Seven hundred and fifty one patients responded to the survey. Participants were predominantly women (51% of patients) with a mean age of 61 years old and 62% of them lived as a couple. The majority of the participants were retired (70%). Every COPD grade was represented and one third of responders received oxygen. Only a quarter of the responders lived in an urban setting. Clinical characteristics are reported in Table 1.
Forty percent had no sexual activity among which, 19% lived as a couple. From the remaining 60%, 74% had to change their rhythm, 64% their frequency and 64% their position. Two thirds of the participants were dissatisfied with their current and expected sexual function and 13% declared that they used specific medications to improve their sexual performance. Forty three percent used routinely (17%) or occasionally (26%) a short-acting bronchodilator before sexual activity. Expressed reasons of sexual dissatisfaction were breathlessness, fatigue and physical problems. Men were more often dissatisfied with their current and expected sexual function (66% of men vs 53% of women, p = 0.0002), however it did not translate into more medication, especially bronchodilators (which respectively concerned 28% of men and 22% of women). Besides, the level of sexual dissatisfaction (assessed by the following evaluation: “improved, stable, worsened”) was unrelated to age (p = 0.391) or gender (p = 0.92, Table 2).
ASEX score revealed an altered sexual appetite: low for 49% of the subjects and absent for 19%. Sexual desire was compromised in 44% of the subjects and 16% lost all desire. However, the deterioration of sexual appetite or sexual desire, assessed with ASEX questionnaire, is not linked to airflow obstruction (Fig. 1f, g). Subjects with COPD had to make adaptations to compensate for their diminishing activity tolerance, increasing dyspnea, role and sexual self-image, anxiety, and increased need for communication. Self-reported libido loss and reduced sexual performance worsened over time for 67% of the responders.
Quality of life and depression and anxiety
Based on the cut-off of 22 for VQ11 score, quality of life was altered among responders with a mean score of 34.8. The increase in airflow obstruction severity was inversely proportional to the quality of life, as assessed with VQ11 augmentation (Fig. 1a). Impaired quality of life (defined as VQ11 ≥ 22) is significantly more frequent among responders with a higher airflow obstruction (Fig. 1b). Specific underscores, including psychological, functional and relational components of quality of life, indicate that every aspect of life is impaired and an increasing with airflow obstruction further impairs the quality of life (Fig. 1c-e).
Mental disorders such as anxiety and depression were associated with COPD severity in the responders. A mean score of 4.6 on the FSS scale translates into a depressive tendency in patients and FSS mean score increases with airflow obstruction severity, as shown in Fig. 2a. Similarly, HAD scale found high proportions of patients with suspected anxiety or depression with a mean score of 10 and 8 for HAD-A and HAD-D respectively. HAD mean score for depression underscore increased with airflow severity (Fig. 2c) but the same was not reflected in HAD mean score for anxiety (Fig. 2b). However, both HAD scores for anxiety and depression increased when responders had at least two episodes of bronchitis in the previous year (Fig. 2d, e).
Mental disorders are also associated with sexual dissatisfaction. Higher depression as assessed by HAD underscore for depression was strongly indicative of decreased sexual appetite and to a lesser extent anxiety as assessed with HAD underscore for anxiety (Fig. 2f, g). Inversely, a higher impairment of sexual desire caused an increase in depression and anxiety (Fig. 2h, i).
Sexuality remains taboo
Discussion of sexual issues remains a cultural taboo. Ninety percent of the responders declared that sexual dysfunction had never been discussed by doctors (general practitioners or pulmonologists) and only 6% had a specialized consultation whereas 36% of them declared that they would have liked a specialized consultation with a sexologist. Twenty one percent would be willing for an online consultation.
We carried out typological analyses to split the population studied into distinct homogeneous groups depending on their responses to the different questionnaires. This allowed us to combine the individuals into distinct homogeneous groups. We were able to isolate five behavioral profiles: Group A Preoccupied (22%), Group B Discouraged (19%), Group C Resigned (23%), Group D Naive (12%) and Group E Familiarized (24%). The map in Fig. 3 provides a pictorial representation of these 5 profiles.
The patients in group A were predominantly female, active, less than 60 years old, with recently diagnosed and non-severe COPD. These patients had a moderate physical impact of COPD, suffering from symptoms of depression and anxiety.
The patients in group B were also predominantly female, but polymorbid, suffering from severe COPD requiring respiratory assistance. They can no longer, or with difficulty, maintain a sexual life, and have important psychological symptoms leading to social isolation. The physical impact of COPD, but above all psychological and relational impact within this subgroup was clearly evident (extreme right-hand side of the graph).
The patients in group C were older than 70, with a long history of severe COPD, requiring daily ventilation. The degradation of their emotional and sexual life could be attributed to inactivity, breathlessness and substantial fatigue. They suffered mainly from physical symptoms, which explain their position at the top of the graph. However, they displayed only minor psychological symptoms.
The patients in group D were young and active, with recently diagnosed, non-severe COPD not requiring any respiratory assistance. Their sexual life was unaffected and for the disease did not require any life modification. Their social and emotional lives were normal. This group is situated at the lower left quadrant of the graph, displaying low limitations on the two axes.
Finally, the patients in group E were elderly, suffered from a longstanding moderate COPD. They remained active despite breathlessness. They were not worried or anxious, and tried to adapt according to their respiratory capacity. These were patients with physical symptoms largely, albeit of a moderate nature.