Where Sex is Concerned, the Doctor is Out

In a lounge at Downstate Medical Center in Brooklyn, two medical students, thumbing through a new textbook, stop to stare and to laugh. At what? No, not at a picture of a loathsome tumor or a suppurating ulcer but at a photo of a sexually stimulated, well-engorged clitoris, as seen from a nose length away. A few pages later, they find one of an erect penis, hand-held and ejaculating. A bit farther on, there's a Japanese erotic print of an elegantly gowned gentleman kneeling between the thighs of a lady and amiably applying his lips to her labia.... This is a medical textbook? Absolutely.

In a darkened classroom at the University of Pennsylvania, 15 latent physicians clustered about a conference table stare raptly at a small film viewer. On its screen, a long penis is rhythmically disappearing into and reappearing from the mouth of an attractive young woman. The film ends; class is over. "Would you want to stay and see another one?" asks the professor. The reply is unanimous: You bet!

In a lecture hall at New York University, three homosexual men and a lesbian are putting on skits for an audience of medical students. In one, an obtuse doctor is talking to a man who says he has been exposed to V.D. "What are your symptoms?" asks the doctor.

"I haven't any," says the patient.

"Then what makes you think you're infected?"

"My contact told me later that he has syphilis."

"I see," says the doctor, who sees very little, "and what was her name?" The medical students, less obtuse than he, laugh appreciatively.

In an auditorium at the University of Minnesota, an audience of medical students watches the screen, stupefied and dazed. Six "explicit" sex films are being shown simultaneously--a veritable smorgasbord of erections and flowering vulvas, heaving buttocks and bouncing breasts, busy hands and mouths, glistening secretions. No wonder the students are stupefied; the show has been going on for what seems like hours and they're saturated and numbed by it.

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According to various studies, at least one patient in six, and perhaps as many as one in two, has a significant sexual problem, often caused by--or causing--other physical ailments. Moreover, the family doctor is the one most people with sexual problems turn to for help, if they can bring themselves to turn to anyone. Obviously, then, sexual problems are a major part of the average doctor's work.

Unfortunately, in the past, medical school deans and department heads considered the topic of human sexual behavior infra dig and would have none of it in their curriculums. As recently as 1960, only three of the 100-odd American medical schools offered any instruction in sexuality; at all the others, medical students were taught nothing about it. Oh, to be sure, they learned about infections, tumors and the like affecting the sexual organs--but about the human meanings of sex, the many problems people have with it and the techniques of dealing with those problems, they heard nothing.

We lay persons assume that our family doctors are both knowledgeable and wise about sex; we do so because of the general awe with which we regard them. But those who know them intimately say otherwise. Dr. William Masters claims that most physicians "know no more and no less about the subject than other college graduates. They share most of the common misconceptions, taboos and fallacies of their nonmedical confreres." Doctors agree: In one recent survey, most general practitioners said that while they themselves were well informed about sex, most of their fellow physicians were not.

Not only wasn't your doctor taught anything about sex in medical school, he probably didn't learn much about it through personal experience, for during the years of training, medical students lead very restricted sex lives; medical school leaves almost no time for the pursuit of personal relationships or pleasure. Indeed, a recent survey shows that today's medical students, like those who went before them, have had distinctly less sexual experience than other college graduates of their age. Even more serious, studies made of medical students in the Sixties and early Seventies report that most of them are obsessive-compulsive personalities--hard-working, precise, perfectionist and self-controlled. All of which is essential to anyone trying to get through medical school; but such a personality configuration also tends to make one sexually rather inhibited, puritanical, distant and thoroughly uncomfortable when forced to discuss sexual matters or to deal with sexually troubled patients.

That is why so many doctors, even today, avoid asking their patients about their sex lives when taking their history as part of the diagnostic search for the root of some malady. A study made a few years ago found that among doctors who see patients in primary care, more than half do not routinely ask them anything about their sex lives, though it can be as clinically revealing as those matters they do routinely ask about--appetite, digestion, elimination and the like. The study also showed that doctors who don't ask about sex are only half as likely to spot sexual problems as those who do, for many patients can't bring themselves to volunteer the information and need to have it drawn out of them.

Doctors who do ask about sex are often so ill at ease when they do so that their patients find it hard to open up to them and try to get off the subject as fast as possible. When a doctor asks, with an oafish bonhomie that hardly conceals his discomfort, "And how are things in the sex department?" you have to be uncommonly dull or thick-skinned not to recognize that the hidden message is, "I really don't want to talk about this."

One distinguished urologist in a major Eastern city recently asked a male patient, "How are things at home?" The patient said everyone was well, thanks. The doctor looked pained. "No," he said, "I mean, how are things at home?" The perplexed patient repeated his answer. At last the doctor said, sternly, "You know what I mean! How are things with the wife?"

"Oh!" said the patient. "You mean sex!" But, of course, by then he was as uncomfortable as the doctor.

A few years ago, I was asked by an orthopedist, "And how often do you service your wife?" I had a bad neck, not a sexual problem, but had it been the latter, I doubt that I could have talked freely about it with someone who considered my married sex life a species of animal husbandry.

Even when doctors do elicit admissions of sexual problems, they often give advice contaminated by their own moral values. Sex educators cite, as common examples, the doctor who unduly alarms a postcardiac patient about the risks of having sex, or even forbids him to; the doctor who warns a prostatectomy patient that he may become impotent, and thereby makes him so; the doctor who assures an anorgasmic woman that hers is a common condition and that she should learn to enjoy intercourse without orgasm; and the doctor who tells a young divorcee that he cannot control her recurrent yeast infections as long as she insists on sleeping around.

Good reasons, all, for teaching human sexuality to medical students. But the most compelling reason is that many doctors-to-be simply are more misinformed and uninformed than most of us would suppose possible. Dr. Harold Lief, professor of psychiatry at the University of Pennsylvania and doyen of medical school sex educators, is the codeveloper of the Sex Knowledge and Attitude Test (SKAT), now widely used in medical schools; he says that recent feedback from schools using SKAT shows that before taking a course in human sexuality, nearly ten percent of today's medical students believe the condom is the most reliable means of birth control; 15 percent believe that masturbation can cause mental illness; 27 percent believe that very few married couples ever have oral sex; and about 40 percent believe that there are two physiologically distinct kinds of female orgasm, the clitoral and the vaginal. That being so, what could they know about such common sexual problems as premature ejaculation, impotence, insufficient vaginal lubrication, painful intercourse, lack of female orgasm, worry about "performance" and the changes in sexual response and capacity that come with the passing of the years or with chronic illness?

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For such reasons, sex education made its way into a handful of medical schools during the increasingly liberated Sixties; by the end of the decade, the movement reached critical mass and exploded.

The time was ripe. The sexual revolution was in full swing; Masters and (continued on page 156) Doctor is Out (continued from page 136) Johnson were making sex therapy a respectable medical specialty; the American Medical Association itself had begun urging medical schools to teach human sexuality; and in 1968, with a grant from the Commonwealth Fund, Dr. Lief set up the Center for the Study of Sex Education in Medicine at Penn and, through it, propagated his faith to medical schools everywhere and passed on all the information he could gather as to the content to be taught in human-sexuality courses and the new techniques for teaching it. Suddenly, sex education was "in"; schools everywhere began adding it to the curriculum. Some, conservatively, tucked a number of lectures on the subject into already existing courses, such as introductory psychology. Others, more boldly, created special courses devoted entirely to human sexuality. And many were entranced by and adopted a razzle-dazzle new approach to sex education called Sexual Attitude Restructuring (SAR), aimed more at loosening up the students' feelings than at adding to their knowledge (though it sought to do that, too). SARs were first given in medical schools in 1970 at Indiana and Johns Hopkins universities, and in 1971 at the University of California, San Francisco; thereafter, they could be found all over the country.

The typical SAR, an intensive assault on the students' inhibitions and prejudices, consisted of 16 or more hours--in a single weekend--of slides, video tapes and sex-action films, plus intimate, small-group discussions of every imaginable kind of sexual activity and malady. A SAR program would start with nonsexual but sensuous films (someone slowly peeling an orange, for instance), then would proceed to films of artistic and historical erotica; and after hours of that, would at last shift into high gear with the "Fuck-arama"--an hour or two of commercial hard-core sex films, four to eight of them being projected simultaneously. The purpose was to overload the senses and carry the students beyond shock and revulsion, beyond fear and disapproval, and even beyond arousal, to a numbed and "desensitized" state. In that condition, they could talk openly, in small groups, about the activities they had seen and the feelings they had had about such things before becoming desensitized; they could also listen--with newly opened minds--to lectures about sexual behavior and sexual problems. Students tested with SKAT before and after such a weekend of total immersion showed not only considerably greater knowledge of the facts, afterward, but distinctly liberalized attitudes toward masturbation, homosexuality and other traditionally disapproved forms of sexual behavior.

Within a few years, the fad for sex education swept through the nation's medical schools. A survey Lief conducted in 1974 showed that, by then, 84 percent of the medical schools were offering special courses in human sexuality, while nearly all the rest were teaching at least a certain amount of human sexuality within other courses. Nearly all the schools still relied, in part, on the traditional lecture format, but nine tenths also used erotic films and small-group discussions, some in the form of SARs and others as part of semester-long courses. There was no general consensus on what should be taught, or how it should be taught, but at least, wrote Lief with considerable satisfaction, "Human sexuality had become an accepted part of the medical curriculum."

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That's the good news. Now for the bad.

First, the enthusiasm for sex education in the medical schools crested in 1973; since then, a few schools have dropped their courses and a few others have cut back on the hours they allot to sex education. Elsewhere, sex educators feel lucky if they hold the line. "Every year," one professor told me--and his complaint is a common one--"we have to defend ourselves before the curriculum committee all over again. They think of sex education as expendable."

A survey by Drs. James Lloyd and Emil Steinberger of the University of Texas Medical School at Houston found that as of the 1975--1976 academic year, nearly a fifth of American medical schools were giving no instruction at all in human sexuality--a distinct retreat since 1973. Fewer than half of the schools were offering special courses in the subject--and in only 20 percent of the schools was the course required. But where it isn't required, most medical students, already overworked, skip it. At Harvard, for instance, where a very good course is available, fewer than half the students take it.

All in all, only about a fifth of today's medical students are currently taking special courses in human sexuality. Most of the rest get a fragmented sexual education, consisting of scattered hours in a variety of other courses--a way of teaching human sexuality that a World Health Organization study says is simply inadequate. And a fifth of all medical students now receive no sex education whatever.

Still, isn't it true that most of today's medical students are taught more about human sexuality than their predecessors? Yes, but not much more. In schools with special courses on sexuality, the average number of hours of instruction is 23; in those in which it is taught in fragmented form, the average number is only 18. That's not much time in which to become well informed on such an immensely subtle and complex subject. Medical students are usually given that many hours on ophthalmology alone and 20 times that many hours on anatomy. Put another way: The average medical student today spends less than one half of one percent of his or her instructional hours learning about human sexuality.

Medical students not only get too little sex education, they get it too soon. It's usually taught in the first or second year; but medical school faculty members say that subjects taught early, unless used and reinforced in the third and fourth years, when students are dealing with actual patients, soon fade from memory. Many of the subjects taught early are used in the later years (anatomy and pharmacology, for instance). But except in a minority of schools, the students' knowledge of human sexuality is not put to clinical use in the third or fourth years. In those years, students peer down innumerable throats, palpate hundreds of bellies and ask endless questions about diet and stool, until they become skilled at such things, but rarely, if ever, are they given the opportunity to practice questioning patients about their sex lives or diagnosing sexual disorders. By the time they have done their internships and residencies and begun to practice medicine, the course in which they learned about human sexuality--possibly the one weekend in which they were taught something about it--is five to seven years in the past.

Dr. Arthur Zitrin, a psychiatrist who teaches sexuality at the New York University School of Medicine, says, "Ideally, the course should be taught during the third and fourth years; then it would become part of what they're actually seeing and doing."

Dr. Robert Dickes, former chairman of the psychiatry department at Downstate, goes further: "I don't know of any medical school--ours included--that gives an adequate sex education. I feel that every (continued on page 234) Doctor is Out (continued from page 156) medical student should have training in human sexuality throughout the four years, and in the latter two, it should include clinical teamwork with an expert in the form of actual cotherapist treatment of patients."

But in many schools, the administration sees things just the other way. Sex education, more often than not, is shoved into waste spaces in the academic year; it's often given as a one-week intersession course, or pushed off into the summer, or crammed into a weekend. Dr. Bernie Zilbergeld, who teaches human sexuality at the University of California, San Francisco, complains, "Instead of giving us a ten-week or 15-week course, they relegate us to a single weekend. Sex education obviously has very low priority here." In desperation, Dr. Zilbergeld and Professor Douglas Wallace, head of the Human Sexuality Program at UCSF, have jammed 20 hours of lectures and case presentations--20!--into their single weekend. It's mind-wracking; it's also murder on the behind. And there isn't even the relief of porn films; Wallace and Zilbergeld felt that the limited time available had to be given to directly useful clinical material rather than to desensitization. "People don't need it as much today as they did half a dozen years ago," says Zilbergeld. "Anyway, there's a limit to how much good it does. I had a physician tell me, 'I've been desensitized right up the ass--but when a patient comes into the office with a sexual problem, I still don't know what to do!' "

Even the truncated and compressed courses, however, seem to yield some valuable results. Although some of the gain may fade out, most of it still exists a year later; that's as long afterward as anyone has done a follow-up study.

There are clearer results, however, in the minority of schools that have first-rate sex-education programs: Medical students in those schools actually progress to the point of being able to interview patients with relative ease, make reasonable diagnoses of their sexual ailments and suggest at least some form of immediate treatment. About one tenth of the medical schools achieve this level of sexual education.

One of them is the University of Minnesota Medical School. With the help of a five-year grant from the National Institute of Mental Health, the school has been able to afford a relatively generous program of 42 required hours, plus electives for those who want them, and to use a number of innovative teaching techniques.

In their first year, students get six hours of straightforward lectures covering basics of sexual physiology and psychology; these are included in a course called Psychological Medicine. In addition, the students are put through an 18-hour weekend SAR that includes the usual multimedia and multifilm overload of sexual imagery, followed by soul-searching small-group discussions.

In the second year, they get another 18 hours, this time in the form of a five-week course called Human Sexuality. In it, they attend a number of lectures and video-tape presentations covering all sorts of sexual behavior and disabilities--everything from normal patterns of arousal and response to the most outré variations in sexual behavior, and from video-taped interviews with prostitutes and sex offenders to a discussion of sex-counseling techniques.

Moving a step closer to actual patient care, in other classroom hours, they see video-taped presentations of patients with sex-related problems--prostatitis, for instance, or a spinal-cord injury--and, at various points, the tape is stopped and the students have to decide how to proceed. They do so on a special answer sheet and then use a marking pen that causes a latent image on the sheet to appear; it tells them what the consequences of their choice would be. Step by step, the students follow the case through in this way; if they goof, they go back and take the presentation again--and again--until they handle the patient successfully. Would that real life gave us such opportunities.

Coming still closer to actual doctoring, the students then practice taking each other's sex histories under faculty supervision. Each gets a chance to play doctor, each to be the patient--but the patient is free to toss in anything fictional or borrowed from reading or other sources without identifying it as such; that preserves privacy, since no student knows what any other student's sexual life actually consists of.

Finally, they get a chance to interact with actual patients. During the second year, students at the University of Minnesota Medical School spend some time in the several university hospitals, acting as assistants to physicians who are treating patients of all sorts on the wards and in the outpatient clinics. In that setting, each student is required to select any two patients and arrange to take their sexual histories privately. Later, they discuss with the human-sexuality staff what they learned about the patients--and about themselves as interviewers.

Thus, by the end of the second year of medical school, the students at Minnesota have acquired a foundation in human sexuality, some degree of skill and comfort speaking with patients about their sex lives and at least some ability to diagnose and suggest appropriate therapy for a number of common sexual problems. Dr. James Maddock, a 37-year-old psychologist who is the course coordinator, is frankly proud of the results, and qualified observers of the scene rate the Minnesota program high among the top ten in medical schools and consider it as effective as any being offered.

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That's what can be done in 42 hours of student-teacher contact (plus a fair amount of outside reading, viewing video tapes and taking sexual histories).

It seems a modest snippet of the four-year total--little enough, considering the scope and importance of the sexual functions and dysfunctions. Then why do so many schools give far less, or make sex education elective rather than required?

There are many reasons; it's hard to say which is the most important.

Departmental politics is one. Unless someone keen on teaching human sexuality has a power base--such as being head of a department--the subject remains a poor cousin, begging for a handout of time. Even at Penn, Harold Lief's headquarters, human sexuality is given only eight required hours; Lief is not a department head.

Another reason is that the medical curriculum is overfull. Every hour spent on human sexuality is an hour that has to be pried away from some other subject--and most of the others are well-entrenched, standard materials, not easily overpowered.

A third reason is that medical school faculties tend to be strongly conservative, both professionally and socially. They don't like change and they don't like the subject of sex. "They're threatened by the subject," one psychiatrist told me. "It makes them anxious." But they cloak their anxiety in fancy dress: One department head at Downstate told Dr. Dickes that he disapproved of teaching human sexuality to medical students because "familiarity breeds contempt" and it would "drive the romance out of it."

Business reasons also play a significant part. Faculties and curriculum committees want their school to look good and to attract the better students, so they favor courses that help students pass the boards. Courses that don't help with the exams--even if they make better doctors--get short shrift. (Happily, California has shown us that we needn't let faculties and curriculum committees have the last word: The state legislature recently passed a law requiring medical students to have had training in human sexuality in order to qualify for a license--and it gave the licensing agency the power to say exactly what kind of course was necessary.)

Still another reason: Lief's grant money ran out in 1974 and, without it, the proselytizing work of his Center for the Study of Sex Education in Medicine, the enthusiasm and momentum of the movement could not be maintained.

The conservative backlash against sexual liberalism may be another factor. With the antigay movement, the antiabortion movement and efforts to attack publishers of sexual materials under way, one would have to expect sex education to run into trouble. Indeed, only two years ago, the human-sexuality program at Minnesota was attacked by a conservative legislator egged on by the John Birch Society. The program survived; one that had no Federal grant to bolster it might have been wiped out.

Last, and perhaps most important, is the matter of values. To what extent should medicine concentrate on saving lives, and to what extent should it seek to make life worth living? A philosopher would argue for a judicious balance of the two goals, but medicine, by ancient tradition, is hell-bent on saving and prolonging life to the exclusion of questions of the worth of that life or of human happiness in general. The leaders of our medical schools view the teaching of human sexuality as unimportant because it has nothing to do with the saving or prolonging of life; happiness and the improvement of the quality of life are, in their eyes, expendable luxuries. Until that primitive viewpoint is changed by law or by public pressure, human sexuality will remain a peripheral part of the medical school curriculum, and most doctors will continue to be inadequately trained to help patients who have sexual problems.

"In schools with special courses on sexuality, the average number of hours of instruction is 23."