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Recognition and training for specialists in sexual medicine and sexology, still a critical issue

ESSM contributions to this developing matter

Francesca Tripodi
Member of the ESSM Educational Committee
Co-Director of the School of Sexual Medicine

Evie Kirana
Chair of the European Psycho- Sexologists Accreditation Committee
Member of the EFS Executive Committee

Mikkel Fode

Chair of the ESSM Educational Committee
Co-Director of the School of Sexual Medicine

Yacov Reisman
President of the ESSM
Member of the Multidisciplinary Joint Committee on Sexual Medicine

About Sexual Medicine

Sexual medicine has historically been an unofficial specialty with no standards of training or recognition. In the early 20th century, therapy for sexual disorders was available on only a limited scale and only to a selected part of the population. However, during the second part of the 20th century, sexual medicine developed into a thriving branch of health care, which is now widely available. Historically, the physicians who provide care within the specialty of sexual medicine have largely been self-taught and come from a variety of medical disciplines including urology, gynaecology, venereology, psychiatry, cardiology, endocrinology, and primary care. The quality of care provided by these physicians has, therefore, been mostly unregulated and has only been demonstrable by audit, presentation of data at meetings, publication in peer-reviewed journals, and by the publication of guidelines by scientific societies (1,2).

One way of promoting high standards of medical care is by the regulation and assessment of education and training, regardless of the specialty (3). Thus, in 2011 on initiative of the European Society for Sexual Medicine (ESSM), the Union Européenne des Médecins Spécialistes (UEMS) established a Multidisciplinary Joint Committee on Sexual Medicine (MJCSM), which included representatives from the European Board of Urology (EBU), the European Board and College of Obstetrics and Gynaecology (EBCOG), and the UEMS Section for Psychiatry together with representatives of ESSM. Representatives from the European Board of Dermato-venerology (EBDV) joined in 2013 and UEMS Endocrinology (UEndo) joined in 2015. The primary purpose of the MJCSM is to develop the highest possible standards of training in sexual medicine in Europe.

In order to achieve this goal, beside the already running yearly ESSM School, a curriculum has been developed, educational standards for training set up, and an assessment framework — including development of an examination to become Fellow of the European Committee for Sexual Medicine (FECSM)— has been established (4). Concurrently with the creation of the MJCSM, the ESSM also initiated the ESSM Education Committee. The primary responsibility of this committee is to build an educational programme for different levels of professions in sexual medicine, to increase knowledge and quality of patient care, and to support trainees in sexual medicine by providing educational opportunities to help them to be successful in the examinations required to become a FECSM (3). Concerning this last objective, two clear outcomes show the process:

  1. the publication of The ESSM Manual of Sexual Medicine (5), indeed a world-wide unique opus, that covers all aspects of Sexual Medicine and should be considered a “must have” for all colleagues either interested in passing the European exam in Sexual Medicine or just in updating themselves in this special medical discipline to serve their patients with sexual problems at the highest available clinical standard in this field;
  2. the condensed 3 days Preparatory Course for the MJCSM certification, which takes place biannually, offering a focused overview of Sexual Medicine through lectures delivered by renowned experts and aimed directly at increasing the chance of success in passing the FECSM exam.
    Many efforts were done in these last 10 years to build educational courses for different levels of professions in sexual medicine and to increase knowledge and quality of patient care. Insights into the management of patients with sexual dysfunctions has advanced enormously in the past couple of decades and a multidisciplinary approach is accepted as the gold standard. That is why a sexual medicine physician with knowledge and skills drawn from clinical sexology, would be able to offer considerable benefits to patients.

About Sexology

The term Sexology includes the interdisciplinary science of sex but also the cumulated knowledge of sex that can be applied in professional practice — for example, in education, counselling, therapy, and treatment. The persons who are active in these domains of sexual issues are called sexologists. The comprehensive history of training in sexology in Europe remains to be written, but based on the available documentation, some important improvements in sexological education in many European countries took place especially in the 1970s. The pioneers of that era were usually members of the medical profession, that had not been formally educated about sexual issues but had studied it informally on their own (6). In most cases, the organizers of the initial efforts at formal education in sexual issues were national or local associations that tried to fill the gaps in sexual knowledge and related skills for social and health professionals, who were understood to represent a very important recourse in promoting sexual well-being. An important step in the European collaboration on sexology was the founding of the European Federation of Sexology (EFS) in 1988, one of the major interests since its foundation being the promotion of education and training for sexologists and other professionals with an interest in sexual issues. In 2006, training in sexology was one aim to emerge from the “Euro-Sexo” study conducted in seven European countries and coordinated by Alain Giami (7). The results from the data collected indicated that most sexologists were non-physician health practitioners and mainly women: mental health and public health nurses, midwives, marital counsellors, and psychologists, who were the most commonly represented professionals. Unfortunately, only a few reported that they had been able to fully implement their knowledge and skills in sexology and sexual issues. From that time on, many efforts have been done, above all by the scientific societies, to establish a clear curriculum and improve the quality of education in the field. Nevertheless, in Europe and worldwide we are still far from a homogeneous situation concerning training programs and high-qualification standards. What is clearer, is that sexologists can be divided into several professional specialties, with different definitions, backgrounds and competencies (8), within which those who need specific clinical training are the following:

Sexual Cousellor:
A person with recognized professional qualifications in one or more of the behavioural sciences and trained specifically in the practice of sexology as it applies to the provision of advice and guidance in personal, psychological, social or spiritual aspects of sexual life.

Sexual Psychotherapist:
A person with a recognised professional qualification in behavioural or clinical sciences, and trained specifically in the practice of sexology as it applies to the appropriate evaluation and psychotherapeutic treatment of sexual disorders.
The need of well-defined and identifiable certification of sexologists is necessary to provide informed choice for patients as well as to enhance the quality of care and facilitate collaborative and complementary work among specialists.

Concerning the recognition of Clinical Sexology specialists, no parallel system to the Union Européenne des Médecins Spécialistes exists for allied health professionals (AHPs) including psychologists; thus, the ESSM appointed a task force with the collaboration of the EFS for the development of similar accreditation processes (European Psycho- Sexologists Accreditation Committee – EPSA), in order to enable psychologists, psychiatrists, and MD with a training in psychotherapy to demonstrate their own competence in the field of sexology in a manner analogous to the FECSM examination and become an EFS & ESSM certified psycho- sexologist (ECPS) (9). Currently, this title is a “mark of excellence” to identify health care professionals who are trained and competent within the frame of a biopsychosocial approach to sexual problems. The EFS and ESSM aimed to provide candidates for the ECPS exam with educational support, beside the yearly ESSM School, in order to assist them in their preparation for the exam. The ESSM Educational Committee took a leading role in this by:

  1. publishing the EFS/ESSM Syllabus in Clinical Sexology, a comprehensive multi-author book covering all topics of the ECPS curriculum (10). This book reflects the knowledge of 61 experts with various scientific backgrounds, contributing to a synthesis of today’s state of the art knowledge on clinical sexology.
  2. organizing a preparatory course for the ECPS exam, aiming to provide lectures on a broad range of topics according to the ECPS curriculum. This is also a great opportunity for candidates from different countries to meet and liaise with each other.

Recalling The Problems That Remain Unmet

AWARENESS AND BASIC EDUCATION
Although the World Health Organization (WHO) includes sexual health in the definition of overall health, well-being, and quality of life, Sexual Medicine and Sexology remain still neglected by most European universities. However, plenty of studies have shown not only the high prevalence of sexual dysfunctions and their impact on intrapsychic, relational, and general health, but also the exquisite ability of the sexual dysfunctions themselves to predict or to be comorbid with a number of Non-Communicable chronic Diseases (NCDs). Finally, the traditional belief that sexology grounds more on opinions than on evidence is no more tenable, considering the significant scientific developments in this field during the last two decades, being a part of the mainstream science.

Therefore, considering the importance of sexual education and counselling in general health during the lifespan and in the large majority of diseases, the large and widespread interest in sexual health, and the need of patients to get professional care and help for their sexual concerns, problems and dysfunctions, the students of medicine, psychology, and health care professionals within various specialties must be prepared to deal with medical and psycho-social aspects related to general sexual health.

HIGH STANDARD OF CARE
To guaranty high level of care, standard education and training programs are needed and recognition of those who are qualified are mandatory.

Although several national scientific associations provide sexology courses for physicians and psychologists at different levels and quality, it is still difficult to find training programs in many countries, with expert and international well-known speakers. Many courses do not follow a biopsychosocial approach, meaning that they offer training from a medical point of view, neglecting psychological or cultural aspects involved in the onset of a sexual problem, or vice versa not considering the biological and medical part when teaching on sexual counselling/therapy.
Moreover, after an education course in sexual medicine or sexology, it could be arduous for one to find a good supervisor, with the amount of experience and clinical skills which are needed. Nevertheless, among the requirements to get qualified titles, individual or group supervision is almost always demanded.

SCIENTIFIC COMMUNITY
A community for sexual medicine and sexology is needed. Understanding why is important: these are multidisciplinary specialties and sexual health is an important aspect of quality of life. Our insight into the anatomy, physiology, psychology, pharmacology, pathophysiology, clinical features, and management of patients with sexual dysfunctions has advanced enormously in the past couple of decades, but sexual medicine and sexology remain fragmented and are practiced by doctors and psychologists who have very different backgrounds and expertise. A sexual medicine physician with knowledge and skills across the breadth of sexual medicine would be able to offer considerable benefits to patients. However, whether the full breadth of sexual medicine can be sensibly practiced by a single physician or therapist is debatable, and expecting all sexual medicine physicians to be able to operate on a penile deformity and also to be able to provide psychosexual counselling to couples is unrealistic. Such a physician could not realistically be trained, which means that we instead need to train several different types of sexual medicine physicians and sexologists, with different practical skills but with a common understanding of the nature of the field and — perhaps most importantly — with the ability to collaborate with each other. Furthermore, scientific improvement and achieving competence in daily clinical practice can only be accomplished through scientific societies that collaborate on national and international levels (2).

Ensuring the future of this important field means that involvement of young medical doctors and psychologists in education, research, and promotional activities is essential. This future generation has the opportunity to acquire the knowledge, skills, and attitude needed for clinical practice from recognized specialists in the field and also to shape their own future and the future of sexual medicine and sexology.

ESSM Contributions In Developing These Issues

Regarding the Awareness and basic training, in 2019 the ESSM brought out the need to improve the impact of Sexual Medicine and Sexology on academic and health care practice at the European level. Guiding this project, ESSM:

  1. endorsed the MJCSM, with the support of the UEMS and its boards involved in sexual medicine, for a petition to the European Parliament and European University Authorities that advocates the need of all students of the European medical schools to receive specific education and formal academic learning in sexual medicine (sign it at https://www.change.org/p/medical-faculties-and-european-union-sexual-health-education-to-all-medical-students-in-europe);
  2. involved the EFS in collaborating for a petition to the European Parliament and European University Authorities that advocates the necessity of all students of the European Psychological Faculties to receive specific education and training in sexual health and sexology by the next academic year (sign it at https://www.change.org/p/euopean-parliament-sexual-health-education-to-all-psychology-students-in-europe)

Hence, European medical school and psychology faculties should:

  • develop students’ knowledge and understanding about sexual function, gender identity, sexual orientation, and the diversity of human sexual expression and behaviour;
  • teach diagnosis and integrated therapies of the major sexual dysfunctions from early to old age;
  • recognize the role of sexual dysfunctions as an early biomarker for identifying NCDs
  • promote the role of medical doctors in Sexual Medicine and psychologists in Sexology and in the prevention of sexual dysfunctions;
  • improve student’s ability to communicate about sexuality and sexual health and about mutual respect of genders and sexual orientations.

Concerning high standard of care, the ESSM developed multidisciplinary training programs intended for clinicians seeking to acquire the knowledge and skills necessary for practice (ESSM School of Sexual Medicine) or to gather advanced knowledge and improve skills (ESSM Advanced Course) in Sexual Medicine and Clinical Sexology, in the frame of the biopsychosocial approach. The International Society for Sexual Medicine (ISSM) and the European Federation of Sexology (EFS) support the School by giving grants for participants coming from developing country or in financial strain. The School program is intended for persons with post-graduate experience in any relevant clinical specialism. Interest in and enthusiasm for Sexual Medicine are the essential qualifications; whilst previous experience in the clinical practice of Sexual Medicine is an advantage, the program is also suitable for those starting out in this fascinating and rapidly developing area of medicine. Psychologists and therapists are welcome to join the program as well and special skills in surgery or psychotherapy are not a requirement for participation. The 10 days residential courses cover a wide range of Sexual Medicine and Clinical Sexology topics and provides the essential background learning from which clinical experience and research can be developed. Professionals who intend to apply for the Advanced course (a novelty of 2019) should have more than 5 years working clinically in Sexual Medicine or Clinical Sexology and attended specific training in Sexual Medicine/Clinical Sexology or ESSM school, plus work in multidisciplinary team or already FECSM or ECPS.

Beside knowledge and skills, these courses aim to offer an “precious experience”, both from a professional and a personal point of view that is quite unique: participants are exposed to a multicultural and multidisciplinary context (specialists coming from all over the world), with an estimated and well-known faculty available to share the clinical experience through lectures, workshops, supervision of clinical cases and role-plays. The social gathering allows participants and speakers to networking and hopefully keeping in contact far beyond the course attendance. This special opportunity is the most appreciate and acknowledged by participant’s feedbacks in the last 7 years, presented officially each year during the ESSM annual congress.

Since 2018 ESSM devoted much energy and financial resources to support recognition of the profession by the European authorities. A task-force with representatives of the ESSM has been established to seek protection of the professional title among the European Commission and highlighting the importance of Sexual Health for quality of life.

Last, but not least, about the Scientific Community, in 2017, the ESSM launched the Young Sexual Medicine Academy (YoSeMa), a new committee to involve young health-care professionals in the field of sexual medicine. YoSeMa aims to promote sexual medicine among young clinicians (up to 40 years old) from various disciplines in order to increase knowledge and skills, to connect residents and young scientists with established specialists, and to define the needs of early- career sexual medicine specialists and sexologists. The committee recognize the difficulties of working within the sexual medicine field, like, isolation in the workplace, difficulty in finding multidisciplinary teams to work with, or lack of established connections to ensure continuing medical education. Therefore, YoSeMA aims to engage young health professionals with an interest in sexual health, to foster networking and education, support the goals of, as well as providing a bridge to ESSM activities. The term ‘young’ is somewhat misleading; in this context it applies to clinicians and researchers at the beginning of their medical career and is not that relevant to age. Eventually, YoSeMa is also in charge of creating initiatives to raise awareness of the specialty as a career option and encourage newly qualified medical doctors and psychologists to consider it.

Conclusion

The vision of ESSM is that Sexual Health will be for everyone and our mission is to promote the highest standards of evidence based sexual medicine clinical care through education, research and the formulation of health care. As describe above, tremendous efforts have been done to achieve these targets in the last decade.

The visionary view of ESSM’s executives have led to an increase in scientific work and knowledge of sexual medicine and to the creation of high-level educational opportunities.

Through education, training, supervision and certification a lot has been done but there is still a way to go to achieve ESSM’s vision and mission. Ultimately, we hope to achieve full recognition of the profession which in turn will ensure high quality of care and patient safety.

References

1. Schultheiss, D., Glina, S. in The ESSM Syllabus of Sexual Medicine (Porst, H., Reisman, Y., eds.) Amsterdam: Medix; 2012:13–28.
2. Eardley, I. A curriculum for sexual medicine? J Sex Med. 2009 6:1195–1198.
3. Reisman Y, Eardley I, Porst H, and the Multidisciplinary Joint Committee on Sexual Medicine. New Developments in Education and Training in Sexual Medicine. J Sex Med. 2013 Apr;10(4):918-23.
4. Reisman, Y., Sarikaya, S. Ensuring a bright present and future for sexual medicine. Nat Rev Urol. 2018 Sep;15(9):523-524.
5. Reisman Y, Porst H, Lowensten L, Tripodi F, Kirana, PS, eds. The ESSM Manual of Sexual Medicine. Amsterdam: Medix; 2015.
6. Kontula, O. An Essential Component in Promoting Sexual Health in Europe is Training in Sexology. International Journal of Sexual Health. 2011;23:168-180.
7. Giami, A., De Colomby, P., & Groupe Euro-Sexo. Sexology as a profession in Europe: Diversity and common perspectives. Sexologies, 2006;15:7–13.
8. World Association for Sexual Health (WAS). Definitions of professional specialties. Definitions accepted by the WAS General Assembly, April 17th, 2007, Sydney Australia.
9. Lowenstein L, Tripodi F, Reisman Y, Paraskevi SK, Simonelli C, Porst H; EFS/ESSM Exam Committee. EFS/ESSM-Certified Psychosexologist with mark of excellence. J Sex Med. 2014 Sep;11(9):2141-2.
10. Kirana PS, Tripodi F, Reisman Y, Porst H, eds. The EFS and ESSM syllabus of clinical sexology. Amsterdam: Medix; 2013.

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