[Film leader] [This Audiovisual has been acquired for distribution by the National Medical Audiovisual Center] [...] [Sexuality in the Medical School Curriculum: An Introduction for Medical Educators] [From the Center for the Study of Sex Education in Medicine, University of Pennsylvania School of Medicine] [Produced by Ortho Pharmaceutical Corporation Department of Educational Services] [Dream sequence music] [Female Voice 1:] [Echo effect] It was nothing like I expected. What a disaster. [Male Voice 1:] [Echo effect] My timing is way off. No matter what I do, I just can't last long enough for her to have an orgasm. And by the time the foreplay is over, I am sure I am going to fail again. [Female Voice 2:] [Echo effect] There must be something wrong with me, because I'm never interested. I'm just kind of numb in that area. [Female Voice 3:] [Echo effect] I cannot stand to have him touch me. [Male Voice 2:] [Echo effect] I just can't seem to get it up anymore. We try to be romantic, and then I get flustered and she gets mad and that's all, that's all. [Male Voice 3:] [Echo effect] We've read all the books and nothing seems to go right. [Male Voice 4:] [Echo effect] We don't communicate. We never communicate, we never have, in bed. [Female Voice 4:] [Echo effect] The worst thing is, there's no one to talk to about it. All he does is turn away when I try to discuss it. [Narrator:] It has been estimated that 50 percent of all married couples in this country suffer from some form of sexual maladjustment. There is hardly a marriage in which sexual problems do not occur at one time or another in the course of the marriage. These problems result in unhappiness, anxiety and often, divorce. [Cosmopolitan magazine cover] The great advances recently made in research into human sexual behavior have been accompanied by a dramatic liberalization of attitudes within our culture towards sex and sexual practices. [Magazine articles on sexual topics] Needing help and becoming increasingly aware that help is possible, more and more people are turning to their physicians for guidance and for treatment of sexual problems. Yet in a recent survey, a majority of physicians felt they had no formal training in human sexuality. And what they did know, was more likely to have come from sources other than their professional medical education. [Female Patient:] And when we go to bed, he goes right to sleep. And I, I toss for hours. [...] I get up, I read, but it doesn't help, doctor. [Male Doctor:] I think you're unnecessarily upset. Why, at your age, should you still be concerned about sex? [Female Patient:] At my age? [Male Doctor:] Why don't we run some tests on you? [Female Patient sighs] [Female Patient:] All right, doctor, if you feel that's what I need. [Narrator:] Each medical student is a product of our times and culture, and of his or her own personal experience and background. As a group, they are no different from other students in their exposure to sexual attitudes and in their own sexual experience. [Female Student 1:] Sex is an area you don't talk about, you just do. [Female Student 2:] As far as my parents are concerned, sex is something that just happens and you don't need to talk about it. [Male Student 1:] My sex education was conspicuous by its absence. I mean, I just didn't have any. [Female Student 3:] How can you talk about something you're not supposed to have done? [Male Student 2:] And when I was examining him for a hernia, he just dropped it on me that he was a homosexual. Man, this really threw me. [Female Student 4:] This is something we just never talked about. My parents never discussed sex in front of me, and even at high school, we didn't talk about it, like it seemed boys do. [Female Student 5:] Do people really do that? [Male Student 3:] Where do you look for help? Or who can you turn to get really straight ideas about dealing with sex? So many professors I've talked to were embarrassed about sexual problems, and when you present them with one of our critical experiences, they just turn you off. [Dr. Harold Lief:] The goals of a sex education program in a medical school are on three levels. The acquisition of information, the modification of attitudes, and the learning of necessary skills in dealing with sexual, marital, and family planning problems. Of these three, the modification of attitudes already acquired is the most difficult, and in many ways, the most important. Without comfort with one's own feelings, one cannot absorb information or make use of it effectively. A first step is to gather information about the medical student himself. Here at the center, we have devised the Sex Knowledge and Attitude Test. The SCAT, is a multipurpose instrument which enables us to conduct general research and to disseminate information. Its primary value for teaching is that through its use, the student becomes aware of his or her own attitudes and knowledge about sex, and how these compare where they was generally held by society and by his peer group. [Narrator:] This instrument has established that almost one out of five medical students still believe that masturbation is ideologically related to mental illness. 30% still believe that direct stimulation to the clitoris is necessary for orgasm. Over 13 percent still believe that the condom is the most reliable contraceptive device. Six percent still believe that venereal disease can be contracted from dirty toilet seats. [David M. Reed, MD, Ph.D.] The first step in sex education is attitude modification. This is accompanied by information, feedback in discussions between faculty and students. Through SCAT, and in discussion with an instructor, students become aware of their own attitudes, and where these attitudes lie in comparison with those generally held by their peers and society at large. The goal of attitude modification is to free students of anxiety, fears, and discomfort in sexual matters, and to move them toward ease and comfort when dealing with sexual problems. The next step in attitude training concerns the process of sensitizing the student to his or her own feelings. There are a number of techniques for accomplishing this goal. One of these is confrontation in group discussions. [Confrontation] In discussion groups, the students learn to explore their feelings and attitudes about the emotionally charged areas of sexuality with which they will have to deal in their professional role. [David Reed:] Now let's talk about the whole issue of premarital sex and whether or not we're caught in a variety of value systems. Now try and answer this question. Whether your parents would have a particular reaction if you wanted to bring someone home with whom you were in love or whatever and wanted to have relations. What would be the reaction do you think of your parents, not yourselves now? How do you see your values from your parents' point of view? Anybody want to? Did you want to start off, Paul? [Paul:] Yeah. I think if I brought someone home, I don't think my parents would really object. I think the way they'd handle it would be to kind of ignore it until it happened, or until it's time to go to sleep or something. And then they'd, I don't they'd mind much. [David Reed:] What is it, what do they believe? What do you think they believe about premarital sexuality? [Paul:] Well, from my point of view, from the point of view of having a son, I think it's OK with them. Probably would be desirable. [David Reed:] Now You say them. Are you speaking for your mother or your father, both the same? [Paul:] Well, sexuality, sex is something that was never really discussed openly in my house. But I just have a feeling that both of them kind of had the same attitude. [David Reed:] Any one of you want to speak as a parent? How your parents might attack this situation? [Male Student 4]: I think my mother would probably say, well, you can do what you want, but kind of don't take it in the house. Like I think if my sister came home with a guy, I don't think they'd like that too much if they slept in the same room. Probably if I came on with a girl, they wouldn't like it either. They'd probably set up separate rooms for us and sneaking into each other's bedroom at night would be, you know... [David Reed:] That'd be better. [Male Student 4:] That would probably be better. As long as you don't come out of the same bedroom in the morning. You know, just. [David Reed:] Leave before breakfast. [Male Student 4:] Yeah, right, yeah. [David Reed:] OK. And they would both feel this way? [Male Student 4:] Well, my father's not alive, but my mother would. [David Reed:] OK, all right. Anybody else? [Male Student 5]: I think the whole business is though that we just haven't confronted them with any situations that would make them uptight. And so it may seem like they wouldn't be upset in some respects. But if we were suddenly to come and say, this is what we've been doing for the past five years, all kinds of emotional things about how we should be, even though we're supposedly growing older, but we're not. And back then when we thought you were such a nice young person. You know, you were doing this and you let us down. I think that still would be involved in what their feelings would be like. [Narrator:] The medical educator leading such group discussions must be particularly able to assist the students in reaching an awareness of their feelings and attitudes. And must take into account his own in the process. Just as physician comfort is the most important factor in the management of sexual problems. So is teacher comfort the most important factor in sex education. The next step and confrontation moves from the abstract and verbal to the visual. [Visual Confrontation] Films and other visual aids made specifically for the purpose, and showing different forms of sexual behavior have a profound impact on students who are trying to come to grips with their own attitudes. [Rhythmic music] [Students watching an explicit film] [Rhythmic music] The visual experience brings students into contact [Students squirm in seats] with their subsurface attitudes more effectively than just talking about them. [Rhythmic music, explicit sex education film plays for students] Medical students must learn about and accept the great diversity of sexual behavior in order to evaluate properly the sexual experiences of patients who come to them later for help. [Rhythmic music] Confrontation and reflection lead to acceptance of what was once taboo or frightening or overly stimulating with an increasing comfort in the whole area. [Heterosexual couple embracing with male on top] [Couple appears to be having oral sexual relations] [Point of view of students watching the projector screen] [Film ends, screen goes dark] The showing of such a film should be followed immediately by a discussion. It is most desirable to have a woman and a man instructor lead the discussion as a team. [Students rearrange chairs for group discussion] [David Reed:] In order to discuss the movie the best way, there's a couple of things to keep in mind. One is your emotional reaction to the film at a spontaneous level. And the other is a technical, intellectual, maybe a professional way. We'd like you to try and tie these together in the discussion. Liz, what do you think they had to go for? [Elizabeth Stanley:] I think another point in particular that we want to go for, [Elizabeth M. G. Stanley] is to try and bring out the differences or maybe similarities, in how the women reacted to the films and how the men reacted to the films. [David Reed:] Let's, let's pitch in. What are your spontaneous feelings about the experience thus far? [Chairs clanging] Anybody want to start? [Male Student 6:] It's a little embarrassing for the first sex film you've ever seen [Laughter] with all your friends sitting aroundyou have to talk about it. [David Reed:] Embarrassing in what way? [Male Student 6:] Well, I don't know quite. Just something I haven't done much before. A little curious about how everybody else took the film and a little afraid to put myself out first and see what happens. [Elizabeth Stanley:] Did it come over as being the real thing or what sort of label could you put on this? Would you call it pornographic? [Male Student 7:] It certainly wasn't anything like any pornographic films I'd seen before. [Elizabeth Stanley:] Mm-hmm. [Male Student 7:] This is sort of, you know, all happy and in nature and they both were enjoying themselves to a great extent. Where the stereotype-- porn film or blue flick that you'd imagine or just where two people suddenly meet. [Elizabeth Stanley:] Did you feel embarrassed at all? [Male Student 7:] Well, in a way I guess I was a little embarrassed. [David Reed:] How many here have seen stag movies? [One visible student raises his hand] And this was somewhat different? You girls didn't have a chance to say much. Sarah? How did it hit you? What was your reaction to it? [Sarah:] It was a happy movie. [Elizabeth Stanley:] How did it make you feel? How did it make you feel? [Sarah:] Made me feel embarrassed. It made me wonder what the people sitting next to me were thinking. [Laughter] [Elizabeth Stanley:] Was there any quality that you felt came over very strongly in this film that perhaps you don't notice in the stag films? [Male Student 8:] Well, the concept of innocence. And I think, that's why it was more difficult to watch it, because when you watch a stag film, it's obvious the objective of it. And it's kind of an understood agreement. But this one was more like just two people making love. And I identified with it. And it was difficult, because I felt I was watching myself or someone had caught me unawares. [David Reed:] That's a good point. How about you girls? You've been kind of quiet here. We got a double standard going, where other men do all the talking? What do some of you think? Either one. [Female Student 6:] I kind of thought the woman was embarrassed in making the film. [David Reed:] She was embarrassed in what sense? [Female Student 6:] I think she blushed when her pants were pulled down. And I identified with that. I think it would have been painful to make the film. [David Reed:] You think she was self-conscious about the film itself. [Female Student 6:] Yes, about being filmed. [David Reed:] Barbara, what did you think? [Barbara:] I guess I objected to the fact that the male was the aggressor in the film and he kept pulling her panties down and she kept pulling them back up. And she was put in a difficult position. And the cameraman spent much more time concentrating on her facial expressions and reaction to the orgasm than he did on his. And much more time concentrating on her naked body than on his. [Male Student:] I didn't see that at all, because after all, she went down on him. She wasn't just the passive one. It's true, he didn't go down on her. I mean, there's a little unevenness in it, but it didn't, didn't really hit me that way. [David Reed:] Was there anything in this kind of a movie for a doctor to know? [Female Student 7:] Well, I think the doctor has to see his own reaction, just like the fellow said. That they didn't notice that the woman was particularly the non-aggressor, so therefore when we talk about it afterwards, we then think, well, maybe we have been sensitized and programmed in various ways, thus not allowing us to see another side. Which I think, unless we sit down talk about it and bring these points out, then only do we see it. And we're going to be counseling, so we best see all sides. If that's possible. [Elizabeth Stanley:] Did anybody feel that any part of them was being suppressed? Saying, or your instinctive responses or the fact when you turn on, did you feel that in this setting that there was any suppression because of the setting? That somehow you felt it wasn't right that the film should turn you on, and therefore, you're shutting that reaction off. Did anybody have any? [Male Student:] I sort of thought in a way kind of the opposite. Like ah.... when I've seen stag films, I've been much more turned on than I was now. And I'm trying to figure out what's inside of me, maybe seeing in some sleazy place makes it more enjoyable. I don't know. I guess it has something to do with something in me. [David Reed:] Could this couple have ever gone to any one of you as a physician with a problem? Could they have ever had a problem as you see them in this movie? [Female Student]: Yes. [Overlapping][Male Student:] You mean previous to this? [David Reed:] Yes, yes, sure. What might they have had? [Male student:] Exhibitionist problem. [Laughter] The thing that's in this movie that we were responding to, was the matched relationship in a way. We made comments about how there may have been exploitation or a game of rape me. But in general, the whole resonance of the film was that they were together and very much doing things that each found enjoyable. [Overlapping voices] [David Reed:] They never could have a problem. [Male Student:] Well, it doesn't it just doesn't look like they have now. And what they may have in the future to go along with some of your comments about older folks, you know, their relationship could change. [Narrator:] Exposure and discussion lead to a decrease of patterns of avoidance and overreaction, and enhance the potential for a future physician comfort in dealing with patients. [Role Playing] When the students achieve a level in which they become aware of their own feelings and responses, and thus become more sensitive to the feelings and attitudes expressed by others, they can move toward the acquiring of necessary skills. Role playing is an effective connecting training technique. Students are given a sexual problem. Playing the role of patients, they present the problem to, another student who is acting as the therapist. [Mike:] Well, Mr. Jones, just what is it exactly that brought the two of you in to see me? [Male Student / Patient:] Well, my wife and I thought that you might be able to help us. You see, we got married about a month ago. [Mike:] Mm-hmm. [Male Student / Patient:] And a friend of hers sort of recommended you to us to help us with this little problem we seem to have developed. [Mike:] Mm-hmm. I don't know where to begin. We got married just the first of last month. And you know, we're very happy together. And well. [Mike:] You have a good sex life? [Male Student / Patient:] Uh, well, you know, we try it every night. [Mike:] There's problems in your sexual relationship? [Male Student / Patient:] Yes. That was sort of why we came here tonight, to talk about this difficulty that we seem to have. [Mike:] It's a problem with your wife and you? [Male Student / Patient:] Mm-hmm. It's just that we don't seem to be getting together. [Mike:] Having trouble with an orgasm? [Male Student / Patient:] Well, sort of having trouble with orgasm. You see, when we go to bed at night, we just, well, doctor, I just don't know. [Mike:] This must be very difficult. [Male Student / Patient:] Well, it's never happened to me like this before you see. I had a great college career, you know, and I had no trouble with anything. And got through all right. And we just, ever since we got married, something's not quite right, if you know what I mean. What do you think, dear? [Sarah:] Everything was OK until our honeymoon, and then it just wouldn't work out. [Mike:] Mm-hmm. And just what exactly was the problem on your honeymoon? [Male Student / Patient:] Well, we, you know, it wasn't quite the same as before we were married. You know, I was naturally nervous about spending all that money down there and everything. I was sort of, didn't know how to make of it. I couldn't think of myself as being married when I got up in the morning. [Mike:] Mm-hmm. [Elizabeth Stanley:] OK, let's just cut it there for the time being. Do you think he was making the couple comfortable? [Male Student:] He's making me seasick with his nodding. [Laughter] [Elizabeth Stanley:] What do you think that indicated? [Male Student:] Well, he's, I suppose he's apprehensive about dealing with [?] He's guarding and he's nodding along. [Elizabeth Stanley:] Do you think the patients are also feeling apprehensive? [Male Student:] Yeah, he's not helping them. [Elizabeth Stanley:] Mm-hmm, mm-hmm. OK, but a whole gamut of things here that. [Unidentified student:] [?] a patient. [Elizabeth Stanley:] Mm-hmm. [Female Student:] I don't think he tried to help draw out the problem in a gentle and easy way. He made it very hard for them. Mike, you kept pinning him down to say that he was impotent. I think that's... [Male Student:] Right. [Male Student:] Seemed also that Mike's real problem was in dealing with the woman. He addressed all his first remarks to the man...[Elizabeth Stanley:] Good point, good point. [Male Student:] and then when the husband actually brought in the woman, he sort of blocked out the woman with his knee like that and drew back and sort of said, well, I'll ask you a question because your husband wants, and goes right back to the question after, to the husband I mean, after the wife makes a few remarks.[Elizabeth Stanley:] Good. [Sarah:] He was being very non-receptive. [Elizabeth Stanley:] I was just going to say that. How did you feel as the wife? Did you feel? [Sarah:] I would feel disgusted at him as he was of him. [Laughter] [Mike:] Thanks a lot. Yeah, I can see that, that I made that mistake with getting in with. [Elizabeth Stanley:] Were you aware, did you find yourself noticing this during the interview or [Mike:] No, just when it was mentioned, yeah. [Elizabeth Stanley:] When it was mentioned. [Male Student:] Were you feeling nervous, Mike? [Mike:] Yeah, just a little bit. You know, I mean, this whole thing is a little nervous, you know, makes you a little nervous. [Narrator:] The objective is to achieve a comfortable balance between objectivity and compassion in the taking of a sex history and the management of the patient with a problem. [...] Another step in the acquiring of skills is the observation of therapy sessions with actual patients presenting problems, which might be new or uncomfortable to some students. [Female Patient:] I can't tell you how much better I feel about this already. At least I'd have some hope now. [Dr. Harold Lief:] Fine. We'll talk about it further at our next session. And as we discussed earlier, I think the next time you come with your husband. [Female Patient:] With my husband? [Dr. Harold Lief:] Yes. [Female Patient:] Together? [Dr. Harold Lief:] Yes. [Female Patient:] I'll talk to him about it. [Dr. Harold Lief:] Fine. Suppose we see if my secretary will make the next appointment. [Female Patient:] Thank you, doctor. [Footsteps] [Students observing from behind a barrier] [Dr. Lief turns on light and addresses students] [Dr. Harold Lief:] Well, I'm sure the problems of this particular patient are intriguing, but that's not the real reason we're here today. We're concentrating on the role of the physician. His comfort, the ease with which he handles the situation, the technical interventions he makes and so on. Now one of the most important things that we want to concern ourselves with is physician comfort. Ann, do you have any comments to make on that? [Ann:] Well, seeing that during the interview, she developed, the patient developed a certain dependence on you. As her therapist, it seems perhaps both as an authority figure and as a male. And it would seem that this would be a problem that any therapist would fall into. Insofar, especially interviewing I think someone of the opposite sex. [Dr. Harold Lief:] And this might be somewhat seductive for the male therapist. I think it's something we always have to be concerned with. Mike, what things did you see? [Mike:] They're obviously going to have a different approach to you. And the wife is going to be back involved in her marital situation. I could see your role changing to try and come in on both sides of their problem. [Dr. Harold Lief:] Right, right. During this first initial session, I had two major goals. To make the patient comfortable and to set up a situation so that her husband would come in the next time. Because with this sexual problem, we have to deal with the couple. Bob, anything you'd like to add? [Fade to black] [Silent] [Dr. Harold Lief joins other instructors for a review] [Elizabeth Stanley:] Hi. [Dr. Harold Lief:] Hi. [David Reed:] Harold, how do you think the course is going now? [Dr. Harold Lief:] Oh, fine. I'm really pleased with the way the students are into it. I know, there are a few things I think we've got to kick around, but-- You know, first I think it might be a good idea for us to review what we think are important for the medical educators seeing this film. Liz, why don't you start. [Elizabeth Stanley:] Well, I feel an important consideration is the selection of sex educators. They should not be selected from the faculty at random, but on the basis of relevant clinical skills with an emphasis on expertise in handling interpersonal relationships. [David Reed:] The effective sex educator is unique in needing to be aware of his own class-bound prejudices about sex. The main thing he teaches is his own comfort. The main thing he demonstrates is communication. [Elizabeth Stanley:] There is a very great value in the concept of team teaching. Having both a man and a woman acting as leaders of group discussion provides a freer and more comfortable atmosphere for fruitful exploration of attitudes and concerns. [David Reed:] The teaching faculty needs to deal not only with physiology, but sociology, ethics, psychology, and especially the normal aspects of sexuality. So an interdisciplinary faculty is best. And I'll second the motion that it's necessary to have women teach. We men cannot really get across the subtleties of female sexuality, particularly in today's sexual revolution. [Dr. Harold Lief stands up] [Dr. Harold Lief:] Medical students effectively trained in human sexuality are better equipped to integrate their knowledge, attitudes, and skills. They will have a greater ease and comfort in dealing with sexual, marital, and family planning problems, increasing their effectiveness as physicians. And this is just the beginning of their professional development. What we have shown you in this film is just an introduction to the subject. We will shortly produce other films that will cover specialized areas we were not able to include in this one. The field is wide open to a great deal more research and inquiry. We hope you will join us. [Narrator:] Sexual problems are among the most sensitive and anguishing patients bring to their physicians. Involving as they do, profound individual and family values. Medical intervention in this area affects the patient's and the family's entire well-being. [Instrumental music] [Narrator:] The physician who receives training in human sexuality and the skills of therapy during his professional training can help to alleviate much unnecessary suffering. And to preserve many marriages which are in serious jeopardy. The relevance of sex education and medical education is not debatable. We really have no choice. Sex education in some form goes on all the time. Usually it's the wrong kind. If the medical profession does not intervene, we will be abdicating a major medical responsibility. [Instrumental music] [...] [Harold I. Lief, M.D. Director of the Center] [David M. Reed, Ph.D., M.P.H. Assistant Director] [Elizabeth M.G. Stanley I.R.C.P., M.R.C.S. Research Associate] [Executive Producer: Charles GalbraithProducer-Director: Stan Carlson] [Written by: David V. RobisonVideo Tape Editor: Bob Howard] ["Rich & Judy" film courtesy of National Sex Forum] [Produced through the facilities of Northwest Mobile Television] [Music fades out] [Film leader] [...]