International Journal of Impotence Research (2003) 15, Suppl 5, S58–S66 & 2003 Nature Publishing Group All rights reserved 0955-9930/03 $25.00 www.nature.com/ijir Medical students’ perceptions of sexual health issues prior to a enhancement

E McGarvey1*, C Peterson2, R Pinkerton1, A Keller1 and A Clayton1

1Department of Psychiatric , of Virginia School of Medicine, Virginia, USA; and 2Department of and Gynecology, University of Virginia School of Medicine, Virginia, USA

The objectives were to compare first, second and third year medical students on self-perceived sexual health knowledge, comfort in addressing sexual health problems, and attitudes towards the importance of addressing sexual health issues with patients as part of a sexual health medical curriculum enhancement project. A paper-and-pencil questionnaire survey was designed and administered to first and second year medical students at the start of the fall semester, resulting in high participation rates for both years (98% and 86%, respectively). Third year students were surveyed through an on-line version of the questionnaire yielding a lower response rate (52%). Multivariate statistical analyses were used to compare knowledge, comfort and attitudes by year in . Results were as follows: As might be expected, sexual health knowledge and comfort in addressing sexual health problems increased linearly from first to third year (Po0.01) for all questions. Unexpectedly, second year students had significantly higher scores on questions assessing attitudes towards the importance of addressing sexual health issues than either first or third year students (Po0.001). Female medical students reported that addressing sexual health issues with patients was significantly more important than did male medical students; however, male students reported higher levels of self-reported knowledge and comforting related to sexual health issues than did female students in a number of areas. In conclusion, knowledge gained from this survey was used to finalize the design of an enhanced, integrated curriculum on sexual health for medical students. Further investigation of gender differences related to training medical students in this area is suggested. International Journal of Impotence Research (2003) 15, Suppl 5, S58–S66. doi:10.1038/ sj.ijir.3901074

Keywords: sexual health; medical school curriculum; sex ; sexual attitudes; medical students

Introduction reality will, for many individuals, require the proactive support of health professionals.3 Conversely, sexual dysfunction is a prevalent 1 The World Health Organization , in concert with the problem. Sexual dysfunction can be General Assembly of the World Association of a primary presentation, a symptom associated with a Sexology (WAS), put forth a report outlining 11 disease process, related to psychosocial concerns, or sexual rights. These include the right to sexual a side effect of medication. A large nationally pleasure; the right to sexual freedom; the right to representative study using the National Health and sexual autonomy, sexual integrity and the safety of Social Life Survey (NHSLS) data reports that 43% of the sexual body; the right to sexual information US women and 31% of US men indicate the based on scientific inquiry; the right to comprehen- presence of a sexual complaint. These reported sive sexuality education; the right to sexual health clinical symptoms include low sexual desire, pro- 2 care and the right to sexually associate freely, etc. blems achieving orgasm, sexual pain and sexual The translation of such policy statements into anxiety.4 Type II diabetic patients commonly suffer from sexual dysfunction, with prevalence ranging from 5–10 *Correspondence: E McGarvey, Department of Psychiatric 35% to 70% . Although this is a long established Medicine, University of Virginia School of Medicine, P.O. and well-known problem among members of this Box 800623, Charlottesville, Virginia, 22908, USA population, a recent report indicated that more than This project was funded through a grant from Pfizer, Inc. 63% of treated Type II diabetic patients had doctors Medical students’ perceptions of sexual health E McGarvey et al S59 who had never inquired about the possibility of increased in their appreciation of the importance these patients experiencing sexual problems.11 A of human sexuality as a part of medical education, number of other medical conditions (eg, urinary were more conscious of their views on sexuality and tract problems, cancer) are also associated with felt more knowledgeable and comfortable in addres- sexual dysfunction.12–16 As such, the avoidance by sing sexual issues with patients after completion of doctors and patients of specifically discussing the LWMS course. No comparison group of students related sexual problems, at least in the United was used to assess whether such changes in States, is probably not uncommon. students’ attitudes could be attributed to the LWMS Sexual dysfunction is also a common side effect of course or the usual curriculum offered by LWMS. In many over-the-counter as well as prescribed medi- addition, one university developed and pilot-tested cations, including widely used antidepressants.17–19 a cross-clerkship curriculum for third year medical A recently published large, multisite study reported students, which was associated with an increase in that 37% of depressed patients on antidepressants comfort level discussing issues of sexuality follow- report sexual dysfunction which varied between 22 ing the clerkships.29 and 43% depending on the type of antidepressant Pfizer, Inc., a pharmaceutical company that has used.20 treating this population report developed an effective medication for treating that reluctance to assess sexual dysfunction stems sexual dysfunction in some men,42 has funded from social barriers, lack of knowledge about sexual several medical schools in the USA to evaluate, functioning, inadequate training for obtaining a expand and appropriately integrate sexual health sexual history, lack of knowledge about how to treat curricula for their undergraduate medical program. sexual dysfunction and fear of their questioning The University of Virginia (UVA) is one such grant being misinterpreted or considered inappropriate.21 recipient. This paper presents the results of the The last decade has witnessed significant ad- baseline questionnaire assessment of self-perceived vancements in understanding the underlying me- sexual health knowledge, comfort in addressing chanisms involved in the sexual functioning of men sexual health problems, and attitude towards the and women22–24. This, combined with the develop- importance of addressing sexual health issues with ment of a variety of effective therapeutic agents, has patients. Sexual health knowledge includes knowl- opened the door for allowing substantial improve- edge of how to take a sexual history, knowledge of ment in this domain of medical practice.25–28 sexual health effects or problems associated with Clearly, both as a proactive issue of wellness and nonsexual health issues, and knowledge of how to as an area of investigation in the management of explain sexual health problems to patients. illness, the quality and satisfaction of a patient’s sexual functioning should be a major area of focus for a . Physicians, however, have indicated Current sexual health curriculum a number of factors that serve as barriers to addressing sexual health with their patients includ- ing: physician’s self-perceived inadequate knowl- The curriculum for first year medical students at the edge and training, time constraints, patient University of Virginia includes five sessions on the embarrassment, as well as physicians own feelings of the pelvis and perineum; and one lecture of discomfort with the topic.29–32 and one lab on each of the following topics: Medical school training can be an important endocrine glands, male reproductive histology, means of promoting the appropriate and effective female reproductive histology, reproduction and management of sexual functioning problems.33–35 pregnancy. The curriculum also includes six lec- Currently, a significant gap in knowledge regarding tures on sexual development and differentiation and existing sexual health components of undergraduate sexual disorders, one lecture on interviewing about medical education exists.36–38 Only a few studies sexual history and health, one lecture on screening have addressed the attitudes and values that may for domestic violence and brief material on family underlie physicians’ medical practices, especially sexual abuse and violence. The weekly small group those related to emotionally sensitive issues such as experience throughout the first year includes sexuality.31,39,40 2 hours with role-playing on taking a sexual history One study has reported on undergraduate medical and a relationship violence history. First year students’ comfort and other attitudes regarding medical students are each evaluated on the relevant patients’ sexual health issues.41 The Leichester- interview skills through videotaped interviews of Warwick Medical School (LWMS) developed a two standardized patients in which taking a sexual course for second year medical students that and violence history is specifically required. utilized desensitization and problem-solving tech- The curriculum for second year medical students niques as well as encouraged students to reflect on includes two lectures on the examination of attitudes that might interfere with their comfort in male and female genitalia (including specimen addressing patients’ sexual concerns. Before and collection); three lectures each on cervical, prostate, after questionnaire data showed that students testis, uterine and vaginal ; two lectures

International Journal of Impotence Research Medical students’ perceptions of sexual health E McGarvey et al S60 on the sexual response cycle, gender identity, sexual first year students (98%: 135 of 138) and good for disorders and paraphilias; and lectures on pituitary second year students (86%: 123 of 143). Those and gonadal hormones. Students also perform a students who failed to complete the questionnaire pelvic examination on a gynecologic teaching were not present in class that day. Third year associate and have one clinical correlation on students begin clerkship rotations and were less colposcopy. accessible to be surveyed. Third year students were There is no standardized curriculum related to solicited via email to complete an online version of sexual health for third and fourth year students. the questionnaire, which resulted in a 52% (66 of Brief comparisons of the planned enhancements to 128) return rate. Third year students were surveyed the existing curriculum are presented in Tables 1 midway into their fall semester. Fourth year stu- and 2. Prior to implementation of the enhancements, dents were not surveyed. a questionnaire survey of first, second, and third Over half (54.6%) of the student participants were year students was completed to obtain baseline data male and 84.0% were unmarried. The largest group for evaluation of the effectiveness of the enhanced of students identified their ethnicity as Caucasian curriculum in changing knowledge and attitudes as (75.3%) with 4.9% African-American, 16.7% Asian well as for planning purposes. or Pacific Islander and 3.1% Hispanic or other. A nearly equal proportion of students reported their family’s income in US dollars as (14.9%) ‘Under $25 999’, (12.7%) ‘$26 000–$51 999’, (11.1%) Methods ‘$52 000–$75 999’ or (15.9%) ‘$76 000–$99,999’, while the largest group of students (45.4%) reported Protocol and sample that their family’s income fell into the highest income category of ‘$100 000 or more’.

First and second year students were administered questionnaires on the first day of class during the Instrument 2001 Fall semester before any planned curriculum enhancements had occurred. Students were offered a pizza lunch as an incentive for participation and A questionnaire was developed for the project by completed questionnaires in their lecture hall after combining items from two existing measures and class. As a result, survey return rates were high for adding a demographic section. The final version was

Table 1 First-year curriculum and enhanced experiences planned

Preclinical experiences course content Preclinical experiences with enhanced sexual health content

Anatomy Same plus a Web-based case with anatomic issue Five sessions on the anatomy of the pelvis and perineum PowerPoint resource provided to students to supplement class lectures Cell and tissue structure /: One lecture and one lab each on: Same plus a Web-based case with histologic issue Endocrine glands PowerPoint resource provided to students to supplement class lectures Male reproductive histology Female reproductive histology Reproduction and pregnancy Six lectures on sexual development and differentiation and sexual disorders Practice of medicine I: One lecture each on: Interviewing about sexual history and health Same plus videotape showing a well-performed sexual history in Screening for domestic violence (1) a wellness visit and (2) a problem-oriented visit. PowerPoint resource provided to students to supplement class lectures Two hours in small groups, with role playing: Taking a sexual history Relationship violence history Evaluation of above by videotaped interviews of two standardized patients in which taking a sexual and violence history is specifically required Human behavior: Brief material on family sexual abuse and violence Additional content to be added on aggression and sexuality

International Journal of Impotence Research Medical students’ perceptions of sexual health E McGarvey et al S61 Table 2 Second-year curriculum and enhanced experiences planned preclinical experiences course content Preclinical experiences with enhanced sexual health content

Practice of Medicine II Two lectures on the examination of female genitalia (including Same plus a videotape showing both history and physical aspects specimen collection) of routine gynecologic exam, including sexual history and review of systems Students perform a pelvic examination on a gynecologic teaching associate Small group session for review of problem-based cases (one PowerPoint resource provided to students to supplement class contraception, one sexually transmitted ) lectures

Pathology Three lectures each: Cervical, prostate and testis, and uterine and vaginal pathology Same plus Web-based case with communication issues concerning a diagnosis with ‘bad news,’ sexually speaking One clinical correlation on colposcopy PowerPoint resource provided to students to supplement class lectures

Introduction to psychiatric medicine: Two lectures: Sexual response cycle, gender identity, sexual disorders and Same plus two or three Web-based cases involving sexual paraphilias function/dysfunction and communication about the patient’s sexual orientation and related concerns Two-hour seminar on sexual orientation and the physician PowerPoint resource provided to students to supplement class lectures

Pharmacology: Lectures on pituitary and gonadal hormones Same plus Web-based case involving hormonal treatment and medications specific to treating sexual dysfunction PowerPoint resource provided to students to supplement class lectures

reviewed, as appropriate, by the University’s Human all knowledgeable’ to 5 ¼ ‘Completely knowledge- Investigation Committee prior to distribution. Items able’. were obtained from a 100-plus item questionnaire The five questions that address Comfort include: developed as part of a project to integrate Human (1) comfort in discussing sexual issues with pa- Sexuality into an associate degree pro- tients; (2) comfort in discussing sexually related 43 44 gram and the Sexual Attitude Scale (SAS), health problems with patients; (3) comfort in which was designed to be useful in determining discussing types of medications for sexual dysfunc- discomfort related to human sexuality. The SAS has tion; (4) comfort in discussing sexual of demonstrated reliability, with excellent internal medications and (5) comfort in discussing sexual consistency (alpha 40.90), and good validity, with problems related to nonsexual health problems. The content, construct and factorial validity coefficients 5-point Likert-style responses range from 1 ¼ ‘Not at of 0.60 or higher. The response format on the final all comfortable’ to 5 ¼ ‘Completely comfortable’. instrument for measuring students’ attitudes, per- The two questions that address Importance in- ceptions and knowledge is a 5-point Likert-style clude: (1) importance of discussing sex life during a scale with a separate 6-point scale to measure routine check-up and (2) importance of discussing opinions on certain sexual issues. In this paper, we sex life during treatment for another problem. The 5- restrict reporting to five questions addressing per- point Likert-style response range from 1 ¼ ‘Not at all ceived knowledge, five questions addressing com- important’ to 5 ¼ ‘completely important’. fort and two questions addressing importance. The five questions addressing Perceived Knowl- edge include: (1) knowledge of how to take a sexual history; (2) knowledge of how to explain sexual Statistical analyses health problems; (3) knowledge of those medica- tions used for treating sexual dysfunction; (4) knowledge of the sexual side effects of medications Students’ responses were examined to determine and (5) knowledge of those sexual problems which preintervention patterns of students’ perceptions by are related to nonsexual health problems. The 5- year in medical school. Chi-square and analyses of point Likert-style responses range from 1 ¼ ‘Not at variance (ANOVAs) were used to test for significant

International Journal of Impotence Research Medical students’ perceptions of sexual health E McGarvey et al S62 mean differences. Bonferroni post hoc analyses were school. Second year students reported a signifi- used to decompose differences for those ANOVAs cantly higher level of knowledge than did first year that met at least a Po0.05 level criterion of students, just as third year students reported a statistical significance. significantly higher level of knowledge than second year students. This same pattern of difference by year was consistent across all areas of knowledge. In Results addition, male students across all years perceived their knowledge to be significantly higher than did females students in two areas: ‘Medication for Table 3 shows means and standard deviations for treating sexual dysfunction’ (F(1,336) ¼ 11.73, each question by year in medical school. All 12 P ¼ 0.001) and ‘Sexual problems related to nonsex- ANOVAs met the Po0.01 criterions for statistical ual health problems’ (F(1.332) ¼ 5.94, P ¼ 0.01). significance.

Students’ perceived comfort in addressing sexual Students’ perceived knowledge about sexual health health problems problems Among the five comfort questions, ‘Discussing First year students’ reported perceiving themselves sexually related health problems’ was the area as least knowledgeable about ‘Taking a sexual students in all three years felt least comfortable history’ (mean ¼ 1.50) and most knowledgeable with. First year students indicated that they felt about ‘Medication for treating sexual dysfunction’ least comfortable ‘Discussing sexually related health (mean ¼ 1.93). Second year students’ reported per- problems’ (mean ¼ 3.05) and most comfortable ‘Dis- ceiving themselves as least knowledgeable about cussing sexual side effects of medications’ ‘Sexual side effects of medications’ (mean ¼ 2.08) (mean ¼ 3.81). Second year students indicated that and most knowledgeable about ‘Taking a sexual they felt least comfortable ‘Discussing sexually history’ (mean ¼ 3.44). Third year students’ reported related health problems’ (mean ¼ 3.47) and most perceiving themselves as least knowledgeable about comfortable with ‘Discussion of sexual side effects ‘Medication for treating sexual dysfunction’ of medications’ (mean ¼ 4.15). Third year students (mean ¼ 2.94) and most knowledgeable about ‘Tak- indicated that they were least comfortable ‘Discuss- ing a sexual history’ (mean ¼ 3.55). Among the five ing sexually related health problems’ (mean ¼ 3.47) knowledge questions, first year students felt least and most comfortable ‘Discussing sexual side effects knowledgeable about ‘how to take a sexual history’ of medications’ (mean ¼ 4.30). All five ANOVAs on while second and third year students felt more items of perceived comfort indicated that mean level knowledgeable in this area than any of the other of comfort significantly differed by year in school for areas. each of the five areas. Post hoc analyses showed that As expected, post hoc analyses revealed a sig- second year students reported a significantly higher nificant increase in perceived knowledge per year in level of comfort than did first year students. Third

Table 3 Medical school student’s ratings of the Importance, Comfort and Knowledge Level related to addressing sexual health topics

First Year Second Year Third Year Mean s.d. Mean s.d. Mean s.d. ANOVA Sig.

Importance Discuss sex life during rountine check-up *** 3.24 0.90 3.98 0.89 3.32 0.96 F( 2, 321)=23.54 P=0.001 Discuss sex life during treatment for another problem* 2.30 0.78 3.01 0.91 2.73 0.95 F( 2, 321)=21.39 P=0.001 Comfort Discussing sexual issues* 3.35 0.92 3.63 0.99 3.68 0.88 F( 2, 321)=4.17 P=0.016 Discussing sexually related health problems* 3.05 1.12 3.47 1.04 3.47 0.95 F( 2, 321)=6.17 P=0.002 Discussing types of medications for sexual dysfunction* 3.60 1.06 4.04 1.00 4.00 0.98 F( 2, 321)=6.89 P=0.001 Discussing sexual side effects of medications* 3.81 0.97 4.15 0.93 4.30 0.91 F ( 2, 321)=7.49 P=0.001 Discussing sexual problems related to nonsexual health problems* 3.73 0.93 4.13 0.88 4.00 0.96 F( 2, 321)=6.20 P=0.002 Perceived Knowledge Taking sexual history* 1.50 0.68 3.44 0.81 3.55 0.91 F( 2, 321)=6.20 P=0.001 Explaining sexual health problems** 1.81 0.78 2.32 0.84 3.03 1.01 F( 2, 321)=250.78 P=0.001 Medication for treating sexual dysfunction ** 1.93 0.79 2.39 0.91 2.94 1.01 F( 2, 321)=46.17 P=0.001 Sexual side effects of medications ** 1.67 0.78 2.08 0.91 3.09 0.99 F( 2, 321)=29.50 P=0.001 Sexual problems related to nonsexual health problems** 1.76 0.73 2.16 0.94 3.02 0.95 F( 2, 321)=47.25 P=0.001

Bonferroni comparisons: *Significant difference is between first and second year students; **significant difference is between second and third year students; ***linear significant difference from first to second to third year students.

International Journal of Impotence Research Medical students’ perceptions of sexual health E McGarvey et al S63 year students were equally comfortable addressing knowledge was higher each year in school. Comfort sexual health issues as second year students. This was higher for second year than first year students same pattern emerged consistently for all five and was equivalent for second and third year comfort questions. Across years in school, male students. Ratings of importance showed unexpected students reported a significantly higher comfort results. As expected, second year students rated level than did female students in discussing ‘sexual ‘Discussing sex life problems’ as significantly more issues’ (F(1,337) ¼ 4.93, P ¼ 0.02) but were no more important than first year students. Unexpectedly, comfortable discussing other issues. however, third year students rated ‘Discussing sex life during treatment for another problem’ as significantly less important than second year stu- dents. Students’ perceived importance of addressing sexual health problems Limitations First, second and third year students all rated ‘Discussing sex life during a routine check-up’ as Interpretation of the student survey data presented more important than ‘Discussing sex life during above is limited in a number of ways due to the fact treatment for another problem’. ANOVAs indicated that data-collection was related to curriculum plan- that student answers in both areas varied depending ning rather than research. First, there was a on their year in school. Post hoc analyses revealed substantially lower return rate among the third year that second year students rated ‘discussing sex life students compared to first and second year students during treatment for another problem’ and ‘during a so that responses may be unrepresentative of the routine check-up’ as more important than did first class as a whole. Second, observing differences by year students. Third year students rated ‘addressing year in medical school can be more accurately sex life during a routine check-up’ as significantly assessed using a longitudinal design that follows a less important than second year students. Third year class or several classes through their years in students rated ‘addressing sex life during treatment medical school to observe changes within a class for another problem’ as less important than second over time. This method is planned for the evaluation year students although this did not rise to the level of the effectiveness of the current project. Third, of statistical significance (P ¼ 0.10). Across years in cross-sectional data do not control for pre-existing school, female students reported that it was sig- differences between classes admitted at different nificantly more important than did male students to times. Finally, third year students were surveyed ‘Discuss sex life during a routing check-up’ midway through their first semester (which includes (F(1,334) ¼ 14.1, P ¼ 0.001) and to ‘Discuss sex life all of the second year of medical school as well as during treatment of another problem’ early clerkship experiences) rendering it difficult to (F(1,334) ¼ 8.8, P ¼ 0.003). Figure 1 illustrates the identify the particular experiences that may lower results by year in medical school indicative of the perceived importance in addressing sexual health. general pattern of results that emerged for knowl- edge, comfort and importance. Self-perceived Discussion

The student data presented above provides a snap- shot of attitudes and perceived knowledge across three stages of the medical school student experi- ence: (1) the start of the first year when student attitudes and knowledge were presumably derived from undergraduate college experiences as well as personal values; (2) the start of the second year following completion of their first year of primarily laboratory and classroom focused work and (3) midway through the first half of the first semester of their third year after having started clerkships and after completion of the second year of primarily classroom and laboratory work. To the best of our Figure 1 Medical school student perceived Importance of knowledge, only one study published within the last discussing patient sex life during a routine check-up, Knowledge of sexual side effects of medications and Comfort level in decade reports on medical school students’ comfort discussing sexual side effects of medications for first, second and perceived knowledge regarding their ability to and third year medical students. address sexual health issues. However, this study

International Journal of Impotence Research Medical students’ perceptions of sexual health E McGarvey et al S64 was conducted with a UK population and did not during their clerkships that students are provided analyze responses by year in school.41 with their first significant patient contact under the First year student data reflect attitudes and close supervision of attending clinical faculty. perceived knowledge brought to the University of During their third year, students are not only Virginia before beginning the medical school pro- experiencing significant patient contact for the first gram. Self-reported comfort and self-perceived time, but are also intensively observing faculty knowledge were, not surprisingly, significantly low- mentors interacting with patients. We speculate that er than for second or third year students. As the lower perceived importance of addressing sex- expected, students’ sense of comfort and perceived ual health among the third year class is related to knowledge regarding their ability to address sexual their experiences on the in-patient wards, health issues with patients is higher among students where students are exposed to patients who are at the start of their second year compared to those at usually suffering from chronic and often life- the start of their first year. The third year students threatening diseasesFa context within which sex- reported higher self-perceived knowledge for all ual health may quite reasonably appear less im- areas of sexual health for which they were surveyed portant. We also speculated that behavior modeled when compared to their junior classmates. Ratings by attending physicians may convey the physician’s of comfort level in discussing sexual health issues, own lack of comfort in addressing sexual health however, peaked among the second year class: issues. This discomfort has been documented by second year students’ comfort was higher than that those few studies published on the attitudes related of first year students but equal to that of their third to physicians addressing sexual health with their year classmates. The average level of comfort for patients.31,39,40 second and third year students was high and ranged After the analysis was complete, students were between ‘Very Comfortable’ and ‘Completely Com- informally asked to comment on the noted differ- fortable’ discussing: (1) types of medications for ence between second and third year importance sexual dysfunction, (2) sexual side effects of ratings. One third year student commented that medications and (3) sexual problems related to ‘ywe realize there are so many things to learn about nonsexual health problems. Students in the second and worry about that inability to have an erection and third year classes, however, fell into the now somehow seems less important than respond- ‘Comfortable’ to ‘Very Comfortable’ range for dis- ing to a myocardial infarction, diagnosing an cussing (1) sexual issues in general and (2) specific appendicitis or suturing up a trauma patient.’ A sexual health problems such as painful intercourse. fourth year student commented ‘During the first and Based on this finding, it is essential that enhance- second year, sexual health is discussed openly and ment programs provide students with educational its importance is stressed. During third year, opportunities specifically directed toward increas- students are observing patient–physician encoun- ing students’ comfort in discussing sexual issues in ters. Unfortunately, in most specialties, sexual general, as well as for discussing specific sexual health is not discussed openly between patient problems. In addition, the finding that female and physician, and it’s [sic] importance is not students reported significantly less comfort than stressed to students.’ Another fourth year student male students suggests that gender differences may stressed relative importance as an issue which did need to be considered in training students in this not lower ‘overall’ importance: ‘I think the same area. about sexual health as I did as a first and second Students’ perception of the importance of dis- year [student], but compared to the demands of cussing sexual health issues with patients showed mastering an encyclopedia of medicine on topics so the most surprising results. As expected, by the start completely varied from in an HIV patient of the second year students felt a greater concern for to pre-eclampsia in a pregnant woman, the time I the importance of discussing ‘sex life’ in both spend thinking about sexual health drops and the contexts than did their first year colleagues. Un- time I spend thinking about a virus or an auto- expectedly, the third year student group rated immune disease rises. Thus the relative importance discussing sex life as less important than second is lower though I don’t necessarily think that the years. This was statistically significant for ‘Discuss- overall value of sexual health is any less than I did ing sex life during a routine check-up.’ Ratings of [during first or second years of medical school].’ importance for ‘Discussing sex life during treatment Our survey findings, coupled with student com- for another problem’ was also lower for third ments suggest that how a young physician is compared to second year students, although this introduced to balancing their management of qual- did not reach statistical significance. ity-of-life related health issues within the context of The third year students, at the point they were life-threatening disease, may have significant con- surveyed, had already completed their classroom sequences for their view of the importance of requirements during their second year and had addressing sexual health matters. Health problems spent half of the first semester of their third year that primarily affect the quality of life, no matter in the midst of their clerkship experience. It is how significant, will be addressed secondarily to

International Journal of Impotence Research Medical students’ perceptions of sexual health E McGarvey et al S65 those with immediate and possibly life-threatening 3 Tiefer L. The emerging global discourse of sexual rights. J Sex consequences. While this is a reasonable ordering of Marital Ther 2002; 28: 439 – 444. priorities, it may be that the needs of 4 Laumann EO, Paik A, Rosen RC. Sexual dysfunction in the : prevalence and predictors. JAMA 1999; 281: patients may occasionally serve as a rationalization 537 – 544. for physician’s inattentiveness in this area, when in 5 Enzlin P et al. Prevalence and predictors of sexual dysfunction reality the physician might simply be too embar- in patients with type 1 diabetes. Diabetes Care 2003; 26: rassed to discuss such issues with their patients. 409 – 414. 6 Chew KK et al. Erectile dysfunction in genral medicine This issue needs to be addressed, especially given pratice: prevalence and clinical correlates. Int J Impot Res that the early clinical experiences of medical school 2000; 12: 41 – 45. students within an acute patient care setting may 7 Fedele D et al. Erectile dysfunction in type 1 and type 2 inadvertently set a precedent for their devaluing diabetics in Italy. On behalf of Gruppo Italiano Studio Deficit sexual health. Erettile nei Diabetici. Int J Epidemiol 2000; 29: 524 – 531. 8 Hekim LS, Goldstein I. Diabetic sexual dysfunction. Endocri- Some research suggests that physicians do in fact nol Metab Clin J N Am 1996; 23: 379 – 400. fail to identify sexual concerns among their patients, 9 Klein R et al. Prevalence of self-reported erectile dysfunction and that this not surprisingly contributes to their in people with long-term IDDM. Diabetes Care 1996; 19: conception of sexual health as relatively unimpor- 135 – 141. 10 Zemel P. Sexual dysfunction in the diabetic patient with tant (Halversen and Metz, 1992). Patients in turn hypertension. Am J Cardiol 1988; 61: 27H – 33H. have been found to have low expectations regarding 11 De Berardis G et al. Quality of Care and Outcomes in Type 2 their physicians’ willingness to be helpful in the Diabetes Study Group. Identifying patients with type 2 area of sexual health. This they attribute to their diabetes with a higher likelihood of erectile dysfunction: the anticipation of physician discomfort and lack of role of the interaction between clinical and psychological 45 factors. J Urol 2003; 169: 1422 – 1428. empathy. The value a physician learns to place on 12 Lagana L, McGarvey EL, Classen C, Koopman C. Psychosexual addressing sexual health problems in medical dysfuncion among gynecological cancer surviors. Journal school is likely to carry over into how they practice of Clinical Psychology in Medical Settings 2001; 8(2): sexual health medicine for the remainder of their 73 – 84. 13 DasGupta R, Fowler CJ. Bladder, bowel and sexual dysfunc- careers. Student experiences that devalue sexual tion in multiple sclerosis: management strategies. Drugs 2003; health as an important area of inquiry for patient 63: 153 – 166. care may substantially contribute to a cycle of 14 Raja M, Azzoni A. Sexual behavior and sexual problems misunderstanding and poor doctor–patient commu- among patients with severe chronic psychoses. Eur Psychiatr: nication patterns. Developing the comfort level J Assoc Eur Psychiatrists 2003; 18: 70 – 76. 15 Vallancien G, Emberton M, Harving N, van Moorselaar RJ. Alf- required to successfully address this sensitive topic One Study Group. Sexual dysfunction in 1,274 European men as well as making the effort to maintain competence suffering from lower urinary tract symptoms. J Urol 2003; 169: in this quickly changing area of knowledge in this 2257 – 2261. emerging area of medicine are both likely predicated 16 Kirschner-Hermanns R, Jakse G. Quality of life following radical prostatectomy. Crit Rev Oncol-Hematol 2002; 43: on appreciating healthy sexual function as a high 141 – 151. priority for patients. 17 The Medical Letter. Drugs that cause sexual dysfunction: an The University of Virginia School of Medicine update. Med Lett 1992; 34: 73 – 78. faculty and administration have demonstrated en- 18 Seagraves RT. Overview of sexual dysfunction complicating thusiasm for the enhancement of the curriculum as the treatment of depression, J Clin Monogr 1992; 10: 4 – 10. concerns the area of sexual health. This level of 19 Thompson JW, Ware MR, Blashfield RK. Psychotropic medi- support has been an essential element of this cation and priapism: a comprehensive review. J Clin Psychia- undertaking, as will most certainly be the case for try 1990; 51: 430 – 433. any school with similar goals. Each school must take 20 Clayton AH et al. Prevalence of sexual dysfunction among newer antidepressants. J Clin Psychiatry 2002; 63: 357 – 366. account of the particular characteristics of their 21 Piazza LA et al. Sexual dysfunction and antidepressant institution’s historical and socio-political climate in . Presented at the 148th annual meeting of the order to facilitate any educational program improve- American Psychiatric Association, May 20–25, Miami, FL. ments undertaken in such a sensitive area as sexual 2002. health. 22 Seidman SN. Hormonal aspects of sexual dysfunction: the therapeutic use of exogenous androgens in men and women. Curr Psychiatry Rep 2000; 2: 215 – 222. 23 Rajfer J et al. Nitric oxide as a mediator of relaxation of the corpus cavernosum in response to nonandrenergic, noncholinergic neurotransmission. N Engl J Med 1992; 326: References 90 – 94. 24 Park K et al. Vasculogenic female sexual dysfunction: the hemodynamic basis for vaginal engorgement insufficiency and 1 World Health Organization. Education and Treatment in clitoral erectile insufficiency. Int J Impot Res 1997; 9: 27 – 37. Human Sexuality: The Training of Health Professionals. 25 Boolell M, Gepi-Attee S, Gingell JC, Allen MJ. Sildenafil, a Report of a WHO Meeting, Q Corporation, 49 Sheridan novel effective oral therapy for male erectile dysfunction. Br J Avenue, Albany, NY 12210, 2000. Urol 1996; 78: 257 – 261. 2 NG EMI, Borras-Valls JJ, Perez-Conchillo M, Colemena E. 26 Heaton JP et al. Recovery of erectile dysfunction by the Sexuality in a New Millennium. Editrice composition: Bolog- oral administration of apomorphine. 1995; 45: na, Italy. 200 – 206.

International Journal of Impotence Research Medical students’ perceptions of sexual health E McGarvey et al S66 27 Rosen RC, Ashton AK. Prosexual drugs: empirical status of the 37 Dunn ME, Alarie P. Trends in sexuality education in the ‘new aphrodisiacs.’ Arch Sex Behav 1993; 22: 521 – 543. United States and Canadian medical schools. J Psychol Hum 28 Seagraves RT, Saran A, Seagraves K, Maguire E. Clomipramine Sexuality 1997; 9: 175 – 184. versus placebo in the treatment of premature ejaculation: a 38 Maddock JW. Healthy family sexuality: positive principles pilot study. J Sex Marital Ther 1993; 19: 198 – 200. for educators and clinicians. Fam Relations 1989; 38: 29 Sack S, Drabant B, Perrin E. Communication about sexuality: 130 – 136. an initiative across the core clerkships. Acad Med 2002; 77: 39 Haboubi NH, Lincoln N. Views of health professionals on 1159 – 1160. discussing sexual issues with patients. Disab Rehab 2003; 25: 30 Epstein R, Morse D, Frankel R, Frarey L, Anderson K, 291 – 296. Beckman H. Awkward moments in patient physician commu- 40 Merrill JM, Laux LF, Thornby JI. Why doctors have difficulty nication about HIV Risk. Ann Intern Med 1998; 128: 435 – 442. with sex histories. Southern Med J 1990; 83: 613 – 617. 31 Humphrey S, Nazareth I. GPs’ views on their management of 41 Dixon-Woods M et al. Teaching and learning about human sexual dysfunction. Fam Practice 2001; 18: 516 – 518. sexuality in undergraduate medical education. Med Educ 32 Murphy BC. Educating mental health professionals about gay 2002; 36: 432 – 440. and lesbian issues. J Homosexuality 1992; 22: 229 – 246. 42 Steers W, Guay AT, Leriche A, Gingell C, Hargreave TB, Wright 33 Andrews WC. Approaches to taking a sexual history. PJ, Price DE, Feldman RA. Assessment of the efficacy and J Women’s Health Gender-Based Med 2000; 9(Suppl.): safety of Viagra (sildenafil citrate) in men with erectile S21 – S24. dysfunction during long-term treatment. Int J Impot Res 34 Middleman AB. Review of sexuality education in the United 2001; 13: 261 – 267. States for health professionals working with adolescents. Cur 43 Hoffman E, Haywood E, Oliver B. Designing a curriculum Opin Pediatr 1999; 11: 283 – 286. model to include sexuality and a procedure for its adminis- 35 Baraitser P, Elliott L, Bigrigg A. How to talk about sex and do it tration. Published report. The University of Texas Medical well: a course for medical students. Med Teacher 1998; 20: Branch, School of Nursing, Galveston, TX, 1978. 237 – 240. 44 Hudson W. The WALMYR Assessment Scales Scoring Man- 36 Barrett M, McKay A. Training in sexual health and STD ual. WALMYR Publishing Co: Tempe, AZ, 1992. prevention in Canadian medical schools. Can J Hum Sexuality 45 Marwick C. Survey says patients expect little physician help 1998; 7: 305 – 320. on sex. JAMA 1999; 281: 2173 – 2174.

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