Introduction

Sexual health is an important dimension of human health, encompassing physical, mental, emotional, and social well-being in relation to sexuality, not merely the absence of disease or dysfunction. As defined by the World Health Organization, it implies a positive, respectful approach to sexuality and intimate relationships, as well as the ability to have safe and satisfying sexual experiences, free from coercion, discrimination, and violence [1, 2]. Sexuality remains an integral element of an individual’s identity, influencing interpersonal relationships, self-esteem, and overall life satisfaction; favorable indicators of sexuality are associated with a higher quality of life and improved psychological well-being [3].

Sexual disorders may co-occur with physical and mental illnesses or be early manifestations of these conditions, including cardiovascular disease, hormonal disorders, or depression, which highlights the importance of a holistic approach [4]. Including sexual health in clinical care promotes early identification of problems, reduces their health and social consequences, and supports patient well-being, while remaining consistent with current WHO recommendations for comprehensive, patient-centered care [5].

Erectile dysfunction (ED) is defined as the persistent or recurrent inability to achieve or maintain an erection sufficient for satisfactory sexual activity [6]. It is the most common sexual problem in men, and its prevalence increases significantly with age: in the young adult population, it affects approximately one-quarter of men, while in older adults, it affects the majority of men, reaching very high rates after the age of 70 [7]. ED remains strongly associated with chronic diseases, including diabetes, hypertension, cardiovascular diseases, obesity, depression, hormonal disorders, and lower urinary tract symptoms, and may sometimes be an early clinical manifestation of these conditions [8, 9].

The consequences of ED extend beyond the somatic sphere and include reduced quality of life, decreased self-esteem, difficulties in partner relationships, and depressive and anxiety symptoms, which negatively impact psychosocial functioning [10]. Despite its high prevalence, this problem remains largely unrecognized – most men meeting the criteria for ED do not seek medical help, and the rate of formal diagnosis is low [11]. The main causes include shame, the belief in the “physiological” nature of age-related symptoms, and insufficient awareness of their association with chronic diseases. Due to the scale of the phenomenon and its consequences, ED should be treated as a significant public health problem requiring active diagnostics and a holistic approach to patient care [12].

The importance of sexuality in nursing care stems from its fundamental role in holistic human health, as defined by the World Health Organization, because sexuality affects the quality of life, mental well-being, and social functioning of patients, and sexual disorders are common in the course of chronic diseases, disabilities, and palliative care [13]. Patients expect that medical personnel, including nurses, will discuss sexuality in an open, supportive, and dignity-respecting manner, especially in the context of long-term treatment and rehabilitation [14, 15]. In clinical practice, however, communication in this area is limited by numerous barriers, such as insufficient knowledge and preparation of staff, personal discomfort, time and privacy deficits, and insufficient organizational support, as well as cultural and social conditions that promote the tabooing of sexuality [16]. Nurses often do not perceive themselves as competent to conduct such conversations or consider them marginal or the responsibility of other professionals [17]. At the same time, the needs of patients are clear – most people with chronic diseases and disabilities expect conversations about sexuality to be initiated by staff and included in routine care, while a relationship based on trust and repeated contacts facilitate effective identification of problems [18].

Despite the recognized importance of sexual health in holistic care, addressing sexuality in nursing practice remains rare, and problems such as ED are often not spontaneously reported by patients or identified in routine care. Consequently, ED remains largely unrecognized and undiscussed in nursing settings. Existing research points to multifactorial communication barriers, but the findings are fragmented and have not yet been synthesized in relation to nursing practice. This underscores the need for a systematic literature review to identify and organize the barriers that hinder conversations about sexuality among patients with ED.

The aim of this study was to systematically analyze the literature on barriers that hinder conversations about sexuality in nursing practice, using ED as a clinical example.

Methods

A study protocol was not registered in an international database such as PROSPERO or the Open Science Framework; however, the review was conducted and reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA 2020) guidelines [19].

Search strategy

A systematic literature search was conducted to identify studies published between January 2020 and January 2026 that addressed barriers to discussing sexuality in nursing practice, with a particular focus on ED. The search included the following electronic databases: PubMed/MEDLINE, Google Scholar, Scopus, and Web of Science, selected for their relevance to nursing, sexual health, and psychosocial aspects of healthcare.

The search strategy combined controlled vocabulary (MeSH terms) and free-text keywords related to sexuality, sexual health, sexual dysfunction, ED, nursing practice, communication, and barriers. Boolean operators (AND, OR) were used to combine the search terms. An example search string included: (“sexual health” OR sexuality OR “sexual dysfunction” OR “erectile dysfunction”) AND (nursing OR nurses OR “nursing practice”) AND (communication OR discussion OR barriers OR attitudes). The search strategy was adapted to the syntax and requirements of each database.

The search was limited to peer-reviewed articles published in English or Polish between 2020 and 2026. Additionally, the reference lists of eligible publications and related reviews were screened to identify potentially relevant studies. This supplementary search did not identify any additional studies meeting the inclusion criteria. All records were exported to a bibliography manager, and duplicates were removed prior to the selection stage.

Eligibility criteria

The review included studies meeting the following criteria: 1) original publications on communication or addressing the topic of sexuality in nursing practice; 2) studies addressing barriers, attitudes, experiences or competencies of nurses in the area of sexual health; 3) studies involving adult patients, including those with ED or other sexual dysfunctions; 4) articles published between 2020 and 2026; 5) publications in English or Polish; 6) peer-reviewed articles available in full text.

The following were excluded: 1) publications focusing solely on pharmacotherapy or treatment of ED without reference to nursing care or communication; 2) papers focusing solely on medical or urological aspects without a nursing component; 3) studies focusing solely on the pediatric population; 4) review articles, commentaries, letters to the editor, case reports, and non-peer-reviewed papers; 5) publications outside the 2020-2026 period; (6) articles not available in full text.

Study selection process

The systematic review was conducted and reported in accordance with the PRISMA 2020 guidelines [19]. The study selection process was conducted independently by two reviewers. Any disagreements regarding the eligibility of studies were resolved through discussion until consensus was reached. In the first stage, titles and abstracts were assessed for compliance with the inclusion criteria. Publications that potentially met the criteria were then selected for full-text analysis. In the second stage, full-text articles were assessed for inclusion and exclusion criteria. The number of excluded publications and the reasons for exclusion were documented at each stage of the selection process. The final number of studies included in the review and the selection process are presented in Figure 1 (PRISMA flowchart).

Data extraction

Data extraction was performed independently by two reviewers using a structured data extraction form developed for this review. The following information was obtained from each included study: author and year of publication, country of study, purpose, study design, sample size, clinical context, scope of research regarding sexuality or ED, identified barriers to communication in nursing practice, and main findings regarding implications for nursing care. The collected data were tabulated and narratively synthesized to identify and categorize barriers to communication about sexuality in nursing practice.

Quality assessment

The methodological quality of the included studies was assessed using the Joanna Briggs Institute (JBI) critical appraisal tools appropriate for the specific study designs. The appraisal was conducted independently by two reviewers. Any disagreements were resolved through discussion until consensus was reached. The purpose of the quality assessment was to evaluate the methodological rigor and potential risk of bias of the included studies.

Results

The review included 10 studies published between 2021 and 2025 and conducted in various countries, including the Netherlands, Italy, Israel, Norway, Denmark, Finland, and Poland. The included studies represented different methodological approaches, including qualitative studies, cross-sectional surveys, validation studies, and literature reviews. The studies addressed barriers to discussing sexual health in different clinical contexts, such as oncology care, neurological care, rehabilitation, and primary care. Detailed characteristics of the included studies are presented in Table 1 [17, 18, 20–27].

Barriers to discussing sexuality on the part of patients

Embarrassment and discomfort experienced by patients were among the most frequently identified communication barriers in the analyzed studies. Hentzen et al. (2022) indicated that in neurological care, patients’ feelings of embarrassment were the main obstacle to discussing sexual dysfunctions [20]. Mortensen et al. (2025) reported that 45.3% of Danish oncology nurses declared a lack of willingness to devote time to sexual health issues, which was partly related to the anticipated discomfort of patients [21].

Aromaa et al. (2025), analyzing data from 402 general practitioners and 299 gynecologists, found that the presence of third parties during consultations was perceived as a factor hindering patients from openly discussing sexual problems [22]. Kelder et al. (2022), in their discourse analysis, also described avoidance strategies used by patients themselves, including delaying the use of potentially sensitive terms and depersonalizing statements about sexuality, which reflected persistent discomfort around this topic [23].

A qualitative study by Pascual et al. (2021) involving 25 rehabilitation nurses found that insufficient privacy in rehabilitation settings limited patients’ ability to freely initiate conversations about sexuality; according to nurses, patients often postponed such conversations until discharge or avoided them altogether [17].

Barriers on the part of nurses

Personal discomfort and lack of confidence in discussing sexuality were consistently cited as barriers among nursing staff. In a cross-sectional study of 538 oncology nurses, Mortensen et al. (2025) found that although 37.8% of respondents reported comfort in providing information about sexual health, 44.1% in initiating conversations, and 45% in discussing these issues, approximately half (45.3%) would not allocate time to address sexuality in their care. Furthermore, only 28.7% of nurses reported regularly discussing this topic with patients [21].

Insufficient educational preparation was also confirmed at the undergraduate and postgraduate levels. Bekman et al. (2023), analyzing data from 14 Israeli nursing schools (response rate 51.8%), found that 79.6% of institutions considered student preparation for discussions about sexual health to be insufficient, and only 2 of 14 schools included sexual health assessment in the curriculum; none required clinical competencies in this area [24]. Lack of knowledge and clinical competencies was also a dominant barrier in Pascual et al.’s (2021) qualitative study, in which all 25 rehabilitation nurses cited insufficient knowledge as the main reason for avoiding discussions about sexuality, emphasizing uncertainty about the scope of information provided, the timing of referral to a specialist, and how to initiate and conduct conversations with patients [17].

The importance of knowledge deficits and systemic support was confirmed by a scoping review by Chen et al. (2022), covering 27 studies, in which barriers among non-medical staff (including nurses) included lack of knowledge about treatment options (15/27 studies), lack of experts to collaborate with (12/27), and insufficient clinical guidelines (18/27) [25]. Fear of negative patient reaction was further documented by Ślusarska and Marcinowicz (2024) in the validation of the SA-SH-Ext questionnaire among Polish nursing and midwifery students; factor analysis showed a significant influence of the factor “fear of negative impact on the future relationship with the patient” reflecting anticipatory anxiety about discussing sexual topics, with high reliability of the tool (Cronbach’s  = 0.91) and very good sample adequacy (KMO = 0.923) [26].

Staff attitudes and personal beliefs also influenced clinical practice. Aromaa et al. (2025) reported that healthcare workers’ beliefs significantly determined the inclusion of questions about sexual problems in interviews, with family physicians being significantly less likely to ask such questions than gynecologists (p < 0.001) [22].

Organizational and cultural barriers

Time constraints were the most frequently cited organizational barrier in the analyzed studies. Mortensen et al. (2025) found that lack of time was among the three most frequently reported obstacles among Danish oncology nurses; 45.3% of respondents declared that they would not allocate time for sexual health issues even if the patient was interested [21]. Similar findings were reported by Hentzen et al. (2022), who identified insufficient consultation time as a structural barrier hindering adequate discussion of sexual dysfunctions in neurological care, including ED in patients with Parkinson’s disease, multiple sclerosis, and spinal cord injury [20]. In a study by Aromaa et al. (2025) involving 701 physicians (402 general practitioners and 299 gynecologists), short consultation time was also identified as a major obstacle, reported by 62% of general practitioners and 48% of gynecologists [22].

The lack of clinical guidelines and procedures was also a significant systemic factor. Chen et al. (2022), in a review of 27 studies, found that the lack of clear guidelines was a key barrier and highlighted the need for institutional support; 18 of the 27 studies (66.7%) indicated a lack of protocols for discussing sexual health with oncology patients [25]. Similar observations were presented by Pascual et al. (2021), where all 25 rehabilitation nurses emphasized the need for clear descriptions of professional roles and procedures defining responsibility for addressing sexuality in multidisciplinary teams; unclear scope of competences was cited as a reason for avoiding this area of care [17]. Cultural and religious considerations also influenced practice. Gradellini et al. (2023), in a multi-center qualitative study of nursing educators in Italy, described religious and cultural norms as a significant barrier to teaching sexuality content, which was exacerbated by the time constraints of educational programs [27]. In the study by Mortensen et al. (2025), cultural sensitivity was reported as a barrier by 32.5% of oncology nurses [21].

The lack of organizational support and resources was further evident at the educational level. Bekman et al. (2023) found that Israeli nursing schools lacked requirements for clinical competencies in sexual health assessment, with only 14.3% of institutions (2 of 14) including this topic in their curricula [24]. In response to these shortcomings, Pascual et al. (2021) advocated for systemic actions, including the development of training, the inclusion of a sexologist in multidisciplinary teams, or the appointment of a nurse specialist in sexual health [17]. The analyzed studies also suggest that the type and intensity of barriers may vary depending on the clinical context in which nursing care is provided. For example, in oncology and neurological care, barriers were often related to time constraints, clinical priorities, and the complexity of patients’ conditions. In rehabilitation settings, insufficient privacy and uncertainty regarding professional roles were more frequently reported. These differences indicate that communication about sexuality in nursing practice may be influenced by the specific organization and priorities of particular clinical settings.

Educational needs and competencies of nurses

Insufficient educational preparation was consistently identified as a significant barrier. Bekman et al. (2023) found that 79.6% of nursing schools (11/14) assessed student preparedness for addressing sexual health as insufficient; only 2 schools (14.3%) included sexual health assessment in their curricula, and none required clinical competencies in this area. Furthermore, only 35.7% of schools (5/14) offered any formal sexual health education [24]. Gradellini et al. (2023) presented similar findings, indicating that nursing educators themselves felt unprepared to teach sexuality content, which was attributed to curricular barriers and limited teaching time; on average, only 8-12 hours were allocated to sexual health throughout the entire course of study [27].

The importance of training for professional readiness was confirmed by the study by Mortensen et al. (2025). Regression analysis showed that participation in sexual health training in the past year was significantly associated with higher PA-SH-D scores (p < 0.05), and knowledge of information sources correlated even more strongly with readiness (p < 0.001). Additionally, work experience remained positively associated with readiness ( = 0.18 per year; p < 0.05), but the effect of training participation was more pronounced: trained nurses achieved 23% higher readiness scores than those without such experience [21]. Specific educational needs were identified by Ślusarska and Marcinowicz (2024), who, in a validation study among Polish students, distinguished two factors, “awareness of the knowledge gap” and “awareness of the need for competence”, reflecting the recognition of both theoretical and practical deficits [26]. Students scored on average 3.8 ±0.6 points for awareness of the knowledge gap and 4.1 ±0.5 points for the need for competence (scale 1-5), indicating a high level of their perceived deficiencies [26].

The effectiveness of targeted educational interventions was confirmed by Paulsen et al.’s (2023) study among 10 Norwegian nurses following training in sexual health communication in gynecological cancer care. After the training, 80% of participants reported comfort in initiating conversations about sexuality, compared to 20% before the intervention, and 90% indicated repeated practice opportunities as crucial for building professional confidence [18]. In line with this, Pascual et al. (2021) recommended educational programs to enhance knowledge, peer coaching, and integrated consultations with sexual health specialists in care pathways; all 25 nurses surveyed declared the need for regular training and access to experts [17].

In terms of communication frameworks, Hentzen et al. (2022) identified the PLISSIT (Permission, Limited Information, Specific Suggestions, and Intensive Therapy) model as a useful, structured tool to support nursing staff in initiating conversations about sexual dysfunctions in neurological care, including ED [20]. Kelder et al. (2022) in a systematic review identified seven specific communication practices that could be learned, including the use of patient language and strategic depersonalization; an analysis of 156 consultations showed that professionals used avoidance strategies in 73% of situations where the topic of sexuality arose [23].

Models and interventions to support communication

Models and interventions supporting nurse-patient communication regarding sexuality, including ED, focus primarily on structured conversational frameworks and developing staff communication skills. Structured communication tools, such as the PLISSIT model, may support nurses in initiating conversations about sexual health and responding to patients’ needs. The authors also emphasized that nurses can play a key role in initiating conversations, and placing the topic of sexuality in the context of other physiological functions promotes its natural initiation [20]. Furthermore, Kelder et al. identified communication practices that facilitate the discussion of sensitive issues, such as the use of patient language, depersonalization, and responding to patient initiatives, which help professionals adequately respond to patients’ needs [23].

Effective approaches also include educational and organizational interventions. Paulsen et al. demonstrated that training combined with repeated practice opportunities increased nurses’ competence and professional confidence with low resource requirements [18]. Pascual et al. and Chen et al. pointed to the importance of systemic support, including clear definition of team roles, availability of sexual health specialists, protocols, and appropriate privacy [17, 25]. Educational and cross-sectional data also confirm that sexual health training in nursing education remains limited, while participation in training and access to knowledge significantly increased willingness to address this topic in clinical practice, as demonstrated by Bekman et al., Mortensen et al., and Ślusarska and Marcinowicz [21, 24, 26].

Discussion

The systematic review indicates that barriers to discussing sexuality in nursing practice are multi-level and interconnected. These include patient-related factors such as shame, limited awareness, and expectations of staff initiative; nurse-related factors, including knowledge deficits, discomfort, personal beliefs, and concerns about the therapeutic relationship; and organizational factors, including lack of time, privacy, and procedures. The discrepancy between the prevalence of ED and its clinical diagnosis remains particularly significant; Mark et al. found that with an ED prevalence of 24.2%, only 7.7% of men meeting diagnostic criteria receive a medical diagnosis [7]. Previous studies also indicate that participation in training programs increases healthcare professionals’ readiness and confidence in addressing sexual health issues in clinical practice [21]. Hentzen et al. and Duroseau and Johnson pointed to the usefulness of structured communication models, such as the PLISSIT model, the BETTER model, and the 8 Ps Framework, which support healthcare professionals in conducting comprehensive sexual health histories [20, 28].

The obtained results are consistent with previous findings in the international literature. Fennell and Grant identified four key factors influencing nurses’ uptake of sexuality education – knowledge, attitudes, comfort with conversation, and organizational barriers – corresponding to the categories identified in this review [13]. O’Connor et al. emphasized that although patient and systemic factors are frequently mentioned, staff perceptions and attitudes have the greatest impact on practice [29]. The low frequency of routinely addressing the topic of sexuality by healthcare workers (14.2%), reported by McGrath et al., confirms the scale of the problem observed in the analyzed studies [30]. Considering the specificity of the male population with ED expands this knowledge; Tereso et al. noted the marginalization of men in the area of sexual health care [31], while Klaeson et al. indicated that targeted training may facilitate engaging in conversations about sexuality with men with chronic diseases [32].

The practical implications of the review indicate the need for routine inclusion of sexuality in nursing interviews and for staff to play an active role in initiating conversations, as Zhang et al. and Igerc and Schrems emphasized that patients expect healthcare professionals to initiate such conversations and rarely raise the topic themselves [11, 14]. Kelder et al. and Duroseau and Johnson pointed to the importance of structured communication models and practices that facilitate conversations about sensitive topics [20, 27]. At the same time, Saunamäki et al. noted staff’s ambivalent emotions towards this topic, which underlines the need for reflection on professional attitudes [15]. Educational data presented by Bekman et al., Aaberg, Cappiello et al., and Walker et al. indicate persistent deficiencies in preparation for sexual health in nursing education [24, 33–35], which, in line with the conclusions of Verrastro et al., supports the inclusion of sexual competencies in educational and professional standards to improve the quality of care [36].

Implications for nursing practice

Implications for nursing practice indicate the need for systematic integration of sexuality into routine patient care, with the nurse playing an active role as the initiator of the conversation. Due to frequent and close contact with patients and the development of trusting relationships, nurses are well positioned to address this topic, which patients typically do not spontaneously raise. Normalizing conversations about sexuality by embedding them in a standard interview and the context of other physiological functions may reduce shame and facilitate communication. Developing staff competencies through training combined with clinical practice is crucial, and may increase willingness to engage in conversations without significantly burdening resources. Effective implementation of care in this area requires organizational support, including clear procedures, adequate privacy and time for conversation, access to specialists, and the inclusion of sexual health assessments in documentation. The PLISSIT model remains a useful practical tool, enabling nurses to conduct basic communication interventions and refer patients who require more in-depth support. Reflection on one’s own attitudes and team support are also important, as they may help overcome personal barriers and normalize the topic of sexuality in nursing practice. Key implications of the research analysis and recommendations for nursing practice regarding communication about sexuality are presented in Table 2.

Limitations of the review

This review has several methodological limitations that should be considered when interpreting the results. First, the search was limited to four databases and to publications in Polish and English from 2020 to 2026, which may have resulted in the omission of some relevant studies published in other languages or outside the adopted time frame. Second, a relatively small number of studies (n = 10) with diverse designs and clinical contexts were included in the analysis, which may limit the generalizability of the conclusions. Third, many of the included studies relied primarily on declarative data from healthcare professionals and qualitative descriptions of experiences, which may affect the strength of the evidence. Furthermore, most of the available studies addressed sexual health in general rather than ED specifically, limiting the direct relevance of some findings to this patient population. Additionally, some of the included studies involved healthcare professionals other than nurses, such as physicians, psychologists, or nursing students. Although these studies were included due to their relevance to communication about sexual health in clinical practice, this may limit the direct applicability of some findings specifically to nursing practice. Despite these limitations, the review provides a coherent picture of communication barriers in nursing practice and identifies key areas requiring further research and intervention.

Conclusions

Barriers to discussing sexuality in nursing practice are multi-level and include factors related to the patient, the nurse, and the organization of care.

Despite the high prevalence of ED, the topic of sexuality remains rarely discussed in nursing care, which may contribute to the underrecognition of sexual problems in patients.

Knowledge deficits, staff discomfort, and a lack of educational preparation are key barriers for nurses, while shame and expectations of staff initiative dominate for patients.

Structured communication models, such as PLISSIT, and training integrated with clinical practice may increase nurses’ willingness to discuss sexuality.

Effective implementation of sexual health care also depends on supportive organizational conditions that facilitate open communication between nurses and patients.

The review findings support the integration of sexual health competencies into nursing education and practice standards.

Further research should focus on the specific needs of men with ED and assess the effectiveness of educational and organizational interventions in clinical practice.

Disclosures

This research received no external funding.

Institutional review board statement: Not applicable.

The authors declare no conflict of interest.

References