A 1999 poll of 500 American adults ages 25 years or older (1) revealed that 71% of respondents were concerned that their doctor would dismiss discussions related to issues of sexual problems and would say that the problems were “just in their head.” In addition, 68% were concerned that their doctor would be uncomfortable talking about the problem because it was sexual in nature, and 76% felt that there were no medical treatments available to help them. Yet this survey also indicated that people felt that sexual health was important—91% of married men and 84% of married women ranked a satisfying sexual life as important, and 94% of those polled stated that sexual enjoyment added to the quality of life at any age. Interestingly, more than 90% of respondents also believed that sexual difficulties cause problems such as depression and emotional distress. In a recent study of 501 undergraduate and graduate students in Vermont (2), 45% of participants preferred most to receive sexual health information from a provider who initiates the conversation, 32% preferred most to receive sexual health information from a provider after they themselves initiate the conversation, and 19% preferred most to receive the information from their provider after first filling out a questionnaire addressing sexual concerns. The same participants least preferred to receive the information from the internet (25%), textbooks or pamphlets (22%), or friends or family members (13%). The majority of this sample also felt much less comfortable when their provider was uncomfortable or ignored their sexual concerns, while almost three-quarters felt much more comfortable when their provider was knowledgeable about sexual concerns. Over two-thirds of the respondents also felt much more comfortable when their provider seemed comfortable addressing sexual concerns. Interestingly, while 75% of 125 medical students in another part of this study perceived that taking a sexual history would be an important part of their future career, only 58% felt adequately trained to do so. In addition, only 38% of medical students in this arm of the study felt adequately trained in addressing and treating sexual concerns of their future patients.
In spite of the obvious limitations of the poll (1) (e.g., date, small sample size) and the very selected population of participants in the study (2), the message seems to be fairly clear: our patients feel that sexuality is important to them and that sexual difficulties may be connected to other mental health issues; they would like to get sexual health information from educated providers. However, we physicians may be inadequately prepared to address the sexual concerns of their patients. These are interesting and sobering notions.
We dare to say that these notions are especially interesting to the field of psychiatry. Many psychological theories are rooted in early sexual experiences and sexual development. Sexual therapy used to be part of residency training at least in some programs. The assessment of both interpersonal and sexual relationships used to be an integral part of a complete biopsychosocial evaluation of our patients. Although the aforementioned survey and study (1, 2) did not focus specifically on psychiatry, their results suggest this may not still be so. Psychiatrists conduct very little research in human sexuality. Major psychiatric journals rarely publish articles focused on human sexuality beyond sexual trauma or a rare discussion related to revising the DSM diagnostic criteria. Even the composition of the DSM-V committee addressing diagnostic issues in human sexuality illustrates the lack of interest in this field—only one committee member is a psychiatrist.
The situation in teaching human sexuality may be similar. The Residency Review Committee for Psychiatry has no specific requirements for teaching human sexuality during residency training. A few years ago, an informal discussion of the editorial board of this journal attended by one of us (RB) suggested a lack of any coherent view of clinical care and education in this area. As psychiatry appears to be moving away from academic and general interest in human sexuality, other fields and disciplines are demonstrating increased attention and interest (e.g., the growth and expansion of the multidisciplinary Journal of Sexual Medicine).
Is the lack of teaching this subject contributing to decreased interest in human sexuality within psychiatry? Several articles addressing various issues in education and human sexuality in general appeared during the 1970s (3–9), a trend noted by Weerakoon and Stiernborg (10). A few articles followed during the 1980s and 1990s (11–18), focused mostly on teaching human sexuality in medical schools and attitudes of medical students toward human sexuality. Interestingly, one of the surveys from 1976 (11) reported that fewer than half of medical school courses in medical reproductive biology and human sexuality covered any aspects of sexual dysfunction and therapy. Some of these articles were primarily focused on teaching about LGBT issues (17, 18).
The last decade has seen an increase in publications related to the teaching of human sexuality (19–33), but mostly in medical schools or other, nonpsychiatric disciplines. Interestingly, in a study by Solursh et al. (23), only 43% of surveyed schools offered clinical programs that focused on treating patients with sexual problems and dysfunctions, and 55% provided medical students in their clerkship with supervision in dealing with sexual issues. These results are similar to those of a survey (11) done 25 years before this study, suggesting little change in the teaching of human sexuality in medical schools.
Only three articles over the last two decades have addressed the teaching of human sexuality specifically in psychiatry (15, 19, 30). The first one, a survey by Verhulst (15), was published in 1992. The author reported that 57% of residency programs had available clinical rotations involving patients with sexual problems. However, 25% of responders had no supervisors with expertise in human sexuality. A national survey of psychiatric training directors published in 2000 (19) revealed that programs rarely offered a clinical rotation involving sexual issues (percentage not specified), which is definitely less than in the survey by Verhulst. The majority of programs in this survey (19) reported having expert faculty in sexual dysfunction (68%), sex therapy (62%), therapy with gay/lesbian patients (59%), and HIV/AIDS (62%). Fewer programs reported having expert faculty in gender issues (43%) and paraphilias (43%). Because the major limitation of this study was a low response rate (36%), these numbers may actually be a bit lower nationally. It is possible that programs without faculty experts were more prone to not respond to this survey. In addition, it is not clear what “self-defined expertise in human sexuality” means and how it translates into teaching. Another interesting finding of this study was that some programs did not cover certain human sexuality topics at all—for example, 13% did not cover assessment of sexual dysfunction, 20% did not teach anything about paraphilias, and 22% did not address therapy with gay/lesbian patients. The last study specific to training in psychiatry was published in 2007 (30). Although 65% of psychiatric trainees felt comfortable taking a detailed psychosexual history, only 34% reported routinely doing so. A little over half (52%) of trainees discussed sexual symptom profiles before commencing pharmacotherapy, and only 30% specifically asked for potential sexual side effects to patients on psychotropic medications. Interestingly, 69% of these trainees felt uncomfortable dealing with psychosexual disorders!
Results of these three studies are even more discouraging than results of the previously mentioned patient surveys (1, 2). They show that psychiatrists, like other physicians, are uncomfortable with both assessment and treatment of patients’ sexual problems. Results also suggest that patients’ beliefs about their physicians’ discomfort with patient sexual issues/concerns are correct (1). Finally, the results illustrate that our teaching of human sexuality is far from being ideal or perhaps even sufficient.
It seems that we need to improve and maybe even revamp our teaching of human sexuality in both medical schools and residency programs. As Rele and Wylie (30) wrote:
Psychiatrists seem to be well placed to deal with [sexual and relationship] problems. They are trained to treat patients as a whole people rather than only focusing on end organ disease or disorder and as such should be strongly encouraged to find the appropriate moment in the interview to introduce delicate topics such as sexual functions. Generally, they are not under pressure to deal with the problem there and then and can take the time to sensitively broach the subject.
However, psychiatrists need to be educated about human sexuality. They must be taught to both inquire about sexual problems in their patients and learn how to treat them. Because there seems to be a dearth of experts in this field, it is vital to train the next generations adequately. As Harris and Hays (32) pointed out in their article about the education of family and marriage therapists,
Sexuality education and supervision experiences are the cornerstone for a therapist’s base level of comfort. It is through sexuality education and supervision that sex knowledge is acquired and comfort levels are increased.
The situation in psychiatry is probably similar—supervision by experts could be one of the cornerstones of human sexuality education. Abandoning human sexuality and relegating it to primary care and pharmacology only, as suggested by Wagner (28), is certainly not in the best interest of our patients.
We hope that this special issue on teaching human sexuality will help all psychiatric educators and training programs and that it will start a national debate on reintegrating human sexuality into psychiatry training.
At the time of submission, the authors reported no competing interests.