Family physicians considered lack of time and knowledge as the most important reasons for not taking a sexual history. In a Dutch study,22 these obstacles were also put forward by the 59% of general practitioners who did not take a sexual history even when an erectile problem was suspected. Family physicians in our study also mentioned a feeling of shame as a barrier for patients and themselves. These arguments also evolved in a survey about the management of involuntary childlessness in German family practice.23 The interviewed physicians in that study were afraid of intrusion and inadequacy when addressing involuntary childlessness and related areas, such as sexuality, which are of an intimate and private nature. To overcome problems such as lack of knowledge or feelings of shame and inadequacy, it may be useful to give the topic of sexuality and sexual problems a higher status in basic medical education, as well as in continuing medical education. Also, key questions on how to start and maintain discussions on sexuality should be developed, evaluated, and then rehearsed.
Our results seem to indicate a correlation between patients’ consulting behavior and physicians’ attitudes and knowledge. More patients talk about sexual concerns to their physicians when the physicians assume that their own knowledge and attitude toward sexual medicine is better than that of their colleagues. This could represent a self-selection process as to patients’ preference. Because these correlations were analyzed on the practice level (as the unit of analysis), the results may not have reached statistical significance because of the low number of observations. Further studies may determine these associations more precisely.
We do not suggest that all patients suffering from sexual problems require treatment. Many of the patients in our study who reported seldom experiencing a sexual problem were just as satisfied with their sexual life as those who reported never having a problem. To date, some family physicians seem to resolve the difficulty of finding out only those sexual problems that need to be treated by neglecting the topic of sexuality during consultation. The physicians’ assumption that this attitude corresponds to the patients’ feeling of shame is not supported by our data: More than half of the patients would appreciate their physicians addressing the topic of sexuality in an active and open way, if appropriate.
Limitations
Compared with patients of the ADT Panel,16,17 older patients, especially those older than 70 years, are under-represented in our study. This may be because this study was performed exclusively in surgeries, while the ADT Panel also included patients who were visited at home and in nursing homes. However, it should be emphasized that the response rate of 84% was excellent, so that a selection bias with regard to patients visiting the surgery is rather unlikely.
A response rate of 43% of the physicians may indicate a selection bias. Physicians who were more open-minded toward sexual problems may have been more likely to participate in our survey. Thus, sexual problems are probably an even less frequent topic during consultation than our data suggest.
Conclusions
The high level of self-reported sexual dysfunction in men and family physicians’ hesitancy to deal with this issue signals a neglected area in primary health care. Possible starting points for communication about sexuality in family practice include the prescription of drugs that trigger sexual disorders, diagnosis of conditions that are associated with sexual problems, and the patients’ personal, social, and occupational background.
Acknowledgments
Parts of our study were supported by Grant 01 KY 9605/7 from the Federal Ministry of Education and Research, Bonn, Germany. The authors would like to thank the practice nurses, physicians, and patients who participated in this survey and answered questions of a very personal nature.