Sexual dysfunction service provision in UK genitourinary medicine clinics in 2007

Transcription

1 ORIGINAL RESEARCH ARTICLE Sexual dysfunction service provision in UK genitourinary medicine clinics in 2007 P Green MBBS DipGUM* and D Goldmeier MD FRCP, for and on behalf of BASHH Special Interest Group in Sexual Dysfunction Q1 *The Bridge Sexual Health Service, Pennine Acute Hospitals NHS Trust, Rochdale, Lancashire; Jane Wadsworth Clinic, St Mary s Hospital, London, UK Summary: Sexual difficulties are common in people attending genitourinary medicine (GUM)/HIV services and many would like professional help. Here, we report the results of the BASHH Special Interest Group in Sexual Dysfunction (SD) survey on the level and type of SD service provision within UK GUM services in Many clinicians expressed an interest in SD, however, only 25% of GUM clinics provide a designated SD service. Marked regional variation in the level of service provision was highlighted. Lack of resources and other pressures on GUM services, notably 48-h access, are barriers to SD service development. In spite of these constraints, we argue that GUM clinics are a highly appropriate place to treat SD. Keywords: sexual dysfunction, genitourinary medicine, service provision INTRODUCTION Sexual difficulties are common in people attending genitourinary medicine (GUM) 1 /HIV 2 8 services and many would like professional help. Here we report the results of the BASHH Special Interest Group in sexual dysfunction (SD) survey on the level and type of SD service provision within UK GUM services in We have sought to identify existing SD services and determine whether provision is in the form of specialist SD clinics, or whether patients who present to GUM with SD are managed as part of the GU Medicine clinic workload. Clinician s views on the provision of SD services in GU Medicine are reported. Further, the recent increased media coverage of women SD and European licensing of the trans-dermal testosterone Q2 patch, Intrinsa w (Proctor & Gamble), 9,10 for the management of low sexual desire in surgically menopausal women on concomitant oestrogen therapy, prompted specific enquiry into the management of female SD in GUM clinics. METHOD A postal survey of the 273 UK and Eire GUM clinics listed in the British Association for Sexual Health and HIV (BASHH) clinic directory was conducted in February A brief questionnaire was circulated to the lead clinician at each clinic. RESULTS A total of 148 completed questionnaires were received (54%). Responses revealed a wide regional variation in the provision Correspondence to: Dr Pippa Green, The Bridge Sexual Health Service, Baillie Street Health Centre, Rochdale OL16 1XS, UK Pippa.Green@pat.nhs.uk of designated SD services by departments of GUM (Table 1). A total of 25% of GUM departments hold at least one dedicated SD clinic per week (16% one clinic/week; 9% two or more clinics/week). Professionals from multidisciplinary backgrounds are involved in patient management within these services (Table 2). It is a routine clinical practice in 21% clinics to ask the GU Medicine patient if he/she is experiencing any difficulty with sexual function. However, it is apparent that patients self-refer to GUM with sexual difficulties and that many are managed within GUM services, women sexual pain disorders being the most common among these (Table 3). A range of psychological interventions including brief counselling, cognitive behavioural therapy, psychosexual therapy, integrated therapy and hypnosis are provided by some GUM and SD services. A total of 26% clinics prescribe pharmacological treatments in SD management. Clinician s comments revealed interest in the management of SD within GUM clinics; however, a number of common factors arose as inhibitors to service development: GUM service priority given to achieve 48-h access (raised by 13 respondents); lack of funding inhibiting service development (raised by 22 respondents); lack of staff trained in management of SD. Existing links with other services were identified in some areas. Ad hoc provision by GUM physicians with a special interest and training in management of SD was apparent. Two respondents questioned the role of GUM in SD management and one stated that management of SD was not his/her job. With regard to female SD, 8% GUM clinics reported seeing at least one woman per week who complains of low sexual desire. Thirty percent of lead clinicians felt that GUM physicians should manage these patients (Table 4). A coordinated multidisciplinary approach, depending on the underlying aetiology and expertise within services was recommended by many DOI: /ijsa International Journal of STD & AIDS 2008; 00: 1 4

2 2 International Journal of STD & AIDS Volume XX Month 2008 Table 1 Region clinics Table 2 Designation of staff Regional responses from GUM clinics Total number of respondents Number of GUM clinics reporting 1 dedicated SD clinic/week Scotland Ireland Wales South west East Anglia Mersey Wessex West Midlands NW NE SW SE S Central N Central North West Yorkshire Northern Trent Oxford Not stated/ Other Total SD, sexual dysfunction; GUM, genitor-urinary medicine Staffing in designated SD clinics Number of SD services in GUM clinics staffed by this practitioner GU consultant GU SAS physician SpR 1 3 Sex therapist Nurse Health adviser 2 5 Psychologist 8 22 Other 7 19 Percentage of GUM clinics in region reporting 1 SD clinic/week (%) SD services in GUM clinics staffed by this practitioner (in %) respondents. Emphasis was placed on the need for management to be by an experienced, interested, appropriately trained and qualified professional. A total of 53% of responding clinicians held the opinion that medication should be considered in the management of women complaining of low sexual desire; some commenting that this would depend on the context, results of investigations or fulfilment of criteria and would not be their first line management. A range of pharmacological agents including hormonal and antidepressant preparations was suggested. 21% would prescribe Intrinsa w at least occasionally for women who complain Table 3 Provision of care for patients who present to GUM with sexual dysfunction Number of clinics SD Number of clinics in which dysfunction managed in GUM (%) in which dysfunction managed in SD clinic (%) Sexual desire problems 22 (15) 34 (22) Female arousal and 20 (14) 31 (20) orgasm problems Erectile dysfunction: 32 (22) 36 (21) psychogenic Erectile dysfunction: 22 (15) 30 (19) organic Vaginismus 44 (30) 31 (20) Vulvadynia 86 (59) 20 (12) Vulval vestibulitis 92 (63) 19 (12) Male sexual pain 53 (35) 20 (12) Rapid ejaculation 24 (17) 35 (22) Delayed ejaculation 16 (11) 35 (22) Paraphilias 7 (5) 19 (12) Gender identity disorder 12 (8) 15 (8) Other 3 (2) (Deep dyspareunia 1 Genital dermatoses 1 Sexual addiction 1) Table 4 GUM Clinicians views as to who should manage women who present to GUM with low sexual desire Practitioner suggested Number of respondents (%) GU Physician 46 (30) Gynaecologist 22 (13) Psychologist 45 (30) General Practitioner 20 (14) Other GU Medicine staff 13 (9) Sex therapist 68 (46) Endocrinologist 10 (7) Other 17 (12) Not stated 7 (5) of low sexual desire. The need for product information and fully informed patient consent was emphasized. Forty percent were unsure about prescribing Intrinsa w, expressing their need for more information about efficacy, evidence base, definitions and treatment criteria. Reasons for not prescribing included lack of funding, inexperience or the opinion that low sexual desire should not be managed in GUM. DISCUSSION Wide disparity in the level of service provision in UK and Eire GUM services is apparent, possibly reflecting the local funding arrangements and the interest, training and skills of individual practitioners. Twenty five percent of GUM services hold at least one designated SD clinic per week. A variety of interventions are provided by multidisciplinary staff at these clinics. Some SD clinics are separately funded from GUM, some accept referrals from primary care others do not. Some services offer an integrated model of sexual health service provision encompassing GUM, FP and SD services; these services report inadequate funding for the large number of patients presenting with sexual difficulties.

3 Green and Goldmeier. Sexual dysfunction services in UK GUM clinics 3 Widespread interest in SD by GUM physicians, with a desire by some to extend their service provision, has been highlighted; however, other pressures on GUM services, in particular 48-h access, often take precedence. Lack of funding inhibits service development and has resulted in the closure of clinics in some areas. Some interested and experienced clinicians continue to provide ad hoc care on a voluntary basis to GUM/ HIV patients. Lack of qualified personnel and opportunities for training are additional barriers to service provision, as previously reported. 1,11 14 While effective links with existing SD services that facilitate patient access have been identified, some with integrated care pathways and shared care protocols, in many areas inadequate provision is reported. The lack of equitable access to specialist services demonstrated by this survey, falls short of UK recommended standards. 15 There is a high rate of SD in the UK. In a population study, 35% of men and 54% of women admitted they had a SD problem for one month or more over the previous year. 16 That study showed that a majority of those who sought help for these did so via their GPs. Whereas in central London a third of GPs felt competent to deal with SD issues, 17 in the provinces GPs and practice nurses may not address sexual health issues proactively with patients. 18 Particular barriers to discussing sexual issues were: if the patient was of the opposite gender; middle aged or elderly; from black or ethnic minorities or nonheterosexual. Constraints of time and lack of expertise were also deemed important. Other researchers have found that physicians in general consider personal embarrassment an obstacle to initiating discussions on female SD. 19 Whereas only 9% of men and 5% of women in the UK population study sought help for their SD at GUM clinics, 20 GU physicians are ideally placed to handle SD for a number of reasons e.g. they are good at taking sexual histories and examining genitalia. 21 SD in men is primarily (but not exclusively) associated with organic problems such as hypertension, diabetes and recent STI diagnoses. 16,22 In women, having small children, relationship issues, anxiety and depression appear to be the major issues associated with SD. 16,22 Similar issues appear to obtain for HIV positive women with SD. 23 Handling the psychological issues are already being undertaken by some sex therapists and psychologists in the GU setting; as evidenced by the results of our current study. The major barrier to this would appear to be funding; a recurrent theme highlighted by many respondents. Further indirect evidence of this is that currently only 25% of clinics have a SD service compared with over 40% in 1997 and ,14 These studies supported the notion that GU physicians were very supportive of the idea of having SD clinics; over 80% endorsing this idea. Intrinsa w, a testosterone patch used for surgically menopausal women with low sexual desire has recently been in the news. 9 Hitherto, in spite of low sexual desire being the commonest SD among both men and women, it appears women have been reluctant to come forward for treatment. More specifically 41% of women in a UK population study admitted to low sexual desire for one or more months over the past year, with 10% saying they had the problem for six or more months over the past year. 22 However, only a proportion of these women are distressed about their condition (between 9 and 26% of those who complain of low desire in the USA 24 ). Such women are now, in the light of the heightened media interest, more likely to present to health care professionals. Our current study suggests that women are already presenting to GU clinics with this problem, and that their physicians feel they would like more information regarding specific therapy (Intrinsa w ), which may be helpful under certain circumstances. An important issue is that unlike medications such as Viagra, medications to help low desire in women will have to be given in conjunction with psychological therapies to ensure reasonable therapeutic outcome. 25 This is a particular issue as the efficacy of Intrinsa w in post-menopausal women with low desire, in terms of satisfactory sexual events (compared to sexual desire outcome for example) appears to be marginal. 26 CONCLUSION There is inequity in SD service provision by GUM clinics across UK and Eire. While 25% clinics surveyed hold at least one designated SD clinic per week, ad hoc provision for selective sexual problems is available in many others for patients who present directly to these services. A variety of models of service provision have been identified where professionals from multidisciplinary backgrounds are involved in the identification, assessment and treatment of SD. This holds implications for education and training. Pressures on GUM services, especially 48-h access, compound lack of resources both financial and personnel, as barriers to service development. In spite of this, we argue, departments of GU Medicine may be an ideal setting to manage patients with SD. REFERENCES 1 Goldmeier D. Sexual dysfunction in genitourinary medicine clinics. Int J STD AIDS 2000;11: Cove J, Petrak J. Factors associated with sexual problems in HIVþ positive gay men. Int J STD/AIDS 2004;15: Catalan J, Meadows J. Sexual dysfunction in gay and bisexual men with HIV infection: evaluation, treatment and implications. AIDS Care 2000;12: Kennedy CA, Skurnick JH, Foley, Louria DB. Gender differences in HIV-related psychological distress in heterosexual couples. AIDS Care 1995;7:S33 8 Q3 5 Lamba H, Goldmeier D, Mackie NE, Scullard G. Antiretroviral therapy is associated with sexual dysfunction and with increased serum oestradiol levels in men. Int J STD & AIDS 2004;15: Lamba H, Scullard G, Mackie N. 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4 4 International Journal of STD & AIDS Volume XX Month Gott BM, Galena E, Hinchcliff S, Elford H. Opening a can of worms : GP and practice nurse barriers to talking about sexual health in primary care. Fam Pract 2004;21: Humphrey S., Nazareth I. GPs views on their management of sexual dysfunction. Fam Pract 2001;18: Bachmann L. Female sexuality and sexual dysfunction: are we stuck on the learning curve? J Sex Med 2006;3: Mercer CH, Fenton KA, Johnson AM, et al. Sexual function problems and health seeking behaviour in Britain: National probability sample survey. BMJ 2003;327: Kell P, Curless E. Who should look after patients with sexual dysfunction? Why genitourinary physicians are well placed. Int J STD AIDS 2001;12: Dunn K, Croft PR, Hackett GI. Association of sexual problems with social, psychological and physical problems in men and women: A cross sectional population survey. J Epidemiol Community Health 1999;53: Bell C, Richardson D, Wall M, Goldmeier D. HIV associated female sexual dysfunction clinical experience and literature review. Int J STD AIDS 2006;17: Leiblum SR, Koochaki PE, Rodenberg CA, Barton IP, Rosen RC. Hypoactive sexual desire disorder in post menopausal women: US results from the Women s International Study of Health and Sexuality (WISHeS). Menopause 2006;13: Althof SE, Leiblum SR, Chevret-Measson M, et al. Psychological and interpersonal dimensions of sexual function and dysfunction. J Sex Med 2005;2: Davis SR, van der Mooren MJ, van Lumsen RH, et al. Efficacy and safety of a testosterone patch for the treatment of hypoactive sexual desire disorder in surgically menopausal women: a randomized placebo controlled trial. Menopause 2006;13: (Accepted 3 August 2007)

5 QUERY FORM Royal Society of Medicine Journal Title: IJSA Article No: AUTHOR: The following queries have arisen during the editing of your manuscript. Please answer the queries by making the requisite corrections at the appropriate positions in the text. Query No. Nature of Query Author s Response Q1 Q2 Please check whether the incorporated details and the edit made to the affiliations are okay. Please provide location for ("Procter & Gamble"). Q3 Please provide initial for Foley in reference [4].