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It is increasingly realized that discussing sexuality is an important issue in the holistic care for cardiac patients. In this review article, the conditions of a good assessment of sexual problems are identified such as creating an appropriate environment, ensuring confidentiality, and using appropriate language. Second, we present different styles and approaches that can be used to start the assessment, differing between settings, persons, or disciplines. The PLISSIT (permission, limited information, specific suggestion, and intensive therapy) model can be helpful to initiate discussion about sexuality with the cardiac patient and his/her partner. This model is a stepwise approach using various levels of discussion or treatment. Open-ended question can facilitate discussion about sexual concerns, and validated questionnaires or diaries can be used to assess sexual problems. Patients with sexual concerns and problems should be counseled and/or treated appropriately, and adequate follow-up is needed. Additional training and research are needed to further improve the quality of sexual assessment and counseling in cardiac patients.

The older generation of patients with haemophilia still has musculoskeletal problems which limit activities and participation. One important aspect of male aging is the changes in sexuality. Sexual desire can be disturbed by fatigue, low testosterone or pain. Sexual excitement (erection) may be influenced by diabetes mellitus, arteriosclerosis, hypertension and side effects of antihypertensive and antiviral medication. Sexual response problems can be caused by antidepressant medication. In aging haemophiliacs arthropathy, iliopsoas muscle bleeding, chronic hepatitis C and HIV medications influence sexuality. The haemophilia care professionals should communicate proactively, give information on various practical aspects of sexuality (suggest suitable positions, recommend painkillers, reflect on prescribing erection-enhancing medication, refer to a sexology expert).

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Dealing with sexual problems due to disease or disability is part of medical rehabilitation, but both patients and professionals experience barriers to discuss sexual issues. A brief discipline-specific sexological training for rehabilitation professionals was therefore developed and evaluated in two rehabilitation centers in The Netherlands. Among the 283 participants were physicians (42), physical therapists (38), occupational therapists (40), psychologists and social workers (26), nurses (101), and other disciplines (36). Measurements before training, after training, and at 3-4 months follow-up showed increase of self-rated sexological competence and of scores on the Knowledge, Comfort, Approach, and Attitudes towards Sexuality Scale (KCAASS) during the training that were maintained at follow-up. Disciplines differed in sexual competence before training and in increase of sexual competence after training. Implementation of the training in other rehabilitation centers is recommended.

Rehabilitation sexology addresses the sexual difficulties of physically disabled people. Sexual dysfunction is prevalent among the patient population of rehabilitation clinics, which work with physical problems such as spinal cord injury, stroke and multiple sclerosis. However, the majority of rehabilitation professionals find sexuality and the sexual issues of their patients difficult to address. Two different surveys showed that 73% of patients, 59% of their partners and 67% of rehabilitation professionals considered sexuality an important topic to discuss. By contrast, only 12% of the professional staff considered themselves sufficiently trained to broach sexual problems with their patients. Motivated by these findings, we developed two different trainings for rehabilitation professionals. The first was discipline-specific, grouping individuals of the same discipline together, and the second was designed for the multidisciplinary rehabilitation team. The results of the training showed an increase in the health professionals' relevant knowledge, in their ability to recognise patients' sexual problems and in their skills in broaching and discussing sexual issues. These improvements had not diminished at the follow-up measurement. We consider this training method, developed for the rehabilitation setting, to be applicable in other settings, such as oncology and psychiatry.

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This article describes the outcome of a behavioral approach with or without preceding surgical intervention in 48 women with the vulvar vestibulitis syndrome. In the first part of the study, 14 women with the vulvar vestibulitis syndrome were randomly assigned to one of two treatment programs: either a behavioral approach or a behavioral approach preceded by surgery. In the second part of the study, 34 women and their partners were given a choice of treatment. Follow-up data were gathered a mean of 3 and 2 1/2 years after treatment, respectively. In the randomized patient population, the intervention had a positive effect on all of them: the complaints disappeared, diminished or did not change but formed less of a problem. The difference in outcome between the two different treatments, a behavioral approach with or without preceding surgery, was not statistically significant. In the second non-randomized part of the study, 28 out of the 34 women (82%) chose the behavioral approach without preceding surgery. The difference in outcome between the two treatments was not statistically significant. Two out of the 28 women who chose behavioral treatment without preceding surgery had to be referred for psychiatric consultation because of serious psycho-sexual problems. In one woman, psychiatric treatment was successful. Three other women, whose behavioral treatment failed, underwent additional surgery, which clearly helped them to overcome the deadlock in the behavioral approach. The behavioral approach should be the first choice of treatment for the vulvar vestibulitis syndrome. Surgical intervention should be considered as an additional form of treatment in some cases with the vulvar vestibulitis syndrome to facilitate breaking the vicious circle of irritation, pelvic floor muscle hypertonia and sexual maladaptive behavior.