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

Since the COVID-19 outbreak, the world as we knew it has changed in almost every respect. The attempts to understand this crisis have created more than 9,500 scientific articles in 4 and a half months featuring “COVID-19” and more than a hundred about “COVID-19 challenges.”

Challenges and unmet needs are not new in our field. As noted by Cellek and Giraldi,¹ struggling with taboos and misconceptions, difficulty with funding and conducting basic and clinical research have been our struggle for years. At this moment in time, there is a new level of complexity because of the ongoing dramatic changes in people's lives and health-care systems.

We have identified major challenges, based on the literature, our own personal experience, and the constant hearty interchange within our professional community.

Lack of scientific-based evidence

In the absence of clinical data, governments, medical systems, health-care professionals, and individuals are forced to make decisions regarding the management of one of the biggest crises of the current century, based on untested hypotheses and insights learned from others. We are confronting a constantly changing and unpredictable reality coupled with a lack of evidence-based knowledge.

We are lacking information about COVID-19 in general, and specifically about COVID-19 and sexual health and function. Absence of information creates fear and anxiety.² We often find ourselves facing our patients with no clear answers. The urgent need for knowledge has produced a flood of fast-track research and publications, with a corresponding range of scientific quality.

Mental health and well-being

We are still learning what the mental effects of COVID-19 on patients are. According to the accumulating literature, the current situation increases negative emotions and decreases positive emotions and life satisfaction.³ Health-care providers are also expressing higher levels of depression, anxiety, stress, and psychological distress.⁴ General public and medical staff all suffer from vicarious traumatization. Non–front-line medical staff are not exempted.⁵ The psychological impact of quarantine covers a broad spectrum, is significant, and can be long-lasting.⁶ Financial problems may mask health needs, as some individuals may have lost their jobs and others may work from home while simultaneously taking care of their children.

Mortality salience may cause disruption in sexual function, increase the likelihood of risk-taking behaviors in certain populations,⁷ and in contrast, promote constructive processes in others, such as the formation and maintenance of committed relationships.⁸

In our clinical practice, we see the entire spectrum of emotions. Some people enjoy the slower pace life has taken, and some cannot wait to go back to routine. Some have increased sexual desire, and some have none. As written by Victor Frankl, “An abnormal reaction to an abnormal situation is normal behavior.”

Changing sexual behaviors

It has been recommended that individuals avoid physical proximity with people outside their households, to avoid spread of the virus. Heeding this warning seriously impacts the sexual activity of persons currently not in a relationship or in a relationship while living apart. Changing behaviors while in quarantine includes the increase in pornography-watching as reported by the popular pornography site Pornhub. The New York City Health Department released its official guide for safer sex, advocating for masturbation as the safest sex practice. So did we, the Israeli Association for Sexual Medicine, in spite of male masturbation being prohibited under Jewish orthodox law.

Both happy and unhappy couples are spending long hours together, which may possibly strain the relationship. Secretary-General of the United Nations, António Guterres, has put out a call to address a global surge in domestic violence toward women and girls, linked to lockdowns. Household roles may be shifting and not necessarily for the benefit of the relationship.

All of these factors affect sexual health and function, as well as the willingness, availability, and ability to access sexual medicine care if needed.

Specific populations

Older adults are at a special disadvantage because some countries contemplate their isolation will be of relatively long duration. This group has a high incidence of sexual dysfunction, their interest in maintaining routine sexual activity, notwithstanding. Even when official restrictions are over, they may not have easy access to medical facilities or to telemedicine.

In our practice, we are witnessing disagreements within the orthodox Jewish community around the “Family Purity” system, which involves the women's immersion in a ritual pool, the Mikvah, 7 days after the end of menstruation. Until the ritual immersion, the couple is not allowed to touch each other. Going to the Mikvah in COVID-19 times may be terrifying for some women. Although there is no evidence that SARS-CoV-2 can survive in pools, concern about proximity to others and touching common surfaces is high. Some Mikvah baths are highly trafficked public areas.

Recently, 2 orthodox women arbiters of Jewish law stated women should not immerse in the Mikvah during this period, arguing that not endangering life supersedes the necessity for marital relations.⁹ Not immersing means withdrawing from intimacy as intimacy without the ritual bath is considered inconceivable. Jewish law is traditionally ruled by (male) Rabbis, and intimate relations between couples are considered vital, especially because male masturbation is not allowed. This debate has caused much tension within the orthodox community.

Therapeutic setting

The therapeutic setting is being threatened. People are refraining from visiting healthcare facilities, to receive treatment for acute and chronic problems.

The traditional configuration, which provides facilities, medical equipment, staff, administrative procedures, and a set of behaviors that guarantee professionalism, safety, and confidentiality, may need to be adjusted or replaced. The COVID-19 pandemic has driven a rapid expansion of telemedicine, especially among younger individuals (ages 20–44 years).¹⁰ Telemedicine requires infrastructure, connectivity, and practical proficiency at both ends of the clinical encounter, as well as laws and regulations, cybersecurity, and reimbursement options. The telemedicine encounter often lacks the patient-physician relationship and trust found in a conventional office meeting.

Tele-sexual-medicine can be especially difficult. Addressing sexual issues from home (the bedroom? with kids around?) can be uncomfortable for both patients and providers. Genital physical examination or even observation is impracticable.

The situation obligates us to be creative and act quickly.

In some countries, hotels were converted into hospitals. Can we improvise temporary sexual medicine clinics? Should we offer home healthcare services, similar to those offered to women with uterine preterm contractions or patients needing palliative care? Should we provide patient outreach programs?

Prioritization

The COVID-19 pandemic has forced medical systems to prioritize patient care and to temporarily reduce or shut down elective care and procedures. Delay in sexual medicine care has short- and long-term consequences for the patients, especially in times of strain.

On the practitioner's side, postponement of nonemergency interventions leads to the disruption of good medical practice, produces an accumulation of caseloads in its aftermath, and causes financial pressure. Physician groups of all specialties and sizes are experiencing the financial impact of the pandemic.¹¹

Research funds are also being prioritized, adding to the budgetary strain our field already confronted before the pandemic.

Education

We have been forced to become instant experts in teleteaching and teleconferencing. How can online and distance learning be effective for training clinical skills? How can we engage students in interactive discussions?

The number of participants in surgeries is now limited to essential personnel. This causes a loss of “hands-on” experience, impacts the workload, and challenges traditional roles of the medical staff.

An opportunity to grow

From a field that began merely as the biological standpoint for sexual function, the bio-psycho-social approach to sexual medicine has been maturing over the years. The COVID-19 era adds new interacting layers of complexity to this model.

Disasters can have devastating effects. However, in recent years, there has been increasing emphasis on resilience building and post-traumatic growth.¹² Unfortunately, our country has faced difficult times, and we have learned that a community approach is crucial for reducing vulnerability and fostering resilience. This is true for the practice of medical care as well.

An example of a response is the initiative by the Israeli Society for Sex Therapy, together with members of the Israeli Sexual Medicine Association, to open a free-of-charge hot line, providing sex counseling by professional volunteers. This was our first effort at dealing with the distress of patients who cannot reach treatment because of temporary clinic closures or apprehension to seek care.

Bad times bring out the best in us. We believe that the field of sexual medicine can grow from this. This is the time for flexibility, adaptability, and creativity. An era when distancing and isolation are identified by some as essential for the maintenance of public health, and by others as a threat to society, provides the ideal opportunity for clamorous discourse about the value of sexuality and sexual function in people's lives. This requires our best professionals to advocate for the importance of our field, in both medical and public arenas. An all-encompassing approach is needed to elevate awareness and to share knowledge throughout society, not just within restricted scientific circles.

Now, more than ever, people are using the internet to gather information, obtain peer support, and access self-help programs. This may be the time to increase our interaction with non-profit patient-based associations and bring our message to them.

The current situation may facilitate the inclusion and/or extension of sexual medicine into the curricula of medical schools and residency programs. This could be an opportunity for health-care providers from all fields to talk among themselves about relationships and sexuality and to encourage them, in turn, to be more open to talking with their patients about these issues. During the first days of the confinement, the Israeli Association of Public Health Physicians contacted the Israel Association for Sexual Medicine, urging us to publish guidelines for sexual behavior in COVID-19 times. This is the first time such an alliance has developed.

We suggest that sexual medicine practitioners widen their view into the psychosocial aspects of patients’ sexual history and increase their participation and cooperation in multidisciplinary and interdisciplinary settings.

This is the time for the various sex education, sexual health, and sexual medicine organizations to align for a common purpose—the validation and expansion of sexual well-being in the broadest sense of the word.

Statement of authorship

Category 1

1. Conception and Design

   Sharon Peleg Nesher; Mijal Luria

2. Acquisition of Data

   Sharon Peleg Nesher; Mijal Luria

3. Analysis and Interpretation of Data

   Sharon Peleg Nesher; Mijal Luria

Category 2

1. Drafting the Article

   Sharon Peleg Nesher; Mijal Luria

2. Revising It for Intellectual Content

   Sharon Peleg Nesher; Mijal Luria

Category 3

1. Final Approval of the Completed Article

   Sharon Peleg Nesher; Mijal Luria

Funding:

None.