International medical graduates (IMGs) are a diverse group of physicians who present medical educators with unique educational opportunities and challenges. IMGs’ cultural and medical education backgrounds may be assets for effective clinical care in some settings. For example, IMGs perform clinical preventive services at higher rates than their U.S. medical school counterparts (1). Moreover, IMGs are more likely to see ethnic minority patients, care for a higher percentage of Medicaid users, and practice in primary care shortage areas (2). Also, in a study of deceptive tactics in medical practice, IMGs were less likely than U.S. graduates to change the patient’s official diagnosis or to withhold a useful service because of utilization rules (3).

In other settings, however, IMGs’ cultural and medical education backgrounds may create a barrier to effective clinical care. For example, an anonymous survey using hypothetical scenarios to compare the attitudes of IMGs and U.S. medical graduates regarding the treatment of latent tuberculosis infection found that IMGs were less likely to treat the latent infection in almost all scenarios (4). Others have noted lower patient satisfaction with IMGs than U.S. graduates and advocated for cultural competency training for IMGs (5).

An area that potentially presents a unique cultural challenge for many IMGs is sexual health. Human sexuality encompasses overt behavior and private experience and is sustained by group values and norms as much as personal experience and preference (6). Besides its obvious biological bases, sexuality is seen as constructed by social, cultural, and historical processes (7). Values and norms in IMGs’ country of origin may be at odds with U.S. sexual mores (8). Reflecting on our experience and observations, we wanted to ascertain the learning needs of IMG psychiatric residents in human sexuality. We conducted a selective review of the medical literature and online data documenting demographic and sociocultural data of IMGs in the United States; the need for sexual medicine competence for practicing psychiatrists; how sexual health is currently taught in foreign medical schools; attitudes toward sexuality and sexual problems among physicians and patients of different cultures; and the management of sexual issues, including sexual boundaries, by IMGs. We hypothesized that IMGs have unique training needs that remain unrecognized and unaddressed by current psychiatric residency training curricula.

We gathered data mixing multiple PubMed searches combining title or abstract words and phrases such as “sexuality,” “sexual health,” “international medical graduates,” “foreign medical graduates,” “psychiatry,” “culture,” “residents,” “medical curriculum,” “attitudes,” and country names where most U.S. IMGs come from; search engines to access publicly available databases on the Internet; and personal communication with foreign medical school faculty. We excluded letters to the editor, opinions, and editorials. The full articles of abstracts judged relevant were subsequently analyzed and data were extracted according to topics by one of us: demographics and the need for sexual medicine competence (LZ); how sexual health is currently taught in foreign medical schools (MS); sexual attitudes and professional boundaries (AS). The reference lists of these articles were searched for additional relevant studies. Finally, we conducted additional searches to document the broader issue of cultural influence on sexuality.

Demographic Data of IMGs

Nationally, more than one-quarter (27.5%) of the residents and fellows in Accreditation Council for Graduate Medical Education (ACGME) training programs were IMGs in 2008 (9). For that year, the percentages of certificates issued to IMGs by the Educational Commission for Foreign Medical Graduates (ECFMG) by world region were South Asia (India and Pakistan), 32.2%; Middle East, 8.8%; East Asia (mostly China and the Philippines), 7.9%; Latin America, 4.9%; Western Europe, 3.2%; and Eastern Europe, 2.4% (10). About a third (33.68%) of all psychiatric residents are non-U.S.-born IMGs (11). The leading source countries for IMGs include India, Pakistan, China, and the Philippines (10).

IMGs’ passing rates in the U.S. Medical Licensing Examination Steps 1 and 2 are 9% and 13%, respectively, higher than U.S. graduates. However, their passing rate for Step 2 Clinical Skills component—which also tests their communication skills—is 11% lower than the rate of U.S. graduates (10). This suggests that their clinical knowledge may be superior to that of U.S. graduates but that their clinical skills, when judged in a U.S. setting, are inferior.

The Importance of Addressing Sexuality in Psychiatric Practice

Competence in taking a sexual history, eliciting sexual problems from patients, and assessing, treating, and educating patients regarding sexual disorders is essential to practicing psychiatrists. Sexual difficulties are relatively common, and psychiatric illness increases the likelihood of developing sexual problems (12, 13).

One reason that sexuality is important in psychiatry is that resolution of sexual concerns can improve the outcome of comorbid psychiatric illness. For example, Seidman and Roose (14) found that when depressed men’s erectile dysfunction was adequately treated, their depressive symptoms improved. Conversely, if the men’s erectile dysfunction was unresponsive to treatment, their depression scores remained elevated (14). Another reason psychiatrists should address sexual functioning in their patients is the commonly encountered psychotropic-induced sexual dysfunction. A review found that selective serotonin reuptake inhibitors induce some form of sexual dysfunction in 30% to 60% of patients (15). Similar side effects have been found with other antidepressants, anticonvulsants, anxiolytics, and antipsychotics. For example, a clinical trial found the following rates of sexual dysfunction associated with medications: quetiapine, 18.2%; olanzapine, 35.3%; haloperidol, 38.1%; and risperidone, 43.2% (16). The importance of treatment-induced sexual dysfunction is further exemplified in high discontinuation and nonadherence rates in patients experiencing this side effect. In one study, up to 90% of patients with treatment-emergent sexual dysfunction discontinued their medication prematurely (17).

There are no data regarding the percentage of psychiatrists who routinely explore patients’ sexual histories before and/or after initiating psychotropic medication management. Also, there are no data on how frequently psychiatrists treat medication-induced sexual side effects. Although psychiatrists make up 5% of all physicians (18), they write less than 3% of prescriptions for sildenafil (19); we speculate that they are not addressing sexual function routinely in their practice.

Medical School Sexual Health Curricula

There is little information on sexual health curricula in medical schools from countries where most IMGs come from. An article describing a model curriculum on sexual and reproductive health developed by the Commonwealth Medical Association Trust (20) states that “Sexual and reproductive health … is significantly underrepresented in basic educational curricula for medical and other health professionals and in the continuing medical education programs for established practitioners in many developing countries” (pp. 49–50). However, no references are provided to support this assertion.

Cross-Cultural Studies of Physicians and Medical Students

Some sexual behaviors are observed regardless of sociocultural contexts, while others seem tightly related to those contexts. For example, sex differences in the desire for sexual variety and courtship have been documented across cultures (21, 22). In contrast, striking cultural differences have been observed in behaviors such as acceptance and use of contraception (23); teen sexuality (24); the degree to which female sexuality is more subject to the influence of culture, learning, and social circumstances than males’ (25); violence against women (26, 27); gender roles (28); and homosexual socialization (29). The robust influence of culture and custom is exemplified in the persistence of traditional female genital surgeries despite extensive controversy and censure (30–32). We conducted several literature searches to identify empirical evidence on how culture influences attitudes toward sexual issues among physicians, medical students, the general population, and patients.

We identified only a few studies that dealt with physicians’ or medical students’ attitudes toward sexual issues other than HIV/AIDS in world regions more likely to supply IMGs to the United States. Among five studies in East Asia, the earliest (33) described the establishment of a human sexuality curriculum at the Hong Kong University Medical School, beginning in 1979. The authors described the students as particularly conservative and with less sex knowledge than their Western counterparts. They explain the changes they adopted over several years to address the educational challenges presented by the students’ beliefs and attitudes. Two later surveys of Chinese medical students found widespread sexual misinformation, which the authors attributed to traditional Chinese beliefs, lack of formal sex education, and reliance on public media for information (34, 35). However, an important shift may have taken place over the years—if attitudes toward homosexuality are an indicator of more general sexual attitudes. A recent survey of attitudes and personal experiences with homosexuality among Chinese medical students revealed permissive attitudes among a majority (e.g., two-thirds thought homosexual and heterosexual partners should have equal rights) and close acquaintance with homosexual individuals (i.e., one-third had at least one homosexual friend) (36). In a nationwide, self-administered survey conducted with 1,313 board-certified Japanese breast surgeons, respondents’ attitudes toward sex-related statements showed that they did not necessarily think that surgeons had a professional responsibility to address these concerns in their patients (37).

For South Asia, we found only one study, a survey conducted in one of the Medical Colleges of Delhi, India, during May-August 1995 (38). Results showed that sex knowledge was satisfactory despite the fact that sex education at grade school and from parents is negligible. In terms of sexual behavior, however, Indian medical students seem less sexually experienced than medical and undergraduate students in Africa, North America, and the United Kingdom; 12.7% of male and 4.7% of female Indian medical students admitted to ever having sexual intercourse (38). In comparison, 60% of medical students in a recent survey of 16 medical schools in the United States were classified as sexually active (39).

In Middle Eastern and Muslim countries, one study (40) examined the attitudes and knowledge of Turkish medical doctors toward sexuality in older people and found that a majority of physicians (69%) had limited information and knowledge regarding geriatric sexual health. The same proportion indicated that they only “sometimes” raise questions about sexuality with these patients. A survey of sexual attitudes and behaviors among medical students of Dokuz Eylul University in Turkey (41) revealed gender differences in attitudes toward premarital sex. Although 78.2% of males and 73.1% of females approved of premarital sex for men, the corresponding percentages of approval of premarital sex for women were 43.5% and 59.5%. Regarding sexual behavior, 67.8% males and 11.4% of females reported having had sexual intercourse (41). Results from a survey of communication skills on delivering bad news and sex education among Iranian interns seem pertinent (42). Female interns were less confident than male interns of their communication skills, and this deficit was particularly notable in sex education (42). In a study using face-to-face interviews of obstetricians and gynecologists in Lebanon (43), most reported feeling comfortable discussing sexuality during consultations, although they attributed their comfort more to professional experience than to formal training. In addition, only 31% of participants nearly always took the initiative to ask patients about their sexual health (43).

A survey of general practitioners in Scotland is the only study to compare non-Western- and Western-trained physicians practicing in the same locale on a professional behavior that reflects attitudes toward sexuality, in this case having sex before the legal age of consent. The study found that physicians who had trained in the Indian subcontinent were significantly less likely to provide contraceptive services to a girl younger than 16 years of age than those who had trained in the United Kingdom (44).

Results from a survey of Kuwaiti family physicians (45) revealed that the majority expressed negative attitudes toward homosexuality and AIDS patients in general. In fact, 83% of Kuwaiti family physicians would opt out of treating AIDS patients, and more than half would avoid coming into social contact with HIV-seropositive persons. Comparable findings were reported in a survey of Turkish surgeons (46), working in a society where, according to the report’s authors, “sexual dysfunction is considered a fault, especially for women,” and “sexuality is a shame, and extramarital sexual relations are damnable.” Despite adequate knowledge of universal precautions, 82% of surgeons were worried about acquiring HIV from professional contact with patients, while 28.1% worried about acquiring the virus from social contact.

The results of these quantitative studies seem related to those of a qualitative study involving semistructured interviews with Muslim IMGs from various specialties (including one psychiatrist) practicing in the United States (47). Themes identified by the study included providing care to populations with lifestyles at odds with Islamic teachings and illustrate the powerful influence of religious convictions to influence specialty choice. For example, the interviewed psychiatrist mentioned that men would refrain from working in obstetrics and gynecology and women would avoid working in urology “because they would not really want to see an exposed patient.” In addition, several participants commented on prohibited medical procedures such as “sex change.”

Cross-Cultural Studies in the General Population

Cross-country or regional comparison studies reveal both cultural similarities and differences in sexual values and attitudes. For example, a study involving 33,590 respondents in 24 countries (8) found that attitudes toward nonmarital sex vary most between European and Asian countries. Using cluster analysis, differences were organized in six moral regimes. Across nations, extramarital sex was most frowned upon, while attitudes toward homosexual sex and teen sex differed significantly between countries and sexual/moral regimes (8).

The Global Study of Sexual Attitudes and Behaviors (48) surveyed 27,500 men and women, aged 40–80 years, in 29 countries regarding the level of satisfaction with the physical and the emotional aspects of their relationships, their level of sexual functioning, and how important sex was overall. Although the mean levels of satisfaction for all four aspects of subjective sexual well-being were lower for women than men everywhere, gender differences were greater in the male-centered regimes, where sexual behavior is more oriented toward reproduction (48). Such regimes tend to discount the relational meaning of sex and the importance of sexual pleasure for women. In contrast, gender-equal regimes emphasize equality between intimate partners and share the normative ideal of the so-called companionate marriage. Thus, in male-centered regimes, sex for both men and women was more likely to be thought of as a duty that was fundamental to the relationship. Asian countries, a source for a substantial proportion of IMGs, reported consistently low levels of satisfaction with sexual functioning and moderate to low levels of satisfaction with their relationships. In addition, Asian respondents tended to discount the importance of sex in their lives (48).

In the same study, both men and women from East Asia were the least likely to seek medical help for a sexual problem or to think that a doctor should spontaneously ask about sexual problems. Interestingly, 35.7% of respondents from the Middle East, East Asia, and Southeast Asia reported that their doctor appeared uneasy when talking about sex, in comparison to 7.5% in Western countries (49). Notably, the frequency of seeking medical help for sexual problems did not vary significantly with respondents’ educational attainment and income, suggesting that cultural factors may play a more decisive role in defining the health-seeking behavior for sexual problems than socioeconomic factors (49). Underlying the importance of culture, Middle Eastern and Southeast Asian countries (where Islam is the predominant religion), reported the highest frequencies of consulting a religious adviser for sexual problems, while this action was rather rare in other regions (49).

Professional and Sexual Boundaries Issues

Given the intensely contextual (i.e., culture-bound) nature of professional boundaries, we wondered if IMGs would experience difficulties managing sexual as well as nonsexual boundaries. We speculated that cultural values regarding time and keeping personal and professional aspects of one’s life separate could increase the likelihood that IMGs cross or violate nonsexual professional boundaries. Similarly, we thought that lack of familiarity with U.S. cultural norms on gender relations and bodily touch could place IMGs at increased risk for sexual boundary violations.

One study (50) documented difficulties with nonsexual boundary management among IMG psychiatric residents, such as repeatedly going over time in therapy sessions, inability to limit responses to patient requests for personal information, engaging in dual relationships with patients, and not respecting patients’ wishes not to involve family members in their treatment.

Although we identified five studies (51–55) of professional misconduct that reported on the risk associated with IMG status, none differentiated nonsexual from sexual boundary violations. Three studies (51–53) found that IMG status was not associated with increased risk for being disciplined by a state medical board or other jurisdiction due to professional misconduct. A fourth study (54) found that IMGs had a higher risk of disciplinary action among physicians licensed by the Oklahoma Board of Medical Licensure and Supervision, although this finding was not confirmed by multivariate analysis. In contrast, a case-control study of physicians disciplined by the California Medical Board (55) found that IMG status was associated with elevated risk for disciplinary action. Although this study had several methodological strengths, including a large sample size, the use of internal medicine as the comparison specialty, and the statistical control for the contributing effects of age, sex, board certification, and international medical education, analyses did not differentiate nonsexual from sexual (8% of reports) professional misconduct.

In a nonsystematic literature review, we found converging evidence that suggests psychiatric residents who are IMGs may experience significant difficulties in acquiring the attitudes and skills required for competent patient care related to sexual health. These challenges are probably felt most acutely by IMGs who are reared and educated in non-Western countries, where traditional, religious, and collectivistic worldviews merge to render sexuality an intensely private or even shameful matter. Psychiatric educators ought to consider those difficulties and offer curricula regarding sexuality that do not single out IMGs, yet are mindful of their learning needs.

Because training programs aim at graduating psychiatrists who are competent in several domains, it seems sensible to place the training needs of IMGs regarding sexual health and dysfunction within the broader umbrella of cultural competence, which is already embedded in several Accreditation Council of Graduate Medical Education competence requirements, most saliently in Interpersonal and Communication Skills. Cross-cultural encounters in health care, in which there is a significant cultural mismatch between the patient and the clinician, are ripe with challenges (56–58). These are highlighted by issues of sexuality or sexual functioning (24, 59, 60). Conflicts between physicians’ values and patients’ sexual practices or needs might impair detection and treatment of sexual dysfunction (61, 62).

Although we were unable to locate information regarding sexual health curricula in medical schools from countries where most U.S. IMGs come from, we reviewed data on sexual knowledge, attitudes, and behaviors of physicians, medical students, and patients from East Asian, South Asian, Middle Eastern, and Muslim countries. These studies provide indirect evidence suggesting that many IMGs practicing in the United States may be less likely than U.S. graduates to spontaneously and comfortably inquire about sexual functioning. As a result, they may be less likely to systematically assess and treat sexual problems, including medication-induced sexual dysfunction. Cultural or religious upbringing with clear-cut prohibitions about premarital and extramarital sex and nonreproductive sexual behaviors, such as sex in older age, masturbation, and homosexuality, may render some IMGs more likely to avoid the discussion of sexual topics with certain groups, such as teens, older adults, and gay and lesbian patients.

Given the nonsystematic nature of our review and that most data are self-reported, our results and recommendations are necessarily tentative. However, our findings can inform future studies conducted in the United States with IMGs. Ideally, such studies would move beyond self-reports to performance-based formative and summative assessments of competence in dealing with sexual problems. For example, the methodology of unannounced standardized patients seems ideally suited to assess actual clinical performance and provide formative feedback to both residents (63) and practicing physicians (64). Psychiatric standardized patients have already been used in structured clinical examination and have been shown to provide a valid assessment of medical students’ (65) and psychiatric residents’ (66) clinical competence.

Meanwhile, our data can also help psychiatric educators design curricula. One educational strategy proposed to address cultural competence involves developing interviewing skills that would enable trainees to broach the subject of cultural diversity with each patient, thereby helping their patients understand how social and cultural factors influence their health (67, 68). Perhaps this strategy can be adapted to include sexual health. Another option is offered by the Myers study (50), which tested a curriculum that successfully addressed culture-based deviations from normative boundary-keeping practices among IMGs. Notably, U.S. graduates in this study also seemed to benefit from the intervention. This suggests that there is no need to segregate IMGs in educational interventions aimed at improving clinical competence in handling sexual issues.

International medical graduates seeking psychiatric training in the United States face formidable educational challenges related to the significant psychological effect of migration, difficulties with English as a second language, and the differing attitudes toward mental illness in Eastern and Western cultures (69). However, many, if not most, IMGs display resilience in successfully dealing with those challenges. For example, one study (70) compared the adaptation process of IMGs and U.S. graduates in six community-based internal medicine residency programs in Baltimore. After controlling for lower personal debt, having previous clinical experience, and not being native English speakers, IMGs had less fatigue, higher self-esteem, and greater personal growth scores. Psychiatric residency training programs seeking to improve the sexual health competence of IMGs may successfully build upon the resourcefulness and adaptability of IMGs, as documented in this study. By providing specific theoretical models and practical tools along with culturally sensitive supervision, training programs will less likely lead IMGs to experience discussions related to patients’ sexuality as another part of overall “culture shock.”

There is evidence that the future supply of physicians from U.S. medical schools will be inadequate (71). As a result, IMGs are likely to make up a large percentage of the physician workforce in the future. Therefore, ensuring that they are comfortable with U.S. patients and their culture-bound behaviors and attitudes is paramount. The ECFMG started an Acculturation Program in 2006 to help IMG residents adapt to life and work in the United States. Part of this program is online, and one item is The One Dozen Most Important Things You May Not Have Known, Understood, or Realized About American Medicine (72). It consists of a series of modules designed to educate IMGs about subjects such as the doctor-patient relationship and the role of the patient’s family. However, the program does not include human sexuality. A module about sexuality in the United States may be an interesting and useful addition.

Sexual functioning is clearly an issue of prime importance to patients that is often insufficiently addressed by psychiatrists. Although few studies exist, it can be inferred that psychiatrists coming from countries where speaking about sex is taboo and education on sexuality is scant are less likely to address this important topic with their patients. To provide the best training to future psychiatrists, psychiatric educators must ensure that IMGs are able to cross the cultural divide that separates them from their patients with sexual problems.

At the time of submission, the authors reported no competing interests.