When I first started experiencing pain during intercourse, I wasn't sure who to turn to. Though I adored my primary care physician—who managed to ask me about my sleep habits, my dry skin, my yoga practice, my breakfast preferences, my Facebook password, and pretty much every last detail of my life other than my sex situation (jk about breakfast and Facebook)—I didn't feel comfortable bringing up the explicit details of my sex life. And though my gynecologist at the time had an up-close look at my vagina every year, my time with her always felt very factory-floor, assembly-line impersonal. Stick in the speculum. Swab. Pull out the speculum. Sayonara. When I was there, my vagina felt so far removed from actual sex, it seemed scandalous to bring it up. So who can you talk to when you're having trouble with your sex-related issues? Short of investing in a few sessions with a sex therapist, it sometimes seems easiest to go searching for answers online. And we all know how that goes. Unfortunately, even if you do work up the nerve to open up to your regular medical care professional, they may not have the answers you're looking for. Unless they specialize in sex, the education they received in med school may not have provided them with all the tools they need to tackle sex-related issues. Quinne Sember, for example, a student in her third year of medical school at the University of Buffalo's Jacobs School of Medicine and Biomedical Sciences, is only able to pinpoint a few instances during which she received a solid amount of sexual health information. And she says that much of the information she received was slotted into other courses on exam techniques, endocrinology and reproduction, and microbiology. "We did have one special session that I can recall," says Sember, citing an informational session from a healthcare service center that specialized in treating sexual minorities. But in the end, Sember feels she probably learned the most during a rotation in obstetrics and gynecology her third year. "I think that our education on this subject felt insufficient to me during the first two years of medical school," she says. Monya De, who was an undergrad at Stanford School of Medicine at the University of California, Irvine, and who is now an internist, remembers receiving "a cursory overview of sexual dysfunction, mostly related to the experiences of older people, and plenty of education about STDs." She remembers that the biggest gaps were in LGBT health. Still, De did have the opportunity to take a course at Stanford called human sexuality. "I would say Stanford did a pretty good job in those offerings," De says.
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From the outside looking in, however, sexual health coverage in medical school seems just as lacking as sexual health coverage in high school sex ed: heavy on the STDs, low on the inclusivity, and completely without mention of sex as a relational activity that might possibly bring on pleasure. Which is why some are working hard to increase the amount of sexual health information students receive during med school. Earlier this month, sexuality education professionals involved in the third Summit on Medical School Education in Sexual Health published a paper in The Journal of Sexual Medicine containing a new set of sexual health competencies for those who develop and implement medical education curricula. Eli Coleman, director of the Program in Human Sexuality at the University of Minnesota (and the brains behind the Summit) saw the Summit as a call to action—a means of revitalizing an aspect of the curriculum that, these days, only offers students less than eight hours of sexual health information, on average, during their entire med school careers. Coleman says, "There's been a move to more integrated learning. So standalone courses are under threat. The question always comes to: Why do we have to have a special course on human sexuality when we can cover this as part of the reproductive health system or in urinary or gynecological issues?" But he insists that when sexuality education is folded into other courses, it doesn't sufficiently get addressed. When it's taught as a small part of a larger subject, the people running the courses tend not to be trained in or comfortable dealing with the subject matter. "We just continue to have these unbelievable rates of sexual health problems compared to the rest of the developed world," says Coleman, hinting at the repercussions of inadequate education. Held every two years, the summits continue to work on developing competencies, curricula, and other tools. "We're working really hard to make it easier for people to have readymade tools and structures for addressing sexual health," says Carey Roth Bayer, an associate professor at the Morehouse School of Medicine. With the move toward integrated education, it's tough to get concrete numbers on the number of sexual health-related hours being taught. At Tufts University School of Medicine, for example, sexual health is included in some way in a variety of presentations, workshops, and courses, such as those on medical interviewing, the doctor-patient relationship, and advanced communications. One course—Foundations of Patient Care—features a series of presentations and workshops throughout the first and second year of school that address sexuality, gender, and LGBTQ topics that could affect patient care. During the course, students see demonstrations of patient interviews and have chances to practice these skills with both real and standardized patients (a standardized patient is someone who has been trained to portray a patient in a medical situation). But while this seems on par with what many medical schools offer, it's not nearly enough. "There should be opportunities for students to practice talking about sex, sexual health, and sexuality beyond just the disease-disaster-dysfunction framework," says Bayer. "Beyond just anatomy and physiology and the various body parts and how they work. They should come out of medical school feeling comfortable asking the types of questions that open the door for patients to talk about what's going well and not so well with their sexual health." Luckily, some school administrators are trying to fill in the gaps they feel exist in this area. At Northwestern University's Feinberg School of Medicine, as at most other schools, every student gets about 7-8 hours of both didactic and skill-building content in the area of sexual health. But those behind the curriculum try to be particularly sensitive to those things that can affect LGBTQ care. When learning to take medical histories and examine patients, for example, there are two sessions devoted to taking a sexual history, and to the importance of sexual health in the overall health and well-being of patients.
There is also a session on the specific health needs of the LGBT community, and on the health needs and health disparities that exist in the lives of LGBTQ patients. This session includes a panel of patients who come to talk to the medical students about their experiences, and about what they wish their doctors had done differently. And there's a plenary session on transitioning genders, where students learn about the health disparities and cultural competency issues that exist in treating patients who are in the process of transitioning.
In this vein, Bayer believes we need to give students a greater awareness of patient experiences that could be different from their own. "Exam questions are an easy place to start," she says. "Instead of using just heterosexually-focused questions, exam questions can include varying behaviors and varying types of relationship structures. It's those nuances that don't take much more time and bring visibility to various aspects of sexual health."
Bayer, Coleman, and others hope that the new teaching and faculty development tools they continue to develop will at least make it easier to implement some of these changes. "My vision for medical school students is for them to graduate with the ability to see sexual health as a part of health and well-being," Bayer says. "Not as a taboo topic."
"My bias is that doctors lose out and the patient loses out when doctors are not equipped to comfortably discuss sexual health with their patients," she continues. "I think we miss essential parts of our patients' lives, relationships, and decisions, and that impacts the care that is provided on the whole. I like to think of patients as holistic beings instead of just parts and pieces."
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