The World Health Organization describes sexual health as a basic human right.5 While often under-addressed, sexual health concerns permeate all fields of medicine, urology is a specialty regularly confronted with issues of genitourinary and sexual function. The results presented in this manuscript demonstrate that less than half of urology resident respondents received any formal sexual health education in residency training, excluding education related to sexually transmitted infections. This highlights the lack of standardization and prioritization of inclusive sexual health education in urology residencies.
When evaluating comfort discussing sex toy/tool usage, most residents did not feel comfortable answering questions about anal stimulation devices, or vaginal or clitoral stimulation devices. Inquiring about patient use of anal and vaginal or clitoral stimulation devices, including anal plugs and clitorovaginal vibrators, is crucial to understanding the landscape of sex practices among patients and advocating for safe usage and proper cleaning and storage of devices. An example of safe usage counseling in a medical setting would include informing the patient to utilize the anal stimulation device with body safe materials and a flared base to prevent retainment of a rectal foreign body. Likewise, counseling about proper cleaning and storage of tools can prevent STI transmission.
Vaginal and clitoral stimulation devices, including vibrators and their medical/therapeutic potential are currently a topic of research. Vibrators are generally inexpensive, well-tolerated and have demonstrated utility in treating sexual dysfunction, stress urinary incontinence, pelvic floor dysfunction and vaginovulvar pain.6 Urologists are commonly confronted with these patient concerns and should be better equipped to confidently counsel patients surrounding their use and application.
Urologists are presumably well-equipped to manage male erectile dysfunction. Unsurprisingly, greater than 90% of residents felt “very comfortable” or “somewhat comfortable” with describing cisgender male sexual dysfunction and performing a physical exam for a cisgender male with sexual dysfunction. However, significantly fewer respondents felt the same towards cisgender female sexual dysfunction. Reported comfort does not necessarily imply proficiency in diagnosis and treatment and may be influenced by trainee attitudes and bias. Nevertheless, this highlights a potential double standard in the field of urology which emphasizes education on cisgender male sexual health with less emphasis on cisgender female, transgender or gender non-conforming sexual concerns. This pattern was similarly identified when respondents were asked about comfort in describing medicines used for sexual function to patients: 100% of residents are comfortable doing so for men, while only 64% are comfortable doing the same for women. Additionally, when counseling transgender males or females on sexual practices, therapies, or surgeries, only 29% of residents felt comfortable. It is important to articulate that the specialty of urology is devoted to genitourinary health regardless of sex or gender; while the focus has historically been on cisgender male concerns and the involvement of organs such as the prostate, non-male identifying patients also have urologic concerns that are often overlooked. Gender dysphoria, genitourinary syndrome of menopause (GSM), interstitial cystitis (IC), pelvic pain, persistent genital arousal disorder (PGAD), persistent orgasm illness syndrome (POIS) and balanitis secondary to clitoral phimosis are just a few of the diagnoses underrepresented in urology research and training - all of which may contribute to sexual dysfunction in patients and may compromise patient outcomes.7–10
Other studies have suggested that urology residency does not pay sufficient attention to sexual communication skills and dysfunction, specifically in the context of treating prostate cancer treatment-related sexual dysfunction.11,12 Krouwel et al. surveyed 87 urology residents in the Netherlands and found the majority did not feel competent to adequately advise about treatment of sexual dysfunction in patients with prostate cancer. Prostate cancer survivorship and its relationship to sexual dysfunction represents an area that our study did not examine directly but remains an opportunity for future investigation. Treating female sexual dysfunction appears to be under-emphasized in both urology and obstetrics and gynecology (OBGYN) training programs. In a 2012 survey of OBGYN physicians, Sobecki et al. found that 28.5% of surveyed physicians reported asking female patients about sexual satisfaction, 27% asked about sexual orientation or identity, and 13.8% inquired about pleasure with sexual activity.13
Sexual health education optimization in medical school and urology residency could fill knowledge gaps for future trainees. Despite the availability of symptom scales and questionnaires, these are not often presented to medical students and are under-utilized in clinical practice.3,14 One solution could be the inclusion of comprehensive sexual history taking workshops in training curriculum where trainees rehearse sexual history taking scripts to become more accustomed to saying words like “vulva,” “vagina,” “orgasm,” “sex tool,” “anal stimulation,” and “lubrication” that can often be tied in societal stigma and taboo. With repetition, providers may become more comfortable with the language required to take a comprehensive sexual history. Physician comfort and knowledge likely influences better patient outcomes. In a study evaluating OBGYN residents' comfort and knowledge when managing transgender patients, use of a culturally relevant curriculum surrounding gender diverse populations (including transgender and gender non-conforming patients) demonstrated improved outcomes in the form of improved comfort and knowledge among residents involved reported positive experiences from standardized patients.15 Investigating sexual health symptoms is crucial because conditions like heart disease, diabetes, cancer, psychiatric illnesses, and rheumatic diseases can manifest with symptoms of sexual dysfunction.16–18 Our survey demonstrated that some of the barriers to care for patient sexual health needs are physician discomfort with some sexual topics and aspects of taking a comprehensive sexual history. It is not possible to identify and treat what one does not look for or inquire about.
Limitations to our study include a small sample size, likely secondary to a short response collecting period. Likewise, recall bias with growing PGY years may also have contributed as a limitation. Additionally, no measures were taken to guarantee heterogeneity of geographic regions of respondents, however survey respondents reported to be diffusely distributed throughout the country. Another limitation is the reliance on respondent subjective reporting and recall bias to report the amount and quality of sexual health education during their medical training. We also found it surprising that when describing medicines used for sexual function in cisgender men, 100% of residents are “very comfortable” or “somewhat comfortable.” Our study did not evaluate the discussion of usage of isosorbide or poppers with patients before prescribing viagra, which can have life threatening consequences, therefore due to lack of granularity on this specific topic, this finding should be considered limited. Our study did not assess trainee’s knowledge of these nuances. Our study also did not address the limitation that medical education of senior residents not necessarily reflecting practices in medical school today. While we investigated physician comfort with transgender identifying patients, our survey also did not evaluate physician comfort with treating non-binary identifying patients, or other gender non-conforming identities. We also did not assess comfort levels in physicians counseling cisgender male-female couples on having children, despite investigating this aspect in same sex couples. This study also lacks an investigation of physician knowledge and comfort discussing other sexual behaviors, such as bondage and discipline, dominance and submission and sadomasochism (BDSM) and the safety considerations associated with sexual kink behaviors and practices. Lastly, when considering the use of the terminology “comfortable” in our competency scoring system, it is important to recognize that comfort is not a skill, and a false sense of comfort may be present in some providers, potentially worsening outcomes. In future investigations, a more granular and broad questionnaire may assist. In total, the limitations of our study reflect opportunities for future research endeavors.
By bringing awareness to knowledge gaps surrounding sexual health among urologists, we hope to highlight the need for improvement in sexual health literacy standards within urology training to better serve patients’ sexual health concerns. This will ideally promote patient satisfaction, comfort, and potentially improve sexual health outcomes. It may also aid in supporting an urgency in the improvement of medical school and residency sexual education. By increasing awareness, one of our goals is to elevate the standard of care for managing patients with sexual health concerns to include asking about gender identity, sexual orientation, types of sex (receptive or insertive anal sex, oral sex, masturbation, etc.), non-monogamy, and types, use and storage of sex tools/toys when taking a urological medical history. Asking more detailed questions about sexual health practices can guide clinical management of sexual dysfunction and other genital health concerns.