Sunday, April 3, 2011

Developing a Curriculum for Medical Professionals

When you think of where people get their sexual health info, your mind might jump to 10th grade health classes, or friends, or even porn. Perhaps you think about social norms delivered through TV or the most recent Sunday sermon. However, when it comes to questions around sexual health, most adults are still asking their doctors. According to several studies done around the millennium, adults still see their physician as a primary source for addressing sexual health concerns (Metz & Seifert, 1990; Marwick, 1999). While this may change slightly with advancements made online, the physician is still a main-stay in sexual health concerns in the U.S. If you ask a medical student or physician, they may note how common sexual concerns are in a patient visit, often referring to sexuality questions as “hand on the door knob” questions. These “hand on the doorknob” questions suggest the real reason a patient comes to see his or her physician is to address some aspect of their sexuality, but are uncomfortable asking. In fact, a study conducted in 1999 found that while most people would ask their physician about a sexual health concern, they would feel uncomfortable doing it. More so, most people felt that their physician wouldn’t provide them with the information or treatment they were looking for (Marwick, 1999). For men in the 90’s, a study showed that while they wanted to get information from their doctor, they were embarrassed to do so and preferred that the physician initiate the conversation (Metz & Seifert, 1990). This attitude may not have shifted much even today.



One reason people may feel uncomfortable with addressing sexual health concerns with their physician may be that the physician him or herself is uncomfortable. A majority of 4th year medical students reported being uncomfortable with taking sexual histories from older and younger people in particular (Malhotra, Khurshid, Hendricks, & Mann, 2008). Physician attitudes, lack of comfort with sexual histories in general , and general communications issues also added to doctor discomfort (Tsimtsiou et al., 2006), A general discomfort with sexual health issues can make it abundantly clear to a patient that sexual health concerns are off-limits.


So what does all of this mean for us as educators?


1. We want to meet as many people as possible in addressing sexuality, so making sure doctors are just as informed as we are is a great way to do this.

2. Medical schools are obviously not giving the time to train students in taking sexual histories, in addressing student attitudes towards different aspects of sexuality, in working on communication around sexuality, and are probably not taking the time to talk about sexual pleasure or advances in sexual medicine.

3. Our place may be in providing sexual health training for medical students and ongoing education to physicians.

 
Training medical students or physicians has its pros and cons. Of course the pros are that we are able to make sure another source of sexuality information is on a positive track, but there may be some issues with having this come to pass.


1. First of all, medical students as well as physicians have a reputation of being slightly, umm, big-headed. Many medical students, as surely practicing physicians, may feel they already know everything and that, furthermore, no one outside of the medical community has a right to instruct them. Hopefully this is a rarer occurrence today, but it may be a small battle in organizing a training.
2. Time is an issue for any professional, but for practicing physicians in general, finding the time to enroll in a sexual health training program may be tricky. If you are attempting to add a sexual health training section to a medical school, it may be quickly shot down with the idea that there is already too much in the students’ schedule.

When organizing a program for training medical students, its best to first get the backing of a medical organization or medical school. That way, you have some sort of credibility behind you for the nay-sayers. More tempting would be setting up some sort of earned credit or certification if possible. This would help dismiss the previous concerns, especially if the class was an elective for credit. Furthermore, as Rebecca Bak and Alexis Light noted in constructing their Sexual Health Scholars Program for the American Medical Student Association, its best to approach a curriculum set up in a variety of steps. According to this duo, following these 7 steps will help when attempting to set up a sexuality training.

1. Identify a Need
2. Seek Help
3. Approach the Administration
4. Logistics
5. Create the Curriculum
6. Evaluation
7. Sustainability
(Bak & Light, 2011)


It may be easy to identify the need for a training in any medical community by assessing their current classes, but it is also important to get student backing and document it. When you approach the administration, it will be much easier to set up a training if you can show student interest in the program. Bak and Light also make a strong point to not go it alone. Seeking help in this endeavor is needed for success. For educators, this might be someone with interest in the medical community or a medical student. Perhaps you team up with a few members of your Planned Parenthood community. Any way you do it, having help, and backing, is mandatory for success in such an unpaved route.


For those of us who have little experience teaching professionals, #5 on this list may be a bit baffling. What do we teach medical students about? Many, if not all, already have some basic information in STI’s and the reproductive system as well as contractive methods. In fact, some of them may know more than you do on the subject. Thus, when developing a curriculum, its best to assess what is needed and what strengths you can play to. If you are teaming up with someone, hopefully they bring another skills set to the table as well. All in all, though, do not attempt to teach over your head. While it may be helpful to explain the most recent sexual medicine to them and how it affects sexual wellbeing, we can’t all be Dr. Kellogg. It is just as important to facilitate on attitudes towards LGBT sexuality and older adult sexuality. However, the Sexual Health Scholars and Center of Excellence for Sexual Health have come up similar topic lists that may be helpful when developing a curriculum.


1. Value of Sexual Health in the Medical Field
2. Taking a Sexual History
3. Models of Sexuality
4. Sex and Language
5. Sexual Anatomy, Reproduction, Response Cycles
6. Sexual Function and Dysfunction
7. Body Image and Self Esteem
8. Sexuality Across the Lifespan
9. Sexuality and Illness and Disability
10. Common Sexual Concerns and Treatments
11. Infertility
12. The Internet and Sex
13. Sexual Orientation, Attitudes and LGBT Health
14. Sexual Abuse
15. Sex Workers
16. Media, Culture and Religion
17. Behaviors, Values and Expressions
(Morehouse School of Medicine, 2011; Sexual Health Scholars Program, 2011)


The list could continue, but it should be obvious with this that there are multiple topics that could be and should be included in a sexual health training.


Advanced training in sexuality for medical professionals is a much needed thing. Hopefully this post inspires you to think about the connections that should be made between our field and the medical one. While only a starting point, this post attempts to give a good jump on initiating that connection. While I didn’t get around to writing about how to facilitate to professional groups, for those of you who have had experience training medical professionals or other professionals, please comment!

-Meg Augustin
References:


Bak, R. & Light, L. (2011) Creating change, one elective at a time [PowerPoint slides]. Retrieved from
http://www.amsa.org/AMSA/Homepage/EducationCareerDevelopment/AMSAAcademy/SHSP.aspx


Malhotra, S., Khurshid, A., Hendricks, K.A., & Mann, J.R. (2008) Medical school sexual health curriculum
and training in the United States. Journal of the National Medical Association, 100(9), 1097-1106.


Marwick, C. (1999) Survey says patients expect little physician help on sex. The journal of the American
Medical Association, 281(23), 2173-2174.


Metz, M.E. & Seifert, M.H. (1990) Men’s expectations of physicians in sexual health concerns. Journal of
sex and marital therapy, 16(2), 79-88.


Morehouse School of Medicine (2011) Sexual health curriculum development. Retrieved from
http://www.msm.edu/research/research_centersandinstitutes/SHLI/aboutUs/CESH/programsI
itiatives.aspx


Sexual Health Scholars Program (2001) Tentative Curriculum. Retrieved from
http://www.amsa.org/AMSA/Homepage/EducationCareerDevelopment/AMSAAcademy/SHSP.
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Tsimtsiou, Z., Hatzimouratidis, K., Nakopoulou, E., Kyrana, E., Salpigidis, G., & Hatzichristou, D. (2006)
Predictors of physicians’ involvement in addressing sexual health issues. Journal of sexual
medicine, 3(4), 583-588.

12 comments:

  1. I strongly believe in sexuality education for the medical profession. Along with politics, culture, and science, medicine has had complex and contradictory implications for the regulation of sexuality, mostly in support of the institution of heterosexuality and marriage. Historically, the medical field has helped to classify homosexuality as a disease and as a symptom of an abnormal sick personality, and to declare masturbation as a serious threat to the physical and mental health of every American (Seidman, 2010). In the Victorian age, the medical world believed that only marriage could contain and control the powerful sexual instinct, which if left unchecked, could result in horrible physical and mental ailments. Fifty years later, as women entered the workforce and encountered social and economic independence, new guidelines were necessary to govern and organize sexuality which were written into being by psychologists, sexologists, psychiatrists, and medical doctors. During this era, the stigmatization of homosexuality through the medical profession, normalized heterosexuality (Seidman, 2010). There are many more examples of medical “insight” too numerous to site.

    The student’s I just taught during my 626 workshop listed doctor’s as a go to source for sexuality information. Meanwhile, my sister is a Physician’s Assistant. During her schooling, sexuality was addressed in a one half day seminar, which provided them with everything they needed to know, while never mentioning intersex. Astounding! I have no facts regarding medical training and the quality or quantity of sexuality education received throughout their education, only hearsay from friends of mine who are physicians. Their comments are “not enough.”

    Considering the historical influence the medical field has had concerning sexuality and the fact that Meg reported that most adults see physicians as a primary sexuality health resource, this is a field that is ripe for sexuality educators.

    Seidman, S. (2010). The social construction of sexuality (2nd ed.). New York: W. W. Norton & Company Ltd.

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  2. Great article! I have started specializing in facilitating sexuality education for physicians. I am consistently stunned by the lack of knowledge and comfort in dealing with sexuality issues, even though I’ve had many docs and med students confirm that they thought sexuality was an important aspect of their work.

    I have some additional studies to further demonstrate the lack of adequate sexuality education for these health professionals. The largest study available to date that aimed to assess the amount and nature of sex education in medical schools in the United States and Canada found that more than half provided only 3-10 hours of sexuality education in their medical training (Solursh, 2003). Less than half of respondents in that study offered clinical programs specializing in the treatment of patients with sexual problems and less than half offered continuing education in human sexuality for medical professionals. A large survey (n=2,261) of medical students in the U.S. and Canada found that 64.4% of first-year medical students did not feel sufficiently trained to deal with sexuality issues in their clinical practice and 81.1% of total respondents still reported feeling comfortable dealing with patients’ sexuality issues (Shindel, 2010).

    A study of 500 patients found that respondents would most prefer to receive sexual health information from their medical provider who initiates the conversation (45.1%) over other sources of information such as the Internet (Wittenberg & Gerber, 2009).

    Clearly, we need to address the medical community to provide more sexuality education and skills training. I am glad to see someone else interested in this audience!

    References

    Shindel, A. W, Ando, K. A., Nelson, C. J., Breyer, B. N., Lue, T. F., & Smith, J.F. (2010). Medical student sexuality: How sexual experience and sexuality training impact U.S. and Canadian medical students' comfort in dealing with patients' sexuality in clinical practice. Academic Medicine, 85(8), 1321-1330.

    Solursh, D. S., Ernst, J. L., Lewis, R. W., Prisant, L. M., Mills, T. M., Solursh, L. P., Jarvis, R. G., & Salazar, W. H. (2003). The human sexuality education of physicians in North American medical schools. International Journal of Impotence Research, 15(Suppl 5): S41–S45.

    Wittenberg, A., & Gerber, J. (2009). Recommendations for improving sexual health curricula in medical schools: results from a two-arm study collecting data from patients and medical students. Journal of Sexual Medicine, 6:362-368.

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  3. Awesome post Meg! I totally agree that there is a strong need for training medical professionals about how to deal with sexuality related topics in their practice. While I have no experience conducting training for medical professionals it is certainly a hot topic in the LBGT community, with a huge emphasis on trans folks. There is a great need for more sensitivity when working with sexual minorities. A major struggle for transgender individuals is often seeking medical assistance. In trainings and discussions I have participated in around being transgender and the treatment they receive from the medical community I have learned some real horror stories about Dr.'s refusing treatment or making individuals feel like a real freak show. It is challenging enough for many transgender patients to even get out the door and go the doctors because there is a great deal of fear that exists about those terrible experiences in the community.

    In thinking about seeking help with talking to medical professionals or getting ideas about what the needs are I also think about patient advocates. In order to make changes or address some of the flaws in patient treatment by medical professionals it may be wise to conduct needs assessments with advocates. I think there is significant opportunities to collaborate and determine some of the common problems patients face with medical professionals who demonstrate discomfort with discussing sexuality issues. Mostly I believe that advocates are a good avenue for planning curriculum because they focus on the sensitivity of the patient and want medical professionals to provide the best practice possible.

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  4. Well-trained, sex-positive medical professionals are such an important ally for us! This topic cannot be talked about enough!

    One reason you mention for why people don’t talk to their doctors about sexual health is that the doctor is uncomfortable with the topic. I agree, but I also think that people may not bring up the topic if the doctor themselves does not bring up the topic. If medical professionals asked about sexual health as part of a routine check-up (and some may), I believe that more people would feel comfortable talking about it.

    I also love that you described a problem...then suggested a way to solve it! The “7 steps to set up a sexuality training” makes this seem completely doable. I’m definitely interested in working with the medical community on issues of sexuality and this post was really inspiring and gave such great suggestions.

    Great resource! Thanks Meg!

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  5. Great discussion! Of course, I always jump in with the Planned Parenthood perspective and I absolutely agree that this is a huge need. It is so important for medical professionals to have a comfort level and knowledge base when it comes to sexuality. I know one thing that we pride ourselves on at PP, is the fact that our medical staff are comfortable with questions and with taking the time to answer them. I often have participants tell me that the first time they actually understood a GYN exam was when they saw a PP clinician. That is not an accident though, it's because the investment has been made in training the medical staff and not just in one day. One of the means we use, is online training as a supplement and I wonder if this could be a way to help get medical professionals around the time constraint issue? Perhaps initial in-person training followed by on-line opportunities aimed at increasing comfort and knowledge could be a model that would work well for this population?

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  6. Alison, I love that idea. The time constraints in med school have to be the hardest thing to overcome. Either you have to make a fantastic case for a sexuality course (although its obviously more helpful for med students to integrate sexual health in all of their classes) to get it into the curriculum or find some type of incentive for taking it outside of the curriculum. I was just thinking, in response to Kate, that it would be almost better to train the professors who teach medical school classes in order to help them integrate sexuality into all of their classes. That way physicians would be less likely to see sexuality in medical issues as an elective issue, but as a part of general health.
    Shannon, thank you so much for the updated info! Its so interesting that those statistics haven't really changed, even with the advent of the internet. Shannon, I would love to hear more about what you are doing and see a medical training workshop. Please email me at megaugust3@gmail.com!

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  7. This is more of a personal insight into the medical field and sexuality. Of the like 10 people in my life who I consider family, 2 are becoming doctors, 1 is an OB/GYN, and 1 is a nurse. I speak to these folks all the time about sex and sexuality because I’m seriously just curious about how they’re interacting with peeps during their work day. It has made me reconsider my previous sentiment of being appalled at the lack of sexuality training doctors receive.

    Someone who is an OBGYN, for example, needs to know how to perform surgery, how to proscribe the correct medicines to someone who is expecting/delivering/breast feeding, how to perform a pelvic exam, how to test for STIs, and even know how to ride a moving stretcher down a hallway, hand in a woman’s vagina, holding a baby’s head in place until they can get that birthing woman to proper facilities (no joke). And more, of course. AND! Many doctors are expected to work crazy, taxing hours (like night shifts or 24 hour shifts).

    That’s a lot to know and a lot to handle already. That’s a lot to have mastery over. Just like it takes people YEARS to become effective sex educators, it takes medical professionals YEARS to become effective practitioners. And although I think that MPs should definitely have more than 10 hours of sexuality training when they’re going into a field that interfaces with sexuality, I actually personally believe that the prioritization of life-saving, illness preventing knowledge for is not necessarily a bad thing. At the end of the day, these folks are human, with human limitation. And from what I’ve gleaned from hearing stories about med school and nursing school, those becoming MPs are already expected to shoulder a huge amount of work.

    So where does that leave me then? It leaves me wondering if we couldn’t have a more sustainable solution. Something like, instead of expecting MPs to also be Sex Educators, we should start to find a way to require Sex Educator presence at medical sites. When the doc gets hit with anything beyond question with an easy answer, the patient can be passed off to someone more qualified to answer. This way, the quality of sex education is high, the doc/nurse/etc isn’t expected to be super-human, and any issues that are coming up with patients during things like intake or exams can be addressed in trainings by the resident sex educator who understands the culture of the hospital/office, etc.

    It’s obviously just a thought. Until something like this is possible, I definitely dig the idea of taking training to the practitioners.

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  8. Hi Meg, great post, I agree with others that this is an important topic. I have an anecdote to share. When I was in college I worked as an intern with Planned Parenthood where we provided a half-day seminar for a medical school about talking about sexuality with patients. The med students met with mock patients who all had some kind of sexual health related problem, and the students had to figure out what it was. I participated in the small group discussions that followed.

    I was so surprised with the level of discomfort expressed by the students in the group with which I was working. One woman said flatly that she refused to ever ask any questions relating to sex and she was not even able to say “penis” out loud. A topic we spent some time on was a mock patient who had an STD. Few students figured out that this was his medical issue because they began by asking him about his marital status and he responded married. They missed any opportunity to check for STDs because they felt that because he was married he could not possibly be at risk. I really struggled to work with many of the students because they could not (or would not) see how having a comfort level with speaking to patients about sexuality is important.

    I recognize that every medical school and med student is different, so doctors graduate with varying experiences relating to what they have learned about sexuality and their comfort discussing it. I really like your list of topics that might be helpful for this group, and I think many would be helpful as a baseline for topics that are necessary for the medical community to at least be exposed to if not proficient in. I agree with Kate – not only do doctors need knowledge but they also need comfort. If they initiate questions about sex as a regular part of an exam than patients will likely feel more comfortable asking more or identifying problems they are experiencing.

    I also really appreciate Becca’s perspective – doctors have so much they need to know that asking them to take on more information and a whole other skill set might be asking too much. At the least I think medical schools need to normalize and familiarize medical professionals with issues around sex. If they are comfortable and ask patients outright questions about sex they can follow up by referring patients to a sex educator or therapist if they do not have the answers to the questions asked. Medical professionals are a major resource for many regarding many health issues. If a doctor or nurse refers a patient to another resource (website or person) the patient will probably feel confident (and I imagine motivated) about consulting that resource. That might be a more effective method in most cases – developing partnerships between medical professionals and sex educators.

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  9. Edit Dr Anna said...
    Thank you for your article. I have heard these complaints from women in my medical practice every day. My program SexualCPR.com may help by addressing some of the many things that create lack of desire. It is an important issue in relationships and we need resuscitation! A virtual class style also gives a level of comfort. As an expert in womens sexual health I needed to find a way to help outside of my office time.

    November 12, 2011 5:10 AM

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