Yuki Takeuchi , Ryohei Otsuka, Hajime Kojima, Michael D Fetters

ABSTRACT

lNTRODUCTlON

Male sexual dysfunction is defined as a clin—ically significant disturbance in a man’s ability to respond sexually or to experience sexual pleasure.1Erectile dysfunction (ED) is the most common problem of male sexual dysfunction and consid—ered primarily a problem of men older than 40 years of age.2Data from the 2015—2016 Nation Health and Well—ness Survey provide estimates of the global prevalence of ED in men aged 40—70 years old—overall 45.2%: Italy (52.5%), France (47.8%), China (47.4%), Spain (46.6%), Germany (46.1%), US (46,1%), UK (42.6%) and Brazil (42.1%).3A meta— analysis estimates that the prevalence of ED in Asia (Japan, Korea, China, Singapore) is 41.5% in men aged 40—49, 61.8% in men aged 50—59 and 69.6% in men aged 60—69.4In Japan, the reported prevalence of ED among at— risk age groups to be 63.7% in men aged 40—49 years, 78.2% in men aged 50—59 years and 90.3% in men aged 60—69 years.4ED is a common condition in the primary care setting and negatively affects quality of life (QOL).56

Historically, treatment of sexual dysfunction was primarily psychosocial until the development of testos—terone replacement in 1970s.7Unfortunately, testosterone injections and patch formulations both have high rates of side effects, and compliance is difficult,8particularly with injected testosterone. Moreover, the Food and Drug Administration in the USA considers testosterone to be a controlled substance which poses a significant barrier to access.9In Japan, only testosterone injection is available, but testosterone replacement therapy is approved only for hypogonadism treatment.10

The advent of phosphodiesterase type 5 (PDE5) inhib—itors created a new opportunity for treatment of ED. PDE5 inhibitors work by inhibiting guanosine 3',5'— cyclic monophosphate (cGMP) hydrolysis. The accumulation of cGMP leads to smooth— muscle relaxation in the corpus cavernosum and increased blood flow to the penis. Thus, an increase in cGMP in smooth muscle cells is respon—sible for prolonging an erection.11Four types of oral PDE5 inhibitors are available in the USA. In Japan, only sildenafil, vardenafil and tadalafil are available, and these three agents can be prescribed by any physician with a medical license including primary care physicians (PCPs). By extrapolating from the 2001—2002 National Health and Nutrition Examination Survey, it has been estimated that the cost associated with treatment of ED would be US$15 billion in the USA if all men affected with ED were to seek treatment.12However, global sales of PDE5 inhibitors were US$4.82 billion in 2017,13suggesting that many men afflicted with ED may be untreated. While not suggesting that all men should be treated for ED, this gap suggests that there may be many men who would benefit from treatment for ED as a component of an overall treat—ment strategy.

Even though ED occurs commonly and effective treat—ment is available, many patients do not seek treatment for sexual dysfunction.14—17Previous international research on barriers to seeking treatment showed many patients were concerned there would be no treatment and doctors would dismiss their complaints.18Compared with men in western countries, men in East Asia (China, Hong Kong, Taiwan, South Korea and Japan) were the least likely to take any action.141517In one study, lack of perception of a problem and the belief that sexual dysfunction is not a medical issue were the most frequent reasons cited for not seeking medical help among East Asian men.17Embarrassment about having a sexual problem has also been found as a main reason in East Asian coun—tries.17Qualitative research in China showed patients perceived sexual dysfunction as embarrassing and poten—tially shameful, and that men preferred consultation with same gender and age PCPs.19A previous study in Korea showed only 2% of people with sexual dysfunction had talked to a medical doctor about their sexual prob—lems due to believing that the problem is not serious, not being bothered by the problem, not having access to medical care and lacking of awareness of available treat—ments.20A previous study conducted in Japan with PCPs identified the perception that the act of seeking sexual dysfunction treatment may be intensely embarrassing for Japanese men.21

While many men may perceive that sexual dysfunction falls primarily in the scope of care of urologists, PCPs far outnumber urologists and are positioned to provide PDE5 inhibitor therapy for men desiring ED treatment. Previous research in China suggests patients view PCPs as the most appropriate professional with whom to discuss sexual problems.19However, Nicolosi et al estimated about 90% of East Asian people with some degree of sexual dysfunction had never talked about the problem with their PCPs.17As treatment could enhance the QOL of men with ED, PCPs need to better understand patient’s perspectives on sexual dysfunction.

Previous research conducted in East Asia showed lack of perception of sexual problems and belief that sexual dysfunction is not a medical issue as main reasons for not seeking medical help.17We hypothesised Japanese patients may not recognise their sexual dysfunction as a medical problem. Our secondary aims were to examine factors that would be barriers to consulting for treatment and gain a greater understanding qualitatively of partic—ipants’ perspectives on sexual dysfunction. Our mixed methods purpose was to integrate the quantitative and qualitative results by merging attitudinal factors with the qualitative perspectives.

The purposes of this research were (1) to examine at— risk Japanese men’s awareness of ED by comparing a single item self— perception assessment of sexual dysfunc—tion with a five— item objective measure of ED, to assess their desire for treatment, and to gauge attitudes about treatment by PCPs, (2) to qualitatively elucidate partic—ipating men’s perspectives about their preferences for sexual dysfunction treatment based on written comments and (3) to merge both types of findings to gain an enhanced understanding of how the men’s awareness of ED, desire for treatment and barriers to access linked with their perspectives about ED using joint display anal—ysis and development of a model.

METHODS

Study design

We conducted a cross— sectional, self— administered mixed methods paper survey22in a 7— week period from 5 November to 21 December 2018, and conducted a chart review of enroled patients to collect their demo—graphic and health information. Our research para—digm was based on pragmatism as we sought a practical and feasible approach requiring both quantitative and qualitative data collection.23This study was approved by a research ethics committee of Teine Keijinkai Hospital (ID 2018—166). All participants provided written informed consent for this study.

Setting

A suburban family medicine residency training programme clinic in Sapporo on the northern Island of Japan served as the research setting. This clinic is similar to many other primary care clinics in Japan, as the physicians deliver full— range primary care to the local population. Established in 2009, the clinic has 14 physicians, including 7 attendings, and 7 residents. The gender of physicians are 10 men and 4 women. The clinic provides a full range of primary care services including women’s healthcare, and care to patients with a wide spectrum of ages spanning from children in the first year of life to old— old adults with the eldest patient’s age in the practice currently at 103 years. The percentage of male patients in the age range of men at risk for ED is similar to the general population.

Participants

We used criterion sampling. The target population was middle— aged men presenting in a primary care setting for a health check— up. These criteria were chosen because middle— aged men who were in the age range of 40—69 are at high risk for ED.24Moreover, the results should reflect a setting informative for family doctors and other PCPs. Finally, the health check— up visit type was chosen as an encounter explicitly framed for opti—mising health. Of eligible participants, 464 patients came into the clinic for routine check— ups during clinic operations. The questionnaire was distributed to 78 men and 70 returned the instrument for a response rate of 90%. Four participants who did not answer the survey questions fully were deemed non— eligible resulting in a sample size of 66 men (full participation rate of 85%, 66/78). Patients deposited completed question—naires into a secure collection box in the lobby. Qual—itative comments were recorded by 32% (21/66) of participants.

Data collection tools

The 11— item survey comprised two sections (see online supplemental appendix). Section A of the question—naire addressed self— reported sexual dysfunction (one question), desire for treatment and open response for rationale (two questions), attitudes about treatment

of sexual dysfunction by PCPs (3 questions, total of 9 items). Section B was the Japanese IIEF—5, a five— item multidimensional, self— administered question—naire developed in Japan for screening and classifying severity of ED.25Based on data collection with 1152 men (1036 with ED, 116 control), the validated IIEF—5 has been shown to have 98% sensitivity and 88% speci—ficity.26The Japanese IIEF—5 is a translation of this vali—dated tool.25The cut— off score is less than 22 points. ED severity is defined as follows: 17—21 points is mild; 12—16 points is mild— to— moderate; 8—11 points is moderate; and less than 8 points is severe.26The chart abstrac—tion protocol involved using the participant unique patient ID number and the recording of marital status, current and past medical history and social history as documented in the most recent regular check— up in the chart of participants.

Data collection and entry procedures

PCPs distributed the confidential survey to eligible patients at the end of their routine primary health check visits. PCPs recorded and linked in a tracking sheet the distributed questionnaire’s identification number with the receiving participants’ electronic chart unique identifier at each visit. A research assis—tant abstracted the patients’ medical information from their electronic charts by using the tracking sheet with the corresponding list of questionnaire identification numbers and electronic chart unique identifiers.

Data analysis

We calculated descriptive statistics on the quantitative data with the software Easy R (EZR V.1.37). Results of the IIEF—5 were expressed in terms of the severity and distri—bution among the subjects. We calculated the SD for the IIEF—5 scores, 95% CI for question answer rates and performed Mann— Whitney U test and Kruskal— Wallis test for IIEF—5 score comparison between each group. The logic of merging the qualitative and quantitative data was to obtain an enhanced understanding of both the survey and qualitative findings,27specifically to examine how patient perspectives reinforced or attenuated the three primary study domains of awareness, desire for treatment and barriers to access. We identified codes for organising the qualitative comments by looking for emerging themes using a template approach.28This involved an immersion/crystallisation process which involves multiple readings of the qualitative text, and development of a coding scheme reflecting the major constructs identified.29The mixed methods integration involved development of a model as a mixed methods joint display figure30that merged the mixed data find—ings. Specifically, we examined directionality of influ—ence, reinforcement or attenuation, of the qualitative findings when linked with the three key quantitative constructs of the survey, awareness, desire for treatment and barriers to treatment. We assessed the ‘fit’, that is, an interpretation of the two types of findings to lookfor convergence, complementarity, expansion or diver—gence and metainferences to be drawn based on the results.3132

Table 1 Characteristics of 66 participants

RESULTS

Participants

Table 1 shows the characteristics of the subjects. As 66 men completed the surveys, and there are 464 men of this age in the clinic, the sample represents about 14% of eligible male patients. As shown, the mean age of participants was 60 years old. Demographic data suggest 98% (65/66) of participants had some lifestyle diseases (hypertension, diabetes or dyslipidaemia) and the most common problem was hypertension (80%, 53/66).

Awareness of sexual dysfunction

Comparison of self-perceived sexual dysfunction and validated measure of ED

Among the respondents, 39% (26/66) self— reported having sexual dysfunction (table 2). Of the 66 partici—pants, 92% (61/66) met ED criteria of the IIEF—5: mild (n=27), mild— to— moderate (n=15), moderate (n=7) or severe (n=12). The severe ED group includes four sexu—ally inactive participants. Figure 1 shows the distribution of self— reported sexual dysfunction and ED according to the IIEF—5 score.

International Index of Erectile Function-5 scores in each group

Table 3 displays the mean IIEF—5 scores in each group. IIEF—5 scores in the 60—69 year— old group were significantlylower than the scores in other groups (40s:60s, p=0.01. 50s:60s, p＜0.01). There was no significant difference between 40—49 year— old group and 50—59 year— old group (p=1). IIEF—5 scores of participants self— reporting sexual dysfunction had significantly lower IIEF—5 scores than the no self— reported sexual dysfunction group. However, variations in responses by self— report and on the objec—tive IIEF—5 instrument as shown in figure 1 suggests ED severity was not the only factor contributing to awareness of their sexual dysfunction.

Table 2 'Yes’ answer rates of Q1-Q2 among all participants

Figure 1 ED distribution among males in a primary care clinic based on comparison of self- reported and objective measures of ED according to age groups and severity (n=66). ED, erectile dysfunction; JIIEF5, Japanese translation of the five- item version of the International Index of Erectile Function (IIEF-5); SD, sexual dysfunction.

Desire for treatment

Tables 2 and 4 illustrate participants’ responses to the inquiries about their views regarding ED. Of respondents, 48% (16/33) desired treatment (table 2). Of the partic—ipants indicating a desire for treatment, 75% (12/16) desired treatment by their PCPs, but only one participant had discussed sexual dysfunction with his PCP (table 4).

Barriers for men desiring treatment

Figure 2 depicts the reasons provided by the subset of men who indicated they would like treatment from their PCPs. The most important barrier was feeling ashamed as reported by seven respondents. The second and third most common reasons given both related to knowledge about availability of treatment, lack of awareness that PCPs can provide treatment and lack of awareness about the availability of treatment. None of the participants chose the physician being a female as a barrier.

Men’s perspectives about the desirability of treatment

Qualitative results

We identified six themes about participants’ perspec—tives on sexual dysfunction from their written comments. Themes included considering sexual dysfunction as normal ageing, attributing sexual dysfunction to decreased libido, importance of sexual activity for a healthy life, good rapport with PCPs, lack of knowledge about treatment and lack of intimate relationship with partner.

Considering sexual dysfunction as normal ageing

Several men shared their belief that sexual dysfunction is a normal part of ageing. For example, a male in his late sixties said, ‘Sexual problem is just caused by normal ageing’. Another male in his late 60s noted, ‘I consider sexual problem as ageing’. A male in his early 50s fatalis—tically concluded, ‘It can’t be helped because it’s ageing’. These perceptions prevented them from considering sexual dysfunction as a medical problem and unaware—ness based on a belief that ‘there was no treatment option for sexual problem’.

Table 3 International Index of Erectile Function-5 scores in each age group

Table 4 Response rate among participants who desired sexual dysfunction treatment

Attributing sexual dysfunction to decreased libido

Some patients considered sexual dysfunction in context of decreasing libido. For example, a male in his mid— 50s surmised his sexual dysfunction as thus, ‘I have sexual problem, but I think it is due to decreased libido’. A man in his late 60s recounted, ‘My libido has been decreasing as I became older’. A man in his mid— 60s confided, ‘I have become reluctant to have sex with females’. A male in his late 60s stated, ‘I don’t need treatment because I have graduated from sexual activities’.

Importance of sexual activity for healthy life

For some men, sexual activity was perceived as important for a healthy life and could be a form of motivation for treatment. Several responses from participants who were interested in sexual dysfunction illustrate this point. A man in his late 60s emphasised, ‘I want to have a vigorous life to keep myself healthy’. A man in his mid— 60s pointed out, ‘I want to become younger by treatment for sexual dysfunction’. A man in his mid— 40s lamented, ‘I have lost confidence due to my sexual problem’.

Good rapport with primary care physicians

The comments from participants indicate their trust in their PCPs. For example, a man in his late 50s shared, ‘My doctor understands my condition and situation well’. A man in his early 50s confided, ‘I trust my doctor because I see him regularly’. Another man in his late 50s reported, ‘I want treatment because my doctor is a good doctor’. These comments suggest that having good rapport with their PCPs can make them comfortable to discuss issues that may be conceived as shameful such as sexual dysfunction.

Lack of knowledge about treatment

Lack of knowledge about sexual dysfunction as a medi—cally treatable condition affected some patient’s attitudes towards sexual dysfunction treatment. For example, a man in his mid— 60s indicated, ‘I didn’t know sexual problems are treatable’. A male in his early 60s responded, ‘I want treatment for sexual problem if it is treatable’. A male in his late 50s disclosed, ‘I had no idea that sexual problem is medical problem’. These examples demonstrate that there are men who felt that if they had been knowledgeable about sexual dysfunction as a treatable medical condition, that they would have like to be treated.

Lack of intimate relationship with partner

Some patients attributed apathy about their sexual dysfunction treatment due to the lack of an intimate relationships with their partners. A male in his late 60s conveyed, ‘My wife hates having sex and even talking about sex’. Another man in his late 60s confided, ‘I and my wife sleep in different rooms. We have not had sex for 35 years’. A man in his early 60s wrote, ‘I have been sexless with my wife for a long time’. The lack of an intimate relationship with a partner not surprisingly negatively affected the patients’ desire for treatment.

lntegration of the mixed data findings

Figure 2 Barriers to seeking treatment for sexual dysfunction reported by participants who indicated they would like treatment from their PCP. PCPs, primary care physicians, PCP, primary care physician.

Figure 3 Factors and mechanisms affecting ED treatment in primary care. ED, erectile dysfunction; JIIEF5, Japanese translation of the 5- item version of the International Index of Erectile Function; PCPs, primary care physicians.

The intent of merging the survey and qualitative findings was to obtain an enhanced understanding of the findings. Joint display analysis facilitated that process. Figure 3 is the resulting mixed methods joint display figure. It pres—ents an integrated mixed methods model of the factors and mechanisms affecting ED treatment in primary care that was developed by merging the quantitative survey results and qualitative themes. The quantitative findings showed ‘low— awareness of sexual dysfunction’. The themes of ‘considering sexual dysfunction as normal ageing’ and ‘attributing sexual dysfunction to decreased libido’ inhibits patients from viewing their sexual dysfunction as a medical condition. Patients with these misconceptions may not seek treatment because they do not consider sexual dysfunction as treatable. In contrast, the theme ‘importance of sexual activity for healthy life’ serves as motivation for patients to treat their sexual dysfunction. Importantly, a ‘lack of intimate relationship with partner’ may diminish men’s consideration of the ‘importance of sexual activity for healthy life’ and attenuate their desire for treatment. From quantitative survey results, the main barriers to access were ‘feeling ashamed’ and ‘lack of knowledge’. ‘Good rapport with PCPs’ can help patients confide with their doctors sensitive topics such as sexual dysfunction, and it could lead patients to receive treat—ment, a point reinforced by concordance with the quali—tative findings. ‘Lack of knowledge about treatment’ can preclude opportunities to access treatment. This integra—tion of the two types of findings for an overall interpreta—tion, so called metainferences,30revealed concordance in how the two types of data fit, confirmed the findings and supported the conclusions as being robust.

DlSCUSSlON

As hypothesised, we identified a gap between self— reported sexual dysfunction and an objective measure of ED. These data suggest that some patients are unaware or do not acknowledge their sexual dysfunction. Findings from the qualitative analysis suggest that some patients may consider sexual dysfunction as normal ageing, or attribute it to decreased libido. While the causes of sexual dysfunction are multifactorial, there are none—theless misconceptions that appear attributable to a lack of knowledge about sexual dysfunction. An East Asian societal stereotype of the ‘asexual older person’19may have led men to consider sexual dysfunction as a normal process of ageing. In fact, some participants resignedly shared their perspectives about sexual problems. From a clinical perspective, providing correct information is necessary to empower men to optimise their sexual health in primary care.

Embarrassment was found to be the most frequent barrier to consultations among these men. Existing literature supports, particularly in East Asian countries, men feeling ashamed about seeking treatment for sexual dysfunction treatment and it poses a considerable barrier for men seeking treatment.16171920Western studies have found feeling ashamed to be a much less frequent reason than East Asian countries.1415East Asian societal percep—tions that sexual activities are not important for older people may reinforce feeling ashamed and reluctance to seek treatment.19The qualitative findings suggest good rapport with men’s PCPs may help them overcome this barrier. A previous qualitative study conducted in China also showed fostering good rapport was important to improve access to treatment.19

In the qualitative comments, some participants empha—sised the importance of sexual activities as contributing to a healthy life. Previous research from China showed having a sexual problem was significantly associated with lower overall life satisfaction and that sexual satisfaction was also significantly associated with better overall life satis—faction and QOL.33The findings of our research suggest sexual activity is also an important factor of healthy life for some Japanese men, and it may be a source of motiva—tion for them to seek treatment. On the other hand, some participants mentioned the lack of an intimate relation—ship with a partner, a factor that would inhibit seeking treatment. Lack of emotional intimacy itself can cause sexual dysfunction.34Clinically, it will be prudent for PCPs to assess the presence and nature of relationships with partners for patients with sexual dysfunction.

While a previous study conducted in China identified male preference for same gender PCPs,19no patients in this study volunteered having a female physician as a barrier. The female PCPs in this study, modern— trained family physicians, may have built good rapport with their patients through good communication skills and thus removed any concern about any gender differences. The possibility that men were too embarrassed to report concern about having a female provided cannot be excluded.

In this study, only one patient volunteered as he had discussed sexual dysfunction with his PCP. Previous research showed the percentages of patients with sexual dysfunction who had talked with their PCPs were 11% in China, 9% in Japan and 3% in South Korea. Reported reasons for not consulting PCPs were lack of percep—tion of a problem, the belief that sexual dysfunction is not a medical issue or embarrassment. A problem with access to medical care was also a main barrier in China.17Although a small sample, in this research, lack of aware—ness that PCPs can provide treatment was the second most frequent barrier following by embarrassment. Conceiv—ably, patients’ perspectives about the role of PCPs may be different between China and Japan. Patients in China viewed PCPs as the most appropriate professional with whom to discuss sexual problem, though some patients were unaware of any other sources of help.19Meanwhile, many patients in Japan may be unaware that PCPs can treat sexual dysfunction. As general medicine/family medicine has been recognised officially as a specialty only in 2017, patients may not know the breadth of care their general medicine/family physician can provide in Japan. For many decades back to the 1950s, an emphasis on subspecialisation in the healthcare system35has compelled patients to see subspecialists for even common problems. This historical context may continue to impel them to believe care for sexual dysfunction should be within the purview of urology even though modern family physicians are trained in the common problems of men’s health including the medical and psychosocial aspects of treatment for sexual dysfunction.

In the population of men between the ages of 40 and 69, there may be as many as 19 million men with ED in Japan, and about 11 million men who are unaware of being afflicted with sexual dysfunction and that treat—ment is available and should they desire it.436For such a common problem, there is insufficient urologist capacity to see all eligible men. It naturally follows that ED treat—ment must fall within the scope of PCPs. Patients have far more visits with PCPs than urologists, and PCPs serve as the first contact of care for general medical problems. They are in the position to provide access to treatment to the very large number of men afflicted with ED that they encounter. The training of the modern family physi—cian also to recognise and treat many psychosocial prob—lems, including those associated with sexual dysfunction, further emphasises the potential and value of PCPs eluci—dating a history of sexual dysfunction and offering treat—ment to men who desire it. These findings thus suggest that development of systematic approaches to identifying men at risk, increasing awareness about ED, addressing misperceptions and fostering good rapport are important needs in the primary care setting.

A mixed methods approach in this study is evidenced by the use of pragmatism as the worldview guiding the work.23The mixed methods study rationale was to merge attitudinal findings with perspectives on treatment37and obtain an enhanced understanding.27Joint display anal—ysis and presentation were used to facilitate drawing of overall interpretations or metainferences about the study.38Consideration of both types of findings provided a more nuanced perspective on primary study domains of awareness of ED, desire for treatment and barriers to treat—ment. An integrated rhetorical approach was followed through explanation of the findings in the text.39

This research provides a methodological contribution to the literature through the use of a mixed methods joint display figure that integrates the quantitative and qualita—tive findings.4041This approach provides an alternative to the use of a table as a joint display. While Bustamante has published a highly elaborate example of joint displays as figure,42there remains relatively few joint display figure examples in the literature. One challenge with a mixed methods joint display figure is the difficulty of including direct metainferences in the joint display figure. In the current study, we have addressed this by drawing metain—ferences and addressing fit through discussion in the text.

Limitations

This research was conducted with a small sample size in a single family medicine multiphysician centre. An important risk of selection bias could be that men with the greatest interest in sexual health may have been the most inclined to volunteer to participate in this research. As physicians in the clinic recruited in the midst of patient care in a busy clinic, the sample was not systematically collected and this could also have introduced selection bias. Thus, precaution is necessary in interpreting gener—alisability and representativeness, especially relative to the proportions and prevalence of attitudes. Importantly, the study was not designed to assess the prevalence of the ED and the proportion of men who want treatment more broadly. However, we do believe the issues identi—fied transfer to the reality of the primary care setting.43While we cannot suggest from these data how many men would desire treatment, we believe these issues to be real and the findings to accurately represent the attitudes and circumstances of the men who participated. Additionally, qualitative data collected through open responses do not have the richness and depth of other primary qualitative data collection strategies. While this choice of data collec—tion was made based on feasibility considerations, it may limit interpretations regarding credibility and confirma—bility of the findings. The authors did not engage in an advanced reflexivity process, though the mixed methods findings suggest the conclusions are nonetheless robust. Prescribing medication for ED is only one strategy of many treatment approaches to address the multifac—eted challenge of sexual dysfunction.44Future research could further elucidate the reasons underlying the gap between self— reporting and the objective measure of sexual dysfunction, and lead to a better understanding of patients’ perspectives about the impact of sexual dysfunc—tion on their lives.

CONCLUSlON

In this Japanese primary care setting, while the vast majority of male patients met ED criteria on the 5— item version of the International Index of Erectile Function for sexual dysfunction, many did not self— report having sexual dysfunction. Clinicians may need to reframe ques—tioning about specifics rather than use a more general question. From the qualitative analysis, some patients were found to consider sexual dysfunction as normal ageing or attribute it to decreased libido. A mixed methods analysis delineated how patients’ misconceptions about sexual dysfunction can lead to low awareness on sexual dysfunc—tion and pose a barrier to access treatment. We conclude PCPs should routinely inquire about sexual dysfunction to facilitate recognition and treatment to improve men’s health in Japanese primary care.

AcknowledgementsThe authors express with great gratitude to Dr Mariko Shimazu and Ms Rania Ajilat for their assistance with this research. We would like to thank the members of Teine Family Medicine Clinic for their hospitality during this research study, where the main results of this paper were obtained.

ContributorsYT, RO contributed to the concept of the study. YT, RO, HK and MDF contributed to the analysis and interpretation of the data. YT and MDF contributed to the drafting of the manuscript. All authors contributed to the critical revision of the manuscript and approved the final version for publication and took responsibility for the accuracy and integrity of the study.

FundingMDF participation in this research was made possible through his work in the Mixed Methods Program supported by the Department of Family Medicine, University of Michigan.

Competing interestsNone declared.

Patient consent for publicationNot required.

Ethics approvalThis study was approved by a research ethics committee of Teine Keijinkai Hospital (ID 2018-166).

Provenance and peer reviewNot commissioned; externally peer reviewed.

Data availability statementData are available upon reasonable request. Deidentified data are available through the corresponding author.

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ORClD iDYuki Takeuchi http:// orcid. org/ 0000- 0003- 4095- 0230