Sexual activity can be an important complement to our most intimate relationships or a source of dissatisfaction and, in some cases, pathology. Concerns related to sexual health and sexual functioning are common among patients and, consequently, should be a focal point of medical school curricula. However, a recent review of sexual health curricula in U.S. medical schools found that nearly half (44%) did not have a formal curriculum in sexual health (1). Additional surveys have found that physicians feel unprepared to address sexual issues (2) and that patients doubt physician competency in this area (3).
To identify current learning objectives and concomitant curricular content in sexual health for U.S. medical students, we studied peer-reviewed literature, physician licensing examinations, and publications by professional organizations. We classified curricular objectives and content according to the classic educational categories: attitudes, skills, and knowledge.
Through midyear 2009, we examined the MEDLINE, PsycINFO, and ERIC databases; the medical college curriculum website, CurMITT; and literature from the Association of American Medical Colleges, Association of Academic Psychiatry, American College of Physicians, and Association of Directors of Medical Student Education in Psychiatry. Keywords included sexuality, sexual functioning, sexual health and medical school, undergraduate medical education, medical student and curriculum, courses, course work, education, and instruction. We also examined the reference lists of documents retrieved from bibliographic databases and professional associations to identify additional articles. Documents were included if they addressed undergraduate medical education programs conducted in the United States or the United States and Canada during the last 15 years and provided sufficient information to infer curricular objectives.
We identified 15 documents related to sexual health curricula for undergraduate medical students in the United States or the United States and Canada. Of these, 10 discussed specific courses, five were model sexual health curricula (4–8), and five were model sexual history-taking courses with attitudinal and informational components (9–13). Three documents were broader surveys of sexual health curricula in North American medical schools (1, 2, 14), and three were recommendations issued by professional organizations (15, 16). Dates of publication ranged from 1997 to 2009.
The notion that sexual health is an integral part of every patient’s health is emphasized in virtually every model curriculum (4–12). The corresponding objective is often framed in terms of student attitudes. Students are “to appreciate the importance of sexual health in overall health” (6) or at least to consider questions about sexual function as “an essential part” of a patient health history (12). Most of the curricula also emphasize the importance of considering sexual functioning across the lifespan. Student physicians are encouraged to discuss sexuality with patient groups not typically thought of as being sexually active, including elders and preadolescents (4, 7–11). Two curricula seek to increase student comfort with sexual health interviews with persons of various ages, social classes, ethnicities, and sexual orientations (5, 10).
Another common attitudinal objective is to sensitize students to a wide variety of sexual preferences and experiences within the scope of normative sexual functioning (5–7, 10, 11). Class discussions—frequently preceded by films or panels of persons who share their experiences as members of minority sexual groups—address topics such as homosexual orientation and sexual activities that are often considered to be outside of mainstream sexual experience, such as partner swapping (6). Course experiences are designed to increase students’ awareness of the potential diversity of their patient population and to help them conduct all-inclusive sexual histories (10). Often these discussions are preceded or followed by student self-reflection to help students identify and manage their values and biases when these might negatively influence communication with patients or conflict with patient care (5–7, 10).
The primary skill-based objective in the model curricula is for student physicians to develop the ability “to communicate effectively with patients” about human sexuality (4–13). A related objective is for student physicians to be able to build rapport (11) and put patients at ease when discussing their sexual functioning (10). Of special emphasis are strategies to increase comfort and promote candid conversations about sexual functioning with patients who are much older than the physician (6, 7, 11). Student physicians learn to integrate questions about sexual activity within the general health interview or to use third-person references when providing advice (e.g., “Some patients find that when they…”) to depersonalize sensitive conversations and validate patients’ experiences and concerns (12).
Several courses also include instruction on screening patients for sexual abuse, either current or previous, and/or approaching patients who are sexually traumatized (4, 6, 7, 11). These courses emphasize the severe and long-lasting effect that sexual abuse can have on an individual’s sexual functioning and stress the importance of counseling. One curriculum addressed the sexual development of young persons and laws related to statutory rape (10).
Although factual information about sexuality and sexual functioning spans various medical disciplines, the knowledge students are expected to master in the model courses examined is surprisingly narrow. Most courses limit instruction to three or four areas, the first of which is sexually transmitted infections. Students are expected to become familiar with the symptoms of various sexually transmitted infections and their diagnosis (4, 8–11). In some courses, HIV risk assessment, testing guidelines, and/or case reporting requirements are also addressed (9–11). Two courses extend instruction on sexually transmitted infections by providing student physicians with information on patient education and health counseling, such as how to talk about the risk of sexually transmitted infections and to encourage condom use if applicable (7, 9).
The second most commonly addressed topics in the model curricula is the effect of illness and medications on patients’ sexual functioning (4, 6, 7, 10, 12). Much of the discussion focuses on diabetes and heart disease and on the side effects of common psychotropic medications. Several courses address sexual dysfunction in general (4, 6, 8, 12), most often in lecture format.
We identified three surveys of sexual health instruction in medical school curricula (1, 2, 14). The course features and authors’ postcourse survey recommendations highlighted the researchers’ unique perspectives.
Citing poor physician screening and counseling for sexually transmitted infections, Malhotra et al. (1) focused their survey of sexual health in medical school curricula on diagnosing and treating these infections. They surveyed fourth-year medical students about sexual history-taking, physical examinations, diagnosing and reporting sexually transmitted infections, counseling on preventing sexually transmitted infections, and sexual health screening. Student physicians were asked whether they had observed or participated in the diagnosis of a patient with a sexually transmitted infection; their comfort conducting a sexual history interview, physical examination, or prevention counseling; and their familiarity with screening guidelines for sexually transmitted infections. The authors also surveyed medical schools about their human sexuality curricula.
Most of the 92 respondent medical schools taught screening for sexually transmitted infections, diagnosis, and prevention counseling in preclinical years. Less time was devoted to developing student physicians’ sexual history-taking skills. Although 89 of the 92 schools reported providing instruction on sexual history-taking, half of the 500 student physician respondents reported that their sexual history-taking skills were rarely or never evaluated.
Solursh et al.’s (2) survey of human sexuality curricula in medical schools focused on diagnosing and treating sexual dysfunctions. Citing studies that noted both physician discomfort in addressing patients’ sexual health and patients’ lack of confidence in physician willingness to discuss sexual matters, the authors surveyed medical schools about didactic and clinical experiences in causes and treatment of sexual dysfunction, discordant sex and gender identification, and issues of sexuality in illness or disability. They found that 81% of the 101 medical schools surveyed required instruction on sexual health. Of these institutions, more than half provided student physicians with 3–10 hours of training in sexual health education. Most schools provided instruction on sexual dysfunction. Fewer programs provided instruction on “altered sexual identification,” and fewer still provided instruction on sexual function in illness and disability. The researchers commented on the tremendous variability in instruction on human sexuality between medical schools.
The third survey of sexuality education in medical schools we identified was conducted by Dunn and Alarie (14) in response to concerns that coursework on human sexuality in medical schools—a high priority in the 1970s—had been abbreviated and replaced with other topics during the more conservative decades that have followed. The results of the survey revealed the opposite. Of 105 U.S. medical schools, 59% reported no change in the number of hours in their overall curricula dedicated to human sexuality, and another 28% reported that class hours in human sexuality had been expanded.
Core instructional objectives are reflected in the content of professional examinations. For U.S. medical students, no examinations are more important than the physician licensure exams–Step 1, Step 2 CK, Step 2 CS, and Step 3 of the United States Medical Licensing Examination (USMLE). To infer the sexuality-related knowledge objectives of the National Board of Medical Examiners (NBME) (the designers of the USMLE), we reviewed the content outlines and sample tests posted on NBME’s website. (Because the NBME does not post the standard patient scenarios that are used in the skills-based Step 2CS exam, the content of this exam is not discussed here.) Although the NBME includes a caveat that “the content outline is not intended as a curriculum development or study guide,” the outlines are extensive and comprehensive, and the sample tests are representative of the actual tests taken by medical students.
The NBME characterizes the Step 1 exam as a measure of a medical student’s basic scientific knowledge. Approximately 5% of the sample questions address sexuality. Two questions address the diagnosis of sexually transmitted infections; two address sexual issues common to postmenopausal women, such as vaginal dryness; one addresses a gender/sex abnormality; and one focuses on the side effects of the erectile dysfunction medication sildenafil. There are no questions on sexual functioning, including sexual arousal and response, or strategies to address sexual performance concerns or dysfunctions. Sexuality-related topics in the Step 1 content outline include sexual development, reproduction, gender, and sexually transmitted infections. The content outline also addresses sexual function explicitly, with reference to orgasm and erectile dysfunction.
The Step 2CK exam assesses whether student physicians have the knowledge necessary to practice in an ambulatory or inpatient setting under supervision. The exam emphasizes conditions included on a “high impact disease list.” A condition is considered “high impact” if it is very prevalent, its clinical course can be greatly altered by early intervention, or there is some notable quality about the condition that is instructive.
Almost 10% of the questions on the sample Step 2CK exam address sexuality, slightly more than those in the Step 1 exam. Although coverage of topics related to human sexuality in the Step 2CK content outline is similar to that of Step 1, the sample Step 2CK exam includes more questions related to sexual intercourse, such as painful urination after a female’s first intercourse and pain with intercourse experienced by a 70-year-old female. One item evaluates students’ ability to address the health concerns of a homosexually active patient whose sexual orientation is not relevant to his medical concerns. Two items specific to males involve a syphilitic lesion on the penis and testicular torsion.
The Step 3 exam assesses requisite knowledge and the ability to apply knowledge to practice general medicine unsupervised. The sample Step 3 examination contains very little content related to human sexuality. Fewer than 5% of the sample questions are devoted to sexual health. The questions related to human sexuality address infertility, side effects of contraception, complications related to HIV infection, and pelvic pain and pregnancy prevention after sexual assault of a female by a male. The exam consists of multiple-choice questions and computerized patient cases. Although the NBME does not publish sample cases, it does provide a sample content outline, which includes only two direct references to sexuality. The first appears within adolescent development; the second, within psychosocial problems.
The professional organizations that would be expected to address sexual health in medical school education in the United States include the American College of Physicians, the Association of Academic Psychiatry, the Association of American Medical Colleges (AAMC) with its physician education and college preparation panel (GPEP), and the Association of Directors of Medical Student Education in Psychiatry (ADMSEP). Neither the American College of Physicians nor the Association of Academic Psychiatry provide guidance on their web sites or associated publications on medical school curricula or physician competencies in sexual health. Although the AAMC has no current curricular guidelines in sexual health, the Medical School Objective Project, a task force established to implement the recommendations of GPEP, has published general guidelines for physician attributes and associated curriculum objectives for medical education (15).
Several of the physician attributes identified by GPEP translate into physician attitudes and associated skills of particular relevance for sexual health. These include maintaining “respect for patients’ privacy and respect for the dignity of patients as persons” and remaining nonjudgmental “when the patient’s beliefs and values conflict with [the physician’s]” (15). As of yet, the Medical School Objective Project has not published guidelines on knowledge objectives or what physicians need to know about human sexuality to practice general medicine competently. They are, however, identifying physician core competencies in areas including behavioral and social sciences, which would likely address human sexuality (16).
ADMSEP published the most extensive objectives for medical student education in sexual health. Unlike the attributes identified by the Medical School Objective Project, which translate into general attitudinal objectives, ADMSEP’s guidelines describe specific skills and associated knowledge that student physicians should master. Under the heading “Psychopathology and Psychiatric Disorders,” student-physician competencies include the ability to:
The ADMSEP objectives focus on conducting a thorough and sensitive sexual history and diagnosing sexual dysfunction and sex/gender dysphoria. As indicated by the heading, sexual health competencies emphasize psychopathology.
In general, the model sexual health courses and curricular recommendations we reviewed are designed to help medical students develop nonjudgmental and inclusive attitudes toward the sexual practices and sexual identities of their patients; to facilitate the development of strong physician-patient communication skills, particularly in sexual history-taking; and to increase their factual knowledge base in a limited number of sexuality-related topics. Our review identified general agreement on basic attitudinal and skill-based sexual health curricular goals, but there was less consensus on knowledge-related objectives.
Attitudinal competencies center on student physicians’ appreciation of the importance of addressing patient sexuality and doing so without judgment or assumptions about whether or how patients of this “type” behave sexually. A central objective is to increase student physicians’ awareness of the variety of ways individuals may express themselves sexually. Increasing student physicians’ awareness of sexual orientation and gender identity are also priorities.
An associated behavioral objective for student physicians is developing the interpersonal skills necessary to put patients at ease and conduct a thorough sexual history. Attitudinal objectives and associated skills are featured in each of the 10 model courses and three surveys we reviewed. There is much less agreement about what student physicians need to know about human sexuality to address patient needs. Most programs instruct on sexually transmitted infections and the effects of illness and/or prescription drugs on sexual functioning. The sample licensing exams also emphasize these topics. Some curricula also address the diagnosis of sexual dysfunction. In addition, rare (albeit instructive) disorders related to gender identity, chromosomes, and anatomical sex are included in licensing exams and curricular guidelines. Beyond these rather disparate topics, there is little agreement about informational objectives in medical school curricula in sexual health. This lack of agreement may reflect an underlying ambivalence about the role physicians should take in maintaining patients’ sexual health and supporting continued sexual satisfaction.
The most striking findings to emerge from our review are what are not included. Medical students appear to receive little to no information about healthy sexual functioning or the multisystem process of sexual arousal and response. Processes like myotonia or vasocongestion, the roles of sympathetic and parasympathetic nervous systems, and the effects of hormones and neurohormones on sexual function and desire are not addressed in any of the model curricula. Only one curriculum mentions providing student physicians with basic behavioral strategies to address common sexual concerns such as rapid ejaculation or delayed female orgasm (10).
It appears that we have made little progress in shifting to a vision of sexual health as something more than the absence of disease. The most coherent objectives we identified were published under the heading “Psychopathology and Psychiatric Disorders.” Indicative of this narrow, disease-oriented vision of sexuality are the topics that are omitted from descriptions of medical school curricula or items on licensing exams.
Very few medical courses provided practical instruction on how to incorporate sexual health screening within the time constraints of busy clinical practices. The discussions of sexual history-taking in the model courses focused on the need for a comprehensive history (e.g., the 35-item sexual history and sexually transmitted infection prevention counseling checklist for evaluation of standard patients in Haist et al. [9]). Only one course complemented this basic instruction with skill-based and practice-minded objectives: first, that students develop the ability to manage time in physician-patient interactions, and second, that they learn to discern which sexual history questions are most relevant for a particular patient (11). Given the limited time physicians can spend with patients, even new patients, a lengthy interview about each patient’s sexual history may not be practical. It is not enough that we encourage student physicians to consider sexual health as an integral part of patient health and that we train them to conduct comprehensive sexual health interviews; we must also arm student physicians with strategies to apply this knowledge clinically.
Our review of model curricula, previous surveys of sexual health education in U.S. medical schools, and guidelines/recommendations from professional organizations suggest that current sexual health objectives are too narrowly focused on disease/dysfunction/pathology and do not always provide students with sufficient knowledge of healthy sexuality. We must develop objectives for medical students related to information on basic sexual functioning—desire, arousal, and response—and we must find a way to ensure that these objectives are met, even when the topics span several departments and therapeutic disciplines.