Sexual medicineTowards an integrated disciplineBMJ 1997; 314 doi: https://doi.org/10.1136/bmj.314.7092.1432 (Published 17 May 1997) Cite this as: BMJ 1997;314:1432
Towards an integrated discipline
Sexual dysfunction is common at any age. The most common problems are loss of sexual drive, anorgasmia, vaginismus in women, and erectile failure and premature ejaculation in men. Up to 38% of women report anxiety and inhibition during sexual activity, 16% complain of lack of pleasure, and 15% have difficulties reaching orgasm.1 Up to 40% of middle aged men report some kind of sexual dysfunction.2 The dysfunction may be purely psychological or physical but is usually a mixture of the two.3
Sexual dysfunction is a particular problem for physically ill or handicapped people. Half of middle aged men with insulin dependent diabetes report erectile dysfunction.4 Between 50% and 90% of patients with multiple sclerosis will develop sexual difficulties.5 Dyspareunia is twice as prevalent in women with inflammatory bowel disease as in healthy matched controls.6
Many patients use self help literature or are managed in general practice or family planning services, but an increasing number are referred to specialties, including urology, gynaecology, psychiatry, and psychology. Specialist psychosexual services have arisen to assess and treat sexual dysfunctions that are considered to have psychological causes.7 This separation and specialisation sometimes deprives patients of a holistic approach to their difficulties.
Many people believe that their doctor is a suitable professional in whom to confide their sexual difficulties, but few doctors are taught how to manage them.8 Although several of Britain's royal colleges take the view that sexual medicine is an important part of training, there is little consistency about the quality or duration of training expected, or how such training might be achieved.
The Royal College of Obstetricians and Gynaecologists expects trainees to acquire skills in reproductive medicine and the ability to recognise, counsel, and refer psychosexual problems.9 The Royal College of Psychiatrists expects training schemes to include the opportunity of experience in psychosexual or marital therapy.10 Although the Royal College of General Practitioners has no set curriculum, sexual health is regarded as an important issue and the college's quality network is about to set up a working party on this topic (Y Carter, personal communication). The Royal College of Physicians is currently revising its curriculum, in which sexual medicine is regarded as relevant to endocrinology, rehabilitation medicine, spinal injury, neurology, genitourinary medicine, and public health (D A Shaw, personal communication). The Royal College of Surgeons has no reference to sexual medicine in its curriculum (A R Mundy, personal communication). There are few specific institutions that provide a general training in sexual medicine for doctors. Most provide training based on approaches that are purely psychosexual (for example, the institutes of psychosexual medicine and psychiatry) or biological (for example, andrology or gynaecology services).
Attitudes to sexuality in society are becoming more relaxed, and people expect their doctor to be able to ask them about sexual problems. Many doctors, however, find it difficult to discuss the sexual details of their patients' lives. The development of sexual medicine is fragmented, and there is a lack of liaison between the royal colleges. Specialist clinics lead to fragmentary care with many referrals between clinics, which means delays for patients and unnecessary cost. The growth of sexual medicine in many medical specialties calls for closer integration. Joint clinics providing a multidisciplinary service are a promising approach for the future. Informal networks of interested specialists who wish to collaborate on clinical work, research, and teaching are arising spontaneously. One example is the Andrology Network at the Royal Free Hampstead NHS Trust.
In an editorial published more than 10 years ago in Canada, Maurice called for the development of sexual medicine as a new medical specialty.11 We suggest that a more appropriate way forward is closer academic and clinical integration of specialists working in gynaecology, urology, endocrinology, and psychiatry. Interdisciplinary clinics such as this are attractive to purchasers and providers alike, provide unequalled training opportunities, and may be the most cost effective option in our quest to improve the sexual health of the nation.