The researcher Harold Lief compiled an exhaustive dataset on the sexual behaviors, attitudes, and beliefs of U.S. medical students in the 1960s and 1970s.6
While these data are of value for historical context, the dramatic social and educational changes of the past 40 years make the contemporary applicability of these data unclear. The sexual practices of the medical student participants of this current study appear to be relatively similar to other observations of age-matched peers from the general population; slight variations exist, but may be attributable to methodological differences.22–24
The implication of this study is that medical students are, for the most part, similar to their age-matched controls. However, the percentage of respondents who had engaged in some same-gender sexual activity (about 17%) was higher in our population than that reported in the recent CDC report of sexual behaviors in contemporary Americans between the ages of 25 and 44 (which reported that about 6.5% of men and 11% of women engaged in some same-gender sexual activity.)24
This difference may be attributable to the fact that the percentage of male respondents in our study who endorsed a homosexual orientation (13.2%) was higher than that reported in the CDC report, in which just 2.3% of men endorsed homosexual orientation and an additional 5.7% reported “nonheterosexuality.”24
The National Health and Social Life (NHSL) study from 1992 estimated the prevalence of ED and early ejaculation in 18- to 29-year-old American men at 7% and 30%, respectively.2
While no single item in that study specifically assessed FSD, difficulties in various specific spheres of sexual life were reported by 16% to 32% of women in this age cohort; problems pertaining to sexual interest, orgasm, and sexual pleasure were most prevalent.2
Data from this age cohort 18–29 are more immediately relevant to our study than the overall rates of sexual problems for the entire population (ages 18 to 59) included in the NHSL. The NHSL data estimates of sexual dysfunction prevalence were based on a single-item question, and thus are not directly comparable to our data. Nevertheless, our data suggest that ED and FSD are more prevalent among medical students than among age-matched controls.
A survey of curriculum directors at U.S. and Canadian medical schools revealed that the majority (54.1%) of the 101 responding schools provided between 3 and 10 hours of sexual medicine training, while a third (32.7%) provided over 11 hours of sexual medicine training.24
Most (81%) of the responding schools listed human sexuality as a lecture requirement, although less than half (42.5%) of the reporting schools offered a clinical program specific to the treatment of patients with sexual problems and/or dysfunction; one-third of the schools with such a program did not report providing supervised clerkship experiences.25
Prior studies have suggested that up to 62% of medical students do not feel that they have been adequately trained to address and treat clinical sexual concerns.26
Given data such as these, we are not surprised that over half of the participants in our survey perceived their training in human sexuality as inadequate.
Other investigators have previously reported the prevalence of medical student discomfort regarding addressing sexuality in the clinical context. Frank and colleagues reported that up to 43% of medical students surveyed did not feel comfortable discussing safer sex with patients.27
Malhotra and colleagues reported a lower prevalence of student discomfort than did Frank and colleagues; however, they noted that students tend to be less comfortable discussing sex with patients at the extremes of age.28
An important study by Merrill and colleagues suggested that even senior students often have difficulty inquiring about sexual health in their patients, and that low self-esteem, shyness, and anxiety were associated with difficulty in addressing sex in the clinical context.29
The potential impact of the inability to discuss sexuality in a frank and honest manner with patients is considerable; a study of HIV counseling practices among clinically experienced medical students indicated that the majority of students failed to ask important questions about patients’ sexual behaviors in a standardized patient teaching session.30
While these important studies illuminate some of the challenges that students face when taking a sexual history, to our knowledge no other study has examined personal sexual practices and functioning as associations of comfort in dealing with patient sexuality.
The percentage of participants in this study who reported feeling comfortable discussing patient sexuality was higher than that reported in prior studies.26,27
One conjecture is that students who were willing to participate in our study were more likely to be comfortable addressing sexuality issues relative to medical students who declined to participate. In addition, the relatively simple method of assessing comfort dealing with sexuality in our study (i.e., a single yes/no item) may also have affected our results, leading to a relatively high estimate of medical student comfort in dealing with sexuality in the clinical context.
In our study, individuals who have not engaged in sexual intercourse were at greater risk of feeling uncomfortable dealing with issues of sexuality in patients. A number of other personal factors assessed in our study (e.g., a lower number of sexual partners, lower sexual frequency, sexual dysfunctions) were also associated with discomfort dealing with sexuality in the clinical context. These findings support a prior report showing that an individual student’s sexual mores and experiences influence his or her perception of sexuality in general.31
Interestingly, students of Asian descent tended to be less likely to report feeling comfortable dealing with sexuality in the clinical context. We cannot determine the reasons for this finding from this data set; however, some have reported that people of Asian descent in the United States and Australia tend to have more conservative views towards sexuality than do Caucasian individuals; our finding may be reflective of this tendency.32,33
Interestingly, year in training was not a strong association of feeling comfortable dealing with sexuality. However, first-year students were more likely to report that they had not received adequate training to address sexual concerns in patients, and multivariate analysis showed that women in the fourth year of training were significantly more likely to be comfortable addressing sexual concerns than were both men and women in the first-year of training; these two observations (i.e., first-year students’ perception of inadequate training and fourth-year women students’ greater comfort) are logical, and they each add credibility to our dataset. Perception of adequacy in training was positively associated with feeling comfortable with sexuality in the clinical context, so we can infer that year in training may play an indirect role in feeling comfortable addressing patient sexuality. However, social, cultural, and personal factors, as well as the overall quality of training, clearly have a stronger influence on an individual student’s comfort in dealing with sexuality in patients than does his or her specific year in training.
Importantly, the most powerful association of lack of comfort in dealing with patients’ sexuality was a perception of inadequate human sexuality training in medical school. Other investigators have demonstrated that curricular innovations in sexuality training can enhance student comfort with sexuality in the clinical context34
and that medical school curricula may have a significant impact on students’ comfort with clinical sexuality issues.35–37
Our data speak to the need for the development of a medical school sexual health curriculum that not only is sensitive to and respectful of the mores and sexual situations of all students but that also simultaneously provides students with the necessary skills to address sexuality in a broad clinical context, perhaps even outside their comfort zone. The specific means by which to institute this enhanced education in sexuality are beyond the scope of this report, but they should be a topic of discussion among medical school curriculum directors.
Our findings are of interest and may be indicative of general trends among medical students but further confirmatory studies are required before these results can be definitively generalized to all U.S. and Canadian medical students.
Participants who are willing to complete an anonymous, Internet-based survey on sexuality and sexual practices may not be representative of the U.S. and Canadian medical student population as a whole. We speculate that the students willing to take such a survey may be generally more sexually comfortable and experienced than those who declined. Greater comfort with sexuality and more sexual experience among responders compared to nonresponders is a common problem in sexuality research, and this phenomenon would bias our results towards overestimating the sexual experiences and comfort of medical students. This survey did not include means by which to objectively assess the quality of students’ education in human sexuality nor their actual facility at addressing sexual issues in the real-world clinical context; some participants in this study may have underestimated their training and overestimated their abilities (or vice versa).
Finally, analysis of quantitative data from instruments designed to assess sexual function cannot be construed as a genuine means of accurately diagnosing clinically significant sexual problems, particularly since none of the instruments we utilized include the means to assess personal distress regarding the situation. We attempted to account for this limitation by asking a single-item question designed to ascertain participants’ personal feelings about their current state of sexual functioning and whether or not they desired change. The clinical relevance of sexual problems for the individual student is not the focus of this report, but we will further explore this in subsequent analyses from this dataset.
While we cannot glean the actual presence of clinically meaningful sexual dysfunction in this population from these data, our instruments are useful as a means to quantify perturbations of normal sexual function, and subsequent analyses based on these data do have merit in our opinion. Whether these instruments, initially designed and validated for use in heterosexual populations, are accurate and valid for use in nonheterosexual populations is another important consideration. The FSFI has been validated in lesbians,19
and a modified IIEF has very recently been validated in HIV positive men who have sex with men,20
but we did not employ the same modifications used in the validated studies. Whether our specific instrument accurately assessed sexual function in nonheterosexual participants is unknown and this uncertainty remains an important limitation of our data collection.
Despite its limitations, this rich dataset represents a comprehensive and thorough assessment of sexuality and sexual function in contemporary medical students. Future analyses and studies of this population will likely shed more light on the ways in which human sexuality education in medical school can be advanced. An area of particular interest is the critical assessment of curricular innovations and/or interventions to determine which are of greatest utility for enhancing medical student comfort in addressing the complete spectrum of sexual health of patients. The development of curricula that are inclusive and that address the needs of a student body whose sexual practices and experiences are diverse is of critical importance for the advancement of sexuality education in medical school.