Continuing Medical Education

Sexual Medicine Education: Review and Commentary

Sharon J. Parish, MD,* and Anita H. Clayton, MD

*Albert Einstein College of Medicine, Bronx, NY, USA; Department of Psychiatry and Neurobehavioral Sciences,
University of Virginia, Charlottesville, VA, USA

ABSTRACT

Introduction. Sexual medicine education is an important and fundamental topic not adequately represented in most
undergraduate and residency training programs.
Aim. The purpose of this article is to better enable the participant to understand the importance of sexual medicine
education, and to review existing models and innovations in undergraduate and graduate medical education. This
activity is designed for the practicing physician.
Methods. A literature review of the topic was performed.
Main Outcome Measure. Current state of, and new developments in, sexual medicine education.
Results. In all countries, medical students, house staff, and practicing physicians currently receive variable, non-
standardized, or inadequate training in sexual history taking and sexual medicine assessment and treatment. There
remain signicant physicianpatient barriers to discussing sexual issues; and patients feel that their physicians are
reluctant, disinterested, or unskilled in sexual problem management. There is a knowledge gap between develop-
ments in sexual medicine and the clinical skills of practicing physicians.
Conclusions. The challenge is to create uniform, widely available programs that provide practicing physicians across
specialties with the needed skills to meet modern patients needs in sexual medicine healthcare delivery. Parish SJ,
and Clayton AH. Sexual medicine education: Review and commentary. J Sex Med 2007;4:259268.
Key Words. Sexual Medicine; Education

Introduction curricula and residency training initiatives that

focus proper attention on this critical subject.

A broad range of content areas needs to be

addressed in medical school and graduate
medical education. Even fundamental subject
Current State of Sexual Health

matter may not be allotted sufcient curriculum
time. Sexual health education is an example of an
often neglected, but very important topic. Sexual-
ity is important to almost all patients; yet this topic
is not adequately represented in most undergradu-
ate and residency training programs. Healthcare
providers are becoming increasingly aware of the
importance of addressing male and female sexual
health. Reecting this societal change, educators
are paying more attention to this gap, assessing it,
and piloting new curricula. The current interest in
this topic will hopefully generate medical school
Numerous studies document the importance of
sexual health to patients. A recent U.S. poll indi-
cates that 94% of adults feel that sexual pleasure
adds to quality of life [1]. However, sexual con-
cerns are common. A widely quoted 1999 analysis
of a survey of U.S. adult sexual behavior (ages
1859 years) revealed that 43% of women and
31% men experience sexual problems that nega-
tively impact on their quality of life [2]. Sexual
dysfunction may occur at any point in the sexual
response cycle (desire, arousal, or orgasm), and can
be a primary problem or a secondary issue related

J Sex Med 2007;4:259268 259

Continuing Medical Education
to another disease process, medication, or psycho-
social issue [3]. The consequences of untreated
sexual dysfunction may include depression, con-
icts within interpersonal relationships, or non-
compliance with prescribed medication regimens
[4,5]. Researchers have made signicant strides in
understanding the anatomy and physiology of the
male and female sexual response. This knowledge
has enabled the development of new medications
and other treatments for sexual dysfunction. The
current challenge is the widespread distribution of
this once-considered taboo information to the
healthcare providers and patient population at
large.
PhysicianPatient Barriers to Sexual Interviewing
Despite the increasing awareness of, and knowl-
edge about, sexual dysfunction and the availability
of treatment options, physicians and their patients
still hesitate to discuss these issues. One study
reports that their primary care physician never
asked 47% of patients whether they are engaged in
a sexual relationship [6]. Only 25% of primary care
physicians actually take a patients sexual history,
citing lack of training as the most common reason
for not doing so [79]. If practitioners do take
sexual histories, they most commonly focus on
sexually transmitted disease (STD) risk assessment
and prevention and/or contraception, rather than
sexual problems. Physicians report other barriers,
such as insufcient knowledge about sexual func-
tion and dysfunction, inadequate communication
skills, discomfort with sexual language, lack of
information about treatment options, time con-
straints, apprehension that their inquiries may
offend the patient, and their own feelings of
embarrassment about the subject. Physicians may
have difculty remaining objective and separating
their personal views from those of their patients
[10]. Physicians in training may have limited sexual
experience, unresolved issues regarding their own
sexuality, or concern about developing sexual feel-
ings toward patients.
Patients are reluctant to bring up sexual issues
with their physicians. Many (75% in one study)
believe that their physicians would dismiss their
sexual health concerns, or fear the topic might
embarrass their physician [1]. Many patients do
not have condence in their physicians skills in
managing sexual problems, and do not believe they
would receive effective treatment. Less than one-
260
third of patients feel comfortable talking to their
physician about sexual concerns, and only 10% of
patients spontaneously discuss concerns if not
prompted by their physician [11]. Most patients
(over 90%) believe that it is a physicians role to
address sexual health concerns, and are grateful
when their physician initiates the discussion [12].
Detection of Sexual Problems
Clinicians infrequently screen for sexual pro-
blems, so detection rates are consequently low. In
one study, English general practitioners (GPs)
recorded sexual problems in only 2% of their
notes, despite a survey prevalence of female sexual
dysfunction of 42% [13]. Improving screening
procedures does improve recognition. In another
study in which clinic physicians were trained to
take a screening sexual history, 53% of the patients
reported a sexual problem [12]. Most (91%) of the
patients said they considered questions about sexu-
ality to be an appropriate part of the interview.
Studies demonstrate the high prevalence of
sexual problems, signicant barriers to addressing
sexuality in clinical settings, improved detection
with focused training in history-taking skills, and
patients acceptance of such discussions. Physician
education, targeted at improving skills, increasing
knowledge, and encouraging awareness of per-
sonal biases, is the key to minimizing obstacles that
interfere with physicians optimally addressing
sexual health.
Physicians Need for Sexual Medicine Education
While physicians typically do not receive adequate
training in sexual medicine and sexual history
taking, they believe that they should address sexual
problems, and that they need more training. Prac-
ticing physicians can gain increased comfort and
experience in managing sexual problems by incor-
porating routine sexual health questions into their
practice, by addressing the barriers discussed
above, by sharing cases with colleagues, and by
exploring their own attitudes toward sexuality [10].
The Importance of Sexual Health in
Medical Education
Given the high prevalence of sexual problems, the
importance of addressing the sexual health con-
cerns of patients, and practicing physicians
J Sex Med 2007;4:259268

perceived lack of, and need for, enhanced training
in sexual medicine, medical school, and postgradu-
ate training are the primary forums in which
doctors should acquire the necessary knowledge
and skills.
In 1974, the World Health Organization
(WHO) organized a meeting on Education and
Treatment in Human Sexuality to address sexual
health training and create denitions of sexual
health. A subsequent international meeting in
2000, sponsored by the WHO and the Pan Ameri-
can Health Organization, resulted in a publication
entitled Promotion of Sexual Health. [14] Their
denition of sexual health is:
. . . the experience of the ongoing process of physical,
psychological and socio-cultural well-being related to
sexuality. Sexual health is evidenced by the free and re-
sponsible expression of sexual capabilities that foster
harmonious personal and social wellness, enriching
individual and social life. It is not merely the absence
of disease, dysfunction or inrmity. [15]
In conjunction with this denition, 11 sexual
rights were enumerated, including the right to
sexual information based on scientic inquiry, the
right to comprehensive sexuality education, and
the right to sexual health care [16].
The World Association for Sexology (WAS)
and other organizations have also made recom-
mendations about sexual health training that apply
to U.S. medical education; however, there is a need
for more information on the specic components
of ideal undergraduate sexual health education. In
1980, the UK General Medical Council (GMC)
stated that, upon graduation, medical students
should be able to communicate effectively and sen-
sitively with patients and their relatives [17]. In
1993, the GMC recommended that primary care
physicians actively promote sexual health and
provide information on healthy sexual lifestyles,
and that the training of medical students incorpo-
rate ethical responsibilities related to sexuality,
such as avoiding sexual discrimination against
patients and colleagues. In the same year, the
National Institutes of Health (NIH)s Consensus
Statement on Impotence determined that health-
care providers are uninformed about sexual
issues and do not manage them effectively. The
NIH Statement recommended three key compo-
nents for sexual health education: (i) human sexu-
ality courses in healthcare professional curricula,
emphasizing sexual history taking; (ii) diagnosis
and management of sexual dysfunction in post-
graduate continuing medical education (CME)
J Sex Med 2007;4:259268
Continuing Medical Education
courses; and (iii) an interdisciplinary approach to
the evaluation and management of sexual dysfunc-
tion [18]. While the NIH conference addressed
impotence, sexual medicine experts concur that
the identied deciencies in skills and knowledge,
and the recommendations for sexual health educa-
tion, should be applied globally to the identica-
tion, assessment, and management of all sexual
disorders.
The Current State of Sexual Medicine Education in
U.S. Medical Schools
Medical educators have only recently become
interested in sexual health education. Increased
societal willingness to discuss sexual health, asso-
ciated with increased availability of treatments
for sexual problems, has raised awareness of the
need for enhanced training in sexual medicine.
However, many medical schools still offer insuf-
cient training in sexual health, and there is a sub-
stantial knowledge gap between the science of
sexual medicine and the clinical skill level or com-
petency of most physicians in managing sexual
problems [19].
In 1976, Lief and Ebert conducted an early
survey regarding sexual health education in
medical schools [20]. They reported that 60% of
U.S. medical schools offered required sexuality
curriculum, and 32% provided elective training. A
more comprehensive 2003 study assessed the edu-
cational experiences related to human sexuality in
125 medical schools in the United States and 16 in
Canada (Association of American Medical Col-
leges [AAMC]) [18]. The survey asked the North
American medical schools about the type of
educational experiences (i.e., lectures, courses),
whether they were mandatory or elective, whether
they were designed by single or multiple disci-
plines, and the number of course hours dedicated
to human sexuality. The questionnaire also
assessed specic content areas, as well as exposure
to and training in clinical settings addressing
sexual problems. Additionally, the survey assessed
the availability of CME programs in sexual medi-
cine and related topics.
The investigators received 101 valid responses
from a possible 141 medical schools. Two addi-
tional schools returned the survey, acknowledging
that their school curriculum dedicated no hours to
sexual health education, and ve other schools that
did respond stated that they were embarrassed at
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Continuing Medical Education
how little time their school devoted to the topic. A
challenge in completing the study was that, at
many schools, no one particular person was
responsible for the sexual health curriculum. Most
schools (87.5%) reported that they used a lecture
format, required at over 80% of schools. Two-
thirds of the schools used a multidisciplinary
approach to teach sexual health, and three-
quarters of the schools reported psychiatry as the
most frequently involved discipline. Over half
of the schools offered 310 hours of training,
whereas one-third offered 11 or more hours on the
subject. The most common topics discussed were:
causes and treatment of sexual dysfunction, sexual
identity/orientation, and sexuality in disabled or
medically ill patients. Additional topics included:
STDs, infertility, sexual abuse, and lifecycle issues.
Slightly more than half of the schools exposed
students to clinical experiences during which they
interacted with patients receiving treatment for, or
education on, sexual issues.
Studies assessing curricula at individual institu-
tions demonstrated that students receive a broad
range of nonstandardized training. For example,
an evaluation of Boston University Medical
Schools sexuality education demonstrated that
students had widely varied experiences, largely
determined by their personal interest and random
assignment to specialized services (e.g., transgen-
der clinic) available to limited numbers of students
[21]. More controversial topics in sexual health
have even less favorable representation. For
example, of the 82 U.S. medical schools that
responded to a survey (65% of the 126 schools
surveyed), eight faculty reported that they had no
teaching on gay and lesbian issues [22]. Cultural
inuences on sexual practices do not appear to be
addressed in most sexuality curricula.
Current State of Sexual Medicine Education in U.S.
Graduate Medical Education and CME Programs
Sexual health training in graduate medical educa-
tion is understudied and largely unaddressed.
According to Rosen et al., Residency training in
sexual medicine has been largely neglected, with
little attention given to educational curriculum
development or implementation, and few pro-
grams have training in sexual problem manage-
ment across disciplines or subspecialties (e.g.
family medicine, internal medicine, obstetrics/
262
gynecology [OB-GYN], urology, and psychiatry)
[19].
Less than half (44.6%) of the medical schools
who responded to the 2003 survey discussed above
offered CME programs for professionals inter-
ested in sexuality-related topics [18].
In response to the increasing demand and inter-
est, some organizations, composed of practicing
physicians in one or several disciplines caring for
patients with sexual problems, now offer lectures,
workshops, and longer courses on the evaluation
and treatment of male and female sexual dysfunc-
tion. Organizations that have provided these
courses include: the American College of Physi-
cians (representing general internists and sub-
specialists), the American Psychiatric Association,
the North American Menopause Society, and the
American Urological Association. Academic soci-
eties, such as the Society for General Internal
Medicine, offer workshops geared toward clinician
educators that address both clinical care and teach-
ing strategies. In the past decade, multidisciplinary,
specialized organizations, such as the International
Society for the Study of Womens Sexual Health,
have been sponsoring meetings that are dedicated
to sexual health research and educational courses
designed to enhance clinical care.
Accreditation Standards for Sexual Medicine
Education
The Liaison Committee on Medical Education
(http://www.lcme.org) determines accreditation
standards for medical schools. The curricular
requirements related to sexual health are general
and include learning about: behavioral subjects;
communication skills; medical consequences of
common societal problems, such as abuse; diverse
cultures and belief systems; and gender biases.
The Accreditation Council for Graduate Medi-
cal Education has outlined residency program
training requirements for all disciplines (http://
www.acgme.org). Sexual medicine requirements
are also very general. Internal medicine residents
should receive instruction and clinical experience
in the prevention, counseling, detection, diagno-
sis, and treatment of gender-specic diseases of
men and women. Family medicine guidelines
mention teaching of human sexuality. Pediatrics
requirements include learning about sexual abuse,
and male and female reproductive health, in-
cluding sexuality, pregnancy, contraception, and
J Sex Med 2007;4:259268

STDs. Urology residents should receive training
in sexual dysfunction. OB-GYN requirements
include topics more directly relevant to sexual
health, including contraception, infertility, meno-
pause, high-risk behavior, as well as specic sexual
medicine skills, such as sexual history taking and
psychosexual counseling. Psychiatry guidelines are
quite vague, with a focus on cultural differences
that address issues of gender, race, ethnicity, socio-
economic status, religion/spirituality, and sexual
orientation (knowledge and attitudes).
Research on Trainees Perceptions of Sexual
Medicine Skills
Clearly, medical schools vary in their attention to
sexual health education. Recognizing this dispar-
ity, the pharmaceutical company, Pzer Inc.,
recently offered seven $100,000 grants to medical
schools to evaluate and enhance their sexual health
programs. Three grant recipients, the University
of Virginia (UVA) School of Medicine, Case
Western Reserve University School of Medi-
cine (CWRU), and University of Massachusetts
Medical School (UMMS), have published data.
Prior to introducing any curriculum enhance-
ments, the UVA School of Medicine conducted
research comparing knowledge of, comfort with,
and attitudes toward the importance of sexual
health care among rst-, second- and third-year
medical students. The existing curriculum at UVA
included information relevant to sexual health in
Anatomy, Embryology Histology, Physiology,
Human Behavior, Pathology, and Introduction to
Psychiatry and Practice of Medicine (POM)
courses. The POM training included: lectures on
obtaining a sexual history and screening for
domestic violence, sexual history taking utilizing
role-play and standardized patients, and gyneco-
logic and genitourinary exams performed on
female and male standardized patients.
The results (published 2003) revealed that rst-
year students felt that they knew the least about
obtaining a sexual history and the most about
medications for treating sexual dysfunction, likely
reecting exposure to the media, while third-year
students said that they knew the least about medi-
cation treatment [23]. All three groups of students
felt the least comfortable discussing sexually
related health problems and the most comfortable
discussing sexual side effects of medications, sug-
gesting students overall discomfort with dis-
J Sex Med 2007;4:259268
Continuing Medical Education
cussing sensitive psychosocial issues. Third-year
students were signicantly less likely to rate dis-
cussing sex in a routine ofce visit as important, a
response that may reect supervising attending
physicians negative attitudes toward, or discom-
fort with, taking a sexual history in the inpatient
setting.
A 1996 Australian study compared students
personal sexual experiences with their condence
and ability to perform female pelvic exams. Both
male and female students who had sexual experi-
ence (153 of 286 students) felt more comfortable
performing the exam, explaining their actions to
their patients and being able to detect pathology
[24].
These and other similar surveys regarding
medical students attitudes toward, and perceived
skills in, sexual medicine offer insights into the
current climate of sexual health education in
medical schools. Further investigation is needed
from many other medical school and residency
training programs to assess trainees abilities and
biases, and to provide the impetus for curricular
change.
New Developments in Sexual Medical Education
A number of medical schools have made improve-
ments to their sexual health education programs,
which address some of these decits. Several
models described below incorporate a multidisci-
plinary approach to enhancing trainees attitudes,
knowledge, skills, and overall comfort in managing
sexual health problems. Table 1 outlines the com-
ponents, including attitudes, knowledge, and skills
training, that have been included in sexual health
curricula.
A Pzer grantee, CWRU, is in the process
of implementing a comprehensive, cross-
disciplinary and innovative curriculum that is
based on three primary objectives for teaching
sexual health: attitude change, behavior change
and knowledge acquisition [25]. Attitude change
is accomplished by promoting students awareness
of their own attitudes toward sexuality. The
revised curriculum provides exposure to normal
variations of sexuality, dispels myths, and teaches
boundary setting, with suggested strategies to
manage situations in which those boundaries are
challenged. Behavior change is being addressed
by enhancing communications skills regarding
all aspects of sexual functioning. Knowledge
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Continuing Medical Education
Table 1 Components of model sexual health curricula
Attitudes Self-awareness of own beliefs, values, attitudes
Reflection/ desensitization
Variations of normal sexual behavior
Ethical issues
Knowledge Biology of sexual development on molecular level
Anatomy and physiology of human sexual
response
Psychological influences on sexual development
Causes of sexual dysfunction (biological,
psychological, and social)
Impact of medical illness, treatment, medications
Sexual health in adolescence
Impact of menopause, aging on sexuality
Sociologic issues (ethnicity, race, culture, religion,
sexual orientation, and economic status)
Sexuality in special populations (disability)
Reproductive biology (contraception, pregnancy,
and infertility)
Sexually transmitted diseases
Sexual abuse/ violence
Gay/ lesbian/ transgender health care
Treatments for sexual dysfunction (pharmacologic
and behavioral)
Skills Sexual history taking
Comfort with sexual language
General communication skills
Gynecological/ genitourinary exams
Integrated diagnosis of sexual dysfunction
Management of sexual disorders
(pharmacological, counseling, and devices)
Management of sexual side effects of
medications
Behavioral therapy
acquisition involves a multidisciplinary approach
to all aspects of sexual health, including topics such
as biology, sexual development, and sociologic
issues, such as the impact of ethnicity, race,
culture, and economic status on sexual health.
Sexual health enhancements were conceptual-
ized simultaneously with the implementation of
revisions throughout the 4-year medical school
curriculum at CWRU. Two such initiatives, the
development of vertical themes across all 4 years
and an Integrated Electronic (web-based) Cur-
riculum, are important tools for promoting new
sexual health education. A sexual health website
was developed to provide the Sexual Health Ver-
tical Theme of the CWRU medical school cur-
riculum in an electronic format. The purpose of
the website is to provide up-to-date, clinically rel-
evant information and cutting-edge research
regarding the broad elds interfacing with sexual
health.
Strategies to incorporate the sexual health
content include: faculty development to enhance
sexual communication skills; additional didactic
264
sessions within the core curriculum; case-based
learning; standardized patient interviews; testing
using multiple-choice questions; and Objective
Structured Clinical Exams, including both sexual
health content in existing stations and stand-alone
stations; assessment of students attitudes using the
Sex Knowledge and Attitudes Test; and the cre-
ation a sexual health website.
Another grant recipient, UMMS, has also
implemented curricular change through the
Sexual Health Initiative Project. The Macy Com-
munication Skills Curriculum Initiative (1999)
fueled the addition of new topics to the third-year
curriculum, including adolescent sexuality, lesbian
and gay health care, reproductive counseling, HIV
risk reduction, and sexual dysfunction caused by
medications [26].
A 2001 survey administered to rst- and
second-year medical students identied barriers to
discussing sexual issues with patients, including
societal messages that sex was private, lack of
knowledge, patient and student discomfort with
the subject overall, and cultural differences. Stu-
dents reported that particularly challenging topics
included extramarital affairs, multiple partners,
sexual violence, gathering sexual information from
older patients, and patients who engage in high-
risk sexual behavior.
Based on these survey results, UMMS imple-
mented other curricular enhancements through-
out the 4 years. During the rst-year anatomy
course, UMMS offered an elective reection
session regarding students reactions to the dissec-
tion of the female pelvis. One-half of the 25% of
the class that participated felt that the session
reduced their apprehension related to the dissec-
tion, and 95% wanted to have more sessions of a
similar nature in the future. Another elective
1-hour session on the Medical Risks of the Gay,
Lesbian, Bisexual and Transgendered Commu-
nity was instituted during an interclerkship day in
the students third year. Of the 50% of the class
that participated, 95% thought the lecture was
effective in promoting awareness of these issues.
UMMS also developed a multidisciplinary 1-week
womens health course available as an elective for
fourth-year students. Although only a handful of
students participated, all of them strongly agreed
that the course increased their skills and comfort
in managing womens health problems.
Some educational initiatives in sexual medicine
have been initiated directly by students. For
J Sex Med 2007;4:259268

example, in 1998, second-year students at the
Stanford University School of Medicine, designed
and implemented nine-weekly lunchtime elective
lectures entitled Current Issues in Reproductive
Health, paired with a University-wide Reproduc-
tive Health Fair [27]. Students reported that the
two most frequently acquired skills were the ability
to discuss an unwanted pregnancy and to commu-
nicate with patients of varying genders, sexual ori-
entations, and cultures. Students said that the most
useful learning methods included discussions with
fellow students, interactive presentations with
faculty, didactics, and teaching peers.
Developments in International Sexual
Medicine Education
Sexual health education reform is also evolving
outside the United States. Some innovative model
curricula have emerged from medical schools in
the United Kingdom. In 1996, Glascow University
developed a sexual health communication skills
training program aimed at improving students
skills across disciplines (gynecology, urology,
family planning, and primary care) [17]. It contains
three components: (i) exploration of students
values and attitudes toward sexual practices, such
as prostitution and termination of pregnancy; (ii)
supervised role-play of clinical scenarios; and (iii)
discussion of referral resources. Nearly all of the
students (97%) thought the course was relevant to
clinical practice.
The University of Cambridge instituted role-
playing mock clinic scenarios, which allows stu-
dents to empathize with the patient, and discover
and test benecial behaviors [28]. Two examples
include: (i) a young homosexual man who has just
come out but does not know how to use a
condom, and (ii) a woman interested in having
an intrauterine device tted. The University of
Cambridge also conducts a session dedicated to
increasing awareness of homosexuality. During the
session, students explore internalized prejudice by
brainstorming all the slang terms they know relat-
ing to homosexuality, and then reecting on them
silently. Students then examine the effects of
prejudice by imagining how they would react to
those terms if they were gay.
Another medical school in the United
Kingdom, Leicester-Warwick Medical School, ini-
tiated a course designed to aid the students in
recognizing their attitudes and values toward sexu-
J Sex Med 2007;4:259268
Continuing Medical Education
ality that may inuence clinical practice [29].
Methods include desensitization, problem solving,
and reection. Students address their embarrass-
ment with sexual topics, including becoming
familiar with slang and medical terms in a safe
environment in which they might rehearse their
reactions and responses. Most students (78%) felt
that the course offered some benet, and a similar
number of students believed that it made them
more sensitive to the needs of patients and the
duties of doctors.
Developments in Residency Sexual
Medicine Education
Few residency training programs have described
innovations in sexual health education. The
Robert Wood Johnson Medical School (RWJMS)
has been an internationally recognized model
for comprehensive sexual health education for
medical students since 1973. Using a small-group
interactive format, the course seeks to provide a
culturally diverse and patient-centered approach,
focusing on three components: (i) integration of
cognitive and attitudinal learning; (ii) role of a
multidisciplinary team in managing sexual prob-
lems; and (iii) clinical skills, including general
communication skills and sexual history taking.
Recently, a parallel model was developed for
training house staff, incorporating the three ele-
ments described above into a half-day program
[19]. The program was designed to assess the fea-
sibility and impact of implementing the educa-
tional model with primarily senior house staff
from RWJMS-afliated residency programs in
multiple specialties, including 46 internal and
family medicine, psychiatry, geriatrics, OB-GYN,
urology, and pediatrics residents. Methods
included: didactic presentations on male and
female sexual dysfunction, physician and patient
panels, an audience response system with feed-
back, and interviewing skills practice. The major-
ity (92.6%) of the 34 respondents to the posttest
evaluation said that the workshop was informa-
tive; about two-thirds (67.4%) said that they
gained greater awareness about sexual problems;
and approximately half said that they increased
their comfort and skill in sexual problem manage-
ment, including the use of specialized referral.
The participants specically praised the live inter-
views and panels.
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Continuing Medical Education
Future Directions and Challenges
To improve their sexual health education, medical
schools and residency programs will need to
analyze their current curricula, as well as imple-
ment new training experiences and assess their
impact. Challenges include overcoming barriers
to effective curricular change. Trainees may have
negative attitudes toward sexual health or resist
developing new communication skills; faculty may
feel ill equipped to provide training, often lacking
the needed skills themselves; and curriculum com-
mittees may be weighing the importance of this
content area against other important topics and
training experiences. Faculty development and
institutional reform are critical to the success of
sexual health initiatives.
Conclusions
Concordant with major advances in the evaluation
and treatment of sexual dysfunction, society has
become more willing to recognize sexual problems
and discuss sexual health. However, many medical
students, house staff, and practicing physicians
continue to receive variable, nonstandardized, or
inadequate training in sexual history taking and
sexual dysfunction assessment and treatment.
Studies demonstrate that there are still signicant
physicianpatient barriers to discussing sexual
issues; and patients feel that their physicians are
reluctant, disinterested, or unskilled in sexual
problem management. Thus, there continues to be
a knowledge gap between developments in sexual
medicine and the clinical skills of practicing phy-
sicians. The remedy for this discrepancy begins
with appropriate training in medical schools.
Some medical schools and a few residency pro-
grams have analyzed the state of their sexual health
education and initiated unique programs or more
comprehensive courses, often linked to larger-
scale curriculum change. However, these new cur-
ricula are frequently offered as electives to a small
number of interested students or those participat-
ing in specialized rotations. Ideal curricular inno-
vation focuses on addressing trainees attitudes, as
well as developing knowledge and enhancing prac-
tical, clinical skills with hands-on training with live
or standardized patients. Hopefully, these models
have established a trend that will inspire all
medical schools to modernize and to offer manda-
tory, comprehensive curricula in sexual health edu-
266
cation. Graduate medical sexual education is in an
early stage of change; much work is needed to give
physician trainees uniform, standardized skills to
meet the demands of current clinical practice.
CME programs are being offered in multiple dis-
ciplines and by specialty multidisciplinary organi-
zations. The challenge is to create widely available
programs that provide practicing physicians across
specialties with the needed skills to meet modern
patients needs in sexual health care.
Corresponding Author: Sharon J. Parish, MD,
Department of Medicine, Centennial 3, Monteore
Medical Center, 111 East 210th Street, Bronx, NY
10467, USA. Tel: 718-920-4783; Fax: 718-920-8375;
E-mail: sparish@monteore.org
Conict of Interest: Sharon J. Parish, MD: No relevant
nancial relationships to disclose.
Anita H. Clayton, MD:
Grants: BioSante Pharmaceuticals, Inc.; Boe-
hringer-Ingelheim; BristolMyersSquibb; Eli Lilly and
Company; Forest Pharmaceuticals; GlaxoSmithKline;
Neurontics; Pzer, Inc.; Sano-Aventis; and Wyeth.
Advisory Board/Consultant: Boehringer-Ingelheim;
BristolMyersSquibb; Eli Lilly and Company;
Fabre-Kramer Pharmaceuticals; GlaxoSmithKline;
Novartis Pharmaceuticals; Pzer, Inc.; Vela Pharma-
ceuticals; and Wyeth.
Speakers Bureau/Honorarium: Eli Lilly; GlaxoSmith-
Kline; Pzer, Inc.; and Wyeth.
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267
Continuing Medical Education

CME Multiple-Choice Questions 3. improved screen procedures does not improve

recognition
The percentage of patients who feel sexual pleasure
4. patients spontaneously raise sexual concerns 50% of
adds to quality of life is:
the time
1. 50%
5. patients agree that a sexual history is relevant to their
2. 94%
health care
3. 43%
4. 75%
5. 23% Which of the following organizations have man-
dated sexual health education?
The estimated prevalence of sexual dysfunc-
1. World Health Organization (WHO)
tion in U.S. women and men ages 1859 is: 2. Pan American Health Organization (PAHO)
1. 43%, 31%, respectively
3. World Association for Sexology (WAS)
2. 43% in both
4. International Society for Sexual Medicine (ISSM)
3. 31% in both
5. 1, 2 and 3
4. 25%, 40%, respectively
5. none of the above
Regarding the current state of sexual health educa-
Physician barriers to talking to patients about
tion in medical schools:
sexual issues include: 1. Over 80% of schools have required lectures
1. lack of training in sexual problem management 2. Over half of the schools offered 20 hours of training,
2. discomfort with sexual language whereas one third offered 25 or more hours on the
3. inadequate communication skills subject
4. time constraints 3. Most students are exposed to clinical experiences
5. all of the above 4. Students are more comfortable taking sexual histo-
Patient barriers to talking about sexual issues ries than discussing sexual side-effects of medications
include: 5. Most schools offer CME programs to practicing
1. concern that physician will be dismissive physicians
2. fear of embarrassing physician
3. do not feel comfortable talking to a physician
Which of the following methods are being used in
4. lack of condence in physicians skills
innovative sexual health education curricula?
5. all of the above
1. interactive didactic sessions
Which of the following is NOT true about screen- 2. case-based conferences
ing for sexual problems? 3. live and standardized patient interviews
1. screening improves detection about 50% 4. web-based courses and materials
2. physician training improves screening rates 5. all of the above

Please indicate your current profession: Name:

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Physician Other Healthcare
Address 1:
Assistant Professional
Nurse Practitioner Other Address 2:
City:
State:
Postal Code:
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Please return this page to: Alternatively, an online version of this activity
William Deluise will be available beginning in March 2007. Please
Assistant Editor, CME visit http://www.blackwellpublishing.com/jsm in
Blackwell Futura Media Services March for further information.
Fax: 781-388-8304

268 J Sex Med 2007;4:259268