1
Oxford School of Sexual Medicine: How Are We Doing? Lior Lowenstein, MD, MS,* Yacov Reisman, MD, PhD,† Francesca Tripodi, PsyD,‡ John Dean, MD,§ Arik Shechter, MD,¶ and Hartmut Porst, MD, PhD¶** *Department of Obstetrics and Gynecology, Rambam Medical Center, Haifa, Israel; †Department of Urology, Ziekenhuis Amstelland, Amstelveen, The Netherlands; ‡Institute of Clinical Sexology, Rome, Italy; §The Leurels Clinic, London, UK; ¶ Department of Family Medicine, Clalit Health Services, Haifa and Western Galilee District, Ruth and Bruce Rappaport Faculty of Medicine, Technion Institute of Technology, Haifa, Israel; **Private Urological/Andrological Practice, Hamburg, Germany DOI: 10.1111/jsm.12719
ABSTRACT
Introduction. Since 2007, the European Society of Sexual Medicine has held an annual 2-week educational residential program at Oxford. The Oxford School of Sexual Medicine provides knowledge and skills learning opportunities for healthcare professionals. Aim. The aim of the current study was to evaluate the impact of Oxford School courses on the daily practice and medical careers of fellows from different countries. Methods. All participants in the Oxford School programs were invited to anonymously complete a self-administered questionnaire. Main Outcome Measures. The questionnaire comprised three sections: socio-demographic characteristics of the respondents; four Likert-scale score items inquiring about professional background; and 17 closed and two open questions to evaluate the impact of Oxford School on the respondents’ practices. Differences in proportions of categorical variables between respondent subgroups were assessed using Pearson χ2 test. Results. The mean age of the 54 fellows who participated in the study was 44 years (range 28–63 years), 71% were men and 29% were women. Fifty (92%) were physicians, two (4%) psychologists, and two (4%) were sex therapists. Following participation in the Oxford School course, significantly more participants reported spending 50% or more of their clinical time practicing sexual medicine than prior to the course (59% [32] vs. 27% [15], P < 0.001, Figure 1); and significantly more reported spending 50% or more of their working time in clinical research (54% [29] vs. 33% [18], P < 0.001, Figure 2). Forty-six fellows (85%) reported current participation in teaching activities, compared with only 29 (54%) prior to participating in the Oxford School course. Conclusion. Educational activities in sexual medicine, such as the Oxford School, may contribute to the advancement of clinical practice, teaching activities, and clinical research of healthcare providers who are interested in sexual medicine. Lowenstein L, Reisman Y, Tripodi F, Dean J, Shechter A, and Porst H. Oxford School of Sexual Medicine: How are we doing? J Sex Med **;**:**–**. Key Words. Education; Sexual Medicine; Survey; Training Program
Introduction
S
exual dysfunctions are highly prevalent [1–4]. A cross-sectional study of attendees to 13 general practitioner offices in London reported at least one International Classification of Diseases and Related Health Problems diagnosis of sexual dysfunction © 2014 International Society for Sexual Medicine
among 40% of the women and among 22% of the men. Although some women talk about their sexual dysfunction with their doctors [5], apparently many do not [6]. Furthermore, a survey of 11,161 young people in Britain reported that more prefer to receive information about sexual matters from healthcare professionals than do so in practice [7]. J Sex Med **;**:**–**
2 Although research in the field of sexual medicine has progressed exponentially, in clinical practice we seem to be lagging behind. A knowledge gap exists between developments in sexual medicine and the clinical skills of practicing physicians. The European Society of Sexual Medicine (ESSM) confronts the challenge of training physicians and healthcare providers who deliver sexual health care. The ESSM offers courses that introduce a collaborative training model aimed to promote ease with the subject among healthcare professional, as well as instill skills in providing optimal care to patients with sexual health concerns and dysfunctions. The ESSM initiated its first 2-week residential program at Oxford in 2007. Offered annually, the course has trained 155 psychologists, social workers, and physicians from Europe, Asia, Australia, and America. The course comprises 75 hours with experts and with simulated patients for practical training in sexual medicine. The program consisted of practicing clinical cases with simulated patients, oral presentations, and discussions in small groups on problems and defined cases (http://www.essm .org/society/mjcsm/the-essm-school-of-sexual -medicine/program-of-the-essm-school-ofsexual-medicine.html). Based on the understanding that centers of excellence in sexual medicine need be implemented by multidisciplinary teams for diagnosis and treatment of sexual dysfunction in men and women [8], the Oxford School of Sexual Medicine initiated a learning opportunity for healthcare professionals of different backgrounds: specialists, psychologists, physiotherapists, and social workers in the field of sexual medicine and sex therapy. Aim
This article aims to evaluate the impact of participation in the Oxford School course on the daily practice and healthcare career of attendees. Based on the findings, we plan to develop the course to meet the expectations and learning needs of participants. Methods
Participants in the Oxford School course, from its establishment in 2007 and until 2012, were invited to anonymously complete a self-administered questionnaire comprised of 25 closed questions and two open questions (Appendix 1). Participants received an email with an invitation to participate in an online, self-administered J Sex Med **;**:**–**
Lowenstein et al. survey. The stated purpose of the survey was to evaluate the impact of the course on participants’ daily practice and career and to apply the information gained to improve future courses and other educational programs in the framework of sexual medicine. Main Outcome Measures
The survey consisted of three sections: the first assessed socio-demographic characteristics of the respondents; the second consisted of four Likertscale score items inquiring about professional background; and the third consisted of 17 closed questions and two open items to evaluate the impact of the Oxford School course on the participants’ daily practice (Appendix 1).
Statistical Analyses Differences in proportions between categorical variables were assessed using the Pearson χ2 test. All statistical tests were performed using SPSS v.19 (IBM Corp., Armonk, NY, USA). All tests were two sided, with the significance level set at 0.05. Results
Overall, 155 healthcare professionals have attended the Oxford School since 2007. Of them, 54 (35%) participated in the study. The mean age was 44 years (range 28–63 years), 71% were men and 29% were women. The vast majority of participants were physicians (50, 92%), two (4%) were psychologists, and two (4%) were sex therapists. The most common primary medical specialism was urology with 19 (38%), 10 (20%) were gynecologists, eight (16%) were family physicians, eight (16%) were psychiatrists, and five (10%) were endocrinologists. The origins of the participants were countries throughout Europe, Saudi Arabia, India, Indonesia, Pakistan, South Africa, United Arab Emirates, Jordan, Lebanon, Uruguay, and Israel. Of the respondents, 25 (46%) had practiced sexual medicine for 5–10 years, 10 (19%) for less than 5 years and 19 (35%) for more than 10 years. Prior to participating in the Oxford School, 30 (55%) participants spent only 25% or less of their working time practicing sexual medicine; following participation in the course, significantly more participants spent 50% or more of their clinical time practicing sexual medicine following the course than prior to the course, 32 (59%) vs. 15 (27%), P < 0.001, with only 16 (30%) spending
Oxford School of Sexual Medicine
3
Figure 1 Study participants according to the proportion of their clinical practice that involves sexual medicine.
only 25% or less of their working time in sexual medicine practice (Figure 1). Similarly, significantly more participants reported spending 50% or more of their working time in clinical research, 29 (54%) vs. 18 (33%), P < 0.001 (Figure 2). More than two-thirds of participants, 39 (72%), reported current activity in a national society of sexual medicine and 40 (74%) attended international conferences about sexual medicine, compared with only 30 (55%) and 29 (53%), respectively, prior to participation in the Oxford School. In addition, 46 (85%) reported current participation in teaching activities, compared with only 29 (54%) prior to attending Oxford School. Thirty-two (59%) reported that the Oxford School dramatically changed their practice, 20 (37%) reported that it somewhat changed, and two (4%) responded that no change occurred in their
practice following participating in the Oxford School. All eligible responders (50) took the Multidisciplinary Joint Committee on Sexual Medicine (MJCSM) exam on 2012 in Amsterdam to become Fellow of the European Committee on Sexual Medicine; the vast majority (41, 82%) reported that the course in Oxford School helped them very much in taking the MJCSM exam, whereas the rest (nine, 18%) reported that it helped them to a certain extent (somewhat). Of the 54 responders, only four (2%) reported that they would not recommend to their colleagues to attend Oxford School in the future.
Comments Sexual dysfunction is highly prevalent [1,2]. Thus, training physicians to adequately address the health burden derived from sexual dysfunction is
Figure 2 Study participants categorized according to the proportion of their time share in research in sexual medicine.
J Sex Med **;**:**–**
4 essential to improving sexual health outcomes and to developing more physicians as leaders in sexual medicine. Improving communication skills related to sexuality and sexual dysfunction is a major challenge that needs to be addressed by physicians; patients need help and encouragement from physicians to raise sexual health issues and to support them in communicating their needs. According to a study conducted by McCance et al., as few as 25% of primary care physicians routinely ask patients about sexual well-being. The majority of physicians who failed to inquire stated that they felt inadequately trained in how to properly take a sexual history or to evaluate sexual problems [9]. Education about sexuality and its problems at medical undergraduate level is typically inadequate to properly prepare future physicians for their roles as sexual health educators [10]. In a recently published review article, Kontula detailed the educational activities that have been conducted in Europe in the last few decades in the realm of sexology. A major effort was invested by the European Federation of Sexology (EFS) to develop a European-based educational program for sexologists. Prof. Osmo Kontula, a member of the EFS, summarized six models of training for sexologists that are currently implemented in European countries. Based on the collected data, the author concluded that in most European universities, sexology is not an integral part of teaching, not even for physicians; it was also stated that there are large gaps of knowledge regarding treatment modalities of sexual dysfunctions and that there is a need to improve training programs, which seem to be generally deficient in the areas of prevention and research methodology [11]. Although there is substantial evidence of patient interest in discussing matters related to sexual health [12], providers’ ability to address sexual health is often limited by their personal uneasiness in discussing the topic, their lack of training, and time constraints. Some providers find it easier to simply order tests rather than to engage in discussions about sexual health [13]. A study conducted by Lindau et al. of Americans older than 50 years reported that just 38% and 22% of men and women, respectively, had discussed sex with their healthcare provider [14]. The 2001 Surgeon General’s call to action to promote sexual health and responsible sexual behavior reinforced the need to work together, respect differences, and find common ground. In their statement, they called to sexual health leaders to continue to work as members of a team and to J Sex Med **;**:**–**
Lowenstein et al. develop teams around them [13]. In the current study, more than half of the respondents reported that attending the Oxford School greatly changed their practice. They reported changes since participation in the course in the following domains: an increase in teaching activities in the field of sexual medicine, devotion of more clinical time to sexual medicine, and the conduct of more research in the field. Whether these changes resulted from participation in the course or were a consequence of practitioners’ preconceived career development plans, or other factors, cannot be known with certainty. We expect that the guidance offered from a broad spectrum of experts in the field of sexual medicine enriched knowledge of the course participants in male and female sexual medicine and contributed to their establishing future careers in sexual medicine. A strength of the educational program is the integration of a theoretic components part, which reviewed the most up-to-date literature in male and female sexual medicine, and a practical component, which involved simulated patients and working in small groups on problemdefined cases and discussions. The feedback of the respondents demonstrate that they valued the course, as was implicit in the statement of the majority of respondents that they will recommend to their colleagues to take the Oxford School course in the future. Though medical students are often instructed in taking sexual histories, this knowledge tends to be lost during clinical rotations and residency when time constraints or other physicians discourage sexual history-taking. Thus, sexual health training should extend into residency and beyond. The Oxford School is one option to develop and refine practicing physicians’ sexual health skills [13]. The challenge of Oxford School and similar programs is to create uniform, widely available means to provide practicing physicians across specialties with the skills to meet their current patients’ needs in sexual medicine healthcare delivery [15]. In their systemic review of randomized controlled trials on sexual history-taking, Coverdale et al. identified 11 trials: seven included medical students, two included residents, one involved community-based physicians, and one involved attending fellows and residents. The authors of the review concluded that the limited data available support the benefit of providing medical professionals opportunities to learn and to practice interviewing patients about aspects of sexual medicine and to receive feedback on their skills [16]. Con-
5
Oxford School of Sexual Medicine comitant with our findings, these conclusions highlight the importance of developing more educational activities in this field. The main limitation of this study is the relatively low respondent rate of our participants. Although contemporaneous, individual feedback on each teaching and learning sessions was obtained during the course, surveys conducted at an interval after participation are useful in deciding the overall impact on physician attitudes and behaviors related to sexual medicine practice. The low respondent rate may subject the study to a selection bias; specifically, the participants in the course who remained more active in sexual medicine may have been more likely to respond. Therefore, any conclusion need be taken cautiously. Furthermore, factors other than participation in the course may have affected the professional activity of the respondents. In addition, the absence of information on prior participation in national training programs is a limitation of the study. In conclusion, 35% of the respondents to our survey indicated that participants in the educational program on sexual medicine at Oxford School increased their involvement in the field, as clinical practitioners, teachers, and researchers, and increased the amount of time that they devoted to the care of patients with sexual concerns and dysfunction. Corresponding Author: Lior Lowenstein, MD, MS, Department of Obstetrics and Gynecology, Rambam Medical Center, Haifa 35254, Israel. Tel: (4)8543118; Fax: (4)8543119; E-mail: [email protected] Conflict of Interest: The author(s) report no conflicts of interest. Statement of Authorship
Category 1 (a) Conception and Design Lior Lowenstein; Yacov Reisman; Francesca Tripodi; Arik Shechter; Hartmut Porst (b) Acquisition of Data Lior Lowenstein; Yacov Reisman; Francesca Tripodi; Arik Shechter (c) Analysis and Interpretation of Data Lior Lowenstein; Yacov Reisman
Category 3 (a) Final Approval of the Completed Article Lior Lowenstein; Yacov Reisman; Francesca Tripodi; Arik Shechter; John Dean; Hartmut Porst References 1 Cohen PG. Sexual dysfunction in the United States. JAMA 1999;282:1229. 2 Correa LQ, Silva MC, Rombaldi AJ. Sexual dysfunction symptoms in men age 40 or older: Prevalence and associated factors. Rev Bras Epidemiol 2013;16:444–53. 3 Moreira ED, Glasser DB, Nicolosi A, Duarte FG, Gingell C. Sexual problems and help-seeking behaviour in adults in the United Kingdom and continental Europe. BJU Int 2008;101:1005–11. 4 Nicolosi A, Buvat J, Glasser DB, Hartmann U, Laumann EO, Gingell C. Sexual behaviour, sexual dysfunctions and related help seeking patterns in middle-aged and elderly Europeans: The global study of sexual attitudes and behaviors. World J Urol 2006;24:423–8. 5 Nazareth I, Boynton P, King M. Problems with sexual function in people attending London general practitioners: Cross sectional study. BMJ 2003;327:423. 6 Vahdaninia M, Montazeri A, Goshtasebi A. Help-seeking behaviors for female sexual dysfunction: A cross sectional study from Iran. BMC Womens Health 2009;9:3. 7 Macdowall W, Wellings K, Mercer CH, Nanchahal K, Copas AJ, McManus S, Fenton KA, Erens B, Johnson AM. Learning about sex: Results from Natsal 2000. Health Educ Behav 2006;33:802–11. 8 Bitzer J, Reisman Y, Lowenstein L. Center of excellence for sexual medicine. J Sex Med 2013;10:2127–8. 9 McCance KL, Moser R Jr, Smith KR. A survey of physicians’ knowledge and application of AIDS prevention capabilities. Am J Prev Med 1991;7:141–5. 10 Shindel AW, Parish SJ. Sexuality education in North American medical schools: Current status and future directions. J Sex Med 2013;10:3–17, quiz 18. 11 Kontula O. An essential component in promoting sexual health in Europe is training in sexology. Int J Sex Health 2011;23:168–80. 12 Ende J, Rockwell S, Glasgow M. The sexual history in general medicine practice. Arch Intern Med 1984;144:558–61. 13 Coleman E, Elders J, Satcher D, Shindel A, Parish S, Kenagy G, Bayer CR, Knudson G, Kingsberg 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. 14 Lindau ST, Schumm LP, Laumann EO, Levinson W, O’Muircheartaigh CA, Waite LJ. A study of sexuality and health among older adults in the United States. N Engl J Med 2007;357:762–74. 15 Parish SJ, Clayton AH. Sexual medicine education: Review and commentary. J Sex Med 2007;4:259–67, quiz 268. 16 Coverdale JH, Balon R, Roberts LW. Teaching sexual historytaking: A systematic review of educational programs. Acad Med 2011;86:1590–5.
Category 2
Appendix 1. Survey
(a) Drafting the Article Lior Lowenstein; Yacov Reisman; Francesca Tripodi; Arik Shechter; John Dean; Hartmut Porst (b) Revising It for Intellectual Content John Dean; Hartmut Porst
Section 1 Demographic data: Please specify your Age:________________ years Sex: □ Male
□ Female
J Sex Med **;**:**–**
6 Country of origin: Country of practice: Year you attended Oxford School:
Lowenstein et al. ____________________ ____________________ ____________________
• Did you attend ESSM, ISSM, EFS or WAS conferences before attending Oxford School? Yes 1□ No 2□
Section 2 Professional background: 1. Please specify your occupation: Physician 1 Psychologist 2 Sexual therapist 3 Physical therapist 4 Nurse (RN) 5 Preclinical researcher 6 Other, please specify_______________________
• Do you regularly attend ESSM, ISSM, EFS or WAS conferences? Yes 1□ No 2□
□ □ □ □ □ □
2. If you are a physician, please specify your specialty Urologist 1□ Gynaecologist 2□ Psychiatrist 3□ Endocrinologist 4□ Cardiologist 5□ General practitioner 6□ Other, please specify __________________ 3. For how long have you been practicing sexual medicine? □ Less 2 □ Between 3 □ More than than 5 years 5 and 10 years 10 years 4. Do you practice in a private clinic or in the public health care system? Academic hospital 1□ Private clinic/private practice 2□ Public health care system 3□ Both private and public health care system 4□ Other, please specify __________________
Section 3 Evaluate the impact of Oxford School on your practice: • Are you a member of the □ ESSM □ ISSM □ EFS □ WAS □ Others: __________________________ □ none • Were you a member of the ESSM, ISSM, EFS or WAS before you attended Oxford School? Yes 1□ No 2□
• What percentage of your clinical practice involves sexual medicine? 100% 1□ 75% 2□ 50% 3□ 25% 4□
Oxford School of Sexual Medicine: How Are We Doing? Lior Lowenstein, MD, MS,* Yacov Reisman, MD, PhD,† Francesca Tripodi, PsyD,‡ John Dean, MD,§ Arik Shechter, MD,¶ and Hartmut Porst, MD, PhD¶** *Department of Obstetrics and Gynecology, Rambam Medical Center, Haifa, Israel; †Department of Urology, Ziekenhuis Amstelland, Amstelveen, The Netherlands; ‡Institute of Clinical Sexology, Rome, Italy; §The Leurels Clinic, London, UK; ¶ Department of Family Medicine, Clalit Health Services, Haifa and Western Galilee District, Ruth and Bruce Rappaport Faculty of Medicine, Technion Institute of Technology, Haifa, Israel; **Private Urological/Andrological Practice, Hamburg, Germany DOI: 10.1111/jsm.12719
ABSTRACT
Introduction. Since 2007, the European Society of Sexual Medicine has held an annual 2-week educational residential program at Oxford. The Oxford School of Sexual Medicine provides knowledge and skills learning opportunities for healthcare professionals. Aim. The aim of the current study was to evaluate the impact of Oxford School courses on the daily practice and medical careers of fellows from different countries. Methods. All participants in the Oxford School programs were invited to anonymously complete a self-administered questionnaire. Main Outcome Measures. The questionnaire comprised three sections: socio-demographic characteristics of the respondents; four Likert-scale score items inquiring about professional background; and 17 closed and two open questions to evaluate the impact of Oxford School on the respondents’ practices. Differences in proportions of categorical variables between respondent subgroups were assessed using Pearson χ2 test. Results. The mean age of the 54 fellows who participated in the study was 44 years (range 28–63 years), 71% were men and 29% were women. Fifty (92%) were physicians, two (4%) psychologists, and two (4%) were sex therapists. Following participation in the Oxford School course, significantly more participants reported spending 50% or more of their clinical time practicing sexual medicine than prior to the course (59% [32] vs. 27% [15], P < 0.001, Figure 1); and significantly more reported spending 50% or more of their working time in clinical research (54% [29] vs. 33% [18], P < 0.001, Figure 2). Forty-six fellows (85%) reported current participation in teaching activities, compared with only 29 (54%) prior to participating in the Oxford School course. Conclusion. Educational activities in sexual medicine, such as the Oxford School, may contribute to the advancement of clinical practice, teaching activities, and clinical research of healthcare providers who are interested in sexual medicine. Lowenstein L, Reisman Y, Tripodi F, Dean J, Shechter A, and Porst H. Oxford School of Sexual Medicine: How are we doing? J Sex Med **;**:**–**. Key Words. Education; Sexual Medicine; Survey; Training Program
Introduction
S
exual dysfunctions are highly prevalent [1–4]. A cross-sectional study of attendees to 13 general practitioner offices in London reported at least one International Classification of Diseases and Related Health Problems diagnosis of sexual dysfunction © 2014 International Society for Sexual Medicine
among 40% of the women and among 22% of the men. Although some women talk about their sexual dysfunction with their doctors [5], apparently many do not [6]. Furthermore, a survey of 11,161 young people in Britain reported that more prefer to receive information about sexual matters from healthcare professionals than do so in practice [7]. J Sex Med **;**:**–**
2 Although research in the field of sexual medicine has progressed exponentially, in clinical practice we seem to be lagging behind. A knowledge gap exists between developments in sexual medicine and the clinical skills of practicing physicians. The European Society of Sexual Medicine (ESSM) confronts the challenge of training physicians and healthcare providers who deliver sexual health care. The ESSM offers courses that introduce a collaborative training model aimed to promote ease with the subject among healthcare professional, as well as instill skills in providing optimal care to patients with sexual health concerns and dysfunctions. The ESSM initiated its first 2-week residential program at Oxford in 2007. Offered annually, the course has trained 155 psychologists, social workers, and physicians from Europe, Asia, Australia, and America. The course comprises 75 hours with experts and with simulated patients for practical training in sexual medicine. The program consisted of practicing clinical cases with simulated patients, oral presentations, and discussions in small groups on problems and defined cases (http://www.essm .org/society/mjcsm/the-essm-school-of-sexual -medicine/program-of-the-essm-school-ofsexual-medicine.html). Based on the understanding that centers of excellence in sexual medicine need be implemented by multidisciplinary teams for diagnosis and treatment of sexual dysfunction in men and women [8], the Oxford School of Sexual Medicine initiated a learning opportunity for healthcare professionals of different backgrounds: specialists, psychologists, physiotherapists, and social workers in the field of sexual medicine and sex therapy. Aim
This article aims to evaluate the impact of participation in the Oxford School course on the daily practice and healthcare career of attendees. Based on the findings, we plan to develop the course to meet the expectations and learning needs of participants. Methods
Participants in the Oxford School course, from its establishment in 2007 and until 2012, were invited to anonymously complete a self-administered questionnaire comprised of 25 closed questions and two open questions (Appendix 1). Participants received an email with an invitation to participate in an online, self-administered J Sex Med **;**:**–**
Lowenstein et al. survey. The stated purpose of the survey was to evaluate the impact of the course on participants’ daily practice and career and to apply the information gained to improve future courses and other educational programs in the framework of sexual medicine. Main Outcome Measures
The survey consisted of three sections: the first assessed socio-demographic characteristics of the respondents; the second consisted of four Likertscale score items inquiring about professional background; and the third consisted of 17 closed questions and two open items to evaluate the impact of the Oxford School course on the participants’ daily practice (Appendix 1).
Statistical Analyses Differences in proportions between categorical variables were assessed using the Pearson χ2 test. All statistical tests were performed using SPSS v.19 (IBM Corp., Armonk, NY, USA). All tests were two sided, with the significance level set at 0.05. Results
Overall, 155 healthcare professionals have attended the Oxford School since 2007. Of them, 54 (35%) participated in the study. The mean age was 44 years (range 28–63 years), 71% were men and 29% were women. The vast majority of participants were physicians (50, 92%), two (4%) were psychologists, and two (4%) were sex therapists. The most common primary medical specialism was urology with 19 (38%), 10 (20%) were gynecologists, eight (16%) were family physicians, eight (16%) were psychiatrists, and five (10%) were endocrinologists. The origins of the participants were countries throughout Europe, Saudi Arabia, India, Indonesia, Pakistan, South Africa, United Arab Emirates, Jordan, Lebanon, Uruguay, and Israel. Of the respondents, 25 (46%) had practiced sexual medicine for 5–10 years, 10 (19%) for less than 5 years and 19 (35%) for more than 10 years. Prior to participating in the Oxford School, 30 (55%) participants spent only 25% or less of their working time practicing sexual medicine; following participation in the course, significantly more participants spent 50% or more of their clinical time practicing sexual medicine following the course than prior to the course, 32 (59%) vs. 15 (27%), P < 0.001, with only 16 (30%) spending
Oxford School of Sexual Medicine
3
Figure 1 Study participants according to the proportion of their clinical practice that involves sexual medicine.
only 25% or less of their working time in sexual medicine practice (Figure 1). Similarly, significantly more participants reported spending 50% or more of their working time in clinical research, 29 (54%) vs. 18 (33%), P < 0.001 (Figure 2). More than two-thirds of participants, 39 (72%), reported current activity in a national society of sexual medicine and 40 (74%) attended international conferences about sexual medicine, compared with only 30 (55%) and 29 (53%), respectively, prior to participation in the Oxford School. In addition, 46 (85%) reported current participation in teaching activities, compared with only 29 (54%) prior to attending Oxford School. Thirty-two (59%) reported that the Oxford School dramatically changed their practice, 20 (37%) reported that it somewhat changed, and two (4%) responded that no change occurred in their
practice following participating in the Oxford School. All eligible responders (50) took the Multidisciplinary Joint Committee on Sexual Medicine (MJCSM) exam on 2012 in Amsterdam to become Fellow of the European Committee on Sexual Medicine; the vast majority (41, 82%) reported that the course in Oxford School helped them very much in taking the MJCSM exam, whereas the rest (nine, 18%) reported that it helped them to a certain extent (somewhat). Of the 54 responders, only four (2%) reported that they would not recommend to their colleagues to attend Oxford School in the future.
Comments Sexual dysfunction is highly prevalent [1,2]. Thus, training physicians to adequately address the health burden derived from sexual dysfunction is
Figure 2 Study participants categorized according to the proportion of their time share in research in sexual medicine.
J Sex Med **;**:**–**
4 essential to improving sexual health outcomes and to developing more physicians as leaders in sexual medicine. Improving communication skills related to sexuality and sexual dysfunction is a major challenge that needs to be addressed by physicians; patients need help and encouragement from physicians to raise sexual health issues and to support them in communicating their needs. According to a study conducted by McCance et al., as few as 25% of primary care physicians routinely ask patients about sexual well-being. The majority of physicians who failed to inquire stated that they felt inadequately trained in how to properly take a sexual history or to evaluate sexual problems [9]. Education about sexuality and its problems at medical undergraduate level is typically inadequate to properly prepare future physicians for their roles as sexual health educators [10]. In a recently published review article, Kontula detailed the educational activities that have been conducted in Europe in the last few decades in the realm of sexology. A major effort was invested by the European Federation of Sexology (EFS) to develop a European-based educational program for sexologists. Prof. Osmo Kontula, a member of the EFS, summarized six models of training for sexologists that are currently implemented in European countries. Based on the collected data, the author concluded that in most European universities, sexology is not an integral part of teaching, not even for physicians; it was also stated that there are large gaps of knowledge regarding treatment modalities of sexual dysfunctions and that there is a need to improve training programs, which seem to be generally deficient in the areas of prevention and research methodology [11]. Although there is substantial evidence of patient interest in discussing matters related to sexual health [12], providers’ ability to address sexual health is often limited by their personal uneasiness in discussing the topic, their lack of training, and time constraints. Some providers find it easier to simply order tests rather than to engage in discussions about sexual health [13]. A study conducted by Lindau et al. of Americans older than 50 years reported that just 38% and 22% of men and women, respectively, had discussed sex with their healthcare provider [14]. The 2001 Surgeon General’s call to action to promote sexual health and responsible sexual behavior reinforced the need to work together, respect differences, and find common ground. In their statement, they called to sexual health leaders to continue to work as members of a team and to J Sex Med **;**:**–**
Lowenstein et al. develop teams around them [13]. In the current study, more than half of the respondents reported that attending the Oxford School greatly changed their practice. They reported changes since participation in the course in the following domains: an increase in teaching activities in the field of sexual medicine, devotion of more clinical time to sexual medicine, and the conduct of more research in the field. Whether these changes resulted from participation in the course or were a consequence of practitioners’ preconceived career development plans, or other factors, cannot be known with certainty. We expect that the guidance offered from a broad spectrum of experts in the field of sexual medicine enriched knowledge of the course participants in male and female sexual medicine and contributed to their establishing future careers in sexual medicine. A strength of the educational program is the integration of a theoretic components part, which reviewed the most up-to-date literature in male and female sexual medicine, and a practical component, which involved simulated patients and working in small groups on problemdefined cases and discussions. The feedback of the respondents demonstrate that they valued the course, as was implicit in the statement of the majority of respondents that they will recommend to their colleagues to take the Oxford School course in the future. Though medical students are often instructed in taking sexual histories, this knowledge tends to be lost during clinical rotations and residency when time constraints or other physicians discourage sexual history-taking. Thus, sexual health training should extend into residency and beyond. The Oxford School is one option to develop and refine practicing physicians’ sexual health skills [13]. The challenge of Oxford School and similar programs is to create uniform, widely available means to provide practicing physicians across specialties with the skills to meet their current patients’ needs in sexual medicine healthcare delivery [15]. In their systemic review of randomized controlled trials on sexual history-taking, Coverdale et al. identified 11 trials: seven included medical students, two included residents, one involved community-based physicians, and one involved attending fellows and residents. The authors of the review concluded that the limited data available support the benefit of providing medical professionals opportunities to learn and to practice interviewing patients about aspects of sexual medicine and to receive feedback on their skills [16]. Con-
5
Oxford School of Sexual Medicine comitant with our findings, these conclusions highlight the importance of developing more educational activities in this field. The main limitation of this study is the relatively low respondent rate of our participants. Although contemporaneous, individual feedback on each teaching and learning sessions was obtained during the course, surveys conducted at an interval after participation are useful in deciding the overall impact on physician attitudes and behaviors related to sexual medicine practice. The low respondent rate may subject the study to a selection bias; specifically, the participants in the course who remained more active in sexual medicine may have been more likely to respond. Therefore, any conclusion need be taken cautiously. Furthermore, factors other than participation in the course may have affected the professional activity of the respondents. In addition, the absence of information on prior participation in national training programs is a limitation of the study. In conclusion, 35% of the respondents to our survey indicated that participants in the educational program on sexual medicine at Oxford School increased their involvement in the field, as clinical practitioners, teachers, and researchers, and increased the amount of time that they devoted to the care of patients with sexual concerns and dysfunction. Corresponding Author: Lior Lowenstein, MD, MS, Department of Obstetrics and Gynecology, Rambam Medical Center, Haifa 35254, Israel. Tel: (4)8543118; Fax: (4)8543119; E-mail: [email protected] Conflict of Interest: The author(s) report no conflicts of interest. Statement of Authorship
Category 1 (a) Conception and Design Lior Lowenstein; Yacov Reisman; Francesca Tripodi; Arik Shechter; Hartmut Porst (b) Acquisition of Data Lior Lowenstein; Yacov Reisman; Francesca Tripodi; Arik Shechter (c) Analysis and Interpretation of Data Lior Lowenstein; Yacov Reisman
Category 3 (a) Final Approval of the Completed Article Lior Lowenstein; Yacov Reisman; Francesca Tripodi; Arik Shechter; John Dean; Hartmut Porst References 1 Cohen PG. Sexual dysfunction in the United States. JAMA 1999;282:1229. 2 Correa LQ, Silva MC, Rombaldi AJ. Sexual dysfunction symptoms in men age 40 or older: Prevalence and associated factors. Rev Bras Epidemiol 2013;16:444–53. 3 Moreira ED, Glasser DB, Nicolosi A, Duarte FG, Gingell C. Sexual problems and help-seeking behaviour in adults in the United Kingdom and continental Europe. BJU Int 2008;101:1005–11. 4 Nicolosi A, Buvat J, Glasser DB, Hartmann U, Laumann EO, Gingell C. Sexual behaviour, sexual dysfunctions and related help seeking patterns in middle-aged and elderly Europeans: The global study of sexual attitudes and behaviors. World J Urol 2006;24:423–8. 5 Nazareth I, Boynton P, King M. Problems with sexual function in people attending London general practitioners: Cross sectional study. BMJ 2003;327:423. 6 Vahdaninia M, Montazeri A, Goshtasebi A. Help-seeking behaviors for female sexual dysfunction: A cross sectional study from Iran. BMC Womens Health 2009;9:3. 7 Macdowall W, Wellings K, Mercer CH, Nanchahal K, Copas AJ, McManus S, Fenton KA, Erens B, Johnson AM. Learning about sex: Results from Natsal 2000. Health Educ Behav 2006;33:802–11. 8 Bitzer J, Reisman Y, Lowenstein L. Center of excellence for sexual medicine. J Sex Med 2013;10:2127–8. 9 McCance KL, Moser R Jr, Smith KR. A survey of physicians’ knowledge and application of AIDS prevention capabilities. Am J Prev Med 1991;7:141–5. 10 Shindel AW, Parish SJ. Sexuality education in North American medical schools: Current status and future directions. J Sex Med 2013;10:3–17, quiz 18. 11 Kontula O. An essential component in promoting sexual health in Europe is training in sexology. Int J Sex Health 2011;23:168–80. 12 Ende J, Rockwell S, Glasgow M. The sexual history in general medicine practice. Arch Intern Med 1984;144:558–61. 13 Coleman E, Elders J, Satcher D, Shindel A, Parish S, Kenagy G, Bayer CR, Knudson G, Kingsberg 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. 14 Lindau ST, Schumm LP, Laumann EO, Levinson W, O’Muircheartaigh CA, Waite LJ. A study of sexuality and health among older adults in the United States. N Engl J Med 2007;357:762–74. 15 Parish SJ, Clayton AH. Sexual medicine education: Review and commentary. J Sex Med 2007;4:259–67, quiz 268. 16 Coverdale JH, Balon R, Roberts LW. Teaching sexual historytaking: A systematic review of educational programs. Acad Med 2011;86:1590–5.
Category 2
Appendix 1. Survey
(a) Drafting the Article Lior Lowenstein; Yacov Reisman; Francesca Tripodi; Arik Shechter; John Dean; Hartmut Porst (b) Revising It for Intellectual Content John Dean; Hartmut Porst
Section 1 Demographic data: Please specify your Age:________________ years Sex: □ Male
□ Female
J Sex Med **;**:**–**
6 Country of origin: Country of practice: Year you attended Oxford School:
Lowenstein et al. ____________________ ____________________ ____________________
• Did you attend ESSM, ISSM, EFS or WAS conferences before attending Oxford School? Yes 1□ No 2□
Section 2 Professional background: 1. Please specify your occupation: Physician 1 Psychologist 2 Sexual therapist 3 Physical therapist 4 Nurse (RN) 5 Preclinical researcher 6 Other, please specify_______________________
• Do you regularly attend ESSM, ISSM, EFS or WAS conferences? Yes 1□ No 2□
□ □ □ □ □ □
2. If you are a physician, please specify your specialty Urologist 1□ Gynaecologist 2□ Psychiatrist 3□ Endocrinologist 4□ Cardiologist 5□ General practitioner 6□ Other, please specify __________________ 3. For how long have you been practicing sexual medicine? □ Less 2 □ Between 3 □ More than than 5 years 5 and 10 years 10 years 4. Do you practice in a private clinic or in the public health care system? Academic hospital 1□ Private clinic/private practice 2□ Public health care system 3□ Both private and public health care system 4□ Other, please specify __________________
Section 3 Evaluate the impact of Oxford School on your practice: • Are you a member of the □ ESSM □ ISSM □ EFS □ WAS □ Others: __________________________ □ none • Were you a member of the ESSM, ISSM, EFS or WAS before you attended Oxford School? Yes 1□ No 2□
• What percentage of your clinical practice involves sexual medicine? 100% 1□ 75% 2□ 50% 3□ 25% 4□
