America may be awash in sexual conversation, but like airbrushed flesh, it is sometimes less revealing than it seems. True, there are endless titillations, scandals, wink-and-nod commercials and tell-all books. And pornography -- segmented into preferences of every type -- is only a few computer keystrokes away. Yet at a time when understanding patients' sexual expectations, let alone their sexual practices, is essential to protecting and promoting their health, doctors can be poorly informed.

Nor are doctors necessarily trained to know -- or schooled in how best to discuss -- the sexual consequences of such everyday medical assaults as prescription drugs, chemotherapy or dialysis. Throw in a pinch of personal discomfort about taking a stranger's sexual history and you have a recipe for silence. Mix further with an insensitivity toward patients who happen to be lesbian, gay, bisexual, transgender or intersex (a person born with sex chromosomes, external genitalia, or an internal reproductive system not considered "standard" for either male or female) and the recipe can poison communication and compromise caregiving, permanently.

Medical schools have long struggled with these twin challenges of sensitive communication and sexuality training, and by most anecdotal accounts, few have ever done it well. More often than not the bulk of human sexuality training has been framed by the study of infectious disease, with implied deviancy or promiscuity as a subtext. An awkward alternative -- never offered at UCSF and often called "Sex Week" -- has lumped lectures, slides and videos with spicy testimonials from a parade of human "abnormals."

Even before implementing its massive overhaul of the medical school curriculum two years ago, UCSF was considered more progressive and enlightened than most. Indeed, in the 1970s UCSF's human sexuality training program, based in the Department of Psychiatry, was a national model. "There were 30 mental health professionals from all over the country and 12 faculty involved in the training program," recalls Linda Alperstein, associate clinical professor in the Department of Psychiatry. "This is not to mention a thriving sex therapy clinic." But the program languished after the death of its founder in 1980.

More than two decades later, information about human sexuality was scant and scattered throughout the curriculum. And it might have remained that way had not a group of UCSF medical students respectfully complained last year and helped set in motion what could be the most thorough, sensitive and integrated sexuality curriculum ever devised at an American medical school. At least, that is the plan.

Early Stirrings

Third-year medical students Karl Jeffries and Genevieve Preer did not start out their medical school careers with any agenda other than to do well and become primary care physicians. But as part of the first class to matriculate in the School of Medicine's new curriculum, they were encouraged to think and act like beta testers. Moreover, as seasoned 30-somethings with life (both are parents of two children) and career experiences beyond the university classroom, they had a contemporary perspective on sexual realities and practices, as well as a handle on the ever-changing vocabulary used to describe both.

So it came as a surprise during their second year of medical school when the initial discussions of human sexuality fell short of their common knowledge, indicted some groups unfairly, or simply misled. "Nothing was ever done maliciously. And it wasn't pervasive," says Jeffries, a former high school chemistry teacher who chose UCSF in part because of its gay-friendly reputation. But the 38 students who ultimately signed a letter of complaint argued that some of the lecture material and accompanying illustrations were callous and inaccurate. As Preer, who spent five years working in community health as a medical assistant, health educator and HIV counselor explains, what was missing was a broad perspective that separated sexuality from behavior. "To imply, for example, that HIV is predominantly a disease of gays or bisexuals, instead of the consequence of risky sexual behaviors that anyone may engage in, is simply not true." Moreover, Preer and her colleagues argued, confusing sexuality with behavior feeds the stereotype that being gay or lesbian or bisexual is just about sex. Worse, it also induces a clinical myopia that, when played out in an examination room, undermines a physician's effectiveness. Think of it this way, says Preer: "Ask a man if he is gay and he may say no. Ask the same man if he ever has sex with other men [known as ‘MSM' in contemporary parlance] and he may say yes because it is the label or the perceived culture he rejects, not the behavior."

As the list of gaffes and gaps grew in the 2002-03 academic year, so did the concern that younger medical students with less life experience might internalize the misimpressions as gospel. "We weren't learning much about so-called normal sexuality either," says Preer. "If we were going to become competent physicians, we needed more information about the sexual implications of menopause, how to persuade a sexually active senior to use condoms, or how to talk about impotence to someone who is afraid to take blood pressure medications." Students also needed to be tested on sexuality topics, the only sure way to get their undivided attention.

The activists, led by Jeffries and Preer, took their case to Helen Loeser, associate dean for curriculum in the School of Medicine, who was convinced both by the logic of their arguments and by the earnest diplomacy with which they pursued them. It helped as well that both Preer and Jeffries had been curriculum ambassadors the summer before and knew the administrative ropes. The existence of a Chancellor's committee on lesbian, gay, bisexual, transgender and intersex issues (LGBTI) added institutional legitimacy to the quest as well. Before long, others were drawn to their cause, including key ally Shane Snowdon, director of UCSF LGBTI Resources, who had helped to organize an analysis of the medicine curriculum shortly before the student reformers mobilized. "We tried to fill some academic holes with lunchtime lectures and presentations on nontraditional health issues. They really were a revelation to most students," Snowdon says. Yet, while popular, the sporadic lectures were no substitute for a comprehensive plan to raise awareness and teach competency, twin objectives that soon crystallized in discussions with the concerned students.

Faculty members, who might have been excused for bristling at the impudence of their charges, rallied instead. Chief among them were Alperstein, Ellen Haller, director of the Adult Psychiatry Clinic, Laura Hill-Sakurai, an assistant professor in family and community medicine, and Lee Jones, then a clinical professor of psychiatry and member of the School of Medicine's Committee on Curriculum and Educational Policy. Together with Snowdon, and backed by letters of support from, among others, Craig Van Dyke, chair of the Department of Psychiatry, the group successfully applied for a $25,000 curricular innovation grant from UCSF's Academy of Medical Educators, which exists to improve, enrich and strengthen the medical school curriculum.

The grant was an important sign of approval and, although small, provided the seed money for some quick fixes in the 2003-04 academic year and a deeper analysis of what kind of reform is needed in the years to come. Says Haller of the five-person curriculum-reform team, "We have to be strategic and think piecemeal for now. It's the only way, particularly during the first two years of medical school, when adding new material means taking away something else."

Page 2 - Shifting Attitudes