Welcome back! As a quick recap, in Pt. I of this series, we chatted about the (recent) history of physicians dismissing patients’ pain—in particular pelvic pain, period problems, and sexy time challenges. This time we’re going to talk about part of the reason why that’s happening. What does the research say is happening in doctor’s offices and what’s their training like? Let’s get into it.

Doctors Aren’t Talking About Sex

A 2006 study reported that 59.3% of family practice doctors asked about sexual activity during routine exams (1). A 2012 study found that, of over 1,000 OBGYNs, 63% routinely asked about sexual activity, and only 40% reported routinely asking about sexual problems or dysfunction (2). A 2010 study among 3rd and 4th year OBGYN residents found that only 19.6% always or often screened patients for sexual functioning challenges, likely because on average they received 5 or fewer lessons (or didactic activities) on female sexual function and dysfunction (3). The vast majority indicated that more learning activities in this area would greatly increase their understanding and confidence. To recap: a little over half of primary care physicians are routinely asking about sex in any capacity, and only ⅕ of new OBGYNs are routinely screening for sexual dysfunction. 

63% of OBGYNs routinely ask about sexual activity, and only 40% routinely ask about sexual problems or dysfunction

As for chronic pelvic pain, well… unfortunately, it still isn’t well-understood—which is part of the problem for doctors; coming up with a diagnosis can be challenging because there are a lot of possible sources, and scientists are still trying to figure out how chronic pelvic pain develops in the first place (4). However, what we do know about diagnosing and treating chronic pelvic pain isn’t always taught. A small 2014 study found OBGYN residents in Colorado reported feeling overwhelmed with chronic pelvic pain patients, indicating they didn’t feel they had enough time to spend with these patients and they wished they had more training (5).

OBGYN residents in Colorado receive, on average, 5 or fewer lessons on female sexual function and dysfunction

We’d hope this would be a thing of the past—that at least future doctors would be receiving better pelvic + sexual health education and training, especially since practicing doctors have expressed that they want more training in order to feel confident diagnosing and treating sexual health concerns. Unfortunately, that’s not the case.

Docs-To-Be Aren’t Always Trained in Sexual Health

Several studies indicate that sexual health education in North American medical schools is limited—only half of U.S. medical schools require formal instruction in sexuality (6). Schools that do provide formal sexual health education primarily cover birth control and STIs with little emphasis on what healthy sexuality looks like (7,8) and relatively little time dedicated to the health of LGBTQ+ populations (9). As a result, while 68.8% of medical students in a 2009 study reported that being able to understand and treat sexual concerns would be important for their future careers, only 37.6% felt they had enough training to do so (10). So, unsurprisingly, when 1,014 medical students in the United States were asked to take a brief sexual health survey, the average score was 66% (6). Of note, only 71.8% of medical students in this study could identify the clitoris, and 24.5% believed doctors can determine if someone has had vaginal intercourse by examining the hymen. Cool cool coooool. 

Only half of U.S. medical schools require formal instruction in sexuality

But all is not lost, dear friends! Some medical schools are recognizing these gaps in education and are seeking to address them—the Morehouse School of Medicine, University of Virginia, Case Western Reserve, and the University of Minnesota for instance have instituted more comprehensive sexual health curricula (11). Plus! Continuing education on sexual and pelvic health is available to existing physicians through organizations like the International Society for the Study of Women’s Sexual Health and the International Pelvic Pain Society. And let’s not forget… we’re talking about it; there are studies now that examine whether doctors are prepared to talk about sexual health, and why so many aren’t so prepared. That in and of itself is progress.

Only 37.6% medical students feel they have the training to understand and treat sexual concerns

When physicians and other healthcare practitioners are not adequately trained to talk about, diagnose, and treat sexual and pelvic pain, patients are left feeling dismissed, distrustful—and still in pain. It’s critical that physicians, particularly in fields where pelvic pain and sexual concerns are likely to be discussed (primary care, OB/GYN, urology, oncology, GI), are well-informed and well-prepared. 

References:

1. Wimberly, Y. H., Hogben, M., Moore-Ruffin, J., Moore, S. E., Fry-Johnson, Y. 2006. Sexual history-taking among primary care physicians. Journal of the National Medical Association 98 (12):1924-1929. PMID: 17225835; PMCID: PMC2569695.
2. Sobecki, J. N., Curlin, F. A., Rasinski, K. A., Lindau, S. T. 2012. What we don’t talk about when we don’t talk about sex: Results of a national survey of United States obstetrician/gynecologists. The Journal of Sexual Medicine 9 (5):1285-1294. doi: 10.1111/j.1743-6109.2012.02702.x
3. Pancholy, A. B., Goldenhar, L., Fellner, A. N., Crisp, C., Kleeman, S., Pauls, R. 2010. Resident Education and Training in Female Sexuality: Results of a National Survey. The Journal of Sexual Medicine 8 (2):361-366. doi: 10.1111/j.1743-6109.2010.02117.x
4. Kaya, S., Hermans, L., Willems, T., Roussel, N., Meeus, M. 2013. Central Sensitization In Urogynecological Chronic Pelvic Pain: A Systematic Literature Review. Pain Physician Journal 16:291-308.  
5. Witzeman, K., Kopfman, J. E. 2014. Obstetrics-Gynecology Resident Attitudes and Perceptions About Chronic Pelvic Pain: A Targeted Needs Assessment to Aid Curriculum Development. Journal of Graduate Medical Education 6 (1):39-43. doi: 10.4300/JGME-D-13-00053.1
6. Warner, C. W., Carlson, S., Crichlow, R., Ross, M. W. 2018. Sexual Health Knowledge of U.S. Medical Students: A National Survey. The Journal of Sexual Medicine 15 (8):1093-1102. doi: 10.1016/j.jsxm.2018.05.019
7. Shindel, A. W., Parish, S. J. 2013. CME Information: Sexuality Education in North American Medical Schools: Current Status and Future Directions (CME). The Journal of Sexual Medicine Highlights 10 (1):3-18. doi: 10.1111/j.1743-6109.2012.02987.x
8. Galletly, C., Lechuga, J., Layde, J. B., Pinkerton, S. 2010. Sexual Health Curricula in U.S. Medical Schools: Current Educational Objectives. Academic Psychiatry 34 (5):333-338. doi: 10.1176/appi.ap.34.5.333
9. Obedin-Maliver, J., Goldsmith, E. S., Stewart, L., White, W., Tran, E., Brenman, S., Wells, M., Fetterman, D. M., Garcia, G., Lunn, M. R. 2011. Lesbian, Gay, Bisexual, and Transgender-Related Content in Undergraduate Medical Education. The Journal of the American Medical Association 306 (9):971-977. doi:10.1001/jama.2011.1255
10. Wittenberg, A., Gerber, J. 2009. Recommendations for improving sexual health curricula in medical schools: results from a two-arm study collecting data from patients and medical students. The Journal of Sexual Medicine 6 (2):362-368. doi: 10.1111/j.1743-6109.2008.01046.x
11. Coleman, E. 2014. Sexual Health Education in Medical School: A Comprehensive Curriculum. American Medical Association Journal of Ethics 16 (11):903-908. doi: 10.1001/virtualmentor.2014.16.11.medu1-1411