Family Practice Vol. 18, No. 2, 161-166
© Oxford University Press 2001
Decision-making in the consultation |
Contradictions in the medical encounter: female sexual dysfunction in primary care contacts
Department of Public Health and Caring Sciences, Uppsala University, Uppsala Science Park, 751 85, Uppsala, Sweden.
Sarkadi A and Rosenqvist U. Contradictions in the medical encounter: female sexual dysfunction in primary care contacts. Family Practice 2001; 18: 161–166.
Received 22 March 2000; Revised 3 August 2000; Accepted 30 October 2000.
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Abstract |
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Background. Over the past two decades, primary care physicians have been encouraged to participate in the management of sexual disturbances. Women with type 2 diabetes, often treated by GPs, are at high risk of experiencing sexual dysfunction.
Objective. Very few qualitative studies have described the impact of sexual dysfunction on the diabetic women experiencing it. Our aim was, therefore, to explore the effects, if any, of type 2 diabetes on ‘womanhood and intimacy’ and investigate whether women wish to receive medical attention for their sexual disturbances.
Methods. We used a purposeful sample of middle-aged and older women (44–80 years) diagnosed with type 2 diabetes (n = 33). Methods triangulation was employed: focus group interviews were combined with observer data and a structured, anonymous questionnaire. We performed content analysis, with co-researcher control for systematic bias during the coding process.
Results. Personal characteristics, such as age, sex, experience and attitude of the doctor, the speciality considered to be appropriate (GP versus gynaecologist) and circumstances (time and privacy) in the primary care setting appeared to significantly influence women's willingness to discuss—if at all—sexual matters with physicians.
Conclusion. GPs should aim to create an open atmosphere to encourage discussion of female sexual dysfunction in the consultation room. However, women with sexual problems might benefit more from peer help through patient or women's organizations. The role of GPs might therefore consist of supporting these services and identifying female sexual dysfunction in type 2 diabetes, a problem that middle-aged and older women have difficulty communicating.
Keywords. GP, middle age, sexual dysfuction, type 2 diabetes, women.
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Introduction |
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Recognition of the high prevalence of sexual dysfunction in the general population1 has led to the conclusion that management of sexual disturbances constitutes ‘a general practice speciality’.2 Investigators have exam-ined patient and physician factors that have hindered discussion of sex issues in the primary care setting,3 and concluded that addressing patients' sexual histories should be part of routine care.4
Research conducted on healthy subjects has indicated that women would seek advice from their family physicians if they had sexual problems5 and would prefer that physicians raised the issue of sexual functioning rather than women themselves having to volunteer the information.6,7
Social aspects of middle-aged and older women's sexuality
The medical profession is often argued to have the power and social authority to set norms of sexuality; some would suggest that it is ethically unacceptable for health care personnel to give sexual advice without considering the social, political and juridical aspects of sexuality.8
From the 19th century until the early feminist movements of the 1930s, female sexuality, other than for the purposes of reproduction, was a taboo subject. Sexual desire was to be mastered, and overactive female sexuality was defined as mental or moral illness.9 Despite the sexual revolution of the 1960s and the resulting openness towards sex and sexuality, these have remained sensitive topics for several generations of women. Brought up with restrictive attitudes towards sexuality, as imposed by the Victorian norms of the 19th and early 20th centuries, guilt and shame often accompany these women throughout their sex lives.10
Despite empirical evidence showing that older people often have an active and enjoyable sex life,11 health care services seem to lack adequate sexual counselling and care, especially for elderly women,12 old people who display their sexuality risk being viewed as "bragging, pathetic, senile or perverse".11
Female sexual dysfunction in diabetes
Although studies vary in results, evidence suggests that women with type 2 diabetes run twice the risk of experiencing disturbed lubrication compared with age-matched, non-diabetic peers.13 Pain during intercourse (i.e. dyspareunia) and decreased sexual desire have also been found to be more common among women with diabetes than in the general population.13 In addition to the physical effects of the disease, diabetic women were also found to experience significantly more concern than non-diabetic women regarding the frequency with which they experienced sexual repulsion and were subject to performance anxiety and its impact.14
Despite the high prevalence of these disturbances, very few qualitative studies have described the impact of sexual dysfunction on the women experiencing it. Therefore, we performed a focus group study with the aim of shedding light on the effects—if any—of type 2 diabetes on ‘womanhood and intimacy’. Our research questions were the following. Do women perceive diabetes to affect their intimacy? Do they relate occurring sexual problems to their diabetes? Do they wish to receive medical attention for their sexual disturbances?
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Patients and methods |
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Our study population consisted of middle-aged and elderly women with type 2 diabetes (n = 33), selected according to the practice of purposeful sampling.15 Our research group was entrusted with the evaluation of a year long group education programme for self-referred type 2 diabetes patients: all women in five consecutive groups terminating the programme were sent written invitations to a group discussion on ‘Diabetes, Womanhood, and Intimacy’. Of the 37 women eligible, four chose not to participate. This left us with 33 women, all of whom gave their informed consent at the time of interview. Approval to conduct the study was obtained from the Research Ethics Committee of Uppsala University.
We used data collection methods triangulation.15 Focus group interviews and a 20-item anonymous questionnaire were employed; an observer provided data on interviewer–group interaction. Five group interviews with 6–8 women, who knew one another, were conducted by the female co-author (AS) of this paper. Interviews lasted 1 hour each and were timed to take place in conjunction with the final meeting of the education programme. A two-question interview guide was used: (i) what did you first think of when you read the subject of this interview, ‘Diabetes, Womanhood, and Intimacy’, in the letter you received?; and (ii) what are your thoughts regarding sexuality in middle-aged and older women as portrayed in the media?
We applied commercial computer software (NUD*IST) to assist technical processing of the interview text during content analysis.15 The initial stages of analysis comprised identification of central themes in the text and designation and revision of categories (through merging or splitting). Thereafter, the original text was re-read to validate categories, and direct quotes from the women were selected to reflect the original material.
The co-author who was not involved in the initial coding process (UR) scrutinized the original text for any statements/themes that might have been systematically neglected. During the analysis procedure, several key words were identified; therefore, text search for these words with the aid of the computer software were performed and selected units once again read through and categorized. Notes from the session with the observer were used during the analysis.
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Results |
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Participant characteristics
The mean age of the women was 65 years (44–80; SD = 8.65) and they had had diabetes for 6.3 years (1–20; SD = 5.20). Approximately two-thirds of participants were married or had a partner (n = 19); one-third (n = 10) considered themselves ‘currently sexually active’. Those sexually active had a mean age of 61 years as opposed to 67 years in the non-active group (P = 0.048). Leading reasons given for not being sexually active (n = 22) were: ‘personal choice’ (n = 5); lack of partner (n = 8); partner ill (n = 3); and partner sexually dysfunctional (n = 3). The majority of the women (n = 15) who answered the question (n = 23) were satisfied with their sex lives; those not sexually active were, however, significantly less satisfied (P = 0.007). Sexual dysfunction was reported by 14 women, most often due to decreased interest (n = 6), desire (n = 8) and lubrication (n = 8).
Qualitative analysis
The content analysis of the original interview material resulted in 12 categories. In this paper, we report findings in the category designated ‘Issues of sexuality in contacts with physicians’. Our analysis of the text sections coded under this category revealed four subcategories described in the following. The women quoted are designated as W1, W2, etc. A given number will not necessarily indicate the same woman in different interview situations.
Personal characteristics of the physician.. The GP's personal features seemed to have the greatest influence on whether or not sexual matters were discussed. When women explained why it was not possible to discuss sexual problems with their GPs, one description was, "he's so shy" and another, "he's not the type".
"Our doctor is a considerate and discreet man, and I am certain that if we mentioned having [sexual] problems, he would help us in every way, but I don't think he would ever bring it up himself."
The age and perceived experience of the physician consulted was also of importance. In Sweden, working at a GPs' surgery for 6 months is part of internship. Thus, women may encounter rather young doctors as their temporary family physicians.
W1: "I didn't think that he [the 25 year-old doctor] had the experience of life to understand what I was talking about because he is so much younger."
W2: "But he gets the pure medical stuff."
W1: "Yeah, yeah, but this might not be a purely medical issue, it's something a bit different (. . .). If I brought it up with a male doctor my age who wasn't a gynaecologist, well, I think maybe he would have experience of women my age, so to speak, and maybe realise what problems might crop up, but a guy of 25 can't put himself in the intercourse situation. (. . .) A girl of 25 who's a doctor could have the same difficulty."
The physician's sex was also clearly an important factor:
W1: "A lot of physicians are male and we are women, so they don't want to ask about something that might be really disturbing and embarrassing."
I: "For whom?"
W1: "For the woman . . . there are many women our age who have not been able to talk about sex."
Some women felt it would be easier to talk to a female doctor about these issues. Another woman explained that physicians simply were not a category of professionals with whom she had considered discussing sexual matters.
W1: "When I see my doctor regularly for my disease [diabetes] . . . it has never even occurred to me to discuss my sex life—intimacy—with him; it has never entered my head (. . .)."
W2: "You'd rather talk to your gynaecologist about that."
W1: "No, I never even considered it . . . that he could do anything about such things."
W3: "No, well."
W1: "(. . .) I see him because I have diabetes, so I just can't get into that sort of thing."
It was interesting to note that the latter reflected the attitude of most women: they did not consider health professionals whom they regularly consulted for their diabetes as sexual counsellors.
Generalist versus specialist. . Most women seemed to agree that sexual function and dysfunction were the domains of the gynaecologist.
W1: "Diabetes is diabetes, it's medicine and this is more, well yes, gynaecologists' [ground]."
I: "The other . . ."
W2: "Yes, sex life and vaginal dryness."
Two women who had female GPs felt that they could both discuss sexual problems with and receive a pelvic examination from their family physicians. These statements provoked lively discussion in one of the groups.
W1: "Family physicians are general practitioners whereas gynaecologists are specialists."
W2: "But my GP [female of 40] can do both . . ."
W1: "I feel . . . it's a special field so I want a specialist."
W2: "My GP is excellent."
W1: "I could never even contemplate that . . . such intimate matters with my GP (. . .)."
W3: "That's knowledge, too; it's a field."
W4: ". . . outside theirs."
W1: ". . . limited, in a way, and so I want an absolute specialist."
Although most participants agreed that gynaecologists were the appropriate health professionals to assist them with sexual problems, few of them had actually consulted a gynaecologist for their disturbances: "bringing that up—matters below the waist—that's what's so difficult when you're older."
Circumstances in the health care setting. . Time constraints were perceived to stand in the way of women bringing up sensitive, intimacy-related issues.
"They [physicians] are too stressed, too rushed, so they listen and hear what you have to say, but what you've said at one point, they'll have forgotten at the other . . ."
"It's hectic, everything goes so fast: to measure the blood pressure and listen a bit [to the heart and lungs] and write out some more medication, the same as before . . ."
"I feel they have enough to deal with when one gets there—they don't have time . . ."
Lack of privacy at primary health centres constituted another obstacle.
W1: "It's annoying that you can never talk in private [when deciding on whom to consult]."
W2: "When you arrive at the surgery and ask for a doctor and you're standing there at the counter."
W3: "Oh, I know."
W2: "You stand there and ‘oh, um, well I'm so dry' . . ."
W4: "Impotent!"
W2: "I'm so dry in my genitals, is there anyone in the surgery who does that?" (LAUGHTER)
Thus, women felt that besides their own shame hindering them from freely discussing the sensitive topic of sexual functioning, circumstances in the primary care setting were far from ideal for this purpose.
Whose initiative? . All groups touched on the issue of who should be responsible for raising the topic of sexual functioning: the patient or the doctor? Some wished that the physician were the one to broach it:
"A doctor who asks questions is great (. . .) Sometimes I wish he'd ask me, ‘was there anything else?’ when I'm at the door, but I don't take the opportunity myself 'cause I know time is short and all that . . ."
Others felt it should be left up to them to mention the issue. Overall, it seemed that there was insecurity on the part of both women and physicians, as perceived by participants.
W1: "It's still not mentioned, it can just be left unsaid (. . .)."
W2: "It's we, ourselves, who don't bring it up."
W3: "I don't think the doctor brings it up if one . . ."
W4: "doesn't bring it up oneself . . ."
W3: "Oh, no, no."
Only one woman reported having received a question on her sexual functioning from her GP ("but he was newly married himself so it could have depended on that"). None of the women had been told by their physicians that diabetes could affect the sexual functioning of females, although "it would be nice to think it could actually be a medical phenomenon, that it's not my situation."
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Discussion |
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The credibility of this study was enhanced by using methods triangulation, involving a co-researcher in the coding process,16 and using computer software-assisted keyword searches of the original interview text. The content validity of the questionnaire proved insufficient for one question: omitting to define ‘sexually active’ probably misled the women to believe that only intercourse with a male was concerned, contrasting with our intention that they might feel free to include whatever they classed as sexual activity.
A relevant issue for dependability is how the interviewer, a young, heterosexual, female PhD student with a medical background, influenced the way in which women chose to act. Questions posed to the interviewer (one medical question, and two on other groups' responses) revealed the women’s aspirations to ‘comply’. The women also considered the interview a rare opportunity to discuss intimacy with others in similar situations. Nonetheless, the fact that the women had to face the prospect of meeting again in everyday situations, combined with pre-interview power relationships within the group, may have affected the scope and depth of the discussion. We elucidated intergroup and interviewer– group interactions by using an observer, and the text was examined specifically for sections demonstrating women's differences of opinion, also reflected in the quotes selected for this paper.
With regard to transferability, sexual activity (31%) and satisfaction (65%) reported by the women in this study compared well with figures established in a US sample of 1216 elderly people.17 Sexually non-active women were found to be older than those sexually active, which is also a known fact.18 The ‘elite bias’ of subject selection was certainly present here as we used participants on a self-referred diabetes education programme. Consequently, results from this study cannot be applied generally to all women with type 2 diabetes, but our descriptions do provide insight into the difficulties that even well-informed women, otherwise capable of expressing their needs, experience in seeking help for their sexual disturbances.
Our preconceptions were that women would not know about the effects of diabetes on sexual functioning and would want their doctors' help for sexual disturbances in general. Most of the women, in fact, did not know that diabetes could cause sexual dysfunction in women, but some of them had read about it and others had experienced a connection between vaginal dryness and high blood sugar levels.
As opposed to our second preconception and earlier findings in the literature,19 women did not feel comfortable discussing issues of sexuality with their GPs. In fact, the interviewer could have biased the women into discussing the physician's role at all in coping with sexual problems, as most women did not seem to consider health professionals whom they regularly consulted for their diabetes as sexual counsellors.
It would seem that there is a gap between hypothetical evidence, i.e. when healthy persons are asked about their attitudes,5,6 and data from patient charts and self-reports on consultations: only a small percentage of those experiencing sexual disturbances actually seek their GP's help for this problem.20,21 Additionally, there seems to be a clear preference for female physicians among women when the subject of consultation is sexual dysfunction22 or specific women's health issues.23 Moreover, women choose a gynaecologist more often than their GP for communication about sexual problems22 or for pelvic examination, especially when the primary care physician is male.24 Consequently, one cannot assume out of hand that women will turn to their GP as the health professional of their choice when experiencing sexual dysfunction.
The contradiction
When a sexual problem is present, women are less willing to seek help from their GPs than fits the perception of family physicians,2,25 whereas the latter provide less help than patients would wish for sexual problems.25 There seems to be a discrepancy between patients' positive perceptions of their GPs' capability of treating sexual dysfunction21 and their own ability to report such dysfunction to them. Another disparity exists between physicians' perceptions of patients' ability to receive and answer direct questions on intimacy (fear of intrusion)3 and patients' expectations that their GPs should address the issue.6,7 We have termed the above phenomenon ‘Contradictions in the medical encounter’ (Fig. 1
).
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It would be erroneous to think that these contradictions are all due to lack of sex match between patient and GP. Differences in expectations, gender-biased preconceptions, social taboos, guilt and shame, and power inequity may all constitute obstacles to a genuine meeting between the woman and her GP (Fig. 1
). Medical socialization affects both female and male physicians, and the advantage of having the same sex quickly disappears if, for example, value judgements regarding ‘medical misconduct’ take over during the consultation. |
Conclusion |
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Despite participants' apparent lack of confidence in their GPs regarding sexual matters, we do believe that increased openness and the often cited ‘permission’ attitude26 is necessary on the part of family physicians, in order to legitimize discussion of female sexual disturbances in the consultation room. However, it is possible that this generation of women would benefit more from peer help offered by patient or women's organizations equipped to provide basic sexual counselling/information and self-care remedies. Family physicians, who have experience of caring for patients with chronic diseases, could certainly provide comprehensive medical back-up for these alternative services. Moreover, GPs are an important, but so far underused, resource for identifying female sexual dysfunction in type 2 diabetes, a problem that middle-aged and older women have difficulty communicating.
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References |
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Philips D, Brooks F. Women patients' preferences for female or male GPs. Fam Pract 1998; 15: 543–547.
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