AMA Journal of Ethics^®

There is a crisis in medical school education about sexual health in the United States [1]. Recent studies indicate that efforts to educate medical students about sexual health may have decreased in the last decade [2]. There is also little consensus about the content and skills that should be covered in sexual health curricula [3, 4]. Recently, interest in more training in LGBT (lesbian, gay, bisexual, and transgender) health has increased, but it is rarely sufficient and rarely connected to a broader integrated curriculum in sexual health [5, 6]. For their part, medical students express dissatisfaction about their sexual health education [7]. Proposals for enhancing sexual health education seem to gain little traction [1, 8, 9].

Finding models of integrated and effective curricula can be challenging. To fill the void, the American Medical Student Association has developed an innovative curriculum that is used in its Sexual Health Scholars Program to train medical students in sexual health [10]. The Morehouse School of Medicine, University of Virginia, and Case Western Reserve University have instituted model curricula on the topic, although these are unpublished and difficult to find [1].

A Comprehensive Curriculum at the University of Minnesota Medical School

This paper offers a description of a comprehensive model of sexual health education used at the University of Minnesota Medical School. Prior to 1970, many medical students had great difficulty talking to patients about matters of sex, especially when the patients’ sexuality differed from their own. They struggled with ethical issues in dealing with their own sexual morality and the vast cultural changes that were occurring regarding social mores during the 1960s. In response to this challenge, the University of Minnesota and many other medical schools around the country began to develop courses to prepare students to better address the sexual health needs of their prospective patients and to deal with their own discomfort and struggles with ethical issues. The University of Minnesota course, developed in 1970, was one of the first comprehensive courses and has remained one of the premier courses in the country ever since [11].

The Human Sexuality course is designed to prepare physicians to render effective primary care when addressing the sexual concerns of patients. Primary care consists of providing patients with basic information and helpful suggestions and referring patients who want or need more specialized forms of care. The course introduces clinical skills that should be part of every physician’s armamentarium regardless of specialty.

Over the years the course has evolved in content and methodology, but the backbone principles have remained. The block course in the preclinical years is combined with clinical electives and externships (e.g., in transgender medicine), and sexual health content is integrated into other courses over the four years of medical school. Over the years the block course has been reduced (from 32 hours to 19 hours) but remains a foundational element of year one.

The course begins with a sexual health seminar that deals with sexual attitudes. Physicians need to be fully aware of their sexual attitudes and comfortable discussing sexuality. It introduces basic topics in sexual health throughout the lifespan [12]. The seminar relies heavily on panel discussions and thus cannot be duplicated by any reading or alternative coursework.

This seminar was originally based upon a two-day seminar called a sexual attitude reassessment (SAR) seminar [13]. Topics covered in the SAR seminar included: communication about sexuality; taking a sexual history; sexuality throughout the lifespan, including masturbation and fantasy; components of sexual health; intimacy; cross-cultural aspects of sexuality; adaptation to illness and infection (HIV, cancer, radical surgeries, and physical disabilities); safer sex guidelines; and sexual health promotion.

A key component of this seminar initially was the use of sexually explicit films and media, the use of which found to be effective [14]. Over the years we have felt less need to overwhelm the students with these films to desensitize them and get them in touch with their feelings and have discovered that patient panel discussions are far more so for today’s medical students. This two-day seminar has been shortened to two half-days and renamed the sexual health seminar.

The course also uses lectures, patient groups, smaller interactive and case-based sessions, and skills-building tutorials. Lecture topics include men’s sexual health, women’s sexual health, contraception, abortion, adult and child victims of sexual abuse, paraphilias and impulsive/compulsive sexual behaviors, and chronic illness and disability. Students work in small groups with a physician and a psychologist with a sexual health background to learn how to take sexual histories and address common clinical problems.

Besides the seminar and lectures, there are four small group tutorials that use cases to explore various attitudes, ethics, and values and to develop effective clinical skills in interviewing about difficult sexual issues. Through role playing of cases in these small group tutorials, students are able to assess gaps in their knowledge and receive feedback from peers and tutors.

Course Objectives

The overall course has both affective/attitudinal objectives and clinical knowledge and skills objectives.

Affective/attitudinal objectives. The student is responsible for:

A. Development of a professional, nonjudgmental attitude toward a wide range of sexual behaviors, attitudes, and values encountered in clinical practice, regardless of the student’s own value system. Students will understand how their own sexual attitudes and values can differ from those necessary for effective clinical practice
B. A recognition of the need for attention to patients’ sexual concerns
C. An appreciation for how human sexuality is integral to other aspects of medical health care
D. Recognition of the boundaries of the patient-doctor relationship

Knowledge and skills objectives. The student is responsible for:

A. Mastery of basic information about sexual health
B. Development of skills in interviewing techniques and responding to patients’ sexual concerns
C. Recognizing a patient’s sexual concern or complaint, whether presented directly or indirectly
D. Judging accurately the components of a sexual problem that require or are amenable to clinical intervention with a biomedical emphasis and those that will require an educational or counseling intervention
E. Developing a realistic planned approach for dealing with sex-related symptoms not immediately recognizable as connected to an organic disease state or a known type of sexual dysfunction
F. Giving accurate and relevant information to patients regarding their sexual concerns or problems
G. Making effective referrals, when appropriate, to specialized resources for the treatment of sexual dysfunctions or sex-related problems
H. Learning about the duty to report

Assignments and Evaluation

Some articles, particularly regarding interviewing patients about sexual matters, are assigned. There are also two recommended optional texts [15, 16].

Requirements include attendance at the sexual health seminar and active participation in small group tutorials. While lecture attendance is encouraged, students can view these lectures online or gain the information from other sources.

There are three multiple-choice formative assessments: two quizzes and a lengthier examination covering the entire course.

Strengths and Areas for Further Development

The strength of our first-year block course is that students are able not only to acquire foundational knowledge for other courses in obstetrics and gynecology, urology, psychiatry, and primary care but also to explore their own sexual health values and ethics to develop comfort with, and empathy and respect for, people different from them. The knowledge gained in the course follows many of the competencies identified by the AMSA curriculum.

The curriculum also includes LGBTI health issues. There is debate about where LGBTI issues should be located in the overall curriculum of medical school, but we believe these topics have a place in discussions of bothhealth disparities or cultural competence and sexual health issues and care. The most important thing is to ensure that these topics are integrated throughout the medical school curriculum.

One weakness of the Minnesota curriculum is that the integration of sexual health content in other courses throughout the four years of medical school is not very clearly specified. It can be challenging to coordinate with other course directors inasmuch as all courses are in flux and directors may change from year to year, but with tools such as Blackbag we are now better able to track how the topic is being taught in the various courses.

Another weakness is that we do not yet have a good mechanism to evaluate students’ attainment of the sexual health curriculum’s objectives. Medical educators need to develop an Objective Structured Clinical Examination (OSCE) with standardized patients and checklists to assess behavior and skills.

Conclusion

My hope is that this description will assist other medical schools in developing similar curricula in sexual health education. More detailed guidance is contained in the report on a summit on medical school education that was held in December 2012 [1] and will be held again in December 2014. Under the guidance of the Joycelyn Elders Chair in Sexual Health Education in the Program in Human Sexuality at the University of Minnesota, we hope to foster comprehensive and effective sexual health curricula in medical schools around the world and certainly here in the United States.