Art of Teaching Sexual Medicine to Medical Students

Sex Is Essence of Human Life

Sexual Medicine Is an Essential Component of Medical Science

It is fascinating to teach sexual medicine to medical students who are the torch bearers of future medical practice and render much needed service to public. Sex and sexuality have always been a subject of assumptions, myths, and misconceptions that have attracted more taboo in the society and people for generations have hesitated to talk. It is indeed a paradox for a country like India, where ancient temples explicitly depicted sexual postures and for hundreds of years, sex was considered as sacred. Unfortunately, in recent times the discussion related to sex attracts more resentment. It has been observed that understanding and skills of medical students in dealing with sensitive issues like rape, child sexual abuse, and homosexuality are grossly lacking. ¹

Resentment about sexual medicine has hindered the advancement of medical science. Though the topic is a “taboo” of society, it is indeed essential for medical students to learn sexual medicine. Medical students with their active interest move from “assumptions” to “awareness” as they understand the anatomy and physiology of sexual organs and sexual functions. Their knowledge and their attitude are expected to change over the course of medical graduation. It is here the teaching of sexual medicine has to occur in systematic manner in all domains of learning such as cognitive, affective, and psychomotor domain. These are the three domains considered important in competency-based medical curriculum.

The competency-based medical curriculum for Indian medical graduate was implemented in 2019 and has been a landmark because it has shifted the focus from mere knowledge to skills. ² It is unfortunate and contrary to needs of public health services in India, the upcoming doctors have nothing from psychiatry or sexual medicine for certification during the entire course. ³ However, teaching skill is an art and science; a teacher can do more with right amount of effort and right method of engaging the medical student in teaching learning process of sexual medicine. There is need to enhance skills of medical teacher. ⁴

The medical education in India with competency-based curriculum has given importance to vertical and horizontal integration of subjects. A first-year medical student may be learning anatomy of sexual organs and at same time learning physiological aspects of sexual organs (horizontal integration), interestingly a case report of illness related to surgical or medical aspect of sexual organ can be taken up (vertical integration) to make the learning meaningful and nearly complete. The other example of integration can be on topic such as female sexual abuse, where forensic medicine, psychiatry, and obstetrics and gynecology can come together. This also means that one teacher has to work sometime with other teachers for integration. This makes the whole process of teaching learning interesting. In adult education process, teachers and the students are considered equal partners, and as such medical school is all about adults who are learning medicine. Hence, a good teacher is first and foremost a lifelong learner.

The current consensus for effective teaching is, the teacher should know exactly what is that he/she wants to teach? To whom is the teaching intended or which year or term of students is being taught? What method of teaching is being considered? And, how will the learning be assessed? Specific learning objectives (SLOs) are designed on these questions. And every teaching learning session, irrespective of whether it is theory class or clinical class or any other format of class, should be taken up after clarifying and listing SLOs. It becomes easy for every teacher to think and plan before each class.

A teacher can begin the class on any topic of sexual medicine by numerous methods such as case scenario, recent events, statistics, multiple choice questions, media report or appropriate movie clip or image, etc. Any of these methods that are related to topic can be used to set induction for the class and for gaining the attention of the students. It is important to make the session interactive right at the beginning. Sexual medicine teaching becomes interesting for the teacher if he/she is able to grasp, how much student know already? And how much enthusiasm the students are showing? This will assist the teacher to tailor the approach and enhance the knowledge and enthusiasm of students.

Every teacher has to mention the SLOs of that particular class to the students at the beginning. They are expected to know, what is that they are going to learn in that session?

Once the teaching learning session moves toward the content of the topic, the teacher should demonstrate his/her hold on the topic, with right emphasis where it is needed and progress systematically, so that students can connect from one aspect of topic to next for example, if prevalence of sexual dysfunction in India is presented and then the gender difference in prevalence of sexual dysfunction is discussed.

A teacher has to remember that in adult learning, there has to be interactive aspect at end of every 15 to 20 minutes of class for few minutes to recapture what students have comprehended or application of their understanding in clinical scenario. This is crucial because teaching learning session is more to bring out the understanding that is beyond what can be gained by mere reading of text book. It is important to keep the content relevant from learners’ point of view and tailoring to needs of the student. The teacher has to decide and ensure there is no overload of content. For example, if the teacher starts to take up detailed presentation on each neurotransmitter implicated in sexual dysfunction, the students may end up comprehending less and time allotted is consumed with less beneficial teaching-learning outcomes for the designated topic.

There are many methods to ensure interaction in the middle of class some of which are as follows: Intelligent interruptions, in which teacher stops at random interval and selects a student, the student can ask a question or makes a comment or challenges a statement as a way to demonstrate that he/she has been processing the topic being discussed. Interpreted lecture, in which the teacher pauses from time to time and randomly selects a student to translate the learning so far in his/her own words. Rapid reflection, in which the teacher pauses at different junctures and students are asked to reflect on the latest segment of teaching, and writes down one insight or clinical application. A few random reflections are shared with entire class. Teacher may bring humor in the teaching learning session but it should not trivialize the sexual medicine.

The conclusion of the teaching learning session should provide logical end in line with SLOs presented at the beginning of session. It should have summary, review of important facts and major concepts of the teaching. It can conclude with follow-up assignments or tasks that further get added to students’ knowledge or enthusiasm to learn sexual medicine.

To summarize, the teacher generates curiosity early in teaching-learning session, presents the content in clear and logical sequence, intelligible and meaningful delivery in covering the topic in concise manner. Teacher should be constructive and accept the criticism from students’ feedback, to further improve upon teaching skills. In every session and irrespective of number of students, the teacher should be prepared, he/she demonstrates the enthusiasm and passion for teaching sexual medicine.

Bedside clinics are important component in teaching sexual medicine. Although some of the principles mentioned above are applicable to bed side clinical teaching, the medical students should be engaged for acquiring predominantly affective and psychomotor skills in sexual medicine. It involves interaction with the patients or simulated patients or designed mannequin. The teacher should never forget that emphasis in bedside clinic is about skill acquisition for the students. The SLO of each session has to be enumerated at beginning of each session. It can be based on learning phase of the students (For example; the first class is about to approach to patient) or the case taken up for discussion on that particular session (for example; a person presenting with premature ejaculation).

The students are usually less in number compared to lecture class. Hence, closer interaction is possible and the teacher in sexual medicine should be well prepared in using appropriate teaching-learning method to ensure learning happens in allotted hours. It is important to teach students through role plays on interviewing skills in sexual medicine history taking. The emphasis should be about normalizing the approach to sexual function in interview like other biological function while being gender and culture sensitive. The session can incorporate ethical and legal issues involved with approach to opposite gender. One or two students can demonstrate the interview skills, particularly approach to the patient and developing rapport. The teacher can facilitate the discussion from other students about “what was better?” and “what could have been better and in what way?”

The teacher in subsequent sessions can engage students in enumerating the components of history taking in sexual medicine and the rationale for incorporating those components. There are many formats for sexual medicine history taking and teacher and students can decide the best format for their learning. The simple way is to make multiple groups of 5 to 6 students and each can come up with different format and teacher facilitates the discussion. It is important to understand that the students as adults learn better when they are part of decision-making process. Bedside clinic should not be converted to didactic lecture; a teacher should resist the natural tendency for monologues. The training imparted in affective domain, for example, the communication skill in the interview is well rehearsed (with terms used in local culture/language) by students and the skill is supervised by faculty in all the bedside clinic sessions. Similarly, the psychomotor skill of the students in examination of the patient or mannequin should be supervised and continuously facilitated in all “patient” interaction with utmost sensitivity to gender issues and privacy issues. It is a skill that students in sexual medicine cannot afford to neglect. The teacher should demonstrate the skills wherever it is needed so that students learn the method by emulating the teacher.

The teacher can focus on each SLO and choose the best and appropriate method to ensure the skill is learnt. For example, to elicit erectile dysfunction. The students are taught on open ended questions for eliciting WHO ICD or DSM criteria or any other accepted criteria for erectile dysfunction. Here the cognitive domain and affective domain are involved and teacher has to facilitate the learning in both domains.

One can use interesting methods in bedside clinic sessions such as “tech break” wherein students are allowed to go through online materials such appropriate education website for e-resources or videos that demonstrate certain skills and students discuss or demonstrate what is learnt, that is relevant to the ongoing session.

It is important that each bedside clinic session is linked with a follow-up assignment to students that is related to cognitive domain such as pharmacological methods in management, for example in erectile dysfunction. The bedside clinic and lectures can be well coordinated to align the learning.

The bedside clinic can also be opportunity for teacher to identify and encourage those students who show more inclination in sexual medicine, such students may be interested in taking up electives in sexual medicine during their MBBS, wherever there is opportunity. There are numerous ways the enthusiastic students can be further engaged such as in short-term research projects in sexual medicine or quiz programs.

Overall, bedside clinic session needs to be a planned collaborative effort of the faculty of an institution across all the phases of MBBS in the current curriculum. It can start with departments of anatomy and physiology handling structural and functional description of sexual organs and human sexual response. While forensic medicine has scope in introducing to sexual dysfunctions and explaining the sexual perversions, sexual offences and related medico legal aspects, faculty of pharmacology need to integrate with general medicine, obstetrics gynecology and psychiatry with regard to medications used for sexual dysfunctions. The faculty of pediatrics has the responsibility of dealing with adolescent sexuality and sexual maturation. General medicine and dermatology have their competencies mainly to set the tone in eliciting and documenting the sexual history, examining and counselling in the context of sexually transmitted diseases. The onus on faculty of psychiatry is to teach core content of psychosexual disorders and gender identity disorders (gender dysphoria) in terms of magnitude and etiology, clinical features, therapy, investigations, pharmacological basis, family education, and specialist referral. They also need to integrate at aforementioned interfaces with other subjects.

To conclude, the art of teaching sexual medicine to medical students is a rewarding opportunity and learning exercise, which every faculty should carry out for progress of medical science and contribution to public health.