European Society for Sexual Medicine Position Statement “Assessment and Hormonal Management in Adolescent and Adult Trans People,With Attention for Sexual Function and Satisfaction”

BackgroundThere is a general lack of recommendations for and basic information tailored at sexologists and other health-care professionals for when they encounter trans people in their practice.AimWe present to clinicians an up-to-date overview of clinical consensus statements on trans health care with attention for sexual function and satisfaction.MethodsThe task force consisted of 7 clinicians experienced in trans health care, selected among European Society for Sexual Medicine (ESSM) scientific committee. The consensus was guided by clinical experience and a review of the available literature and by interactive discussions on trans health, with attention for sexual function and satisfaction where available.OutcomesThe foci of the study are assessment and hormonal aspects of trans health care.ResultsAs the available literature for direct recommendations was limited, most of the literature was used as background or indirect evidence. Clinical consensus statements were developed based on clinical experiences and the available literature. With the multiple barriers to care that many trans people experience, basic care principles still need to be stressed. We recommend that health-care professionals (HCPs) working with trans people recognize the diversity of genders, including male, female, and nonbinary individuals. In addition, HCPs assessing gender diverse children and adolescents should take a developmental approach that acknowledges the difference between prepubescent gender diverse children and pubescent gender diverse adolescents and trans adults. Furthermore, trans people seeking gender-affirming medical interventions should be assessed by HCPs with expertise in trans health care and gender-affirming psychological practice. If masculinization is desired, testosterone therapy with monitoring of serum sex steroid levels and signs of virilization is recommended. Similarly, if feminization is desired, we recommend estrogens and/or antiandrogen therapy with monitoring of serum sex steroid levels and signs of feminization. HCPs should be aware of the influence of hormonal therapy on sexual functioning and satisfaction. We recommend HCPs be aware of potential sexual problems during all surgical phases of treatment.Clinical ImplicationsThis is an up-to-date ESSM position statement.Strengths & LimitationsThese statements are based on the data that are currently available; however, it is vital to recognize that this is a rapidly changing field and that the literature, particularly in the field of sexual functioning and satisfaction, is limited.ConclusionThis ESSM position statement provides relevant information and references to existing clinical guidelines with the aim of informing relevant HCPs on best practices when working with transgender people.T'Sjoen G, Arcelus J, De Vries ALC, et al. European Society for Sexual Medicine Position Statement “Assessment and Hormonal Management in Adolescent and Adult Trans People, With Attention for Sexual Function and Satisfaction”. J Sex Med 2020;17:570–584.     

Hormonal Contraception and Female Sexuality: Position Statements from the European Society of Sexual Medicine (ESSM)

IntroductionHormonal contraception is available worldwide in many different forms. Fear of side effects and health concerns are among the main reasons for not using contraceptives or discontinuing their use. Although the safety and efficacy of contraceptives have been extensively examined, little is known about their impact on female sexual function, and the evidence on the topic is controversial.AimTo review the available evidence about the effects of hormonal contraceptives on female sexuality in order to provide a position statement and clinical practice recommendations on behalf of the European Society of Sexual Medicine.MethodsA comprehensive review of the literature was performed.Main Outcome MeasureSeveral aspects of female sexuality have been investigated, including desire, orgasmic function, lubrication and vulvovaginal symptoms, pelvic floor and urological symptoms, partner preference, and relationship and sexual satisfaction. For each topic, data were analyzed according to the different types of hormonal contraceptives (combined estrogen-progestin methods, progestin-only methods, and oral or non-oral options).ResultsRecommendations according to the Oxford Centre for Evidence-Based Medicine 2011 Levels of Evidence criteria and specific statements on this topic, summarizing the European Society of Sexual Medicine position, were developed.Clinical ImplicationsThere is not enough evidence to draw a clear algorithm for the management of hormonal contraception-induced sexual dysfunction, and further studies are warranted before conclusions can be drawn. A careful baseline psychological, sexual, and relational assessment is necessary for the health care provider to evaluate eventual effects of hormonal contraceptives at follow-up.Strengths & LimitationsAll studies have been evaluated by a panel of experts who have provided recommendations for clinical practice.ConclusionThe effects of hormonal contraceptives on sexual function have not been well studied and remain controversial. Available evidence indicates that a minority of women experience a change in sexual functioning with regard to general sexual response, desire, lubrication, orgasm, and relationship satisfaction. The pathophysiological mechanisms leading to reported sexual difficulties such as reduced desire and vulvovaginal atrophy remain unclear. Insufficient evidence is available on the correlation between hormonal contraceptives and pelvic floor function and urological symptoms.Both S, Lew-Starowicz M, Luria M, et al. Hormonal Contraception and Female Sexuality: Position Statements from the European Society of Sexual Medicine (ESSM). J Sex Med 2019;16:1681–1695.     

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

BackgroundTestosterone deficiency (TD) is an increasingly common problem with significant health implications, but its diagnosis and management can be challenging.AimTo review the available literature on TD and provide evidence-based statements for UK clinical practice.MethodsEvidence 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.OutcomesTo 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.Results25 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 ImplicationsTo help guide UK practitioners on effectively diagnosing and managing primary and age-related TD.Strengths and LimitationsA 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.ConclusionImproving 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.     

New Developments in Education and Training in Sexual Medicine

Introduction.The past 12 months have been historic ones for the field of Sexual Medicine in that we have seen the creation of the European Board examination in Sexual Medicine with the title of “Fellow of the European Committee on Sexual Medicine” (FECSM) offered to successful candidates.Aim.The study aims to promote a high standard of care in Sexual Medicine.Methods.An important way of promoting high standards of care is by the development of training, regulation, and assessment framework. The background to these developments and the recent educational activities of the European Society for Sexual Medicine (ESSM) are described in this article.Results.The creation of the Multidisciplinary Joint Committee on Sexual Medicine (MJCSM) under the auspices of the European Union of Medical Specialists, with the primary purpose to develop the highest possible standards of training in Sexual Medicine in Europe, made it possible to create a process for qualification in Sexual Medicine. The ESSM educational activities created opportunities to support trainees in Sexual Medicine and the first MJCSM exam was held in Amsterdam with a high overall success rate.Conclusion.These activities are intended to improve quality. The FECSM examination is the first of its type and provides a real opportunity for Sexual Medicine physicians to demonstrate and document their knowledge.     

Ethical Aspects of Sexual Medicine. Internet,Vibrators, and Other Sex Aids: Toys or Therapeutic Instruments?

IntroductionSexual health is the result of a complex interplay between social, relational, intrapsychic, and medical aspects. Sexual health care professionals (SHCP) may face several ethical issues. Some SHCP prescribe Internet pornography for both diagnosis and therapy and some others directly sell vibrators and sex aids in their offices.MethodsFive scientists, with different perspectives, debate the ethical aspects in the clinical practice of the SHCP.Main Outcome MeasureTo give to the Journal of Sexual Medicine's reader enough data to form her/his own opinion on an important ethical topic.ResultsExpert #1, who is Controversy's Section Editor, together with two coworkers, expert psycho‐sexologists, reviews data from literature regarding the use of the Internet in the SHCP. Expert #2 argues that licensed professionals, who treat sexual problems, should not sell sexual aids such as vibrators, lubricants, erotica, and instructional DVDs to their clients. On the other hand, Expert #3 is in favor of the possibility, for the patient, to directly purchase sexual aids from the SHCP in order to avoid embarrassment, confusion, and non‐adherence to treatment.ConclusionEvidence and intelligence would suggest that both the Internet (in selected subjects) and the vibrators (in the correct clinical setting), with the due efforts in counseling the patients and tailoring their therapy, are not‐harmful, excellent tools in promoting sexual health. Jannini EA, Limoncin E, Ciocca G, Buehler S, and Krychman M. Ethical aspects of sexual medicine. Internet, vibrators and other sex aids: Toys or therapeutic instruments? J Sex Med 2012;9:2994–3001.     

Education in sexual medicine: proceedings from the international consultation in sexual medicine, 2009

IntroductionSexual problems in men and women are common; and physicians endorse many barriers to addressing these issues, including lack of knowledge about the diagnosis and management of sexual problems and inadequate training in sexual health communication and counseling.AimTo update the recommendations published in 2004, from the International Consultation on Sexual Medicine (ICSM) relevant to the educational aspects of sexual health in undergraduate, graduate, and postgraducate medical education.MethodsA third international consultation in collaboration with the major sexual health organizations assembled over 186 multidisciplinary experts from 33 countries into 25 committees. Three experts from three countries contributed to this committee's review of Education in Sexual Medicine.Main Outcome MeasureExpert opinion was based on a comprehensive review of the medical literature, committee discussion, public presentation, and debate.ResultsA comprehensive review about the current state of undergraduate, graduate, and postgraduate sexual health education worldwide is provided. Recommendations about ideal sexual health curricula across training levels are provided. Best methods for achieving optimal training approaches to sexual health communication and interviewing, clinical skills and management, and counseling are described.ConclusionsCurrent sexual health education for undergraduate and practicing physicians is inadequate to meet the advancing science and technology and increasing patient demand for high-quality sexual health care. There is a need for enhanced training in medical institutions responsible for physician sexual health training worldwide. Future training programs at all levels of medical education should incorporate standardized measures of sexual health clinical skills acquisition and assessments of the impact on patient outcomes into the design of educational initiatives. Parish SJ, and Rubio-Aurioles E. Education in sexual medicine: Proceedings from the international consultation in sexual medicine, 2009.     

Clinical Interviewing Techniques and Sexuality Questionnaires for Male and Female Cancer Patients

IntroductionSexuality is an important aspect of quality of life; however, cancer and its treatments may impact the sexual function of men and women. Both cancer survivors and healthcare providers have barriers to addressing sexual problems in the clinical encounter.AimTo summarize the key points from the two authors' oral presentations at the Cancer Survivorship and Sexual Health Symposium, International Society for Sexual Medicine‐Sexual Medicine Society of North America (ISSM‐SMSNA) Joint Meeting, Washington, DC, June 2011.MethodsTo describe patient‐centered communication skills that can improve communication without excessively increasing the length of the visit. To review the validated sexuality measures that can assist clinicians in gathering sexual health information and assessing the response to therapeutic interventions for sexual problems.Main Outcome MeasuresSexual health interviewing skills including screening, assessment, open‐ended questions, empathic delineation, and counseling are discussed. Key sexuality scales including the rationale for their use, psychometric properties, and patient‐reported outcomes are summarized.ResultsOptimal approaches to the spectrum of communication challenges in the male and female sexual health encounter are exemplified. Advantages and limitations of the array of measures, including structured interviews, self‐administered questionnaires, daily diaries, and event logs, are explained.ConclusionsPractitioners can improve their detection and management of sexual concerns in cancer survivors by employing efficient patient‐centered communication skills in conjunction with validated sexuality scales.     

Low-Intensity Shock Wave Therapy in Sexual Medicine—Clinical Recommendations from the European Society of Sexual Medicine (ESSM)

IntroductionLow-intensity shockwave therapy (LISWT) has been investigated for the treatment of uroandrological disorders including erectile dysfunction (ED), Peyronie’s disease (PD) and chronic prostatitis/chronic pelvic pain syndrome (CP/CPPS) with controversial findings.AimTo review the evidence on LISWT for ED, PD, and CP/CPPS and provide clinical recommendations on behalf of the European Society of Sexual Medicine.MethodsMedline and Embase databases were searched for randomized clinical trials (RCTs), meta-analyses and open-label prospective or retrospective studies investigating the effect of LISWT on ED, PD, or CP/CPPS.OutcomesThe panel provided statements on clinically relevant questions concerning LISWT: (i) treatment efficacy, (ii) treatment protocol, (iii) clinical indications, and (iv) safety. The level of evidence was provided according to the Oxford 2011 criteria and graded using the Oxford Centre for Evidence-Based Medicine recommendations.Results11 RCTs and 5 meta-analyses investigated LISWT for ED. RCTs provided controversial results on the efficacy of LISWT and were affected by high heterogeneity and the small number of patients included. Pooled-data analysis showed an overall positive effect in terms of erectile function improvement but reported small estimates and included a largely heterogeneous cohort of patients. 4 RCTs and 1 meta-analysis assessed LISWT for PD. All trials showed positive findings in terms of pain relief but no effect on penile curvature and plaque size. Inclusion criteria vary widely among studies, and further investigation is needed. 5 RCTs investigated LISWT for CP/CPPS. Data showed a possible effect on pain relief, although there is no evidence supporting that pain relief was maintained or any improvement in pain over time.Clinical ImplicationsLISWT needs to be further investigated in the context of sexual medicine and is almost but not yet ready for clinical practice.Strengths and limitationsAll studies have been evaluated by a panel of experts providing recommendations for clinical practice.ConclusionsLISWT is a safe and well-tolerated procedure but its efficacy for the treatment of ED is doubtful and deserves more investigation. Patients reporting pain associated with PD may benefit from LISWT, although no effect is expected on disease progression. LISWT is not a primary treatment for CP/CPPS, but it may be considered as an option to relieve pain.Capogrosso P, Frey A, Jensen CFS, et al. Low-Intensity Shock Wave Therapy in Sexual Medicine—Clinical Recommendations from the European Society of Sexual Medicine (ESSM). J Sex Med 2019;16:1490–1505.     

Clinical Recommendations From the European Society for Sexual Medicine Exploring Partner Expectations,Satisfaction in Male and Phalloplasty Cohorts,the Impact of Penile Length,Girth and Implant Type,Reservoir Placement,and the Influence of Comorbidities and Social Circumstances

IntroductionTo date, several aspects of inflatable penile prosthesis (IPP) surgical procedure have been poorly studied.AimThe aim of this study was to review the evidence associated with IPP implantation and provide clinical recommendations on behalf of the European Society for Sexual Medicine (ESSM). Overall, 130 peer-reviewed studies and systematic reviews, which were published from 2007−2018 in the English language, were included.MethodsMEDLINE and EMBASE were searched for randomized clinical trials, meta-analyses, and open-label prospective and retrospective studies.Main Outcome MeasureThe panel provided statements exploring patients and partner expectations, satisfaction in male and phalloplasty cohorts, the impact of penile length, girth and implant type, reservoir placement, the influence of comorbidities, and social circumstances. Levels of evidence were provided according to the Oxford 2011 criteria and graded as for the Oxford Centre for Evidence-Based Medicine recommendations.ResultsIn the preoperative setting, it is fundamental to identify and interact with difficult patients with the intention of enhancing the surgeon’s ability to establish the surgeon-patient relationship, reduce physical and legal risk, as well as enhancing patient satisfaction. To address this need, the mnemonic Compulsive, Unrealistic, Revision, Surgeon Shopping, Entitled, Denial, and Psychiatric (“CURSED”) has been suggested to identify patients who are at high risk of dissatisfaction. The current recommendations suggest improving glycemic control in patients with diabetes. Available evidence suggests evaluating transplant recipients with the criteria of Barry, consisting of stable graft function for >6 months, avoidance of intra-abdominal reservoir placement, and low-dose immunosuppression. HIV status does not represent a contraindication for surgery. Smoking, peripheral vascular disease, and hypertension may be associated with an increased risk of revision surgery. Patients with spinal cord injury may receive IPP. Patients aged ≥70 years, as well as obese patients, can be offered IPP. The IPP implantation can be performed in patients with stable Peyronie’s disease. Ectopic high submuscular reservoir placement can be considered as an alternative method.Clinical ImplicationsThere is a relevant lack of high-level data and definite conclusions in certain areas remain difficult to draw.Strength & LimitationsAll studies have been evaluated by a panel of experts providing recommendations for clinical practice. Because of lack of sufficient prospective data, some of the included studies are retrospective and this could be stated as a limitation.ConclusionThis ESSM position statement provides recommendations on optimization of patient outcome by patient selection, and individualized peri- and intra-operative management. ESSM encourages centers to collaborate and to create prospective, multicenter registries in order to address this topic of increasing importance.Osmonov D, Christopher AN, Blecher GA, et al. Clinical Recommendations from the European Society for Sexual Medicine Exploring Partner Expectations, Satisfaction in Male and Phalloplasty Cohorts, the Impact of Penile Length, Girth and Implant Type, Reservoir Placement, and the Influence of Comorbidities and Social Circumstances. J Sex Med 2020;17:210–237.     

Existing and Future Educational Needs in Graduate and Postgraduate Education

IntroductionThis review was designed to make recommendations on future educational needs, principles of curricular development, and how the International Society for Sexual Medicine (ISSM) should address the need to enhance and promote human sexuality education around the world.AimTo explore the ways in which graduate and postgraduate medical education in human sexuality has evolved and is currently delivered.MethodsWe reviewed existing literature concerning sexuality education, curriculum development, learning strategies, educational formats, evaluation of programs, evaluation of students, and faculty development. We reviewed literature relating to four main areas: (i) the current status of the international regulation of training in sexual medicine; (ii) the current delivery of education and training in sexual medicine; (iii) resident and postgraduate education in sexual medicine surgery; and (iv) education and training for allied health professionals.ResultsThe main findings in these four areas are as follows. Sexual medicine has grown considerably as a specialty during the past 20 years, with many drivers being identified. However, the regulatory aspects of training, assessment, and certification are currently in the early stages of development and are in many ways lagging behind the scientific and clinical knowledge in the field. However, there are examples of the development of curricula with accompanying assessments that have attempted to set standards of education and training that might underlie the delivery of high-quality care to patients in sexual medicine. The development of competence assessment has been applied to surgical training in sexual medicine, and there is increasing interest in simulation as a means of enhancing technical skills training. Although the focus of curriculum development has largely been the medical profession, there is early interest in the development of standards for training and education of allied health professionals.ConclusionOrganizations of professionals in sexual health, such as the ISSM, have an opportunity, and indeed a responsibility, to provide and disseminate learning opportunities, curricula, and standards of training for doctors and allied health professionals in sexual medicine.Eardley I, Reisman Y, Goldstein S, et al. Existing and Future Educational Needs in Graduate and Postgraduate Education. J Sex Med 2017;14:475–485.     

Physicians' Attitude toward Female Genital Plastic Surgery: A Multinational Survey

IntroductionThe demand for female genital plastic surgery (FGPS) has increased over the last few decades. Yet, to date, there are no objective explicit measurements to define “abnormal” appearance of genital organs. Using the results of this study, we aimed to produce a statement of the European Society for Sexual Medicine (ESSM) on FGPS practice.AimsTo evaluate the prevalence of demand for FGPS and to explore the attitudes of sexual medicine specialists toward indications for FGPS.MethodsAttendees of the 2012 Annual Congress of the ESSM in Amsterdam, the Netherlands, were asked to participate in a survey during the congress.Main Outcome MeasureA 25-item self-report, closed-question questionnaire subdivided into three sections: sociodemographic data, professional background, and personal attitudes toward FGPS.ResultsOverall, a total of 360 physicians (mean age 48 years; range 23–72) from different medical disciplines completed the survey. There were diverse responses among participants regarding the definition of abnormal labial appearance and the techniques for labial reduction they perform. Overall, 65% responded that FGPS is frequently or occasionally demanded by the patients they treat. Likewise, most physicians (63%) reported that they never perform FGPS. Conversely, only 14% reported that they either frequently or occasionally perform FGPS. Almost one-third of participants believe that FGPS (labial surgery) improves sexual function. Fifty-two percent of participants answered that they believe that self image is the main reason for women to ask for labial surgery.ConclusionsSelf-image was regarded as the main factor in the demand for FGPS. Many practitioners in the field of sexual medicine recommend that women be referred for consultation with a psychiatrist or psychologist before undergoing FGPS. Lowenstein L, Salonia A, Shechter A, Porst H, Burri A, and Reisman Y. Physicians' attitude toward female genital plastic surgery—A multinational survey. J Sex Med 2014;11:33–39.     

Standard Operating Procedures for Female Orgasmic Disorder: Consensus of the International Society for Sexual Medicine

IntroductionAs the field of sexual medicine evolves, it is important to continually improve patient care by developing contemporary “standard operating procedures” (SOPs), reflecting the consensus view of experts in sexual medicine. Few, if any, consensus SOPs have been developed for the diagnosis and treatment of Female Orgasmic Disorder (FOD).AimThe objective is to provide standard operating procedures for FOD.MethodsThe SOP Committee was composed of a chair, selected by the International Society for the Study of Sexual Medicine, and two additional experts. To inform its key recommendations, the Committee used systematic reviews of available evidence and discussions during a group meeting, conference calls and e-mail communications. The Committee received no corporate funding or remuneration.ResultsA total of 12 recommendations for the assessment and treatment of FOD were generated, including suggestions for further research.ConclusionsEvidence-based, practice recommendations for the treatment of FOD are provided that will hopefully inform clinical decision making for those treating this common condition. Laan E, Rellini AH, and Barnes T. Standard operating procedures for female orgasmic disorder: Consensus of the International Society for Sexual Medicine. J Sex Med 2013;10:74-82     

The birth and development of sexual medicine: reflections of my personal journey

IntroductionThe phrase “sexual medicine” has become commonplace, as there is now the International Society for Sexual Medicine, the British Society for Sexual Medicine, the European Academy for Sexual Medicine, and the Journal of Sexual Medicine. The historic origin of the phrase “sexual medicine” is somewhat obscure.AimThe goal of this report is to provide my own individual journey as a physician to recall the use of the phrase “sexual medicine.”MethodsLiterature review, personal historic recall.ResultsGorm Wagner has identified three publications in the German language that include “Sexualmedizin” in the titles, the first published as early as 1908, and the other two publications were published in 1915 and 1931. I have no recollection of having heard the term “sexual medicine” before a meeting in 1970 on nonconsummation. I met Dr. Eric Trimmer, editor of “Medical News,” who discussed with me the idea of introducing a new journal devoted to sexual issues. I suggested the title “British Journal of Sexual Medicine.” The term “sexual medicine” was preferred because it encompassed both organic and psychological issues of sexual function and its problems. The British Journal of Sexual Medicine was published in 1973 to 1985. Other titles using Sexual Medicine appeared in other texts over the years.ConclusionsFrom my perspective, including a search of the literature in the English language published in or before 1970 that failed to find any reference to sexual medicine, I conclude that the phase “sexual medicine” was popularized in the 1970s. Riley A. The birth and development of sexual medicine: Reflections of my personal journey.     

Standard Operating Procedures for Taking a Sexual History

IntroductionWhile there is evidence of increased professional and public awareness of sexual problems, both male and female sexual dysfunctions remain underdiagnosed and undertreated by health care professionals around the world. Health care professionals (HCPs) are typically reluctant, disinterested, or unskilled in sexual problem management and regrettably are often disinclined to inquire about sexual issues. HCPs in all countries receive variable, nonstandardized, or inadequate training in sexual history taking and its treatment.AimThis article presents a standard operating procedure (SOP) for taking a sexual history from men or women with sexual problems or performance concerns.MethodsReview of relevant evidence-based literature identified through a PubMed search, integrated with expert opinion.ResultsGuidelines for taking a sexual history are presented along with the relevant domains, opening and follow-up questions.conclusionThe SOP presented in this article offers HCPs a brief, structured, and uniform method for obtaining a sexual history from men or women seeking health care services. Sexual history taking should be based on three basic principles, which serve as the foundation for managing sexual problems in men and women. These include the following: (i) a patient-centered approach; (ii) evidenced-based diagnostic and treatment recommendations; and (iii) use of a unified management approach for men and women. Sexual history taking should always be conducted in a culturally sensitive manner, taking account of the individual's background and lifestyle, status of the partner relationship, and the clinician's comfort and experience with the topic. Sexual inquiry should be incorporated into all new patient encounters, when possible, if only to ask one or two broad questions such as the following: “Are you sexually active? Do you have any sexual concerns or problems you would like to discuss?” Sexual history taking is a cornerstone of sexual medicine clinical practice. All patients should be provided an opportunity for frank and open discussion of sexual issues or concerns, conducted in an atmosphere of sensitivity and respect. Althof SE, Rosen RC, Perelman MA, and Rubio-Aurioles E. Standard operating procedures for taking a sexual history. J Sex Med **;**:**–**.     

Guidelines for Sexual Health Care for Prostate Cancer Patients: Recommendations of an International Panel

BackgroundPatients with prostate cancer suffer significant sexual dysfunction after treatment which negatively affects them and their partners psychologically, and strain their relationships.AimWe convened an international panel with the aim of developing guidelines that will inform clinicians, patients and partners about the impact of prostate cancer therapies (PCT) on patients’ and partners’ sexual health, their relationships, and about biopsychosocial rehabilitation in prostate cancer (PC) survivorship.MethodsThe guidelines panel included international expert researchers and clinicians, and a guideline methodologist. A systematic review of the literature, using the Ovid MEDLINE, Scopus, CINAHL, PsychINFO, LGBT Life, and Embase databases was conducted (1995–2022) according to the Cochrane Handbook for Systematic Reviews of Interventions. Study selection was based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Each statement was assigned an evidence strength (A-C) and a recommendation level (strong, moderate, conditional) based on benefit/risk assessment. Data synthesis included meta-analyses of studies deemed of sufficient quality (3), using A Measurement Tool to Assess Systematic Reviews (AMSTAR).OutcomesGuidelines for sexual health care for patients with prostate cancer were developed, based on available evidence and the expertise of the international panel.ResultsThe guidelines account for patients’ cultural, ethnic, and racial diversity. They attend to the unique needs of individuals with diverse sexual orientations and gender identities. The guidelines are based on literature review, a theoretical model of sexual recovery after PCT, and 6 principles that promote clinician-initiated discussion of realistic expectations of sexual outcomes and mitigation of sexual side-effects through biopsychosocial rehabilitation. Forty-seven statements address the psychosexual, relationship, and functional domains in addition to statements on lifestyle modification, assessment, provider education, and systemic challenges to providing sexual health care in PC survivorship.Clinical ImplicationsThe guidelines provide clinicians with a comprehensive approach to sexual health care for patients with prostate cancer.Strengths & LimitationsThe strength of the study is the comprehensive evaluation of existing evidence on sexual dysfunction and rehabilitation in prostate cancer that can, along with available expert knowledge, best undergird clinical practice. Limitation is the variation in the evidence supporting interventions and the lack of research on issues facing patients with prostate cancer in low and middle-income countries.ConclusionThe guidelines document the distressing sexual sequelae of PCT, provide evidence-based recommendations for sexual rehabilitation and outline areas for future research.Wittmann D, Mehta A, McCaughan E, et al. Guidelines for Sexual Health Care for Prostate Cancer Patients: Recommendations of an International Panel. J Sex Med 2022;19:1655–1669.     

ICD-11 Paraphilic Disorders: A South African Analysis of Its Utility in the Medico-Legal Context

BackgroundIn an effort to improve the clinical utility of the ICD-10, the WHO Working Group on the Classification of Sexual Disorders and Sexual Health recommended a new classification of Paraphilic Disorders in the ICD-11 to replace the ICD-10 section on Disorders of Sexual Preference. The proposed classification may have different implications for different countries. AIM: To examine South African national laws and policies, within which Paraphilic Disorders are encountered, and to assess the implications of the new classification.MethodA South African working group - representing experts within the disciplines of criminal law, psychiatry, psychology, public health, and criminology - reviewed: (i) national laws affected by reclassification, (ii) current practices in the psycho-legal assessment of sexual offenders, (iii) the implications of the reclassification for assessment and decision-making in forensic practice and other health settings, (iv) specific implications of the reclassification for diagnosis, and (v) implications of the reclassification as it relates to the demographic and sociocultural context of South Africa.OutcomesAs a rule, South African courts do not accept the existence of a Paraphilic Disorder on its own to be sufficient grounds to absolve any defendant from criminal responsibility though defence. Nevertheless, a diagnosis such as coercive sexual sadism disorder runs the risk of medicalization of criminal behavior with inappropriate use to mitigate sentences.Clinical ImplicationsThe ICD-11 approach is clinically useful in emphasizing that a broad range of sexual behavior fall under the rubric of healthy sexual behavior, but also that compulsive sexual behavior can be pathological.Strengths and LimitationsThis analysis was conducted by an interdisciplinary expert group, aligning international forensic mental health and national legal constructs in a low-middle income country (LMIC). The analysis is limited by its reliance on expert opinion rather than empirical data.ConclusionsIt is recommended that the ICD-11 includes a cautionary statement for forensic use, highlighting the fact that the mere inclusion of a diagnosis in the ICD-11 does not necessarily have forensic relevance.Artz L, Swanepoel M, Nagdee M, et al. ICD-11 Paraphilic Disorders: A South African Analysis of Its Utility in the Medico-Legal Context. J Sex Med 2021;18:526–538.     

Standard Operating Procedures in the Disorders of Orgasm and Ejaculation

IntroductionEjaculatory/orgasmic disorders are common male sexual dysfunctions and include premature ejaculation (PE), inhibited ejaculation, anejaculation, retrograde ejaculation, and anorgasmia.AimTo provide recommendations and guidelines of the current state-of-the-art knowledge for management of ejaculation/orgasmic disorders in men as standard operating procedures (SOPs) for the treating health care professional.MethodsThe International Society of Sexual Medicine Standards Committee assembled over 30 multidisciplinary experts to establish SOPs for various male and female sexual medicine topics. The SOP for the management of disorders of orgasm and ejaculation represents the opinion of four experts from four countries developed in a process over a 2-year period.Main Outcome MeasureExpert opinion was based on grading of evidence-based medical literature, limited expert opinion, widespread internal committee discussion, public presentation, and debate.ResultsPE management is largely dependent upon etiology. Lifelong PE is best managed with PE pharmacotherapy (selective serotonin reuptake inhibitors and/or topical anesthetics). The management of acquired PE is etiology specific and may include erectile dysfunction (ED) pharmacotherapy in men with comorbid ED. All men seeking treatment for PE should receive basic psychosexual education. Graded behavioral therapy is indicated when psychogenic or relationship factors are present and is often best combined with PE pharmacotherapy in an integrated treatment program. Delayed ejaculation, anejaculation, and/or anorgasmia may have a biogenic and/or psychogenic etiology. Men with age-related penile hypoanesthesia should be educated, reassured, and instructed in revised sexual techniques which maximize arousal. Retrograde ejaculation is managed by education, patient reassurance, and pharmacotherapy.ConclusionsAdditional research is required to further the understanding of the disorders of ejaculation and orgasm. McMahon CG, Jannini E, Waldinger M, and Rowland D. Standard operating procedures in the disorders of orgasm and ejaculation. J Sex Med **;**:**–**.     

Sexual Rehabilitation After Treatment for Prostate Cancer—Part 1: Recommendations From the Fourth International Consultation for Sexual Medicine (ICSM 2015)

IntroductionSexual dysfunction is common in patients after radical prostatectomy (RP) for prostate cancer.AimTo provide the International Consultation for Sexual Medicine (ICSM) 2015 recommendations concerning prevention and management strategies for post-RP erectile function impairment in terms of preoperative patient characteristics and intraoperative factors that could influence erectile function recovery.MethodsA literature search was performed using Google and PubMed databases for English-language original and review articles published up to August 2016.Main Outcome MeasuresLevels of evidence (LEs) and grades of recommendations (GRs) based on a thorough analysis of the literature and committee consensus.ResultsNine recommendations are provided by the ICSM 2015 committee on sexual rehabilitation after RP. Recommendation 1 states that clinicians should discuss the occurrence of postsurgical erectile dysfunction (temporary or permanent) with every candidate for RP (expert opinion, clinical principle). Recommendation 2 states that validated instruments for assessing erectile function recovery such as the International Index of Erectile Function and Expanded Prostate Cancer Index Composite questionnaires are available to monitor EF recovery after RP (LE = 1, GR = A). Recommendation 3 states there is insufficient evidence that a specific surgical technique (open vs laparoscopic vs robot-assisted radical prostatectomy) promotes better results in postoperative EF recovery (LE = 2, GR = C). Recommendation 4 states that recognized predictors of EF recovery include but are not limited to younger age, preoperative EF, and bilateral nerve-sparing surgery (LE = 2, GR = B). Recommendation 5 states that patients should be informed about key elements of the pathophysiology of postoperative erectile dysfunction, such as nerve injury and cavernous venous leak (expert opinion, clinical principle).ConclusionsThis article discusses Recommendations 1 to 5 of the ICSM 2015 committee on sexual rehabilitation after RP.Salonia A, Adaikan G, Buvat J, et al. Sexual Rehabilitation After Treatment for Prostate Cancer—Part 1: Recommendations From the Fourth International Consultation for Sexual Medicine (ICSM 2015). J Sex Med 2017;14:285–296.     

Controversies in Sexual Medicine: Is Sex Just Fun? How Sexual Activity Improves Health

IntroductionWith nonscientific, religious, or magic arguments, sexual activity has been regarded in the past as dangerous to health. This opinion is now rejected, and intercourse is generally considered healthy. However, while some aspects of the equation “more sex equals more health” have been demonstrated, others still need robust data for confirmation.MethodsFour scientists (an endocrinologist, a psychologist, a gynecologist, and a urologist) with expertise in the area of sexual medicine were asked to contribute with their opinions.Main Outcome MeasureExpert opinion supported by currently available literature.ResultsExpert 1, who is Controversy's section editor, demonstrates that sexual activity stimulates testosterone production. He infers that this physiological stimulus to androgenic production is one of the reasons why sexual activity improves general health. He is partially supported by the psychological findings in the couple having sex dissected by expert 2 and by the experimental evidences discussed by expert 3, who found that general benefits of sexual activity are not just for men. Expert 4 critically discusses contrasting findings so far published on the relationship between sexual activity and prostate cancer. He, in general agreement with the remainder of the faculty, stresses the need for more research on this entire topic.ConclusionReaders of The Journal of Sexual Medicine will judge if safe, satisfactory, and frequent sexual activity can be prescribed as a medicine in order to improve both general and sexual health of individuals and of the couples. Jannini EA, Fisher WA, Bitzer J, and McMahon CG. Is sex just fun? How sexual activity improves health. J Sex Med 2009;6:2640–2648.