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.
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 (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. 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.
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. 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.
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.
Risk factors for sexual dysfunction
The risk of developing a sexual dysfunction increases with age in both men and women. There are several risk factors that are associated with sexual dysfunction in both men and women. Cardiovascular disease, diabetes mellitus, genitourinary disease, psychological/psychiatric disorders, and presence of a chronic disease are all common risk factors for developing a sexual dysfunction.
- Genito-pelvic pain-penetration disorder
Non-exclusive
- Lack or loss of sexual desire (Libido)
- Hypoactive sexual desire disorder
- Sexuality issues
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.
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.
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. 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 (MDMA, cocaine, heroin, amphetamine), leads to a decrease in sexual desire, inability to achieve orgasm, and a reduction of sexual satisfaction.
Challenges
While the awareness of sexual health importance has increased in regards to individuals' 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. Sexual medicine is a unique component of the medical practice that has its own challenges. 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. 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.