https://orcid.org/0000-0002-8746-4275
Introduction
Sexual dysfunction is prevalent in inflammatory bowel disease (IBD) and occurs in up to half of women and one-quarter of men.1 Addressing issues of sexual dysfunction is necessary to improve quality of life and functioning.2,3
Chronic pain4 and persistent fatigue,5 both quite common in patients with IBD, adversely affect sexual desire and arousal. Arthralgias and arthritis may also result in limited mobility and reduced sexual pleasure. Body image concerns may arise from diarrhea, incontinence, perianal complications, draining fistulae, skin tags, scars, and the presence of an ostomy all may increase embarrassment and decrease confidence and therefore impair sexual function.1 Importantly, psychiatric disorders are associated with sexual dysfunction and must be addressed, given the prevalence of depression and anxiety in IBD.1
Patients with IBD value sexual health highly but describe a lack of conversation with their treating physicians.6 Despite this discrepancy in communication and care, the reasons underlying this deficiency of attention have not been explored or addressed. We performed a survey to assess gastroenterologists’ knowledge, attitudes, and practice regarding sexual function in patients with IBD, as well as barriers to providing sexual health care.
Methods
A Web-based questionnaire was developed after a structured literature review focusing on sexual function in IBD, and was emailed to U.S. gastroenterologists in the American Gastroenterological Association. The questionnaire (Supplementary Materials) was reviewed prior to finalization by 4 IBD faculty and piloted by 15 gastroenterology fellows. It contained 45 questions utilizing both descriptive scales and binary answers relating to barriers to addressing sexual function, as well as knowledge, experience, and desire of the physician to obtain further education regarding sexual dysfunction. Only gastroenterologists who saw IBD patients monthly were included. The study was deemed exempt by the Institutional Review Board.
Statistical Analysis
Descriptive statistics were presented and multivariate analysis considering factors such as gender, age, formal training, comfort with exploring sexual dysfunction, and number of monthly IBD patients was performed utilizing STATA 11.0 (StataCorp, College Station, TX, USA). A 2-sided P value of .05 was considered to be statistically significant.
Results
Physician Demographics
Of 4807 eligible participants, 326 surveys were completed. A total of 30% saw 21 or more patients with IBD per month, 30% saw 11 to 20 patients per month, and 40% of respondents saw 10 or fewer patients with IBD per month. A total of 70% of respondents were men, 64% were <45 years of age, and approximately 60% had <10 years of experience in gastroenterology. Half of respondents practiced within an academic unit.
Gastroenterologists’ Understanding
One-third of physicians reported not knowing the percentage of patients in their practice experiencing sexual dysfunction. Of the remaining respondents, three-quarters thought ≤25% of patients with IBD experienced sexual dysfunction. A total of 63% of respondents felt that IBD significantly impacted sexuality, and medications were described as significant by 62%. A total of 81% identified surgical management of IBD as having an impact on sexual function, and 71% and 72% recognized the impact of IBD and its management on body image and forming sexual relationships, respectively.
Gastroenterologists’ Practices and Comfort
A total of 70% of clinicians reported that they believed that assessment of sexual function should be routinely included in the management of patients with IBD; however, only 14% did so either most or all the time (Figure 1). A total of 59% of respondents felt that IBD specialists should be responsible for asking patients about sexual dysfunction, and the general physician, obstetrics and gynecology specialists, and urologists were identified as alternative clinicians who should be addressing sexual dysfunction.
Barriers to clinicians addressing sexual dysfunction in inflammatory bowel disease patients.
Among those clinicians who routinely inquired about sexual dysfunction, 39% reported they did so based on having a suspicion of an underlying issue. A total of 11% inquired routinely on first visit and 25% only if the patient brought the issue up. Issues prompting discussion included patients who required operative management or a stoma or those who were experiencing anxiety or depression. A total of 47% agreed that the presence of these factors warranted sexual health exploration, while 56% would inquire in patients with perianal or fistulizing disease. A total of 20% of clinicians felt uncomfortable discussing sexual dysfunction with their patients.
On multivariate analysis, female sex of the physician (adjusted odds ratio [AOR], 2.74, 95% confidence interval (CI), 1.17-6.42; P = .020), comfort with discussing sexual dysfunction (AOR, 21.39; 95% CI, 2.86-161.44; P = .003), rating one’s knowledge of sexual dysfunction treatment options as very good or excellent (AOR, 5.27; 95% CI, 2.38-11.66; P < 0.0001), and having had formal training in assessing and managing sexual dysfunction (AOR, 4.80; 95% CI, 1.24-18.80; P = .023) predicted routine assessment of sexual function concerns in patients with IBD (Table 1).
Multivariate analysis of variables affecting likelihood of clinicians undertaking routine assessment of sexual dysfunction in IBD patients
| Variable | AOR (95% CI) | P Value |
|---|---|---|
| Having undergone formal training in managing sexual dysfunction | 4.80 (1.23-18.80) | .023 |
| Number of IBD patients seen monthly | 1.34 (1.00-1.81) | .051 |
| Duration practicing as a gastroenterologist (years) | 1.04 (0.69-1.58) | .820 |
| Age | 1.27 (0.73-2.21) | .230 |
| Female | 2.74 (1.17-6.42 | .020 |
| Rating of sexual dysfunction knowledge as very good or excellent | 5.27 (2.37-11.66) | <.001 |
| Rating of comfort level | 21.39 (2.83-161.4) | .003 |
| Variable | AOR (95% CI) | P Value |
|---|---|---|
| Having undergone formal training in managing sexual dysfunction | 4.80 (1.23-18.80) | .023 |
| Number of IBD patients seen monthly | 1.34 (1.00-1.81) | .051 |
| Duration practicing as a gastroenterologist (years) | 1.04 (0.69-1.58) | .820 |
| Age | 1.27 (0.73-2.21) | .230 |
| Female | 2.74 (1.17-6.42 | .020 |
| Rating of sexual dysfunction knowledge as very good or excellent | 5.27 (2.37-11.66) | <.001 |
| Rating of comfort level | 21.39 (2.83-161.4) | .003 |
Abbreviations: AOR, adjusted odds ratio; CI, confidence interval; IBD, inflammatory bowel disease.
Multivariate analysis of variables affecting likelihood of clinicians undertaking routine assessment of sexual dysfunction in IBD patients
| Variable | AOR (95% CI) | P Value |
|---|---|---|
| Having undergone formal training in managing sexual dysfunction | 4.80 (1.23-18.80) | .023 |
| Number of IBD patients seen monthly | 1.34 (1.00-1.81) | .051 |
| Duration practicing as a gastroenterologist (years) | 1.04 (0.69-1.58) | .820 |
| Age | 1.27 (0.73-2.21) | .230 |
| Female | 2.74 (1.17-6.42 | .020 |
| Rating of sexual dysfunction knowledge as very good or excellent | 5.27 (2.37-11.66) | <.001 |
| Rating of comfort level | 21.39 (2.83-161.4) | .003 |
| Variable | AOR (95% CI) | P Value |
|---|---|---|
| Having undergone formal training in managing sexual dysfunction | 4.80 (1.23-18.80) | .023 |
| Number of IBD patients seen monthly | 1.34 (1.00-1.81) | .051 |
| Duration practicing as a gastroenterologist (years) | 1.04 (0.69-1.58) | .820 |
| Age | 1.27 (0.73-2.21) | .230 |
| Female | 2.74 (1.17-6.42 | .020 |
| Rating of sexual dysfunction knowledge as very good or excellent | 5.27 (2.37-11.66) | <.001 |
| Rating of comfort level | 21.39 (2.83-161.4) | .003 |
Abbreviations: AOR, adjusted odds ratio; CI, confidence interval; IBD, inflammatory bowel disease.
Barriers in Assessing Sexual Dysfunction
Barriers to assessing sexual dysfunction included lack of time (47% of respondents), more important issues to discuss regarding IBD diagnosis and treatment (42% of respondents), and a lack of training in this area (33% of respondents) or lack of knowledge of whom to refer to for assistance (36% of respondents) (Figure 1).
A total of 24% of respondents felt that their knowledge and consequent treatment of sexual dysfunction was excellent or very good, with 73% considering their knowledge as fair or poor. Only 5% had undergone formal training in management of sexual dysfunction, and 86% expressed interest in learning more, and 89% identified that formal training should be required during completion of gastroenterology fellowship.
Format Preferences for Addressing Knowledge Gap
To address the knowledge gap, 36% of respondents would like education in conference meetings, 46% would prefer education via an Internet learning tool, 44% would prefer a slide show, 41% would prefer a published paper with guidelines, 43% would prefer a didactic lecture, and 48% would like small group meetings.
Discussion
Though sexual dysfunction is common among patients with IBD, this survey provides evidence that it is a neglected element of IBD care. Only 14% of gastroenterologists reported that they routinely inquire about sexual health. Barriers such as a lack of time, lack of knowledge, and discomfort with the topic were identified as reasons for the lack of inquiry.
The importance of practitioner knowledge regarding sexual dysfunction and health cannot be overstated. Despite this, only 24% of gastroenterologists described their knowledge and treatment of sexual dysfunction to be excellent or very good. A total of 89% of respondents supported a need for further formal training prior to fellowship completion, and 86% expressed an interest in learning more about sexual health. Respondents provided a range of methods in which they would like to be educated on the topic, including small group meetings, having a published paper with guidelines, or having access to an internet learning tool. Prior studies have demonstrated that those who have confidence in the adequacy of their sexual health training describe more comfort addressing related issues,7 and hence training pathways should be prioritized. Meanwhile, integrating sexual health care into routine IBD care provision can be achieved with the use of sexual health assessment tools such as the IBD-specific Male and Female Sexual Dysfunction Scales.8,9 However, despite the availability of these scales, they have had limited uptake clinically. It is unknown whether this is due to the knowledge, skills, or attitudes of the IBD physicians.
The findings of our study mirror the barriers identified in similar surveys in other medical specialties and chronic disease management: time constraints, lack of confidence owing to inadequate training, fear of embarrassing themselves or their patients, and physicians’ own religious beliefs have been found to contribute to the relegation of sexual health–related consultations.10,11 Time constraints are difficult to overcome; however, this study demonstrates that the unilateral focus on symptom and disease control in the majority of patients may occur to the exclusion of other patient needs including psychosocial issues and sexual function concerns. Interestingly, in our study, female physicians were generally more likely to discuss sexual health with their patients. This may be partly explained by other studies that have demonstrated that female doctors are more likely to spend a longer time with patients and are less likely to view psychosocial problems as burdensome.12,13
A further barrier to optimal management of sexual health in IBD patients is a lack of consensus regarding what clinical specialty should be responsible for IBD-related sexual health. Almost half of respondents in our study felt that it was not the responsibility of the IBD specialist to ask patients about sexual health. However, this differs from patient expectations in which patients report that the impact of IBD on intimacy and sexuality should be explained and addressed at diagnosis, and that it should be the treating gastroenterologist who initiates this discussion.14 Appropriate referral pathways must be available and evidence-based management guidelines implemented. Attendance at a multidisciplinary sexual health clinic, which has been successfully implemented in oncology and in other chronic illnesses like multiple sclerosis,15 would be easily reproducible and transferrable to the IBD population.
Limitations of this study include the inherent respondent bias which limit the generalizability of the findings. The low response rate not only is likely multifactorial, but does raise the question of whether physicians felt a reluctance in responding due to their discomfort discussing sexual issues as reported in this survey. It may also be because the mailing list used includes recipients with no specific interest in IBD.
Conclusions
Sexual dysfunction is prevalent in patients with IBD and is known to have a significant impact on psychosocial and emotional health. We identify the relative lack of attention to this important health care issue and the clear need for formalized sexual health training for gastroenterologists, as well as the development of tools to address this neglected aspect of IBD care.
Acknowledgments
The Institutional Review Board was notified about the study and recommendations obtained. Ethical approval was not required.
Author Contributions
Guarantor of the article: B.C. Authorship contributions: B.C. and D.T.R. devised the study plan and survey. BC administered the survey and was responsible for data collection and collation. R.E.P. and B.C. undertook data analysis and BC drafted the manuscript. A.H.A.-A., E.Z., A.B., B.C., and D.T.R. critically reviewed and edited the manuscript. All authors approved the final version of the manuscript.
Conflicts of Interest
This was an investigator-initiated study with no external funding. None of the authors have relevant conflicts of interest. B.C. has received speaking fees from AbbVie, Jansen, Pfizer, Takeda, and Ferring; received research grants from Janssen and Ferring Pharmaceuticals; and served on the advisory board for Gilead and Novartis. D.T.R. has received grant support from Takeda and served as a consultant for AbbVie, Altrubio, Arena Pharmaceuticals, Boehringer Ingelheim, Bristol-Myers Squibb, Genentech/Roche, Gilead Sciences, Iterative Scopes, Janssen Pharmaceuticals, Lilly, Pfizer, Prometheus Biosciences, Reistone, Takeda, and Techlab Inc. All other authors disclose no conflicts.
