Attitudes and Performance of Cardiologists Regarding Sexual Problems: Implications for Patient Care

Sexuality is a lifelong human experience that has important positive effects on physical and psychological well-being. Likewise, sexual dysfunction can have a negative effect on emotional health and the quality of interpersonal relationships. Although sexuality may not always be the first priority for patients with cardiovascular diseases (CVD), it is a part of everyone’s life and sexual satisfaction is an important component of quality of life.

Sexual problems, such as decreased libido, cessation of sexual intercourse or erectile dysfunction (ED) in men and pain during sexual intercourse or decreased vaginal discharge in women, can frequently occur in relationship with some diseases, including CVD. There are numerous studies that have reported the high prevalence of sexual dysfunction in men and women with CVD.

There is an association between sexual problems and CVD that includes physical vascular causes. Psychological concerns about a cardiac event or sudden death during sexual activity are the most common stressful problems in CVD patients and their partners.

There is evidence to suggest that some medications for cardiac patients, including lipid-lowering drugs and β-blockers, may have side effects on sexual function in these patients.  

Furthermore, recent studies have suggested a strong association between sexual dysfunction and comorbid conditions such as diabetes mellitus, dyslipidemia, hypertension, and cardiac surgery in patients with CVD. The high prevalence of several risk factors for sexual dysfunction in this group of patients indicates the importance of this problem and suggests the need for regular follow-up visits.

Recent guidelines on sexual activity in patients with CVD have recommended that sexual counseling be considered an important part of cardiac rehabilitation services. However, most patients and healthcare professionals avoid talking about sexual issues due to some barriers, such as shame, lack of knowledge or training, cultural background, religious beliefs, and negative attitudes about sexuality.

Cardiologists play an important role in helping cardiac patients experiencing sexual dysfunction learn how to live with their disability and return to normal sexual activity. Therefore, it is necessary for cardiologists to evaluate these problems in this group of patients. Lack of such provision could have long-term side effects for patients and their partners.

Therefore, the aim of the present study was to evaluate the attitudes and performance of cardiologists regarding sexual problems in patients with CVD; examined whether cardiologists in Iran assessed sexual problems with their patients and, if not, their reasons for not doing so.

Methods

A nationwide survey was conducted on a sample of cardiologists, representatives of Iranian cardiologists, in 2015. Appropriate questionnaires were developed and used to ask participants about their attitudes, performance and barriers regarding discussing sexual topics with patients with cardiovascular diseases.

Results

Characteristics of the participants

The study population consisted of 202 cardiologists (138 men and 63 women) whose average age was 44.25 years. Of these, 165 (81.70%) were married. A statistically significant difference was found between the mean age of women and men (mean = 46.39 ± 9.026 in women vs. mean = 39.68 ± 6.296 in men; P = 0.007).

Of the 202 participants, 145 (73.8%) were cardiologists and 53 (26.2%) were in cardiology fellowships; 54.5% of participants had less than 10 years of work experience, 27.2% had 10 to 20 years of work experience, and 14.9% had more than 20 years of experience.

Attitude of cardiologists towards sexual problems of patients with CVD

The total attitude scores obtained (theoretical range = 9-45) ranged from 26 to 45 (average score = 37.6 ± 3.62). When asked about the importance of patients’ sexual problems, 91.10% of cardiologists stated that it was important from their own point of view, and 90.10% of cardiologists said that these problems were important from their own point of view. of his patients.

In general, the majority of cardiologists (93.15%) agreed with the importance of sexual education and sexual problems in cardiac patients, and 79.9% of the respondents were aware of the association between the diseases cardiovascular and sexual problems of cardiac patients.

When asked about their responsibility in treating sexual health problems in this group of patients, 76.7% of respondents agreed that cardiologists were responsible, but only 33% of them trusted their knowledge and skills.

Experienced cardiologists were significantly more confident in their knowledge and skills (mean 3.31, SD = 0.967, for ≥20 years of experience; mean = 3.21, SD = 0.853, for 10-20 years of experience; mean = 2 .93, SD = 0.863, for 0-10 years of experience; P = 0.045).

There was no significant association of attitudes, awareness, and responsibility with participants’ characteristics, such as age, sex, marital status, education, area of ​​activity, and years of work experience. There was a significant association between trust and marriage. Trust was higher in married participants (mean = 3.15, SD = 0.904, for married; mean = 2.80, SD = 0.925, for single; P = .034).

Performance and barriers of cardiologists in the treatment of sexual problems in patients with CVD

The total practice score could theoretically range from 10 to 50, with higher scores indicating better performance by cardiologists in sexual health care. The scores obtained ranged between 10 and 45 (mean score = 29.18 ± 6.48).

To the question "Do you answer patients’ questions about sexual problems?" 18.5% of cardiologists responded “never” or “rarely,” 30% responded “sometimes,” and 51.5% responded “often” or “always.”

Only 10.6% of cardiologists reported that they regularly evaluated sexual problems in their patients, and 9.5% of them talked to the patient’s partner about the patient’s sexual problem, while the rest reported that they never, rarely, or sometimes occasionally addressed this problem.

Only 32% of cardiologists always or frequently tested heart function for sexual activity and only 10.9% of them prescribed a medication to treat ED.

To the question "Do you recommend your patients with sexual problems to other professionals?" 32.7% of cardiologists responded “never” or “rarely,” 38.2% responded “sometimes,” and 29.2% responded “often” or “always.” Most patients were referred to urologists (59%), psychiatrists (31.7%), psychologists (9.5%), and gynecologists (9.7%); multiple responses were possible.

Approximately 34% of cardiologists routinely evaluated sexual side effects of cardiovascular medications and 42% of them asked about their patients’ use of phosphodiesterase-5 inhibitors. Overall, the majority of cardiologists (93.8%) believed they needed training on sexual problems related to CVD. No significant differences were observed between male and female physicians (P = .873) or between single and married cardiologists (P = .873).

Cardiologists were asked to indicate their agreement with a list of reasons for refraining from asking about sexuality. The barriers that respondents agreed with were "patients who feel uncomfortable" (75.2%), "cultural restrictions" (57.4%), "presence of third parties" (50%), "lack of knowledge and skills" ( 50%), "Too little time" (45.5%), "opposite sex of patient" (42.6), "ambiguities about responsibility" (39.5%), "no common words and phrases for sexual problems" (34.7%) and “cardiologists feel uncomfortable” (25.2%). Few cardiologists stated additional reasons for avoiding discussion of sex in an open section.

Discussion

This study is the first nationwide survey in Iran to investigate cardiologists’ attitudes and performance on sexual problems in CVD patients. The key findings of this study conclude that there is a gap between cardiologists’ attitudes and their actual practices.

Most cardiologists agreed with the importance of sexual problems for cardiac patients, but did not routinely discuss sexuality with their patients.

Almost half of the participants reported that if patients ask questions about their sexual activities, they answer them regularly (passive performance); Survey results indicated that cardiologists believed that conversation about sexual topics should be initiated by patients. This finding is similar to the study by Nicolai et al, which indicated that more than half of respondents expected the patient to take the initiative when discussing sexual function.

In addition to this passive performance, in all elements of practice that need the active role of cardiologists in treating sexual problems, most of them frequently or always failed to take action. Most cardiologists accepted their responsibility to address the sexual problems of CVD patients, but only a third of them were confident in their knowledge and skills.

In the survey by Nicolai et al. Approximately one-third of cardiologists accepted their responsibility to discuss sexual issues with their patients and most stated that they had "some" or "a lot" of the knowledge necessary to discuss sexual problems with their patients. In these two studies, cardiologists did not routinely discuss sexuality with their patients.

Patient discomfort and cultural and religious reasons appear to be important obstacles for most participants in the present study. These findings are alarming because, since 1999, several recommendations for the clinical management of sexual function in men and women with CVD have been provided to help clinicians communicate with patients about sexual activity.

Several factors may be effective in cardiologists’ lack of routine evaluation of sexual problems. The first assumption is that they have insufficient knowledge about the sexual problems of CVD patients. We did not examine cardiologists’ knowledge of sexual problems in CVD patients, but approximately two-thirds of cardiologists stated that they did not have sufficient knowledge and skills.

Because the majority of cardiologists stated that patients’ sexual problems are important from their own point of view and that most of them are motivated to receive additional training, it appears that more knowledge and training is needed to help them understand how perform a sexual assessment and offer counseling.

In the study on doctors’ knowledge of erectile dysfunction in Saudi Arabia, cardiologists scored lower than urologists and andrologists. Another study conducted on Dutch cardiologists indicated that most cardiologists had insufficient knowledge about the effects of cardiovascular drugs on sexual function.

A comprehensive review on the state of sexual health education around the world has shown that sexual medicine education is inadequate in most centres; Therefore, cardiologists may need more knowledge and specific practical training to carry out sexual evaluation and counseling of cardiac patients.

The study demonstrated that professional responsibility is a significant factor for better performance in treating patients’ sexual problems.

Because more cardiologists are routinely engaged in drug-related practice, one assumption is that they perceive more responsibility for addressing drug-related sexual problems of patients and have the misconception that other domains of sexual care for patients They are under the responsibility of other specialties.

The effect of cardiovascular agents on sexual function is important, but aside from medication side effects, the association between CVD and sexual dysfunction has been identified, so cardiologists should consider these issues as part of their professional responsibility. They may need further information and training related to their own professional responsibility to explore sexual issues and advice and support patients.

Professionals experience barriers when discussing sexual topics. Having an understanding of the barriers is helpful in improving the treatment of sexual problems and the intervention needed. Patient discomfort was a major barrier reported by cardiologists to discussing sexual health topics.

Previous studies in other countries have shown that a common barrier to this problem was embarrassment in patients and doctors. It could help cardiologists discuss the topic of sexual concerns within the context of evaluating the side effects of medications or in a general discussion about the consequences of the disease and asking patients about changes in sexual function.

Interestingly, cultural and religious reasons that were not found to be significant barriers in previous research appeared to be important obstacles for the majority of participants in the present study. This could be due to the different cultures and religions in Iran.

Open and frank discussions about sexuality between doctors and patients are critical to addressing treatable causes of sexual dysfunction, but such conversations must be conducted in a culturally sensitive manner.

Broad questions such as "Do you have any sexual concerns you would like to discuss?" could help start discussions about sexual topics. Communication skills have been identified as a predictor to help clinicians assimilate a patient’s sexual history.

However, discussions about sexual topics should be carried out in an atmosphere of sensitivity and respect. A hands-on workshop with more common scenarios could help cardiologists really practice writing and focusing.

Another major barrier reported by cardiologists is lack of time , which was found to be a barrier in other research. This finding is also consistent with surveys of other professionals, such as breast surgeons and oncologists, who reported that they often have limited time to evaluate sexual problems. Most doctors believe that sexual well-being is not the top priority for cancer or CVD patients when there is not enough time.

Sexual dysfunction is common in men and women with CVD, and patients and their partners are concerned about their sexual activity and need counseling and educational services to address this problem. Therefore, cardiologists should pay attention to sexual problems and, if they cannot dedicate enough time to do so, they should consider referring their patients to a sexual health care specialist.

As in previous studies, respondents stated that lack of knowledge and training was a reason for not asking about sexual problems. Fortunately, most cardiologists indicated that they would benefit from training in this part of patient care. Specific training courses could help them develop the knowledge and skills to discuss sexual issues in their practice and become more sexologically competent.

The present study is the first research effort to evaluate the attitude and performance of cardiologists regarding sexual problems in patients with CVD in a representative sample of cardiologists in Iran. Therefore, the results of this study provide new information on this topic that could help further intervention.

A common problem for a mail survey is that the finding can be affected by response rate and non-response bias. Although the response rate in the present study is higher than in similar studies, cardiologists who did not respond to the study could be even more passive in discussing sexual problems with patients or have negative attitudes about it.

Therefore, the results of this study could be an underestimate of the real situation. Despite this underestimation, it is notable that cardiologists do not routinely discuss sexual problems with their CVD patients.

Future research is needed to identify the level of knowledge of cardiologists regarding sexual assessment and counseling of patients with CVD. Furthermore, research to assess CVD patients’ attitudes toward discussing sexual problems and their perceived barriers may be useful for future planning and intervention.