Challenges in the Practice of Sexual Medicine in the Time of COVID-19 in Brazil

The new Coronavirus disease 2019 (COVID-19) outbreak was initially reported in China and spread across the world between December 2019 and January 2020, reaching the status of pandemic in March 11, 2020.¹ In Brazil, the first case was reported on February 26, 2020, and within 1 month, the national government has declared a national state of emergency. As of May 12, 2020, there have been 168,331 confirmed infections and 11,519 deaths, exceeding the official number of deaths in China.^1,2 The current impact of COVID-19 has been unprecedented, leading to national health system overload and severe economic consequences. Unfortunately, according to our infection curve, the situation is still expected to worsen.

As a result of high demands in the health-care system and concerns with increased contamination rates in medical facilities, medical entities and governmental agencies recommended that all nonessential medical services be suspended, including in-office visits and surgical interventions. Therefore, the practice of sexual medicine has been dramatically impacted, as most consultations and procedures are essentially elective. In fact, the Brazilian Urological Society released a statement in accordance with international publications considering sexual medicine surgical procedures such as penile implants and reconstructive surgery for Peyronie's disease as low priority during the pandemic.³

However, it is noteworthy to mention that many patients consider themselves in profound suffering due to sexual complaints and have been urging to obtain medical counseling despite the critical global situation. In agreement with publications from previous pandemics, recent studies have already demonstrated an increased psychological burden during COVID-19, a result of both fear from the disease and issues arising from social isolation.⁴ Therefore, given the well-known link between mental and sexual health, it is expected that patients would need closer follow-ups as they might be at a greater risk of decompensating preexisting sexual dysfunction.

In addition, there have been concerns that COVID-9 might be transmitted during sexual encounters, as physical closeness might predispose for respiratory contamination. In fact, the controversy of early studies regarding the presence of SARS-CoV-2 in semen, vaginal fluid, and feces of infected individuals has not ruled out the possibility of sexual transmission.^5–8 The most recent study evaluating 38 male subjects in the acute phase of COVID-19 has demonstrated that 15% of participants had positive tests in the semen.⁷ These uncertainties might have eventually led to an increased search for sexual medicine professionals. Sexual avoidance and decreased intimacy can also be the trigger for the onset of sexual dysfunction in a couple. Fortunately, the International Society of Sexual Medicine has released a document pertaining the safety of sexual encounters during the pandemic which might help guiding professionals and patients.⁹

Brazil has a distinct interplay between public and private health institutions. Interestingly, working in both public and private institutions simultaneously is not only allowed but also very common. Particularly in the field of sexual medicine, most of the installed infrastructure is found within the private sector and most often in a fee-for-service fashion. Therefore, the economic recession together with worrying predictions has the potential to undermine both patient accessibility to sexual medicine services and the income of many professionals. As it is not possible to predict when routine sexual medicine practice will return, the financial impact on many sexual health-care providers can be dramatic. On the other hand, public services have been mostly devoted to the fight against COVID-19, and many sexual medicine experts who are public employees have been allocated to work in the frontline or in regulation services. The reality is that many public sexual medicine referral centers have been closed down, in which all consultations and surgeries were canceled, and there is still no forecast for their normalization. The longer this situation lasts, the bigger will be the delay in these elective procedures, overloading the public system.

Another significant challenge in our country is the fact that telemedicine was not previously regulated. As a result, there has been an urgent need for the development of new regulations and a rapid implementation nationwide. However, patients, providers, and insurance companies have not easily accepted this process, which will probably need more time to adapt. Providers are reluctant because many insurance companies are not paying for online consultations. Some advocate that the use of telemedicine through expensive platforms may impair the practice of local physicians, leaving its management in the hands of wealthy institutions. Also, being a country where Latin culture predominates, patients tend to prefer the traditional face-to-face contact and a closer relationship to their caregivers. Online consultations have been refused by some patients on the grounds that they might undermine the emotional bond to the interviewing professional. Others have complaints about the lack of privacy during remote consultations. As many families are isolated together, some individuals are afraid that the conversation might be overheard, exposing sensitive issues such as masturbation habits, multiple sexual partners, bizarre sexual practices, to name a few.

Following up patients has also been challenging during the pandemic. Routine laboratory assessments have become unnecessary exposure to contamination. At-home visits for diagnostic workup are expensive and unfortunately beyond the financial reality of the vast majority of our population. Taken together, this scenario imposes a great risk for treatment discontinuation or suboptimal care. Managing complicated surgical cases has also been difficult. For instance, there are reports of patients who had prolonged hospital stay or even death after severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) following uneventful surgical procedures.¹⁰ To avoid exposing the team, patients, and family members to these risks, surgeons may feel pressured to undergo more conservative measures and delay necessary in-hospital interventions.

Furthermore, the spread of COVID-19 has definitely impacted academic endeavors in our country. As many multispecialty academic hospitals have been turned into strategic facilities to host COVID-19 patients, physicians with academic functions have been transferred to frontline duties. Although compensation with online activities has been proposed in some institutions, in others, the academic routine has been simply abandoned as a result of an intense workload. The consequences to medical students, interns, and residents are yet unknown, and some institutions are considering canceling the current academic year.

In the research arena, it has also been difficult for many training professionals and grant holders, as most research activities had to be stopped or postponed. Ongoing clinical trials that demand time-dependent patient recruitment, laboratory assessment, or office visits may face significant drawbacks.

Although COVID-19 pandemic has been very impactful in our country, demanding immediate solutions, it may still create opportunities in different areas. It is our feeling that some of these changes driven by the current state of facts will eventually be proven effective and beneficial, being adopted in the postpandemic world, and perhaps changing the practice of sexual medicine for the better.

As telemedicine is a reality in many countries, there is probably going to be pressure for leaders to maintain the new regulations afterward. Its use could gradually become routine with better acceptance from patients and providers. It is even likely that new technologies might create strategies to overcome the lack of physical contact in the future. As a result, many patients could benefit from having access to sexual medicine experts without the need to travel long distances, which is particularly relevant in our country with continental dimensions and limited offer of specialized professionals. As interviews are the main core of sexual medicine practice, telemedicine might be more easily applied within our specialty. In addition, other professionals such as psychologists and nutritionists have been allowed to perform online consultations for years, and their successful experience in our country could be a model for sexual medicine to build on.

It is also possible that academics will experience a new concept of medical conferences. It is our understanding that virtual participation will not completely replace traditional conferences and symposiums, as social interactions are one of the main purposes of scientific encounters. Nevertheless, hybrid events that allow online participation for both lecturers and attendees might become an interesting modality, reducing costs and increasing attendance. This new paradigm could help develop multiinstitutional collaborations and high-quality meetings everywhere.

Finally, COVID-19 is also creating research opportunities. Although the economic crisis will inevitably compromise the total amount of research funds, the Brazilian government has allocated resources for sponsoring research related to different aspects of COVID-19. The investigation of potential sexual health consequences of the pandemic is surely an opportunity in the sexual medicine field, analyzing disease burden on sexual function and behavior. Understanding the role of sexual transmission in COVID-19 is another aspect worth investigating.

Statement of authorship

Category 1

1. Conception and Design

   Eduardo P. Miranda; Bruno Nascimento; Luiz Otavio Torres; Sidney Glina

2. Acquisition of Data

   Eduardo P. Miranda; Bruno Nascimento

3. Analysis and Interpretation of Data

   Eduardo P. Miranda; Bruno Nascimento

Category 2

1. Drafting the Article

   Eduardo P. Miranda; Bruno Nascimento

2. Revising It for Intellectual Content

   Luiz Otavio Torres; Sidney Glina

Category 3

1. Final Approval of the Completed Article

   Eduardo P. Miranda; Bruno Nascimento; Luiz Otavio Torres; Sidney Glina

Funding:

None.