560 group read the printed handout, discussed it with the trainer, and were advised to study it and revise symptom repertoires before the second interview.

Scoring Scoring was again based on the histories of the second interviews, and the procedure was the same as in the first experiment. The two scorers worked blind, and each scored half the histories from the trained group and half from the part-trained group. Results The results were analysed by the Wilcoxon matchedpairs test,3 and are given in table n. In total, trained stuTABLE II-SECOND EXPERIMENT: ITEMS OF INFORMATION

BY

SCORED,

ponents of training, the evidence is already sufficient to encourage us to develop the programme. One possibility might be to supplement the printed handout by a li.’e demonstration of the suggested procedures.4 Perhaps, also, more sessions might be included, and training might more usefully take place at the very beginning of the student’s clinical course or even earlier. Above all, though, more economic ways of giving the training must be sought. Individual tuition with video-playback is verv costly, and the saving would be considerable if, for example, some form of group training, or self-instruction and assessment, or even audio-feedback, could be developed. These would all be valuable refinements, but whether they can be achieved without detriment to the programme’s effectiveness only further research will tell,

CATEGORY

This research was conducted while the authors were in the departof psychiatry at the University of Oxford. D.R.R. was supported by the Mental Health Trust and Research Fund and the Medical Research Council. We thank the patients and staff of the Warneford and Littlemore Hospitals, Oxford. ment

REFERENCES 1. 2.

Maguire, G. P., Rutter, D. R. Lancet, 1976, ii, 556. Maguire, G. P., Rutter, D. R. in Communication Between Doctors and Patients (edited by A. E. Bennett); p. 47. Oxford, 1976. 3. Siegel, S. Non-parametric Statistics. New York, 1956. 4. Maguire, G. P., Clarke, D., Jolly, B. Unpublished.

I

*N=number of pairs, N.s.=not

excluding those with difference

I

scores

I

of 0.

1 °

EDUCATION

significant.

dents reported a median of 25.5relevant and accurate items of information against 21.5for the part-trained group. Because the difference was consistent across pairs, it achieved statistical significance (T==9-5; P< 0-001); but, because it was very small and was reflected in only 1 of the 9 categories, it is of little practical significance. The clear implication is that video-feedback is not the most important component in determining the amount of data reported in the histories. DISCUSSION

We conclude that our programme proved very much effective than traditional training methods. The first experiment demonstrated that students who underwent the full programme reported almost three times as much relevant and accurate information at the end of the test interview as did those who received only a traditional training. The second experiment suggested that the most important components may be studying and discussing the printed handout. Against our expec tations, video-playback appears to have contributed very little to training. Considered in retrospect, perhaps this is not surprising. Only one aspect of performance, the amount of information reported after the test interview, was assessed, and only one training session was given. While feedback may not help the student to report information, it may very well have an important part to play in, for example, teaching him appropriate techniques and ways of achieving rapport with the patient. Moreover, it may be that, if training were extended, feedback would prove valuable in later sessions when the student has assimilated the history-taking scheme and can turn his attention to performance. Whatever the relative importance of the various commore

HUMAN SEXUALITY AND MEDICAL

DAVID J. LORD JAMES Department of Psychological Medicine, University of Otago, Dunedin, New Zealand

BASIL

"I have often wondered why sexual topics are often euphemisttcdh termed ’medical questions’ since doctors receive no technical instruction whatsoever concerning them. Actually, their only daim to h more than the laity about them-since anatomical knowledge is almost entirely irrelevant-is that medical students are prone to indulge in ribald jokes and stories. But so is the Navy, and I am told that the Stock Exchange surpasses both in this sphere. Though it is perhaps better than nothing, since it does at least break the ice of prudishness, it would seem a very feeble basis for coping with the extraordinarilv involved problems of sexual pathology that later on come the way of most practitioners."-ERNEST JONES in Free Associations, p, s6. London: Hogarth Press. 1959.

Human sexuality is a topical but still highly controversial issue. The works of Kinsey and his colleagues,’*’ and then of Masters and johnson,34 widely publicised and widely read by professional and non-professional people alike, have established a baseline of data on human sexual behaviour. They provide a scientific background against which to view the marked cultural changes which have taken place during the present century, and which might be summarised as the replacement of Victorian morality by more permissive anJ tolerant attitudes to sexual behaviour. The medical implications of such changes are great. In general, the psy chological and social factors involved in states of heaitr and disease are receiving more emphasis than formeris. in particular, attention is being drawn to specific aspect of psychosocial functioning, including the sexual, ne boundaries of traditional medical practice are belr.i extended, a point highlighted by Symonds,’ who canc)’ tured the situation by describing gynaecological chr

561

operating in a climate of relaxed ing-stations for sexual casualties.

abortion laws

as

clear-

DOCTORS AND SEXUAL DISORDERS

incidence of sexual disorder,67 ranges from less than 1% to over 25%, and although, not surprisingly, this varies from specialty to specialty, it seems likely that the rate of case-detection is more a reflection of the behaviour of the doctor than of the patients who consult him. Pauly and Goldstein8 believe that an estimate of a 10% prevalence of sexual dysfunction is conservative, and they have shown that a major reason for low-rate reporting is failure to ask the necessary questions of the patient. 83% of doctors in the United States were found to have had no formal training in human sexuality, and to have felt unable to deal with sexual problems. Most were embarrassed, and the most common positive response to patients was to offer them a book on the subject. Later, in 1971, Pauly9 showed an interesting capacity by doctors for self-deception. Whilst only 5% admitted inadequate knowledge of human sexuality themselves, 40% thought that "most doctors" were deficient in this respect. Obstetricians and gynaecologists seemed no more confident or competent in the management of their patients’ sexual dysfunction than did physicians and surgeons, and the author commented upon the disproportionate allocation of time in undergraduate curricula to the physical aspects of the reproductive system, whereas the behavioural or sexual aspects received little or no attention. He suggested that medical educators seemed to be operating on the notion that the only acceptable motive for sexual intercourse was reproduction. It is not only education that has been affected by individual moral attitudes or idiosyncratic experiences; clinical practice has suffered even more. Earlier in this century prevailing morality permitted the ghastly mutilations of clitoridectomy and genital blistering to masquerade as treatment for masturbation, and popular and respectable texts were replete with detailed advice for parents on how to persecute their children in the interests of detecting the "vicious" habit. The reading of novels was considered by one authority to be "one of the greatest causes of uterine disease in young women" because of its tendency to rouse the passions. Although such opinions may not be openly expressed today, there is evidence that personal prejudice exerts strong influences upon clinical behaviour.8 11-14 Masters4 claimed that in general doctors know no more and no less than other college graduates, sharing most of the common misconceptions, taboos, and fallacies of their non-medical colleagues. At Australia’s Monash University, it was shown 15 that 70% of the students felt that they learned more from just growing up than specifically through the medical course. Even so, there is some evidence that in the U.S. not only do doctors who have qualified comparatively recently (since 1960) consider themselves to be more adequate in their sexual understanding than do their predecessors, but that also they are more tolerant of their patients’ behaviour and beliefs when these conflict with their own; in addition, they are more likely to seek a second (consultant) opinion when they doubt their own abilities. 16 Tolerance of difference, rather than actively seeking The

reported

current

change attitudes, is the medical approach increasingly recommended in the literature. 17 18 Shatin19 has suggested that the ability to adopt this approach may be more important than specific knowledge, and Marcotte 20 specified the main aim of his course on human sexuality as being the development of tolerance. He emphasised that a person may continue to hold conservative (or liberal) personal views concerning sexual behaviour, but should still be able to develop a tolerant attitude to those whose view is different. Religion is an important influence shaping an individual’s moral code. Alzape21 stated that it was impossible to divorce Christian morality from sexual behaviour, and that this issue was often the centre of controversial discussion. Flecknoe-Brown and his co-workers15 found that the degree of tolerance towards various kinds of sexual behaviour, including promiscuity and premarital sex, correlated negatively with the degree of religious belief. Interestingly, Pauly9 found that doctors replying to a questionnaire perceived themselves to be much less affected by their religious beliefs than "most doctors". He drew attention to the overlapping of individual and to

professional positions; patients receiving idiosyncratic opinions and advice from a doctor may be misled into thinking that they have been given a medical or profes-. sional statement. The ability of the doctor to distinguish between his own personal ideological or moral viewpoint, and an opinion based on actual and available information, may determine whether or not a patient is led incorrectly to feel abnormal and hence guilty. THE DUNEDIN EXPERIENCE

Starting in 1970, teaching on aspects of sexual behaviour incorporated in the third-year behavioural sciences course at the University of Otago; in 1973, partly in response to student wishes, a fifth-year, clinically oriented, course was introduced, entitled Sexuality and its Vicissitudes. There were few existing guidelines regarding content or style, and to some extent the form of the teaching was determined by allocation of curricular time. Topic-oriented whole-class lectures followed by small group discussions constituted the original course structure, but although this had certain advantages, had been

such as. economy of teacher time for the lecture component, it also had the shortcoming of requiring several staff tutors concurrently for a task which turned out to require unusual maturity, skill, and sensitivity. Furthermore, there was only limited opportunity for more personal involvement using clinical presentations, audiovisual aids, and so on. Role play of interviews, however, did evolve as a particularly profitable ex-

perience. Subsequent time-tabling changes permitted experiment with a variety of formats, most of which involved small-group teaching for 2 afternoons a week for 5 consecutive weeks. The existence of 5 such groups meant that the course had to be repeated 5 times during the academic year, but at least the disadvantages of the earlier arrangement were overcome. Each session was devoted to a particular topic (for example, intimacy, normal sexuality, sexual dysfunctions, deviant sexual behaviours, sexuality in the ageing, sexuality in the disabled, sexual problems presenting in general practice). Different topics were allocated to different teachers, though a course coordinator attended all sessions. In addition, an extra staff member was usually present in an attempt to teach teachers something of the difficulties such a programme uncovered, and something of the skills required. General comment from students indicated a degree of satisfaction, but it became clear that what was most required dur-

.

562

ing the sessions

was not factual information (which was available or could be made so in written form) but the opportunities for developing a comfortable professional attitude to sexuality, through the exploration of attitudes and feelings. Pre-planned topics, presented verbally, were viewed as a less satisfactory way of learning than were the presentation of patients, or the use of teaching aids such as films. By 1975 topic-centred seminars had been abandoned, and more films and greater contact with patients were introduced. The seminars which were retained focussed mainly on the group members themselves. The films served to convey factual information, but also, by depicting, quite explicitly, sexual techniques and practices, they made the students examine and discuss their own attitudes and emotions, and the effect these could have on clinical

sionally. Obviously this can occur only as a result 0:’ education. Thus the teacher must create for the student. as the doctor must create for the patient, the opportunity to identify and express, in a setting of respect and acceptance, feelings and beliefs, not so that they mav be changed to conform with those of the teacher (or doctor but rather that they can better appreciate the effect of such feelings and beliefs on their professional (or personal) relationships. The doctor as a private individual has of course his right to believe or behave in his own chosen way; but equally the patient has the right to expect the doctor to behave professionally. Professional behaviour may involve the replacement of one set of

judgment.

sensitivities for another. GUIDELINESS

Flexible

in the literature, and our exin running the course, permit the formulation of some guidelines for education in The

findings reported perience over four years

Sexual

All Doctors

The fact that only a few currently practising doctors will have had such education has important implications for continuing education as well as for the undergraduate curriculum. Sexuality touches on every branch of clinical medicine, not just psychiatry and obstetrics and gyneecology.22 Cardiology, respiratory medicine, neurology, orthopaedic surgery, rheumatology, and gastroenterology, not to mention general practice, can, without too much difficulty, be seen to be involved, quite frequently, with problems and anxieties in the sexual field.

goals. Teaching Professional Behaviour As has been described, medical students and doctors, as individual persons (unless they are involved in specific educational programmes) bring to the subject of sexuality beliefs, and more importantly, attitudes, as varied as do their patients. It seems almost unnecessary to state that the constitutional make-up and developmental, family, and moral experiences of students and doctors are as idiosyncratic and are no less powerful as determinants of behaviour and psychological set, as are those of non-medical persons. Yet in these matters as well as in matters involving the exploration of intimate and private physical areas, there is a general expectation that the doctor can suspend his "natural" responses of embarrassment, or even revulsion, and act profes-

and will continue to be in the main

as well as the content and nature of the instruction, should be capable of being varied to suit different needs, The variability of needs is readily apparent in the educational group setting, and it would be undesirable, even if it were possible, to prescribe details of method and form. What may prove successful for one group or individual may prove the reverse for another. Similarly, the capacities of one teacher may differ from those of another. The demonstration of sensitivity to individual requirements, and the acceptance of differing capabtlities, are in themselves powerful models in such a situation-clinical or educational.

Moral Attitudes

Factual information regarding normal and dysfunctional sexual behaviour is necessary but insufficient .23-26 Without wishing to diminish the importance of acquiring physiological and epidemiological data, we believe that the development of the appropriate professional attitudes and related clinical skills requires even 27-29 Although moral attitudes greater emphasis.14 of be enormous to importance in everyday cliniappear cal transactions, and often, in the individual, a major impediment to the detection and management of a variety of problems, they constitute a dimension of practice insufficiently acknowledged, and usually conspicuous by their absence in the designation of teaching

matters are

essentially private, and just as the doctor must provide for the patient the appropriate physical setting for privacy to be maintained and the interpersonal climate of trust to be assured, so must similar conditions prevail for the- learning of professionalism in dealing with sexual problems. Thus, small groups are preferable to large and continuity of membership, including the instructor, is important; and the duration and intensity of the course,

sexuality. Sexual Education for

Teaching Methods

General Principles

However, certain principles seem, in the light of experience, to be generally applicable, and are judged to be of sufficient value to record. We believe that:

;

(1) The optimum group size is between 8 and 10. (2) The group should contain both sexes; although even one representative of a sex is better than none, not less than three is a desirable goal. (3) The total duration of the course should not be less than 16 hours. No session should be less than 2 hours (though a brief break in the middle is important), and a twice-week!) meeting for 5 weeks seems to work very well. It is probabi; that a more concentrated course, say occupying a weekenu, (4)

could also be successful. Although different instructors might be involved at M ferent points in the course, too much variation produce, fragmentation, particularly as the group discussion retat to morality and attitudes evolves. The provision of co’r tinuity by the presence throughout of a constant grmf leader is vital; this leadership can with advantage be shar by a man and a women, both of whom are present at ? session.

Content

of Courses

Courses for doctors on human sexuality should if FC" sible contain the following components:

(1) The presentation of real patients with real sexual prLb.-,--,

563

12’The presentation of simulated sexual problems (in Dunedin professional actors and actresses are employed), which allows participation by the students and, by the repetition of the same incident, can demonstrate the varied results of different kinds of medical intervention.

3’Role play, which gives students the opportunity to experience the difficulties patients may sometimes have in communicating with a resistant or embarrassed doctor. of value

only because they demonstrate skills in communication, but also because, by illustrating sexual techniques and therapies, they evoke

4 firms, which

are

not

emotional responses in the students which jected into the discussion.

can

then be in-

choice of leaders for these discussions must rest on much more than a knowledge of sexual anatomy, physiology, and physical pathology. It is perhaps less important in what medical discipline the leader is trained than that he has had training and experience in group processes and leadership. A medical qualification is, however, desirable if the wish is to teach medical students and doctors that sexual investigation and counselling is an integral part of medical practice; and the professional background in the physical aspects of is sexuality, including experience of physical examinations, certainly not without its own special value.11 16 21 26 *

*

Patients are increasingly turning to their doctors for help with their sexual problems, and there is ample evidence that the medical profession is poorly prepared to meet their needs. It is the very variety of human behaviour that brings both the pleasures and the problems of human sexuality. Only if doctors are educated to approach these problems with understanding and tolerance as well as knowledge will they be able to claim any special qualification for offering help to patients with sexual difficulties. -

REFERENCES A. C., Pomeroy, W. B., Martin, C. E. Sexual Behaviour in the Human Male. Philadelphia, 1948. 2. Kinsey, A. C., Pomeroy, W. B., Martin, C. E. Sexual Behaviour in the Human Female. Philadelphia, 1957. 3 Masters, W. H., Johnson, V. E. The Human Sexual Response. Boston, 1966. 4. Masters, W. H., Johnson, V. E. Human Sexual Inadequacy. Boston, 1970. 5 Symonds, E. M. Med. J. Aust. 1973, i, 37. 6. Burnap, D. W., Golden, J. S. J. med. Educ. 1967, 42, 673. 7. Herndon, C. W., Nash, E. M. J. Am. med. Ass. 1962, 180, 395. 8. Pauly, I. B., Goldstein, S. G. Med. Asp. hum. Sexuality, 1970, 4, 48. 9 Pauly, I B. Aust. N. Z. J. Psychiat. 1971, 5, 206. 10. Kellogg, J. H. Ladies’ Guide. New York, 1901. 11 Lief, H. I. in Marriage Counseling in Medical Practice (edited by E. M. Nash, L. Jessner, and D. W. Abse); Chapel Hill, 1964. 12. Lief, H. I. Pacif Med. Surg. 1965, 73, 52. 13 Pauly, I B., Goldstein, S. G. Med. Asp. hum. Sexuality, 1970 5, 32. 14. Woods, S. N., Natterson, J. Am. J. Psychiat. 1967, 124, 323. 15. Flecknoe-Brown, S., Bosisto, S. de V., Cunningham, A., Menogue, N., Williams, N. Panacea, 1971, 4, 45. 16. Pauly, I. B , Goldstein, S. G. J. med. Educ. 1970, 45, 745. 17. Cade, J., Jesse, W. ibid. 1971,46, 64. 18. Chez, R ibid p. 971. 19. Shatin, L. Dis nerv. Syst. 1966, 27, 462. 20. Marcotte, D B. J. med. Educ. 1973, 48, 285. 21. Alzape, H ibid 1974, 49, 438. 22. Romano, J ibid. 1968, 43, 878. 23. Lief, H. I Pediat. Clins. N. Am. 1969, 16, 447. 24. Lief, H. I. J. med. Educ. 1971, 46, 373. 25. Marcotte, D B., Kilpatrick, D. G. ibid. 1974, 49, 703. 26. Tyler, E. A ibid. 1970, 45, 1025. 27. Cahn, S., Belzer, E. G. ibid. p. 588. 28. Garrard, J, Vaitkus, A., Chilgren, R. A. ibid. 1972, 47, 772. 29. Golden, J. Liston, E. ibid. p. 761.

1. Kinsey,

Survey

DOPAMINE AND SCHIZOPHRENIA T. E. C.

J. CROW JOHNSTONE

J. F. W. DEAKIN A. LONGDEN

Clinical Research Centre, Northwick Park Hospital, Harrow, Middlesex HA1 3UJ, and National Institute for Medical Research, Mill Hill, London NW7 1AA

Summary

,5) Group discussions, without which a course would run the danger of demonstrating the very antithesis of appropriate medical behaviour in relation to sexuality, and thus of consolidating impediments to comfortable participation. The

*

Occasional

The

antipsychotic actions and extrapyramidal side-effects of neuroleptic are drugs strongly correlated with their ability to block central dopaminergic transmission. It is argued that the former are more closely related to actions on dopaminergic mechanisms in the "mesolimbic dopamine" system, and the latter to similar actions in the striatum. Although the amphetamine psychosis closely resembles paranoid schizophrenia and may be due to excess dopamine release, clinical, biochemical, and endocrine studies suggest that dopaminergic overactivity is not a necessary concomitant of schizophrenic illnesses. It is suggested that the primary defect in schizophrenia does not lie in the dopamine neuron. It remains to be excluded that the receptors, particularly in the mesolimbic dopamine areas, become supersensitive, or that there is a deficit in a system which normally acts in antagonism to the mesolimbic dopamine system. INTRODUCTION

THERE

are two

major clues to the pathology of schizpsychosis induced by large doses of

that the

ophrenia : amphetamine closely resembles acute paranoid schizophrenia,l and that a range of psychotropic drugs (termed neuroleptics) are therapeutically effective in schizophrenia.2 These clues have been tied together in the dopamine hypothesis of schizophrenia. 3-8 The hypothesis states that, since many behavioural effects of the amphetamines are due to increased central dopamine release and since most neuroleptic compounds are blockers of central dopamine receptors, the symptoms of schizophrenia may be due to an abnormal increase in central dopamine release and the effects of this increase are diminished by partial blockade of the receptor site. AMPHETAMINE PSYCHOSIS AS A MODEL OF SCHIZOPHRENIA

Connell drew attention

the close resemblance amphetamine psychosis and acute paranoid schizophrenia-an observation supported by others.9-11 The psychosis is unlikely to be an idiosyncratic response since it occurs in most, if not all, volunteers when a large enough dose is given, and can occur before sleep deprivation is an important factor.12 Thus the psychotic change is likely to be a direct pharmacological effect of the drug. The amphetamines resemble the two catecholamines dopamine and noradrenaline in structure, but the absence of ring hydroxyl groups enables them to enter the central nervous system and the presence of a methyl group on the oc carbon atom may protect them against breakdown by monoamine oxidase. In various animals they induce a syndrome of stereotyped repetitive behaviours.13 The syndrome is blocked by the drug cx-methyl-

between

to