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ORIGINAL RESEARCH—EDUCATION General Practitioners’ Procedures for Sexual History Taking and Treating Sexual Dysfunction in Primary Care Sofia Ribeiro, MD,* Violeta Alarcão, D. Sociol.,* Rui Simões, MSc,* Filipe Leão Miranda, MA,* Mário Carreira, MD,* and Alberto Galvão-Teles, PhD*† *Institute of Preventive Medicine, Faculty of Medicine, University of Lisbon, Lisboa, Portugal; †Endocrinology, Diabetes and Obesity Unit, Lisbon, Portugal DOI: 10.1111/jsm.12395
ABSTRACT
Introduction. Good history-taking skills are the first step towards achieving a correct diagnosis of sexual dysfunction (SD). However, studies show most general practitioners (GPs) do not take the initiative to ask the patient about SD, and when diagnosing a condition, they tend to give preference to their own criteria over clinical guidelines. Aim. The aim of this study is to characterize GPs’ attitudes towards taking sexual history, identifying its frequency and focus, and to describe GPs’ diagnostics and therapeutic approaches including the use of clinical guidelines, exploring patients’ and doctor-related differences. Methods. Cross-sectional study using confidential self-administrated questionnaires applied to GPs working in primary healthcare units in the Lisbon region. Main Outcome Measures. Data concerning GPs’ consultation of guidelines, active exploration of SD in male and in female patients, and focus on sexual history taking was collected. Results. Of the 50 participants (73.5% response rate), 15.5% actively ask their patients about SD. The main reasons for asking patients about their sexuality are diabetes (84.0%), prescription of medication with adverse effects on sexuality (78.0%), and family planning (72.0%), the latter being a significantly more frequent reason for GPs with 20 or less years of practice. Routine sexual history taking (22.0%) appears as one of the least mentioned motives. The percentage of appointments with active exploration of SD was positively associated with guidelines’ consultation, as well as considering the specialty as a good source of information and having longer appointments when SD is mentioned. However, 76.0% report not having consulted any guidelines in the previous year. Lack of time (31.6%) and low accessibility (25.0%) were referred to as the main reasons for not consulting guidelines. Conclusions. Routine sexual history taking and consultation of guidelines about SD are not yet a generalized practice in primary care. Data should be interpreted with caution as they are self-reported. Further objective measurement such as direct observation or clinical files consultation should be implemented. Ribeiro S, Alarcão V, Simões R, Miranda FL, Carreira M, and Galvão-Teles A. General practitioners’ procedures for sexual history taking and treating sexual dysfunction in primary care. J Sex Med 2014;11:386–393. Key Words. Sexual Dysfunction; General Practitioners; Primary Healthcare; Disease Management; Sexual History Taking; Diagnostic and Therapeutic Approaches
Introduction
G
ood history-taking skills are the first step toward achieving a correct diagnosis of sexual dysfunction (SD). However, studies show there are both lack of opportunities for medical students to learn how to do a sexual history [1] and lack of
J Sex Med 2014;11:386–393
opportunistic sexual history taking by doctors [2]. Four key areas for improvement have been identified: time constraints, ethico-legal, clinical, and personal aspects [3]. These factors have been recognized as barriers in the overall management of SD [4,5]. Many courses have been developed to teach sexual history taking and management of SD, some spe© 2013 International Society for Sexual Medicine
General Practitioners’ Sexual History Taking and Treating Procedures cific to primary care (PC) setting [3,6] and others to common residency training [7], but evaluation of educational interventions is still needed [3,7]. Clinical practice guidelines aim to make everyday practice uniform and effective, therefore improving quality of care [8,9]. However, studies have shown their limited impact [10,11]. A review article identified several barriers to adherence to practice guidelines, including lack of familiarity and awareness (volume of information, time, and accessibility), lack of agreement and of outcome expectancy, lack of self-efficacy, and motivation [12]. Despite increasing availability of SD guidelines [13], studies regarding its use in diagnosis and treatment are still missing. A study conducted among Swiss general practitioners (GPs) and urologists showed that both prefer using their own diagnostic criteria in male SD, which are often not reliable nor valid [14,15]. Another study among U.S. PC physicians and gynecologists revealed similar predictors to confidence in female SD management: On one hand, time constraints to elicit information and perceived lack of effective therapies to treat sexual problems (SPs) were negatively related to their confidence in treating decreased sexual desire; on the other hand, the volume of patients seen per week and practice experience were positive predictors of confidence [16]. A study focusing on the management of erectile dysfunction (ED) in PC found that only a minority (9.6%) of GPs routinely asked for ED in patients over 40 years, but this number increased (45.2%) when the patients had risk factors for this condition; older GPs were less likely to prescribe therapy and more likely to refer the patient to a specialist, and female GPs had more probability of being uncomfortable in diagnosing of SD than male GPs [17]. Our hypothesis was that gender and years of practice influence attitudes toward taking sexual history, diagnostics and therapeutic approaches, and in the use of clinical guidelines. Methods
A cross-sectional study using anonymous questionnaires answered by GPs of primary health centers (PHCs) of one Lisbon Region Health Cluster was conducted between February and May 2011. Consenting GPs working at the selected PHC were considered eligible. Sampling and data collection procedures have been detailed in a previous article [18].
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Main Outcome Measures Outcome measure for use of clinical guidelines was gathered on question “Over the last year, did you use guidelines about diagnosis and treatment of sexual dysfunctions to support your clinical practice?” and for active exploration on “Which percentage of your patients do you inquire about sexual problems during appointments?” (Supporting Information Appendix S1). Statistical Analysis To compare GPs according to gender and years of practice, nonparametric Mann–Whitney test was used for continuous variables as data normality assumption was not satisfied, and chi-squared tests (or Fisher’s exact test) were used for categorical variables. A barriers score was calculated by summing up the number of potential barriers (11 barriers in a 10-point scale from 1 = not a barrier to 10 = major barrier) in starting a dialog with a patient about sexual health. The “attitudes and beliefs” item had a corrected item–total correlation of 0.030 (very low), and therefore was excluded, resulting in a scale with possible values ranging from 10 (no barriers) to 100 (important barriers) and a very good internal consistency (Cronbach’s alpha of 0.82) for quantifying potential barriers in starting a dialog with a patient about sexual health as a whole. Multiple logistic regressions were conducted to explore the association between GPs habits and GPs characteristics. Multiple linear regression was conducted to examine the association between guideline consultation as a function of GPs’ sociodemographic characteristics and medical practice details, active exploration of SD, self-perceived competences in the discussion and treatment of SD, self-perceived need of training, adequacy of specialization as a source of information in SD, duration of appointments/week in which SD is mentioned, the ability to discuss SPs if the patient raises the issue, and the barriers score. Considering nine predictors, a minimum sample of 54 participants would allow a 95% confidence interval and 80% statistical power level. Models were adjusted by GPs’ years of practice instead of GPs’ age as the two variables were too correlated (Spearman’s rho = 0.75, P < 0.001), and the former had the highest predictive power. Analyses were performed with IBM SPSS Statistics for Windows, Version 20.0 (IBM Corp., Armonk, NY, USA). J Sex Med 2014;11:386–393
388 Table 1
Ribeiro et al. Participants’ demographic and medical practice characteristics by sex and years of practice GP’s years of practice†‡
GP’s sex*
Age (years) Years since start of GP career Approximate size of patients’ list Number of medical appointments/week Number of medical appointments/week in which SD is mentioned Time of medical appointments in which SD is mentioned (minutes) Estimated percentage of patient’s GPs actively ask about patient’s sexual problems Estimated percentage of patients that actively ask about sexual problems
Male GP (N = 20) Mean ± SD
Female GP (N = 30) Mean ± SD
20 or less (N = 17) Mean ± SD
More than 20 (N = 30) Mean ± SD
Total (N = 50) Mean ± SD
49.8 ± 10.0 19.5 ± 8.7 1,738.8 ± 256.3 102.6 ± 27.1 5.4 ± 6.8
53.2 ± 7.5 22.0 ± 7.8 1,541.7 ± 399.6 96.9 ± 30.9 8.3 ± 8.4
44.4 ± 10.6 — 1,616.8 ± 489.9 108.6 ± 31.2 10.0 ± 10.0
56.1 ± 2.8 — 1,611.8 ± 288.7 94.6 ± 27.4 5.5 ± 5.9
51.9 ± 8.6 21.0 ± 8.6 1,613.4 ± 363.9 99.2 ± 29.2 7.4 ± 7.9
21.4 ± 6.5
25.7 ± 8.8
24.7 ± 6.5
23.8 ± 9.1
24.0 ± 8.2
13.2 ± 12.4
17.0 ± 17.0
18.5 ± 14.9
13.3 ± 16.0
15.5 ± 16.7
11.6 ± 9.9
15.4 ± 15.0
18.1 ± 14.1
9.9 ± 11.1
13.9 ± 13.2
The values highlighted in bold are statistically significant (P < 0.05) *Mann–Whitney test between GPs’ sex †Mann–Whitney test between GPs’ years of practice, P < 0.05 ‡ There are three missing subjects for “years of practice” variable GP = general practitioner; SD = standard deviation
Results
The PHC call had a 90.0% participation rate, and 50 responses were obtained from the 68 eligible GPs (73.5% response rate).
Participants’ Characteristics GPs had a mean age of 51.9 ± 8.6 years, with a mean of 21.0 ± 8.6 years of practice. The medical appointments where SD was mentioned lasted on average 24.0 ± 8.2 minutes. GPs with less than 20 years of practice indicated a higher percentage of patients (18.1 ± 14.1) who actively asked about SP (Table 1). Taking a Sexual History GPs preferred approach to inquiry about patients’ sexual history was an open conversation (90.0%) rather than a structured one. Male GPs were more likely to perform open conversation than female GPs (odds ratio [OR] = 11.23), and years of practice presented a positive association with open conversation (OR = 1.11). Diagnoses tend to be based more on GPs’ own criteria (52.6%), especially for GPs with more than 20 years of practice (OR = 1.58) than on International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10) (31.6%) or Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) (15.8%). GPs that based their SD diagnosis on ICD-10 or DSM-IV were less likely to perform open conversation compared with those who based SD diagnosis on their own criteria (OR = 0.14 and 0.45, respectively). J Sex Med 2014;11:386–393
GPs consider that the exploration of the definition of “sexual life without sexual problems” depends highly on the patient at hand (81.6%), as does “sexual satisfaction as a whole” (85.4%). Only 15.5% of GPs actively ask patients for SD. The main reasons for asking patients about their sexuality are diabetes (84.0%), prescription of medication with adverse effects on sexuality (78.0%), family planning (72.0%), and urologic diseases (66.0%). Routine sexual history taking (22.0%) appears as one of the least mentioned motives for asking patients about their sexuality (Table 2). Gender differences were found in “neurological” and “other endocrinal diseases” which were reasons more often indicated by female GPs. GPs with 20 or less years of practice identify family planning as a prominent reason for inquiring for SD (82.2% vs. 63.3%), whereas GPs with more than 20 years of practice elected andropause more often (56.7% vs. 23.5%), P < 0.05. On the other hand, 14.0% of the GPs reported being asked by patients about SP. The most common SDs reported by patients were ED (92.0%), decreased libido (82.0%), dyspareunia (68.0%), and premature ejaculation (50.0%). Table 3 shows the most frequently asked SD according to four main categories of diseases: cardiovascular, endocrine, urologic, and mental. In men with diagnosed cardiovascular disease, male GPs ask considerably more about decreased libido (70.0%) than female GPs (33.3%), P = 0.02. In women with cardiovascular disease, dyspareunia is only asked by female GPs (23.3%), P = 0.03. We found significant differences regarding years of practice in patients with diagnosed mental illness:
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General Practitioners’ Sexual History Taking and Treating Procedures Table 2
Reasons for asking for sexual dysfunction according to GP’s sex and years of practice GP’s years of practice†§
GP’s sex* In your clinical practice, what makes you inquire your patient about sexuality? Diabetes Prescription of medication with adverse effects on sexuality Family planning Urologic diseases Menopause Cardiovascular diseases Andropause Mental diseases Neurologic diseases Obesity Routine history taking Other endocrinal diseases
Male GP (N = 20) n (%)
Female GP (N = 30) n (%)
20 or less (N = 17) n (%)
More than 20 (N = 30) n (%)
Total (N = 50) n (%)
15 (75.0)‡ 15 (75.0)‡
27 (90.0)‡ 24 (80.0)‡
16 (94.1)‡ 14 (82.4)‡
26 (86.7)‡ 24 (80.0)‡
42 (84.0) 39 (78.0)
13 13 11 11 10 6 2 4 4 1
23 20 21 17 14 12 13 8 7 8
15 11 10 10 4 6 5 3 4 4
(65.0) (65.0) (55.0) (55.0) (50.0) (30.0) (10.0) (20.0)‡ (20.0)‡ (5.0)‡
(76.7) (66.7) (70.0) (56.7) (46.7) (40.0) (43.3) (26.7)‡ (23.3)‡ (26.7)‡
(88.2)‡ (64.7) (58.8) (58.8) (23.5) (35.3) (29.4) (17.6)‡ (23.5)‡ (23.5)‡
19 19 21 16 17 10 10 8 7 5
(63.3)‡ (63.3) (70.0) (53.3) (56.7) (33.3) (33.3) (26.7)‡ (23.3)‡ (16.7)‡
36 33 32 28 24 18 15 12 11 9
(72.0) (66.0) (64.0) (56.0) (48.0) (36.0) (30.0) (24.0) (22.0) (18.0)
The values highlighted in bold are statistically significant (P < 0.05) *Chi-squared test between GPs’ sex † Chi-squared test between GPs’ years of practice ‡Fisher’s exact test, P < 0.05 § There are three missing subjects for “years of practice” variable GP = general practitioner
GPs with 20 or less years of practice ask more about orgasmic disturbances than those who have more than 20 years of practice. Dyspareunia (56.0%) and ED (68%) are the leading SD asked for when a patient has a known urologic disease. The large majority (92.0%) of the GPs report inquiring about the consumption of medication and other substances that might cause SD. The most commonly asked medications are psychotropics (97.8%), antihypertensives and drugs used in prostatic diseases (both with 87.0%), and antiandrogenics (69.6%).
Diagnostic and Therapeutic Approaches The most popular approaches for hypoactive desire disorder were searching for a solution together with the patient (62.0% in male vs. 72.0% in female patients, P = 0.29), followed by involving the partner (50.0% vs. 62.0%, P = 0.23) and referral to other specialist (48.0% vs. 34.0%, P = 0.15), whereas pharmacologic treatment was the least chosen option (36.0% vs. 18.0%, P = 0.04). Regarding orgasmic disorders, the majority of GPs preferred to refer the patient to other specialists (58.0% vs. 64.0%, P = 0.54). Again, drug prescription is the least common approach, being less frequent for female patients (24.0% vs. 6.0%, P = 0.01). Laboratorial exams were always the ones GPs use the most to clarify an SP (66.0%) except in GPs with more than 20 years of practice, followed by physical examination (52.0%) and consultation by other specialist (42.0%). Female GPs pre-
scribed more laboratorial exams than male GPs (OR = 1.89), and years of practice presented a positive association with laboratorial exams prescription (OR = 1.05).
Factors Related to GPs’ Guidelines Consultation Most doctors (76.0%) did not consult guidelines about diagnosis and treatment of SD during the previous year. The main reason for consulting guidelines was the need to clarify issues that arose during the practice (91.7%) followed by the will to keep updated about clinical recommendations (50.0%). Lack of time (31.6%) and low accessibility (25.0%) were referred as the main reasons for not consulting guidelines. The percentage of appointments with active exploration was found to be a positive predictor of guidelines’ consultation (P < 0.05), as well as considering the specialty as a good source of information and having longer appointments when SD is mentioned (P ≤ 0.20). The logistic regression model explained more than 30% of the guideline consultation phenomenon (R2 of Nagelkerke = 0.32 and Hosmer & Lemeshow goodness-of-fit statistic = 5.52, P = 0.70) (Table 4). Discussion and Conclusion
Our response rate was higher than other studies, but we acknowledge that it may not be truly representative because of selection bias. J Sex Med 2014;11:386–393
390 (26.0) (38.0) (56.0)
(42.0)‡
(44.0)
30 15 28 — 21 — 13 19 28 (52.0) (32.0) (44.0) (28.0) (30.0)† (34.0) (30.0)
(30.0) (56.0) (24.0) (44.0)
(48.0) (0.0) (14.0) (68.0) (40.0) (46.0) (42.0)
(30.0)
(40.0) (14.0)§ (40.0)
(10.0)
(50.0)
11 0 4 — 5 — 20 7 20 24 0 2 32 7 1 23 — 25 Decreased libido Increased libido Sexual aversion Erectile dysfunction Orgasmic disturbances Premature ejaculation SD because of a general medical condition Dyspareunia SD related to substance use
(48.0)* (0.0) (4.0) (64.0) (14.0) (2.0) (46.0)
n (%)
J Sex Med 2014;11:386–393
*Female GP (n = 1, 33.3%) vs. male GP (n = 14, 70.0%)—P = 0.02 †GPs with 20 or less years of practice (n = 11, 64.7%) vs. GPs with more than 20 years of practice (n = 3, 10.0%)—P < 0.01 ‡GPs with 20 or less years of practice (n = 11, 64.7%) vs. GPs with more than 20 years of practice (n = 8, 26.7%)—P = 0.01 § Female GP (n = 7, 23.3%) vs. male GP (n = 0, 0.0%)—P = 0.03 GP = general practitioner; SD = standard deviation
(40.0) (32.0) (28.0)
(36.0) (20.0) (8.0) (60.0) (22.0) (10.0) (36.0)
18 10 4 30 11 5 18 — 15 (22.0) (0.0) (8.0)
n (%)
23 12 13 — 13 — 20 16 14
(26.0)
24 0 7 34 20 23 21 — 22 (46.0) (24.0) (26.0)
n (%)
16 2 9 — 8 — 15 28 12
(16.0)
26 16 22 14 15 17 15 — 22 (32.0) (4.0) (18.0)
n (%)
Male Patients
Mental illness
Female Patients Male Patients
Urologic diseases
Male Patients
Female Patients
Endocrine diseases
Male Patients
Female Patients
Cardiovascular diseases
Regarding these diseases, please indicate the sexual problems you usually inquire patients about
Table 3
Percentage of physicians who inquire about sexual problems, according sexual problem, patient gender, and to some categories of patients’ diseases
Female Patients
(60.0) (30.0) (56.0)
Ribeiro et al.
Taking a Sexual History In our study, the majority of GPs indicate preference for an open conversation when it comes to talking about SP, which is consistent with previous findings [14]. Routine sexual history taking (22%) appeared as the least reported motive for asking patients about their sexuality, similarly to other studies such as the Global Study of Sexual Attitudes and Behaviors, in which only 9% of men and women report having been asked by their GP about sexual difficulties over the previous 3 years [19]. Other studies [20–22] also indicate that sexual health is not yet discussed routinely. Furthermore, routine sexual history taking is the best way to systematically explore SD bearing three specific aspects in mind: comorbid medical conditions, organic and psychogenic causes, and concomitant medications [13]. In our study, diabetes was the leading cause (84.0%) for asking patients about their sexuality, closely followed by family planning (72.0%). The differences found between GPs’ years of practice and prominent reasons for asking about SD seem interesting as younger GPs seem more willing to use family planning for discussing SD than older GPs. In another study about SP in male patients in family practice, diabetes (79%) and family planning (53%) were also highly reported as opportunities for discussion of SP [23]. The nongeneralized sexual history taking is problematic as the primary healthcare setting is often the first contact patients have with the healthcare system, as is the fact that only a small percentage of patients engage in conversation about SP. In a study concerning the management of ED in general practice, 45.7% of GPs reported inquiring for ED only when patients initiated the discussion, and only 9.5% of GPs asked men older than 40 about ED on a routine basis [17]. Our study reveals that SD is scarcely mentioned by GPs (16%) and their patients (14%), in contrast with the high SD prevalence rates reported in the literature [24,25]. ICD-10 was mentioned in the questionnaire as a diagnostic tool together with the DSM; however, we acknowledge the limitations in reflecting an accurate clinical diagnosis. In Portugal, family planning is performed by GPs and was elected as one of the main reasons for asking for SD, meaning these consultations are being used as an opportunity for scanning for SD. However, these specific appointments are mostly attended by women, which leaves men mostly uncovered because, as previously stated, routine
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General Practitioners’ Sexual History Taking and Treating Procedures Table 4
Factors associated with consultation of sexual dysfunction guidelines in the previous year
Variable
Univariate model OR (95% CI)
Adjusted univariate model‡ OR (95% CI)
Multivariate model§¶ OR (95% CI)
GP’s sex male (female—reference) Years of practice Percentage of appointments with active exploitation Self-perceived competence in treating SD Self-perceived competence in discussing SD Adequacy of specialization as a source of information in SD Ability to discuss sexual problems if the patient actively raises the issue Duration of medical appointments in which SD is mentioned Barriers to initiate a conversation of sexual health score**
0.69 0.98 1.04 0.69 0.81 1.18 1.01 1.05 1.01
— — 1.04 0.66 0.82 1.21 1.01 1.06 1.01
2.32 0.96 1.07 0.38 1.10 0.58 1.02 1.12 1.03
(0.18–2.68) (0.90–1.06) (1.00–1.09)† (0.37–1.29) (0.42–1.55) (0.85–1.65) (0.99–1.03) (0.96–1.15) (0.97–1.06)
(1.00–1.09)† (0.34–1.26) (0.42–1.58) (0.85–1.71) (0.99–1.03) (0.96–1.17) (0.97–1.05)
(0.23–23.12) (0.84–1.08) (1.00–1.14)† (0.03–4.17) (0.14–8.78) (0.24–1.36)* (0.99–1.05) (0.95–1.31)* (0.96–1.11)
*P < 0.20; †P < 0.05 ‡Adjusted for GP’s gender and years of practice § 2 R Nagelkerke, 0.32; Hosmer and Lemeshow goodness-of-fit statistic, 5.52 with 8 degrees of freedom (P = 0.70) ¶Number of GPs included in the multivariate model: 41 **Score from 10 (no barriers) to 100 (important barriers) GP = general practitioner; SD = sexual dysfunction; OR = odds ratio; CI = confidence interval
sexual history taking is the least reported reason to ask for SD. Drug therapy with psychotropics, antihypertensives, drugs used in prostatic diseases, and antiandrogenics was recounted as a reason for asking for SD as they may all affect sexual function as a side effect. This is not surprising as these medications are commonly prescribed in PHC. Despite the growing evidence relating SD to cardiovascular disease (CVD), CVD was not among the main reasons for asking patients about their sexual function (56%). In the previously cited study, 45.2% of GPs investigated the presence of ED in patients with risk factors, age, history of cardiovascular disease, diabetes, prostatectomy, and depression—which have been correlated with ED [17]. Sixty percent of GPs reported asking for ED in male patients presenting with endocrine diseases, which is consistent with another Swiss study in which GPs reported asking 58.3% of their male patients within said disease group [14]. In male patients with diagnosed mental illness, however, decreased libido is the most inquired SD (52%) above the results found in another study (40.4%) [14]. In this same study, decreased libido was the most inquired SD, and ED was the second in men with mental illness. That is only partially consistent with our study, with sexual aversion and substance abuse coming in as the second most inquired SD.
Diagnostic and Therapeutic Approaches In our sample, laboratorial exams are more used than physical examination, which is consistent with literature that postulates that, despite the
importance of a physical examination in the evaluation of SD, it will miss to identify the specific underlying cause in most cases and is not always strictly mandatory, especially if the underlying cause seems to be because of situational problems, mental illness, or social problems [13]. Pharmacologic treatment was more frequent in male than in female patients, which is consistent with an article in which both GPs and gynecologists mention a lack of effective therapies for hypoactive sex disorder in women [16]. Furthermore, in another study, 98% of GPs had not prescribed any treatment for this condition [26]. On the other hand, nowadays, ED is more mentioned, and effective therapies are easily available, which might account for the pharmacologic treatment being more frequent in male patients. Using a standard operating procedure could help professionals in sexual history taking by providing a brief and structured method and by limiting barriers such as knowledge and perceived difficulties in dealing with SD [27].
Factors Related to GPs’ Guidelines Consultation Most GPs (76.0%) report not having consulted any guidelines about SD in the previous year. When diagnosing SD, 44.0% use their own diagnostic criteria, whereas 32.0% mention ICD-10 and 20.0% DSM-IV. This is worrying as classification manuals are more reliable and valid, and therefore lead to more accurate diagnosis. However, the reported use of guidelines is superior to what we found in literature, namely in a Swiss study in which no GPs reported having based their diagnosis on either ICD-10 or DSM-IV [14]. GPs J Sex Med 2014;11:386–393
392 consulted guidelines mainly for the need to clarify issues that arose during the practice (22.0%), followed by the will to keep updated about clinical recommendations. Lack of time (24.0%) and low accessibility (18.0%) were reported as the main reasons for not consulting guidelines, which is not surprising as “lack of time” had been chosen as one of the main barriers in managing SD in the same sample [18] and also because the average number of medical appointments per week was 99.2 with every physician managing a list of 1,613.4 patients. The barriers involved in the consultation of clinical guidelines have been previously reported [12]. Consulting guidelines could lead to increased knowledge on SD, which ultimately draws attention to the issue and its importance, and encourages active exploration. However, there are other sources of information such as review articles, which were not taken into account. One study showed that 38% of GPs were not confident in evaluating and managing sexual desire problems, and, as previously stated, knowledge is one of the main barriers GPs face in managing SD in general [28]. A high self-perceived competence in discussing SD raises the comfort of the GP and is likely to act as a motivation to discuss SD during appointments. Furthermore, GPs with more clinical practice may invest more in the quality of their appointments.
Strengths and Limitations Despite the existence of some studies concerning SD management in primary healthcare settings, they are often restricted to a specific dysfunction and are focused on the comparison of GPs with other medical specialists (urologists and gynecologists), disregarding gender and age/years of practice differences. A national representative sample could eventually identify other possible factors associated with sexual history taking and procedures, revealing differences in gender and years of medical practice, or regional training differences. Nevertheless, multivariate analysis reaches moderate level of explanation and could constitute a valuable exploratory model for the understanding of the factors that influence guidelines consultation. As data were self-reported, and no direct observation or clinical file consultations were made, there are no guarantees that it corresponds to the reality of all patients. Our response rate was among the highest reported in literature, possibly indicating GPs’ interest in this area, supported by the fact that 98.0% agreed that SD is an important public health issue. J Sex Med 2014;11:386–393
Ribeiro et al.
Recommendations and Future Plans This study would benefit from obtaining a wider sample to amplify our conclusions. Nevertheless, it enabled for the identification of future research purposes and provided a questionnaire for use in other investigations. A detailed mapping of the state of art in Portugal concerning pre and postgraduate education in SD would allow the identification of existing gaps and opportunities for intervention. A set of national guidelines for the diagnosis and treatment of SD should be prepared, and measures should be taken to ensure their accessibility not only to GPs but also to other medical specialists, such as gynecologists and urologists who deal with SD on their daily practice. Finally, an interventional model for strengthening the competences of GPs in the management of SD should be implemented as GPs reported the need of further education and the willingness to engage in such programs. Acknowledgment
We would like to thank ACES-Odivelas Health Units and SEXOS Study Research Team. Corresponding Author: Violeta Alarcão, D. Sociol, Epidemiology Unit of the Institute of Preventive Medicine, Lisbon Faculty of Medicine, Av. Prof. Egaz Moniz, Lisboa 1649-028, Portugal. Tel: (+351) 217985130 Ext: 47091; Fax: (+351) 217999421; E-mail: violeta.alarcao @gmail.com Conflict of Interest: The author(s) report no conflicts of interest. All authors declare that they have no competing interests. This study is part of the SEXOS Pilot Study, supported by a scientific grant from Merck Sharpe and Dohme Foundation and by the Program “Educação pela Ciência”, GAPIC/FMUL. The supporters did not have any role in the design and conduct of the study, neither in the collection, management, analysis, and interpretation of the data, or in the preparation, review, or approval of the article.
Statement of Authorship
Category 1 (a) Conception and Design Violeta Alarcão; Sofia Ribeiro; Rui Simões; Filipe Leão Miranda; Mário Carreira; Alberto Galvão-Teles (b) Acquisition of Data Violeta Alarcão; Sofia Ribeiro; Filipe Leão Miranda; Alberto Galvão-Teles
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General Practitioners’ Sexual History Taking and Treating Procedures (c) Analysis and Interpretation of Data Violeta Alarcão; Sofia Ribeiro; Rui Simões; Filipe Leão Miranda; Mário Carreira; Alberto Galvão-Teles
Category 2 (a) Drafting the Article Violeta Alarcão; Sofia Ribeiro; Rui Filipe Leão Miranda; Mário Carreira; Galvão-Teles (b) Revising It for Intellectual Content Violeta Alarcão; Sofia Ribeiro; Rui Filipe Leão Miranda; Mário Carreira; Galvão-Teles
Simões; Alberto Simões; Alberto
Category 3 (a) Final Approval of the Completed Article Violeta Alarcão; Sofia Ribeiro; Rui Simões; Filipe Leão Miranda; Mário Carreira; Alberto Galvão-Teles
References 1 O’Keefe R, Tesar CM. Sex talk: What makes it hard to learn sexual history taking? Fam Med 1999;31:315–6. 2 Temple-Smith MJ, Mulvey G, Keogh L. Attitudes to taking a sexual history in general practice in Victoria, Australia. Sex Transm Infect 1999;75:41–4. 3 Skelton JR, Matthews PM. Teaching sexual history taking to health care professionals in primary care. Med Educ 2001;35: 603–8. 4 Gott M, Hinchliff S. Barriers to seeking treatment for sexual problems in primary care: A qualitative study with older people. Fam Pract 2003;20:690–5. 5 Humphery S, Nazareth I. GPs’ views on their management of sexual dysfunction. Fam Pract 2001;18:516–8. 6 Mas M, Garcia-Giralda L, Rey JR, Martinez-Salamanca JI, Guirao L, Turbi C. Evaluating a continuous medical education program to improve general practitioners awareness and practice on erectile dysfunction as a cardiovascular risk factor. J Sex Med 2011;8:1585–93. 7 Rosen R, Kountz D, Post-Zwicker T, Leiblum S, Wiegel M. Sexual communication skills in residency training: The Robert Wood Johnson model. J Sex Med 2006;3:37–46. 8 Audet AM, Greenfield S, Field M. Medical practice guidelines: Current activities and future directions. Ann Intern Med 1990;113:709–14. 9 Chassin MR. Practice guidelines: Best hope for quality improvement in the 1990s. J Occup Med 1990;32:1199–206. 10 Davis DA, Taylor-Vaisey A. Translating guidelines into practice. A systematic review of theoretic concepts, practical experience and research evidence in the adoption of clinical practice guidelines. CMAJ 1997;157:408–16. 11 Grilli R, Apolone G, Marsoni S, Nicolucci A, Zola P, Liberati A. The impact of patient management guidelines on the care of breast, colorectal, and ovarian cancer patients in Italy. Med Care 1991;29:50–63. 12 Cabana MD, Rand CS, Powe NR, Wu AW, Wilson MH, Abboud PA, Rubin HR. Why don’t physicians follow clinical practice guidelines? A framework for improvement. JAMA 1999;282:1458–65.
13 Hatzichristou D, Rosen RC, Derogatis LR, Low WY, Meuleman EJ, Sadovsky R, Symonds T. Recommendations for the clinical evaluation of men and women with sexual dysfunction. J Sex Med 2010;7:337–48. 14 Platano G, Margraf J, Alder J, Bitzer J. Frequency and focus of sexual history taking in male patients-a pilot study conducted among Swiss general practitioners and urologists. J Sex Med 2008;5:47–59. 15 Platano G, Margraf J, Alder J, Bitzer J. Psychosocial factors and therapeutic approaches in the context of sexual history taking in men: A study conducted among Swiss general practitioners and urologists. J Sex Med 2008;5:2533–56. 16 Abdolrasulnia M, Shewchuk RM, Roepke N, Granstaff US, Dean J, Foster JA, Goldstein AT, Casebeer L. Management of female sexual problems: Perceived barriers, practice patterns, and confidence among primary care physicians and gynecologists. J Sex Med 2010;7:2499–508. 17 De Berardis G, Pellegrini F, Franciosi M, Pamparana F, Morelli P, Tognoni G, Nicolucci A; EDEN Study Group. Management of erectile dysfunction in general practice. J Sex Med 2009;6:1127–34. 18 Alarcão V, Ribeiro S, Miranda FL, Carreira M, Dias T, Garcia e Costa J, Galvão-Teles A. General practitioners’ knowledge, attitudes, beliefs, and practices in the management of sexual dysfunction-results of the portuguese SEXOS study. J Sex Med 2012;9:2508–15. 19 Moreira ED Jr, Brock G, Glasser DB, Nicolosi A, Laumann EO, Paik A, Wang T, Gingell C; GSSAB Investigators’ Group. Help-seeking behaviour for sexual problems: The global study of sexual attitudes and behaviors. Int J Clin Pract 2005;59: 6–16. 20 Sadovsky R, Nusbaum M. Sexual health inquiry and support is a primary care priority. J Sex Med 2006;3:3–11. 21 Tsimtsiou Z, Hatzimouratidis K, Nakopoulou E, Kyrana E, Salpigidis G, Hatzichristou D. Predictors of physicians’ involvement in addressing sexual health issues. J Sex Med 2006;3:583–8. 22 Hartmann U, Burkart M. Erectile dysfunctions in patientphysician communication: Optimized strategies for addressing sexual issues and the benefit of using a patient questionnaire. J Sex Med 2007;4:38–46. 23 Aschka C, Himmel W, Ittner E, Kochen MM. Sexual problems of male patients in family practice. J Fam Pract 2001;50: 773–8. 24 Derogatis LR, Burnett AL. The epidemiology of sexual dysfunctions. J Sex Med 2008;5:289–300. 25 Teles AG, Carreira M, Alarcão V, Aragüés JM, Lopes L, Mascarenhas M, Costa JG. Prevalence, severity, and risk factors for erectile dysfunction in a representative sample of 3,548 portuguese men aged 40 to 69 years attending primary healthcare centers: Results of the Portuguese erectile dysfunction study. J Sex Med 2008;5:1317–24. 26 Harsh V, McGarvey EL, Clayton AH. Physician attitudes regarding hypoactive sexual desire disorder in a primary care clinic: A pilot study. J Sex Med 2008;5:640–5. 27 Althof SE, Rosen RC, Perelman MA, Rubio-Aurioles E. Standard operating procedures for taking a sexual history. J Sex Med 2013;10:26–35. 28 Parish SJ, Clayton AH. Sexual medicine education: Review and commentary. J Sex Med 2007;4:259–67.
Supporting Information Additional Supporting Information may be found in the online version of this article at the publisher’s website: Appendix S1 Self-administered questionnaire for GPs.
J Sex Med 2014;11:386–393
ORIGINAL RESEARCH—EDUCATION General Practitioners’ Procedures for Sexual History Taking and Treating Sexual Dysfunction in Primary Care Sofia Ribeiro, MD,* Violeta Alarcão, D. Sociol.,* Rui Simões, MSc,* Filipe Leão Miranda, MA,* Mário Carreira, MD,* and Alberto Galvão-Teles, PhD*† *Institute of Preventive Medicine, Faculty of Medicine, University of Lisbon, Lisboa, Portugal; †Endocrinology, Diabetes and Obesity Unit, Lisbon, Portugal DOI: 10.1111/jsm.12395
ABSTRACT
Introduction. Good history-taking skills are the first step towards achieving a correct diagnosis of sexual dysfunction (SD). However, studies show most general practitioners (GPs) do not take the initiative to ask the patient about SD, and when diagnosing a condition, they tend to give preference to their own criteria over clinical guidelines. Aim. The aim of this study is to characterize GPs’ attitudes towards taking sexual history, identifying its frequency and focus, and to describe GPs’ diagnostics and therapeutic approaches including the use of clinical guidelines, exploring patients’ and doctor-related differences. Methods. Cross-sectional study using confidential self-administrated questionnaires applied to GPs working in primary healthcare units in the Lisbon region. Main Outcome Measures. Data concerning GPs’ consultation of guidelines, active exploration of SD in male and in female patients, and focus on sexual history taking was collected. Results. Of the 50 participants (73.5% response rate), 15.5% actively ask their patients about SD. The main reasons for asking patients about their sexuality are diabetes (84.0%), prescription of medication with adverse effects on sexuality (78.0%), and family planning (72.0%), the latter being a significantly more frequent reason for GPs with 20 or less years of practice. Routine sexual history taking (22.0%) appears as one of the least mentioned motives. The percentage of appointments with active exploration of SD was positively associated with guidelines’ consultation, as well as considering the specialty as a good source of information and having longer appointments when SD is mentioned. However, 76.0% report not having consulted any guidelines in the previous year. Lack of time (31.6%) and low accessibility (25.0%) were referred to as the main reasons for not consulting guidelines. Conclusions. Routine sexual history taking and consultation of guidelines about SD are not yet a generalized practice in primary care. Data should be interpreted with caution as they are self-reported. Further objective measurement such as direct observation or clinical files consultation should be implemented. Ribeiro S, Alarcão V, Simões R, Miranda FL, Carreira M, and Galvão-Teles A. General practitioners’ procedures for sexual history taking and treating sexual dysfunction in primary care. J Sex Med 2014;11:386–393. Key Words. Sexual Dysfunction; General Practitioners; Primary Healthcare; Disease Management; Sexual History Taking; Diagnostic and Therapeutic Approaches
Introduction
G
ood history-taking skills are the first step toward achieving a correct diagnosis of sexual dysfunction (SD). However, studies show there are both lack of opportunities for medical students to learn how to do a sexual history [1] and lack of
J Sex Med 2014;11:386–393
opportunistic sexual history taking by doctors [2]. Four key areas for improvement have been identified: time constraints, ethico-legal, clinical, and personal aspects [3]. These factors have been recognized as barriers in the overall management of SD [4,5]. Many courses have been developed to teach sexual history taking and management of SD, some spe© 2013 International Society for Sexual Medicine
General Practitioners’ Sexual History Taking and Treating Procedures cific to primary care (PC) setting [3,6] and others to common residency training [7], but evaluation of educational interventions is still needed [3,7]. Clinical practice guidelines aim to make everyday practice uniform and effective, therefore improving quality of care [8,9]. However, studies have shown their limited impact [10,11]. A review article identified several barriers to adherence to practice guidelines, including lack of familiarity and awareness (volume of information, time, and accessibility), lack of agreement and of outcome expectancy, lack of self-efficacy, and motivation [12]. Despite increasing availability of SD guidelines [13], studies regarding its use in diagnosis and treatment are still missing. A study conducted among Swiss general practitioners (GPs) and urologists showed that both prefer using their own diagnostic criteria in male SD, which are often not reliable nor valid [14,15]. Another study among U.S. PC physicians and gynecologists revealed similar predictors to confidence in female SD management: On one hand, time constraints to elicit information and perceived lack of effective therapies to treat sexual problems (SPs) were negatively related to their confidence in treating decreased sexual desire; on the other hand, the volume of patients seen per week and practice experience were positive predictors of confidence [16]. A study focusing on the management of erectile dysfunction (ED) in PC found that only a minority (9.6%) of GPs routinely asked for ED in patients over 40 years, but this number increased (45.2%) when the patients had risk factors for this condition; older GPs were less likely to prescribe therapy and more likely to refer the patient to a specialist, and female GPs had more probability of being uncomfortable in diagnosing of SD than male GPs [17]. Our hypothesis was that gender and years of practice influence attitudes toward taking sexual history, diagnostics and therapeutic approaches, and in the use of clinical guidelines. Methods
A cross-sectional study using anonymous questionnaires answered by GPs of primary health centers (PHCs) of one Lisbon Region Health Cluster was conducted between February and May 2011. Consenting GPs working at the selected PHC were considered eligible. Sampling and data collection procedures have been detailed in a previous article [18].
387
Main Outcome Measures Outcome measure for use of clinical guidelines was gathered on question “Over the last year, did you use guidelines about diagnosis and treatment of sexual dysfunctions to support your clinical practice?” and for active exploration on “Which percentage of your patients do you inquire about sexual problems during appointments?” (Supporting Information Appendix S1). Statistical Analysis To compare GPs according to gender and years of practice, nonparametric Mann–Whitney test was used for continuous variables as data normality assumption was not satisfied, and chi-squared tests (or Fisher’s exact test) were used for categorical variables. A barriers score was calculated by summing up the number of potential barriers (11 barriers in a 10-point scale from 1 = not a barrier to 10 = major barrier) in starting a dialog with a patient about sexual health. The “attitudes and beliefs” item had a corrected item–total correlation of 0.030 (very low), and therefore was excluded, resulting in a scale with possible values ranging from 10 (no barriers) to 100 (important barriers) and a very good internal consistency (Cronbach’s alpha of 0.82) for quantifying potential barriers in starting a dialog with a patient about sexual health as a whole. Multiple logistic regressions were conducted to explore the association between GPs habits and GPs characteristics. Multiple linear regression was conducted to examine the association between guideline consultation as a function of GPs’ sociodemographic characteristics and medical practice details, active exploration of SD, self-perceived competences in the discussion and treatment of SD, self-perceived need of training, adequacy of specialization as a source of information in SD, duration of appointments/week in which SD is mentioned, the ability to discuss SPs if the patient raises the issue, and the barriers score. Considering nine predictors, a minimum sample of 54 participants would allow a 95% confidence interval and 80% statistical power level. Models were adjusted by GPs’ years of practice instead of GPs’ age as the two variables were too correlated (Spearman’s rho = 0.75, P < 0.001), and the former had the highest predictive power. Analyses were performed with IBM SPSS Statistics for Windows, Version 20.0 (IBM Corp., Armonk, NY, USA). J Sex Med 2014;11:386–393
388 Table 1
Ribeiro et al. Participants’ demographic and medical practice characteristics by sex and years of practice GP’s years of practice†‡
GP’s sex*
Age (years) Years since start of GP career Approximate size of patients’ list Number of medical appointments/week Number of medical appointments/week in which SD is mentioned Time of medical appointments in which SD is mentioned (minutes) Estimated percentage of patient’s GPs actively ask about patient’s sexual problems Estimated percentage of patients that actively ask about sexual problems
Male GP (N = 20) Mean ± SD
Female GP (N = 30) Mean ± SD
20 or less (N = 17) Mean ± SD
More than 20 (N = 30) Mean ± SD
Total (N = 50) Mean ± SD
49.8 ± 10.0 19.5 ± 8.7 1,738.8 ± 256.3 102.6 ± 27.1 5.4 ± 6.8
53.2 ± 7.5 22.0 ± 7.8 1,541.7 ± 399.6 96.9 ± 30.9 8.3 ± 8.4
44.4 ± 10.6 — 1,616.8 ± 489.9 108.6 ± 31.2 10.0 ± 10.0
56.1 ± 2.8 — 1,611.8 ± 288.7 94.6 ± 27.4 5.5 ± 5.9
51.9 ± 8.6 21.0 ± 8.6 1,613.4 ± 363.9 99.2 ± 29.2 7.4 ± 7.9
21.4 ± 6.5
25.7 ± 8.8
24.7 ± 6.5
23.8 ± 9.1
24.0 ± 8.2
13.2 ± 12.4
17.0 ± 17.0
18.5 ± 14.9
13.3 ± 16.0
15.5 ± 16.7
11.6 ± 9.9
15.4 ± 15.0
18.1 ± 14.1
9.9 ± 11.1
13.9 ± 13.2
The values highlighted in bold are statistically significant (P < 0.05) *Mann–Whitney test between GPs’ sex †Mann–Whitney test between GPs’ years of practice, P < 0.05 ‡ There are three missing subjects for “years of practice” variable GP = general practitioner; SD = standard deviation
Results
The PHC call had a 90.0% participation rate, and 50 responses were obtained from the 68 eligible GPs (73.5% response rate).
Participants’ Characteristics GPs had a mean age of 51.9 ± 8.6 years, with a mean of 21.0 ± 8.6 years of practice. The medical appointments where SD was mentioned lasted on average 24.0 ± 8.2 minutes. GPs with less than 20 years of practice indicated a higher percentage of patients (18.1 ± 14.1) who actively asked about SP (Table 1). Taking a Sexual History GPs preferred approach to inquiry about patients’ sexual history was an open conversation (90.0%) rather than a structured one. Male GPs were more likely to perform open conversation than female GPs (odds ratio [OR] = 11.23), and years of practice presented a positive association with open conversation (OR = 1.11). Diagnoses tend to be based more on GPs’ own criteria (52.6%), especially for GPs with more than 20 years of practice (OR = 1.58) than on International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10) (31.6%) or Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) (15.8%). GPs that based their SD diagnosis on ICD-10 or DSM-IV were less likely to perform open conversation compared with those who based SD diagnosis on their own criteria (OR = 0.14 and 0.45, respectively). J Sex Med 2014;11:386–393
GPs consider that the exploration of the definition of “sexual life without sexual problems” depends highly on the patient at hand (81.6%), as does “sexual satisfaction as a whole” (85.4%). Only 15.5% of GPs actively ask patients for SD. The main reasons for asking patients about their sexuality are diabetes (84.0%), prescription of medication with adverse effects on sexuality (78.0%), family planning (72.0%), and urologic diseases (66.0%). Routine sexual history taking (22.0%) appears as one of the least mentioned motives for asking patients about their sexuality (Table 2). Gender differences were found in “neurological” and “other endocrinal diseases” which were reasons more often indicated by female GPs. GPs with 20 or less years of practice identify family planning as a prominent reason for inquiring for SD (82.2% vs. 63.3%), whereas GPs with more than 20 years of practice elected andropause more often (56.7% vs. 23.5%), P < 0.05. On the other hand, 14.0% of the GPs reported being asked by patients about SP. The most common SDs reported by patients were ED (92.0%), decreased libido (82.0%), dyspareunia (68.0%), and premature ejaculation (50.0%). Table 3 shows the most frequently asked SD according to four main categories of diseases: cardiovascular, endocrine, urologic, and mental. In men with diagnosed cardiovascular disease, male GPs ask considerably more about decreased libido (70.0%) than female GPs (33.3%), P = 0.02. In women with cardiovascular disease, dyspareunia is only asked by female GPs (23.3%), P = 0.03. We found significant differences regarding years of practice in patients with diagnosed mental illness:
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General Practitioners’ Sexual History Taking and Treating Procedures Table 2
Reasons for asking for sexual dysfunction according to GP’s sex and years of practice GP’s years of practice†§
GP’s sex* In your clinical practice, what makes you inquire your patient about sexuality? Diabetes Prescription of medication with adverse effects on sexuality Family planning Urologic diseases Menopause Cardiovascular diseases Andropause Mental diseases Neurologic diseases Obesity Routine history taking Other endocrinal diseases
Male GP (N = 20) n (%)
Female GP (N = 30) n (%)
20 or less (N = 17) n (%)
More than 20 (N = 30) n (%)
Total (N = 50) n (%)
15 (75.0)‡ 15 (75.0)‡
27 (90.0)‡ 24 (80.0)‡
16 (94.1)‡ 14 (82.4)‡
26 (86.7)‡ 24 (80.0)‡
42 (84.0) 39 (78.0)
13 13 11 11 10 6 2 4 4 1
23 20 21 17 14 12 13 8 7 8
15 11 10 10 4 6 5 3 4 4
(65.0) (65.0) (55.0) (55.0) (50.0) (30.0) (10.0) (20.0)‡ (20.0)‡ (5.0)‡
(76.7) (66.7) (70.0) (56.7) (46.7) (40.0) (43.3) (26.7)‡ (23.3)‡ (26.7)‡
(88.2)‡ (64.7) (58.8) (58.8) (23.5) (35.3) (29.4) (17.6)‡ (23.5)‡ (23.5)‡
19 19 21 16 17 10 10 8 7 5
(63.3)‡ (63.3) (70.0) (53.3) (56.7) (33.3) (33.3) (26.7)‡ (23.3)‡ (16.7)‡
36 33 32 28 24 18 15 12 11 9
(72.0) (66.0) (64.0) (56.0) (48.0) (36.0) (30.0) (24.0) (22.0) (18.0)
The values highlighted in bold are statistically significant (P < 0.05) *Chi-squared test between GPs’ sex † Chi-squared test between GPs’ years of practice ‡Fisher’s exact test, P < 0.05 § There are three missing subjects for “years of practice” variable GP = general practitioner
GPs with 20 or less years of practice ask more about orgasmic disturbances than those who have more than 20 years of practice. Dyspareunia (56.0%) and ED (68%) are the leading SD asked for when a patient has a known urologic disease. The large majority (92.0%) of the GPs report inquiring about the consumption of medication and other substances that might cause SD. The most commonly asked medications are psychotropics (97.8%), antihypertensives and drugs used in prostatic diseases (both with 87.0%), and antiandrogenics (69.6%).
Diagnostic and Therapeutic Approaches The most popular approaches for hypoactive desire disorder were searching for a solution together with the patient (62.0% in male vs. 72.0% in female patients, P = 0.29), followed by involving the partner (50.0% vs. 62.0%, P = 0.23) and referral to other specialist (48.0% vs. 34.0%, P = 0.15), whereas pharmacologic treatment was the least chosen option (36.0% vs. 18.0%, P = 0.04). Regarding orgasmic disorders, the majority of GPs preferred to refer the patient to other specialists (58.0% vs. 64.0%, P = 0.54). Again, drug prescription is the least common approach, being less frequent for female patients (24.0% vs. 6.0%, P = 0.01). Laboratorial exams were always the ones GPs use the most to clarify an SP (66.0%) except in GPs with more than 20 years of practice, followed by physical examination (52.0%) and consultation by other specialist (42.0%). Female GPs pre-
scribed more laboratorial exams than male GPs (OR = 1.89), and years of practice presented a positive association with laboratorial exams prescription (OR = 1.05).
Factors Related to GPs’ Guidelines Consultation Most doctors (76.0%) did not consult guidelines about diagnosis and treatment of SD during the previous year. The main reason for consulting guidelines was the need to clarify issues that arose during the practice (91.7%) followed by the will to keep updated about clinical recommendations (50.0%). Lack of time (31.6%) and low accessibility (25.0%) were referred as the main reasons for not consulting guidelines. The percentage of appointments with active exploration was found to be a positive predictor of guidelines’ consultation (P < 0.05), as well as considering the specialty as a good source of information and having longer appointments when SD is mentioned (P ≤ 0.20). The logistic regression model explained more than 30% of the guideline consultation phenomenon (R2 of Nagelkerke = 0.32 and Hosmer & Lemeshow goodness-of-fit statistic = 5.52, P = 0.70) (Table 4). Discussion and Conclusion
Our response rate was higher than other studies, but we acknowledge that it may not be truly representative because of selection bias. J Sex Med 2014;11:386–393
390 (26.0) (38.0) (56.0)
(42.0)‡
(44.0)
30 15 28 — 21 — 13 19 28 (52.0) (32.0) (44.0) (28.0) (30.0)† (34.0) (30.0)
(30.0) (56.0) (24.0) (44.0)
(48.0) (0.0) (14.0) (68.0) (40.0) (46.0) (42.0)
(30.0)
(40.0) (14.0)§ (40.0)
(10.0)
(50.0)
11 0 4 — 5 — 20 7 20 24 0 2 32 7 1 23 — 25 Decreased libido Increased libido Sexual aversion Erectile dysfunction Orgasmic disturbances Premature ejaculation SD because of a general medical condition Dyspareunia SD related to substance use
(48.0)* (0.0) (4.0) (64.0) (14.0) (2.0) (46.0)
n (%)
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*Female GP (n = 1, 33.3%) vs. male GP (n = 14, 70.0%)—P = 0.02 †GPs with 20 or less years of practice (n = 11, 64.7%) vs. GPs with more than 20 years of practice (n = 3, 10.0%)—P < 0.01 ‡GPs with 20 or less years of practice (n = 11, 64.7%) vs. GPs with more than 20 years of practice (n = 8, 26.7%)—P = 0.01 § Female GP (n = 7, 23.3%) vs. male GP (n = 0, 0.0%)—P = 0.03 GP = general practitioner; SD = standard deviation
(40.0) (32.0) (28.0)
(36.0) (20.0) (8.0) (60.0) (22.0) (10.0) (36.0)
18 10 4 30 11 5 18 — 15 (22.0) (0.0) (8.0)
n (%)
23 12 13 — 13 — 20 16 14
(26.0)
24 0 7 34 20 23 21 — 22 (46.0) (24.0) (26.0)
n (%)
16 2 9 — 8 — 15 28 12
(16.0)
26 16 22 14 15 17 15 — 22 (32.0) (4.0) (18.0)
n (%)
Male Patients
Mental illness
Female Patients Male Patients
Urologic diseases
Male Patients
Female Patients
Endocrine diseases
Male Patients
Female Patients
Cardiovascular diseases
Regarding these diseases, please indicate the sexual problems you usually inquire patients about
Table 3
Percentage of physicians who inquire about sexual problems, according sexual problem, patient gender, and to some categories of patients’ diseases
Female Patients
(60.0) (30.0) (56.0)
Ribeiro et al.
Taking a Sexual History In our study, the majority of GPs indicate preference for an open conversation when it comes to talking about SP, which is consistent with previous findings [14]. Routine sexual history taking (22%) appeared as the least reported motive for asking patients about their sexuality, similarly to other studies such as the Global Study of Sexual Attitudes and Behaviors, in which only 9% of men and women report having been asked by their GP about sexual difficulties over the previous 3 years [19]. Other studies [20–22] also indicate that sexual health is not yet discussed routinely. Furthermore, routine sexual history taking is the best way to systematically explore SD bearing three specific aspects in mind: comorbid medical conditions, organic and psychogenic causes, and concomitant medications [13]. In our study, diabetes was the leading cause (84.0%) for asking patients about their sexuality, closely followed by family planning (72.0%). The differences found between GPs’ years of practice and prominent reasons for asking about SD seem interesting as younger GPs seem more willing to use family planning for discussing SD than older GPs. In another study about SP in male patients in family practice, diabetes (79%) and family planning (53%) were also highly reported as opportunities for discussion of SP [23]. The nongeneralized sexual history taking is problematic as the primary healthcare setting is often the first contact patients have with the healthcare system, as is the fact that only a small percentage of patients engage in conversation about SP. In a study concerning the management of ED in general practice, 45.7% of GPs reported inquiring for ED only when patients initiated the discussion, and only 9.5% of GPs asked men older than 40 about ED on a routine basis [17]. Our study reveals that SD is scarcely mentioned by GPs (16%) and their patients (14%), in contrast with the high SD prevalence rates reported in the literature [24,25]. ICD-10 was mentioned in the questionnaire as a diagnostic tool together with the DSM; however, we acknowledge the limitations in reflecting an accurate clinical diagnosis. In Portugal, family planning is performed by GPs and was elected as one of the main reasons for asking for SD, meaning these consultations are being used as an opportunity for scanning for SD. However, these specific appointments are mostly attended by women, which leaves men mostly uncovered because, as previously stated, routine
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General Practitioners’ Sexual History Taking and Treating Procedures Table 4
Factors associated with consultation of sexual dysfunction guidelines in the previous year
Variable
Univariate model OR (95% CI)
Adjusted univariate model‡ OR (95% CI)
Multivariate model§¶ OR (95% CI)
GP’s sex male (female—reference) Years of practice Percentage of appointments with active exploitation Self-perceived competence in treating SD Self-perceived competence in discussing SD Adequacy of specialization as a source of information in SD Ability to discuss sexual problems if the patient actively raises the issue Duration of medical appointments in which SD is mentioned Barriers to initiate a conversation of sexual health score**
0.69 0.98 1.04 0.69 0.81 1.18 1.01 1.05 1.01
— — 1.04 0.66 0.82 1.21 1.01 1.06 1.01
2.32 0.96 1.07 0.38 1.10 0.58 1.02 1.12 1.03
(0.18–2.68) (0.90–1.06) (1.00–1.09)† (0.37–1.29) (0.42–1.55) (0.85–1.65) (0.99–1.03) (0.96–1.15) (0.97–1.06)
(1.00–1.09)† (0.34–1.26) (0.42–1.58) (0.85–1.71) (0.99–1.03) (0.96–1.17) (0.97–1.05)
(0.23–23.12) (0.84–1.08) (1.00–1.14)† (0.03–4.17) (0.14–8.78) (0.24–1.36)* (0.99–1.05) (0.95–1.31)* (0.96–1.11)
*P < 0.20; †P < 0.05 ‡Adjusted for GP’s gender and years of practice § 2 R Nagelkerke, 0.32; Hosmer and Lemeshow goodness-of-fit statistic, 5.52 with 8 degrees of freedom (P = 0.70) ¶Number of GPs included in the multivariate model: 41 **Score from 10 (no barriers) to 100 (important barriers) GP = general practitioner; SD = sexual dysfunction; OR = odds ratio; CI = confidence interval
sexual history taking is the least reported reason to ask for SD. Drug therapy with psychotropics, antihypertensives, drugs used in prostatic diseases, and antiandrogenics was recounted as a reason for asking for SD as they may all affect sexual function as a side effect. This is not surprising as these medications are commonly prescribed in PHC. Despite the growing evidence relating SD to cardiovascular disease (CVD), CVD was not among the main reasons for asking patients about their sexual function (56%). In the previously cited study, 45.2% of GPs investigated the presence of ED in patients with risk factors, age, history of cardiovascular disease, diabetes, prostatectomy, and depression—which have been correlated with ED [17]. Sixty percent of GPs reported asking for ED in male patients presenting with endocrine diseases, which is consistent with another Swiss study in which GPs reported asking 58.3% of their male patients within said disease group [14]. In male patients with diagnosed mental illness, however, decreased libido is the most inquired SD (52%) above the results found in another study (40.4%) [14]. In this same study, decreased libido was the most inquired SD, and ED was the second in men with mental illness. That is only partially consistent with our study, with sexual aversion and substance abuse coming in as the second most inquired SD.
Diagnostic and Therapeutic Approaches In our sample, laboratorial exams are more used than physical examination, which is consistent with literature that postulates that, despite the
importance of a physical examination in the evaluation of SD, it will miss to identify the specific underlying cause in most cases and is not always strictly mandatory, especially if the underlying cause seems to be because of situational problems, mental illness, or social problems [13]. Pharmacologic treatment was more frequent in male than in female patients, which is consistent with an article in which both GPs and gynecologists mention a lack of effective therapies for hypoactive sex disorder in women [16]. Furthermore, in another study, 98% of GPs had not prescribed any treatment for this condition [26]. On the other hand, nowadays, ED is more mentioned, and effective therapies are easily available, which might account for the pharmacologic treatment being more frequent in male patients. Using a standard operating procedure could help professionals in sexual history taking by providing a brief and structured method and by limiting barriers such as knowledge and perceived difficulties in dealing with SD [27].
Factors Related to GPs’ Guidelines Consultation Most GPs (76.0%) report not having consulted any guidelines about SD in the previous year. When diagnosing SD, 44.0% use their own diagnostic criteria, whereas 32.0% mention ICD-10 and 20.0% DSM-IV. This is worrying as classification manuals are more reliable and valid, and therefore lead to more accurate diagnosis. However, the reported use of guidelines is superior to what we found in literature, namely in a Swiss study in which no GPs reported having based their diagnosis on either ICD-10 or DSM-IV [14]. GPs J Sex Med 2014;11:386–393
392 consulted guidelines mainly for the need to clarify issues that arose during the practice (22.0%), followed by the will to keep updated about clinical recommendations. Lack of time (24.0%) and low accessibility (18.0%) were reported as the main reasons for not consulting guidelines, which is not surprising as “lack of time” had been chosen as one of the main barriers in managing SD in the same sample [18] and also because the average number of medical appointments per week was 99.2 with every physician managing a list of 1,613.4 patients. The barriers involved in the consultation of clinical guidelines have been previously reported [12]. Consulting guidelines could lead to increased knowledge on SD, which ultimately draws attention to the issue and its importance, and encourages active exploration. However, there are other sources of information such as review articles, which were not taken into account. One study showed that 38% of GPs were not confident in evaluating and managing sexual desire problems, and, as previously stated, knowledge is one of the main barriers GPs face in managing SD in general [28]. A high self-perceived competence in discussing SD raises the comfort of the GP and is likely to act as a motivation to discuss SD during appointments. Furthermore, GPs with more clinical practice may invest more in the quality of their appointments.
Strengths and Limitations Despite the existence of some studies concerning SD management in primary healthcare settings, they are often restricted to a specific dysfunction and are focused on the comparison of GPs with other medical specialists (urologists and gynecologists), disregarding gender and age/years of practice differences. A national representative sample could eventually identify other possible factors associated with sexual history taking and procedures, revealing differences in gender and years of medical practice, or regional training differences. Nevertheless, multivariate analysis reaches moderate level of explanation and could constitute a valuable exploratory model for the understanding of the factors that influence guidelines consultation. As data were self-reported, and no direct observation or clinical file consultations were made, there are no guarantees that it corresponds to the reality of all patients. Our response rate was among the highest reported in literature, possibly indicating GPs’ interest in this area, supported by the fact that 98.0% agreed that SD is an important public health issue. J Sex Med 2014;11:386–393
Ribeiro et al.
Recommendations and Future Plans This study would benefit from obtaining a wider sample to amplify our conclusions. Nevertheless, it enabled for the identification of future research purposes and provided a questionnaire for use in other investigations. A detailed mapping of the state of art in Portugal concerning pre and postgraduate education in SD would allow the identification of existing gaps and opportunities for intervention. A set of national guidelines for the diagnosis and treatment of SD should be prepared, and measures should be taken to ensure their accessibility not only to GPs but also to other medical specialists, such as gynecologists and urologists who deal with SD on their daily practice. Finally, an interventional model for strengthening the competences of GPs in the management of SD should be implemented as GPs reported the need of further education and the willingness to engage in such programs. Acknowledgment
We would like to thank ACES-Odivelas Health Units and SEXOS Study Research Team. Corresponding Author: Violeta Alarcão, D. Sociol, Epidemiology Unit of the Institute of Preventive Medicine, Lisbon Faculty of Medicine, Av. Prof. Egaz Moniz, Lisboa 1649-028, Portugal. Tel: (+351) 217985130 Ext: 47091; Fax: (+351) 217999421; E-mail: violeta.alarcao @gmail.com Conflict of Interest: The author(s) report no conflicts of interest. All authors declare that they have no competing interests. This study is part of the SEXOS Pilot Study, supported by a scientific grant from Merck Sharpe and Dohme Foundation and by the Program “Educação pela Ciência”, GAPIC/FMUL. The supporters did not have any role in the design and conduct of the study, neither in the collection, management, analysis, and interpretation of the data, or in the preparation, review, or approval of the article.
Statement of Authorship
Category 1 (a) Conception and Design Violeta Alarcão; Sofia Ribeiro; Rui Simões; Filipe Leão Miranda; Mário Carreira; Alberto Galvão-Teles (b) Acquisition of Data Violeta Alarcão; Sofia Ribeiro; Filipe Leão Miranda; Alberto Galvão-Teles
393
General Practitioners’ Sexual History Taking and Treating Procedures (c) Analysis and Interpretation of Data Violeta Alarcão; Sofia Ribeiro; Rui Simões; Filipe Leão Miranda; Mário Carreira; Alberto Galvão-Teles
Category 2 (a) Drafting the Article Violeta Alarcão; Sofia Ribeiro; Rui Filipe Leão Miranda; Mário Carreira; Galvão-Teles (b) Revising It for Intellectual Content Violeta Alarcão; Sofia Ribeiro; Rui Filipe Leão Miranda; Mário Carreira; Galvão-Teles
Simões; Alberto Simões; Alberto
Category 3 (a) Final Approval of the Completed Article Violeta Alarcão; Sofia Ribeiro; Rui Simões; Filipe Leão Miranda; Mário Carreira; Alberto Galvão-Teles
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Supporting Information Additional Supporting Information may be found in the online version of this article at the publisher’s website: Appendix S1 Self-administered questionnaire for GPs.
J Sex Med 2014;11:386–393
