Results of a World Health Organization Scoping of Sexual Dysfunction–Related Guidelines: What Exists and What Is Needed

Abstract

Background

Sexual dysfunction has long been overlooked in the broader context of sexual and reproductive health services. As a result, and in the absence of international sexual dysfunction treatment guidelines, recommendations have instead been developed by a variety of professional associations, worldwide.

Aim

We conducted a mapping of existing recommendations addressing a wide array of conditions related to sexual function/dysfunction.

Methods

We contacted 25 professional associations from around the world and held an online open call for guidelines.

Outcomes

Eligible submissions had to provide recommendations on treatment related to male or female sexual dysfunction.

Results

Twelve guidelines from 11 associations were included. Of the 195 recommendations extracted, 61% were related to men, 53% were related specifically to treatment, and 48% did some form of evidence assessment.

Conclusion

Recommendations from this exercise are provided for WHO, international and national research institutions, ministries of health, and professional associations.

Gonsalves L, Cottler-Casanova S, VanTreeck K, et al. Results of a World Health Organization Scoping of Sexual Dysfunction–Related Guidelines: What Exists and What Is Needed. J Sex Med 2020;17:2518–2521.

Introduction

In 2017, the World Health Organization (WHO) Department of Sexual and Reproductive Health and Research published an operational framework describing all intervention areas, which together comprise comprehensive sexual and reproductive health,¹ This, and a complementary package of services described by the Guttmacher-Lancet Commission on Sexual and Reproductive Health,² informs countries' efforts to identify sexual and reproductive health services for inclusion in health benefits packages. Countries, particularly low- and middle-income countries, rely heavily on WHO clinical and public health guidelines for recommendations on how to implement these services.

For some intervention areas, WHO has decades worth of research and guidelines to draw from (eg, maternal health, prevention and control of HIV), reflecting a traditional focus on addressing mortality and reducing the spread of communicable disease. As a result, there has been limited development of other intervention areas. One of these “overlooked” areas is “sexual function and psychosexual counseling interventions,” which includes treatment of sexual dysfunctions.

Here, international and national professional associations and medical groups have developed their own guidelines on treatment of a wide array of conditions related to sexual function/dysfunction. However, with a Sustainable Development Goal target to “ensure universal access to sexual and reproductive health care services” (Target 3.7), globally applicable recommendations on treatment and counseling for sexual function/dysfunction are important. Therefore, we undertook a scoping of the guidelines in this area to develop a database of existing recommendations. This brief communication describes the result of this mapping exercise.

Methods

This mapping was conducted to prepare for a special symposium at the 24th Congress of the World Association for Sexual Health (WAS), entitled “A conversation with the WHO about guidelines for treatment of sexual dysfunction: what exists and what is needed?”.³

In July 2019, we reached out to 25 national, regional, and international professional associations and societies who have developed sexual dysfunction guidelines. Associations were identified through past collaboration with the WHO or the WAS and contacted individually. In addition, an open call for sexual dysfunction–related guidelines was posted on the WHO Department of Sexual and Reproductive Health and Research website and disseminated over social media and through networks. Finally, we conducted a manual search online for additional guidelines.

Eligible submissions provided recommendations on treatment related to sexual dysfunction in men or women. Submissions were not eligible if they were adaptations of another association's guidelines (in which case, the original guideline was considered), if they did not include practice recommendations, if they did not include any scientific peer-reviewed evidence as rationale for recommendation, or if they were not focused on an individual's health care (eg, policy guidance). Information about each recommendation was extracted into a Google Sheets template.

High-level observations were presented at the WAS symposium and served as the basis for a broader panel discussion with congress attendees. Key observations and discussion takeaways are summarized in the subsequent sections.

Results

A total of 11 associations responded, submitting a total of 31 guidelines. An additional guideline was identified by manual search. In total, 12 guidelines met our inclusion criteria:

• •Guideline on Erectile Dysfunction, American Urological Association (AUA) (2018)
• •Guideline on Peyronie's Disease, AUA (2015)
• •Guideline on Priapism, AUA (2010)
• •Guideline on the Pharmacologic Management of Premature Ejaculation, AUA (2010)
• •Evaluation and Management of Testosterone Deficiency: AUA Guideline, AUA (2018)
• •Guidelines on Adult Testosterone Deficiency, British Society for Sexual Medicine (2017)
• •Guidelines on the Management of Erectile Dysfunction in Men, British Society for Sexual Medicine (2018)
• •Process of Care for the Identification of Sexual Concerns and Problems in Women, International Society for the Study of Women's Sexual Health (2019)
• •Process of Care for Management of Hypoactive Sexual Desire Disorder in Women, International Society for the Study of Women's Sexual Health (2017)
• •Management of genitourinary syndrome of menopause in women with or at high risk for breast cancer: consensus recommendations, International Society for the Study of Women's Sexual Health/the North American Menopause Society (2018)
• •Treatment of Symptoms of the Menopause: Clinical Practice Guideline, The Endocrine Society (2018)
• •Androgen Therapy in Women: Clinical Practice Guideline, The Endocrine Society (2014)

Of the total 195 recommendations extracted from the 12 guidelines, 61% of them were recommendations related to male sexual functioning. The dysfunctions covered by these guidelines were erectile dysfunction, Peyronie's disease, priapism, premature ejaculation, and testosterone deficiency. For women, guidelines covered female sexual dysfunction (unspecified), hypoactive sexual desire disorder, menopause symptoms, and androgen therapy.

Recommendations were related to counseling, screening, diagnosis, adjunctive testing, treatment, and follow-up. Treatment recommendations were the most prevalent (53%) and included psychological (eg, counseling) as well as pharmacologic, medical, and surgical interventions. Treatment recommendations for men were more clinical in their tone (see Box 1). By contrast, treatment recommendations for women appeared to take a more holistic approach to addressing functioning, with more detail on education/counseling steps.

Box 1. Treatment recommendations for men vs women.

Erectile Dysfunction (ED) Guideline. American Urological Association.

Evaluation and Diagnosis: “Men presenting with symptoms of ED should undergo a thorough medical, sexual, and psychosocial history; a physical examination; and selective laboratory testing.”

Process of Care for the Identification of Sexual Concerns and Problems in Women.

International Society for the Study of Women's Sexual Health.

Engaging with the patient (Step 1 of 4): “The first step is to elicit a narrative description of the problem and it's affect on the patient's life, emotional state, and relationships. The goal is to help the patient discover and describe her distress, her functional impairment, and the effect the problem is having on her life.”

Across recommendations, 48% did some form of evidence assessment. An additional 10% were considered “clinical principles,” that is a “best practice” that clinicians would agree upon, independent of whether there was evidence (eg, counselling men that erectile dysfunction can be associated with cardiovascular disease and other underlying conditions). The remaining 42% of recommendations were based on “expert opinion,” that is consensus built from the experience, training, and judgment of clinicians developing the guideline.

Discussion

The purpose of this mapping exercise was to identify existing guidelines related to sexual dysfunctions. We found that guidelines addressing male sexual dysfunctions were more numerous and addressed specific conditions, as compared with guidelines addressing women's sexual functioning. This likely reflects the greater attention, research, and funding traditionally afforded to understanding and addressing men's sexual functioning.⁴ The sexual dysfunction conditions relevant to women, which are now located in a new sexual health chapter of the International Classification of Diseases 11th Revision (ICD-11),⁵ as well as a growing comfort globally with acknowledging women's sexuality at all stages in life,⁶ will hopefully provide impetus for additional research and guideline development for women.

The content was also different between recommendations for men vs women, and is likely a result of different professional associations developing these guidelines in the tone appropriate for their memberships. Finally, a large percentage of recommendations were developed based on “expert opinion,” that is no objective and systematic evaluation of the evidence. This could be the result of several factors. First, some professional organizations may not have the resources to undertake the rigorous systematic reviews of the literature required to collect, review, and grade the available evidence. However, second, the benefit of conducting a systematic review is limited when there is not sufficient evidence in the literature. As such, for certain under-researched sexual dysfunctions or treatments (particularly for women, as described previously), recommendations developed through expert opinion and consensus processes may be the most pragmatic way to provide evidence-informed services. Stronger recommendation development processes follow improved evidence, but robust research again requires acknowledgment of the importance of sexual functioning to overall health and well-being and corresponding funding and prioritization.

These findings and the consultations on this issue at the WAS Congress symposium reveal the following opportunities to strengthen global availability and consistency of sexual dysfunction guidelines:

• •The WHO and professional associations must make the case for countries to include sexual functioning services when planning for comprehensive sexual and reproductive health services.
• •Research around the development and evaluation of sexual dysfunction treatments should be prioritized by national and international research institutions. The broader sexual and reproductive health community should advocate for more evidence where it is needed.
• •Ministries of health and national institutes of health can lead in the development of national sexual dysfunction treatment guidelines, in close consultation with professional organizations and the WHO.
• •Professional associations who currently develop guidelines can look for opportunities to work with peer associations in dissemination efforts (eg, sharing the guidelines identified through this mapping process). Collaborative guideline dissemination efforts can also improve guidelines’ reach across the diverse communities of practitioners who work on sexual dysfunction.
• •Professional associations who currently develop guidelines can collaborate on guideline development, too. Where evidence exists, pooling financial resources may make rigorous reviews feasible.
• •Finally, professional associations who currently develop guidelines should clearly identify conflicts of interest among contributors and report how significant conflicts of interest are managed. Commercial funding of guideline development processes should be avoided.
• •Professional associations should seek to strengthen networks and improve awareness of existing guidelines among practitioners in low- and middle-income countries.

Statement of authorship

Lianne Gonsalves: Conceptualization, Methodology, Formal Analysis, Writing - Original Draft, Writing - Review and Editing, Supervision. Sara Cottler-Casanova: Methodology, Investigation, Formal Analysis, Writing - Review and Editing. Kelly VanTreeck: Investigation, Formal Analysis, Writing - Review and Editing, Visualization. Lale Say: Conceptualization, Writing - Review and Editing, Supervision.