Patients expect the modern physician to have knowledge and comfort when approached with a sexual concern (1, 2), but few medical schools or residencies prepare the physician for this role by offering adequate training (3). Physicians are often uncomfortable discussing sexual matters and are viewed by patients as unprepared to deal with sexuality issues (4). The psychiatrist with training in sexual medicine might play an important role in helping physicians in practice. The nature of psychiatric training involves learning to deal with emotionally challenging issues, developing comfort taking a detailed history, and organizing the strands of information the patient offers. The psychiatrist treats patients in more intimate ways than most other medical specialties and thus may have an important role in teaching other medical professionals about sexuality and treating sexual concerns.

Unfortunately, the Accreditation Council for Graduate Medical Education’s recommendations for psychiatry (5) do not require any specific training in human sexuality other than the ability to recognize and treat sexual abuse and understand “the biological, genetic, psychological, sociocultural, economic, ethnic, gender, religious/spiritual, sexual orientation and family factors that … influence … development throughout the life cycle.” Although psychiatry textbooks generally devote several chapters to human sexuality (6, 7), this may not translate into classroom or clinical time spent on the subject. Although data are limited, research shows that only a few psychiatry programs offer specific classes on sexual issues, sexual history taking, or sexual dysfunctions and their treatment (8). A few programs offer a required course in sex and marital therapy, and several others offer an elective. The absence of this material in the curriculum represents a significant void in the preparation of the modern psychiatrist. Other mental health specialists fare no better, with few programs even offering a human sexuality elective (9). Most psychiatrists trained in earlier years have not had exposure to this material. For a psychiatrist, or any other trained mental health specialist, to be knowledgeable enough to teach other physicians, postresidency training or a specific interest in the field may be required. Many of the outstanding lecturers, researchers, and writers in the field are psychiatrists. They have taken additional courses and training, read widely, and had case supervision. They now teach others and contribute significantly to physician education. When we refer to the “well-trained psychiatrist,” we are speaking of the psychiatrist who has been educated in sexual medicine during residency or postresidency training. A well-trained psychiatrist is able to teach most topics in a sexuality curriculum (10). We will highlight areas where the psychiatrist trained in human sexuality may have particular skill in educating fellow physicians.

The Sexual History

Medical specialists often do not include a sexual history in the medical history because they find it difficult or embarrassing, even though it may lead to a clearer diagnosis (11). The well-trained psychiatrist can teach the basics of sexual history taking and how to incorporate the sex history as a natural part of the medical history and may, due to psychiatric training, be particularly skilled at time management and ways of efficiently gathering information. Most psychiatrists have skill initiating emotionally charged discussions and are sensitive to the nuances and subtleties that reveal anxiety and depression. They are able to follow themes and tease out relational, cultural, or psychiatric factors and can model how to ask about difficult issues such as sexual abuse. A psychiatrist with additional training in human sexuality can teach basic counseling strategies for the various dysfunctions and provide more specific information about issues in human sexuality including paraphilias, Internet erotica (12), and other substitutes for partnered sex. They can also speak on diagnostic criteria (13).

Patient and Physician Communication Skills

Psychiatrists and other specialists may be aware of the role of illness, disability, medications, and hormones on sexual function and also know the physiological mechanisms underlying sexual response or dysfunction. The subtle role of anxiety or conflict may be less evident to the nonpsychiatrist practitioner but play an important role in the patient’s recovery (14). Physicians are often puzzled when suggestions or treatments they have offered fail. They may have overlooked signs reflected in patients’ body language or failed to address concerns that patients communicated nonverbally (15). The psychiatrist has been trained to attend to patients’ unspoken clues and to help them reveal these. In history taking, the psychiatrist has learned how to move from nonthreatening material into areas that might cause the patient discomfort. They may be more comfortable asking about the specific details of sexual interactions or sexual trauma. They can guide other specialists in how to elicit such material.

Recognizing the Partner’s Role

Masters and Johnson (16) said, “There is no such entity as an uninvolved partner in a marriage contending with any form of sexual inadequacy.” Many times, when patients do not resume their normal sexual life after illness or surgery or when treatments for sexual problems fail, the partner plays a role (17). A classic example is the partner’s common fear that sex may be dangerous for his or her mate after myocardial infarction (18); another is not recognizing that as men get older, they need more tactile stimulation to achieve an erection (19, 20). Sexual problems may also reflect conflicts in the relationship or the partner’s sexual difficulties (21). Patients rarely consult their physicians in the company of their partners. Psychiatrists are generally sensitive to the role of the partner and family in helping a patient maintain mental health. It may be easier for psychiatrists to ask the patient questions that tease out relational factors, and psychiatrists can communicate these skills to other professionals.

Recognizing Effects of Depression on Sexual Health or Response

Sexual dysfunction is common in psychiatric illness (22). Depression is commonly comorbid with many medical and psychiatric diagnoses, and physicians need to be aware of the effect of depression on sexual health (23). Antidepressants (e.g., selective serotonin reuptake inhibitors) may contribute to sexual dysfunction (24) such as decreased libido, decreased arousal, and changes in orgasmic capacity. Patients commonly will not adhere to a treatment regime if they experience sexual side effects. Thus the psychiatrist may be called on to teach the sexual side effects of psychiatric drugs commonly prescribed by other specialists, suggest alternatives or potential antidotes for the iatrogenic dysfunction (25), and offer counseling strategies (26). Other specialists may also need guidance in when and how to refer to a psychiatrist.

Sexual Trauma and Abuse

The evaluation and treatment of sexual assault is frequently the responsibility of other specialists. Psychiatrists may help educate these physicians regarding the acute and long-term psychological sequelae of sexual trauma (27). The psychiatrist is trained to treat victims and understand the behavior that enables people to deal with trauma, its sequelae, and its effects on physical health (28, 29). Psychiatrists can offer information on how to deal with perpetuators and suggest appropriate referrals outside or within court-mandated treatment.

Physical, Intellectual, and Developmental Disabilities

Even today there may be a lack of information about the range of physical, intellectual, and developmental disabilities and the need for disabled individuals to experience a healthy sexual life (30, 32). The psychiatrist can offer guidance on handling sexuality issues in this population and tailor information appropriate to developmental levels (33, 34). Psychiatrists can also help other specialists understand the risk of sexual exploitation to which these groups might be subjected (35).

(Sexual) Boundary Issues

Although attempts are ongoing to reinforce sexual boundaries between patient and physician (36), one could argue that psychiatrists, in their intimate work with patients, may have clinical experience and knowledge that could help other physicians avoid boundary crossings and violations (37, 38). Other issues of interest are the effects of physician personality profiles on the risk of sexual offending and boundary crossings (39). Experienced psychiatrists will be able to help clinicians prevent costly and career-damaging mistakes, from boundary violations to full-blown boundary crossings.

The Lesbian, Gay, Bisexual, and Transgendered Population

In 1987 “ego-dystonic homosexuality” was removed from the DSM as a diagnosis (40). Specialists in other fields may be unaware that homosexuality is no longer considered a mental illness and may need guidance meeting the medical and sexual needs of the lesbian, gay, bisexual, and transgendered population. History taking that avoids labels and heterosexist assumptions can be taught and helps the physician distinguish between patients’ self-reported orientation and sexual behavior (41).

Psychiatrists can help other medical specialists gain “cultural competence” with this population (42). Sensitivity to issues of confidentiality, particularly with gay youth, can also be taught (43). Psychiatrists can teach other physicians how to maintain a welcoming, nonjudgmental environment that engenders trust (44). Special skills and more research may be needed to address the sexual health concerns of the transgendered and intersex population. We know little about the psychological effect of genital modification or the new use of puberty blocking hormones in transgendered children.

Translating Knowledge into Teaching Other Specialists

Clearly the well-trained psychiatrist has much to offer other specialties on issues of human sexuality. With the exception of Masters and Johnson, most sex therapy training programs have been founded by psychiatrists, and several are still directed by psychiatrists. These psychiatrists have trained hundreds of other psychiatrists and mental health practitioners as well as obstetricians, gynecologists, urologists, and primary care doctors.

Many psychiatrists have written books, (45), book chapters (46), and articles aimed at other specialties (47–49) and have been involved in web-based teaching programs or self-help media (50). Psychiatrists have also been active in multidisciplinary sexological organizations where they routinely share their perspectives at conferences and have held major offices in several of these organizations.

Other specialties welcome grand round talks on sexuality. Family medicine, urology, and internal medicine programs may be open to lectures on the emotional and relational factors at play in sexual dysfunction. Gynecology programs may respond well to talks on female sexuality. Pediatric specialists may be interested in talks on childhood and adolescent sexuality or sexual counseling for people with developmental disabilities and their parents. Psychiatrists are often consultants or on the faculties of residency programs in family medicine and obstetrics and gynecology, and they collaborate with the faculty to teach sexuality and other topics to residents.

Psychiatrists are often asked to participate on advisory boards when new drugs for sexual dysfunction are in development to give their perspectives on psychological and relational factors.

The well-trained psychiatrist can play an important role in teaching other medical specialists about sexuality. The psychiatrist’s experience with detailed history taking, emotionally challenging material, and consideration of psychological and relational factors gives him or her skills that can be usefully taught. Often physicians in other specialties take a mechanistic approach to sexual problems and ignore the subtle but important influence of emotional factors. The psychiatrist with special interest and training in sexual medicine can offer insights that add greatly to the knowledge, comfort, and skill level of other practitioners.

Dr. Dunn is a consultant to Eli Lilly, Boehringer Ingelheim, Shionogi Pharma, Palitin Technologies, and Sinclair Institute. At the time of submission, Dr. Abulu reported no competing interests.