Professional Documents
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ABSTRACT
Introduction. Sexual medicine education is an important and fundamental topic not adequately represented in most
undergraduate and residency training programs.
Aim. The purpose of this article is to better enable the participant to understand the importance of sexual medicine
education, and to review existing models and innovations in undergraduate and graduate medical education. This
activity is designed for the practicing physician.
Methods. A literature review of the topic was performed.
Main Outcome Measure. Current state of, and new developments in, sexual medicine education.
Results. In all countries, medical students, house staff, and practicing physicians currently receive variable, non-
standardized, or inadequate training in sexual history taking and sexual medicine assessment and treatment. There
remain signicant physicianpatient barriers to discussing sexual issues; and patients feel that their physicians are
reluctant, disinterested, or unskilled in sexual problem management. There is a knowledge gap between develop-
ments in sexual medicine and the clinical skills of practicing physicians.
Conclusions. The challenge is to create uniform, widely available programs that provide practicing physicians across
specialties with the needed skills to meet modern patients needs in sexual medicine healthcare delivery. Parish SJ,
and Clayton AH. Sexual medicine education: Review and commentary. J Sex Med 2007;4:259268.
Key Words. Sexual Medicine; Education
matter may not be allotted sufcient curriculum Numerous studies document the importance of
time. Sexual health education is an example of an sexual health to patients. A recent U.S. poll indi-
often neglected, but very important topic. Sexual- cates that 94% of adults feel that sexual pleasure
ity is important to almost all patients; yet this topic adds to quality of life [1]. However, sexual con-
is not adequately represented in most undergradu- cerns are common. A widely quoted 1999 analysis
ate and residency training programs. Healthcare of a survey of U.S. adult sexual behavior (ages
providers are becoming increasingly aware of the 1859 years) revealed that 43% of women and
importance of addressing male and female sexual 31% men experience sexual problems that nega-
health. Reecting this societal change, educators tively impact on their quality of life [2]. Sexual
are paying more attention to this gap, assessing it, dysfunction may occur at any point in the sexual
and piloting new curricula. The current interest in response cycle (desire, arousal, or orgasm), and can
this topic will hopefully generate medical school be a primary problem or a secondary issue related
to another disease process, medication, or psycho- third of patients feel comfortable talking to their
social issue [3]. The consequences of untreated physician about sexual concerns, and only 10% of
sexual dysfunction may include depression, con- patients spontaneously discuss concerns if not
icts within interpersonal relationships, or non- prompted by their physician [11]. Most patients
compliance with prescribed medication regimens (over 90%) believe that it is a physicians role to
[4,5]. Researchers have made signicant strides in address sexual health concerns, and are grateful
understanding the anatomy and physiology of the when their physician initiates the discussion [12].
male and female sexual response. This knowledge
has enabled the development of new medications
Detection of Sexual Problems
and other treatments for sexual dysfunction. The
current challenge is the widespread distribution of Clinicians infrequently screen for sexual pro-
this once-considered taboo information to the blems, so detection rates are consequently low. In
healthcare providers and patient population at one study, English general practitioners (GPs)
large. recorded sexual problems in only 2% of their
notes, despite a survey prevalence of female sexual
dysfunction of 42% [13]. Improving screening
PhysicianPatient Barriers to Sexual Interviewing
procedures does improve recognition. In another
Despite the increasing awareness of, and knowl- study in which clinic physicians were trained to
edge about, sexual dysfunction and the availability take a screening sexual history, 53% of the patients
of treatment options, physicians and their patients reported a sexual problem [12]. Most (91%) of the
still hesitate to discuss these issues. One study patients said they considered questions about sexu-
reports that their primary care physician never ality to be an appropriate part of the interview.
asked 47% of patients whether they are engaged in Studies demonstrate the high prevalence of
a sexual relationship [6]. Only 25% of primary care sexual problems, signicant barriers to addressing
physicians actually take a patients sexual history, sexuality in clinical settings, improved detection
citing lack of training as the most common reason with focused training in history-taking skills, and
for not doing so [79]. If practitioners do take patients acceptance of such discussions. Physician
sexual histories, they most commonly focus on education, targeted at improving skills, increasing
sexually transmitted disease (STD) risk assessment knowledge, and encouraging awareness of per-
and prevention and/or contraception, rather than sonal biases, is the key to minimizing obstacles that
sexual problems. Physicians report other barriers, interfere with physicians optimally addressing
such as insufcient knowledge about sexual func- sexual health.
tion and dysfunction, inadequate communication
skills, discomfort with sexual language, lack of
Physicians Need for Sexual Medicine Education
information about treatment options, time con-
straints, apprehension that their inquiries may While physicians typically do not receive adequate
offend the patient, and their own feelings of training in sexual medicine and sexual history
embarrassment about the subject. Physicians may taking, they believe that they should address sexual
have difculty remaining objective and separating problems, and that they need more training. Prac-
their personal views from those of their patients ticing physicians can gain increased comfort and
[10]. Physicians in training may have limited sexual experience in managing sexual problems by incor-
experience, unresolved issues regarding their own porating routine sexual health questions into their
sexuality, or concern about developing sexual feel- practice, by addressing the barriers discussed
ings toward patients. above, by sharing cases with colleagues, and by
Patients are reluctant to bring up sexual issues exploring their own attitudes toward sexuality [10].
with their physicians. Many (75% in one study)
believe that their physicians would dismiss their
The Importance of Sexual Health in
sexual health concerns, or fear the topic might
Medical Education
embarrass their physician [1]. Many patients do
not have condence in their physicians skills in Given the high prevalence of sexual problems, the
managing sexual problems, and do not believe they importance of addressing the sexual health con-
would receive effective treatment. Less than one- cerns of patients, and practicing physicians
perceived lack of, and need for, enhanced training courses; and (iii) an interdisciplinary approach to
in sexual medicine, medical school, and postgradu- the evaluation and management of sexual dysfunc-
ate training are the primary forums in which tion [18]. While the NIH conference addressed
doctors should acquire the necessary knowledge impotence, sexual medicine experts concur that
and skills. the identied deciencies in skills and knowledge,
In 1974, the World Health Organization and the recommendations for sexual health educa-
(WHO) organized a meeting on Education and tion, should be applied globally to the identica-
Treatment in Human Sexuality to address sexual tion, assessment, and management of all sexual
health training and create denitions of sexual disorders.
health. A subsequent international meeting in
2000, sponsored by the WHO and the Pan Ameri-
The Current State of Sexual Medicine Education in
can Health Organization, resulted in a publication
U.S. Medical Schools
entitled Promotion of Sexual Health. [14] Their
denition of sexual health is: Medical educators have only recently become
interested in sexual health education. Increased
. . . the experience of the ongoing process of physical,
psychological and socio-cultural well-being related to societal willingness to discuss sexual health, asso-
sexuality. Sexual health is evidenced by the free and re- ciated with increased availability of treatments
sponsible expression of sexual capabilities that foster
harmonious personal and social wellness, enriching for sexual problems, has raised awareness of the
individual and social life. It is not merely the absence need for enhanced training in sexual medicine.
of disease, dysfunction or inrmity. [15]
However, many medical schools still offer insuf-
In conjunction with this denition, 11 sexual cient training in sexual health, and there is a sub-
rights were enumerated, including the right to stantial knowledge gap between the science of
sexual information based on scientic inquiry, the sexual medicine and the clinical skill level or com-
right to comprehensive sexuality education, and petency of most physicians in managing sexual
the right to sexual health care [16]. problems [19].
The World Association for Sexology (WAS) In 1976, Lief and Ebert conducted an early
and other organizations have also made recom- survey regarding sexual health education in
mendations about sexual health training that apply medical schools [20]. They reported that 60% of
to U.S. medical education; however, there is a need U.S. medical schools offered required sexuality
for more information on the specic components curriculum, and 32% provided elective training. A
of ideal undergraduate sexual health education. In more comprehensive 2003 study assessed the edu-
1980, the UK General Medical Council (GMC) cational experiences related to human sexuality in
stated that, upon graduation, medical students 125 medical schools in the United States and 16 in
should be able to communicate effectively and sen- Canada (Association of American Medical Col-
sitively with patients and their relatives [17]. In leges [AAMC]) [18]. The survey asked the North
1993, the GMC recommended that primary care American medical schools about the type of
physicians actively promote sexual health and educational experiences (i.e., lectures, courses),
provide information on healthy sexual lifestyles, whether they were mandatory or elective, whether
and that the training of medical students incorpo- they were designed by single or multiple disci-
rate ethical responsibilities related to sexuality, plines, and the number of course hours dedicated
such as avoiding sexual discrimination against to human sexuality. The questionnaire also
patients and colleagues. In the same year, the assessed specic content areas, as well as exposure
National Institutes of Health (NIH)s Consensus to and training in clinical settings addressing
Statement on Impotence determined that health- sexual problems. Additionally, the survey assessed
care providers are uninformed about sexual the availability of CME programs in sexual medi-
issues and do not manage them effectively. The cine and related topics.
NIH Statement recommended three key compo- The investigators received 101 valid responses
nents for sexual health education: (i) human sexu- from a possible 141 medical schools. Two addi-
ality courses in healthcare professional curricula, tional schools returned the survey, acknowledging
emphasizing sexual history taking; (ii) diagnosis that their school curriculum dedicated no hours to
and management of sexual dysfunction in post- sexual health education, and ve other schools that
graduate continuing medical education (CME) did respond stated that they were embarrassed at
how little time their school devoted to the topic. A gynecology [OB-GYN], urology, and psychiatry)
challenge in completing the study was that, at [19].
many schools, no one particular person was Less than half (44.6%) of the medical schools
responsible for the sexual health curriculum. Most who responded to the 2003 survey discussed above
schools (87.5%) reported that they used a lecture offered CME programs for professionals inter-
format, required at over 80% of schools. Two- ested in sexuality-related topics [18].
thirds of the schools used a multidisciplinary In response to the increasing demand and inter-
approach to teach sexual health, and three- est, some organizations, composed of practicing
quarters of the schools reported psychiatry as the physicians in one or several disciplines caring for
most frequently involved discipline. Over half patients with sexual problems, now offer lectures,
of the schools offered 310 hours of training, workshops, and longer courses on the evaluation
whereas one-third offered 11 or more hours on the and treatment of male and female sexual dysfunc-
subject. The most common topics discussed were: tion. Organizations that have provided these
causes and treatment of sexual dysfunction, sexual courses include: the American College of Physi-
identity/orientation, and sexuality in disabled or cians (representing general internists and sub-
medically ill patients. Additional topics included: specialists), the American Psychiatric Association,
STDs, infertility, sexual abuse, and lifecycle issues. the North American Menopause Society, and the
Slightly more than half of the schools exposed American Urological Association. Academic soci-
students to clinical experiences during which they eties, such as the Society for General Internal
interacted with patients receiving treatment for, or Medicine, offer workshops geared toward clinician
education on, sexual issues. educators that address both clinical care and teach-
Studies assessing curricula at individual institu- ing strategies. In the past decade, multidisciplinary,
tions demonstrated that students receive a broad specialized organizations, such as the International
range of nonstandardized training. For example, Society for the Study of Womens Sexual Health,
an evaluation of Boston University Medical have been sponsoring meetings that are dedicated
Schools sexuality education demonstrated that to sexual health research and educational courses
students had widely varied experiences, largely designed to enhance clinical care.
determined by their personal interest and random
assignment to specialized services (e.g., transgen-
Accreditation Standards for Sexual Medicine
der clinic) available to limited numbers of students
Education
[21]. More controversial topics in sexual health
have even less favorable representation. For The Liaison Committee on Medical Education
example, of the 82 U.S. medical schools that (http://www.lcme.org) determines accreditation
responded to a survey (65% of the 126 schools standards for medical schools. The curricular
surveyed), eight faculty reported that they had no requirements related to sexual health are general
teaching on gay and lesbian issues [22]. Cultural and include learning about: behavioral subjects;
inuences on sexual practices do not appear to be communication skills; medical consequences of
addressed in most sexuality curricula. common societal problems, such as abuse; diverse
cultures and belief systems; and gender biases.
The Accreditation Council for Graduate Medi-
cal Education has outlined residency program
Current State of Sexual Medicine Education in U.S.
Graduate Medical Education and CME Programs
training requirements for all disciplines (http://
www.acgme.org). Sexual medicine requirements
Sexual health training in graduate medical educa- are also very general. Internal medicine residents
tion is understudied and largely unaddressed. should receive instruction and clinical experience
According to Rosen et al., Residency training in in the prevention, counseling, detection, diagno-
sexual medicine has been largely neglected, with sis, and treatment of gender-specic diseases of
little attention given to educational curriculum men and women. Family medicine guidelines
development or implementation, and few pro- mention teaching of human sexuality. Pediatrics
grams have training in sexual problem manage- requirements include learning about sexual abuse,
ment across disciplines or subspecialties (e.g. and male and female reproductive health, in-
family medicine, internal medicine, obstetrics/ cluding sexuality, pregnancy, contraception, and
STDs. Urology residents should receive training cussing sensitive psychosocial issues. Third-year
in sexual dysfunction. OB-GYN requirements students were signicantly less likely to rate dis-
include topics more directly relevant to sexual cussing sex in a routine ofce visit as important, a
health, including contraception, infertility, meno- response that may reect supervising attending
pause, high-risk behavior, as well as specic sexual physicians negative attitudes toward, or discom-
medicine skills, such as sexual history taking and fort with, taking a sexual history in the inpatient
psychosexual counseling. Psychiatry guidelines are setting.
quite vague, with a focus on cultural differences A 1996 Australian study compared students
that address issues of gender, race, ethnicity, socio- personal sexual experiences with their condence
economic status, religion/spirituality, and sexual and ability to perform female pelvic exams. Both
orientation (knowledge and attitudes). male and female students who had sexual experi-
ence (153 of 286 students) felt more comfortable
performing the exam, explaining their actions to
Research on Trainees Perceptions of Sexual
their patients and being able to detect pathology
Medicine Skills
[24].
Clearly, medical schools vary in their attention to These and other similar surveys regarding
sexual health education. Recognizing this dispar- medical students attitudes toward, and perceived
ity, the pharmaceutical company, Pzer Inc., skills in, sexual medicine offer insights into the
recently offered seven $100,000 grants to medical current climate of sexual health education in
schools to evaluate and enhance their sexual health medical schools. Further investigation is needed
programs. Three grant recipients, the University from many other medical school and residency
of Virginia (UVA) School of Medicine, Case training programs to assess trainees abilities and
Western Reserve University School of Medi- biases, and to provide the impetus for curricular
cine (CWRU), and University of Massachusetts change.
Medical School (UMMS), have published data.
Prior to introducing any curriculum enhance-
New Developments in Sexual Medical Education
ments, the UVA School of Medicine conducted
research comparing knowledge of, comfort with, A number of medical schools have made improve-
and attitudes toward the importance of sexual ments to their sexual health education programs,
health care among rst-, second- and third-year which address some of these decits. Several
medical students. The existing curriculum at UVA models described below incorporate a multidisci-
included information relevant to sexual health in plinary approach to enhancing trainees attitudes,
Anatomy, Embryology Histology, Physiology, knowledge, skills, and overall comfort in managing
Human Behavior, Pathology, and Introduction to sexual health problems. Table 1 outlines the com-
Psychiatry and Practice of Medicine (POM) ponents, including attitudes, knowledge, and skills
courses. The POM training included: lectures on training, that have been included in sexual health
obtaining a sexual history and screening for curricula.
domestic violence, sexual history taking utilizing A Pzer grantee, CWRU, is in the process
role-play and standardized patients, and gyneco- of implementing a comprehensive, cross-
logic and genitourinary exams performed on disciplinary and innovative curriculum that is
female and male standardized patients. based on three primary objectives for teaching
The results (published 2003) revealed that rst- sexual health: attitude change, behavior change
year students felt that they knew the least about and knowledge acquisition [25]. Attitude change
obtaining a sexual history and the most about is accomplished by promoting students awareness
medications for treating sexual dysfunction, likely of their own attitudes toward sexuality. The
reecting exposure to the media, while third-year revised curriculum provides exposure to normal
students said that they knew the least about medi- variations of sexuality, dispels myths, and teaches
cation treatment [23]. All three groups of students boundary setting, with suggested strategies to
felt the least comfortable discussing sexually manage situations in which those boundaries are
related health problems and the most comfortable challenged. Behavior change is being addressed
discussing sexual side effects of medications, sug- by enhancing communications skills regarding
gesting students overall discomfort with dis- all aspects of sexual functioning. Knowledge
Table 1 Components of model sexual health curricula sessions within the core curriculum; case-based
Attitudes Self-awareness of own beliefs, values, attitudes learning; standardized patient interviews; testing
Reflection/ desensitization using multiple-choice questions; and Objective
Variations of normal sexual behavior Structured Clinical Exams, including both sexual
Ethical issues
health content in existing stations and stand-alone
Knowledge Biology of sexual development on molecular level
Anatomy and physiology of human sexual stations; assessment of students attitudes using the
response Sex Knowledge and Attitudes Test; and the cre-
Psychological influences on sexual development ation a sexual health website.
Causes of sexual dysfunction (biological,
psychological, and social) Another grant recipient, UMMS, has also
Impact of medical illness, treatment, medications implemented curricular change through the
Sexual health in adolescence Sexual Health Initiative Project. The Macy Com-
Impact of menopause, aging on sexuality
Sociologic issues (ethnicity, race, culture, religion, munication Skills Curriculum Initiative (1999)
sexual orientation, and economic status) fueled the addition of new topics to the third-year
Sexuality in special populations (disability) curriculum, including adolescent sexuality, lesbian
Reproductive biology (contraception, pregnancy,
and infertility) and gay health care, reproductive counseling, HIV
Sexually transmitted diseases risk reduction, and sexual dysfunction caused by
Sexual abuse/ violence medications [26].
Gay/ lesbian/ transgender health care
Treatments for sexual dysfunction (pharmacologic A 2001 survey administered to rst- and
and behavioral) second-year medical students identied barriers to
Skills Sexual history taking discussing sexual issues with patients, including
Comfort with sexual language societal messages that sex was private, lack of
General communication skills
Gynecological/ genitourinary exams knowledge, patient and student discomfort with
Integrated diagnosis of sexual dysfunction the subject overall, and cultural differences. Stu-
Management of sexual disorders dents reported that particularly challenging topics
(pharmacological, counseling, and devices)
Management of sexual side effects of included extramarital affairs, multiple partners,
medications sexual violence, gathering sexual information from
Behavioral therapy older patients, and patients who engage in high-
risk sexual behavior.
Based on these survey results, UMMS imple-
acquisition involves a multidisciplinary approach mented other curricular enhancements through-
to all aspects of sexual health, including topics such out the 4 years. During the rst-year anatomy
as biology, sexual development, and sociologic course, UMMS offered an elective reection
issues, such as the impact of ethnicity, race, session regarding students reactions to the dissec-
culture, and economic status on sexual health. tion of the female pelvis. One-half of the 25% of
Sexual health enhancements were conceptual- the class that participated felt that the session
ized simultaneously with the implementation of reduced their apprehension related to the dissec-
revisions throughout the 4-year medical school tion, and 95% wanted to have more sessions of a
curriculum at CWRU. Two such initiatives, the similar nature in the future. Another elective
development of vertical themes across all 4 years 1-hour session on the Medical Risks of the Gay,
and an Integrated Electronic (web-based) Cur- Lesbian, Bisexual and Transgendered Commu-
riculum, are important tools for promoting new nity was instituted during an interclerkship day in
sexual health education. A sexual health website the students third year. Of the 50% of the class
was developed to provide the Sexual Health Ver- that participated, 95% thought the lecture was
tical Theme of the CWRU medical school cur- effective in promoting awareness of these issues.
riculum in an electronic format. The purpose of UMMS also developed a multidisciplinary 1-week
the website is to provide up-to-date, clinically rel- womens health course available as an elective for
evant information and cutting-edge research fourth-year students. Although only a handful of
regarding the broad elds interfacing with sexual students participated, all of them strongly agreed
health. that the course increased their skills and comfort
Strategies to incorporate the sexual health in managing womens health problems.
content include: faculty development to enhance Some educational initiatives in sexual medicine
sexual communication skills; additional didactic have been initiated directly by students. For
example, in 1998, second-year students at the ality that may inuence clinical practice [29].
Stanford University School of Medicine, designed Methods include desensitization, problem solving,
and implemented nine-weekly lunchtime elective and reection. Students address their embarrass-
lectures entitled Current Issues in Reproductive ment with sexual topics, including becoming
Health, paired with a University-wide Reproduc- familiar with slang and medical terms in a safe
tive Health Fair [27]. Students reported that the environment in which they might rehearse their
two most frequently acquired skills were the ability reactions and responses. Most students (78%) felt
to discuss an unwanted pregnancy and to commu- that the course offered some benet, and a similar
nicate with patients of varying genders, sexual ori- number of students believed that it made them
entations, and cultures. Students said that the most more sensitive to the needs of patients and the
useful learning methods included discussions with duties of doctors.
fellow students, interactive presentations with
faculty, didactics, and teaching peers.
Developments in Residency Sexual
Developments in International Sexual Medicine Education
Medicine Education
Few residency training programs have described
Sexual health education reform is also evolving innovations in sexual health education. The
outside the United States. Some innovative model Robert Wood Johnson Medical School (RWJMS)
curricula have emerged from medical schools in has been an internationally recognized model
the United Kingdom. In 1996, Glascow University for comprehensive sexual health education for
developed a sexual health communication skills medical students since 1973. Using a small-group
training program aimed at improving students interactive format, the course seeks to provide a
skills across disciplines (gynecology, urology, culturally diverse and patient-centered approach,
family planning, and primary care) [17]. It contains focusing on three components: (i) integration of
three components: (i) exploration of students cognitive and attitudinal learning; (ii) role of a
values and attitudes toward sexual practices, such multidisciplinary team in managing sexual prob-
as prostitution and termination of pregnancy; (ii) lems; and (iii) clinical skills, including general
supervised role-play of clinical scenarios; and (iii) communication skills and sexual history taking.
discussion of referral resources. Nearly all of the Recently, a parallel model was developed for
students (97%) thought the course was relevant to training house staff, incorporating the three ele-
clinical practice. ments described above into a half-day program
The University of Cambridge instituted role- [19]. The program was designed to assess the fea-
playing mock clinic scenarios, which allows stu- sibility and impact of implementing the educa-
dents to empathize with the patient, and discover tional model with primarily senior house staff
and test benecial behaviors [28]. Two examples from RWJMS-afliated residency programs in
include: (i) a young homosexual man who has just multiple specialties, including 46 internal and
come out but does not know how to use a family medicine, psychiatry, geriatrics, OB-GYN,
condom, and (ii) a woman interested in having urology, and pediatrics residents. Methods
an intrauterine device tted. The University of included: didactic presentations on male and
Cambridge also conducts a session dedicated to female sexual dysfunction, physician and patient
increasing awareness of homosexuality. During the panels, an audience response system with feed-
session, students explore internalized prejudice by back, and interviewing skills practice. The major-
brainstorming all the slang terms they know relat- ity (92.6%) of the 34 respondents to the posttest
ing to homosexuality, and then reecting on them evaluation said that the workshop was informa-
silently. Students then examine the effects of tive; about two-thirds (67.4%) said that they
prejudice by imagining how they would react to gained greater awareness about sexual problems;
those terms if they were gay. and approximately half said that they increased
Another medical school in the United their comfort and skill in sexual problem manage-
Kingdom, Leicester-Warwick Medical School, ini- ment, including the use of specialized referral.
tiated a course designed to aid the students in The participants specically praised the live inter-
recognizing their attitudes and values toward sexu- views and panels.
Please return this page to: Alternatively, an online version of this activity
William Deluise will be available beginning in March 2007. Please
Assistant Editor, CME visit http://www.blackwellpublishing.com/jsm in
Blackwell Futura Media Services March for further information.
Fax: 781-388-8304