A Letter to the Editor on the Article by Farnam et al

The study by Farnam and colleagues is a useful and much needed contribution to examine the effectiveness of sexual counseling models in health care [1]. It is, however, debatable whether the authors should have concluded that the Sexual Health Model (SHM) is a cost-effective option for sexual counseling. Given the mentioned need to find a more cost-effective alternative for standard models, such as the Permission, Limited Information, Specific Suggestions, Intensive Therapy (PLISSIT) model, we expected the authors to have performed a costeffectiveness study. These data, however, were not collected, and a less firmly formulated conclusion regarding the suspected costeffectiveness of SHM would be appropriate here. Even more so, as the SHM group still scores above the Female Sexual Distress Scale-Revised (FSDS-R) cut-off (≥11) at 28 weeks (mean [standard deviation (SD)] FSDS-R 11.7 [10.5]), while the PLISSIT group is below the cut-off (mean [SD] FSDS-R 6.8 [7.5]). It was also surprising that there are borderline significant (P = 0.051) differences reported between the groups for sexual function and sexual distress at 28 weeks, while their table 3 suggests otherwise when looking at sexual distress. Even though sexual function and sexual distress were measured with separate questionnaires on separate scales, they seem to have been analyzed as a “combined outcome” in the multivariate analysis of variance (manova). The authors, however, do not present this score, nor explain how it was constructed or is to be interpreted. Yet, they focus their discussion and conclusion on these analyses, which does not do justice to their other (univariate) analyses. Furthermore, as the manovas suggest (borderline) significant differences between groups, treatment weeks, and groups*treatment weeks, it would have been interesting to see the data for the second assessment (10 weeks) as well. It would aid the interpretation of the findings if these items were further clarified by the authors. Another issue that would benefit from clarification is that, compared with SHM, no effort seemed to have been made to make the PLISSIT model cultural specific as well. What this cultural specification might entail, also for SHM, and how this affected the outcome could be discussed. The PLISSIT model is applied based on the care provider’s competence and is tailored to the individual’s problem [2]. These features do not seem to hinder a more cultural-specific application of this model than SHM. Finally, a more in-depth discussion could also be created by speculating on the effects of certain decisions. For example, could the exclusion of patients with serious medical conditions and family issues lead to selection bias? Or how the findings may have been affected by the author (F.F.) performing sexual counseling in both study groups. Conflict of interest: The authors report no conflicts of interest.