Although the prevalence of sexual problems that impair quality of life is greater than that of major depressive disorder, fewer than 50% of U.S. and Canadian medical schools spend more than 2 hours on sexual health (1, 2). Recent surveys indicate that only 43% of North American medical schools offer clinical exposure to the diagnosis and treatment of sexual dysfunction (3). Moreover, graduate medical education focusing on sexual health in the United States has also been “largely neglected” (4).

The aim of this study was to determine how residents are being educated regarding sexual health and their perceptions of this process. We also assessed the barriers to evaluating patients’ sexuality, including deficiencies in formal education, assumptions that the topic lacks importance, cultural concerns, and personal discomfort.

An Internet survey based on a questionnaire developed by Rosen et al. (2) was sent to 195 residents in psychiatry, obstetrics and gynecology, family medicine, and internal medicine at Wayne State University School of Medicine. One hundred seventeen surveys were completed, for a response rate of 60%. The survey was anonymous, and participants were instructed that its completion indicated informed consent. The university institutional review board approved the study.

The analysis focused on descriptive statistics. Chi-square analyses were used to explore differences among residency programs. All tests were two-sided.

Sixty-two percent of respondents were men, and approximately 60% were younger than age 30. Internal medicine residents comprised 46% of the sample, psychiatry 24%, obstetrics and gynecology 19%, and family medicine 10%. First-year residents comprised 25% of participants. Second- and third-year residents were evenly split at 31%. Fourth-year residents had the lowest response rate (12%), which was expected because internal and family medicine residencies are 3-year programs. Twenty-nine percent of participants classified themselves as Indian (n=33.9), 24% Caucasian (n=28.1), 12% Arabic (n=14), 10% Hispanic (n=11.7), 10% Asian (n=11.7), 4% Pakistani (n=4.7), 2% African American (n=2.3), and 8% other (n=9.4).

Responses to all of the questions, except for the two-item knowledge-base assessment, are summarized in Table 1. Two questions were posed to assess participants’ general knowledge of evaluating patients presenting with sexual dysfunction. Eighty-eight percent (n=103) of residents answered the question based on a female patient correctly, and 96% (n=112.3) answered correctly for the male patient.

Almost all residents (93%) believed that it was important to know about their patients’ sexual health. Similarly, 99% of respondents believed that sexual health was an important contributor to their patients’ quality of life. Approximately 80% of residents reported that they felt comfortable routinely completing a sexual history on their patients. Results were similar for physician comfort with patient-initiated discussions of sexual health, with approximately 86% feeling comfortable. In clinical situations, more than half of participants reported confidence managing sexual problems. The combined category of comfort and perceived importance of sexuality in patients’ lives significantly differed (p=0.017) when compared by residency program. Residents in internal medicine had the worst mean score (3.43±0.93); psychiatry, the best (2.79±0.96).

Having more educational experiences was associated with routinely asking patients from other cultures about sexual health (p=0.023), but was not associated with all patients (p=0.48). Responses did not differ significantly by gender, age, or year of postgraduate training.

Given the large number of residents who report no previous curriculum related to sexual health, it is clear from this survey that the “neglect” of sexual education described by Parish and Clayton (4) is real. The demand for improvement in training, however, is present: 52% of respondents reported dissatisfaction with the quality of the educational experience. Surprisingly, this lack of reported formal education does not significantly affect residents’ understanding of the evaluation process for sexual difficulties, because almost all answered the two knowledge-based questions correctly. It is not known how well they would do with more challenging questions or clinically, with patients. Given that most participants believed that their patients’ sexual health is an important topic and that sexuality affects quality of life, there is a discrepancy between how often residents routinely inquire about sexual issues with their patients.

In this survey the major barrier to assessing sexual health was lack of time. Although hectic clinical schedules are certainly a factor in residency training, this response may have been convenient to minimize acknowledgment of personal discomfort. Fortunately, neither comfort with nor confidence about the topic seems to be a formidable barrier to assessing sexual health.

Cultural differences influence initial screening regarding sexuality. When residents were asked the general question “Do you routinely ask all your patients about their sexual history?” 61% responded yes. When asked if they inquired about the sexual concerns of patients from other cultures, this number dropped to 50%. Most participants believed that their vocabulary might not be adequate to discuss sexuality with culturally diverse patients.

This study has several limitations. The response rate was acceptable for psychiatry (90%) and family medicine (75%) but less so for the other participating programs. Because a psychiatry faculty member initiated the survey, psychiatric residents may have been biased to report positive attitudes and behaviors. The study was completed at one medical school and sent to only four residency programs, limiting generalizability. We would suggest including all graduate medical programs and additional institutions in the future. Most residents finished the survey quickly, with 23 questions completed in about 4 minutes. The two knowledge-based questions covered broad concepts. Even with a lack of training, almost everyone answered correctly. Despite these limitations, the data are consistent with other findings that suggest a lack of education for physicians in sexual health.

There is a lack of organized teaching of sexual health to medical residents. What can be done to improve resident education programs? Rosen et al. (2) reported on a half-day intensive workshop for residents that focused on communication skills and managing sexual difficulties. Participation led to increased discussion of sexual health with patients and improvements in physician comfort. Concerns about deficiencies in appropriate vocabulary necessary to address patients from other cultures could be easily addressed in curricular programs as well. Most important, the implementation of formal education related to sexuality, whether “intensive,” as described by Rosen et al. (2), or distributed throughout didactic and clinical experiences, will indicate to residents that medical educators perceive sexual health to be an important part of residency education. We hope that, in turn, residents will learn the importance of taking time to address their patients’ sexual health care needs.

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