Kpl 4-12.pmd

Jukka Virtanen
For a long time those in the medical profession have understood that sexuality is part ofhealth, but its significance at the clinical level is a new phenomenon. The traditionalapproach has only considered problems related to reproduction, organic diseases of thegenitals, and sexually transmitted diseases. Sexual problems were viewed as psychiatricabnormalities. Thus, traditionally the medical profession has been interested in sexualityonly when perceived as connected with organic disorders or mental problems. Treatmentof sexual problems has been divided among medical specialists in a variety of areasincluding endocrinology, neurology, gynaecology, urology, psychiatry, and forensicmedicine. The interest in clinical sexology has been increasing in gynaecology becauseof reproduction and infertility questions. The fast development of drug treatment andsurgery for erectile dysfunction has contributed to greater interest in clinical sexologyamong urologists as well. A comprehensive understanding of human sexuality and sexualproblems has not been included in basic medical education of Finnish general practitionersor in postgraduate education for medical specialists. Clinical sexology has not been a separatespeciality or subspecialty but has been integrated in the whole medical practice in Finland.
Clinical services of sexual medicine have been offered in both public and privatehealthcare without any integrated or coordinated national planning. The idea of nationwide service groups providing clinical services in sexual medical has been under discussionduring the last two or three years. In the current national public healthcare system,general practitioners and specialists already diagnose and provide basic treatments forthe most common sexological diseases. The more complicated cases are treated in fiveuniversity central hospitals and their clinics. But these clinics usually do not have anintegrated system of services for clinical sexology. Patients seek help from a variety ofspecialists and clinics. Jyväskylä Central Hospital is the first public healthcare unit inFinland planning to offer a Clinic for Sexual Medicine.
Patients can also choose private medical services. Some patients do so because of thebelief that the quality of private healthcare is better than the quality of public service, orthey worry about their privacy at municipal health centres where they are well known.
Some private medical centres have gynaecologists and urologists who have specialtraining to provide clinical services for sexual healthcare. National organisations such asthe Family Federation of Finland and SEXPO (Finnish Foundation for Sex Education and Therapy) have private clinics and therapy centres for sexual health. The lack of anational register of sexual healthcare professionals creates problems for patients in findingservice providers and clinical practitioners.
Both public and private sexual healthcare service are available to patients. The choiceof public or private depends on many factors including education, economical resources,and local public services. Economical factors are a major determinant in many cases.
The annual service fee for local municipal healthcare in Finland is about 20 to 40 dollarsper patient. This includes all basic medical services and laboratory and radiologicalexaminations. Private medical services cost about 40 to 80 dollars per visit, and thebasic laboratory examinations cost between 80 and 2000 dollars, depending on the test.
When long term psychotherapy or demanding surgery is needed, the difference in costbetween public and private sexual healthcare is significant, often thousands of dollars.
For example, surgery for cavernosal leakage in erectile dysfunction costs a few hundreddollars in the public sector and a couple thousand dollars in the private sector.
The choice between municipal and private medical service also depends on the patient’sknowledge of human sexuality and its problems. The more a patient knows about thebackground and pathological mechanisms of his or her sexual problem, the more likelyhe or she is to choose a specialist in the private sector. In this case the patient canchoose his or her physician or therapist, an option not possible in municipal or publichealth service. Patients who recognise their sexual problems based on simple symptomslike “I have no erection” or “I have no desire” tend to choose public or occupationalhealthcare, but patients with complicated multilevel disorders more often use a privateservice, especially when the problem includes serious psychological components orrelationship concerns. The choice of a private specialist from medical specialities (e.g.,endocrinology, gynaecology, urology, or psychiatry) seems to depend on the patient’shealth behaviour, medical history, and his or her earlier contacts with medical practitioners.
Some national patient organisation and rehabilitation centres have well organised,integrated sexual healthcare services. The service group typically consists of two tofour healthcare professionals co-operating with each other at the same unit. An effectiveservice group is, for example, a four-member team including nurse, physiotherapist, sexcounsellor and physician who work in co-operation or a three-member team of nurse,physician, sex therapist. However, this kind of clinical practice is available only in afew special units such as the Family Federation of Finland, some private hospitals, andpatient organisations.
Clinical sexology diagnoses and treats sexological health problems and diseases by usingmethods from health sciences and psychology. Sexual medicine is a part of clinicalsexology and a speciality branch of the general medical profession.
The fast development of modern sexual medicine in Finland started in the 1980s. Inthat decade, new pharmacotherapies (intracavernous injections) and penile implant surgeryfor erectile dysfunction became available. These treatments increased the awareness ofthe general public and the media to sexual health and sexual medicine. Reproductivemedicine and new diagnostic and therapeutic methods like insemination and in vitrofertilisation were also introduced during this period. Consequently, problems of bio-medical ethics in reproductive medicine appeared in public and official discussions.
The rapid progress of sexual medicine has produced an increasing number of sexologicalarticles in Finnish medical journals. Members of the Finnish medical organisation Duo-decim wrote many of these articles as well as the Textbook of Sexuality (Hovatta et al.,1995) for basic medical education. Medical schools only offer one to two credit units ofvoluntary sexology courses for medical students, and sexology is not included in theofficial medical degree programs. Education in clinical sexology has been offered onlyat Helsinki Polytechnic and the Jyväskylä Polytechnic where students can take a short10 credit unit program for sex counselling, a 40 credit unit continuing education programfor basic clinical sexology, and an 80 credit unit clinical sexology degree program.
The first guidebook of sexuality for the general public, written by a Finnish physician,was published only recently (Palo et al. 1999). Professor Risto Pelkonen, aninternationally known and highly respected physician, is an endocrinologist who hasbeen a pioneer of sexual medicine in Finland; his efforts have greatly promoted this newmedical speciality. Sildenafil citrate or Viagra became available in Finland in 1998.
When Viagra was introduced, it attracted tremendous publicity in the media and openedpublic discussion of sexual medicine and the possibilities of modern pharmacology.
Specialists in clinical sexology are trained to provide treatments for male and femalesexual dysfunctions, problems in variations of sexual desire, and reproductive problems.
Functional disorders involving a patient’s sexual identity, structure of personality, andsexual desire require a different type of treatment than disorders associated with somekind of anatomical, physiological or pharmacochemical factor that disturbs erection,ejaculation, orgasm, or vaginal lubrication.
Exhibitionism, voyeurism, fetishism, sadomasochism and paedophilia are examples offorms of sexual behaviour which were traditionally labelled as perversions or disordersbut are being redefined in the latest psychiatric handbooks as paraphilias or variationsof sexual desire.
Gynaecologists treat patients with fertility functional disorders. Public and private clinicsas well as some organisations offer infertility diagnostics and therapies. Gynaecologiststreat female infertility by using hormonal induction of ovulation, microsurgery,insemination and in vitro fertilisation (IVF). Male infertility is treated by urologists orgynaecologists with a male sexual problems subspecialty. Treatments includeendocrinological pharmacotherapy, induction of ejaculation, urological surgery,insemination, and IVF. Usually a general practitioner or a couple’s family doctor is partof the infertility team of specialists. Couples often experience infertility as a crisis, andthis contributes to problems in a couple’s relationship.
Vaginal lubrication disorders are treated by general practitioners in public healthcare,but female orgasmic disorders such as painful intercourse (dyspareunia) and arousaland desire disorders require gynaecologists and in some cases the attention of psychiatrists.
Psychiatry mainly offers consultations for diagnostics and supportive psychotherapies.
Patients can also go directly to a sex counsellor or sex therapist without first visiting aphysician, especially when the symptoms include problems with sexual identity or arelationship. Sex counsellors and sex therapists have professional skills to workindependently with a patient or in co-operation with a physician.
Diagnosis and treatment of male erectile dysfunction (ED) have changed quite radicallyduring the 1990s. About 15 years ago most cases were treated by testosteronesupplementation, and the more complicated erectile dysfunctions were referred toendocrinologists or psychiatrists. Andrology (the treatment of men’s sexual problems) isnot an independent speciality in Finland, but some endocrinologists and gynaecologistshave practised it as an unofficial subspecialty. Rapid developments in clinical sexologyin urology have changed treatment methods. Penile implants and vascular surgery forerectile dysfunction became available in the 1980s. Urologists offer implant surgery andsome manufacturers require that only specially trained and licensed urologists are allowedto implant their prostheses. But today most manufacturers are more lenient in thisregard.
Erectile dysfunctions are quite often caused by problems of blood circulation. There isa high incidence of common cardiovascular diseases in the Finnish population. Surgeryof the blood vessels of the penis was supposed to increase arterial inflow and help manypatients, but the long-term results of the procedure have not been satisfactory. Arterialsurgery for erectile dysfunction is a demanding operation with many risks and currentlyis no longer a treatment choice. Surgical closure of penile cavernosal leakage has a better record of effective treatment, at least in many cases; it is also possible to close thepathological outflow from cavernous bodies by using operative procedures in the veins.
Today, most cases of erectile dysfunction are treated by pharmacotherapy.
Intracavernous penile injections (e.g. papaverine, phentolamine, alprostadil) becameavailable for patients about a decade ago. They were the first new generation ofpharmacotherapy for ED and are still in use. The drug of choice for ED is oral sildenafilcitrate (Viagra) which has turned out to be a very effective treatment with a low incidenceof side effects. But sometimes giving a prescription for sildenafil citrate may beinappropriate and even considered medical malpractice. A physician may considersexological patients too demanding and time consuming and therefore avoid or evenneglect to take a careful sexual history or perform a thorough examination. Prescriptionof drugs is so easy and time saving that it will be difficult for some physicians to considerother treatment options.
The most demanding and difficult male sexual problems are premature ejaculation,delayed ejaculation, hypoactive sexual desire disorder, and orgasmic disorders. Sexualmedicine has not yet found effective treatments for them. In most cases, these disordershave complex and multilevel etiologies. Therefore, their diagnosis is often difficult andtime consuming. Co-operation with a sex counsellor, sex therapist, or psychiatrist mayhelp a general practitioner in treating men with these problems. The incidence of maledesire disorders seems to have increased in the Finnish population, but this is only aclinical observation without any survey-based evidence.
Problems in variations of sexual desires, previously called disorders of sexual preferenceand sexual identity make up a minority of cases of clinical sexology in Finland, but theystill require attention. Undergraduate degree program curricula at Finnish medical schoolsdo not include education in variations of sexual desire. In postgraduate programs onlypsychiatry and forensic medicine offer medical education in this very complex field ofsexology.
Variations of sexual desires or paraphilias were only considered perversions in certainpsychoanalytic revisions of Freud’s original writings. Recent psychoanalytic researchersargue that Freud came close to what would be the accepted enlightened language today:in ‘variations’ we have not perversions but simply versions (May 1995, 161). The newversion of the international psychiatric standard, Kaplan and Sadock’s ComprehensiveTextbook of Psychiatry reminds that throughout the late-nineteenth and twentieth centurythe terms inversion, perversion and deviance were used by mental health professionals to denote the paraphilias but that these term are now officially out of favour becausethey no longer connote acceptable standards of objectivity and they have been genericallyapplied to any unconventional aspect of sexual identity – cross-dressing, homosexualorientation, or sexual sadism (Levine 2000, 1634).
One of the main problems is to establish a diagnostic border between normal butslightly atypical sexual behaviour and real psychopathological states. Most normal peopleengage in behaviour that traditionally was defined as a disorder of sexual behaviour,such as sucking, biting, and light bondage, for example. Erotic fantasies may includeeven more extreme portrayals of such behaviours without any intention by the onehaving such fantasies to actually engage in these unconventional acts. Sexual violence,rape and pedophilia are topics of public debate but more as ethical and criminal problemsthan as medical phenomena.
The first question when planning treatment strategies for problems in sexual variationsis to determine if the patient really requires therapy. What kind of therapy is needed isthe second question, and what will be its likely effects is the third. Municipal healthcarecentres do not have resources to offer this kind of service in Finland. Patients withproblems in sexual variations are referred to university clinics with psychiatrists andclinical psychologists who have experience in clinical sexology. Private sexual healthcareoffers specialist level medical service and sex therapy in a few special units. Use of aprivate or public health service is up to the individual and depends on factors discussedearlier. Kuopio Central Prison in north east Finland has started a voluntary 6-monththerapy program for men convicted of rape or pedophilia.
Problems in variations of sexual desire can be treated in municipal mental health centres,public local hospitals, and central hospitals. However, it is usually difficult to find aprivate physician who is familiar with these sexual problems. In many variations suchas transgenderism, transvestism, and fetishism, a patient feels fine and does not see anyneed for medical help. The demand for therapy usually comes from relatives, friends,or the authorities. Sometimes it is difficult to determine if the primary problem issociological (caused by societal attitudes) or medical (so severe it needs professionalattention).
Sexual medicine also deals with issues involving sexuality during childhood andadolescence and with sexual problems of specific patient groups, such as the disabledand people from different cultures and religions. In the 1990s politicians have reducedthe funding for sex education in schools. Thus, sexual problems among young peopleand the incidence of adolescent pregnancies have increased in Finland during recent years.
The significant increase of older people in the population has created a situation wheresexual healthcare professionals encounter more and more ageing patients every year.
This phenomenon has also been noticed in undergraduate and postgraduate medicaleducation. Globalisation has changed Finnish society, and healthcare professionals needto understand the sexuality of different cultures and religions.
There are also special questions that involve a minority of individuals such as transsexuals,those having problems with variations of sexual desire, those dealing or suffering fromHIV or AIDS, and sex workers. Only a few physicians have experience in diagnosingand treating transsexualism. Treatment involving plastic surgery for transgenderedpersons is offered only at Tampere University Hospital in Central Finland. Finnishtranssexuals were forced to find their medical help abroad for many years, but theactivity of the Finnish National Organisation for Sexual Equality (SETA) has improvedservices for those with identity problems in Finland. SETA offers counselling fortranssexuals and other sexual minorities. HIV diagnostics is carried out nationally inmunicipal basic healthcare, treatment services are concentrated in special infectiousdisease units, and a national AIDS support centre network helps people with HIV. ThePro Support Centre and few private projects offer preventive healthcare and medicalservices for sex workers.
References
Duodecim (Seksologia (Sexology) 15/1988.
Hovatta, Outi, Ojanlatva, Ansa, Pelkonen, Risto, Salmimies, Pekka. 1995. Seksuaali- suus (Sexuality) Helsinki: Duodecim.
May, Robert. 1995. Re-reading Freud on homosexuality. In Domenici, Thomas & Lesser, Ronnie C. (Eds.) Disorienting sexuality. Psychoanalytic reappraisals of sexualidentities. New York: Routledge.
Levine, Stephen. 2000. Paraphilias. In Sadock, Benjamin and Sadock, Virginia (Eds.) Kaplan & Sadock’s Comprehensive Textbook of Psychiatry. Baltimore: LippincottWilliams & Wilkins.
Palo, Jorma and Palo, Leena-Maija. 1999. Rakkaudesta seksiin (For the love of

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