Integrated services for sexual health care are the way forward

Editor—In their editorial, Jona Lewin and Michael King concluded that there was an urgent need for the emergence of sexual medicine as a new specialty.1 They called for closer liaison between medical and other relevant disciplines. Family planning, genitourinary medicine, gynaecology services, and primary care are separated in geographical and political terms. Furthermore, the narrow focus of most medical training compounds the problem. Integrated services are the way forward.

In light of this radical vision for the future it was depressing to read Virginia Royston's personal view on the forced change in her family planning service from one available to all to one geared only towards young people.2 She claims that general practice is for the “really ill” and not an appropriate place for women with contraceptive problems. In fact, the bulk of a general practitioner's workload consists of psychosocial and preventive care. General practitioners should (and usually do) provide a holistic response to their patients' health needs. They are well placed to address the contraceptive needs of their patients. General practitioners have access to their patients' medical and social histories, unlike practitioners in family planning clinics, who carry a great responsibility in terms of eliciting a thorough family and personal history of risk factors from young patients.

In 1992 the British government made sexual health a priority in the Health of the Nation strategy. The new Labour government must also take sexual health seriously. Doctors at undergraduate and postgraduate levels must be trained in the practice of sexual medicine. Payments for contraceptive care in general practice must be linked to some criteria showing evidence of competence.

Royston also raises the issue of choice. The concept of a general practitioner as the first point of contact for patients is well established. So long as family planning clinics and general practitioners continue to compete for the same clients, there is little hope of cooperation in terms of a sensible delegation of the workload or a more coordinated approach to the problem of unwanted pregnancy.

During the next decade there may still be problems within primary care in terms of attitudes towards sexuality. This is particularly true when the needs of young people and women with unwanted pregnancies are concerned. For this reason an easily accessible contraceptive service catering to these groups should continue.

In the longer term, the emergence of family planning and reproductive health care as a consultant led specialty supporting primary care should help eliminate outdated ideas about sexual medicine. Providing training for doctors to enable them to discuss sexual health issues with ease is another essential strategy.

Models of integrated sexual health services already exist

Editor—As officers of the Faculty of Family Planning and Reproductive Health Care of the Royal College of Obstetricians and Gynaecologists we were disappointed not to have been consulted by Jona Lewin and Michael King as part of the preparation for their editorial on sexual medicine.1 This faculty was established in 1993 and is at an advanced stage in preparing a syllabus for higher specialist training. The syllabus includes a compulsory unit on training in sexual dysfunction together with an option for further specialist training. Our discipline clearly fulfils a need in society; so far there are 72 consultants in family planning, reproductive health care, or community gynaecology in the United Kingdom.

There are already models of integrated sexual health services—for example, between family planning and genitourinary medicine—and some of these have input from psychological or psychiatric services. We support closer liaison between relevant medical disciplines in the development of better sexual health services and suggest that our faculty's training programme may be a useful model for the training of other specialists.

Genitourinary medicine clinics are an obvious place for treatment of sexual dysfunction

Editor—Jona Lewin and Michael King are correct in emphasising the importance of a collaborative approach to the treatment of sexual dysfunction and the need to provide training in sexual medicine.1 We are concerned, however, at their lack of recognition of the increasingly important role of genitourinary medicine clinics in the treatment of sexual dysfunction.

Several studies have suggested that the prevalence of sexual dysfunction is high among those attending genitourinary medicine clinics.2 3 This may be associated with the open access nature of these clinics, which attract patients who feel uncomfortable discussing their sexual health needs with their general practitioners. As a result of the increase in the number of patients attending these clinics, many services have established specific multidisciplinary sexual dysfunction clinics.4

Additionally, the Genitourinary Physicians Study Group in Sexual Dysfunction—of which one of us is the chairman (PK) and one the secretary (WD)—has been established and has hosted several interdisciplinary meetings at the Royal Society of Medicine.5 The study group has discussed issues of standards of care for sexual dysfunction within genitourinary medicine and also looked at training in sexual medicine, but unlike the authors, the group thinks that there are courses that offer balanced training, in both London and Manchester among other places. The group has also set up a network of clinics where colleagues have gained practical experience in the management of sexual dysfunction, particularly erectile dysfunction. The study group will hold further meetings dealing directly with how to establish a specialist clinic in sexual medicine.

We agree with Lewin and King that a holistic approach to sexual medicine is required. We suggest that as genitourinary medicine sheds its old image of treating only venereal infection and addresses more general sexual health needs, genitourinary medicine clinics are an obvious place for treating sexual dysfunction.