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SPOTLIGHT: Intimate Details

Schools shy away from sexuality training

The New Physician October 2007
Will any of your future patients need advice on the function of the clitoris, the timing of ovulation, the etiology of sexual dysfunction or the safety of coitus in late pregnancy? It’s highly likely. But will you have the answers—or be able to help them ask the questions?

Sadly enough, Cosmopolitan may prove to be a better sex-information resource than your average physician-in-training. For more than four decades, studies have found sexual ignorance running amuck in medical schools worldwide, with information beyond the biological rarely given proper time and attention.

Sexual function is a major quality-of-life factor, and sexual health impacts one’s physical, emotional and psychological well-being. Yet most medical schools are failing to train future physicians adequately, despite the modern-day doctor’s role as health educator, counselor and resource.

Sorely Lacking “Sexpertise”

“It surprised me that many of my colleagues didn’t have a background in sex ed,” shares Dustin Costescu, a fourth-year at University of Western Ontario School of Medicine & Dentistry. “Many of them have the same questions patients do. They don’t have more than public knowledge.”

Bias, anxiety, gaps in knowledge, misconceptions and discomfort with the subject are some reasons many physicians are ill-equipped and deficient in providing sex information and counseling to their patients. “In terms of sexuality [information], we’re not producing capable physicians,” states S. Michael Plaut, associate professor of psychiatry at the University of Maryland School of Medicine. “We need to, for example, think about who we conceive of as a sexual person beyond young, heterosexual people who can reproduce. If you’re over a certain age, or with chronic illness, disabilities, mental retardation…nobody wants to talk about that—and these people do have sexual issues.”

Not surprisingly, medical students find it difficult to develop comfort and the ability to discuss sexuality with patients, as New York-based sex counselor Eric Garrison can attest: “One thing that strikes me is how heterosexist medical students are,” he says. “I also find their knowledge of reproductive anatomy appalling, despite physiology classes. They confuse vagina with vulva all the time.” In his work training medical students and clinicians, Garrison often hears students ask why taking a sexual history is so important, and wonder aloud why patients won’t just volunteer what’s wrong. “They don’t get it,” he asserts.

He also finds that students can be very judgmental in the area of sex. “You can see it in their facial expressions—they can’t say herpes or HPV without cringing. I actually had a female medical student ask a patient, ‘You do what?’—and it all ended right there.”

A 2001 study among Harvard and University of Massachusetts medical students found that only 6 percent were “very comfortable” taking a sexual history of patients 55 years and older. Also, students were more comfortable discussing male erectile dysfunction than loss of libido or vaginal dryness in postmenopausal women. And there was a marked difference in students’ comfort levels in taking a sexual history from heterosexual versus homosexual patients, with the majority of respondents feeling unprepared to provide sexual counseling to the group not sharing their orientation. Based on the study’s findings, Harvard went on to create a sexual health awareness elective in 2005.

Thanks to mass media and the Internet, patients are becoming more sexually savvy. A better informed—and often misinformed—public now sees sex as suitable for discussion, is more concerned about sexual performance and is more willing to get help for sexual problems. Michael W. Ross, lead author of the book Sexual Health Concerns: Interviewing and History Taking for Health Practitioners, highlights the dilemma: “Because the physician is the first point of contact and referral, patients expect physicians to know about sex and to have a basic level of competence. We discovered this when Viagra came on the market. Doctors were shocked by the number of men who came in with erectile dysfunction, demonstrating how many physicians aren’t talking about it. [They] can’t talk about it or don’t want to raise the issue.”

A major consequence of this silence is that the sexual history is not taken often enough. Among the reasons physicians cite for not doing this are concerns over patient discomfort, belief that a sexual history is irrelevant to the chief complaint, inadequate training or knowledge about what to do with information collected, and their own personal embarrassment. Yet the need to take a sexual history is great, regardless of a physician’s specialization, for reasons like:

  • Preventive medicine: Condom use and Pap smears are just a couple of the areas where physicians are expected to provide education, especially since counseling can reduce high-risk behaviors.

  • Ailment interplay: In diagnosing and treating patients, physicians must consider how sexual performance may indicate underlying medical problems, e.g., diabetes or depression, or how
    sexual functioning may be affected
    by medications—including nonadherence—or disabling conditions. Research has found, for example, that most patients with chronic coronary disease expect their cardiologist to discuss sexual functioning.

  • Sexual dysfunction: A doctor is the most frequently consulted person when it comes to sex problems. Physicians, therefore, need to be factually knowledgeable about sexual disorders, and be able to convey the information in spite of their own emotional response to the subject. In addition, since many people have difficulty discussing sexual topics, it’s important for physicians to use a nonjudgmental, patient-centered approach that allows patients to express themselves.

Ultimately, the goal of a physician should be to integrate sexual health care into patients’ general care. If this is omitted, a major aspect gets overlooked, significantly reducing the clues to diagnosis and basic treatment.

Until about 1956, medical schools found it all too easy to ignore completely the subject of human sexuality, laden as it was with misinformation based on scientific ignorance and contradictory emotional, cultural, religious, moral, ethical, political and social messages. But along came Dr. Mary Calderone, medical director for the Planned Parenthood Federation during the ’50s and early ’60s. She is credited with integrating the study of family planning into U.S. medical school curricula, and was among the first to point out the disturbing lack of birth control information in four of the major obstetrical textbooks.

Yet by 1960, only three medical schools offered formal sexuality instruction, despite research indicating that doctors were using questionable sources of information and personal values in counseling patients. Faculty resisted on moral grounds, and few were trained adequately to teach such subjects.

It was not until 1968, backed by the sex research of Dr. William Masters and psychologist Virginia Johnson, that larger numbers of medical schools started offering sexuality programs. Medical education finally had sound scientific knowledge based on reproducible lab evidence. Coupled with the sexuality explosion of the time, and increased expectations that primary care doctors be willing and able to handle patient sexuality concerns, medical school courses of the 1970s often included two- to five-day explicit multimedia presentations, large and small group discussions, lectures, counseling demonstrations, panel discussions, workshops and written exams. The goal was to demythologize sexual behavior, desensitize overreaction to stimuli, re-sensitize one in the direction of human and professional understanding, develop tolerance, and understand one’s own sexuality and that of others.

Almost all U.S. medical schools were involved in teaching human sexuality by 1975, thanks in large part to Dr. Harold Lief, who championed comprehensive sex education through his work with the Center for the Study of Sex Education in Medicine at the University of Pennsylvania. By 1977, 81 percent of American medical schools offered such instruction, but only 45 percent offered organized courses and only 42 percent had required courses.

But by the 1980s, efforts were diminishing. Even the program at the University of California, San Francisco, School of Medicine, considered a national model with its thriving sex therapy clinic, slowly died out. In 1995, Barnaby B. Barratt, of the American Association of Sex Educators, Counselors, and Therapists, reported that 90 percent of medical schools are doing essentially nothing in the realm of human sexuality. “What [is] significant is that since the mid-’80s, sex education in medical schools had definitely dropped off. Some schools dropped their sex class to pick up an HIV course, which can make what is taught more negative.”

Out of the Brown Bag

Dealing with a subject often framed by infectious diseases or “deviant” behaviors, medical schools have struggled with delivering adequate sexuality and sensitive-communication training, with few success stories today. Students identify many curricular gaps in areas like sexual assault, abortion, lesbian-gay-bisexual-transgender health and HIV, with some schools simply handling matters over a brown-bag lunch. Others, however, are taking matters more seriously.

Hailed as an extremely sophisticated program, Quebec’s Université de Sherbrooke Faculty of Medicine’s four-day, required “Human Sexuality Camp” is led by a clinical sexologist and urologist, and involves an intensive self-examination of attitudes and sensitivities toward various aspects of sexuality.

The University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School hosts a required “Sex Week” for second-years. Based on the belief that physicians should be well-rounded people first, the program goes beyond facts to delve into ethics, values, beliefs and attitudes. Within the 40-hour, five-day human sexuality course, student “sexpertise” is cultivated through films and slides, lectures, small group interactions, testimonials and panel discussions.

The University of Minnesota’s flagship Program in Human Sexuality is respected for its knowledgeable faculty, leadership and curriculum. It hosts a sexuality course for first-year medical students, equipping them with the knowledge needed for the primary care of patients’ sexual concerns.

Apart from these recognized standouts, it is difficult to really evaluate who else is doing what well, given that there are no curricular standards for sex education. Data collected from 73 medical schools by the Association of American Medical Colleges exemplifies this lack of structure, with courses covering a mishmash of sexual development, sexual abuse, gender disorders, sex and culture, sex and spirituality, with some programs seemingly more active than others.

Complicating matters further is just how little sexuality is covered within more general courses. Barratt stresses, “Human sexuality gets continually squeezed out of medical education. In comprehensive curricula, it gets integrated, but it is an orphan topic, along with domestic abuse, cross-cultural issues, drug and alcohol treatment…depending on faculty.”

The most recent assessment of the 125 U.S. and 16 Canadian medical schools of how they prepare physicians to diagnose and treat sexual issues was a 2003 study from the Medical College of Georgia. It recommended that an “expansion of human sexuality education in medical schools may be necessary to meet the public demand of an informed health provider,” based on the following findings:

  • 83.2 percent of schools relied on a lecture format.
  • The majority provided just three to 10 hours of education.
  • Fewer than one-third offered a required course, and fewer teach how to take a detailed sexual history.
  • Less than 64 percent used multidisciplinary faculty to teach sexuality.
  • About half didn’t offer continuing medical education courses on sexuality.
  • Only 43 schools offered clinical programs with a focus on treating client sexual dysfunctions and problems.

More than one-quarter of schools did not respond to the survey at all.

Interestingly, Canadian schools devoted more time to exploring attitudes and beliefs related to sexuality, whereas American schools appeared to stress facts more.

The findings are a far cry from what students like Costescu want: “A good program involves a motivated professor who can speak to issues, and faculty that support progressive medical education. They have not only medical facts, but psychological information, like risk factors for teen pregnancy.”

For many students, “sex education is very much self-directed,” he adds. “You need to find people doing research, find articles and read up on it.”

To create their own learning experiences, students should shoot for activities that nurture a knowledge base and skills building, recognizing that challenges for student-initiated electives include securing funding, finding administrative support and guaranteeing sustainability. Among the strategies students can use for molding sex education initiatives at their school are: inviting outside experts to speak; talking to students at other schools to find out what’s working on their campuses; encouraging premedical students to take human sexuality courses; hosting events that take a formative, student-centered approach in pursuing active learning techniques; and working with sexuality organizations in drafting enticing curricula, backed by faculty and a plan of implementation with which to woo deans into action.

“Medical education does not incorporate the kind of curriculum with standards and expectations as it relates to sexual education,” holds Jay Bhatt, immediate past president of the American Medical Student Association. “The content students and schools can develop in this area will help the next generation of physician-leaders adequately deal with issues of sexual orientation, environment and pathology in a way that is sensitive and appropriate.”
Yvonne K. Fulbright, Ph.D., is a sex
educator, consultant and author of several books. Her Web site is www.sexuality Direct comments about this article to