Sexual dysfunction after cancer: gender differences, tumor-specific patterns, and implications for sexual medicine practice.

Arriving at the diagnosis of female sexual dysfunction

Back to table of contents Previous article Next article Members in the NewsFull AccessPsychiatrist's Specialty Finds Him on Rarely Trodden PathJoan Arehart-TreichelJoan Arehart-TreichelPublished Online:21 Nov 2008https://doi.org/10.1176/pn.43.22.0008Although psychiatrists have a long history of discussing sexual themes in psychotherapy, relatively few actually specialize in helping patients with sexual problems (see Original article: Psychiatry and Sexual Medicine). An exception is Canadian psychiatrist Ronald Stevenson, M.D.Certainly it's a delicate mission, the tall, sandy-haired, laid-back clinician recently acknowledged in an interview in his Vancouver, British Columbia, office. "It means talking with people about things they may have never spoken with anyone about before, even their own partners."Ronald Stevenson, M.D.: "It's extremely rewarding to help people with their sexual difficulties."Credit: Joan Arehart-TreichelStevenson was born in 1949 in the Okanagan Valley of southern British Columbia, a terrain of breathtaking beauty and challenging outdoor adventures. He lived there until age 12, when his family moved to Calgary, Alberta. That's where he spent his adolescence and in 1975 where he received his medical degree. After that he returned to British Columbia, but this time to Vancouver for his family practice residency, which lasted until 1977.It was during his residency that he took an elective course in what then was called "sexual medicine." "The reason, to be honest, is that it sounded intriguing and quite different from anything else [that was] offered," he said. "But I was immediately fascinated by it. It required both medical knowledge and an awareness of relationship psychology as well as a sensitivity and comfort in exploring highly personal themes."So from 1981 to 1990, Stevenson, as a family physician, joined a specialized sexual medicine clinic in Vancouver."But I also came to realize that the problems I was most interested in helping patients with were a lot more complicated than I had the training to deal with," he explained. "So I decided to undertake a psychiatry residency as well, from 1990 to 1994." Then in 1994, after he had become a psychiatrist, he decided to practice sexual medicine from both perspectives in Vancouver."I've known Ron for decades," said Michael Myers, M.D., a former Vancouver psychiatrist who now works in New York and is a member of the Psychiatric News Editorial Advisory Board. "We used to work in the same hospital when he was a family physician specializing in sexual medicine.... I was running a couples clinic there and would refer couples to him.... He is very highly regarded as someone who is very balanced and very good at what he does."Today Stevenson works in a clinic in Vancouver that is devoted exclusively to helping people with sexual-dysfunction problems. The clinic is staffed not just by Stevenson, but also by other psychiatrists and specialists with expertise in sexual medicine. It is part of a publicly funded health care organization called Vancouver Coastal Health, which in turn provides a wide range of medical services to people throughout British Columbia. Stevenson and his clinic colleagues accept only patients who have been referred by other physicians.Initially patients, who are usually accompanied by their partners, might find it difficult to discuss their sexual concerns, Stevenson said, but he tries to be reassuring and supportive to put them at ease. Usually they become comfortable discussing their sex lives with him rather quickly and more so over a series of visits.What soon follows is the challenge of diagnosis—determining whether sexual problems are predominantly physiological or psychological or a complicated mixture of both. This is no small task, he explained, since" sex is never entirely physical or entirely psychological. Physical disorders can have emotional or psychological consequences, and emotional or psychological problems can manifest themselves in physical ways. Our perspective here is a very biopsychosocial one. We don't just look at the psychological or physical manifestations, we always look at both."After he has determined the cause or causes of a patient's sexual problems, he works up a treatment plan. The mainstay psychological treatment is cognitive-behavioral therapy such as "sex therapy" and sometimes more intensive insight-oriented psychotherapy. Relationship or couples counseling is often used as well. The physiological treatments can run the gamut from erectile-dysfunction medications to hormone supplements to antidepressants. More often than not, psychological and physiological treatments are combined.Treatment Options in Arsenal"Any sexual problem can cause great suffering, but in some ways, erectile dysfunction is the best of the sexual dysfunctions to have because there are a number of treatment options," Stevenson explained." The new oral medications Cialis, Levitra, and Viagra have revolutionized its treatment, and if they aren't sufficient, there are a number of other options that can be tried as well. Moreover, if hormone tests reveal that a patient has an abnormally low level of testosterone, testosterone supplements might be in order. And if medical illnesses—say, diabetes, multiple sclerosis, Parkinson's disease, or spinal cord injury—contribute to the dysfunction, we address those issues as well."Stevenson also treats men with premature ejaculation, he said. "I had a fellow recently in his 50s who had suffered from lifelong premature ejaculation, but who decided that he finally wanted to do something about it. I saw him with his wife. Cognitive-behavioral therapy combined with a small amount of antidepressant to suppress his sexual response just a little solved his premature ejaculation problem. He and his wife were delighted."Unfortunately drugs for erectile dysfunction are generally not useful when women have orgasm problems, Stevenson said. Nonetheless he can often assist them by "helping them learn about their bodies and how to focus more intently on pleasurable sensations of the moment, thereby improving their sexual response. And in some cases, I can help them with postsurgical or postmenopausal issues that bear on their problem, and, as with men, sometimes hormonal supplements are indicated and can be helpful."Disinterest the Biggest ChallengeThe toughest sexual-dysfunction problem to treat in either men or women is sexual disinterest, Stevenson reported, "because it is often related to very broad psychological issues such as trust, control, and self-esteem as well as to overall mental, physical, and interpersonal/relationship health—all those things that feed into one's sexual interest. So, motivation by the patient to address those issues psychologically becomes extremely important."Stevenson also tries to help older couples cope with their sexual difficulties. Erectile-dysfunction problems are more prevalent as men age and experience other health problems. "We see men here in their 70s and even their 80s who are keen on sex and being sexually active, and we are often able to be of some help to them with a combination of counseling, medication, or devices that facilitate erection," he said.Also, he pointed out, "I try to help men and women understand that sexual responses don't happen as quickly as people get older, that not all senior erectile problems can be corrected with medications, and that it can be equally important to explore ways of [sexually] pleasing each other that don't involve intercourse. True, for some older couples, such information entails a major adjustment in their perspective, but inevitably changes in our bodies and our response capacities are part of the realities that we all have to adjust to as we grow older."He continued, "People sometimes disparage sexual problems, and sexuality can be a rich source of material for humorists. But, in fact, sex is a pretty fundamental part of a full and healthy life. So in terms of quality-of-life issues, it is tremendously important, and for me, it's extremely rewarding to be able to help people with their sexual difficulties." ▪ ISSUES NewArchived

Rosemary Basson: working to normalise women's sexual reality

P-972: Study on female sexual dysfunction in rural areas, China

Women and ESRD: Modalities, Survival, Unique Considerations

Symptoms of sexual dysfunction and somatic symptom disorder may resemble each other in their presentation as lasting and distressing alterations of expected bodily "functioning"; their co-occurrence has not yet been studied in nonclinical settings or by DSM-5 criteria (Diagnostic and Statistical Manual of Mental Disorders, fifth edition). To investigate (1) the association of indicators consistent with DSM-5 sexual dysfunction and somatic symptom disorder diagnoses, (2) whether individuals with different sexual dysfunction diagnoses differ in somatic symptoms and their perception, and (3) whether distress from sexual difficulties is related to somatic symptoms and symptom perception. We examined links among sexual dysfunctions/distress from sexual difficulties (Brief Questionnaire on Sexuality), somatic symptom severity (Patient Health Questionnaire-15 [PHQ-15]), and symptom perception (Somatic Symptom Disorder-B Criteria Scale) in 9333 participants of the Hamburg City Health Study aged 45 to 74 years. For a sensitivity analysis, we repeated all analyses after excluding an item on sexual difficulties from the PHQ-15 score. Outcomes included scores on the Brief Questionnaire on Sexuality indicating sexual difficulties and dysfunction according to DSM-5, PHQ-15 for somatic symptom severity, and Somatic Symptom Disorder-B Criteria Scale for symptom perception. Indicators consistent with DSM-5 sexual dysfunction and somatic symptom disorder diagnoses were linked (P = .24) before the sensitivity analysis but not after. Individuals with different sexual dysfunction diagnoses did not differ in their somatic symptom severity or their symptom perception. Distress from sexual difficulties was weakly correlated with somatic symptom severity (after sensitivity analysis: ρ = .19, P = .01) and symptom perception (ρ = .21, P = .01). Both correlations were stronger for men than for women. Our results convey that it is worth exploring sexual difficulties and somatic symptom disorder in patients presenting with either complaint but also that sexual difficulties should still be regarded as an independent phenomenon. Our sample consisted of participants from one metropolitan region who were >45years of age and thus does not demographically represent the general population. Assessing via self-report questionnaires may have influenced the reporting of symptoms, as may have prevailing shame around experiencing sexual dysfunction. The final sample size was reduced by missing values from some questionnaires. Despite these limitations, sample sizes for all analyses were large and offer meaningful new observations on the subject. Our data suggest that indicators for sexual dysfunction and somatic symptom disorder somewhat overlap but still represent distinct phenomena and should be treated accordingly in research and clinical practice.

Sexual dysfunctions and difficulties are common experiences that may impact importantly on the perceived quality of life, but prevalence estimates are highly sensitive to the definitions used. We used questionnaire data for 4415 sexually active Danes aged 16-95 years who participated in a national health and morbidity survey in 2005 to estimate the prevalence of sexual dysfunctions and difficulties and to identify associated sociodemographic factors. Overall, 11% (95% CI, 10-13%) of men and 11% (10-13%) of women reported at least one sexual dysfunction (i.e., a frequent sexual difficulty that was perceived as a problem) in the last year, while another 68% (66-70%) of men and 69% (67-71%) of women reported infrequent or less severe sexual difficulties. Estimated overall frequencies of sexual dysfunctions among men were: premature ejaculation (7%), erectile dysfunction (5%), anorgasmia (2%), and dyspareunia (0.1%); among women: lubrication insufficiency (7%), anorgasmia (6%), dyspareunia (3%), and vaginismus (0.4%). Highest frequencies of sexual dysfunction were seen in men above age 60 years and women below age 30 years or above age 50 years. In logistic regression analysis, indicators of economic hardship in the family were positively associated with sexual dysfunctions, notably among women. In conclusion, while a majority of sexually active adults in Denmark experience sexual difficulties with their partner once in a while, approximately one in nine suffer from frequent sexual difficulties that constitute a threat to their well-being. Sexual dysfunctions seem to be more common among persons who experience economic hardship in the family.

Background Self-reported sex problems among women diagnosed with reproductive and nonreproductive cancers before the age of 40 are not fully understood. This study aimed to determine sexual dysfunction in young women following a cancer diagnosis in relation to women of the general population. Furthermore, to identify factors associated with sexual dysfunction in women diagnosed with cancer. Materials and Methods A population-based cross-sectional study with 694 young women was conducted 1.5 years after being diagnosed with cancer (response rate 72%). Potential participants were identified in national quality registries covering breast and gynecological cancer, lymphoma and brain tumors. The women with cancer were compared to a group of women drawn from the general population (N = 493). Sexual activity and function were assessed with the PROMIS® SexFS. Logistic regression was used to assess differences between women with cancer and the comparison group, and to identify factors associated with sexual dysfunction. Results The majority of the women with cancer (83%) as well as the women from the comparison group (87%) reported having had sex the last month (partner sex and/or masturbation). More than 60% of the women with cancer (all diagnoses) reported sexual dysfunction in at least one of the measured domains. The women with cancer reported statistically significantly more problems than women of the comparison group across domains such as decreased interest in having sex, and vaginal and vulvar discomfort. Women with gynecological or breast cancer and those receiving more intense treatment were at particular high risk of sexual dysfunction (≥2 domains). Concurrent emotional distress and body image disturbance were associated with more dysfunction. Conclusion The results underscore the need to routinely assess sexual health in clinical care and follow-up. Based on the results, development of interventions to support women to cope with cancer-related sexual dysfunction is recommended.

Introduction Sexual health concerns and genitourinary syndrome of menopause (GSM) are prevalent among breast cancer survivors, with studies reporting symptoms in over 70% of this population. Despite guidelines from major medical organizations, most survivors report inadequate support for sexual health from healthcare providers. Limited training in sexual medicine for oncologists and gynecologists further exacerbates this gap. The consequences of untreated symptoms, including vaginal dryness, dyspareunia, and sexual dysfunction, significantly impact survivors’ quality of life and relationships. Objective To evaluate breast cancer survivors’ access to medical help for sexual health concerns, including treatment for GSM and sexual dysfunction, and assess distress levels, satisfaction with care, and sources of useful information. Methods An anonymous survey was conducted using Survey Monkey, targeting breast cancer survivors through social media platforms and email listservs. Participants (n = 1775) were queried on demographics, sexual health symptoms, access to care, and sources of information. Responses were analyzed descriptively, focusing on access to vaginal hormone treatments, referrals, and patient-reported distress. Results Among respondents (mean age: 47.5 years), 89.5% reported moderate to significant sexual health changes due to breast cancer or its treatment, and 84.8% experienced moderate to significant distress. Common symptoms included decreased libido (85.7%), vaginal dryness (78.3%), and painful intercourse (59.5%). Notably, 73% of participants did not receive information about sexual health from their healthcare teams, and 71% had to initiate discussions themselves. Fewer than half (45.4%) of participants were offered non-hormonal options for GSM, and only 28.7% were prescribed vaginal hormones. Among hormone receptor-positive patients, 22% reported vaginal hormone prescriptions, often with conflicting advice from oncologists and gynecologists. Furthermore, 67% of respondents did not receive referrals to specialists, such as sexual medicine experts or pelvic floor therapists. Participants expressed high levels of dissatisfaction, with 50% feeling dissatisfied or very dissatisfied with the care they received for sexual health concerns. Many reported finding the most valuable information on social media (39%) and patient support groups (19%), highlighting a gap in healthcare-provided resources. Conclusions Sexual health dysfunction in breast cancer survivors remains an unmet need, with low access to guideline-based care and high levels of distress reported. Lack of access to vaginal estrogen and insufficient referrals exacerbate the problem. Survivors frequently rely on social media and patient networks for information, underscoring the need for improved education and proactive discussions by healthcare providers. Addressing these gaps through enhanced training, patient-centered care, and leveraging social media as an educational tool could significantly improve outcomes. Disclosure No.

Sexual dysfunction is a very important but often overlooked symptom of multiple sclerosis. To investigate the type and frequency of symptoms of sexual dysfunction in patients suffering from multiple sclerosis, we performed a case-control study comparing 108 unselected patients with definite multiple sclerosis, 97 patients with chronic disease and 110 healthy individuals with regard to sexual function, sphincteric function, physical disorders impeding sexual activity and the impact of sexual dysfunction on social life. Information has been collected from a face-to-face structured interview performed by a doctor of the same gender as the patient. The disability, the cognitive performances, the psychiatric conditions and the psychological profile of patients and controls have been assessed. Sexual dysfunction was present in 73.1% of cases, in 39.2% of chronic disease controls and in 12.7% of healthy controls (P<0.0001). Male cases reported symptoms of sexual dysfunction more frequently than female cases (P<0.002). Symptoms of sexual dysfunction more commonly reported in patients with multiple sclerosis were anorgasmia or hyporgasmia (37.1%), decreased vaginal lubrication (35.7%) and reduced libido (31.4%) in women, and impotence or erectile dysfunction (63.2%), ejaculatory dysfunction and/or orgasmic dysfunction (50%) and reduced libido (39.5%) in men. Seventy-five per cent of cases, 51.5% of chronic disease controls and 28.2% of healthy controls (P<0.0001) experienced symptoms of sphincteric dysfunction. In conclusion, a substantial part of our sample of patients with multiple sclerosis reported symptoms of sexual and sphincteric dysfunction. Both sexual and sphincteric dysfunction were significantly more common in patients with multiple sclerosis than in either control group. Our findings suggest that a peculiar damage of the structures involved in sexual function is responsible for the dysfunction in patients with multiple sclerosis, but the highly significant lower frequency of symptoms of depression and anxiety in healthy controls may also imply a possible causative role of psychological factors.

Introduction Understanding and addressing sexual dysfunction is of paramount importance to enhance the overall well-being and quality of life of individuals worldwide. While significant progress has been made in the field of sexual medicine, variability in practice patterns among healthcare professionals remains a potential barrier to optimal patient care. To bridge this knowledge gap and identify the prevailing trends in sexual dysfunction management, we conducted an international survey targeting urologists specializing in Andrology, Sexual Medicine, and related fields. Objective This international survey aimed to assess male and female sexual dysfunction management practices among sexual medicine physicians across to globe to identify variability in practice patterns. Methods A survey was distributed globally to urologists specializing in Andrology, Sexual Medicine, and related fields who are members of International Society for Sexual Medicine (ISSM) or affiliated regional societies (SMSNA, ESSM, MESSM, APSSM, SASSM, SLAMS, ISSWSH, SIU). Demographic information (age, gender, specialty, and practice setting) and treatment approaches for male and female sexual dysfunction were collected. Respondents also reported the percentage of their practice dedicated to sexual dysfunction and whether treatments were covered by health insurance. Results A total of 200/3000 practitioners participated, with 101 (50.7%) identifying as urologists. The majority were male (72.9%) and worked in private practice or community hospitals (32.7%) or a mixture of both (34.2%). Male sexual dysfunction was treated by 71.4% of respondents, with 25.7% dedicating 75-100% of their practice to it. Female sexual dysfunction was treated by 36.9% of respondents, with 64% dedicating 0-25% of their practice to it. Health insurance covered 25-49% of their care for 41.2% of respondents, predominantly provided by private companies (45.9%). The most common treatments for erectile dysfunction were oral medications (86.5%), injections (61.7%), and inflatable penile prostheses (45.1). For Peyronie's disease, oral therapies (59.1%) and penile traction therapy (34.4%) were most frequently offered, while surgical treatment for Peyronie's disease was offered by 58.2% of respondents, with penile prostheses being the primary choice (79.7%). Regarding female sexual dysfunction, 58.4% of respondents offered treatments for genitourinary syndrome of menopause/atrophic vaginitis, with vaginal estrogen being the most common choice (50%). For dyspareunia due to vaginismus/hypertonic pelvic floor dysfunction, 50.3% of respondents offered treatment, with pelvic floor exercise/physiotherapy being the most recommended (66%). Conclusions This study provides valuable insights for healthcare professionals, policymakers, and researchers regarding the current landscape of sexual dysfunction management. The results underscore the importance of continuous efforts to develop comprehensive and individualized approaches, ensuring that both male and female patients receive effective and accessible care for their sexual health concerns. By addressing issues related to insurance coverage and fostering interdisciplinary collaboration, the medical community can collectively work towards improving sexual well-being and quality of life for patients worldwide. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Advisory board and speaker for Coloplast; consultant for Cynosure; advisory board and speaker for Halozyme; intellectual property with Masimo; advisory board for Promescent; consultant for Sprout; advisory board for Xialla.

Introduction Understanding and addressing sexual dysfunction is of paramount importance to enhance the overall well-being and quality of life of individuals worldwide. While significant progress has been made in the field of sexual medicine, variability in practice patterns among healthcare professionals remains a potential barrier to optimal patient care. To bridge this knowledge gap and identify the prevailing trends in sexual dysfunction management, we conducted an international survey targeting urologists specializing in Andrology, Sexual Medicine, and related fields. Objective This international survey aimed to assess male and female sexual dysfunction management practices among sexual medicine physicians across to globe to identify variability in practice patterns. Methods A survey was distributed globally to urologists specializing in Andrology, Sexual Medicine, and related fields who are members of International Society for Sexual Medicine (ISSM) or affiliated regional societies (SMSNA, ESSM, MESSM, APSSM, SASSM, SLAMS, ISSWSH, SIU). Demographic information (age, gender, specialty, and practice setting) and treatment approaches for male and female sexual dysfunction were collected. Respondents also reported the percentage of their practice dedicated to sexual dysfunction and whether treatments were covered by health insurance. Results A total of 200/3000 practitioners participated, with 101 (50.7%) identifying as urologists. The majority were male (72.9%) and worked in private practice or community hospitals (32.7%) or a mixture of both (34.2%). Male sexual dysfunction was treated by 71.4% of respondents, with 25.7% dedicating 75–100% of their practice to it. Female sexual dysfunction was treated by 36.9% of respondents, with 64% dedicating 0–25% of their practice to it. Health insurance covered 25–49% of their care for 41.2% of respondents, predominantly provided by private companies (45.9%). The most common treatments for erectile dysfunction were oral medications (86.5%), injections (61.7%), and inflatable penile prostheses (45.1). For Peyronie's disease, oral therapies (59.1%) and penile traction therapy (34.4%) were most frequently offered, while surgical treatment for Peyronie's disease was offered by 58.2% of respondents, with penile prostheses being the primary choice (79.7%). Regarding female sexual dysfunction, 58.4% of respondents offered treatments for genitourinary syndrome of menopause/atrophic vaginitis, with vaginal estrogen being the most common choice (50%). For dyspareunia due to vaginismus/hypertonic pelvic floor dysfunction, 50.3% of respondents offered treatment, with pelvic floor exercise/physiotherapy being the most recommended (66%). Conclusions This study provides valuable insights for healthcare professionals, policymakers, and researchers regarding the current landscape of sexual dysfunction management. The results underscore the importance of continuous efforts to develop comprehensive and individualized approaches, ensuring that both male and female patients receive effective and accessible care for their sexual health concerns. By addressing issues related to insurance coverage and fostering interdisciplinary collaboration, the medical community can collectively work towards improving sexual well-being and quality of life for patients worldwide. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Advisory board and speaker for Coloplast; consultant for Cynosure; advisory board and speaker for Halozyme; intellectual property with Masimo; advisory board for Promescent; consultant for Sprout; advisory board for Xialla.

Male infertility (MI) and male sexual dysfunction (MSD) can often coexist together due to various interplay factors such as psychosexual, sociocultural and relationship dynamics. The presence of each form of MSD can adversely impact male reproduction and treatment strategies will need to be individualized based on patients’ factors, local expertise, and geographical socioeconomic status. The Asia Pacific Society of Sexual Medicine (APSSM) and the Asian Society of Men’s Health and Aging (ASMHA) aim to provide a consensus statement and practical set of clinical recommendations based on current evidence to guide clinicians in the management of MI and MSD within the Asia-Pacific (AP) region. A comprehensive, narrative review of the literature was performed to identify the various forms of MSD and their association with MI. MEDLINE and EMBASE databases were searched for the following English language articles under the following terms: “low libido”, “erectile dysfunction”, “ejaculatory dysfunction”, “premature ejaculation”, “retrograde ejaculation”, “delayed ejaculation”, “anejaculation”, and “orgasmic dysfunction” between January 2001 to June 2022 with emphasis on published guidelines endorsed by various organizations. This APSSM consensus committee panel evaluated and provided evidence-based recommendations on MI and clinically relevant MSD areas using a modified Delphi method by the panel and specific emphasis on locoregional socio-economic-cultural issues relevant to the AP region. While variations exist in treatment strategies for managing MI and MSD due to geographical expertise, locoregional resources, and sociocultural factors, the panel agreed that comprehensive fertility evaluation with a multidisciplinary management approach to each MSD domain is recommended. It is important to address individual MI issues with an emphasis on improving spermatogenesis and facilitating reproductive avenues while at the same time, managing various MSD conditions with evidence-based treatments. All therapeutic options should be discussed and implemented based on the patient’s individual needs, beliefs and preferences while incorporating locoregional expertise and available resources.

Prevalence of Sexual Dysfunction in Parkinsonian Men: A Literature Review

Opioids are the cornerstone for pain treatment with significant recent increases in the number of prescriptions. Sexual dysfunction (SD) is a major side effect of opioid therapy. The goal of this review is to examine the current literature on the effects of opioids on male SD (erectile dysfunction [ED], hypogonadism, ejaculatory dysfunction) and infertility. High prevalence of SD exists in men with opioid use as compared to the general population, with an abundance of evidence suggesting an association between opioid use and ED and hypogonadism. There appears to be a role for testosterone replacement therapy for hypogonadism in men on opioid therapy. Screening for low testosterone levels is recommended in men on opioid therapy with signs and symptoms of androgen deficiency. Data on fertility, ejaculatory, and orgasmic dysfunction are limited. SD is significantly affected by opioid therapy in men. Data demonstrate the benefits of screening for SD and treatment for hypogonadism.