Challenges in Taking Sexual History: A Qualitative Study of Indian Postgraduate Psychiatry Trainees.

CONTEXT: In India, psychiatrist is an important point of helpseeking for sexual complaints. A detailed sexual history can go a long way in understanding sexual difficulties. In this background, there is inadequate information on the difficulties that psychiatry postgraduate trainees experience while taking a sexual history as part of a routine mental health evaluation. AIMS: The aim was to study the difficulties experienced by postgraduate psychiatry trainees while taking sexual history as a part of routine mental health evaluation.
SETTING: This study was conducted in an Indian medical college general hospital psychiatry setting.
MATERIALS AND METHODS: This is a qualitative study using focus group discussions and in-depth interviews with postgraduate psychiatry trainees. STATISTICAL ANALYSIS: Content analysis was used to identify direct and latent themes.
RESULTS: Thematic saturation was achieved with 17 participants. Major themes of difficulties that emerged included trainee-related factors such as gender and sociocultural background of the trainee; patient-related factors such as age, gender, and sexual orientation; setting-related factors; and language-related difficulties.
CONCLUSIONS: Specific and regular training in taking a sexual history is essential in addressing the difficulties faced by postgraduate psychiatry trainees in India.

INTRODUCTION

Sexuality encompasses a variety of issues such as gender identity, sexual orientation, sexual abuse, and sexual disorders.[1] The World Health Organization defines sexual health as “the integration of the somatic, emotional, intellectual and social aspects of sexual beings in ways that are positively enriching and that enhances personality, communication and love.”[2] However, medical education about sexuality is universally inadequate.[3] This is of concern as problems related to unsafe sex are among the leading causes of death and disability in adolescents.[4] Issues pertaining to sexual orientation and trauma are associated with an increased risk for suicidal behaviors and other psychiatric conditions.[5678] In India, sexual practices are often labeled pathological or normal depending on the context, and sexual minorities have faced multiple hardships.[9101112] Despite contrary arguments from professional bodies, homosexuality is criminalized in India.[1213] Hence, in India, mental health professionals have multiple roles to play in relation to sexuality and associated issues.

Psychiatrist in India is a primary point of helpseeking for sexual complaints.[1415] Psychiatrists have to treat sexual problems such as erectile dysfunction, premature ejaculation, and vaginismus.[1617] Psychiatrists have to help individuals with distress related to sexual issues and misconceptions.[18] Psychiatrists have to address sexual issues arising from mental illnesses and their treatments.[1920] Psychiatrists are expected to assist in profiling sexual offenders, designing sexual education curriculums as part of medical education, and formulating policies and legislations related to sexuality.[1] In today's globalized world, where there is a large migration of general populations and health-care personnel, it is essential that all mental health professionals are culturally competent in matters pertaining to sexuality.[21]

The art of taking a sexual history is a necessary skill that can aid mental health professionals in understanding and relieving emotional distress in individuals.[22] Most health-care professionals, however, do not take detailed sexual histories from their patients unless there is a primary sexual complaint.[2324] Psychiatrists manage complex emotional and mental health problems and hence can serve as resource persons for sexual history training.[25] This reiterates the need to focus on training requirements for psychiatry postgraduate trainees with respect to sexuality and sexual history taking.[26] In this background, we report on the difficulties experienced by psychiatry postgraduate trainees in India while eliciting a sexual history as part of the routine mental health evaluation.

MATERIALS AND METHODS

The authors aimed to study the difficulties Indian postgraduate psychiatry trainees face in taking a sexual history while performing routine mental health evaluations. The authors employed a qualitative study design using the COREQ checklist and other standard recommendations.[2728] Refer to Appendix 1.

Settings

The study was conducted in a private medical college in South India. The study site has been running a nationally recognized postgraduate psychiatry training program of >10 years. The corresponding author performed interviews with all the participants at the study site except two interviews that were conducted through teleconferencing.

Methodology

The authors performed this study on a purposive sample of postgraduate psychiatry students. Postgraduate students from the study site as well as students from other institutions posted in the study site for training in consultation-liaison psychiatry were approached face to face. The authors selected participants who had completed at least a year of psychiatry residency, as this would have given students enough time to learn adequate interviewing skills and obtain experience in working with patients. The authors conducted the study through in-depth interviews or focus group discussions and recorded interviews on audio and transcribed them.

Ethical considerations

The authors were aware that all potential participants in this study were being simultaneously taught and supervised by this study authors and thus could find it difficult to refuse consent. Hence, written informed consent was obtained at two time periods. First, participants were recruited after making them aware of the purpose of the study and obtaining informed consent. Second, transcripts were returned once again to the participants for their feedback as well as approval for inclusion in the study. The study was approved by the Institutional Ethics committee of the institution in July 2014 (IEC Approval no: 105/2014). In addition, the authors ensured confidentiality in the data analysis and use of illustrative quotes by removing all identifiers and assigning an alphanumeric coding to each participant.

Interview guide

The authors used the following probes as the interview guide:

What are the details they elicit as part of the sexual history?

What are the difficulties they experience as part of eliciting sexual history?

What are the ways in which they resolve these difficulties?

After conducting a pilot in-depth interview, study recruitment was initiated. After completing 2–3 interviews, the authors would code and analyze the transcripts. The authors recruited individuals and coded and analyzed transcripts till data saturation was achieved. As part of this process, the authors conducted one focus group discussion (n = 6), one dyadic interview (n = 2), one triadic interview (n = 3), and eight single-participant interviews. The mean duration of all interviews pertaining to probes about sexual history was approximately 15 min. One participant was excluded as authors did not receive consent from that participant at the second level. Authors were not able to obtain text transcription from another audio recording. The authors achieved thematic saturation after completing analysis of transcripts of 17 participants and subsequently discontinued data collection.

Statistical analysis

The first author and the corresponding author jointly analyzed the data using framework of content analysis.[2829] No assumptions were made prior to the study. The authors resolved disagreements by reaching consensus. The authors coded in vivo and used expressed words and phrases in the transcript to identify significant units of meaning. The authors also inferred from the underlying meaning of the text and generated an overall impression.

To reduce the number of themes into categories, data were further analyzed by comparison and refinement. A set of main categories was established by grouping together all the subcategories with similar meanings. Illustrative quotations for the subcategories were chosen from the transcripts for themes.,[2829]

RESULTS

The ages of all participants were within the range of 25–35 years. There were ten male and seven female postgraduate psychiatry trainees. Ten of the participants were from the study site itself, six were from an Indian tertiary mental health institution, and one was from an Indian government medical institute with general hospital psychiatry unit. Thus, participants hailed from diverse training settings [Table 1]. The study was conducted over 18 months since the time of ethical approval.

Table 1

Distribution of participants' sex and years of training

Figure 1 and Table 2 show all major and minor themes with some illustrative statements.

Figure 1

Coding scheme of major and minor themes in difficulties in taking a sexual history

Table 2

Illustrative quotations associated with themes

The authors further reflected on these themes and have represented the relationship between them using a model [Figure 2]. As illustrated in Figure 2, it is hypothesized that a combination of gender, trainee, and language-related factors in the presence of crowded settings makes it difficult for psychiatry trainees to take a detailed sexual history.

Figure 2

Model showing the hypothesized interactions between various domains

DISCUSSION

These authors aimed to study the difficulties postgraduate psychiatry trainees experienced while taking a sexual history as part of a routine mental health evaluation. The findings are discussed below under the subheadings of the major themes [Figure 1].

Characteristics of participants (doctors)

In this study, postgraduate psychiatry trainees perceived differences between their own sociocultural backgrounds and that of their patients as barriers in taking a sexual history. Gender differences between the trainee and the patient were also experienced as prominent barriers. This finding gets support from other studies that indicate doctors report gender differences as a source of difficulty in taking sexual histories from patients.[3031]

In this study, male psychiatry trainees especially experienced difficulties in interviewing women with respect to sexual matters. Previous research has indicated that female therapists have perceived themselves to be more competent in providing help to sexual abuse victims.[24] This gender-based finding should be kept in mind while training psychiatry postgraduate trainees.

Characteristics of patients

Certain characteristics that acted as barriers included patient's age, gender, and sexual orientation. Participants of this study experienced a greater hesitation in taking a sexual history from the adolescents as well as the elderly. Several other studies have similarly reported that the age of the patients was a barrier while inquiring their sexual activities.[313233] It is to be noted that adolescent and elderly age groups are vulnerable populations. The National Family Health Survey 2015–2016 (NFHS) showed that in the age group of 15–19 years, 5% of the girls had a live birth and 3% were pregnant.[34] Nearly 38% of women and 7% of men in the age groups of 25–49 years had their first sexual intercourse before the age of 18 years.[34] The NFHS demonstrates that a significant proportion of adolescents in India are sexually active and it is important for psychiatrists to take an adequate sexual history from adolescent patients.[34]

In a study on the health-care needs of the elderly, the topic of sexual health came up only once.[35] This indicates that discussion on sexual needs in elderly in India is a taboo subject.[35] It is essential that psychiatrists become comfortable in discussing sexual health topics in these vulnerable populations as these populations tend to face increased medical problems associated with sexual practices while simultaneously having inadequate resources to discuss related issues.

This study also showed that women were reluctant to discuss sexual matters with trainees. This reluctance has also been noted by other authors.[36] In a qualitative analysis of data gathered from a study on women survivors of breast cancer, it was noted that several participants refused to answer questions pertaining to sexual functioning.[36] Sexual and reproductive health is an essential aspect of women's mental health, and an inability to elicit adequate sexual histories from women will impact their care.[37] Mental health professionals need to probe into this barrier systematically.

Postgraduate trainees in this study experienced difficulties in taking a sexual history from those individuals with alternate sexual orientations. This difficulty has also been reported by other authors who noted that medical students and residents experienced increased discomfort while interviewing lesbian, gay, bisexual, transgender, and questioning populations for sexual history.[38]

Characteristics of settings

Another major theme in this study was the lack of privacy and crowded outpatient settings. Adequate sexual history is obtained only when doctor–patient confidentiality is ensured. Despite the suboptimal logistic organization in health-care services in India, it is still essential to keep patient-friendly infrastructure as a priority so that patients as well as doctors derive confidence to discuss sexual matters.[39]

Language-related difficulties

A final major theme that the authors encountered during the analysis was language-related difficulties. The lack of understanding of what the patient is trying to tell the doctor can pose several difficulties in obtaining an adequate sexual history. In addition to knowing the language, it is essential to know the terms or “slang” that is commonly used to describe various sexual terms such as masturbation and premature ejaculation. This is an impediment in India where postgraduate trainees might hail from different parts of the country and hence might not be fluent in the local languages. Several other authors have proposed guidelines for managing these difficulties.[164041]

Finally, results from an anonymous web-based survey on psychiatry residents showed that psychiatry residents reported inadequate experience in multiple aspects of sexual health.[42] Psychiatry residents also reported that outpatient clinical work and didactic training were the best forms of training.[42] This study similarly demonstrates that psychiatry postgraduate trainees experience multiple difficulties while taking sexual history as part of a routine mental health evaluation.

Recommendations

The authors propose that psychiatry postgraduate trainees and other mental health and medical trainees should be imparted specific training in taking sexual history, taking into account barriers posed by their gender and sociocultural backgrounds.[4344] Training should also take into account the possibility that vulnerable groups of patients will initially hesitate in opening up about sexual matters. Adapting Western models of interviewing to Indian settings is challenging. Hence, training should include culturally appropriate demonstrations of establishing rapport with this population of patients.[16] This recommendation is endorsed by research which shows that adequate training increases confidence of doctors in taking a sexual history.[44] This training could be mandated as part of their curriculum and could use interactive workshops, role-plays, and video-assisted standardized interview training sessions as proposed by other studies.[44]

While India continues to remain significantly underresourced in terms of health-care infrastructure as compared to other parts of the world, it is still recommended that priority should also be given to designing patient interview rooms to ensure patient confidentiality.[39]

The authors of this study also propose that in multilingual settings, there should be a focus on local language training as part of medical education. The local language training should include colloquial terms for various sexual practices without offending sensitivities. This is a feasible proposal, due to availability of a large number of bilingual individuals who can serve as trainers in a country like India.

Overall, the authors of this study recommend that there should be an active emphasis on training in sexuality and sexual issues as a part of medical and mental health education using various innovative as well as conventional strategies.[44]

Strengths and limitations

This study has a robust qualitative design and obtained information on matters pertaining to sexual education as part of postgraduate psychiatry training in India. A limitation of this study is that, as the authors knew the participants prior to the interviews, it is possible that the participants did not reveal certain aspects with respect to their difficulties in taking a sexual history. Furthermore, this study focused only on certain limited aspects of sexuality, and discussions on other topics such as gender identity and sexual practices did not arise during the participant interviews.

CONCLUSIONS

The difficulties associated with taking a sexual history as part of routine mental health evaluation for postgraduate psychiatry trainees include trainee and patient factors in addition to setting- and language-related barriers. Specific and regular training at all levels of medical education could go a long way in improving the quality of conversations about sexual matters between psychiatrists in training and patients.

Author information

All the authors are practicing psychiatrists, employed as faculty in the study site and have completed their postgraduation in psychiatry with a combined experience of >20 years in training psychiatry postgraduates. The first and corresponding authors jointly did all aspects of the analysis and reporting. All the authors contributed to the writing of the manuscript and its critique.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.