Whither a Welfare-Funded 'Sex Doula' Programme?

The sexual citizenship of disabled persons is an ethically contentious issue with important and broad-reaching ramifications. Awareness of the issue has risen considerably due to the increasingly public responses from charitable organisations which have recently sought to respond to the needs of disabled persons-yet this important debate still struggles for traction in academia. In response, this paper continues the debate raised in this journal between Appel and Di Nucci, concurring with Appel's proposals that sexual pleasure is a fundamental human right and that access to sexual citizenship for the severely disabled should be publicly funded. To that endeavour, this paper refutes Di Nucci's criticism of Appel's sex rights for the disabled and shows how Di Nucci's alternative solution is iniquitous. To advance the debate, I argue that a welfare-funded 'sex doula' programme would be uniquely positioned to respond to the sexual citizenship issues of disabled persons.

Burden of Sexual Dysfunction.

Similar to the burden of other diseases, the burden of sexual dysfunction has not been systematically studied. However, there is growing evidence of various burdens (e.g., economic, symptomatic, humanistic) among patients suffering from sexual dysfunctions. The burden of sexual dysfunction has been studied a bit more often in men, namely the burden of erectile dysfunction (ED), premature ejaculation (PE) and testosterone deficiency syndrome (TDS). Erectile dysfunction is frequently associated with chronic conditions such as cardiovascular disease, diabetes, and depression. These conditions could go undiagnosed, and ED could be a marker of those diseases. The only available report from the United Kingdom estimated the total economic burden of ED at £53 million annually in terms of direct costs and lost productivity. The burden of PE includes significant psychological distress: anxiety, depression, lack of sexual confidence, poor self-esteem, impaired quality of life, and interpersonal difficulties. Some suggest that increase in female sexual dysfunction is associated with partner's PE, in addition to significant interpersonal difficulties. The burden of TDS includes depression, sexual dysfunction, mild cognitive impairment, and osteoporosis. One UK estimate of the economic burden of female sexual dysfunctions demonstrated that the average cost per patient was higher than the per annum cost of ED. There are no data on burden of paraphilic disorders. The burden of sexual dysfunctions is underappreciated and not well studied, yet it is significant for both the patients and the society.

Assessment of sexual activity and dysfunction in medically underserved women with gynecologic cancers.

BACKGROUND: Sexual dysfunction is a common long-term side effect of treatments for gynecologic cancer. Studies of sexual problems in gynecologic cancer survivors overrepresent White non-Hispanic, highly educated, and married women. Less is known about the sexual health needs of women in medically underserved populations. We therefore conducted a study to characterize sexual activity and sexual function in this population. METHODS: We recruited patients attending two gynecologic oncology clinics in a large public healthcare system that primarily serves uninsured and low-income patients. Participants were invited to complete a one-time survey to assess sexual function, sexual communication, sexual distress, relationship adjustment, depression, anxiety, prior help-seeking and help-seeking preferences, and reasons for sexual inactivity. Data were analyzed using descriptive statistics and multivariate models to predict sexual activity status and sexual dysfunction. RESULTS: Among 243 participants, the majority (n=160, 65.8%) were not sexually active in the past 4weeks, most often due to lack of a partner or lack of desire for sex. Just over one-fourth of sexually active participants were identified as likely cases of sexual dysfunction. Greater endorsement of depressive symptoms predicted both sexual inactivity and sexual dysfunction in multivariate analyses. Prior help-seeking for sexual problems was uncommon; however, a significant minority of participants expressed interest in receiving care for sexual problems. CONCLUSIONS: Gynecologic cancer survivors in our medically underserved population have high rates of sexual inactivity and sexual dysfunction. Future research should identify feasible strategies to address barriers to sexual healthcare in low-resource settings.

Exploring the feasibility and acceptability of couple-based psychosexual support following prostate cancer surgery: study protocol for a pilot randomised controlled trial.

BACKGROUND: Men who undergo surgery for prostate cancer frequently experience significant side-effects including urinary and sexual dysfunction. These difficulties can lead to anxiety, depression and reduced quality of life. Many partners also experience psychological distress. An additional impact can be on the couple relationship, with changes to intimacy, and unmet psychosexual supportive needs in relation to sexual recovery and rehabilitation. The aim of this exploratory randomised controlled trial pilot study is to determine the feasibility and acceptability of a novel family-relational-psychosexual intervention to support intimacy and reduce distress among couples following prostate cancer surgery and to estimate the efficacy of this intervention. METHODS/DESIGN: The intervention will comprise six sessions of psychosexual and relationship support delivered by experienced couple-support practitioners. Specialist training in delivering the intervention will be provided to practitioners and they will be guided by a detailed treatment manual based on systemic principles. Sixty-eight couples will be randomised to receive either the intervention or standard care (comprising usual follow-up hospital appointments). A pre-test, post-test design will be used to test the feasibility of the intervention (baseline, end of intervention and six-month follow-up) and its acceptability to couples and healthcare professionals (qualitative interviews). Both individual and relational outcome measures will assess sexual functioning, anxiety and depression, couple relationship, use of health services and erectile dysfunction medication/technologies. An economic analysis will estimate population costs of the intervention, compared to usual care, using simple modelling to evaluate the affordability of the intervention. DISCUSSION: Given the increasing incidence and survival of post-operative men with prostate cancer, it is timely and appropriate to determine the feasibility of a definitive trial through a pilot randomised controlled trial of a family-relational-psychosexual intervention for couples. The study will provide evidence about the components of a couple-based intervention, its acceptability to patients and healthcare professionals, and its influence on sexual and relational functioning. Data from this study will be used to calculate sample sizes required for any definitive trial. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01842438.Registration date: 24 April 2013; Randomisation of first patient: 13 May 2013.

Violence against women with chronic maternal disabilities in rural Bangladesh.

This study explored violence against women with chronic maternal disabilities in rural Bangladesh. During November 2006-July 2008, in-depth interviews were conducted with 17 rural Bangladeshi women suffering from uterine prolapse, stress incontinence, or fistula. Results of interviews showed that exposure to emotional abuse was almost universal, and most women were sexually abused. The common triggers for violence were the inability of the woman to perform household chores and to satisfy her husband's sexual demands. Misconceptions relating to the causes of these disabilities and the inability of the affected women to fulfill gender role expectations fostered stigma. Emotional and sexual violence increased their vulnerability, highlighting the lack of life options outside marriage and silencing most of them into accepting the violence. Initiatives need to be developed to address misperceptions regarding the causes of such disabilities and, in the long-term, create economic opportunities for reducing the dependence of women on marriage and men and transform the society to overcome rigid gender norms.

The comparison of combination SSRI and PDE-5 inhibitor therapy to SSRI monotherapy in men with premature ejaculation.

OBJECTIVE: To evaluate whether combination therapy with a selective serotonin reuptake inhibitor (SSRI) and phosphodiesterase-5 (PDE-5) inhibitor is superior to SSRI monotherapy in the treatment of premature ejaculation. DATA SOURCES: A literature search of MEDLINE (January 1980-April 2011) and International Pharmaceutical Abstracts (January 1970-April 2011) was conducted using the search terms premature ejaculation, phosphodiesterase-5 inhibitor, and selective serotonin reuptake inhibitor. STUDY SELECTION AND DATA EXTRACTION: All English-language human studies assessing the use of a PDE-5 inhibitor and SSRI in the treatment of premature ejaculation were evaluated. Additional references were retrieved from reference citations. DATA SYNTHESIS: Premature ejaculation is a multi-component disorder with several treatment options. Studies have demonstrated that both SSRIs and PDE-5 inhibitors used as monotherapy can delay time to ejaculation. Four clinical trials have been conducted to compare the efficacy of SSRI monotherapy versus combination SSRI-PDE-5 inhibitor therapy for the treatment of premature ejaculation. All studies focused on the treatments' ability to delay time to ejaculation. A statistically significant delay in time to ejaculation was found in patients using both an SSRI and PDE-5 inhibitor when compared to those on an SSRI alone. Average time to ejaculation was increased by approximately 50-78 seconds in patients using combination therapy when compared to monotherapy. The data also show greater delay in ejaculation with combination therapy in patients previously using SSRI monotherapy but dissatisfied with its effects. Adverse drug reactions including headache and flushing were higher in the combination group. CONCLUSIONS: Although a modest delay in ejaculation is seen when using an SSRI and PDE-5 inhibitor together, the combination also comes with increased risks for adverse drug reactions and is more expensive. SSRI monotherapy should continue to be first-line treatment for premature ejaculation due to a better adverse drug reaction profile, lower cost, and high efficacy. Combination therapy may be prescribed for those who fail SSRI monotherapy or have concomitant erectile dysfunction.

The burden of testosterone deficiency syndrome in adult men: economic and quality-of-life impact.

INTRODUCTION: Testosterone deficiency syndrome (TDS) causes a wide range of symptoms that can lead to significant morbidity. Preliminary evidence has also linked TDS with premature mortality and with a number of comorbid diseases including diabetes and metabolic syndrome. Such associations can lead to substantial economic and quality-of-life implications, the magnitude of which remains largely unknown. AIM: To review the economic and quality-of-life consequences of a largely untreated condition and to consider the likely health economic benefits of testosterone treatment. METHODS: A systematic review of four main areas: epidemiological evidence of the magnitude of TDS, estimates of cost of illness, impact on quality-of-life, and cost-effectiveness of testosterone treatment. MAIN OUTCOME MEASURE: Review of peer-reviewed literature. RESULTS: The lack of clear universally accepted diagnostic criteria and the uncertainty surrounding the link between TDS and some of its consequences complicate the estimation of the burden of illness of TDS. Consequences of TDS that potentially lead to increased economic burden include depression, sexual dysfunction, mild cognitive impairment, osteoporosis, cardiovascular disease, and mortality. However, although good evidence exists demonstrating an association between TDS and sexual dysfunction and cognitive impairment, evidence is less strong for depression, the incidence of fractures and mortality, and highly controversial for cardiovascular disease. The consequences that are likely to impact on patients' quality of life include sexual function, energy levels, body composition, mood, and cognitive function. CONCLUSION: Understanding the burden is only the first step decision makers need to take to decide whether to allocate scarce resources to treat the condition. To make informed decisions on when and who to treat information is also needed on the cost-effectiveness of available treatments. Such data would highlight the benefits of treatment of TDS to physicians, patients, and to society as a whole.