RESEARCH – Are sexual and reproductive health and rights taught in medical schools? Results from a global survey

by Margit Endler, Taghreed Al-Haidari, Chiara Benedetto, Sameena Chowdhury, Jan Christilaw, Faysal El Kak, Diana Galimberti, Miguel Gutierrez, Shaimaa Ibrahim, Shantha Kumari, Colleen McNicholas, Desiré Mostajo Flores, John Muganda, Atziri Ramirez-Negrin, Hemantha Senanayake, Rubina Sohail, Marleen Temmerman, Kristina Gemzell Danielsson

International Journal of Gynecology and Obstetrics, 9 July 2022  (Open access)

Our aim was to investigate the inclusion of sexual and reproductive health and rights (SRHR) topics in medical curricula and the perceived need for, feasibility of, and barriers to teaching SRHR. We distributed a survey with questions on SRHR content, and factors regulating SRHR content, to medical universities worldwide using chain referral. Associations between high SRHR content and independent variables were analyzed using unconditional linear regression or χ2 test. Text data were analyzed by thematic analysis. We collected data from 219 respondents, 143 universities and 54 countries. Clinical SRHR topics such as safe pregnancy and childbirth (95.7%) and contraceptive methods (97.2%) were more frequently reported as taught compared with complex SRHR topics such as sexual violence (63.8%), unsafe abortion (65.7%), and the vulnerability of LGBTQIA persons (23.2%). High SRHR content was associated with high-income level (P=0.003) and low abortion restriction (P=0.042) but varied within settings. Most respondents described teaching SRHR as essential to the health of society. Complexity was cited as a barrier, as were cultural taboos, lack of stakeholder recognition, and dependency on fees and ranking.

The questionnaire was answered by 219 respondents from 143 universities in 54 countries. Data synthesized from multiple responses represented 21 universities. Most respondents were teachers (n=123, 89%). Forty-four percent of respondents were from universities in Asia/Oceania, the remaining respondents were evenly distributed among the other regions. The student population ranged from below 500 to 5,000 students. Half of all universities had SRHR as a specified topic (n=74, 51.7%). One-third (n=45, 31.5%) had teachers appointed to teach SRHR. A minority of respondents (n=12, 8.4%) estimated that more than 20 hours were spent on SRHR topics in the curriculum. SRHR as a specified topic, SRHR-appointed teachers, and more than 20 hours allotted to teach SRHR, were associated with a high total SRHR score.…

Most curricula included clinical SRHR topics such as the treatment of sexually transmitted infections and HIV (n=139, 97.9%), contraceptive methods (n=138, 97.2%), and safe pregnancy and childbirth (n=134, 95.7%). Fewer curricula included topics related to SRHR violations and complications, such as unsafe abortion (n=92, 65.7%), sexual violence and rape (n=90, 63.8%), and gender-based and domestic violence (n=74, 52.8%). Fewer than half of the curricula contained complex SRHR topics such as the determinants of SRHR (n=65, 45.8%), interculturality (n=52, 37.4%), and the vulnerability of LGBTQIA persons (n=33, 23.2%), or international recommendations on SRHR (n=29, 20.6%).

Clinical SRHR topics were universally taught in medical schools across the study settings, whereas complex SRHR topics were more variably taught. Overall, SRHR content was associated with both income level and abortion legislation. Respondents recognized the need and urgency of teaching SRHR given their substantial societal impact and believed it to be feasible despite identifying contextual risks and barriers that would have to be mitigated to achieve this.

The present study is, to our knowledge, the first global survey among providers of medical education on what SRHR topics are included in medical education and how they perceive the need for, feasibility of, and barriers to including SRHR topics in the curriculum. The study has several limitations. The data are self-reported, so are subject to the biases and limitations in knowledge with which the respondents answered the questionnaire. The survey was chain-referred to recipients across the world and although all continents are represented, we are unable to determine the overall response rate, so the extent to which our sampling adequately and proportionally reflects our study population is unknown. Our text data were extracted based on only three questions with narrowly focused research questions, which although providing nuance to the quantitative data, are limited in the scope of the analysis. For a comprehensive understanding of the contextual factors regulating SRHR content, in-depth interviews would have been required. The survey was available in English and Spanish, language barriers may have resulted in the exclusion of some potential respondents. Our results therefore provide only an estimate of the extent to which SRHR topics are taught, the contextual variations that exist, and the barriers that exist to teaching them at medical universities.

Our results indicate that clinical SRHR topics are uncontroversial components of most curricula, supported by the lack of association to contextual factors and a low variance in clinical SRHR scores. Complex SRHR topics were, however, often missing from curricula. This is consistent with a Swedish report that found that topics such as sexual violence, sex for compensation, and heteronormativity were universally missing from medical curricula. Our findings suggest that complex SRHR issues may be omitted from medical education to an increased degree in countries with lower income and restricted access to abortion. It was also in relation to teaching complex SRHR topics that some respondents expressed reservations. In these settings SRHR sensitization among students should be prioritized to advance gender equality and health equity.

Student attitudes to SRHR seem to influence how students go on to provide SRH services. In our study, teachers and students alike cited their lack of knowledge of SRHR as an incentive, but also as a barrier to the incorporation of these topics in curricula. Previous research supports that both teachers and students are unfamiliar with SRHR concepts, particularly non-normative and social aspects of SRH.

Universal access to SRHR is integral to achieving not only improved reproductive health and gender equality but also poverty reduction and reduced global inequality. Non-stigmatized, accessible SRH services will develop in the joint presence of an empowered demand from the public and a recognition from providers of the value of these services. Medical education is a natural forum for sensitizing future doctors to their role in this equation. Doctors who know how the safe expression of gender identity and sexuality influences autonomy, how child marriage affects literacy, and how informed contraceptive choice and safe abortion influence poverty reduction, are better equipped to lead reforms toward universal and equitable health services. Our results support that SRHR topics should be integrated longitudinally in medical curricula. To achieve global reach, a universal curriculum for SRHR should be considered.

In conclusion, the results support that while complex SRHR topics are often omitted from medical curricula, teachers both support and recognize the value of comprehensive inclusion of SRHR education in medical school, and recognize context-specific barriers.