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Sexual medicine or psychosexual medicine as defined by Masters and Johnsons in their classic Textbook of Sexual Medicine, is "that branch of medicine that focuses on the evaluation and treatment of sexual disorders, which have a high prevalence rate." 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.
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.
In fact, urologists were the first medical specialty to practice sexual medicine. Not only does their practice focus on the urinary tract (the kidneys, urinary bladder, and urethra), 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 psychologists and social workers, to name a few.
What really opened the doors for societal normalcy of sexual medicine was the Massachusetts Male Aging Study performed in 1994 that clearly defined erectile dysfunction (ED) 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 (FDA) for the treatment of ED. The approval of Sildenafil transformed the way America talked about a topic that was once very private before.
There is some anxiety that arises when sex comes up for discussion, especially between a healthcare provider and an individual. It is reported that only 35% of primary care physicians have taken a sexual history and, due to this, there is a gap in achieving holistic healthcare. Clinicians fear individuals 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 lack of training, lack of structured tools and knowledge to assess a sexual history, and fears of offending individuals they are treating. Thus, knowing how to take an objective sexual history can help a clinician narrow down the pathogenesis of an individual's sexual health problem. (2026). 9789811312250 ISBN 9789811312250
Issues related to sexual or reproductive medicine may be inhibited by a reluctance of an individual to disclose intimate or uncomfortable information. Even if such an issue is on an individual's mind, it is important that the physician initiates the subject. Some familiarity with the doctor generally makes it easier for people to talk about intimate issues such as sexual subjects, but for some people, a very high degree of familiarity may make an individual reluctant to reveal such intimate issues. 'The Cringe Report' By Susan Quilliam. Posted: 28 June 2011; J Fam Plann Reprod Health Care. 2011;37(2):110–112. When visiting a health care 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 an individual with a sexual dysfunction. A sexual history incorporates social, medical, and surgical information, and should touch on all factors that affect an individual's sexuality. Essentially, it is a conversation between a health care provider and an individual that is geared towards obtaining information about the person's sexual health status. If this is done properly, it will be easier for the physician to address concerns the individual may have. Some people 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 those they are working with to speak openly.
Sexual dysfunctions in men are often associated with testosterone deficiency. Signs and symptoms of testosterone deficiencies vary in each individual. Therefore, physical examinations could be done for men who suspect testosterone deficiencies to identify physical signs of the disorder. Common physical signs include fatigue, increased body fat, weight gain, muscle weakness, and depressed mood.
Laboratory tests may also be used to assist with diagnosis, such as blood glucose levels, lipid panel, and hormonal profile. Additionally, diagnostic categories of sexual disorders are listed in both the ICD-10 and DSM-5. ICD-10 categorizes the disorders by sexual desire, sexual arousal, orgasm, and sexual pain, while DSM-5 categorizes the dysfunctions by gender, substance/medication induced, paraphilic, or gender dysphoria.
Sociocultural factors may also contribute to sexual problems, such as personal, religious, or cultural beliefs about sex. Personal well-being may also impact an individual's sexual activity. Stress and fatigue may contribute to developing a decreased sexual response or interest. Fatigue may result from poor sleep or another underlying medical problem. Current or past sexual abuse, whether physical or emotional, is also a risk factor for developing sexual problems.
Examples of conditions which may be treated by specialists in this field include:
Female
Male
Non-exclusive
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 (AUA) ED guidelines recommend shared medical decision-making between patient and provider over first-, second-. and third-line therapies. However, phosphodiesterase-5 (PDE5) inhibitors, such as sildenafil (Viagra) and tadalafil (Cialis), 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 (prostaglandin E1), 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 (SSRIs), 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.
Treatment approach is dependent on the type of dysfunction the women is experiencing.
The treatment of female sexual dysfunction is varied as multiple causes are often identified. Following evaluation of symptoms and diagnosis, the woman's goals for treatment are determined and used to track progress. Health professionals are also trained to include the woman's sexual partner in the treatment plan, including noting any sexual dysfunction of the partner. Referral of the woman or couple to a sex therapist is also common to increase communication and expression of concerns and desires. Finally, conditions associated with the documented sexual dysfunction are simultaneously treated and included in the treatment plan.
Non-pharmacologic treatment for female sexual dysfunction can include lifestyle modifications, biofeedback, and physical therapy. Pharmacologic therapy can include topical treatments, hormone therapy, antidepressants, and muscle relaxants.
In fact, low sexual desire is the most common sexual problem for women at any age. With this, sexual ideas and thoughts are also absent. Counseling sessions addressing changes the couple can make can improve a woman's sexual desire.
Sexual pain is another large factor for women, caused by Genitourinary Syndrome of Menopause (GSM), which includes hypoestrogenic vulvovaginal atrophy, provoked pelvic floor hypertonus, and vulvodynia. These can all be treated with lubricants and moisturizers, estrogen, and ospemifene.
Sexual medicine experts are responsible for promoting healthy lifestyle habits 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.
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. Pharmacokinetics and Pharmacodynamics 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 (FSD) include hypoactive sexual desire disorder (HSDD), female sexual arousal disorder (FSAD), female orgasmic disorder (FOD) and female sexual pain disorders (FPD). 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.
The issue of psychological dilemmas that are associated with sexual dysfunctions is another challenge that is faced in sexual medicine. There are many psychological aspects that are tied in with sexual dysfunctions. Despite much of sex therapy originating from psychological and cognitive-behavioral practices, many of the psychological dynamics have been lost in the sexual medicine protocols. Approaching from a psychological and existential perspective helps link the understanding between sexual function and sexual dysfunction in the individual. Because the psychological aspects underneath the sexual distress are not being addressed within sexual therapy and treatments are mostly focused on the specific symptoms in sexual medicine, there are many situations where individuals still experience disappointment and dissatisfaction within sexual activities despite the dysfunction being resolved.
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