There is substantial knowledge about human immunodeficiency virus—type 1 (HIV) and a belief that education is an effective tool for preventing infection. Although most physicians and medical students are knowledgeable about HIV, many are still uncomfortable taking a patient's sexual history (1—3). Medical students were rated as excellent in taking sexual histories when they were being instructed; however, significant decreases in performance were observed when students were not directed while taking the histories of patients with an HIV risk factor (4). Physicians' efficacy in caring for patients at risk of sexually transmitted diseases and HIV does not appear to be related to their level of education. Boekeloo et al. (5) reported that physicians' perceptions of the importance of addressing sexual issues and risk reduction were not altered after they received educational information on that topic. Additionally, negative attitudes toward homosexuality and persons with HIV persist (6,7). The AIDS epidemic has led to fear and ostracism not only by the lay community, but by physicians as well (7,8). Physicians may be shunning areas of medicine that deal with HIV/AIDS. Psychiatric residents, family practice residents, and psychiatric faculty in a Canadian medical school were found not to have general knowledge of AIDS or to be aware of published statistics on the disease (7). Knowledge of HIV/AIDS, as well as perceptions and motivations, may influence personal and professional choices of physicians (9).
Physicians are expected to provide information and counseling on healthy lifestyles, yet many physicians have not accepted this role (9). Their patients expect and want these exchanges (10). When dealing with sexuality, however, physicians tend to be conservative and to have difficulty addressing such issues with their patients. Although these studies found that physicians have trouble discussing sexual matters with their patients, there are no studies examining whether physicians are able to discuss and negotiate sexual behaviors with their own partners. It is possible that this discomfort with expressing sexual attitudes, behaviors, and practices places not only patients, but also physicians themselves at risk.
A review of the literature identified only two studies that examined the sexual behaviors of physicians. One study surveyed gay male physicians in 1984 and 1985, focusing on HIV transmission and the changes that gay physicians had made in social, health-related, and sexual activities since the AIDS epidemic (3). Although physicians had significantly lowered their participation in risky behaviors and replaced these with more "erotic and sexual" activities, these changes were associated with decreased satisfaction, suggesting that sustained change was questionable and recidivism likely. In another study, Klein et al. (11) examined sexual behaviors and attitudes about AIDS and its transmission in homosexual physicians and male university students. The researchers designed a self-report questionnaire that assessed knowledge and attitudes about AIDS, health concerns, lifestyle, gay community concerns, social support, and changes in sexual activities since the onset of the AIDS epidemic. Both groups reported marked decreases in AIDS risk behaviors, acknowledging that high numbers of sexual partners, specific sexual acts, and exchanges of bodily fluids were factors for transmission. The physicians had more personal knowledge than students did of individuals who had contracted AIDS or died from AIDS, and level of knowledge was correlated with change in behaviors. There were no similar studies on heterosexual physicians and medical students.
The question of whether physicians are engaging in risky sexual behavior or whether they are making use of their medical knowledge and experiences to avoid it needs to be explored. Importantly, there is doubt as to whether education changes behavior, and there are multiple reasons why people place themselves at risk (12—16). In order to understand possible reasons for engaging in risky behavior, each subgroup must be identified and examined. This pilot study assesses the sexual practices of resident physicians who have knowledge and patient experiences attained through a medical education regarding HIV/AIDS, as compared with graduate students who lack this specialized education.
A cross-sectional survey of residents (psychiatry, internal medicine, surgery, obstetrics/gynecology, and pediatrics) and graduate students (social work and law) was conducted at a state university. The Safe Sex Behavioral Questionnaire was placed in campus mailboxes, followed by a second mailing 2 weeks later. A letter describing the project and informing potential participants of confidentiality and anonymity was also included, along with a return-addressed envelope. DiIorio's Safe Sex Behavior Questionnaire, a valid and reliable instrument assessing sexual practices (17), is composed of 27 items rated on a four-point scale ranging from never (1) to always (4). Thus, higher scores reflected increased risk-taking behaviors, such as always engaging in oral sex without a condom or always having sex without a condom if a partner insists. Safe sex behaviors included sexual practices that avoided or reduced the risk of exposure to HIV. The items asked about protection during intercourse, avoidance of risky behaviors, avoidance of bodily fluids, and interpersonal skills to elicit history and negotiate the use of safe sex practices, as well as demographic information including the number of partners over the previous 5 years. The survey took 5 minutes to complete. In addition, brief postsurvey face-to-face interviews were conducted with participants who wanted to provide feedback.
Descriptive statistical analyses were conducted. Subjects who were sexually inactive were excluded from further analyses. Factor analyses were used to reduce the number of variables. Chi-square tests and t-tests were then used to assess differences in perspective on sexual practices by gender and type of education.
Of the 230 surveys sent out to the medical residents, 44 (19%) were returned. This total included 24 returned surveys from 38 psychiatry residents surveyed, yielding a response rate of 63% among only the psychiatry residents. Of the 60 social work students surveyed, 39 (65%) responded. The 258 law students, who had only one mailing, returned 49 surveys (19%). Thus, the overall response rate for graduate students was 28%.
The two groups (residents and students) were similarly composed of multiethnic participants, including Caucasians (n=40), Pacific Islanders (n=5), Asians (n=45), mixed (n=17), and other groups (χ2=8.44, df=6, P=0.21). Seventy-five percent of the graduate students and 40.5% of the residents were younger than 30 years of age (χ2=33.43, df=4, P<0.001). However, we did not consider this difference to be socially significant. There was no difference by gender (χ2=2.98, df=1, P=0.084).
Of the 132 participants in the study, 39% reported having 1 partner in the last 5 years, 43.7% reported having between 2 and 5 partners, 9% had 6 to 10 partners, and 4% reported more than 11 partners. Six participants were not sexually active. The sexual orientation reported by 92.4% was heterosexual; 5.3% identified themselves as homosexual and the remainder as bisexual. The majority were single (68%).
Factor analysis indicated separate gender-related factors. For women (n=84), the sexual behavior factors were 1) assertion or proactive behavioral history-taking and preparation, such as carrying a condom and having a mental plan; 2) condom use; 3) oral and anal sexual behavior; and 4) risk (sex on first dates, drug and alcohol use). The factors for men (n=48) included 1) assertion (condom use and preparation); 2) history taking; 3) homosexual behavior; and 4) risk (sex on first dates, drug and alcohol use).
The differences between female residents and female graduate students in each of the factors were not statistically significant. However, women were at significant risk. High-risk behaviors (mean scores) included not carrying condoms (2.82), not insisting on condoms (2.72), not stopping foreplay for condom use (2.59), not avoiding body fluids (3.16), not planning for safer sex (2.36), not initiating the topic of safe sex (2.26), not using a condom or dental dam when engaging in oral sex (2.88), and not asking about homosexual history (2.70) and drug history (2.45) (F1).
There was no significant difference between the number of partners and respondent's field of educational study. Regardless of field of education, women with two or more partners were more likely to engage in risky behaviors, specifically in sex on the first date (mean scores: one partner, 1.12; two or more partners, 1.33; t=2.23, P=0.028) and in oral sex (one partner, 2.64; two or more partners, 3.12; t=2.07, P=0.043). They were also less likely to abstain from sex when partner's history was unknown (one partner, 1.60; two or more partners, 2.19; t=2.42, P=0.018) and less likely to state their point of view (one partner, 1.32; two or more partners, 1.68; t=2.23, P=0.028).
Among men, there were no significant differences between the cohorts. However, men were still at high risk. Men were more likely (by mean scores) to engage in risky (2.90) and homosexual behaviors (2.84) and not to use condoms (2.77) or obtain histories (2.21). Specifically, men reported not carrying condoms (2.83); not insisting on condoms (2.56); not refusing intercourse without a condom (2.60); not stopping foreplay for condom use (2.47); not avoiding body fluids (3.28); not planning for safer sex (2.36); not initiating the topic of safe sex (2.71); not asking about sexual (2.76), homosexual (3.36), or drug histories (2.76); not abstaining for unknown history (2.61); and engaging in oral sex (2.84) (F2).
There was no significant difference between the number of partners reported by men and their field of educational study. Regardless of education, men with multiple partners were more likely to use condoms (mean score: one partner, 3.00; two or more partners, 2.24; t=2.05, P=0.048) and to be prepared for sex (one partner, 3.30; two or more partners, 2.31; t=2.70, P=0.011).
An intrinsic limitation of this pilot study was the sensitivity of the topic, affecting the response rate. Even when assured of confidentiality, the potential participants were reluctant to complete the survey. Those who did respond, particularly residents, reported an unwillingness to discuss sexual behaviors with either their partners or their patients. Those more likely to participate in high-risk behaviors may not have completed the survey, making the results conservative. Regardless, the results show that physicians are resistant to examining their own sexual behavior, as also seen in earlier studies (3,11).
Higher response rates in two other studies that used the same sample provide support for the role of subject matter in the response rates. In two recent surveys of resident physicians in Hawaii, response rates were significantly better. Yun et al. (submitted for publication) reported a response rate of 91% in their study on attitudes among resident physicians toward the pharmaceutical industry, and Ham and Luke (submitted for publication) reported a 94% response rate among resident physicians in their study on attitudes toward patient medication noncompliance. Both of these studies included the same resident samples as this pilot study, as well as similar anonymous surveying methods. This large difference in response rates, as well as comments provided by participants, lend credence to the idea that the sensitivity of the subject matter deterred participation.
In the present study, the law school allowed only one mailing, citing the sensitive topic as a major reason. Comparing the data of a sample that received only one mailing with those of a sample that received two mailings was not an issue, however, because 95% of the responses were from the initial mailing.
Although the overall response rate of the resident physician population was 19%, the response rate among psychiatry residents was significantly higher at 63%. By nature of their training, psychiatry residents are exposed to various difficult-to-discuss topics such as death and dying, thoughts of suicide, child sexual abuse, and gender identity disorders. Perhaps, because of this exposure, they are more comfortable in discussing sexual behaviors and sexuality in general than are physicians in other areas of medicine. While physicians in some specialties, such as obstetrics and gynecology, would be expected to discuss sexual behavior and sexual health on a daily basis, those in other specialties such as pediatrics and surgery would rarely do so. This unfamiliarity with the topic may not only cause awkwardness when these physicians attempt to treat patients, but also affect private interpersonal relations with their own sexual partners. Because of the small sample size, statistical analysis of specialty differences among the resident physicians was not possible. However, future research would want to address whether a difference in sexual risk behaviors does exist among medical specialties and whether it is related to personal choices and patient care.
There are findings of interest on how long it has taken for education to affect smoking among physicians. Magnus (18) examined the smoking trends in physicians from 1964 to 1982, finding it took 18 years to modify behavior. Likewise, the question of whether physicians are engaging in "risky" sexual behavior or whether they are utilizing their medical knowledge and experiences about HIV needs to be further explored. Education alone may not have a significant influence on altering sexual risk behaviors. In addition, because sexual behaviors are more private, they lack the many social reinforcements that are seen with the antismoking campaign. That is, messages such as "no smoking" signs and billboards and commercials stating the consequences of smoking are frequent in our daily lives. Sexual behavior lacks this social reinforcement of what is safe and appropriate. Messages promoting safe sex are not as widespread as those about the dangers of smoking, and consequently the importance of changing sexual behaviors may not be appreciated.
This pilot study showed essentially no difference among sexual risk practices of resident physicians and graduate students. It did not show a causal impact of education. Future research should examine whether HIV/AIDS education provided in medical school curricula, as well as experience with HIV-infected patients, influences the sexual practices of residents when compared with graduate students. Such research should also examine other influential variables such as perceptions and motivations.
As expected, we found gender differences, and we therefore analyzed the data separately by gender. Although the sample size was relatively small for conducting factor analysis, the author of the scale recommended that it be done if an adult sample was used (17). Our findings will need to be validated in a larger study. Among women, there were no differences between the cohorts. However, both groups reported engaging in high-risk behaviors, especially among those with multiple partners. That is, between 50% and 75% of the time, they reported participating in fewer safe-sex behaviors such as using condoms. Among men, there were no significant differences between residents and graduate students. However, men with multiple partners were slightly less risk-taking, suggesting better response by men than by women to AIDS education. This may be a consequence of the early AIDS awareness campaign having targeted primarily the male population and only recently addressing women, or it may be a consequence of different attitudes toward sexual behavior in the groups. Women may be more passive and men more apt to take charge. Nevertheless, reasons and motivations for placing oneself at risk are numerous (12). For example, nonuse of protective barriers may be rooted in culture or religion, or it may be a gesture of love and trust. The reasons why this young, highly educated population of physicians and graduate students continue to place themselves at risk are unknown.
Just as it took years for the percentage of smoking physicians to drop below that of the general population, perhaps it will take years before physicians' sexual behaviors are significantly safer than those of the general population. Physicians may perceive themselves as members of a low-risk group because of their socioeconomic status when actually their behaviors place them at significant risk. The need to examine risk-taking and susceptibility to HIV is critical because perception of risk is related to subgroup characteristics (9,19,20). While it is important to identify risk behaviors and perception to risk, it is also important to understand reasons and motivations behind the behaviors. It is important to note that although physicians or young professionals may not be defined as a high-risk group such as men who have sex with men or injection drug users, the behaviors of this population do place them at risk. Research may be doing a disservice to physicians and to young professionals in general by assuming their socioeconomic status precludes them from risk.
Although this pilot study suggests that knowledge does not necessarily influence behavior, there are other implications specifically addressing the training of physicians. That is, physicians are engaging in high-risk behaviors just as graduate students are, even though they have more education, training, and patient experiences pertinent to sexual risk behaviors. More research is therefore needed to understand the factors influencing the sexual risk choices of physicians. The medical curriculum may need not only to address the teaching of facts relevant to the sexual health of patients, but also to address physicians' values, perceptions, and motivations—factors relevant to personal and professional choices. A curriculum addressing these issues could be not only used for physicians, but also modified for other populations such as young professionals in general, to help increase communication regarding relationships, sex, sexual risks, and sexual health. It is important to acknowledge that physicians are becoming infected with HIV, and not solely due to work-related patient exposure. Medicine has taken steps in addressing some difficult-to-discuss topics such as substance abuse and impaired physicians, showing the reality that physicians are all too human; that while highly educated, they deal with many of the same problems as the rest of society. Medicine now needs to address another difficult-to-discuss subject, personal sexual health. The present study is a pilot and needs to be replicated with a larger sample as well as with other professional populations whose members may believe they can exclude themselves from risk because of their socioeconomic status. Future research is needed to examine the discrepancy between knowledge and practice among physicians; to address resistance to studying sexual risk-taking behaviors and attitudes; and to attempt to understand the reasons why these behaviors and attitudes persist.
The authors thank Jane Waldron, Ph.D., for her input on this study and her stimulating discussion of the topic.