Introduction There are limited outcome data on the efficacy of psychological interventions for male and female sexual dysfunction and the role of innovative combined treatment paradigms. Aim To highlight the salient psychological and interpersonal issues contributing to sexual health and dysfunction; to offer a four-tiered paradigm for understanding the evolution and maintenance of sexual symptoms; and to offer recommendations for clinical management and research. Methods An International Consultation assembled over 200 multidisciplinary experts from 60 countries into 17 committees. The recommendations of committee members represent state-of-the-art knowledge and opinions of experts from five continents were developed in a process over a 2-year period. Concerning the Psychological and Interpersonal Committee of Sexual Function and Dysfunction, there were nine experts from five countries. Main Outcome Measure Expert opinion was based on grading of evidence-based medical literature, widespread internal committee discussion, public presentation, and debate. Results Medical and psychological therapies for sexual dysfunctions should address the intricate biopsychosocial influences of the patient, the partner, and the couple. The biopsychosocial model provides a compelling reason for skepticism that any single intervention (i.e., a phosphodiesterase type 5 inhibitor, supraphysiological doses of a hormone, processing of childhood victimization, marital therapy, pharmacotherapy of depression, etc.) will be sufficient for most patients or couples experiencing sexual dysfunction. Conclusions There is need for collaboration between healthcare practitioners from different disciplines in evaluation, treatment, and education issues surrounding sexual dysfunction. In many cases, neither psychotherapy alone nor medical intervention alone is sufficient for the lasting resolution of sexual problems. Assessment of male, female, and couples’ sexual dysfunction should ideally include inquiry about: predisposing, precipitating, maintaining, and contextual factors. Treatment of lifelong and/or chronic dysfunction will be different from acquired or recent dysfunction. Research is needed to identify efficacious combined and/or integrated treatments for sexual dysfunction.

IntroduçãoNo século XX, o comportamento sexual tornouse objeto de estudo empírico, afastando-se da classificação nosológica médica de crimes e perversões sexuais que abundaram no século anterior. Um desses marcos são os estudos de Kinsey, que na década de 1950 promovem essa ruptura ao desenvolver inquéritos populacionais sobre comportamento sexual na população geral, deixando assim de lado a idéia de "desvios sexuais" 1 . No Brasil, as pesquisas sobre comportamento sexual sofrem um incremento e interesse especialmente após o advento da AIDS. As mudanças sociais advindas após essa epidemia mobilizaram a comunidade acadêmica e se tornaram prioridade de pesquisa no campo sócio-antropológico 2 .Nesse aumento do interesse pelo tema, porém, prevaleceu, até o momento, o enfoque na sexualidade masculina 3 . A maior disponibilidade de tratamentos para disfunção erétil com intensa exposição da disfunção sexual masculina aumentou a procura de homens por consulta e tratamento, o que abriu caminho também para discussão da sexualidade feminina 4 . Contudo, embora haja cada vez mais estudos, ainda hoje pouco se conhece sobre a epidemiologia das disfunções sexuais femininas 5,6 , e poucos tratamentos estão disponíveis para as mulheres em comparação com os homens 7 . ARTIGO ARTICLE 416Cad. Saúde Pública, Rio de Janeiro, 24(2):416-426, fev, 2008

The commonly used Standards of Care for people with gender dysphoria, including those of the World Professional Association for Transgender Health and The Royal College of Psychiatrists in the United Kingdom, as well as those standards used in many other countries, usually require that two signatures of approval from qualified mental health professionals be provided before genital reconstructive surgery (GRS) À sometimes called sexual reassignment surgery or gender confirmation surgery À is undertaken. This is different from surgeries which are similarly irreversible and remove reproductive capacity carried out on cisgender people. This paper explores the transspecific issues from a standpoint of medical ethics and argues that, provided sufficient safeguards are in place, including assessment within a multidisciplinary team, a nuanced approach utilising a single signature may instead be appropriate.

While psychological issues are present in most patients with premature ejaculation (PE), whether as a cause or a consequence of the disorder, the effectiveness of psychological intervention for PE is not clear. Searches of the MEDLINE, EMBASE, PsychINFO, LILACS and the Cochrane Library electronic databases find little high-quality evidence for the psychosexual and behavioral approaches to treatment of PE. Five randomized and four quasi-randomized trials were included in this Review. Little evidence was found that psychological interventions are effective in the treatment of PE. Three studies showed strong evidence in support of improved intravaginal ejaculatory latency times following psychosexual therapy combined with pharmacotherapy, compared with monotherapy. One study found that functional-sexological treatment markedly improved duration of intercourse, sexual satisfaction, and sexual function. Limitations of published studies include a lack of randomization, uncertain clinical significance of outcomes, absence of compelling follow-up data that show long-term response and lack of reproducibility. Randomized trials with large sample sizes are still needed to expand the currently available evidence on psychological intervention for treating PE. Besides examining the main effects of treatment, trials in this field should also address the complex interactions between patient characteristics, PE subtype and treatment approach.

O paciente homem que procura diagnóstico e tratamento para disfunções sexuais pode ter em mente possíveis razões causais para tais dis- funções. Essa crença prévia da etiologia da disfunção erétil secundária pode relacionar-se com a aceitação dos possíveis tratamentos, para o que estudou-se retrospectivamente 201 pacientes através das informações obti- das nas entrevistas de anamnese e psicológica, parte de diagnóstico multidisciplinar daquela queixa. A etiologia mais referida pelo paciente foi a orgânica (57%), seguida da psicológica (40,46%). A psicoterapia, ou terapia sexual, foi indicada a 61% dos pacientes, sendo aceita por 56%; a aceitação maior deu-se entre os pacientes que se outorgavam causas sócio-educacionais (100%), psicológicas (61%), que não tinham hipóteses a priori (60%) ou mistas, orgânicas e psicológicas (55%). A prótese peniana foi proposta a 20% dos pacientes,sendo aceita por 45%, mormente entre os pacientes que se outor garam causas sócio-educacionais (100%), mistas (60%) ou orgânicas (56%).Os tratamentos mais aceitos entre os homens com disfunção erétil secundária são os menos agressivos e que envolvem menor tempo para a solução do problema. Assim, a revascularização, a prótese e a psicoterapia receberam menor aceitação. Medicações e hormônios são os tratamentos mais aceitos. Sob tais condições, os profissionais da área têm que lidar com situações extremamente sedutoras, em que paciente aceita nem sempre o que lhe seria adequadamente indicável.