The elephant in the room: a study on the dialogue about sexuality during Assisted Reproductive Technology visits

Abstract

Despite ongoing medical advancements in infertility treatment, the significant impact of sexuality on this journey often goes unaddressed. The present research aims to examine sexual conversations during ART visits, including who initiate the conversation and their content.This quali-quantitative study delves into analyzed video-recorded ART visits to explore how “sex” conversations are broached during healthcare interactions. Our findings reveal a strikingly low proportion of utterances related to sexuality, accounting for only 1.3% of the total 14,372 utterances analyzed. Sex utterances were mainly introduced by physicians (72%), while regarding those introduced by the couple, 64% were reported by men. From the qualitative analysis on the utterances emerged three distinct levels of communication about sex: explicit, almost explicit, and implicit. While physicians and males exhibit an almost balanced distribution across the 3 levels, female patients primarily respond to explicit and almost explicit communication initiated by physicians. The low percentage of sexual utterances underscores the rarity of these conversations during ART interactions, despite the clinical field where sexual health should deserve a crucial attention. Opening the door to conversations about sexuality could help to create a safe and supportive space for patients to talk about sex, with a potential impact on well-being and quality of care during the ART process.

Keywords:

• Doctor-patient communication
• sexuality
• reproductive health
• sexual health
• health communication

Introduction

Infertility is defined as the failure to achieve pregnancy after 12 months of regular unprotected intercourse [1]. According to the World Health Organization (WHO), around 15% people globally face infertility, with a similar prevalence in Italy [2,3]. Thus the utilization of Assisted Reproductive Technology (ART) is increasing worldwide [4,5]. The literature highlights that the diagnosis of infertility may expose psychological and relational challenges, including stress, grief, and identity concerns [6–7], while the ART treatments may exacerbate emotional strain, with couples experiencing anxiety, depression, and other negative emotions [8]. Further factors of burden and distress for couples are: complexity and uncertainty of medical procedures, low success rates, financial costs, ethical dilemmas, and societal pressures [9–11]. While guidelines emphasize mental health care during infertility treatments [12, 13], no specific best practices recommendations are provided in Italy [8]. Several studies have shown that infertility affects individuals across multiple dimensions, including psychological well-being, marital relationships, quality of life, and sexual relationships [14]. While extensive research covers the first three dimensions, the fourth, about sexuality, remains comparatively underexplored.

Several studies have shown that sexuality is defined not merely as a reproductive behavior, but as one of the basic needs of most humans [15]. Healthy sexuality is an essential protective factor for psychological wellbeing and quality of life [16]. The fact that infertility and sexuality have a close relationship is easily conceivable and literature confirms the biunivocal causal nature of it [17]. Sexual dysfunction (SD) can occur in both partners during diagnostic-treatment protocols, leading to various sexual difficulties. Recently, studies have conceptualized the Inferto-Sex Syndrome [17] that describes the SDs infertile couples may experience while undergoing ART treatments. These dysfunctions are related to various factors, like the pressure and urgency surrounding conception, necessitating specific sexual practices at designated times. These factors affect emotional, psychological, and sexual aspects, impacting self-identity, mental well-being, marital relationships, and treatment adherence [18]. Infertility can not only induce sexual disturbances and disorders but also maintain and worsen them. Severe SDs have been found to be a primary cause of infertility in patients undergoing ART treatments [19]. Moreover, SD in one partner can influence the other one, as they are interrelated within a couple [20]. Evaluating and treating SDs can enhance fertility for both partners, leading to more satisfying sexual experiences, increased activity, and reduced stress and anxiety, fostering a conducive environment for conception [21]. In addition, in Italy infertility treatment is strictly regulated by Law 40/2004 which lays out subjective requirements for couples who could access ART such as an effective sexual activity [22].

The effect of discussing sexuality during ART visits remains unexplored. The present study aims to examine sexual conversations during ART visits, including who initiate the conversation (doctor, male or female patient) and their content.

Materials and methods

Our study is based on a quantitative and qualitative analysis of video-recorded ART visits with the purpose to explore how sexual conversations are broached during these interactions. The dataset employed in the present study is extract from a larger dataset of our research team’s previous study [23]. It involved a convenience sample of 85 videotaped visits conducted at eight different ART Centers in Italy and verbatim transcribed.

For the present study, a total of 20 videos were considered from corpus of 85 visits, including initial consultations (45%) and checkup consultations. The selection was carried out through a random process, considering only those with both male and female patients involved, and ensuring that both male and female healthcare providers were represented in the dataset (60% women). The infertility causes were heterogeneous: idiopathic (30%), organic (30%) or yet unknown (40%).

The previous project based on these videos used Roter Interaction Analysis System–RIAS [24] to support the quantitative analysis. The RIAS is a well validated and widely used coding system for categorizing verbal exchanges during doctor-patient interactions. The unit of analysis of this coding system is “utterance.” This term refers to the statement reflecting a complete thought or phrase, which may vary in length from a word to a long sentence. RIAS data analysis generates an output with the number of total utterances.

For the present study, all the utterances identified by the RIAS and addressing sexuality during the visits were considered. For each of them, the researchers recorded who introduced the topic: the physician, the male patient or the female patient. These quantitative data were analyzed through descriptive statistics, mainly frequencies.

A qualitative analysis was also conducted. Two authors (MM, RB) analyzed the transcriptions using inductive thematic analysis [25] to independently identified the contents of sexual conversations. The researchers met to compare, resolve discrepancies and categorize the issues.

Results

Quantitative results

Table 1 outlines the frequencies of utterances related to sexuality. Among 14,372 analyzed utterances across 20 ART visits, 196 (1.3%) addressed sex, either introducing or replaying to a sexual conversation. Of the total utterances introducing sexual topics (n = 101), healthcare professionals initiated the discussion in 73 instances (72%). Couples contributed a total of 95 utterances related to sex; among these, 28 utterances involved the initiation of the sex topic, with men introducing the discussion in 18 utterances (64%), and women in 10 utterances (36%). This suggests a lower initiation rate among female patients compared to their male counterparts. Additionally, in responding to someone else initiating the sex topic, couples provided 67 utterances; women contributed 43 (64%), while men provided 24 (36%).

Table 1. N° utterances related the topic of sexuality.

	196 n° total SEX utterances	101 n° INTRODUCING SEX COMMUNICATION utterances
Physicians’ utterances	101 (52%)	73 (72%)
Couples’ utterances	95 (48%)	28 (28%)
Men’s utterances	42 (21%)	18 (18%)
Women’s utterances	53 (27%)	10 (10%)

Qualitative results

The qualitative analysis identified three levels of sexual communication (Result 1) and three content issues about sexuality (Result 2). The results are reported below with physicians and patients’ excerpts.

Qualitative result 1 –levels of sexual communications in ART visits

Through an exploration of the three distinct levels of communication—explicit, almost explicit, and implicit – which have been conceptualized by the two coders of the analysis, we unravel the complexities of patient-physician interactions in addressing sexual concerns.

Explicit sexual communication: includes openly discussing sexual health topics between healthcare providers and patients. It includes addressing sexual concerns, questions, and issues clearly and directly, without avoiding explicit details. Physicians discuss aspects like sexual activity, function, reproductive health, contraception, and fertility using clear and accurate terminology, ensuring patient understanding.

“How is the quality of the sexual intercourse? You don’t suffer of erectile dysfunction, do you?” (BO070300, female physician)

“I guess there are better moments to conceive …” (TN020300, male patient)

“Well, to be honest we have never used condoms” (FD180500, female patient)

Almost explicit sexual communication: includes indirect or subtle ways in which sexual health topics are addressed or conveyed between healthcare providers and patients. Unlike explicit communication, which involves direct and open discussions, this communication may not explicitly mention sexual matters but still convey important information. Providers might use euphemisms or less explicit language to discuss sexual health topics.

“Oh, I see, you were more focused on this” (FD180500, female physician)

“Maybe the problem is us, maybe we make mistakes …” (TN020300, male patient)

“In the meantime, we met, got engaged, married and started trying to have a baby 2 years ago” (BO080300, female patient)

Implicit sexual communication: includes an extremely subtle or indirect approach to discussing sexual sensitive topics between healthcare providers and patients. It requires patients to infer the intended message without explicit statements. This vague form of communication may lack clarity, leading to misunderstandings about analogies or metaphors related to sexual topics.

“It’s not like you can always … you sleep outside?" (FD170400, female physician)

“First, I want to figure out whether it is a lifestyle issue. She has a very stressful lifestyle, we travel a lot, when we get home in the evening, we are often exhausted … we don’t see each other even for two or three days a week. How much impact can this have on …” (FD170400, male patient)

“I mean, I want to know, is everything normal?" (FD180500, female patient)

Qualitative result 2 – content issues about sexuality

Based on the utterances regarding sexuality, the inductive thematic analysis highlights the presence of three underlying issues about sexuality, referring to three functions underlying the sex dialogue.

To share sex information: as cited above, prerequisites for accessing ART treatment are related to the attempts to achieve a pregnancy after 12 months or more of regular unprotected sexual intercourse. Physicians in ART centers tend to collect information about sex following presumably the guidelines for an anamnestic gathering of information focused on infertility.

“So, did you have free sexual intercourse, without precautions, for one year?” (FD170400, female physician)

To improve sex activity: regardless of the ART treatments, couples wish to receive a sexual education to improve their sexual intercourses. Explicitly or implicitly, here seems to emerge the patients’ thought that infertility may be caused by sexual difficulties and could be resolved with proper education.

“I guess there are better times to conceive for women, to be able to …” (TN020300, male patient)

To legitimate sex: undergoing ART treatments, couples wish to know whether they are legitimized to achieve a pregnancy on their own efforts and whether having an active sexual life could compromise the effect of the cures.

“From today to the next medical appointment, can we keep working on?” (TN020300, male patient)

Quantitative and qualitative results

Table 2 reported the distribution of frequencies of the three levels of communication about sexuality -explicit, almost explicit, implicit- across the communication actors -physician, men, women.

Table 2. Three levels of communication about sexuality across speakers.

Variable	N(%)	N introducing SEX topic
N° physicians SEX utterances	101	73
Explicit level	44 (43%)	37 (51%)
Almost Explicit level	32 (32%)	20 (27%)
Implicit level	25 (25%)	16 (22%)
N° men SEX utterances	42	18
Explicit level	15 (36%)	5 (28%)
Almost Explicit level	13 (31%)	5 (28%)
Implicit level	14 (33%)	8(44%)
N° women SEX utterances	53	10
Explicit level	17 (32%)	0 (0%)
Almost Explicit level	18 (34%)	4 (40%)
Implicit level	18 (34%)	6 (60%)

While explicit communication by physicians is significant (43%), a larger proportion (57%) involves almost explicit and implicit communication styles. Notably, almost explicit communication is employed by physicians in 32% of cases involving the use of euphemisms or less explicit language while implicit communication is observed in 25% of cases, signifying a more subtle and indirect approach that requires patients to infer the intended message without explicit statements. Male and female patients exhibit a balanced distribution across explicit, almost explicit, and implicit communication styles.

When focusing on the introduction of the sex topic, physicians predominantly use explicit communication, accounting for 51% of cases. Implicit communication is utilized in 1/5 of cases. On the contrary, female patients and male patients exhibit a preference for implicit communication respectively in 60% and 44% of cases. To note, there is an absence of direct initiation by female patients in explicit communication.

Discussion

Infertility treatments, particularly those involving ART, are demanding journeys for couples seeking to realize their dream of parenthood. The emotional challenges related to ART procedures have been widely explored, along with some aspects of physician-patients communication. However, sexual conversations within ART visits are mainly unexplored.

Our findings reveal a strikingly low proportion of utterances related to sexuality, accounting for only 1.3% of the total 14,372 utterances analyzed. This discrepancy between the potential significance of discussing sexual matters and their actual consideration during ART visits is noteworthy. Physicians initiated discussions about sexuality in 73 out of 101 instances, indicating their proactive role in addressing sensitive topics. However, the reasons behind the relatively low frequency of such initiations warrant further exploration. Our exploration highlights a significant gap in the care provided to couples, despite the undeniable link between sexual health, emotional well-being, and fertility outcomes [18,21,26,27]. It seems that the main physician’s purpose about addressing this intimate topic is related to ask couples if they fit with the definition of infertility [1] rather than engaging in meaningful discussions about sexuality. This may be attributed to adherence to guidelines for anamnestic collection, which prioritize technical aspects of diagnosis and treatment over dialogue and sexuality assessment.

Gender-based communication dynamics in this study align with literature showing women’s talkativeness in couples [28]. However, while women contributed more utterances overall (53 vs 42), men exhibited a noteworthy inclination to initiate discussions about sexuality within the couple dynamic (18 vs 10). This distinction may suggest differences in communication styles or comfort levels regarding this topic. Cultural and social factors likely influence how patients approach sexual health discussions. Notably, both genders mainly use implicit communication when introducing the sex topic, indicating a cautious approach. The absence of direct initiation by female patients in explicit communication may imply a reliance on healthcare providers to lead discussions, influenced by gender norms and provider responses. Further exploration of these gender-based variation is needed to ensure all patients feel empowered to engage in these conversations.

In the extensive dataset, only a subset of 28 (0.2%) reflects utterances where the couple initiates discussions about sexuality. This finding warrants further investigations. When facing a sexual problem, people very rarely consult a doctor and, during a medical visit, prefer to let the physician address the issue [29]. Various barriers hinder healthcare professionals from conducting sexual assessments, including discomfort with sexual terminology, perceived lack of competence, and concerns about offending patients. Contrary to doctors’ beliefs, patients may appreciate sexual history being integrated into medical consultations. Moreover, sexual education is often lacking in medical training programs, leaving physicians ill-prepared to address sexuality in practice [26]. Healthcare professionals play a crucial educational role and may need to attend training courses to feel confident in supporting this argument. It’s important to recognize that patients may not always feel comfortable sharing intimate details of their lives. However, when physicians open the door, simply asking questions regard sexuality, they are creating a comfort zone where new opportunities to increase someone’s global well-being are provided.

Limitations

The study is a pilot and has two main limitations. First, the study utilized a relatively small sample size, in which the number of sex-related utterances is very small, emphasizing the need for cautious interpretation and consideration of the specific context in which these interactions occur. Second, the study was conducted in the Italian context, which has its unique perspectives and attitudes toward sex. As a result, the findings may be influenced by the specific cultural context and may not be universally applicable. Therefore, the considerations and insights discussed in this study should be viewed as a starting point for further research in the ART context.

Future directions

In conclusion, consistent with our quantitative findings, sex topic appears to be an elephant in the living room: doctors and couples knows it is there, but no one wants to talk about it. Research underscores the interconnectedness of a couple’s well-being, relationship dynamics, and ART treatment effectiveness with sexual health [17]. Thus, addressing sexual concerns during ART visits should not be merely an additional aspect of care but an integral component. Our study seems to suggest the urgent need for a change in how sexual discussions are approached in infertility care. Future research should investigate the barriers to sexual conversations and develop strategies to integrate these discussions into standard care practices, including training programs. Additionally, examining how different communication styles (explicit, almost explicit or implicit) affect the general and sexual health of couples undergoing ARTvisits would provide a better understanding. Longitudinal studies should assess the long-term effects of integrating sexual health discussions on patient outcomes, including emotional well-being and treatment success rates. These insights could help healthcare providers improve their communication strategies to better support patients’ needs.

Ethics

The present study analyzes data from a main research project that was approved by the Ethical Review Board of the University of Milan and by the Ethical Review Boards of the eight participating ART clinics. Written informed consent was obtained from each participant included in the study, and data were managed according to local regulations regarding privacy.

Publisher’s note

It is essential to acknowledge that our study utilizes the terms “male” and “female” within the context of a binary sex categorization. We recognize that individuals may identify beyond this binary framework and our use of these terms is solely based on the participants’ self-identification. Additionally, it is important to note that our study sample comprises exclusively cisgender heterosexual couples.

Disclosure statement

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

Data availability statement

Data are available from the corresponding author upon request. The data are not publicly available due to privacy reasons.

Additional information

Funding

The author(s) reported there is no funding associated with the work featured in this article.