The main finding of this study reveals how painful hip and knee OA affects sexual health. The participants described adjustments and strategies to maintain their sexual life despite pain related to OA. The issue of sexual health had not been addressed in their contact with physiotherapists or other health care professionals, indicating that patients with OA may have unmet needs regarding their sexual health. Prior survey studies have reported that most of those who undergo hip and knee replacement surgery are sexually active, but the prevalence of impaired sexual health is high [16–19]. To the best of our knowledge, no previous studies have explored OA patients’ experiences of sexual health. One advantage of qualitative research is the possibility to describe and understand the complexity of a patient’s situation [23]. Because the research on sexual health in patient populations is scarce, we will below discuss the findings of this study compared with previous research on sexual health in other patient populations, such as RA and fibromyalgia patients. Persons with RA and fibromyalgia have affected sexual health due to pain and reduced joint mobility, but other symptoms such as fatigue, cognitive dysfunction, sleep disorders, and depression may also have an impact on their sexual health [5, 7, 11] thus making comparisons with OA patients difficult.
To feel bothersome pain before, during and after intercourse can affect sexual life, as described by the participants in this study as well in another study with RA patients [7]. The pain experience could lead to negative feelings such as fear of pain, which in turn could lead to avoidance of sexual activities, although some patients stated that pain did not impede their sexual life. Fear of increased pain and difficulties to find good positions during intercourse are, however, also described by persons with fibromyalgia, RA and chronic pain [7, 10, 25]. In this study, the participants described a lot of “trial and error” intercourse and that their daily functioning determined whether sexual activity was possible at all. They expressed sadness over this loss of spontaneity.
There were some participants in this study who said that their sexual health was not affected at all. The extent to which sexual health is affected by OA may be related to the impact of the disease and ordinary circumstances in life, but it may also reflect the dynamics of individual relationships [15]. It may also be in line with the findings from a previous qualitative study in persons with RA who described that their sexual life was impaired when RA first appeared, but over the years they had found ways of adapting to their new situation [26]. The participants in our study described adjustments and strategies to cope with their impairments and maintain sexual health, with or without intercourse. This was often achieved through open communication with their partner. A variety of strategies were described, such as changing or choosing certain positions during intercourse and interrupting sexual intercourse and replacing it with caresses or other ways to express intimacy. These strategies have previously been acknowledged as self-management strategies [26, 27]. The adjustments were made and strategies adopted with varying degrees of acceptance and evoked emotions of calmness but also resignation and sadness, which in itself may impair sexual health. Sexual health is an important part of quality of life, including those with chronic diseases and poor health, which points to the fact that these issues need to be addressed [4, 28].
Since sexual dysfunction appears to be highly prevalent among both men and women with inflammatory arthritis [15] and OA [16–19], increased clinician awareness of this impairment is needed to guide provision of tailored information and support. In the present study, as well as in earlier research [8, 26, 27, 29], patients have stated that health care professionals do not include sexual health in their assessment or interventions without prompting. Patients may be unaware of the impact of the disease on their sexual function or assume that no help is available [30]. None of the participants in the present study had been asked about their sexual health by their physiotherapist or another health care professional; neither had any of them initiated conversations about their sexuality with their health professional.
This finding adds to previous research suggesting that sexuality is still a sensitive and taboo subject in the health care system [29, 30]. Even though individual needs vary, the opportunity to discuss sexual health should be given by health care professionals. As suggested by Traumer, only by routinely addressing sexual health with patients diagnosed with chronic diseases can this taboo be broken and thereby signal to patients that it is acceptable and safe to discuss sexual health with health care [29].
The majority of the participants in this study stated that they would value sexual health being addressed within the health care system, such as information provided in a brochure or as part of the information in the OA school, which is offered by physiotherapists for all OA patients in Sweden. The participants emphasized the importance of having confidence and trust in the health care professional before discussing sexual health, and some suggested physiotherapists as an excellent conversation partner. At times, even if physiotherapists could play an important role as a promoter for sexual health, they may in general not have the required knowledge to address sexual health [31, 32]. Further studies are needed to investigate whether and how sexual health should be routinely addressed by physiotherapists within OA assessment and interventions, and reported in the BOA National Quality Register.
Methodological considerations
This study employed qualitative content analysis to explore experiences of sexual health in persons with hip and/or knee OA. Qualitative findings from information-rich samples can be applied to other samples with similar characteristics under similar conditions [23]. This study focused on experiences of persons with hip and/or knee OA in an attempt to learn more about how OA affects sexual health. The strategic sample from the BOA Register provided a nationwide variation regarding sex, age, and hip and knee OA, which enables the reader to judge whether the findings are transferable to other populations with knee or hip OA.
Additional studies investigating whether and how sexual health can be addressed in health care are needed. The interviews were held over the phone, allowing recruitment of participants from across Sweden. In addition to decreased costs and increased reach of geographically disparate participants, telephone interviews may allow participants to feel relaxed and speak freely and disclose intimate or sensitive information, but without evidence of producing lower data quality [33]. M.E.H. was a highly experienced physiotherapist with excellent knowledge about OA. Continuing discussions were held between her and E.N.S. during data collection to enhance interview techniques. In addition, the interview guide and the data analysis were discussed between the authors, one of whom is a qualified qualitative researcher. Trustworthiness was determined by following rigorous methodology for inclusion, data collection and analysis. The checklist for reporting qualitative studies was used to improve transferability [24].