Textbook of Female Sexual Function and Dysfunction E-Book

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 841

Veröffentlichungsjahr: 2018

Beschreibung

A comprehensive text on female sexual function and dysfunction that offers a multi-disciplinary, biopsychosocial approach to diagnosis and treatment Textbook of Female Sexual Function and Dysfunction offers a multi-disciplinary, biopsychosocial approach and provides guidance for the safe and effective diagnosis and treatment of various sexual health issues. With contributions from an international panel of experts, the text provides the scientific basis of the clinical recommendations for dealing with problems of sexual, desire, arousal, orgasm and pain. The text is clearly organised around the four major disease states in female sexual dysfunction (FSD) and is officially endorsed by the International Society for the Study of Women's Sexual Health (ISSWSH). The authors cover a wealth of topics such as hypoactive sexual desire disorder, psychological management of sexual disorders, anatomy and physiology of sexual dysfunction and pain and information on future developments and research. In addition, the text reviews all FDA approved medications for sexual dysfunction and contains consideration of off-label treatments for FSDs. This important text: * Offers the only textbook to highlight female sexual dysfunction in light of recently approved FDA medications * Contains a unique biopsychosocial approach from a collaborative team of physicians, psychologists, physical therapists as well as other sexual health professionals * Presents a comprehensive text led by one of the foremost global experts in Women's Sexual Health, Irwin Goldstein, founder of ISSWSH, with three other past presidents and one president-elect Written for any professional dealing with women's sexual health, Textbook of Female Sexual Function and Dysfunction offers an invaluable guide to the most safe and effective diagnosis and treatment.

Leseprobe

Textbook of Female Sexual Function and Dysfunction

Diagnosis and Treatment

Edited by

Irwin Goldstein, MD, IF

Sexual MedicineAlvarado HospitalDepartment of SurgeryUniversity of California, San DiegoSan Diego Sexual MedicineSan Diego, CA, USA

Anita H. Clayton, MD, IF, FAPA, FASCP

Department of Psychiatry and Neurobehavioral Sciences University of Virginia School of MedicineCharlottesville, VA, USA

Andrew T. Goldstein, MD, FACOG, IF

Department of Obstetrics and GynaecologyThe George Washington University School of Medicine and Health SciencesCenters for Vulvovaginal DisordersWashington, DC, USA

Noel N. Kim, PhD, IF

Institute for Sexual MedicineSan Diego, CA, USA

Sheryl A. Kingsberg, PhD, IF

Division of Behavioral MedicineDepartment of OB/GYNUniversity Hospitals Cleveland Medical CenterDepartments of Reproductive Biology and PsychiatryCase Western Reserve University School of MedicineCleveland, OH, USA

This edition first published 2018© 2018 by John Wiley & Sons Ltd

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The right of Irwin Goldstein, Anita H. Clayton, Andrew T. Goldstein, Noel N. Kim, and Sheryl A. Kingsberg to be identified as the author of the editorial in this work has been asserted in accordance with law.

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Library of Congress Cataloging‐in‐Publication Data

Names: Goldstein, Irwin, editor. | Clayton, Anita H., editor. | Goldstein, Andrew, M.D., editor. | Kim, Noel N., editor. | Kingsberg, Sheryl A., editor.Title: Textbook of female sexual function and dysfunction : diagnosis and treatment/edited by Irwin Goldstein, Anita H. Clayton, Andrew T. Goldstein, Noel N. Kim, Sheryl A. Kingsberg.Description: Hoboken, NJ : Wiley, 2018. | Includes bibliographical references and index. |Identifiers: LCCN 2017055314 (print) | LCCN 2017056729 (ebook) | ISBN 9781119266112 (pdf) | ISBN 9781119266150 (epub) | ISBN 9781119266136 (oBook) | ISBN 9781119266099 (cloth)Subjects: | MESH: Sexual Dysfunction, Physiological–diagnosis | Sexual Dysfunction, Physiological–therapy | Women | Sexuality–physiologyClassification: LCC RC556 (ebook) | LCC RC556 (print) | NLM WP 610 | DDC 616.85/83–dc23LC record available at https://lccn.loc.gov/2017055314

Cover Design: WileyCover Image: © Vectorig/Getty Images

List of Contributors

Stanley E. Althof, PhD, IFCenter for Marital and Sexual Health of South FloridaWest Palm Beach, FL, USA

Sophie Bergeron, PhDDépartement de PsychologieUniversité de MontréalMontréal, QC, Canada

Johannes Bitzer, MD, IFUniversity Hospital BaselMultidisciplinary Center for Sexual MedicineBasel, Switzerland

Karen Brandon, DSc PT WCS, BCB‐PMDKaiser PermanenteFontana, CA, USA

Anita H. Clayton, MD, IF, FAPA, FASCPDepartment of Psychiatry and Neurobehavioral SciencesUniversity of Virginia School of MedicineCharlottesville, VA, USA

Leonard R. Derogatis, PhDMaryland Center for Sexual HealthTowson, MD, USA

Melissa A. Farmer, PhDDepartment of PhysiologyFeinberg School of MedicineNorthwestern UniversityChicago, IL, USA

Eleni Frangos, PhDPain and Integrative Neuroscience BranchNCCIH–NIHBethesda, MD, USA

Andrew T. Goldstein, MD, FACOG, IFDepartment of Obstetrics and GynecologyThe George Washington University School of Medicine and Health SciencesCenters for Vulvovaginal DisordersWashington, DC, USA

Irwin Goldstein, MD, IFSexual MedicineAlvarado HospitalDepartment of SurgeryUniversity of California, San DiegoSan Diego Sexual MedicineSan Diego, CA, USA

Sue W. Goldstein, CSE, CCRC, IFSan Diego Sexual MedicineSan Diego, CA, USAEmmanuele A. Jannini, MDDepartment of Systems MedicineUniversity of Rome Tor VergataRome, Italy

Sherri L. Jones, PhDDouglas Mental Health University InstituteDepartment of Psychiatry, McGill UniversityMontreal, QC, Canada

Susan Kellogg Spadt, PhD, CRNP, IF, FCST, CSCCenter for Pelvic MedicineBryn Mawr, PA, USA

Noel N. Kim, PhD, IFInstitute for Sexual MedicineSan Diego, CA, USA

Sheryl A. Kingsberg, PhD, IFDivision of Behavioral MedicineDepartment of OB/GYNUniversity Hospitals Cleveland Medical CenterDepartments of Reproductive Biology and PsychiatryCase Western Reserve University School of MedicineCleveland, OH, USA

Barry R. Komisaruk, PhDDepartment of PsychologyRutgers UniversityNewark, NJ, USA

Tuuli M. Kukkonen, PhD, CPsychDepartment of Family Relations and Applied NutritionUniversity of GuelphGuelph, ON, Canada

Fiona McMahon, PT, DPTBeyond Basics Physical Therapy, LLCNew York, NY, USA

Sara Nasserzadeh, PhD, DipPSTRelationship & Sexual Health ConsultantsPalo Alto, CA, USA

Sharon J. Parish, MD, IFDepartment of Medicine in Clinical PsychiatryDepartment of Clinical MedicineWeill Cornell Medical CollegeNew York, NY, USA

Kwangsung Park, MD, PhD, IFDepartment of UrologyChonnam National University Medical SchoolGwangju, Republic of Korea

James G. Pfaus, PhD, IFCenter for Studies in Behavioral NeurobiologyDepartment of Psychology, Concordia UniversityMontréal, QC, Canada

Caroline F. Pukall, PhD, CPsychDepartment of PsychologyQueen’s UniversityKingston, ON, Canada

Tami Serene Rowen, MD, MS, IFDepartment of Obstetrics, Gynecology and Reproductive SciencesUniversity of California, San FranciscoSan Francisco, CA, USA

Sara K. Sauder, PT, DPTAustin, TX, USA

Isbelia Segnini, MSc, CCRC, C‐AASECTClinical El CedralCaracas, Venezuela

James A. Simon, MD, CCD, NCMP, IF, FACOGIntimMedicine Specialists™George Washington University School of MedicineWashington, DC, USA

Amy Stein, DPT, BCB‐PMD, IFBeyond Basics Physical Therapy, LLCNew York, NY, USA

Linda Vignozzi, MDSexual Medicine and Andrology UnitDepartment of Experimental and Clinical Biomedical SciencesUniversity of FlorenceFlorence, Italy

Nan Wise, PhDDepartment of PsychologyRutgers UniversityNewark, NJ, USA

Foreword

It is a unique honor and privilege for me to introduce readers to this outstanding new volume on female sexual function and dysfunction from the International Society for the Study of Women’s Sexual Health (ISSWSH). The depth and breadth of coverage of this complex and rapidly evolving area of women’s health is impressive, to say the least, and the inclusion of much new research and clinical data attests to the enormous energy and dedication of growing numbers of researchers and clinicians dedicated to studies in female sexual health. This latest textbook is truly comprehensive in its coverage of both physical and psychological sexual disorders, in addition to providing up‐to‐date, basic science formulations of underlying mechanisms and processes; all from a consistent and coherent biopsychosocial perspective. As a psychologist and former sex therapist, it is especially gratifying to see this biopsychosocial model applied increasingly across female sexual disorders and problems, regardless of etiology or treatment approaches. The editors have done the field a great service in balancing these perspectives both within and across chapters. The textbook is unique also in the depth of scholarship and extensive reference lists provided with each of the chapters – what a resource for graduate students, residents and fellows!

This new textbook is also a testament to the success of ISSWSH, which, in the 18 years since it was founded, has become the major professional society with a unique focus on female sexual health. Many of us recall the first meeting of the society in Boston in 2000, at which the initial mission statement was drafted and officers elected. The organization has grown in leaps and bounds since then, and this textbook provides impressive testimony to the expanding knowledge base and clinical interests of the society. Since its inception, ISSWSH has benefited greatly from the devotion and energy of its founding members and officers; with special credit due to Sue and Irwin Goldstein, Sharon Parish, Sheryl Kingsberg, Anita Clayton, Stan Althof, Len Derogatis, Jim Simon, Noel Kim, Annamaria Giraldi, and others. I would like to acknowledge also a special debt to my late friend and colleague, Sandra Leiblum, who served as the first president of ISSWSH. Her contributions are cited throughout this volume, and her spirit and energy did much to inspire her colleagues, students and others to pursue clinical or research interests in women’s sexuality. Sandy was also a dedicated educator who taught human sexuality and women’s sexual health to literally thousands of students and residents during her 40 year career at Rutgers. Her spirit lives on in these pages!

Finally, a special word of appreciation is due to Sue Goldstein – associate editor of this volume and much loved “mother hen” of the society. No one has taken on more roles for the society, or worked as tirelessly as Sue in achieving the goals of ISSWSH. This volume is finally a testament to Sue’s enduring and much appreciated contributions to the field. Thank you Sue on behalf of all!

Raymond C. Rosen, PhDChief Scientist, New England Research InstitutesFormer Professor of Psychiatry, Rutgers Medical SchoolCo‐Director, Human Sexuality Program

Preface

The International Society for the Study of Women’s Sexual Health (ISSWSH) is an international, multidisciplinary, academic, clinical and scientific organization dedicated to providing opportunities for communication among scholars, researchers and practitioners about women’s sexual health; to support the highest standards of ethics and professionalism in research, education and clinical practice of women’s sexual health; and to provide the public with accurate information about women’s sexual health.

ISSWSH strongly emphasizes and fervently supports the biopsychosocial management of women with sexual dysfunction. With that encompassing mission and scientific focus in mind, the ISSWSH Textbook of Female Sexual Function and Dysfunction: Diagnosis and Treatment has been written by ISSWSH members primarily to help healthcare providers in the various disciplines involved in women’s sexual health, including sex therapy, pelvic floor physical therapy and medical therapy, better manage women with distressing sexual health issues. Since ISSWSH is the largest society comprised of specialists in women’s sexual health, the idea for an ISSWSH textbook to provide the optimal scientific, multidisciplinary clinical practice guidelines for use by providers was natural. With millions of women needing help, ISSWSH members can provide accurate data for the providers in the various disciplines caring for women with sexual health concerns. By writing a textbook on female sexual dysfunction based on published laboratory and clinical research and expert clinical experience, ISSWSH is able to further its mission of communication, professionalism and disseminating information.

The multidisciplinary field of women’s sexual health has come a long way since the inaugural meeting of ISSWSH in 2000. For almost two decades, ISSWSH has fostered research in the study, nosology, diagnosis and treatment of women with sexual health disorders. ISSWSH funds research projects in women’s sexual health, especially important in an era where government funds are lacking. ISSWSH supports numerous educational opportunities including annual meetings, educational courses, and publications from consensus‐based panels resulting in nomenclature, white paper and process of care documents. ISSWSH, an affiliate member society of the International Society for Sexual Medicine (ISSM), has three official journals: The Journal of Sexual Medicine, Sexual Medicine, and Sexual Medicine Reviews. Using these and other journals that publish in women’s sexual health, ISSWSH has helped grow scientific peer‐reviewed publications in women’s sexual health, expanding from 273 scientific peer‐reviewed publications found in PubMed in 2000 (by using the key phrase “female sexual dysfunction”) to 772 in 2016 – almost tripling available literature, much of which has been authored by ISSWSH members.

This ISSWSH textbook is intended to provide clinical practice guidelines for both novice and expert practitioners treating women with sexual health concerns. In the ten years since the publication of the first multidisciplinary textbook in the field, Women’s Sexual Function and Dsyfunction, our knowledge has expanded and medications for treating various sexual dysfunctions have been added in some countries to the nonpharmacologic treatment strategies already available. As an official publication of the society, this material has been vetted by the editors on behalf of ISSWSH. Four of the editors (Clayton, I. Goldstein, A. Goldstein, Kingsberg) have been presidents of the society while the fifth (Kim) is president‐elect. We have all given of our time freely because of our passion for the field and our passion for ISSWSH, as has the associate editor, Sue W. Goldstein. In particular, Sue spent countless hours as the central communicator, tracker of progress, and editorial associate, guiding this book from initial development to final publication. We would also like to thank Gail Goldstein for her time and efforts in helping to edit the pain section.

It is imperative that clinicians understand the various conditions impacting sexual desire, arousal, orgasm, and pain, how to make a correct diagnosis, the therapeutic options available, and the science behind the various treatments, in order to provide optimal patient management and improve patient quality of life. All women have the right to health, including sexual health. The Textbook of Female Sexual Function and Dysfunction: Diagnosis and Treatment will serve as a valuable tool to all those involved in helping women maintain or restore their sexual health.

For ease of use, the text is divided into four basic sections: Hypoactive Sexual Desire Disorder, Arousal Disorders, Orgasm Disorders, and Sexual Pain Disorders. Within each section there is content on the nosology and epidemiology, anatomy and physiology, and diagnosis and treatment from both psychologic and biologic points of view, including musculoskeletal management where appropriate.

It is anticipated that ISSWSH will update this textbook as needed. The field of women’s sexual medicine is rapidly evolving and ISSWSH members have been influential in paving the way for expansion of knowledge in the field of female sexual dysfunction – this textbook reflects current understanding. We hope that you agree and find the Textbook of Female Sexual Function and Dysfunction to be an essential resource in caring for women and their sexual health.

Irwin Goldstein, MD, IFAnita H. Clayton, MD, IFAndrew T. Goldstein, MD, IFNoel N. Kim, PhD, IFSheryl A. Kingsberg, PhD, IF

1History of the International Society for the Study of Women’s Sexual Health (ISSWSH)

Sue W. Goldstein

Abstract

The International Society for the Study of Women’s Sexual Health (ISSWSH) emanated from a course assembling experts in different disciplines, becoming the model for the society. Seventeen years later the society remains multidisciplinary, with annual meetings featuring state of the art lectures, symposia on controversial topics, and abstracts judged on scientific merit. Educational efforts expanded from a half day precourse to a fall course and another in conjunction with the National Association of Nurse Practitioners in Women’s Health annually. Evidence‐based conferences have included consensus panels for nomenclature for desire, arousal, and orgasm; pain; genitourinary syndrome of menopause (GSM); clinical guidelines for identification of sexual health problems; and a process of care for the management of hypoactive sexual desire disorder. ISSWSH is now established as the leading organization for disseminating valuable information to providers, researchers and educators regarding management of distressing sexual dysfunction in women.

Keywords:ISSWSH; women’s sexual health; female sexual dysfunction; multidisciplinary; desire; arousal; orgasm; pain; GSM; nomenclature

The International Society for the Study of Women’s Sexual Health (ISSWSH) is the only professional organization dedicated to women’s sexual function and dysfunction. The society was founded less than two decades ago. Therefore, the history of the society is directly linked to the history of the field.

The approval of sildenafil in 1998 by regulatory agencies and a publication in the New England Journal of Medicine [1] led women to call urologist Irwin Goldstein to demand a medication for their sexual health problems. There was a paucity of information about the physiology of sexual function and the pathophysiology of sexual dysfunction in women, but Goldstein wanted to change that. Under the auspices of Boston University School of Medicine, he developed a course entitled New Perspectives in Female Sexual Dysfunction, assembling experts in different disciplines to share their information in an effort to piece together available knowledge. This became the model on which the society was developed three years later.

The course was held in the Boston area in 1998, 1999 and 2000. The first year there were over 200 registrants from around the world. Associated with the 1998 course, the American Foundation for Urologic Diseases sponsored a consensus conference with 19 international experts, resulting in the development of nomenclature for use in women’s sexual dysfunction [2]. Prior to this time all nomenclature was based on the Diagnostic and Statistical Manual of Mental Disorders (DSM) of the American Psychiatric Association [3]. With the recognition of biologic components to sexual function, and the need to understand sexual dysfunction in women, the course was lengthened and podium and poster sessions added. Attendance doubled in 1999 with many returning registrants. When queried about interest in initiating a society, the response was negative. The following year, however, the group had an overwhelmingly positive response and the Female Sexual Function Forum was born.

The society was developed in a multidisciplinary manner with by‐laws designating that each committee and the board of directors be balanced in terms of gender, geography, and discipline. All disciplines with an interest in women’s sexual health would be welcome in the society, with all active members having equal import, regardless of profession, specialty or degree. Many members of the inaugural board continue to be active members, a testament to both the strength of and need for the organization. One of the first society benefits was the start of a moderated on‐line forum (ISSWSHNET) for difficult cases that facilitated communication among people from various locations, disciplines, and perspectives. Having gone through multiple iterations, ISSWSHNET remains a benefit for society members.

The format of the first meeting set the tone for future meetings, with state of the art lectures, symposia on controversial topics, and abstracts judged on scientific merit for podium or poster presentation. The hot topic through the first several annual meetings was the use of androgens in women, transitioning later to oral contraceptives and sexual dysfunction. The first business meeting and election were held on 28 October 2000, with Sandra Leiblum voted in as the first president (Figure 1.1).

Figure 1.1 Sandra Leiblum, PhD, first president of the International Society for the Study of Women’s Sexual Health, presiding over the business meeting.

After a year as the Female Sexual Function Forum it was noted that the word “female” could refer to animals, so, in 2001, the organization was renamed the International Society for the Study of Women's Sexual Health. Alessandra Graziottin from Italy ascended to the presidency but the board remained stable to help the fledging society. Only active or honorary members could serve on the board or as committee chairs, as affiliate members were associated with industry. The society struggled financially but survived through the fierce passion of the board and the support of its management company.

Nearly 400 people attended the 2002 meeting in Vancouver – the first time this group met away from Boston. Held shortly after the publication of the widely publicized Women’s Health Initiative [4], the leadership responded by adding a lunch seminar to disseminate accurate information and help dispel myths propagated by the press. Symposia were designed to span both the biological and psychological realms in the basic science and clinical arenas. While moving the 2003 meeting to Amsterdam was exciting, it put the society at risk, with a decrease in attendance and increase in meeting costs. Under Cindy Meston’s leadership, a development committee was established to seek industry support to help underwrite the conference, as is common among many other societies, with the long term goal of financial stability.

Lorraine Dennerstein put her presidential stamp on the society by recruiting young researchers in an attempt to grow both the society and the field. With the return to the United States in 2004 the society collaborated with the National Institutes of Health, cosponsoring the meeting “Vulvodynia and Sexual Pain Disorders in Women” held the day before the Atlanta ISSWSH meeting [5]. For the first time, several pharmaceutical companies arranged their advisory board meetings around the annual meeting, thus supporting ISSWSH financially and giving increased visibility to the young society. A half‐day precourse on the “Practical Management of Women’s Sexual Dysfunction” preceded the annual meeting, a response to the increasing demand for instruction for both the novice and advanced health‐care provider. The precourse enrollment that first year exceeded expectations with 160 attendees. The board responded by naming an education committee to develop a program of educational courses during the annual meeting, as well as a free‐standing three‐day course to be held at another time of year.

With these changes ISSWSH was beginning to make its true mark on the field of medicine. In 2005, ISSWSH was under the leadership of its first male president, Stan Althof, and in 2006 the annual meeting moved from October to February, in an attempt to find a dedicated time slot not conflicting with other societies, leaving the October time available for the three‐day educational “Fall Course”. The rotation of east coast, west coast, Europe for annual meetings would continue for a few years (Table 1.1), until it made more financial sense to stay in the United States, as attendees and drug development programs were based in the United States, allowing for growth of sponsorship opportunities.

Table 1.1 Dates and locations of ISSWSH annual meetings and the presidents at that time.

Term

President

Meeting location

2000–2001

Sandra R. Leiblum, PhD

Boston, MA (10/01)

2001–2002

Alessandra Graziottin, MD

Vancouver, Canada (10/02)

2002–2003

Cindy M. Meston, PhD, IF

Amsterdam, The Netherlands (10/03)

2003–2004

Lorraine Dennerstein, MBBS, PhD, DPM, IF

Atlanta, GA (10/04)

2004–2005

Stanley E. Althof, PhD, IF

Las Vegas, NV (10/05)

2005–2006

Anita H. Clayton, MD, IF, FAPA

Lisbon, Portugal (03/06)

2006–2007

Anita H. Clayton, MD, IF, FAPA

Lake Buena Vista, FL (02/07)

2007–2008

Annamaria Giraldi, MD, PhD, IF

San Diego, CA (02/08)

2008–2009

Rosella E. Nappi, MD, PhD

Florence, Italy (02/09)

2009–2010

Sheryl A. Kingsberg, PhD, IF

St. Petersberg, FL (02/10)

2010–2011

Alan Altman, MD, IF

Scottsdale, AZ (02/11)

2011–2012

Alan Altman, MD, IF

Jerusalem, Israel (02/12)

2012–2013

Andrew T. Goldstein, MD, IF, FACOG

New Orleans, LA (02/13)

2013–2014

Andrew T. Goldstein, MD, IF, FACOG

San Diego, CA (02/14)

2014–2015

Sharon J. Parish, MD, IF, NCMP

Austin, TX (02/15)

2015–2016

Sharon J. Parish, MD, IF, NCMP

Charleston, SC (02/16)

2016–2017

Irwin Goldstein, MD, IF

Atlanta, GA (02/17)

2017–2018

Irwin Goldstein, MD, IF

San Diego, CA (02/18)

In 2011, the term of president (and consequently both president elect and past president) was changed from one to two years, allowing leadership to develop projects and see them through fruition. With the approval by the Food and Drug Administration of medications for women with various sexual dysfunctions, industry support grew and the society became fiscally sound. The ability to obtain unrestricted educational grants meant the society could fund educational projects outside of the annual meeting. Under the leadership of Andrew Goldstein a new nomenclature for pain was developed in conjunction with International Society for the Study of Vulvovaginal Disease and International Pelvic Pain Society [6], and at a consensus meeting with the North American Menopause Society vulvovaginal atrophy was renamed as genitourinary syndrome of menopause or GSM [7], which is now the accepted term. President Sharon Parish assembled a nomenclature consensus conference to define disorders of desire, arousal, and orgasm [8, 9], and coordinated a meeting sponsored by ISSWSH to ensure these definitions would be considered as part of the new ICD‐11 coding [10]. Irwin Goldstein supported the global development committee, securing grants for projects, including a white paper on hypoactive sexual desire disorder [11], and a process of care for the management of women with generalized, acquired hypoactive sexual desire disorder [12]. For the first time, the society was finally able to set aside money in an investment account in 2015 and to use its funds to offer grants to trainees and researchers early in their careers, resulting in future presentations at ISSWSH annual meetings.

With ISSWSH dedicated solely to women’s sexual health, other organizations have turned to the society for education. ISSWSH has co‐sponsored a course with the National Association of Nurse Practitioners in Women’s Health since 2014, providing educational content. The society has taught CME courses at the International Society for Sexual Medicine, American College of Obstetrics and Gynecology, and the International UroGynecology Association, providing evidence‐based content to non‐ISSWSH members and spreading awareness of women’s sexual function and dysfunction.

In recent years, the society has moved into advocacy and has developed useful tools, including publication of clinical pearls and assembling an official educational slide‐set, both benefits for members. Online content for both providers and patients has been and will continue to be developed. Consensus panels have convened to establish clinical guidelines in different aspects of sexual dysfunction in women. ISSWSH is now established as a leading organization in disseminating valuable information to providers, researchers, and educators in order to improve management of distressing sexual dysfunction in women.

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2Sexual Medicine Education and Training

Sharon J. Parish and Johannes Bitzer

Abstract

Sexual health care is part of general medical care and is needed throughout the life cycle of women. Education and training for clinicians is based on a biopsychosocial model of sexual health and should progress from undergraduate level through postgraduate and specialist training programs. The curriculum for each level must be competency based and include learning objectives; describe the knowledge, skills and attitudes; and include methods of monitoring the acquisition of new skills and knowledge. Undergraduate training must include general knowledge about the human sexual response, diagnostic categories and classifications, and skills to communicate about sexuality. Postgraduate and specialized training should provide a broader understanding of the biological, psychological, and social factors contributing to sexual dysfunction; the basis for comprehensive diagnosis; the ability to establish a therapeutic plan in collaboration with the patient; and the capacity to perform interventions or refer.

Keywords:sexual health education; female sexual dysfunction; sexuality communication skills; sexual medicine competencies

Sexual health care is part of general health care and is needed throughout the life span of women and men.

Education and training for health‐care professionals are based on a biopsychosocial model of sexual health and should start at undergraduate level and be included in postgraduate and specialist training programs.

The program of each level must include learning objectives; describe the knowledge, skills and attitudes from a competency perspective; and include methods of monitoring the learning process.

Introduction

Sexual problems and sexual dysfunctions have a high prevalence worldwide. As sexual health is part of general health, women consider health‐care professionals as the “right persons” to help. The high prevalence and high complexity of sexual health problems create the need for services from both primary care clinicians and sexual medicine specialists. This array of needs implies that all physicians should receive basic education and training in sexual medicine and that a subgroup with interest and commitment in the field should receive specialized postgraduate training [1].

Many institutions in different countries have tried to develop concepts about the learning objectives and competencies in sexual medicine for undergraduate, graduate and postgraduate levels [2]. Based on the analyses of these programs and the literature about patients’ needs, we propose a model of three levels of competence in female sexual dysfunction (FSD) that should be achieved through education and training programs (Table 2.1) [3].

Table 2.1 Competencies for undergraduate, graduate and generalist physicians, and postgraduate specialists.

Competence level 1: undergraduate

Competence level 2: graduate and generalist physicians

Competence level 3: postgraduate specialists

Female sexual dysfunctions (low desire, arousal dysfunction, orgasmic disorders, sexual pain disorders)

Know definition Screen, diagnose Know about contributing factors and therapeutic options

Diagnose based on standards Assess contributing factors Establish descriptive and comprehensive diagnosis (biopsychosocial model) Elaborate treatment options

Hormonal & drug treatment Sensate focus Couples therapy Physiotherapy

Oncologic diseases

Know impact and prevalence Ask and screen

Establish a comprehensive diagnosis including pre‐existing factors, disease related factors, and emotional, cognitive and behavioral responses Develop treatment plan Conservative treatment

Specialized surgical interventions Mechanical intervention Hormonal intervention Physiotherapy

Metabolic and neurologic diseases

Know impact and prevalence Ask and screen

Establish a comprehensive diagnosis including pre‐existing factors disease related factors, and emotional, cognitive and behavioral response Develop treatment plan Conservative treatment

Modified sensate focus Mechanical intervention Drug therapy Physiotherapy

Undergraduate (level 1)

Education and training for medical students is based on the transference of knowledge about human sexuality, prevalence of sexual problems, and principles and skills related to communication about sexuality, including strategies and techniques to help patients to disclose problems and difficulties in this intimate and vulnerable domain of life [4]. The core framework for sexuality education focuses on knowledge, skills, and attitudes [5, 6]. Attitudinal training primarily focuses on the development of self‐awareness and the cultivation of nonjudgmental behavior and professionalism when interacting with patients with sexuality concerns [6].

Knowledge includes:

anatomy of sexual organs;

basics of endocrine, central nervous system, neurological, and neuromuscular processes involved in central and peripheral sexual response;

models of human sexual response;

contraception, sexually transmitted diseases, safer sex practices.

Skills incorporate:

how to encourage patients to ask questions about sexuality and talk about (disclose) difficulties;

attitude toward discussing and managing sexual problems;

openness towards the wide spectrum of sexual expression and sexual life styles;

how to discuss and explain treatment plans, discuss benefits and risks.

Expert recommendations for enhancement of sexual health education in medical schools call for a multidimensional approach that incorporates curricular reform and innovation aimed at educational infrastructure [7]. Elements include developing a skills‐based curriculum, establishing multidisciplinary teams, integrating sexual health content across core curriculum courses and longitudinally throughout medical school, creating mandatory blocks and electives, and including assessment of sexual health knowledge in licensing examinations [7]. Ideally, at least one “champion” should be involved at each institution to ensure that sexuality education is included and effectively integrated into the entire curriculum [6].

Sexuality education should be multidisciplinary and include psychiatry, gynecology, urology, and primary care, and also may incorporate sex therapists, psychologists, epidemiologists, and sexologists. Sexual medicine content is optimally delivered through an array of interactive modalities that enable skills training and assessment. These include didactics, panel discussions, small group case‐based seminars, role play, standardized patients, observed structured clinical examinations with direct and immediate feedback, community/peer education, and immersion/desensitization activities [5, 6].

A recent survey regarding lesbian, gay, bisexual, and transgender‐related content in United States and Canadian allopathic and osteopathic medical schools reported that dedicated content hours to these topics was small and that the perceived quality was variable. Suggested improvements included increased curricular time dedicated to lesbian, gay, bisexual, and transgender‐related health and disparities, instruction about the difference between behavior and identity, and faculty engagement to teach these topics [8].

Graduate and Postgraduate (Level 2 and 3)

Graduate and generalist physicians, as well as medical specialists, should be able to understand the sexual suffering of their patients and translate it into a descriptive and a comprehensive diagnosis as the basis for a preliminary or more elaborate treatment plan.

The treatment plan may include education and behavioral advice or more specialized interventions, such as hormonal and other pharmacological treatment, surgery, physiotherapy, and specialized psychotherapeutic interventions. The latter competencies need special training (level 3) [9, 10].

The International Consultation in Sexual Medicine published a review of the current state and future educational needs in graduate and postgraduate sexual health education. The key points summarized that: (i) sexual medicine has grown as a specialty in the recent decades; but regulatory aspects of training, assessment, and certification are lagging behind scientific developments and clinical knowledge; (ii) examples of curricula and associated assessments may be related to high quality sexual medicine care; (iii) competency assessment has been applied to surgical training (primarily male), reflecting increased interest in simulation for skills training; (iv) although curriculum development has been primarily executed in medical training, interest is emerging in similar standards for training allied health professionals [2].

Despite the emergence of some training opportunities employing varied methodologies, objective measures of the impact of graduate and postgraduate physician training in sexual health on patient satisfaction and objective health outcomes are lacking [11].

Education and Training in Female Sexual Health Care for Practicing Clinicians

To provide patients with competent sexual health care, professionals need to train and develop knowledge, skills and attitudes related to the following key principles [12]:

Sexuality is an intimate part of the patient’s identity, self‐esteem, shame, and vulnerabilities. Therefore, talking about sexuality requires openness, empathy, a nonjudgmental approach, and a respectful attitude focusing on resources and not on deficits.

Sexual problems and dysfunctions are usually the result of an interaction of factors that are best identified using the biopsychosocial model. This means that physicians have to be open to, and interested in, different perspectives, ranging from physiology/pathophysiology to psychology/psychopathology to social psychology and sociology [13].

Solutions to sexual problems and treatment of dysfunctions may be a long‐term process and, invariably, require the active collaboration of the patient or couple. This implies that clinicians frequently need to include partners in the process, involve patients in decision making, and adapt strategies that match the resources and capacities of the patient [14].