Addressing sexuality as part of health care has been an emerging concept in medicine the past two decades. In 2001, Surgeon General Satcher commented on the importance of sexuality as an overall contributor to quality of life:
Sexuality is an integral part of human life. It carries the awesome potential to create new life. It can foster intimacy and bonding as well as shared pleasure in our relationships. Sexual health is inextricably bound to both physical and mental health (1).
Multiple illnesses and disease treatments can significantly affect sexual health. As management of chronic illness advances, patients must learn to cope with the long-term side effects of treatment, including sexual dysfunction. Unfortunately, data suggest that physicians lack formal education in assessing sexuality, are uncomfortable discussing the topic with patients, and are unaware of professionals with expertise in this area who might be able to provide valuable resources (2, 3).
This commentary will explore how physicians can learn about sexual health by collaborating with experts to provide comprehensive care for their patients. We will review the extant literature on sexual health education in medical training and describe an evolving model at the University of Michigan, which is based on several collaborative initiatives between the medical school, the psychiatric residency program, the department of social work, and several medical departments. We propose a collaborative training model that would facilitate future physicians’ comfort with the subject and the acquisition of skills necessary to provide optimal care for patients who present with sexual health concerns.
Current Sexual Health Education in Medicine
Although no literature addresses a collaborative approach toward treating sexual dysfunction during recovery from serious medical illness, the need to address sexual health is seen as important (4, 5). Tsimtsiou et al. (6) found that the best predictor of a physician’s ability to take a sexual history was previous training in communication skills. Shabsigh and colleagues’ (7) study addressed sexual health education for physicians in urology. They found that physicians with regular continuing medical education in treating sexual difficulties were more comfortable addressing patients’ concerns. Articles on continuing medical education indicate the need to study and understand the way in which such education affects physician behavior and patient/clinical outcomes (8, 9).
A systematic approach to teaching medical sexual communication skills is the program for comprehensive sexual health education for residents at the Robert Wood Johnson Medical School, developed in 1973 (10). Residents complete a mandatory, week-long multidisciplinary course in human sexuality, focusing on the integration of cognitive and attitudinal learning in sexual medicine; the role of a multidisciplinary team approach in managing sexual problems; and the development of clinical management skills, including communication and sexual-interviewing techniques. Didactic presentations are balanced with small group discussions in which participants evaluate personal reactions and rehearse sexual history taking and interviewing.
Individuals diagnosed with serious illness and their partners routinely cite sexual dysfunction as an ongoing concern (11, 12). This reflects data on the psychosexual side effects of medical treatments (13–15). Physicians may be aware that patients care about sexual health but often cite lack of time and expertise to provide more than rudimentary sexual information to patients (16, 17). Patients protect physicians by not expecting them to address sexuality issues that might be uncomfortable (18). Academic journals and medical textbooks call for better training about sexual health, but most health care providers feel they are not adequately trained to provide more than superficial information (17, 19, 20), and they do not find multidisciplinary approaches to sexual health feasible (21).
Physicians must have more than just adequate communication skills to address their patients’ sexual health concerns. Understanding human sexuality requires a breadth of information and is fundamentally interdisciplinary. Sexual function involves, but is not limited to, anatomy, physiology, endocrinology, individual behavior, couples’ dynamics, and cultural influences. Clinical experience suggests that conscientious physicians feel frustrated by the persistence of sexual problems requiring treatment that they are not trained to provide. If training is to prepare physicians for a confident approach to sexual health, it is necessary that they have at least a rudimentary understanding of the physiologic and psychosocial aspects of the human sexual response and an awareness of professionals with whom they can collaborate to ensure optimal outcomes for their patients.
The Role of a Sex Therapist
Sex therapists are experienced individual and couple therapists who are clinically trained in the fields of psychology, social work, or psychiatry. They acquire further training in sexual health and treatment with both academic and clinical components to become certified by the American Association of Sexuality Educators, Counselors, and Therapists. Sex therapists are equipped to design an academic curriculum and to provide clinical education in sexual health. As courses progress from medical student to residency training, the provided information is increasingly more sophisticated relative to the learners’ complexity of understanding patients’ medical problems.
Sexual health training begins in medical school with lectures by certified sex therapists on the human sexual response, sexual functioning, sexual dysfunctions, and treatments. After the basic concepts are covered in medical school, courses in residency discuss the evaluation and treatment of sexual dysfunction and how various medical conditions affect sexual health. Both in medical school and residency, sex therapists emphasize that the way in which patients cope with the loss of sexual functioning includes the process of grief and mourning as a gateway to accepting sexual changes and adapting to new sexuality.
Although psychiatric residents at all levels are taught how to take a sexual health history, only fourth year residents in psychiatry are able to choose an elective in sexual health during which they can be supervised in providing sexual health intervention. In the past year, four residents completed the elective. Each committed two half days per week. They shadowed sex therapists who were conducting sexual health assessments in the gynecology-vulvodynia clinics and in the urology-prostate cancer survivorship clinics. After observing several assessments, they were able to do supervised assessments and received immediate feedback. These residents also observed more in-depth assessments in the sexual health outpatient counseling clinic. When patients permitted, residents were able to sit in on sex therapy sessions. The residents’ evaluations reflected enthusiasm for this elective, a greater sense of competency in addressing sexual health with patients, transfer of skills, and wish for more intensive training. On the basis of this feedback, future residents will have the option of following their own patients under a sex therapist supervisor for four or more months.
Interdisciplinary collaboration is thus introduced early in medical education and reinforced by the use of sex therapists as instructors throughout training. Case discussion fosters comfort with the subject and appreciation of the relevance of sexual issues in medical practice.
Addressing Sexual Health in a Team
In some departments that care for patients whose medical condition specifically affects sexual health, sex therapists are members of an interdisciplinary team. At the University of Michigan, the department of obstetrics and gynecology has long supported addressing sexual issues as part of usual care. In four subspecialty gynecologic clinics—Adolescent Sexual Health, Developmental Disabilities, Disorders of Sexual Development, and Center for Vulvar Diseases—sex therapists assess new patients and respond to ad hoc referrals. In many cases, patients’ partners are included in the assessment. Ongoing communication among medical and sexual health team members aims to integrate the physical, mental, and sexual aspects of care. Four additional subspecialty clinics are requesting the interdisciplinary team model because of persistent requests from patients to address their sexual health and psychosexual concerns: Urogenital Surgery Clinic (vaginal prolapse), Alternatives to Hysterectomy (fibroids and related concerns), Pelvic Pain Clinics, and Healthy Healing after Delivery (for patients with bowel and bladder repair after difficult deliveries).
This interdisciplinary model allows medical students and residents to be present as the sex therapist initially assesses and evaluates a patient. As the trainees increase their understanding of the interview process, the sex therapists encourage them to participate in the assessment, gaining skill in information gathering and comfort with sexual terminology.
Integrating Sexual Health Into a Medical Specialty
When a sex therapist becomes a member of a medical department, his or her expertise contributes not only to the care of patients but also to the departmental mission. The sex therapist can participate in sexual health clinics, training, and research. At the University of Michigan, the department of urology has developed the role of a sexual health coordinator as part of its core staffing. The sexual health coordinator, who is both a social worker and certified sex therapist, develops interdisciplinary programs that address sexual health, treats patients with sex therapy, educates patients and medical staff, and designs research projects that further the understanding of sexual health issues and concerns in urologic patient care. Interdisciplinary consultation among surgeons, nurses, and the sexual health coordinator is part of daily clinical, teaching, and research practice. In these collaborations, trainees learn about the role of sexuality in their patients’ lives and become aware of patients’ sexual concerns.
Trainees, particularly psychiatric residents, who have learned to interview patients about their sexual concerns have commented on the transfer of skills in sexual health interviewing to their overall specialty practice. Participating in research enables trainees and faculty to learn about assessments of sexual functioning, such as the Brief Index of Sexual Functioning for Women or the expanded prostate index composite, and related individual and couple functioning measures, such as the Dyadic Adjustment Scale (22–24). This can lead to the formulation of research questions that are based on the sexual health needs or difficulties experienced by the specialty patient population. Sexual health research presentations by the sexual health coordinator at grand rounds facilitate the integration of sexual health into a holistic perspective on health and recovery from illness. A future training goal is to encourage Grand Rounds presentations by residents in psychiatry who are rotating through the center for sexual health.
Sexual Health Consultation and Referral
Physicians should be encouraged to identify and contact available certified sex therapists for case consultation or referral for sexual health assessment and counseling. When physicians refer a patient to a sex therapist within the medical system, the sex therapist’s notes become part of the medical record. The physician is updated about the clinical outcome through the medical record and direct discussion of the case. Because many patients have ongoing medical problems, mutual consultations can be ongoing.
Sex therapists benefit from this collaboration when their patients, treated for sexual dysfunction, require medical assessment or intervention. Referral to medical providers on the basis of familiarity with each other’s expertise enhances patient care and strengthens collaborative care relationships. Referrals to sex therapists within the community require a release of information endorsement by the patient for consultation to proceed and can be equally beneficial for the continuity of care and an ongoing interdisciplinary collaboration.
Outreach to physicians, nurses, and community groups is accomplished through presentations at grand rounds, patient support group meetings, and professional conferences. Intensive workshops for particular provider groups are also offered, covering topics such as the effects of chronic medical illness on sexuality, sexual changes associated with aging, sexual side effects of psychotropic medication, adolescent sexuality, and treatment of sexual dysfunction.
Collaboration is increasingly seen as essential to the care of patients who have sexual problems. Whether through formal courses, partnership in interdisciplinary teams, consultation and referral, or the inclusion of a sexual health expert within a specific medical specialty, collaboration can lead to a holistic approach to assessment and treatment.
Collaboration requires openness on each discipline’s part to learning the language and treatment protocols of the other discipline involved. It requires the coupled awareness of humility about the scope of one’s practice and regard for the perspective and contributions of other disciplines. Collaboration is profoundly respectful of the patient, because it recognizes that sexual health is an important part of the quality of a patient’s life.