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ORIGINAL RESEARCH—EDUCATION Sexuality Education in Brazilian Medical Schools Andrea Cronemberger Rufino, PhD,* Alberto Madeiro, PhD,* and Manoel João Batista Castello Girão, PhD† *Department of Gynecology, State University of Piauí, Teresina, Brazil; †Department of Gynecology, Federal University of Sao Paulo, Sao Paulo, Brazil DOI: 10.1111/jsm.12476
ABSTRACT
Introduction. Sexuality education has been valued since the 1960s in medical schools worldwide. Although recent studies reaffirm the importance of incorporating sexuality into medical education, there are data gaps concerning how this happens in Brazil. Aim. To understand how Brazilian medical school professors teach sexuality in undergraduate courses. Methods. An exploratory, cross-sectional descriptive study was conducted. A total of 207 professors from 110 Brazilian medical schools responded to an online semistructured questionnaire about the characteristics of the sexuality-related topics offered. Main Outcome Measures. The main variables assessed were contact hours devoted to sexuality, disciplines in which sexuality topics were taught, sexuality-related course titles, and sexuality-related topics addressed. Questionnaires were tabulated and analyzed using descriptive statistics for frequency distribution. Results. The response rate to the questionnaire was 77.2%. Almost all professors (96.3%) addressed sexuality-related topics mainly in the third and fourth years as clinical disciplines, with a 6-hour load per discipline. Gynecology was the discipline in which sexuality-related topics were most often taught (51.5%), followed by urology (18%) and psychiatry (15%). Sexuality-related topics were addressed mainly in classes on sexually transmitted diseases and AIDS (62.4%) and on the anatomy and physiology of the reproductive system (55.4%). About 25% of the professors reported teaching courses with a sexuality-related title. There was emphasis on the impact of diseases and sexual habits (87.9%) and sexual dysfunction (75.9%). Less than 50% of professors addressed nonnormative sexuality or social aspects of sexuality. Conclusions. The teaching of sexuality in Brazilian medical schools occurred in a nonstandardized and fragmented fashion across several disciplines. The topic was incorporated with an organic and pathological bias, with a weak emphasis on the social aspects of sexuality and the variety of human sexual behaviors. The results point to the need for change in the provision of sexuality education in Brazilian medical schools. Rufino AC, Madeiro A, and Girão MJBC. Sexuality education in Brazilian medical schools. J Sex Med 2014;11:1110–1117. Key Words. Sexuality Education; Sexuality in Undergraduate Training; Medical Education; Medical Students
Introduction
T
he educational field of sexuality comprises a range of concepts associated with sexual health, sexual rights, and social justice. Sexual health includes the presence of physical, emotional, and social satisfaction related to sexuality, as well as the absence of pathology. It also includes J Sex Med 2014;11:1110–1117
positive aspects such as eroticism, pleasure, and the freedom to experience sexuality without any violence [1]. The practice of medicine is besieged by a variety of sexual issues [2,3], which include the high prevalence of sexual dysfunctions and STDs in the population, including HIV infection and AIDS, as well as the impact of diseases and drugs © 2014 International Society for Sexual Medicine
1111
Sexuality Education in Brazilian Medical Schools on sexual function [4–7]. There are also requests for assistance with health problems related to gender issues such as sexual violence and abortion and with health care for specific groups such as lesbians, gays, bisexuals, and transgender individuals (LGBT) [8–10]. The general population expects doctors to be prepared to understand and treat such sexual problems. Recent publications have highlighted the importance of training in sexual medicine to adequate health care [11–13]. Therefore, teaching human sexuality is considered essential for medical education [2,3,5,11]. Several initiatives, experiences, and assessments regarding the integration of sexuality into the curricula of medical schools in the United States and the United Kingdom have been published, increasing in number over the last decade [2,3,14– 16]. These sexuality education programs were established on the basis of a multidisciplinary approach aiming at knowledge sharing, reflection, and changing attitudes in relation to sexual matters, coupled with skills development for appropriate care. Another model proposed for the curricula in those countries proposes the verticalization of sexual health issues, which would be taught over the full duration of the medical program and be covered completely in the curriculum [2,3,15–19]. The International Society for Sexual Medicine has recently published some reviews about sexual medicine education. The research highlights several obstacles faced by doctors in the treatment of sexual problems, such as lack of knowledge and training, personal discomfort in relation to sexual topics, and beliefs about normative heterosexuality, thus reinforcing the idea that medical schools around the world should improve the quality and the amount of sexuality education offered to their students. Some recommendations have been made to create a model for modular and multidisciplinary curricula in undergraduate medical schools that could possibly be adapted for different cultures [20,21]. The current state of sexuality teaching in Brazilian medical schools is unknown. Therefore, we decided to investigate how Brazilian medical schools teach sexuality through the perspectives of professors. We investigated the disciplines in which sexuality was taught, years during which sexuality was taught, contact hours devoted to sexuality in these disciplines, and number of professors involved in teaching the discipline, as well as sexuality-related course titles, teaching methods, and sexuality topics addressed.
Methods
Study Design and Ethical Issues We performed an exploratory, cross-sectional descriptive study with medical school professors in Brazil from March 2010 to July 2011. We provided an online semistructured questionnaire and set informed consent as a prerequisite for responding to the questionnaire. The Ethics Committee of the Federal University of Sao Paulo (UNIFESPEPM) approved this study under Register No. 0045/10, following the guidelines of Resolution 196/96 of the National Health Council, in compliance with the Declaration of Helsinki. Samples During the period when this study was being carried out, there were 181 medical schools in operation in Brazil. A total of 144 of those schools offered programs that would be completed by July 2011, the final period for data collection [21]. As such, these schools were considered eligible for this study, and their professors composed the unit of analysis for the research. The 37 schools with ongoing courses were not considered in order to avoid a bias in selection caused by the absence of courses or topics addressing sexuality that could still be covered. Subjects We conducted a study with a convenience sample due to the unknown number of professors involved in sexuality education and also due to the multiplicity of teaching methodologies and variety of curricula adopted by Brazilian medical schools. For medical schools with a subject-structured curriculum, we selected professors of gynecology, psychiatry, urology, and medical psychology, which comprise the disciplinary field of sexology in Brazil. As for the medical schools with curricula that were not structured by subject, the selection of professors was made through direct indication from course coordinators. Dissemination We informed medical program coordinators about this study by telephone. Coordinators, in turn, indicated the professors who taught the previously mentioned disciplines or other disciplines who could be eligible to participate in the study. Initial telephone contact with professors was made to present the research and its objectives. Then a cover letter about the study was sent via e-mail J Sex Med 2014;11:1110–1117
1112 containing explanations on how to participate. We contacted 268 professors from 144 medical schools by phone and e-mail. The strategy used to reinforce participation in the research was to call and e-mail coordinators and professors every 3 to 4 weeks with a total of 4 attempts. We received responses from 213 professors from 110 medical schools.
Instrument An instrument with open and closed questions was designed and divided into two domains. The first domain asked about the professor’s institution and the presence of sexuality-related topics in a specific course or classes. The second domain asked about the characteristics of the course, the sexuality content offered by the professor, the type of educational activities carried out, course titles, and aspects of sexuality addressed in classes. We used the “Sexual Health for the Millennium” declaration and technical document published by the World Association for Sexual Medicine as a reference for the choice of questions about the different sexuality-related topics [22]. Validation Test A pilot project was developed to validate the questionnaire. Initially, three gynecologists and one sexology expert analyzed the instrument with regard to questionnaire instructions, clarity, question relevance, and suitability for the proposed objectives. The questionnaire was then offered to 12 gynecology, urology, and psychiatry professors from four medical schools located in the Northeast Region of Brazil. In this step, we analyzed difficulties with accessing and using the online questionnaire, submitting responses, and understanding the questions, as well as the time spent to answer them. After making the necessary adjustments in the questionnaire, the responses for the validation test were disregarded. Data Analysis The responses to the 213 answered questionnaires were sent to an electronic database and then exported to a spreadsheet (Microsoft Excel 2010 for Windows). An initial analysis of the questionnaires led to the exclusion of six of them because most of the questions were unanswered. Then, the data collected from the remaining 207 questionnaires were tabulated and analyzed using descriptive statistics for frequency distribution. Among them, 188 (90.8%) were answered completely, J Sex Med 2014;11:1110–1117
Rufino et al. whereas 19 had one or two unanswered questions, not enough to affect the percentage distribution of the data. Results
Medical Schools in Brazil In Brazil, medical schools are distributed heterogeneously across regions. As of the year 2000, there were 106 medical schools in operation in Brazil, and the Ministry of Education approved a number of new medical schools for opening between 2000 and 2013. In March 2010, when this study began, we identified 181 medical schools in operation. From 2011 to 2013, 20 new medical schools were opened, totaling 201 institutions in operation as of 2013 [21]. Professors Involved in the Teaching of Sexuality Throughout Brazil, among the 268 professors contacted, 207 responded to the questionnaire (77.2%). These professors were distributed across 110 medical schools, with response rates varying according to the region of the country, with a higher concentration of responses in the Southeast and Northeast Regions (Figure 1). Out of the total number of professors, 200 (96.3%) mentioned classes that addressed sexuality-related topics. Disciplines, Contact Hours, and Learning Activities Most professors who reported teaching sexuality classes taught clinical disciplines (187 or 93.5%), especially gynecology (103 or 51.5%). A small number of them mentioned including sexuality in preclinical disciplines such as anatomy and physiology (2%) or teaching a specific discipline on sexuality (3%), as shown in Figure 2. All 200 professors indicated that they taught sexuality during the third and fourth years, while 29 of them (14.5%) also taught it in the first and the second years, and 59 (29.5%) in the fifth and sixth years. About half of the professors (113 or 56.5%) devoted 6 contact hours to sexuality, but 38 of them taught 7–15 hours (19%). Professors addressed sexual themes through teacher-centered (143 or 93.5%) and practical activities (122 or 79.7%). Among the teacher-centered activities, lectures were predominant (122 or 79%), followed by seminars and discussion groups (53 or 34.6%) and movies (22 or 14.4%). Professors reported integrating sexuality into practical clinical activities (82 or 53.6%) and classroom activities (62 or 40.5%).
Sexuality Education in Brazilian Medical Schools
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Figure 1 Response rate of Brazilian medical schools and professors by region. Dark bars = response rate of professors; light bars = response rate of medical schools.
Specific Classes Most professors (186 or 93%) mentioned the specific classes in which they addressed sexuality topics. Classes on STDs and AIDS were mentioned the most (116 or 62.4%). About half reported classes on the anatomy and physiology of the reproductive system (103 or 55.4%) or on contraception (99 or 53.4%). Professors mentioned courses with sexuality-related titles (47 or 25.3%), with emphasis on disorders, sexual dysfunctions, and paraphilias (22 or 11.8%) or on eroticism (19 or 10.2%). Aspects of Sexuality Included in Class When addressing sexuality, professors mostly commented on the impact of diseases and sexualityrelated habits (168 or 87.9%), with emphasis on
STDs and AIDS (126 or 66%). They emphasized the clinical features, diagnosis, and treatment of sexual problems, with special attention to sexual dysfunctions (145 or 75.9%). Professors mentioned eroticism in lectures on the sexual response cycle (149 or 78%) and less often in discussions of pleasure, erogenous zones, and masturbation (119 or 62.3%). They referred to the social context of sexuality, featuring sexual violence (90 or 47.1%) and human sexual development (91 or 47.6%). However, the number of professors who spoke about the significance of sociocultural gender roles (76 or 39.8%), sexual and reproductive rights (69 or 36.1%), and homophobia (29 or 15.2%) was small. Professors spoke about sexual orientation, addressing mainly heterosexuality (122 or 61.8%). Less than half of them talked about homosexuality (91 or 47.6%) or bisexuality (69 or 36.1%). Sexuality in
Figure 2 Disciplines involved in teaching sexuality. “Other disciplines” refers to oncology, mastology, geriatrics, obstetrics, infectious diseases, and surgery. “Thematic modules” refers to humanistic basis of medicine and tutorial.“Social disciplines” refers to bioethics, mental health, and family medicine.
J Sex Med 2014;11:1110–1117
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Rufino et al.
Figure 3 Sexuality-related topics addressed in classes by professors. Topics under “eroticism” include pleasure, erogenous zones, and masturbation. “Sexuality in special populations” refers to sexuality in adolescents, the elderly, and pregnant women.
special groups, such as adolescents, pregnant women, and the elderly, was discussed by 64.9% of the professors (Figure 3). Discussion
We investigated sexuality teaching in Brazilian medical schools from the perspectives of 207 professors from 110 schools in all regions of the country, which resulted in a response rate of 77.2% of the medical professors contacted and 76.4% of medical schools. Previous surveys in medical schools worldwide showed response rates ranging from 71% to 95%, similar to the Brazilian professors’ response rate [23–26]. We found a high number of professors who reported including sexuality in their classes. This may reflect Brazilian professors’ interest in talking about sexualityrelated topics. We observed that sexuality was mainly offered by third- and fourth-year clinical discipline professors, especially those teaching gynecology. The profile of professors participating in the study, mostly gynecologists, probably influenced the results obtained. Almost half of the professors pointed out a variety of other disciplines that deal with sexuality-related topics. We noticed that sexuality teaching was a transversal event, which was distributed across several independent disciplines. However, the instrument used did not allow us to assess the overlap between courses in order to consider the interdisciplinary aspect of sexuality education. Including sexuality education in interdisciplinary courses has been advocated in American J Sex Med 2014;11:1110–1117
medical schools since the mid-1960s [27]. Several sexuality education programs in multi- and interdisciplinary models have been described, including activities in preclinical and clinical courses, thus enhancing the integration among them and the verticalization of the topic of sexuality [2,14,15]. Recent publications on sexuality education in medical education also reinforce these recommendations for many countries, suggesting the problematization of cases as a teaching strategy [15,18–20]. In 1980, a study evaluated the inclusion of sexuality education in American medical schools and found a wide range of courses offering reproductive health- and sexuality-related topics among 97 schools surveyed. Gynecology was the discipline that devoted the most hours to these matters, although the topics were also offered in psychiatry, anatomy, and physiology [28]. In 2003, another survey of 101 US and Canadian schools indicated that 63% offered sexuality education in various disciplines. In 75% of the schools, psychiatry was most associated with the teaching of sexuality [26]. In regard to contact hours, 50% of the Brazilian professors devoted up to 6 hours of their classes to sexuality-related topics. This result suggests that the professors took sexuality into consideration but did not plan sexuality content for the entire curriculum. In a study of American and Canadian medical schools published in 2003, 54% were found to provide less than 10 hours of curriculum time for sexuality education [26]. It has been suggested that mandating any less than 10 hours for sexuality education in undergraduate medical
Sexuality Education in Brazilian Medical Schools school is not satisfactory for appropriate training in sexual health [23,26,27]. Brazilian professors approached sexuality primarily using theoretical lectures and, to a lesser extent, ambulatory care activities as pedagogical resources. Desensitization of students to issues related to sexuality would help to promote a change in attitudes toward sexuality when offering treatment. In this vein, some authors support the use of media coupled with small discussion groups as well as the reduction of the number of theoretical lectures offered [2,16–19]. Other teaching resources have been suggested in order to improve practical training in skills used to collect sexual history. The use of recorded interviews with standardized patients and the simulation of medical consultations have also been proposed [2,15,17–19]. The specific classes and aspects of sexuality listed by Brazilian professors reflect the prominence given to the organic and biological aspects of sexuality. We also observed the importance given to the impact of diseases on sexuality and issues related to STDs and AIDS. Even in specific sexuality classes, professors emphasized sexual dysfunctions and paraphilias to the detriment of pleasure. A similar result was found in American medical schools in the 2003 study described above, where the diagnosis and treatment of sexual dysfunctions and sexuality in various diseases were taught more frequently than social aspects like sexual abuse [26]. We observed low incorporation of the social aspects of sexuality into the Brazilian lesson plans through the presence of occasional topics on sexual violence, gender relations, and sexual and reproductive rights. In 2012, a qualitative study among Mexican undergraduate students noted sexuality education to be conducted mainly in gynecology, urology, and psychiatry disciplines, with a strong organic bias. Students reported difficulties dealing with their own sexuality as well as aspects of patients’ sexuality that were not related to organic and reproductive intercourse issues. They reported a lack of emotional skills in talking about eroticism and sexual violence or gender [29]. We noted that sexual orientation was addressed by a little more than 50% of the Brazilian professors, with a bias toward heterosexuality. Thus, the variety of human sexual behaviors was poorly addressed. In 2012, a study investigated the offering of health-related content to the LGBT community in the American and Canadian medical curricula. Among the 150 schools evaluated, 63%
1115 offered such content, but with a bias toward organic and psychological aspects and little emphasis on social, behavioral, and sexual identity aspects [23]. The results of this study have direct implications for the training of qualified sexual health consultants for the Brazilian population. In Brazil, curricula should also be aligned with public health policies, which are designed with particular attention to the sexual and reproductive health of the population. Initially, these data show that almost all the professors mentioned teaching sexuality topics in classes with several different course titles. This highlights the personal interest of the majority of professors in addressing sexual issues in medical education. Therefore, these data also affirm the vitality of the field of sexuality in the country. However, we noted that sexuality topics were offered in a transversal, nonstandardized, fragmented way in several clinical courses, which may have been due to the lack of national curriculum standards for this topic. Professors discussed sexuality with emphasis on biological and organic aspects, highlighting the impact of diseases, sexual dysfunction, STDs, and AIDS. The topics related to the social construction of sexuality that give meaning to sexual behavior were inadequately discussed. Sexual diversity, gender, and sexual violence received little attention, although they may permeate sexual complaints brought to consultations. This reductionist view of sexuality may compromise the quality of the medical education necessary for proper sexual health consultations. This study has some limitations that should be taken into consideration. As it is an exploratory study, the use of nonprobability sampling may have caused a selection bias. The number of professors and disciplines in each medical school involved with sexuality education was unknown. However, we chose professors from several disciplines in an attempt to minimize this limitation and to provide more reliable knowledge about sexuality education. The cross-sectional methodological design chosen may provide reproducible results at another time. Thus, reassessments to update these data may be needed. This is the first nationwide Brazilian study on sexuality education in medical schools. We obtained a satisfactory response rate from professors in all regions of the country and also a large number of completely answered questionnaires. Thus, the results of this study can provide a current overview of sexuality education as offered in Brazilian undergraduate medical institutions. J Sex Med 2014;11:1110–1117
1116 Conclusions
This research aimed to discover how sexuality education is currently offered by Brazilian medical schools through the perspectives of professors. Almost all the professors in Brazilian medical schools included in this sample offered sexuality topics. These topics were taught during the third and fourth years as part of clinical disciplines such as gynecology, psychiatry, and urology. Half of the professors devoted 6 hours per discipline to sexuality topics. Classes on STDs and AIDS were those in which professors were most likely to address sexuality-related topics. Professors mainly emphasized the impact of diseases and sexual dysfunction. Few of them addressed nonnormative sexuality or social aspects of sexuality. We hope the results of this study will stimulate reflection on and changes in the teaching of sexuality in Brazilian medical schools. Our recommendations are as follows. First, interest medical schools in offering curricula with sexuality topics. Second, encourage the provision of sexuality topics in interdisciplinary programs with equal emphasis on clinical, social, and psychological aspects. Third, enhance the use of varied teaching resources to facilitate the provision of knowledge, changes in attitudes, and the provision of skills training with regard to sexuality topics. In this way, it will be possible to train physicians who are better able to provide comprehensive care for the sexual health of the Brazilian population.
Acknowledgments
The authors thank the Piaui Research Foundation (Fundação de Amparo à Pesquisa no Piauí—FAPEPI) for funding this research. Corresponding Author: Andrea Cronemberger Rufino, PhD, State University of Piauí, Medicine, R Cel Costa Araújo 3033 Horto Florestal, Av Cel Costa Araujo 3033, Teresina, Piaui 64052820, Brazil. Tel: +558694522797; Fax: +558632213170; E-mail: andreacrufi[email protected] Conflict of Interest: The authors report no conflicts of interest.
Statement of Authorship
Category 1 (a) Conception and Design Andrea Cronemberger Rufino; Alberto Madeiro; Manoel João Batista Castello Girão J Sex Med 2014;11:1110–1117
Rufino et al. (b) Acquisition of Data Andrea Cronemberger Rufino (c) Analysis and Interpretation of Data Andrea Cronemberger Rufino
Category 2 (a) Drafting the Article Andrea Cronemberger Rufino; Alberto Madeiro; Manoel João Batista Castello Girão (b) Revising It for Intellectual Content Andrea Cronemberger Rufino; Alberto Madeiro; Manoel João Batista Castello Girão
Category 3 (a) Final Approval of the Completed Article Andrea Cronemberger Rufino; Alberto Madeiro; Manoel João Batista Castello Girão References 1 World Health Organization. Measuring sexual health: Conceptual and practical considerations and related indicators. 2010. Available at: http://whqlibdoc.who.int/hq/2010/who _rhr_10.12_eng.pdf (accessed May 13, 2013). 2 Leiblum SR. An established medical school human sexuality curriculum: Description and evaluation. Sex Relat Ther 2001;16:59–70. 3 Wylie K, Halam-Jones R, Daines B. Review of an undergraduate medical school training programme in human sexuality. Med Teach 2003;25:291–5. 4 Nazareth I, Boynton P, King M. Problems with sexual function in people attending London general practitioners: Cross sectional study. BMJ 2003;327:1–6. 5 Shindel AW, Horberg MA, Smith JF, Breyer BN. Sexual dysfunction, HIV, and AIDS in men who have sex with men. AIDS Patient Care STDS 2011;25:341–9. 6 Javaroni V, Neves MF. Erectile dysfunction and hypertension: Impact on cardiovascular risk and treatment. Int J Hypertens 2012:627278. Available at:: http://www.ncbi.nlm.nih.gov/pmc/ articles/PMC3357516/pdf/IJHT2012-627278.pdf (accessed May 13, 2013). 7 Wittenberg A, Gerber J. Recommendations for improving sexual health curricula in medical schools: Results from a twoarm study collecting data from patients and medical students. J Sex Med 2009;6:362–8. 8 Pedrosa CM, Spink MJP. A violência contra mulher no cotidiano dos serviços de saúde: Desafios para a formação médica. Saude Soc 2011;20:124–35. 9 Farias RS, Cavalcanti LF. Atuação diante das situações de aborto legal na perspectiva dos profissionais de saúde do Hospital Municipal Fernando Magalhães. Ciênc Saúde Colet 2012;17:1755–63. 10 Xavier J, Hitchcock D, Hollinshead S, Keisling M, Lewis Y, Lombardi E, Lurie S, Sanchez D, Singer B, River Stone M, Williams B. An overview of US trans health priorities: A report by the Eliminating Disparities Working Group. Washington, DC: National Coalition for LGBT Health, 2004. Available at: http://www.transequality.org/PDFs/HealthPriorities.pdf (accessed May 13, 2013). 11 Coleman E, Elders J, Satcher D, Shindel A, Parish S, Kenagy G, Bayer CR, Knudson G, Kinsgsberg S, Clayton A, Lunn MR, Goldsmith E, Tsai P, Light A. Summit on medical school education in sexual health: Report of an expert consultation. J Sex Med 2013;10:924–38.
Sexuality Education in Brazilian Medical Schools 12 Goldstein I. Integrating women’s sexual health into women’s health education. J Sex Med 2012;9:2983–5. 13 Reisman Y, Eardley I, Porst H; Multidisciplinary Joint Committee on Sexual Medicine. New developments in education and training in sexual medicine. J Sex Med 2013;10:918–23. 14 Dixon-Woods M, Regan J, Robertson N, Bridget Y, Cordle C, Tobim M. Teaching and learning about sexuality in undergraduate medical education. Med Educ 2002;36:432–40. 15 Ferrara E, Pugnaire MP, Jonassen JA, O’Dell K, Clay M, Hatem D, Carlin M. Sexual health innovations in undergraduate medical education. Int J Impot Res 2003;15(5 suppl):S46– 50. 16 Tucker P, Candler C, Hamm RM, Smith EM, Hudson JC. Assessing changes in medical student attitudes toward nontraditional human sexual behaviors using a confidential audience response system. Sex Educ 2010;10:37–45. 17 Wagner E, McCord G, Stockton L, Gilchrist VJ, Fedyna D, Schroeder L, Sheth S. A sexual history-taking curriculum for second year medical students. Med Teach 2006;28:184–6. 18 Eardley I. A curriculum for sexual medicine? J Sex Med 2009;6:1195–8. 19 Parish SJ, Rubio-Aurioles E. Education in sexual medicine: Proceedings from the International Consultation in Sexual Medicine, 2009. J Sex Med 2010;7:3305–14. 20 Shindel AW, Parish SJ. Sexuality education in North American medical schools: Current status and future directions. J Sex Med 2013;10:3–18. 21 Associação Médica Brasileira. Escolas médicas do Brasil de 2000 a 2010. 2013. Available at: http://www.escolasmedicas .com.br/novas.php (accessed May 12, 2013).
1117 22 World Association for Sexual Health. Sexual health for the millennium: A declaration and technical document. Minneapolis, MN: World Association for Sexual Health; 2008. Available at: http://176.32.230.27/worldsexology.org/wp-content/ uploads/2013/08/millennium-declaration-english.pdf (accessed May 12, 2013). 23 Obedin-Maliver J, Goldsmith ES, Stewart L, White W, Tran E, Brenman S, Wells M, Fetterman DM, Garcia G, Lunn MR. Lesbian, gay, bisexual, and transgender-related content in undergraduate medical education. JAMA 2011;306: 971–7. 24 Malhotra S, Khurshid A, Hendricks KA, Mann JR. Medical school sexual health curriculum and training in the United States. J Natl Med Assoc 2008;100:1097–106. 25 Cade JD, Jesse WF. Sex education in American medical schools. J Med Educ 1971;46:64–8. 26 Solursh DS, Ernst JL, Lewis RW, Prisant ML, Mills TM, Solursh LP, Jarvis RG, Salazar WH. The human sexuality education of physicians in North American medical schools. Int J Impot Res 2003;15(5 suppl):S41–5. 27 Lief HI. Preparing the physician to become a sex counselor and educator. Pediatr Clin North Am 1969;16:447– 58. 28 Lloyd JA, Steinberger E. Survey and analysis of educational efforts in reproductive biology and human sexuality in American medical schools. J Reprod Med 1980;24:17–21. 29 Salinas-Urbina AA. La confrontación de la sexualidad en la práctica profesional de los futuros médicos: La mirada de los pasantes de medicina. Ciênc Saúde Colet 2013;18: 733–42.
J Sex Med 2014;11:1110–1117
ORIGINAL RESEARCH—EDUCATION Sexuality Education in Brazilian Medical Schools Andrea Cronemberger Rufino, PhD,* Alberto Madeiro, PhD,* and Manoel João Batista Castello Girão, PhD† *Department of Gynecology, State University of Piauí, Teresina, Brazil; †Department of Gynecology, Federal University of Sao Paulo, Sao Paulo, Brazil DOI: 10.1111/jsm.12476
ABSTRACT
Introduction. Sexuality education has been valued since the 1960s in medical schools worldwide. Although recent studies reaffirm the importance of incorporating sexuality into medical education, there are data gaps concerning how this happens in Brazil. Aim. To understand how Brazilian medical school professors teach sexuality in undergraduate courses. Methods. An exploratory, cross-sectional descriptive study was conducted. A total of 207 professors from 110 Brazilian medical schools responded to an online semistructured questionnaire about the characteristics of the sexuality-related topics offered. Main Outcome Measures. The main variables assessed were contact hours devoted to sexuality, disciplines in which sexuality topics were taught, sexuality-related course titles, and sexuality-related topics addressed. Questionnaires were tabulated and analyzed using descriptive statistics for frequency distribution. Results. The response rate to the questionnaire was 77.2%. Almost all professors (96.3%) addressed sexuality-related topics mainly in the third and fourth years as clinical disciplines, with a 6-hour load per discipline. Gynecology was the discipline in which sexuality-related topics were most often taught (51.5%), followed by urology (18%) and psychiatry (15%). Sexuality-related topics were addressed mainly in classes on sexually transmitted diseases and AIDS (62.4%) and on the anatomy and physiology of the reproductive system (55.4%). About 25% of the professors reported teaching courses with a sexuality-related title. There was emphasis on the impact of diseases and sexual habits (87.9%) and sexual dysfunction (75.9%). Less than 50% of professors addressed nonnormative sexuality or social aspects of sexuality. Conclusions. The teaching of sexuality in Brazilian medical schools occurred in a nonstandardized and fragmented fashion across several disciplines. The topic was incorporated with an organic and pathological bias, with a weak emphasis on the social aspects of sexuality and the variety of human sexual behaviors. The results point to the need for change in the provision of sexuality education in Brazilian medical schools. Rufino AC, Madeiro A, and Girão MJBC. Sexuality education in Brazilian medical schools. J Sex Med 2014;11:1110–1117. Key Words. Sexuality Education; Sexuality in Undergraduate Training; Medical Education; Medical Students
Introduction
T
he educational field of sexuality comprises a range of concepts associated with sexual health, sexual rights, and social justice. Sexual health includes the presence of physical, emotional, and social satisfaction related to sexuality, as well as the absence of pathology. It also includes J Sex Med 2014;11:1110–1117
positive aspects such as eroticism, pleasure, and the freedom to experience sexuality without any violence [1]. The practice of medicine is besieged by a variety of sexual issues [2,3], which include the high prevalence of sexual dysfunctions and STDs in the population, including HIV infection and AIDS, as well as the impact of diseases and drugs © 2014 International Society for Sexual Medicine
1111
Sexuality Education in Brazilian Medical Schools on sexual function [4–7]. There are also requests for assistance with health problems related to gender issues such as sexual violence and abortion and with health care for specific groups such as lesbians, gays, bisexuals, and transgender individuals (LGBT) [8–10]. The general population expects doctors to be prepared to understand and treat such sexual problems. Recent publications have highlighted the importance of training in sexual medicine to adequate health care [11–13]. Therefore, teaching human sexuality is considered essential for medical education [2,3,5,11]. Several initiatives, experiences, and assessments regarding the integration of sexuality into the curricula of medical schools in the United States and the United Kingdom have been published, increasing in number over the last decade [2,3,14– 16]. These sexuality education programs were established on the basis of a multidisciplinary approach aiming at knowledge sharing, reflection, and changing attitudes in relation to sexual matters, coupled with skills development for appropriate care. Another model proposed for the curricula in those countries proposes the verticalization of sexual health issues, which would be taught over the full duration of the medical program and be covered completely in the curriculum [2,3,15–19]. The International Society for Sexual Medicine has recently published some reviews about sexual medicine education. The research highlights several obstacles faced by doctors in the treatment of sexual problems, such as lack of knowledge and training, personal discomfort in relation to sexual topics, and beliefs about normative heterosexuality, thus reinforcing the idea that medical schools around the world should improve the quality and the amount of sexuality education offered to their students. Some recommendations have been made to create a model for modular and multidisciplinary curricula in undergraduate medical schools that could possibly be adapted for different cultures [20,21]. The current state of sexuality teaching in Brazilian medical schools is unknown. Therefore, we decided to investigate how Brazilian medical schools teach sexuality through the perspectives of professors. We investigated the disciplines in which sexuality was taught, years during which sexuality was taught, contact hours devoted to sexuality in these disciplines, and number of professors involved in teaching the discipline, as well as sexuality-related course titles, teaching methods, and sexuality topics addressed.
Methods
Study Design and Ethical Issues We performed an exploratory, cross-sectional descriptive study with medical school professors in Brazil from March 2010 to July 2011. We provided an online semistructured questionnaire and set informed consent as a prerequisite for responding to the questionnaire. The Ethics Committee of the Federal University of Sao Paulo (UNIFESPEPM) approved this study under Register No. 0045/10, following the guidelines of Resolution 196/96 of the National Health Council, in compliance with the Declaration of Helsinki. Samples During the period when this study was being carried out, there were 181 medical schools in operation in Brazil. A total of 144 of those schools offered programs that would be completed by July 2011, the final period for data collection [21]. As such, these schools were considered eligible for this study, and their professors composed the unit of analysis for the research. The 37 schools with ongoing courses were not considered in order to avoid a bias in selection caused by the absence of courses or topics addressing sexuality that could still be covered. Subjects We conducted a study with a convenience sample due to the unknown number of professors involved in sexuality education and also due to the multiplicity of teaching methodologies and variety of curricula adopted by Brazilian medical schools. For medical schools with a subject-structured curriculum, we selected professors of gynecology, psychiatry, urology, and medical psychology, which comprise the disciplinary field of sexology in Brazil. As for the medical schools with curricula that were not structured by subject, the selection of professors was made through direct indication from course coordinators. Dissemination We informed medical program coordinators about this study by telephone. Coordinators, in turn, indicated the professors who taught the previously mentioned disciplines or other disciplines who could be eligible to participate in the study. Initial telephone contact with professors was made to present the research and its objectives. Then a cover letter about the study was sent via e-mail J Sex Med 2014;11:1110–1117
1112 containing explanations on how to participate. We contacted 268 professors from 144 medical schools by phone and e-mail. The strategy used to reinforce participation in the research was to call and e-mail coordinators and professors every 3 to 4 weeks with a total of 4 attempts. We received responses from 213 professors from 110 medical schools.
Instrument An instrument with open and closed questions was designed and divided into two domains. The first domain asked about the professor’s institution and the presence of sexuality-related topics in a specific course or classes. The second domain asked about the characteristics of the course, the sexuality content offered by the professor, the type of educational activities carried out, course titles, and aspects of sexuality addressed in classes. We used the “Sexual Health for the Millennium” declaration and technical document published by the World Association for Sexual Medicine as a reference for the choice of questions about the different sexuality-related topics [22]. Validation Test A pilot project was developed to validate the questionnaire. Initially, three gynecologists and one sexology expert analyzed the instrument with regard to questionnaire instructions, clarity, question relevance, and suitability for the proposed objectives. The questionnaire was then offered to 12 gynecology, urology, and psychiatry professors from four medical schools located in the Northeast Region of Brazil. In this step, we analyzed difficulties with accessing and using the online questionnaire, submitting responses, and understanding the questions, as well as the time spent to answer them. After making the necessary adjustments in the questionnaire, the responses for the validation test were disregarded. Data Analysis The responses to the 213 answered questionnaires were sent to an electronic database and then exported to a spreadsheet (Microsoft Excel 2010 for Windows). An initial analysis of the questionnaires led to the exclusion of six of them because most of the questions were unanswered. Then, the data collected from the remaining 207 questionnaires were tabulated and analyzed using descriptive statistics for frequency distribution. Among them, 188 (90.8%) were answered completely, J Sex Med 2014;11:1110–1117
Rufino et al. whereas 19 had one or two unanswered questions, not enough to affect the percentage distribution of the data. Results
Medical Schools in Brazil In Brazil, medical schools are distributed heterogeneously across regions. As of the year 2000, there were 106 medical schools in operation in Brazil, and the Ministry of Education approved a number of new medical schools for opening between 2000 and 2013. In March 2010, when this study began, we identified 181 medical schools in operation. From 2011 to 2013, 20 new medical schools were opened, totaling 201 institutions in operation as of 2013 [21]. Professors Involved in the Teaching of Sexuality Throughout Brazil, among the 268 professors contacted, 207 responded to the questionnaire (77.2%). These professors were distributed across 110 medical schools, with response rates varying according to the region of the country, with a higher concentration of responses in the Southeast and Northeast Regions (Figure 1). Out of the total number of professors, 200 (96.3%) mentioned classes that addressed sexuality-related topics. Disciplines, Contact Hours, and Learning Activities Most professors who reported teaching sexuality classes taught clinical disciplines (187 or 93.5%), especially gynecology (103 or 51.5%). A small number of them mentioned including sexuality in preclinical disciplines such as anatomy and physiology (2%) or teaching a specific discipline on sexuality (3%), as shown in Figure 2. All 200 professors indicated that they taught sexuality during the third and fourth years, while 29 of them (14.5%) also taught it in the first and the second years, and 59 (29.5%) in the fifth and sixth years. About half of the professors (113 or 56.5%) devoted 6 contact hours to sexuality, but 38 of them taught 7–15 hours (19%). Professors addressed sexual themes through teacher-centered (143 or 93.5%) and practical activities (122 or 79.7%). Among the teacher-centered activities, lectures were predominant (122 or 79%), followed by seminars and discussion groups (53 or 34.6%) and movies (22 or 14.4%). Professors reported integrating sexuality into practical clinical activities (82 or 53.6%) and classroom activities (62 or 40.5%).
Sexuality Education in Brazilian Medical Schools
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Figure 1 Response rate of Brazilian medical schools and professors by region. Dark bars = response rate of professors; light bars = response rate of medical schools.
Specific Classes Most professors (186 or 93%) mentioned the specific classes in which they addressed sexuality topics. Classes on STDs and AIDS were mentioned the most (116 or 62.4%). About half reported classes on the anatomy and physiology of the reproductive system (103 or 55.4%) or on contraception (99 or 53.4%). Professors mentioned courses with sexuality-related titles (47 or 25.3%), with emphasis on disorders, sexual dysfunctions, and paraphilias (22 or 11.8%) or on eroticism (19 or 10.2%). Aspects of Sexuality Included in Class When addressing sexuality, professors mostly commented on the impact of diseases and sexualityrelated habits (168 or 87.9%), with emphasis on
STDs and AIDS (126 or 66%). They emphasized the clinical features, diagnosis, and treatment of sexual problems, with special attention to sexual dysfunctions (145 or 75.9%). Professors mentioned eroticism in lectures on the sexual response cycle (149 or 78%) and less often in discussions of pleasure, erogenous zones, and masturbation (119 or 62.3%). They referred to the social context of sexuality, featuring sexual violence (90 or 47.1%) and human sexual development (91 or 47.6%). However, the number of professors who spoke about the significance of sociocultural gender roles (76 or 39.8%), sexual and reproductive rights (69 or 36.1%), and homophobia (29 or 15.2%) was small. Professors spoke about sexual orientation, addressing mainly heterosexuality (122 or 61.8%). Less than half of them talked about homosexuality (91 or 47.6%) or bisexuality (69 or 36.1%). Sexuality in
Figure 2 Disciplines involved in teaching sexuality. “Other disciplines” refers to oncology, mastology, geriatrics, obstetrics, infectious diseases, and surgery. “Thematic modules” refers to humanistic basis of medicine and tutorial.“Social disciplines” refers to bioethics, mental health, and family medicine.
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Figure 3 Sexuality-related topics addressed in classes by professors. Topics under “eroticism” include pleasure, erogenous zones, and masturbation. “Sexuality in special populations” refers to sexuality in adolescents, the elderly, and pregnant women.
special groups, such as adolescents, pregnant women, and the elderly, was discussed by 64.9% of the professors (Figure 3). Discussion
We investigated sexuality teaching in Brazilian medical schools from the perspectives of 207 professors from 110 schools in all regions of the country, which resulted in a response rate of 77.2% of the medical professors contacted and 76.4% of medical schools. Previous surveys in medical schools worldwide showed response rates ranging from 71% to 95%, similar to the Brazilian professors’ response rate [23–26]. We found a high number of professors who reported including sexuality in their classes. This may reflect Brazilian professors’ interest in talking about sexualityrelated topics. We observed that sexuality was mainly offered by third- and fourth-year clinical discipline professors, especially those teaching gynecology. The profile of professors participating in the study, mostly gynecologists, probably influenced the results obtained. Almost half of the professors pointed out a variety of other disciplines that deal with sexuality-related topics. We noticed that sexuality teaching was a transversal event, which was distributed across several independent disciplines. However, the instrument used did not allow us to assess the overlap between courses in order to consider the interdisciplinary aspect of sexuality education. Including sexuality education in interdisciplinary courses has been advocated in American J Sex Med 2014;11:1110–1117
medical schools since the mid-1960s [27]. Several sexuality education programs in multi- and interdisciplinary models have been described, including activities in preclinical and clinical courses, thus enhancing the integration among them and the verticalization of the topic of sexuality [2,14,15]. Recent publications on sexuality education in medical education also reinforce these recommendations for many countries, suggesting the problematization of cases as a teaching strategy [15,18–20]. In 1980, a study evaluated the inclusion of sexuality education in American medical schools and found a wide range of courses offering reproductive health- and sexuality-related topics among 97 schools surveyed. Gynecology was the discipline that devoted the most hours to these matters, although the topics were also offered in psychiatry, anatomy, and physiology [28]. In 2003, another survey of 101 US and Canadian schools indicated that 63% offered sexuality education in various disciplines. In 75% of the schools, psychiatry was most associated with the teaching of sexuality [26]. In regard to contact hours, 50% of the Brazilian professors devoted up to 6 hours of their classes to sexuality-related topics. This result suggests that the professors took sexuality into consideration but did not plan sexuality content for the entire curriculum. In a study of American and Canadian medical schools published in 2003, 54% were found to provide less than 10 hours of curriculum time for sexuality education [26]. It has been suggested that mandating any less than 10 hours for sexuality education in undergraduate medical
Sexuality Education in Brazilian Medical Schools school is not satisfactory for appropriate training in sexual health [23,26,27]. Brazilian professors approached sexuality primarily using theoretical lectures and, to a lesser extent, ambulatory care activities as pedagogical resources. Desensitization of students to issues related to sexuality would help to promote a change in attitudes toward sexuality when offering treatment. In this vein, some authors support the use of media coupled with small discussion groups as well as the reduction of the number of theoretical lectures offered [2,16–19]. Other teaching resources have been suggested in order to improve practical training in skills used to collect sexual history. The use of recorded interviews with standardized patients and the simulation of medical consultations have also been proposed [2,15,17–19]. The specific classes and aspects of sexuality listed by Brazilian professors reflect the prominence given to the organic and biological aspects of sexuality. We also observed the importance given to the impact of diseases on sexuality and issues related to STDs and AIDS. Even in specific sexuality classes, professors emphasized sexual dysfunctions and paraphilias to the detriment of pleasure. A similar result was found in American medical schools in the 2003 study described above, where the diagnosis and treatment of sexual dysfunctions and sexuality in various diseases were taught more frequently than social aspects like sexual abuse [26]. We observed low incorporation of the social aspects of sexuality into the Brazilian lesson plans through the presence of occasional topics on sexual violence, gender relations, and sexual and reproductive rights. In 2012, a qualitative study among Mexican undergraduate students noted sexuality education to be conducted mainly in gynecology, urology, and psychiatry disciplines, with a strong organic bias. Students reported difficulties dealing with their own sexuality as well as aspects of patients’ sexuality that were not related to organic and reproductive intercourse issues. They reported a lack of emotional skills in talking about eroticism and sexual violence or gender [29]. We noted that sexual orientation was addressed by a little more than 50% of the Brazilian professors, with a bias toward heterosexuality. Thus, the variety of human sexual behaviors was poorly addressed. In 2012, a study investigated the offering of health-related content to the LGBT community in the American and Canadian medical curricula. Among the 150 schools evaluated, 63%
1115 offered such content, but with a bias toward organic and psychological aspects and little emphasis on social, behavioral, and sexual identity aspects [23]. The results of this study have direct implications for the training of qualified sexual health consultants for the Brazilian population. In Brazil, curricula should also be aligned with public health policies, which are designed with particular attention to the sexual and reproductive health of the population. Initially, these data show that almost all the professors mentioned teaching sexuality topics in classes with several different course titles. This highlights the personal interest of the majority of professors in addressing sexual issues in medical education. Therefore, these data also affirm the vitality of the field of sexuality in the country. However, we noted that sexuality topics were offered in a transversal, nonstandardized, fragmented way in several clinical courses, which may have been due to the lack of national curriculum standards for this topic. Professors discussed sexuality with emphasis on biological and organic aspects, highlighting the impact of diseases, sexual dysfunction, STDs, and AIDS. The topics related to the social construction of sexuality that give meaning to sexual behavior were inadequately discussed. Sexual diversity, gender, and sexual violence received little attention, although they may permeate sexual complaints brought to consultations. This reductionist view of sexuality may compromise the quality of the medical education necessary for proper sexual health consultations. This study has some limitations that should be taken into consideration. As it is an exploratory study, the use of nonprobability sampling may have caused a selection bias. The number of professors and disciplines in each medical school involved with sexuality education was unknown. However, we chose professors from several disciplines in an attempt to minimize this limitation and to provide more reliable knowledge about sexuality education. The cross-sectional methodological design chosen may provide reproducible results at another time. Thus, reassessments to update these data may be needed. This is the first nationwide Brazilian study on sexuality education in medical schools. We obtained a satisfactory response rate from professors in all regions of the country and also a large number of completely answered questionnaires. Thus, the results of this study can provide a current overview of sexuality education as offered in Brazilian undergraduate medical institutions. J Sex Med 2014;11:1110–1117
1116 Conclusions
This research aimed to discover how sexuality education is currently offered by Brazilian medical schools through the perspectives of professors. Almost all the professors in Brazilian medical schools included in this sample offered sexuality topics. These topics were taught during the third and fourth years as part of clinical disciplines such as gynecology, psychiatry, and urology. Half of the professors devoted 6 hours per discipline to sexuality topics. Classes on STDs and AIDS were those in which professors were most likely to address sexuality-related topics. Professors mainly emphasized the impact of diseases and sexual dysfunction. Few of them addressed nonnormative sexuality or social aspects of sexuality. We hope the results of this study will stimulate reflection on and changes in the teaching of sexuality in Brazilian medical schools. Our recommendations are as follows. First, interest medical schools in offering curricula with sexuality topics. Second, encourage the provision of sexuality topics in interdisciplinary programs with equal emphasis on clinical, social, and psychological aspects. Third, enhance the use of varied teaching resources to facilitate the provision of knowledge, changes in attitudes, and the provision of skills training with regard to sexuality topics. In this way, it will be possible to train physicians who are better able to provide comprehensive care for the sexual health of the Brazilian population.
Acknowledgments
The authors thank the Piaui Research Foundation (Fundação de Amparo à Pesquisa no Piauí—FAPEPI) for funding this research. Corresponding Author: Andrea Cronemberger Rufino, PhD, State University of Piauí, Medicine, R Cel Costa Araújo 3033 Horto Florestal, Av Cel Costa Araujo 3033, Teresina, Piaui 64052820, Brazil. Tel: +558694522797; Fax: +558632213170; E-mail: andreacrufi[email protected] Conflict of Interest: The authors report no conflicts of interest.
Statement of Authorship
Category 1 (a) Conception and Design Andrea Cronemberger Rufino; Alberto Madeiro; Manoel João Batista Castello Girão J Sex Med 2014;11:1110–1117
Rufino et al. (b) Acquisition of Data Andrea Cronemberger Rufino (c) Analysis and Interpretation of Data Andrea Cronemberger Rufino
Category 2 (a) Drafting the Article Andrea Cronemberger Rufino; Alberto Madeiro; Manoel João Batista Castello Girão (b) Revising It for Intellectual Content Andrea Cronemberger Rufino; Alberto Madeiro; Manoel João Batista Castello Girão
Category 3 (a) Final Approval of the Completed Article Andrea Cronemberger Rufino; Alberto Madeiro; Manoel João Batista Castello Girão References 1 World Health Organization. Measuring sexual health: Conceptual and practical considerations and related indicators. 2010. Available at: http://whqlibdoc.who.int/hq/2010/who _rhr_10.12_eng.pdf (accessed May 13, 2013). 2 Leiblum SR. An established medical school human sexuality curriculum: Description and evaluation. Sex Relat Ther 2001;16:59–70. 3 Wylie K, Halam-Jones R, Daines B. Review of an undergraduate medical school training programme in human sexuality. Med Teach 2003;25:291–5. 4 Nazareth I, Boynton P, King M. Problems with sexual function in people attending London general practitioners: Cross sectional study. BMJ 2003;327:1–6. 5 Shindel AW, Horberg MA, Smith JF, Breyer BN. Sexual dysfunction, HIV, and AIDS in men who have sex with men. AIDS Patient Care STDS 2011;25:341–9. 6 Javaroni V, Neves MF. Erectile dysfunction and hypertension: Impact on cardiovascular risk and treatment. Int J Hypertens 2012:627278. Available at:: http://www.ncbi.nlm.nih.gov/pmc/ articles/PMC3357516/pdf/IJHT2012-627278.pdf (accessed May 13, 2013). 7 Wittenberg A, Gerber J. Recommendations for improving sexual health curricula in medical schools: Results from a twoarm study collecting data from patients and medical students. J Sex Med 2009;6:362–8. 8 Pedrosa CM, Spink MJP. A violência contra mulher no cotidiano dos serviços de saúde: Desafios para a formação médica. Saude Soc 2011;20:124–35. 9 Farias RS, Cavalcanti LF. Atuação diante das situações de aborto legal na perspectiva dos profissionais de saúde do Hospital Municipal Fernando Magalhães. Ciênc Saúde Colet 2012;17:1755–63. 10 Xavier J, Hitchcock D, Hollinshead S, Keisling M, Lewis Y, Lombardi E, Lurie S, Sanchez D, Singer B, River Stone M, Williams B. An overview of US trans health priorities: A report by the Eliminating Disparities Working Group. Washington, DC: National Coalition for LGBT Health, 2004. Available at: http://www.transequality.org/PDFs/HealthPriorities.pdf (accessed May 13, 2013). 11 Coleman E, Elders J, Satcher D, Shindel A, Parish S, Kenagy G, Bayer CR, Knudson G, Kinsgsberg S, Clayton A, Lunn MR, Goldsmith E, Tsai P, Light A. Summit on medical school education in sexual health: Report of an expert consultation. J Sex Med 2013;10:924–38.
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