within female sexual dysfunctions include hypoactive sexual desire disorder, female sexual arousal disorder, female orgasmic disorder and female sexual pain disorders. Because many of these domains overlap, it is difficult to identify the target of treatment and many limitations are placed in the approach for research. Risk factors for female sexual dysfunctions were observed to be embedded with biopsychosocial aspects in epidemiological studies such as depression, urinary tract symptoms, cancer and cancer treatment, relationship problems, and menopausal transition. As a result, a multidimensional approach must be taken in the identification and treatment of female sexual dysfunctions.