Complexity of sexual history taking in patients with diabetes and hypertension in routine primary care consultations in South Africa

Abstract

ABSTRACT Background Research globally confirmed the lack of screening for sexual dysfunction in routine consultations by primary care doctors. Various barriers to sexual history taking were identified, such as differences in age, sex, and culture. Doctors justified the lack of sexual history taking also on their lack of knowledge and skill. As sexual wellbeing also influences the quality of life, patients want to talk to doctors about their sexual health needs but are often shy, or they fear they will embarrass their doctors. Unfortunately, they also find that their complaints are often ignored. Aim The aim of the study was to observe and describe the patient-doctor interaction dynamics of routine consultations in primary health care settings in North-West province South Africa, to improve sexual history taking. Methods The study design was a grounded theory approach. One hundred and fifty-one consecutive consultations with adult patients at risk of sexual dysfunction due to diabetes and hypertension, were video recorded. All the doctors working at 10 primary care facilities were recruited. Doctor-patient interactions were recorded during a normal working day using a discreet camera and laptop. Following the consultations, patients completed demographic questionnaires and sexual dysfunction questionnaires (IIEF and FSFI). After completion of consultation and patient data collection, doctors completed a vignette study with hypothetical scenarios. At the end of the recordings, doctors reflected on their consultations and sexual history taking. Analysis entailed open coding followed by focused and verbatim coding using MaxQDA 2018 software. Some information was quantified using descriptive statistics and Fischer Exact test for associations. Results No history taking for sexual dysfunction took place. Ninety-four percent of the 81 sexually active women had sexual dysfunction symptoms and only 2% of 48 men reported no erectile dysfunction. One patient presented with pain after sexual intercourse. There was no evidence of help seeking for sexual challenges which could be contributed to low education, passive, or low engagement in the health setting or the disconnect between doctors and patients. Patients wanted receptive doctors to ask about their sexual health, whilst doctors expected patients to tell. Doctors admitted that they did not even think about sexual dysfunction and did not consider it a priority. A vignette study with hypothetical scenarios showed that the doctors’ clinical reasoning was generally poor and did not incorporate sexual functioning as a differential diagnosis. The consultations revealed inadequate communication and consultation skill competence. The patient-doctor interaction was doctor centered. Doctors and patients blamed an influx of patients and long waiting times for sub-standard consultations. Consultation time was lost on poorly organized patient files and laboratory results that were retrieved on the doctors’ personal mobile phones. Conclusion Sexual history was inhibited by patient, doctor, and health system factors. Although sexual history is an integral part of comprehensive history taking during a routine consultation, patient-doctor-system engagement need to change to facilitate sexual history taking. Disclosure Work supported by industry: no.