Carmen Aschka

Sexual dysfunction in men is common. A large study¹ in the United States with a sample of 1410 men found a 31% 12-month prevalence of sexual dysfunction. In a small US survey² of 62 men, nearly all participants reported sexual concerns at any time during their life. One third of 789 men in a British general practice reported a current sexual problem.³ Three fourths of 78 patients surveyed in another British general practice suffered from general sexual problems; 35% reported a specific sexual dysfunction, such as premature ejaculation or erectile dysfunction.⁴

Sexual dysfunction may have organic or psychological causes. The family practice setting seems to be ideal for the evaluation and management of sexual dysfunction, because family physicians usually know the personal and family situation of their patients.^5-8Also, sexual dysfunction is sometimes related to common diseases, such as diabetes mellitus.^9,10 Medications frequently prescribed in family practice, such as antihypertensive and psychiatric drugs, may also adversely affect sexual performance.^11,12 Finally, the popularity of sildenafil (Viagra) and the accompanying publicity may encourage an increasing number of patients with erectile problems to consult their family physicians in case of sexual problems.¹³

It is important for the family physician to recognize the spectrum of sexual problems among men, since these concerns may affect their patients’ health, wellbeing, and relationships. There are only a few small studies on sexual dysfunction in family practice,^2-4,14 with limited generalizability. Most of the authors did not correlate physicians’ and patients’ views on this topic. Little is known about what men expect from their family physicians in cases of sexual disorders. We performed a survey of male patients and their physicians, focusing on the frequency and types of sexual problems in family practice, the men’s expectations of their physicians in case of sexual problems, the physicians’ perception and management of sexual problems, and the influence of physicians’ knowledge of and attitude toward sexual medicine on patients’ help-seeking behavior.

Methods

Study Population

All board-certified family physicians in the 2 districts of Hildesheim (Lower Saxony) and Heiligenstadt (Thuringia, the former East Germany) in the North of Germany were asked to take part in the study and complete a self-administered questionnaire. For one day all male patients in the participating practices 18 years or older and capable of reading the German language were asked to complete a questionnaire in a separate room of the practice and, after finishing, to put it into a box. Neither the physician nor the practice nurses had access to the box.

Questionnaires

We developed a 3-page questionnaire for family physicians and a 4-page patient questionnaire. A multiple-choice format was chosen with some room for personal comments. The patient questionnaire was pilot tested on a sample of 20 men attending a family practice; these men did not take part in the final study. The patient questionnaire had 3 parts: the quality of the patient’s relationship with the family physician with regard to sexual problems; the frequency, presumed causes, and effects of sexual dysfunction; and the patient’s view of the physician’s management of sexual problems.

In the second part of the questionnaire a list of potential sexual problems was presented. The patients were asked to indicate whether they suffered never, seldom, sometimes, often, or always from 1 or more of these problems.

The physician questionnaire, which was piloted in cooperation with 3 family physicians, focused on the frequency of sexual problems in male patients, the treatment of sexual problems in family practice, and the reasons for not talking about sexual problems with the patient.

Data were analyzed using SAS software, version 8 for Windows (SAS Institute; Cary, NC). To test for differences, we used the chi-square test, as appropriate. Correlations among ordinal variables were determined by the Spearman rank correlation.¹⁵ The units of analysis were the patient and the physician, respectively. For comparison of the patients’ and their physicians’ statements, the unit of analysis was the practice. Since not all patients answered all items of the questionnaire, we report the denominator where relevant.

Results

Physicians and Patients

Of the 46 family practices approached, 20 (43%), all single handed, gave approval to interview patients in their surgery. Seventeen of these practices were located in a major city, and 3 were in a small town. Nearly all (19/20) answered the physician questionnaire. The participating physicians were, on average, aged 49 years (range=36-61 years). When asked why they did not want to take part in the study, physicians most often said they had only a small number of patients with sexual problems in their practice (6/26) or their patients would not consent to a study dealing with sexuality (8/26). Only 21% of the women physicians addressed took part in the study, compared with 53% of the men.

A total of 307 men (84%) returned the patient questionnaire. Lack of time, feeling too sick, and unwillingness were the reasons most often given by the 57 patients who refused to participate. Demographic characteristics are shown in Table 1. The age distribution is compared with the representative ADT (Accounting Data Record) Panel of the Central Institute of Ambulatory Health Care in Germany (Zentralinstitut für die kassenärztliche Versorgung).^16,17

More than 90% of the participating men (279/307) had been consulting their particular physician for more than 1 year. According to their own assessment, 245 patients had informed their physicians about their personal, family, and social background.

Frequency of Sexual Problems

More than 90% of the male patients (251/270) reported having 1 sexual problem at least seldom. Figure 1 illustrates the frequency of sexual problems. These results were not influenced by the patients’ marital status.

Low sexual desire (73%) and premature ejaculation (66%) were dominant problems. More than one third of the respondents suffered at least sometimes from these problems Figure 2. Approximately 5% to 6% of the men reported fear of failure and erectile dysfunction as often or permanent problems. Thirty-seven men (12%) did not answer any of the questionnaire items that referred to sexual problems. These men did not differ in marital status from those who answered these items; however, on average the 37 men were older than the remainder (55 years vs 44 years). Even if we make the (rather unlikely) assumption that all patients who did not answer the sex-related items represent men without any sexual problems, more than 80% of the sample (251/307) suffered at least occasionally from a reported sexual problem. Low sexual desire and erectile problems were weakly or moderately associated with age (rho=0.18; P=.0049 and rho=0.38; P=.0001, respectively).

Half of the patients who had sexual concerns (107/201) considered occupational stress to be a cause of their problems. Pressure resulting from expectations of self (28%), difficulties in relationships (19%), and comorbid diseases (13%) were also considered common causes of their sexual dysfunction. Less common causes included medicines (9%), inhibitions resulting from strict sexual education (8%), pressure resulting from expectations of others (8%), and involuntary childlessness (3%).

As a consequence of their sexual difficulties, 46 of 257 (18%) experienced depression and depression-like symptoms, 36 (14%) sleeplessness, and 35 (14%) difficulties in their relationships. Patients’ satisfaction with their sexual lives was moderately correlated with the frequency of their sexual problems (rho = -0.33; P <.001). Patients who reported suffering sexual problems never or seldom reported satisfaction scores of 7.5 or 7.6, respectively. Patients reporting sexual problems often or always were less satisfied Figure 3. Sexual-life satisfaction and age were not correlated (rho = -0.05; P=.41)

Patients’ Expectations

Most patients considered it important to talk with their family physicians about their sexual concerns (84%). Almost half of the respondents (133/295) preferred that their physician initiate any discussions about sexuality. These expectations were not influenced by patient age (data not shown). More than two thirds of the respondents would have liked their physicians to signal his or her open-mindedness by directly addressing sexual topics during the consultation.

Management of Sexual Problems

Only 12% (34/288) of the respondents had already consulted their family physicians because of sexual problems, and most (23/34) of these patients were satisfied with the physician’s treatment (discussion about the difficulties in 56% of cases, prescription of drugs in 29%, and specialist referral in 24%).

The physicians remembered only a few consultations about sexual problems. On average, they recalled seeing 7 patients every 3 months primarily because of sexual difficulties. In an additional 6 patient contacts, sexual problems were raised during the consultation.

The physicians stated that they initiated discussion about sexual problems only sometimes (53%) or seldom (37%) during the consultation. They considered the following occasions or conditions as good opportunities to start a discussion: psychosomatic complaints (16/19; 84%), family planning (53%), questions concerning human immunodeficiency virus (47%), and diseases, such as diabetes mellitus (79%) or hypertension (63%).

In cases of sexual problems, most family physicians in our sample would have changed medication if relevant (79%) or would have referred patients to urologists (74%). According to the experience of approximately half of the physicians (9/19), sildenafil motivated more patients with sexual concerns to consult their physicians.

The physicians were asked for possible reasons for not talking about sexuality Table 2. Regarding physician-related factors, most physicians (53%) considered the lack of time a barrier to addressing sexual topics. Nearly all physicians (17/19) presumed that a feeling of shame keeps patients from talking about sexuality.

Importance of Sexual Medicine

On average, physicians rated the importance of sexual knowledge in family practice at a value of 7.2 on a 10-point Likert scale where 1 = not important at all and 10 = highly important. They rated the quality of their own knowledge 6.05.

There was a (nonsignificant) correlation between the physicians’ assumed knowledge and the patients’ wish to contact them in the case of sexual problems (rho=0.26; P=.29). Correspondingly, men were more likely to contact their physician for sexual problems if the physician assessed counseling in sexual medicine to be more important (rho=0.18; P=.47). The practice was the unit of analysis for calculating these correlations and their P values.

Discussion

Our study shows that sexual problems are widespread among male family practice patients and confirms the public health importance of this area. The high rate of men reporting sexual problems (93%) includes all patients who have or have had a sexual problem, independently of how often they suffered from it. Even if we consider the missing data (n=37) as representing patients without any sexual problem, the rate is still more than 80% and exceeds the incidence found by other authors.^3,4,14,18 Our results confirm the survey of Metz and Seifert,² in which nearly every patient had a sexual problem (97%) at some time during his life. Interestingly, this situation does not seem to be significantly different from the experience of women patients, according to a recently published survey of sexual problems among women seeking routine gynecologic care from the departments of family practice and obstetrics and gynecology.¹⁹ Nearly all the 964 women (99%) reported 1 sexual concern or more.

Health surveys reflect self-reported problems, not medically defined diseases. However, because sexual problems affect well-being and interact with other somatic and psychological complaints, family physicians should be aware that nearly all patients experience and report sexual concerns. Also, it should be recognized that 20% of patients suffer often or always from at least 1 sexual problem. These patients were significantly less satisfied with their sexual life than the remainder.

Similar to the results of other studies,^1,9,20,21 we found that erectile dysfunction and low sexual desire increase with age. However, this was only a moderate correlation and should alert physicians to be cautious about regarding erectile dysfunction as an elderly man’s complaint. According to the patients’ own assessments, many sexual problems are related to occupational stress. Therefore, the family physician, with his or her knowledge of the patient’s family and social situation, is well prepared to identify men with sexual problems. For some men of our sample, these problems may be associated with sleeplessness or depression. In these cases, the family physician should address the interaction of diseases or drugs with sexual disorders.

The participating physicians were hesitant about initiating a discussion about sexual problems. This corresponds with the results of the patient survey, as only 12% of the men had already consulted their physicians in cases of sexual concerns. Half of the physicians stated that they have had more consultations about sexual concerns since the discussion about sildenafil started. This is in line with the hypothesis of Tiefer¹³ that the availability of sildenafil could motivate an increasing number of patients suffering from sexual problems to consult their family physicians.

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.

Sexual dysfunction in men is common. A large study¹ in the United States with a sample of 1410 men found a 31% 12-month prevalence of sexual dysfunction. In a small US survey² of 62 men, nearly all participants reported sexual concerns at any time during their life. One third of 789 men in a British general practice reported a current sexual problem.³ Three fourths of 78 patients surveyed in another British general practice suffered from general sexual problems; 35% reported a specific sexual dysfunction, such as premature ejaculation or erectile dysfunction.⁴

Sexual dysfunction may have organic or psychological causes. The family practice setting seems to be ideal for the evaluation and management of sexual dysfunction, because family physicians usually know the personal and family situation of their patients.^5-8Also, sexual dysfunction is sometimes related to common diseases, such as diabetes mellitus.^9,10 Medications frequently prescribed in family practice, such as antihypertensive and psychiatric drugs, may also adversely affect sexual performance.^11,12 Finally, the popularity of sildenafil (Viagra) and the accompanying publicity may encourage an increasing number of patients with erectile problems to consult their family physicians in case of sexual problems.¹³

It is important for the family physician to recognize the spectrum of sexual problems among men, since these concerns may affect their patients’ health, wellbeing, and relationships. There are only a few small studies on sexual dysfunction in family practice,^2-4,14 with limited generalizability. Most of the authors did not correlate physicians’ and patients’ views on this topic. Little is known about what men expect from their family physicians in cases of sexual disorders. We performed a survey of male patients and their physicians, focusing on the frequency and types of sexual problems in family practice, the men’s expectations of their physicians in case of sexual problems, the physicians’ perception and management of sexual problems, and the influence of physicians’ knowledge of and attitude toward sexual medicine on patients’ help-seeking behavior.

Methods

Study Population

All board-certified family physicians in the 2 districts of Hildesheim (Lower Saxony) and Heiligenstadt (Thuringia, the former East Germany) in the North of Germany were asked to take part in the study and complete a self-administered questionnaire. For one day all male patients in the participating practices 18 years or older and capable of reading the German language were asked to complete a questionnaire in a separate room of the practice and, after finishing, to put it into a box. Neither the physician nor the practice nurses had access to the box.

Questionnaires

We developed a 3-page questionnaire for family physicians and a 4-page patient questionnaire. A multiple-choice format was chosen with some room for personal comments. The patient questionnaire was pilot tested on a sample of 20 men attending a family practice; these men did not take part in the final study. The patient questionnaire had 3 parts: the quality of the patient’s relationship with the family physician with regard to sexual problems; the frequency, presumed causes, and effects of sexual dysfunction; and the patient’s view of the physician’s management of sexual problems.

In the second part of the questionnaire a list of potential sexual problems was presented. The patients were asked to indicate whether they suffered never, seldom, sometimes, often, or always from 1 or more of these problems.

The physician questionnaire, which was piloted in cooperation with 3 family physicians, focused on the frequency of sexual problems in male patients, the treatment of sexual problems in family practice, and the reasons for not talking about sexual problems with the patient.

Data were analyzed using SAS software, version 8 for Windows (SAS Institute; Cary, NC). To test for differences, we used the chi-square test, as appropriate. Correlations among ordinal variables were determined by the Spearman rank correlation.¹⁵ The units of analysis were the patient and the physician, respectively. For comparison of the patients’ and their physicians’ statements, the unit of analysis was the practice. Since not all patients answered all items of the questionnaire, we report the denominator where relevant.

Results

Physicians and Patients

Of the 46 family practices approached, 20 (43%), all single handed, gave approval to interview patients in their surgery. Seventeen of these practices were located in a major city, and 3 were in a small town. Nearly all (19/20) answered the physician questionnaire. The participating physicians were, on average, aged 49 years (range=36-61 years). When asked why they did not want to take part in the study, physicians most often said they had only a small number of patients with sexual problems in their practice (6/26) or their patients would not consent to a study dealing with sexuality (8/26). Only 21% of the women physicians addressed took part in the study, compared with 53% of the men.

A total of 307 men (84%) returned the patient questionnaire. Lack of time, feeling too sick, and unwillingness were the reasons most often given by the 57 patients who refused to participate. Demographic characteristics are shown in Table 1. The age distribution is compared with the representative ADT (Accounting Data Record) Panel of the Central Institute of Ambulatory Health Care in Germany (Zentralinstitut für die kassenärztliche Versorgung).^16,17

More than 90% of the participating men (279/307) had been consulting their particular physician for more than 1 year. According to their own assessment, 245 patients had informed their physicians about their personal, family, and social background.

Frequency of Sexual Problems

More than 90% of the male patients (251/270) reported having 1 sexual problem at least seldom. Figure 1 illustrates the frequency of sexual problems. These results were not influenced by the patients’ marital status.

Low sexual desire (73%) and premature ejaculation (66%) were dominant problems. More than one third of the respondents suffered at least sometimes from these problems Figure 2. Approximately 5% to 6% of the men reported fear of failure and erectile dysfunction as often or permanent problems. Thirty-seven men (12%) did not answer any of the questionnaire items that referred to sexual problems. These men did not differ in marital status from those who answered these items; however, on average the 37 men were older than the remainder (55 years vs 44 years). Even if we make the (rather unlikely) assumption that all patients who did not answer the sex-related items represent men without any sexual problems, more than 80% of the sample (251/307) suffered at least occasionally from a reported sexual problem. Low sexual desire and erectile problems were weakly or moderately associated with age (rho=0.18; P=.0049 and rho=0.38; P=.0001, respectively).

Half of the patients who had sexual concerns (107/201) considered occupational stress to be a cause of their problems. Pressure resulting from expectations of self (28%), difficulties in relationships (19%), and comorbid diseases (13%) were also considered common causes of their sexual dysfunction. Less common causes included medicines (9%), inhibitions resulting from strict sexual education (8%), pressure resulting from expectations of others (8%), and involuntary childlessness (3%).

As a consequence of their sexual difficulties, 46 of 257 (18%) experienced depression and depression-like symptoms, 36 (14%) sleeplessness, and 35 (14%) difficulties in their relationships. Patients’ satisfaction with their sexual lives was moderately correlated with the frequency of their sexual problems (rho = -0.33; P <.001). Patients who reported suffering sexual problems never or seldom reported satisfaction scores of 7.5 or 7.6, respectively. Patients reporting sexual problems often or always were less satisfied Figure 3. Sexual-life satisfaction and age were not correlated (rho = -0.05; P=.41)

Patients’ Expectations

Most patients considered it important to talk with their family physicians about their sexual concerns (84%). Almost half of the respondents (133/295) preferred that their physician initiate any discussions about sexuality. These expectations were not influenced by patient age (data not shown). More than two thirds of the respondents would have liked their physicians to signal his or her open-mindedness by directly addressing sexual topics during the consultation.

Management of Sexual Problems

Only 12% (34/288) of the respondents had already consulted their family physicians because of sexual problems, and most (23/34) of these patients were satisfied with the physician’s treatment (discussion about the difficulties in 56% of cases, prescription of drugs in 29%, and specialist referral in 24%).

The physicians remembered only a few consultations about sexual problems. On average, they recalled seeing 7 patients every 3 months primarily because of sexual difficulties. In an additional 6 patient contacts, sexual problems were raised during the consultation.

The physicians stated that they initiated discussion about sexual problems only sometimes (53%) or seldom (37%) during the consultation. They considered the following occasions or conditions as good opportunities to start a discussion: psychosomatic complaints (16/19; 84%), family planning (53%), questions concerning human immunodeficiency virus (47%), and diseases, such as diabetes mellitus (79%) or hypertension (63%).

In cases of sexual problems, most family physicians in our sample would have changed medication if relevant (79%) or would have referred patients to urologists (74%). According to the experience of approximately half of the physicians (9/19), sildenafil motivated more patients with sexual concerns to consult their physicians.

The physicians were asked for possible reasons for not talking about sexuality Table 2. Regarding physician-related factors, most physicians (53%) considered the lack of time a barrier to addressing sexual topics. Nearly all physicians (17/19) presumed that a feeling of shame keeps patients from talking about sexuality.

Importance of Sexual Medicine

On average, physicians rated the importance of sexual knowledge in family practice at a value of 7.2 on a 10-point Likert scale where 1 = not important at all and 10 = highly important. They rated the quality of their own knowledge 6.05.

There was a (nonsignificant) correlation between the physicians’ assumed knowledge and the patients’ wish to contact them in the case of sexual problems (rho=0.26; P=.29). Correspondingly, men were more likely to contact their physician for sexual problems if the physician assessed counseling in sexual medicine to be more important (rho=0.18; P=.47). The practice was the unit of analysis for calculating these correlations and their P values.

Discussion

Our study shows that sexual problems are widespread among male family practice patients and confirms the public health importance of this area. The high rate of men reporting sexual problems (93%) includes all patients who have or have had a sexual problem, independently of how often they suffered from it. Even if we consider the missing data (n=37) as representing patients without any sexual problem, the rate is still more than 80% and exceeds the incidence found by other authors.^3,4,14,18 Our results confirm the survey of Metz and Seifert,² in which nearly every patient had a sexual problem (97%) at some time during his life. Interestingly, this situation does not seem to be significantly different from the experience of women patients, according to a recently published survey of sexual problems among women seeking routine gynecologic care from the departments of family practice and obstetrics and gynecology.¹⁹ Nearly all the 964 women (99%) reported 1 sexual concern or more.

Health surveys reflect self-reported problems, not medically defined diseases. However, because sexual problems affect well-being and interact with other somatic and psychological complaints, family physicians should be aware that nearly all patients experience and report sexual concerns. Also, it should be recognized that 20% of patients suffer often or always from at least 1 sexual problem. These patients were significantly less satisfied with their sexual life than the remainder.

Similar to the results of other studies,^1,9,20,21 we found that erectile dysfunction and low sexual desire increase with age. However, this was only a moderate correlation and should alert physicians to be cautious about regarding erectile dysfunction as an elderly man’s complaint. According to the patients’ own assessments, many sexual problems are related to occupational stress. Therefore, the family physician, with his or her knowledge of the patient’s family and social situation, is well prepared to identify men with sexual problems. For some men of our sample, these problems may be associated with sleeplessness or depression. In these cases, the family physician should address the interaction of diseases or drugs with sexual disorders.

The participating physicians were hesitant about initiating a discussion about sexual problems. This corresponds with the results of the patient survey, as only 12% of the men had already consulted their physicians in cases of sexual concerns. Half of the physicians stated that they have had more consultations about sexual concerns since the discussion about sildenafil started. This is in line with the hypothesis of Tiefer¹³ that the availability of sildenafil could motivate an increasing number of patients suffering from sexual problems to consult their family physicians.

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.

Sexual dysfunction in men is common. A large study¹ in the United States with a sample of 1410 men found a 31% 12-month prevalence of sexual dysfunction. In a small US survey² of 62 men, nearly all participants reported sexual concerns at any time during their life. One third of 789 men in a British general practice reported a current sexual problem.³ Three fourths of 78 patients surveyed in another British general practice suffered from general sexual problems; 35% reported a specific sexual dysfunction, such as premature ejaculation or erectile dysfunction.⁴

Sexual dysfunction may have organic or psychological causes. The family practice setting seems to be ideal for the evaluation and management of sexual dysfunction, because family physicians usually know the personal and family situation of their patients.^5-8Also, sexual dysfunction is sometimes related to common diseases, such as diabetes mellitus.^9,10 Medications frequently prescribed in family practice, such as antihypertensive and psychiatric drugs, may also adversely affect sexual performance.^11,12 Finally, the popularity of sildenafil (Viagra) and the accompanying publicity may encourage an increasing number of patients with erectile problems to consult their family physicians in case of sexual problems.¹³

It is important for the family physician to recognize the spectrum of sexual problems among men, since these concerns may affect their patients’ health, wellbeing, and relationships. There are only a few small studies on sexual dysfunction in family practice,^2-4,14 with limited generalizability. Most of the authors did not correlate physicians’ and patients’ views on this topic. Little is known about what men expect from their family physicians in cases of sexual disorders. We performed a survey of male patients and their physicians, focusing on the frequency and types of sexual problems in family practice, the men’s expectations of their physicians in case of sexual problems, the physicians’ perception and management of sexual problems, and the influence of physicians’ knowledge of and attitude toward sexual medicine on patients’ help-seeking behavior.

Methods

Study Population

All board-certified family physicians in the 2 districts of Hildesheim (Lower Saxony) and Heiligenstadt (Thuringia, the former East Germany) in the North of Germany were asked to take part in the study and complete a self-administered questionnaire. For one day all male patients in the participating practices 18 years or older and capable of reading the German language were asked to complete a questionnaire in a separate room of the practice and, after finishing, to put it into a box. Neither the physician nor the practice nurses had access to the box.

Questionnaires

We developed a 3-page questionnaire for family physicians and a 4-page patient questionnaire. A multiple-choice format was chosen with some room for personal comments. The patient questionnaire was pilot tested on a sample of 20 men attending a family practice; these men did not take part in the final study. The patient questionnaire had 3 parts: the quality of the patient’s relationship with the family physician with regard to sexual problems; the frequency, presumed causes, and effects of sexual dysfunction; and the patient’s view of the physician’s management of sexual problems.

In the second part of the questionnaire a list of potential sexual problems was presented. The patients were asked to indicate whether they suffered never, seldom, sometimes, often, or always from 1 or more of these problems.

The physician questionnaire, which was piloted in cooperation with 3 family physicians, focused on the frequency of sexual problems in male patients, the treatment of sexual problems in family practice, and the reasons for not talking about sexual problems with the patient.

Data were analyzed using SAS software, version 8 for Windows (SAS Institute; Cary, NC). To test for differences, we used the chi-square test, as appropriate. Correlations among ordinal variables were determined by the Spearman rank correlation.¹⁵ The units of analysis were the patient and the physician, respectively. For comparison of the patients’ and their physicians’ statements, the unit of analysis was the practice. Since not all patients answered all items of the questionnaire, we report the denominator where relevant.

Results

Physicians and Patients

Of the 46 family practices approached, 20 (43%), all single handed, gave approval to interview patients in their surgery. Seventeen of these practices were located in a major city, and 3 were in a small town. Nearly all (19/20) answered the physician questionnaire. The participating physicians were, on average, aged 49 years (range=36-61 years). When asked why they did not want to take part in the study, physicians most often said they had only a small number of patients with sexual problems in their practice (6/26) or their patients would not consent to a study dealing with sexuality (8/26). Only 21% of the women physicians addressed took part in the study, compared with 53% of the men.

A total of 307 men (84%) returned the patient questionnaire. Lack of time, feeling too sick, and unwillingness were the reasons most often given by the 57 patients who refused to participate. Demographic characteristics are shown in Table 1. The age distribution is compared with the representative ADT (Accounting Data Record) Panel of the Central Institute of Ambulatory Health Care in Germany (Zentralinstitut für die kassenärztliche Versorgung).^16,17

More than 90% of the participating men (279/307) had been consulting their particular physician for more than 1 year. According to their own assessment, 245 patients had informed their physicians about their personal, family, and social background.

Frequency of Sexual Problems

More than 90% of the male patients (251/270) reported having 1 sexual problem at least seldom. Figure 1 illustrates the frequency of sexual problems. These results were not influenced by the patients’ marital status.

Low sexual desire (73%) and premature ejaculation (66%) were dominant problems. More than one third of the respondents suffered at least sometimes from these problems Figure 2. Approximately 5% to 6% of the men reported fear of failure and erectile dysfunction as often or permanent problems. Thirty-seven men (12%) did not answer any of the questionnaire items that referred to sexual problems. These men did not differ in marital status from those who answered these items; however, on average the 37 men were older than the remainder (55 years vs 44 years). Even if we make the (rather unlikely) assumption that all patients who did not answer the sex-related items represent men without any sexual problems, more than 80% of the sample (251/307) suffered at least occasionally from a reported sexual problem. Low sexual desire and erectile problems were weakly or moderately associated with age (rho=0.18; P=.0049 and rho=0.38; P=.0001, respectively).

Half of the patients who had sexual concerns (107/201) considered occupational stress to be a cause of their problems. Pressure resulting from expectations of self (28%), difficulties in relationships (19%), and comorbid diseases (13%) were also considered common causes of their sexual dysfunction. Less common causes included medicines (9%), inhibitions resulting from strict sexual education (8%), pressure resulting from expectations of others (8%), and involuntary childlessness (3%).

As a consequence of their sexual difficulties, 46 of 257 (18%) experienced depression and depression-like symptoms, 36 (14%) sleeplessness, and 35 (14%) difficulties in their relationships. Patients’ satisfaction with their sexual lives was moderately correlated with the frequency of their sexual problems (rho = -0.33; P <.001). Patients who reported suffering sexual problems never or seldom reported satisfaction scores of 7.5 or 7.6, respectively. Patients reporting sexual problems often or always were less satisfied Figure 3. Sexual-life satisfaction and age were not correlated (rho = -0.05; P=.41)

Patients’ Expectations

Most patients considered it important to talk with their family physicians about their sexual concerns (84%). Almost half of the respondents (133/295) preferred that their physician initiate any discussions about sexuality. These expectations were not influenced by patient age (data not shown). More than two thirds of the respondents would have liked their physicians to signal his or her open-mindedness by directly addressing sexual topics during the consultation.

Management of Sexual Problems

Only 12% (34/288) of the respondents had already consulted their family physicians because of sexual problems, and most (23/34) of these patients were satisfied with the physician’s treatment (discussion about the difficulties in 56% of cases, prescription of drugs in 29%, and specialist referral in 24%).

The physicians remembered only a few consultations about sexual problems. On average, they recalled seeing 7 patients every 3 months primarily because of sexual difficulties. In an additional 6 patient contacts, sexual problems were raised during the consultation.

The physicians stated that they initiated discussion about sexual problems only sometimes (53%) or seldom (37%) during the consultation. They considered the following occasions or conditions as good opportunities to start a discussion: psychosomatic complaints (16/19; 84%), family planning (53%), questions concerning human immunodeficiency virus (47%), and diseases, such as diabetes mellitus (79%) or hypertension (63%).

In cases of sexual problems, most family physicians in our sample would have changed medication if relevant (79%) or would have referred patients to urologists (74%). According to the experience of approximately half of the physicians (9/19), sildenafil motivated more patients with sexual concerns to consult their physicians.

The physicians were asked for possible reasons for not talking about sexuality Table 2. Regarding physician-related factors, most physicians (53%) considered the lack of time a barrier to addressing sexual topics. Nearly all physicians (17/19) presumed that a feeling of shame keeps patients from talking about sexuality.

Importance of Sexual Medicine

On average, physicians rated the importance of sexual knowledge in family practice at a value of 7.2 on a 10-point Likert scale where 1 = not important at all and 10 = highly important. They rated the quality of their own knowledge 6.05.

There was a (nonsignificant) correlation between the physicians’ assumed knowledge and the patients’ wish to contact them in the case of sexual problems (rho=0.26; P=.29). Correspondingly, men were more likely to contact their physician for sexual problems if the physician assessed counseling in sexual medicine to be more important (rho=0.18; P=.47). The practice was the unit of analysis for calculating these correlations and their P values.

Discussion

Our study shows that sexual problems are widespread among male family practice patients and confirms the public health importance of this area. The high rate of men reporting sexual problems (93%) includes all patients who have or have had a sexual problem, independently of how often they suffered from it. Even if we consider the missing data (n=37) as representing patients without any sexual problem, the rate is still more than 80% and exceeds the incidence found by other authors.^3,4,14,18 Our results confirm the survey of Metz and Seifert,² in which nearly every patient had a sexual problem (97%) at some time during his life. Interestingly, this situation does not seem to be significantly different from the experience of women patients, according to a recently published survey of sexual problems among women seeking routine gynecologic care from the departments of family practice and obstetrics and gynecology.¹⁹ Nearly all the 964 women (99%) reported 1 sexual concern or more.

Health surveys reflect self-reported problems, not medically defined diseases. However, because sexual problems affect well-being and interact with other somatic and psychological complaints, family physicians should be aware that nearly all patients experience and report sexual concerns. Also, it should be recognized that 20% of patients suffer often or always from at least 1 sexual problem. These patients were significantly less satisfied with their sexual life than the remainder.

Similar to the results of other studies,^1,9,20,21 we found that erectile dysfunction and low sexual desire increase with age. However, this was only a moderate correlation and should alert physicians to be cautious about regarding erectile dysfunction as an elderly man’s complaint. According to the patients’ own assessments, many sexual problems are related to occupational stress. Therefore, the family physician, with his or her knowledge of the patient’s family and social situation, is well prepared to identify men with sexual problems. For some men of our sample, these problems may be associated with sleeplessness or depression. In these cases, the family physician should address the interaction of diseases or drugs with sexual disorders.

The participating physicians were hesitant about initiating a discussion about sexual problems. This corresponds with the results of the patient survey, as only 12% of the men had already consulted their physicians in cases of sexual concerns. Half of the physicians stated that they have had more consultations about sexual concerns since the discussion about sildenafil started. This is in line with the hypothesis of Tiefer¹³ that the availability of sildenafil could motivate an increasing number of patients suffering from sexual problems to consult their family physicians.

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.