Are geriatricians guilty of failure to take a sexual history?

The Ethics of Medical Sexual Health Education and Its Provision

Purpose of Review

The purpose of this paper is to open a discussion of the ethics of medical sexual health education (SHE) and its provision in medical education. The paper utilizes a qualitative analysis of currently available literature on medical SHE and a medical ethics framework of the four prima facie principles of (1) respect for autonomy, (2) beneficence, (3) non-maleficence, and (4) justice, together with expert opinion. The result is a review of the ethics of medical SHE as well as the ethics of the decision to provide, or not to provide, comprehensive SHE.

Recent Findings

Recent literature has underscored the many ways in which comprehensive medical SHE supports trainees’ ability to provide sexual health care and improve their delivery of general health care, as well as the many ways sexual health is correlated with systemic health. The literature also provides evidence that the provision of comprehensive SHE is limited in undergraduate and graduate medical education. There is a dearth of literature specifically examining the ethics of medical SHE provision.

Summary

This analysis demonstrates the ways in which comprehensive medical SHE and its provision conforms with the principles of the ethical practice of medicine. The analysis also supports that a lack of inclusion of SHE in medical education programs may be a violation of these principles and increases the risk of future unethical practice by medical professionals.

MESH Headings: Ethics, Medical, Social justice, Sexual health, Sexuality, Human, Education, Medical, Undergraduate, Education, Medical, Graduate

A Medical Education Recommendation for Improving Sexual Health and Humanism and Professionalism

INTRODUCTION

Sexual health in the United States is poor, yet most physicians do not address the topic. Sexual health education (SHE) guidelines are available but not used. The lack of SHE in undergraduate medical education (UME) impacts sexual and general health outcomes, as SHE in UME increases physicians' awareness of and ability to address sexual health, which is bidirectionally correlated with other health.

OBJECTIVE

To design and assess the need, feasibility, and outcomes of an educational recommendation for increased incorporation of SHE in UME.

METHODS

Comprehensive literature review was used to assess current and future needs of SHE in UME and humanism and professionalism education (HPE). Qualitative analysis was used to assess a potential solution. The main outcome measure was an educational recommendation based on qualitative analysis of (1) the benefits of SHE and HPE in UME, (2) the SHE and HPE overlap, and (3) the potential effect of a formally combined delivery on UME and patient and practitioner outcomes.

RESULTS

Available literature on medical SHE supports increased SHE is necessary and should be incorporated into existing HPE whenever possible, secondary to numerous intersections. Qualitative analysis supports HPE could be enhanced when consistently exemplified through SHE, and this approach could be beneficial for (1) increased understanding, retention, application, and advocacy of both topics; (2) long-term improvement of sexual and general health at the patient and population levels; and (3) increased practice of humanism and professionalism, potentially resulting in better patient outcomes and professional satisfaction for physicians.

CONCLUSION

Cross-disciplinary qualitative analysis supports using SHE as the primary topic to teach HPE is a viable method to increase SHE and potentially creates physicians who address sexual health and practice with increased humanism and professionalism, leading to population-level sexual and general health improvements. Gordon EG. A Medical Education Recommendation for Improving Sexual Health and Humanism and Professionalism. Sex Med Rev 2021;9:23-35.

"Shades of Grey": Exploring Public Opinion about Later-Life Sexuality

Public opinion on later-life sexuality affects older people's sexual health, behaviour, and satisfaction. In this study, we explored public opinion on later-life sexuality by participants' responding to an open-ended question rather than rank their level of agreement or disagreement with different statements about older people's sexuality. Responses from 135 men and women reflecting on how sexuality changes in older age were thematically analysed. Five themes emerged, varying from positive to negative perceptions of later-life sexuality. Older people's sexuality was described as declining, non-existent, conservative, narrow, tedious, and boring, but also as encompassing more emotions and feelings; being better and more "complete". This study provides qualitative data and an opportunity to gain insights on valuable opinions on what young and middle-aged people think about later-life sexuality. Assessing what people think about later-life sexuality is the first stage in instilling more liberating views about the diversity of sexual expressions in old age.

Best Practices in North American Pre-Clinical Medical Education in Sexual History Taking: Consensus From the Summits in Medical Education in Sexual Health

INTRODUCTION

This article discusses a blueprint for a sexual health communication curriculum to facilitate undergraduate medical student acquisition of sexual history taking skills and includes recommendations for important elements of a thorough sexual history script for undergraduate medical students.

AIM

To outline the fundamentals, objectives, content, timing, and teaching methods of a gold standard curriculum in sexual health communication.

METHODS

Consensus expert opinion was documented at the 2012, 2014, and 2016 Summits in Medical Education in Sexual Health. Additionally, the existing literature was reviewed regarding undergraduate medical education in sexual health.

MAIN OUTCOME MEASURES

This article reports expert opinion and a review of the literature on the development of a sexual history taking curriculum.

RESULTS

First-year curricula should be focused on acquiring satisfactory basic sexual history taking skills, including both assessment of sexual risk via the 5 Ps (partners, practices, protection from sexually transmitted infections, past history of sexually transmitted infections, and prevention of pregnancy) as well as assessment of sexual wellness-described here as a sixth P (plus), which encompasses the assessment of trauma, violence, sexual satisfaction, sexual health concerns/problems, and support for gender identity and sexual orientation. Second-year curricula should be focused on incorporating improved clinical reasoning, emphasizing sexual history taking for diverse populations and practices, and including the impact of illness on sexual health. Teaching methods must include varied formats. Evaluation may be best as a formative objective structured clinical examination in the first year and summative in the second year. Barriers for curriculum development may be reduced by identifying faculty champions of sexual health/medicine.

CLINICAL IMPLICATIONS

Medical students will improve their skills in sexual history taking, which will ultimately impact patient satisfaction and clinical outcomes. Future research is needed to validate this proposed curriculum and assess the impact on clinical skills.

STRENGTHS & LIMITATIONS

This article assimilates expert consensus and existing clinical guidelines to provide a novel structured approach to curriculum development in sexual health interviewing in the pre-clinical years.

CONCLUSION

The blueprint for developing sexual history taking skills includes a spiral curriculum with varied teaching formats, incorporation of a sexual history script that incorporates inquiry about sexual wellness, and longitudinal assessment across the pre-clinical years. Ideally, sexual health communication content should be incorporated into existing clinical interviewing and physical examination courses. Rubin ES, Rullo J, Tsai P, et al. Best Practices in North American Pre-Clinical Medical Education in Sexual History Taking: Consensus From the Summits in Medical Education in Sexual Health. J Sex Med 2018;15:1414-1425.

Sexual functioning in 4,418 postmenopausal women participating in UKCTOCS: a qualitative free-text analysis

OBJECTIVE

Sexual well-being can contribute significantly to the overall quality of women's lives. This qualitative study aimed to examine sexual activity, functioning, and satisfaction in a large sample of postmenopausal women from the UK Collaborative Trial of Ovarian Cancer Screening (UKCTOCS) METHODS:: Thematic analysis was used to evaluate the free-text data of the Fallowfield Sexual Activity Questionnaire (FSAQ) completed by UKCTOCS participants at baseline before annual screening.

RESULTS

A total of 24,305 women completed the baseline FSAQ and 4,525 (19%) provided free-text data, with 4,418 comments eligible for analysis. Median age was 64 years; 65% had a partner and 22.5% were sexually active. Four interrelated themes were derived: partner availability, physical and sexual health, mental well-being, and interpersonal relationships. Primary reason for absence of sexual activity was lack of a partner, mainly due to widowhood (n = 1,000). Women discussed how partner's medical condition (27%) or sexual dysfunction (13.5%), their own physical health (18%) or menopause-related symptoms (12.5%), and prescribed medication (7%) affected sexual activity. Impact of low libido in self (16%) or partner (7%), relationship problems (10.5%) or logistics (6%), and perceptions of ageing (9%) were also mentioned. Few (3%) referred to positive sexual experiences or had sought medical help for sexual problems (6%).

CONCLUSIONS

This qualitative analysis explored postmenopausal women's perspective on their sexual functioning. Having an intimate partner and good physical health are key factors for continuation of sexual activity and satisfaction. Further sexual education for healthcare professionals is needed to raise awareness about sexuality and sexual difficulties in later life. : Video Summary: Supplemental Digital Content 1, http://links.lww.com/MENO/A426.

Let's talk about sex – what do older men and women say about their sexual relations and sexual activities? A qualitative analysis of ELSA Wave 6 data

In 2012/2013 the English Longitudinal Study of Ageing (ELSA) included a comprehensive Sexual Relationships and Activities Questionnaire (SRA-Q). A total of 7,079 men and women mainly aged 50 to >90, primarily heterosexual and in a coupled relationship, completed the SRA-Q, answering a series of questions about their attitudes to sexual relationships, their own sexual activities, problems and concerns with sexual functioning, and quality of intimate relationships. The questions aimed to gain insights into the ways in which sexual relations and activities related to health, wellbeing and other lifestyle factors change as people grow older. The primary mode of data collection was a tick box response to a series of questions. However, at the end of the questionnaire an open comment box was provided, which asked respondents whether there was anything else that they would like to say; 1,084 respondents provided additional information and these comments created a unique qualitative data-set. The analysis of the data then illustrated how people's health, relationships, experiences and perceptions of ageing, along with sexual satisfaction, impact on sexual relationships and activities.

Sexuality, sexual health and older people: A systematic review of research on the knowledge and attitudes of health professionals

OBJECTIVES

Sexuality remains important to older people and should be recognised as an important part of their overall care. However, this appears to be poorly understood and addressed by many healthcare professionals. This systematic review reports on knowledge and attitudes of health professionals towards sexuality and sexual health of older people, including factors that impact knowledge and perceptions.

REVIEW METHODS AND DATA SOURCES

The review, conducted using Joanna Briggs Institute methods, included 23 studies of varied methodology published between January 2004 and January 2015.

RESULTS

Findings indicated that healthcare professionals often consider older people's sexuality as outside their scope of practice and there is lack of knowledge and confidence in this area. Cultural norms and taboos, length of time spent working with older people, familiarity with the older person, previous training and degree of exposure to people who are not heterosexual were all identified as factors that impact knowledge and attitude.

CONCLUSIONS

Better role modelling and education are needed to improve knowledge and attitudes toward later life sexuality.

Let's talk about sex: older people's views on the recognition of sexuality and sexual health in the health-care setting

Objective

To report on the findings of a systematic review which examined the experiences and views of older people aged 65 years and over on health professionals’ recognition of sexuality and sexual health and whether these aspects of the person are incorporated into care.

Review methods

The review followed the methods laid out by the Joanna Briggs Institute. Eleven electronic databases were searched using the terms sexual*, aged, ageing/aging, attitudes and care in any health‐care setting. Only quantitative and qualitative research and opinion papers written in English and offering unique commentary published between January 2004 and January 2015 were eligible.

Results

A total of 999 papers were initially identified and of these, 148 were assessed by two reviewers. Eighteen studies – seven quantitative, eight qualitative and three opinion papers – met the inclusion criteria and were appraised. The importance of sexuality to well‐being, language used, expressing sexuality, discomfort discussing sexuality, inadequate sexuality health education and treatment and deficient communication with health‐care professionals were all identified as significant issues in a range of settings. Fourteen categories and five syntheses summarize the 43 findings.

Conclusions

Sexuality remains important for many older people; however, embarrassment, dissatisfaction with treatment, negative attitudes and seeming disinterest by health professionals can all inhibit discussions. Professionals and health‐care services need to adopt strategies and demonstrate characteristics which create environments that are more supportive of sexuality. Issues related to sexuality and sexual health should be able to be discussed without anxiety or discomfort so that older people receive optimal care and treatment.