Dr. Ruth on sex education for medical students

Q. Dr. Ruth, how do you view sex education for medical students in 2006? 

A. In the United States in 2006, we have the best knowledge, with a vast amount of scientifically validated data about human sexuality, from the true giants in the field: Kinsey, Masters and Johnson, Helen Singer Kaplan. Our objective should be to convey this knowledge. The excuse often put forth is that the curriculum is already overloaded. You don't need a vast amount of time—six sessions are sufficient. Students are vitally interested. They will profit; their patients will profit.

Q. What do you think should be included in this curriculum? 

A. Students need to learn about their own feelings and attitudes. They need to know that it is quite normal to experience arousal when examining a patient of either gender. They need to know that this does not make them a bad physician. They need to learn that they should not act on their feelings. They need to learn how to walk out of the room, wash their faces with cold water, and to continue to evaluate the patient. This is not sensitivity training.

They need to learn to examine patients who are older than they are, of their parents' and grandparents' age, and realize that they too are sexual beings. Many students have still not learned to accept older people as sexual beings.

All students need to know the basics of contraception and sexually transmitted diseases. This knowledge should not just be learned by gynecologists. They also need to learn that if they do not have the answers to a patient's particular problem, that they need to refer the individual to the appropriate specialist.

Fortunately, over the last 25 years, sexual literacy in this country has improved considerably. We have fewer unintended pregnancies. There are fewer women who are anorgasmic. Women have heard the message that they have to teach their partners what they need. But we need to make sure our students understand this as well.

We need to continue to bury the myths about masturbation. Of course, we need to teach that indiscriminate activity is inappropriate and that certain activities should be private. And of course, I always tell students that I am a “square”—but I do believe in monogamous, committed relationships—and that is totally consonant with liberal sexual education.

Q. Are there any specialty subjects that should be covered in this curriculum? 

A. Look—medical students are smart people, and knowledge of Masters and Johnson is not rocket science. Once this information is provided, it is easily learned. Male sexual dysfunction is often overlooked. Students need to learn that physical problems can lead to erectile dysfunction and that a urologist often times needs to be consulted. But a common problem like premature ejaculation can be easily treated, and I would teach this.

Another vital area for all to learn is the difference in sexual response in younger and older people. Given the burgeoning older population in this country, this knowledge is vital—and it prompted me to write my latest book, Sex Over 50. Students need to know and be able to convey that as men age, they need physical stimulation to produce an erection—it is normal not to experience psychogenic erections. Many couples don't know this—and they equate this physiologic event with a loss of interest in the partner—which is not true.

Older couples need to take advantage of normal physiology. Testosterone levels in the male are highest in the morning. So I encourage my older couples to get a good night's sleep, get up, and eat a light breakfast—and then go back to bed. Intercourse will likely be more enjoyable at that time.

The majority of women lose vaginal lubrication as they go through menopause. Most require at least a lubricant to avoid painful intercourse, and many need some estrogen to avoid dyspareunia. And as you and I agree, a normal person would not want to have intercourse if it hurts.

And people need to understand that the orgasmic response is different as we age. Nothing will make the orgasmic response of a 70 year old the same as for a 20 year old. But that does not mean that the 70 year old should not be sexually active and orgasmic—I always say you can be sexually active until you are 99.

Among specifics of education, I would teach students to recommend that patients use fantasies to enhance their sexual response. The medical professional's granting of permission to a patient is often very important. Physicians regularly have contact with patients who would never have an opportunity to be educated in matters of sexuality.

Of course, physicians need to remind patients that although it is wonderful to have a fantasy, never share it with your partner—no one likes to be compared with a previous partner.

And I would teach students about the use of vibrators, while reminding them that women should not rely exclusively on vibrators. No penis can match the intense stimulation of any vibrator.

Q. Would you include information about the role of hormonal therapy for both men and women? 

A. Certainly. But I always emphasize that the most important sexual organ in the body is above the shoulders, not between the waist and the knees. Yes, physicians should discuss the role of hormones as part of the curriculum, but they should discuss them in the context of relationships—as well as their central effects.

Q. Are there any specifics you would like to recommend in how a human sexuality course should be taught? 

A. Absolutely. I always like to have a box for questions at any lecture. Then people can ask questions anonymously, without embarrassment. That may account for the original success of my radio show.

Also, this course needs to be taught with humor. In the Talmud, it is said that a lesson taught with humor is a lesson learned. The Talmud also teaches that if you stand on the shoulders of giants, you can see farther—so we should take our current knowledge and go farther.

It does bother me that currently there are no major human sexuality programs in this country, to expand our knowledge. For example, there are no programs comparable to that of Helen Singer Kaplan, who led the program at Cornell when I was in training. If we had some new programs, we would hopefully foster new studies, such as a new “Kinsey Report.”

Q. Are there any particular areas in which you would like to see further research? 

A. There is very little biological knowledge about homosexuality—and that is the major area that I think needs the most research.

Q. I know we are speaking primarily about medical student education. Is there anyone else you would like to see included in this type of education? 

A. Anyone who comes in contact with patients needs education in human sexuality. I would include physician assistants, nurse practitioners, nurse midwives, social workers. Again, remember that any contact with a patient may bring up sexuality issues. Perhaps these courses need to be taught separately—social workers may not need the same curriculum as the medical students. But some human sexuality education needs to be offered to all groups.

And I would like to encourage physicians to continue their human sexuality education beyond medical school. Just as your knowledge of molecular biology should not end at medical school graduation, your knowledge of human sexuality should not end in May of your senior year.

Medical schools and professional organizations should sponsor continuing medical education (CME) courses in human sexuality. They need to be taught by sex therapists, like myself, teamed up with gynecologists, or other physicians who regularly deal with sexual dysfunction problems. And physicians should be given CME credits for attending such courses. Again, the more schools and organizations promote such education, the more they legitimize taking care of the sexual health of our patients.

Q. Is there one bit of advice you think your readers can put to use for themselves and their patients today? 

A. We are all subject to tremendous stressors and pressures, and they tend to accompany us all into the bedroom. I encourage my clients to take all these problems, wrap them up into a package, and leave it outside the bedroom door. Don't worry—no one else wants this package, and it will be there in the morning. But in the meanwhile, leave it outside the door.

Thank you for asking me to speak with your readers. Health care providers interested in reproductive medicine should lead the way in ensuring sexual education of future practitioners.