Experiences of Sexual Health in Persons with Hip and Knee Osteoarthritis from A Physiotherapeutic Perspective: A Qualitative Study

Background: Osteoarthritis (OA) is the world’s most common form of arthritis and a common cause of musculoskeletal pain and disability. Persons living with chronic diseases often have affected sexual health because of pain and limited function. Osteoarthritis is a chronic disease but there is scarce knowledge about how sexual health is experienced. The aim of this study was to explore the experience of sexual health in persons with hip and/or knee OA. Methods: This study has a qualitative design. Participants were recruited from the Swedish Quality Register Better Management of Patients with Osteoarthritis (BOA). To reach a variety of experiences and strengthen credibility, a strategic sampling strategy based on age, sex and hip and knee OA was used. Semi-structured telephone interviews were held with 20 persons with hip and/or knee OA. Data were analysed with qualitative content analysis and inductive category development was applied. Results: The analysis resulted in two main categories: Individual differences in how sexual health is affected by hip and knee OA; and Varying needs for communication about sexual health. Each main category comprised two subcategories. Conclusions: Painful hip and knee OA limits sexual health and individuals make adjustments or develop strategies to maintain sexual life. Sexual health is not talked about during consultations with physiotherapists or other health care professionals, indicating that patients with OA may have unmet needs regarding their sexual health. Further research is needed on how to provide support and information about sexual health in OA.

to activity limitations, such as difficulties in walking, carrying objects and dressing, as well as reduced quality of life [1][2][3]. An important domain of quality of life is sexual health, defined by the World Health Organization (WHO) as -… a state of physical, emotional, mental and social well-being in relation to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled [4].
Previous research has reported high prevalence of impaired sexual health among persons living with chronic diseases such as rheumatoid arthritis (RA) [5][6][7][8][9], fibromyalgia [10,11] and multiple sclerosis [12]. Sexual dysfunction is also reported to be higher among persons with RA compared with healthy control groups, and the main influencing factor is pain [13,14]. Restoux et al. (2020) concluded, in a recent systematic review based on 50 quantitative and six qualitative studies, that sexual dysfunction is highly prevalent among both men and women with inflammatory arthritis, and called for increased clinician awareness of this impairment, so as to guide provision of tailored education and support [15].
As OA is a chronic joint disease, it can be expected that sexual health might be affected, but there is scarce scientific knowledge. Previous research has primarily assessed sexual health before and after total hip arthroplasty [16][17][18] or knee arthroplasty [19]. Approximately 45% of those with knee OA [19] and 64-82% of those with hip OA who will undergo arthroplasty report impaired sexual health [16,17]. However, the expectations of sexual activity after surgery are not always fulfilled [16].
Experiences of living with hip and knee OA, and how it affects the person's life at many levels, have previously been explored [20][21][22], but, to the authors' knowledge, without addressing sexual health.
The aim of this study was to explore experiences of sexual health in persons with hip and/or knee OA.

Methods
This study has a qualitative explorative design based on data collected through individual semi-structured telephone interviews with persons with hip and/or knee OA. An explorative study design can provide insight into a research area that has not previously been investigated and interviews may give a rich understanding of participants' experiences of the world, expressed in their own words [23].
Setting and sampling strategy Participants were recruited from the Swedish National Quality Register for patients with OA, Better Management of Patients with Osteoarthritis (BOA). In 2017 there were approximately 90 000 persons registered with BOA nationwide. Inclusion criteria were: hip and/or knee OA; and living with someone.
Exclusion criteria were: joint arthroplasty in hip and/or knee; difficulties walking for reasons other than hip and/or knee pain; and being registered at the clinic where the physiotherapist responsible for conducting the interviews (M.E.H.) was working. To obtain a variety of experiences, the sample strived to be heterogeneous regarding sex, age and OA in hip and knee. A strategic sample of 126 persons were randomly selected from the BOA Register in January 2017 (Fig. 1). Brief information about the study and the request for permission for contact details to be forwarded to the researcher was sent by post from the BOA Register administration. Forty-three persons, who returned written consent to be further contacted, were sent extended written information about the study and conditions for participation. Twenty persons answered and 17 gave their written consent to be contacted, which was done in January-May 2017. Six of these 17 persons were included: eight were excluded because of surgery to the hip or knee; two did not wish to participate; and one could not be reached.
To enhance sample size and data quality, a second recruitment was performed in May 2017 following the same procedure as for the first recruitment. A strategic sample of 70 persons were randomly selected from the BOA Register. Twenty-seven persons who returned a written informed consent to be contacted, were sent extended information about the study and conditions for participation. Twentyone persons answered and 20 gave their written consent to be contacted, which was done in September 2017-May 2018. Five persons were excluded because of surgery to either the hip or the knee, and one person could not be reached. Fourteen persons remained for interview in this second recruitment. In total therefore, 20 persons were finally included in the study, 13 women and seven men. The participants were between 52 and 77 years old, eleven had knee OA, six had hip OA and three had both knee and hip OA.

Data analysis
The data analysis was performed after all the interviews had been held. Participants were recruited until the sample size was judged to yield maximum variation. In this study, informational redundancy was deemed to have been reached since the last interviews did not provide any relevant new information. Qualitative content analysis and an inductive category development was used [23]. Only the visible and obvious in the text, i.e. the manifest meaning of the text, was analysed according to the aim of the study, which was to describe the participants' experiences from their own perspective.
Initially, every transcript was read thoroughly to get a sense of each participant's story and, next, a sense of the whole by reading all transcripts. During additional reading and by the use of Nvivo, statements in the text (meaning units) responding to the study aim were identified. These meaning units were coded as close as possible to the text and provided with a label describing each individual statement. These codes were compared and contrasted and then merged into subcategories and, finally, categories based on similarities and differences. The content within each category had to be internally homogenous while separate categories should be externally heterogeneous. Tentative categories were modified and redefined, and new categories were developed when needed. This analytical process involved working back and forth between the categories and text to verify the meaningfulness and accuracy of the categories [23].
The analysis was performed by M.E.H. and continuous discussions on consistency of codes, final subcategories and categories were held with E.N.S. throughout the analysis process until agreement was reached. Quotes capturing the essence of the interviews were selected to illustrate the different subcategories. The selected quotes from the transcript were translated into English and then retranslated into Swedish, to ensure that the meaning was retained.

Ethical considerations
Permission to conduct the study was approved by the regional ethical board in Uppsala, Sweden (No. 2016/242). The participants provided written informed consent after receiving both written and oral information about the study, including assurance of the voluntary nature of participation and the possibility to withdraw at any time without explanation and, further, assurance that all collected data would be handled confidentially and no individual would be identifiable in the quotes or results. Only the authors had access to the original audio files, transcripts and informed consents. The data and the coding key were stored separately and locked away safely. The participants were informed of the interviewer's professional background, and that the interview data would be analysed, and published in a research journal. The study followed the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist [24].

Results
Two categories emerged that described the participants' experiences of sexual health: Individual differences in how sexual health is affected by hip and knee OA, and Varying needs for communication about sexual health. The findings are presented in four subcategories developed in the analysis (Table 1). Quotes from the participants are presented in the text to illustrate each of the subcategories.

Pain limits sexual health
The participants' experiences ranged from having impaired sexual health and feeling limited in their sexual life because of OA, which could evoke negative emotions, to having unaffected sexual life despite pain and stiffness. The vast majority of the participants described that OA in hip and/or knee led to pain during sexual activity and hindered them from being fully sexually active, despite a desire to continue as previously. Some described that their sexual life was not affected at all as they only had knee OA, but when OA also occurred in the hip it became more difficult. Impaired hip mobility made it too painful and affected sexual life more than did the reduced mobility in the knee joints. In the quotation below, a participant describes situations during intercourse when the affected joint ends up at a painful angle because of the reduced joint mobility.

Discussion
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][17][18][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][17][18][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].

Funding
The study was financially supported by Region Örebro County, Sweden. No external funding or benefits were received. The funder had no influence on the design or conduct of the study; data collection, analysis, and interpretation of the data; preparation, review, writing and approval of the manuscript; or decision to submit the manuscript for publication.

Availability of data and materials
The data generated and analysed during the current study are governed by the legal provisions of Region Örebro County, Sweden. The datasets generated and analysed during the current study are not publicly available owing to the sensitive and personal nature of the data, according to Swedish Data Protection Law, but will be available from the corresponding author on reasonable request.

Ethics approval and consent to participate
The study was approved by the Regional Ethical Review Board of Uppsala, Sweden (No.: 2016/242).
Participants provided written informed consent, and were informed that participation was on voluntary basis and that they could withdraw from the study at any time. Confidentiality was guaranteed.

Consent for publication
Not applicable.  Figure 1 Flow chart of the sampling process