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528
Family Practice Vol. 21, No. 5 © Oxford University Press 2004, all rights reserved. Printed in Great Britain
Doi: 10.1093/fampra/cmh509, available online at www.fampra.oupjournals.org
“Opening a can of worms”: GP and practice nurse
barriers to talking about sexual health in
primary care
Merryn Gott, Elisabeth Galena, Sharron Hinchliff and Helen Elford
Gott M, Galena E, Hinchliff S and Elford H. “Opening a can of worms”: GP and practice nurse
barriers to talking about sexual health in primary care. Family Practice 2004; 21: 528–536.
Background. There is evidence that health professionals do not discuss sexually related
issues in consultations as often as patients would like. Although primary care has been
identified as the preferred place to seek treatment for sexual health concerns, little is known
either of the factors that prevent GPs and practice nurses initiating such discussions or of how
they feel communication in this area could be improved.
Objective. The purpose of the present study was to identify barriers perceived by GPs and
practice nurses to inhibit discussion of sexual health issues in primary care and explore
strategies to improve communication in this area.
Methods. Semi-structured interviews were conducted with 22 GPs and 35 practice nurses
recruited from diverse practices throughout Sheffield.
Results. The term ‘can of worms’ summarized participants’ beliefs that sexually related issues
are highly problematic within primary care because of their sensitivity, complexity and
constraints of time and expertise. Particular barriers were identified to discussing sexual health
with patients of the opposite gender, patients from Black and ethnic minority groups, middle-
aged and older patients, and non-heterosexual patients. Potential strategies to improve
communication about sexual health within primary care included training, providing patient
information and expanding the role of the practice nurse; however, several limitations to these
approaches were identified.
Conclusion. GPs and practice nurses do not address sexual health issues proactively with
patients, and this area warrants further attention if policy recommendations to expand the role
of primary care within sexual health management are to be met.
Keywords. Primary care, sexual health, sexuality, sexual problems, training.
Received 27 October 2003; Accepted 17 May 2004.
Sheffield Institute for Studies on Ageing, University of
Sheffield, UK. Correspondence to Dr Merryn Gott,
Community Sciences Centre, Northern General Hospital,
Sheffield S5 7AU, UK; E-mail: m.gott@sheffield.ac.uk
Introduction
The National Sexual Health Strategy has identified a
‘broader role’ for primary care in sexual health
management.
13
Whilst some commentators agree that
“general practice is the only hope to improve [sexual
health] services as it is the only provider with the capacity
needed,”
2
others acknowledge that “primary care already
feels overburdened” and practitioners may be unen-
thusiastic.
3
Indeed, there is evidence that this broader role
may be a significant departure from the current low
prioritization of sexual health at a practice level. The Royal
College of General Practitioners, for example, whilst
recognizing that sexual health is an important issue within
general practice, also recognize that it is rarely prioritized.
4
Similarly, the Royal College of Nursing identifies that
sexual health relates to the holistic care of patients and
clients,
5
but again there is evidence that issues pertaining to
sexuality are not routinely addressed in nursing practice.
6,7
Training for doctors and nurses in managing sexual health
at both undergraduate and postgraduate levels has also
been deemed inadequate.
8
There has been little published about patient–-
professional communication about sexual issues in
primary care, particularly empirical research studies.
However, the little information available indicates that
this is a problematic area. A questionnaire survey of 133
GPs, for example, reported that most participants identified
more than one barrier to managing sexual dysfunction,
with the most commonly cited barriers including concerns
Sexual health management in primary care
529
about their own knowledge and expertise in this area,
fears of opening a ‘floodgate’ and personal
embarrassment.
9
A questionnaire survey of 234 practice
nurses (PNs) identified similar barriers, including lack of
time, lack of training and concerns about not being able to
cope with the issues raised by the patient.
10
A postal
survey of oncology nurses
7
and a qualitative study
involving staff nurses working in acute surgical wards
11
indicate that nurses will only discuss sexual health issues if
such discussions are initiated by the patient.
Although data are not available regarding patient
attitudes towards PN health management, limited data
are available regarding patient attitudes towards GPs. A
survey of 170 patients attending a London general
practice, for example, identified that 35% of male and
42% of female participants reported some form of sexual
dysfunction, but that despite 70% of participants seeing
the GP as an appropriate person with whom to discuss
sexual health issues, such discussions were only recorded
in 2% of the participants’ GP notes.
12
A Swedish study of
older women’s sexual health needs identified that none of
the 33 patients with diabetes interviewed had been
informed by their GP that this condition could cause
sexual problems, although most would have welcomed
such a discussion.
13
Similarly, a UK study which involved
discussing sexual issues with people aged 50–92 years
identified that the GP was seen as the main source of
professional help if sexual health concerns were
experienced.
14
However, none reported that their GP had
mentioned the sexually related side effects of health
conditions and prescribed medications which had led a
high proportion of the sample to experience sexual
problems. Again, most wanted to have this discussion, but
felt unable to raise sexual issues proactively with their GP.
Several commentators have therefore recommended
that GPs and PNs need to be more proactive in
managing sexual health needs,
15
and this is certainly true
if the recommendations of the National Sexual Health
Strategy
1
are to be met. However, overall, little is known
about how GPs and PNs view sexual health manage-
ment within primary care, why they may be unwilling to
raise sexual issues within patient consultations and how
they feel communication in this area could be improved.
The study discussed in this paper aimed to address this
gap in current knowledge.
Our aims were to identify barriers perceived by GPs
and PNs to inhibit discussion of sexual health issues in
primary care and identify those strategies they feel have
the potential to overcome these barriers.
Methods
Potential participants were identified from a published
list of GPs and PNs covering all primary care practices
within Sheffield, and purposive sampling was used to
maximize diversity of participant characteristics. We felt
it important to include GPs working both in single-sex
and mixed-sex practices given the impact that gender of
GP and patient may have on willingness to discuss sexual
health concerns.
9
A key concern also was to ensure
participation from practitioners working within dif-
ferent areas of Sheffield given the wide variety in socio-
economic circumstances within the city, and efforts were
made to recruit approximately equal numbers of
practitioners from each Primary Care Trust (PCT). As
there is also variation in socio-economic factors within
PCTs, efforts were made to sample across each PCT
area. Variables guiding sampling therefore included:
practice type, including single-handed practices, single-
sex practices and mixed-sex practices; and location of
practice. The selection of GP participants was also
stratified by gender (all PNs listed were female).
Unfortunately, no further demographic information was
available for practitioners, including age and ethnicity.
Within practices with multiple GP partners and/or PNs,
the practitioner to be contacted was selected at random
(although for GPs this was in line with the stratification
by gender). Letters of invitation to participate in the
study were sent to 64 GPs and 61 PNs. These stated that
the study aimed to explore how GPs and PNs perceive
and manage the sexual health needs of patients.
All GPs, and the first 35 PNs who responded
positively to the invitation to participate, were included
in the study, resulting in semi-structured interviews
being conducted with 13 male and nine female GPs aged
34–57 years and 35 female PNs aged 32–60 years. Particip-
ants were recruited from all four PCTs within Sheffield
and worked at a socio-demographically diverse range of
practices. Interviews with GPs were conducted between
November 2001 and April 2002, and with PNs between
April and October 2002. All interviews were conducted
by experienced female research associates aged between
24 and 32 at the time of the interviews (SH, EG and
HE). Interviews took place at the participants’ practice
and lasted between 45 and 90 min. The interviews
followed a ‘guided conversation’ format
16
and covered
the following themes (although not necessarily in this
order): the meaning of sexual health within primary care
and the role of primary care within sexual health man-
agement; GP/PN barriers to discussing sex; patient
barriers to discussing sex; the influence of external
factors on sexual health management within primary
care (including national policies and guidelines);
potential strategies to overcome perceived barriers;
demographic details about the participant; and further
information about their practice. Although the original
intention had been to explore barriers to discussing
sexual health with middle-aged and older adults, this
was done within a broad context and all participants
were asked about, and referred to, their attitudes and
experiences of consultations with patients of all ages.
The professional barriers we identified to talking about
sex within primary care are therefore applicable to
patients of all ages and, where barriers were identified
to be specific to particular demographic groups, includ-
ing middle-aged and older patients, this is clearly indic-
ated. Interviews were tape-recorded with permission,
and additional field notes were taken after the inter-
view. These incorporated interviewers’ reflexive
accounts of the interview process and were used as aids
to analysis. Participant confidentiality was ensured at all
stages of the research and the study had the approval of
the local ethics committee.
Data analysis
Interviews were transcribed verbatim and transcripts
anonymized. In the analysis, the broad themes devel-
oped for the interview guide were used as the major
categories for the organization of data, although more
detailed coding and analysis within each of these
categories was pursued. This approach to analysis is akin
to ‘selective coding’
17
which uses a mix of inductive and
deductive thinking to identify conceptual patterns and
relationships in the data and enables the identification of
unexpected themes. To be certain of consistency within
analysis and that similar views were held regarding the
interpretation of data and the formation of themes, each
researcher initially focused on the analysis of one theme.
The resultant themes were then exchanged and the
researchers checked that they shared an understanding
and interpretation of the many meanings within the data.
Once such cohesiveness had been reached, the data were
analysed further to develop more thematic categories
which encompassed all the issues raised by participants
and explored in the interviews. As a result of this process,
six core categories were identified. A qualitative data
software package was used to assist the analytical
process: QSR NUD*IST.
Results
The role of primary care within sexual health
management
Overall, participants perceived the role of primary care
within sexual health management as encompassing a
range of tasks from diagnosing and treating sexual
health problems, having general discussions about
sexual health concerns, providing referrals to other
sexual health services and promoting safe sex. Primary
care was identified as the first point of contact with
health services for most people with sexual health
concerns and, as such, as playing an important role in
sexual health management, particularly for middle-aged
and older patients who were seen as less willing to access
Genitourinary Medicine and Family Planning services.
When asked whether primary care fulfilled its role in
sexual health management effectively, views were
mixed. Participants acknowledged the demands of other
priorities and perceived that sexual health management
tended to focus on the prevention and management of
sexually transmitted infections (STIs), providing
contraceptive advice and performing smear tests; sexual
dysfunction received very low priority. Moreover,
although most participants were happy to address sexual
issues when raised by a patient, a majority of both PN
and GP participants identified that they did not
routinely initiate discussions of sexual health issues
within consultations. Despite a general recognition that
sexual health could be an important part of some
people’s lives and an area with which primary care could
be effectively involved, pressures of time and resources,
as well as the complex and difficult nature of issues
pertaining to sexuality, were acknowledged to result in
sexual health being afforded low priority within both
primary care policy and day to day clinical practice. The
specific barriers to discussing sexual issues with patients,
particularly if these were not presented as the main
reason for the consultation, are discussed in detail below.
The role of sexual health in medical and nursing care
A key difference to emerge between the attitudes of GPs
and PNs related to the perceived role that sexual health
was seen to play within each specialty. Nurse participants
regarded sexual health to form part of holistic nursing
care and, as such, as an important aspect of their role.
“If we’re going to look after people as a whole then
that [sex] is part of it, part of life and we can’t ignore
it.” (PN: aged 30–39)
In contrast, some GPs expressed concerns about
whether sexual health was actually a ‘medical’ issue or not.
“Again, thinking about issues that you have raised,
how much of this is health-related, how much of it is
outside our sphere all together and should we be
trying to influence things which are especially
outside our control and more particularly outside
our gift? I think it’s one of the things that was very
clearly highlighted when Viagra did become
available, it was something very accessible and all of
a sudden it seemed to be creating a demand which
was previously not seen as a health problem at all, it
was seen as a social problem or a relationship
problem or whatever, but not specifically to do with
doctors and nurses, and all of a sudden it was, it was
like taking over that area. Are we the appropriate
people to be doing it? Should we be doing it?” (male
GP: aged 40–49)
This sentiment was also apparent in concerns
expressed by GP, but not PN participants, as to whether
patients would perceive sexual issues as legitimate topics
for discussion within a medical consultation. Fears were
expressed that mentioning such issues could transgress
the public–private boundary and, potentially, offend the
patient by “prying into something that’s none of my
business” (male GP: aged 40–49). The risks inherent in
Family Practice—an international journal
530
Sexual health management in primary care
531
so doing were discussed in relation to the doctor–patient
relationship and, in extreme cases, this was felt to be in
danger of being jeopardized:
“If you mention this will affect your sex life to an
older woman who hasn’t slept with her husband for
years and years, you know she might be quite
sensitive to the fact that she hasn’t slept with her
husband for years and years and might be quite
upset if you said that and I think that’s going to
break down your doctor–patient relationship if
somebody says that. You have to be very careful
sometimes or you’ll never see them again. They’ll go
to see somebody else.” (female GP: aged 30–39)
Although PN participants also discussed the potential
to cause offence, risks to the patient–professional
relationship were not mentioned and, overall, this was
not felt to be a significant deterrent to initiating a
discussion of sexual issues.
‘The can of worms’
When discussing the key barriers to talking to patients
about sexual issues within primary care, both GP and PN
participants referred to sexual health as a ‘can of worms’
or ‘Pandora’s box’. This analogy was seen to characterize
participant’s feelings about addressing sensitive and
complex problems within the time and resource
limitations of primary care. As one nurse participant
identified:
“It is difficult, especially if it opens up a can of worms,
because once you’ve opened up that can of worms
you’ve got to follow it through, you can’t then say oh
‘I haven’t time for this you need to make another
appointment’, you can’t do that especially where it’s
sexual health that’s involved.” (PN: aged 40–49)
Time constraints were identified as critical. For both
GPs and PNs, limited time available within consulta-
tions was the key barrier identified to initiating discus-
sions of sexual health issues. PNs felt that there was
insufficient time available during consultations to build
up a good rapport with the patient, something seen as
essential if sensitive issues such as sexual health were to
be discussed. For GPs, tight limits on consultation times
were seen as significantly limiting the opportunities
afforded to GPs to explore issues beyond that with
which the patient was immediately presenting. As one
participant commented:
GP: “Hypertensives for instance, gosh a lot of them
cause impotence… I haven’t got anything to back
this up with, but my feeling is that the sexual side
effects would be mostly neglected, cause it’s a sort
of Pandora’s box isn’t it?”
R: “…you don’t sort of want to open up all sorts of
thing?”
GP: “No because normally sexual problems take up
a long time and therefore are best avoided.” (female
GP: aged 50–59)
Concerns about expertise were also expressed in this
context. The fact that sexual health management often
could require specialist knowledge and skills was seen to
limit professionals’ ability to address these concerns
adequately. This left some participants wondering
whether it was actually fair to the patient to broach a
subject that they felt ill-equipped to deal with.
“There is another issue that you haven’t raised yet
and this is a can of worms issue in if you’re running
to a schedule and you broach areas which are
potentially incredibly complicated and insoluble
and maybe you’re outside the ability to do anything
about it anyway and then what good does it do you
or them?” (male GP: aged 40–49)
Particular concerns were expressed about choosing
the language to use to address sexual issues and being up
to date with the latest developments in the field. Nurse
participants also identified that their inability to
prescribe, as well as for some the inability to refer to
specialist clinics, limited the extent to which they could
address patient’s sexual concerns and, as a result, their
motivation to raise such issues in the first place.
Primary care priorities
GP participants identified that the time pressures they
worked within meant that their priority had to be
diagnosing health conditions and prescribing medica-
tion, meaning little, if any, time was available to discuss
the impact of the condition upon the patient’s life,
including their sex life:
“[Time] is a major factor to how much you explore
ill health on people’s lives in general and I think we
often really limit what we offer patients; we don’t
really understand the impact of even quite straight
forward problems, how it affects people day to day,
because we don’t really have the time to do that…
it’s sort of little bits that are often again tagged on
the end, they might talk about whatever condition
and by the time you’ve talked about the disease and
the drugs and the side effects, you know how it
actually affects somebody’s life disappears or is sort
of on the bottom of the list and how it affects their
sex life, you know if it’s there at all.” (female GP,
aged 40–49)
Moreover, wider policy developments were also seen
to influence the issues that both GPs and PN had to
prioritize within their clinical practice. Although the
impact of initiatives such as the National Service
Frameworks upon day to day working was disputed,
there was a general feeling that these channelled time
and resources away from areas not prioritized in this
way. As one PN identified:
R: “So when you say you’ve got enough on your plate,
does that mean time constraints are a big factor?”
PN: “Oh I just haven’t got the time, I just have not
got the time. The issues at the moment are with the
National Service Frameworks, that is bogging us
down without adding in other things like sexual
health etc. I’m afraid that’s the way things are, we
are just too over-laden with chronic disease
management to be able to go into the other aspects
of health.” (PN: aged 60–69)
A national focus on the prevention of management of
STIs among younger people and the prevention of
teenage pregnancy within UK sexual health policy was
also seen to translate into day to day practice, with issues
such as sexual dysfunction and other non-STI-related
sexual problems receiving very low priority.
Barriers to talking about sexual issues with particular
patient groups
In addition to general barriers to discussing sexual issues
identified above, both GP and PN participants raised
specific concerns about addressing such issues with
particular patient groups. These included patients of the
opposite gender, middle-aged and older patients,
patients from Black and ethnic minority groups, and
non-heterosexual patients. As explored below, these
barriers related in the main to practitioner attitudes.
Gender. Overall, a preference for same-gender consul-
tations about sexual health issues was identified. This
was seen as both a professional and a patient preference
and was consistent for both GPs and PNs. Some
participants identified that their preference stemmed
from feeling more comfortable discussing sexual issues
with same-gender patients and concerns that patients of
the opposite gender may sexualize the consultation
(some GP participants gave examples of when this had
happened). However, a more common theme to emerge
was that the tendency of patients to self-select along
gender lines when presenting with sexual concerns mean
that both GPs and PN could become de-skilled in certain
areas of sexual health management. As one PN
identified:
“I would feel much more comfortable with a woman
because I think would know what to say to her,
whereas to the man, I don’t know enough about the
devices to help.” (PN: aged 40–49)
The pattern of same-gender consultations meant that
PNs tended mainly to manage, and certainly felt more
comfortable managing, women’s sexual health concerns;
the implications of this for the expansion of nursing
input into primary care sexual health management are
explored below.
Ethnicity. When participants were asked to reflect on
barriers to talking about sex with particular patient
groups, issues specific to ethnicity were raised. (‘Black
and ethnic minority group’ is the term we are using to
characterize the group of patients to which participants
were referring in this context. Participants themselves
did not use this term, but referred to ‘ethnic minority’,
‘Asian’, ‘Afro-Caribbean’ and ‘Muslim’ patients.) There
was a common perception that sex was something that
was less openly discussed by people from certain Black
and ethnic minority groups:
“I think maybe a lot of the Asian and similar folk
probably have been brought up not to discuss these
types of things because they were brought up in a
less liberal society.” (male GP: aged 30–39)
Participants also related potential differences in
attitudes amongst patients from Black and ethnic
minority groups to religious beliefs (although in many
instances participants did not indicate to which religion
they were referring). For example, one PN stated that
“with some religions it’s not always looked upon to have
someone look down below and start probing into things
like that.” (PN: aged 40–49). However, interestingly,
very few participants reported actually having held
discussions about sexual issues with this patient group,
indicating that their discussions were based upon pre-
existing beliefs rather than direct experience. Indeed,
participants who had held such discussions reported that
these perceived difficulties did not reflect their expe-
riences. One GP, for example, reported that when she
moved to a practice with a high proportion of Pakistani
patients, she was “surprised… [because] they are ready
to discuss it [sex]” (23223, female GP), although this
related only to female, not male patients.
Difficulties of discussing a sensitive subject such as
sex when a common language was not shared were also
raised. Indeed, the use of an interpreter, although
essential in certain circumstances, was identified as
problematic. In particular, difficulties in translating
specific medical terms, fears that the interpreter could
compromise patient confidentiality and the risk that the
presence of a third party could depersonalize the
consultation were identified as complicating factors
introduced when an interpreter was used. Furthermore,
in relation to discussions of sexual health issues, the
potential for the translator to be embarrassed themselves
by the discussion was also acknowledged. The use of
relatives as translators was also identified as highly
problematic within this context. Overall, both GP and
PN participants and, in particular those working at
practices with a high proportion of non-English-speaking
patients, identified the sexual health management of
these patients as a training priority.
Age. As already mentioned, the role of primary care in
terms of sexual health management was seen to assume
Family Practice—an international journal
532
Sexual health management in primary care
533
increasing importance with patient age due to the limited
availability/accessibility of other sexual health services
for older people. However, older age was seen to present
a significant barrier to discussing sexual health issues
within a primary care context, both for professionals and
for patients. Indeed, overall, participants acknowledged
that they raised sexual issues far less often with older
patients than with younger patients.
“I suppose you would realistically be more likely to
raise issues like that with a 30 year old than an
80 year old yeah, I mean sometimes you might do
but I would look for more distinct cues from them,
in an older person, before I raise the issues, whereas
in a younger person I might be more inclined to
raise the issues myself I think yeah [.] yeah I think
that’s probably true.” (PN: aged 40–49)
Interestingly, when participants talked about the
impact of age upon their management of sexual health, it
became apparent that perceptions of ‘older patients’
within this context included, for many participants,
patients in their 40s and over. This age group was
considered by most participants to perceive sexual issues
as more personal and sensitive than younger people and,
potentially, be more easily offended if such issues were
raised. However, there was a recognition that the
professionals’ attitude may form the largest barrier to
raising sexual issues with this age cohort of patients:
R: “Do you think that your approach or attitude is
affected by the age of somebody, the patient,
younger or older?”
GP: “Yes I think I find it more difficult with older
people.”
R: “Why do you think that?”
GP: “It’s strange isn’t it. Why do I think that?
Perhaps it’s me and not them, I think they are more
likely to be offended, but I recognize that may well
be to do with me not them, I somehow feel it’s
harder to raise it.” (male GP: aged 30–39)
It is also worth noting that discussions about sexual
risk taking were not initiated routinely with this age
group. Issues specific to the sexual health management
of middle-aged and older people by GPs are discussed in
more detail in a separate publication.
18
Non-heterosexual patients. A significant number of GP
participants identified that they felt uncomfortable
discussing sexual health issues with non-heterosexual
patients, with some expressing concerns about how to
reconcile their own views about non-heterosexuality with
their clinical practice. (We use the term ‘non-heterosexual’
to characterize the group of patients to whom
participants are referring within this theme. Participants
themselves did not use this term, but commonly referred
to ‘gay’, ‘homosexual’ and ‘lesbian’ patients.) One
participant, for example, questioned the ethics of
prescribing Viagra to gay men, particularly if they were
not in a stable relationship. However, in the main,
discussions centred around how GPs could sensitively
manage the needs of their non-heterosexual patients.
Within this context, some GP participants raised worries
about their own ability to do so appropriately.
“I think especially in homosexual relationships
where the phrases they use for certain sexual acts
can be quite or what we would feel is inappropriate
but it is the common terms and sometimes you have
to alter the way you talk to them and say you know
‘this is what I want to talk to you about, do you
understand that?’ and if they don’t understand what
we would say is the normal phrase or clean phrase
then I would go and use whatever words they use to
refer to their sex act.” (male GP: aged 30–39)
It was apparent through the language typically used
by participants that most were positioning themselves as
heterosexual (although we did not ask participants to
disclose their sexual orientation). For example, in the
above extract, the GP participant talks about ‘homo-
sexuals’ as ‘they’, rather than ‘we’. Moreover, his discus-
sion also indicates that he believes non-heterosexual
relationships are not ‘normal’ or ‘clean’, indicating an
underlying, perhaps subconscious prejudice. The impli-
cations of beliefs such as these for training and education
of practitioners are considered in the Discussion.
Again, the importance of choosing the right language
to address sexual issues was perceived as highly import-
ant, and a potential area where training input would be
useful. Although most PN participants felt that they had
few problems managing the sexual health needs of non-
heterosexual patients appropriately, there was a low
level of awareness that they may have non-heterosexual
patients, again indicating a need for training.
Overcoming barriers
Training. All participants were asked to consider how
the barriers they identified to sexual health management
within primary care could be addressed. Although many
of these barriers, and in particular time and resource
pressures and competing priorities, were seen to be
structural and, as such, beyond their control, the value of
training in this area was considered. Views about this
were mixed. Several PN participants in particular
identified a need for, and desire to, pursue training
opportunities if they arose. However, the time and
resource pressures within primary care led them to
question how feasible pursuing such options would be.
“It’s not always easy to get the time off for training
because there are so many new things coming up all
the time and it’s prioritizing and you have to look at
your workload and try and define which are the
most important of the aspects of that to focus on.”
(PN: aged 40–49)
This was also a key barrier for the minority of GP
participants who would have liked to take up training in
this area. Indeed, although there was a recognition of
the value of communication skills training in enabling
GPs to discuss these issues in consultations and an
awareness that training currently provided in this area
was not adequate, again competing time and resource
demands were seen to limit training opportunities.
Providing patient information. Providing information
was seen as an important means of enabling patients to
initiate discussions of their sexual health concerns
during consultations. Within this context, written
information such as leaflets or posters was seen as
valuable, particularly as a means of bypassing awkward-
ness and embarrassment in consultations for both the
patient and the professional. One PN, for example,
talked about how she used this strategy to encourage
women to talk about vaginal dryness during smear tests:
“There’s a poster by where the wall is where we do
the smears, and they will often be so relieved to be
able to talk about it and they don’t really want to
take HRT and then I say why not use KY jelly,
try these samples and they go off with KY jelly, or
whatever, and they’ve got an answer to it and its not
something that you can easily come out with I don’t
suppose, its only in that setting that you would
discuss it.” (PN: aged 40–49).
However, participants acknowledged that, on the
whole, there were few sources of written information
available that covered sexual health issues, apart from in
relation to STIs, and even in this instance it was
identified that this tended to be targeted at young
people. In addition, concerns were expressed that patients
may feel too embarrassed to pick up a leaflet about a
sexual problem in the practice waiting room and that if
information was provided, someone had to be available
to answer any questions it may raise for patients.
Expanding the role of the PN. As noted earlier, policy
recommendations have identified the potential for the
role of nurses to be expanded within sexual health
management, and this was an issue we addressed with all
participants within the context of primary care. GP
participants were overwhelmingly supportive of this
idea, not only because of the implications it may have for
their workload, but also due to a recognition by many
participants that nurses may be better equipped to
manage sexual concerns than doctors.
“They certainly have appointment times longer than
mine and I always see the nurses as more holistic than
doctors, doctors do tend to have more of a medical
sort of model don’t they and they home in on various
diagnoses [laughs], whereas I often imagine practice
nurses to be chatting about things and maybe asking
more questions.” (male GP, aged 40–49)
PN participants, however, disputed the idea that they
had significantly more time to spend with patients,
although they were in the main happy to consider
assuming a broader role in sexual health management.
However, as identified earlier, they tended mainly to
manage the sexual health concerns of female patients
and certainly felt that both they and the patient felt most
comfortable with this arrangement. In addition,
structural barriers such as an inability to refer to
specialist clinics (although this varied by practice) and
an inability to prescribe led participants to question how
their role in this area could expand. A real need for such
an initiative to be supported with training was also
identified.
Discussion
Our findings confirm, and significantly extend, previous
work and commentary which indicate that sexual health
represents a very difficult topic for GPs and PNs to
address proactively within primary care consultations.
Participants identified similar barriers to discussing
sexual problems as reported by questionnaire surveys of
GPs
9
and PNs,
10
including time pressures, complexity
and lack of training. However, the qualitative methodo-
logy adopted allowed a more in-depth understanding of
how these barriers operate. For example, the ‘can of
worms’ analogy could be unpicked to gain an under-
standing of how pressures of time, concerns about
medical legitimacy and worries about personal
expertise, in addition to the sensitive and often complex
nature of sexual health issues, combine to make this a
highly problematic topic to raise within primary care
consultations.
Certain limitations of the study must be acknowledged.
First, participation rates were relatively low, particularly
amongst GPs, and it is likely that professionals who took
part in the study would be more interested in sexual
health issues than non-participants, although it was
evident that many were not. The sample was drawn
from only one UK city, although there is little to suggest
that the situation differs elsewhere. Finally, a wide range
of conditions were discussed under the terms ‘sexual
health’; however, the barriers to discussing this range of
conditions were similar, as their complexity and sensi-
tivity were related to the fact they were sexually related.
Particular barriers were identified to discussing
sexual issues with patients of the opposite gender,
patients from Black and ethnic minority groups, middle-
aged and older patients, and non-heterosexual patients.
Preferences for same-gender consultations about sexual
Family Practice—an international journal
534
Sexual health management in primary care
535
issues were reported by PNs participating in a UK
survey
10
and are known to influence some patients’
decisions to consult GPs for any condition.
16
Profes-
sional difficulties in talking to middle-aged and older
patients about sexual issues are evident in patient
accounts
13,14
and professional commentary, but have not
been explored in detail previously within a primary care
context. Similarly, there is a lack of research addressing
how the sexual health needs of patients from Black and
ethnic minority groups can be met, although Serrant-
Green
19
confirms that men from minority ethnic groups,
although perceived as at particular risk of contraction of
an STI, are not having their needs met appropriately by
sexual health services. However, overall sexual health
management with ethnic minority groups represents an
under-researched area and warrants more attention.
Similarly, little work has looked at professional attitudes
towards addressing the sexual health needs of non-
heterosexual patients within primary care, although a
lack of skills and awareness training in this area has been
noted.
20
Indeed it is likely that the situation in the UK is
similar to that in the USA, where a survey identified that
the average time devoted to this issue in undergraduate
medical curricula was 3 h in 4 years training.
21
It was apparent from the interviews we conducted
that many of the participants were prevented from
mentioning sexual issues within a consultation by
stereotyped ideas about particular patient groups. For
example, a commonly voiced opinion about both older
patients and patients from Black and ethnic minority
groups was that mentioning sex could ‘cause offence’.
However, when questioned, few participants could give
examples of when they had caused offence in this
situation and it was apparent that their attitudes and
behaviours were based more upon preconceived ideas
about these patients groups than direct experience of
individual patients. Lupton argues that the pressures of
time within clinical consultations encourage medical
students to categorize patients into ‘unidimensional
stereotypes’.
22
However, it was also apparent that such
stereotyping reflected underlying, often prejudicial
beliefs. For example, in the Results, we cite the example
of a GP who talks of his need to learn the terminology
for non-heterosexual sexual behaviours so he can better
meet the needs of this group of his patients. However,
his use of the words ‘normal’ and ‘clean’ to describe
heterosexual behaviours indicates that he would also
benefit from education that addressed his apparently
subconscious prejudices towards non-heterosexuality.
Indeed, overall, our findings indicate that training
offered in sexual health management within primary
care needs to extend beyond imparting information to
challenge beliefs and underlying attitudes held by some
professionals about sexuality and sexual health, particu-
larly in relation to groups of patients who are subject to
stereotyping. Therefore, training using “experiential
methods to recognize each individual’s unique experience
of sex and sexuality” is required.
15
Another means of
overcoming barriers to talking about sexual issues,
particularly with patient groups such as these, was seen
to be empowering patients through the provision of
information about sexual issues so as to enable them to
feel more able to raise sexual issues within consul-
tations. The need for an expanded range of sexual health
information suitable for a diverse audience has also
been voiced by patients themselves.
23
Overall, improving communication about sexual
issues within primary care must be prioritized if primary
care is to adopt a broader role in sexual health manage-
ment, particularly if this role is to be proactive. The
recommendation within the National Sexual Health
Strategy
1
that nurses may be able to become more
involved in this area was explored in this study, and we
identified that, although many PNs were interested in
this idea in principle and GPs were overwhelmingly
supportive, key barriers to this being achieved within
primary care were identified. These included structural
issues of nurses’ ability to refer to secondary services,
prescribe relevant medications and issues of time, as
well as something more potentially insoluble, namely
patient and professional preference for same-gender
consultations about sexual issues. The potential for male
sexual health needs to be marginalized as a result of
increased nursing involvement in this area must
therefore be recognized.
Acknowledgements
We would like to than all GPs and practice nurses who
took part in the study.
Declaration
Funding: The study was funded by an unrestricted
educational grant from Pfizer Ltd.
Ethical Approval: The study was granted ethical
approval by the North Sheffield Ethics Committee.
Conflicts of interest: None.
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