As psychiatrists, we seek to understand and foster mental health in relation to many aspects of life, including intimate life and the deeply personal domain of sexuality. In this special issue of Academic Psychiatry, we take a careful look at psychiatry’s role in teaching medical students, psychiatric residents, and colleague physicians about human sexuality and the sexual concerns that arise in clinical care.
The authors in this issue discuss the ways in which medical professionals address sensitive sexual health-related topics with their patients and how the medical system at times fails patients by neglecting the important role of sexual health in human health and well-being. The work in this collection articulates critical implications for undergraduate medical curricula and psychiatric training programs. And, taken together, the collection makes the persuasive argument that assessment of sexual function and treatment of sexual concerns is certainly within the purview—and some would suggest the imperatives—of the field of psychiatry.
Sexual concerns are common. Most people believe that healthy sexual function is an extremely important factor in one’s quality of life (1). Individuals rely on clinicians to answer questions about normal sexual functioning, safe sexual practices, contraception, family planning, and sexually transmitted illnesses. Clinicians, in turn, are better able to diagnose and treat medical conditions when their patients are honest with them about sexual practices that may be relevant to their medical concerns. Sexual function may be compromised by common medical conditions such as diabetes mellitus (2), or by the hormonal changes associated with normal aging (3). In some cases, sexual dysfunction may be related to psychological concerns such as paraphilias (4), anxiety, stress (5), or the direct result of psychopharmacologic treatments for mood disorders, anxiety, or psychosis (6).
Patients do not bring sexual concerns to their physician’s attention. Despite the fact that healthy sexual function is important, patients report that they feel uncomfortable discussing such issues with their physician. Studies show that patients feel uncomfortable talking about sexual issues and believe that their clinician will be similarly ill at ease (7). More concerning are the beliefs that they will be judged as being “abnormal” and the fears that their concerns will not be validated or taken seriously. Patients also report that they do not ask their medical provider about sexual problems due to concerns that there will not be an effective intervention or treatment available to them (7). Lesbian, gay, bisexual, and transgender (LGBT) patients, in particular, are more likely not to seek medical care—and therefore neglect their personal health—due to barriers accessing the health care system such as systemic discrimination, ineligibility of extended health care coverage to same-sex partners, and a dearth of health data collection for LGBT populations (8).
A surprising number of physicians do not feel comfortable discussing sexual issues. Fewer than 50% of U.S. and Canadian medical schools have formal curricula (>2 hours) devoted to teaching human sexuality, and those that do have a very limited amount of time to cover the information in a way that leaves trainees feeling adequately prepared (9). The majority of graduates feel that they lack the necessary training to competently address sexual concerns with their patients, and a number of studies suggest that trainees vary significantly in the accuracy of their medical knowledge pertaining to normal sexual function and the assessment and treatment of sexual concerns. Some providers admit to feeling embarrassed or uncomfortable addressing sexual concerns, and as one of the articles in this collection highlights (10), this appears to be particularly common in international medical graduates who are originally from areas of the world that are culturally very different from the United States. Similarly, U.S. graduates acknowledge feeling uncomfortable initiating conversations about sexual function with their patients, but a higher percentage report feeling more comfortable talking about sex when the conversation is initiated by the patient (11). Physicians also cite lack of adequate time in an outpatient setting to do justice to their patients’ concerns about sexual health (9). Many admit that they avoid talking about sexual issues with a patient from a different culture out of concern that the discussion might be deemed unwelcome or inappropriate (9).
Sexual trauma is prevalent and can play a significant role in sexual health and sexual function. Too often, however, victims do not report assaults, or their attempts to get help are not adequately addressed (12). It is estimated, for instance, that only a minority (3%–26%) of sexual assaults are brought as complaints to the police (13). Individuals and health care providers may fail to make the connection between a traumatic event and the mental and physical sequelae that follow. Both discrete traumatic events and ongoing mistreatment can result in chronic psychological and physical symptoms. The World Health Organization (14) cites the fact that, in some countries, up to one-third of young women experience forced sexual activity as their initial sexual experiences. Many coerced sexual experiences center on behaviors that are profoundly degrading or humiliating, beyond the physical risks of pregnancy, sexually transmitted diseases, and injury. A national survey found that 34% of women were victims of sexual coercion by a husband or intimate partner in their lifetime (15). International studies suggest that between 20% and 50% of all women have been subjected to gender-based violence, including domestic violence, sexual assault, and significant sexual harassment (14). Women are not the only victims of sexual assault: according to the 2000 National Violence Against Women Survey, 78% of victims of rape and sexual assault are women and 22% are men (16).
Survivors of sexual trauma may present with ongoing mood symptoms, anxiety, substance abuse, eating disorders, somatic concerns, and posttraumatic stress symptoms (avoidance, re-experiencing the event, nightmares, and hypervigilance) (17). The effect of sexual trauma on both the individual and societal levels is significant. In addition, each of the previously mentioned co-occurring conditions can directly and indirectly affect future sexual functioning. For example, disabling flashbacks may lead to an individual’s inability to engage in intercourse. Victims may experience decreased libido due to depression or anorgasmia related to serotonin reuptake inhibitors prescribed to target mood and anxiety symptoms. In the physician’s office, practitioners need to be sensitive to the fact that individuals may have experienced a sexual trauma and must be particularly careful when performing medical examinations that may trigger a re-experiencing of traumatic events.
Sexual medicine is increasingly carried by disciplines outside of psychiatry, even though psychiatry programs may be uniquely positioned to help in the provision of treatment for sexual disorders. As medical knowledge grows and society increasingly focuses on biological treatment for disorders—historically thought to be primarily psychological in nature—our colleagues in urology, gynecology, family medicine, and internal medicine are taking on increased responsibility as the primary caregivers for patients presenting with sexual dysfunction (18, 19). Unfortunately, patients may not be referred to mental health providers when indicated, out of concern that the patient will resist evaluation. Many still fear the stigma of having a mental illness rather than a purely physiological problem. On the other hand, in a more modern approach, many medical centers appropriately employ a multidisciplinary model for diagnostic assessment and treatment, which includes a mental health evaluation. That said, the mental health role in such teams is often assigned to psychologists or masters-level mental health clinicians rather than to psychiatrists who can bring a full range of expertise related to physical and mental health issues.
As the field of psychiatry has become more focused on “cutting edge” psychopharmacology, neuroimaging, and evidence-based psychotherapeutic modalities, there has been arguably less focus on teaching human sexuality and on all forms of psychosocial therapy, including sex therapy (18). Authors in this collection make the argument that, despite the fact that psychiatrists historically have made the major contributions to our understanding of human sexuality (e.g., Freud, Kraft-Ebbing, Wolpe, and Brady) (18), contemporary psychiatry lacks a significant number of “experts” in sexual health who can help advance the field for our own trainees, much less for those in other medical specialties. Nonetheless, psychiatric training is unique among medical specialties in that it provides trainees with supervision and support while they increase their experience talking with patients about sensitive and difficult topics. We learn to empathically inquire about psychosocial issues that affect both physical and mental health and are attuned to the importance of the patient’s relationships with others (18) as well as the relationship between patient and physician. We must also be astute to the importance of maintaining professional boundaries and learn to be open to ongoing supervision when discussing deeply personal issues such as intimacy and sexual relationships (20). This unique training experience makes psychiatrists well-prepared participants in multidisciplinary treatment teams and, many would argue, distinguishes us as the medical professionals best suited to teach our nonpsychiatric colleagues about therapeutic alliance, boundaries, and sensitive interviewing techniques. Such skills are important not only in the specialized treatment of sexual disorders but also in taking a complete sexual history in the context of routine medical care.
Undergraduate medical education and residency training programs need to do a better job of preparing physicians to competently handle sexual concerns in an empathic, gentle, and respectful manner. Accreditation Council of Graduate Medical Education (ACGME) requirements for training in psychiatry do not specify parameters for training in human sexuality aside from the ability to identify sexual abuse and to recognize factors (such as gender and sexual orientation) that influence normal development (11). Undergraduate Liaison Committee on Medical Education (LCME) standards for teaching human sexuality are similarly vague (21). If we hope to graduate more capable, competent, and compassionate physicians, we must develop more explicit and standardized guidelines for training, and we must protect the time to devote to that training. Given that many curricula in medical education already feel overburdened with “essential” clinical topics, we can anticipate that this will be no small undertaking.
We are learning about how to best teach early career physicians about sexual health concerns. The heartening news is that individual programs are performing needs assessments and responding to perceived gaps in comfort, knowledge, and experience by developing didactic series and specialized clinical experiences in sexual health. One such program (22) polled residents about their training experience in sexual medicine and found that the majority wanted more exposure than the 6 hours of didactic seminars that were already available to them. Residents felt that didactic seminars and outpatient clinical experiences were the best settings in which to learn the material. Another program (23) introduced the Sexual Events Classification System, which provides clinicians with an outline for a comprehensive sexual history. Residents were observed taking sexual histories from simulated patients before and after learning the Sexual Events Classification System, and a substantial percentage reported increased competence and comfort in taking a sexual history. Johns Hopkins has a specialized program, consisting of didactic seminars and case observation, for teaching residents about paraphilic disorders (24). Similarly, in undergraduate medical education settings, schools are experimenting with a number of methods to teach human sexuality, including didactic seminars, small group discussion, simulated patients presenting with a number of “standard” complaints, and pre- and postprogram assessment of students participating in the curriculum (21).
Clearly, sexual health is clinically important across specialties, and all medical providers need to feel comfortable addressing this sensitive topic. Many patients with sexual concerns will never see a mental health clinician. Nonetheless, psychiatrists possess distinct training and skills that are valuable in both patient care and in the training of clinicians in other specialties. As suggested by this collection, it is vital that academic psychiatrists step up their efforts to define and advance the role of our field in the care and teaching of sexual health. This need is especially true when it comes to the shadowy and difficult matters that arise in relation to our patients’ experiences of sexual trauma and the untoward effects of our therapeutic interventions for psychiatric disorders, such as impotence and anorgasmia associated with many psychotropic medications. Helping our trainees and colleagues to work with these sensitive health concerns is also critical, and our curricular efforts, as yet, are insufficient to bring sexual health care into a modern era of psychiatry.
At the time of submission, Dr. Derenne reported no competing interests. Disclosures of editors are published in each January issue.