Heather Honoré Goltz

Sexual Dysfunction among Male Veterans Returning from Iraq and Afghanistan: Prevalence and Correlates

INTRODUCTION Sexual dysfunction (SD) is not well described in the Iraq/Afghanistan veteran population despite high prevalence of multiple risk factors for this issue. AIM To estimate the prevalence and examine the association of various sociodemographic, mental health, comorbid conditions and life style factors with sexual dysfunction in Iraq/Afghanistan veterans. METHODS This exploratory cross-sectional study was conducted using data from the VA administrative database. A total of 4,755 Iraq/Afghanistan veterans were identified who sought treatment from the Michael E. DeBakey Veterans Affairs Medical Center inpatient and outpatient clinic between September 2007 and August 2009. MAIN OUTCOME MEASURES Sexual dysfunction was determined by ICD9-CM codes related to sexual health issues and/or by specific medications, primarily phosphodiesterase-5 inhibitors (PDE5i), prescribed for erectile dysfunction. RESULTS The overall prevalence of sexual dysfunction was 5.5% (N = 265). By age category, it was 3.6% (N = 145) for Iraq/Afghanistan veterans aged 18-40 years and 15.7% (N = 120) for Iraq/Afghanistan veterans aged > 40 years, respectively. A multivariate logistic-regression model revealed that annual income, marital status, post-traumatic stress disorder, and hypertension were significant risk factors of SD (all P < 0.05) among younger Iraq/Afghanistan veterans, whereas among the older Iraq/Afghanistan veterans, being African American and having PTSD and hypertension were significant risk factors of SD (all P < 0.05). There was marked discrepancy between documented erectile dysfunction and prescription of a PDE5i. CONCLUSIONS These data demonstrate that a significant proportion of Iraq/Afghanistan veterans have SD and that the risk factors differ between younger and older veterans. Our findings also suggest that SD is likely under-coded. To better identify the scope of the problem, systematic screening for sexual dysfunction may be appropriate perhaps as part of an initial post-deployment health evaluation.

Assessment and Documentation of Sexual Health Issues of Recent Combat Veterans Seeking VHA Care

INTRODUCTION Sexual health is an important aspect of human existence associated with disease and overall health. Despite these associations and the existence of medical treatments to improve sexual function, sexual health is often overlooked in health care. Recent combat veterans may be particularly vulnerable to sexual health issues due to their deployment-related health issues such as mental health conditions, prescription medications use, and psychosocial challenges. AIM This study assesses the sexual health issues of recent combat veterans seeking care at a Veterans Affairs Medical Center (VAMC) documented in the primary care and mental health notes from the first 6 months of care. MAIN OUTCOME MEASURES Documentation of sexual health issues in the progress notes (coded into categories), primary care vs. mental health care visit note, initial vs. follow-up visit notes, and templated vs. non-templated text. METHODS This is a retrospective chart review of the first 158 consecutive patients seen for an initial assessment in the VAMC post-deployment clinic. Medical records were reviewed and text of sexual health issues and relevant patient and care characteristics were abstracted and coded into variables. RESULTS Almost 25% of patients had documented sexual health issues in the first 6 months of care. We coded 52 separate sexual health issues into 13 distinct categories. Overall, most sexual health issues were documented in mental health care notes, in non-templated text, and at follow-up visits. The use of templated text appeared to drive the documentation of low libido (the most common sexual health issue) in mental health care notes. CONCLUSIONS Sexual health issues are prevalent in recent combat veterans seeking care at a VAMC, but patterns of documentation suggest that they may be under-reported or incompletely addressed. A more systematic and provider-initiated approach to assessment of sexual health may promote fuller discussion of sexual health issues and optimize management.

Autoethnography in action research for health education practitioners

We propose a methodological framework for conducting collaborative and analytic autoethnography (CAAE) in action research inquiry. Similar to other action research methodologies, CAAE is: (a) systematic, framed by a research question and employing explicit, transparent methods; (b) problem-based, drawn from health educators’ practices; and (c) cyclical, predicated on the assumption that a plan for implementing changes is derived from the findings and will be tested in subsequent action research cycles. The autoethnographic action research framework comprises four phases: inductive stage/formative assessment—developing a hypothesis (phase 1), pre-deductive stage—organizing the study (phase 2), deductive stage/summative evaluation—collecting data and testing the hypothesis (phase 3), and synthesis stage—constructing meaning (phase 4). Collaborative analytic autoethnography supports reflexivity, awareness, and agency by providing practitioners with an explicit framework for continually evaluating the complexities of self, the Other (i.e. experiencing self from another’s perspective), and context.

Correlates of chronic disease and patient-provider discussions among middle-aged and older adult males: Implications for successful aging and sexuality.

Objective: Effective erectile dysfunction (ED) treatments and cardiovascular disease (CVD) and diabetes risk assessments are available, but require patient–provider communication. The present study explored this issue using 2010 National Social Life, Health and Aging Project data for males age 57 years and older (n = 1011).Methods: Multinomial logistic regression was performed to compare factors associated with being without CVD/diabetes (39.9%), being diagnosed with CVD only (43.1%), and having comorbid CVD/diabetes (CVD 17.0%). Logistic regression compared factors associated with having ever discussed sexual issues with physicians.Results: CVD-only participants were more likely to be ≥75 years (p = 0.004) and smoke (p = 0.019); CVD&D participants were more likely to report activity limitations (p < 0.001) and less likely to have sex within the previous year (p = 0.014). Compared to CVD-only, men with CVD&D were more likely to be minorities, obese, have daily activity limitations, and report erectile difficulties (all p < 0.05). Males discussing sexual issues with physicians were more likely to report higher education [OR = 1.68, p = 0.001], have sex in previous year [OR = 1.73, p = 0.006], and have erectile difficulties [OR = 2.26, p < 0.001].Discussion: Increased patient and provider awareness and communication are needed to lifestyle behaviors, promote self-care practices, and improve health care utilization among male patients affected by chronic disease and ED.

A Pilot Study of HIV/STI Risk among Men Having Sex with Men Using Erectile Dysfunction Medications: Challenges and Opportunities for Sexual Medicine Physicians

INTRODUCTION A growing literature suggests relationships between erectile dysfunction medications (EDM) and riskier sexual behavior among men who have sex with men (MSM). Questions remain concerning EDM use and related HIV/sexually transmitted infections (STI) risk among older MSM, particularly those 40 years and over, for whom EDM may be medically warranted. AIM This exploratory pilot study explores the relationship between EDM and risky sexual behavior in a convenience sample of MSM using EDM and attending historic sex-on-premises venues. METHODS We examined anonymous surveys from 139 MSM. Bivariate relationships were examined. We then fit a multiple logistic regression model to determine predictors of engaging in unprotected anal intercourse (UAI) at last EDM, using variables identified as being significantly related to UAI in the bivariate analyses. Potential predictors entered the model in a stepwise fashion. MAIN OUTCOME MEASURES The primary outcome measure was engaging in UAI at last EDM use. RESULTS MSM participating in the study ranged from 27 to 77 years and averaged 52.0 years (standard deviation = 10.73 years). These participants were primarily older MSM; fewer were younger MSM (12.12%), under age 40. Participants reporting UAI at last EDM use (N = 41) were significantly younger (P < 0.01). Men visiting bars within the last 6 months reported less UAI (P < 0.01). Both variables were independent predictors of UAI in the logistic regression model (P < 0.01). CONCLUSIONS Similar to reports from younger MSM, our findings suggest older MSM using EDM and reporting UAI are also recreational drug users. We include recommendations for urologists and other sexual medicine physicians treating MSM who may be at elevated risk for HIV/STI infection because of joint EDM and club drug use.

Transforming Practices A Primer on Action Research

Action research (AR) is a powerful tool for health education and promotion practitioners who want to focus on improving the quality of their programs and services. In this Tool, we describe the characteristics and controversial aspects of AR, differentiate between traditional and action research, present the benefits of applying AR methods/techniques for investigating problems related to professional practice, and offer a four-phase methodological framework for conducting AR studies. Unlike traditional research, AR is a methodology that links theory, research, and practice; advances new knowledge and understandings via iterative action cycles; employs frontline health practitioners as researchers; and promotes collaborative practitioner–community partnerships. Egalitarian in its approach, AR offers an “insider’s perspective” centered on context-specific problems and issues related to health promotion. AR falls into two categories: large-scale community-based research and small-scale practice-based research. Each cycle of the AR framework includes four phases: (a) preplanning/needs assessment, (b) planning/study organization, (c) action and observation/study implementation, and (d) reflection and planning/data analysis and interpretation. Using the AR primer in this Tool has the potential to empower health education/promotion practitioners, encourage collaborative partnerships, enhance practitioners’ knowledge base, and promote social change.

Racial differences in sexual dysfunction among postdeployed Iraq and Afghanistan veterans

This study examined the racial/ethnic differences in prevalence and risk factors of sexual dysfunction among postdeployed Iraqi/Afghanistan veterans. A total of 3,962 recently deployed veterans were recruited from Houston Veterans Affairs medical center. The authors examined sociodemographic, medical, mental-health, and lifestyle-related variables. Sexual dysfunction was diagnosed by ICD9-CM code and/or medicines prescribed for sexual dysfunction. Analyses included chi-square, analysis of variance, and multivariate logistic regression. Sexual dysfunction was observed 4.7% in Whites, 7.9% in African Americans, and 6.3% in Hispanics. Age, marital status, smoking, and hypertension were risk factors for Whites, whereas age, marital status, posttraumatic stress disorder and hypertension were significant for African Americans. For Hispanics, only age and posttraumatic stress disorder were significant. This study identified that risk factors of sexual dysfunction varied by race/ethnicity. All postdeployed veterans should be screened; and psychosocial support and educational materials should address race/ethnicity-specific risk factors.

Correlates of CVD and discussing sexual issues with physicians among male military veterans

PURPOSE This study aims to identify socio-demographic and health behavior factors associated with cardiovascular disease (CVD) diagnosis and patient-physician communication concerning sexual issues among older Veterans. METHODS Cross-sectional data were collected from 635 male Veterans over age 55 years as part of the 2010 National Social Life, Health and Aging Project, a nationally-representative, population-based study of community-dwelling older Americans. Two independent logistic regression analyses were performed. RESULTS Over 33% of Veterans were aged 75 years or older. Over one-half of participants reported having a CVD diagnosis (58%) and sexual intercourse within the previous year (58%); over one-third (37%) reported having one or more sexual dysfunctions and discussing sexual issues with their physician (42%). Veterans diagnosed with CVD were significantly more likely to self-identify as racial/ethnic minorities (OR=1.89, P=0.021), have more chronic disease comorbidities (OR=1.23, P=0.041), and have more sexual dysfunctions (OR=1.19, P=0.028). Veterans diagnosed with CVD were significantly less likely to report having sex within the previous year (OR=0.53, P=0.005). Veterans who reported discussing sexual issues with a physician were significantly more likely to be ≥75 years (OR=1.79, P=0.010), and report more than a high school education (OR=1.62, P=0.016), CVD diagnosis (OR=1.59, P=0.015), sex within the previous year (OR=1.69, P=0.033), and trouble achieving/maintaining an erection (OR=3.39, P<0.001). IMPLICATIONS These findings suggest older male Veterans, particularly racial/ethnic minorities and those less-educated, may benefit from VA and community-based aging and sexual health/counseling services. These services should promote increased patient-physician communication as well as referrals between physicians and sex health/counseling specialists.

Gay Men and Prostate Cancer: Opportunities to Improve HRQOL and Access to Care

Little previous research has focused on gay and bisexual men who develop prostate cancer. However, a few small studies have recently been published that begin to tell the story of the specific problems gay and bisexual men with prostate cancer face. In this chapter, we summarize this recent literature and offer specific suggestions for changes to made by urologists and other cancer treatment providers to address the unique needs of gay and bisexual men for survivorship services. In addition, we discuss techniques that providers can use to make their practice more welcoming for gay and bisexual men facing prostate cancer.

Forming and Developing Your Professional Identity Easy as PI

Health education and promotion specialists and professional organizations have worked hard to successfully establish and maintain the status of health education/promotion (HE/P) as a unique and essential profession and to solidify practitioners’ sense of professional identity. A professional identity is critical to a person’s sense of self: It is about connecting with roles, responsibilities, values, and ethical standards unique to a specific profession. Professional identity is a complex issue in the HE/P profession; the distinction between personal and professional identities has been debated repeatedly over the years (e.g., should HE/P professionals be role models for clients?). The purpose of this Tool is to explain the concept of professional identity; provide new, emerging, and experienced HE/P with a greater understanding of what it means to have a professional identity; present processes and benchmarks of professional identity development; and offer specific tips and strategies for developing and enhancing an HE/P professional identity.