Undergraduate Medical Training
A United Kingdom study (3) identified that student doctors received only 1–2 hours teaching about sexuality at five medical schools, and only 12 medical schools offered an integrative course of more than 12 hours in the clinical years. A review of medical schools in North America found that the majority provided fewer than 10 hours of human sexuality education (4).
A review of the literature (5) from between 1970 and 1995 suggested several obstacles that prevent sexual health from being adequately addressed in health professionals’ curriculum, including low priority given to the topic and lack of standardized objectives and means for evaluating current curriculum. Since then, several publications have described changes to undergraduate programs in the United States and Europe (6–9).
Given raised awareness that medical conditions can result in sexual dysfunction and the fact that sexual problems may be the presenting symptom for significant underlying disease, the argument for adequate training in the field is apparent (10). Wagner (11) has summarized why the new field of sexual medicine has changed the training needs and focus for primary care physicians. Yet a review of 1,700 medical schools globally revealed that only a minority had a multidisciplinary teaching curriculum, and more than 60% of the responding schools had fewer than 6–10 hours devoted to the topic. To adequately meet patients’ needs will require that the sexual medicine curriculum move between the boundaries of somatic- and nonsomatic-inclined sides and provide an integrated curriculum that includes psychology and medicine as well as sociology, anthropology, and other related disciplines.
This need for an interdisciplinary curriculum as a basis for individual and population health is supported by other research on sexuality, including negative views about homosexuality and how this may affect treatment of certain minority populations (12–14) and gender-specific perspectives recommended by WHO regional office for Europe (15). Further, new guidance from the General Medical Council in the United Kingdom (16) mentions the need to protect patients and improve care (presumably across all areas of health, including sexual health and sexual well-being) by “promoting individual and population health.”
General Postgraduate Training
Giami (17) conducted a “Euro-Sexo” study in Denmark, Finland, France, Italy, Norway, Sweden, and the United Kingdom. Most people working in sexology and sexual health were nonmedical health professionals, including psychologists, nurses, midwives, physiotherapists, and social workers. Most of these professionals mentioned sexology as a second career (i.e., their primary career was as a physician, nurse, teacher, etc.). Interest in sexology developed later, thus explaining the finding that the average age of sexologists is higher than that of other, nonsexological health professionals. Giami (17) commented that most correspondents who received training in sexology, sexual health, and/or psychotherapeutic techniques had undergone personal therapy and supervision, which suggests that they were active seekers of further education (18).
A special edition of the journal Sexual and Relationship Therapy was commissioned in 2006 to review sexological training in Europe. Amid the current emphasis on medical solutions for sexual dysfunction, the articles explored training in the intrapsychic, interpersonal, and social dimensions of sexual conduct, which so often lie beneath patients’ sexual problems. One paper (19) looked at the institutional context and strategic perspectives from both historical and current viewpoints. Recent therapeutic advances and the diversification of professionals are argued as a particular area where training should be reviewed and consolidated if possible. Porto (19) distinguishes the medical research training in urology, endocrinology, pharmacology, and psychiatry from a second category inspired by behavioral sciences from psychology, sociology, physiotherapy, and sex educators.
The Nordic Association for Clinic Sexology was founded in 1978, and in 2000 it agreed on a three-level educational program for sexologists with identical rules for authorization in Nordic countries. Rischel and Kristensen (20) describe the progress of 12 employees who entered the program at different points, including one junior doctor who graduated in 2004. Specialist teachers from non-Nordic countries linked the Nordic traditions to orientations in other parts of the world.
The sexological clinic in Copenhagen, Denmark, was established in 1986 as a separate unit of the psychiatric department. A group of therapists in the outpatient psychiatric clinic started to offer sex therapy in 1973. The current team is a mixed group of specialists in psychiatry, psychology, physiotherapy, and social work. The three main fields of treatment are sexual dysfunctions, gender dysphoria, and sexual offenders.
New courses under development include a postgraduate program in Stockholm. Likewise, a freestanding university course in andrology focuses on sexual health at a specialized sexual disorder clinic and Ersta Skondal University College in Sweden. The course is intended to give fundamental theoretical knowledge of andrology (the medical specialty that deals with male health, particularly relating to the problems of the male reproductive system and urological problems that are unique to men) and to initiate and develop methods of confronting and working with men’s sexual problems and queries. While the andrological field forms the base, psychological and cultural perspectives are also considered.
The course comprises three sections: basic andrology; sexology and methods, covering sexual physiology, various functional disorders (e.g., premature ejaculation, erectile dysfunction, and lack of sexual desire), medication, and exposing oneself or others to risk; and men’s sexuality in connection with aging.
Postgraduate Medical Training
Even within countries there are often several alterative training routes for sexual health and sexual medicine and no national certifying body responsible for accreditation. For example, in the United Kingdom it is not necessary to have any specific training in sexology or related fields to practice medicine where treatment of sexual dysfunction may occur. Most urologists, gynecologists, psychiatrists, and primary care physicians (general practitioners) do not have any specialist training as mandatory within postgraduate training programs. Even when it is specified, for example in gynecology, clinical experience is often minimal, and there is no specific training in place to achieve the competencies specified (21).
In postgraduate gynecology, within the module on women’s sexual and reproductive health, skill requirements include history taking, psychosexual counseling, and learning referral pathways. Knowledge is expected in fertility, sexually transmitted infection, sexual dysfunction, and anatomy and physiology of the sexual response cycle. It extends to include the principles of psychosexual counseling, sexual problems in special needs groups (e.g., people with physical and learning disabilities), and covert presentations of psychosexual problems and childhood sexual abuse (22).
For general practitioners working in primary care, the Royal College of General Practitioners Curriculum Statement 10.1 has a greater focus on sexual health than earlier documents within the women’s health section under sexual dysfunction including psychosexual conditions, with advice that a “patient-centered, nonjudgemental approach” should be adopted when discussing sexual/psychosexual problems. Likewise for men, there is a focus in sexual dysfunction including premature ejaculation and erectile dysfunction (23). The general medicine curriculum focuses on history-taking skills and the ability to interpret laboratory investigations pertinent to sexual health (24).
The Institute of Psychosexual Medicine (London) offers 2-year training on basic skills for clinicians (12 hours of seminars per term and 3 terms a year provide a total of 72 hours of training). A further 2 years of seminar training allow physicians to then accept referrals as accredited specialists, should they be successful in passing the membership examination. In essence, this is another 72 hours of seminars over 2 years.
Doctors trained in this approach of psychosexual medicine use counseling skills such as active listening and reflection to understand patients’ feelings and barriers to sexual performance and enjoyment. The inclusion of physician examination of the genitals is seen as an important tool by which Institute of Psychosexual Medicine-trained psychosexual doctors understand the negative links between mind and body in relation to sex. Physical examination in these circumstances is used as a “psychosomatic tool,” not simply as a clinical procedure. The attitudes, anxieties, and fantasies revealed during the consultation and physical examination are all relevant to understanding the sexual problem and the possibility of change.
The training is only offered to doctors who are licensed to practice by the U.K. General Medical Council. The training process provides an opportunity to increase skills rather than knowledge, and the method of training is concerned with practice rather than theory. The doctors undergoing such training are likely to be working in general practice, family planning, gynecology, genito-urinary medicine, or psychiatry. Other health professionals can join the seminars to improve their skills but cannot take the examinations.
In postgraduate surgery, the focus for urologists in training includes andrology—the assessment and treatment of patients with conditions affecting sexual and reproductive function, including male factor infertility and other benign disorders of penile function. As expected, there is considerable detail contained in the syllabus, including knowledge about normal female sexuality, including genital function and orgasm; central nervous control of micturition and sexual function; physiology and neurophysiology of sexual function in men and women; and pharmacology of drugs used to treat male and female sexual dysfunction. Other topics include pathophysiology of sexual dysfunction in congenital and acquired diseases of the central and peripheral nervous system, understanding the effects of neurological diseases on bladder and sexual function, and conservative management including medical therapy of urinary incontinence and sexual dysfunction. Embryology of the male genitalia with particular emphasis on congenital anomalies and their effects on male sexual function and drugs and their effects on male reproduction and sexual function are also mentioned (25).
The functional anatomy (blood supply and venous/lymphatic drainage of the penis), physiology, and neurophysiology of penile erection including neurotransmitters involved in penile erection; cardiovascular function relevant to sexual dysfunction; and endocrinologies of male sexual function (hypothalamic-pituitary function and testosterone metabolism) are all mentioned. Desire, orgasm, physiology of ejaculation, and the role of the prostate in sexual function are also mentioned. Likewise, the physiology of female sexual function is included. Specific clinical skills include appropriate assessment of the man with erectile dysfunction, penile deformity, or prolonged erection.
Postgraduate Psychiatry Training
Low sexual desire is a recognized symptom of depression (26), and estimates of sexual dysfunction in patients with unipolar depression range from 25% to 47% (27). Sexual dysfunction has been reported in other psychiatric disorders, such as posttraumatic stress disorder (28) and anxiety disorders (29, 30).
Sexual dysfunctions and related adverse effects are a significant factor in nonadherence of patients on antidepressant medication. Researchers report that 60%-75% of adverse event-related treatment discontinuations are due to the side effects of sexual dysfunction, weight gain, and sleep disturbance (31, 32). Another study reports a 45% incidence of sexual dysfunction in patients stabilized on antipsychotic medication relative to 17% of healthy control subjects (33). Estimates of sexual dysfunction associated with selective serotonin reuptake inhibitors vary, ranging from small percentages to more than 80% (25).
In addition to the general review of the literature, a search of journals using www.psychiatryonline.org and employing the term sex education to articles from 1980–2009 did not result in a single study on specific training programs on sexuality for mental health professionals. However, five articles did mention training (34–38).
In a U.K. study, although 65% of psychiatry trainees felt comfortable taking a detailed psychosexual history, only 24% reported routinely doing so. Despite the high risk of sexual side effects with psychotropic medications, only 30% asked patients about this issue. Unfortunately, 81% of trainees reported inadequate training in psychosexual disorders. Only 30% reported asking patients for potential sexual side effects from psychotropic medication (39).
Although 88% of U.K. psychiatrists agree that good sexual function is important to patients, only one-third routinely inquire about sexual dysfunction (40). Most practitioners (82%) have had no training in this area but would like to acquire more knowledge (40). Not surprisingly, only 17% of psychiatrists feel competent assessing sexual dysfunction (40).
Patients in Turkey with bipolar disorder and schizophrenia were found to often be unaware of effects of their medication on their sexual life, and clinicians were found to pay insufficient attention to the sexual problems of psychiatric patients (41).
A review of residency training programs in psychiatry by Zisook et al. (42) identified sexology training in only a minority of the 10 countries considered. In the Czech Republic, there is mention of subspecialty training in sexology for 3 years following a 3-year training in general psychiatry. Recent changes in the curriculum allow for an elective period of 2 months of sexology in a 60-month training scheme. More recently, a 5-year postgraduate training program has been introduced for all disciplines in the Czech Republic. In India, as part of residency training, sexual disorders within specialty clinics may form part of the psychiatric training program. Sexual problems are not mentioned for the other countries in the article (i.e., United States, Canada, Chile, United Kingdom, Brazil, Sweden, China, and Korea). In Armenia, a 2-year, full-time training program is available to graduates in medicine and culminates in the specialty of medical sexologist.
In the United Kingdom, sexual dysfunction is not specifically mentioned in the syllabus for general adult psychiatry (43), although the core curriculum mentions sexual development, including the development of sexual identity and preferences within the section on human development.
U.K. postgraduate training courses in psychiatry aim to prepare the trainee for the Royal College (of Psychiatrists) examinations and to acquire the factual basis for sound clinical psychiatric practice. Most of the examination process is clinically based rather than dependent on recall of factual knowledge. This inevitably restricts the time available on postgraduate training programs for specialty subject areas where clinical examination will be minimal. Because sexual problems do not form a substantial part of clinical workload for psychiatrists, overall clinical exposure is minimal.
In the United Kingdom, accreditation as a specialist may be sought from either an interdisciplinary approach, such as through training courses accredited by the British Association for Sexual and Relationship Therapy (e.g., the postgraduate diploma and masters program at Sheffield Hallam University), or within a specific specialty (i.e., qualified medical practitioners) offered by the Institute of Psychosexual Medicine. Wylie (44) has reviewed these courses. It has also been reported that in psychology there is little sex education and training during graduate school and internship (45). In an Internet-based study (46), 105 clinical and counseling psychologists responded to a questionnaire on whether they were receiving continuing education that may assist them in providing intervention to clients with sexual issues. The results suggested that observational opportunities were underutilized and more training related to sexual problems than healthy sexuality appeared to be the norm.
A curriculum for sexual medicine has recently been developed as a joint venture between the European Society for Sexual MEDLINE and the European Federation for Sexology. Initially under the auspices of the European Academy for Sexual Medicine and now under the union of European Medical Specialists, a short syllabus has been devised. Eardley (47) points out that regions and countries have very different views on the needs of their particular health care system and suggests that the curriculum can perhaps be viewed as a starting point.
The curriculum is clearly defined and provided through lectures at summer school in Oxford, England, with subsequent training opportunities adjunct to European Society for Sexual MEDLINE and European Federation for Sexology meetings. Clinical placements are also mandatory in recognized clinical facilities. Eventually an examination will entitle individuals to become fellows of the European Academy of Sexual Medicine.
Providing information outside of the traditional classroom setting is also necessary. Typically, online content of educational packages have been restricted to individuals who are enrolled with particular academic institutions or through instructional material from a particular scholar. A free online curriculum in sexual health has been available for several years by the Archive for Sexology at Humboldt University, Berlin, Germany, (www2.hu-berlin.de/sexology). Plans to use the curriculum and free material within this site and attendance at professional congresses continues to be negotiated and may provide an entry-level certification. This site also lists all of the training courses available worldwide for practitioners (http://www2.hu-berlin.de/sexology/TRAIN/index.htm).
A major development of online sexuality education has been produced at the University of Sydney, Australia. Modern technology offers an excellent opportunity and means for developing skills in sex-related issues (48, 49). The pedagogic model must be based on a sound curriculum and instructional design appropriate to learning sexual health (48). Learning activities need to foster attitudes, values clarification, and collaborative team learning and include opportunities for skills development in counseling and delivery of sexual health care.
The Graduate Program in Sexual Health uses the Blackboard learning management system to provide a competency base in sexual health as core units of study, followed by the choice of streamed learning in therapy/counseling or education/research, with the flexibility to develop specialist skills in areas of particular interest. The program is built on a constructivist learning paradigm with activities that encourage collaborative learning and the development of community.