Sexual Health During Postgraduate Training-European Survey Across Medical Specialties.

BACKGROUND: Sexual health problems are common. Therefore, training in sexual health is relevant for the clinical practice of trainees and early-career specialists in several specialties who deal with patients with sexual health problems. However, little is known about how sexual health training is provided across countries and specialties. AIM: To assess (i) sexual health training during postgraduate training programs in psychiatry, obstetrics and gynecology, urology, and endocrinology across Europe; (ii) the confidence of trainees and early-career specialists in dealing with patients with sexual health problems; and (iii) their need for further training in sexual health during postgraduate training programs.
METHODS: The study was based on a collaboration among European societies of trainees in these 4 specialties. An online survey was developed and conducted from January 2015 through June 2016. MAIN OUTCOME MEASURES: Self-reported questionnaire.
RESULTS: We collected 366 completed surveys from 40 countries. Sexual health training was considered an important or very important part of specialty training by 78.7% of participants. Overall, 62.3% of participants had not received any training in sexual health. Especially in obstetrics and gynecology, the large majority did not have training in sexual health (82.8%), followed by psychiatry (59.8%), urology (58.4%), and endocrinology (56.1%). There were statistically significant differences among specialties in the confidence of participants in managing patients with sexual health problems. In general, trainees and early-career specialists who had received sexual health training felt more confident in dealing with patients with gender dysphoria (P = .011), need for sexual therapy (P = .0004), paraphilic disorders (P = .0003), and sexual dysfunction (P = .0017).
CONCLUSIONS: Trainees and early-career specialists found sexual health training important for their future medical practice; however, less than half received it during their postgraduate training. Participants felt more confident in managing patients with sexual health problems when sexual health training was included in the postgraduate training program. Kristufkova A, Pinto Da Costa M, Mintziori G, et al. Sexual Health During Postgraduate Training-European Survey Across Medical Specialties. Sex Med 2018;6:255-262.

Introduction

According to the World Health Organization (WHO), sexual health is a state of physical, mental, and social well-being in relation to sexuality. It requires a positive and respectful approach to sexuality and sexual relationships and the possibility of having pleasurable and safe sexual experiences free of coercion, discrimination, and violence. The WHO also includes sexual health in the definition of overall health, well-being, and quality of life.1, 2

Studies have shown a high prevalence of sexual dysfunction in adult men and women.3, 4, 5 Therefore, doctors within various specialties should be prepared to deal with sexual health problems.

Expectations of what doctors can and should be able to do are shifting, knowledge is progressing fast, and doctors need to address different skills to respond to the new demands.6, 7 Specialties dealing with sexual health problems in clinical practice include primarily urology, obstetrics and gynecology (OB-GYN), psychiatry, and endocrinology. Although the importance of sexual health training during medical school and postgraduate training has been highlighted, training programs and management of sexual health problems vary across specialties and countries.6, 8, 9, 10 Despite previous studies conducted in psychiatry and urology gathering opinions from trainees concerning their training,10, 11, 12 little is known about the extent of sexual health training during training in these specialties.

Aim

The main objectives of this study were to explore (i) the extent of sexual health training during postgraduate training in psychiatry, OB-GYN, urology, and endocrinology across Europe; (ii) the confidence of trainees and early-career specialists in dealing with patients with sexual health problems; and (iii) their need for further training in sexual health during postgraduate training programs in the 4 medical specialties.

Methods

This was an online cross-sectional questionnaire conducted in collaboration with European societies of trainees in 4 specialties: psychiatry (European Federation of Psychiatric Trainees), OB-GYN (European Network of Trainees in Obstetrics and Gynecology), urology (European Society of Residents in Urology), and endocrinology (European Young Endocrine Scientists).

The survey was developed for this study with single-choice questions (about demographics), multiple-choice questions, and open questions (Supplement 1). The survey was divided into 3 parts—(i) demographic information, (ii) experience with and opinion of sexual health, and (iii) confidence in managing patients with sexual health problems—in 6 fictional scenarios about: gender dysphoria, history of sexual abuse, need for sexual therapy, paraphilic disorders, sexual dysfunction, and sexually transmitted infections (STI). The questionnaire was circulated using a web-based survey program (SurveyMonkey Inc, San Mateo, CA, USA). The survey was sent to trainees and early-career specialists within the 4 specialties from January 2015 through June 2016 by each of the societies to their contact database by e-mail and through their social media accounts. All participants were asked to give informed consent before initiating the questionnaire, which was self-administered anonymously. The questionnaire was distributed in the English language because trainees and early-career specialists were deemed to have sufficient command of English to reliably answer the questions.

1-way analysis of variance was used to test the relation between categorical and ordinal-interval variables. Dichotomous variables were compared using the unpaired t-test. Pearson correlation coefficient was used to assess the strength of relations between 2 ordinal-interval variables. The effect of trainee type on the confidence of managing patients with sexual problems (6 fictional scenarios) was tested using a general linear model, with age, sex, and years of training as covariates and specialization as a fixed factor. Tukey test was used to test differences between all pairs of trainee types. The error term for the Tukey test was computed from the sums of squared residuals from the general linear model. All presented P values are 2-sided. A P value less than .05 was considered statistically significant. GraphPad Prism 6 for Windows (www.graphpad.com) was used for all statistical analyses.

Results

The survey was completed by 380 respondents. However, 14 were excluded because these respondents were from medical specialties other than the 4 surveyed. The analysis was based on the 366 respondents from 40 countries (Table 1).

Table 1

Characteristics of respondents according to specialty and overall group characteristics

	Psychiatry	Endocrinology	Obstetrics and gynecology	Urology	Overall
n (%)	102 (27.9)	57 (15.6)	58 (15.9)	149 (40.7)	366
Age (y), median (range)	30 (25–45)	30 (22–39)	32 (25–55)	30 (24–50)	31 (22–55)
Training (y), median (range)	3 (1–6)	3 (1–7)	3 (1–6)	3 (1–6)	3 (1–7)
Early career specialists, n (%)	—	18 (31.6)	8 (13.8)	15 (10.1)	41 (11.2)
Sex, n (%)
Women	71 (69.6)	40 (70.2)	46 (79.3)	67 (45.0)	224 (61.2)
Men	31 (30.4)	17 (29.8)	12 (20.7)	82 (55.0)	142 (38.8)

Overall Demographic Analysis

Trainees were primarily in their 4th year of training (23.4%) and 11.2% were early-career specialists. More women completed the survey (61.2%). The median age of participants was 31 years (range = 22–55). According to specialty, 40.7% of respondents were from urology, 27.9% were from psychiatry, 15.8% were from OB-GYN, and 15.6% were from endocrinology. The group characteristics are listed in Tables 1 and 2.

Table 2

Participating countries in each specialty

Country	Psychiatry	Endocrinology	Obstetrics and gynecology	Urology
Albania	X
Austria			X
Azerbaijan	X
Bosnia and Herzegovina	X	X
Belarus	X	X
Belgium	X			X
Bulgaria	X
Croatia	X
Cyprus	X
Czech Republic	X		X
Denmark	X		X	X
Estonia	X		X	X
Finland	X		X
France	X	X
Georgia	X	X
Germany	X	X	X	X
Greece	X	X	X	X
Hungary			X	X
Ireland	X		X
Italy	X	X		X
Lithuania				X
Latvia			X
Makedonia		X
Malta			X
Moldova	X
The Netherlands	X			X
Norway			X
Poland	X	X	X	X
Portugal	X
Romania	X	X
Russia	X	X
Serbia	X	X
Slovakia	X	X	X	X
Slovenia	X		X
Spain	X	X	X
Sweden	X
Switzerland	X			X
Turkey	X		X	X
Ukraine	X
United Kingdom	X	X	X

Sexual Health Training Among Trainees and Early-Career Specialists

In this sample of trainees and early-career specialists, sexual health training was considered an important or very important part of specialty training by 78.7%. It was considered very important by trainees in OB-GYN in particular (43.1%), but also by trainees in urology (37.6%), endocrinology (36.8%), and psychiatry (34.4%).

Overall, 62.3% of trainees and early-career specialists had not received any sexual health training. Especially those in OB-GYN had no exposure (82.8%); nevertheless, more than half the respondents in psychiatry (59.8%), urology (58.4%), and endocrinology (56.1%) had no exposure either. Sexual health training was stated as available by 28.7% of respondents and unavailable by 42.6%, and the remaining respondents did not know if it was available.

Of respondents only 25.7% had sexual health training as a mandatory (13.4%) or optional (12.3%) part of their training curriculum, whereas 48.1% did not have it as a part of their curriculum. When sexual health training was incorporated in the training curriculum, it was most frequently as a combination of theoretical and clinical training (50.0%) or only theoretical training (44.9%; Table 3).

Table 3

Attendance, availability, and form of sexual health training according to specialty

	Psychiatry (n = 102)	Endocrinology (n = 57)	Obstetrics and gynecology (n = 58)	Urology (n = 149)	Overall (N = 366)
Have you done any sexual health training?
Yes	34 (33.3%)	23 (40.4%)	7 (12.1%)	52 (34.9%)	116 (31.7%)
No	61 (59.8%)	32 (56.1%)	48 (82.8%)	87 (58.4%)	228 (62.3%)
Is sexual health training available in your country?
Yes	41 (40.2%)	9 (15.8%)	13 (22.4%)	42 (28.2%)	105 (28.7%)
No	27 (26.5%)	32 (56.1%)	32 (55.2%)	65 (43.6%)	156 (42.6%)
I don't know	26 (25.5%)	13 (22.8%)	7 (12.1%)	29 (19.5%)	75 (20.5%)
Is sexual health training part of your training curriculum?
Yes, mandatory	13 (12.7%)	9 (15.8%)	24 (41.4%)	1 (0.7%)	49 (13.4%)
Yes, optionally	10 (9.8%)	11 (19.3%)	3 (5.2%)	21 (14.1%)	45 (12.3%)
No	56 (54.9%)	26 (45.6%)	38 (65.5%)	56 (37.6%)	176 (48.1%)
I don't know	15 (14.7%)	8 (14.0%)	8 (13.8%)	35 (23.5%)	66 (18.0%)
In which form is sexual health training done?
Theoretical	18 (50.0%)	7 (25.0%)	6 (46.2%)	39 (49.4%)	70 (44.9%)
Clinical	2 (5.6%)	3 (10.7%)	0	3 (3.8%)	8 (5.1%)
Both	16 (44.4%)	18 (64.3%)	7 (53.8%)	37 (46.8%)	78 (50.0%)

There were statistically significant differences among specialties regarding confidence in the management of patients with gender dysphoria (P < .0001), history of sexual abuse (P < .0001), need for sexual therapy (P < .0001), paraphilic disorder (P = .0003), sexual dysfunction (P < .0001), and STI (P < .0001). OB-GYN respondents did not feel confident with patients who needed sexual therapy or had a paraphilic disorder, whereas urologists were less confident with patients disclosing a history of sexual abuse and gender dysphoria and psychiatrists were less secure with patients who had sexual dysfunction and STI. The detailed analysis is presented in Table 4.

Table 4

Comparison of confidence in the management of patients with different sexual health problems among specialties (P value)

	Psychiatry	Urology	OB-GYN	Endocrinology
Gender dysphoria
Psychiatry	—	.0001∗	.01∗	1.00
Urology	.0001∗	—	1.00	.01∗
OB-GYN	.01∗	1.00	—	.04∗
Endocrinology	1.00	.01∗	.04∗	—
History of sexual abuse
Psychiatry	—	.00002∗	.07	.02∗
Urology	.00002∗	—	.18	.43
OB-GYN	.07	.18	—	.99
Endocrinology	.02∗	.43	.99	—
Need for sexual therapy
Psychiatry	—	.00002∗	.00002∗	.0001∗
Urology	.00002∗	—	.07	1.00
OB-GYN	.00002∗	.07	—	.26
Endocrinology	.0001∗	1.00	.26	—
Paraphilic disorder
Psychiatry	—	.001∗	.004∗	.46
Urology	.001∗	—	.98	.64
OB-GYN	.004∗	.98	—	.48
Endocrinology	.46	.64	.48	—
Sexual dysfunction
Psychiatry	—	.00002∗	.26	.00002∗
Urology	.00002∗	—	.00002∗	.99
OB-GYN	.26	.00002∗	—	.00005∗
Endocrinology	.00002∗	.99	.00005∗	—
STI
Psychiatry	—	.01∗	.00005∗	.96
Urology	.01∗	—	.18	.27
OB-GYN	.00005∗	.18	—	.004∗
Endocrinology	.96	.27	.004∗	—

OB-GYN = obstetrics and gynecology; STI = sexually transmitted infection.

Statistically significant.

The level of confidence in managing patients with sexual health problems was influenced by a number of factors. In the univariate analysis, years of training had no significant influence. The confidence in managing patients who needed sexual therapy decreased with age (P = .0387); however, this was not confirmed by the multivariate analyses. The multivariate analyses uncovered the significant influence of older age in dealing with STI.

In the univariate analyses men felt more confident than women in dealing with patients with sexual dysfunctions (P = .0003), whereas there were no significant differences between men and women in dealing with other sexual health problems. The influence of sex was confirmed in the multivariate analysis.

Respondents who considered sexual health training to be very important or important during their specialty training felt significantly more confident in managing patients who needed sex therapy (P = .0244), had a paraphilic disorder (P = .0362), and had an STI (P = .0001; Table 5).

Table 5

Confidence of trainees in specific sexual health scenarios according to importance, acquisition, and availability of sexual health training (univariate analyses)

	Gender dysphoria		History of sexual abuse		Need for sexual therapy		Paraphilic disorder		Sexual dysfunction		STI
	Mean∗ (95% CI)	P value	Mean∗ (95% CI)	P value	Mean∗ (95% CI)	P value	Mean∗ (95% CI)	P value	Mean∗ (95% CI)	P value	Mean∗ (95% CI)	P value
Importance of sexual health training		NS		NS		.0244		.0362		NS		.0001
Very important	2.8 (2.6–3.0)		2.8 (2.6–3.0)		3.4 (3.2–3.6)		2.6 (2.4–2.8)		3.6 (3.4–3.8)		4.1 (3.9–4.2)
Important	2.8 (2.6–2.9)		2.8 (2.6–3.0)		3.2 (3.0–3.4)		2.5 (2.3–2.7)		3.3 (3.1–3.5)		3.6 (3.4–3.8)
Moderately important	2.6 (2.2.–2.9)		2.6 (2.3–2.9)		3.1 (2.7–3.4)		2.0 (1.8–2.3)		3.2 (2.8–3.5)		3.5 (3.2–3.8)
Little importance	2.2 (1.3–3.1)		2.6 (1.8–3.4)		2.3 (1.4–3.2)		2.0 (1.2–2.8)		3.0 (2.1–3.9)		3.2 (2.3–4.1)
Received any kind of training		.0108		NS		.0004		.0003		.0017		NS
Yes	3.0 (2.7–3.2)		2.9 (2.7–3.2)		3.5 (3.3–3.8)		2.8 (2.5–3.0)		3.7 (3.5–3.9)		3.9 (3.7–4.1)
No	2.6 (2.5–2.8)		2.7 (2.5–2.8)		3.1 (2.9–3.2)		2.3 (2.1–2.4)		3.2 (3.1–3.4)		3.7 (3.6–3.8)
Sexual health training available		NS		NS		NS		NS		NS		NS
Yes	2.9 (2.7–3.1)		3.0 (2.7–3.2)		3.4 (3.2–3–7)		2.5 (2.3–2.8)		3.4 (3.1–3.6)		3.8 (3.6–4.0)
No	2.6 (2.4–2.8)		2.7 (2.5–2.9)		3.1 (2.9–3.3)		2.4 (2.2–2.6)		3.5 (3.3–3.7)		3.7 (3.6–3.9)
I don't know	2.7 (2.4–3.0)		2.6 (2.3–2.8)		3.2 (2.9–3.5)		2.3 (2.1–2.6)		3.1 (2.8–3.4)		3.7 (3.5–3.9)
Sexual health in training curriculum		NS		NS		NS		NS		<.0001		NS
Yes, optional	2.9 (2.6–3.3)		2.9 (2.5–3.3)		3.6 (3.2–4.0)		2.7 (2.3–3.1)		3.9 (3.6–4.3)		4.0 (3.6–4.3)
Yes, mandatory	2.8 (2.5–3.1)		2.7 (2.3–3.0)		3.3 (3.0–3.6)		2.5 (2.2–2.8)		3.8 (3.5–4.0)		4.0 (3.7–4.2)
No	2.7 (2.5–2.9)		2.8 (2.6–3.0)		3.2 (3.0–3.4)		2.3 (2.2–2.5)		3.1 (2.9–3.3)		3.6 (3.5–3.8)
I don't know	2.5 (2.2–2.8)		2.6 (2.3–2.8)		3.0 (2.7–3.3)		2.4 (2.1–2.7)		3.4 (3.2–3.6)		3.8 (3.6–4.1)

NS = non-significant; STI = sexually transmitted infection.

Confidence of trainee: 1 = not at all confident; 2 = lacking in confidence; 3 = undecided; 4 = reasonably confident; 5 = totally confident.

Trainees and early-career specialists who had received sexual health training during their postgraduate training felt significantly more confident in dealing with patients with gender dysphoria (P = .0108), need for sexual therapy (P = .0004), paraphilic disorder (P = .0003), and sexual dysfunction (P = .0017; Table 5).

When sexual health was included in the training curriculum, trainees and early-career specialists felt more confident in dealing with patients with sexual health problems, especially patients with sexual dysfunction (P < .0001; Table 5). The type of training (theoretical and/or clinical) did not influence the level of confidence.

Discussion

This study showed that European trainees in OB-GYN, psychiatry, urology, and endocrinology lack training in sexual health during their postgraduate training programs, although they find it important for their future medical practice. Especially European OB-GYN trainees have no exposure to sexual health training, followed by trainees in psychiatry, urology, and endocrinology.

We found significant differences among the 4 specialties in trainees’ confidence in taking care of patients with sexual health problems. It is evident that the knowledge, extent, and content of training in sexual health differ among specialties. However, these findings present the lack in each specialty of specific subjects in sexual health training, raising awareness of the need for basic skills in sexual health to be taught in all 4 specialties. For example, dealing with an STI, taking a history of sexual abuse, and the capacity to refer for sexual therapy should be ordinary procedures for trainees in all 4 specialties. Nevertheless, our results indicate that trainee’s confidence in dealing with these sexual problems is often insufficient within these specialties. These findings concur with the results of a study in Portugal, in which sexual health was within the top 3 matters that psychiatric trainees requested more training in. Moreover, previous studies found that despite the willingness of patients to discuss sexual health with their care providers, health professionals often have difficulties in addressing sexual health needs for reasons such as shame and lack of sufficient training.13, 14 Sex is a fundamental quality-of-life matter, and therefore all physicians should inquire about sexual behaviors and responses as a routine part of caring for each patient.

Our findings showed that the confidence of trainees and early-career specialists in managing patients with sexual health problems is influenced by many aspects, such as age (especially in dealing with STI) and sex, which influenced the level of confidence in dealing with sexual dysfunction, in which men felt more confident than women, but not by years of training. It could be speculated that this was because urologists, who are mostly men, are more confident in dealing with sexual dysfunction. However, in the multivariate analysis, sex continued to significantly influence the confidence level after adjustment for specialty, age, and years of training. Our findings regarding sexual dysfunction correlates with the results of a German study about sexual health training in urology.

Not surprisingly, trainees who considered sexual health training an important part of their training felt more confident in dealing with patients with sexual health problems. This is probably because of their interest and motivation to acquire knowledge. Trainees and early-career specialists who received or had sexual health training as part of their curriculum felt more confident. This indicates that experience with sexual health care during training increases the confidence level of future specialists and their competency level, providing better health care for patients.

The literature about sexual health training in psychiatry, OB-GYN, urology, and endocrinology is limited, even if sexual health problems are seen daily in these specialties.

Karimian et al pointed out that sexuality training modules need to be based on evidence and systematically evaluated, culturally sensitive, and skillfully implemented to build good professional capacity. It also stands to reason that it is challenging to deliver culturally sensitive and appropriate sexuality-related health care in a context without training modules integrated in medical education programs. Importantly, studies have shown that patients with severe mental or physical illnesses are particularly dissatisfied with their sex lives.15, 17 These findings advocate for the need for sexual health training to be integrated in the postgraduate medical curricula. However, even in developed countries such as the United Kingdom, the budget for sexual health is small.

The Multidisciplinary Joint Committee of Sexual Medicine (MJCSM) is a committee of the European Union of Medical Specialists, with representatives from the boards of urology, OB-GYN, and psychiatry, and with expressions of interest from the boards of endocrinology and venereology. The primary purpose of the MJCSM is to develop the highest possible standards of training in sexual medicine in Europe. To achieve this objective, there are different functions that are being addressed by the committee, including development of a curriculum in sexual medicine; setting of educational standards for training institutions; accreditation of training institutions; identification of minimal requirements for training; and development of an assessment framework, including development of an examination.

The European Board and College of Obstetricians and Gynaecologists and the European Society of Endocrinology are in the process of developing new pan-European training curriculums. The OB-GYN curriculum, in which training in sexual health will be incorporated, is planned to be finalized in 2018.6, 19

The strength of this study is that it is the 1st to assess sexual health training across several specialties. However, this survey is limited by the unequal distribution of countries, specialties among participants, and sex. In addition, the study could have been affected by selection bias, because trainees with an interest in sexual health might have been more prone to answer the survey. Because only data about participants’ age and years of training in the specialty were collected, the amount of time spent on sexual health in the training curriculum or participation in congresses or extracurricular events on sexual health is missing, which can make the results biased. The responses about sexual health also might have been influenced by religion, culture, and ethical beliefs across countries.

Several medical conditions can contribute to sexual dysfunction, as can the treatments prescribed. This is mostly the case with antihypertensives, antidepressants, antipsychotics, and antiandrogens. Therefore, clinicians’ knowledge of the potential for drug-induced sexual problems and their negative effects on patients’ adherence to treatment should be increased, enabling them to adjust the treatments.

Conclusions

Trainees found sexual health training important for their future medical practice in psychiatry, OB-GYN, urology, and endocrinology. Nevertheless, they report that this training is rarely available. When sexual health was included in the postgraduate training program, trainees and early-career specialists felt more confident in managing patients with sexual health problems. Our results suggest that more focus should be directed toward including and improving sexual health training in the postgraduate training programs in these specialties, and national sexual medicine societies could be involved in this process.

Alexandra Kristufkova; Mariana Pinto Da Costa; Gesthimani Mintziori; Juan Luis Vásquez; Anna J.M. Aabakke; Mikkel Fode

Statement of authorship

Conception and Design

Mariana Pinto Da Costa

Acquisition of Data

Alexandra Kristufkova; Mariana Pinto Da Costa; Gesthimani Mintziori; Juan Luis Vásquez; Anna J.M. Aabakke; Mikkel Fode

Analysis and Interpretation of Data

Alexandra Kristufkova; Mariana Pinto Da Costa

Drafting the Article

Alexandra Kristufkova; Mariana Pinto Da Costa

Revising It for Intellectual Content

Alexandra Kristufkova; Mariana Pinto Da Costa; Gesthimani Mintziori; Juan Luis Vásquez; Anna J.M. Aabakke; Mikkel Fode

Final Approval of the Completed Article

Alexandra Kristufkova; Mariana Pinto Da Costa; Gesthimani Mintziori; Juan Luis Vásquez; Anna J.M. Aabakke; Mikkel Fode