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Are medical students interested in sexual health education? A nationwide survey

Abstract

The majority of medical students and medical healthcare providers do not feel comfortable when addressing sexual problems. It was suggested that more courses in sexual health are needed at medical schools to overcome this shortcoming. To assess medical students’ interest in and attitude about sexual health education at medical schools in Germany, a 13-item online questionnaire was developed. The link to the questionnaire was distributed at all medical schools in Germany. In total, 3264 medical students (69.9% female) from all 37 medical schools in Germany participated. Students from all universities indicated that contents related to sexual health are taught at their university. The majority (n=1809; 62.1%) answered that courses in sexual health should be mandatory. The types of educational experiences that were viewed as most appropriate were lectures (n=2281, 78.3%) and seminars without patient contact (n=1414, 48.5%). Students were most interested in child sexual abuse and sexually transmitted infections. It should be ensured that all medical students have acquired basic knowledge in diagnosing and treating frequent sexual problems at the end of their medical studies. Suggestions are made about how to improve current efforts of sexual health education at medical schools.

Introduction

Physical and mental health as well as overall well-being are closely related to sexual health and sexual satisfaction underlining the importance of sexuality for the medical profession.1, 2 Mainly due to lacking knowledge and inadequate training, many students and medical healthcare providers feel uncomfortable when addressing and discussing sexual problems with their patients.3, 4, 5 Moreover, patients prefer healthcare providers with sufficient knowledge and comfort regarding sexual concerns.5 Thus, it was suggested that more elaborated and interdisciplinary sexual health courses are needed at medical schools, so that medical students, and in the sequel medical healthcare providers become more secure.6 Ideally, such courses should be run throughout the whole study progress, focusing on sexual well-being and sexual diversity, as well as on sexuality related problems.6, 7, 8 Solursh et al.9 found that, although >90% of US and Canadian medical schools provided at least some form of education in sexual health, only 40% offered a specific sexual health program, whereas the vast majority offered lectures only. Similarly, a study conducted in the UK during the 1990s revealed that 22 of the 23 participating medical schools (82% of all medical schools in the UK) covered at least some aspects of human sexuality, however, only 12 universities had a specific sexual health course, and only five invested >10 h throughout the whole study course.10 To our best knowledge, comparable data for Germany are missing so far. All the more, these numbers are surprising because previous research found that students’ self-perceived ability to assess and treat sexual problems increased after attending a structured sexual health course consisting of lectures, seminars and role plays underscoring the usefulness of such specific programs.11 Although the official national learning objectives for medical students in Germany include a variety of topics related to human sexuality and sexual health (for example, sexual dysfunctions, psychosexual development and menstrual cycle, for a complete overview of the topics, please refer to ref. 12), no further specifications are made on who and how these topics should be taught. Thus, it can be hypothesized that there exists great variability concerning sexual health education at medical schools in Germany. Furthermore, just recently educators have recognized the importance of co-created courses incorporating students into the development process.13, 14, 15 Co-creation implies a mutual process that equally considers the ideas from educators and students by mobilizing and using their individual resources and know-how.13 Thereby, a greater involvement of students led to more satisfaction, greater success, more motivation to persist in the course and a higher personal identification with the contents of the course.16, 17 Nevertheless, concerning education in human sexuality at medical schools the students’ voice has mostly been neglected so far.

The present study aims at filling this gap by identifying medical students’ general interest in sexual health education, their attitude about the importance of sexual health for their later careers as medical healthcare providers, their interest in different sexuality related topics and their preferred types of educational experiences in a sexual health course.

Methods

Participants

Sociodemographic information were available of 3264 participants (see Table 1). Of those initially included in the study, 2928 (89.7%) completed the whole questionnaire. Participants came from all 37 medical schools in Germany. Most participants were studying in Berlin (n=517), Hamburg (n=490) and Dresden (n=206), whereas the smallest groups of participants came from Muenster (n=35), Greifswald (n=35) and Frankfurt am Main (n=29).

Table 1 Sociodemographic information of study participants (n=3264)

Data acquisition

For the purpose of the present study, an online questionnaire was developed. Access to the questionnaire was provided via the online platform unipark—QuestBack (www.questback.com), a company that is specialized on conducting online surveys. All data were saved on QuestBack servers that meet all national requirements concerning data protection according to the German Federal Office for Information Security (for further information, see http://www.questback.com/de/datenschutz-datensicherheit). At the single universities, the link to the questionnaire was distributed by local student representatives, who in turn were recruited by a representative of the German Medical Students’ Association (Bundesvertretung der Medizinstudierenden in Deutschland). The questionnaire was accessible via computers and other smart devices (cell phones, tablets) from the beginning of October 2014 to the end of March 2015.

Questionnaire

Intending to keep the dropout rate as low as possible and to recruit as many participants as possible, it was decided that answering the questionnaire should not exceed 3 min. Three of the authors (DT, TON and LH) created a first version of the questionnaire that was reviewed and commented by the remaining authors. All authors have prior experience in sexual health education either as lecturers or as medical students. In the next step, the online questionnaire was assessed by five medical doctors of different specialties (all were professors of medicine: gynecology, urology, anatomy, dermatology and legal medicine) and was revised according to their suggestions. The final version of the questionnaire consisted of 13 items.

At the beginning of the questionnaire, participants were informed that all answers are completely anonymous, and that the study can be stopped at any time by closing the internet browser. Furthermore, the students were asked to provide their consent that their data could be used anonymously for analysis and publication by checking a box on the first page.

Age, gender, location of university, number of semesters, preclinical or clinical point of study, citizenship, migration background and religious affiliation were assessed as demographic background variables.

At first, students had to indicate their general interest in sexual health courses within their medical studies on a scale reaching from 0 to 10, where a rating of 10 was considered as a very strong interest. Thereafter, the participants were asked if there were any courses about sexual health at their medical school, followed by six questions assessing students’ opinion about the importance of different aspects of sexual health for their future profession as medical healthcare providers (for example, 'When working as a medical doctor I will need knowledge concerning the treatment of frequent sexual problems; for example erectile dysfunctions, chronic pelvic pain disorders, sexually transmitted diseases, gender incongruence'). In the last part, participants were asked to indicate the types of learning experiences (for example, lectures, seminars with or without patients) they would prefer most in a sexual health course, and to select from a list of contents related to sexual health, those five topics they were most interested in.

Statistical analysis

All statistical analyses were conducted using IBM SPSS Statistics for Macintosh, Version 22.0 (Armonk, NY, USA). In a first step, all questions were analyzed descriptively displaying frequency distributions. Evaluating the influence of sociodemographic characteristics on the general interest in sexual health education, and on the opinion about the importance of sexual health for the students’ later career as medical healthcare providers, stepwise linear logistic regression analyses were calculated. Age, gender, semester, migration background and citizenship were used as independent variables. Point biserial correlation was determined for semester and the opinion if sexual health is taught.

Results

Concerning their general interest in sexual health education, students had a mean rating of 6.59 (s.d.=2.32; median=7; range=0–10), and 478 (15.3%) had a rating below five. The stepwise linear logistic regression analysis (R2=0.06, F=15.32, P<0.001) revealed that not being a German citizen (β=0.62, confidence interval (CI) 95% 0.28–0.95, P<0.001) and being in a higher semester (β=0.05, CI 95% 0.03–0.07, P<0.001) was significantly associated with a higher general interest in sexual health courses.

In total, 41.7% (n=1301) of the students confirmed that contents related to sexual health are taught at their medical school, 21.9% (n=684) indicated that such contents are not taught and the remaining 36.4% (n=1136) answered that they did not know. There were students at every university who indicated that contents related to sexual health are taught at their location (range=28.8–54.1% per medical school). Likewise, there were students at every institution who indicated that there is no sexual health education (range=11.1–39.6% per medical school). No association was found between semester and the opinion if there are sexual health courses or not (r=−0.004, P=0.826).

The majority of medical students were of the opinion that different issues of sexual health will be an important part in their future profession as medical healthcare providers (see Table 2). To determine the influence of the sociodemographic characteristics, we calculated an index by aggregating the six questions concerned with the students’ opinion about the importance of sexual health for their later careers. In the stepwise linear logistic regression (R2=0.09, F=22.69, P<0.001), it was found that being male (β=−0.15, CI 95% −0.20 to −0.10, P<0.001), being younger (β=−0.01, CI 95% −0.02 to −0.01, P<0.05) and not being a German citizen (β=0.11, CI 95% 0.01–0.20, P<0.01) was associated with the attitude of a higher importance of sexual health for the students' later career as medical healthcare providers.

Table 2 Students’ attitude about the importance of sexual medicine for their future profession as healthcare providers

Furthermore, the majority of participants (n=1809, 62.1%) answered that courses in sexual health should be mandatory, whereas 43.1% (n=1271) were of the opinion that sexual health education should be offered in voluntary classes (multiple answers possible). Only 25 students (0.9%) answered that issues related to sexual health should not be taught at all. Comparably, 73.6% (n=2168) were of the opinion that medically relevant aspects of sexuality and sexual problems should be taught within an own subject called sexual medicine.

The types of educational experiences that were viewed as most appropriate for sexual health education in medical schools were the following ones (multiple answers possible): lectures (n=2281, 78.3%), seminars without patient contact (n=1414, 48.5%), seminars with patient contact (n=1384, 47.5%), seminars with patient actors (n=1384, 47.5%), small-group work (n=1037, 35.6%), movies (n=692, 23.7%), clinical internships (n=652, 22.4%) and e-learning platforms (n=473, 16.2%). The contents students were most interested in are summarized in Table 3. Hereby, students expressed the greatest interest in child sexual abuse, sexually transmitted diseases and (side-) effects of pharmaceuticals on sexuality.

Table 3 Medical students’ interest in different topics related to sexual medicine (n=2894)

Discussion

At every German medical school, some students were of the opinion that contents related to sexual health are taught during the course of their medical studies. However, there were also a considerable number of students at each university with a different opinion. Noticeably, no association was found between number of semesters, and the answer to this question, ruling out the possibility that only students in lower semesters indicated that there are no sexual health courses at their university, because they simply did not attend the relevant lessons yet. Thus, it seems as if not all students receive sexual health education pointing to the great variability between the medical schools. Comparably, although contents related to sexual health are taught at most US medical schools, usually <10 h throughout the whole study process are invested, and many courses are voluntary and unstructured.9, 18 However, in light of the importance of sexual health for people’s overall well-being and quality of life, and the importance of sexuality in the communication between healthcare providers and patients, it can be requested that every medical student should have knowledge of at least the basic concepts of sexual health at the end of his or her medical studies.1, 5, 7, 19 This applies all the more as most students expressed a general interest in sexual health and most students were of the opinion that courses in sexual health should be mandatory. Moreover, acknowledging the importance of sexual health for their later profession as medical healthcare providers, and confirming previous research findings, the great majority of the participants stated that they will need knowledge and skills in the diagnostics and treatment of frequent sexual problems, in sexual history taking and in the initial support of victims of child sexual abuse or sexual violence.3, 20 Interestingly, males and younger students showed a greater awareness of the importance of sexual health. Taking these findings into account, it can be requested that all medical schools should provide at least some mandatory lectures specifically concerned with sexual health, explaining its significance and interdisciplinary character, and giving a basic overview about the topics students seem to be most interested in (child sexual abuse, sexually transmitted diseases, (side-) effects of pharmaceuticals on sexuality, fertility problems and artificial insemination). This would also meet the students’ wishes, because similar to previous research, most students preferred lectures for sexual health education.11 Clinicians from different medical disciplines could present relevant disorders in more detail and could refer to the impact these disorders have on their patients’ sexual health more clearly. However, in contrast to previous findings, the results of the present study showed that many students would even prefer an own subject specifically concerned with sexual medicine or sexual health.12, 21 Thus, medical schools that have the financial, structural and teaching capacities should think about providing elective, but more comprehensive courses for interested students. According to the results of the present study, such a comprehensive sexual health curriculum should incorporate lectures, seminars with and without real or actor patients, and small-group work. In consideration of the suggestions made by Shindel and Parish,22 more theoretical topics, for example, effects of sexually transmitted infections on the sexual experience and sexual functioning of patients, (side-) effects of pharmaceuticals on sexual functioning (for example, β-blockers and antidepressants), the etiology of sexual disorders (for example, ED and pain during sexual intercourse) and physiological reactions during sexual intercourse, could be taught in lectures. More sensitive and controversial topics, for example, child sexual abuse and sexual violence against adults, causes and treatment of fertility problems, ethical controversies of induced abortion or gender incongruence in childhood could be dealt within seminars without patients. In such a context, students would have the possibility to consider all facets of these complex issues in more detail. According to Hawton,23 before students become at ease in addressing issues related to sexuality with patients, they should become comfortable in discussing these topics with each other first, and thus seminars without patients would provide an appropriate space for practicing these skills.10, 23 Topics like addressing sexual problems in older-aged patients, and addressing and treating sexual problems in patients with physical disabilities, could be taught in small groups of students talking to a real patient who shares his medical history. This would increase the understanding of the students by giving them a personal insight into the particularities of sexual behavior and sexual problems of different minorities or otherwise special patient groups.22

Limitations and future research

It can be assumed that primarily students with a per sé higher interest in sexual health participated in the present study. Hence, the actual interest of the whole student population could be overestimated. The list of sexually related contents included in the present study is certainly not exhaustive, and thus some topics students would have viewed as relevant for sexual health education as well, might have been missed. Furthermore, it has to be pointed out that the present survey included medical students from Germany only, thereby limiting generalizability of our findings, however, it is conceivable that medical students from other countries would have comparable attitudes towards education in sexual health. Nevertheless, future studies should evaluate students’ attitude and wishes concerning sexual health education in different countries of the world and compare them with the official status quo, for example, by interviewing the Deans of every university or the person who is responsible for curriculum development. As comparable studies were already performed, for example, in the US, Brazil, Canada and the UK, this would offer the possibility to compare the current state of sexual health education between different countries and cultural backgrounds.9, 10, 24 Thereby, strengths and weaknesses of different educational systems could be uncovered and lessons could be learned from each other.

Conclusion

It can be concluded that medical students seem to recognize that there is a need for more sexual health education at medical schools. Furthermore, based on the principles of a co-created curriculum, the students’ wishes and preferences should be considered when developing new courses. By continuously publishing research about different steps in the implementation of new curricula, other researchers and educators can profit from prior experiences and can further improve currently existing efforts.

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Acknowledgements

We want to thank the Federal Representation of Medical Students in Germany for their support in data collection. We also want to thank the Dean’s office of the University Medical Center Hamburg-Eppendorf for supporting the present study with a grant.

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Correspondence to D Turner.

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Turner, D., Nieder, T., Dekker, A. et al. Are medical students interested in sexual health education? A nationwide survey. Int J Impot Res 28, 172–175 (2016). https://doi.org/10.1038/ijir.2016.25

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