Sexuality is important to patients but often not addressed by physicians. A large majority (94%) of adults feel that sexual pleasure improves quality of life (1). However, physicians rarely ask patients about sexual health and feel uncomfortable discussing it (2, 3). Because over 90% of patients want their doctors to address sexual health concerns, physicians need to be educated to do so (1). Psychiatrists are in a unique position to help patients with these issues because their training includes the psychological and medical aspects of health and disease and psychopharmacological and psychotherapeutic modalities of treatment. Therefore, psychiatric residency training should adequately address sexual health education. This report illustrates a resident’s perspective of sexual health education by analyzing results of a survey sent by one resident to other residents within the same psychiatry training program to query perceptions about current sexual health education and how it could be improved.
In the didactic portion of the Wayne State University/Detroit Medical Center psychiatric residency program, one class currently focuses on sexual health and occurs near the end of the third postgraduate year (PGY-3). It consists of six lecture hours and includes information about typical sexual functioning, assessment and treatment of male and female sexual disorders, and paraphilias. Education related to sexual health occurring beyond structured didactics in clinical discussions varies depending on both the resident and supervising attending physician. There are no intensive seminars about sexual health and no clinical rotations that focus specifically on sexual issues. Less didactic time is spent on sexual health than on other areas within psychiatry. In psychopathology and psychopharmacology didactics, approximately 4 hours each are spent on mood, anxiety, and psychotic disorders. These topics are also frequently discussed in other didactics, including weekly psychopharmacology rounds and journal club during PGY-3, the weekly therapy case conference during PGY-3 and -4 and during informal didactics on clinical rotations.
The first author (EW), who was a resident at the time, sent a web-based survey to all other residents (N=33) in the Wayne State University/Detroit Medical Center psychiatric residency program. The survey was anonymous and included an information sheet; it was approved by the university institutional review board. Returning the survey implied informed consent and the response rate was 69.7%. To maintain confidentiality in this small sample, residents were identified only by postgraduate year. Out of the 23 completed surveys, seven (30.4%) were from first-year residents, six (26.1%) from second-year residents, four (17.4%) from third-year residents, and six (26.1%) from fourth-year residents.
The survey contained questions on residents’ didactic, clinical, and supervisory experiences in 24 topics related to sexual health (Table 1). Residents rated the level of experience they had with each topic, recommended if more or less time be spent on each topic in the future, and reported their opinion about which teaching modality would best facilitate learning.
The lack of exposure to educational experiences was captured by combining “too little” and “none” to both didactic and clinical experiences. The first- and second-year residents were combined in one group (early residents, n=13; 56.5% of responders), and the third- and fourth-year residents were combined in the second group (late residency, n=10; 43.5% of responders) with the expectation that the late residency group would have more exposure than the early residents. Statistical testing used a 2-sided Fisher’s exact test with alpha set at 0.05 a priori.
The percentage of psychiatric residents who responded “none” or “too little” to both clinical and didactic experiences are shown in Table 1. At least 61.5% (n=13) of the early residency group reported “none” or “too little” experience in every topic of sexual health included in this survey.
In contrast, only 20% (n=10) or greater of the late residency group reported “none” or “too little” experience in every topic. Eighty percent or more of late residents rated only three topics as having “none” or “too little” exposure: gender identity, sexual addiction, and adolescent sexuality. Significant differences were found between the early and late residents when rating the following topics in the “none” or “too little” categories: hypoactive sexual desire disorder, premature ejaculation, psychotherapy for sexual disorders, discussing sexual disorders with patients, and pharmacotherapy for sexual disorders.
Residents also rated how much time should be spent on each topic. In the early residency group, between 92.3% and 100% of responders rated each topic as needing “more time” or “much more time.” “Less time” or “none” were never chosen. In the late residency group 40% (n=10) or more of respondents felt that “more time” or “much more time” should be spent on every topic. Sexual addiction, paraphilias, and psychotherapy for sexual disorders were reported most often as needing “more time” or “much more time.” Sexual dysfunction, medical factors leading to sexual dysfunction, and sexual dysfunction secondary to medication use were reported least often as needing “more time” or “much more time.” A response for “less time” was given by a single resident, who reported this answer for 70.8% of the questions. “None” was never chosen. Overall, 52.2% (n=23) of residents responded “more time” for every one of the 24 topics in sexual health, and 4.3% (n=23) responded “much more time” for every topic.
Residents were also asked about which modality they felt would be most beneficial for learning about sexual health. The seven learning modalities included didactics, outpatient, intensive seminar, supervision, inpatient, journal club, and self-directed learning. In the early residency group, one (7.7%) resident chose inpatient, journal club, and self-directed learning; two (15.7%) residents chose an intensive seminar and supervision; and three (23.1%) residents chose outpatient and didactics. The late residency group was evenly split between only two choices, outpatient clinical work, and didactics.
To our knowledge, this is the first study to survey psychiatric residents about their sexual health curriculum, specifically focusing on a broad range of sexual health topics. The findings clearly indicate that psychiatric residents lack formal and clinical training in sexual health in PGY-1 and PGY-2, at least at this site. Residents in later years reported that they had received more training in multiple topics within sexual health, particularly in taking sexual histories, discussing sexual disorders with patients, and using pharmacotherapy treatments. However, across years, residents report that sexual health education is an important topic and that they want more experience than the 6 hours of didactics already offered.
Unfortunately, few studies exist about the specific structure of sexual health education in psychiatric residency programs, and even fewer have surveyed residents. Sansone and Wiederman (4) surveyed psychiatric residency program directors about curricula in seven areas of sexual health, including sexual dysfunction, sex therapy and counseling, therapy with gay and lesbian patients, HIV/AIDS, typical and healthy sexual functioning, gender disorders, and paraphilias. Although the response rate was low (35.9%), approximately 80% of programs offer such training and most programs use formal didactic settings (4). Very few programs (1.4%) reported any plan to increase the quantity of clinical experiences related to sexual health (4). The Wayne State University/Detroit Medical Center psychiatric residency program appears similar, with formal learning regarding sexual health occurring mostly in didactics.
U.S. training programs for other health professionals and medical specialties on human sexuality also found deficiencies (2, 4, 5). Morreale et al. (5) surveyed residents in multiple specialties and reported that 52% of the residents were dissatisfied with their residency’s formal curriculum on human sexuality. Reassuringly, the psychiatric residents in that study felt more comfortable discussing sexuality with their patients than residents from other specialties (5).
Sexual health education appears to be lacking in other countries as well. In a survey of physicians in Greece (6), only 29.5% reported training in sexual health communication skills. In a survey of residents in the United Kingdom (7), 81% found their training in sexual disorders during their psychiatry training inadequate. The same study found that only 30% of residents ask about sexual side effects to psychotropic medication, and 69% reported feeling uncomfortable with sexual disorders (7). These studies underscore that lack of adequate training in sexual health is widespread.
As programs develop curricula addressing sexual health, they must be sensitive to the discomfort that some residents might experience. In our study, one resident consistently requested less time spent on each sexual health topic. It is possible that residents who refused to complete the survey also shared this feeling.
Our findings suggest that residents at the Wayne State University/Detroit Medical Center residency program value learning about sexual health during their outpatient rotation and didactics. This may not generalize to other programs because the faculty member with the most expertise in sexual health currently teaches the sexual health didactic class and supervises residents in the outpatient department.
Although this study provides information about resident opinions, it has several limitations. The small sample size limited analysis; there may be important difference across residents by age, gender, religion, and cultural heritage. The survey was completed by residents in only one program, which also limits generalizability. There was no comparison of how residents rated learning about sexual health against other psychiatric topics. Knowledge of faculty interest in sexual health may have biased resident responses. Because completion of the survey was optional, residents who chose to participate may place a higher value on learning about sexuality. Replication of these findings in different training programs and other specialties would help address these limitations.
Despite these limitations, the results demonstrate that psychiatric residents in one training program value learning about sexual health and are open to further training. Specific recommendations for curriculum enhancement include offering more than 6 hours of didactic education, starting to teach sexual health in postgraduate years 1 and 2, and focusing on sexual health during the outpatient year of training. Additionally, the curriculum must be designed to address possible discomfort with the topic felt by some residents. Because psychiatrists are in a unique position to assess and treat issues related to sexual health, it is important to improve training during residency so that each graduating psychiatrist acquires the knowledge, skill, and comfort needed to adequately approach this topic with patients.
At the time of submission, the authors reported no competing interests.