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Teaching Sexual-History-Taking Skills to Psychiatry ResidentsDonald Fidler, MD, FRCP-I, Justin Petri, MD, Mark Chapman, MSIII

Department of Behavioral Medicine and Psychiatry West Virginia University School of Medicine

Purpose

Psychiatry residents should be competent in taking a sexual history. We introduced psychiatry residents to a comprehensive and systematic method of sexual history taking, the Sexual Events Classification System (SECS), as part of a short course on sexual-history-taking skills. To determine the value of the course and the SECS, we asked the residents to complete an anonymous survey.

Background

Psychiatry residents must be competent in sexual history taking because sexual problems are highly prevalent worldwide, and patient’s often rely on physicians to broach the subject of sexual health as well as guide the sexual history.1

• Pfizer’s global study of sexual attitudes and behaviors found that 43% of men and 49% of women reported at least one sexual problem.2

• Only a small minority of physicians ask about sexual orientation, types of sexual practices, and sexual practices of the patient’s partner.3

• Less than half of physicians ask even the most basic sexual health-related questions.3

A plausible explanation for the lack of may be that physicians are not trained to competently address sexual health.

• A study of North American medical schools found that between 61 and 67 percent of the schools taught less than 10 hours of human sexuality.4

• Medical school and residency training programs often teach sexual-history-taking skills in a passive, lecture- orientated style.

The Sexual Events Classification System

In response to a perceived lack of well-developed methods for gathering and classifying information related to sexual thoughts and behaviors, a group of physicians and medical students at West Virginia University School of Medicine developed the Sexual Events Classification System (SECS).

The SECS:

• is a comprehensive and systematic method of sexual history taking

• is multi-dimensional (Figure 1), which reflects different aspects of patients’ sexual thoughts and/or behaviors which are the clinical focus.

• provides a means for clinicians to conceptualize patients’ sexuality in a more holistic fashion.

• guides clinicians to focus on specific characteristics of sexual thoughts and behaviors which are often overlooked, including patients’ sexual emotions, meanings, and motivations.

• encourages clinicians to use objective terms to describe sexual thoughts and behaviors, rather than using judgmental or confusing jargon.

Classification and Dimensions for Gathering Information for the Sexual Events Classification System (SECS)

Sexual events are classified on six dimensions as listed below:

Dimension One: General Sexual Assessment

Dimension Two: Initial Descriptive Summary of Sexual Thoughts and Behaviors which are of Clinical Focus

Dimension Three: Characteristics of Sexual Behaviors and Fantasies of a Sexual Event or Series of Sexual Events which are of Clinical Focus

Dimension Four: Motivations and Emotions Related to a Sexual Event or Series of Sexual Events which are the Clinical Focus

Dimension Five: Factors which Impact Subject's Sexual Experiences

Dimension Six: Summary and Assessment

Methods

Sexual-History-Taking Course Outline

1. Pre-course, video-recorded, resident interview with simulated patient

2. Lecture One: General overview of human sexuality and introduction to the SECS structured interview

3. Individual meeting between the course instructor and each resident to offer feedback on the resident’s video recorded interview

4. Lecture Two: Residents watch actors’ renditions of “Bad” sexual interviewing techniques and then discuss ways to avoid these common mistakes

5. Outside of class the residents individually watch a simulated interview that employs “Good” sexual history taking techniques; while watching the video the residents “score” the interview using a Competency Score Sheet

6 . Lecture Three: Discussion of the residents’ impressions from watching and grading the “Good” interview; residents practice case study formulations using the SECS model

Seven PGY-II general psychiatry residents at West Virginia University were enrolled in a brief sexual-history-taking course. The course outline (Figure 2) contains the components of the course in the order in which the residents’ completed them. Following the course, residents were supplied with anonymous surveys to assess their perceptions of the usefulness of the course for improving their sexual-history-taking skills.

Results

Figure 1

Figure 2

Discussion

Of the seven residents originally enrolled in the sexual-history-taking course, six filled out anonymous surveys of their experiences. The anonymous survey consisted of 14 items. The averaged results of the resident post-course survey are represented in Figure 3. The question options and corresponding assigned values are listed below the table.

Figure 3

The results suggest that the residents had minimal experience taking sexual histories prior to this course. The majority of the residents indicated that they found the course to be helpful in improving their abilities to be “comprehensive” and “comfortable” while taking detailed sexual histories. We were surprised to see that only 50% of the residents felt that they had made “good” improvement at being non-judgmental while taking a sexual history. The majority of the residents indicated that the SECS represented an improvement over their previous methods of taking sexual histories. Limitations include 1) small sample size 2) resident response bias due to acquaintance with SECS creators and due to survey being an optional part of the course 4) non-specific responses to the survey questions 5) non-validation of the SECS as an instrument for sexual history taking. In conclusion, the results of this small pilot study indicate that the SECS construct may offer a useful method for teaching residents to take in-depth and non-judgmental sexual histories. We believe that this will ultimately lead to more effective communication between clinicians and patients with improved clinical outcomes. In order to draw more definitive conclusions, it will be necessary to repeat this study at multiple training sites.

1American Association of Retired Persons, TNS NFO Atlanta. “Sexuality at midlife and beyond: 2004 update of attitudes and behaviors, Washington DC. 2005. http://assets.aarp.org/rgcenter/general/2004_sexuality.pdf

2Moreira ED Jr, Brock G, Glasser DB, et al. ”Help-seeking behaviour for sexual problems: the global study of sexual attitudes and behaviors.” International Journal of Clinical Practice. 2005; 59(1): 6-16

3Wimberly YH, Hogben M, Moore-Ruffin J, Moore SE, Fry-Johnson Y. “Sexual history-taking among primary care physicians.” Journal of the National Medical Association. 2006; 98(12): 1924–1929.

4Solursh DS, Ernst JL, Lewis, RW, et al. “The human sexuality education of physicians in North American medical schools.” International Journal of Impotence Research. 2003; 15, Suppl 5, S41–S45.

Survey Question Topic Average Response Value (N=6)

1. Prior number of sexual histories taken 0.50 2. Prior sexual-history-taking skills 1.50 3. Knowledge of sexual-history-taking (post- course)

2.83

4. Comprehensiveness with patient (post- course)

2.67

5. Non-judgmental with patient (post- course)

3.00

6. Comfortableness with patient (post- course)

2.67

7. Usefulness of SECS-based interview 2.83 8. Practicality of a SECS-based interview 2.83 9. Appropriateness of SECS question- content

3.67

10. Usefulness of interviewing a simulated patient

3.33

11. Usefulness of the SECS for health-care professionals

3.33

12. Recommend health-care professionals learn the SECS

3.50

13. Future change in clinical behaviors 3.50 14. Current change in clinical behaviors 2.17 Question 1: Survey options with corresponding values: None = 0, 1-5 = 1, 6-10 = 2 , more than 10 = 3 Questions 2-11 – Survey options with corresponding values: No response = 0, Poor = 1, Fair = 2, Good = 3, Excellent = 4 Questions 12-14 – Survey options with corresponding values: No response = 0, Definitely would not or did not = 1, Possibly would not or did not = 2, Possibly would or did = 3

References