Toward implementation of sexual healthcare, Response to: 'The opinion and practices of providers toward the sexual issues of cervical cancer patients undergoing treatment'.

With great interest we read the article by Bedell et al. reporting the opinion and practices of care providers toward the sexual issues of cervical cancer patients undergoing treatment (Bedell et al., 2017). The results of this study emphasize that relevant training regarding sexual dysfunction is warranted for clinicians who treat cervical cancer patients; a welcome improvement according to the majority of care providers. As researchers in the field of sexual health care, we are aware that health care providers throughout all medical departments rarely bring up sexual issues. This is striking, especially since patients often experience sexual problems, regardless of their disease (Rathi and Ramachandran, 2012, Bronner et al., 2004, Dusing, 2005). As little is known about the actual format of current sexual care, our research group performed multiple evaluations in a range of Dutch health care departments, including Oncology (Krouwel et al., 2015a, Krouwel et al., 2015b, Krouwel et al., 2015c, van Ek et al., 2015). We aimed to evaluate the attitude of clinicians toward addressing sexual health, as well as their perceived barriers, knowledge and accountability. The findings of Bedell et al. were similar to our findings among Dutch health care providers, accentuating the difficulty of discussing sexual health. Maybe even more so since the results of Bedell et al. where found in the gynaecology department, were care providers are often used to discuss sensitive subjects.

Simultaneously to your results, we found that in most medical departments problems in discussing sexual health derived from lack of knowledge and training. Underlying to this finding may be the omissions in current sexual training that was pointed out by 63–94% of the oncologic healthcare providers in our surveys (Krouwel et al., 2015a, Krouwel et al., 2015b, Krouwel et al., 2015c). However, if lack of knowledge and education are the only underlying causes remains questionable. A recent study evaluated the outcomes of intervention in sexual health care education among 136 oncology health care professionals in Iceland. Although the intervention was efficient in improving perception of having enough knowledge and training in providing sexual healthcare, it remained difficult to start the discussing on sexual health (Jonsdottir et al., 2016). Maybe care providers' experience is also of influence on the level of discussion. In our study among surgical oncologists more experienced providers discuss sexual health more often. However this was in contrast with your results, since you found more experienced providers had more reservations on bringing up sexual health (Krouwel et al., 2015a).

Seen in the light of this contradiction, one could presume that another component is withholding care providers from providing sexual care since they do feel responsible for bringing up the subject (Krouwel et al., 2015a, Krouwel et al., 2015c). For instance, organisational problems within their departments. In day-to-day practise there is a lack of time, guidelines and multidisciplinary consultation for sexual health, resulting in ambiguity regarding responsibility for bringing up sexual health. Besides, the referral rate for sexual problems to specialized healthcare providers is low (Krouwel et al., 2015a, Krouwel et al., 2015b, Krouwel et al., 2015c, van Ek et al., 2015). With these observations, we reveal the main problem: the lack of merging sexual health care in daily clinical practice. Attention regarding sexual health care should not only be focused on knowledge and training of the health care providers, but also on actual implantation of sexual care for patients. We would suggest to focus sexual research on the developing of adequate methods to enhance sexual care in the current system. New approach, such as e-health or specialized nurses, should be examined. To be able to do that, financial support must be made available. Besides, after implementation of these sexual health care developments an evaluation should be performed to test for effectiveness and usefulness. In order to optimize current sexual care, the partner should also be involved in future sexual health research; sexual dysfunction should be seen as an couple issue (Rottmann et al., 2017). By this integrated approach sexual health of patients and their partners will get the attention it deserves.

We declare no competing interests.