The question, “How should clinical sexuality be taught to psychiatrists during their training?” presumes that the subject should be taught. Today it is largely not taught, and when it is, it is not taught comprehensively.
There has been almost no recent literature on educating psychiatrists about sexual life. Sexuality teaching routinely occurs in many medical schools during the preclinical years. Sexuality education during psychiatric residency would seem to demand a more sophisticated, clinically oriented curriculum to provide a skill set for thinking about and dealing with the diversity of problems that residents will encounter after training. Curriculum planners need to address four related questions: What do we mean by sexuality? How do we prioritize sexual topics for our trainees? What are the goals of the curriculum? Who will teach the subject and how?
What Do We Mean By Sexuality?
Sexuality as a topic has both breadth and depth. Almost all specialty training programs, from pediatrics to geriatrics, can find something relevant to present to their residents. Table 1 lists 17 topics that routinely impinge upon various branches of medicine, particularly psychiatry. Of all specialties, psychiatry is generally expected to have the most comprehensive grasp of the topic. The educational challenges of sexuality involve the sexual diagnoses, in addition to sexual problems and concerns.
The Delineation of a Sexual Disorder
Sexual patterns that meet DSM-IV-TR criteria are known as sexual disorders. Disorders are the subject of research and many publications. Disorders that might respond to drug treatment generate most of the research. Epidemiology informs clinicians about prevalence of the disorders and describes how these data vary with criteria employed by the investigation. For instance, for decades the prevalence of premature ejaculation was stated as 40% of men younger than age 40. Recent studies with more stringent criteria reduced the prevalence to less than 10% (1).
The Importance of Sexual Concerns and Problems
All people periodically have concerns about their sexual lives (e.g., Will I be pleasing to my sexual partner?) and experience sexual problems that do not meet criteria for a disorder (e.g., I ejaculate too fast, within 5 minutes, and my partner has lost her desire for sex with me). Concerns and problems are rarely systematically studied, even though psychiatrists routinely hear about them. When patients look for assistance with disorders, concerns, or problems, they assume that we have a confident, knowledgeable comfort with the subject. They are often wrong.
Prioritizing Sexual Topics
Four topics are basic to any sexuality curriculum: understanding the dimensions of individual sexuality, grasping the concept of the couple as the unit for understanding partnered sexual behavior, overcoming discomfort over listening to sexual stories, and understanding the First Principle of Clinical Sexuality. After these four items are addressed, individual programs should feel free to develop their own priorities, which undoubtedly will evolve from year to year.
The Dimensions of Individual Sexuality
An individual’s sexuality consists of two major dimensions—sexual identity and sexual function—and each has three components. Sexual identity is an evolving sense of self-that derives from gender identity, orientation, and intention. Each of these identity components has a subjective, private, psychological, conscious, erotic subcomponent and a behavioral, scientifically measurable subcomponent. Residents need to appreciate that erotic and behavioral subcomponents do not necessarily match. For instance, a homoerotic person may behave heterosexually. A bierotic person may only behave homosexually. Sexual identity is more complex than is sexual function, which is usually spoken of as simply consisting of desire, arousal, and orgasm components. In sexual dysfunctional states, however, the inability to have painless vaginal penetration illustrates that mechanical receptivity is a subtle component of sexual function as well. Psychiatric residents should first have a basic competence in conceptualizing and entering into thoughtful assessments of the components of sexual identity and function.
Understanding Couple’s Sexuality
Sexual behavior with a partner brings together the sexual identities and sexual functional capacities of two people. The challenge of having sex is usually thought of as a social process of deciding to have sex and the orchestration of behaviors that lead to sexual arousal and orgasm of both partners. When these processes are dysfunctional, the problems are usually described in individual terms—her anorgasmia, his erectile dysfunction, her lack of desire, his premature ejaculation. Although these descriptions are in keeping with medicine’s traditional approach to the individual patient, when a dysfunction is psychogenic, these descriptions often delay the understanding of the pathogenesis of the problem and its reversal. In 1970, Masters and Johnson (2) asserted, after working with hundreds of sexually dysfunctional couples, that the proper unit for understanding couple’s sexual lives is the couple, not the individual. This was a radical departure from psychiatry’s assumption that the symptom bearer is the proper unit of study. Psychiatric residents should be introduced to this issue and grasp the advantages and disadvantages of both the traditional individual and the couple’s approach to understanding pathogenesis.
Growing Comfortable Listening to Sexual Stories
The previous concepts are relatively useless if residents cannot overcome their natural anxieties about talking to patients about sex. The sources of these anxieties need to be recognized (3). A useful technique is to ask residents to describe their experiences so far when patients have brought up some sexual issue and describe their private reactions. Having residents interview the seminar leader, who pretends to be a patient, also brings this into the foreground quite efficiently.
The First Principle of Clinical Sexuality
Here is the formal statement of the concept that prepares residents to understand the causal influences on sexual phenomena: All sexual behavior, solitary and partnered, normal and abnormal, is simultaneously influenced by biological, personal, interpersonal, and cultural forces (4). Sexual behavior is richly multidetermined. Every person’s sexuality slowly evolves over decades and more rapidly oscillates during short periods of time.
All branches of medicine are forced to oversimplify etiology to be practical. Urology and gynecology, for instance, tend to emphasize biological determinants, whereas psychologists tend to focus on developmental, psychological, and interpersonal contributions. Understanding the First Principle helps residents and teachers alike to be humble about their grasp of its complexity.
In keeping with the rest of medicine, psychiatry focuses on the symptoms, causes, and treatment of the mental disorders delineated in the DSM-IV-TR. Residents are immersed in the modern literature of mood disorders, schizophrenia, anxiety disorders, and so on. Although sexual disorders exist, and sexual dysfunctions are recognized by our nosology, a typical educational emphasis would emphasize the disorders and conceptualize their treatments. A sexuality curriculum should go beyond this approach to encompass the idea that ordinary life processes throughout adolescence and adulthood generate numerous sexual concerns and problems, which occasionally rise to the level of a sexual disorder. Meeting criteria for a disorder comes and goes much more frequently than sexual concerns and problems do. Clinical life involves taking care of individuals, not just disorders. Moreover, many significant sexual concerns are not considered disorders and are not addressed by the DSM-IV-TR. For example, concerns about the emergence of homoeroticism significantly affect approximately 10% of the population, and a majority of women in midlife notice a dramatic loss of sexual interest and capacity. Such concerns have a major effect on the course of life for these individuals and their partners.
The Goals of Residency Sexual Education
Residency education only introduces the processes that clinicians will improve upon throughout their lives. The goal is to show residents the topic; increase their comfort and interest in it; and demonstrate the possibility that concerns, problems, and disorders can be significantly resolved—and sometimes cured.
Because sexuality is relevant to humans at every stage of life and not just to those with a sexual disorder, one strategy is to discuss the topic in every year and in all rotations. This might be considered a vertical integration of sexuality throughout residency. Why not discuss the influence of narcissistic personality disorder on the sexual patterns and capacities of the patient and his or her partner? Why not inquire about sexual capacities of a patient who is about to be put on a serotonergic agent? If the topic is approached vertically, residents come to be interested in and adept with thinking about how a person may come to be sexually disordered. Various teachers will invoke the processes of developing as a child, adolescent, and young, middle aged, and older adult. Residents will learn about the ordinary complexity of having sex within an evolving relationship. They will grapple with sexual concerns and the problems that accompany each developmental phase. They will see that focusing on a sexual disorder involves more than medication, even when an appropriate medication is available.
Who Will Teach the Subject and How?
We need not restrict sexuality teaching to a seminar with a sex therapist who has to be imported into the department because no one else is knowledgeable. Local faculty, rather than imported ones, should be strongly encouraged to teach the subject in seminar, case conferences, and clinics. This can be accomplished in the first several years by creating a small committee of faculty and residents to take on the task of initiating and evolving the approach. It can be accomplished with diverse methods including seminars, lectures, case conferences, reading assignments from books and journal articles, and rotations in clinics devoted to sexual problems.
Novel Clinical Sexuality for Senior Residents
Four years ago, due to concerns about the absence of significant educational experiences, I (SBL) offered residents an opportunity to spend at least one half day a week sitting in as I worked with my patients. The residents worked with me for 6 months. Patients were chosen only on the basis of their willingness to allow a resident to witness the process. The residents’ role was to take notes and, after getting to know the patient, to interject a question or comment. Primarily, however, the residents eagerly but silently participated. Residents also spent an hour each week in a conference in which staff of all levels of experience presented the cases that were causing them concern. Residents were asked to read relevant chapters in the Handbook of Clinical Sexuality for Mental Health Professionals (5) every week for every patient seen with me or discussed in conference. They were also asked to read Demystifying Love: Plain Talk for the Mental Health Professional (6) during their rotation, along with occasional journal articles. The experience was supposed to provide them a stimulating model for how to talk to people about their sexual lives; how to conceptualize the psychodynamics of a person’s life; how to relate to patients in a warm, friendly, and objective manner that maintains respect for the patient’s boundaries and individual views; and how one senior clinician actually conducts therapy.
Having a resident in the room enabled me to indirectly communicate to the patient by explaining things to the resident. Patients quickly realize that while discussing some conceptual aspect of what just happened, I was elucidating the event for them as well. The patient often joined in the process of teaching by giving even more detail about personal life experience. Although some patients asked not to have the resident in the room for the next session, the vast majority of patients came to “not mind” and some to “really enjoy” the extra attention and learning opportunities.
The Residents’ Perspective
A recent study by Miller and Byers (7) examining the education and training in sexuality of psychologists found that direct observation of a senior clinician working with a patient was the best way to learn about sexuality, but that the opportunity to directly observe was rarely available. The clinical sexuality rotation described here is one of the most popular electives available to advanced residents in psychiatry at University Hospitals of Cleveland. Approximately 75% of the residents choose to participate in the elective. Seven of 12 residents from the previous 2 years provided data: five in the form of a survey with added comments and two with only narrative comments. The elective received an average score of 4.6 on a scale of 1 to 5 (5=outstanding experience).
Not all of the benefits of the experience are apparent during the rotation. The increased comfort with sexual matters and the chance to observe a senior clinician have lasting influence on residents’ clinical skills. Residents report taking a better sexual history and being less uncomfortable with the information they obtain. The residents also report being more inclined to provide psychotherapy to their patients.
Overall, residents appreciate the opportunity to directly observe a senior clinician working in the field of sexuality. We believe that the findings of Miller and Byers are applicable to psychiatric residents and that direct observation of a senior clinician is the best method for residents to acquire skills in clinical sexuality.
Regardless of the diverse settings in which residents will be practicing psychiatry in the future, their patients will bring sexual concerns, problems, and, sometimes, diagnosable disorders to their attention. Developing a vertical curriculum during residency will increase the likelihood that psychiatrists will be able to deliver on patients’ expectations for meaningful assistance. Training programs should guard against thinking that there is only one basic way to accomplish the goals discussed here.