Journal of Sexual & Reproductive Medicine

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*Corresponding Author:
Herta Fidler
University of Calgary, Faculty of Medicine, Office of Continuing Medical Education and Professional Development, 3330 Hospital Drive Northwest, Calgary, Alberta T2N 4N1.
Telephone: 403-220-4268
Fax: 403-210-8188
E-mail: [email protected]


BACKGROUND: Family physicians are the first point of contact for men who are experiencing erectile dysfunction (ED) and andropause. At the same time, most patients with ED are not identified or treated by health care professionals. This can result in under-recognition and inadequate management of sexual health pathology. OBJECTIVES: The present study undertook to identify Canadian primary care physicians’ demographics, learning needs and preferences for continuing medical education in relation to ED. The results would aid in the development of educational programs in the area of male sexual dysfunction. METHODS: Surveys were distributed to a stratified, proportionate, random sample of 5000 Canadian physicians. The survey asked about screening practices, comfort with sexual history taking, preferred educational format, perceived difficulty and incidence of common male sexual problems, barriers to treatment and demographic information. RESULTS: Almost 40% of physicians reported being nonscreeners. Those who reported asking all male patients about their sexual health (global screeners) reported statistically higher comfort levels than those who only screened selectively (selective screeners) or not at all (nonscreeners). The most common and most difficult condition to treat was found to be sexual problems in couples. The greatest challenge in managing ED was reported to be treating couples by nonscreeners, treatment failures by selective screeners and time required to treat for global screeners. A 1 h overview course was the most preferred educational format. CONCLUSION: The results suggest that any educational intervention that increases comfort with sexual history taking will also increase screening among family physicians. However, educators need to consider the specific learning needs for each group of screeners.


Continuing medical education; Male sexual dysfunction; Needs assessments; Screening

Since the advent of more ‘patient-friendly’ medications for the treatment of erectile dysfunction (ED) and andropause, family physicians have become the first point of contact for most men who complain of sexual problems [1]. As the role of the family physician has grown, so has the number of educational opportunities available for nonspecialists to learn about the management of male sexual heath problems.

It has been long recognized that health care professionals have not identified most patients with ED. Despite extensive public education, as many as 85% of patients with ED have not been identified or treated. While there may be many reasons for this, it has been shown that patients expect that physicians will routinely ask about their sexual health. If physicians do not routinely screen patients for sexual problems, there will be an under-recognition and inadequate management of sexual health pathology.

In the present study, primary care physicians were divided into three hypothetical groups according to their screening behaviours. One group of physicians (global screeners) asked most or all of their patients screening questions about sexual health. A second group selectively screened patients at high risk for sexual problems – for example, diabetic patients. A third group, nonscreeners, did not initiate any screening questions, but may have responded by investigating sexual health complaints that their patients initiated.

There are no published data that define the characteristics, learning needs or preferences of each group.

The University of Calgary, Alberta, in conjunction with the Fédération des Médecins omnipraticiens du Québec, undertook a survey of the demographics, learning needs and preferences of primary care physicians from across Canada in anticipation of developing educational programs for family physicians in the area of male sexual health.

Data and Methods

A computer-scored survey was sent out to 5000 randomly selected family physicians across Canada. The survey was distributed to each region in numbers that reflected the proportion of family physicians in each province. Family physician demographics included primarily those who were in primary care and in full-time practice.

The questionnaire (Appendix 1) asked about usual screening practices, comfort level with sexual history taking, preferred educational format, perceived difficulty and incidence of common male sexual problems, barriers to treating ED and demographic information.


Of the 5000 surveys distributed (3800 to English-speaking physicians in Canada and 1200 to French-speaking physicians in Canada), 69 surveys were returned unanswered and 905 surveys were returned completed – 122 (10%) from Quebec and 783 (21%) from the rest of Canada, giving an overall response rate of 18%. Sixty-five per cent of respondents were men and 35% were women.

Screening approaches

The number of responses in each screening group is reported in Table 1. Almost 40% of family physicians reported being nonscreeners. There were no significant differences in sex distribution among the screening groups.

Level ofscreening French-speakingQuebec (%) Rest ofCanada (%) Total (%)
Nonscreeners 56 (49.5) 291 (38.2) 351 (39.7)
Selective screeners 35 (31.0) 295 (38.7) 334 (37.7)
Global screeners 22 (19.5) 177 (23.2) 200 (22.6)

Table 1: Number of questionnaire responses in each screening group.

There appeared to be differences in screening rates across the country. For the ease of analysis, responses were divided into five regions: Atlantic Canada, Quebec, Ontario, the prairies and British Columbia. The results displayed in Table 2 demonstrate that the highest rates of selfreported screening (selective screening plus global screening) occurred in Atlantic Canada (71.8%) and the prairies (67.2%). The lowest screening rates were in Quebec (51.8%) and British Columbia (57.9%).

Region Nonscreeners (%) Selective screeners (%) Global screeners (%)
Atlantic Canada 20 (28.2) 40 (56.3) 11 (15.5)
Quebec 67 (47.2) 44 (31.0) 31 (21.8)
Ontario 123 (39.4) 108 (34.7) 81 (25.9)
Prairies 57 (32.8) 71 (40.8) 46 (26.4)
British Columbia 69 (42.1) 66 (40.2) 29 (17.7)

Table 2: Number of questionnaire responses by region of Canada

There were significantly fewer (P=0.008) rural family physicians who were global screeners (42 of 260) compared with urban family physicians (153 of 605).

Comfort levels with sexual history taking

Participants were asked to rate their comfort level with sexual history taking (1 = very uncomfortable; 5 = very comfortable). Comfort levels of global screeners (mean 4.09) were significantly higher than those of selective screeners (mean 3.84) and nonscreeners (mean 3.37).

Comfort level of sexual history taking was greater in English-speaking physicians (mean 3.73) than in Frenchspeaking physicians (mean 3.58), although this did not reach statistical significance.

Commonality and difficulty of various sexual problems

Participants were asked how common certain sexual dysfunctions were in practice (1 = very uncommon; 5 = very common) and how difficult these conditions were to treat (1 = not at all difficult; 5 = very difficult). It was proposed that by summing these two results, higher values would provide a strong indication of areas of high perceived need for educational programming (ie, situations that were both common and difficult to treat).

Table 3 reports the mean of commonality and the degree of difficulty of each clinical problem, along with the sum of these scores. Rankings are shown in brackets.

  Mean score Mean score for Sum of the
Clinical situation for commonality difficulty (ranking) means (ranking)
Sexual problems in couples 3.39 3.43 (5) 6.82 (1)
Patients with low desire 3.21 3.35 (6) 6.56 (2)
Issues of infidelity 2.85 3.46 (4) 6.31 (3)
Patients with painful intercourse 2.60 3.32 (7) 5.92 (4)
Patients with erectile dysfunction 3.21 2.63 (8) 5.84 (5)
Patients with rapid ejaculation 2.27 3.50 (3) 5.77 (6)
Patients with delayed ejaculation 1.88 3.73 (2) 5.61 (7)
Patients with retrograde ejaculation 1.66 3.90 (1) 5.56 (8)
Patients with low testosterone 2.27 2.60 (9) 4.86 (9)

Table 3: Mean of commonality and degree of difficulty of clinical situations, along with the sum of these scores

Challenges to the management of ED

The greatest challenges to the management of ED are reported in Table 4. Respondents were asked to rate each factor according to how much of a barrier it presented to the management of ED (1 = not at all challenging; 5 = highly challenging). Scores are presented in descending order of most challenging, based on the nonscreening group. The rank order of the other screening groups is shown in parentheses. Clinical significance (P<0.05) between the groups in denoted by an asterisk.

  Nonscreeners Selective screeners Global screeners Group results
Challenge to treatment (ranking) (ranking) (ranking) (ranking)
Treating couples* 3.63 (1) 2.76 (6) 2.64 (6) 3.48 (1)
Treatment failures* 3.53 (2) 3.45 (1) 3.32 (2) 3.45 (2)
Availability of resources 3.42 (3) 3.45 (1) 3.30 (3) 3.40 (3)
Time required to treat 3.39 (4) 3.23 (3) 3.32 (1) 3.32 (4)
Laboratory evaluation 3.38 (5) 3.21 (4) 3.30 (3) 3.30 (5)
Nonlaboratory evaluation* 3.32 (6) 3.03 (5) 2.97 (5) 3.13 (6)
Knowing who to treat* 3.01 (7) 2.76 (6) 2.64 (6) 2.83 (7)
Comfort with screening* 3.00 (8) 2.58 (8) 1.96 (9) 2.61 (8)
Cardiac risk* 2.54 (9) 2.34 (9) 2.26 (8) 2.40 (9)

Table 4: Inter-rater comparison for diagnosis of bacterial vaginosis (concordance 97.5%, kappa for inter-rater reliability 0.94, [95% CI 0.79 to 0.97]).

Preferred educational formats

Physicians were asked what type of continuing medical education (CME) event on male sexual dysfunction they would prefer to attend: a 1 h overview course, a 3 or 4 h MAINPRO- C course, a full-day MAINPRO-C course, or a short, 30 to 40 min drug company lunch. Respondents were asked to indicate if it was ‘very likely’, ‘perhaps likely’ or ‘not at all likely’ that they would attend a CME event on male sexual dysfunction. The results are shown in Table 5.

Type of event Not very likely (%) Perhaps likely (%) Very likely (%)
1 h overview course 88 (10.3) 279 (32.8) 484 (56.9)
3 or 4 h MAINPRO-C course 137 (16.1) 311 (36.5) 403 (47.5)
Full-day MAINPRO-C course 427 (52.7) 270 (33.3) 113 (14.0)
30 to 40 min drug company lunch 206 (24.8) 278 (33.5) 345 (41.6)

Table 5: Respondents? likelihood of attending a continuing medical education event on male sexual dysfunction.

There were differences in the preferred learning formats between the screening groups. These differences are detailed in Table 6. Nonscreeners were less likely to attend programs on male sexual health and preferred shorter educational programs, while those who were more active in screening patients for sexual problems preferred to attend longer programs.

  Nonscreeners Selective screeners Global screeners
Format of program who may attend (%) who may attend (%) who may attend (%)
1 h overview course 87.4 92.0 89.1
3 or 4 h MAINPRO-C course 78.6 85.9 89.4
Full-day MAINPRO-C course 43.8 45.7 54.6
Short, 30 to 40 min drug company lunch 72.5 75.8 72.3

Table 6: Preferred learning formats of respondents.

Level of intervention in the management of ED

The level of intervention was examined among the screening groups. Four options were presented with respect to the management of ED – ‘do not see this problem’, ‘refer with a minimum of inquiry’, ‘refer after obtaining ancillary information and ‘attempt to fully assess and treat’. The results are shown in Table 7.

Management of erectile problems Non-screeners (%) Selective screeners(%) Global screeners (%)
Do not see this problem 5.2 1.2 1.0
Refer with a minimum of inquiry 21.8 5.2 3.6
Refer after obtaining ancillary information 32.8 25.9 23.3
Attempt to fully assess and treat 40.1 67.6 72.0

Table 7: Respondents? levels of intervention for the management of erectile dysfunction.


The level of global screening for male sexual health problems was disappointingly low. Only 22% of respondents indicated that they routinely asked most of their male patients about their sexual health.

It appears that the comfort level with sexual history taking correlates strongly with screening for sexual dysfunction. The more comfortable physicians are with taking sexual histories, the more likely they are to screen their patients for sexual problems. This suggests that any educational intervention that increases comfort in sexual history taking will also increase the level of screening among family physicians.

There is evidence that increasing physicians’ comfort levels with sexual history taking through a structured educational activity will increase physicians’ comfort levels with sexual history taking and, thus, their levels of intervention. This suggests that the best way to encourage nonscreeners to become more active in asking their male patients about their sexual health is to increase their comfort levels with sexual history taking.

In general, couples’ sexual problems were reported to be common and difficult to treat. Associated couple-based problems (low desire, infidelity and ED) were also reported to be common and difficult problems to treat.

Rapid ejaculation, which is felt by experts to be a very common male sexual health problem, was considered to be uncommon based on the questionnaire responses. This learning gap should be addressed by an educational activity.

Overall, there was a lower ‘challenge’ score for global and selective screeners (2.9 and 3.1, respectively) compared with nonscreeners (3.3). This was statistically significant (P<0.05), and may indicate a higher level of self-efficacy for screeners.

It is interesting that nonscreeners listed ‘treating couples’, ‘treatment failures’ and the ‘availability of resources’ as the greatest barriers to management. If nonscreeners do not ask their patients about ED or sexual problems, how can ‘treating couples’ or ‘treatment failures’ be barriers? It may suggest that these are the greatest presumed barriers, rather than actual barriers. It is interesting to note that those who do screen their patients see ‘treating couples’ as a lesser challenge.

‘Time required to manage’ was reported to be the greatest challenge to global screeners. However, this group also reported the highest comfort level with sexual history taking and the highest intervention level of managing patients with ED.


The findings of the present study suggest that educators should develop a variety of educational programs that target the specific needs of each group. To encourage greater screening for sexual problems in men, CME should promote the skill of sexual history taking.


This study was supported with an unrestricted financial grant from Pfizer Canada.