Righting the wrongs: the need to increase sexual health education in medicine to achieve ethical medical practice

We, the medical community, have a problem. We are not consistently addressing, supporting, and treating the sexual health of our patients. Not doing so presents a risk for increased morbidity in the general population and could be deemed a clear violation of biomedical ethics, as I have discussed previously.¹

The cause of this issue is a lack of sexual health education (SHE) within medical training. The solution is increased SHE in training programs. Increased SHE would ensure that physicians are prepared to address sexual health, prevent morbidity, and practice ethically.¹

Discussion

Addressing sexual health within medicine is necessary. Sexuality is “a central aspect of being human throughout life.”² Sexual function and well-being are linked with all health: physical, psychological, relational, communal, cultural, and economic. Ensuring that sexual health enhances general well-being, as sexual well-being is associated with increased mental health, goal accomplishment, and quality of and total satisfaction with life.¹ Sexual health is predictive of and comorbid with numerous chronic diseases. Research supports the impact of sexual dysfunction (SD) as significant enough to consider SD a systemic disease with several general health comorbidities.³ As physicians, we must be aware of these health connections and ensure that our patients’ physical, mental, and sexual health do not negatively impact each other.

Beyond individual consequences, the full impact of poor sexual health crosses generations and affects communities and the nation. Addressing and supporting sexual health can improve the sexual and general health of our patients and the greater population.¹

Also, we must consistently address sexual health because we provide medications and treatments that cause sexual morbidity. Because sexual function is dependent on so many bodily systems, many medications have potential to directly or indirectly create SD. All treatments that affect erogenous zones, any part used in sex, or sexual self-image can negatively impact sexual function. Additionally, we have evidence that patients want physicians to have and initiate sexual health conversations, but unfortunately, physicians are not addressing or supporting sexual health.⁴

Sexual health requires access to comprehensive, scientifically accurate information and sexual healthcare, and an environment that affirms and promotes sexual health.² Yet, physicians receive varying amounts of sexual health education before medical training, and sexuality is a highly stigmatized topic. Sexual stigma is created by social and cultural norms and perpetuated by the lack of quality education. Stigma feeds bias and directly contributes to poor health outcomes, through internalized stigma in patients, which directly causes poor health, and in physicians, which affects or limits treatment and perpetuates stigma for patients. The counter to stigma is education and normalization. Without SHE, physicians are not prepared to improve their sexual health support and may not realize they are acting with bias and unethically.¹

Let us consider how the provision of SHE complies with and supports ethical practice through the lens of the 4 principles of biomedical ethics.¹

Nonmaleficence and beneficence

As trainees begin with varied ability to recognize their biases and support sexual health, SHE is proven to improve capacity to do both, and the provision of SHE complies with the principle of beneficence. Given that without this education physicians may cause harm actively (medications and treatments) or passively (stigma-based avoidance of the topic and stigma perpetuation), the lack of SHE may be considered failing the standard of nonmaleficence and beneficence. SHE ensures that trainees understand their biases around sexuality and how to prevent stigma-based avoidance from interfering with care or perpetuating sexual stigma, preventing harm. Quality SHE ensures that trainees know that medical practice may cause harm and how to mitigate these effects, preventing violation of nonmaleficence. SHE normalizes sexual health and teaches trainees to consistently address it, supporting normalization and education for the public (ie, beneficence).

Patients want to discuss sexual health, yet are reluctant, fearing making physicians uncomfortable or doubting physicians’ competence with the topic. When physicians do not initiate the conversations, they place the burden on the patient. Compelling patients to initiate, which should be within the scope of practice for physicians, creates both unnecessary momentary discomfort for patients and the potential for an unsafe environment for those vulnerable to having their sexual concerns dismissed or ignored in the context of a power differential. Therefore, passively compelling patients’ actions can be considered a form of infringement against the principle of nonmaleficence as well as a failure of beneficence.

Given the bidirectional correlations between sexual and general health, physicians ignoring sexual health violates nonmaleficence, while treating it and improving other health indirectly complies with the principle of beneficence. Last, sexual health is desired by many. SHE teaches this and encourages using this as part of health motivation, complying with the principle of beneficence.

Autonomy

Sexual medicine research extensively documents the profound sexual side effects of many treatments and medications that are regularly used by physicians. When physicians do not disclose known sexual health ramifications as part of informed consent, they are directly violating the principle of autonomy. Additionally, sexual side effects are common reasons that patients stop medications for general health. Not disclosing, monitoring for, and mitigating these risks creates potential increased morbidity, violating the principles of autonomy and nonmaleficence. Adequate SHE counters this possibility by teaching the sexual health impacts of treatments and ensuring that physicians initiate these discussions.

Justice

SHE provision supports the well-being theory of social justice. It is the job of health justice to secure core elements of health and wellbeing. Yet, stigma attached to sexuality and SD, along with the lack of adequate SHE to counter this stigma, means that sexual health concerns are often ignored or dismissed. SHE ensures that physicians address sexuality and SD and provide treatment without bias, on their own or through interdisciplinary collaboration. Therefore, SHE provision helps secure sexual health, an important core element of health and well-being. In addition, increased SHE allows more physicians to be basic access points for sexual health and treatment, key components of health and distributive justice.

Sexual stigma is a primary contributor to poor health outcomes in gendered and sexual minority populations and likely in other minority populations, as many explanatory models of difference encompass sexual stigma. SHE can attenuate the expression of stigma and increase physicians’ perceived comfort, a key element of perceived support. Perceived support is correlated with positive physical and mental health. In this way, SHE upholds the principle of justice for disadvantaged groups. By having these conversations easily with everyone, physicians are also able to mitigate cultural stigma around sexuality, supporting community health.

Increased SHE would also likely create more physicians/future public health professionals who advocate for sexual health research, education (both for medicine and the public), and policy (improving legislation and health coverage for sexual health). These outcomes support both the principles of beneficence and social justice.

Cited barriers

Finally, let us also consider the cited barriers to increased SHE provided in literature and to sexual medicine educators: financial constraints, a lack of time and/or faculty, and a lack of accreditation standards and limited inclusion of SHE in evaluations by supervising medical education committees. Though less openly acknowledged, stigma is a likely contributor, too.

These stated arguments are flimsy. There are multiple proposed solutions for increasing SHE despite the limitations of finances, time, and faculty. Additionally, the lack of SHE requirements and testing has been verbally reported to be connected to a lack of research on the effectiveness of SHE. This is a circular argument. The limited amounts and nonstandardization of SHE currently provided, together with the associated stigma and limited research funds, make further research into the long-term effectiveness difficult. And while more research in this area is extremely important, even when SHE is provided and research undertaken, the degree to which the information is retained and used likely will be influenced by the perceived importance of the knowledge. Perceived importance is dependent on both easily discernable factors (eg, whether a course is mandatory and/or evaluated) and less obvious ones (eg, the stigma attached, the hidden curriculum, the valuation by the faculty and administration). However, if comprehensive SHE is provided and there is perceived importance, research would likely demonstrate that SHE would be both retained and used, just like other standardized, mandatory, institutionally supported core health curricula.

Conclusion

Ultimately, though medical educators have claimed that they are acting on the basis of fair adjudication in the face of curricular pressures, to abstain from increasing SHE in our medical training programs can be viewed as an active choice to limit physicians’ ability to provide sexual healthcare and allow for unethical practice and for sexual and associated general health morbidity to continue unchecked. Instead, to support the ethical practice of medicine and the health of our patients and the public, let us embrace the ready solution of increased SHE in medical education.

Author contributions

E.G.G. (Conceptualization-Lead, Writing – original draft-Lead, Writing – review & editing-Lead).

Conflicts of interest: E.G.G. has served (unpaid) on the Science and Medical Advisory Board for Volonte, a Sexual Well Being Blog.

References