The concept of sexuality includes sex, gender identity, sexual orientation, intimacy, eroticism and pleasure as well as reproduction.¹ Sexual health is an integral part of overall health and well-being and is fundamental to the sustainable development of societies worldwide. The World Health Organization (WHO) defines sexual health as ‘a state of physical, emotional, mental, and social well-being in relation to sexuality’.¹ Sexual dysfunction, defined as ‘a significant disturbance in one’s ability to sexually perform or experience sexual pleasure’, is a common problem worldwide.² In order to identify and address sexual health concerns, it is necessary to understand sexual function and common disorders.

The sexual response starts with sexual desire that is followed by arousal. Sexual arousal may lead a person to participate in sexually stimulating activities such as intercourse and masturbation. There are four phases of the sexual response cycle: desire (libido), arousal (excitement), orgasm and resolution.

Sexual dysfunctions are characterised by a significant disturbance in a person’s ability to respond sexually or to experience sexual pleasure. An individual may have multiple sexual dysfunctions concurrently, and all dysfunctions need to be addressed. The main classifications of sexual dysfunctions include female (sexual interest and arousal disorder, orgasmic disorder and genito-pelvic pain and penetration disorder) and male (desire disorder, erectile disorder, premature ejaculation and delayed ejaculation) sexual dysfunctions.^2,3

Disturbances in desire, arousal, orgasm and pain that are present for 6 months or more and which cause distress require clinical care. Sexual disorders may be present lifelong or be acquired. They can also range in intensity from mild to severe and be situation-specific or generalised.

The Global Study of Sexual Attitudes and Behaviours, an international survey among adults aged 40–80 years across 29 countries, reported that sexual difficulties are relatively common between 40% and 45% of women and 20% and 30% of men throughout the world.⁴ Premature ejaculation and a difficulty in achieving and maintaining an erection were the problems reported most commonly by men, affecting 24% and 17%, respectively. The most commonly reported sexual dysfunction reported among women was a lack of sexual interest and an inability to reach orgasm, affecting 32% and 25%, respectively.⁴ Studies conducted in the South African context highlight the prevalence of sexual dysfunction among local communities. A study conducted in KwaZulu-Natal reported that the prevalence of erectile dysfunction (ED) prevalence was as high as 65% among adult males attending a primary care facility.⁵ Another study that was conducted among patients with chronic illnesses in South Africa reported that 98% of male clients had ED symptoms while up to 91% of female clinic attendees reported sexual dysfunction symptoms.⁶

People living with chronic non-communicable diseases (NCDs) such as diabetes mellitus and cardiovascular diseases are at significantly increased risk for sexual dysfunction.⁷ The estimated prevalence of ED in patients with diabetes in Africa was noted to be as high as 71.45%.⁸ Interestingly, ED has been identified as an independent marker for cardiovascular disease.⁹ In response to emerging evidence on the risk factors for sexual dysfunction, local guidelines have been adapted to include routine screening of people living with diabetes for sexual dysfunction.¹⁰ Other associated risk factors for sexual dysfunction include increased age, depression, mental health conditions, chronic pain, obesity, substance abuse, HIV and certain medications.^11,12

Cancer is also commonly associated with adverse effects on sexual health, with up to 60% of women and up to 80% of men affected, regardless of cancer type.¹³ As life expectancy increases, the prevalence of comorbidities associated with sexual dysfunction will increase. Sexual dysfunction is known to adversely affect quality of life. In order to attain the Sustainable Development Goal target (Target 3.7) to ‘ensure universal access to sexual and reproductive healthcare services’, it is necessary that evidence-based guidelines on managing sexual health and dysfunction are implemented.¹⁴ It is therefore recommended that primary health providers address sexual health and functioning in all patients, especially those living with chronic diseases. However, there are significant challenges to providing sexual healthcare in primary healthcare systems despite the prevalence of sexual dysfunction.

The scope of sexual healthcare services ranges from education, prevention and screening, to management of sexual dysfunction. The delivery of sexual healthcare services at the primary care level should be person centred, respectful to all patients regardless of age, religion and ethnic origin, and sensitive to transgender and gender-diverse individuals. Primary care providers are ideally positioned to address the sexual health concerns of patients and enhance overall well-being.¹⁴ However, despite the availability of local guidelines on sexual history taking up to 75% of health professionals reportedly do not address their patients’ sexual health concerns.^15,16 Factors for health professionals failing to identify and manage patients with sexual dysfunction could be time constraints, low awareness of sexual dysfunction, lack of training about diagnostic tools and treatment options, cultural barriers and fear of broaching the topic.^17,18 In contrast, up to 91% of patients indicated that they would be comfortable if their health professional raised the issue.¹⁸ In addition, many people with sexual health concerns do not even attempt to seek medical help.¹⁹ Consequently, patients with sexual health concerns do not receive adequate care. It is thus imperative that health professionals not only include sexual health in routine history taking but help increase awareness of sexual health in communities. This is only possible if health providers are able and willing to address sexual health concerns in their consultations.

Unfortunately, there has been minimal inclusion of sexual health in most undergraduate medical and nursing curricula.²⁰ Hence, most health professionals are inadequately prepared to address sexual health concerns in patients. Additionally, there have been few opportunities for postgraduate training in sexual health.

Management of patients with sexual dysfunction should be individualised to address the patient’s specific physical, psychological, interpersonal and socio-cultural concerns. Attention should be addressed to each area of sexual dysfunction, that is, desire, arousal, orgasm and pain. The available modalities for management range from education and psychotherapy, to lifestyle interventions, pelvic floor exercises, medications and mechanical devices.

Detailed management of sexual dysfunction in people living with diabetes will be available in the updated Society for Endocrinology, Metabolism and Diabetes of South Africa (SEMDSA) guidelines for the management of diabetes.¹⁰

Primary care practitioners play a crucial role in addressing the sexual health concerns of patients. By initiating conversations around sexual health, creating a safe and non-judgemental environment for history-taking, utilising evidence-based screening and management tools such as the ICSM-5 algorithm, PCPs can provide quality patient-centred sexual healthcare. Screening for sexual dysfunction in patients with chronic illnesses can promote a predictive personalised preventative participatory approach and lead to risk factor reduction. However, further research is needed in South Africa to explore the impact of sexual health recommendations on local communities. The WHO and professional associations must advocate for countries to include sexual health services as part of primary care. Multicomponent implementation programmes are needed to improve health professionals’ knowledge, competence and comfort when addressing sexual health.