Neglected Sexual Health in India’s Medical Education and Regulation: Time for a Change

India has given Kamasutra to the world and hosts temples which promote sexuality in Khajuraho, Konark, Belu, and Halebidu. Yet, sexuality education is a forbidden terrain, and its façade can be seen only in a few documents. Various organizations and leaders have put herculean efforts to bring it into the education system of India, but it is still missing, especially from the lives of people who are in need of it the most. The Adolescence Education Program was launched in India between 2003 and 2005 through collaboration between Ministry of Human Resource Development and National AIDS Control Organization, and was implemented in schools along with life skills training by Central Board of Secondary Education and Kendriya Vidyalaya Sangathan. However, in 2007, due to conflicts and opposition by the gatekeepers, only traces of the program can be found in the current curriculum. ¹ This not only resulted in continued ignorance among the population but also increased the public’s resistance to be educated in this essential subject. The importance of sexuality education in reducing the sexually transmitted infections/HIV, teenage and unwanted pregnancies, sexual abuse, increased number of sexual partners, and early sexual activity are fairly neglected even now. ²

Sexual health is the most neglected part of an individual’s health. Various studies in India have reported a wide range of sexual disorders among males and females. Sexual disorders can be related to desire, arousal, orgasm, and painful sexual intercourse. The common problems related to sexual health are premature ejaculation, delayed ejaculation, nocturnal emission, Dhat syndrome, erectile dysfunction, performance anxiety, guilt about masturbation, hypo- or hyper-active sexual desire, anorgasmia, vaginismus, dyspareunia, sexual aversion, and infections of the reproductive system.^{3, 4} To address these sexual disorders, India lacks trained professionals since there is no specific course for becoming a sexologist or a sex therapist. Currently in urban settings, various medical specialties like dermatology, obstetrics and gynecology, psychiatry, urology, and endocrinology attend to patients with sexual disorders. The lack of a sexual health specialist confuses patients regarding where to seek care. Patients may first consult their friends or may look on the Internet for self-help remedies, and eventually may land up with a quack or untrained professional. ⁵ Studies done in North India had found that 81% of men and 82% of women perceived themselves to have at least one sexual disorder. These patients were reluctant to seek care due to social stigma and lack of awareness.^{6, 7} A study done in rural areas in South India, which screened the population using validated and structured tools, found the prevalence of at least one (or more) sexual disorders among men and women to be 21.2% and 15.8%, respectively. ⁸ This difference in the prevalence of sexual disorders shows stigma and lack of sexuality education among the general population. Even in the absence of sexual health disorders, people feel they are suffering from it. This misinformation and stigma can be dealt with by community awareness and education programs enforced by schools, colleges, clinics, and media.

There is a substantial prevalence of sexual health disorders in India. At least a primary care physician is expected to address the common sexual health problems, especially in a rural setting. It is disheartening to see that our medical graduates lack this basic knowledge. ⁹ The common sources of sexual health knowledge for our young doctors are friends, pornographic films, and magazines. ¹⁰ We would expect the source to be the medical textbooks which are based on scientific knowledge, which would also provide knowledge about diagnosis and management of sexual health disorders. Unfortunately, this topic is often ignored in the syllabus and training. How can we expect our physicians to address the sexual health disorders? Even in the syllabus of post-graduates’ students of related specialties, topics like female sexual dysfunctions and gender incongruence are barely touched upon. All this clearly indicates the ignorance toward sexual health as a part of human health in medical training. The government of India had initiated Adolescent Reproductive Sexual Health (ARSH) clinics in 2006 to address sexual and reproductive issues. Currently, these ARSH clinics are nonfunctional at most of the primary health centers and community health centers of India. These clinics were proven to have a positive impact in the community but to be sustained, trained professionals and community awareness are essential. ¹¹

In India, most of the sexual health problems are dealt with by a psychiatrist or gynecologist. Even among those, few may not prefer to practice sexual medicine as sex is considered still to be a taboo in India. This is another reason for the dearth of trained doctors in the field of sexual medicine. Also, there are few challenges in managing certain sexual disorders in India. For example, in the field of sexual medicine, a masturbating device can be advised for conditions like hypo- or hyper-sexual disorders, for patients with a lack of sexual gratification or for sperm collection. However, in India, the sale of such devices or products is prohibited by section 292 of the Indian Penal Code. This law bans products which are deemed to be obscene and can deprave and corrupt a person but exempts the printed material (if for public good) and ancient monuments. It is difficult to understand that if a product is used for the management of a sexual disorder or is benefiting someone’s sexual health, then why is it banned? However, these products are sold online and in the market under the disguise of toys or massagers. A brand selling these products in India conducted a study which analyzed the data of 7.5 years, and reported 22 million visitors on their website who placed 3.35 lakh orders. Among the buyers, 65% were males. They found that these products had promising results in increasing the sexual satisfaction to a person. Products were also used by couples to enhance sex life, and they improved strained marriages for 34% couples. ¹² This indicates the presence of a public demand for these devices to be sold. As per the information received from various ministries in India (under the Right to Information), there are no guidelines for selling or testing the safety of these sexual health-related devices/products. This is also an example of how rules and regulations are not formed or updated, keeping sexual health in mind. The unregulated sale of these devices and products causes the sales to escape from paying taxes. This leads to an economic loss for the government. Generally, these sexual health-related devices have electrical and chemical components. Most of them when sold are marked as safe but are not tested for safety. These products can cause serious health consequences and side effects. ¹³

It is high time to change the current medical education and regulations of India. Our policymakers and stakeholders need to address the sexual health of people. To produce more trained professionals, a sexual health module for undergraduate medical education should be implemented. A specific post-graduation course of Doctor of Medicine (MD) can be introduced for sexual health to provide experts in the field. By including sexual health in the medical curriculum, competent doctors can be trained to reduce the burden of sexual disorders. Simultaneously, laws and regulations for the sale of sexual health-related devices should be reformed. These devices should undergo safety testing and certification. For a sexually healthy community, the public demand for sexuality education is vital which can be achieved by providing awareness regarding the benefits of it. With modern technology and mass media, various approaches can be used to implement sexuality education among adolescents and young adults.