Sexual medicine

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Sexual medicine or psychosexual medicine as defined by Masters and Johnsons in their classic Textbook of Sexual Medicine, is "that branch of medicine that focuses on the evaluation and treatment of sexual disorders, which have a high prevalence rate." [1] Examples of disorders treated with sexual medicine are erectile dysfunction, hypogonadism, and prostate cancer. Sexual medicine often uses a multidisciplinary approach involving physicians, mental health professionals, social workers, and sex therapists. Sexual medicine physicians often approach treatment with medicine and surgery, while sex therapists often focus on behavioral treatments. [2]

Contents

While literature on the prevalence of sexual dysfunction is very limited especially in women, about 31% of women report at least one sexual dysfunction regardless of age. [3] [4] About 43% of men report at least one sexual dysfunction, and most increase with age except for premature ejaculation. [5] [4]

Scope

Sexual medicine addresses issues of sexual dysfunction, sex education, disorders of sex development, sexually transmitted infections, puberty, and diseases of the reproductive system. The field connects to multiple medical disciplines with varying degrees of overlap including reproductive medicine, urology, psychiatry, genetics, gynaecology, andrology, endocrinology, and primary care. [6]

However, sexual medicine differs from reproductive medicine in that sexual medicine addresses disorders of the sexual organs or psyche as it relates to sexual pleasure, mental health, and well-being, while reproductive medicine addresses disorders of organs that affect reproductive potential.

History

The concept of sexual medicine did not arise in North America until the latter half of the 20th century, specifically around the time of the sexual revolution during the 1960s and 70s where the baby boomer generation had an increase in birth control pill use. Prior to that, open discussion of sex was seen as taboo. Psychoanalytic theories about sexuality, such as those proposed by Sigmund Freud and Helene Deutsch, were considered highly controversial. It was not until the post-World War II baby boom era and the sexual revolution of the 1960s and 1970s that sex, and subsequently sexual disorders, became a more accepted topic of discussion. [7]

In fact, urologists were the first medical specialty to practice sexual medicine. Not only does their practice focus on the urinary tract (the kidneys, urinary bladder, and urethra), there is a large emphasis on male reproductive organs and male fertility. Today, sexual medicine has reached a wider range of medical specialties, as well as psychologists and social workers, to name a few. [2]

What really opened the doors for societal normalcy of sexual medicine was the Massachusetts Male Aging Study performed in 1994 that clearly defined erectile dysfunction (ED) as a condition that affects a large population of American males. [2] It also had reported that, if possible, men would be willing to improve their sexual performance if a medication was deemed to be safe. On March 27, 1998, sildenafil citrate was approved by the Food and Drug Administration (FDA) for the treatment of ED. The approval of Sildenafil transformed the way America talked about a topic that was once very private before. [2]

Diagnosis

Sexual medicine plays a role in a wide range of medical specialties, from a primary care provider to a sexual health physician to a sexologist. A physician's role in taking a sexual history is vital in diagnosing someone who presents with a sexual dysfunction.

There is some anxiety that arises when sex comes up for discussion, especially between a healthcare provider and an individual. It is reported that only 35% of primary care physicians have taken a sexual history and, due to this, there is a gap in achieving holistic healthcare. [8] Clinicians fear individuals are not willing to share information, but in reality, it may be that the provider is shying away from the discussion. This steering away can be a result of lack of training, lack of structured tools and knowledge to assess a sexual history, and fears of offending individuals they are treating. Thus, knowing how to take an objective sexual history can help a clinician narrow down the pathogenesis of an individual's sexual health problem. [4]

Issues related to sexual or reproductive medicine may be inhibited by a reluctance of an individual to disclose intimate or uncomfortable information. Even if such an issue is on an individual's mind, it is important that the physician initiates the subject. Some familiarity with the doctor generally makes it easier for people to talk about intimate issues such as sexual subjects, but for some people, a very high degree of familiarity may make an individual reluctant to reveal such intimate issues. [9] When visiting a health care provider about sexual issues, having both partners of a couple present is often necessary, and is typically a good thing, but may also prevent the disclosure of certain subjects, and, according to one report, increases the stress level. [9]

Taking a sexual history is an important component of sexual medicine when diagnosing an individual with a sexual dysfunction. A sexual history incorporates social, medical, and surgical information, and should touch on all factors that affect an individual's sexuality. Essentially, it is a conversation between a health care provider and an individual that is geared towards obtaining information about the person's sexual health status. If this is done properly, it will be easier for the physician to address concerns the individual may have. Some people may not be comfortable in sharing information, but it is the role of the physician to create a comfortable and non-judgemental, private environment for those they are working with to speak openly. [10]

Sexual dysfunctions in men are often associated with testosterone deficiency. Signs and symptoms of testosterone deficiencies vary in each individual. Therefore, physical examinations could be done for men who suspect testosterone deficiencies to identify physical signs of the disorder. [11] Common physical signs include fatigue, increased body fat, weight gain, muscle weakness, and depressed mood. [11]

Laboratory tests may also be used to assist with diagnosis, such as blood glucose levels, lipid panel, and hormonal profile. Additionally, diagnostic categories of sexual disorders are listed in both the ICD-10 and DSM-5. ICD-10 categorizes the disorders by sexual desire, sexual arousal, orgasm, and sexual pain, while DSM-5 categorizes the dysfunctions by gender, substance/medication induced, paraphilic, or gender dysphoria. [12]

Risk factors for sexual dysfunction

The risk of developing a sexual dysfunction increases with age in both men and women. [13] There are several risk factors that are associated with sexual dysfunction in both men and women. Cardiovascular disease, diabetes mellitus, genitourinary disease, psychological/psychiatric disorders, and presence of a chronic disease are all common risk factors for developing a sexual dysfunction. [13] Endothelial dysfunction is a risk factor that is specifically associated with erectile dysfunction. [13] Past family medical history of sexual dysfunction disorders are also a risk factor for development.

Sociocultural factors may also contribute to sexual problems, such as personal, religious, or cultural beliefs about sex. Personal well-being may also impact an individual's sexual activity. Stress and fatigue may contribute to developing a decreased sexual response or interest. Fatigue may result from poor sleep or another underlying medical problem. Current or past sexual abuse, whether physical or emotional, is also a risk factor for developing sexual problems.

Disorders of sexual function

Sexual dysfunctions are sexual problems that are continuous in a person's life, adding stress and difficulty to personal relationships. Congenital or acquired, these conditions refer to any pathology which interferes with the perception of satisfactory sexual health. Varied conditions include absent sexual organs, hermaphrodite and other genetic malformations, or trauma such as amputation or lacerations.

Examples of conditions which may be treated by specialists in this field include:

Female

Male

Non-exclusive

Treatment

Once a diagnosis of sexual dysfunction has been made, treatment is often integrative and individualized. Sexual medicine experts aim to discover both the physical and psychologic factors that are the cause of an individual's sexual dysfunction.

Male sexual dysfunction

The most common male sexual dysfunction disorders are erectile dysfunction (ED), low libido, and ejaculatory dysfunction.

Once etiology and cardiovascular risk factors for ED have been identified, lifestyle or non-pharmacological therapy can be initiated to mitigate risk factors. As of 2018, the American Urological Association (AUA) ED guidelines recommend shared medical decision-making between patient and provider over first-, second-. and third-line therapies. However, phosphodiesterase-5 (PDE5) inhibitors, such as sildenafil (Viagra) and tadalafil (Cialis), are often recommended due to their favorable efficacy and side effect profile and work by increasing the lifespan of the vasodilator nitric oxide in the corpus cavernosum. Alternative treatments for ED are the use of vacuum-assisted erection devices, intracavernosal injection or intraurethral administration of alprostadil (prostaglandin E1), and surgery if necessary. [17]

Treatment for decreased libido is often directed towards the cause of the low libido. Low levels of hormones such as testosterone, serum prolactin, TSH, and estradiol can be associated with low libido, and thus hormone replacement therapy is often used to restore the levels of these hormones in the body. [18] Low libido can also be secondary to use of medications such as selective serotonin reuptake inhibitors (SSRIs), and so reduction of dose of the SSRI is used to improve libido. [19] Additionally, low libido due to psychological causes is often approached with psychotherapy.

Similarly, treatment of ejaculatory dysfunction such as premature ejaculation is dependent on the etiology. SSRIs, topical anesthetics, and psychotherapy are commonly used to treat premature ejaculation. [18]

Female sexual dysfunction

Similar to male sexual dysfunctions, sexual problems in women are also prevalent; however, they differ in the kind of dysfunction. For example, males have more problems related to function of their reproductive organs, where as for women it is more common to experience psychological problems, like lack of a sexual desire and more pain related to sexual activity. In 2008, 40% of U.S. women reported they were experiencing low sexual desire. [20]

Treatment approach is dependent on the type of dysfunction the women is experiencing. [21]

The treatment of female sexual dysfunction is varied as multiple causes are often identified. Following evaluation of symptoms and diagnosis, the woman's goals for treatment are determined and used to track progress. Health professionals are also trained to include the woman's sexual partner in the treatment plan, including noting any sexual dysfunction of the partner. Referral of the woman or couple to a sex therapist is also common to increase communication and expression of concerns and desires. Finally, conditions associated with the documented sexual dysfunction are simultaneously treated and included in the treatment plan. [22]

Non-pharmacologic treatment for female sexual dysfunction can include lifestyle modifications, biofeedback, and physical therapy. Pharmacologic therapy can include topical treatments, hormone therapy, antidepressants, and muscle relaxants. [23]

In fact, low sexual desire is the most common sexual problem for women at any age. With this, sexual ideas and thoughts are also absent. Counseling sessions addressing changes the couple can make can improve a woman's sexual desire. Other ways to treat include: trying a new sex position, using a sexual toy or device, having sex in an unusual location. Also, a woman enjoying her time with her partner outside of the bedroom, on a "date night", can improve the relationship inside the bedroom.

Sexual pain is another large factor for women, caused by Genitourinary Syndrome of Menopause (GSM), which includes hypoestrogenic vulvovaginal atrophy, provoked pelvic floor hypertonus, and vulvodynia. These can all be treated with lubricants and moisturizers, estrogen, and ospemifene. [21]

Psychiatric barriers

Sexual disorders are common in individuals with psychiatric disorders. Depression and anxiety disorders are strongly connected with reduced sex drive and a lack of sexual enjoyment. [2] These individuals experience a decreased sexual desire and sexual aversion. Bipolar disorder, schizophrenia, obsessive–compulsive personality disorder, and eating disorders, are all associated with an increased risk of sexual dysfunction and dissatisfaction of sexual activity. [2] Many factors can induce sexual dysfunction in individuals with psychiatric disorders, such as the effects of antipsychotics and antidepressants. Treatment may include switching medications to one with less sexual dysfunction side effects, decreasing the dose of the medication to decrease these side effects, or psychiatric counseling therapy.

Lifestyle barriers

General health greatly relates to sexual health in both males and females. Sexual medicine specialists take into consideration unhealthy lifestyle habits that may contribute to the sexual quality of life of individuals who are experiencing sexual dysfunction. Obesity, tobacco smoking, alcohol, substance abuse, and chronic stress are all lifestyle factors that may have negative impacts on sexual health and can lead to the development of sexual dysfunctions. [24] Both obesity and tobacco smoking have negative impacts on cardiovascular and metabolic function, which contributes to the development of sexual dysfunctions. Chronic smoking causes erectile dysfunction in men due to a decrease in vasodilation of vascular endothelial tissue. [25] Alcohol dependence can lead to erectile dysfunction in mend and reduced vaginal lubrication in women. [26] Long term substance abuse of multiple recreational drugs (MDMA, cocaine, heroin, amphetamine), leads to a decrease in sexual desire, inability to achieve orgasm, and a reduction of sexual satisfaction. [24] Chronic stress may potentially contribute to sexual dysfunction, as it can induce high levels of cortisol, which may cause harmful effects in if it remains altered long term. High levels of cortisol have been shown to cause a reduction in gonadic steroids and adrenal androgens. [24] Studies have shown that these steroids and adrenal androgens have effects on genital arousal as well as sexual desire. [24]

Sexual medicine experts are responsible for promoting healthy lifestyle habits in order to help prevent sexual dissatisfaction. Adoption of healthy lifestyle routines include: avoiding drugs, smoke, and excessive alcohol, as well as incorporating regular physical activity accompanied by a balanced diet and use of stress-management strategies. [24] These habits can be proposed before trying to incorporate pharmacological therapies and/or psychiatric therapies.

Sexual dysfunction in transgender persons

Limited research has been performed on sexual dysfunction in those who are transgender, but preliminary research suggests that initiating a sexual relationship is difficult for some. One recent study published in the Journal of Sexual Medicine surveyed 518 transgender individuals about sexual dysfunction and disturbances and reported that difficulty initiating sexual encounters and difficulties achieving orgasm were the most prevalent sexual dysfunctions experienced in the study sample. [27]

Challenges

While the awareness of sexual health importance has increased in regards to individuals' general health and well-being, there is still a taboo that follows sexual health. [28] The perception of sexual health varies among different cultures, as the notion is tied with many cultural norms, religion, laws, traditions, and many more. [29] Sexual medicine is a unique component of the medical practice that has its own challenges. [29] The main obstacle that stands between these discussions have been reported as the lack of education regarding sexual issues in individuals. The discussion of sexual health and taking a sexual history faces barriers as physicians infrequently address these topics in visits, and individuals are reluctant to discuss openly due to the perception that it is the physician's duty to initiate the topic and fears that the conversation will make the physician uncomfortable. [28]

Another challenge in sexual medicine is that in a standard process of drug discovery and development, human tissue and cells are not used in testing the candidate drug. [28] Instead, animal models are often used to study sexual function, pathophysiology of diseases that cause sexual dysfunction, and new drugs. [30] Pharmacokinetic and pharmacodynamic relationships are studied in animal models to test the safety and efficacy of candidate drugs. With animal models, there is a limitation to understanding sexual dysfunction and sexual medicine, as the results achieved can only mount to predictions. [28]

Identification and treatment of female sexual dysfunctions are also a challenge as women often encounter difficulty within multiple disorders and sexual phases. The various sexual phases that are encompassed within female sexual dysfunctions (FSD) include hypoactive sexual desire disorder (HSDD), female sexual arousal disorder (FSAD), female orgasmic disorder (FOD) and female sexual pain disorders (FPD). [28] Because many of these domains overlap, it is difficult to identify the target of treatment and many limitations are placed in the approach for research. [28] Risk factors for female sexual dysfunctions were observed to be embedded with biopsychosocial aspects in epidemiological studies such as depression, urinary tract symptoms, cancer and cancer treatment, relationship problems, and menopausal transition. [28] As a result, a multidimensional approach must be taken in the identification and treatment of female sexual dysfunctions.

The issue of psychological dilemmas that are associated with sexual dysfunctions is another challenge that is faced in sexual medicine. [31] There are many psychological aspects that are tied in with sexual dysfunctions. Despite much of sex therapy originating from psychological and cognitive-behavioral practices, many of the psychological dynamics have been lost in the sexual medicine protocols. [31] Approaching from a psychological and existential perspective helps link the understanding between sexual function and sexual dysfunction in the individual. Because the psychological aspects underneath the sexual distress are not being addressed within sexual therapy and treatments are mostly focused on the specific symptoms in sexual medicine, there are many situations where individuals still experience disappointment and dissatisfaction within sexual activities despite the dysfunction being resolved. [31]

See also

Related Research Articles

Erectile dysfunction (ED), also referred to as impotence, is a form of sexual dysfunction in males characterized by the persistent or recurring inability to achieve or maintain a penile erection with sufficient rigidity and duration for satisfactory sexual activity. It is the most common sexual problem in males and can cause psychological distress due to its impact on self-image and sexual relationships.

In psychology, libido is psychic drive or energy, usually conceived as sexual in nature, but sometimes conceived as including other forms of desire. The term libido was originally used by the neurologist and pioneering psychoanalyst Sigmund Freud who began by employing it simply to denote sexual desire. Over time it came to signify the psychic energy of the sexual drive, and became a vital concept in psychoanalytic theory. Freud's later conception was broadened to include the fundamental energy of all expressions of love, pleasure, and self-preservation.

An aphrodisiac is a substance alleged to increase libido, sexual desire, sexual attraction, sexual pleasure, or sexual behavior. These substances range from a variety of plants, spices, and foods to synthetic chemicals. Natural aphrodisiacs, such as cannabis or cocaine, are classified into plant-based and non-plant-based substances. Synthetic aphrodisiacs include MDMA and methamphetamine. Aphrodisiacs can be classified by their type of effects. Aphrodisiacs that contain hallucinogenic properties, such as bufotenin, have psychological effects that can increase sexual desire and sexual pleasure. Aphrodisiacs that have smooth muscle relaxing properties, such as yohimbine, have physiological effects that can affect hormone concentrations and increase blood flow.

Premature ejaculation (PE) is a male sexual dysfunction that occurs when a male expels semen soon after beginning sexual activity, and with minimal penile stimulation. It has also been called early ejaculation, rapid ejaculation, rapid climax, premature climax and (historically) ejaculatio praecox. There is no uniform cut-off defining "premature", but a consensus of experts at the International Society for Sexual Medicine endorsed a definition of around one minute after penetration. The International Classification of Diseases (ICD-10) applies a cut-off of 15 seconds from the beginning of sexual intercourse.

Dyspareunia is painful sexual intercourse due to medical or psychological causes. The term dyspareunia covers both female dyspareunia and male dyspareunia, but many discussions that use the term without further specification concern the female type, which is more common than the male type. In females, the pain can primarily be on the external surface of the genitalia, or deeper in the pelvis upon deep pressure against the cervix. Medically, dyspareunia is a pelvic floor dysfunction and is frequently underdiagnosed. It can affect a small portion of the vulva or vagina or be felt all over the surface. Understanding the duration, location, and nature of the pain is important in identifying the causes of the pain.

Persistent genital arousal disorder (PGAD), originally called persistent sexual arousal syndrome (PSAS), is spontaneous, persistent, unwanted and uncontrollable genital arousal in the absence of sexual stimulation or sexual desire, and is typically not relieved by orgasm. Instead, multiple orgasms over hours or days may be required for relief.

Hypoactive sexual desire disorder (HSDD), hyposexuality or inhibited sexual desire (ISD) is sometimes considered a sexual dysfunction, and is characterized as a lack or absence of sexual fantasies and desire for sexual activity, as judged by a clinician. For this to be regarded as a disorder, it must cause marked distress or interpersonal difficulties and not be better accounted for by another mental disorder, a drug, or some other medical condition. A person with ISD will not start, or respond to their partner's desire for, sexual activity. HSDD affects approximately 10% of all pre-menopausal women in the United States, or about 6 million women.

Sexual dysfunction is difficulty experienced by an individual or partners during any stage of normal sexual activity, including physical pleasure, desire, preference, arousal, or orgasm. The World Health Organization defines sexual dysfunction as a "person's inability to participate in a sexual relationship as they would wish". This definition is broad and is subject to many interpretations. A diagnosis of sexual dysfunction under the DSM-5 requires a person to feel extreme distress and interpersonal strain for a minimum of six months. Sexual dysfunction can have a profound impact on an individual's perceived quality of sexual life. The term sexual disorder may not only refer to physical sexual dysfunction, but to paraphilias as well; this is sometimes termed disorder of sexual preference.

Sexual arousal disorder is characterized by a lack or absence of sexual fantasies and desire for sexual activity in a situation that would normally produce sexual arousal, or the inability to attain or maintain typical responses to sexual arousal. The disorder is found in the DSM-IV. The condition should not be confused with a sexual desire disorder.

Sex therapy is a therapeutic strategy for the improvement of sexual function and treatment of sexual dysfunction. This includes dysfunctions such as premature ejaculation and delayed ejaculation, erectile dysfunction, lack of sexual interest or arousal, and painful sex ; as well as problems imposed by atypical sexual interests (paraphilias), gender dysphoria, highly overactive libido or hypersexuality, a lack of sexual confidence, and recovering from sexual abuse ; and also includes sexual issues related to aging, illness, or disability.

<span class="mw-page-title-main">Sexual frustration</span> Frustration resulting from lack of desired sexual activity

Sexual frustration is a sense of dissatisfaction stemming from a discrepancy between a person's desired and achieved sexual activity. It may result from physical, mental, emotional, social, financial, religious or spiritual barriers. It can derive from displeasure during sex due to issues such as anorgasmia, anaphrodisia, premature ejaculation, delayed ejaculation or erectile dysfunction. A sense of incompatibility or discrepancy in libido between partners may be involved. It may also relate to broader existential frustration.

Female sexual arousal disorder (FSAD) is a disorder characterized by a persistent or recurrent inability to attain sexual arousal or to maintain arousal until the completion of a sexual activity. The diagnosis can also refer to an inadequate lubrication-swelling response normally present during arousal and sexual activity. The condition should be distinguished from a general loss of interest in sexual activity and from other sexual dysfunctions, such as the orgasmic disorder (anorgasmia) and hypoactive sexual desire disorder, which is characterized as a lack or absence of sexual fantasies and desire for sexual activity for some period of time.

<span class="mw-page-title-main">Men's health</span> Broad subject that encompasses all facets of mens health

Men's health is a state of complete physical, mental, and social well-being, as experienced by men, and not merely the absence of disease. Differences in men's health compared to women's can be attributed to biological factors, behavioural factors, and social factors.

Sex and drugs date back to ancient humans and have been interlocked throughout human history. Both legal and illegal, the consumption of drugs and their effects on the human body encompasses all aspects of sex, including desire, performance, pleasure, conception, gestation, and disease.

Delayed ejaculation (DE) is a man's inability or persistent difficulty in achieving orgasm, despite typical sexual desire and sexual stimulation. Generally, a man can reach orgasm within a few minutes of active thrusting during sexual intercourse, whereas a man with delayed ejaculation either does not have orgasms at all or cannot have an orgasm until after prolonged intercourse which might last for 30–45 minutes or more. Delayed ejaculation is closely related to anorgasmia.

Sexual motivation is influenced by hormones such as testosterone, estrogen, progesterone, oxytocin, and vasopressin. In most mammalian species, sex hormones control the ability and motivation to engage in sexual behaviours.

<span class="mw-page-title-main">Sexuality after spinal cord injury</span> Aspect of human sexuality

Although spinal cord injury (SCI) often causes sexual dysfunction, many people with SCI are able to have satisfying sex lives. Physical limitations acquired from SCI affect sexual function and sexuality in broader areas, which in turn has important effects on quality of life. Damage to the spinal cord impairs its ability to transmit messages between the brain and parts of the body below the level of the lesion. This results in lost or reduced sensation and muscle motion, and affects orgasm, erection, ejaculation, and vaginal lubrication. More indirect causes of sexual dysfunction include pain, weakness, and side effects of medications. Psycho-social causes include depression and altered self-image. Many people with SCI have satisfying sex lives, and many experience sexual arousal and orgasm. People with SCI may employ a variety of adaptations to help carry on their sex lives healthily, by focusing on different areas of the body and types of sexual acts. Neural plasticity may account for increases in sensitivity in parts of the body that have not lost sensation, so people often find newly sensitive erotic areas of the skin in erogenous zones or near borders between areas of preserved and lost sensation.

Drugs and sexual desire is about sexual desire being manipulated through drugs from various approaches. Sexual desire is generated under the effects from sex hormones and microcircuits from brain regions. Neurotransmitters play essential roles in stimulating and inhibiting the processes that lead to libido production in both men and women. For instance, a positive stimulation is modulated by dopamine from the medial preoptic area in the hypothalamus and norepinephrine. At the same time, inhibition occurs when prolactin and serotonin are released for action.

The medicalisation of sexuality is the existence and growth of medical authority over sexual experiences and sensations. The medicalisation of sexuality is contributed to by the pharmaceutical industry, along with psychiatry, psychology, and biomedical sciences more generally.

Drugs and Sexual Performance refers to the influence of substances on sexual function and experience. Sexual performance is known as the execution of the act of sex and the quality of sexual activity. This includes elements such as libido, sexual function, sensation . Drugs are termed as any chemical substance that produces a physiological and or psychological change in an organism. Drugs categorized as psychoactive drugs, antihypertensive drugs, antihistamines, cancer treatment, and hormone medication have a significant impact on sexual performance. Various drugs result in different effects, both positive and negative. Negative effects may include low libido, erection issues, vaginal dryness and anorgasmia. Positive effects usually address these issues, overall enhancing sexual performance and contributing to a more enjoyable sexual experience. It is crucial to know that the impact of drugs on sexual performance varies among individuals, especially among different genders. 

References

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  24. 1 2 3 4 5 Mollaioli, Daniele; Ciocca, Giacomo; Limoncin, Erika; Di Sante, Stefania; Gravina, Giovanni Luca; Carosa, Eleonora; Lenzi, Andrea; Jannini, Emmanuele Angelo Francesco (2020). "Lifestyles and sexuality in men and women: the gender perspective in sexual medicine". Reproductive Biology and Endocrinology. 18 (1): 10. doi: 10.1186/s12958-019-0557-9 . ISSN   1477-7827. PMC   7025405 . PMID   32066450.
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  26. ↑ Peugh, Jordon; Belenko, Steven (2001). "Alcohol, Drugs and Sexual Function: A Review". Journal of Psychoactive Drugs. 33 (3): 223–232. doi:10.1080/02791072.2001.10400569. ISSN   0279-1072. PMID   11718315. S2CID   27215932.
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  28. 1 2 3 4 5 6 7 Cellek, Selim; Giraldi, Annamaria (2012). "Challenges in sexual medicine". Nature Reviews Urology. 9 (9): 537–542. doi:10.1038/nrurol.2012.134. ISSN   1759-4812. PMID   22777290. S2CID   9544154.
  29. 1 2 Baazeem, Abdulaziz (2016). "Challenges to Practicing Sexual Medicine in the Middle East". Sexual Medicine Reviews. 4 (3): 221–228. doi:10.1016/j.sxmr.2016.04.001. PMID   27871955.
  30. ↑ Ventura-Aquino, Elisa; Paredes, Raúl G. (1 January 2017). "Animal Models in Sexual Medicine: The Need and Importance of Studying Sexual Motivation". Sexual Medicine Reviews. 5 (1): 5–19. doi:10.1016/j.sxmr.2016.07.003. ISSN   2050-0521. PMID   27566910.
  31. 1 2 3 Watter, Daniel N. (1 January 2018). "Existential Issues in Sexual Medicine: The Relation Between Death Anxiety and Hypersexuality". Sexual Medicine Reviews. 6 (1): 3–10. doi:10.1016/j.sxmr.2017.10.004. ISSN   2050-0521. PMID   29129680.
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