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More MS news articles for August 2003

Multiple Sclerosis and Sexuality

A Survey of MS Health Professionals’ Comfort, Training, and Inquiry About Sexual Dysfunction

http://mscare.com/a0306/page_03.htm

International Journal of MS Care
page 3, Volume 5, Issue 2
Summer 2003
Germaine A. Griswold, MA; Frederick W. Foley, PhD; June Halper, MSN; Nicholas G. LaRocca, PhD; and Vance Zemon, PhD

Germaine A. Griswold and Frederick W. Foley are affiliated with the Ferkauf Graduate School of Psychology and Albert Einstein College of Medicine, Yeshiva University in the Bronx, New York, and the Bernard W. Gimbel Multiple Sclerosis Comprehensive Care Center in Teaneck, New Jersey. June Halper is affiliated with the Bernard W. Gimbel Multiple Sclerosis Comprehensive Care Center. Nicholas G. LaRocca is affiliated with the National Multiple Sclerosis Society in New York City. Vance Zemon is affiliated with the Ferkauf Graduate School of Psychology and Albert Einstein College of Medicine, Yeshiva University.

Abstract

When health care professionals were asked about their perceptions of, assessment of, and treatment methods for sexual dysfunction, they acknowledged that sexual dysfunction was a frequent problem for MS patients, although few addressed the issue with their patients. Most also believed that very few of the patients actually sought help for sexual dysfunction. In addition to comfort level and training as the strongest predictors determining inquiry behavior, respondents indicated that lack of time with patients was an important factor in not inquiring about sexual function. As a whole, the group had minimal training in human sexuality. This questionnaire-based study found that amount of training was a significant predictor of both comfort level in discussing sexual functioning and the frequency in which discussions were initiated with patients. The results suggest that more training would facilitate MS health care professionals’ comfort and assessment behaviors of sexual dysfunction.

Suggested citation: Int J MS Care serial on-line. 2003;5(2).

Multiple sclerosis (MS) is a demyelinating disease of the central nervous system (CNS) resulting in a wide array of impairments that may include difficulties with gait, balance, sensation, pain, bladder and/or bowel control, vision, sexuality, and cognitive function.1 Sexual dysfunction is reported to occur in more than 70% of persons with MS, a frequency greater than that reported with other chronic diseases.2 In reports of men with MS, sexual dysfunction has ranged from 23% to 85%.1,3 Women, who are diagnosed with MS at a ratio of 2:1 compared to men, report sexual dysfunction up to 85% of the time.1-3 MS patients followed for a two-year period indicated that the prevalence of sexual dysfunction remained higher than 70%, with additional sexual complaints and worsening of previous symptoms.4

Sexual dysfunction in MS has multiple causes. Anatomically, it is thought that lesions that affect the thoracic spine and autonomic nerves are the main factors that affect sexual function in MS patients.5 However, many of the problems of sexual dysfunction in MS patients are not directly related to disease processes. A model of the categories of sexual dysfunction has been developed by Foley and Iverson.6 Primary sexual dysfunction in MS is a direct result of demyelinating lesions in the CNS, which subsequently affect the sexual response and/or sexual feelings.3 Primary sexual dysfunction may include a decrease or loss of libido, decreased or unpleasant genital sensations, or decreased orgasmic response in both men and women.3,6 For men, there may be problems in achieving and maintaining an erection, and diminished frequency of ejaculation.7 Women may experience reduced vaginal lubrication in addition to inorgasmia and a lowered sex drive.8

Secondary sexual dysfunction occurs when systems that are not directly involved in the neural pathways that connect to the genitals are affected. Symptoms of secondary sexual dysfunction occur as a result of bladder and bowel problems, fatigue, spasticity, muscle weakness, tremors, cognitive changes, and sensory paresthesias in nongenital parts of the body.3,7,8 Secondary sexual dysfunction may also occur as a result of adverse effects from medications that either directly treat MS or treat symptoms of MS (eg, spasticity, depression, bladder dysfunction).7

Tertiary sexual dysfunction occurs as a result of disability-related psychosocial and cultural issues that affect sexual response or pleasure.3,7These issues may include changes in family roles, altered self-image, lowered self-esteem, depression, demoralization, fears of being rejected by one’s partner, and feeling less attractive. As with many diseases that can create physical disabilities, sexual dysfunction can affect how others perceive the patient and can have a negative influence on the patient’s sense of self-worth.9

In a study that examined the direct impact of MS on sexuality and relationships, McCabe et al1 asked MS patients to fill out a questionnaire regarding perceived impact of MS on sexuality, social and intimate relationships, and various aspects of life, as well as coping strategies employed to deal with problems in these areas of life. Results indicated that 79.6% of the sample experienced problems in sexual functioning and, further, that the greatest area of difficulty was the level of satisfaction with sexuality. On a positive note, however, results suggested that if the relationship was already a strong source of social support, then it continued that way and appeared to be relatively unaffected by sexual dysfunction.

A second study examined the effect of sexual dysfunction on the quality of life of MS patients and their partners, as well as what mechanisms patients were using in order to deal with this problem. Dupont10 found that both male and female patients’ sex lives were significantly affected by MS. Results also showed that sexual dysfunction was not significantly correlated with the patient’s age, duration of diagnosed MS, or the mood of the patient. Partners of MS patients, however, were found to have sexual dysfunction that was related to the patient’s age, duration of illness, and the impact of the illness. It was clear that sexual dysfunction not only affected MS patients but also profoundly affected their partners.

It is evident that sexual dysfunction is a complex interaction of disease-related and psychological factors. The effects on the patient and his/her partner can be quite devastating. Two general responses tend to transpire in the wake of sexual dysfunction: reduced sexual activity and silence.11 Couples merely stop engaging in sexual activities for fear of being rejected or because they feel incapable of performing at a satisfactory level, and then find it difficult to talk about these changes with their partners or their health care providers.6

The Doctor/Patient Relationship: A Brief Overview

The interactions between patient and doctor are complex. They involve interactions between persons who are not in equal positions that are often nonvoluntary and emotionally charged, and that involve issues of great concern to the patient.12 Different styles of doctor/patient interactions have been described. The first, known as “doctor/patient behavior,” is goal-oriented and directed by the physician’s hypotheses about what is wrong with the patient and what type of treatment should be instituted. The second, known as “patient-centered behavior,” relies more on an egalitarian relationship between the doctor and the patient, where the patient is seen as vital in understanding the origin of the problem and what course of treatment is needed.13,14

Physicians employ a limited set of hypotheses when talking to patients and usually direct their inquiries according to these hypotheses.14,15 The line of inquiry described in the literature most frequently chosen by doctors often leads to a prescription, referral, or a follow-up visit.16 The dynamic that is created by this sort of interaction is one that is typically limited in time, which in turn restricts the content of most consultations and in fact may discourage the patient from asking about different health-related topics.

The patient affects the direction of the interactions as well. Several studies on doctor/patient communication have shown that patients are often left feeling as though they have not received enough information regarding their health.15-17 In a study in which patients were asked to fill out a questionnaire regarding their interest in information, it was found that patients often had a strong desire for information that they were hesitant to ask their physicians about. Another finding of the study showed that patients were less apt to assume responsibility for medical decisions, placing that task upon the doctor.16

A review of doctor/patient communication is necessary to examine the role of health care professionals in discussing sexual dysfunction. It is important to know not only the patient’s role in the doctor/ patient relationship but also how the doctor or health care professional may view these interactions and their purposes. If doctors are primarily focused on diagnosis and treatment of disease, they may never find out from their patients that there are problems with sexual functioning—the doctors may not direct their questioning towards this sensitive topic. In turn, if the patients want their doctors to have more responsibility in treatment decisions, then they may not think to inquire about sexual functioning because their doctors are simply not asking questions about it.

Many health care professionals are hesitant to address sexual functioning with their patients, and oftentimes, the patient is too embarrassed to broach the subject.8 The sensitive nature of sexuality and disability can lead to health care professionals either not asking about sexual functioning or believing that their disabled patients are asexual or have not had the desire to have sex since the onset of their disability.17 The reluctance of health care professionals to talk about sexual concerns arises in part from feelings of being unable to solve this sensitive problem.18 White et al8 suggested that medical professionals ask about sexual functioning routinely, because treatment may be as simple as prescribing medication. Physicians are not the only health care professionals who can assist the MS patient with sexual difficulties. Occupational and physical therapists can address more practical concerns, such as positioning techniques or the use of sexual aids that may increase sexual response and/or pleasure.19

Sexual dysfunction research in MS has been sparse to date. Most of the sexual dysfunction literature in medical patients focuses on spinal cord injury rather than chronic diseases.9 However, one recent small study demonstrated that cognitive behavior psychotherapy and sexuality-sensitive MS symptom management can improve marital communication, satisfaction, and sexual functioning in MS patients and their partners.20 Although research on improving sexual dysfunction in MS is sparse, even less is known about health care professionals’ inquiries and practice patterns regarding sexual dysfunction.

The purpose of the present study was to assess: 1) health care professionals’ perceptions of the impact of sexual dysfunction on the MS patients’ lives and relationships; 2) the extent to which they think patients would benefit from treatment of sexual dysfunction; 3) who is and who they think should be treating sexual dysfunction; 4) what methods of assessment and treatment are being used; 5) the amount of training that the health care professionals had received in sexual dysfunction; and 6) their comfort level in addressing sexual functioning.

It was hypothesized that amount of training in sexual dysfunction as well as comfort level would predict the degree to which health care professionals ask their patients about sexual dysfunction. It was also hypothesized that there would not be any differences among the types of professionals (eg, physicians, nurses, physical and occupational therapists, social workers, and psychologists) in terms of how each perceived, assessed, and treated sexual dysfunction.

Methods

Questionnaire Development

The survey questionnaire was constructed following a thorough review of the literature. Questions were selected to sample relevant content domains, which included demographics, percent/time exposure to MS treatment, beliefs about MS and sexuality, training and comfort with discussions on the topic with patients, and practice patterns. Following the initial questionnaire development, it was distributed to nine MS health professionals (including two neurologists, three psychologists, and four nurses) for review. Two MS patients reviewed it as well and offered several suggestions for additional items. Questions were added or eliminated based on the qualitative input received, and the format was changed to improve clarity.

Sample Description

The sample consisted of members of the Consortium of Multiple Sclerosis Centers attending a workshop on sexual dysfunction in MS (see Table 1 for a description of the sample members and the overall membership of the Consortium at the time of the survey). The current sample was compared to the membership database of the Consortium of Multiple Sclerosis Centers. A chi-square goodness-of-fit test was used to analyze whether the respondents provided an accurate representation of the distribution of the different professional groups making up the Consortium membership. The category “Other Professionals” was not present in the Consortium membership, and therefore was omitted from the analysis. As shown in Table 1, the sample did not accurately represent the overall Consortium membership. Physicians were underrepresented in the sample, while nurses were overrepresented [c2 (5) = 98.99, P < .001].
 
Profession Consortium
members
Membership
percentage
Sample
members
Physician 900 65% 12
Nurse 230 17% 39
Physical therapist 60 4% 4
Occupational therapist 61 4% 2
Social Worker 60 4% 7
Clinical psychologist 70 5% 3
Other professional -- -- 5
Total n 1381 100% 72

Table 1: Description of the members of the Consortium and the sample as determined by health care profession

The majority of the sample were women (n = 65), with most of the women being nurses (n = 39). The men (n = 5) in the sample were mainly physicians with one psychologist and one administrator. The mean age of the sample was 44.7 (SD, 8.9), with a range from 24 to 66. Most of the health professionals in the sample spent their professional time in the outpatient hospital clinic setting (65%), followed by “other” work setting (24%), inpatient rehabilitation hospital work setting (21%), inpatient acute care hospital setting (19%), an office or group practice setting (14%), or in community care agency work settings (3%). Work setting totals exceed 100% because some respondents indicated that they work in multiple settings. The mean percentage of time that the health care professionals spent in the clinical care of MS was 49.3% (SD, 4.3), while the average number of years experience working with MS was 8.4 (SD, .83).

Results

Analysis of Variance

One-way Analysis of Variance (ANOVA) was used to examine health professional differences for each question. Health professionals were divided into three groups: nurses, physicians, and other health care professionals. The other health care professionals category included social workers (n = 7), physical and occupational therapists (n = 4 and 2, respectively), psychologists (n = 3), and “other professionals,” who were administrators (n = 3).

Amount of Training in the Sample

The “amount of training in sexuality” was evaluated in the sample to determine whether there were differences in health care professional groups on this factor. There were no significant differences for health care professionals (F2,71 = .420, P = .66).

Beliefs About the Prevalence of Sexual Dysfunction

Although most of the sample had not received a great deal of training in human sexuality, the majority believed that at least 40% to 80% of MS patients experience changes in sexual function due to MS. There were no significant health professional differences in answering this question (F2,69 = 1.09, P = .342).

Beliefs About the Impact of Sexual Dysfunction on Intimate Relationships

There were no significant differences among health professionals when answering about the impact of sexual dysfunction in MS on intimate relationships (F2,69 = 1.42, P = .249). The groups as a whole agreed that sexual dysfunction has a “moderate to large” negative impact on intimate relationships (86%).

Similarly, all groups of health professionals surveyed believed that there was a “somewhat to moderate” extent to which sexual dysfunction in MS contributes to divorce or separation in long-term intimate relationships.

Beliefs About the Need for Professional Care in the Treatment of Sexual Dysfunction

Concerning the perception of respondents who estimated a patient’s ability to cope with sexual dysfunction (without professional care), there were no significant differences among health care professionals (F2,67 = .377, P = .687). The overall sample believed that “few or none” to only “some” of the patients could cope with sexual dysfunction without the help of professional intervention (76%). Most of the sample reported that “many” to “very many” persons with MS could benefit significantly from professional help in dealing with sexual dysfunction (65%). There was a significant difference among health professionals when answering what percentage of persons with MS would significantly benefit from help (F2,69 = 4.07, P = .02). Tukey post hoc analyses revealed that physicians believed that a smaller percentage of patients (40% to 60%) would significantly benefit from professional care (mean, 1.9 [“many”] [SD, 1.0]), while both nurses and other professionals thought that a larger percentage of MS patients would benefit from professional care (60% to 80%) (mean nurses, 2.6 [“very many”] [SD, 1.0]; mean other professionals, 2.9 [“very many”] [SD, .79]).

There were no significant differences among health care professionals in estimating the percent of persons with MS who actually seek professional help for sexual dysfunction (F2,68 = .530, P = .591). The majority of the sample (93%) thought that “few or none” to only “some” of persons with MS actually sought help for sexual dysfunction. Similarly, when asked about the percentage of persons with MS who are asked about sexual dysfunction by their health care providers, health care professionals answered “few to none.”

Discussion of Sexual Concerns With MS Patients

Most of the sample reported feeling “somewhat” to “very” comfortable in discussing sexual functioning with MS patients (64%). There were no significant differences among nurses, physicians, and other health professionals (F2,70 = .865, P = .426). However, when assessing the frequency of direct inquiry or initiating discussions about sexual functioning with MS patients, the majority of the sample answered “seldom.”

Reasons for Not Inquiring About Sexual Functioning

MS health care professionals’ reasons for not inquiring about sexual function were limited time with patients (44%), “outside my role” (15.3%), patient discomfort (12.5%), lack of professional training or comfort (6.9%), other priorities (5.6%), limited medical coverage so they can’t afford treatment (2.8%), and too intrusive for patients (2.8%); 8.3% of the sample did not answer the question.

Methods Used to Assess Sexual Dysfunction

The sample reported that the most often used method to assess sexual dysfunction in MS patients was the informal report of the patient (54% of the time), followed by a neurological exam (13%), sexual function not assessed at all (8%), other primary assessment methods (7%), interview by a mental health professional (4%), a physical exam (3%), and psychological or personality testing (3%).

Who Is Responsible for Assessing and Treating Sexual Dysfunction?

The sample endorsed the idea that the health care professional most responsible for the assessment, treatment, or management of sexual dysfunction was a urologist (32%), followed by a nurse (21%), and then a psychologist (18%). Only eight people in the sample indicated that a neurologist was the health care professional most responsible, with even fewer members of the sample indicating psychiatrists, other physicians, social workers, or physical and occupational therapists. Interestingly, the majority of the sample (71%), when asked if the person who assesses, treats, and manages sexual dysfunction was a consultant, answered no.

Interventions Used to Treat Sexual Dysfunction

The two final questions asked respondents about specific types of interventions used to treat sexual dysfunction in their respective workplaces and the primary or most frequent treatment intervention used; responses are included in Table 2.
 
Treatment Method Number of respondents using this method Percentage of respondents using this method
Medical sex education 22 30.4%
Oral medications 19 26.4%
Sexual dysfunction not treated 9 12.5%
Sex therapy 6 8.3%
Intracorporeal injections of meds for erectile dysfunction 3 4.2%
Noninvasive physical treatment for erectile dysfunction 2 2.8%
Surgery 1 1.4%
Other treatment interventions 1 1.4%
Did not answer the question 9 12.5%

Table 2: Number and percentage of respondents reporting the use of various methods for the treatment of sexual dysfunction in MS

What Predicts Professionals’ Frequency of Discussion With Patients About Sexual Dysfunction?

Hierarchical multiple regression was used to help determine what combination of factors predicted both “frequency of discussion” and “comfort level” (with discussing sexual function), respectively. Planned regression analyses were performed to minimize the number of analyses performed. The first analysis used “frequency of discussion” as the dependent variable. The first step in the hierarchical regression contained the control variables: sex, age, and number of years’ experience working with MS patients. A second step in the regression included the primary independent variable of interest, “amount of training in sexual functioning.” The results of the regression were that demographics did not predict frequency of discussion but “amount of training” in sexual dysfunction significantly predicted frequency of discussion, when the demographic variables in the first step were controlled (F4,64 = 6.35, P < .01). Health care professionals who had received more training in sexuality asked about sexual dysfunction more often.

A second sequential regression analysis on the dependent variable “frequency of discussion about sexual dysfunction” was performed using the same demographic variables in the first step and comfort level in the second step. Sex, age, and number of years’ experience did not predict frequency of discussion.

When the variances attributable to sex, age, and number of years’ experience were controlled, comfort level predicted the “frequency of discussion” (F4,64 = 18.2, P < .01). Health care professionals who had a higher comfort level asked their patients about sexual dysfunction more often.

What Predicts Professionals’ Comfort Level About Discussing Sexual Dysfunction With Patients?

A third sequential regression analysis was performed using “comfort level” as the criterion variable. The first step included sex, age, and number of years’ experience with MS patients as control variables, while the second step included “amount of training,” which was the independent variable of interest. Sex, age, and number of years’ experience did not predict health care professionals’ comfort level with discussing sexual functioning. When the variances attributable to sex, age, and number of years’ experience were controlled, “amount of training” significantly predicted the health care professionals’ “comfort level” in handling sexual matters (F4,64 = 10.44, P < .01). More training in human sexuality was associated with a higher level of comfort in talking about sexual functioning among the health care professionals in this sample.

Are There Differences Among MS Health Care Professionals When Controlling for Amount of Training and Comfort Level?

Since the hierarchical regressions indicated that comfort level (with discussing sexual dysfunction) and training in sexuality predict practice patterns, further analyses were performed to evaluate potential differences in health care professionals’ responses to survey questions while controlling for amount of training in sexuality and comfort level. Hence, Analysis of Covariance (ANCOVA) was performed on each question. Prior to performing ANCOVA, a test for homogeneity of the regression coefficient was performed to determine if the interaction between the covariant (amount of training or comfort level) and the independent variable (groups of different medical professionals), was significant for each comparison. Since the interactions were not significant, comparisons among the medical professionals were conducted while covarying out amount of training and comfort level.

Table 3 contains results of significant ANCOVAs with amount of training as a covariate. While controlling for the amount of training in human sexuality, a significant difference was found among health care professionals in the frequency of discussion about sexual functioning (F2,70 = 3.76, P = .03). Nurses and physicians both reported asking about sexual functioning at a “fairly often” level of frequency, while other professionals only reported asking about sexual functioning occasionally.
 
Significant survey questions Physicians mean (SD) Nurses mean (SD) Other health care professionals 
mean (SD)
F-statistic P value ETA squared
Frequency of discussion 1.8 (.31) 2.0 (.18) 1.4 (.24) 3.76  .03 .101
% who would benefit from processional care 2.0 (.27) 2.6 (.15) 2.9 (.21) 3.68 .03 .100

Table 3: Significant survey questions with amount of training in human sexuality as a covariate

When amount of training was controlled, a significant difference was found among health professionals when responding to a question about the percentage of patients who would benefit significantly from professional care of sexual dysfunction (F2,70 = 3.68, P = .03). When amount of training was controlled for, nurses and other professionals believed that a larger percentage of patients would benefit from professional care of sexual dysfunction (60% to 80%), while physicians believed that only 40% to 60% of patients would benefit significantly from professional care.

Comfort Level

A second set of ANCOVAs comparing the health care professional groups’ responses to each question was performed, controlling for comfort level. See Table 4 for significant results of ANCOVAs with comfort level as a covariate. Only two significant differences were found, and no other trends emerged from this analysis. While controlling for comfort level, a significant difference among health professionals was found in the frequency of discussion about sexual functioning (F2,71 = 8.34, P = .001). Nurses reported initiating discussions about sexual functioning more frequently than both physicians and other health care professionals.
 
Significant survey questions Physicians mean (SD) Nurses mean (SD) Other health care professionals 
mean (SD)
F-statistic P value ETA squared
Frequency of discussion 1.4 (.25) 2.1 (.14) 1.3 (.18) 8.34 .001 .19
% who would benefit from processional care 1.9 (.27) 2.6 (.15) 2.9 (.21) 4.77 .01 .12

Table 4: Significant survey questions with comfort level in discussing sexual functioning as a covariate

While controlling for comfort level, a significant difference was found among health professionals in assessing the percentage of patients who would benefit from the professional care of sexual dysfunction in MS (F2,69 = 4.77, P = .012). Nurses and other professionals reported that at least 60% to 80% of patients would significantly benefit from professional care, while physicians thought that 40% to 60% of the patients would significantly benefit from professional care.

Discussion

Health care professionals who attended a workshop on sexual dysfunction at an MS conference were asked to complete a questionnaire that assessed their opinions regarding sexual dysfunction, its impact on the lives of patients with MS, and their practice patterns related to assessment and treatment. The sample was not completely representative of the distribution of professional membership of the Consortium of Multiple Sclerosis Centers, with fewer physicians proportionately to the organization membership.

Results demonstrated some significant differences among health care professionals in their perceptions, assessment, and treatment of sexual dysfunction. Regarding the effects of sexual dysfunction on the intimate relationships of MS patients, all health care professionals agreed that sexual dysfunction has a significant impact and contributes to divorce. When asked about the percentage of patients who experience changes in sexual functioning due to MS, there were no differences among health care professionals’ answers. All indicated that a large percentage of MS patients were affected (40% to 60%). The MS health care professionals in this sample acknowledged that sexual dysfunction is not merely a minor problem but one that has a large impact on the lives of their patients. This is in keeping with another study in the general population that found that sexual dysfunction has a large impact on the quality of life.21

The survey found no significant differences among health care professionals in the amount of training that they had received in human sexuality. Most of the sample had received some minimal training on human sexuality, such as attending a workshop or reading on the topic. Since the study found that amount of training was a significant predictor of both comfort level in discussing sexual functioning and the frequency in which discussions were initiated with patients, one could make the argument that more training would facilitate professionals’ comfort and assessment behaviors of this symptom. Another conclusion from these results is that more training may be needed for all professional groups since no one group of health care professionals was better trained than another.

Although most of the sample believed that MS patients would benefit greatly from the treatment of sexual dysfunction, most also believed that very few of the patients actually sought help for sexual dysfunction, and the majority of the practitioners inquired “seldom” about this symptom. The sensitive nature of sexual dysfunction may contribute to this belief on the part of health care professionals; in their experience, perhaps, few patients had actually sought treatment for sexual dysfunction because of embarrassment or other medical priorities.

Results showed no significant differences in the sample in the comfort level in asking about sexual functioning. Most of the health care professionals reported feeling somewhat to very comfortable. However, the majority of the practitioners seldom initiated discussion, citing “lack of time,” “outside my professional role,” and “patient discomfort” as the three most frequent reasons for not inquiring about sexual dysfunction.
Respondents believed that the person most likely to be responsible for assessing and treating problems with sexual functioning is a urologist, with a nurse being the next most likely. Perhaps other health care professionals, such as occupational and physical therapists, social workers, and psychologists, may not ask about sexual functioning because they see it as a medical problem that is outside their scope of practice. However, the health care professional group that ranked third on the list of those responsible for assessing and treating sexual dysfunction was psychologist. Once again, there are many aspects to sexual dysfunction that need to be addressed, including medical, psychological, and emotional, as well as practical issues that can be handled by all groups of health care professionals, not just physicians, nurses, or psychologists.

As indicated in the results section, when asked directly about why they had not initiated discussions about sexual functioning, 44% of the sample said that they had limited time with patients. Sexual dysfunction may be considered more of a “quality-of-life” symptom, with disease progression and management of other disabling symptoms remaining as treatment priorities. According to the “cure” orientation of medical treatment, physicians prefer to steer treatment towards curing the patient or effectively managing symptoms. With sexual dysfunction there are few definitive cures, especially for women. Doctors and other health care professionals may simply ignore sexual dysfunction because it takes too much time or they feel that it cannot be helped and/or that addressing it is secondary to other medical needs.

In terms of who initiates discussion about sexual functioning, most health care professionals stated that they found out about their patients' problems through the patients’ informal reporting. Once again, if health care professionals were trained to address this issue, they might feel more comfortable in bringing up the topic of sexual functioning.

The most popular treatment methods for sexual dysfunction endorsed by the respondents were “medical sex education” followed by “oral meds.” While controlling for the amount of training in sexuality, physicians believed that a smaller percentage of MS patients would benefit from the professional care of sexual dysfunction, while nurses and other health care professionals believed that a larger percentage would benefit. Future research should investigate this difference in perception.

When comfort level in inquiring about sexuality was controlled for, nurses asked about sexual functioning more frequently than both physicians and other health care professionals. Perhaps the nurses asked more frequently about sexual dysfunction because they are often in the role of having more time with patients than physicians and can discuss a variety of issues. At the same time, the patients may in turn feel more comfortable with nurses because they are not as rushed as physicians and yet are capable of addressing medical and sometimes psychological issues. Perhaps other health care professionals do not see themselves in the role of asking about sexual dysfunction, although the reasons for these differences in inquiry among nurses, physicians, and other MS health professionals should be investigated in future research.

Limitations

There were several limitations to this study. First, this was a cross-sectional survey with a limited number of participants that underrepresented MS-specialty physicians. The number of analyses reported was appropriate for an exploratory survey but inflated the statistical probability of finding results of “significance.” Future research should acquire a larger, more representative sample and provide better experimental alpha protection.

Conclusion

When health care professionals were asked about their perceptions of, assessment of, and treatment methods for sexual dysfunction, they acknowledged that sexual dysfunction was a frequent problem for MS patients. Since few addressed the problem with their patients, they may not have felt sufficiently comfortable or adequately trained to manage sexual dysfunction. In addition to comfort level and training as the most potent predictors determining inquiry behavior, respondents indicated that lack of time with patients was an important variable in not inquiring about sexual function.
The sample believed that sexual dysfunction was a complication of MS that could have deleterious consequences for the patients’ relationships. The group had minimal training in human sexuality. Results from this study suggested that training of MS health care professionals in symptom management should include assessment and treatment of sexual dysfunction.

Acknowledgments: Project funded by the Consortium of Multiple Sclerosis Centers, Teaneck, NJ

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