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Current Literature Review
© 2014 International Society for Sexual Medicine
Survey of Literature Current Literature Review
Basic Science
Infection and cellular defense dynamics in a novel 17β-estradiol murine model of chronic human group B Streptococcus genital tract colonization reveal a role for hemolysin in persistence and neutrophil accumulation. AJ Carey, CK Tan, S Mirza, H Irving-Rodgers, RI Webb, A Lam, GC Ulett. J Immunol 2014;192:1718– 31. Editorial Comment: During a vaginal birth, babies are colonized by maternal vaginal and fecal bacteria. The initial bacterial colonies resemble the maternal vaginal microbiome—predominantly Lactobacillus, Prevotella, and Sneathia. In contrast, babies born by cesarean delivery are primarily colonized by the bacteria in the hospital environment and maternal skin. Various bacteria reside in the vaginal tract; some convey positive benefits to the newborn, and some can cause increased neonatal morbidity and sepsis. Group B Streptococcus (GBS), or Streptococcus agalactiae, exists in around 7–38% of healthy women, and the U.S. Centers for Disease Control and Prevention advise pregnant women to get screened for GBS prior to delivery so that antibiotics can be administered. GBS also causes a variety of acute diseases in adults. This study reports on the development and analysis of a mouse model of chronic human GBS colonization. Mice were given 17β-estradiol to induce estrus and were infected with GBS. Cervical–vaginal swabs were collected every 3 days to assess bacterial loads, and experiments continued for 90 days. Analyses included cellular and bacterial assessments and histological and immunological analysis. GBS persisted in the genital tract throughout the course of the study and activated an increase in lymphocyte infiltration and polymorphonuclear leukocytes at the superficial layers of the vagina. Various soluble inflammatory mediators were activated, including granulocyte– macrophage colony-stimulating factor and tumor 1892
necrosis factor alpha. However, despite the release of local inflammatory factors, GBS persisted, possibly due to the organisms’ β-hemolysin production. This paper provides an interesting model that might mimic the human condition of long-term GBS persistence and may provide a useful model to examine how GBS clearance can be enhanced. Lesley Marson, PhD Genital herpes simplex virus type 2 infection in humanized HIV-transgenic mice triggers HIV shedding and is associated with greater neurological disease. B Nixon, E Fakioglu, M Stefanidou, Y Wang, M Dutta, H Goldstein, BC Herold. J Infect Dis 2014;209:510–22. Editorial Comment: Herpes simplex virus type 2 (HSV-2) causes genital herpes, which is widely prevalent worldwide, and there is a synergistic relationship when people are infected with human immunodeficiency virus (HIV). Clinical and subclinical HSV-2 reactivation increases the risk of acquiring HIV and may increase the transmission rates for the passage of HIV from the mother to child. In addition, HIV-infected individuals have a higher risk of having recurrent HSV-2 infections. This paper describes a modified mouse model in which co-infection of HIV and HSV-2 was studied. Difficulties in translating mouse models to human HIV have been hampered by their lack of susceptibility to infection with HIV. This paper describes use of transgenic mice for HIV-1 provirus and human cyclin T1 under control of a CD4 promoter (JR-CSF/hu-cyeT1) in which the HIV production can be amplified. The HIV-positive transgenic mice were more susceptible to HSV-2 infection and demonstrated more neurological disease (urinary and fecal retention and reduced function of the hind limbs), which was associated with a down-regulation of secretory leukocyte protease inhibitor expression. A synergic relationship was observed between HIV and HSV-2 infection load, and genital inflammatory mediators J Sex Med 2014;11:1892–1897
were increased in response to HSV-2 infection, but the response appeared to be delayed in the HIV-TG-infected mice. The interplay of viral susceptibility in this model appears to be similar to that seen in humans. Further studies characterizing this model and others and examining the interplay between coinfections will be useful in understanding and translating preclinical animal models to the human experience. Lesley Marson, PhD Psychology
Egalitarianism, housework, and sexual frequency in marriage. S Kornrich, J Brines, K Leupp. Am Sociol Rev 2012;78:26–50. Level of Evidence: 3 Editorial Comment: Although this study is over a year old, it was featured in a recent New York Times Magazine article by Lori Gottlieb entitled “Sexless but Equal” because of its finding that, paradoxically, increasing egalitarianism in relationships may be a recipe for lower sexual satisfaction and frequency. Indeed, marriages today are more egalitarian with more fluidity between “male” and “female” roles and a tendency for both partners to share equally in the household duties. Certainly there is evidence that in marriages where husbands do more housework, women’s ratings of marital satisfaction increase. Moreover, couples who have more equal division of labor are less likely to divorce. However, the assumption that egalitarian marriages are sexier has never been empirically tested. The goal of this paper was to review the literature on two competing theories that examine the relationship between egalitarian relationships and sexual frequency. Their overall conclusion was that gendered sexual scripts significantly predict sexual frequency, with more gender-traditional divisions of labor being associated with higher sexual frequency. According to social exchange theory, because men, on average, desire sex more than women, this means that women could trade sex for resources that men control. Qualitative evidence supports this in regard to household chores (which are desired by neither partner) in that women are more likely to have sex in relationships where men engage more in household chores. However, according to sexual scripts theory, the opposite relationship would be predicted. Here, egalitarianism may be associated with boredom or creating a sibling-like tone between partners, which ultimately damages sexual frequency. In J Sex Med 2014;11:1892–1897
other words, because individuals in egalitarian relationships perform less traditionally masculine and feminine behaviours, they are less likely to activate scripts linking displays of difference to desire. In this study, the authors examined data from Wave II of the National Survey of Families and Households (1992–1994). Sexual frequency was captured with the single item “About how often did you and your husband/wife have sex during the past month?” Marital happiness/satisfaction was controlled for in all analyses to account for the possibility that egalitarian relationships impact sexual frequency because of levels of relationship happiness. Data were gathered from a total of 4,184 husbands and 4,153 wives who had sex, on average, five times over the past month. Sexual frequency was highest in households with traditionally gendered divisions of labour. To examine effect sizes, shifting from a household in which women carry out all of the core chores to a household in which women perform none of the core chores was associated with a reduction in sexual frequency of 1.6 times/month. This finding was the case whether results from men and women were pooled or whether each of their ratings was examined independently. Although the authors concluded that the traditional performance and displays of gender are important for sexual desire and frequency, it is notable that only sexual frequency, and not desire, was measured in this study. In conclusion, the authors stated that sexual frequency is more under the influence of sexual scripts than it is of social exchange. Lori A. Brotto, PhD, RPsych Sensate focus: Clarifying the Masters and Johnson’s model. L Weiner, C Avery-Clark. Sex Relatsh Ther 2014;29:307–19. Level of Evidence: 4 Editorial Comment: Sensate Focus is one of the oldest sex therapy techniques, developed and explained by sex therapy giants, Masters and Johnson, in their 1970 publication “Human Sexual Inadequacy”. Unfortunately, over the decades since it was originally described, tested, and evaluated, there has been much confusion about the original goals of Sensate focus. Indeed, clinicians have described it in a variety of ways with a range of different goals. The authors of this paper, Weiner and Avery-Clark attempted to clarify some of these misconceptions and errors in our clinical practice. Although this manuscript is not a review of an empirical paper, many of the readers of JSM are 1893
clinicians in practice where familiarity of these methods is imperative. Since both authors are graduates of the Masters and Johnson Institute and worked at the Institute for five years, this paper comes with a certain level of authority that the readers of the JSM might heed. The original research of Masters and Johnson focused on examining the natural, physiological aspects of sexual responsiveness, so sensate focus was primarily aimed at these disturbances in natural functions like erection, lubrication, orgasm, and desire. Patients were encouraged to focus on those aspects of function over which they could exert voluntary control. In examining those individuals with a robust sexual response, Masters and Johnson noted that they: (i) touched for their own involvement as opposed to their partner’s; (ii) they defined touching as focusing on sensations rather than on making their partner aroused; and (iii) they redirected attention back to sensations when their mind wandered. When an individual is anxious or experiencing other difficulties sexually, the refocusing of attention on their own sensations is a way of paying attention to something reliable, and presumably under their voluntary control. Because of how quickly the mind shifts from noticing sensations to paying attention to thoughts, the instructions for sensate focus stage 1 make explicit the need to focus on the body sensations. The authors note the high level of similarity in how sensate focus was described and mindfulness—the latter defined as present-moment, non-judgmental awareness. Although Masters and Johnson did not use the term “mindfulness”, it is readily evident that individuals are indeed encouraged to practice mindfulness by paying attention to moment-bymoment body sensations and redirecting attention away from thoughts to the body. In stage 1, participants focus on qualities of the touch including temperature, pressure, and texture, and the receiver of the touch is invited to non-verbally provide feedback to the giver of the touch (e.g., by moving the hand away or towards). In stage 1, breasts and genitals are off-limits. The authors note that clinicians often confuse the goals and instructions of sensate focus. For example, they describe the steps to patients as if they were intended to elicit sexual arousal; they are not, and there is explicit instruction to avoid any effort to please the partner. There is also no explicit goal to create relaxation or enjoyment or a massage or an erotic encounter. Masters and Johnson refined 1894
these instructions in their 1980 training modules to make the goals clear. It is only in the later stages of sensate focus that individuals start to focus on responding to partner communication about pleasurable and erotic emotional experiences during the touching. Stage 2 of sensate focus more actively accentuates partner communication since these are an important part to long-term intimacy. Lori A. Brotto, PhD, RPsych The history of sexual medicine. MA Perelman. In: Tolman DL, Diamond LM eds. APA Handbook of sexuality and psychology. Volume 2. Washington DC: American Psychological Association; 2014:137–79. Level of Evidence: 4 Editorial Comment: In this comprehensive and beautifully written chapter, Michael Perelman reviews the history of sexual medicine in North America from key events during the 20th century up to the present time. Perelman credits sexual medicine’s current epidemiological focus back to the pioneering work of Alfred Kinsey (1894– 1956), who was among the first to carefully catalog sexual behaviors in American men and women. Perelman also notes that the establishment of the Kinsey Institute in 1947 laid an important foundation for the sexual medicine movement. Masters and Johnson are best known for their development of the human sexual response cycle (1966) and for establishing sensate therapy in their book on Human Sexual Inadequacy (1970); however, they also published The Textbook on Sexual Medicine, which emphasized the couple rather than the individual as the unit for sex therapy. Masters and Johnson’s 2-week residential program of sex therapy showed outstanding efficacy and attracted many to the field of sex therapy. In the mid-1970s, Helen Singer Kaplan and Harold Lief independently emphasized sexual desire as the critical first step in Masters and Johnson’s sexual response cycle. Perelman also notes that in 1995 Kaplan described and illustrated “inciters” and “suppressors” of sexual desire, which paved the way for Bancroft and Janssen’s later “dual-control model.” Perelman also credits Kaplan for establishing the first medical school-based sex therapy training and treatment program in the USA at the Payne Whitney Clinic of New York Hospital. The following two decades saw wide dissemination of sex therapy concepts, and many new hospital-based treatment centers were established. Perelman notes that the Stony Brook Program (LoPiccolo, J Sex Med 2014;11:1892–1897
Lobitz, and Heiman) was involved in more behaviorally focused interventions, which continues today. The University of Medicine and Dentistry of New Jersey group (Leiblum, Rosen) was heavily involved in training (“Sex Week”) and publishing studies on sexual medicine. The establishment of journals devoted to the science of sexuality and sex therapy (Journal of Sex & Marital Therapy, Archives of Sexual Behavior) as well as professional societies (Eastern Association of Sex Therapists, now Society for Sex Therapy and Research; Society for the Scientific Study of Sexuality; American Association of Sex Educators, Counselors, and Therapists; World Association for Sexology, now World Association for Sexual Health). Over about the same two-decade period, urologists became very interested in the field of sexual medicine, which coincided with rapid advances in the science of the biological underpinnings of sexual dysfunction and with the success of new diagnostic and surgical procedures, primarily for erectile dysfunction, especially throughout the 1990s. Discovery of the important role of nitric oxide in smooth muscle relaxation led to the eventual approval of sildenafil citrate (Viagra; Pfizer) by the US FDA in March 1998 and the widespread acceptance of the new oral medication as a treatment for erectile dysfunction (ED). Media attention to Viagra, and to the ED it was designed to treat, skyrocketed. Within years, other PDE5 inhibitors were approved: vardenafil (Levitra; Bayer) and tadalafil (Cialis, Lilly/ICOS)—the latter differentiated due to its much longer half-life. Coinciding with this interest in sexual pharmaceuticals, some psychologists took this opportunity to emphasize opportunities for collaboration between physicians and sex therapists, as the latter had unique skills in educating on methods to optimize success, adherence, and satisfaction with these drugs. Methodologically trained psychologists were also centrally involved in pharmaceutical company-funded studies of instrument development and prevalence, which Perelman argues would not have been possible without industry financial support. The pharmaceutical industry was also keenly interested in education; sex therapists became involved in training primary-care physicians how to take a brief, focused sex history. Such educators were strongly encouraged to keep industry bias out of their education so as to minimize the perception of a conflict of interest (and contributing to the medicalization of sexual problems). Perelman notes J Sex Med 2014;11:1892–1897
that despite the extensive industry-funded campaign on “disease awareness education,” the average proportion of physicians taking a sex history improved only to a modest degree (from 10% of physicians to 30%). A key highlight in the modern sexual medicine era was the establishment of the Journal of Sexual Medicine, edited by urologist Irwin Goldstein. But there was another side of Viagra’s success: it became known that 20–50% of men did not benefit from the drug due to a variety of reasons, including psychological resistance on the part of the man or his partner. Perelman noted that by 2011, the second largest specialty group listed in the Journal of Sexual Medicine were psychological sex therapists, many of whom were women, which had a great positive impact on the sexual medicine movement. A few International Consultations on Sexual Medicine took place (1999, 2003, 2009), the latter few also including chapters on female sexual function. At the 2003 meeting, a lively debate between American psychologist and sex therapist Leonore Tiefer and British cardiologist Graham Jackson pointed squarely at the concerns among a growing number of professionals in the field about the medicalization of women’s sexuality, which continues to this day. The 2000 Female Sexual Function Forum then evolved into the International Society for the Study of Women’s Sexual Health in 2001, an organization devoted to the study of women’s sexual health. Over the years since Viagra’s approval, there has also been an intense race to find a medication to treat female sexual dysfunction; despite a multimillion-dollar effort, no medication, to date, has been approved by the FDA. Some of those medications tested include Intrinsa (testosterone patch), bupropion (oral dopaminergic drug), bremelanotide (an intranasal synthetic melanocortin, now being tested subcutaneously), and flibanserin (an oral 5-HT1A agonist/weak dopamine D4 agonist). Another significant advance was the publication of Rosemary Basson’s circular sexual response cycle in 1999, which emphasized the impact of sexual arousal on eliciting sexual desire and on the multiple motivations that move women from sexual neutrality toward being receptive to sexual activity. Her work was challenged by research showing that only one-third of nurses endorsed such a circular sexual response cycle and that those who did tended to have more evidence of sexual difficulty. Another controversy surrounded 1895
the development of the DSM-5 and the proposal to expand the category of sexual desire to include responsive desire and other indicators of sexual interest (sexual interest/arousal disorder) and to delete the category of female sexual arousal disorder, with its focus on vaginal lubrication. Debates at various sexual medicine and sex therapy meetings ensued and, Perelman notes, centered around the question “What constitutes normal?” Turf battles between sexual medicine physicians and psychological sex therapists continue, and Perelman notes that multidisciplinary collaboration is an obvious solution, though not always possible. To that end, Perelman describes biopsychosocial models and combination treatments as a solution. Two examples of such models that articulate the delicate balance between biological and psychosocial contributions to sexual response are Bancroft and other Kinsey Institute colleagues’ “dual control model” and Perelman’s “sexual tipping point model.” Perelman ends his thorough chapter noting that sexual medicine will continue to evolve with new questions and areas of research focus, in particular in domains related to ethical, social policy, economic, and medical aspects. Lori A. Brotto, PhD, RPsych Clinical Research—Female
Female genital cutting/mutilation in Africa deserves special concern: An overview. I Khalaf. Afr J Urol 2013;19:119–22. Level of Evidence: 4 Editorial Comment: This issue of the African Journal of Urology was sponsored by the Pan African Urological Surgeons’ Association and devoted to female genital cutting/mutilation (FGC). The editorial introduction includes a map of estimated FGC prevalence in Africa, using World Health Organization data, although FGC persists robustly in areas of Asia and the Middle East. Prevalence ranges from 50% in Egypt and Ethiopia up to 97.8% in Somalia, with 28 Arab, African, and Asian countries continuing active FGC in certain communities. Mythologies are reviewed in this issue, with authors elaborating on the fact that FGC is not a religious practice, with many countries that strictly follow Islamic rules, such as Saudi Arabia, Libya, Jordan, Turkey, Syria, the Maghreb countries of northwest Africa, Iran, and Iraq, not advocating or known to routinely practice FGC. “The Jewish Falashas are the sole community in Ethiopia practicing [FGC], which points to a cultural rather 1896
than a religious background.” Reviews on current legislation in FGC zones, international eradication programs, and the black-market “medicalization” of FGC procedure in countries to which FGCpracticing immigrants live are each presented by various authors in this groundbreaking issue of the African Journal of Urology. Lauri J. Romanzi, MD The Islamic view on female circumcision. A Gomaa. Afr J Urol 2013;19:123–6. Level of Evidence: 4 Editorial Comment: In a groundbreaking issue devoted to traditional female genital cutting (FGC), the second article in the 19th issue of the African Journal of Urology is an historical discourse from Grand Mufti Ali Gomaa of Cairo, Egypt, long considered the birthplace of genital cutting in its most mutilating form: “Pharaonic” FGC, which excises the clitoris down to the bone and completely removes the labia minora and most or all of the labia majora, after which the child/woman is sewn shut, leaving a 1–2 cm opening for urine and menses distally, just anterior to the perineum. The Grand Mufti makes it clear that FGC is not “Muslim”; it is cultural, believed in large part to predate the birth of Islam. He further clarifies passages of the Holy Qur’an in which Allah says “O mankind! Be careful of your duty to your Lord Who created you from a single soul and from it created its mate and from them twain hath spread abroad a multitude of men and women. Be careful of your duty toward Allah in whom ye claim (your rights) of one another, and toward the wombs (that bare you).” He takes the stand that the Qur’an makes clear the equal, complementary roles of women and men, which stands in contrast to the current notion of male/ female competition prevalent in the Christian cultures of today. Further passages warning against the practice of female infanticide are mentioned, along with the 1966 Egyptian Ministry of Health decree #261 that decried increased FGC practices, following a 1959 law that attempted to limit FGC: “Female circumcision is prohibited, regardless of whether it is performed in a hospital or a public or private health clinic. The performance of female circumcision is not permitted except in cases of medical necessity which are to be determined by the head of the Women’s Disease and Birth department of the hospital and based on the recommendation of the patient’s doctor.” The Grand Mufti points out the futility of legislation that is not J Sex Med 2014;11:1892–1897
enforced: “the actual perpetrators as well as initiators . . . must be subject to the full extent of the law in view of the seriousness of the crime against society’s most vulnerable members.” And “While [FGC] was previously practiced as a social custom (and not as a religious matter) the state of today’s knowledge makes clear the serious negative effects . . . As such it becomes a religious obligation to say unequivocally that the practice of [FGC] is today forbidden in Islam.” Given the ancient roots and modern tenacity of FGC across the globe, where girls are raised in FGC-practicing expatriate communities of industrialized nations with education, literacy, and access to the Internet, only to be “shipped home” for summer vacation, where they are “cut” in order to meet the marriageability standards of their culture, this message from the Grand Mufti of Egypt is to be not only celebrated but engaged with in full by the international community. Lauri J. Romanzi, MD
J Sex Med 2014;11:1892–1897
Editor’s Note
Commentaries on clinical studies include a “level of evidence” rating to assist readers in evaluating the significance of the findings and conclusions. The simplified rating scale below is adapted from the more complete recommendations of the Centre for Evidence-Based Medicine (http://www .cebm.net/index.aspx?o=1025). Level of evidence 1a 1b 2a 2b 3
4
Type of evidence Evidence from systematic reviews or meta-analysis of randomized controlled trials Evidence from at least one randomized controlled trial Evidence from at least one controlled study without randomization Evidence from at least one other type of quasi-experimental study Evidence from non-experimental descriptive studies, such as comparative studies, correlation studies, and case–control studies Evidence from expert committee reports or opinions and/or clinical experience of respected authorities
1897
Survey of Literature Current Literature Review
Basic Science
Infection and cellular defense dynamics in a novel 17β-estradiol murine model of chronic human group B Streptococcus genital tract colonization reveal a role for hemolysin in persistence and neutrophil accumulation. AJ Carey, CK Tan, S Mirza, H Irving-Rodgers, RI Webb, A Lam, GC Ulett. J Immunol 2014;192:1718– 31. Editorial Comment: During a vaginal birth, babies are colonized by maternal vaginal and fecal bacteria. The initial bacterial colonies resemble the maternal vaginal microbiome—predominantly Lactobacillus, Prevotella, and Sneathia. In contrast, babies born by cesarean delivery are primarily colonized by the bacteria in the hospital environment and maternal skin. Various bacteria reside in the vaginal tract; some convey positive benefits to the newborn, and some can cause increased neonatal morbidity and sepsis. Group B Streptococcus (GBS), or Streptococcus agalactiae, exists in around 7–38% of healthy women, and the U.S. Centers for Disease Control and Prevention advise pregnant women to get screened for GBS prior to delivery so that antibiotics can be administered. GBS also causes a variety of acute diseases in adults. This study reports on the development and analysis of a mouse model of chronic human GBS colonization. Mice were given 17β-estradiol to induce estrus and were infected with GBS. Cervical–vaginal swabs were collected every 3 days to assess bacterial loads, and experiments continued for 90 days. Analyses included cellular and bacterial assessments and histological and immunological analysis. GBS persisted in the genital tract throughout the course of the study and activated an increase in lymphocyte infiltration and polymorphonuclear leukocytes at the superficial layers of the vagina. Various soluble inflammatory mediators were activated, including granulocyte– macrophage colony-stimulating factor and tumor 1892
necrosis factor alpha. However, despite the release of local inflammatory factors, GBS persisted, possibly due to the organisms’ β-hemolysin production. This paper provides an interesting model that might mimic the human condition of long-term GBS persistence and may provide a useful model to examine how GBS clearance can be enhanced. Lesley Marson, PhD Genital herpes simplex virus type 2 infection in humanized HIV-transgenic mice triggers HIV shedding and is associated with greater neurological disease. B Nixon, E Fakioglu, M Stefanidou, Y Wang, M Dutta, H Goldstein, BC Herold. J Infect Dis 2014;209:510–22. Editorial Comment: Herpes simplex virus type 2 (HSV-2) causes genital herpes, which is widely prevalent worldwide, and there is a synergistic relationship when people are infected with human immunodeficiency virus (HIV). Clinical and subclinical HSV-2 reactivation increases the risk of acquiring HIV and may increase the transmission rates for the passage of HIV from the mother to child. In addition, HIV-infected individuals have a higher risk of having recurrent HSV-2 infections. This paper describes a modified mouse model in which co-infection of HIV and HSV-2 was studied. Difficulties in translating mouse models to human HIV have been hampered by their lack of susceptibility to infection with HIV. This paper describes use of transgenic mice for HIV-1 provirus and human cyclin T1 under control of a CD4 promoter (JR-CSF/hu-cyeT1) in which the HIV production can be amplified. The HIV-positive transgenic mice were more susceptible to HSV-2 infection and demonstrated more neurological disease (urinary and fecal retention and reduced function of the hind limbs), which was associated with a down-regulation of secretory leukocyte protease inhibitor expression. A synergic relationship was observed between HIV and HSV-2 infection load, and genital inflammatory mediators J Sex Med 2014;11:1892–1897
were increased in response to HSV-2 infection, but the response appeared to be delayed in the HIV-TG-infected mice. The interplay of viral susceptibility in this model appears to be similar to that seen in humans. Further studies characterizing this model and others and examining the interplay between coinfections will be useful in understanding and translating preclinical animal models to the human experience. Lesley Marson, PhD Psychology
Egalitarianism, housework, and sexual frequency in marriage. S Kornrich, J Brines, K Leupp. Am Sociol Rev 2012;78:26–50. Level of Evidence: 3 Editorial Comment: Although this study is over a year old, it was featured in a recent New York Times Magazine article by Lori Gottlieb entitled “Sexless but Equal” because of its finding that, paradoxically, increasing egalitarianism in relationships may be a recipe for lower sexual satisfaction and frequency. Indeed, marriages today are more egalitarian with more fluidity between “male” and “female” roles and a tendency for both partners to share equally in the household duties. Certainly there is evidence that in marriages where husbands do more housework, women’s ratings of marital satisfaction increase. Moreover, couples who have more equal division of labor are less likely to divorce. However, the assumption that egalitarian marriages are sexier has never been empirically tested. The goal of this paper was to review the literature on two competing theories that examine the relationship between egalitarian relationships and sexual frequency. Their overall conclusion was that gendered sexual scripts significantly predict sexual frequency, with more gender-traditional divisions of labor being associated with higher sexual frequency. According to social exchange theory, because men, on average, desire sex more than women, this means that women could trade sex for resources that men control. Qualitative evidence supports this in regard to household chores (which are desired by neither partner) in that women are more likely to have sex in relationships where men engage more in household chores. However, according to sexual scripts theory, the opposite relationship would be predicted. Here, egalitarianism may be associated with boredom or creating a sibling-like tone between partners, which ultimately damages sexual frequency. In J Sex Med 2014;11:1892–1897
other words, because individuals in egalitarian relationships perform less traditionally masculine and feminine behaviours, they are less likely to activate scripts linking displays of difference to desire. In this study, the authors examined data from Wave II of the National Survey of Families and Households (1992–1994). Sexual frequency was captured with the single item “About how often did you and your husband/wife have sex during the past month?” Marital happiness/satisfaction was controlled for in all analyses to account for the possibility that egalitarian relationships impact sexual frequency because of levels of relationship happiness. Data were gathered from a total of 4,184 husbands and 4,153 wives who had sex, on average, five times over the past month. Sexual frequency was highest in households with traditionally gendered divisions of labour. To examine effect sizes, shifting from a household in which women carry out all of the core chores to a household in which women perform none of the core chores was associated with a reduction in sexual frequency of 1.6 times/month. This finding was the case whether results from men and women were pooled or whether each of their ratings was examined independently. Although the authors concluded that the traditional performance and displays of gender are important for sexual desire and frequency, it is notable that only sexual frequency, and not desire, was measured in this study. In conclusion, the authors stated that sexual frequency is more under the influence of sexual scripts than it is of social exchange. Lori A. Brotto, PhD, RPsych Sensate focus: Clarifying the Masters and Johnson’s model. L Weiner, C Avery-Clark. Sex Relatsh Ther 2014;29:307–19. Level of Evidence: 4 Editorial Comment: Sensate Focus is one of the oldest sex therapy techniques, developed and explained by sex therapy giants, Masters and Johnson, in their 1970 publication “Human Sexual Inadequacy”. Unfortunately, over the decades since it was originally described, tested, and evaluated, there has been much confusion about the original goals of Sensate focus. Indeed, clinicians have described it in a variety of ways with a range of different goals. The authors of this paper, Weiner and Avery-Clark attempted to clarify some of these misconceptions and errors in our clinical practice. Although this manuscript is not a review of an empirical paper, many of the readers of JSM are 1893
clinicians in practice where familiarity of these methods is imperative. Since both authors are graduates of the Masters and Johnson Institute and worked at the Institute for five years, this paper comes with a certain level of authority that the readers of the JSM might heed. The original research of Masters and Johnson focused on examining the natural, physiological aspects of sexual responsiveness, so sensate focus was primarily aimed at these disturbances in natural functions like erection, lubrication, orgasm, and desire. Patients were encouraged to focus on those aspects of function over which they could exert voluntary control. In examining those individuals with a robust sexual response, Masters and Johnson noted that they: (i) touched for their own involvement as opposed to their partner’s; (ii) they defined touching as focusing on sensations rather than on making their partner aroused; and (iii) they redirected attention back to sensations when their mind wandered. When an individual is anxious or experiencing other difficulties sexually, the refocusing of attention on their own sensations is a way of paying attention to something reliable, and presumably under their voluntary control. Because of how quickly the mind shifts from noticing sensations to paying attention to thoughts, the instructions for sensate focus stage 1 make explicit the need to focus on the body sensations. The authors note the high level of similarity in how sensate focus was described and mindfulness—the latter defined as present-moment, non-judgmental awareness. Although Masters and Johnson did not use the term “mindfulness”, it is readily evident that individuals are indeed encouraged to practice mindfulness by paying attention to moment-bymoment body sensations and redirecting attention away from thoughts to the body. In stage 1, participants focus on qualities of the touch including temperature, pressure, and texture, and the receiver of the touch is invited to non-verbally provide feedback to the giver of the touch (e.g., by moving the hand away or towards). In stage 1, breasts and genitals are off-limits. The authors note that clinicians often confuse the goals and instructions of sensate focus. For example, they describe the steps to patients as if they were intended to elicit sexual arousal; they are not, and there is explicit instruction to avoid any effort to please the partner. There is also no explicit goal to create relaxation or enjoyment or a massage or an erotic encounter. Masters and Johnson refined 1894
these instructions in their 1980 training modules to make the goals clear. It is only in the later stages of sensate focus that individuals start to focus on responding to partner communication about pleasurable and erotic emotional experiences during the touching. Stage 2 of sensate focus more actively accentuates partner communication since these are an important part to long-term intimacy. Lori A. Brotto, PhD, RPsych The history of sexual medicine. MA Perelman. In: Tolman DL, Diamond LM eds. APA Handbook of sexuality and psychology. Volume 2. Washington DC: American Psychological Association; 2014:137–79. Level of Evidence: 4 Editorial Comment: In this comprehensive and beautifully written chapter, Michael Perelman reviews the history of sexual medicine in North America from key events during the 20th century up to the present time. Perelman credits sexual medicine’s current epidemiological focus back to the pioneering work of Alfred Kinsey (1894– 1956), who was among the first to carefully catalog sexual behaviors in American men and women. Perelman also notes that the establishment of the Kinsey Institute in 1947 laid an important foundation for the sexual medicine movement. Masters and Johnson are best known for their development of the human sexual response cycle (1966) and for establishing sensate therapy in their book on Human Sexual Inadequacy (1970); however, they also published The Textbook on Sexual Medicine, which emphasized the couple rather than the individual as the unit for sex therapy. Masters and Johnson’s 2-week residential program of sex therapy showed outstanding efficacy and attracted many to the field of sex therapy. In the mid-1970s, Helen Singer Kaplan and Harold Lief independently emphasized sexual desire as the critical first step in Masters and Johnson’s sexual response cycle. Perelman also notes that in 1995 Kaplan described and illustrated “inciters” and “suppressors” of sexual desire, which paved the way for Bancroft and Janssen’s later “dual-control model.” Perelman also credits Kaplan for establishing the first medical school-based sex therapy training and treatment program in the USA at the Payne Whitney Clinic of New York Hospital. The following two decades saw wide dissemination of sex therapy concepts, and many new hospital-based treatment centers were established. Perelman notes that the Stony Brook Program (LoPiccolo, J Sex Med 2014;11:1892–1897
Lobitz, and Heiman) was involved in more behaviorally focused interventions, which continues today. The University of Medicine and Dentistry of New Jersey group (Leiblum, Rosen) was heavily involved in training (“Sex Week”) and publishing studies on sexual medicine. The establishment of journals devoted to the science of sexuality and sex therapy (Journal of Sex & Marital Therapy, Archives of Sexual Behavior) as well as professional societies (Eastern Association of Sex Therapists, now Society for Sex Therapy and Research; Society for the Scientific Study of Sexuality; American Association of Sex Educators, Counselors, and Therapists; World Association for Sexology, now World Association for Sexual Health). Over about the same two-decade period, urologists became very interested in the field of sexual medicine, which coincided with rapid advances in the science of the biological underpinnings of sexual dysfunction and with the success of new diagnostic and surgical procedures, primarily for erectile dysfunction, especially throughout the 1990s. Discovery of the important role of nitric oxide in smooth muscle relaxation led to the eventual approval of sildenafil citrate (Viagra; Pfizer) by the US FDA in March 1998 and the widespread acceptance of the new oral medication as a treatment for erectile dysfunction (ED). Media attention to Viagra, and to the ED it was designed to treat, skyrocketed. Within years, other PDE5 inhibitors were approved: vardenafil (Levitra; Bayer) and tadalafil (Cialis, Lilly/ICOS)—the latter differentiated due to its much longer half-life. Coinciding with this interest in sexual pharmaceuticals, some psychologists took this opportunity to emphasize opportunities for collaboration between physicians and sex therapists, as the latter had unique skills in educating on methods to optimize success, adherence, and satisfaction with these drugs. Methodologically trained psychologists were also centrally involved in pharmaceutical company-funded studies of instrument development and prevalence, which Perelman argues would not have been possible without industry financial support. The pharmaceutical industry was also keenly interested in education; sex therapists became involved in training primary-care physicians how to take a brief, focused sex history. Such educators were strongly encouraged to keep industry bias out of their education so as to minimize the perception of a conflict of interest (and contributing to the medicalization of sexual problems). Perelman notes J Sex Med 2014;11:1892–1897
that despite the extensive industry-funded campaign on “disease awareness education,” the average proportion of physicians taking a sex history improved only to a modest degree (from 10% of physicians to 30%). A key highlight in the modern sexual medicine era was the establishment of the Journal of Sexual Medicine, edited by urologist Irwin Goldstein. But there was another side of Viagra’s success: it became known that 20–50% of men did not benefit from the drug due to a variety of reasons, including psychological resistance on the part of the man or his partner. Perelman noted that by 2011, the second largest specialty group listed in the Journal of Sexual Medicine were psychological sex therapists, many of whom were women, which had a great positive impact on the sexual medicine movement. A few International Consultations on Sexual Medicine took place (1999, 2003, 2009), the latter few also including chapters on female sexual function. At the 2003 meeting, a lively debate between American psychologist and sex therapist Leonore Tiefer and British cardiologist Graham Jackson pointed squarely at the concerns among a growing number of professionals in the field about the medicalization of women’s sexuality, which continues to this day. The 2000 Female Sexual Function Forum then evolved into the International Society for the Study of Women’s Sexual Health in 2001, an organization devoted to the study of women’s sexual health. Over the years since Viagra’s approval, there has also been an intense race to find a medication to treat female sexual dysfunction; despite a multimillion-dollar effort, no medication, to date, has been approved by the FDA. Some of those medications tested include Intrinsa (testosterone patch), bupropion (oral dopaminergic drug), bremelanotide (an intranasal synthetic melanocortin, now being tested subcutaneously), and flibanserin (an oral 5-HT1A agonist/weak dopamine D4 agonist). Another significant advance was the publication of Rosemary Basson’s circular sexual response cycle in 1999, which emphasized the impact of sexual arousal on eliciting sexual desire and on the multiple motivations that move women from sexual neutrality toward being receptive to sexual activity. Her work was challenged by research showing that only one-third of nurses endorsed such a circular sexual response cycle and that those who did tended to have more evidence of sexual difficulty. Another controversy surrounded 1895
the development of the DSM-5 and the proposal to expand the category of sexual desire to include responsive desire and other indicators of sexual interest (sexual interest/arousal disorder) and to delete the category of female sexual arousal disorder, with its focus on vaginal lubrication. Debates at various sexual medicine and sex therapy meetings ensued and, Perelman notes, centered around the question “What constitutes normal?” Turf battles between sexual medicine physicians and psychological sex therapists continue, and Perelman notes that multidisciplinary collaboration is an obvious solution, though not always possible. To that end, Perelman describes biopsychosocial models and combination treatments as a solution. Two examples of such models that articulate the delicate balance between biological and psychosocial contributions to sexual response are Bancroft and other Kinsey Institute colleagues’ “dual control model” and Perelman’s “sexual tipping point model.” Perelman ends his thorough chapter noting that sexual medicine will continue to evolve with new questions and areas of research focus, in particular in domains related to ethical, social policy, economic, and medical aspects. Lori A. Brotto, PhD, RPsych Clinical Research—Female
Female genital cutting/mutilation in Africa deserves special concern: An overview. I Khalaf. Afr J Urol 2013;19:119–22. Level of Evidence: 4 Editorial Comment: This issue of the African Journal of Urology was sponsored by the Pan African Urological Surgeons’ Association and devoted to female genital cutting/mutilation (FGC). The editorial introduction includes a map of estimated FGC prevalence in Africa, using World Health Organization data, although FGC persists robustly in areas of Asia and the Middle East. Prevalence ranges from 50% in Egypt and Ethiopia up to 97.8% in Somalia, with 28 Arab, African, and Asian countries continuing active FGC in certain communities. Mythologies are reviewed in this issue, with authors elaborating on the fact that FGC is not a religious practice, with many countries that strictly follow Islamic rules, such as Saudi Arabia, Libya, Jordan, Turkey, Syria, the Maghreb countries of northwest Africa, Iran, and Iraq, not advocating or known to routinely practice FGC. “The Jewish Falashas are the sole community in Ethiopia practicing [FGC], which points to a cultural rather 1896
than a religious background.” Reviews on current legislation in FGC zones, international eradication programs, and the black-market “medicalization” of FGC procedure in countries to which FGCpracticing immigrants live are each presented by various authors in this groundbreaking issue of the African Journal of Urology. Lauri J. Romanzi, MD The Islamic view on female circumcision. A Gomaa. Afr J Urol 2013;19:123–6. Level of Evidence: 4 Editorial Comment: In a groundbreaking issue devoted to traditional female genital cutting (FGC), the second article in the 19th issue of the African Journal of Urology is an historical discourse from Grand Mufti Ali Gomaa of Cairo, Egypt, long considered the birthplace of genital cutting in its most mutilating form: “Pharaonic” FGC, which excises the clitoris down to the bone and completely removes the labia minora and most or all of the labia majora, after which the child/woman is sewn shut, leaving a 1–2 cm opening for urine and menses distally, just anterior to the perineum. The Grand Mufti makes it clear that FGC is not “Muslim”; it is cultural, believed in large part to predate the birth of Islam. He further clarifies passages of the Holy Qur’an in which Allah says “O mankind! Be careful of your duty to your Lord Who created you from a single soul and from it created its mate and from them twain hath spread abroad a multitude of men and women. Be careful of your duty toward Allah in whom ye claim (your rights) of one another, and toward the wombs (that bare you).” He takes the stand that the Qur’an makes clear the equal, complementary roles of women and men, which stands in contrast to the current notion of male/ female competition prevalent in the Christian cultures of today. Further passages warning against the practice of female infanticide are mentioned, along with the 1966 Egyptian Ministry of Health decree #261 that decried increased FGC practices, following a 1959 law that attempted to limit FGC: “Female circumcision is prohibited, regardless of whether it is performed in a hospital or a public or private health clinic. The performance of female circumcision is not permitted except in cases of medical necessity which are to be determined by the head of the Women’s Disease and Birth department of the hospital and based on the recommendation of the patient’s doctor.” The Grand Mufti points out the futility of legislation that is not J Sex Med 2014;11:1892–1897
enforced: “the actual perpetrators as well as initiators . . . must be subject to the full extent of the law in view of the seriousness of the crime against society’s most vulnerable members.” And “While [FGC] was previously practiced as a social custom (and not as a religious matter) the state of today’s knowledge makes clear the serious negative effects . . . As such it becomes a religious obligation to say unequivocally that the practice of [FGC] is today forbidden in Islam.” Given the ancient roots and modern tenacity of FGC across the globe, where girls are raised in FGC-practicing expatriate communities of industrialized nations with education, literacy, and access to the Internet, only to be “shipped home” for summer vacation, where they are “cut” in order to meet the marriageability standards of their culture, this message from the Grand Mufti of Egypt is to be not only celebrated but engaged with in full by the international community. Lauri J. Romanzi, MD
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Editor’s Note
Commentaries on clinical studies include a “level of evidence” rating to assist readers in evaluating the significance of the findings and conclusions. The simplified rating scale below is adapted from the more complete recommendations of the Centre for Evidence-Based Medicine (http://www .cebm.net/index.aspx?o=1025). Level of evidence 1a 1b 2a 2b 3
4
Type of evidence Evidence from systematic reviews or meta-analysis of randomized controlled trials Evidence from at least one randomized controlled trial Evidence from at least one controlled study without randomization Evidence from at least one other type of quasi-experimental study Evidence from non-experimental descriptive studies, such as comparative studies, correlation studies, and case–control studies Evidence from expert committee reports or opinions and/or clinical experience of respected authorities
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