|Year : 2022 | Volume
| Issue : 2 | Page : 101-107
Awareness of sexual medicine among a sample of mental health providers
Mona Reda1, Mohammad G Sehlo2, Usama M Youssef2, Dina A Seleem2
1 Department of Psychiatry, Ain Shams University, Cairo, Egypt
2 Department of Psychiatry, Zagazig University, Zagazig, Egypt
|Date of Submission||22-Oct-2021|
|Date of Decision||07-Dec-2021|
|Date of Acceptance||16-Jan-2022|
|Date of Web Publication||24-Jun-2022|
MD Dina A Seleem
Zagazig University, Zagazig, Sharkia, 44519
Source of Support: None, Conflict of Interest: None
Back ground Routine sexual history taking is an important component of psychiatric case formulation, and while sexual health problems are common, they are often left underdiagnosed in clinical practice. This study aimed to identify Egyptian mental health professionals’ knowledge, skills, and attitudes toward sexual medicine and psychosexual history taking. In this cross-sectional online survey study, 242 mental health professionals (160 psychiatrists and 82 psychologists) currently practicing in Egypt completed the survey.
Results About 98.3% of surveyed professionals were in agreement that collecting sexual history is vital to efficient clinical assessments. However, nearly half the participants believed that they lacked sufficient knowledge (51.7%) or clinical experience (50%) in psychosexual health matters, and one-third (34.7%) did not believe that they are confident in managing such problems. More than half (56.4%) do not routinely initiate taking sexual history, and about one-fifth (20.6%) were not comfortable initiating such questions. Common barriers included inadequate education and training (49.2%), irrelevance to patient’s chief complaint (39.7%), limited time (38%) and privacy (34.7%), worry of offending the patient (28.5%), feeling of awkwardness (27.3%), lack of confidence (24%), and to a lesser extent, poor rapport (15.3%) and fear of being judged by the patients (10.3%).
Conclusion Egyptian mental health professionals do not routinely discuss sexual health issues with their patients, despite understanding its importance, due to multiple social, educational, and personal barriers. Perceived lack of knowledge, limited clinical experience, personal difficulties, and social constraints are considered the main barriers.
Keywords: attitude, Egyptian, mental health professionals, sexual health, sexual history
|How to cite this article:|
Reda M, Sehlo MG, Youssef UM, Seleem DA. Awareness of sexual medicine among a sample of mental health providers. Egypt J Psychiatr 2022;43:101-7
| Background|| |
Sexual health is a fundamental component of general health, quality of life, and overall well-being. It is even embedded in the universal human rights of the Declaration for Sexual Rights by the World Association for Sexual Health (World Association for Sexual Health, 2014). Sexual health is a state of physical, emotional, mental, and social well-being. It is not merely the absence of disease, dysfunction, or infirmity. ‘Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having delightful and safe sexual experiences, free of coercion, discrimination, and violence’ (World Association for Sexual Health, 2014).
In a large survey (Mitchell et al., 2016), 22.8% of sexually active women and 38.2% men reported sexual problems, indicating the dire need for integrating sexual health issues by health care professionals in patient management and treatment (Nusbaum and Hamilton, 2002).
Every mental health care professional must consider the impact of sexual health issues to meet patients’ needs. This can be achieved through managing and integrating the topic of sexual health in daily routine checkups and building a multidisciplinary and multiprofessional network of sexual health experts to afford patients the specialized care they require (Seitz et al., 2020).
Many sexual-related health problems, such as sexually transmitted diseases, sexual dissatisfaction, anorgasmia, and other sexual-desire disorders that show no physical signs, emphasize the importance of patient–physician communication to identify problems and promote positive sexual health outcomes. It is recommended to incorporate routine sexual health discussions during medical visits for the benefit of quality patient care (Loeb et al., 2011).
However, how mental health providers initiate history collection is a sensitive matter among certain populations. Asking direct questions about sexual health problems can provoke discomfort in the clinician–patient relationship, which then might inhibit proper history taking, diagnosis, and management. Avoidance in taking relevant history and subsequent incomplete case formulation is commonly attributed to inadequacy of training in the sexual health field (Ross et al., 2021).
Few studies have investigated how physicians take sexual history or how they assess patients’ sexual function and satisfaction. Other studies have investigated mental health professional’s characteristics such as gender, age, race, sexual orientation, location of medical education, and type of practice with mixed results (Sobecki et al., 2012).
To our knowledge, few studies have investigated the awareness and attitudes of Egyptian mental health professionals toward sexual medicine and obtaining a sexual history, and the obstacles interfering with providing efficient service to patients with sexual health problems.
Consequently, identifying the deficiencies in knowledge, skills, and attitudes of mental health professionals, and the obstacles they face during interviews with sexual-dysfunction cases, will subsequently help improve the services provided for those patients in the future.
This study aims to assess the knowledge, skills, and professional attitude of mental health professionals toward sexual history taking.
| Patients and methods|| |
Research design and setting
This is a descriptive cross-sectional online survey study.
Ethics approval and consent to participate: this study was approved by the Institutional Review Board of Zagazig University Hospitals with approval number (6286). The participants provided a written consent to participate in the study by answering a question included at the beginning of the online survey.
The study included 242 mental health professionals (160 psychiatrists and 82 psychologists) actively working in Egypt, all of whom consented to taking the online survey designed for this experiment. The authors uploaded the survey using Google forms and the participants were recruited by sharing the survey online with them through social platforms and they were invited to share it with other mental health professionals using snowball-sampling technique from September 2020 to November 2020. Only completed forms were included in the study.
The survey entailed a newly designed questionnaire divided into three sections. The first section contained sociodemographic data (age, gender, and professional details). The second section contained 15 multiple-choice questions assessing sexual medicine education and experience, attitudes of mental health professionals during taking sexual history, and the challenges they face during practice. The third section contained three questions assessing their knowledge of factors affecting sexual health in patients.
| Results|| |
A total of 242 mental health professionals completed the survey. About 75.6% (n=183) of the study sample were females, while 24.4% (n=59) were males. All participants were above 25 years old, with the largest age-group demographic being 30–35 years old representing 33.5% of participants. Among the participants, 66.1% (n=160) were psychiatrists and 33.9% (n=82) were psychologists. For additional sample characteristics, see [Table 1].
Taking sexual history and knowledge about sexual health
For a list of the responses to the survey questions, see [Table 2].
| Discussion|| |
It has been shown that sexual satisfaction correlates with a higher quality of life (Flynn et al., 2016) and longevity (Yang and Gu, 2020). Psychosexual history taking is a crucial component of psychiatric case management, despite being often underestimated during routine assessment of mental health patients, patients in general practice (Mitchell et al., 2016), or even in gynecological practice (Pauls et al., 2005). Thus, the need for assessing the attitudes and barriers facing mental health professionals that prevent mental health professionals from integrating sexual history case formulation and providing adequate and efficient health service.
This study aimed to assess knowledge, skills, and professional attitude of mental health professionals toward sexual history taking with the intention to tackle the present barriers preventing mental health professionals from providing the necessary care required in addressing sexual health-related problems.
The results from this research showed that almost half the participants did not believe they have the adequate academic knowledge (51.7%) or clinical experience (50%) or confidence (34.7%) in managing such problems. Yet, nearly all of them (98.3%) recognize the importance of acquiring a sexual history and the role it plays in patients’ quality of life. About one-third of the participants doubted their knowledge of the effects of illnesses (35.1%) or medication (33.1%) on sexual health, and about two-thirds (68.4%) had less than good knowledge about the role of medications in sexual-dysfunction field.
In a previous study by Reda and Hussein (2006); 49 Egyptian hospital residents were surveyed about obtaining sexual history. They were asked about their knowledge about the impact of sexual dysfunction on patient medical condition and the effect of prescribed medication on sexual life of the patient. There was a very high statistically significant association between knowledge and specialty of residency as knowledge was the highest in endocrinology and dermatology residents followed by gynecology and obstetrics residents, then urologist.
An Egyptian study showed medical students to have insufficient knowledge (91.7%) of sexual health problems (Maraee et al., 2016). Hautamäki et al. (2007) and Kotronoulas et al. (2009) identified that lack of knowledge and skills are the main barriers for discussing this sensitive and important issue. Studies from the United States, United Kingdom, and Australia have found a lack of opportunistic sexual history taking (Temple-Smith et al., 1999) among doctors, a lack of opportunities available for medical students to observe doctors while they take sexual history (O’Keefe and Tesar, 1999), and a feeling that they were not adequately trained in such area (Merrill et al., 1990). As consistent with our results, the physician’s feeling of being inadequately trained is a reason often discussed in literature (Nusbaum and Hamilton, 2002; Tsimtsiou et al., 2006; Parish and Clayton, 2007; Waineo et al., 2010; Coverdale et al., 2011; Bitzer et al., 2013). Studies show that medical training in human sexuality medicine and routinely taking sexual history can promote comfort in doctor–patient relationship while addressing sexual-related problems (Schechtel et al., 1997).
This study also showed that more than half (56.4%) of the mental health professionals in Egypt do not routinely initiate taking sexual history, and about one-fifth (20.6%) were not comfortable initiating such questions. However, this discomfort was less (12%) when they were required to respond to patients’ sexual health-related questions. Even when the participants asked about details of sexual-cycle phases, it was more frequent to ask about less-embarrassing questions like dysfunction or desire rather than more intimate details like excitement, orgasm, resolution, and postcoital pain. This is not surprising, given that physician’s embarrassment is an often-mentioned across a variety of literature discussing the reasons for not addressing sexual health (Nusbaum and Hamilton, 2002; Morand et al., 2009; Seitz et al., 2020). In contrast, it has been shown that revealing and containing sexual health problems are more likely to happen with physicians who are comfortable talking about sexual health (Burnap and Golden, 1967; Bachmann et al., 1989) with patients preferring their doctors initiating the subject (Meystre-Agustoni et al., 2011).
Reda and Hussein (2006) found that 63.5% of residents asked less than half of the questions of sexual history, indicating that they had a disinterested attitude toward sexual-history obtaining. They found that residents of endocrinology, dermatology, urology and gynecology, and obstetrics ask about sexual history more frequently than residents of cardiology, neuropsychiatry, general surgery, and general medicine. As consistent with our results, they found that residents focused on asking about sexual dysfunction and desire rather than other sexual-cycle phases.
In the opinion of Egyptian mental health professionals, the main barriers that may interfere with proper sexual history taking are inadequate education and training (49.2%), irrelevance to patient’s chief complaint (39.7%), limited time (38%) and lack of privacy (34.7%), worry of offending the patient (28.5%), feeling of awkwardness (27.3%), lack of confidence (24%), and to a lesser extent, poor rapport (15.3%) and fear of judgment from patients (10.3%).
Reda and Hussein (2006) found that the main barriers were that the questions of sexual history were not usually included in the master history-taking sheet, finding this topic unimportant or irrelevant, and lack of finding the proper wording to ask in Arabic, which indicates a lack of sexual health training.
Seitz et al. (2020) surveyed 100 psychiatrists about the reasons for not addressing sexual health issues in psychiatrists’ daily routine and found the main reason (38.6%) to be the impression that other problems were more important for the patients. Other reasons were lack of time, abilities of recommendation for consultation, and treatment of sexual problems even if sexual issues are addressed, age, religion, and culture of the patient (Seitz et al., 2020). Time barrier is a well-reported barrier in sexual history taking (Rashidian et al., 2016).
As we found, literature showed that there is a lack of understanding about the importance of sexual health issues among physicians (Nusbaum and Hamilton, 2002; Morand et al., 2009) and a severe underestimation of the prevalence (Nusbaum and Hamilton, 2002; Papaharitou et al., 2008; Abdolrasulnia et al., 2010). In other studies, gender or culture differences between doctor and patient were reported as a source of difficulty in sexual history taking (Burd et al., 2006; Hautamäki et al., 2007; Löffler-Stastka et al., 2016; Seitz et al., 2020). Our results are consistent with other studies that shared similar barriers such as embarrassment with sexual language, recognized lack of training or skill related to the management of sexual health, fear of limited personal knowledge of sexual practices, fear of offending the patient, and the perception of nonrelevance to the chief complaint (Peck, 2001; Kingsberg et al., 2019). Clinical barriers such as lack of time, patient reluctance, discomfort discussing sexual activities, lack of staff support, and fear of insensitivity have also been reported by providers (Barbee et al., 2015).
| Conclusions|| |
In conclusion, Egyptian mental health professionals do not routinely discuss sexual health issues with their patients, despite understanding its importance due to multiple barriers. Perceived lack of knowledge, clinical experience and management skills, feeling of embarrassment, and worries of offending the patient are considered the main barriers.
This study is limited by the small number of the sample size and the cross-sectional nature of the sampling technique. Holding the survey online lacks the advantages of face-to-face assessment, although this study design was the most convenient timely wise and to allow comfortable and nonbiased answers.
From the results of our study, we recommend holding further research on a nationwide scale to gain better insight into the status of sexual medicine knowledge and practice, and the challenges facing mental health professionals during their practice. Efforts should be directed toward improving sexual health education and training, and including sexual history taking in everyday clinical practice.
The authors would like to thank all the participants in this study.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Abdolrasulnia M, Shewchuk RM, Roepke N, Granstaff US, Dean J, Foster JA, Casebeer L (2010). Management of female sexual problems: perceived barriers, practice patterns, and confidence among primary care physicians and gynecologists. J Sex Med 7:2499–2508.
Bachmann GA, Leiblum SR, Grill J (1989). Brief sexual inquiry in gynecologic practice. Obstet Gynecol 73(3 Pt 1):425–427.
Barbee LA, Dhanireddy S, Tat SA, Marrazzo JM (2015). Barriers to bacterial STI testing of HIV-infected men who have sex with men engaged in HIV primary care. Sex Transm Dis 42:590.
Bitzer J, Giraldi A, Pfaus J (2013). Sexual desire and hypoactive sexual desire disorder in women. Introduction and overview. Standard operating procedure (SOP Part 1). J Sex Med 10:36–49.
Burd ID, Nevadunsky N, Bachmann G (2006). EDUCATION: impact of physician gender on sexual history taking in a multispecialty practice. J Sex Med 3:194–200.
Burnap DW, Golden JS (1967). Sexual problems in medical practice. Acad Med 42:673–680.
Coverdale JH, Balon R, Roberts LW (2011). Teaching sexual history-taking: a systematic review of educational programs. Acad Med 86:1590–1595.
Flynn KE, Lin L, Bruner DW, Cyranowski JM, Hahn EA, Jeffery DD, Weinfurt KP (2016). Sexual satisfaction and the importance of sexual health to quality of life throughout the life course of US adults. J Sex Med 13:1642–1650.
Hautamäki K, Miettinen M, Kellokumpu-Lehtinen PL, Aalto P, Lehto J (2007). Opening communication with cancer patients about sexuality-related issues. Cancer Nurs 30:399–404.
Kingsberg SA, Schaffir J, Faught BM, Pinkerton JV, Parish SJ, Iglesia CB, Simon JA (2019). Female sexual health: Barriers to optimal outcomes and a roadmap for improved patient-clinician communications. J Womens Health 28:432–443.
Kotronoulas G, Papadopoulou C, Patiraki E (2009). Nurses’ knowledge, attitudes, and practices regarding provision of sexual health care in patients with cancer: critical review of the evidence. Support Care Cancer 17:479–501.
Loeb DF, Lee RS, Binswanger IA, Ellison MC, Aagaard EM (2011). Patient, resident physician, and visit factors associated with documentation of sexual history in the outpatient setting. J Gen Intern Med 26:887–893.
Löffler-Stastka H, Seitz T, Billeth S, Pastner B, Preusche I, Seidman C (2016). Significance of gender in the attitude towards doctor-patient communication in medical students and physicians. Wien Klin Wochenschr 128:663–668.
Maraee AH, Elmoselhy HM, El-Gamel TA (2016). Knowledge and attitude as regards sexual health among medical students of Menoufia University, Egypt. Menouf Med J 29:1085.
Merrill JM, Laux LF, Thornby JI (1990). Why doctors have difficulty with sex histories. South Med J 83:613–617.
Meystre-Agustoni G, Jeannin A, Dubois-Arber F (2011). Talking about sexuality with the physician: are patients receiving what they wish?. Swiss Med Wkly 141:0910.
Mitchell KR, Jones KG, Wellings K, Johnson AM, Graham CA, Datta J, Field N (2016). Estimating the prevalence of sexual function problems: the impact of morbidity criteria. J Sex Res 53:955–967.
Morand A, McLeod S, Lim R (2009). Barriers to sexual history taking in adolescent girls with abdominal pain in the pediatric emergency department. Pediatr Emerg Care 25:629–632.
Nusbaum MR, Hamilton C (2002). The proactive sexual health history: key to effective sexual health care. Am Fam Physician 66:1705.
O’Keefe R, Tesar CM (1999). Sex talk: what makes it hard to learn sexual history taking?. Fam Med 31:315–316.
Papaharitou S, Nakopoulou E, Moraitou M, Tsimtsiou Z, Konstantinidou E, Hatzichristou D (2008). Exploring sexual attitudes of students in health professions. J Sex Med 5:1308–1316.
Parish SJ, Clayton AH (2007). Continuing medical education: sexual medicine education: review and commentary (CME). J Sex Med 4:259–268.
Pauls RN, Kleeman SD, Segal JL, Silva WA, Goldenhar LM, Karram MM (2005). Practice patterns of physician members of the American Urogynecologic Society regarding female sexual dysfunction: results of a national survey. Int Urogynecol J 16:460–467.
Peck SA (2001). The importance of the sexual health history in the primary care setting. J Obstetr Gynecol Neonat Nurs 30:269–274.
Rashidian M, Minichiello V, Knutsen SF, Ghamsary M (2016). Barriers to sexual health care: a survey of Iranian-American physicians in California, USA. BMC Health Serv Res 16:1–11.
Reda M, Hussein H (2006). Difference in obtaining sexual history among residents of Ain Shams University Hospitals. Curr Psychiatry 13:3.
Ross MW, Newstrom N, Coleman E (2021). Teaching sexual history taking in health care using online technology: A PLISSIT-Plus zoom approach during the coronavirus disease 2019 shutdown. Sex Med 9:100290.
Schechtel J, Coates T, Mayer K, Makadon H (1997). HIV risk assessment: physician and patient communication. J Gen Intern Med 12:722.
Seitz T, Ucsnik L, Kottmel A, Bitzer J, Teleky B, Löffler-Stastka H (2020). Let us integrate sexual health—do psychiatrists integrate sexual health in patient management?. Arch Womens Ment Health 23:527–534.
Sobecki JN, Curlin FA, Rasinski KA, Lindau ST (2012). What we don’t talk about when we don’t talk about sex1: results of a national survey of US obstetrician/gynecologists. J Sex Med 9:1285–1294.
Temple-Smith MJ, Mulvey G, Keogh L (1999). Attitudes to taking a sexual history in general practice in Victoria, Australia. Sex Transm Infect 75:41–44.
Tsimtsiou Z, Hatzimouratidis K, Nakopoulou E, Kyrana E, Salpigidis G, Hatzichristou D (2006). EDUCATION: predictors of physicians’ involvement in addressing sexual health issues. J Sex Med 3:583–588.
Waineo E, Arfken CL, Morreale MK (2010). Sexual health education: a psychiatric resident’s perspective. Acad Psychiatry 34:357–360.
Yang F, Gu D (2020). Predictors of loneliness incidence in Chinese older adults from a life course perspective: a national longitudinal study. Aging Ment Health 24:879–888.
[Table 1], [Table 2]