Sexsmarts - Medicine: Karl Jeffries & Genevieve PreerShifting AttitudesMost California citizens are probably unaware that a 1981 state law requires that medical schools teach human sexuality. But there has never been a primer on how to do so. "The question has always been one of time, not disinterest," says Haller. Historically, student attitudes and institutional culture have also played a part. UCSF was once known as an exclusive grooming site for medical specialists like surgeons and anesthesiologists, a place where basic science was enshrined and, with a few exceptions, where learning doctor-patient communication skills was, if not exactly slighted, then deemphasized. In this environment, primary care was a lesser calling. The rise of managed care in the late 1980s, with its emphasis on prevention, the spread of AIDS around the world, which engendered more frank discourse about sex and sexuality, and changes in state law, which mandated a higher percentage of medical school graduates in such primary care fields as pediatrics and family medicine, elevated the status and importance of primary care. Not surprisingly, students raised in this new world entered medical school in the 21st century with different expectations from those of their peers just a decade before. "Of course, in the past there were always students who felt that they were being shortchanged in sexuality training or offended by something taught in class or who didn't want to bother with anything that wasn't basic science," says Alperstein. "But the complaints did not galvanize into an official protest. That's why this group of students is so special. They realize that sexuality is more than something medical and biological. It's psychological, political and sociological too." But are there hidden dangers in expecting too much of a medical school? Could this reform movement -- with its insistence on correct terminology, LGBTI-sensitive training, and the rejection of offensive attitudes -- represent political correctness run amok? Moreover, is it realistic, or wise, to separate moral guidelines from medical advice as the faculty reformers recommend? Haller responds: "Our job is to train effective doctors, period. It would be great if we could teach every student to be nonjudgmental, too, but we know that's impossible." What is possible, she insists, is the teaching of understanding and competence. "Doctors don't have to approve of what their patients do or who they are, but they certainly should be expected to suspend their prejudices, open their eyes and offer the best care they can to whoever is on the other side of that examination room door. We want to prepare our students for that moment." It's a tall order. "If we truly succeed," says Alperstein, "there's no doubt that UCSF could be at the top of the list when it comes to the teaching of sexuality in medical schools." But will its reach exceed its grasp? Sex, Lies and VideotapeGood intentions and savvy students do not necessarily translate into effective classroom experiences or satisfying conversations with patients. To learn about human sexuality, students, who enter medical school with different degrees of sexual experience, varying religious and cultural beliefs and wide ranges of personalities, must also learn about sex. How best to do that? And how best to make this learning process integral and the curriculum itself integrated? Ironically, considering all the emphasis on sensitivity training, one of the first tasks in both the old and new curricula is to desensitize students to sex acts. "Students need to learn about sexual variation so that they can be competent physicians," says Hill-Sakurai, whose research interests center on patient-doctor communications. One desensitization method used at UCSF and elsewhere, and now largely abandoned or made optional, has been the mandatory viewing of sexually explicit videos, which range from the instructional (people with physical disabilities having sex) to same-sex couplings. More instructive have been physician lectures, designed to help medical students develop tools for thinking in a nonjudgmental way. In one example, two openly gay faculty members now lecture on medical issues affecting the lesbian, gay, bisexual, transgender and intersex populations. A new lecture on HIV and sexually transmitted diseases, given by a member of UCSF's Center for AIDS Prevention Studies, has already won student plaudits for including more information on prevention and epidemiology, instead of focusing exclusively on vaccine research. Adolescent health, part of a curriculum block known as Life Cycle, also is getting high marks for its refreshing candor about and useful insights into contemporary teen sexuality. And in a series of panel presentations in the fall of 2003 (which will likely become a regular feature as well), a handful of UCSF faculty members volunteered sexuality-centered vignettes from their own clinical experience. The stories were not always flattering, but to organizers, that was the point. Taking sexual histories, tempering shock, surprise or disgust, and discarding prejudices are not easy -- even for those practiced at it. The takeaway message to students: Assume nothing, always be respectful and be ready for anything. "We want our students to be compassionate and curious, not uncomfortable or unsure," adds Alperstein. Part of being prepared also means practicing how to perform physical examinations with the help of stand-in patients, taking sexual histories with the help of patient actors and role-playing different clinical scenarios. Again, the goal is to desensitize, demystify and disarm, as well as equip students -- many of whom Hill-Sakurai describes as "sexually conservative" -- with new information and strategies. This extends to alternative methods for achieving sexual pleasure, a topic that employee-educators from San Francisco's Good Vibrations store, known for its selection of sex toys, discuss in an elective "gear workshop" for medical students. "We depend on the student leaders to guide us in a lot of these areas," says Haller, praising the work of those who cleansed the syllabus of I3 (a second-year curriculum block covering immunity, infection and inflammation) of its outdated and pejorative terminology: "Drug addict" has been replaced with "injection drug user," for example. Online learning opportunities for third-year students are being expanded as well, thanks to the creation of a mandatory case-based web module for family practice (unveiled in spring 2004), which will be followed by similar ones in psychiatry and pediatrics. "The cases will reflect the real-life situations that doctors encounter, like treating a sick child who has two mothers. There are critical issues that can come up at these moments that have been largely ignored in medical schools," Haller explains. The true test will come in the months ahead as Alperstein, Hill-Sakurai, Jones, Snowdon and Haller meet with more course and clerkship directors to discuss how to infuse existing courses and clinical rotations with human sexuality perspectives. No one thinks the integration process will be easy. "Sometimes I think the only way to do this is to have someone pop up in every class with a pertinent sexual consideration or fact," says Alperstein. It's a pipe dream, of course, but it illustrates an important point. How do you know when you know enough, particularly when there is so much to learn and so little time to do so? Preer has been pondering the same question. "It's very difficult to ensure that sexuality and related topics are taught well throughout the entire four years. Things are already rushed." But she and her fellow activists, who now include both first- and second-year students, are undeterred. Says Jeffries, "I feel like we've been heard. There's no going back now."
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