[Sexual medicine in daily practice : Germany-wide questionnaire of urologists]. / Sexualmedizin im ärztlichen Alltag : Bundesweite Umfrage unter Ärzten in der Urologie.

BACKGROUND: Sexual-related problems are very prevalent. Physicians of different disciplines are frequently contacted by men with those problems. OBJECTIVES: The aim of this study was to investigate the situation of sexual medicine in daily practice and to evaluate German urologists' need for further training in this field with a focus on gender-specific differences. MATERIALS AND METHODS: A five-page questionnaire included questions about sexual medicine in daily practice. A focus was set on physicians dealing with sexual medicine in daily practice and their need for further training in this field. In April/Mai 2015, questionnaires were sent per mail to 5955 urologists, urology residents and andrologists throughout Germany. The questionnaire was developed based on previously published studies and a pretest was performed to evaluate comprehensibility. A χ2 test was performed to determine significant gender-specific differences; for this propose response options were dichotomised. P values ≤0.05 were considered significant. RESULTS: The response rate was 16.0%, representing 955 questionnaires. A total of 50 questionnaires from non-urologists were excluded, so 905 questionnaires were analysed. The mean age was 47.7 ± 10.4 years, 78.9% were male, 97.0% had studied in Germany, 86.7% were specialists and 37.7% had further qualification in andrology. CONCLUSION: Our results emphasize the need for further training in sexual medicine, especially for female physicians. This study underlines the demand for advanced qualification in sexual medicine.

Education in sexual medicine - a nationwide study among German urologists/andrologists and urology residents.

Although sexual-related problems are very prevalent, inadequate training for physicians has been reported. The aim was to investigate the educational situation in sexual medicine, including sexual dysfunctions, gender dysphoria and paraphilia, among German physicians in urology and andrology. Additional, barriers when addressing sexual health issues and confidence in taking care of patients with sexual-related problems were evaluated. A questionnaire was sent to 5955 urologists, urology residents and andrologists throughout Germany. The results of this study emphasise the need for continuing education and training in sexual medicine including sexual dysfunctions (83.9%), gender dysphoria (58.2%) and paraphilia (56.6%). Physicians, especially when working in urology, need basic skills in order to feel confident (89.0% in taking care of patients with sexual dysfunctions, 25.8% with gender dysphoria and 22.9% with paraphilia) and be able to reduce several barriers when addressing sexual health issues. The main reported barriers were lack of time (61.0%), inadequate financial compensation (42.5%), lack of necessity (29.9%) and the assumption of patients feeling uncomfortable (20.9%). It is within the competence of urologists and andrologists to correctly assess the situation and to refer patients to multidisciplinary support, such as psychologists, psychosomatics or couple therapists.

Human face processing is tuned to sexual age preferences.

Human faces can motivate nurturing behaviour or sexual behaviour when adults see a child or an adult face, respectively. This suggests that face processing is tuned to detecting age cues of sexual maturity to stimulate the appropriate reproductive behaviour: either caretaking or mating. In paedophilia, sexual attraction is directed to sexually immature children. Therefore, we hypothesized that brain networks that normally are tuned to mature faces of the preferred gender show an abnormal tuning to sexual immature faces in paedophilia. Here, we use functional magnetic resonance imaging (fMRI) to test directly for the existence of a network which is tuned to face cues of sexual maturity. During fMRI, participants sexually attracted to either adults or children were exposed to various face images. In individuals attracted to adults, adult faces activated several brain regions significantly more than child faces. These brain regions comprised areas known to be implicated in face processing, and sexual processing, including occipital areas, the ventrolateral prefrontal cortex and, subcortically, the putamen and nucleus caudatus. The same regions were activated in paedophiles, but with a reversed preferential response pattern.

[The sexual health of men from a sexual-medical perspective]. / Sexuelle Gesundheit von Männern aus sexualmedizinischer Sicht.

Men's sexual health can be impaired by a variety of sexual disorders, including numerous sexual dysfunctions (primary or due to general medical conditions or their treatment), but also paraphilias and gender identity disorders. These different disorders are often interwoven. This paper offers an overview of the prevalence, symptoms, and etiological factors of major sexual-medical disorders and of the basics of diagnostics and therapy. Special emphasis is given to the couple dimension and the biopsychosocial foundation of human sexuality, which requires an interdisciplinary approach. The paper argues for an improvement of continuing education in sexual medicine for healthcare providers in an effort to satisfy patients' needs for preservation or restoration of sexual health as a major component of quality of life.

Brain potentials related to corpus cavernosum electromyography.

The aim of this study was to elucidate the relation between electrical activity in the corpus cavernosum (CC), penile responses and brain processes. EEG potentials, penile circumference and electrical activity of the CC (CC-EMG) were recorded simultaneously while male subjects were exposed to visual sexual stimuli. The trials were sorted by the penile response of the subjects (erection, maintenance or detumescence). The corresponding EEG recordings were subjected to independent component analysis (ICA) and then correlated with CC activity. We found that CC activity was decreased in the case of erection. EEG activity was found to be correlated with CC activity in most cases at the same instant or with subsequent CC activity. EEG activity at early time points after stimulus onset (<300 ms) was found to be correlated with CC activity, indicating penile response preparation at a pre-attentive processing level. These data indicate that (i) CC activity is under the control of brain processing and (ii) autonomous input reaches the CC in fractions of a second after sexual stimulus onset. Our experimental paradigm should be used for the study of psychogenic erectile dysfunctions and could help in the development of an objective measurement of this disturbance.

Brain potentials related to the human penile erection.

The aim of this study was to elucidate the brain processes preceding penile responses. Electroencephalographic (EEG) potentials and penile circumference were recorded simultaneously while male subjects were exposed to visual sexual stimuli (VSS). The trials were sorted by the penile response of the subjects (erection, maintenance or detumescence). The corresponding EEG recordings were then subjected to independent component analysis. We found that 200 ms after VSS onset brain potentials differ according to the genital response to follow. Whereas early posterior negativity (EPN) was predominantly related to erection and maintenance, P3-like activity was found to precede detumescence. EPN indicates a more 'emotional' processing state of the brain, whereas P3-like activity related to detumescence indicates a more 'cognitive' processing state. The latter is assumed to reflect activity of the locus coeruleus-norepinephrine system. Further research should evaluate the contribution of P3-related brain activity to psychogenic erectile dysfunction.

[Psychosexual aspects of intersex syndromes]. / Sexualmedizinische Aspekte bei Intersexsyndromen.

Disorders of somatosexual development that lead to ambiguous genitalia occur in one from 3,000-5,000 newborns. Parents and health care professionals are confronted with a number of crucial questions: to what sex should the child be assigned, what is the appropriate treatment in terms of hormonal and surgical interventions, when and how should these take place, and what impact do they have on the development of gender identity (GI), psychosexual well-being and fertility? This paper reviews the etiology, treatment and outcome in terms of GI and sexual health for the following syndromes: congenital adrenal hyperplasia (CAH), complete and partial androgen insensitivity (cAIS, pAIS), and pure and mixed gonadal dysgenesis (pGD, mGD). Emphasis is focussed on the current discussion involving the timing and extent of genital surgery. Finally, a procedure is introduced that covers the sexual-medical needs of patients, parents and health care professionals.

Congenital adrenal hyperplasia - how to improve the transition from adolescence to adult life.

Congenital adrenal hyperplasia (CAH) is caused by a defect in the biosynthesis of cortisol that results in maximal activity of the hypothalamic-pituitary adrenal axis with hyperplasia of the adrenals and hyperandrogenism due to the accumulation of androgen precursors. In the salt-wasting subtype of the disorder, which accounts for appr. 75 % of patients with classical CAH, patients are unable to synthesise sufficient amounts of aldosterone and are prone to life-threatening salt-losing crises, whereas the simple virilising form is predominantly characterized by clitoris hypertrophy and posterior labial fusion. In addition, a non-classical variant can be discerned which in most cases is diagnosed at the time of puberty or early adolescence when hirsutism and menstrual irregularities may occur. The vast majority of CAH patients have 21-hydroxylase deficiency (90 - 95 %). Less common forms, such as 11beta-hydroxylase deficiency, will not be discussed in this review. Unfortunately, a considerable number of CAH patients is lost to regular and competent follow-up once they move out of paediatric care. This is most probably the result of insufficient co-operation between paediatric and adult endocrinologists at the time of transition from adolescence to adulthood. Furthermore, there is a lack of clinical guidance regarding psychosexual development in these patients. In this overview we will focus on special aspects of CAH treatment in adolescence and adulthood, and report on our 10-year experience with a transfer system for endocrine patients from paediatric to internal medical care, known as the "Kieler Modell". For practical purposes, we here provide charts for follow-up of CAH patients that can be adapted for use in any endocrine outpatient clinic.

[Diagnosis and therapy of sexual disorders. An interdisciplinary challenge]. / Diagnostik und Therapie sexueller Störungen. Eine interdisziplinäre Herausforderung.

In view of the changes in moral values as a consequence of sexual liberation, the high incidence of sexual dysfunction and the existence of effective pharmacological treatment for erectile dysfunction, sexual disorders should be a common issue in the medical practice. This is, however, not the case. A reason could be that physicians are not prepared to talk about sexuality in a clinical setting. Moreover, clinical practice reveals that to focus simply on "fixing the function" could fail the needs of the patient and his or her partner.

[Transexual gender identity disorders: diagnostic and legal issues]. / Diagnostische und arztrechtliche Probleme bei transsexuellen Geschlechtsidentitätsstörungen]

The current classification systems (ICD-10, DSM-IV), epidemiology, symptoms and diagnostic features of gender identity disorders are discussed. In the best interest of the patients, and in view of the legal situation, treatment has to follow set "standards of care". The necessity of a psychotherapeutically guided real life test, lasting at least 1 year before somatic treatment can begin, is again pointed out.

[Standards for treatment and expert opinion on transsexuals. The German Society for Sexual Research, The Academy of Sexual medicine and the Society for Sexual Science]. / and the Society for Sexual Science]chtung von Transsexuellen der Deutschen Gesellschaft für Sexualforschung, der Akademie für Sexualmedizin und der Gesellschaft für Sexualwissenschaft.

Over the last two-and-a-half years a committee of experts, consisting of members of the three leading German sexology associations, developed guidelines for treating and assessing transsexuals. Their purpose is to improve the care for patients with sex identity disorders and to ensure that such care is of uniform quality to avoid erroneous decisions to the disadvantage of those affected. The guidelines are set out in full.

A higher rate of hyperandrogenic disorders in female-to-male transsexuals.

In an effort to elucidate the aetiology of female-to-male transsexualism (FM-TS) 12 out of an annual sample of 16 untreated female-to-male transsexuals (FMT), aged 19 years 7 months (19;7) to 44 years 8 months (44;8) [median age (M) 27;5] were assessed by means of sexual-medical questionnaires, physical and endocrinological examination. The control group consisted of 15 healthy women (CF), aged 19 years 2 months (19;2) to 36 years 1 month (36;1) (M 22;7) without gender identity disorder, who were not under hormonal medication (including contraceptives). Baseline levels of testosterone (T; ng/dl), androstenedione (A4; ng/dl), dehydroepiandrosterone sulfate (DHEAS; ng/ml), luteinizing hormone (LH; IU/l), follicle stimulating hormone (FSH; IU/l), and sex-hormone binding globuline (SHBG; microgram/dl) were measured. A standard single-dose ACTH stimulation test (250 micrograms ACTH IV; Synacthen) was performed with all subjects. Aldosterone (ALDO), corticosterone (B), deoxycorticosterone (DOC), progesterone (PROG), 17-hydroxyprogesterone (17OHP), 11-deoxycortisol (S), cortisol (F), cortisone (E), pregnenolone (PREG) and 17-hydroxypregnenolone (OHPREG) were assessed before and 60 min after ACTH stimulation. Transvaginal ultrasound was performed in nine out of 12 FMT (20;11 to 44;8, M 27;5; m 29.1 +/- 7.5) but not in CF. Results showed that 10 FMT (83.3%) and five CF (33.3%) were above normal values for at least one of the measured androgens. Baseline levels of T and A4 were significantly higher in FMT than in CF (T: 54.0 +/- 13.8 vs. 41.1 +/- 12.8; A4: 244.8 +/- 73.0 vs. 190.5 +/- 49.3; p < .05), whereas DHEAS, SHBG, LH and FSH did not differ between the groups. Unbound T (T/SHBG ratio) was higher in FMT (72.0 +/- 67.6) than in CF (26.4 +/- 15.1). Baseline levels of 17OHP, OHPREG and DOC were higher in FMT than in CF (p < .05). After ACTH stimulation 17OHP and OHPREG remained higher in FMT than in CF (p < .05). Single case analysis of ACTH stimulation test together with physical examination revealed symptoms for non-classical congenital adrenal hyperplasia (NC-CAH) in six FMT (50%) and two CF (13.3%). Eight out of nine FMT who were assessed by means of transvaginal ultrasound (i.e. 88.9%; 50.0% of 16) had polycystic ovaries (PCO). Oligomenorrhoea or menstrual dysregularities (81.7% of 16 FMT vs. 0% of CF), hirsutism (56.2% of 16 FMT vs. 13.3% of 15 CF) and adiposity (25.0% vs. 0%) were frequent in FMT, but not in CF. Hyperandrogenism with polycystic ovarian syndrome (PCOS) and adrenocortical hyperresponsiveness to ACTH seems to be a common finding in FMT. This offers support for a hormonal factor in the genesis of FM-TS. Because the prevalence of PCOS and NC-CAH in the female population is higher than FM-TS, the true nature of this factor and its interaction with environmental influences remains unknown.

Anthropometrical measurements and androgen levels in males, females, and hormonally untreated female-to-male transsexuals.

To elucidate the relationship between body build, androgens, and transsexual gender identity, anthropometric measurements were assessed in 15 hormonally untreated female-to-male-transsexuals (FMT). Nineteen healthy women (CF) (X = 22 years; 2 months), and 21 healthy men (CM) (X = 23; 7) were enrolled as controls. Baseline levels of testosterone (T; ng/dl), androstenedione (A4; ng/dl), dehydroepiandrosterone sulfate (DHEAS; ng/ml), and sex-hormone binding globulin (SHBG; microgram/ml) were assessed in 12 FMT, 15 CF, and in all CM. No control was under hormonal medication (including contraceptives). Absolute measurements in FMT were in accordance with their biological sex: they showed only small differences from the CF. However, FMT differed from CF in 7 of 14 sex-dimorphic indices of masculinity/femininity in body build. Of these 14 indices, 9 did not show a difference between FMT and CM. Hence, FMT presented a more masculine body build, particularly in fat distribution and bone proportions. Levels of T and A4 were significantly higher in FMT than in CF (T: 54.0 +/- 13.8 vs. 41.1 +/- 12.8; A4: 244.8 +/- 73.0 vs. 190.5 +/- 49.3), while DHEAS was higher in CM (3335 +/- 951) than in CF (2333 +/- 793) and in FMT (2679 +/- 1089). Altogether, 83.3% of FMT and 33.3% of CF were above normal values for at least one measured androgen. SHBG in FMT (1.21 +/- 0.70) and CF (1.87 +/- 0.91) was higher than in CM (0.49 +/- 0.18) and tended to be higher in CF than in FMT. Unbound T (T/SHBG ratio) was higher in FMT (72.0 +/- 67.6) than in CF (26.4 +/- 15.1) and correlated positively with manly body shape. Findings are discussed in relation to etiology of transsexualism.

[Interdisciplinary concepts of surgical sex transformation in transsexual patients]. / Interdisziplinäre Konzepte zur operativen Geschlechtstransformation bei Transsexuellen.

From the introduction of the law on recognition of transsexuals (TSG) in 1980, over 1400 decisions were made by German regional district judges up to 1990. In over 90% of the cases the desired gender was accepted and attested officially. In the near future, a growing number of requests has to be expected. Generally, transsexual patients desire surgery to achieve a complete sex change. Since the foundation of an interdisciplinary gender dysphoria identity committee at our institution in 1989, we have developed criteria on indications, operative techniques and follow-up, which would overtax a urology department, but which can be managed by an interdisciplinary team. Operative techniques may be regarded as well standardized in male-to-female transsexuals and may be performed by the urologist alone; in female-to-male transsexuals sex transformation remains complex interdisciplinary challenge to urologists and plastic surgeons, mainly due to urethral complications. Continuous psychiatric guidance and endocrinological monitoring of the patients facilitates indications for surgery and perioperative management.

[Current status of sex education of preschool children]. / Zum aktuellen Stand der Geschlechtserziehung im Vorschulalter.

The quantity of empirical data on contents and sources of sexual knowledge and sex-typical attitudes at preschool children is out of all proportion to the importance of this age for the formation of sexual behaviour and the establishment of relations between the sexes in family and society in the course of ontogenesis. The results of standardized interviews of 190 boys and 176 girls aged four to seven years at urban and rural nursery schools on their sexual knowledge and on their ideas of properties, roles and functions of the sexes (sex role ideas) will help fill this gap. Compared to previous retrospective studies on elder children and adolescents, sexual knowledge has become more wide-spread and correct and increasingly comes from the desired sources of information. The emotional and educational factors involved in impairing the information, however, are not yet sufficiently developed and the incidence of attitudes promoting an equal cooperation between the sexes is rather limited. The necessity of enabling the educators for sexual education is again emphasized.