Changes in Sexual Behavior and Satisfaction and Violent Behavior during COVID-19 Lockdown: Explorative Results from the Italian Cross-Sectional Study of the I-SHARE Multi-Country Project.

BACKGROUND: The COVID-19 pandemic has had effects on sexual and reproductive health and intimate partner violence (IPV). This study aims to describe changes in sexual health and IPV in the Italian population both during and after the lockdowns. METHODS: This cross-sectional online study was conducted, as part of the I-SHARE multicountry project, between June 2020 and January 2021. Recruitment was carried out through convenience sampling; a total of 329 participants were included in the analysis. A generalized linear model was used to analyze the difference in sexual health and IPV variables before, during, and after the lockdown. RESULTS: Fifty-three percent of the participants reported having sexual problems during the first wave of the pandemic. Sexual satisfaction decreased during the first wave, and then, returned to the pre-lockdown level. While during the lockdown, some activities were reduced (such as kissing, cuddling, and sexual activities with a steady partner), for other activities, no difference was reported (such as masturbation, sexual activities with casual partners, or sexting). Few participants reported having issues accessing HIV testing and contraception. There was no difference in terms of physical and sexual violence, while there was a significant decrease in feeling vulnerable to sexual or physical assault during the first wave. CONCLUSIONS: The first wave of the pandemic has had significant effects on sexual health. This should be taken into consideration when preparing for future epidemics and health emergencies.

How the smartphone apps can improve your sexual wellbeing.

The use of smartphones and other technological devices has rapidly increased in the last few years, along with the availability of various applications that can be downloaded on iOS or Android devices. In this narrative review, we included most of the literature found on the specific topic of smartphone apps related to sexual health. Using the two databases PubMed and PsycInfo, we conducted research by the following terms: "apps" and "sexual wellbeing"; "apps" and "sexual health"; "mhealth" and "sex"; "mhealth", "apps" and "sex". We selected all articles written in English within the last 6 years to ensure the accessibility and consider the rapid changes in this field. The article highlights that many populations are interested in gaining information on a wide range of topics relating to sexual practices, potential risks, coercion, sexual violence and the prevention and recognition of potentially dangerous situations. Some findings suggest that sex education for sexual minority adolescents should focus on online sexual safety. Despite their value, many concerns and limitations must be solved, and future research studies are needed to explore how to fix them.

Family Attachment, Sexuality, and Sexual Recidivism in a Sample of Italian Sexual Offenders: Preliminary Results.

OBJECTIVE: The research aims to investigate family communication regarding sexuality and the possible link between insecure attachment, violence in relationships, and the tendency toward sexual sensation-seeking in a sample of Italian sexual offenders. DESIGN AND METHOD: We evaluated 29 male sexual offenders in two correctional facilities of Southern Lazio (Italy) (mean age = 40.76; SD = 11.16). The participants completed general questions about their family and sexual education and fulfilled the following questionnaires: Compulsive Sexual Behavior Inventory (CSBI), Sexual Sensation-seeking Scale (SSSS), and the High-Risk Situation Checklist, adapted in Italian, as well as the Attachment Style Questionnaire (ASQ), validated in Italian. RESULTS: Most of the participants had never talked about sex within their family and perceived a severe or abusive education during childhood. In addition, positive correlations emerged between SSSS and the two scales of the CSBI, as well as between insecure attachment style, CSBI, and sexual sensation-seeking. The participants also reported some critical issues regarding the personal perception of high-risk situations linked to sexual relapse. CONCLUSIONS: The data suggest factors to investigate, such as family education and relationships and the personal perception of sexual recidivism. The results might be effective in treatment and prevention programs among sex offenders.

Intimate Partner Violence During COVID-19 Restrictions: A Study of 30 Countries From the I-SHARE Consortium.

Intimate partner violence (IPV) causes substantial physical and psychological trauma. Restrictions introduced in response to the COVID-19 pandemic, including lockdowns and movement restrictions, may exacerbate IPV risk and reduce access to IPV support services. This cross-sectional study examines IPV during COVID-19 restrictions in 30 countries from the International Sexual HeAlth and REproductive Health (I-SHARE) study conducted from July 20th, 2020, to February, 15th, 2021. IPV was a primary outcome measure adapted from a World Health Organization multicountry survey. Mixed-effects modeling was used to determine IPV correlates among participants stratified by cohabitation status. The sample included 23,067 participants from 30 countries. A total of 1,070/15,336 (7.0%) participants stated that they experienced IPV during COVID-19 restrictions. A total of 1,486/15,336 (9.2%) participants stated that they had experienced either physical or sexual partner violence before the restrictions, which then decreased to 1,070 (7.0%) after the restrictions. In general, identifying as a sexual minority and experiencing greater economic vulnerability were associated with higher odds of experiencing IPV during COVID-19 restrictions, which were accentuated among participants who were living with their partners. Greater stringency of COVID-19 restrictions and living in urban or semi-urban areas were associated with lower odds of experiencing IPV in some settings. The I-SHARE data suggest a substantial burden of IPV during COVID-19 restrictions. However, the restrictions were correlated with reduced IPV in some settings. There is a need for investing in specific support systems for survivors of IPV during the implementation of restrictions designed to contain infectious disease outbreaks.

Sexting, Self-esteem, and Social Media: A Comparison among Frequent, Occasional, and Non-sexting Italian Adolescent Girls.

Background: The phenomenon of sexting consists of sending and sharing sexual images, videos, or messages using smartphones and social networks. Sexting is spreading dangerously among adolescents who share private and explicit sexual content, ignoring the negative and risky consequences associated with this behavior. According to recent literature, sexting behavior is strongly related to the participants' level of self-esteem and social media's influence on them. Objective: Our study was a descriptive community-based study focused on the central-south Italian context, which aimed to investigate sexually risky behavior and the main motivations for sexting, and to compare differences in self-esteem and social media's influence among three groups of Italian girls: non-sexters, occasional sexters, and frequent sexters. Design: Our research involved 569 Italian girls (14-19 years old) who completed the following questionnaires: the Health and Sexual Behavior Questionnaire; the Sexting Behavior Scale; the Multidimensional Self-Concept Scale; and the Sociocultural Attitudes Toward Appearance Questionnaire-3. Results: Our results showed that most participants sexted with their partner, and had a responsible attitude toward sexuality and kept sexual risk low. Moreover, frequent sexters had higher scores on social media's influence relative to the internalization of the body image and model for beauty and athleticism, as well as lower levels of global, academic, and competence self-esteem. Conclusion: Our results could promote interventions in the school context in order to: a) improve awareness among youth about social media use, sexting, and safe sexuality; b) reduce the risk associated with sexting and the influence of social networks; and c) stimulate reflections by teachers and parents on adolescents' sense of identity and self-esteem.

The International Sexual Health And REproductive Health during COVID-19 (I-SHARE) Study: A Multicountry Analysis of Adults from 30 Countries Prior to and During the Initial Coronavirus Disease 2019 Wave.

BACKGROUND: There is limited evidence to date about changes to sexual and reproductive health (SRH) during the initial wave of coronavirus disease 2019 (COVID-19). To address this gap, our team organized a multicountry, cross-sectional online survey as part of a global consortium. METHODS: Consortium research teams conducted online surveys in 30 countries. Sampling methods included convenience, online panels, and population-representative. Primary outcomes included sexual behaviors, partner violence, and SRH service use, and we compared 3 months prior to and during policy measures to mitigate COVID-19. We conducted meta-analyses for primary outcomes and graded the certainty of the evidence. RESULTS: Among 4546 respondents with casual partners, condom use stayed the same for 3374 (74.4%), and 640 (14.1%) reported a decline. Fewer respondents reported physical or sexual partner violence during COVID-19 measures (1063 of 15 144, 7.0%) compared to before COVID-19 measures (1469 of 15 887, 9.3%). COVID-19 measures impeded access to condoms (933 of 10 790, 8.7%), contraceptives (610 of 8175, 7.5%), and human immunodeficiency virus/sexually transmitted infection (HIV/STI) testing (750 of 1965, 30.7%). Pooled estimates from meta-analysis indicate that during COVID-19 measures, 32.3% (95% confidence interval [CI], 23.9%-42.1%) of people needing HIV/STI testing had hindered access, 4.4% (95% CI, 3.4%-5.4%) experienced partner violence, and 5.8% (95% CI, 5.4%-8.2%) decreased casual partner condom use (moderate certainty of evidence for each outcome). Meta-analysis findings were robust in sensitivity analyses that examined country income level, sample size, and sampling strategy. CONCLUSIONS: Open science methods are feasible to organize research studies as part of emergency responses. The initial COVID-19 wave impacted SRH behaviors and access to services across diverse global settings.

The Sexual and Parenting Rights of People with Physical and Psychical Disabilities: Attitudes of Italians and Socio-Demographic Factors Involved in Recognition and Denial.

The sexual and parenting rights (SPRs) of people with disabilities (PwDs) are under-recognized. Sociodemographic factors may influence attitudes towards them. The aims of this study were: (1) to analyze the levels of agreement of a sample of Italian people with some SPRs of PwDs; (2) to inquire if the SPRs of people with psychical disabilities (PwPSYDs) were less recognized than those with physical disabilities (PwPHDs); (3) to verify if sociodemographic characteristics associated with under-recognition. An online anonymous survey was distributed using non-random sampling methods to conduct an inquiry into the level of agreement with statements regarding the SPRs of PwPHDs and PwPSYDs to have satisfying sexuality, to marry, and to adopt children. Answers from 973 Italian participants, aged 18-84 years (71.1% females) were analyzed. At least 70% of respondents declared in favor of the SPRs of PwPHDs. The SPRs of PwPSYDs were always subjected to higher under-recognition. Religiosity, male sex, higher age, and lower education were the factors most often associated with being against the SPRs of PwDs. Improved identification of the less tolerant respondents and the less recognized categories may allow for specific strategies for promoting the recognition of the SPRs for PwDs.

The International Sexual Health And Reproductive Health Survey (I-SHARE-1): A Multi-Country Analysis of Adults from 30 Countries Prior to and During the Initial COVID-19 Wave.

BACKGROUND: The COVID-19 pandemic forced billions of people to shelter in place, altering social and sexual relationships worldwide. In many settings, COVID-19 threatened already precarious health services. However, there is limited evidence to date about changes to sexual and reproductive health (SRH) during the initial wave of COVID-19 disease. To address this gap, our team organized a multi-country, cross-sectional online survey as part of a global consortium. METHODS: Consortium research teams conducted online surveys in 30 countries. Sampling methods included convenience, online panels, and population-representative. Primary outcomes included sexual behaviors, partner violence, and SRH service utilization, and we compared three months prior to and three months after policy measures to mitigate COVID-19. We used established indicators and analyses pre-specified in our protocol. We conducted meta-analyses for primary outcomes and graded the certainty of the evidence using Cochrane methods. Descriptive analyses included 22,724 individuals in 25 countries. Five additional countries with sample sizes <200 were included in descriptive meta-analyses. RESULTS: Respondents were mean age 34 years; most identified as women (15160; 66.7%), cis-gender (19432; 86.6%) and heterosexual (16592; 77.9%). Among 4546 respondents with casual partners, condom use stayed the same for 3374 (74.4%) people and 640 (14.1%) people reported a decline. Fewer respondents reported physical or sexual partner violence during COVID-19 measures (1063/15144, 7.0%) compared to the period before COVID-19 measures (1469/15887, 9.3%). COVID-19 measures impeded access to condoms (933/10790, 8.7%), contraceptives (610/8175, 7.5%), and HIV/STI testing (750/1965, 30.7%). Pooled estimates from meta-analysis indicate during COVID-19 measures, 32.3% (95% CI 23.9-42.1) of people needing HIV/STI testing had hindered access, 4.4% (95% CI 3.4-5.4) experienced partner violence, and 5.8% (95% CI 5.4-8.2) decreased casual partner condom use (moderate certainty of evidence for each outcome). Meta-analysis findings were robust in sensitivity analyses that examined country income level, sample size, and sampling strategy. CONCLUSION: Open science methods are feasible to organize research studies as part of emergency responses. The initial COVID-19 wave impacted SRH behaviors and access to services across diverse global settings.

Sexual Violence and Trauma in Childhood: A Case Report Based on Strategic Counseling.

Children and adolescents are too often victims of sexual abuse and harassment. According to the World Health Organization (WHO), approximately 150 million girls and 73 million children <18 have been victims of violence and sexual exploitation during their childhood. Data show that females are more likely to be a victim of abuse and violence than males (20% vs. 5-10%). Such abuses lead to long-term psychophysical and relational consequences and victims are often afraid of asking for support from both parents and professionals. This case report shows the story of a 17-year-old adolescent, Sara, involved by her mother in a strategic counseling process, to solve BDSM-type sexual addiction (slavery and discipline, domination and submission, sadism and masochism), self-aggressive behavior, and alcohol abuse issues. The strategic counseling process is structured in 15 sessions and was based on problem-solving techniques and corrective behavioral strategies. During the sessions, it emerged that Sara had been a victim of sexual violence at the age of 6 and that she had never talked about the rape with anyone. At the age of 12, she began to experience social anxiety and shame, feelings that led her to use alcohol and seek violent sexual partners and bondage relationships. During the counseling sessions, Sara elaborated on her trauma, becoming more aware of her resources and her desires, and she learned to manage the sense of guilt and shame associated with the violence suffered, through alternative strategies. At the end of the process, Sara normalized her relationship with sex and alcohol, regaining her identity.

The Global Impact of the COVID-19 Pandemic on Individuals' and Couples' Sexuality.

The COVID-19 pandemic and its related restrictions significantly impacted individuals' health, wellbeing, and security. Isolation, limitation of movement, social distancing, and forced cohabiting have had a strong influence on all areas of people's lives as well as on their sexuality. Investigating how the COVID-19 outbreak and its consequences impacted people's sexuality was the primary aim of this review. Particularly, we focused on: (1) the variables associated with the improvement or the deterioration of individuals' and couples' lives during the pandemic; (2) the use of sex as a coping strategy; (3) the impact of COVID-19 outbreak on LGBT people. Results have shown that the worsening of sexual life seems to be related to couples' conflict, emotions and psychological difficulties, being female, being single or away from the partner, being a health care worker, and having children. Moreover, a detrimental effect on sexuality was associated with stress, forced cohabitation, routine, anxiety and worry about the job and the pandemic, feeling partner distance, being unhappy with their partner, and lack of privacy. On the other hand, improvements in sexuality were associated with living happily with a partner, being happy and satisfied with a partner, feeling less stressed and more bored, having more free time, having fewer recreation opportunities, and having minor workload. During the pandemic, there was an increase in using sex toys, pornography consumption, masturbating, and trying sexual experimentations. Among LGBT people, an increase was found in the number of casual sexual partners potentially due to the perceived lower likelihood of transmission through sex. Moreover, the increase in sexual activity may have represented a coping strategy to quarantine-related distress.

Perception of Cyberbullying in Adolescence: A Brief Evaluation Among Italian Students.

Cyberbullying is associated with the expansion of digital devices and the Internet. In Italy and other European and non-European countries, the phenomenon is growing. Young people who suffer from cyberbullying develop psychopathological symptoms of anxiety, depression, and social phobia that can lead to extreme acts, such as suicide. The pressure, the sense of isolation, and helplessness experienced by cyber-victims also affect their family and the school context. Cyberbullying is acted through digital tools, it is often anonymous, and aims to destroy and psychologically humiliate the victim. There are various forms of cyberbullying that involve different reactions and consequences. However, few studies have focused on adolescents' perception of cyberbullying. Youths often engage in aggressive behaviors, ignoring the feelings and reactions of the victims. Based on these considerations, our article aims to provide a general overview of the spread of the phenomenon and to understand the various types of cyberbullying and its consequences on victims. We will also illustrate a brief evaluation conducted in Italian schools investigating the perception of cyberbullying in a sample of 600 Italian adolescents (11-14 years old). Our work aims to investigate the cognition and the personal perception of youths about cyberbullying and its consequences and to promote educational interventions within and outside the context of school.

Medical and Health Care Professionals' Sexuality Education: State of the Art and Recommendations.

Sexuality is considered an important aspect of holistic care, but research has shown that it is often not considered, as it should be, in health services. Addressing clients' sexuality requires a multidisciplinary approach and is not the responsibility of a single professional. The literature underlines that university students or those working in hospitals and other health care facilities are not adequately prepared to meet patients' needs regarding sexuality. The objective of this study was, therefore, to review the scientific literature addressing training courses for health professionals in sexuality between 2000 and 2020. Several studies have shown enhancement in health care professionals' ability to deal with patients' sexuality issues after participating in sexuality education programs, regardless of the course load and modality, even if the long-term effects have still to be proved. Health care professionals therefore require education in the area of sexuality, regardless of their discipline. According to the articles reviewed, in order to improve the performance and comfort level of health care professionals to deal with patients' sexuality, investments in training are necessary. Further evaluations of interdisciplinary sexuality education programmes should use larger samples and explore the differences across disciplines.

Sexual well-being in adolescent and young adults born with arm: the perspective of the patients.

PURPOSE: Sexual well-being and sexual functioning are understudied in patients born with ARM. The aim of this exploratory study was to investigate sexual history, main fears, and problems encountered during sexual relationships. METHODS: Before participating in a sexual education intervention, 21 adolescents or young adults (12 males; mean 28.8; SD 10.6) born with ARM, answered a ten-item questionnaire specifically developed to evaluate sexual well-being. Percentages and Chi-square were calculated. RESULTS: 52.4% were married/had a partner. The majority (71%) declared that had sexual relationships. Mean age of the first sexual relationship was 18.8 (2.7) and 22.7 (3.8) for males and females, respectively. Females reported both more fear and experience of pain during sexual intercourse, compared to males. Main experienced problems and fears for male patients were loss of feces and premature ejaculation, followed by the fear of lack of erection and managing contraception. Main experienced problems and fears in females were loss of feces, pain, lack of desire, and lack of lubrication. In only few cases, patients asked for advices to a pediatric surgeon or to an adult surgeon specialized in ARM. CONCLUSIONS: Adult and adolescent patients may benefit of andrological/gynecological evaluation, psychological support, and sexual counseling to improve their sexual well-being.

[Smartphone applications : useful for sex education, counselling and therapy ?] / Applications pour smartphones - Peuvent-elles être utiles pour l'éducation sexuelle, le counseling et la thérapie ?

In recent years, the number of smartphone users has exploded worldwide and downloads of applications for these phones have increased significantly. The purpose of this article is to present a review of the literature on the use of smartphone applications to improve sexual health, suggesting how they can be used in sex education, counselling and therapy ; the use of smartphone applications to provide sexual health information, particularly to younger populations, could increase awareness of risky sexual behaviours before first sexual intercourse. This article could help sexologists use smartphone applications to facilitate their work. It is very important that clinicians have specific knowledge of online sexual issues, otherwise they may be vulnerable to stereotypes and judgments.

Ces dernières années, le nombre d'utilisateurs de smartphones a explosé dans le monde entier et les téléchargements d'applications pour ces téléphones ont considérablement augmenté. Le but de cet article est de présenter une revue de la littérature sur l'utilisation des applications des téléphones intelligents pour améliorer la santé sexuelle, suggérant comment elles peuvent être utilisées dans l'éducation sexuelle, le counseling et la thérapie. Cet article pourrait aider les sexologues à utiliser les applications des téléphones intelligents pour faciliter leur travail. Il est très important que les cliniciens aient une connaissance spécifique des questions sexuelles en ligne, sinon ils peuvent être vulnérables aux stéréotypes et aux jugements.

Sleep quality as predictor of BMI in non-depressed caregivers of people with dementia.

PURPOSE: Although most cross-sectional and longitudinal studies of children and adolescents have found a link between short duration of sleep and obesity, the literature related to adults provides a non-consensual framework. The aim of the present study was to examine the association between sleep quality and BMI in a population of caregivers looking after people suffering from dementia, with a view to identifying the moderating role of depressive symptoms in the relationship between sleep problems and BMI. METHODS: A total of 117 subjects took part in the study, filling in a Sociodemographic Questionnaire, the Pittsburgh Sleep Quality Index, the Eating behavior Questionnaire and The Center for Epidemiologic Studies-Depression. RESULTS: Depressive symptoms were greater in females than in males. The sample was divided into two subgroups based on depressive-symptom scores. Only within the subsample with low depressive symptoms, higher sleep disturbances influenced BMI positively. Within this subsample of participants with low depressive symptoms, the variables that seem to play a pivotal role in explaining a high BMI are: female gender, sleep problems, and diet quality, while within the subsample with high depressive symptoms only the female gender factor was found to influence BMI. CONCLUSIONS: Depressive symptoms seem to act as moderators in the relationship between sleep and BMI. They should be evaluated to identify the risk of high BMI, and to differentiate clinical intervention, at least in this population, which experiences the stress of caregiving chronically, though not suffering from clinical eating disorders. LEVEL OF EVIDENCE: Level II, cross-sectional study.

Is poor sleep associated with obesity in older adults? A narrative review of the literature.

INTRODUCTION: To address the worldwide epidemic of obesity, a sizable literature implicates sleep problems in the onset of obesity in younger populations. However, less is known about how this process may operate among older adults, which is of concern, given demographic shifts that have resulted in a much higher proportion of developed nations around the world reaching late life. METHODS: We offer a current review of the literature studying older adults and examining associations between sleep quality and obesity in this population. We consider both subjective and objectively measured sleep as well as both cross-sectional and longitudinal studies offering stronger causal inference. RESULTS: We discuss seemingly contradictory literature showing that shorter sleep duration as well as longer sleep duration are associated with obesity risk, then review studies that tested for non-linear relationships and reported a U-shape pattern, suggesting that too much or too little sleep is detrimental. Besides sleep duration, we discuss evidence showing that other forms of sleep dysfunction related to night-time awakenings, REM sleep, slow-wave sleep, and daytime sleepiness, which are indicators of sleep quality, are also linked to obesity. Specific psychological and physiological mediators and moderators, suggesting possible mechanisms whereby sleep problems may affect obesity in older adults, are described. CONCLUSION: We conclude by discussing areas, where additional research could help clarify this association, considering such factors as medical comorbidities common in late life, and health-related behaviors that may stem from poor sleep (such as disordered eating behavior). Such insights will have great value for clinical practice. LEVEL OF EVIDENCE: Level V, narrative review.

Female sexual pain disorders: dyspareunia and vaginismus.

PURPOSE OF REVIEW: To analyze literature on sexual pain disorders and to review and summarize the articles published throughout 2013 which contribute to the current knowledge on this subject. RECENT FINDINGS: By age 40, 7.8% of women reported vulvar pain. Diagnostic and Statistical Manual of Mental Disorders, fifth edition, has combined vaginismus and dyspareunia into the same diagnostic label. The research reviewed in this article seems to differently point toward two conditions, focusing on different aspects both on the etiological and on the treatment area. Higher levels of partner-perceived self-efficacy and lower levels of partner catastrophizing were associated with less pain intensity in women with entry dyspareunia, independent of women's pain perception and self-efficacy. Alexithymia and fear were found to be important etiological factors in vaginismus. SUMMARY: The present findings did not provide clear evidence in support of the superiority of any treatment and highlight the need for randomized, placebo-controlled trials that compare treatments in the future. A lot of work remained to be done to understand such a complex and multifaceted disturbance as genital sexual pain, but the articles examined showed that we are slowly adding more knowledge on the etiological cause and treatment models for such conditions.

Delayed ejaculation and alexithymia: what is the relationship?

Delayed Ejaculation (DE) is probably the least studied and understood of the male sexual dysfunctions (MSD). There is still little unanimity concerning its psychological/interpersonal aetiology. Previous studies found that MSD are strongly related with alexithymia, a multifaceted personality construct that describes a disturbance in the regulation of emotions.The aim of this study was to investigate the presence of alexithymia in men with DE and correlate alexithymia levels with DE severity. According to specific features of the symptoms, we hypothesized that alexithymia would not be correlated with this specific sexual disorder. 54 outpatients with a diagnosis of DE assessed at the Institute of Clinical Sexology and the Urology Department of Sapienza, University in Rome were enrolled in the study. DE was diagnosed after a specialist examination and according to Diagnostic and Statistical Manual of Mental Disorders -IV-TR criteria. Participants were provided with the Toronto Alexithymia Scale (20 items; TAS-20), a self-measure of the Intravaginal Ejaculation Latency Time and an ad hoc questionnaire to collect anamnestic data. 9.3% of patients could be categorized as alexithymics, 9.3% of them as borderline, while 81.4% of the sample was found to be non-alexithymic. The overall average TAS-20 score was 45.46. Results show that alexithymia is correlated neither with the presence of DE nor with its severity, in contrast to other MSDs, where this condition was found in about 30% of patients. The data presented suggest that DE, although not correlated to alexithymia, is probably related to other psychogenic features such as hypercontrol configuration. This paper can contribute to the understanding of DE, by excluding one of the possible etiological factors, previously found to be important in the onset and the maintenance of the other MSDs. More studies are needed in order to better understand DE and provide recommendations about treatment.