Psychiatrists and general practitioners perspectives on sexual wellbeing: Why it matters?

Abstract

Objective

Sexual wellbeing is a fundamental component of overall wellbeing and is often impacted by common psychiatric disorders such as depression. Despite this, research suggests it is underexplored in clinical practice. This preliminary study aimed to examine whether this is the case in both psychiatrists and general practitioners (GPs).

Method

GPs and psychiatrists completed a survey examining the exploration of various sexual wellbeing domains with patients. It included open-ended questions regarding factors that influence this exploration, whether clinicians felt this was their responsibility, and their level of training in this area.

Results

Clinicians who felt it was their responsibility to enquire about sexual wellbeing reported exploring it in more patients than those who did not endorse this perspective. Overall, clinicians from both specialties demonstrated a reluctance to explore most sexual wellbeing topics, and this appeared to be due to many factors including views held by clinicians themselves. Most clinicians felt they had not received adequate training in this area.

Conclusions

Domains of sexual wellbeing are largely underexplored by clinicians from both specialties. Educational materials and training for clinicians are needed to facilitate the exploration of this important area with patients, specifically in the context of mental health.

Psychiatric illnesses have a profound impact on the occupational, social, and physical functioning of a person’s life. One domain that is often overlooked is sexual wellbeing, but the reasons for this are not fully understood. One explanation is that sexual wellbeing is a multifaceted concept that is affected by a broad range of factors, making it difficult to characterize and capture clinically.

Previously, we have described the many components of sexual wellbeing and how these may be explored in clinical practice. ¹ In these articles, we broadly define sexual wellbeing as encompassing aspects of sex, gender identity, and sexual orientation, along with sexual behavior and experiences. ¹ Further, sexual wellbeing is impacted by biological, psychological, social, economic, political, cultural, legal, historical, religious, and spiritual factors, many of which intersect and interact. In sum, it is a complex, multifaceted construct (for a more detailed discussion, especially in the context of mental health, see^2–4).

In psychiatry, it is important to note that mental illnesses can impact sexual wellbeing both directly, as a consequence of the illness (e.g., the negative impact on one’s sense of self, confidence and libido), and indirectly, because of the treatments used to manage the psychiatric disorder, such as antidepressants. ⁵ Further, the relationship between sexual wellbeing and psychiatric disorders can be bidirectional. For example, depression can compromise sexual wellbeing, and poor sexual wellbeing can contribute to depression. ⁶

Intriguingly, despite the importance of sex in an individual’s overall wellbeing, and its role in common psychiatric disorders such as depression, research suggests that it is not given sufficient consideration in clinical practice. ⁵

Aim

To examine the extent to which sexual wellbeing is explored in clinical practice, and whether there are differences between clinicians in primary care (i.e., general practitioners; GPs) and mental health specialists (i.e., psychiatrists).

Methodology

We assessed whether clinicians were asking about sexual wellbeing and the factors (facilitators or barriers) affecting such inquiry. We then examined the similarities and differences between GPs and psychiatrists.

From May to September 2022, we surveyed 149 clinicians across 10 teaching sessions in QLD and NSW. The sample comprised clinicians from both psychiatry (n = 86) and general practice (n = 63), including registrars and specialists. Clinicians attended separate teaching sessions specific to their specialty; hence, we were able to separate the responses from each group. The teaching sessions were not focused on sexual wellbeing and hence the sample were not primed or biased regarding the sexual wellbeing survey. At the beginning of each teaching session, clinicians were provided with a QR code to complete the questionnaire electronically on their personal devices. Participation in the survey was completely optional, and clinicians were informed that their responses may be utilized for research purposes, including publications. All clinicians completed the same questionnaire, with one question changed to reflect the respective specialty being surveyed. The survey was originally conducted to inform educational materials for clinicians, and therefore no personal information was collected, and the data was completely deidentified at source. Thus, ethics approval was not deemed necessary and formal approval was not sought. Clinician specialty was determined by the teaching event attended (specifically for GPs, or psychiatry registrars/consultants).

The survey consisted of two broad sets of questions. The first asked, “For the below topics, please indicate in what proportion of patients you would explore this subject:”. The topics are listed as shown in Supplemental Table 1. For each topic, participants could indicate their response using a six-point Likert scale and clinicians were asked to identify any facilitators or barriers that determined how often they would explore each of these topics. Finally, clinicians were asked three further questions assessing (1) their sense of responsibility to ask about sexual wellbeing, (2) the extent to which they feel they have received adequate training on sexual wellbeing, and (3) which component(s) of sexual wellbeing they would like more training on.

Analysis

Nearly everyone who attended the teaching sessions completed the questionnaire ¹ . Of those that attempted the survey, two GPs did not complete the full questionnaire, leaving 61 GPs with a complete dataset, and an overall complete dataset of N = 147. The clinicians varied in terms of age, gender, and years of experience; however, this data was not collected.

Data was collected through RedCap (University of Sydney) and analyzed using IBM SPSS Statistics v.29 for Mac. Scores for each item (sexual wellbeing topic) under Question one could range from 0 (No patients) to 6 (All patients) with higher scores indicating a larger proportion of patients with whom the topic is discussed. Scores for each topic were compared between specialties and between clinicians who responded affirmatively or negatively to Question 2. Independent samples t-tests and chi-squared tests were used to examine these differences.

Results

Independent samples t-tests showed a significant difference between GPs and psychiatrists in the proportion of patients with whom they explored the topics of gender (t = 2.07, p < .05), sexual orientation (t = 1.58, p < .05), and partnered sexual practices (t = 3.80, p < .001). For each of these topics, GPs explored them in a greater proportion of patients than psychiatrists. Clinicians did not differ significantly in their exploration of libido, masturbation, or sexual satisfaction.

Comparisons were then made based on whether a clinician believed their specialty should be responsible for exploring sexual wellbeing with patients. Overall, 83% of clinicians stated that they believed it was the responsibility of their respective specialty, with 88.5% of GPs and 79% of psychiatrists endorsing this view, with no significant difference between specialties, X ² (1, N = 147) = 2.2602, p = .13. Clinicians who endorsed this perspective reported enquiring about all sexual wellbeing topics (except gender) in a higher proportion of their patients than those who did not endorse this perspective.

The differences between the specialties were then re-examined, including only those who believed it was their responsibility to enquire about sexual wellbeing (n = 122). The results remained largely the same (see Table 1 below), with significant differences found in the exploration of gender (t = 1.99, p < .05) and partnered sexual practices (t = 3.94, p < .001).

Table 1.

Differences between GPs and psychiatrists who feel responsible for exploring sexual wellbeing, in the proportion of patients with whom they explore each sexual wellbeing topic

	General practice (n = 54)		Psychiatry (n = 68)
	Mean	SD	Mean	SD	df	t	p	Cohen’s d
Gender a	2.22	1.78	1.65	1.28	92.71	1.99*	.049	.377
Sexual orientation	2.59	1.72	2.21	1.51	120	1.32	0.189	.241
Libido	2.54	1.42	2.75	1.41	120	−0.83	0.411	−.151
Masturbation	1.20	1.42	0.90	1.12	120	1.33	0.185	.243
Partnered sexual practices a	1.76	1.63	0.75	1.07	87.60	3.94**	<.001	.751
Satisfaction	1.81	1.56	1.44	1.34	120	1.40	0.164	.255

^aWelch test is reported^a as Levene’s test indicated that the homogeneity of variances assumption was not met for this variable.

p < .05.

p < .001.

SD = Standard Deviation.

Finally, when asked whether clinicians felt they had received adequate training on the topic of sexual wellbeing, 73.8% of GPs and 84.9% of psychiatrists answered “no.” General practitioners and psychiatrists did not significantly differ in their response to this question, X ² (1, N = 147) = 2.7832, p = .095.

In addition to ratings and structured responses, clinicians were also asked to provide open-ended remarks as to what influenced them to ask about each sexual wellbeing domain. More than 100 responses were provided, and these were scrutinised by two of the authors to identify common themes. The responses were collated according to each of the six domains of interest and representative responses have been presented in Table 2. These are also referenced in the discussion.

Table 2.

Verbatim accounts of factors influencing whether various domains of sexual wellbeing are explored according to specialty

	Specialty
Domain	General practice	Psychiatry
Gender identity	“New patient questionnaires” “Gut instincts”	“If they look alternative” “[Patient] raises issue” “Older people”
Sexual orientation	“Initial history for new patients” “New patient questionnaires” “Clients bring it up themselves”	“If they seem same sex attracted” “Geriatric [patient]” “Usually not asked because its available in the past history” “Depends on age of patient”
Libido	“Menopause” “Whether I’m prescribing an antidepressant” “If patient raises [or] related to medical care”	“Always ask” “As part of mood assessment” “Usually only in the context of medication side effect”
Masturbation	“My embarrassment” “Stigma” “Porn addiction” “When assessing erectile dysfunction due to medications”	“Not relevant” “Embarrassing” “Intrusive” “Uncomfortable” “Taboo” “Cultural issue”
Partnered sexual practices	“Menopause, STI checks” “Taboo” “Only if I think they partake in risky practice” “Only if STI attendance/in the context of an STI workup”	“Only if this is an issue for the patient” “Embarrassing” “Private” “Taboo” “Too intimate” “Cultural Issue”
Sexual satisfaction	“Only if sexual problems raised by patient” “Not part of interview” “Why should I care?”	“Fear of being labelled a pervert” “Never asked” “Rarely relevant” “Spontaneously volunteered [by patient]”

Discussion and implications

Our survey reveals that there are important differences between the specialties in terms of their interest in enquiring about sexual wellbeing as part of anamnesis, and these may be a function of the degree to which clinicians regard this topic to be their responsibility. However, there are also many other factors in play—many of which concern the views held by clinicians themselves.

Comparing general practitioners and psychiatrists

GPs explore sexual wellbeing more so than psychiatrists, reflecting perhaps the broader nature of their clinical work. Further, self-report screens in primary care routinely ask about gender, providing a gateway for further enquiry with the doctor. Sexual practices can also be readily explored in the context of STI screenings and when discussing contraception and menopause (see Table 2).

Regarding the various aspects of sexual wellbeing, questions regarding gender and sexual orientation were prompted by impressions and “gut instincts.” For instance, “if they seem same-sex attracted” or “if they look alternative.” A key trigger was the patient themselves, with many clinicians stating they only ask if the patient “brings it up themselves.”

Both GPs and psychiatrists actively explored libido, reflecting the fact that it is a key feature of mood disorders and is known to be affected by medications. In contrast, both groups showed little interest in asking about masturbation and partnered sexual practices, possibly because these seem less directly relevant to medical diseases and psychiatric disorders. However, somewhat surprisingly, many clinicians in both groups reported being “embarrassed,” “uncomfortable,” and regarded the topics “taboo,” “too intimate,” and “intrusive.” Indeed, even sexual satisfaction appeared to raise similar reservations in both GPs and psychiatrists and some “never asked” about this as they found it “rarely relevant.” This reluctance to explore these topics and the perception that they are taboo is surprising, given that both specialties encounter other sensitive topics such as trauma and suicide in their clinical work. Hence the reluctance to enquire about these normative practices is notable.

Contrary to our expectations, logistical factors such as duration of consultation did not limit the clinician’s ability to discuss sexual wellbeing. In fact, GPs who have much less time were more proactive than psychiatrists in exploring these topics and did not raise time constraint as a reason for not exploring sexual wellbeing.

Reliance on patients

Clinicians relying on patients to raise the topic themselves is not a novel finding and has been shown across various clinical specialties (i.e., nursing, psychology, and psychiatry). ⁵ This approach is problematic, as it means many patients will not be asked about their sexual wellbeing. Notably, the reporting of sexual dysfunction almost doubles (from 35% to 69%) when clinicians engage in active enquiry rather than relying on spontaneous declarations. ⁷ However, as we have found, many doctors are uncomfortable asking about sexual wellbeing. This is particularly surprising regarding psychiatrists, given they regularly explore challenging topics such as suicide, trauma, and sexual and physical abuse. Thus, it is unclear why there is a particular reluctance to explore sexual wellbeing, and why its domains are perceived differently to other sensitive topics.

Clinician responsibility

Predictably, clinicians who felt it was their responsibility to explore sexual wellbeing reported doing so in a greater proportion of patients. This is important, as evidence suggests that in a mental health context, it is the responsibility of clinicians to raise sexual wellbeing with all patients if possible.^5,8 Of course, this may not always be feasible, for example, during a brief assessment, or it may not be appropriate if, for example, a patient is distressed or raising issues such as sexual trauma or abuse. However, it is important that clinicians do not base their exploration on the patient’s age or cultural background, as some in our sample reported (see Table 2). This is because sexual wellbeing remains important in older adults^9,10 and impacts overall wellbeing and quality of life for this age group. ¹¹ Furthermore, discussion of sexual wellbeing with patients of diverse cultural backgrounds in a clinical setting is critical, as these patients may have few other supports in this regard, and especially so if their culture regards discussions of sexuality, mental illness, and suicide as taboo.

Adequate training

Our survey reveals a strong consensus among clinicians that they lack sufficient training in sexual wellbeing, with many reporting they would like more training on “All of it.” Indeed, one clinician who did not feel it was their responsibility to enquire about sexual wellbeing stated “not covered in training programs” as a justification. Thus, if the findings of this survey are replicated in larger, representative samples, this may provide an impetus for professional colleges to develop training materials to facilitate clinicians to enquire about sexual wellbeing. This is critical, as sexual wellbeing is not only directly relevant to mental health, ⁸ but it is also an overall indicator of general health and wellbeing.^10,12

Limitations

The key constraints are the modest sample size and lack of demographic data, hence why this report is termed exploratory. Nevertheless, the survey (delivered face-to-face) had high engagement and it identifies a need for further enquiry and points to potential specialty-specific factors.

Conclusion

This exploratory study illustrates the perspectives of clinicians on exploring sexual wellbeing in clinical practice, and in particular, their perception of its relevance to more general care. Our findings show that clinicians who feel it is their responsibility to explore sexual being do so in a greater proportion of patients, however many domains of sexual wellbeing remain underexplored, and clinicians feel ill-equipped to do so based on the limited training they have received.

Supplemental Material

Supplemental Material - Psychiatrists and general practitioners perspectives on sexual wellbeing: Why it matters?

Supplemental Material for Psychiatrists and general practitioners perspectives on sexual wellbeing: Why it matters? by Gin S. Malhi, Uyen Le, andErica Bell in Australasian Psychiatry