
==== Front
Phys Ther
Phys Ther
ptj
Physical Therapy
0031-9023
1538-6724
Oxford University Press

39014294
10.1093/ptj/pzae083
pzae083
Perspective
AcademicSubjects/MED00110
ptj/18
Holistic Care for People Living With Chronic Musculoskeletal Pain: The Relevance and Importance of Sexual Function
Ackerman Ilana N PT, PhD School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia

Restoux Laura PT, MClinPhys Physiotherapy Department, Central Coast Local Health District, Central Coast, New South Wales, Australia

Dobo Brooke PT, MPhSt Vera Women’s Wellness, Mount Samson, Queensland, Australia
The Wesley Hospital, Brisbane, Queensland, Australia

Slater Helen PT, PhD, FACP Curtin School of Allied Health and Curtin enAble Institute, Faculty of Health Sciences, Curtin University, Perth, Western Australia, Australia

Ross Megan H PT, PhD School of Health and Rehabilitation Sciences, The University of Queensland, Brisbane, Queensland, Australia

Briggs Andrew M PT, PhD, FACP Curtin School of Allied Health and Curtin enAble Institute, Faculty of Health Sciences, Curtin University, Perth, Western Australia, Australia

Address all correspondence to Prof Ackerman at: ilana.ackerman@monash.edu. Twitter: @IlanaAckerman
8 2024
16 7 2024
16 7 2024
104 8 pzae08330 10 2023
15 2 2024
18 4 2024
02 9 2024
© The Author(s) 2024. Published by Oxford University Press on behalf of the American Physical Therapy Association.
2024
https://creativecommons.org/licenses/by/4.0/ This is an Open Access article distributed under the terms of the Creative Commons Attribution License (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

 

People living with chronic primary or secondary musculoskeletal pain conditions such as low back pain, fibromyalgia, and inflammatory arthritis typically experience wide-ranging impacts on their physical function, activity participation, and psychosocial wellbeing. These can extend to negative impacts on a person’s sexual function and their intimate relationships. While sexual function is an important component of wellbeing, it is often not considered within musculoskeletal pain care. Without awareness or targeted training, physical therapists may lack the confidence and skills to screen, assess, and manage the impacts that pain may be having on a person’s sexual function and can miss the opportunity to tailor their care and optimize wellbeing. This article seeks to raise awareness among physical therapists of how living with chronic musculoskeletal pain can impact a person’s sexual function and intimate relationships, and provide guidance on how to consider these issues within a person-centered approach to care. It describes why considering sexual function and intimate relationship issues as part of a person’s lived musculoskeletal pain experience may be relevant, outlines the use of validated patient-reported outcome measures to assess sexual dysfunction, and suggests practical strategies for sensitively raising sexual function in consultations. Management approaches and possible referral pathways are also presented, to assist physical therapists in understanding available care options. This article seeks to support holistic care by improving physical therapists’ knowledge and understanding of sexual dysfunction and its management in people living with chronic musculoskeletal pain.

Impact

Considering sexual function as a valued functional activity, together with other activities of daily living, will assist physical therapists to provide more holistic and person-centered care. This article covers the main considerations for raising sexual function and intimate relationship issues with people living with chronic musculoskeletal pain, as well as management options and potential referral pathways. Physical therapists are encouraged to seek targeted training to improve their confidence and skills in this area, and to use inclusive, respectful language for discussions around sexual function and intimate relationships.

Clinical Assessment
Intimate Relationships
Musculoskeletal Pain
Physical Therapy
Referral Pathways
Sexual Function
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pmcIntroduction

In this article, we aim to inform readers about the prevalence and impact of sexual dysfunction (difficulty or impairment in undertaking sexual activity or in experiencing sexual pleasure and satisfaction) experienced by people living with chronic musculoskeletal pain. Incorporating this important, yet potentially overlooked, aspect of a person’s wellbeing into clinical care (when indicated and when in scope of practice) is fundamental to holistic care. We offer practical suggestions for sensitively raising sexual wellbeing in clinical consultations. An overview of assessment and management strategies and potential referral pathways is also provided. We use inclusive definitions of sex, gender identity, sex characteristics, and sexual orientation and intend for this information to be inclusive and broadly applicable across diverse groups.

Why should we consider sexual function among people who seek care for chronic musculoskeletal pain? The importance of identifying and responding to the unique profile of biological, psychological, and social factors that contribute to a person’s experience of chronic musculoskeletal pain is well accepted,1 yet sexual function (defined by the American Sexual Health Association as the ability to experience sexual pleasure and satisfaction when desired2) may not be explicitly considered. Sexual activity (activity that results in sexual satisfaction and/or meets relational or reproductive needs3) is indisputably an important activity for many people, contributing to general wellbeing and healthy relationships.4–7 However, sexual function is not usually included in pre-licensure training or routinely considered within musculoskeletal clinical assessment; it is commonly considered the remit of physical therapists who specialize in pelvic health (or related titling, which varies by jurisdiction). The World Health Organization (WHO) identifies sexual health as “fundamental to the overall health and wellbeing of individuals, couples and families”.8 We now know, from numerous studies conducted internationally, that sexual dysfunction is relatively common among people who experience chronic musculoskeletal pain. With respect to the WHO International Classification of Functioning, Disability and Health (ICF), sexual dysfunction can be considered across multiple ICF domains including body functions (specifically, genitourinary and reproductive functions, and neuromusculoskeletal and movement-related functions), activity and participation (specifically, interpersonal interactions and relationships), and body structures (specifically, structures related to the genitourinary and reproductive systems).9 The burden of sexual dysfunction has been highlighted by recent systematic reviews10–13 that have focused on people with inflammatory arthritis (including rheumatoid arthritis, ankylosing spondylitis, systemic sclerosis, and systemic lupus erythematous) and people with chronic non-inflammatory musculoskeletal pain (including fibromyalgia/chronic widespread pain, low back pain, and osteoarthritis). While comparison with general population rates is difficult due to inconsistent definitions and assessment tools, these reviews highlight the high prevalence of sexual dysfunction among women and men, as indicated by low Female Sexual Function Index (FSFI) scores and low International Index for Erectile Function (IIEF) scores, respectively. Additionally, 2 systematic reviews focusing on hip replacement surgery (most commonly performed for osteoarthritis) have shown that sexual dysfunction is relatively common prior to surgery.14,15 On an average, 77% of patients (range 38%–90%) reported “sexual difficulties” prior to surgery and these difficulties started, on average, 2.5 years before hip replacement.15

The Impacts of Chronic Musculoskeletal Pain on Sexual Function

Given consistent associations between chronic musculoskeletal pain and sexual dysfunction or disrupted intimate relationships, there is a need to raise clinicians’ awareness of the impacts of chronic musculoskeletal pain which extend beyond pain, joint swelling, stiffness, and fatigue. In describing these impacts, we recognize the limitations of the current literature, which focuses largely on binary constructs of sex and gender and heterosexual relationships (usually among people who are married), and acknowledge the significant evidence gaps for sexual- and gender-diverse populations who identify as lesbian, gay, bisexual, transgender, queer, intersex, asexual and other related identities (LGBTQIA+). We have also identified in our own systematic reviews10,12 that most research in this area has been conducted on women, suggesting likely knowledge gaps around men’s experiences, which are likely to be different.12 Notwithstanding these limitations, there is now substantial evidence that living with painful musculoskeletal conditions can affect diverse constructs related to sexual function, including the initiation (or avoidance) of foreplay and intercourse, sexual satisfaction, sexual desire, sexual distress, self-identity and relationship quality.10,12 Importantly, these impacts have been observed irrespective of pain classification or diagnosis. A meta-analysis of 6 studies involving women with fibromyalgia and sexual dysfunction reported impairments in desire, arousal, orgasm, pain, lubrication, and satisfaction.16 A meta-synthesis of 6 studies involving people with inflammatory arthritis conditions found that sexual function was impacted by pain, lower sexual desire, erectile dysfunction, fatigue, fluctuations in disease activity, altered self-image, and confidence in sexuality, with negative impacts on intimate relationships with partners.10 Similarly, a meta-synthesis involving people with non-inflammatory chronic musculoskeletal pain found that the experience of pain not only impacted sexual activity, but also intimate relationships, sexual identity, body image, and perceptions of self-worth.12 A recent study involving men with inflammatory arthritis confirmed the breadth of sexual function and relationship impacts (based on 34 opinion statements) and emphasized that these impacts vary depending on life stage.17

Sexual dysfunction has a multifactorial etiology. While chronic musculoskeletal pain may be an important contributor to a person’s experience of sexual dysfunction, other factors can be involved. These can include trauma, comorbidities or multimorbidity, and interactions between conditions and/or their treatments. Examples include anxiety and depression, endocrine conditions, cancer, neurological conditions, cardiac conditions, chronic pelvic pain, pelvic organ prolapse, urological conditions, colorectal conditions, and gastroenterological conditions,18 many of which co-exist with chronic musculoskeletal pain.19,20 Hormonal and physical changes associated with perimenopause and menopause may also play a role, as can alcohol consumption, smoking, illicit drug use and sedentary lifestyles.21 Prescribed medications (including serotonin reuptake inhibitors used to treat depression) can also negatively impact sexual function and desire by decreasing pleasurable sensations and delaying or inhibiting orgasm.22

Current Clinical Guidelines for Chronic Musculoskeletal Pain

Contemporary clinical practice guidelines consistently recommend a person-centered, biopsychosocial approach to care, underpinned by shared decision making.23 These care recommendations are consistent across clinical guidelines for common chronic musculoskeletal conditions,24–38 across reviews of primary guidelines for musculoskeletal pain,23 low back pain,23,39 and osteoarthritis,40 and in priorities expressed by people living with chronic pain.41 While guidelines recommend the holistic assessment of chronic musculoskeletal pain in line with a person’s preferences and priorities,41 specific guidance around assessing sexual function and intimate relationships is rarely provided outside of chronic pelvic pain guidelines.42 We reviewed widely-used (English language) musculoskeletal clinical practice guidelines and published guideline reviews23–28,30–40,43,44 (excluding guidelines for chronic pelvic pain) and identified only 2 guidelines that explicitly recommended that “sexual relationships be considered”27 and “sexual advice”44 be provided. These both focused on rheumatoid arthritis (RA), which may reflect the known impacts of RA on sexual relationships, due to disease manifestations and the potentially harmful effects of disease-modifying medications in pregnancy. The NICE guideline for the assessment and management of chronic pain28 recommends that “social interactions and relationships” be considered, although sexual function is not explicitly mentioned.

Addressing Sexual Function Within Clinical Consultations

Although studies indicate that many clinicians believe sexual dysfunction should be addressed in health care, it is not routinely included in undergraduate training programs or addressed in clinical practice.17,45–54 A systematic review revealed common barriers to clinicians discussing sexuality with their patients, including clinician discomfort, concerns about causing offense and a perceived lack of training and resources,48 which we have highlighted previously.55 Some evidence suggests that discussions around sexual function are dependent on a clinician’s age, years of experience, area of practice, comfort with their own sexuality, and level of rapport with their patients.45 Similarly, many people do not feel comfortable raising this topic with their treating clinician55–57 (even where there is a belief that sexual dysfunction is related to chronic musculoskeletal pain or its pharmacological management57) and would prefer clinicians raise sexual dysfunction issues with them.51

Identifying Sexual Dysfunction: The Role of Patient-Reported Measures

Patient-reported outcome measures (PROMs) may be an appropriate starting point for identifying sexual dysfunction as part of holistic care. A range of validated PROMs are available for use; the content, scoring and interpretation of some commonly used instruments are outlined in the Table. In addition to a clinical history, these instruments can provide a snapshot of a person’s current sexual functioning and related impairments, either as a separate construct, or within the broader context of physical functioning and quality of life. Targeted instruments may be preferable in some clinical situations (eg, to assess conditions with pelvic organ or nerve involvement), although this is beyond the scope of this paper. We recognize the lack of validated sexual function evaluation tools for transgender and gender-diverse communities, and that available tools may not include activities relevant to all sexual orientations; this is a barrier to proper assessment and understanding of sexual function.

Table Examples of Relevant Patient-Reported Outcome Measures for Screening and Assessing Sexual Functiona

Instrument	Items	Constructs	Score Range	Available Example	Published Clinical Thresholds	
Female Sexual Function Index74	19	Sexual desire, sexual arousal, lubrication, orgasm, satisfaction, and pain	2 (worst) - 36 (best)	https://scireproject.com/outcome/female-sexual-function-index-fsfi/	Sexual dysfunction is indicated by a score ≤ 26.574	
6-item Female Sexual Function Index59	6	Sexual desire, sexual arousal, lubrication, orgasm, satisfaction, and pain	2 (worst) - 30 (best)	https://www.surrey.ac.uk/sites/default/files/2022-09/FSFI-6-information.pdf	Score of <19 indicates a very high probability of sexual dysfunction and need for further investigations59	
International Index for Erectile Function60	15	Erectile function, orgasmic function, sexual desire, intercourse satisfaction, overall sexual satisfaction	Erectile function: 5 (worst) - 30 (best)
Orgasmic function: 0 (worst) - 10 (best)
Sexual desire: 2 (worst) - 10 (best)
Intercourse satisfaction: 0 (worst) - 15 (best)
Overall sexual satisfaction: 2 (worst) - 10 (best)	https://www.browardurologycenter.com/pdf/International-Index-of-Erectile-Function-IIEF-Questionnaire.pdf	Erectile dysfunction is indicated by a score ≤ 25 on the erectile function subscale60	
Changes in Sexual Functioning Questionnaire75	14 (CSFQ-14 version, available in female and male versions)	Sexual desire (frequency and interest), arousal/excitement, orgasm/completion	0 (worst) - 70 (best)	https://www.dbsalliance.org/wp-content/uploads/2019/02/Restoring_Intimacy_CSFQ_Handout.pdf	Sexual dysfunction is indicated by a score < 41 for males and a score < 47 for females75	
WHOQOL-Bref76	26 (including 1 item on sex life)	Multi-dimensional (quality of life, health, pain, satisfaction)	Four domain scores each ranging from 4 (worst) - 20 (best)	https://www.who.int/tools/whoqol/whoqol-bref	Not available	
Oswestry Disability Index
(Oswestry Low Back Pain Disability Questionnaire - original version)62	10 (including 1 item on sex life)	Pain intensity, personal care, lifting, walking, sitting, standing, sleeping, sex life, social life, and traveling	0% (best) - 100% (worst)	https://www.melbournepaingroup.com.au/sites/default/files/oswestry_disability_scale.pdf	Not available	
a CSFQ-14 = Changes in Sexual Functioning Questionnaire-14.

Completion of PROMs instruments that signal potential sexual dysfunction provides clinicians with an opportunity to initiate sensitive conversations. These PROMs could also be used to track improvements or deterioration and to assess the outcome of management strategies. The 2 most widely-published instruments are sex-specific, the FSFI and the IIEF. The FSFI contains 19 items spanning 6 domains that include sexual desire, sexual arousal, lubrication, orgasm, satisfaction, and pain. It is available in more than 20 languages, and a total FSFI score of 26.55 or below is considered to indicate sexual dysfunction.58 A shortened 6-item version (the FSFI-6) is also available and covers the same 6 domains as the full-length FSFI; an FSFI-6 score of less than 19 indicates a very high probability of sexual dysfunction.59 We note that both versions of the FSFI will produce artificially lower scores if people report “no sexual activity” or that they “did not attempt intercourse” for the relevant items (which could be for reasons other than pain). Therefore, interpretation of FSFI scores should be made with this in mind, and where appropriate, clarified with sensitive communication with the person. The IIEF contains 15 items across 5 subscales. A score of 25 points or less on the erectile dysfunction subscale is considered to indicate erectile dysfunction60 (erectile dysfunction is considered a form of male sexual dysfunction61). The IIEF has been translated into 32 languages. These instruments are not disease-specific and can be administered regardless of the presenting health condition. Sex-specific versions of the Changes in Sexual Functioning Questionnaire are also available. The non–disease-specific WHOQOL-Bref questionnaire (the short-form WHO quality of life questionnaire) contains 1 item relating to sex life. To our knowledge, the only musculoskeletal disease-specific instrument to consider sexual function is the Oswestry Disability Index (also known as the Oswestry Low Back Pain Disability Questionnaire). The original version of this instrument includes 1 optional item on sex life.62 In situations where understanding low back pain-related disability in relation to sexual activity is important, the original version of this instrument is preferable to modified versions that do not include this item. In the Supplemental Material, we provide 2 hypothetical case studies that demonstrate how clinical conversations around low back pain and sexual function might be initiated in different scenarios.

Sensitively Raising Sexual Function and Impacts on Intimate Relationships

Given a lack of pre-licensure training in this area, clinicians may be understandably reluctant to raise the topic of sexual function with people who experience chronic musculoskeletal pain. We offer the following practice points to assist clinicians in sensitively raising sexual function:

Ensure that inclusive and appropriate language is used, especially when speaking with people who have diverse gender identities, sexual orientations, or sex characteristics. Inclusive and affirming language is language that ensures people feel seen and respected and avoids assumptions and discrimination. If the person’s preferred terminology around their gender identity is unknown (eg, their preferred pronouns), consider using open-ended questions and allowing them to explain their individual circumstances. Avoid assumptions about sexual activities or behaviors based on gender or sexual orientation.

Acknowledge it can be difficult for people to communicate their sexual problems to others (Fig. 1) and ask for permission to discuss these issues.17,63 When clinicians take steps to actively listen and legitimize a person’s thoughts and feelings, this provides a safe space to discuss sexual function and intimacy.64,65 Knowing that their experiences are not unusual can be profound, as can the therapeutic benefit of trusted clinical interactions.64,65 A similar approach has been recommended in stroke rehabilitation, where the initial steps of a sexuality interview guide focus on normalizing the presence of sexual difficulties and offering examples of common difficulties.66

Highlight that, as many activities of daily living are affected by chronic musculoskeletal conditions (eg, due to pain, reduced joint mobility, and fatigue), sexual function can also be affected by these issues (Fig. 1).

Explain that providing holistic care means that sexual function is typically screened as an integral part of a musculoskeletal assessment. Indicate that, together with other functional activities of daily living, this is assessed and reassessed at follow-up, as appropriate and with consent45,63 (Fig. 1).

Seek explicit consent to include sexual function screening, as appropriate, respecting that in some cultures and contexts (like the presence of past trauma), individuals may not wish to discuss this. Alternatively, people may prefer to return to these discussions at different life stages, for example, when meeting a new partner, planning for pregnancy, or during peri/menopause.

Maintain professional communication standards. Use respectful, open, and supportive language within a private consultation space to support people to freely discuss their concerns. While humor may help the clinician feel more comfortable, this approach may be inappropriate or not well received.45

Figure 1 Practical examples for sensitively raising sexual function.

Other considerations include the need for a safe space for discussions, ideally a private room (rather than cubicles) where the consultation cannot be overheard by others and potential interruptions can be avoided. The involvement of a different clinician may be appropriate, if the person’s preference is to speak with someone of a specific gender. It is important to allow enough time so the person does not feel rushed. To facilitate this, scheduling a specific appointment for these discussions may be preferable, rather than trying to cover too much in a single consultation. Having additional resources available, such as information leaflets or links to online resources, can support conversations and allow people to privately reflect on relevant information.

To support physical therapists in being better equipped and confident to raise these issues clinically, targeted education in sexual dysfunction screening, assessment, and person-focused communication that is sensitive, respectful, and culturally safe is recommended.17,45 This type of education could be provided as part of professional, postgraduate, and continuing education programs, to ensure access for both new and experienced physical therapists. Appropriate education can also assist clinicians to identify and address any beliefs or biases they may hold about sexuality (including biases based on age, gender, culture, or ethnicity),48 which could inadvertently contribute to inequities in care. Time and practice in learning effective ways to screen and discuss sexual function with people can enhance clinician confidence45 and, coupled with appropriate training, can improve clinician knowledge and expertise in identifying, on-referring, or helping support people with sexual health issues.50–53,67–69 However, educational offerings may not adequately consider diverse populations including people of older age, people who identify as LGBTQIA+ and/or people with specific needs (eg, people with cognitive impairments, physical disabilities, and/or intellectual disabilities),50,51,67 and further guidance can be sought from clinical colleagues with specific expertise and from relevant consumer organizations.

Approaches to Person-Centered Management

This section provides physical therapists with an overview of potential person-centered management for sexual dysfunction. Some care will be within scope of practice, whereas other care will require onward referral. Our case studies illustrate how this care may be clinically operationalized (Suppl. Material). First, it is important to identify and understand the person’s experience of sexual function in the context of their musculoskeletal pain, including the contribution of physical and biological factors (musculoskeletal function), psychological factors (general wellbeing, fear, mood, distress, fatigue, trauma), and social context (relationships and social roles). Understanding the person’s preferences and care priorities, including their current and past experiences of care, helps inform a tailored, supportive management plan. Where symptoms of neurological involvement are described (eg as part a spinal assessment), a neurological examination may be indicated. Assessing musculoskeletal function more broadly is relevant, including functional activities, joint range of motion (eg hip and lumbopelvic), strength and conditioning, and identifying unhelpful protective behaviors (hypervigilance, fear, and avoidance).

Physical therapists can also use their expertise to offer advice, which may include education regarding more comfortable sexual positions. Published guidance on safe sexual positions after hip replacement surgery (to reduce the risk of postoperative hip dislocation) is not routinely provided,70 but is available from professional body or health services websites.71,72 Advice on activity pacing may also be helpful in the context of pain fluctuations or disease flares, and fatigue that might be most problematic later in the day.10

Referral Pathways

Individuals with suspected or actual sexual dysfunction (identified eg, during the clinical conversation or through the use of a PROMs instrument) should be referred to an appropriately trained and experienced clinician. Different referral options may be appropriate, depending on the person’s specific needs, priorities, and preferences. A summary of common referral pathways is provided in Fig. 2. It is often appropriate in the first instance to recommend consultation with a pelvic health physical therapist.73 If pelvic floor muscle dysfunction is suspected, examination by a pelvic health physical therapist may be indicated (eg a vaginal or rectal examination or transperineal or transabdominal ultrasound) to assess pain, pelvic floor resting tone, muscle coordination, and urogenital tissue integrity. Care provided by pelvic health physical therapists can include specific pelvic floor muscle training (including using biofeedback), manual therapy, muscle relaxation with vaginal or rectal dilator therapy and/or breath awareness, and education around the sexual response cycle and optimizing urogenital tissue health. Potential contributing factors such as signs and symptoms of pelvic organ prolapse, bowel or bladder dysfunction, erectile dysfunction, sexual organ pain, or a history of childhood trauma or sexual trauma may be identified by pelvic health physical therapists and require onward referral.

Figure 2 Overview of potential referral options. a In some jurisdictions, allied health services may require a medical referral.

Further referral options for the comprehensive assessment and management of sexual dysfunction are varied. For some individuals, medical review may be needed. A general practitioner or primary care physician can evaluate whether current medications or comorbidities are contributing to sexual dysfunction. General practitioners and primary care physicians can also provide referrals for specialist medical services and can co-ordinate multidisciplinary care. While referral to medical specialists may not be within the scope of physical therapist practice (depending on the jurisdiction, qualifications, and scope of practice), within a multidisciplinary team-based paradigm it is important for physical therapists to still be cognizant of the available options. Review by a relevant medical specialist (eg rheumatologist, sport and exercise physician, pain physician and/or orthopaedic surgeon) may be needed if musculoskeletal pain factors require additional management. Urology, andrology, or gynecology review may be necessary if the person is experiencing dysuria (pain or discomfort with urination) or dysmenorrhea (painful menstrual periods). Gynecology review may also be warranted for complaints of dyspareunia (painful penetrative intercourse). Referral to a vulval dermatologist may also be appropriate for vulvodynia (pain or discomfort in the vulval area) that may result from psoriasis, lupus, lichen sclerosus, or low estrogen levels in peri/menopausal women. Referral to a gastroenterologist or colorectal specialist may be considered if a person describes abdominal or pelvic pain that requires investigation. Referral to a colorectal specialist may be beneficial for people with anorectal prolapse, chronic anal fissures, or hemorrhoids.

Psychology, psychiatry, relationship counseling, and sex therapy can play an important role in managing sexual dysfunction and a range of medical, cognitive, emotional, and behavioral interventions may be used. These therapies can be helpful in supporting the person in their relationships, addressing lack of desire or arousal, improving sexual satisfaction or orgasm, and addressing previous trauma. Accessing an appropriately trained clinician to help support couples to discuss sexual dysfunction issues may also be appropriate. In some settings, referrals to these types of services may not be required (other than for psychiatry, as a medical specialty) although care coordination by a general practitioner or primary care physician may still be beneficial.

Conclusion

Sexual function is an important contributor to quality of life and an important activity for many people. Chronic musculoskeletal pain is commonly associated with sexual dysfunction, although significant evidence gaps remain for LGBTQIA+ populations. Ensuring clinicians feel confident to sensitively raise sexual function, as appropriate, is a key starting point given the major role that physical therapists play in musculoskeletal management. An understanding of available screening tools, management approaches, and referral pathways for sexual dysfunction will assist clinicians to provide more holistic, tailored care to people with chronic musculoskeletal pain.

Supplementary Material

2023-0727_R1_Supplemental_material_Physical_Therapy_pzae083

Author Contributions

Conceptualization: I.N. Ackerman, L. Restoux, B. Dobo, H. Slater, M.H. Ross, A.M. Briggs

Project administration: I.N. Ackerman and A.M. Briggs

Resources: I.N. Ackerman

Writing - original draft: I.N. Ackerman, L. Restoux, B. Dobo, H. Slater, A.M. Briggs

Writing - review and editing and final approval: I.N. Ackerman, L. Restoux, B. Dobo, H. Slater, M.H. Ross, A.M. Briggs

Funding

There is no funding to report for this work.

Disclosures

The authors completed the ICMJE Form for Disclosure of Potential Conflicts of Interest and reported no conflicts of interest.
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References

1. Hutting N , CaneiroJP, Ong'wenOM, MiciakM, RobertsL. Person-centered care for musculoskeletal pain: putting principles into practice. Musculoskelet Sci Pract. 2022;62 :102663. 10.1016/j.msksp.2022.102663.36113362
2. American Sexual Health Association . Sexual functioning. Accessed February 14, 2024. https://www.ashasexualhealth.org/?s=function.
3. American Occupational Therapy Association . Occupational therapy practice framework: domain & process (3rd edition). Am J Occup Ther. 2014;68 :S1–S48. 10.5014/ajot.2014.68S1.
4. Lindau ST , SchummLP, LaumannEO, LevinsonW, O'MuircheartaighCA, WaiteLJ. A study of sexuality and health among older adults in the United States. New Engl J Med. 2007;357 :762–774. 10.1056/NEJMoa067423.17715410
5. Flynn KE , LinL, BrunerDWet al. Sexual satisfaction and the importance of sexual health to quality of life throughout the life course of U.S. adults. J Sex Med. 2016;13 :1642–1650. 10.1016/j.jsxm.2016.08.011.27671968
6. Lee DM , VanhoutteB, NazrooJ, PendletonN. Sexual health and positive subjective well-being in partnered older men and women. J Gerontol. 2016;71 :698–710. 10.1093/geronb/gbw018.
7. Orr J , LayteR, O'LearyN. Sexual activity and relationship quality in middle and older age: findings from The Irish Longitudinal Study on Ageing (TILDA). J Gerontol B Psychol Sci Soc Sci. 2019;74 :287–297. 10.1093/geronb/gbx038.28444243
8. World Health Organization . Sexual Health. Accessed October 9, 2023. https://www.who.int/health-topics/sexual-health#tab=tab_1.
9. International Classification of Functioning, Disability and Health (ICF) . WHO-FIC Maintenance Platform. Accessed February 14, 2024. https://icd.who.int/dev11/l-icf/en.
10. Restoux LJ , DasarirajuSR, AckermanIN, Van DoornumS, RomeroL, BriggsAM. Systematic review of the impact of inflammatory arthritis on intimate relationships and sexual function. Arthritis Care Res. 2020;72 :41–62. 10.1002/acr.23857.
11. Katz H , Newton-JohnTRO, ShiresA. Sexual difficulties in the population with musculoskeletal chronic pain: a systematic review. Pain Med. 2021;22 :1982–1992. 10.1093/pm/pnaa451.33576430
12. Briggs AM , SlaterH, Van DoornumSet al. Chronic primary or secondary non-inflammatory musculoskeletal pain is associated with disrupted sexual function and relationships: a systematic review. Arthritis Care Res. 2021;74 :1019–1037. 10.1002/acr.24711.
13. Minopoulou I , PyrgidisN, TishukovMet al. Sexual dysfunction in women with systemic autoimmune rheumatic disorders: a systematic review and meta-analysis. Rheumatology. 2023;62 :1021–1030. 10.1093/rheumatology/keac457.35951753
14. Harmsen RT , HaanstraTM, SiereveltINet al. Does total hip replacement affect sexual quality of life? BMC Musculoskelet Disord. 2016;17 :198. 10.1186/s12891-016-1048-1.27141980
15. Issa K , PierceTP, BrothersA, FestaA, ScilliaAJ, MontMA. Sexual activity after total hip arthroplasty: a systematic review of the outcomes. J Arthroplast. 2017;32 :336–340. 10.1016/j.arth.2016.07.052.
16. Besiroglu MDH , DursunMDM. The association between fibromyalgia and female sexual dysfunction: a systematic review and meta-analysis of observational studies. Int J Impot Res. 2019;31 :288–297. 10.1038/s41443-018-0098-3.30467351
17. Perez-Garcia LF , RöderE, PastoorH, BoltJM, vanExelJ, DolhainRJ. It is not just about sex: viewpoints of men with inflammatory arthritis on the overall impact of the disease on their sexual health. RMD Open. 2021;7 :e001821. 10.1136/rmdopen-2021-001821.34580174
18. Rosenbaum TY . Musculoskeletal pain and sexual function in women. J Sex Med. 2010;7 :645–653. 10.1111/j.1743-6109.2009.01490.x.19751383
19. Simões D , AraújoFA, SeveroMet al. Patterns and consequences of multimorbidity in the general population: there is no chronic disease management without rheumatic disease management. Arthritis Care Res. 2017;69 :12–20. 10.1002/acr.22996.
20. Foley HE , KnightJC, PloughmanM, AsghariS, AudasR. Association of chronic pain with comorbidities and health care utilization: a retrospective cohort study using health administrative data. Pain. 2021;162 :2737–2749. 10.1097/j.pain.0000000000002264.33902092
21. Basson R , BrottoLA, LaanE, RedmondG, UtianWH. Assessment and management of women's sexual dysfunctions: problematic desire and arousal. J Sex Med. 2005;2 :291–300. 10.1111/j.1743-6109.2005.20346.x.16422860
22. Rosen RC , LaneRM, MenzaM. Effects of SSRIs on sexual function: a critical review. J Clin Psychopharmacol. 1999;19 :67–85. 10.1097/00004714-199902000-00013.9934946
23. Lin I , WilesL, WallerRet al. What does best practice care for musculoskeletal pain look like? Eleven consistent recommendations from high-quality clinical practice guidelines: systematic review. Br J Sports Med. 2020;54 :79–86. 10.1136/bjsports-2018-099878.30826805
24. Bannuru RR , OsaniMC, VaysbrotEEet al. OARSI guidelines for the non-surgical management of knee, hip, and polyarticular osteoarthritis. Osteoarthr Cartil. 2019;27 :1578–1589. 10.1016/j.joca.2019.06.011.
25. National Institute for Health and Care Excellence . Low back pain and sciatica in over 16s: Assessment and management. London: National Institute for Health and Care Excellence; 2016.
26. National Institute for Health and Care Excellence . Spondyloarthritis in over 16s: diagnosis and management. London, UK: National Institute for Health and Care Excellence; 2017.
27. National Institute for Health and Care Excellence . Rheumatoid arthritis in adults: Management. London, UK: National Institute for Health and Care Excellence; 2020.
28. National Institute for Health and Care Excellence . Chronic pain (primary and secondary) in over 16s: assessment of all chronic pain and management of chronic primary pain. London, UK: National Institute for Health and Care Excellence; 2021.
29. National Institute for Health and Care Excellence . Osteoarthritis in over 16s: diagnosis and management. London: National Institute for Health and Care Excellence; 2022.
30. Fraenkel L , BathonJM, EnglandBRet al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Rheumatol. 2021;73 :1108–1123. 10.1002/art.41752.34101376
31. Geenen R , OvermanCL, ChristensenRet al. EULAR recommendations for the health professional's approach to pain management in inflammatory arthritis and osteoarthritis. Ann Rheum Dis. 2018;77 :797–807. 10.1136/annrheumdis-2017-212662.29724726
32. Kolasinski SL , NeogiT, HochbergMCet al. 2019 American College of Rheumatology/Arthritis Foundation guideline for the management of osteoarthritis of the hand, hip, and knee. Arthritis Rheumatol. 2020;72 :220–233.31908163
33. Macfarlane GJ , KronischC, DeanLEet al. EULAR revised recommendations for the management of fibromyalgia. Ann Rheum Dis. 2017;76 :318.27377815
34. National Institute for Health and Care Excellence . Osteoarthritis: care and management. London, UK: National Institute for Health and Care Excellence; 2014.
35. Scottish Intercollegiate Guidelines Network . Management of early rheumatoid arthritis. Edinburgh, UK: Scottish Intercollegiate Guidelines Network; 2011.
36. Scottish Intercollegiate Guidelines Network . Management of chronic pain. Edinburgh, UK: Scottish Intercollegiate Guidelines Network; 2013.
37. Ward MM , DeodharA, AklEAet al. American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network 2015 recommendations for the treatment of ankylosing spondylitis and nonradiographic axial spondyloarthritis. Arthritis Rheumatol. 2016;68 :282–298.26401991
38. Zangi HA , NdosiM, AdamsJet al. EULAR recommendations for patient education for people with inflammatory arthritis. Ann Rheum Dis. 2015;74 :954–962.25735643
39. Meroni R , PiscitelliD, RavasioCet al. Evidence for managing chronic low back pain in primary care: a review of recommendations from high-quality clinical practice guidelines. Disabil Rehab. 2021;43 :1029–1043.
40. Nelson AE , AllenKD, GolightlyYM, GoodeAP, JordanJM. A systematic review of recommendations and guidelines for the management of osteoarthritis: the chronic osteoarthritis management initiative of the U.S. bone and joint initiative. Sem Arthritis Rheum. 2014;43 :701–712.
41. Slater H , JordanJE, O’SullivanPBet al. “Listen to me, learn from me”: a priority setting partnership for shaping interdisciplinary pain training to strengthen chronic pain care. Pain. 2022;163 :e1145–e1163. 10.1097/j.pain.0000000000002647.35384928
42. EAU Guidelines . Edn. Presented at the EAU Annual Congress Milan 2023. ISBN 978-94-92671-19-6. Accessed October 9, 2023. https://uroweb.org/guidelines/chronic-pelvic-pain.
43. Oliveira CB , MaherCG, PintoRZet al. Clinical practice guidelines for the management of non-specific low back pain in primary care: an updated overview. Eur Spine J. 2018;27 :2791–2803.29971708
44. England BR , SmithBJ, BakerNAet al. 2022 American College of Rheumatology guideline for exercise, rehabilitation, diet, and additional integrative interventions for rheumatoid arthritis. Arthritis Care Res. 2023;75 :1603–1615.
45. O’Connor SR , ConnaghanJ, MaguireRet al. Healthcare professional perceived barriers and facilitators to discussing sexual wellbeing with patients after diagnosis of chronic illness: a mixed-methods evidence synthesis. Patient Ed Counseling. 2019;102 :850–863.
46. Hill J . The impact of rheumatoid arthritis on patients' sex lives. Nurs Times. 2004;100 :34–35.
47. Miedany Y , GaafaryM, AroussyN, YoussefS, AhmedI. Sexual dysfunction in rheumatoid arthritis patients: arthritis and beyond. Int J Rheum Dis. 2012;31 :601–606.
48. Dyer K , dasNairR. Why don't healthcare professionals talk about sex? A systematic review of recent qualitative studies conducted in the United Kingdom. J Sex Med. 2013;10 :2658–2670.22846467
49. Haboubi N , LincolnN. Views of health professionals on discussing sexual issues with patients. Disabil Rehab. 2003;25 :291–296.
50. Gott M , GalenaE, HinchliffS, ElfordH. “Opening a can of worms”: GP and practice nurse barriers to talking about sexual health in primary care. Fam Pract. 2004;21 :528–536.15367475
51. Gott M , HinchliffS, GalenaE. General practitioner attitudes to discussing sexual health issues with older people. Soc Sci Med. 2004;58 :2093–2103.15047069
52. Hinchliff S , GottM, GalenaE. GPs' perceptions of the gender-related barriers to discussing sexual health in consultations: a qualitative study. European J Gen Prac. 2004;10 :56–60.
53. Stead ML , BrownJ, FallowfieldL, SelbyP. Lack of communication between healthcare professionals and women with ovarian cancer about sexual issues. British J Cancer. 2003;88 :666–671.
54. Stein A , SauderSK, RealeJ. The role of physical therapy in sexual health in men and women: evaluation and treatment. Sexual Med Rev. 2019;7 :46–56.
55. Van Doornum S , AckermanIN, BriggsAM. Sexual dysfunction: an often overlooked concern for people with inflammatory arthritis. Expert Rev Clin Immunol. 2019;15 :1235–1237.31657976
56. Nilsing Strid E , Ekelius-HampingM. Experiences of sexual health in persons with hip and knee osteoarthritis: a qualitative study. BMC Musculoskelet Disord. 2020;21 :576. 10.1186/s12891-020-03596-5.32838770
57. Stransky O , HuntN, RichardsJS, TalabiMB. Exploring family planning, parenting, and sexual and reproductive health care experiences of men with rheumatic diseases. J Rheumatol. 2022;49 :251–255.34782452
58. Wiegel M , MestonC, RosenR. The female sexual function index (FSFI): cross-validation and development of clinical cutoff scores. J Sex Marital Ther. 2005;31 :1–20.15841702
59. Isidori AM , PozzaC, EspositoKet al. Development and validation of a 6-item version of the female sexual function index (FSFI) as a diagnostic tool for female sexual dysfunction. J Sex Med. 2010;7 :1139–1146.19968774
60. Rosen RC , CappelleriJC, GendranoN3rd. The international index of erectile function (IIEF): a state-of-the-science review. Int J Impot Res. 2002;14 :226–244.12152111
61. Anderson D , LaforgeJ, RossMMet al. Male sexual dysfunction. Health Psychol Res. 2022;10 :37533.35999971
62. Fairbank JC , PynsentPB. The Oswestry disability index. Spine. 2000;25 :2940–2952.11074683
63. McInnes RA . Chronic illness and sexuality. Med J Aust. 2003;179 :263–266.12924976
64. Annon JS . The PLISSIT model: a proposed conceptual scheme for the behavioral treatment of sexual problems. J Sex Ed Ther. 1976;2 :1–15.
65. Taylor B , DavisS. The extended PLISSIT model for addressing the sexual wellbeing of individuals with an acquired disability or chronic illness. Sex Disabil. 2007;25 :135–139.
66. Auger LP , PituchE, FiliatraultJ, CourtoisF, RochetteA. Implementation of a sexuality interview guide in stroke rehabilitation: a feasibility study. Disabil Rehabil. 2021;44 :1–9.
67. Abbott D , HowarthJ. Still off-limits? Staff views on supporting gay, lesbian and bisexual people with intellectual disabilities to develop sexual and intimate relationships? J Appl Res Intell Disabil. 2007;20 :116–126.
68. Hinchliff S , GottM, GalenaE. “I daresay I might find it embarrassing”: general practitioners’ perspectives on discussing sexual health issues with lesbian and gay patients. Health Social Care Comm. 2005;13 :345–353.
69. Rubin R . Communication about sexual problems in male patients with multiple sclerosis. Nurs Stand. 2005;19 :33.
70. Neonakis EM , PernaF, TrainaFet al. Total hip arthroplasty and sexual activity: a systematic review. Musculoskelet Surg. 2020;104 :17–24.32030656
71. American Association of Hip and Knee Surgeons . A guide to returning to sexual activity following hip or knee replacement surgery. Accessed October 9, 2023. https://hipknee.aahks.org/wp-content/uploads/2019/01/sex-after-joint-surgery-AAHKS.pdf.
72. UC San Diego Health . Sex positions after joint replacement. Accessed October 9, 2023. https://myhealth.ucsd.edu/RelatedItems/3,40019.
73. World Physiotherapy . International Organization of Physical Therapists in Pelvic and Women's Health (IOPTPWH). Accessed October 9, 2023. https://world.physio/subgroups/pelvic-womens-health.
74. Rosen R , BrownC, HeimanJet al. The female sexual function index (FSFI): a multidimensional self-report instrument for the assessment of female sexual function. J Sex Marital Ther. 2000;26 :191–208.10782451
75. Keller A , McGarveyEL, ClaytonAH. Reliability and construct validity of the changes in sexual functioning questionnaire short-form (CSFQ-14). J Sex Marital Ther. 2006;32 :43–52.16234225
76. Skevington SM , LotfyM, O'ConnellKA. The World Health Organization's WHOQOL-BREF quality of life assessment: psychometric properties and results of the international field trial. A report from the WHOQOL group. Qual Life Res. 2004;13 :299–310.15085902
