Bibliotherapy for Sexual Dysfunctions: A Systematic Review and Meta-Analysis.

AIM: The objective of this study was to assess the efficacy of bibliotherapy for sexual dysfunctions, when compared with no treatment and compared with other interventions. METHODS: MEDLINE, EMBASE, and PsycINFO were searched from 1970 to January 2020. Selection criteria were randomized controlled trials evaluating assisted or unassisted bibliotherapy for all types of sexual dysfunctions compared with no treatment (wait list or placebo) or with other psychological interventions. Bibliotherapy is defined as psychological treatment using printed instruction to be used by the individual or couple suffering from sexual dysfunction. Primary outcome measures were male and female sexual functioning level and continuation/remission of sexual dysfunction. Secondary outcomes were sexual satisfaction and dropout rate. Sexual functioning and sexual satisfaction were self-reported by participants using validated questionnaires. RESULTS: Fifteen randomized controlled trials with a total of 1,113 participants (781 women; 332 men) met inclusion criteria. Compared with no treatment, unassisted bibliotherapy resulted in larger proportions of female participants reporting remission of sexual dysfunction, and sexual satisfaction was higher in treated participants, both female and male participants. Compared with no treatment, assisted bibliotherapy had significant positive effects on female sexual functioning; no effects on male sexual functioning were found. Results of unassisted and assisted bibliotherapy did not differ from those of other intervention types on any outcome. Throughout, no differences between study conditions were found regarding dropout rates. The certainty of the evidence for all outcomes was rated as very low. CONCLUSION: We found indications of positive effects of bibliotherapy for sexual dysfunctions. Across studies, more significant effects were found for women than for men. However, owing to limitations in the study designs and imprecision of the findings, we were unable to draw firm conclusions about the use of bibliotherapy for sexual dysfunction. More high quality and larger trials are needed. Relevant outcome measures for future studies should be defined as well as unified grading systems to measure these endpoints. In addition, future studies should report on treatment acceptability and adherence. van Lankveld JJDM, van de Wetering FT, Wylie, K et al. Bibliotherapy for Sexual Dysfunctions: A Systematic Review and Meta-Analysis. J Sex Med 2021;18:582-614.

British Society for Sexual Medicine Guidelines on the Management of Erectile Dysfunction in Men-2017.

BACKGROUND: This is an update of the 2008 British Society for Sexual Medicine (BSSM) guidelines. AIM: To provide up-to-date guidance for U.K. (and international) health care professionals managing male sexual dysfunction. METHODS: Source information was obtained from peer-reviewed articles, meetings, and presentations. A search of Embase, MEDLINE, and Cochrane Reviews was performed, covering the search terms "hypogonadism," "eugonadal or hypogonadism or hypogonadal or gonadal," and "low or lower testosterone," starting from 2009 with a cut-off date of September 2017. OUTCOMES: We offer evidence-based statements and recommendations for clinicians. RESULTS: Expert guidance for health care professionals managing male sexual dysfunction is included. CLINICAL TRANSLATION: Current U.K. management has been largely influenced by non-evidence guidance from National Health Service departments, largely based on providing access to care limited by resources. The 2008 BSSM guidelines to date have been widely quoted in U.K. policy decision making. CONCLUSIONS: There is now overwhelming evidence that erectile dysfunction is strongly associated with cardiovascular disease, such that newly presenting patients should be thoroughly evaluated for cardiovascular and endocrine risk factors, which should be managed accordingly. Measurement of fasting serum glucose, lipid profile, and morning total testosterone should be considered mandatory in all newly presenting patients. Patients attending their primary care physician with chronic cardiovascular disease should be asked about erectile problems. There can no longer be an excuse for avoiding discussions about sexual activity due to embarrassment. Hackett G, Kirby M, Wylie K, et al. British Society for Sexual Medicine Guidelines on the Management of Erectile Dysfunction in Men-2017. J Sex Med 2018;15:430-457.

Transgender people: health at the margins of society.

In this paper we examine the social and legal conditions in which many transgender people (often called trans people) live, and the medical perspectives that frame the provision of health care for transgender people across much of the world. Modern research shows much higher numbers of transgender people than were apparent in earlier clinic-based studies, as well as biological factors associated with gender incongruence. We examine research showing that many transgender people live on the margins of society, facing stigma, discrimination, exclusion, violence, and poor health. They often experience difficulties accessing appropriate health care, whether specific to their gender needs or more general in nature. Some governments are taking steps to address human rights issues and provide better legal protection for transgender people, but this action is by no means universal. The mental illness perspective that currently frames health-care provision for transgender people across much of the world is under scrutiny. The WHO diagnostic manual may soon abandon its current classification of transgender people as mentally disordered. Debate exists as to whether there should be a diagnosis of any sort for transgender children below the age of puberty.

Serving transgender people: clinical care considerations and service delivery models in transgender health.

The World Professional Association for Transgender Health (WPATH) standards of care for transsexual, transgender, and gender non-conforming people (version 7) represent international normative standards for clinical care for these populations. Standards for optimal individual clinical care are consistent around the world, although the implementation of services for transgender populations will depend on health system infrastructure and sociocultural contexts. Some clinical services for transgender people, including gender-affirming surgery, are best delivered in the context of more specialised facilities; however, the majority of health-care needs can be delivered by a primary care practitioner. Across high-income and low-income settings alike, there often remains a dearth of educational programming for health-care professionals in transgender health, although the best evidence supports introducing modules on transgender health early during clinical education of clinicians and allied health professionals. While these challenges remain, we review the increasing evidence and examples of the defined roles of the mental health professional in transgender health-care decisions, effective models of health service provision, and available surgical interventions for transgender people.

British Society for Sexual Medicine Guidelines on Adult Testosterone Deficiency, With Statements for UK Practice.

BACKGROUND: Testosterone deficiency (TD) is an increasingly common problem with significant health implications, but its diagnosis and management can be challenging. AIM: To review the available literature on TD and provide evidence-based statements for UK clinical practice. METHODS: Evidence was derived from Medline, EMBASE, and Cochrane searches on hypogonadism, testosterone (T) therapy, and cardiovascular safety from May 2005 to May 2015. Further searches continued until May 2017. OUTCOMES: To provide a guideline on diagnosing and managing TD, with levels of evidence and grades of recommendation, based on a critical review of the literature and consensus of the British Society of Sexual Medicine panel. RESULTS: 25 statements are provided, relating to 5 key areas: screening, diagnosis, initiating T therapy, benefits and risks of T therapy, and follow-up. 7 statements are supported by level 1, 8 by level 2, 5 by level 3, and 5 by level 4 evidence. CLINICAL IMPLICATIONS: To help guide UK practitioners on effectively diagnosing and managing primary and age-related TD. STRENGTHS AND LIMITATIONS: A large amount of literature was carefully sourced and reviewed, presenting the best evidence available at the time. However, some statements provided are based on poor-quality evidence. This is a rapidly evolving area of research and recommendations are subject to change. Guidelines can never replace clinical expertise when making treatment decisions for individual patients, but rather help to focus decisions and take personal values and preferences and individual circumstances into account. Many issues remain controversial, but in the meantime, clinicians need to manage patient needs and clinical expectations armed with the best clinical evidence and the multidisciplinary expert opinion available. CONCLUSION: Improving the diagnosis and management of TD in adult men should provide somatic, sexual, and psychological benefits and subsequent improvements in quality of life. Hackett G, Kirby M, Edwards D, et al. British Society for Sexual Medicine Guidelines on Adult Testosterone Deficiency, With Statements for UK Practice. J Sex Med 2017;14:1504-1523.

Psychological and Interpersonal Dimensions of Sexual Function and Dysfunction.

INTRODUCTION: Psychological, interpersonal, and sociocultural factors play a significant role in making one vulnerable to developing a sexual concern, in triggering the onset of a sexual difficulty, and in maintaining sexual dysfunction in the long term. AIM: To focus on psychological and interpersonal aspects of sexual functioning in women and men after a critical review of the literature from 2010 to the present. METHODS: This report is part 1 of 2 of our collaborative work during the 2015 International Consultation on Sexual Medicine for Committee 2. MAIN OUTCOME MEASURES: Systematic review of the literature with a focus on publications since 2010. RESULTS: Our work as sexual medicine clinicians is essentially transdisciplinary, which involves not only the collaboration of multidisciplinary professionals but also the integration and application of new knowledge and evaluation and subsequent revision of our practices to ensure the highest level of care provided. There is scant literature on gender non-conforming children and adolescents to clarify specific developmental factors that shape the development of gender identity, orientation, and sexuality. Conversely, studies consistently have demonstrated the interdependence of sexual function between partners, with dysfunction in one partner often contributing to problems in sexual functioning and/or sexual satisfaction for the other. We recommend that clinicians explore attachment styles of patients, childhood experiences (including sexual abuse), onset of sexual activity, personality, cognitive schemas, infertility concerns, and sexual expectations. Assessment of depression, anxiety, stress, substance use and post-traumatic stress (and their medical treatments) should be carried out as part of the initial evaluation. Clinicians should attempt to ascertain whether the anxiety and/or depression is a consequence or a cause of the sexual complaint, and treatment should be administered accordingly. Cognitive distraction is a significant contributor to sexual response problems in men and women and is observed more consistently for genital arousal than for subjective arousal. Assessment of physical and mental illnesses that commonly occur in later life should be included as part of the initial evaluation in middle-aged and older persons presenting with sexual complaints. Menopausal status has an independent effect on reported changes in sex life and difficulties with intercourse. There is strong support for the use of psychological treatment for sexual desire and orgasm difficulties in women (but not in men). Combination therapies should be provided to men, whenever possible. CONCLUSION: Overall, research strongly supports the routine clinical investigation of psychological factors, partner-related factors, context, and life stressors. A biopsychosocial model to understand how these factors predispose to sexual dysfunction is recommended.

Ethical and Sociocultural Aspects of Sexual Function and Dysfunction in Both Sexes.

AIMS: This study aimed to highlight the salient sociocultural factors contributing to sexual health and dysfunction and to offer recommendations for culturally sensitive clinical management and research as well for an ethically sound sexual health care, counseling and medical decision-making. BACKGROUND: There are limited data on the impact of sociocultural factors on male and female sexual function as well as on ethical principles to follow when clinical care falls outside of traditional realms of medically indicated interventions. METHODS: This study reviewed the current literature on sociocultural and ethical considerations with regard to male and female sexual dysfunction as well as cultural and cosmetic female and male genital modification procedures. RESULTS: It is recommended that clinicians evaluate their patients and their partners in the context of culture and assess distressing sexual symptoms regardless of whether they are a recognized dysfunction. Both clinicians and researchers should develop culturally sensitive assessment skills and instruments. There are a number of practices with complex ethical issues (eg, female genital cutting, female and male cosmetic genital surgery). Future International Committee of Sexual Medicine meetings should seek to develop guidelines and associated recommendations for a separate, broader chapter on ethics.

Penile Dysmorphic Disorder: Development of a Screening Scale.

Penile dysmorphic disorder (PDD) is shorthand for men diagnosed with body dysmorphic disorder, in whom the size or shape of the penis is their main, if not their exclusive, preoccupation causing significant shame or handicap. There are no specific measures for identifying men with PDD compared to men who are anxious about the size of their penis but do not have PDD. Such a measure might be helpful for treatment planning, reducing unrealistic expectations, and measuring outcome after any psychological or physical intervention. Our aim was, therefore, to validate a specific measure, termed the Cosmetic Procedure Screening Scale for PDD (COPS-P). Eighty-one male participants were divided into three groups: a PDD group (n = 21), a small penis anxiety group (n = 37), and a control group (n = 23). All participants completed the COPS-P as well as standardized measures of depression, anxiety, social phobia, body image, quality of life, and erectile function. Penis size was also measured. The final COPS-P was based on nine items. The scale had good internal reliability and significant convergent validity with measures of related constructs. It discriminated between the PDD group, the small penis anxiety group, and the control group. This is the first study to develop a scale able to discriminate between those with PDD and men anxious about their size who did not have PDD. Clinicians and researchers may use the scale as part of an assessment for men presenting with anxiety about penis size and as an audit or outcome measure after any intervention for this population.

Tramadol for premature ejaculation: a systematic review and meta-analysis.

BACKGROUND: Tramadol is a centrally acting analgesic prescribed off-label for the treatment of premature ejaculation (PE). However, tramadol may cause addiction and difficulty in breathing and the beneficial effect of tramadol in PE is yet not supported by a high level of evidence. The purpose of this study was to systematically review the evidence from randomised controlled trials (RCT) for tramadol in the management of PE. METHODS: We searched bibliographic databases including MEDLINE to August 2014 for RCTs. The primary outcome was intra-vaginal ejaculatory latency time (IELT). Methodological quality of RCTs was assessed. Between-group differences in IELT and other outcomes were pooled across RCTs in a meta-analysis. Statistical and clinical between-trial heterogeneity was assessed. RESULTS: A total of eight RCTs that evaluated tramadol against a comparator were included. The majority of RCTs were of unclear methodological quality due to limited reporting. Pooled evidence (four RCTs, 721 participants), suggests that tramadol is significantly more effective than placebo at increasing IELT over eight to 12 weeks (p = 0.0007). However, a high level of statistical heterogeneity is evident (I-squared = 74%). Single RCT evidence indicates that tramadol is significantly more effective than paroxetine taken on-demand, sildenafil, lidocaine gel, or behavioural therapy on IELT in men with PE. Tramadol is associated with significantly more adverse events including: erectile dysfunction, constipation, nausea, headache, somnolence, dry mouth, dizziness, pruritus, and vomiting, than placebo or behavioural therapy over eight to 12 weeks of treatment. However, addiction problems or breathing difficulties reported by patients for PE is not assessed in the current evidence base. CONCLUSIONS: Tramadol appears effective in the treatment of PE. However, these findings should be interpreted with caution given the observed levels of between-trial heterogeneity and the reporting quality of the available evidence. The variability across placebo-controlled trials in terms of the tramadol dose evaluated and the treatment duration does not permit any assessment of a safe and effective minimum daily dose. The long-term effects and side effects, including addiction potential, for men with PE have not been evaluated in the current evidence base. TRIAL REGISTRATION: The review is registered on PROSPERO 2013: CRD42013005289 .

Sexual health risk reduction interventions for people with severe mental illness: a systematic review.

BACKGROUND: Despite variability in sexual activity among people with severe mental illness, high-risk sexual behavior (e.g. unprotected intercourse, multiple partners, sex trade and illicit drug use) is common. Sexual health risk reduction interventions (such as educational and behavioral interventions, motivational exercises, counselling and service delivery), developed and implemented for people with severe mental illness, may improve participants' knowledge, attitudes, beliefs behaviors or practices (including assertiveness skills) and could lead to a reduction in risky sexual behavior. This systematic review evaluates the effectiveness of sexual health risk reduction interventions for people with severe mental illness. METHODS: Thirteen electronic databases (including MEDLINE, EMBASE and PsycINFO) were searched to August 2014, and supplemented by hand-searching relevant articles and contacting experts. All controlled trials (randomized or non-randomized) comparing the effectiveness of sexual health risk reduction interventions with usual care for individuals living in the community with severe mental illness were included. Outcomes included a range of biological, behavioral and proxy endpoints. Narrative synthesis was used to combine the evidence. RESULTS: Thirteen controlled trials (all from the USA) were included. Although there was no clear and consistent evidence that interventions reduce the total number of sex partners or improved behavioral intentions in sexual risk behavior, positive effects were generally observed in condom use, condom protected intercourse and on measures of HIV knowledge, attitudes to condom use and sexual behaviors and practices. However, the robustness of these findings is low due to the large between study variability, small sample sizes and low-to-moderate quality of included studies. CONCLUSIONS: There is insufficient evidence at present to fully support or reject the identified sexual health risk reduction interventions for people with severe mental illness. Given the serious consequences of high-risk sexual behaviors, there is an urgent need for well-designed UK based trials, as well as training and support for staff implementing sexual health risk reduction interventions. TRIAL REGISTRATION: PROSPERO CRD42013003674 .

People with gender dysphoria who self-prescribe cross-sex hormones: prevalence, sources, and side effects knowledge.

INTRODUCTION: There is a scarcity of research into the use of non-physician-sourced cross-sex hormones in the transgender population. However, when medication is not prescribed by health professionals, users' knowledge of such medication may be adversely affected. AIMS: This study aims to define the prevalence of Internet-sourced sex hormone use in a population attending for initial assessment at a gender identity clinic, to compare the prevalence between gender-dysphoric men and women, and to compare knowledge of cross-sex hormone side effects between users who source cross-sex hormones from medical doctors and those who source them elsewhere. METHODS: In the first part of the study, a cross-sectional design is used to measure the overall prevalence of sex hormone use among individuals referred to a gender clinic. The second part is a questionnaire survey aiming at measuring sex hormone knowledge among individuals referred to this clinic. MAIN OUTCOME MEASURES: Main outcome measures were (i) categorical data on the prevalence and source of cross-sex hormone use and (ii) knowledge of sex hormone side effects in a population referred to a gender clinic. RESULTS: Cross-sex hormone use was present in 23% of gender clinic referrals, of whom 70% sourced the hormones via the Internet. Trans men using testosterone had a sex hormone usage prevalence of 6%; one-third of users sourced it from the Internet. Trans women had a sex hormone usage prevalence of 32%; approximately 70% of users sourced hormones from the Internet. Cross-sex hormone users who sourced their hormones from physicians were more aware of side effects than those who used other sources to access hormones. CONCLUSION: One in four trans women self-prescribe cross-sex hormones before attending gender clinics, most commonly via the Internet. This practice is currently rare among trans men. Self-prescribing without medical advice leaves individuals without the knowledge required to minimize health risks.

A subpubic cartilaginous cyst causing neurological and sexual symptoms in a 69-year-old man.

INTRODUCTION: Subpubic cartilaginous cysts (SCCs) are rare. AIM: This is the first reported case of a male patient presenting with neurological and sexual symptoms due to an SCC. METHOD: We describe the clinical history of a patient who reported neuralgic pain, numbness in the groin and base of his penis, and loss of sexual function. RESULTS: A magnetic resonance imaging revealed the presence of an SCC with associated mass effect. A conservative approach was adopted and within 12 months, the cyst had decreased in size and his symptoms had improved. CONCLUSIONS: Men who present with erectile dysfunction and neurological symptoms merit a thorough assessment including appropriate investigation to exclude organic pathology.

Beliefs about penis size: validation of a scale for men ashamed about their penis size.

INTRODUCTION: No measures are available for understanding beliefs in men who experience shame about the perceived size of their penis. Such a measure might be helpful for treatment planning, and measuring outcome after any psychological or physical intervention. AIM: Our aim was to validate a newly developed measure called the Beliefs about Penis Size Scale (BAPS). METHOD: One hundred seventy-three male participants completed a new questionnaire consisting of 18 items to be validated and developed into the BAPS, as well as various other standardized measures. A urologist also measured actual penis size. MAIN OUTCOME MEASURES: The BAPS was validated against six psychosexual self-report questionnaires as well as penile size measurements. RESULTS: Exploratory factor analysis reduced the number of items in the BAPS from 18 to 10, which was best explained by one factor. The 10-item BAPS had good internal consistency and correlated significantly with measures of depression, anxiety, body image quality of life, social anxiety, erectile function, overall satisfaction, and the importance attached to penis size. The BAPS was not found to correlate with actual penis size. It was able to discriminate between those who had concerns or were dissatisfied about their penis size and those who were not. CONCLUSIONS: This is the first study to develop a scale for measurement of beliefs about penis size. It may be used as part of an assessment for men who experience shame about the perceived size of their penis and as an outcome measure after treatment. The BAPS measures various manifestations of masculinity and shame about their perceived penis size including internal self-evaluative beliefs; negative evaluation by others; anticipated consequences of a perceived small penis, and extreme self-consciousness.

A qualitative study of heterosexual women's attempts to renegotiate sexual relationships in the context of severe sexual problems.

Previous qualitative research on women's sexual problems has documented the ways in which they can impact psychological well-being as well as women's close interpersonal relationships. However, little attention has been paid to the ways that women with sexual problems negotiate sexual contact in the context of a relationship where sexual activity has a central role. This article draws on qualitative data from in-depth interviews with 23 heterosexual women who experienced sexual desire loss or vulvar pain. The data were analyzed within a material-discursive framework and this identified the centrality of relational and broader social factors in women's sexual negotiation. Key findings included: avoiding potentially intimate situations; engaging in intercourse when it was painful or the women had no desire to; and mentally planning and preparing themselves for sex. Other sexual activities were almost always regarded as a prelude to intercourse, yet around half of the sample had adapted their sexual repertoire to compensate for an absence of intercourse. The implications for future research and treatment in the area of women's sexual problems are discussed.

Children with Trans Parents: Parent-Child Relationship Quality and Psychological Well-being.

Objective. Families with trans parents are an increasingly visible family form, yet little is known about parenting and child outcomes in these families. This exploratory study offers the first quantitative assessment of parent-child relationship quality and child socio-emotional and behavioral adjustment in families with a self-identified trans parent with school-aged children. Design. A sample of 35 families (37 trans parents, 13 partners, and 25 children aged 8-18 years) was recruited primarily through social media. Parents, children, and teachers were administered a range of standardized interview and questionnaire assessments of parent-child relationship quality, quality of parenting, psychological adjustment, and gender-related minority stress. Results. Parents and children had good quality relationships, as assessed by both parents and children, and children showed good psychological adjustment. Child age at the time the parent communicated their gender identity to the child was unrelated to child outcomes. Conclusions. Parents and children in trans parent families had good quality relationships and children showed good psychological adjustment. The findings of this exploratory study challenge commonly held concerns about the potentially negative effects on children of growing up with a trans parent.

Psychological and interpersonal dimensions of sexual function and dysfunction.

INTRODUCTION: There are limited outcome data on the etiology and efficacy of psychological interventions for male and female sexual dysfunction as well as the role of innovative combined treatment paradigms. AIM: This study aimed to highlight the salient psychological and interpersonal issues contributing to sexual health and dysfunction, to offer an etiological model for understanding the evolution and maintenance of sexual symptoms, and to offer recommendations for clinical management and research. METHODS: This study reviewed the current literature on the psychological and interpersonal issues contributing to male and female sexual dysfunction. MAIN OUTCOME MEASURE: This study provides expert opinion based on a comprehensive review of the medical and psychological literature, widespread internal committee discussion, public presentation, and debate. RESULTS: Medical and psychological therapies for sexual dysfunctions should address the intricate biopsychosocial influences of the patient, the partner, and the couple. The biopsychosocial model provides an integrated paradigm for understanding and treating sexual dysfunction. CONCLUSIONS: There is need for collaboration between healthcare practitioners from different disciplines in the evaluation, treatment, and education issues surrounding sexual dysfunction. In many cases, neither psychotherapy alone nor medical intervention alone is sufficient for the lasting resolution of sexual problems. The assessment of male, female, and couples' sexual dysfunction should ideally include inquiry about predisposing, precipitating, maintaining, and contextual factors. Research is needed to identify efficacious combined and/or integrated treatments for sexual dysfunction.

International perspective on teaching human sexuality.

OBJECTIVE: The authors outline international training programs in human sexuality. METHODS: The authors reviewed the international literature and Internet resources to identify key training opportunities and curricula, with particular emphasis on training opportunities for psychiatrists. RESULTS: The authors outline key resources and training courses outside the United States. CONCLUSION: Training in human sexuality, sexology, and sexual medicine is evolving across many clinical disciplines, but courses remain limited in number and far apart geographically.