Pleasure from sex or the enjoyment of having sex is an essential part in a person’s physical, mental, and spiritual well-being. It has been shown that the desire for sexual enjoyment is preserved right into old age in men.¹ Yet, the loss of sexual power is often considered by many people and even by some health professionals as a natural ageing process; hence, many sufferers are reluctant to discuss their problem with another person including their own partner, friends or doctors.

Erec tile d ysfunc tion (ED) is a hig hly pr evalen t cond ition that increases with age. A survey in Hong Kong showed that 62% of men aged between 40-80 years old had experienced it.² ED can result in having a significant impact on one’s social and personal life, ranging from the loss of confidence in oneself and his self-esteem to a major depression.³

The recent advance in oral treatment of ED has benefited many men to restore their sexual function. However, a significant proportion of men do not respond to oral treatment.^{4, 5} It has been shown that for men not responding to oral ED treatment, the psychological and social impact on them were even more pronounced as compared to those men not receiving treatment.⁶ The psychological impact of ED knows no border. Studies conducted in different parts of the world demonstrated similar effects on affected men; for examples, the reduced self-esteem and confidence seen among Spanish men⁷ and the lowered quality of life felt among the Japanese.⁸

Despite there are effective treatments for ED and demonstrated benefits in gaining self-esteem, confidence and relationship satisfaction after treatment⁹, there are many sufferers who are still reluctant to seek help and medical assistance for their condition.^10,11 Many younger physicians, although they are aware and consider ED a significant problem, lack the knowledge, skills and mot iv at io n to in it ia te h elp fo r pa t ie n t s wi th thi s condition.^12,13 Baldwin et al¹⁴ cited some reasons for this phenomenon. In their study, 74% of men failed to d is cu ss the p ro b lem wi th their d o ctor b ec au se o f embarrassment; 12% felt that ED was a natural part of ageing; 10% did not consider the problem worthy of attention. These results indicate that there is still a lack of openness in discussing sexual issues among male patients and with their doctor. This may be related to the social values and the stigma attached to sexual problems and talking about sex. Similar results were also found in Japan where only 4.8% of male with ED had consulted a physician.¹¹ The main reasons cited by these men included ED having no influence on their daily life or they were not bothered by their ED, no sex drive, feeling shy, unsure where to seek medical help and perceiving a high cost of the treatment.

A cross-nation study studied the attitudes of men with ED¹⁴ showed there were comparable attitudes held by men in different counties which are summarized below:

• men in all countries agreed ED is a source of great sadness for themselves and their partners;
• nearly all disagreed that they were too old for sex;
• men in all countries agreed that it was important to know that they had the capacity to perform sexually;
• half of all men reported they would do “nearly anything” to cure their ED; and,
• men in all countries agreed that their doctor was the best source of information on sexual issues.

Further exploration by Metz and Seifert¹⁵ also showed that men believed that physicians were the most preferred professionals for consultations regarding their concerns on sexual issues, and 82% of men preferred their doctors to initiate the discussion.¹⁰ This latter passive attitude is good both ways: in that it serves as a means for the patients to off-load the responsibility to the health professionals, in particular the family physicians who are judged among patients to be the most appropriate person to help their predicament and the doctors to take the lead.¹²

At the same time, there are many doctors, some even family physicians, believe that ED is not a serious problem – only psychological in nature and consider treatment for ED is only for recreational function and enjoyment. A study of some Chinese physicians revealed that they would only deal with the problem if the patients had complained about it and many would not consider diagnosing and treating ED as their primary role.¹³ Similar findings were shown in ano ther study from USA sug gesting that physicians’ attitudes towards ED could be fairly universal across different societies.¹⁶

The effects of ED often extend beyond an individual and can affect the whole family which is well illustrated in the case report by Fogelman and Bloch in this issue. This report further demonstrated that the attitude of health professionals could have great impact on the health-seeking behaviour of patients and what differences could be made when a doctor played an active role in the management process. The article by Li and Ng also illustrated the importance of having a comprehensive, multi-disciplinary approach to ED. As the causes of ED are often multifactorial, its management often goes beyond a prescription of o ra l me di ca tion . Inv olveme nt o f othe r he al th professionals such as nurses, psychologist, sex therapist and marriage counsellor can provide much better outcomes.

Furthermore, there is strong evidence to suggest that the importance of managing ED can also be a predicting factor for coronary disease, especially in the diabetic patients.¹⁷ This places further importance on family physicians to screen for ED. The audit report by Chiu provides a good reflection on our daily practice in anticipatory care as prevention is one of the key roles of family physicians.

Changes to the current situation of poor diagnosis and management of ED require changes in both the attitudes and belief system of both doctors and patients. Training courses on ED management have been shown to be effective in providing the necessary knowledge; enhancing doctors’ communication skills with ED patients; and, ensuring patient-centred approach when dealing with ED patients.¹⁸ Se x u a l he a l th i s a mu c h n e g l e c t e d a r e a in b o th undergraduate and postgraduate medical training. More sexual health education should be available for health professionals with an emphasis on a holistic approach towards sex, not just on ED alone. It would be ideal to envision the formation of an association of sexual health care providers which makes up a group of interested interdisciplinary team members to conduct research and provide training for younger family physicians in Hong Kong.