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E-Sexual Health: A Position Statement of the European Society for Sexual Medicine

Paraskevi-Sofia Kirana
Institute for the Study of Urological Diseases, Thessaloniki, Greece

Ahmet Gudeloglu
Department of Urology, Hacettepe University Hospital, Ankara, Turkey

Andrea Sansone
Department of Experimental Medicine, Sapienza University of Rome, Rome, Italy

Mikkel Fode
Department of Urology, Zealand University Hospital, Roskilde, Denmark

Yacov Reisman
Men’s Health Clinic, Amstelland Hospital, Amsterdam, The Netherlands

Giovanni Corona
Endocrinology Unit, Medical Department, Azienda USL, Maggiore-Bellaria Hospital, Bologna, Italy

Andrea Burri
Institute for Sex Counseling and Sexual Sciences, Zurich, Switzerland

Abstract

Background:

Opportunities and pitfalls of e-health have been described and assessed in various health domains, but in the field of sexual health, the respective literature is limited.

Aim:

The aim of this document is to present the European Society of Sexual Medicine’s (ESSM) current position statement on e-sexual health.

Methods:

This statement article is an expert opinionebased proposal that was developed under the auspices of the ESSM with input from the e-sexual health subcommittee of the ESSM Scientific Committee.

Outcomes:

ESSM statements were provided on four domains: health information for patients, e-learning for professionals, health interventions, and health research.

Results:

e-Sexual health is the use of information and communication technologies for sexual health including sexual health care, surveillance, education, knowledge, and research. Quality indicators have to be applied on Web pages that provide sexual health information, e-learning can increase educational opportunities for professionals, online treatment interventions can be effective but needs to be available to the public, and online health research can provide access to difficult to reach populations.

Clinical Implications:

The ESSM acknowledges the necessity for the use of information and communication technologies to meet the sexual health needs of citizens and patients and also the professional needs of sexual healthcare providers, in an evidence-based manner.

Strengths & Limitations:

ESSM statements on this topic were provided based on expert opinion and summarize the ESSM position in this field.

Conclusion:

The ESSM believes that e-sexual health can provide opportunities for the improvement of the sexual health of the population. Kirana PS, Gudeloglu A, Sansone A, et al. E-Sexual Health: A Position Statement of the European Society for Sexual Medicine. J Sex Med 2020;17;1246e1253.

Copyright © 2020, International Society for Sexual Medicine. Published by Elsevier Inc. All rights reserved.

Key Words:

e-Sexual Health; Digital; Web; Web-Based Sexual Intervention; Online Sex Research

Introduction

The Web provides easily accessible information to anonymous users. It is therefore not surprising that for some highly confidential topics, such as sexual health, younger people are usually more likely to search for an answer on the Internet rather than ask their parents.1 In adult age, and even more in aging men, the Internet often provides a quick answer to questions concerning sexual dysfunctions, thus bypassing the need to disclose personal information to a health care provider.2 Therefore, it seems that for sexual health problems, which have long been associated with
stigma, shame, and low treatment-seeking rates, the Web can provide an attractive opportunity to anonymously access information and, in some cases, also treatments. At the same time, sexual health professionals can use the Web to increase their access to reach patient groups either for treatment or for research purposes. Opportunities and pitfalls of e-health have been described and assessed in various health domains; however, in the field of sexual health, the respective literature is limited.3 Today, there is an emerging need to initiate discussions and research on this topic from a scientific perspective.

The European Society for Sexual Medicine (ESSM) developed this statement proposal in order to increase awareness on the needs and opportunities related to the use of digital technology in sexual medicine. This document is intended for not only sexual medicine clinicians and researchers, but also relevant scientific organizations that would like to build on the current achievements of e-health. The manuscript presents ESSM’s position statements on the following domains: (i) e-sexual health information for patients, (ii) e-learning for sexual health professionals, (iii) e-sexual health interventions, and (iv) e-sexual health research. Data indicating the current achievements across each of these domains are presented. As this is a relevantly new field, data indicating the use of digital technology by other health sciences, beyond sexual medicine, were considered essential.

Research Methods

This statement paper is an expert opinion-based proposal that was developed under the auspices of the ESSM with input from the E-Sexual Health Sub-Committee of the ESSM Scientific Committee. After planning a conference call, the sub-committee conducted a literature search of publications after 2005 on PubMed, Web of Science, MEDLINE, and Cochrane including the following words: online sexual health information, e-learning for sexual health professionals, online sexual health interventions, sexual health research, digital, Web, e-sexual health. Only the manuscripts that focused on sexual dysfunctions were included. The committee summarized the literature across 4 domains: (i) research in sexual health, (ii) online interventions in sexual health, (iii) e-learning for sexual health professionals, and (iv) health information for the population. Each committee member was responsible for 1 domain. Subsequently, the committee discussed the literature and agreed on the statements that best indicate the opportunities and challenges of e-sexual health. These were presented during the Annual ESSM Congress, so additional feedback and discussions were incorporated. A panel of sexual medicine experts reviewed the first draft, which was then approved by the ESSM Executive Committee and by each of the ESSM affiliate societies.

Definitions of e-Health and Sexual Health

The term “e-health” nowadays seems to serve as a general “buzzword,” used to characterize not only “Internet medicine,” but also virtually everything related to computers and medicine. According to Eysenbach (2001), the term was first used by industry leaders and marketing people rather than academics.4 They created and used this term in line with other “e-words” such as e-commerce, e-business, e-solutions, and so on, in an attempt to convey the promises, principles, and excitement around e-commerce (electronic commerce) to the health arena, and to give an account of the new possibilities the Internet is opening up to the area of health care. Because the Internet created new opportunities and challenges for the traditional health care information technology industry, the use of a new term to address these issues seemed appropriate. Up until today experts often contest what the term means exactly—and to add to the confusion, it is also frequently used as a synonym for health information technology. Therefore, not surprisingly, a number of definitions exist and what becomes clear is that ehealth is used as a broad term, referring to the use of information and communication technologies (ICT) in health care and encompassing more than a mere technological development. According to the World Health Organization, eHealth is the use of ICT for health and is defined as “the cost-effective and secure use of information and communication technologies in support of health and health-related fields, including health care services, health surveillance, health literature, and health education, knowledge and research.”5 Based on the definition of e-health, esexual health may be defined as “the cost effective and secure use of information and communication technologies in support of sexual health and well-being, including health care, surveillance, research, education and knowledge.”

Sexual Health Information on the Web for Patients

Statement # 1: Web-based resources can uniquely provide sexual health information that is relevant and free of prejudice to users regardless of their gender, age, sexual orientation, and location (Table 1).

Statement # 2: Some Web-based resources may be of low quality and provide misinformation to patients.

Statement # 3: Direct and proxy quality indicators should be applied to websites providing sexual health information and included in the website. For example, the website content, the design, the site’s performance, the links, and supporting references are only some of website’s characteristics to support the quality of the website’s information. For an example of quality indicators for websites providing sexual health information, see Table 2.

Evidence

Health Information on the Web

The Internet is a common resource that people use to access health-related information. Individuals do much of their health information management through the Internet and consider it a valid source of health advice. The reliability of the health websites has been an important concern and core quality indicators have been described.6 These are criteria that directly assess the quality of information provided. They include accuracy, completeness, and currency of information, and require health experts to provide this evaluation. On the other hand, proxy indicators are indirect indicators of quality, objective, and easy to assess. These include readability, design, disclosures, provision of the author’s qualifications, citations, etc. Scoring systems have been developed based on proxy indicators of quality to standardize evaluation. These scoring systems are a set of indicators of quality applied to a website in order to derive a quality score. There are more than 243 tools, but the most widely used are Health On the Net Foundation Code, the Journal of American Association benchmarks, and the DISCERN tool. These tools do not assess accuracy of the medical information presented, but seem to rely mostly on proxy indicators of quality and aspects of ethics related to information. Websites that have complied with such scoring systems display a sign that indicates this.

The quality of health information on the Web can be assessed not only by health experts but also by health consumers. The way health consumers perceive and appraise information is different to that of experts. A qualitative study on consumers identified 5 dimensions of information quality for health websites: completeness of information, understandability of information, relevance of information, depth of information, and accuracy of information.7 Completeness of information and understandability of information were rated as the 2 most important quality dimensions by the study participants. Results indicated that these 5 information quality dimensions for health websites were indicated by the following main driver themes: content, design, links, consumer resources, search functionality, supporting references, user focus, content frequently asked questions, open access, policy statements, and site performance.

The likelihood that a patient will view a specific page is strongly influenced by the order with which it appears on search engines. Therefore, Google ranking plays an important role on health information that is distributed. However, studies have shown that website popularity and Google ranking do not correlate with health quality of the websites.8

Sexual Health Information on the Web

At the moment, there is only one systematic review on websites providing information on sexual disorders and it is focused on male sexual disorders.3 This showed that there were 20 million websites on erectile dysfunction, 2 million on premature ejaculation, 1 million on Peyronie/testosterone, and 25 million on infertility.9 The authors analyzed the 10 top ranked websites and found that 31.6% were owned by a health institution, 51.6% were owned by health professional, 23% sold services or products, 46.7% displayed advertisements, and only 33% provided references or external links. The analysis showed a worrisome percentage of websites (42%) not covering minimum quality standards such as the identification of the author or institution providing the information, the presence of references, or the presence of a quality seal supporting the accuracy of the published information. Other authors performing a more thorough assessment of the quality of websites dealing with specific fields of sexual health (such as fertility and prostate cancer) found poorer standards of quality.10e12 The low quality seems to be related to the overall commercial tone of most sites, which either sell products or services or receive funding from advertisements or pharmaceutical companies sponsorship. We found no published research papers assessing quality of Web health information for women facing sexual dysfunctions.

Remarks

Approximately half of the websites providing sexual health information for men do not cover minimum quality standards. There is a lack of data on the extent to which the users actually behaviorally apply the information provided and on the effectiveness of the available sexual health websites. There is also a need for consensus regarding the appropriate quality indicators and best methodology to assess the quality of the available websites. In addition, there is a need for an assessment of the available Web resources on female sexual dysfunctions and disorders. No relative publication was found, although the available websites providing such information are numerous.

E-Learning

Statement # 4: E-learning can increase effective educational opportunities for sexual health providers. For example, e-learning could be particularly useful not only for sexual medicine scientists that live in countries lacking sexual medicine opportunities for training, but also for education by lecturers with very specific fields of expertise (Table 1).

Statement # 5: E-learning can provide health education that is comparable to that provided in traditional learning.

Evidence

E-Learning for Health Care Providers

The use of e-learning, defined as any educational intervention mediated electronically via the Internet, has steadily increased among health professionals worldwide. Several studies have attempted to measure the effects of e-learning in medical practice, which has often been associated with large positive effects when compared to no intervention and with small positive effects when compared with traditional learning (without access to e-learning). However, the results are not conclusive. Even if e-learning could be more successful than traditional learning in particular medical education settings, general claims of it as being inherently more effective than traditional learning may be misleading. In a very recent Cochrane review, the authors analyzed 16 randomized trials assessing the effectiveness of elearning vs traditional learning for health professionals.13 When compared to traditional learning, e-learning was shown to make little or no difference in patient outcomes or health professionals’ behaviors, skills, or knowledge.

E-Learning for Sexual Health Professionals

Numerous e-learning opportunities exist for sexual health care providers, but to our knowledge there is a lack of studies providing relevant descriptive data (how many e-learning courses, training objectives, number of students, etc), and there is also a considerable lack of studies assessing the effectiveness of these courses. In 2010, the Geneva Foundation for Medical Education and Research, in collaboration with the World Health Organization and partner institutions, developed an online postgraduate course on Sexual and Reproductive Health Research. Data on the effectiveness of this course showed that it had a positive effect on the research activity of the participants.14 However, this course was made for researchers, and therefore the e-learning opportunities for clinical knowledge were not addressed.

Remarks

With the dissemination of the Internet, e-learning provides a convenient opportunity to access education on sexual medicine. However, there is a lack of studies specifically on e-learning opportunities for sexual health care providers. There is a need for studies assessing the effectiveness of e-learning for sexual health providers and the impact on professional’s knowledge, behaviors, and skills.

Online Health Interventions

Statement # 6: Online sexual health interventions can have beneficial effects on sexual and relationship outcomes (Table 1).

Statement # 7: Effective evidence-based sexual health interventions need to be available on functional websites and the public needs to be assisted in locating these.

Evidence

Online Health Interventions

Online health interventions usually refer to websites that contain useful information that could help people stay healthy, ameliorate risky behaviors, recognize early disease, or assist with treatment of their existing disorders. Recently, a systematic review of meta-analyses was conducted in order to discover the range of health-related topics that are addressed through Internet delivered interventions.15 Within the 71 meta-analyses, there were 1,733 studies. Of these studies, there were 268 unique randomized controlled trials (RCTs) that tested self-help Internet-based interventions; in most cases, the Internet delivered interventions were offered only to the study participants in the context of the RCT. In only 21.3% (57/268) of instances, there were functional websites available for general use for the interventions after the conclusion of the trial. These included evidence-based Web programs on substance abuse, mental health, and on diet and physical activity. There were also evidence-based programs on insomnia, chronic pain, cardiovascular risk, and childhood health problems. Unfortunately, the review does not describe the effectiveness of these interventions.

Online Sexual Health Interventions

Online sexual health interventions on sexual dysfunctions have been conducted and assessed. A very recent review of online interventions for sexual dysfunctions in cancer patients revealed 4 RCTs (2 on prostate cancer and 2 on breast/gynecologic cancer). 16 3 of them also included the partner. The interventions included information, forums coordinated by health providers, online logbooks and cognitive behavior therapy exercises, videos with survivors, and online counseling. The outcome measures included physical, psychological, or sexual distress, and quality of life and were assessed with validated questionnaires. Positive results for both physical and psychological outcomes were demonstrated. These were reduction in sexual distress, improvement in erectile function, improvement in female sexual function of patients and partners, as well as improvement of sexual interest in menopausal women. However, high dropout rates (22e41%) were also described. Such dropout rates are common in online health interventions because of the self-guided nature. Another review focused on online interventions on female sexual dysfunctions.17 4 RCTs were identified, with most interventions offering Web-based therapeutic content within a more or less preprogrammed structure and also offered prescheduled and/or participant-initiated contact with a sexual health care professional. Positive outcomes on sexual and relationship functioning were reported and they were maintained after 6 months. Concerning online interventions for erectile dysfunction, 3 studies have shown positive outcomes, but again the dropout rates reported were high.18–20

In summary, online sexual health interventions have been found to have positive outcomes for cancer patients, females with sexual dysfunctions, and men with erectile dysfunction. These interventions include multiple modes of delivery, some with a preprogrammed structure and some including contact with a health professional.

Remarks

It is not clear how many of the effective interventions on sexual health are currently available on functional websites. Strategies to decrease dropout rates need to be described.

Health Research

Statement # 8: Web-based surveys are especially useful in the field of sexual medicine and sexology, because of patients’ privacy and stigma-related concerns (Table 1).

Statement # 9: Qualitative studies applied online can have interesting potential for the study of sexual health as these can be applied to individuals that otherwise would be very hard to reach for face-to-face interviews. For example, video communication can bring together individuals or groups irrespective of

geographical place.

Statement # 10: Quantitative studies applied online can have the potential to reach large groups across the world, with rare conditions. In addition, they can be useful in reaching areas where few people seek in person consultations.

Statement # 11: Online RCTs may have potential benefits, but the methodologies are complex. For example, online RCTs in the field of sexual medicine could be applied when the interventions or the assessment of the outcomes do not require face-to-face interaction between the subjects and the investigators.

Evidence

Online Health Research

Surveys, registry-based medical research, RCTs, and qualitative studies can all be conducted through the Internet.

Internet-based surveys may be conducted by means of interactive interviews or by questionnaires designed for selfcompletion. Electronic one-to-one interviews can be conducted via e-mail or using chat rooms and video calls. Questionnaires can be administered by e-mail (eg, using mailing lists), by posting to newsgroups, and on social media using fill-in forms. In “open” Web-based surveys, selection bias may occur due to the nonrepresentative nature of the Internet population, and (more importantly) through self-selection of participants.21 Guidelines for Web-based surveys have been published, and technical and ethical issues to be addressed.21

Registry-based medical research assesses health care interventions in the general population.22 These are observational studies used to establish effectiveness while randomized clinical

trials assess efficacy in an experimental manner targeting a carefully selected population of patients. Current medical registries benefit from the explosion in medical informatics. The growth in the electronic health record for individual patients and hospitals provides online wealth of data that are expected to bring more value to quality of care.

With the rise in availability and reliability of the Internet, some or all of the steps to conduct a conventional RCT can now be conducted over the Internet. In particular, it is possible to recruit participants, allocate interventions, measure outcomes, and enter data using the Internet. Several trials have combined Internet-based trial methods with traditional trial methods. Others have abandoned traditional trial methods altogether and conducted trials fully online. In a wholly Internet-based randomized trial, the investigators never meet participants—neither the application of the intervention nor the assessment of the outcomes requires face-to-face interaction between the subjects and the investigators. A systematic review of RCTs of any health intervention conducted fully or primarily on the Internet was carried out, and 23 fully and 27 primarily Internet-based RCTs were identified.23 Only one trial was identified as meeting all criteria for adequate methodological quality. A particular problem was high rates of loss to follow-up (fully online: mean 47%; primarily online: mean 36%).

Internet-based qualitative research can be especially useful for hard to reach populations. For example, online qualitative research has been used for the study of the use of sexually explicit material, for the study of polyamorous parenting, and for nontransgender partners of transgender persons. Online qualitative studies can conduct interviews or focus groups, collect data using asynchronous or synchronous methods, and use only text or incorporate visual media. Recommendations and methodological issues have been published.24

Online Sexual Health Research

Areas with low consultation rates or privacy concerns can benefit from online surveys. Epidemiology, sociodemographic characteristics, and treatment satisfaction can be assessed in large populations. Online surveys have allowed data collection on samples above 1,000 men with premature ejaculation or erectile dysfunction.25e27 Large samples of men who have sex with men have provided data on disease prevalence and risk behaviors of very large samples, which would be impossible face to face. But are the data retrieved online reliable? This question was assessed in a study that compared online data to responses of patients at a face-to-face interview and found a high correlation between groups and strong consistency in the online responses.28

Remarks

Online research methods, beyond surveys, such as online qualitative studies and RCTs have not been applied on sexual health issues.

Conclusion

It is quite evident that digital technology is opening a window of great opportunity and potential for the development of sexual medicine. At the same time, this goes with great challenges as scientists may not be familiar with the spectrum of technological tools, legal aspects of using them, marketing issues, and also their effectiveness. SexualMedicine Societies could work together in order to develop an organization that would aim to design, set standards of practice, and support scientific initiatives in using digital methods. Such an organization would require multidisciplinary teams of experts including sexual medicine experts, web developers, and legal advice and digital marketing experts. For example, this organization could have 4 departments (see Figure 1):

1) Sexual health information on the Web: This organization may (i) define the quality standards of the websites providing sexual health information, (ii) provide a certificate of quality to websites after assessment, (iii) annually review certificates, and (iv) respond to any violations reported by users.

2) Digital sexual health research: This organization could provide services to support researchers, such as (i) sample selection, (ii) validate questionnaires for online use, (iii) electronic case report forms, (iv) inform legal and technical ways to protect confidentiality of the study participants, and (v) define methodologies for online research methods.

3) E-learning for sexual medicine professionals: This organization could (i) develop the curriculum for online learning in sexual medicine, (ii) support the development of courses that comply with this curriculum avoiding overlapping projects, and (iii) provide assessment tools for these educational opportunities.

4) Online sexual health interventions: This is probably the most sensitive aspect of e-sexual health as it directly influences people’s health. The organization may implement research on the effectiveness of e-sexual health interventions and digitally promote these interventions in ways that make them available to the population.

Sexual Medicine Societies need to take initiatives and work hard in order to respond to the needs of the population and the scientists using the Web for sexual medicine information, interventions, and research. This would need to comply with ethical, scientific, legal, and technical standards.

The ESSM believes that e-sexual health can provide opportunities for the improvement of the sexual health of the population. The field of sexual health is particularly influenced by (i) social stigma hindering treatment seeking and (ii) lack of sexual health educational opportunities for health care providers. The ESSM acknowledges the necessity for the use of ICT to meet the sexual health needs of citizens and patients, and also the professional needs of sexual health care providers, in an evidence based manner. Websites providing information on sexual health need to comply with quality indicators. E-learning opportunities for health professionals need to be assessed for their effectiveness compared to traditional teaching methods. Online health interventions can be beneficial, but these also need to be available after the completion of the study trials. Online research can go beyond surveys to include qualitative studies and online RCTs.

Corresponding Author:

Paraskevi-Sofia Kirana, PhD, Institute for the Study of Urological Diseases, Thessaloniki, Greece. Tel: 00302310810280; Fax: 00302310228028; E-mail: pskirana@gmail.com

Conflict of Interest: The authors report no conflicts of interest.
Funding: None.

Statement of Authorship

Category 1

(a) Conception and Design

Paraskevi-Sofia Kirana; Ahmet Gudeloglu; Andrea Sansone; Mikkel Fode; Yacov Reisman; Giovanni Corona; Andrea Burri

(b) Acquisition of Data

Paraskevi-Sofia Kirana; Ahmet Gudeloglu; Andrea Sansone; Andrea Burri

(c) Analysis and Interpretation of Data

Paraskevi-Sofia Kirana; Ahmet Gudeloglu; Andrea Sansone; Andrea Burri

Category 2

(a) Drafting the Article

Paraskevi-Sofia Kirana; Ahmet Gudeloglu; Andrea Sansone; Andrea Burri

(b) Revising It for Intellectual Content

Paraskevi-Sofia Kirana; Ahmet Gudeloglu; Andrea Sansone; Mikkel Fode; Yacov Reisman; Giovanni Corona; Andrea Burri

Category 3

(a) Final Approval of the Completed Article

Paraskevi-Sofia Kirana; Ahmet Gudeloglu; Andrea Sansone; Mikkel Fode; Yacov Reisman; Giovanni Corona; Andrea Burri

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