The present chapter outlines the sexual aftermath of cancer treatment and strategies for improvement. Sexual dysfunction is underdiagnosed and undertreated after surgery, chemotherapy, radiation, and hormone-modulating therapies. The treatment of genitourinary syndrome of menopause (GSM) is multimodal and includes behavioral modifications, local therapy, and physical therapy. Vaginal estrogen should be first-line treatment for GSM in women with hormone non-responsive cancer. For those with ovarian, endometrial, and breast cancer, vaginal estrogen may be considered with persistent symptoms after regular use of non-hormonal moisturizers. As an alternative, vaginal androgens may be of utility in improving libido and vaginal health. The authors do not endorse the use of compounded formulas due to a lack of formula standardization and a dearth of safety and efficacy data. Vaginal lasers, including CO2 lasers, are discouraged after two sham-controlled randomized trials found they were not effective, and adverse events have been reported in women with cancer. Dyspareunia is common, especially if encountered in the setting of radiation-induced vaginal stenosis. Treatment may involve addressing GSM, serial vaginal dilation, pelvic floor therapy, and/or psychological therapy. In those with low sexual desire, filbanserin and bremelanotide are novel FDA-approved therapies with central mechanisms that may change the landscape for treating female sexual desire disorders.

Improvements in multimodality treatment of anal and colorectal cancer has led to increased numbers of women survivors who experience gynecologic problems in long-term survivorship. The etiology of gynecologic problems after anal and colorectal cancer treatment is complex and multifactorial. Pelvic radiation, surgery and chemotherapy can all cause anatomic, hormonal and psychological changes. Consideration of preventative measures can ideally reduce the risk of vaginal stenosis, dyspareunia, sexual dysfunction, infertility, premature menopause and pelvic pain after therapy. Proactive screening and appropriate treatment of cancer therapy late effects can improve patients’ quality of life during survivorship.

Which SSRI has the longest half-life and least likely chance of producing withdrawal upon cessation?

Which of the following are a common cause of sexual problems in patients with depression?

Surgical correction of Peyronie’s disease remains the gold standard of treatment. The goals of surgery should be cosmetic improvement and the preservation or restoration of sexual function. Preoperative workup should include objective assessment of both curvature and erectile function, and shared decision-making with the patient to clearly understand expectations for surgery is critical, as there is a risk of penile shortening and erectile dysfunction with any Peyronie’s surgery. Peyronie’s surgeries fall into three broad categories: plication procedures, plaque incision and grafting, and placement of a penile prosthesis. While direct comparative studies are rare, plication surgeries are the most commonly performed, as they are technically simpler and have excellent satisfaction rates. Grafting techniques are most indicated for more severe cases. Prosthetic placement is appropriate for patients with concurrent erectile dysfunction, and placement alone can correct cases of mild curvature. Additional techniques to straighten the penis can be employed if needed.

A diagnosis of infertility in the male or female partner within a couple can cause significant stress, leading to sexual dysfunction in either or both partners. The causes of infertility and the related sexual dysfunction can be organic or psychosocial in nature but are frequently linked. Here, we discuss the interplay between infertility and sexual dysfunction, specifically in the man and the couple, and focus on psychosocial interventions for the couple as they struggle to build their family.

This chapter describes pseudoscience and questionable ideas related to sexual interest/arousal disorder, orgasmic disorder, genito-pelvic pain/penetration disorder, hypoactive sexual desire disorder, erectile disorder, premature ejaculation, and delayed ejaculation. The chapter opens by discussing questionable assumptions and models such as the four-stage sexual response cycle. Diagnostic controversies are also considered. Dubious treatments include historical quack medicine cures, jade eggs, vaginal steaming, penile enlargement, and aphrodisiacs. The chapter closes by reviewing research-supported approaches.

Sexuality, including sexual functioning, is an important part of health and well-being. Sexual dysfunction is the persistent impairment in a domain of sexual function (desire, arousal, or orgasm) or sexual pain that is associated with significant personal distress. The relationship between infertility and sexual dysfunction is not well understood, though evidence suggests that this relationship is likely bidirectional and individuals with infertility have higher rates of disruptions in sexual functioning. The etiology of male and female sexual dysfunction is most commonly multifactorial and treatment for sexual dysfunction typically requires an interdisciplinary approach. Routine screening for sexual dysfunction is recommended. Infertility mental health professionals are well-suited to screen for sexual dysfunction, and therapeutic interventions for the management of sexual dysfunction exist. Commonly used existing approaches that are summarized here include cognitive–behavioral therapy, sensate focus sex therapy, mindfulness-based behavior therapy or mindfulness-based cognitive–behavioral therapy, and directed masturbation training.

How to talk about variations in sex development is a major theme for impacted individuals and families. This is the topic of Chapter 12. The author summarizes the research literature with caretakers and with adults about the difficulties of disclosure. Considerable criticism has been levied at health professionals for failing to role model affirming communication. For sure there are gaps in health professionals’ talk, but the biggest contributor to the difficulties is to do with the widespread misunderstanding about the biological variations. Psychological care providers are not there to put a cheerful gloss over clients’ negative expressions. However, they can be part of the favorable social condition in which a wider range of meanings about bodily differences are negotiated. In the practice vignette, the author highlights how tentative and uncertain the enabling process is, where a negative view of sex variations is still widely endorsed in the social context.

In a gendered world, doctors and caretakers took for granted that making atypical bodies more typical was a humane way out of a difficult situation for child and family. Had the professionals carried out proper research, they would have learned from their young patients that the approach was physically and psychologically risky. But research on the long-term effects was not carried out, certainly not from the patients’ perspective. There was also no comparison group made up of people growing up with unaltered genital variations. Research with adults is the topic of Chapter 4 of this book. Since the 1990s, a number of outcome studies with adults have identified many problems of childhood surgery, such as multiple operations, scarring, shrinkage, sensitivity loss, unusual genital appearance and sexual difficulties.

Difficulties with communication about bodily differences are strongly linked to sexual experiences. In Chapter 13, the author critiques the dominant ways of talking about sexuality in the wider society. These oppressive ideas can give rise to insecurities, self-objectification and body shame for people in general. Adults who have been medically managed are particularly vulnerable to the effects of objectification and shame. The author outlines typical components of sex therapy programs. However, rather than fix sexual problems, which can perpetuate people’s sense of inadequacy, the author suggests that psychological care providers support clients to process any trauma and develop a more relaxed and appreciative relationship with the body. This work, which requires generic therapy knowledge and skills, can be integrated with a range of specific sex therapy techniques and resources to reimagine a sexual future that focuses on bodily pleasure rather than gender performance. Although the practice vignette is built around a female couple, one of whom has partial androgen insensitivity syndrome, the care principles have wide applications for people with variations more generally.

Inconsolable distress is neither a universal nor inevitable response to inability to have biological children. In Chapter 14, the author criticizes research with clinic samples that has produced a problem-saturated account of childlessness that obscures a wide range of alternative responses. The author examines the influence of pronatalist ideology on people who are impacted by infertility including many people with sex variations. Away from the treatment context, psychological input can guide individuals, couples and groups to explore personal meaning of nonparenthood. It can facilitate service users to grieve for what is not possible, challenge feelings of deviance and shame, reengage with a range of life goals and, perhaps most important of all, recast adult identities. Through the practice vignette built around a heterosexual couple, one of whom has a late diagnosis of Klinefelter syndrome, the author teases out the difficulties of working psychologically in a treatment context, where complex existential issues and relational dynamics are compressed into the frame of pressurized treatment decisions.

Psychological care is endorsed in DSD medicine. Psychosocial research has been on the increase. But these positive moves have not given psychological practice the kind of collective focus that is enjoyed by the biomedical disciplines. However, psychological care providers have a wide variety of thinking tools and practice techniques to draw on, if to work in an ad hoc way at times. These tools and techniques do not change, but some are more useful and relevant than others for this service context. In Chapter 7, the author discusses the strengths and weaknesses of key theoretical frameworks in healthcare psychology. A major weakness of the individualistic models is their lack of capacity to address structural inequalities in psychological wellness and distress. The author introduces aspects of the Power Threat Meaning Framework and describes how to draw from its theoretical richness to think systemically about what sex variations pose to individuals and families in the social context and how they are responded to. The Framework provides the theoretical backbone for some of the practice vignettes in the final section of the book (Chapters 9–14).

In the 1990s, some former patients mounted street protests in front of medical conferences to draw attention to their trauma. They reclaimed intersex as a personal identity and campaigned for healthcare reform. These developments are the focus of Chapter 5. Intersex is coming out of the closet more and more, through being a topic in television documentaries, novels, films and art. Intersex activists challenge medical authority to change practice. Furthermore, they are not waiting for doctors and scientists to come to their viewpoints. They have successfully lobbied human rights agencies to position childhood genital surgery as a violation of their human rights. They demand that surgery is delayed until the child can give informed consent or is at least old enough to participate in the discussion and offer their agreement.

Sexual behavior in pregnancy is affected by many factors, including biological, psychological, social, and environmental, that vary throughout its course. To assess the demographics of sexual behavior in pregnancy, several research tools have been developed. The Female Sexual Function Index (FSFI) is a brief self-report measure that is commonly used to assess female sexual function in research studies. In general, the literature has shown that sexual frequency and sexual function decline over the course of pregnancy. Most studies demonstrate a decrease in the first trimester, no change or an increase in the second trimester, and then a sharp decrease in the third trimester and early postpartum period. In order to address the decline in sexual function over the course of pregnancy, it is important to understand and recognize the factors contributing to sexual dysfunction in pregnancy. Some of these factors include discomfort, nausea, fatigue, fear of harming the fetus or causing infection, and negative self-perception. Physicians should create a supportive environment in which patients feel comfortable discussing their concerns regarding sexuality in pregnancy. Exploring and addressing patient fears may alleviate unnecessary abstinence and the associated stress this places on a relationship.