What do physicians know about human sexuality? What do they know about healthy sexual functioning, psychosexual development, sexual disorders, sexual orientation, and the behaviors of those who commit sexual offenses? Are physicians appropriately educated to approach patients’ potential reluctance in discussing sexuality and sexual health? Should not medical educators ensure that physicians are adequately educated on all aspects of the topic, given its likelihood to present for almost every specialty? It is an obvious topic for obstetrics and gynecology, urology, and family medicine, but it is also clearly significant for psychiatry, emergency medicine, pediatrics, geriatrics, surgery, internal medicine, and every other specialty that has occasion to address sexual dysfunction or prescribe a medication with possible sexual side effects.
This is not a new topic, nor is it new to address the content of instruction appropriate for medical curriculum. An editorial from a 1966 issue of the Annals of Internal Medicine (1) referenced a study comparing medical and law students and found that students entering each program were equal in their limited knowledge of sexual topics. The medical graduates scored better than the law school graduates but still scored below what was expected of physicians.
The Liaison Committee on Medical Education (LCME) accreditation standards (2) require that “the curriculum must include behavioral and socioeconomic subjects, in addition to basic science disciplines.” The LCME standards do not clarify the meaning of “behavioral and socioeconomic subjects” beyond listing content that includes “human development/life cycle, human sexual/gender development and human sexuality/sexual functioning.” Although human sexuality is considered one topic that must be covered under this standard, no guidelines exist for implementation. Medical schools must independently institute curriculum that adddresses sexual health. This column describes one attempt using a multidisciplinary and multiple modality approach and serves as a starting point for dialog among medical educators.
Sexual Knowledge and Attitude Test
Before beginning the sexuality section of Introduction to Clinical Medicine, students at University of South Carolina School of Medicine use the Internet to anonymously complete a shortened form of the Sexual Knowledge and Attitude Test (SKAT) originally developed by Lief and Reed in 1967 (3). The class SKAT results are reviewed on the first day of the human sexuality section; this typically creates lively discussion in small groups and emphasizes that even among first-year medical students, sexual knowledge, attitudes, and behaviors vary. It also reinforces the need for all physicians to have baseline knowledge for competent treatment of their patients. Haslegrave and Olatunbosun (4) suggested that the curriculum should include a means for students to acquire understanding of their own sexuality and its potential to affect patient care. This exercise facilitates awareness and tolerance, just as Wood and Natterson (5) advocated 40 years ago and the Surgeon General (6) promoted again at the beginning of this decade. The questionnaire results can also be used in didactics by providing accurate information of which students’ responses indicate misconceptions and ignorance. By using anonymous results, no student is highlighted for embarrassment, which is counterproductive to learning. The SKAT is the most commonly used instrument of its type in medical school programs and the most psychometrically supported (7). Self-reporting bias must be considered, but this is likely lessened in the anonymous format.
Of the 17.5 hours devoted to human sexuality in Introduction to Clinical Medicine, approximately 7 hours are lecture. Topics include sexual development throughout the life cycle, child and adolescent sexual problems, adult sexual dysfunction, normal pregnancy, paraphilias, and the health needs of gay and lesbian patients. Haslegrave and Olatunbosun (4) suggest that the curriculum include “counseling and communication skills,” soliciting and managing sensitive information, cultural and social factors affecting sexual behavior and disclosures, and awareness of the variety of sexual behaviors.
Since the early 2000s, the human sexuality section has begun with a panel of “sexperts” who answer questions that students submit anonymously. Three to four faculty members, representing internal medicine, pediatrics, and psychiatry/psychology, respond to the class. Although many questions are provocative, the panel strives to provide medically accurate information while acknowledging students’ anxiety and curiosity about sex. Past questions have ranged from basic genital anatomy and physiology to more subjective issues such as social “normalcy” of various sexual practices.
A highlight of the section is for students to interact with community members. The presentations have included a family physician and transsexual patient and physicians and other health practitioners who treat HIV-positive patients. Since the introduction of the course, one consistent guest has been a local mental health professional who was in a car accident, resulting in his being wheelchair-bound since his teen years. Students have heard about his initial despair, his subsequent marriage, and his fathering of children. He puts a human face on sexuality for a person with a spinal cord injury, and students appreciate his willingness to share his perspective with them.
Using film in the human sexuality section has diminished somewhat to decrease controversy, encourage students to focus on the important content, and make way for more experiential learning. Students are shown the “Biology of Love” from The Learning Channel’s series The Human Animal, which covers the sexual response cycle. Students also see a film on taking a sexual history that shows health practitioners taking sexual histories from actual patients. Nusbaum and Hamilton (8) suggest that observing faculty appropriately addressing the topic improves tolerance and facilitates learning. Wimberly and Moore (9) also support the use of modeling by faculty physicians for medical students and residents to learn how to take an appropriate sexual history.
During each week of the 3-week human sexuality section of Introduction to Clinical Medicine, students meet in small groups to discuss the material that has been presented in all the formats noted earlier. Groups meet for 1.5 hours during the first 2 weeks and for 3 hours the final week, when simulated patient interviews are incorporated. The general structure of the Introduction to Clinical Medicine course is for students to meet in small groups every week with one or two facilitators. By the time we reach the human sexuality section, the same students have been meeting together for two semesters, which seems to allow for a more open discussion of human sexuality than might otherwise happen if the groups were newly formed. Care is taken to also have the same small-group facilitators, but because of scheduling conflicts this has not always occurred. As Woods (10) described 40 years ago, and others have echoed several times since, the group format can provide a natural cross-section of sexual knowledge, experience, values, perspectives, and possibly socioeconomic histories. Ideally, the result is a sampling of the social strata, allowing students to hear firsthand the sexual opinions, perspectives, and sometimes the experiences of others. The setting also facilitates the discussion of controversial and affect-laden subjects in an already typically personal, and thus secretive, area of human functioning.
Small-group topics include SKAT results, panel discussion questions, and these didactic presentation topics: Sexuality in Culture and Medicine, Sexuality through the Life Cycle, Psychosexual and Gender Development, Child and Adolescent Sexual Problems, Normal Pregnancy, Paraphilias, Health Needs of Gay and Lesbian Patients, Taking a Sexual History, Male and Female Sexual Dysfunction, Spinal Cord Injuries and Sexuality, and the Sexual Response Cycle. Faculty members are recruited from both primary care and behavioral health specialties. Because sexual health can cross multiple disciplines, Haslegrave and Olatunbosun (4) recommend having faculty from various specialties involved.
A new addition to the human sexuality section is the use of simulated patients, with whom students practice taking a sexual history. Consistent with the literature, we have found that sometimes even just getting students to ask patients about sexual behavior is difficult, and this experience allows them to do so as part of a small group exercise and in the context of taking a sexual history of a patient. Each simulated patient presents with a common clinical problem (e.g., impotence, lack of desire, or symptoms of a sexually transmitted disease) that requires a student to take a sexual history (sample scenarios available from authors on request). This activity also introduces students to a diverse group of individuals and sexual practices, not unlike their future patient population. Faculty facilitators use these sessions to correct inaccurate factual knowledge, promote tolerance, and demonstrate history-taking approaches for students.
With the recent opening of a sexual behaviors evaluation, research, and treatment clinic and laboratory at the University of South Carolina School of Medicine, students and residents can take electives focused exclusively on human sexual behaviors. Both clinical and research options are available, and students can also combine these into a single elective. Third-year students can take a 2-week elective, and fourth-year students can take a 4-week elective. The clinical variation includes participation in evaluations of problem and/or offending sexual behaviors for treatment providers and criminal and civil courts. In addition, both individual and group treatment of persons with histories of paraphilic, obsessive-compulsive, and offending and other problem sexual behaviors are offered. Students are introduced to both psychoeducational and pharmacological treatment and management approaches.
Methods for teaching sexual health that appeal to multiple learning styles and settings and that simulate the world of practice, when an actual health setting is unavailable or impractical, are preferred. A multifaceted approach can be implemented with minimal resources yet can provide a broad learning experience. There is always potential for improvement, but the model presented here can serve as a foundation for others to draw from and to encourage further discussion of sexual health topics among medical educators.