Let’s talk about sex, rheumy

4 minute read

Despite the high prevalence of sexual dysfunction in female SARD patients, it remains both underrecognised and undertreated by clinicians.

Many female patients with systemic autoimmune rheumatic diseases (SARDs) experience severely impaired sexual function.

But despite the high prevalence of sexual dysfunction (SD), it remains both underrecognised and undertreated by clinicians. Rheumatologists therefore need to discuss SD directly with patients, according to the authors of a systematic review of research in the area.

The review, published in Rheumatology, was conducted by a team from the Aristotle University of Thessaloniki in Greece, King’s College London and Nuremberg Hospital in Germany.

The researchers aimed to explore the prevalence of SD in females with SARDs. Their findings were based on 68 studies, which included a total more than 5000 females diagnosed with a SARD. Overall SD prevalence was 63%, although if only sexually active females were included, SD prevalence was estimated as 60%.

Across the different SARDs, women with Sjogren’s syndrome and systemic sclerosis reported the highest levels of SD, at 74% and 69% respectively.

The researchers concluded rheums should not shy away from discussing sexual dysfunction with female SARDs patients.

“In line with the EULAR recommendations for the generic core competencies of health professionals in rheumatology, clinicians should assess the impact of SARDs not only on physical health but also on everyday relations and societal participation,” the authors wrote.

“Although healthcare professionals consider sexual function important for the holistic patient approach in SARDs, they rarely discuss it with their patients.”

One of the studies reviewed found that 71.6% of patients with SARDs displayed sexual difficulties, but most had never discussed these with their treating doctor.

Unfortunately, the tools available to clinicians don’t include everything needed to assess sexual dysfunction.

“The Oswestry Disability Index measures sexual difficulty in people who have low back pain,” said physiotherapy professor Andrew Briggs, of Curtin University’s School of Allied Health. “But a majority of tools typically used to measure function don’t contain items that relate to sexual function, so it’s hidden, or not really measured in an objective way.”

The researchers saw some promise in the Qualisex questionnaire, developed recently by a French team to evaluate sexual function exclusively in SARDs patients. The questionnaire comprises 10 questions to assess the effects of SARD, rheumatic medications, pain and general health on partnership, sexuality and self-perception.

“Qualisex was originally designed to assess SD in individuals with rheumatoid arthritis, but it has been also validated in patients with ankylosing spondylitis,” according to the study. “However, it failed to get validated in patients with systemic lupus erythematosus and systemic sclerosis. Therefore, more studies are [required] to conclude whether Qualisex represents a reliable screening tool for female SD in patients with SARDs.”

The researchers suggested the most likely reason why SD might be absent from consultations.

“This may be predominantly attributed to the embarrassment of the patient or the physician, the lack of time or privacy, and the insufficient knowledge about diagnosis and treatment of SD,” the authors wrote.

“Still, it seems that patients want to discuss their sexual problems since the benefits from such conversations outweigh their initial embarrassment.”

But according to Professor Briggs, this cuts two ways.

“It’s whether the patients actually reveal sexual problems to the treating practitioner – whether they’re a nurse, doctor, pharmacist or physio – so as to allow the physician to then take appropriate action. But the other side is that patients may well be very reluctant to discuss it, and then the onus is on the clinician, if they have a respectful relationship, to raise that in a way that’s not threatening.

“There’s responsibility on both sides.”

According to the paper, some rheums may find this challenging,

“Given that two-thirds of physicians report that they have received no training for the diagnosis and management of SD, it is mandatory to include this type of training in the health professionals’ education,” the authors concluded.

“Establishing communication channels about sexual health between physicians and patients with SARDs deserves to be a component of future healthcare delivery to help alleviate their sexual difficulties.”

But Professor Briggs said mandatory training wasn’t necessarily the answer.

Clinicians are “bombarded with requirements to do training” so a better approach might be to raise awareness and support those who feel they need extra support around communication, the tools to use, and ways to have that conversation, he said.

“We also need to respect that lots of clinicians are very well experienced,” he said, “and maybe it is just simply that they don’t think about asking this question. I think it’s more about awareness raising first before we say you’re not doing good job, you need to be trained.”

Rheumatology 2022, online 11 August

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