Sexual health is fundamental to overall health, and taking a valid sexual history is an essential clinical skill for all physicians. Sexual history-taking enables clinicians to identify and treat different types of sexual dysfunction, which, considered together, are highly prevalent.1,2 Obtaining a sexual history is also a crucial component of public health strategies in the primary and secondary prevention of sexually transmitted infections, including AIDS. Exploring sexual health issues carefully, accurately, and compassionately is especially important in psychiatric settings because psychiatric disorders are frequently comorbid with sexual disorders3,4 and because patients with major mental disorders have higher risks than comparison groups for having unwanted pregnancies,5,6 contracting sexually transmitted infections,6,7 and being the adult victim of sexual abuse.8
Despite the need to conduct a thorough sexual history, the identification of sexual health concerns or risk behaviors is sometimes lacking in primary care9–11 or psychiatric outpatient settings.12,13 This lack may be due either to an insufficient understanding of the relevance of sexual health to overall health or to the uneasiness of clinicians and patients alike in addressing an area that is deeply personal and highly sensitive. Helping medical students and residents across all clinical specialties to be prepared to elicit information about sexual health and sexual risk behaviors is imperative if they are to serve as competent practitioners. Indeed, according to the standards of best evidence medical education,14,15 faculty educators and program directors should take account of published information on teaching sexual history-taking and evaluate the teaching of this topic throughout the curricula. Information on educational programs designed to enhance sexual history-taking skills is vital in guiding the development of efficacious teaching on sexual history-taking and enhancing the requisite knowledge, attitudes, and skills. Nevertheless, a majority of medical student respondents in two separate surveys16,17 thought that they had not been sufficiently trained to address clinical sexual concerns.
Clearly, the academic medicine community must do more to address this neglected curricular and competence domain in medical training. Psychiatry faculty most frequently meet this responsibility at U.S. and Canadian medical schools,18 although faculty from other disciplines, such as obstetrics–gynecology, commonly provide this training as well.
The purpose of this systematic review was to identify all randomized controlled trials for teaching sexual history-taking, including those involving psychiatry and obstetrics–gynecology residents, and to reveal the efficacy of those interventions for improving skills. We also sought to identify the strengths and weaknesses of the published studies across medical disciplines and levels of training and to describe the methods used for teaching how to take sexual histories. Finally, we hoped to inform the development of sexual history-taking curricula and teaching programs and to highlight the need for educational research in this area.
We used standard methodologies for conducting systematic reviews on educational topics.19,20 We searched the PubMed, PsycINFO, and SCOPUS databases, as well as the reference lists of relevant research publications and reviews, using combinations of the following key terms: sexual history-taking, teaching, medical students, residents or registrars, sexual health, sexually transmitted infections, HIV, and AIDS. Our criteria included English language, a focus on teaching sexual history-taking, and the presence of a control or comparison group in the research design. We also screened the bibliographies of all articles that fulfilled the inclusion criteria in order to identify other articles of relevance. We conducted the search in 2010 during the months of June to November.
We excluded reports if they described a study without a comparison group21–31 or if a later publication using the same methodology incorporated results from an earlier publication.32 We excluded one research report because the outcome measures for the comparison group were entirely different from those for the experimental group, and we could make no meaningful conclusions about the relative efficacy of the teaching interventions.33 We excluded another report that randomized primary care physicians to announced or unannounced visits by a standardized patient instructor34 because the focus of the study concerned the convenience and feasibility of using standardized patient instructors in office settings. We extended the review beyond medical school and residency programs to include controlled and comparison studies of practicing clinicians because these programs can serve as a model for medical school and residency programs.
At least two of us (J.C., R.B) critically and independently appraised all the reports that met our inclusion criteria. To score the articles, we used and extended the standards developed by the Evidence-Based Medicine Working Group35 for establishing the validity of a study. These criteria included the following:
- the presence of randomization;
- the adequacy of the method of concealing the randomization;
- the identification of differences at baseline;
- the presence of blinding;
- reports of dropout rates;
- reports of the intention to treat; and
- the validity and reliability of the outcome measures used.
We scored each article dichotomously for a maximum score of seven points. We resolved any differences in scoring through further discussion until we reached consensus.
Eleven studies met the inclusion criteria (Table 1).36–46 These included four randomized controlled trials,36,37,39,41 six controlled nonrandomized trials,40,42–46 and one trial that mixed randomized and nonrandomized controls.38 Seven of the studies included medical students,38,40,42–46 one included family practice residents,37 one included internal medicine residents,41 one included office-based primary care physicians,39 and one included internal medicine attendings, fellows, and residents.36 Eight of the studies addressed general sexual problems,36–38,42–46 and three focused on identifying risks for sexually transmitted infections.39–41 Educational interventions included workshops or small groups,36–38,41,43–46 readings,38 lectures,38,40–42 mailed materials,39 role-plays,37,40–42,46 individual instruction,39 and skills training.37,42,46 Assessment methods were heterogeneous; no two used precisely the same outcome measures. The researchers of five studies directly observed and assessed sexual history-taking skills as an outcome measure.37,39,41,45,46
Table 2 summarizes the validity assessments of the trials with the total scores ranging from 0 to 6. Eight studies had rates of follow-up greater than 70%,36–39,41,44–46 although none used a power analysis to determine sample size. Seven used valid outcome measures,37–39,41,44–46 including face or content validity, but only two assessed the reliability of the outcome measures.37,39 Six studies identified differences between groups at baseline.36,38,39,41,45,46 One study40 reported on similarities between classes, but this information was not specific to the intervention and comparison groups. Only one study described the method of randomization.39 Furthermore, none described a method of concealment of randomization, and only three used blinded raters.37,39,41
We assigned the randomized controlled trial by Rabin and colleagues39 the highest validity rating among the studies (six out of seven points). This study lost only one point for not describing whether the researchers concealed the allocation of participants to groups. Rabin and colleagues randomized primary care providers into three groups, including a no-intervention control group, by using a random numbers table. The participants in the two experimental groups received educational materials by mail, and the members of one of these two groups also received an unannounced instructor visit within three months of the mailing. The instructor played the role of a woman with a sexually transmitted infection who remained at risk for further infections; the physicians reportedly did not suspect this role. At the end of the clinical encounter, this instructor provided written and oral feedback on the clinical interaction, which the physician could then apply to his or her practice. The main outcome measure was the rating of the risk assessment and counseling of each of the physicians (in all three groups) by an evaluator playing the role of a woman with a history of sexually transmitted infections who visited the physicians some months after the initial intervention. The evaluator did not know the study group of the physician visited, and few of the physicians suspected this role. Physicians who received educational materials along with the instructor's visit performed better on the evaluator's risk assessment than physicians in the other experimental group (who received educational materials alone) and the control group (no intervention).
Both of the studies that ranked second in quality (each scored 4) were randomized controlled trials. Liese and colleagues37 studied 24 residents in one family practice program who received two hours of training. For the first hour, all the residents received training in active listening and effective questioning skills and practiced through role-plays. For the second hour of training, researchers randomly assigned residents into one of two groups; in the first, residents learned to address sexual issues openly through readings and discussion of that material (skills oriented), whereas the aim of the second was to heighten residents' awareness of their own sexuality (awareness oriented). One week later, residents conducted a 15-minute videotaped interview with a simulated patient blinded to groups. Judges, also blinded to groups, counted the number of times residents addressed sexual issues, and they evaluated residents' questioning style and counseling expertise. The interviews of residents from the skills-oriented group were rated significantly higher than those of residents from the awareness-oriented group; they addressed more sexual issues and asked more open-ended questions.
Madan and colleagues41 trained medical residents to assess HIV risk. The researchers assigned 12 residents to either a one-hour didactic lecture or a one-hour intervention training workshop that provided information, included mock interviews with standardized patients, and incorporated feedback. Evaluations included self-reports and a standardized patient objective structured clinical examination (OSCE) that was evaluated by the standardized patient and an independent physician, both of whom were blinded to the group assignments. The interaction group performed significantly better in basic interviewing and asking necessary questions.
Five other studies were noteworthy.36,38,44–46 In one,36 the patients of participants who received training for sexual history-taking in five 1-hour sessions were significantly more likely to report having been asked about sexual functions than were patients seen by physicians in the comparison group who received no training. In the second,38 two groups of students conducted or observed a brief sexual history with a community volunteer; a third control group had no intervention. In a comparison of the two experimental groups, the group who conducted interviews showed greater improvements in knowledge, attitudes, and perceived personal skills in taking a sexual history than the group who observed interviews. In the third study,44 attendance at a sexual health workshop was associated with subsequent self-reports on asking patients about sexual health. In the fourth study,45 attendees at a four-hour educational workshop with a standardized patient demonstrated better clinical sexual history-taking and HIV counseling skills on an examination that involved standardized patients than those who did not attend the workshop. In the fifth study,46 one cohort of medical students who received a multimodal sexual history-taking module in addition to a traditional physical diagnosis curriculum were more likely to initiate a sexual history when evaluating a standardized patient when a sexual history was relevant.
We could calculate a number needed to teach (NNT, or the number of students who needed to be taught in order for one student to benefit) for only five of the studies36,39,42,44,46 (Table 1). In the first,36 82% of the patients seen by physicians in the education group, but only 32% of the patients seen by physicians in the comparison group, reported that their medical interview included a discussion of their sexual functioning (NNT = 2). In the second,39 73% of physicians who received educational materials plus an instructor visit reported an increase in counseling patients about reducing risky sexual behavior, in comparison with 42% of the control (no intervention) group (NNT = 3.2). In the third,42 59% of the students who attended a reproductive health fair reportedly learned 9 or 10 of the 10 competencies taught in comparison with 7% of students who did not attend (NNT = 1.9). In the fourth,44 54% of students who attended a sexual health workshop reported that they asked about sexual health one year after the workshop in comparison with 38% of nonattendees (NNT = 6.2). In the fifth,46 98% of the students who had participated in a sexual history-taking module asked at least one sexual history question in one standardized patient case compared with 83% of the comparison group (NNT = 6.6).
Sexual history-taking is an important clinical skill that formal medical school curricula have historically neglected. As attention to sexual health increases and as clinical skill acquisition or competency gains importance, evaluating the effectiveness of medical educators who teach sexual history-taking skills becomes vital to public health. We found 11 randomized controlled trials or controlled nonrandomized trials on teaching sexual history-taking,36–46 7 of which provided direct practice.38–41,44–46 The quality of studies varied considerably. We deemed only one trial to be of high methodological quality,39 and it involved primary care physicians, not medical students or trainees. Standards such as using acceptable tools for randomization, concealing randomization,47,48 and blinding raters48,49 are difficult to achieve; nonetheless, medical education researchers should attempt to do so.50 The finding of a general dearth of controlled studies, including high-quality studies, about how to enhance sexual history-taking skills limits the evidence base on which to develop sexual history-taking curricula for medical students and residents.
One concern is that outcome measures were inconsistent across studies and that none included patient outcomes. Two important goals for this area of research are to standardize outcome measures across studies and to use validated and reliable assessment tools. OSCEs or other examinations involving simulated patients, which some researchers used,37,39,41,45,46 are relatively time-consuming and expensive to implement, but they provide detailed information and assess skills that are routine in clinical settings.
The available data support the provision of opportunities to learn and practice interviewing and to receive feedback on skills. In seven studies,38–41,44–46 participants had opportunities to practice sexual history-taking and received feedback. In one,39 an unannounced simulated patient provided feedback on the adequacy of an interview. In others, attending an interactive workshop was superior to attending a didactic presentation41 (or nonattendance44,45)— even though lectures on human sexuality are the most common educational interventions in U.S. and Canadian medical schools.18 When considered together, these studies demonstrate the utility of formal educational programs for improving sexual history-taking skills.
Of interest, none of the studies that met our inclusion criteria included an intervention to teach sexual history-taking to obstetrics–gynecology residents, despite the obvious importance of sexual health topics to this specialty. Nor did any of the studies that we reviewed include psychiatry residents, which is consistent with evidence that teaching on sexual health is insufficient in psychiatric settings.51,52 Considering the vulnerability of many patients who either have major mental disorders or have experienced sexual trauma,53 it is imperative that medical educators evaluate teaching in this area and share the data.
Moreover, only three studies that met our inclusion criteria involved residents.36,37,41 All trainees should learn to sensitively and efficaciously address family planning needs, risks for sexually transmitted infections, and histories of suffering sexual abuse in the context of a wider inquiry about sexual functioning, sexual satisfaction, and quality of life. Obtaining a sufficient sample size is a particular problem for smaller residency programs. The three studies in our sample that included residents36,37,41 had few participants, and none of the studies conducted a power analysis. Thus, residency programs should consider conducting multisite trials.
There are several limitations to this review. We did not search the gray literature, and we did not search for any non-English-language studies. Our data are also limited by our inclusion of only studies that included control or comparison groups; inclusion of a wider range of study designs might have provided additional useful information. We did not use a data extraction tool when we retrieved information from individual studies in order to appraise those studies. Nonetheless, our data show that, with training, learners can become more skilled at taking sexual histories.
Healthy sexual functioning is an important public health matter, so by sensitively eliciting information about sexual health, which can be challenging to do well, physicians meet their obligations to patients and contribute to the overall health of populations. Educational interventions supported by beneficial outcomes warrant close attention in curricular design. We also suggest that educators should tailor curricula to fit the needs of specific contexts, as well as the styles and levels of learners. Curriculum design should follow standard methods including needs assessments, developing goals and objectives, and ongoing and thorough evaluations of the content and processes of implementation.54 Our review has demonstrated a need for developing rigorous educational research on sexual history-taking, a somewhat neglected, but vitally important clinical area.
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