We thank Ms Knafo and colleagues for their commentary on our study and for the summary of recent publications that further illustrate the negative impact that SSc may have on sexual function in female patients. Several specifically scleroderma-related problems were recently identified by Impens et al as contributing factors to sexual difficulties, with fatigue, bodily pain, and vaginal dryness and discomfort being most frequently mentioned by 101 female SSc patients (1). We agree with the recommendation that more research is needed in order to identify predictors of sexual impairment. Indeed, the lack of correlation between levels of sexual functioning and disease classification in our study may be due to the small sample size. However, in the larger study by Impens et al, the same lack of correlation was found (1).
Considering the growing evidence discussed previously, we believe that a health professional's simple question (e.g., Are problems in sexual functioning present?) would be acceptable for most patients. Moreover, considering the frequently mentioned scleroderma-specific complaints (1), it is very likely that a considerable number of female patients may benefit from simple health interventions (vaginal lubricants, medication advice, relaxation techniques, and energy conservation) provided by either their rheumatologist or another consulted health professional.
In other chronic impairments, it has been recognized that dealing with sexual problems should be addressed in medical rehabilitation (2, 3), although reluctance of both patients and health professionals to discuss sexuality is known. The low percentage (16%) of our patients indicating a need to talk about possible sexual problems cannot be explained easily and demonstrates the need for further studies. The reported proportion pertains to the whole group we studied, and not to the subgroup of patients with sexual impairments. Moreover, there is research illustrating that patients expect sexual issues to be brought up by the health professional and not by themselves (4). Although basic patient education through pamphlets (as advocated by Knafo et al) contributes to open communication, it also leaves the initiative with the patient and creates a risk of avoidance of the subject.
We agree with Knafo and colleagues that an important condition for discussing matters of sexuality is a health professional who is comfortable with the subject. In a large British survey, it was found that doctors discussed sexual issues significantly more often than other health professionals (n = 813) (5). The self-rated sexologic competence (scale of 0–10 with 10 being excellent) of 42 physicians in the Netherlands (6) was found to be less than sufficient before training (mean ± SD 5.8 ± 1.1) and sufficient after a training (mean ± SD 6.7 ± 1.2), which illustrates the need for improvement of competences.