Anita H Clayton, Sharon J Parish
Given the broad range of areas that need to be addressed in medical school and residency training, even fundamental subject matter may not be allotted the appropriate amount of curriculum time. Sexual health education is an example of an often neglected, but very important topic. Sexuality and associated issues play an incredibly important role in the lives almost all patients, yet this weight is not adequately reflected in most undergraduate and graduate medical education programs. Recently, educators are paying more attention to this gap, assessing it and piloting new curricula. The current interest in this topic will hopefully, in the next decade, generate medical school curricula that focus proper attention on this critical subject.
The current state of sexual health
A recent US poll indicates that 94% of adults feel that sexual pleasure adds to quality of life.1 Another national study published in 1999 showed that 43% of women and 31% men have sexual complaints.2 These statistics signify that sex is a vital part of many people’s lives, and problems can undercut the enjoyment it provides. Sexual dysfunction may occur at any point in the sexual response cycle (desire, arousal, or orgasm) and can be a primary problem or a secondary issue related to another disease process or medications (see Chapters 3.1—3.4 and 6.1—6.5 of this book). The consequences of untreated sexual dysfunction may include, for example, depression, conflicts within interpersonal relationships, or noncompliance with prescribed medication regimens.3,4,5 Researchers have made significant strides in understanding the mechanisms powering the male and female sexual response. This knowledge has enabled the development of new drugs capable of treating some forms of sexual dysfunction (see Chapters 13.1-13.3, 14.1, and 14.2). The next milestone will be the widespread distribution of this once considered taboo information to the patient population at large.
Despite the recognition of sexual dysfunction and the availability of treatment options, physicians and their patients still hesitate to discuss these issues (see Chapters 17.1-17.6). One study reports that 47% of patients have never been asked by their primary care physician if they are engaged in a sexual relationship.6 (see Chapters 17.1 and 17.5). Only 25% of primary care physicians actually take a patient’s sexual history, citing lack of training as the most common reason for not doing so.7,8,9 Physicians report other barriers such as insufficient knowledge of sexual function and dysfunction, lack of information about treatment options, time constraints during the patient encounter, personal biases about sexual issues, apprehension that their inquiries may offend the patient, and their own feelings of embarrassment about the subject.1,10,11,12
Patients are reluctant to bring up sexual issues with their doctors. A survey indicated that 75% of patients believe that their doctors would dismiss their sexual health concerns if their patients confronted them with that information. A substantial number (68%) feel that they would embarrass their doctors if they were to broach the topic.1 Ninety-one percent of patients, however, do believe that it is a physician’s role to address sexual health concerns; but only 10% of patients request assistance with these concerns if not prompted by their doctor.13
The data show that a chasm exists between doctor and patient. Physician education targeted at increasing knowledge and encouraging the recognition of personal biases is the key to minimizing obstacles that interfere with doctors addressing and optimizing sexual health.
The importance of sexual health in medical education
Sex is certainly a topic given much coverage in today’s popular society. However, medical school education and, consequently, accurate patient education on this subject have fallen far behind. Given the amount of misinformation that is available, it is critical that physicians disseminate correct information to their patients. Medical school and postgraduate training are the primary forums in which doctors need to acquire the necessary knowledge and skills.
In 1974, the World Health Organization assumed the task of clarifying the term “sexual health”.14 Their definition, revised in 2000, states that sexual health is: the experience of the ongoing process of physical, psychologic and socio-cultural well-being related to sexuality. Sexual health is evidenced by the free and responsible expression of sexual capabilities that foster harmonious personal and social wellness, enriching individual and social life. It is not merely the absence of disease, dysfunction or infirmity.15
Following this definition, 11 sexual rights were enumerated, including the right to sexual information based on scientific inquiry, the right to comprehensive sexuality education, and the right to sexual health care.16
Medical schools are charged with the responsibility of ensuring that these needs are met. Crucial areas to cover in medical school include conducting a comprehensive sexual health interview, awareness of causes and treatments of sexual dysfunction, recognizing and responding to signs of sexual violence, prevention and treatment of sexually transmitted infections, and understanding issues related to gay and lesbian sexual health. As well, medical schools should teach about the relationship between sexual dysfunction and other, more life- threatening health problems. They also need to teach students to recognize and handle their personal biases about sex. While it is important for students not to compromise their own values, it is equally imperative that these principles not interfere with patient care.17 The combination of increasing knowledge and confronting biases about sexual health in the forum of undergraduate medical education is an excellent start to dismantling the communication barriers that exist between doctor and patient concerning the issue of sexual health.
The current state of sexual education in medical school
Despite the statistics indicating that sexual dysfunction is prominent, affecting men and women of all age groups, races, and socioeconomic levels, sexual health education in the medical profession has only recently become a subject of interest. The slow dissolution of the taboo associated with this topic is associated with a concomitant rise in society’s willingness to discuss the subject. It should follow that physicians are adequately prepared to accommodate this paradigm shift, and the training to do so should begin in medical school.
A study in 2003 assessed the state of sexual health education in medical schools: a questionnaire was issued to 125 medical schools in the USA and 16 in Canada asking several questions about their education techniques.18 This survey was the first of its kind since the 1970s, when Harold Lief and his colleagues, fueled by the reform brought about by the sexual revolution, attempted a similar undertaking.19
In this recent study, the investigators received 101 valid responses. Two schools that did not complete the survey admitted that their curriculum dedicated no hours to sexual health education, and five other schools that did submit the survey stated that they were embarrassed at how little time their school devoted to the topic. At many schools, no one particular person was in charge of the sexual health curriculum. Most schools (83.1%) reported that they used a lecture format, and 81.2% of schools made attendance mandatory. Two-thirds of the schools used a multidisciplinary approach to teach sexual health. Members of the Department of Psychiatry were the most frequently utilized teachers and were incorporated into the curriculum at 75.3% of schools. About half of the schools offered 3-10 hours of training, whereas one-third spent 11 hours or more on the subject. The most common topics discussed were sexual dysfunction and its treatment, sexual identity/ orientation, and issues of sexuality in disabled or medically ill patients. Approximately half the schools allowed students to interact with patients receiving treatment for or education on sexual issues during their clinical experience.18
Postgraduate education in sexual health is understudied and unaddressed, lagging behind even the rudimentary efforts made in medical school. Much work is needed to create adequate curriculum and skills training in sexual health assessment and treatment in residency programs and beyond.
Research on sexual health education
Clearly, a wide range of effort is dedicated to sexual health education in medical schools. This disparity was also recognized by the pharmaceutical company, Pfizer, Inc., with the recent offer of seven grants to medical schools to evaluate and enhance their sexual health curricula. To apply, schools presented an outline of course work spanning the four years of undergraduate medical education covering the medical, psychologic, social, and ethical issues of sexual health care, and proposed assessments of and enhancements to the curriculum. Among the schools selected, the University of Virginia School of Medicine, Case Western Reserve University School of Medicine, and the University of Massachusetts Medical School have published data. Internationally, there have been also been efforts to evaluate the state of sexual health education.
In 2003, the University of Virginia School of Medicine released a study comparing knowledge of, comfort with, and attitudes toward the importance of sexual health among first-, second-, and third-year medical students.20 The University of Virginia uses a multidisciplinary approach to teaching sexual health, providing pertinent information within the following courses: Anatomy, Embryology, Histology, Physiology, Human Behavior, Pathology, Introduction to Psychiatry, and Practice of Medicine. The Practice of Medicine training included lectures on obtaining a sexual health history and screening for domestic violence, sexual history taking while role-playing and interacting with standardized patients, and gynecologic and genitourinary examinations performed on female and male standardized patients. First- and second-year students were given questionnaires on the first day of their autumn term before any curriculum improvements had been implemented, and third-year students participated via an email survey.
First-year students felt that they knew the least about obtaining a sexual history and the most about medications for treating sexual dysfunction.20 Interestingly, these students have not yet had a course in pharmacology, so their responses may reflect the prevalence of this information in the media. Both second- and third-year students claimed to be the most knowledgeable about taking a sexual history. Second-year students believed that they knew the least about sexual side effects of medications, while third-year students indicated that they knew the least about medications for treating sexual dysfunction.20 This difference in the perception of second- and third-year students about their knowledge and skills from first-year students may indicate that this information is not frequently addressed during the clinical years.
All three groups of students felt the least comfortable discussing sexually related health problems and the most comfortable discussing sexual side effects of medications.20 These responses may reflect students’ overall discomfort with discussing sensitive psychosocial issues. Of note, female students reported significantly less comfort in discussing these topics than male students.20
All three groups also agreed that discussing sexual health during a routine checkup was more important than during a problem-focused appointment. Second-year students thought that it was more important to discuss sex during office visits than either first- or third-year students. This decrease in perceived importance in the third year, which is the first clinical year the student experiences, may reflect the attending physician’s negative attitude toward a thorough sexual history in the inpatient setting, or the attending physician’s embarrassment in discussing sexual health with patients.20
In 2003, an Australian study reported the status of lesbian health care in medical education. Lesbians often delay seeking care despite specific risk factors associated with the population.21 This hesitance is understandable given that 23% of lesbian, gay, bisexual, and transgendered patients felt that they experienced discrimination in these situations.22 In 1994, half (52%) of the members of a US-based gay and lesbian medical association stated that they had observed colleagues providing less than adequate care to patients according to sexual orientation, and 88% have overheard fellow physicians make disparaging remarks about their patients’ sexual orientation.23 Finally, in a US survey, eight of the 82 medical schools that responded stated that they offered no teaching on gay and lesbian issues.24 This is clearly a gap in sexual health education that needs to be addressed.
An Australian study published in 1996 compared students’ personal sexual experiences with their confidence and ability to perform female pelvic examinations.25 Both male and female students who had sexual experience (153 of 286 students) felt more comfortable performing the examination, explaining their actions to their patients, and being able to detect disorder. The male students who had no sexual experience felt an overall lack of confidence and were more likely to want to perform gynecologic examinations with the patient under anesthesia.25
These data provide some insight into the current status of sexual health education in medical schools. Perhaps these data will motivate schools to conduct investigations into their own training programs, assess student knowledge and biases, and ascertain the most appropriate way to correct the problems that they discover.
New developments in medical sexual education
Some schools have already begun to reform their sexual health education programs. Case Western Reserve University School of Medicine is “in the process of implementing a comprehensive, cross-disciplinary and innovative curriculum that is based on three primary objectives for teaching sexual health: attitude change, behavior change, and knowledge acquisi- tion”.26 The first goal, attitude change, is being accomplished by encouraging the students to achieve a sense of self-awareness. The new curriculum emphasizes normal variations of sexuality and provides exposure to them, dispels myths, and teaches boundary setting, as well as appropriate ways to handle situations in which those boundaries are challenged. The second objective, behavior change, is being approached by enhancing communications skills among both faculty and students. Patients often will not initiate a discussion with their physicians if they appear uncomfortable or unwilling to discuss sexual health. The third goal, knowledge acquisition, involves a multidisciplinary approach to ensuring that all facets of sexual health are taught.
The school outlines several arenas in which these changes will take place, including “faculty development, additional didactics, case-based learning, testing and assessment, and electronic (computer/web-based) enhancements”.26 This innovative, multidisciplinary sexual health education initiative appears to be an excellent model for other schools.
The University of Massachusetts Medical School is also enhancing its current sexual health education curriculum. In the 1999-2000 academic year, several topics were added to the third-year curriculum, including teenage sexuality, health care for gay youth, lesbian health care, reproduction counseling in relation to HIV risk, and sexual dysfunction caused by medica- tions.27 In autumn 2001, the University of Massachusetts Medical School surveyed first- and second-year medical students to find the gaps in sexual health education. The problems identified included the idea that sex is private, students’ lack of knowledge, patient and student discomfort with the subject, and cultural differences. Specific topics that were considered to be particularly difficult were extramarital affairs, multiple partners, sexual violence, gathering sexual information from older patients, and patients who continue with high-risk sexual behavior despite education.27
Based on this survey data, the curriculum was further modified throughout the four years of medical education. During the first year, Anatomy students participated in a reflection session to discuss the thoughts and feelings they might have concerning the dissection of the female pelvis. Half of those who participated (with a 25% class participation rate) felt that the session reduced their apprehension about the dissection, and 95% wanted to have more sessions of a similar nature in the future.27 A one-hour session on the medical risks of the gay, lesbian, bisexual, and transgendered community was instituted during an interclerkship day in the students’ third year. About half of the class participated; and of those that did, 95% evaluated it as effective.27 The third modification was the addition of a one-week women’s health course available as an elective for fourth-year students. In this program, a multidisciplinary group of faculty utilized a variety of teaching methods. After attending this course, the students felt that their comfort level in discussing these subjects with their patients improved.27
In 1998, at the Stanford University School of Medicine, the medical students took the initiative to provide their own sexual health education. Second-year students organized a nine-session, weekly, lunchtime, elective lecture series entitled “Current Issues in Reproductive Health”.28 Students were given credit for simply attending the course. By 2001, attendance had grown to one-sixth of the preclinical medical student body. At this time, a “reproductive health fair” was added as part of the course, and opened to the university community with great success.28 Students who attended were surveyed in 2000 and 2001. They reported that the two most frequently acquired skills were the ability to discuss an unwanted pregnancy and the ability to communicate with patients of varying gender, sexual orientation, and culture. The survey also identified what the students considered the most useful learning methods, including having discussions with fellow students, engaging in interactive presentations with faculty, listening to traditional lectures, and teaching their peers.28 Stanford’s program offers a number of novel strategies that extend beyond the traditional methods, and that certainly could be implemented by other institutions.
Developments in international sexual medicine education
The recognition of and effort to correct the lack of sexual health education is not limited to the USA. Medical schools in the UK have also been reviewing and revising their curricula. The University of Cambridge initiated role-playing as a means of exploring sexual health issues.29 One of 14 scenarios was given to students, who alternate playing the physician and the patient. Two examples include a young homosexual man who has just “come out” but doesn’t know how to use a condom, and a woman interested in having an intrauterine device fitted. The goal of these mock clinic scenarios is to allow students to react to such situations, empathize with the patient, and discover and test beneficial behaviors.29 The University of Cambridge also has, for the last 20 years, conducted a session for its medical students dedicated to increasing awareness of homosexuality in the patient population.30 There are two main goals of the course. The first is to allow students “to explore internalized prejudice”; this is accomplished by having students brainstorm all the slang terms they know relating to homosexuality and then reflect silently on them for a few minutes. The second goal is “to look at the effects of prejudice”; students are asked to imagine that they are gay and decide how those terms would make them feel and what their subsequent behavior would be.30
Another medical school in the UK, Leicester-Warwick Medical School, recognized the importance of how medical students’ attitudes and values may influence their interactions with patients. This school initiated a course designed to help students to recognize their feelings; this involved the techniques of desensitization, problem solving, and reflection with the ultimate goal of self-development.31 Human sexuality is covered as part of a 12-week module on human diversity in the second year. A combination of teaching techniques is used, and the course moves from relatively unthreatening topics to those that may challenge students more. Sessions often contain attempts to desensitize the students to embarrassment by the discussion of sexual topics, including becoming familiar with slang and medical terms.31 The intent of these sessions is to provide students with a safe environment in which they can rehearse their reactions and responses to difficult topics related to sexual health. Most students (78%) felt that the course offered some benefit, and a similar number believed that it made them more sensitive to the needs of patients and the duties of doctors.31 This program is another thoughtful and innovative approach to the correction of the deficiency of sexual health education.
Society has become more willing to recognize and discuss sexual health, and physicians should be at the forefront of this campaign; yet, according to the data, that is not currently the case. To correct this deficiency, the process must begin with appropriate training in medical schools. The first step involves the analysis of the current state of sexual health education in medical schools. When the various needs are ascertained, new curricula can be developed that will give medical students the tools to provide good patient care to those with sexual health concerns. Such changes are being undertaken in both the USA and abroad. Hopefully, these schools will establish a trend that will inspire all medical schools to modernize their curriculum in sexual health education. Graduate medical education in sexual health is in its infancy, with much work remaining in order to enhance the practitioner’s ability to meet patient needs.
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