Value of questionnaire
The scores for items regarding the frequency of neurosurgeons asking their patients about sexual health showed a very high internal consistency (α = 0.93).
Internal consistency between the items regarding reasons not to inquire about sexual health was good with Cronbach’s α 0.79.
Of the 161 eligible participants, 99 returned the survey, either after first invitation (n = 55) or after first (n = 26) or second (n = 18) reminder, resulting in a total response rate of 61.5 %. Eight participants used the option of returning the questionnaire empty with specification of a reason; indicated reasons were lack of experience (n = 3), lack of interest (n = 2), lack of time (n = 1) and other reasons such as working with a specific group of patients not suitable for this study (n = 1) or merely treating patients in emergency settings (n = 1). One participant returned the questionnaire empty without specifying a reason; another returned it almost empty with too little information available for analysis. This resulted in a total of 89 questionnaires that were suitable for analysis.
Of the participants, 83.3 % were male. Mean age was 42.4 years (SD 9.6), with 71.6 % of respondents being a neurosurgeon versus 28.4 % being a resident. Mean experience in neurosurgical care was 9 years. Of the respondents, 42.5 % indicated to have spinal surgery as his or her specific field of interest. Characteristics of the respondents are summarized in Table 1. Male respondents were significantly older than female respondents [mean age 43.6 (SD 9.43) versus 36.3 (SD 8.35); p = 0.006].
Discussing sexual health
Participants answered the question ‘In how many percent of your patients with general spine problems do you think sexual function has changed because of spine problems?’ with a mean of 34.4 % (SD 29.7). Neurosurgeons working in neurosurgical care for a shorter time evaluated this percentage to be higher (p = 0.026); so did younger neurosurgeons (p = 0.025) and residents (p = 0.023). When asked how often sexual health is discussed with patients, 72.4 % said ‘(almost) never’, 20.7 % ‘in less than half of the cases’, 3.4 % ‘in half of the cases’, 2.3 % ‘in more than half of the cases’ and 1.1 % ‘(almost) always’. Sexual health is significantly less frequently discussed with female than with male patients (80.9 % ‘(almost) never’ versus 68.5 %; p = 0.003). This was not statistically significant associated with doctor’s gender (p = 0.86).
Whether sexual health is discussed, is highly influenced by patients’ age. Patients between 20 and 35 years are most often being asked about sexual health (Table 2); this difference is statistically significant (p < 0.0001) except between the groups 20–35 years and 36–50 years. No significant associations with gender, age or other demographic data of neurosurgeon were found.
Participants consider discussing sexual function more frequently if specific diseases are present; especially in the case of cauda equina syndrome (CES), in which 86.7 % of neurosurgeons discuss sexual health (Table 3). In the specific case of CES, sexual health is significantly less often discussed if the field of interest of the respondent is spinal surgery (78.4 versus 94.0 %; p = 0.030) and if the neurosurgeon does not feel responsible to discuss sexual health (75.0 versus 94.7 %; p = 0.007). Asking CES patients about sexual health was associated with significantly more referrals to health care professionals specializing in sexual health (p = 0.023).
Reasons spontaneously mentioned by respondents to discuss sexual health were spinal dysraphias such as tethered cord (n = 2), a HNP fully obtruding the canal (n = 1), chronic lumbago (n = 1), vascular diseases (n = 1) or ‘if the patient brings it up’ (n = 1). One respondent indicated to not discuss SD but to refer to the rehabilitation specialist. Sexual health is never discussed by 4.5 % of respondents, regardless of disease.
Responsibility of discussing sexual health
Of respondents, 35.3 % believed that the neurosurgeon is responsible for discussing sexual health; 37.5 % disagrees and 27.3 % do not know. The shorter the time spent in neurosurgical care, the more feelings of responsibility are present, though this association only approached statistical significance (p = 0.051). Neurosurgeons who deemed themselves responsible discussed sexual health significantly more often (p = 0.006). When given a list of options with more than one option possible, 64 % stated that the neurosurgeon is (partly) responsible for discussing sexual health (Table 4). Almost 63 % indicated that it is the patients responsibility, even though the majority of participants (81.6 %) also stated that patients ‘(almost) never’ bring up sexual health issues themselves. To the question ‘Do you mention risks on sexual health when you inform patients about surgery risks (obtaining informed consent)?’, 51.7 % said ‘(almost) never’, 19.5 % ‘in less than half of the cases’, 3.5 % ‘in half of the cases’, 3.5 % ‘in more than half of the cases’ and 21.8 % ‘(almost) always’. During check up visits, 69.3 % do not discuss sexual health; 6.8 % does this always.
To the question ‘How important is it to screen patients with general spine problems for SD?’, 42.7 % stated to find this ‘somewhat important’, 21.3 % ‘important’ and 1.1 % ‘very important’. It was seen as ‘unimportant’ by 18 % and the remaining 16.9 % did not know whether it is important. Neurosurgeons who thought screening is important, discussed sexual health significantly more often than those who found it unimportant (p = 0.005).
The majority of respondents (52.3 %) stated they have ‘very little knowledge’; 10.2 % said to have ‘no knowledge at all’ about SD and treatment options. One-third of respondents said to have ‘some knowledge’ and 3.3 % describes his/her knowledge as ‘sufficient’. More knowledge was associated with more experience in neurosurgical care (p = 0.046) and higher age of neurosurgeon, though the latter was just not statistically significant (p = 0.052). More knowledge was not associated with higher frequency of discussing sexual health (p = 0.565). To the question ‘Do you wish to enhance your knowledge about discussing sexual health with your patients?’ respondents were much divided as 50.6 % answered ‘yes’ and 49.4 % ‘no’. Neurosurgeons below 36 years of age answered significantly more often affirmative (71.4 versus 41.7 %; p = 0.034) and so did residents (68.0 versus 42.9 %; p = 0.033).
Barriers to discuss sexual health
Respondents were asked to what extent they agreed with given reasons to not discuss sexual health. Reasons most agreed with were old age of patient (41.6 %), lack of training/knowledge (37.5 %) and lack of patients’ initiative to bring up the subject (36 %). Characteristics of respondents were analyzed and several factors were statistically significantly associated with reasons not to inquire about sexual health (Table 5). Lack of time was the third most important barrier (26.1 %), especially for young and inexperienced doctors.
In the past year, an estimated 1.5 % of patients (SD 5.9) was referred to another health care professional because of SD; 69.8 % of respondents did not refer any patient in the past year. The majority of respondents (74.2 %) stated to have referral options within their own center, specified in Table 6. Twenty-three percent did not know if there was a health care professional in their center to refer a patient with SD to; this was not significantly associated with the demographics of the neurosurgeon. A directory of health care professional to whom SD patients can be referred to seemed helpful to 66.3 % of respondents; these respondents were significantly younger (p = 0.026), more often resident (p = 0.006) and had less experience in neurosurgical care (p = 0.004).