Continuing Medical Education: Sexual Medicine Education: Review and Commentary (CME)

What we don't talk about when we don't talk about sex: results of a national survey of U.S. obstetrician/gynecologists

INTRODUCTION

Sexuality is a key aspect of women's physical and psychological health. Research shows both patients and physicians face barriers to communication about sexuality. Given their expertise and training in addressing conditions of the female genital tract across the female life course, obstetrician/gynecologists (ob/gyns) are well positioned among all physicians to address sexuality issues with female patients. New practice guidelines for management of female sexual dysfunction and the importance of female sexual behavior and function to virtually all aspects of ob/gyn care, and to women's health more broadly, warrant up-to-date information regarding ob/gyns' sexual-history-taking routine.

AIMS

To determine ob/gyns' practices of communication with patients about sexuality, and to examine the individual and practice-level correlates of such communication.

METHOD

A population-based sample of 1,154 practicing U.S. ob/gyns (53% male; mean age 48 years) was surveyed regarding their practices of communication with patients about sex.

MAIN OUTCOME MEASURES

Self-reported frequency measures of ob/gyns' communication practices with patients including whether or not ob/gyns discuss patients' sexual activities, sexual orientation, satisfaction with sexual life, pleasure with sexual activity, and sexual problems or dysfunction, as well as whether or not one ever expresses disapproval of or disagreement with patients' sexual practices. Multivariable analysis was used to correlate physicians' personal and practice characteristics with these communication practices.

RESULTS

Survey response rate was 65.6%. Sixty-three percent of ob/gyns reported routinely assessing patients' sexual activities; 40% routinely asked about sexual problems. Fewer asked about sexual satisfaction (28.5%), sexual orientation/identity (27.7%), or pleasure with sexual activity (13.8%). A quarter of ob/gyns reported they had expressed disapproval of patients' sexual practices. Ob/gyns practicing predominately gynecology were significantly more likely than other ob/gyns to routinely ask about each of the five outcomes investigated.

CONCLUSION

The majority of U.S. ob/gyns report routinely asking patients about their sexual activities, but most other areas of patients' sexuality are not routinely discussed.

Teaching sexual history-taking: a systematic review of educational programs

PURPOSE

Because of the importance of sexual history-taking, the authors attempted to identify all randomized controlled trials on teaching this topic and reviewed the methods used for teaching and the efficacy of the educational interventions.

METHOD

From June to November 2010, the authors searched the published English-language literature indexed in PubMed, PsycINFO, and SCOPUS, using the key terms sexual history-taking, teaching, medical students, residents, sexual health, sexually transmitted infections, HIV, and AIDS. The authors selected and critically appraised randomized controlled trials and controlled nonrandomized trials of educational programs designed to enhance sexual history-taking skills.

RESULTS

Of 11 trials identified, 7 included medical students, 2 included residents, 1 involved community-based physicians, and 1 involved attendings, fellows, and residents. The educational interventions and outcome measures were heterogeneous, and the quality of study methodologies varied widely. The authors judged only 1 study to be of very high quality, although 8 studies explicitly mentioned at least one of the following: group differences at baseline, blinding, follow-up, and validated measurement tools. In the highest-quality study, primary care physicians who were mailed educational materials and received an unannounced instructor visit performed better in risk assessment and counseling than two comparison groups. Evidence also supported interactive workshops over didactic presentations.

CONCLUSIONS

The dearth of high-quality controlled studies hampers the development of sexual history-taking curricula for medical students and residents. The available literature supports formal opportunities to directly practice and receive feedback on interviewing skills. More rigorous research on sexual history-taking education is needed.

Resource utilization and cost-effectiveness of counselor- vs. provider-based rapid point-of-care HIV screening in the emergency department

Background

Routine HIV screening in emergency department (ED) settings may require dedicated personnel. We evaluated the outcomes, costs and cost-effectiveness of HIV screening when offered by either a member of the ED staff or by an HIV counselor.

Methods

We employed a mathematical model to extend data obtained from a randomized clinical trial of provider- vs. counselor-based HIV screening in the ED. We compared the downstream survival, costs, and cost-effectiveness of three HIV screening modalities: 1) no screening program; 2) an ED provider-based program; and 3) an HIV counselor-based program. Trial arm-specific data were used for test offer and acceptance rates (provider offer 36%, acceptance 75%; counselor offer 80%, acceptance 71%). Undiagnosed HIV prevalence (0.4%) and linkage to care rates (80%) were assumed to be equal between the screening modalities. Personnel costs were derived from trial-based resource utilization data. We examined the generalizability of results by conducting sensitivity analyses on offer and acceptance rates, undetected HIV prevalence, and costs.

Results

Estimated HIV screening costs in the provider and counselor arms averaged $8.10 and $31.00 per result received. The Provider strategy (compared to no screening) had an incremental cost-effectiveness ratio of $58,700/quality-adjusted life year (QALY) and the Counselor strategy (compared to the Provider strategy) had an incremental cost-effectiveness ratio of $64,500/QALY. Results were sensitive to the relative offer and acceptance rates by strategy and the capacity of providers to target-screen, but were robust to changes in undiagnosed HIV prevalence and programmatic costs.

Conclusions

The cost-effectiveness of provider-based HIV screening in an emergency department setting compares favorably to other US screening programs. Despite its additional cost, counselor-based screening delivers just as much return on investment as provider based-screening. Investment in dedicated HIV screening personnel is justified in situations where ED staff resources may be insufficient to provide comprehensive, sustainable screening services.

Factors influencing patient disclosure to physicians in birth control clinics: an application of the communication privacy management theory

The focus of the current study is whether, and why, female patients limit or alter their personal histories when discussing sensitive subject matter with their physician in birth control clinics. Fifty-six female patients (M = 21.6 years, SD = 3.05) completed anonymous questionnaires exploring their comfort with and ability to disclose personal histories in the immediately preceding interview with the physician. The present study used communication privacy management (CPM) as the theoretical lens through which to view the interaction. Approximately one-half of the sample (46%) reported limiting or altering information. Patients with a highly permeable privacy orientation, as evidenced by a history of open communication regarding sexual issues, were those who reported fully disclosing to their physicians. Of the physician characteristics considered to map onto patient privacy rules, the physician's gender, hurriedness, friendliness, use of a first-name introduction, and open-ended questions were significantly related to patients' reported ease in fully disclosing personal information (p < .05). This study presents a novel application of CPM and has implications for training medical students and for parent-child communication regarding sexual issues.

Sexual health of Dutch medical students: nothing to worry about

INTRODUCTION

Little is known about the sexual lives and development of medical students because of relatively small sample sizes and, in particular, low response rates in research. Enhancing medical students' awareness and understanding of sexual behavior is imperative, as gaps in knowledge might impede effective sexual health consultations in their later professional practice.

AIM

The aim of this study was to provide insight into the sexual lives and development of medical students.

MAIN OUTCOME MEASURES

The main outcome measures of this study are demographic, contextual, and sexual data based on validated surveys.

METHODS

Preclinical medical students aged under 26 years were approached during scheduled classes and by e-mail to complete a web-based questionnaire. Our results were compared with international and Dutch normative data. Ordinal regression analysis and Pearson's correlation analysis were used to assess relationships between variables.

RESULTS

A total of 1,598 questionnaires were returned (response rate 52%: 1,198 by women, 400 by men). There were 719 first-year students (mean age 19.17 years) and 879 third-year students (mean age 21.5 years). Gender distribution differences were seen in all the cohorts and were corrected for. Compared with international and Dutch (88%) normative data, our first- (62.7%; P<0.001) and third-year (79.9%; P=0.018) medical students had less sexual experience and showed different advancements in sexual behavior. However, these differences decreased, which suggests that medical students "catch-up" as their age increases. Sexual behavior in our sample did not differ from international data, except for a strikingly high sexual satisfaction (80%). We also confirmed that social and environmental characteristics change with alterations in sexual behavior. Although contraceptive measures were used more frequently (98%; P=0.006), sexually transmitted diseases were more common (4.6%; P=0.008), which suggests inappropriate use of protective measures. Independent predictive determinants for protective sexual behavior were the form of relationship (P<0.001; OR=1.97) and sexual orientation (P=0.009; odds ratio=2.26).

CONCLUSION

These data provide insight into the sexuality of medical students. The results of this study reliably clarify previous findings and form a solid basis for further research.

Flibanserin: A Potential Treatment for Hypoactive Sexual Desire Disorder in Premenopausal Women

Hypoactive Sexual Desire Disorder (HSDD) is defined as a persistent or recurrent deficiency of sexual fantasies and desire for sexual activity, which causes marked personal distress or interpersonal difficulty, and is not better accounted for by another psychiatric disorder or the direct physiological effects of a substance (e.g., a medication) or medical condition. HSDD is believed to be the most common form of Female Sexual Dysfunction and is associated with emotional distress and relationship problems. No pharmacologic therapy is approved for the treatment of HSDD in premenopausal or naturally postmenopausal women. Flibanserin is a 5-HT1A agonist/5-HT2A antagonist that is under investigation as a treatment for HSDD in women. The aim of this article is to present an overview of the pharmacology, clinical efficacy and safety of flibanserin. Flibanserin is an investigational drug that is not licensed for any indication in any country.

Management of hypoactive sexual desire disorder in women: current and emerging therapies

Hypoactive sexual desire disorder (HSDD) is a common multifactorial condition which is characterized by a decrease in sexual desire that causes marked personal distress and/or interpersonal difficulty. The general idea that HSDD is a sexual dysfunction difficult to treat is due to the large number of potential causes and contributing factors. Indeed, a balanced approach comprising both biological and psycho-relational factors is mandatory for accurate diagnosis and tailored management in clinical practice. There are currently no approved pharmacological treatments for premenopausal women with HSDD, while transdermal testosterone is approved in Europe for postmenopausal women who experience HSDD as a result of a bilateral oophorectomy. Even though the role of sex hormones in modulating the sexual response during the entire reproductive life span of women is crucial, a better understanding of the neurobiological basis of sexual desire supports the idea that selective psychoactive agents may be proposed as nonhormonal treatments to restore the balance between excitatory and inhibitory stimuli leading to a normal sexual response cycle. We conclude that the ideal clinical approach to HSDD remains to be established in term of efficacy and safety, and further research is needed to develop specific hormonal and nonhormonal pharmacotherapies for individualized care in women.

Providers' perspectives on challenges to contraceptive counseling in primary care settings

BACKGROUND

Although three quarters of reproductive-age women see a health provider annually, less than half receive recommended contraceptive counseling services. We sought to explore providers' perspectives on the challenges to contraceptive counseling in primary care clinics to develop strategies to improve counseling services.

METHODS

A qualitative, focus group (n = 8) study was conducted in November and December 2007; 48 of 90 providers practicing in four primary care clinics at the University of Pittsburgh Medical Center participated. Providers included physicians, nurses, and pharmacists working in these clinics' multidisciplinary teams. Discussions explored perceived barriers to the provision of counseling services. All groups were audiorecorded, transcribed, and entered into Atlas.Ti, a qualitative data management software. The data were analyzed using a grounded theory approach to content analysis.

RESULTS

Perceived patient, provider, and health system barriers to contraceptive counseling were identified. Perceived patient barriers included infrequent sexual activity, familiarity with a limited number of methods, desire for pregnancy despite medical contraindications, and religious beliefs. Provider barriers included lack of knowledge, training, and comfort; assumptions about patient pregnancy risk; negative beliefs about contraceptive methods; reliance on patients to initiate discussions; and limited communication between primary care providers (PCPs) and subspecialists. Health system barriers included limited time and competing medical priorities.

CONCLUSIONS

PCPs vary widely in their knowledge, perceived competence, and comfort in providing contraceptive counseling. General efforts to improve integration of contraceptive counseling into primary care services in addition to electronic reminders and efficient delivery of contraceptive information are needed.

Practical strategies for the management of sexual problems in Parkinson's disease

INTRODUCTION

Patients with Parkinson's disease (PD) report frequent sexual dissatisfaction, desire, arousal and orgasmic problems. Motor and non-motor symptoms contribute to further manifestations of sexual dysfunction (SD). Studies have indicated that the need for intimacy and sexual expression are important dimensions of quality of life for PD patients. Inquiry about sexual functioning may be overlooked by neurologists due to time constraints, confusion about sexual conversation, and lack of proper training.

METHODS

Practical strategies will be presented. "Open Sexual Communication" (OSEC) module will be used to overcome barriers for sexual discussion. Suggestion for further assessment and analysis of cases will enable understanding of specific sexual interventions adapted for PD patients.

RESULTS

Physicians will be empowered to address sexual problems of PD patients and encounter a range of practical interventions.

CONCLUSIONS

The physical and emotional changes in PD and treatment of the disease have a major effect on SD of patients and their partners. All patients may experience impairment of sexual function and quality of life. Health care providers can proactively address sexual health issues by providing information, by recognizing and treating the sexual needs of PD patients and by referring them to specialists.

Recommendations for improving sexual health curricula in medical schools: results from a two-arm study collecting data from patients and medical students

INTRODUCTION

Although patients commonly have sexual concerns, providers often feel uncomfortable or inadequately trained to address these concerns.

AIMS

The first aim of this study was to determine how patients most prefer to receive sexual health information and how provider characteristics affect patient comfort. The second aim was to look at the sexual health curriculum at one medical school and determine its effectiveness. The third aim was to incorporate student and patient responses to create guidelines for more effective sexual health curricula.

METHODS

Undergraduate and graduate students served as the study sample in arm one (N = 501). Medical students in their third and fourth year served as the study sample in arm two (N = 125). Participants were surveyed anonymously using standard forms.

MAIN OUTCOME MEASURES

A cross-sectional descriptive analysis was generated from all collected data using SPSS software.

RESULTS

Patients most prefer to receive sexual health information from their provider who initiates the conversation (45.1%) and least prefer information from the Internet (25.4%). Patients are most comfortable with providers who are "knowledgeable about sexual concerns" (74.5%) and "seem comfortable addressing sexual concerns" (68.3%). The majority of medical students (75.2%) feels that taking a sexual history will be an important part of their future careers, yet only 57.6% feel adequately trained to do so. Furthermore, 68.8% feel that addressing and treating sexual concerns will be an important part of their future careers, and only 37.6% feel adequately trained to do so.

CONCLUSION

Patients prefer to receive sexual health information from knowledgeable providers who are comfortable with sexual health. Current medical students see value in sexual health curricula and feel this training will be important to their future careers, however, they feel inadequately trained. Sexual health curricula must be modified for increased effectiveness with additional lectures and opportunity for students to practice these skills.

The sexual lives of residents and fellows in graduate medical education programs: a single institution survey

INTRODUCTION

The prevalence of sexual problems among resident physicians has not been investigated.

AIM

To explore the sexual behavior of residents and fellows in training and to determine the incidence of sexual dysfunction in this population.

METHODS

Residents and fellows at our institution were invited to complete a demographic questionnaire, as well as two to three gender-specific validated instruments for the assessment of human sexuality.

MAIN OUTCOME MEASURES

The validated survey instruments selected were the International Index of Erectile Function (IIEF), the Index of Premature Ejaculation (IPE), and the Self-Esteem and Relationship Quality (SEAR) survey for male residents, and the Female Sexual Function Index (FSFI) and the Index of Sex Life (ISL) for female residents. Results were compared with established normative data and validated cut-off scores that were available. Pearson correlation coefficient was used to assess for relationships between variables.

RESULTS

There were 180 responses (83 female, 97 male, mean age 29 years), for a response rate of 20%. Among men, 90%, 67%, and 98% were in a relationship, married, and heterosexual, respectively. Among women, the same numbers were 80%, 55%, and 96%, respectively. Based on validated cut-off scores for the IIEF and FSFI, 13% of men reported ED (3% reported mild ED, 4% reported moderate ED, and 6% reported severe ED) and 60% of women were classified as "at high risk" for sexual problems, with desire disorders the most prevalent and orgasmic disorders the second most prevalent. There were significant gender differences with respect to the associations between sexual and relationship problems.

CONCLUSIONS

Sexual problems may be prevalent among residents in training, particularly female residents. Additional, larger studies that assess other quality of life measures and query sexual partners of residents are needed.

Psychosocial factors and therapeutic approaches in the context of sexual history taking in men: a study conducted among Swiss general practitioners and urologists

INTRODUCTION

Male sexual dysfunction is a common medical condition, which is addressed mainly from a biomedical perspective by Swiss general practitioners (GPs) and urologists as the results of part I of our study showed. A psychosocial orientation in sexual history taking (SHT) leads to a truly patient-centered approach and is crucial for improving therapy decisions related to sexual dysfunction.

AIM

To analyze to what extent Swiss GPs and urologists have a psychosocial orientation in SHT, and what therapeutic options they focus on when confronted with male sexual dysfunction.

METHODS

A semistructured interview was developed and used in face-to-face encounters with 25 GPs and 25 urologists.

MAIN OUTCOME MEASURES

Content and frequency of interview responses.

RESULTS

The GPs and urologists differed significantly from each other in 5 out of 22 psychosocial factors. Summarizing these psychosocial factors in four domains showed a difference between the GPs and urologists in only one domain. Both groups focus on an open conversation as their approach in SHT. No GP and only a minority of urologists based their diagnosis on criteria of the International Classification of Diseases (10th edition) (ICD-10) or Diagnostic and Statistical Manual of Mental Disorders (4th edition) (DSM-IV). The GPs and urologists differed significantly from each other in 4 out of 16 combinations resulting from the given therapeutic options and form of sexual dysfunction. The urologists focus more strongly on medication as a therapeutic option.

CONCLUSIONS

The results of part II additionally justify establishing guidelines and training resources related to SHT in Switzerland. Swiss physicians should be encouraged to apply a more psychosocial orientation in SHT. This will contribute to a better patient-centered approach with positive consequences on physicians' therapeutic decisions. Optimizing the approach in SHT and the choice of therapeutic options may better facilitate real sexual satisfaction for the patient and ultimately result in fewer health insurance costs.

Dealing with difficult sexual questions during consultations: a new training program

For over 30 years gynecological teaching associates have made a valuable contribution to undergraduate and postgraduate medical education, by allowing medical students to perform a pelvic examination on them. These women are skilled in giving detailed feedback to the medical students about their examination performance. In this study we describe a new training program: gynecological teaching associates act as simulated patients portraying a gynecological/sexual problem, in addition to allowing themselves to be examined by the students. This creates the opportunity of immediate feedback on the entire process of the consultation. Conditions are addressed that should be met to ensure the feasibility of this method.

The sexual lives of medical students: a single institution survey

INTRODUCTION

Little is known about the personal sexual lives of medical students.

AIM

To assess sexual habits and determine the presence of sexual dysfunction among medical students.

MAIN OUTCOME MEASURES

Demographic and sexual experience data and domain scores on validated sexuality surveys. Instruments selected included the International Index of Erectile Function, the Index of Premature Ejaculation, and the Self Esteem and Relationship Quality Survey for male medical students and the Female Sexual Function Index (FSFI), and the Index of Sex Life for female medical students.

METHODS

Medical students at our institution were invited to complete a demographic questionnaire and gender- appropriate sexuality surveys. Results were compared with established normative data and validated cut-off scores when available. Linear regression and Pearson coefficient were used to assess relationships between variables.

RESULTS

There were 132 responses (78 female mean age 24 years, 54 male, mean age 25 years). Condoms and oral contraceptives were the most popular form of contraception. Among men, 81.5%, 37%, and 93% were in a relationship, married, and heterosexual, respectively. Among women, 64%, 18%, and 95% were in a relationship, married, and heterosexual. Erectile dysfunction was reported by 30% of men. Proxy measures of other sexual problems in men revealed a 28% prevalence of dissatisfaction with sex life, a 28% prevalence of problems controlling ejaculation, an 11% prevalence of orgasmic dysfunction, and a 6% prevalence of low sexual desire. Based on validated FSFI scoring, 63% of women were at high risk of sexual dysfunction. Proxy measures of other problems in women indicated disorders of pain, orgasms, desire, sex satisfaction, lubrication, and arousal in 39%, 37%, 32%, 28%, 26%, and 24% of female respondents, respectively.

CONCLUSIONS

These data provide insight into the sexual lives of medical students. Rates of sexual dysfunction are higher than expected based on normative data. Further research is required.

Frequency and focus of sexual history taking in male patients--a pilot study conducted among Swiss general practitioners and urologists

INTRODUCTION

General practitioners (GPs) and urologists are the first medical contacts for men with sexual dysfunction. Previous studies have shown that many GPs hesitate to address sexual issues and little is known about the sexological skills of urologists.

AIM

To analyze sexual history taking (SHT) by Swiss GPs and urologists, in terms of active exploration, focus, and competence in discussing and treating sexual dysfunction.

METHODS

A semi-structured interview was developed and used in face-to-face encounters with 25 GPs and 25 urologists.

MAIN OUTCOME MEASURES

Content and frequency of interview responses.

RESULTS

Urologists reported a significantly higher frequency of actively asking male patients about sexual dysfunction (22.80% vs. 10.42%, P = 0.01). GPs and urologists avoided actively asking certain patient groups about sexual dysfunction (e.g., "immigrants,""macho men"). GPs reported a significantly lower percentage of male patients who spontaneously address sexual problems (6.35% vs. 18.40%, P < 0.001). Both physician groups emphasized erectile dysfunction in SHT. Eight percent of GPs and 28% of urologists considered their competence in discussing sexual dysfunction as very good. No GP and 20% of urologists considered their competence in treating sexual dysfunction as very good. Urologists reported having significantly greater competence in discussing (P = 0.02) and treating (P < 0.001) sexual dysfunction than the GPs. Competence in discussing correlated positively with competence in treating sexual dysfunction for GPs (P = 0.01) and urologists (P < 0.001). The majority of GPs (92%) and urologists (76%) reported a need for continuing education in sexual issues.

CONCLUSIONS

Our results justify establishing guidelines for SHT in Switzerland to better meet the sexual health needs of male patients. Physicians should be encouraged to routinely inquire about sexual issues, overcome their discomfort with the subject, and regard male sexuality as more than erectile function. A clear need exists for relevant continuing education for Swiss GPs and urologists.