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Medical and midwifery students need increased sexual medicine education to overcome barriers hindering bringing up sexual health issues – A national study of final-year medical and midwifery students in Finland

  • Author Footnotes
    1 ORCID: 0000-0001-5680-4161.
    Sanna-Mari Manninen
    Correspondence
    Corresponding author at: Department of Obstetrics and Gynecology, Turku University Hospital and University of Turku, Savitehtaankatu 5, 20520 Turku, Finland.
    Footnotes
    1 ORCID: 0000-0001-5680-4161.
    Affiliations
    Department of Obstetrics and Gynecology, University of Turku, Turku, Finland

    Department of Health Promotion, Metropolia University of Applied Sciences, Helsinki, Finland
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  • Author Footnotes
    2 ORCID: 0000-0003-4439-1819.
    Katja Kero
    Footnotes
    2 ORCID: 0000-0003-4439-1819.
    Affiliations
    Department of Obstetrics and Gynecology, Turku University Hospital and University of Turku, Turku, Finland
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  • Author Footnotes
    3 ORCID: 0000-0002-2479-3944.
    Markus Riskumäki
    Footnotes
    3 ORCID: 0000-0002-2479-3944.
    Affiliations
    Department of Clinical Medicine, Biostatistics, University of Turku, Turku, Finland
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  • Author Footnotes
    4 ORCID: 0000-0002-4935-3056.
    Tero Vahlberg
    Footnotes
    4 ORCID: 0000-0002-4935-3056.
    Affiliations
    Department of Clinical Medicine, Biostatistics, University of Turku, Turku, Finland
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  • Author Footnotes
    5 ORCID: 0000-0003-0665-0306.
    Päivi Polo-Kantola
    Footnotes
    5 ORCID: 0000-0003-0665-0306.
    Affiliations
    Department of Obstetrics and Gynecology, Turku University Hospital and University of Turku, Turku, Finland
    Search for articles by this author
  • Author Footnotes
    1 ORCID: 0000-0001-5680-4161.
    2 ORCID: 0000-0003-4439-1819.
    3 ORCID: 0000-0002-2479-3944.
    4 ORCID: 0000-0002-4935-3056.
    5 ORCID: 0000-0003-0665-0306.
Open AccessPublished:October 29, 2022DOI:https://doi.org/10.1016/j.ejogrb.2022.10.021

      Highlights

      • Previous studies show that patients’ possible sexual problems are seldomly inquired.
      • The students expressed being competent in discussing sexual issues with patients.
      • However, a majority considered being unable to assess patients’ sexual problems.
      • Both student groups reported several barriers hindering raising sexual issues.
      • Thus, sexual medicine education should be increased, especially in medical schools.

      Abstract

      Objectives

      Physicians and midwives meet patients with sexual health issues regularly; however, they may have limited sexual medicine education. The study’s aim was to evaluate the self-reported competence of medical and midwifery students to bring up sexual health issues with their patients and to assess the barriers that hinder these discussions. The need for additional education was also evaluated.

      Study design

      A web-based questionnaire was sent to the last-year medical and midwifery students graduating between December 2018 and May 2019 in Finland. In total, 233 medical students and 131 midwifery students participated in the study. Three fields were evaluated: the self-reported competence in discussing sexual health issues and treating patients with these issues, the barriers to bringing up sexual problems, and the need for education in sexual medicine.

      Results

      The students self-reported better competence in discussing sexual health issues than in treating patients’ sexual problems. For the medical students, the most important barriers hindering bringing up sexual health issues were lack of i) time (89.2 %), ii) experience with sexual medicine (88.1 %), and iii) knowledge (82.1 %). For the midwifery students, the most important barriers were i) lack of experience with sexual medicine (73.3 %), ii) fear of failing to respond to patients’ sexual health issues (64.9 %), and iii) lack of knowledge (62.5 %). A higher percentage of the midwifery students (96.2 %) reported an interest in sexual medicine education compared to the medical students (55.4 %) (OR 13.89, 95 % CI 5.32–35.71, P <.001). Majority (76.5 %) of the medical students and almost half (45.0 %) of the midwifery students reported receiving too little sexual medicine education (OR 7.30, 95 % CI 4.00–13.33, P <.001).

      Conclusions

      Both student groups reported several barriers hindering bringing up sexual health issues with their patients and expressed a need for more education, particularly the medical students.

      Keywords

      Introduction

      Good sexual health is essential for both physical and emotional health and well-being. However, sexual problems are rather common, occurring both independently and in connection with various diseases [
      • Dekker A.
      • Matthiesen S.
      • Cerwenka S.
      • Otten M.
      • Briken P.
      Health, sexual activity, and sexual satisfaction.
      ]. Therefore, in clinical practice, health care personnel often meet patients with sexual health issues. In a study [
      • De Rose A.F.
      • Gallo F.
      • Bini P.M.
      • Gattuccio I.
      • Chiriacò V.
      • Terrone C.
      Epidemiology of sexual disorders in general medical practice: An Italian survey.
      ] with 5,441 patients of general practitioners, 33 % reported having symptoms of sexual problems; however, only some of the problems were diagnosed. Additionally, according to another study [
      • Kim S.H.
      • Lee Y.M.
      • Park J.T.
      Patients' perspectives on sexual history taking in Korea.
      ], nearly 75 % of patients reported that physicians never asked about sexual issues during their medical encounters. These results can be interpreted as indicating that sexual issues are not commonly brought up during appointments. Health care personnel having fluency in addressing sexual health issues is crucial, as patients typically prefer to receive sexual health information from a provider who initiates the conversation [
      • Wittenberg A.
      • Gerber J.
      Recommendations for improving sexual health curricula in medical schools: results from a two-arm study collecting data from patients and medical students.
      ].
      In general, important characteristics for a good physician to have in addition to good competence in the medical field are a positive personality, sensitivity to emotions, and good communication skills [
      • Borracci R.A.
      • Álvarez Gallesio J.M.
      • Ciambrone G.
      • Matayoshi C.
      • Rossi F.
      • Cabrera S.
      What patients consider to be a 'good' doctor, and what doctors consider to be a 'good' patient.
      ]. For midwives, the essential abilities are being aware of their strengths, knowledge gaps, and limits as well as having the right attitude and effective communicative skills [
      • Butler M.M.
      • Fraser D.M.
      • Murphy R.J.
      What are the essential competencies required of a midwife at the point of registration?.
      ]. Nevertheless, despite having sufficient abilities, many factors may hinder physicians and midwives in addressing their patients’ sexual health issues. As reported in other studies [
      • Alarcão V.
      • Ribeiro S.
      • Miranda F.L.
      • Carreira M.
      • Dias T.
      • Garcia e Costa J.
      • et al.
      General practitioners’ knowledge, attitudes, beliefs, and practices in the management of sexual dysfunction – results of the Portuguese SEXOS study.
      ,
      • Byrne M.
      • Doherty S.
      • McGee H.M.
      • Murphy A.W.
      General practitioner views about discussing sexual issues with patients with coronary heart disease: a national survey in Ireland.
      ], we also found in our previous study with general practitioners that the three most important barriers were lack of the following: time, knowledge about sexual medicine, and experience with it [
      • Manninen S.M.
      • Kero K.
      • Perkonoja K.
      • Vahlberg T.
      • Polo-Kantola P.
      General practitioners' self-reported competence in the management of sexual health issues - a web-based questionnaire study from Finland.
      ]. Nurses have also reported time constraints [
      • Magnan M.A.
      • Reynolds K.
      Barriers to addressing patient sexuality concerns across five areas of specialization.
      ,
      • Leyva-Moral J.M.
      • Aguayo-Gonzalez M.
      • Palmieri P.A.
      • Guevara-Vasquez G.
      • Granel-Grimenez N.
      • Dalfó-Pibernat A.
      Attitudes and beliefs of nurses and physicians about managing sexual health in primary care: A multi-site cross-sectional comparative study.
      ] as a barrier as well as nurses’ perceptions that patients do not expect nurses to ask about sexual concerns [
      • Magnan M.A.
      • Reynolds K.
      Barriers to addressing patient sexuality concerns across five areas of specialization.
      ]. Other reported hindrances have included insufficient training to manage sexual health problems [
      • Leyva-Moral J.M.
      • Aguayo-Gonzalez M.
      • Palmieri P.A.
      • Guevara-Vasquez G.
      • Granel-Grimenez N.
      • Dalfó-Pibernat A.
      Attitudes and beliefs of nurses and physicians about managing sexual health in primary care: A multi-site cross-sectional comparative study.
      ,
      • Barnhoorn P.C.
      • Zuurveen H.R.
      • Prins I.C.
      • van Ek G.F.
      • den Oudsten B.L.
      • den Ouden M.E.M.
      • et al.
      Unravelling sexual care in chronically ill patients: the perspective of GP practice nurses.
      ] and gender (where the patient is the opposite gender) [
      • Alarcão V.
      • Ribeiro S.
      • Miranda F.L.
      • Carreira M.
      • Dias T.
      • Garcia e Costa J.
      • et al.
      General practitioners’ knowledge, attitudes, beliefs, and practices in the management of sexual dysfunction – results of the Portuguese SEXOS study.
      ,
      • Byrne M.
      • Doherty S.
      • McGee H.M.
      • Murphy A.W.
      General practitioner views about discussing sexual issues with patients with coronary heart disease: a national survey in Ireland.
      ,
      • Abdulghani H.M.
      • Haque S.
      • Irshad M.
      • Al-Zahrani N.
      • Al-Bedaie E.
      • Al-Fahad L.
      • et al.
      Students' perception and experience of intimate area examination and sexual history taking during undergraduate clinical skills training: A study from two Saudi medical colleges.
      ].
      In Finland, the first two and a half years of midwifery studies consist of basic nursing studies. The last two years focus on gynecology and obstetrics in which it is more suitable to consider sexual health issues. Furthermore, many of the teachers in midwifery schools are certified sexual counselors. In contrast, medical studies consist of large range of subjects which do not necessarily include education in sexual medicine. The duration of the course of gynecology and obstetrics is only two months, which does not leave much space for education of sexual health issues. In addition, the teachers in medical schools typically lack of special pedagogy in sexual medicine. Therefore, it is plausible that education in sexual medicine is more limited in medical studies, resulting in bringing up sexual health issues being more difficult for physicians than for midwifes.
      The main objectives of our study were to assess and compare the self-reported competence and the barriers to bringing up patients’ sexual health issues between Finnish medical and midwifery students. In addition, we aimed to evaluate the need for education in this field. According to our hypothesis, education in sexual medicine is currently inadequate; therefore, there are several barriers hindering practitioners’ ability to bring up sexual health issues. We suggest that more education could reduce these barriers.

      Materials and methods

      Subjects

      The participants in this Sexual Medicine Education (SexMEdu) sub-study were the medical and midwifery students who graduated between December 2018 and May 2019 in Finland. In Finland, there are five universities with faculties of medicine educating medical students and eight universities of applied sciences educating midwifery students; all these schools participated in this study. The average study duration in Finland is six years for medical studies and four and a half years for midwifery studies. In Finland, it is possible to work as a substitute doctor/midwife at the end of the studies. During the study period, a total of 562 medical students and 253 midwifery students graduated, of whom 233 medical students and 131 midwifery students responded, giving the response rates of 41.5 % and 51.8 %, respectively. The mean age of the medical students was 28.5 years (SD 4.0, range 24–48 years); 60.5 % (n = 141) were women and 39.5 % (n = 92) were men. All of the midwifery students were women, and their mean age was 28.1 years (SD 5.0, range 23–50 years). Replying to the questionnaire implied consent, which was made clear to the respondents via the questionnaire. The Ethics Committee of Turku University approved the study protocol (44/2017).

      Questionnaires

      The study questionnaire included 17 questions which we adopted and slightly modified from the Portuguese SEXOS study [
      • Alarcão V.
      • Ribeiro S.
      • Miranda F.L.
      • Carreira M.
      • Dias T.
      • Garcia e Costa J.
      • et al.
      General practitioners’ knowledge, attitudes, beliefs, and practices in the management of sexual dysfunction – results of the Portuguese SEXOS study.
      ] with general practitioners and a German study [
      • Turner D.
      • Nieder T.O.
      • Dekker A.
      • Martyniuk U.
      • Herrmann L.
      • Briken P.
      Are medical students interested in sexual health education? A nationwide survey.
      ] with medical students with permission from both research groups. It was also used in our earlier SexMEdu sub-study for general practitioners [
      • Manninen S.M.
      • Kero K.
      • Perkonoja K.
      • Vahlberg T.
      • Polo-Kantola P.
      General practitioners' self-reported competence in the management of sexual health issues - a web-based questionnaire study from Finland.
      ]. We piloted the questionnaire with 27 medical students and used their feedback to make amendments to the content. The study questionnaire consisted of three independent fields (A–C, Appendix): A) The self-reported competence in discussing sexual health issues and treating patients (four questions/statements), B) The barriers to bringing up sexual health problems with a patient (nine issues), C) The need for education in sexual medicine (four questions).

      Statistical analysis

      Data are described using frequencies (percentages). In the analyses, each question was dichotomized in fields A and B [A: 1) ‘not at all’ or ‘once’ versus ‘a few times’ or ‘many times’; 2) ‘no problem’ or ‘a minor problem’ versus ‘a moderate problem’ or ‘a major problem’; 3) and 4) ‘agree’ or ‘totally agree’ versus ‘disagree’ or ‘totally disagree’; B: ‘much’ or ‘very much’ versus ‘some’ or ‘not at all’] except for question 1b in field A (‘If yes, what was the result?’), where every option was analyzed separately. In field C, question 1 was dichotomized (‘not at all’ or ‘a little’ versus ‘fairly’ or ‘very’). In questions 2 and 3 in field C, every option was analyzed separately. Question 4 in field C was a multiple-choice question with several options. The ‘cannot say’ responses in all fields were omitted from the analyses. The associations between the students’ ages and genders and the three fields of interests (A–C) were analyzed using multivariable logistic regression (examining each question separately in each field in the analyses). The gender associations were carried out only in the sub-analysis for the medical students as all the midwifery students were women. The results are presented using adjusted odds ratios (ORs) with 95 % confidence intervals (CIs). P values <0.05 were considered statistically significant. Statistical analyses were performed using the SAS System for Windows, version 9.4 (SAS Institute Inc., Cary, NC).

      Results

      A) The self-reported competence in discussing sexual health issues and treating patients

      While working as a substitute doctor or midwife, a majority (60.0 %) of the medical students and one third (36.7 %) of the midwifery students reported having met patients with sexual problems a few or many times (OR 2.22, 95 % CI 1.33–3.71, P =.002). The age of the student showed no associations. In the sub-analysis for medical students, the male students were more likely to report being able to help the patient with sexual health issues (OR 2.43, 95 % CI 1.22–4.84, P =.012).
      Both the medical and the midwifery students reported a good competence in discussing sexual health issues with patients. If the patient had addressed the issue, only 6.9 % of the medical students and 2.3 % of the midwifery students reported having moderate or major problems with discussing the topic (OR 3.33, 95 % CI 0.89–12.41, P =.073 between the student groups). Compared to the midwifery students, the medical students were more likely to report not being able to bring up sexual health issues easily with their patients (36.5 % versus 16.0 %; OR 3.41, 95 % CI 1.91–6.08, P <.001). A majority of both the medical and the midwifery students considered themselves unable to evaluate patients’ sexual problems and determine the need to refer patients to specialists (67.8 % versus 51.2 %, respectively); this was the case with a higher percentage of the medical students (OR 2.02, 95 % CI 1.23–3.33, P =.006).

      B) The barriers to bringing up sexual health problems with a patient

      The results of determining the barriers to bringing up sexual health issues are described in Table 1. The most important barriers varied somewhat between the two student groups. For the medical students, the most important barriers were lack of time, lack of experience with sexual medicine, lack of knowledge about sexual medicine, and sexual health issues not being a priority at the moment. For the midwifery students, the most important barriers were lack of experience with sexual medicine, fear of failing to respond to patients’ sexual health issues, lack of knowledge about sexual medicine, and sexual health issues not being a priority at the moment. In addition, compared to the midwifery students, the medical students were more likely to report that almost all assessed factors were barriers to bringing up sexual health issues, except in responses concerning personal attitudes and beliefs and disability of the patient (Table 1). The age of the student was statistically significant only concerning the lack of experience; the older the student, the less the lack of experience was a barrier (OR 0.92, 95 % CI 0.87–0.98, P =.006). No other associations emerged. The female students were more likely to report the fear of failing to respond to patients’ sexual health issues as a barrier (OR 3.02, 95 % CI 1.70–5.35, P <.001), whereas the male students were more likely to report sexual health issues not being a priority at the moment as a barrier (OR 2.30, 95 % CI 1.12–4.73, P =.023).
      Table 1Differences between medical and midwifery students in barriers to bringing up sexual health issues with patients.
      Medical student N = 233Midwifery student N = 131
      Much or very muchMuch or very muchOR95 %CIP
      Lack of time89.2 % (n = 207/232)49.6 % (n = 61/123)9.224.79–17.76<0.001
      Sexual health issues are not a priority in the patient’s treatment at the moment78.8 % (n = 178/226)53.5 % (n = 68/127)2.491.48–4.170.001
      The provider’s personal attitudes and beliefs10.9 % (n = 25/229)7.6 % (n = 10/131)1.130.47–2.720.778
      The provider’s personal discomfort when addressing sexual health issues16.4 % (n = 38/232)9.2 % (n = 12/131)2.161.03–4.500.041
      Lack of knowledge of sexual medicine82.1 % (n = 184/224)62.5 % (n = 80/128)3.752.05–6.87<0.001
      Lack of experience with sexual medicine88.1 % (n = 200/227)73.3 % (n = 96/131)3.911.91–7.990.001
      Fear of failing to respond to the patient's sexual health issues66.1 % (n = 148/224)64.9 % (n = 85/131)1.731.01–2.960.044
      Gender differences (where the patient is the opposite gender)26.8 % (n = 62/231)15.5 % (n = 20/129)2.221.21–4.050.010
      Disability of the patient34.1 % (n = 71/208)26.4 % (n = 33/125)1.640.96–2.810.072
      OR (age and gender adjusted logistic regression) higher than 1 indicates higher barriers for medical students (two categories: much or very much versus some or not at all; the responses 'cannot say' omitted from the analyses) to bringing up sexual health issues with patients.
      OR = odds ratio.
      CI = confidence interval.

      C) The need for education in sexual medicine

      A higher percentage of the midwifery students (96.2 %) reported an interest in sexual medicine education than the medical students (55.4 %) (OR 13.89, 95 % CI 5.32–35.71, P <.001). Overall, 76.5 % of the medical students and 45.0 % of the midwifery students reported receiving too little sexual medicine education (OR 7.30, 95 % CI 4.00–13.33, P <.001). The female students reported receiving too little education at a higher percentage compared to the male students (85.5 % versus 62.8 %, respectively; OR 3.45, 95 % CI 1.79–6.64, P <.001). Compared to the midwifery students (6.1 %), the medical students (20.6 %) were more likely to suggest that the education should be voluntary (OR 3.00, 95 % CI 1.29–6.98, P =.011). The medical students preferred sexual medicine education to be integrated into other subjects (58.1 %) at a higher percentage than the midwifery students (27.2 %) (OR 3.47, 95 % CI 2.05–5.85, P <.001). The responses to various forms of education are illustrated in Fig. 1. The most preferred form of education for the medical students was workshops (n = 155), followed by lectures (n = 115). The midwifery students also preferred these forms, but with the opposite priority (lectures n = 114 and workshops n = 62).
      Figure thumbnail gr1
      Fig. 1The medical students’ (total n = 233) and the midwifery students’ (total n = 131) responses to preferences for the forms of education in sexual medicine (more than one option could be chosen).

      Discussion

      According to our study, both medical and midwifery students self-reported a good competence in discussing sexual health issues with patients. Issues related to sexual health and sexuality have become more acknowledged and liberal in recent years. For example, the effect of #MeToo has presumably resulted in more openness to talking about sexual health issues. In contrast, however, a majority of both student groups considered themselves to have difficulties in assessing patients’ sexual problems and evaluating the need to refer patients to specialists, particularly the medical students. Several factors also hindered bringing up sexual health issues, primarily lack of experience and knowledge. Accordingly, the findings emphasized the importance of education in sexual medicine. A majority of both medical and midwifery students reported an interest in education in sexual medicine, which they considered to be insufficient during their studies.
      Among all subjects, the course of gynecology and obstetrics is a logical subject to educate sexual medicine. When comparing medical and midwifery curricula, medical studies include a two-month course of gynecology and obstetrics, whereas in midwifery studies, the duration of gynecology and obstetrics education is two years. For a midwifery student, it is mandatory to take care, for example, 100 pregnant women, 40 vaginal births, and 100 puerperal women to complete the degree of midwifery in Finland. In midwifery education, sexual health is constantly present and thus, midwifery students inevitably meet patients whose sexual health should be addressed. Nevertheless, the students still felt unable to assess patients’ sexual problems. For medical students, there are no numerical objectives in the curriculum. However, the medical students’ uncertainty of evaluating sexual problems was concordant with the results from a Malaysian study [
      • Ariffin F.
      • Chin K.L.
      • Ng C.
      • Miskan M.
      • Lee V.K.
      • Isa M.R.
      Are medical students confident in taking a sexual history? An assessment on attitude and skills from an upper middle income country.
      ] with 379 final-year medical students in which only 27 % felt having adequate skills to take sexual history and 38 % having enough exposure to these situations.
      The fact that lack of experience and especially lack of knowledge were in the top three barriers for both student groups emphasizes that the amount of the education in sexual medicine is insufficient. Previous studies have reported similar results [
      • Leyva-Moral J.M.
      • Aguayo-Gonzalez M.
      • Palmieri P.A.
      • Guevara-Vasquez G.
      • Granel-Grimenez N.
      • Dalfó-Pibernat A.
      Attitudes and beliefs of nurses and physicians about managing sexual health in primary care: A multi-site cross-sectional comparative study.
      ,
      • Barnhoorn P.C.
      • Zuurveen H.R.
      • Prins I.C.
      • van Ek G.F.
      • den Oudsten B.L.
      • den Ouden M.E.M.
      • et al.
      Unravelling sexual care in chronically ill patients: the perspective of GP practice nurses.
      ,
      • Abdulghani H.M.
      • Haque S.
      • Irshad M.
      • Al-Zahrani N.
      • Al-Bedaie E.
      • Al-Fahad L.
      • et al.
      Students' perception and experience of intimate area examination and sexual history taking during undergraduate clinical skills training: A study from two Saudi medical colleges.
      ,
      • Ariffin F.
      • Chin K.L.
      • Ng C.
      • Miskan M.
      • Lee V.K.
      • Isa M.R.
      Are medical students confident in taking a sexual history? An assessment on attitude and skills from an upper middle income country.
      ,
      • Walker S.H.
      • Davis G.
      Knowledge and reported confidence of final year midwifery students regarding giving advice on contraception and sexual health.
      ,
      • Percat A.
      • Elmerstig E.
      “We should be experts, but we're not”: Sexual counselling at the antenatal care clinic.
      ,
      • Gerbild H.
      • Larsen C.M.
      • Junge T.
      • Laursen B.S.
      • Areskoug-Josefsson K.
      Danish health professional students' attitudes toward addressing sexual health: a cross-sectional survey.
      ]. In a mixed-method study from the United Kingdom with 86 midwifery students [
      • Walker S.H.
      • Davis G.
      Knowledge and reported confidence of final year midwifery students regarding giving advice on contraception and sexual health.
      ] and a qualitative study from Sweden [
      • Percat A.
      • Elmerstig E.
      “We should be experts, but we're not”: Sexual counselling at the antenatal care clinic.
      ] with 9 midwifery students, participants reported lack of knowledge [
      • Walker S.H.
      • Davis G.
      Knowledge and reported confidence of final year midwifery students regarding giving advice on contraception and sexual health.
      ,
      • Percat A.
      • Elmerstig E.
      “We should be experts, but we're not”: Sexual counselling at the antenatal care clinic.
      ] and inadequate training in sexology [
      • Percat A.
      • Elmerstig E.
      “We should be experts, but we're not”: Sexual counselling at the antenatal care clinic.
      ] to be barriers. In a Danish study [
      • Gerbild H.
      • Larsen C.M.
      • Junge T.
      • Laursen B.S.
      • Areskoug-Josefsson K.
      Danish health professional students' attitudes toward addressing sexual health: a cross-sectional survey.
      ] with 584 health professional students, participants self-reported lack of knowledge and training in sexual health issues. In a Dutch study [
      • Barnhoorn P.C.
      • Zuurveen H.R.
      • Prins I.C.
      • van Ek G.F.
      • den Oudsten B.L.
      • den Ouden M.E.M.
      • et al.
      Unravelling sexual care in chronically ill patients: the perspective of GP practice nurses.
      ] with 337 general practice nurses, the participants reported insufficient training as the number-one barrier. As for medical students, both a Saudi study [
      • Abdulghani H.M.
      • Haque S.
      • Irshad M.
      • Al-Zahrani N.
      • Al-Bedaie E.
      • Al-Fahad L.
      • et al.
      Students' perception and experience of intimate area examination and sexual history taking during undergraduate clinical skills training: A study from two Saudi medical colleges.
      ] with 234 participants and a Malaysian study [
      • Ariffin F.
      • Chin K.L.
      • Ng C.
      • Miskan M.
      • Lee V.K.
      • Isa M.R.
      Are medical students confident in taking a sexual history? An assessment on attitude and skills from an upper middle income country.
      ] with 379 final-year medical students named lack of training as a barrier. Furthermore, a UK study [
      • Jackson K.B.
      • Fraser D.
      A study exploring UK midwives' knowledge and attitudes towards caring for women who have been sexually abused.
      ] with 372 midwives identified avoidance of harm as a barrier, as some participants were worried about giving an inappropriate response to the patient and therefore making the situation worse. In our study, almost seven out of ten students in both groups considered fear of failing to respond to patients’ sexual health issues to be a barrier.
      Another barrier reported in our study was lack of time, particularly for the medical students. This finding confirms the assumption that dealing with sexual health issues is considered time-consuming. Previous studies have also reported time constraints [
      • Magnan M.A.
      • Reynolds K.
      Barriers to addressing patient sexuality concerns across five areas of specialization.
      ,
      • Leyva-Moral J.M.
      • Aguayo-Gonzalez M.
      • Palmieri P.A.
      • Guevara-Vasquez G.
      • Granel-Grimenez N.
      • Dalfó-Pibernat A.
      Attitudes and beliefs of nurses and physicians about managing sexual health in primary care: A multi-site cross-sectional comparative study.
      ,
      • Barnhoorn P.C.
      • Zuurveen H.R.
      • Prins I.C.
      • van Ek G.F.
      • den Oudsten B.L.
      • den Ouden M.E.M.
      • et al.
      Unravelling sexual care in chronically ill patients: the perspective of GP practice nurses.
      ,
      • Walker S.H.
      • Davis G.
      Knowledge and reported confidence of final year midwifery students regarding giving advice on contraception and sexual health.
      ,
      • Percat A.
      • Elmerstig E.
      “We should be experts, but we're not”: Sexual counselling at the antenatal care clinic.
      ,
      • Ören B.
      • Zengin N.
      • Yazıcı S.
      • Akıncı A.Ç.
      Attitudes, beliefs and comfort levels of midwifery students regarding sexual counselling in Turkey.
      ]. In a US study [
      • Magnan M.A.
      • Reynolds K.
      Barriers to addressing patient sexuality concerns across five areas of specialization.
      ] with 302 nurses from various specialties, the participants reported time constraints as one of the main barriers. In addition, midwives in the above-mentioned Swedish study [
      • Percat A.
      • Elmerstig E.
      “We should be experts, but we're not”: Sexual counselling at the antenatal care clinic.
      ] described time as a very important factor, as a good relationship with trust must be developed between patient and midwife before raising issues related to sexuality [
      • Percat A.
      • Elmerstig E.
      “We should be experts, but we're not”: Sexual counselling at the antenatal care clinic.
      ].
      In our study, a majority of the medical students and around half of the midwifery students reported receiving too little sexual medicine education. These results confirmed the findings of earlier studies showing the need for continuous education [
      • Walker S.H.
      • Davis G.
      Knowledge and reported confidence of final year midwifery students regarding giving advice on contraception and sexual health.
      ,
      • Percat A.
      • Elmerstig E.
      “We should be experts, but we're not”: Sexual counselling at the antenatal care clinic.
      ,
      • Jackson K.B.
      • Fraser D.
      A study exploring UK midwives' knowledge and attitudes towards caring for women who have been sexually abused.
      ,
      • Ören B.
      • Zengin N.
      • Yazıcı S.
      • Akıncı A.Ç.
      Attitudes, beliefs and comfort levels of midwifery students regarding sexual counselling in Turkey.
      ,
      • Warner C.
      • Carlson S.
      • Crichlow R.
      • Ross M.W.
      Sexual health knowledge of U.S. medical students: a national survey.
      ,
      • Komlenac N.
      • Siller H.
      • Hochleitner M.
      Medical students indicate the need for increased sexuality education at an Austrian medical university.
      ]. In a US study [
      • Warner C.
      • Carlson S.
      • Crichlow R.
      • Ross M.W.
      Sexual health knowledge of U.S. medical students: a national survey.
      ] with 1,014 medical students, only 36.4 % of the participants reported receiving excellent or adequate education in sexual medicine during their medical studies. Midwifery studies have collected similar reports [
      • Walker S.H.
      • Davis G.
      Knowledge and reported confidence of final year midwifery students regarding giving advice on contraception and sexual health.
      ,
      • Percat A.
      • Elmerstig E.
      “We should be experts, but we're not”: Sexual counselling at the antenatal care clinic.
      ,
      • Jackson K.B.
      • Fraser D.
      A study exploring UK midwives' knowledge and attitudes towards caring for women who have been sexually abused.
      ,
      • Ören B.
      • Zengin N.
      • Yazıcı S.
      • Akıncı A.Ç.
      Attitudes, beliefs and comfort levels of midwifery students regarding sexual counselling in Turkey.
      ]. Furthermore, in our study, a majority of both student groups preferred mandatory education. In concordance with an Austrian study [
      • Komlenac N.
      • Siller H.
      • Hochleitner M.
      Medical students indicate the need for increased sexuality education at an Austrian medical university.
      ] with 391 medical students, the medical students in our study preferred that sexual medicine be integrated into other subjects. As for the method of education in sexual medicine, both student groups preferred lectures and workshops. These are practical and widely used teaching techniques in both medical and midwifery education that previous studies have also discussed [
      • Walker S.H.
      • Davis G.
      Knowledge and reported confidence of final year midwifery students regarding giving advice on contraception and sexual health.
      ,
      • Komlenac N.
      • Siller H.
      • Hochleitner M.
      Medical students indicate the need for increased sexuality education at an Austrian medical university.
      ].
      Our study was essential, as it was the first study to explore and to compare the education in sexual medicine among medical and midwifery students in Finland and, to the best of our knowledge, in Scandinavia overall. Furthermore, our study was one of the few studies evaluating several aspects of the barriers to bringing up sexual health issues among medical and midwifery students. The number of participants in our study can be considered sufficient even though it was not as high as in some of the previous studies in the same field [
      • Ören B.
      • Zengin N.
      • Yazıcı S.
      • Akıncı A.Ç.
      Attitudes, beliefs and comfort levels of midwifery students regarding sexual counselling in Turkey.
      ,
      • Warner C.
      • Carlson S.
      • Crichlow R.
      • Ross M.W.
      Sexual health knowledge of U.S. medical students: a national survey.
      ]. We included only final-year students in order to account for the full scope of their education, and thus when compared to similar studies [
      • Abdulghani H.M.
      • Haque S.
      • Irshad M.
      • Al-Zahrani N.
      • Al-Bedaie E.
      • Al-Fahad L.
      • et al.
      Students' perception and experience of intimate area examination and sexual history taking during undergraduate clinical skills training: A study from two Saudi medical colleges.
      ,
      • Ariffin F.
      • Chin K.L.
      • Ng C.
      • Miskan M.
      • Lee V.K.
      • Isa M.R.
      Are medical students confident in taking a sexual history? An assessment on attitude and skills from an upper middle income country.
      ] with medical students, we reached similar participant levels. Furthermore, as Finland is a country with a small population (approximately 5.5 million), thus having a smaller annual number of students in both medical and midwifery colleges, it could be assumed that our participant size represented the examined issue rather well. Our response rates of 41.5 % and 51.8 % (for medical and midwifery students, respectively) could be considered only moderate; however, they fell into the range of previous studies, from 12.3 % [
      • Komlenac N.
      • Siller H.
      • Hochleitner M.
      Medical students indicate the need for increased sexuality education at an Austrian medical university.
      ] to 70.0 % [
      • Ariffin F.
      • Chin K.L.
      • Ng C.
      • Miskan M.
      • Lee V.K.
      • Isa M.R.
      Are medical students confident in taking a sexual history? An assessment on attitude and skills from an upper middle income country.
      ]. The link to our questionnaire was distributed to the participants mainly via their teachers or teaching coordinators. This could have had either a positive or a negative influence on the students’ willingness to participate in our study. In addition, graduating students often get surveys, so our questionnaire might not have aroused higher interest compared to the other possible survey topics. One of the merits of our study was the piloting of our study questionnaire, allowing us to revise the content. As we included only students who studied in Finland, our results may not be directly applicable to medical and midwifery students in other countries. It is also possible that students who are particularly interested in sexual medicine participated in our study. However, we assessed the frequency of facing patients with sexual problems and found that students without this experience also participated; therefore, it is unlikely that the students’ special interest in sexual medicine would have biased our results.

      Conclusions

      Although both medical and midwifery students considered themselves to be fluent in discussing sexual health issues with their patients, they undisputedly revealed having difficulties in evaluating the patients’ sexual problems. Several barriers to bringing up sexual health issues with their patients also emerged. Hence, our study clearly showed a great need to enhance sexual medicine education in the curriculum, especially for medical students.

      Declaration of Competing Interest

      The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

      Acknowledgments

      The authors would like to thank the medical and the midwifery students who contributed their time to this research.
      The SexMEdu Study was supported by grant from The Finnish Medical Society Duodecim and The Federation of Finnish Midwives.

      Appendix A. Supplementary data

      The following are the Supplementary data to this article:

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      Biography

      Sanna-Mari Manninen is Master of Health Care, a registered midwife/nurse and a certified sexual counselor. She is currently finishing her PhD studies in the Faculty of Medicine, University of Turku, Finland. Her research focuses on developing education of sexual medicine especially in medical and midwifery studies. She has worked for over 10 years with medical students teaching e.g. examination of pregnant women. Currently she works as a senior lecturer in midwifery in Metropolia University of Applied Sciences in Helsinki, Finland.
      Katja Kero is a post-doctoral researcher at the Department of Obstetrics and Gynecology in Turku University Hospital and at the University of Turku, Finland. Her research focus is improving the sexual medicine education, screening of domestic violence and HPV infection and vaginal microbiota. As she is a gynecologist, sexual counselor and psychotherapist, her clinical work focuses on treating sexual disorders, trauma after sexual violence and other issues related to sexual health. She loves both research and clinical work and dreams of a world where sexual rights are truly recognized and implemented as a part of human rights.
      Markus Riskumäki works for the University of Turku in the Unit of Biostatistics, which belongs to the Department of Clinical Medicine, as a biostatistician. He works with all kinds of different research groups in the scientific field of medicine. His work entails consulting, data management, performing statistical analyses, as well as publication writing.
      Tero Vahlberg is a biostatistician at the Department of Biostatistics at the University of Turku.
      Päivi Polo is Professor in Obstetrics and Gynecology in Turku University, Finland and a specialist in Obstetrics and Gynecology in Turku University Hospital. Her scientific research comprises topics in menopause, hormone replacement therapy, cognition, sleep quality (both in menopause and in pregnancy), hyperemesis gravidarum, induction of labor and sexual medicine education. She has published in international journals and books altogether 111 articles and reviews. Päivi Polo has supervised 8 PhD thesis and is currently supervising 8 PhD thesis. She has gained altogether 15 honors and prizes from her research and teaching.