Lacunae in Addressing Sexual Problems in Postgraduate Psychiatry Training in India

Sexual health is defined as a state of physical, emotional, mental, and social well-being in relation to sexuality by the World Health Organisation (WHO); it is not merely the absence of disease, dysfunction, or infirmity. Sexual wellness necessitates a good, respectful attitude towards sexuality and sexual interactions, as well as the opportunity to have joyful and safe sexual encounters devoid of coercion, discrimination, and violence.

Sexual dysfunction is quite common in the general population. It is estimated that around 43% of women and 31% of men have some form of sexual dysfunction.

Sexual dysfunction is common in psychiatric patients and is associated with psychopathology and treatment. Sexual dysfunction is caused by depression and anxiety, which can be exacerbated by antidepressants, particularly selective serotonin reuptake inhibitors. Schizophrenia’s negative symptoms hinder one’s capacity to engage in interpersonal and sexual interactions. First-generation antipsychotics impair erectile and orgasmic function much more. Sexual dysfunction is also linked to eating disorders and personality problems, particularly borderline personality disorder. In some circumstances, sexual dysfunction in these cases is caused by strained interpersonal interactions.

Sexual dysfunctions are underrecognized and underdiagnosed in clinical settings, even though they are highly prevalent. It is also noted that clinicians also lack understanding about the approach to identifying and evaluating the sexual problem. It is generally advised that treating psychiatrists and collaborating professionals have a thorough understanding of human sexuality and an appropriate attitude towards it.

Despite the growing awareness and understanding of sexuality and sexual dysfunction, as well as the availability of treatment alternatives, both clinicians and their patients are still reluctant to discuss these difficulties. Patients are hesitant to discuss sexual problems with their doctors. Many people believe that their doctors will reject their sexual health concerns or that the subject will embarrass their doctor. Most patients (over 90%) believe it is a doctor’s responsibility to address sexual health concerns and are happy when their doctor opens the conversation. Patients are hesitant to seek treatment because of societal stigma and a lack of understanding.

On the contrary, physicians report barriers such as stigma, lack of knowledge about sexual functions and its dysfunctions, poor communication skills, discomfort with sexual language, a lack of information about treatment options, time constraints, concern that their questions will offend the patient, and their feelings of embarrassment about the subject. Physicians in training may have limited sexual experience, unresolved issues regarding their own sexuality, or concern about developing sexual feelings toward patients. Physicians may have difficulty remaining objective and separating their personal views from their patients.

It is to be believed that this incapacitation of knowledge ensues right from the undergraduate training in medicine as there is no formal training in basic sex education or any of the sexual dysfunctions apart from the physical aspect of the reproductive system and reproduction which by all means reinforces the primitive belief that sex is only for procreation! This hiatus has been the primary fuel in enabling the “Quacks” to run the show in the sexual medicine field, which by all means does more harm than any good to the patients, such as reinforcing the myths associated with the conditions and usage of unscientific methods leading to various other illnesses. As long as no stringent laws are enforced upon them, this will only worsen as time goes by.

Currently, the scenario in the postgraduate curriculum is no different in any of the specialties; more importantly, the lack of sexual medicine training is alarming in the field of psychiatry as it is widely understood that most of the inroads in the field of sexual medicine will by far eventually lead to a psychosocial etiopathology.

Therefore, it is imperative that the medical fraternity engage our undergraduate medical students, especially our PG residents, in a structured formal sexual medicine education curriculum with constant guidance from their teachers and periodic evaluation. This will confidently equip them in the early identification of sexual problems, assessment in a scientific way, accurate diagnosis, and effective management of the conditions using the biopsychosocial model. These trained and competent clinicians will eventually lessen the burden of sexual disorders.

One of the most underserved fields in modern medicine is psychosexual medicine. It has been surpassed by the emerging field of andrology, which is governed by urologists, urosurgeons, dermatologists, endocrinologists, and physicians. This is due, in part, to the minimal number of mental health specialists who devote most of their time to the core category of psychiatric diseases.

It is welcoming to see that the Indian Psychiatric Society has taken a leap in this initiative by publishing an exclusive textbook focusing on psychosexual medicine—IPS Textbook of Sexuality and Sexual Medicine. With respect to other resources, we have enriching articles in renowned psychiatric journals. We also have the IPS Clinical Practice Guidelines in managing sexual dysfunctions published in the Indian Journal of Psychiatry in 2017. In India, at the time of writing this article, only one university (JSS University) formally provides psychosexual medicine courses, which are offered as a 1-year fellowship program, a 6-month certificate course conducted onsite, and an online program in a dual mode to benefit students from across the country and abroad. The international society for sexual medicine also runs an online program training in the holistic management of sexual problems. Many organizations like the Council for Sex Education and Parenthood International (CSEPI) and the International Association of Sexual Medicine Practitioners—Modern Medicine (IASMP-MM) made attempts at training by conducting workshops and online programs.

In summary, it is the collective onus of the medical fraternity to acknowledge these lacunae and identify innovative methods to plug them at the earliest and bolster the academic strength and confidence in our fraternity to the field of psychosexual medicine.