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In some parts of the World, one can barely imagine that a woman could have a sexual relationship with another woman. However, in other countries, same-sex marriage has become accepted and legalised.As a logical part of that social and legal development, lesbian couples can decide on pregnancy and motherhood. This chapter will deal with relevant aspects of sexuality and reproductive options in lesbian couples who have decided to start a family with their own children. At first, some information is shared on the prevalence of lesbianism and lesbian motherhood and then on the marital and reproductive rights of women with a non-mainstream orientation.In the next part, the chapter will pay attention to the phase of decision, conception, and beyond. It will also make recommendations on providing good care to the lesbian couple, especially concerning sexuality. Those lessons are relevant for everyone, especially for HCPs in cultures where people have not yet developed a greater degree of acceptance (and respect) for lesbian women.This chapter is part of ‘Midwifery and Sexuality’, a Springer Nature open-access textbook for midwives and related healthcare professionals.

The majority of women treated for primary breast cancer (BC) will receive adjuvant endocrine treatment (AET). A treatment, which has several side effects with a varying degree of severity. In some cases, they result in impaired quality of life of the breast cancer survivors (BCS). For younger BCS, these side effects are often augmented by the fact, that premenopausal women may turn postmenopausal by the adjuvant chemotherapy. Among the most common side effects are hot flashes, sweating, vaginal dryness and arthralgia. Sexual problems are also common; however, sexual dysfunction (SD), defined as impairments in sexual function causing personal distress, are inadequately described among BCS on AET. Hence, SD may be underreported in both clinical studies and the daily clinic. The primary aim of this study was to estimate the prevalence of clinically relevant SD and to identify possible predictors of SD among BCS on AET. We conducted a cross-sectional survey among BCS who have been treated with AET's for more than 3 months, with no actual signs of recurrent disease and no previous cancer diagnosis. The survey consisted of questions regarding demographic factors, present and previous symptoms. The following validated questionnaires were used: Female Sexual Function Index (FSFI), Sexual Complaint Screener - Women (SCS-W), Beck Depression Inventory (BDI), International Consultation on Incontinence Modular Questionnaire - Female Sexual Matters associated with Lower Urinary Tract Symptoms (ICIQ-FLUTSsex) and subscales of the Cancer Rehabilitation Evaluation System (CARES). Additionally, data concerning tumor characteristics and cancer treatment were collected from the medical records. In total, 333 women with a mean age of 58.7 years were included in the study, of which 227 were sexually active. All were heterosexual. In the entire cohort, the most prevalent impairments were low libido (54%), anorgasmia (26%) and lack of arousal (25%). Although dyspareunia was the least frequent impairment reported by BCS (21%), it was the most distressing symptom. Urogenital symptoms were common with 47% of the women reporting vaginal dryness and 38% reporting pain with sexual intercourse. The sexually active BCS were younger, more often partnered, and more satisfied with their sexual life before the cancer diagnosis than those women being sexually inactive. Among the 227 sexually active women, 134 (59%) qualified for having SD. Of these 134 women, 78 (58%) perceived the cancer treatment as the primary reason for their sexual problems. In a multivariate analysis, the risk of having SD was significantly associated with experiencing more vaginal dryness and less psychological well-being. Whereas age, relationship satisfaction and duration of AET were not significantly associated with the risk of having SD. In conclusion, SD was highly prevalent among sexually active BCS on AET and was perceived as a long-term side effect of BC treatment by two thirds of BCS with SD. Vaginal dryness was the strongest predictor of SD. Of note, age was not related to neither prevalence of SD nor the degree of distress caused by the impairments. Hence sexual health is an important topic for BCS and should be addressed by the clinicians at follow up visits of BCS independent of their age. Citation Format: Mia F Andersen, Astrid Højgaard, Charlotte B Rotboel, Anders Bonde Jensen. Sexual dysfunction among breast cancer survivors in adjuvant endocrine treatment [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P2-13-14.

Background Persons with assigned male sex at birth (AMAB) might wish to obtain feminization and/or demasculinization according to the person's gender identity and are therefore treated with estradiol and/or antiandrogens. Aim The aim was to evaluate biochemical changes and side effects in AMAB individuals treated with guideline-based feminizing hormone treatment (FHT). Methods Medical charts of 99 AMAB individuals ≥ 18 years referred to the Center for Gender Identity; Aalborg University hospital, Denmark, between January 2017 and July 2019 were reviewed to identify adverse side effects. Furthermore, data from the laboratory information system (Labka II) were retrieved to obtain biochemical parameters. Biochemical plasma concentrations after initiation of FHT were compared to concentrations prior to FHT and to existing guidelines. Outcomes After 11–19 months, 29% of the trans feminine individuals had plasma estradiol concentrations within the treatment target. Results The plasma concentration of estradiol varies greatly during FHT. Plasma levels of estrogen were within the treatment target after 11–19 months of treatment, whereas 100% had concentrations within the reference range for premenopausal cis-women. Furthermore, plasma concentrations of lipids and hematological parameters approached female reference ranges after 11 months of FHT. Clinical Implications The target levels of plasma estradiol concentrations during FHT could be expanded, making the wanted physiological changes easier to obtain. Strengths & Limitation This cohort study included 99 AMAB individuals and biochemical evaluation was possible in 67 individuals. Only one individual was lost during follow-up. However, the follow-up period was limited making evaluation of long-term side effects impossible. Conclusion Plasma concentration of estradiol varies greatly during guideline based FHT, making plasma estradiol levels within the target level difficult to attain.

Background The demand for gender-affirming hormone therapy is increasing worldwide prompting a growing requirement for solid evidence for efficacy and safety. Aim We aimed to report on the organization of transgender care and the current clinical practice of feminizing hormone therapy in specialized clinics in the Nordic countries. Methods This study was a cross-sectional study performed as a questionnaire survey. A quantitative questionnaire was sent to 15 specialized clinics prescribing feminizing hormone therapy in the Nordic countries. Outcomes Twelve clinics responded to the inquiry. RESULTS The answers showed great variance in both number of clinics in each country as well as number of doctors responsible for prescribing gender-affirming hormone therapy. There was great difference in the width of the target ranges for estrogen plasma concentrations and in preferred route of administration for estrogens. Likewise, the risk assessment and monitoring of side effects were diverse. Clinical Implications To gather solid data on efficacy and safety of feminizing hormone therapy, the treatment regimens and the recording of side effects need to be consistent across the clinics responsible for the treatment of transfeminine patients. Strenghts & Limitations: This is to our knowledge the first report on treatment regimens for feminizing hormone treatment in the Nordic countries. The response rate was 80%; however, the included clinics only cover approximately 30% of the expected numbers of transfeminine individuals. CONCLUSION Despite the great diversity across clinics as regard to organization of clinics and to treatment regimens, the vast majority of clinics operated within the guidelines defined by The Endocrine Society.

BACKGROUND: Impairments in sexual function are common among breast cancer survivors (BCSs), particularly in BCSs receiving adjuvant endocrine therapy (AET). Whether these impairments cause distress, thus qualifying for a more clinically relevant diagnosis of sexual dysfunction (SD), is inadequately described among BCSs and represents an important research gap. Hence, the primary aim of this study was to estimate the prevalence of clinically relevant SD, in this context: impairments with associated distress, and to identify factors associated with SD among BCSs on AET. Secondly, to explore the extent of distress caused by specific impairments in sexual function.MATERIALS AND METHODS: In this cross-sectional study of BCSs on adjuvant treatment with endocrine therapy for at least three months, participants completed an online survey comprising standardized measures of sexual and psychosocial function. Female Sexual Function Index (FSFI) and Sexual Complaint Screener - Women (SCS-W) were used to asses clinically relevant SD. Multiple regression analyses were performed to identify factors significantly associated with SD.RESULTS: In total, 333 BCSs with a mean age of 58.7 years were included in the study, of whom 227 were sexually active. Among sexually active BCSs, 134 (59%) met the criteria for having clinically relevant SD, of whom 78 (58%) perceived cancer treatment as the primary reason for their sexual problems. Factors associated with SD included vaginal dryness (adjusted OR= 2.25, 95% CI: 1.52-3.34, p CONCLUSION: SD was highly prevalent among sexually active BCSs on AET. Sexual health is important to address independent of the woman's age.

Objective: The quality-of-life concept has increasingly gained attention, but an important aspect has been neglected, which is the sexual function of patients with kidney cancer after surgery. The aim of this study was to explore the impact of nephrectomy on sexual function in patients with kidney cancer and the information patients received with this regard. Material and methods: We conducted a retrospective study of patients who underwent nephrectomy or nephro-ureterectomy within a 5-year period at the Department of Urology, Odense University Hospital, Denmark. Among 310 patients having undergone surgery, 226 were still alive and eligible for participation. Their records were reviewed, and a validated questionnaire concerning their sex life was mailed to them. All participants were invited to take part in a semi-structured interview in person or by phone. Results: Of 154 former patients who replied, 95 were men (mean age, 66 years, range 37–89), 59 were women (mean age 63 years, range 26–87). A significant difference was observed regarding problems with sexual relationships prior to operation compared after (P

Background Neonatal male circumcision is a painful skin-breaking procedure that may affect infant physiological and behavioral stress responses as well as mother-infant interaction. Due to the plasticity of the developing nociceptive system, neonatal pain might carry long-term consequences on adult behavior. In this study, we examined whether infant male circumcision is associated with long-term psychological effects on adult socio-affective processing. Methods We recruited 408 men circumcised within the first month of life and 211 non-circumcised men and measured socio-affective behaviors and stress via a battery of validated psychometric scales. Results Early-circumcised men reported lower attachment security and lower emotional stability while no differences in empathy or trust were found. Early circumcision was also associated with stronger sexual drive and less restricted socio-sexuality along with higher perceived stress and sensation seeking. Limitations This is a cross-sectional study relying on self-reported measures from a US population. Conclusions Our findings resonate with the existing literature suggesting links between altered emotional processing in circumcised men and neonatal stress. Consistent with longitudinal studies on infant attachment, early circumcision might have an impact on adult socio-affective traits or behavior., Psychology; Clinical research; Neonatal pain; Attachment style; Empathy; Personality; Stress; Sociosexuality.

Background: Women with inflammatory bowel disease (IBD) may have decreased sexual function. To understand how common this condition is in our female patients, we developed a new IBD-specific Female Sexual Dysfunction Scale (the IBD-FSDS).Methods: We performed a prospective cross-sectional study of 454 female IBD patients ≥18 years of age attending 1 of 3 IBD clinics in the United States or Denmark. We gathered information on sexual function via a de novo 23-item scale. General sexual functioning was measured with the Female Sexual Function Index (FSFI) and the Female Sexual Distress Scale-Revised (FSDS-R). Depressive symptoms were measured with the Patient Health Questionnaire-9 (PHQ-9). Medical history and sociodemographic data were collected via chart review. Exploratory factor analyses (EFAs) of the English language version of IBD-FSDS assessed unidimensionality, factor structure, reliability, criterion validity, and construct validity.Results: EFAs suggested retaining 15-items creating a unidimensional scale with strong internal consistency reliability (α = 0.93). Validity of the English language IBD-FSDS was measured using Spearman's coefficient, demonstrating significant criterion validity with the FSDS-R (P < 0.05) and the FSFI (P < 0.05) and significant construct validity with the composite for cases of active IBD (P < 0.05) and PHQ-9 (P < 0.05). Sexual dysfunction in women with IBD was significantly associated with depression (P = 0.042), active IBD (P = 0.002), and no history of surgery (P = 0.044).Conclusions: We have developed and validated an IBD-specific scale to assess the psychosexual impact of IBD in women. This novel screening questionnaire may help health care providers recognize factors contributing to impaired sexual function in their female patients.

Summary Introduction In Denmark, an increasing number of therapists are female. It is unknown whether this constitutes a problem to patients with a sexual dysfunction. Likewise, patients’ preferences as to the age and profession of the therapist are unknown. Aim To elucidate patients’ preferences regarding their therapist's gender, age and profession a priori and to investigate whether the personal contact with a therapist influences the patients’ attitude. Method Survey with items concerning preferences regarding, age, gender and profession of the therapist before and after the first consultation to the Sexological Centre at a university hospital in Denmark. Results A total of 159 patients of which 108 were men were included. The gender of the therapist was unimportant to 79 of the men 22 of the women. Eighty-seven male patients and 27 female patients stated that age did not matter. When not indifferent, men preferred to be treated by a physician, women by a psychologist. Of the 159 patients, 120 patients met a therapist of their preferred profession or were indifferent before and/or after their consultation. A total of 93 patients had a consultation with a therapist of another professional background than preferred, a majority of 66 patients claimed satisfaction or indifference after the consultation. Conclusion Gender and age of the therapist is of less importance for sexological patients. Regarding profession, most patients prefer a physician or a psychologist, but the actual consultation with any professional results in either indifference or a change in preference towards the professional background of their therapist.

Sexual health is a state of physical, emotional, mental, and social well-being in relation to sexuality. It is not merely the absence of disease, dysfunction, or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination, and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected, and fulfilled. That goes for heterosexuals as well as for people with a different sexual orientation.

OBJECTIVE: To evaluate serum human chorionic gonadotropin (hCG) ratio, progesterone and inhibin A as single parameters and in combination for the prediction of spontaneous resolution of pregnancies of unknown location (PUL).STUDY DESIGN: Prospective observational study of 105 consecutive patients with a diagnosis of PUL. Serum levels of hCG, progesterone and inhibin A were determined at the first visit and after 2 days. Patients were followed clinically until a final diagnosis of spontaneously resolving PUL, viable or non-viable intrauterine pregnancy, or ectopic pregnancy with need of laparoscopic intervention had been reached. Different combinations of hCG ratio (hCG at 48 h/hCG at 0 h), s-progesterone and s-inhibin A were investigated to find the best predictor for successful expectant management.RESULTS: The final pregnancy outcomes were: 52 spontaneously resolving PUL (49.5%), 37 viable intrauterine pregnancies (35.2%), 8 non-viable intrauterine pregnancies (7.6%), 7 ectopic pregnancies (6.7%), and one molar pregnancy (1.0%). An hCG ratioCONCLUSION: Our results suggest that patients with PUL and hCG ratio < 0.80 display a high probability of spontaneously resolving PUL with minimum need of follow-up. In cases of hCG ratio ≥ 0.80, a combination of s-progesterone < 20 nmol/l and s-inhibin A < 30 pg/ml, may be a reliable predictor of spontaneously resolving PUL. The safety of this approach should be tested in large prospective studies.

Retrograde ejaculation (RE) and erectile dysfunction may be caused by diabetes mellitus (DM), but the prevalence of RE among DM patients is unknown. A prospective, blinded case-control study comparing men with DM with matched controls according to RE and erectile dysfunction was performed. Twenty-seven men with DM matched the inclusion criteria and agreed to participate in the study, and of these 26 delivered an ejaculate. We were able to recruit 18 matching controls, and of these 16 delivered an ejaculate. Nine of 26 men with DM who delivered an ejaculate had RE, whereas none of 16 controls had RE (p < 0.01). The mean duration of DM was longer for DM patients with RE (20 years) compared with DM patients in whom RE could not be demonstrated (13 years), but the difference was not statistically significant. RE could not be associated with BMI, waist circumference, blood pressure, Haemoglobin A1c (HgbA1c), high-density lipoprotein HDL cholesterol, triglycerides, fasting glucose, or s-testosterone. Diabetics suffering from RE more frequently exhibited erectile dysfunction compared with non-diabetics and diabetics without RE, and the last-mentioned group again more frequently than controls. These findings could not be explained by use of antihypertensive drugs. Whereas none of the included control participants showed signs of abnormal ejaculation, every third man with DM exhibited retrograde ejaculation. It is important to be aware of this association, and that post-ejaculatory urine is routinely analysed from aspermic fertility clinic attendants and diabetics with low ejaculate volumes.

Amniotic fluid embolism is a rare unpredictable complication of pregnancy with high maternal morbidity and mortality rates because of the risk of cardio-respiratory collapse and/or disseminated intravascular coagulation (DIC). We here report a case of a patient who survived without any sequelae after two cardiac arrests and subsequent DIC due to amniotic fluid embolism during a caesarean section. Early consideration of the diagnosis after prompt resuscitation is needed to reduce morbidity and mortality.

A 54-year-old woman who had earlier been treated for cervical dysplasia complained of recurrent cystitis, urgency and frequency, but without signs of genital prolapse. At cystoscopy with biopsies, leukoplakia of the bladder was diagnosed. We describe how the condition is distinguished from squamous metaplasia of the trigone as seen in normal premenopausal women. An association between leukoplakia and cancer is widely accepted. Against this background, a follow-up program is outlined. The possibility of leukoplakia as a multicentric disorder of the genito-urinary tract is briefly discussed.

A 50-year-old woman developed rhabdomyolysis and myoglobinuric renal impairment after an oral dose of 250 mg nitrazepam and 1,250 mg doxepin. Serum creatinine increased from 70 mumol/l to 472 mumol/l in two days. Serum creatine phosphokinase reached a maximal level of 391 mu kat/l (reference range less than 2.5 mu kat/l) on the third day and serum myoglobin was maximally 910 nmol/l (reference range less than 4.5 nmol/l) on the fourth day after the overdose. Passive and active movements of the knees and ankles became increasingly restricted, but the patient felt no muscle pain. Diuresis decreased to 20-22 ml/hour in spite of repetitive doses of furosemide, but was enforced to greater than 100 ml/hour by vigorous infusion of saline. Haemodialysis was avoided on this regimen. It is suggested that in patients intoxicated with nitrazepam and/or doxepin, rhabdomyolysis should be suspected when a rapidly increasing serum concentration of creatinine is found, even in the absence of muscle pain.

The levonorgestrel-releasing intrauterine device (IUD) (Mirena) is a frequently used and effective method of contraception, with a Pearl index of 0.1. The ectopic pregnancy rate is 0.02 per 100 woman-years. Special attention is needed in situations where pregnancy is detected with a levonorgestrel-releasing IUD in situ, because almost two thirds of these pregnancies are ectopic. We describe one of these rare cases of ectopic pregnancy in a woman aged 37 years, who was admitted to hospital with abdominal pain and vaginal bleeding.