Physicians’ perspectives on the assessment of referrals for sex therapy—qualitative description with SWOT analysis

Physicians’ perspectives on the assessment of referrals for sex therapy—qualitative description with SWOT analysis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Physicians’ perspectives on the assessment of referrals for sex therapy—qualitative description with SWOT analysis Susanna Alhonkoski, Mika Alhonkoski, Hanna Koivikko, Leena Salminen, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8415620/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 12 You are reading this latest preprint version Abstract Background: An increase in sexual challenges demands that physicians address sexuality with patients more intensively. However, current knowledge presents a lack in the treatment of sexual health, and sex therapy, for instance, seems to be underutilized despite its benefits. For this reason, this study aimed to describe the perspectives of physicians when assessing the need for referrals to sex therapy. Method: This study was conducted using individual interviews with physicians (n=20). The interviews and thematic analysis were guided by the “Strengths, Weaknesses, Opportunities and Threats” framework. Findings: As a finding, the physicians described the following themes: 1) Strengths: “openness” and “the role of the work,” 2) Weaknesses: “ignorance,” “confusion about protocols,” and “attitudes,” 3) Opportunities: “knowledge supporting the professional community” and “sex therapy as a form of treatment,” and 4) Threats: “resources” and “lacks in healthcare services.” Conclusion: As a conclusion, it seems that physicians don’t have sufficient knowledge of sex therapy as a treatment for sexual health-related issues. This may be connected to general ignorance about sexuality itself in medical education. This study also emphasizes that the responsibility for addressing sexual needs to be clarified in medical education, and that sexuality is an important part of human wellbeing. addressing sexuality medical referral physicians sex therapy sexual health sexuality Figures Figure 1 Figure 7 Background Discussing sexuality and sexual health with patients is often difficult for healthcare professionals [ 1 – 2 ]. This may reflect the fact that sexuality is a base part of humanity, with multiple dimensions that encompass all areas of human life, including emotions, self-expression and identity [ 3 – 4 ]. However, humans have always a need to have accurate information about issues related to sexuality [ 5 ]. Moreover, challenges related to sexuality may influence wellbeing in unexpected ways, such as challenges in mental health [ 6 ]. These challenges can also be connected to several health issues, which can cause sexual dysfunction or decrease sexual desire [ 2 , 7 ]. According to earlier research, there is often a lack of knowledge about sexuality provided to patients in healthcare settings [ 1 – 2 , 8 ]. Healthcare professionals, especially physicians, should be able to identify the need for help and support for sexual health and sexuality related issues in patients, even though providing more precise care may not always be possible due to time constraints or resources [ 1 , 8 – 9 ]. As a minimum healthcare professionals should have the knowledge to be able to offer sex therapy when it is justified in patient care [ 8 , 10 ]. Sex therapy is a form of therapy that focuses on patients’ sexuality and utilizes therapeutic interventions to solve sexual challenges [ 11 ]. It is an effective form of therapy for patients with sexual dysfunction, among others [ 6 , 11 – 12 ]. Despite the possible effectiveness, there is a lack of evidence-based knowledge about the availability of sex therapy, which can make it difficult for patients to access services [ 6 ]. Physicians have key role in assessing the need for sex therapy and both guiding and referring patients to the appropriate clinical treatment [ 13 ]. However, medical education does not have a structured content in curricula for sexology or detailed sexual issues [ 14 ]. In Finland, for instance, the content of medical education curriculum and the scope of teaching are determined independently by each university, which has led to situation, where there is no structural framework for teaching sexual issues in medical education [ 15 ]. Moreover, the Directive of European Parliament and of the Council [ 16 ] regulating physicians’ professional qualifications does not include any reference to competence in sexual health. This study analyzed the knowledge about how physicians describe the internal (strengths and weaknesses) and external dimensions (opportunities and threats) concerning the assessment of referral to sex therapy. The findings of this study can be used to provide physicians with a deeper understanding of current issues related to the referral process in medical education and continuing professional development. They may also be better equipped to address sexuality and more accurately assess the possible need for sex therapy. Sex therapy and therapists Sex therapy is a therapeutic treatment, which can be seen as the final and deepest form of the commonly referred framework “Permission, LImited Information, Specific Suggestions and Intensive Therapy (PLISSIT),” which describes the phases of the treatment of sexual wellbeing [ 17 ]. Sex therapy treats adult patients in every age group, and it can be connected to the treatment of different illnesses [ 13 ]. Sex therapy is a broad concept because it encompasses several therapeutic and medical elements in multiple contexts, such as the effect of cultural elements on sensitive sexual issues or sicknesses [ 18 ]. From educational perspective, there are several ways to train as a sex therapist or counselor [ 19 ]. However, there is a lack of global standards for qualifications in sex therapy [ 19 – 20 ]. Efforts to standardize training and requirements for sex therapists include the Nordic Sexology Education and Authorization scheme [ 21 ]. For example, in Finland, a sex therapist may be accredited by the Nordic Association for Clinical Sexology (NACS) after completing 60 ECTs [ 22 ]. Theoretical framework The theoretical framework of this study was the “strengths, weaknesses, opportunities, and threats” (hereafter SWOT) framework [ 23 ]. SWOT is divided into two dimensions: internal and external. The internal dimension includes strengths and weaknesses, while the external dimensions consist of opportunities and threats. Essentially, SWOT creates a framework that examines the influencing elements in the actual context of that moment (e.g., physicians’ work) and those that may influence outside the context in the future (e.g., patients’ knowledge) [ 23 – 24 ]. Generally, SWOT is a widely used framework in economic research relating to business or company operations [ 23 ], but it can be seen as a useful framework in healthcare as well [ 25 ]. In healthcare, SWOT has been utilized in the evaluation of early hearing detection and intervention [ 26 ] and implementation of patient safety in medical education [ 27 ]. Moreover, SWOT has been utilized in medical education by Woratanarat & Woratanarat [ 25 ], who evaluated “good” physicians’ attributes and underlines that SWOT is not limited to organizational strategy, but can also serve an analytical tool for examining professional behaviors and attributes. In this study, SWOT provides a structured framework for examining the internal and external dimensions of physician perspectives, while remaining flexible enough to support a deep analysis of the case. Basically, this means that physicians’ perspectives of referrals practices encompass both negative and positive aspects. In addition, SWOT provides a framework, which can be adapted for qualitative research [ 28 ]. Study aims and design The aim of this study is to describe the perspectives of physicians when assessing the need for a referral for sex therapy. This qualitative study design was conducted using individual semi-structured interviews. Four research questions guided this study: What factors do physicians describe as strengths when they assess the need for referrals to sex therapy? What factors do physicians describe as weaknesses when they assess the need for referrals to sex therapy? What factors do physicians describe as opportunities when they assess the need for referrals to sex therapy? What factors do physicians describe as threats when they assess the need for referrals to sex therapy? Participants and recruitment Participants were licensed physicians (n = 20) working in the public and/or private health sectors in Finland. The inclusion criteria for participants were as follows: 1) licensed physician in Finland, 2) willingness to participate in this study, and 3) specialization in general medicine, obstetrics and gynecology, urology, and occupational health. The participants were recruited by the first author using purposive sampling to obtain a sample as appropriate as possible for the study's aims and questions [ 29 ]. The sample size was deemed sufficient for this qualitative study because all participants represented the same professional groups [ 30 ]. Data collection The data was collected between February and May 2025 through individual semi-structured interviews. The interview framework was developed to this study, even though it followed the structure of the SWOT and still allowing for a more open and flexible discussion of the topic (supplementary data). The first author conducted all the interviews (n = 20) via Teams. Data saturation was reached after these interviews. As background information, the physicians were asked about their experience, specialties, working sector, and if they had made any referrals to sex therapy. The interviews were recorded and transcribed immediately using Teams. After each interview, the researcher verified the written transcription and destroyed the voice recordings. Each interview lasted between 20 and 45 minutes. Data analysis The data were analyzed deductively using thematic analysis, guided by a SWOT analysis [ 23 ]. The thematic analysis was conducted in five different phases [ 31 – 33 ]. Firstly, the compilation phase included the creation of the written data [ 31 , 33 ]. Secondly, the disassembly phase consisted of pre-coding, and similarities were identified based on the SWOT factors [ 31 ]. This meant that the factors guided the content of the meaning unit, which was essentially a sentence or expression referring to a SWOT factor and a referral to sex therapy [ 23 , 31 ]. Thirdly, in the reassembly phase, these codes were gathered under each factor (strengths, weaknesses, opportunities, and threats), and themes and subthemes were created deductively [ 31 ]. Fourthly, in the interpretation phase, the researcher examined the relationship between themes and subthemes with the help of a thematic map of all factors, themes, and subthemes related to those factors [ 31 , 33 ]. In this phase, the researcher ensured that the themes were described using the SWOT framework [ 23 ]. Finally, in the conclusion phase, the themes and subthemes were defined in their final form and examined in relation to the research questions [ 31 – 33 ]. In this phase, the first author decided to use certain direct quotes from the data. A more precise description of the data analysis is provided in Table 1 . Table 1 An example of the process of the thematic analysis. Dimension Internal External Factor Strength Weakness Opportunity Threat Examples from the original data “And later they (patient) came back to say thank you - said they were really happy with it” (19) “ Not much is known about it (sex therapy), so people don’t really know how to guide anyone there ” (01) “If we could just get that kind of down-to-earth sex ed out there—the kind sex therapists do too—we could prevent so much stuff before it even gets to the point where someone needs sex therapy” (07) “…. this whole lack of reliable professional registry ” (09) Code Positive feedback Insufficient training in sexology was provided The importance of sexual education is emphasized Sex therapy is not a protected regulated profession, which challenges trust Subtheme A good relationship between the patient and the physician Limited knowledge of sex therapy The increased awareness of sexuality The quality of the service producers Theme Openness Ignorance Knowledge supporting the professional community Lacks in healthcare services Ethical considerations The study followed ethical guidelines throughout the entire process. Before implementing the study, ethical approval was granted by the Ethics Committee at the University of Applied Sciences (South-Eastern Finland University of Applied Sciences 1/2025, supplementary data). Each participant was informed about the research, and before interviews they gave informed consent by typing it to the teams, which were restored. Participants were informed that they could withdraw from the study at any time without providing a reason. The demographic data, which was collected, concerned work-experience, specialty, working place (public or private) and if they have made a referral to sex therapy. Other sociodemographic data—for example, age or gender—was not collected, as this was considered irrelevant to the aims of the study. [34.] Findings During the process, the “consolidated criteria for reporting qualitative research (COREQ)” has been utilized [ 35 ]. The participants (N = 20) were specialists in general medicine, obstetrics and gynecology, urology, and occupational health. They had between 5 and 30 years of work experience and worked in both the private and public healthcare sectors. Fourteen (n = 14) of them had made a referral or guided patients to sex therapy. As a finding, this study presents themes and subthemes that describe the strengths and weaknesses (internal dimension) and opportunities and threats (external dimension) of participants’ perspectives. These themes and subthemes reflect the current state (internal dimension) of the assessment of referrals to sex therapy as well as the issues (external dimension) that may relate in the future to the assessment process (Fig. 1 ). The descriptions of the themes and their related subthemes are shown in Table 2 . Table 2 The description of the themes and subthemes related to SWOT Dimension Main themes Subthemes Strength Openness Understanding the significance of sexuality A good relationship between the patient and the physician Multidisciplinarity The role of the work Professional growth Private sector as an employer Weakness Ignorance Deficiencies in medical education Limited knowledge of sex therapy Lack of professional networking Confusion about the protocols Confusion about referral protocols Confusion about costs Confusion about the benefits of the sex therapy Attitudes Addressing sexuality Stigma and assumptions Prioritization of care Opportunity Knowledge supporting the professional community Further education Increased awareness of sexuality Sex therapy as a form of treatment The role of sex therapy Multidisciplinary network Adequacy of resources Motivation Threat Resources Public sector Money The use of time Lacks in healthcare services The lack of care pathways The quality of the service producers [Table 2 near here] Strengths Strengths consisted of two main themes: “Openness” and “The role of the work.” “Openness” included three subthemes and “The role of the work” included two subthemes. (Table 2 .) In the theme “Openness” the role of sexuality was generally understood among participants, while they underlined the importance of understanding the significance of sexuality . They were aware of the possibility of making a referral, even if they had never actually done so. Another strength that participants highlighted was a good relationship between the patient and the physician , which indicates a more fluent assessment process of referral for sex therapy. In this kind of open and transparent relationship between physician and patient, both parties are equal, and they can talk honestly about sensitive issues like sexuality. This creates a situation where addressing sexuality is easier for the physician and enables a valid and comprehensive assessment of the referral for sex therapy. In addition, multidisciplinarity , in this case, good co-operation with sex therapists, was underlined as a strength when physicians are assessing the referral for sex therapy. The participants noted that the professional view of sex therapists can be vital to the assessment of the referral to sex therapy, especially if the sex therapist is familiar to the physician. According to the participants, this lowers the threshold for physicians to implement a consultancy and enables them to conduct referrals more easily. “ Honest collaboration should be the baseline, no one can do it all alone and definitely not when we are talking about things like this. ” (05) In the theme “The role of the work” participants described professional growth , such as continuing education in sexual medicine or even sexual advisors or sex therapists’ degrees, as a strength. This training enables physicians to gain a more valid perspective to evaluate referrals for sex therapy. In addition, the physicians may have personal interests in sexology, which can help inform the assessment of the referral. Additionally, besides the educational element, participants explained that long working experience was connected to a more fluent process of assessment of sexual issues, whereby physicians are more self-confident in addressing sexuality. “ Life has just kind of taught me along the way and I have always been curious ” (01) The private sector as an employer was underlined in this study. According to the participants, the private sector enables more resources for patients, which indicates that sexual issues can be evaluated more thoroughly. This strength was also related to the private sector’s flexibility to refer to any sex therapist, while physicians in the public sector are restricted to referring to only certain ones. Weaknesses Weaknesses consisted of three main themes: “Ignorance,” “Confusion about the protocols,” and “Attitudes.” Each main theme included also three subthemes. (Table 2 .) In the theme “Ignorance” the participants mentioned deficiencies in medical education , which referred to the issue that basic medical education does not include enough knowledge for assessing sexual issues or skills to talk about sexuality with patients. Also, limited knowledge of sex therapy was emphasized, as in general, physicians do not have sufficient valid information about sex therapy itself as a healthcare service. In other words, physicians do not understand the outlines of sex therapy, and such therapeutic interventions are unfamiliar to physicians. “ Then… We don’t really dare to bring it (sexuality) up or ask about it, especially if we are not totally sure how it might actually help the patient. ” (03) Another weakness, lack of professional networking , was emphasized by the participants. Even though physicians generally have good networks, these networks do not usually include sex therapists. This increases the challenges in the assessment process of referral to sex therapy, as physicians do not have the necessary professionals to consult. In the theme “Confusion about the protocols” participants described the general confusion about the referral protocol process. Physicians don’t have any guidance about the content of referrals to sex therapy. This refers to the content of the written documentation in the referral. In addition, physicians are confused about the costs ; they are unclear about the structure of the costs of sex therapy—are patients expected to pay for themselves, or is sex therapy under some financial support system (e.g., a national system)? Finally, the participants noted that there is general confusion about the benefits of sex therapy , which refers to valid information about the treatment itself, which decreases physicians’ abilities to assess the referrals. “… if you never find out whether any of the patients actually went or got anything out of it, of course, that makes you less likely to keep referring others ” (06) In the theme “Attitudes” participants suggested that a possible reason behind the weakness in addressing sexuality is the uncertainty of their own competence in discussing sexual issues with patients. They felt that paying attention to patients’ sexuality often depends too much on the physician’s personal interest. However, in general, some physicians feel that addressing sexuality and focusing on sexual issues can cause reputational damage to their professional image. Because of this stigma and assumptions , sexuality continues to be seen as a taboo topic. “… is it like good quality medicine to guide patients to sex therapy? ” (10) Finally, as a weakness, the participants highlighted prioritization of care , which indicates that the care of general sicknesses, such as somatic issues, is considered more common and more concrete for physicians, while addressing sexuality remains a lower priority. This means that physicians are expecting patients to take responsibility for their sexual concerns themselves, e.g., addressing sexuality with physicians. Opportunities Opportunities consisted of two main themes: “Knowledge supporting the professional community” and “Sex therapy as a form of treatment.” The main theme “Information supporting the professional community” included two subthemes and the main theme “Sex therapy as a form of treatment” included four subthemes. (Table 2 .) In the theme “Knowledge supporting the professional community” the participants suggested that further education for physicians should include multiple elements of addressing sexuality and sexual issues. They also hoped that knowledge of sex therapy would be added to medical education, or that it should have a solid role in continuing education for healthcare professionals. This could help physicians assess referrals to sex therapy and adapt them so they become more fluent. “ Yeah just like…what kinds of things it (sex therapy) can be used for? Or even just basic info about what sex therapy actually is. ” (11) The participants also emphasized the increased ability of patients to address sexual challenges directly with physicians and even to ask for a referral to sex therapy as an opportunity. They argued that this may be connected to wider increased awareness of sexuality , e.g., via social media, where, for example, the publications of other physicians and sexologists can be easily found. Additionally, the meaning of sex education was underlined by the participants, who stated that, in general, there is a growing need to understand sexuality as a meaningful part of humanity. In the theme “Sex therapy as a form of treatment” the participants suggested that, in the future, there should be an opportunity to create structured guidance on the assessment of referrals to sex therapy. This could enhance sex therapy to become a concrete element of treatment recommendation and in treatment processes, while indicating the more reliable role of sex therapy. However, the participant also stated that sex therapists should “make more noise” themselves, which can lead to better awareness of sex therapy, thus making the process of assessing referrals to sex therapy easier. “ Like, maybe something more targeted (guidance)—like, a ‘here is what is available in your area’ list. ” (02) According to the participants, another opportunity in the future would be the development of a multidisciplinary network , because sexuality will become increasingly difficult to ignore. This development is dependent on the adequacy of resources , which reflects on whether the implementation of sex therapy is realistic if the actual referral has been made. The participants described that there will be good availability of sex therapy, as there is a decent number of sex therapists, at least in the private sector. Finally, the participants underlined that in general, improving patients’ access to sex therapy requires the common motivation of physicians and patients. Therefore, the possibility of access to sex therapy should be offered through a referral at the right time, when patients can truly benefit from it. Threats Threats consisted of two main themes: “Resources” and “Lacks in healthcare services.” The main theme “Resources” included three subthemes and the main theme “Lack in healthcare services” included two subthemes. (Table 2 .) In the theme “Resources” participants perceived as a future threat concerning the assessment process of referrals for sex therapy. This threat focused on the public sector , where a lack of resources can decrease physicians’ possibilities to assess referrals to sex therapy. In addition, money was identified as a meaningful threat within the overall resource allocation, if the patients do not have sufficient financial support for sex therapy or sex therapy is not included in the terms of health insurance. “ The main challenge is patients’ financial challenges. ” (18) The participants also underlined the use of time , especially being busy or in a hurry, which can challenge physicians’ ability to implement a valid assessment of referral for sex therapy. This means that a pervading sense of busyness or organizational hurry creates a vicious circle, where physicians focus only on the main illness, and the initiative to address sexuality is overshadowed by time constraints. In the theme “Lacks in healthcare services” participants noted, if a lack of care pathways continues to exist in the future, it will threaten the valid assessment process of referrals to sex therapy. These threats can be highlighted regionally, which increases the unequal opportunities of patients receiving sex therapy as a treatment. Additionally, there can be uncertainty in terms of safety and the quality of the service producers , especially because the role of sex therapist is not a licenced profession. This can threaten the confidence of the physicians in sex therapy as a form of treatment. Besides, participants identified as a realistic threat, referring to the physician and patient’s fear and shame in addressing sexuality. As a finding, the themes related to sexuality and gender are met not only with silence but even with negativity or hostility. “ At best, physicians just kind of ignore it (patients’ sexuality), but at worst they start making jokes about it. ” (15) In addition, the participants raised the concern that the world is becoming more conservative. At the same time, cultural diversity can increase challenges in terms of language barriers and create assumptions that questions about sexuality are no longer needed. Discussion The findings of this study indicate various elements that may be connected to the assessment of referral for sex therapy. As an entity, the findings reflect challenge-dominance (weakness and threat) in the referrals’ assessment, which may mean that there are limits to patients’ opportunities to receive a referral to sex therapy. The main challenges were connected to negative attitudes and presumptions among physicians, and the existing lack of current knowledge about sexual issues and sex therapy. However, some issues, such as working in the private sector (strength and opportunity), were described from a positive perspective as well, which may lower the threshold for addressing sexuality with patients and providing assessing referrals to sex therapy. Previous research has underlined physicians’ poor knowledge about sexuality and sexual issues [ 36 – 37 ] and sexual counseling [ 38 ], which in this study reflects the theme “Ignorance” and acts as a weakness when physicians are assessing referrals to sex therapy. As this theme presents and other research supports, sexology is lacking in basic medical education [ 36 , 39 ]. However, according to this study, the lack of knowledge may turn into a strength (“the role of the work”) if the physicians want to have continuing education on sexology or if they are personally interested in valid knowledge about sexuality, which may enable them to assess referrals for sex therapy. Educational strength is supported by Verrasto et al. [ 40 ] and Igerc & Screms [ 2 ], who argue that sexuality needs to be more focused on both basic and continuing medical education. In that way, physicians can gain more competence to address sexual issues with patients [ 2 , 40 ], and, underlining the current study, patients may have more opportunities to enroll in sex therapy. The theme “Attitude” in this study warrants emphasis because it is supported by results from several other studies that identify significant challenges in physicians’ attitudes toward addressing sexuality and sexual issues with patients [ 2 , 7 ]. This reflects the finding that physicians are uncertain and feel shame and fear when addressing sexuality with patients [ 2 , 41 ]. These results are concerning because patients wait for healthcare professionals to address these issues with them [ 2 , 42 ]. According to the Igerc and Screms [ 2 ], the patients have expressed even the actual need of provided referral to sexologist in some cases. However, according to the theme “Attitude” in this study, physicians may assume that patients should be responsible for addressing sexuality themselves. This may lead to a situation where no one addresses it during appointments with physicians, and referrals to sex therapy may not even be assessed. Another meaningful element in the theme “Attitude” was that, according to the participants, the care of traditional illnesses may overshadow the need to address sexuality, and in that way decrease the possible assessment of referral for sex therapy. This phenomenon is supported by Ramlachan & Naidoo [ 43 ], who discuss inadequate prioritization of competence among physicians regarding sexual issues. This is a clear weakness, together with the issue that sexuality and sexual health are difficult topics to address and assess, not to mention providing referrals for sex therapy. One interesting theme in terms of weaknesses was “Confusion about protocols,” which revealed that physicians find sex therapy and protocols related to it relatively unknown treatment possibilities. This naturally creates a situation where physicians are unable to assess even the possibility of referral for sex therapy, because the role of the treatment is invisible— the role of sex therapy is still quite vague [ 44 ]. However, the participants of this study suggested that there may be an opportunity (“sex therapy as a form of treatment”) to have sex therapy as a solid part of the treatment recommendation in the future. This theme is supported by the research of Manninen et al. [ 15 ], who argue that sexual advice should play a clear role in care processes. As a counterweight to opportunity, the participants of this study also described that future referral assessments are threatened by the fact that sex therapists are not licensed professionals (“lack of knowledge”). This insight is supported by Emelianchik-Key et al. [ 19 ], who discuss the lack of general standards for sex therapy and the negative effect this has on the treatment of sexual health. A significant body of research has examined the relationship between the private and public health sectors, concluding that the private sector is more supportive of patients' access to treatment [ 45 – 47 ]. Supportiveness is linked to resources, as this study also highlights. Further, this study argues that the private sector as an employer enables physicians to assess sexual health and implement referrals to sex therapy validly. However, these resources may not be enough in the future if the costs of sex therapy are totally self-funded by patients. This can cause a paradoxical situation where the availability of sex therapy is good, but individuals cannot afford sex therapy, even though they have had a referral. These findings reveal the need for the promotion of sexuality and an open discussion within healthcare organizations. In other words, the general awareness of sexuality needs to be increased, which can be seen as a promising opportunity for patients to have referrals for sex therapy. It is noteworthy that comparable findings have been observed globally earlier, as several other researchers [ 48 – 49 ] argue that awareness of sexual issues should be emphasized in the future because it supports individual rights, for example. However, participants also suggested the possibility of the opposite effect as a threat: if societies turn towards conservative values, this can raise negative assumptions towards sex therapy, as is already the case [ 50 ]. Finally, the researchers wish to conclude that addressing or discussing sexuality, or providing basic counselling may enhance patient's wellbeing in some situations, which means that referrals may not always be necessary. This refers to the PLISSIT framework, which emphasizes that sex therapy should be considered for and directed toward individuals who can participate in and benefit from a therapeutic relationship [ 17 ]. This reflects the importance of the assessment process of referrals for sex therapy so that the possibility of sex therapy meets the professional assessment of the physicians, as well as the motivation of individuals. In that way, the individual may have the necessary preparedness for a deep and long-term therapeutic relationship related to sexual issues with a sex therapist. Limitations and trustworthiness The findings of this study should be critically examined from a trustworthiness perspective for several reasons [ 51 ]. First, this study was conducted in Finland, and contextual factors, such as democratic values, may be relevant. This can be considered more precisely, for example, in discussions related to the public and private health sectors. Secondly, the sample size (n = 20) was moderate for individual interviews, although it can be argued that this was sufficient and saturated for a deep understanding of the research questions [ 30 ]z. Thirdly, individual interviews as a method should be critically considered, as the interviewer's role may have significantly influenced the interviews. On the other hand, the interviewer reflected on each interview and remained objective. It is also notable that the interviews were semi-structured and allowed open-ended responses, which deepened the content of the responses. In addition, the first author discussed the findings with research group throughout the analysis process, which confirmed their validity. Conclusion In conclusion, the findings reveal that it seems that physicians do not heglinave sufficient knowledge of the benefits of sex therapy, which may be connected to general ignorance of sexuality itself in medical education. Confusion regarding the referral process and the invisible role of sex therapy as a beneficial treatment are also preventing patients from accessing referrals to sex therapy. Finally, this study emphasized that the responsibility for addressing sexuality needs to be clarified with physicians, as sexuality is an important part of people’s wellbeing. Without this change in culture, sexual challenges will remain undertreated and a patient’s care will be incomplete In the future, researchers should focus on the advantages of sex therapy and explore what physicians truly understand about it and its benefits. Another key area should be establishing valid treatment guidelines for sex therapy, which would help validate it as an effective treatment for patients. Declarations Ethics approval and consent to participate This study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki [ 52 ]. Before implementing the study, ethical approval was granted by the Ethics Committee at the University of Applied Sciences (South-Eastern Finland University of Applied Sciences 1/2025, supplementary data). Consent for publication Not applicable. Funding No funding was received. Author Contribution SA was the major contributor in this manuscript with following roles: conceptualization, data curation, formal analysis, investigation, methodology, writing original draft, writing, reviewing and editing. MA’s role was partly the same with SA, but more narrowed with the following roles: conceptualization, form analysis, investigation, resources, writing, reviewing and editing. HK contributed in following roles: investigation, form analysis, resources and writing. LS and M-LR contributions were mainly supervisors with following roles: supervision, form analysis , project administration, writing, reviewing, editing and final approval of version to be published. All authors have approved the manuscript for submission. Acknowledgements Not applicable. Data Availability The datasets generated and analysed during the current study are not publicly available due considerations of the university, but are available from the corresponding author on reasonable request. References Aromaa A, Polo-Kantola P, Manninen S-M, Grönlund J, Riskumäki M, Vahlberg T, Kero K. Attitudes and practice patterns of Finnish obstetrician-gynecologists regarding patients’ sexual problems. Maturitas. 2024;185(107993):1–9. https://doi.org/10.1016/j.maturitas.2024.107993 . Igerc I, Screms B. (2023). Sexual well-being needs of patients with chronic illness expressed in health care: A scoping review. Journal of Clinical Nursing. 2023; 32:19–20: 6832–6848. https://doi.org/10.1111/jocn.16773 WHO, World Health Organization. High-value referrals: learning from challenges and opportunities of the COVID-19 pandemic. Concept paper. Copenhagen: WHO Regional Office for Europe. 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Qualitative content analysis in nursing research: concepts, procedures and measures to achieve trustworthiness. Nurse Educ Today. 2004;24(2):105–12. https://doi.org/10.1016/J.NEDT.2003.10.001 . World Medical Association. World Medical Association Declaration of Helsinki: Ethical principles for medical research involving human subjects. 2024. Retrieved from https://www.wma.net/policies-post/wma-declaration-of-helsinki/' Accessed 02.01.2025. Additional Declarations No competing interests reported. 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analysis","fulltext":[{"header":"Background","content":"\u003cp\u003eDiscussing sexuality and sexual health with patients is often difficult for healthcare professionals [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. This may reflect the fact that sexuality is a base part of humanity, with multiple dimensions that encompass all areas of human life, including emotions, self-expression and identity [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. However, humans have always a need to have accurate information about issues related to sexuality [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e]. Moreover, challenges related to sexuality may influence wellbeing in unexpected ways, such as challenges in mental health [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. These challenges can also be connected to several health issues, which can cause sexual dysfunction or decrease sexual desire [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAccording to earlier research, there is often a lack of knowledge about sexuality provided to patients in healthcare settings [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Healthcare professionals, especially physicians, should be able to identify the need for help and support for sexual health and sexuality related issues in patients, even though providing more precise care may not always be possible due to time constraints or resources [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. As a minimum healthcare professionals should have the knowledge to be able to offer sex therapy when it is justified in patient care [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSex therapy is a form of therapy that focuses on patients\u0026rsquo; sexuality and utilizes therapeutic interventions to solve sexual challenges [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e]. It is an effective form of therapy for patients with sexual dysfunction, among others [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e]. Despite the possible effectiveness, there is a lack of evidence-based knowledge about the availability of sex therapy, which can make it difficult for patients to access services [\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Physicians have key role in assessing the need for sex therapy and both guiding and referring patients to the appropriate clinical treatment [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. However, medical education does not have a structured content in curricula for sexology or detailed sexual issues [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. In Finland, for instance, the content of medical education curriculum and the scope of teaching are determined independently by each university, which has led to situation, where there is no structural framework for teaching sexual issues in medical education [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Moreover, the Directive of European Parliament and of the Council [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] regulating physicians\u0026rsquo; professional qualifications does not include any reference to competence in sexual health.\u003c/p\u003e \u003cp\u003eThis study analyzed the knowledge about how physicians describe the internal (strengths and weaknesses) and external dimensions (opportunities and threats) concerning the assessment of referral to sex therapy. The findings of this study can be used to provide physicians with a deeper understanding of current issues related to the referral process in medical education and continuing professional development. They may also be better equipped to address sexuality and more accurately assess the possible need for sex therapy.\u003c/p\u003e\n\u003ch3\u003eSex therapy and therapists\u003c/h3\u003e\n\u003cp\u003eSex therapy is a therapeutic treatment, which can be seen as the final and deepest form of the commonly referred framework \u0026ldquo;Permission, LImited Information, Specific Suggestions and Intensive Therapy (PLISSIT),\u0026rdquo; which describes the phases of the treatment of sexual wellbeing [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eSex therapy treats adult patients in every age group, and it can be connected to the treatment of different illnesses [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Sex therapy is a broad concept because it encompasses several therapeutic and medical elements in multiple contexts, such as the effect of cultural elements on sensitive sexual issues or sicknesses [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFrom educational perspective, there are several ways to train as a sex therapist or counselor [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. However, there is a lack of global standards for qualifications in sex therapy [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e]. Efforts to standardize training and requirements for sex therapists include the Nordic Sexology Education and Authorization scheme [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. For example, in Finland, a sex therapist may be accredited by the Nordic Association for Clinical Sexology (NACS) after completing 60 ECTs [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eTheoretical framework\u003c/h2\u003e \u003cp\u003eThe theoretical framework of this study was the \u0026ldquo;strengths, weaknesses, opportunities, and threats\u0026rdquo; (hereafter SWOT) framework [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. SWOT is divided into two dimensions: internal and external. The internal dimension includes strengths and weaknesses, while the external dimensions consist of opportunities and threats. Essentially, SWOT creates a framework that examines the influencing elements in the actual context of that moment (e.g., physicians\u0026rsquo; work) and those that may influence outside the context in the future (e.g., patients\u0026rsquo; knowledge) [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Generally, SWOT is a widely used framework in economic research relating to business or company operations [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e], but it can be seen as a useful framework in healthcare as well [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eIn healthcare, SWOT has been utilized in the evaluation of early hearing detection and intervention [\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e] and implementation of patient safety in medical education [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Moreover, SWOT has been utilized in medical education by Woratanarat \u0026amp; Woratanarat [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e], who evaluated \u0026ldquo;good\u0026rdquo; physicians\u0026rsquo; attributes and underlines that SWOT is not limited to organizational strategy, but can also serve an analytical tool for examining professional behaviors and attributes. In this study, SWOT provides a structured framework for examining the internal and external dimensions of physician perspectives, while remaining flexible enough to support a deep analysis of the case. Basically, this means that physicians\u0026rsquo; perspectives of referrals practices encompass both negative and positive aspects. In addition, SWOT provides a framework, which can be adapted for qualitative research [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy aims and design\u003c/h3\u003e\n\u003cp\u003eThe aim of this study is to describe the perspectives of physicians when assessing the need for a referral for sex therapy. This qualitative study design was conducted using individual semi-structured interviews. Four research questions guided this study:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eWhat factors do physicians describe as strengths when they assess the need for referrals to sex therapy?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eWhat factors do physicians describe as weaknesses when they assess the need for referrals to sex therapy?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eWhat factors do physicians describe as opportunities when they assess the need for referrals to sex therapy?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eWhat factors do physicians describe as threats when they assess the need for referrals to sex therapy?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e\n\u003ch3\u003eParticipants and recruitment\u003c/h3\u003e\n\u003cp\u003eParticipants were licensed physicians (n\u0026thinsp;=\u0026thinsp;20) working in the public and/or private health sectors in Finland. The inclusion criteria for participants were as follows: 1) licensed physician in Finland, 2) willingness to participate in this study, and 3) specialization in general medicine, obstetrics and gynecology, urology, and occupational health. The participants were recruited by the first author using purposive sampling to obtain a sample as appropriate as possible for the study's aims and questions [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. The sample size was deemed sufficient for this qualitative study because all participants represented the same professional groups [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e].\u003c/p\u003e"},{"header":"Data collection","content":"\u003cp\u003eThe data was collected between February and May 2025 through individual semi-structured interviews. The interview framework was developed to this study, even though it followed the structure of the SWOT and still allowing for a more open and flexible discussion of the topic (supplementary data). The first author conducted all the interviews (n\u0026thinsp;=\u0026thinsp;20) via Teams. Data saturation was reached after these interviews. As background information, the physicians were asked about their experience, specialties, working sector, and if they had made any referrals to sex therapy. The interviews were recorded and transcribed immediately using Teams. After each interview, the researcher verified the written transcription and destroyed the voice recordings. Each interview lasted between 20 and 45 minutes.\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eThe data were analyzed deductively using thematic analysis, guided by a SWOT analysis [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. The thematic analysis was conducted in five different phases [\u003cspan additionalcitationids=\"CR32\" citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Firstly, the compilation phase included the creation of the written data [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. Secondly, the disassembly phase consisted of pre-coding, and similarities were identified based on the SWOT factors [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. This meant that the factors guided the content of the meaning unit, which was essentially a sentence or expression referring to a SWOT factor and a referral to sex therapy [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Thirdly, in the reassembly phase, these codes were gathered under each factor (strengths, weaknesses, opportunities, and threats), and themes and subthemes were created deductively [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Fourthly, in the interpretation phase, the researcher examined the relationship between themes and subthemes with the help of a thematic map of all factors, themes, and subthemes related to those factors [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. In this phase, the researcher ensured that the themes were described using the SWOT framework [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Finally, in the conclusion phase, the themes and subthemes were defined in their final form and examined in relation to the research questions [\u003cspan additionalcitationids=\"CR32\" citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e]. In this phase, the first author decided to use certain direct quotes from the data. A more precise description of the data analysis is provided in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAn example of the process of the thematic analysis.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDimension\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eInternal\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eExternal\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFactor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eStrength\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWeakness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eOpportunity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eThreat\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eExamples from the original data\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;And later they (patient) came back to say thank you - said they were really happy with it\u0026rdquo;\u003c/em\u003e (19)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eNot much is known about it (sex therapy), so people don\u0026rsquo;t really know how to guide anyone there\u003c/em\u003e\u0026rdquo; (01)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u003cem\u003e\u0026ldquo;If we could just get that kind of down-to-earth sex ed out there\u0026mdash;the kind sex therapists do too\u0026mdash;we could prevent so much stuff before it even gets to the point where someone needs sex therapy\u0026rdquo;\u003c/em\u003e (07)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026ldquo;\u0026hellip;. \u003cem\u003ethis whole lack of reliable professional registry\u003c/em\u003e\u0026rdquo; (09)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCode\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePositive feedback\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eInsufficient training in sexology was provided\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eThe importance of sexual education is emphasized\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSex therapy is not a protected regulated profession, which challenges trust\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSubtheme\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eA good relationship between the patient and the physician\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLimited knowledge of sex therapy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eThe increased awareness of sexuality\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eThe quality of the service producers\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTheme\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOpenness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIgnorance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eKnowledge supporting the professional community\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eLacks in healthcare services\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eEthical considerations\u003c/h2\u003e \u003cp\u003e The study followed ethical guidelines throughout the entire process. Before implementing the study, ethical approval was granted by the Ethics Committee at the University of Applied Sciences (South-Eastern Finland University of Applied Sciences 1/2025, supplementary data). Each participant was informed about the research, and before interviews they gave informed consent by typing it to the teams, which were restored. Participants were informed that they could withdraw from the study at any time without providing a reason. The demographic data, which was collected, concerned work-experience, specialty, working place (public or private) and if they have made a referral to sex therapy. Other sociodemographic data\u0026mdash;for example, age or gender\u0026mdash;was not collected, as this was considered irrelevant to the aims of the study. [34.]\u003c/p\u003e \u003c/div\u003e"},{"header":"Findings","content":"\u003cp\u003eDuring the process, the \u0026ldquo;consolidated criteria for reporting qualitative research (COREQ)\u0026rdquo; has been utilized [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e]. The participants (N\u0026thinsp;=\u0026thinsp;20) were specialists in general medicine, obstetrics and gynecology, urology, and occupational health. They had between 5 and 30 years of work experience and worked in both the private and public healthcare sectors. Fourteen (n\u0026thinsp;=\u0026thinsp;14) of them had made a referral or guided patients to sex therapy.\u003c/p\u003e \u003cp\u003eAs a finding, this study presents themes and subthemes that describe the strengths and weaknesses (internal dimension) and opportunities and threats (external dimension) of participants\u0026rsquo; perspectives. These themes and subthemes reflect the current state (internal dimension) of the assessment of referrals to sex therapy as well as the issues (external dimension) that may relate in the future to the assessment process (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The descriptions of the themes and their related subthemes are shown in Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eThe description of the themes and subthemes related to SWOT\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDimension\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMain themes\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSubthemes\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStrength\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eOpenness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eUnderstanding the significance of sexuality\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eA good relationship between the patient and the physician\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMultidisciplinarity\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eThe role of the work\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eProfessional growth\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePrivate sector as an employer\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWeakness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIgnorance\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eDeficiencies in medical education\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLimited knowledge of sex therapy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLack of professional networking\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eConfusion about the protocols\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eConfusion about referral protocols\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eConfusion about costs\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eConfusion about the benefits of the sex therapy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAttitudes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAddressing sexuality\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStigma and assumptions\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePrioritization of care\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOpportunity\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eKnowledge supporting the professional community\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFurther education\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eIncreased awareness of sexuality\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSex therapy as a form of treatment\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThe role of sex therapy\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMultidisciplinary network\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAdequacy of resources\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMotivation\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eThreat\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eResources\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePublic sector\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eMoney\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThe use of time\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLacks in healthcare services\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThe lack of care pathways\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eThe quality of the service producers\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e[Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e near here]\u003c/p\u003e\n\u003ch3\u003eStrengths\u003c/h3\u003e\n\u003cp\u003eStrengths consisted of two main themes: \u0026ldquo;Openness\u0026rdquo; and \u0026ldquo;The role of the work.\u0026rdquo; \u0026ldquo;Openness\u0026rdquo; included three subthemes and \u0026ldquo;The role of the work\u0026rdquo; included two subthemes. (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.)\u003c/p\u003e \u003cp\u003eIn the theme \u0026ldquo;Openness\u0026rdquo; the role of sexuality was generally understood among participants, while they underlined the importance of \u003cem\u003eunderstanding the significance of sexuality\u003c/em\u003e. They were aware of the possibility of making a referral, even if they had never actually done so. Another strength that participants highlighted was \u003cem\u003ea good relationship between the patient and the physician\u003c/em\u003e, which indicates a more fluent assessment process of referral for sex therapy. In this kind of open and transparent relationship between physician and patient, both parties are equal, and they can talk honestly about sensitive issues like sexuality. This creates a situation where addressing sexuality is easier for the physician and enables a valid and comprehensive assessment of the referral for sex therapy. In addition, \u003cem\u003emultidisciplinarity\u003c/em\u003e, in this case, good co-operation with sex therapists, was underlined as a strength when physicians are assessing the referral for sex therapy. The participants noted that the professional view of sex therapists can be vital to the assessment of the referral to sex therapy, especially if the sex therapist is familiar to the physician. According to the participants, this lowers the threshold for physicians to implement a consultancy and enables them to conduct referrals more easily.\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eHonest collaboration should be the baseline, no one can do it all alone and definitely not when we are talking about things like this.\u003c/em\u003e\u0026rdquo; (05)\u003c/p\u003e \u003cp\u003eIn the theme \u0026ldquo;The role of the work\u0026rdquo; participants described \u003cem\u003eprofessional growth\u003c/em\u003e, such as continuing education in sexual medicine or even sexual advisors or sex therapists\u0026rsquo; degrees, as a strength. This training enables physicians to gain a more valid perspective to evaluate referrals for sex therapy. In addition, the physicians may have personal interests in sexology, which can help inform the assessment of the referral. Additionally, besides the educational element, participants explained that long working experience was connected to a more fluent process of assessment of sexual issues, whereby physicians are more self-confident in addressing sexuality.\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eLife has just kind of taught me along the way and I have always been curious\u003c/em\u003e\u0026rdquo; (01)\u003c/p\u003e \u003cp\u003e \u003cem\u003eThe private sector as an employer\u003c/em\u003e was underlined in this study. According to the participants, the private sector enables more resources for patients, which indicates that sexual issues can be evaluated more thoroughly. This strength was also related to the private sector\u0026rsquo;s flexibility to refer to any sex therapist, while physicians in the public sector are restricted to referring to only certain ones.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eWeaknesses\u003c/h2\u003e \u003cp\u003eWeaknesses consisted of three main themes: \u0026ldquo;Ignorance,\u0026rdquo; \u0026ldquo;Confusion about the protocols,\u0026rdquo; and \u0026ldquo;Attitudes.\u0026rdquo; Each main theme included also three subthemes. (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.)\u003c/p\u003e \u003cp\u003eIn the theme \u0026ldquo;Ignorance\u0026rdquo; the participants mentioned \u003cem\u003edeficiencies in medical education\u003c/em\u003e, which referred to the issue that basic medical education does not include enough knowledge for assessing sexual issues or skills to talk about sexuality with patients. Also, \u003cem\u003elimited knowledge of sex therapy\u003c/em\u003e was emphasized, as in general, physicians do not have sufficient valid information about sex therapy itself as a healthcare service. In other words, physicians do not understand the outlines of sex therapy, and such therapeutic interventions are unfamiliar to physicians.\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eThen\u0026hellip; We don\u0026rsquo;t really dare to bring it (sexuality) up or ask about it, especially if we are not totally sure how it might actually help the patient.\u003c/em\u003e\u0026rdquo; (03)\u003c/p\u003e \u003cp\u003eAnother weakness, \u003cem\u003elack of professional networking\u003c/em\u003e, was emphasized by the participants. Even though physicians generally have good networks, these networks do not usually include sex therapists. This increases the challenges in the assessment process of referral to sex therapy, as physicians do not have the necessary professionals to consult.\u003c/p\u003e \u003cp\u003eIn the theme \u0026ldquo;Confusion about the protocols\u0026rdquo; participants described the general \u003cem\u003econfusion about the referral protocol\u003c/em\u003e process. Physicians don\u0026rsquo;t have any guidance about the content of referrals to sex therapy. This refers to the content of the written documentation in the referral. In addition, physicians are \u003cem\u003econfused about the costs\u003c/em\u003e; they are unclear about the structure of the costs of sex therapy\u0026mdash;are patients expected to pay for themselves, or is sex therapy under some financial support system (e.g., a national system)? Finally, the participants noted that there is general \u003cem\u003econfusion about the benefits of sex therapy\u003c/em\u003e, which refers to valid information about the treatment itself, which decreases physicians\u0026rsquo; abilities to assess the referrals.\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u0026hellip;\u003cem\u003eif you never find out whether any of the patients actually went or got anything out of it, of course, that makes you less likely to keep referring others\u003c/em\u003e\u0026rdquo; (06)\u003c/p\u003e \u003cp\u003eIn the theme \u0026ldquo;Attitudes\u0026rdquo; participants suggested that a possible reason behind the weakness in \u003cem\u003eaddressing sexuality\u003c/em\u003e is the uncertainty of their own competence in discussing sexual issues with patients. They felt that paying attention to patients\u0026rsquo; sexuality often depends too much on the physician\u0026rsquo;s personal interest. However, in general, some physicians feel that addressing sexuality and focusing on sexual issues can cause reputational damage to their professional image. Because of this \u003cem\u003estigma and assumptions\u003c/em\u003e, sexuality continues to be seen as a taboo topic.\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u0026hellip;\u003cem\u003eis it like good quality medicine to guide patients to sex therapy?\u003c/em\u003e\u0026rdquo; (10)\u003c/p\u003e \u003cp\u003eFinally, as a weakness, the participants highlighted \u003cem\u003eprioritization of care\u003c/em\u003e, which indicates that the care of general sicknesses, such as somatic issues, is considered more common and more concrete for physicians, while addressing sexuality remains a lower priority. This means that physicians are expecting patients to take responsibility for their sexual concerns themselves, e.g., addressing sexuality with physicians.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eOpportunities\u003c/h2\u003e \u003cp\u003eOpportunities consisted of two main themes: \u0026ldquo;Knowledge supporting the professional community\u0026rdquo; and \u0026ldquo;Sex therapy as a form of treatment.\u0026rdquo; The main theme \u0026ldquo;Information supporting the professional community\u0026rdquo; included two subthemes and the main theme \u0026ldquo;Sex therapy as a form of treatment\u0026rdquo; included four subthemes. (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.)\u003c/p\u003e \u003cp\u003eIn the theme \u0026ldquo;Knowledge supporting the professional community\u0026rdquo; the participants suggested that \u003cem\u003efurther education\u003c/em\u003e for physicians should include multiple elements of addressing sexuality and sexual issues. They also hoped that knowledge of sex therapy would be added to medical education, or that it should have a solid role in continuing education for healthcare professionals. This could help physicians assess referrals to sex therapy and adapt them so they become more fluent.\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eYeah just like\u0026hellip;what kinds of things it (sex therapy) can be used for? Or even just basic info about what sex therapy actually is.\u003c/em\u003e\u0026rdquo; (11)\u003c/p\u003e \u003cp\u003e The participants also emphasized the increased ability of patients to address sexual challenges directly with physicians and even to ask for a referral to sex therapy as an opportunity. They argued that this may be connected to wider \u003cem\u003eincreased awareness of sexuality\u003c/em\u003e, e.g., via social media, where, for example, the publications of other physicians and sexologists can be easily found. Additionally, the meaning of sex education was underlined by the participants, who stated that, in general, there is a growing need to understand sexuality as a meaningful part of humanity.\u003c/p\u003e \u003cp\u003e In the theme \u0026ldquo;Sex therapy as a form of treatment\u0026rdquo; the participants suggested that, in the future, there should be an opportunity to create structured guidance on the assessment of referrals to sex therapy. This could enhance sex therapy to become a concrete element of treatment recommendation and in treatment processes, while indicating the more reliable \u003cem\u003erole of sex therapy.\u003c/em\u003e However, the participant also stated that sex therapists should \u0026ldquo;make more noise\u0026rdquo; themselves, which can lead to better awareness of sex therapy, thus making the process of assessing referrals to sex therapy easier.\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eLike, maybe something more targeted (guidance)\u0026mdash;like, a \u0026lsquo;here is what is available in your area\u0026rsquo; list.\u003c/em\u003e\u0026rdquo; (02)\u003c/p\u003e \u003cp\u003eAccording to the participants, another opportunity in the future would be the development of a \u003cem\u003emultidisciplinary network\u003c/em\u003e, because sexuality will become increasingly difficult to ignore. This development is dependent on \u003cem\u003ethe adequacy of resources\u003c/em\u003e, which reflects on whether the implementation of sex therapy is realistic if the actual referral has been made. The participants described that there will be good availability of sex therapy, as there is a decent number of sex therapists, at least in the private sector. Finally, the participants underlined that in general, improving patients\u0026rsquo; access to sex therapy requires the common \u003cem\u003emotivation\u003c/em\u003e of physicians and patients. Therefore, the possibility of access to sex therapy should be offered through a referral at the right time, when patients can truly benefit from it.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eThreats\u003c/h2\u003e \u003cp\u003eThreats consisted of two main themes: \u0026ldquo;Resources\u0026rdquo; and \u0026ldquo;Lacks in healthcare services.\u0026rdquo; The main theme \u0026ldquo;Resources\u0026rdquo; included three subthemes and the main theme \u0026ldquo;Lack in healthcare services\u0026rdquo; included two subthemes. (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e.)\u003c/p\u003e \u003cp\u003e In the theme \u0026ldquo;Resources\u0026rdquo; participants perceived as a future threat concerning the assessment process of referrals for sex therapy. This threat focused on the \u003cem\u003epublic sector\u003c/em\u003e, where a lack of resources can decrease physicians\u0026rsquo; possibilities to assess referrals to sex therapy. In addition, \u003cem\u003emoney\u003c/em\u003e was identified as a meaningful threat within the overall resource allocation, if the patients do not have sufficient financial support for sex therapy or sex therapy is not included in the terms of health insurance.\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eThe main challenge is patients\u0026rsquo; financial challenges.\u003c/em\u003e\u0026rdquo; (18)\u003c/p\u003e \u003cp\u003eThe participants also underlined \u003cem\u003ethe use of time\u003c/em\u003e, especially being busy or in a hurry, which can challenge physicians\u0026rsquo; ability to implement a valid assessment of referral for sex therapy. This means that a pervading sense of busyness or organizational hurry creates a vicious circle, where physicians focus only on the main illness, and the initiative to address sexuality is overshadowed by time constraints.\u003c/p\u003e \u003cp\u003eIn the theme \u0026ldquo;Lacks in healthcare services\u0026rdquo; participants noted, if a \u003cem\u003elack of care pathways\u003c/em\u003e continues to exist in the future, it will threaten the valid assessment process of referrals to sex therapy. These threats can be highlighted regionally, which increases the unequal opportunities of patients receiving sex therapy as a treatment. Additionally, there can be uncertainty in terms of safety and the \u003cem\u003equality of the service producers\u003c/em\u003e, especially because the role of sex therapist is not a licenced profession. This can threaten the confidence of the physicians in sex therapy as a form of treatment. Besides, participants identified as a realistic threat, referring to the physician and patient\u0026rsquo;s fear and shame in addressing sexuality. As a finding, the themes related to sexuality and gender are met not only with silence but even with negativity or hostility.\u003c/p\u003e \u003cp\u003e\u0026ldquo;\u003cem\u003eAt best, physicians just kind of ignore it\u003c/em\u003e (patients\u0026rsquo; sexuality), \u003cem\u003ebut at worst they start making jokes about it.\u003c/em\u003e\u0026rdquo; (15)\u003c/p\u003e \u003cp\u003eIn addition, the participants raised the concern that the world is becoming more conservative. At the same time, cultural diversity can increase challenges in terms of language barriers and create assumptions that questions about sexuality are no longer needed.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThe findings of this study indicate various elements that may be connected to the assessment of referral for sex therapy. As an entity, the findings reflect challenge-dominance (weakness and threat) in the referrals\u0026rsquo; assessment, which may mean that there are limits to patients\u0026rsquo; opportunities to receive a referral to sex therapy. The main challenges were connected to negative attitudes and presumptions among physicians, and the existing lack of current knowledge about sexual issues and sex therapy. However, some issues, such as working in the private sector (strength and opportunity), were described from a positive perspective as well, which may lower the threshold for addressing sexuality with patients and providing assessing referrals to sex therapy.\u003c/p\u003e \u003cp\u003ePrevious research has underlined physicians\u0026rsquo; poor knowledge about sexuality and sexual issues [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e] and sexual counseling [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e], which in this study reflects the theme \u0026ldquo;Ignorance\u0026rdquo; and acts as a weakness when physicians are assessing referrals to sex therapy. As this theme presents and other research supports, sexology is lacking in basic medical education [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. However, according to this study, the lack of knowledge may turn into a strength (\u0026ldquo;the role of the work\u0026rdquo;) if the physicians want to have continuing education on sexology or if they are personally interested in valid knowledge about sexuality, which may enable them to assess referrals for sex therapy. Educational strength is supported by Verrasto et al. [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e] and Igerc \u0026amp; Screms [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], who argue that sexuality needs to be more focused on both basic and continuing medical education. In that way, physicians can gain more competence to address sexual issues with patients [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e], and, underlining the current study, patients may have more opportunities to enroll in sex therapy.\u003c/p\u003e \u003cp\u003eThe theme \u0026ldquo;Attitude\u0026rdquo; in this study warrants emphasis because it is supported by results from several other studies that identify significant challenges in physicians\u0026rsquo; attitudes toward addressing sexuality and sexual issues with patients [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. This reflects the finding that physicians are uncertain and feel shame and fear when addressing sexuality with patients [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. These results are concerning because patients wait for healthcare professionals to address these issues with them [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. According to the Igerc and Screms [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e], the patients have expressed even the actual need of provided referral to sexologist in some cases. However, according to the theme \u0026ldquo;Attitude\u0026rdquo; in this study, physicians may assume that patients should be responsible for addressing sexuality themselves. This may lead to a situation where no one addresses it during appointments with physicians, and referrals to sex therapy may not even be assessed. Another meaningful element in the theme \u0026ldquo;Attitude\u0026rdquo; was that, according to the participants, the care of traditional illnesses may overshadow the need to address sexuality, and in that way decrease the possible assessment of referral for sex therapy. This phenomenon is supported by Ramlachan \u0026amp; Naidoo [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e], who discuss inadequate prioritization of competence among physicians regarding sexual issues. This is a clear weakness, together with the issue that sexuality and sexual health are difficult topics to address and assess, not to mention providing referrals for sex therapy.\u003c/p\u003e \u003cp\u003eOne interesting theme in terms of weaknesses was \u0026ldquo;Confusion about protocols,\u0026rdquo; which revealed that physicians find sex therapy and protocols related to it relatively unknown treatment possibilities. This naturally creates a situation where physicians are unable to assess even the possibility of referral for sex therapy, because the role of the treatment is invisible\u0026mdash; the role of sex therapy is still quite vague [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. However, the participants of this study suggested that there may be an opportunity (\u0026ldquo;sex therapy as a form of treatment\u0026rdquo;) to have sex therapy as a solid part of the treatment recommendation in the future. This theme is supported by the research of Manninen et al. [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e], who argue that sexual advice should play a clear role in care processes. As a counterweight to opportunity, the participants of this study also described that future referral assessments are threatened by the fact that sex therapists are not licensed professionals (\u0026ldquo;lack of knowledge\u0026rdquo;). This insight is supported by Emelianchik-Key et al. [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e], who discuss the lack of general standards for sex therapy and the negative effect this has on the treatment of sexual health.\u003c/p\u003e \u003cp\u003eA significant body of research has examined the relationship between the private and public health sectors, concluding that the private sector is more supportive of patients' access to treatment [\u003cspan additionalcitationids=\"CR46\" citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. Supportiveness is linked to resources, as this study also highlights. Further, this study argues that the private sector as an employer enables physicians to assess sexual health and implement referrals to sex therapy validly. However, these resources may not be enough in the future if the costs of sex therapy are totally self-funded by patients. This can cause a paradoxical situation where the availability of sex therapy is good, but individuals cannot afford sex therapy, even though they have had a referral.\u003c/p\u003e \u003cp\u003eThese findings reveal the need for the promotion of sexuality and an open discussion within healthcare organizations. In other words, the general awareness of sexuality needs to be increased, which can be seen as a promising opportunity for patients to have referrals for sex therapy. It is noteworthy that comparable findings have been observed globally earlier, as several other researchers [\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e] argue that awareness of sexual issues should be emphasized in the future because it supports individual rights, for example. However, participants also suggested the possibility of the opposite effect as a threat: if societies turn towards conservative values, this can raise negative assumptions towards sex therapy, as is already the case [\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eFinally, the researchers wish to conclude that addressing or discussing sexuality, or providing basic counselling may enhance patient's wellbeing in some situations, which means that referrals may not always be necessary. This refers to the PLISSIT framework, which emphasizes that sex therapy should be considered for and directed toward individuals who can participate in and benefit from a therapeutic relationship [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. This reflects the importance of the assessment process of referrals for sex therapy so that the possibility of sex therapy meets the professional assessment of the physicians, as well as the motivation of individuals. In that way, the individual may have the necessary preparedness for a deep and long-term therapeutic relationship related to sexual issues with a sex therapist.\u003c/p\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003eLimitations and trustworthiness\u003c/h2\u003e \u003cp\u003eThe findings of this study should be critically examined from a trustworthiness perspective for several reasons [\u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e]. First, this study was conducted in Finland, and contextual factors, such as democratic values, may be relevant. This can be considered more precisely, for example, in discussions related to the public and private health sectors. Secondly, the sample size (n\u0026thinsp;=\u0026thinsp;20) was moderate for individual interviews, although it can be argued that this was sufficient and saturated for a deep understanding of the research questions [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]z. Thirdly, individual interviews as a method should be critically considered, as the interviewer's role may have significantly influenced the interviews. On the other hand, the interviewer reflected on each interview and remained objective. It is also notable that the interviews were semi-structured and allowed open-ended responses, which deepened the content of the responses. In addition, the first author discussed the findings with research group throughout the analysis process, which confirmed their validity.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eIn conclusion, the findings reveal that it seems that physicians do not heglinave sufficient knowledge of the benefits of sex therapy, which may be connected to general ignorance of sexuality itself in medical education. Confusion regarding the referral process and the invisible role of sex therapy as a beneficial treatment are also preventing patients from accessing referrals to sex therapy. Finally, this study emphasized that the responsibility for addressing sexuality needs to be clarified with physicians, as sexuality is an important part of people\u0026rsquo;s wellbeing. Without this change in culture, sexual challenges will remain undertreated and a patient\u0026rsquo;s care will be incomplete\u003c/p\u003e \u003cp\u003eIn the future, researchers should focus on the advantages of sex therapy and explore what physicians truly understand about it and its benefits. Another key area should be establishing valid treatment guidelines for sex therapy, which would help validate it as an effective treatment for patients.\u003c/p\u003e"},{"header":"Declarations","content":" \u003cp\u003e \u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e \u003cp\u003eThis study was conducted in accordance with the ethical principles outlined in the Declaration of Helsinki [\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e]. Before implementing the study, ethical approval was granted by the Ethics Committee at the University of Applied Sciences (South-Eastern Finland University of Applied Sciences 1/2025, supplementary data).\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eConsent for publication\u003c/strong\u003e \u003cp\u003eNot applicable.\u003c/p\u003e \u003ch2\u003eFunding\u003c/h2\u003e \u003cp\u003eNo funding was received.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eSA was the major contributor in this manuscript with following roles: conceptualization, data curation, formal analysis, investigation, methodology, writing original draft, writing, reviewing and editing. MA\u0026rsquo;s role was partly the same with SA, but more narrowed with the following roles: conceptualization, form analysis, investigation, resources, writing, reviewing and editing. HK contributed in following roles: investigation, form analysis, resources and writing. LS and M-LR contributions were mainly supervisors with following roles: supervision, form analysis , project administration, writing, reviewing, editing and final approval of version to be published. All authors have approved the manuscript for submission.\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e \u003cp\u003eNot applicable.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe datasets generated and analysed during the current study are not publicly available due considerations of the university, but are available from the corresponding author on reasonable request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eAromaa A, Polo-Kantola P, Manninen S-M, Gr\u0026ouml;nlund J, Riskum\u0026auml;ki M, Vahlberg T, Kero K. Attitudes and practice patterns of Finnish obstetrician-gynecologists regarding patients\u0026rsquo; sexual problems. 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World Medical Association Declaration of Helsinki: Ethical principles for medical research involving human subjects. 2024. Retrieved from \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://www.wma.net/policies-post/wma-declaration-of-helsinki/'\u003c/span\u003e\u003cspan address=\"https://www.wma.net/policies-post/wma-declaration-of-helsinki/'\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e Accessed 02.01.2025.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"addressing sexuality, medical referral, physicians, sex therapy, sexual health, sexuality","lastPublishedDoi":"10.21203/rs.3.rs-8415620/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8415620/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground: An increase in sexual challenges demands that physicians address sexuality with patients more intensively. However, current knowledge presents a lack in the treatment of sexual health, and sex therapy, for instance, seems to be underutilized despite its benefits. For this reason, this study aimed to describe the perspectives of physicians when assessing the need for referrals to sex therapy.\u003c/p\u003e\n\u003cp\u003eMethod: This study was conducted using individual interviews with physicians (n=20). The interviews and thematic analysis were guided by the “Strengths, Weaknesses, Opportunities and Threats” framework.\u003c/p\u003e\n\u003cp\u003eFindings: As a finding, the physicians described the following themes: 1) Strengths: “openness” and “the role of the work,” 2) Weaknesses: “ignorance,” “confusion about protocols,” and “attitudes,” 3) Opportunities: “knowledge supporting the professional community” and “sex therapy as a form of treatment,” and 4) Threats: “resources” and “lacks in healthcare services.”\u003c/p\u003e\n\u003cp\u003eConclusion: As a conclusion, it seems that physicians don’t have sufficient knowledge of sex therapy as a treatment for sexual health-related issues. This may be connected to general ignorance about sexuality itself in medical education. This study also emphasizes that the responsibility for addressing sexual needs to be clarified in medical education, and that sexuality is an important part of human wellbeing.\u003c/p\u003e","manuscriptTitle":"Physicians’ perspectives on the assessment of referrals for sex therapy—qualitative description with SWOT analysis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-22 07:15:23","doi":"10.21203/rs.3.rs-8415620/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-03-26T06:23:42+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-20T08:47:27+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-19T07:59:11+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-17T11:27:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"91526695374728397176284554171261607353","date":"2026-02-20T15:00:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"1460670359391520919244525333645078314","date":"2026-02-20T07:47:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"30596621244794640148479349384255861006","date":"2026-02-20T06:59:57+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-19T14:33:33+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-15T19:27:25+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-01-02T09:47:31+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-02T08:30:28+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2026-01-02T08:21:01+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"72c08a00-9718-4303-bcdb-0a7f287efb7b","owner":[],"postedDate":"January 22nd, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-16T21:23:22+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-22 07:15:23","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8415620","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8415620","identity":"rs-8415620","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}