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[Richard M. Stallman <RMS@MIT-OZ>]

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 Sexuality and the Physician


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      Physicians grow in confidence and competence through practice and
experience, medical students are taught again and again, but for that most
challenging confrontation, the first time, one cannot practice.  The only
softening of its blunt arrival comes from first plunging into one's
imagination, recognizing the situation that would, on its first time, shock
or unsettle, and exploring all the consequences one's feelings could create.
Those for which the average medical student is least prepared, even when
trained rigorously in medicine and ethics, Nancy Gagliano suggested as the
premise for tonight's meeting, are situations in which sexuality abruptly
bares itself in an otherwise sterile professional setting, in performing
one's first pelvic exam, for example, or extracting one's first sexual
history.

     For Nancy, the recognition of how unnerving the intrusion of sexuality
could be in a professional situation startled her.  She had spent the summer
doing library research for a neurologist at the Veteran Administration's 
Hospital, when he asked that she investigate the dentate ligament,
which runs between the corpora cavernosa of the penis.  Now she had not
only to read the literature, but also to dissect human specimens!
"I couldn't admit to the big, friendly man who ran the anaytomy lab
what I needed.  I stalled.  Finally I said, 'I need some specimens;'
and then I shrieked, 'some PENISES!'"

     In her future as a physician, Nancy wondered, how would she ever
be comfortable discussing intimate aspects of the body with her patients if
she
could not even say the word "penis" to an anatomist?  She acknowledged
that after seeing more patients, she would undoubtedly become more com-
fortable in the clinic with not only the vocabulary but also the entire
subject of sexuality but that it could only ease her trepidations to 
face them now. 

     Thus she ushered in the meeting's topic, "Sexuality and the Physician"
with a baring of her own apprehensions.  She hoped that by explicitly
introducing the multifaceted role sexuality plays in the daily practice
of medicine, she could incite the group to air similar anxieties and appre-
hensions, share attitudes and experiences and thereby educate and liberate
itself in a subject largely neglected in formal curriculums.  Her incite-
ment resulte in a discussion which ranged further than the issue of sexuality
into the fundamental aspects of the patient-physician relationship.  The
group confronted the barrier imposed by the roles that patient and physician
play and asked when it must be torn down in order to reach the underlying 
naturalness and sensitivity of ordinary humanity.

     Several articles the group had read helped to provide starting-points
for the discussion.  The first, by Julius Buchwald in                       
reported the beneficial results of a similar seminar in which students 
beginning ob-gyn rotations revealed emotional attitudes and reactions 
to performing the first pelvic examination.  Nancy summarized their
main fears: 1) of hurting the patient, 2) of being inept or being judged
inept, 3) of the patient or oneself getting sexaully aroused, and 4)of
finding the patient and/or the situation repulsive.  

     These concerns were in turn mirrored and elaborated on by the group as
they discussed intimate clinical examinations and situations.  Nancy
Gagliano wondered, "How will I walk in and do a genital exam on a young
attractive male?  I wouldn't be able to do it now without smiling and
blushing."  The patient would sense her embarrassment and lack of profession-
alism, and surely, she thought, she would only grow more self-conscious.
However, after her experiences this summer, she understood better what
was going on inside herself and perceived the problem as one of learning
to treat all bodies in a non-sexaul way, when she had been accustomed
to handling only certain male bodies in a sexual way.  It would be fascinating
to perform her first pelvic exam, yet at the same time awkward and disquieting
to touch a female patient.  The kay to overcoming her anxiety, she thought,
would be to be able to separate at will the human body from its sexuality.

     (               ) wondered why she did not share the worry some of her
friends expressed of becoming aroused while examining patients.  Was it
because her feelings on the subject were still in the "pluripotential
stage" and she had not yet reached a decisive attitude or because she
consciously blocked out her fears?  If the latter, then she worried what
would happen if she did get aroused by patients; her guilt would be
magnified by its unexpectedness.  "On the other hand," she said, "I do
worry that I might arouse my patient, by making a wrong move or being too 
tentative and schoolgirlish."

     (                     ) said that he had heard stories of male patients
getting erections under the examination of the more incompetent I.C.M.
students.  Allan Hobson doubted the report saying he'd never  known or heard
of a patient to get so aroused.  "As for myself," he continued, "I've
always been too nervous under the circumstances to feel anything sexual."

     Echoing Allan,  (                      ) said that her own performance
anxiety would be so high, she simply wouldn't be able to find the situation
erotic.  Steven Denlinger doubted for another reason that he could
be aroused in clinical situations.  "I have a history," he said,"of
decidedly not finding medical pictures of nudes erotic."

     "But what happens," countered (                ), "when the body is
living, breathing, warm, and standing in front of you?"

     Analyzing these concerns on another level, Clare Bloom admitted that
she had also worried how she would manage an aroused patient, but that she
had reognized a trick in hr thinking: as when she had first performed
venupuncture and nervously worried about her patient's nervousness,
now she felt she had projected her own anxiety about getting aroused onto
the patient.  "I can distill my nervousness, and not feel it, simply by
putting it onto someone else!"

     Worse for him than fears of sexuality, said (               ), was the
prospect of examining a "250-300 pound body.  It would revolt me, and yet I
would feel guilty for my disgust."  This concern struck a chord in the
group.  (                      ) said she dreaded above all the confrontation with
obesity, and (                    )
 confessed that he had been apalled in his third
year of medical school by the extent of human ugliness.  One unnamed student,
described by (             ), was so worried about seeing fat patients that
he planned to brave Boston's 'combat zone' for the first time to photo-
graph particularly fat nd ugly people in order to desensitize himself in 
preparation for the clinic.  Surely a patient with a personal history could
never be as offensive as such photographs, commented (                )!

     Until now the discussion had dealt with the problems of confronting
physical aspects of sexuality in a clinical setting, in switching from
a sexual to a clinical attitude when in intimate contact with another body.  
What might happen to us, though, asked(                        ), when we then 
switched back to the sexual setting?   Would the clinical sights and experi-
ences change our views of our personal seual lives?

     The answers must depend on what one's attitudes toward sex had been
before starting in the clinic, said (                   ).  If one's
sexual experiences had been overly objective and dijoint from the rest
of one's life, she continued, then, yes, the clinical view of sexuality
might be even more alienating.  But if one's sexuality were well-defined and
integrated in one's life, then surely it could sustain new comfrontations \n from the clinical realm.

     Clare Bloom extended the question, wondering whether "once we begin to
see living pathology in the whole body, will we be able to look at friends
and lovers in the same way as before?"  Allan Green answered that his 
colleagues and he, although not unaffected by thier clinical experiences,
had not changed so dramatically as to lose their nervousness or sensitivity
during delicate situations.  Their humanity had been preserved, he
concluded.

     Recalling her dissections of human penises, Nancy Gagliano said
that she'd had the distinct fear she would not be able to look at the
erect penis of her lover again without seeing the erect penis of a
cadaver.  Although she did have flashbacks occasionally,she said, more
importantly, she felt more comfortable with genitals as a result of
her work.  Simply by becoming more familiar with the anatomy of
sexuality, she could better view genitals as parts of a whole rather
than as parts separate in themselves.  Several others agreed on the
beneficial effects of such familiarity and knowledge   

     Allan Hobson proposed that although it would seem that in switching 
between settings, one might get one's wires crossed, the context wielded
a remarkable power to keep them straight.  "The context explains why
I'm in no way aroused in clinical/pathological settings, and yet, having
seen all sorts of pathology, I'm in no way impaired in non-clinical 
settings."
      
      The patients too are not simply passive objects in the clinical 
situation but contribute to its dynamics with their own feelings and 
attitudes.  The burden of one's role as a physician is lifted not only
by closely examining one's feelings, but also by shifting to the patient's
point of view.  Two articles the group read illustrated this shift.  In
"The Pelvic Examination: A View From the Other End of the Table,"  Joni 
Magee suggests ways to make the pelvic exam less unpleasant for the
patient, base on her experiences both as a patient and gynecologist.
Implicit in her article is the urge to focus on the patient's feelings 
as if they were one's own; one can thus displace one's discomfort in
a healthy way and gain new insight into the situation.  

     Along similar lines, Judith Mitchell in "Male Adolescents' Concern
About a Physical Exam Conducted By a Female" present findings that the
average male adolescent is afraid of a female examiner touching him; afraid
specifically of her touching his genitls; afraid of her not taking his
word on his health; and, most of all, "afraid of what the other guys would
think" to know he had been examined by a female.  She argues that these
concerns should be honored in such examinations with careful consideration.
Nancy remarked that the article was important also for illuminating the fact
that although "men may have a corner on the market" in examining the opposite
sex, one must consider equally the difficulties and concerns that arise when
female physicians examine men.

     Other articles that Nancy summarized dealt with more subtle
attitudes affecting the interaction between patient and physician.
The first, by (                     ), reported a bias amongst patients
towards the physician's gender.  All patients, male or female, were
more likely to choose a male over a female g.p., but males were much
less likely than females to choose a female g.p., so that female g.p.s
had a patient population 70% female, 30% male, whereas male g.p.s had
one 50% female, 50% male.

     Another study reported a correlation between the attractiveness of the
physician and the openness of the patient in reporting his symptoms. 
Generally, a patient gave more information to a doctor of the same sex, but,
on the whole, patients told most to a highly attractive male doctor.  
Members of the seminar raised objections, however, to the method of the
study, in which a subject looked at pictures of physicians that had been
rated on physical attractiveness and chose those to whom he would most likely
tell his problems.  Allan Green said that attractiveness in the actual
presence of the physician might be measured in terms different from
physical qualities, such as ability to listen or to make the patient feel at
ease; furthermore, his own observations of successful physicians didn't
concur with the results.  (                     ) also pointed out
that the concept of attractiveness varied widely; how could the pictures be
accurately rated when males may equate it with strength and power, while
females may view attractiveness as something completely different?  Nancy
agreed that the study ignored the live patient-physician interaction,
and, harking back to the earlier discussion, Alan Green commented that
the interaction might even change significantly if the physician was so
attractive as to actually arouse the patient.

     Yet if the results were to be accepted, how might they be interpreted,
asked (                     )?  Did they mean that attractive male doctors were
trusted more than female ones?  Steven Denlinger wondered if the phenomenon
might not be similar to what happens at a cocktail party, when one tries
to seek out and hold the attention of the person he finds most attractive;
the patient may have similar desires and fantasies in trying to describe 
his problems so well that he elicits the physician's personal interest
in response.   Nancy commented that the bias may simply reflect the fact that
there are more male than female physicians; the males therefore have more
patients and the females haven't yet been fully accepted or treated equally
by society.

     In a similar study that Nancy reported, the physician's bias towards
the patient's gender was revealed.  Physicians were three times more 
likely to describe a female's complaint - illustrated in a vignette -
as psychosomatic than a male's, and more likely to prescribe sedatives 
to her than to him.  On the other hand, physicians tended to deny the
emotional aspects of a male's complaint and instead to treat it as purely
physical, further denying the less open male patient of emotional and
psychological support.  

    In light of these statistics, (                        )'s anecdote
was particularly interesting.  She once worked under a very tough, machismo
ex-Marine policeman, who, hearing of her plans for medical school, said
he would 'love to go to a female doctor,' that he couldn't tolerate a 
male touching his body.  Perhaps, (                ) wondered, when
"push came to shove," he might have preferred the traditional male, but she
felt there was truth in his desire: many men find themselves physically
more comfortable and emotionally more intimate with women and this ease
may extend to the clinic.

     Nancy then introduced another aspect of the patient-physician
relationship.  Delicate clinical examinations normally arouse fears and
discomforts, she said, yet they have the potential also to evolve into
abusive situations, in which feelings on both sides may change radically.
Where is the line drawn, and how do the attitudes of patients and
physicians change when abuse threatens?

      [Insert]

  (                 ) told a simialr story of a gynecologist who
"put his patients on the table and instead of a speculum inserted his
penis."  His patients, generally of a low socio-economic class, although
certainly aware that his behavior was abnormal, had never accused him,
and he had been neither arrested nor prosecuted.

     Allan Hobson remarked that these silent patients were most likely 
intimidated by the medical context, in which they played an ignorant,
supplicant role, and dared not question the physician's procedure.  Some 
certainly blamed themselves for the incomprehensible occurrence of sex.
Nancy added that some patients, should they have had the courage, might not
have known what they could do to defend themselves.

     The question then arose of how physicians with such potential to 
abuse patients were allowed into the profession.  (             )
related an experience he had as a third year medical student on a gynecology
rotation.  A senior resident who was generally believed to have a sexual
problem one morning made a revealingly crude comment about his activities
with female patients.  On another occasion when (               )'s female
partner asked if she could do anything to help in the O.R., the resident
replied , "Yeah, take off all your clothes."  When his behaviour later
came up in conversation, he admitted to (                   ) that he had a
problem, but that he had gone into gynecology specifically to "resolve
it," by exposure.  Allan Hobson remarked that screening should, but clearly
didn't, eliminate that type of problem-solving.

     Nancy wondered if it were true that the incidence of such sexual abuse 
were highest among gynecologists and psychiatrists.  Alan Green replied,
yes, they, of all physicians, have the most intimate contact with patients."
He asked the group to consider, however, is it were ever appropriate for 
a physician to have a sexual relationship with a patient to whom he is 
attracted, whether inside or outside the medical context.  (            )
thought that in any therapeutic setting, whether psychological or physical,
the professional relationship precluded a more personal one, and if the
boundary were crossed, the patient should post-haste be referred to another
physician.  The conclusion voiced by Alan Green was that in no circumstance
could such an intimate relationship be justified; the patient, whether
a woman in stirrups or a man in a blood-pressure cuff, is in an "extremely 
vulnerable position" and the physician must recognize his power and not take
advantage of it.  Even when affairs or marriages between patient and physician
occur long after treatment has ended, they cannot be condoned.


     Having highlighted these tensions involved in delicate clinical situa-
tions, the group then turned to weays of ameliorating them.  Nancy Gagliano
began by considering how one simply talked about sexualtiy with a patient.
Taking a sexual history is in itself a delicate procedure and Nancy 
illustrated the point by contrasting two questionnaires; the first, taken\n from a counselor's examination, included questions such as : "What are
{your} individual needs for optimal sexual functioning?," "How do {you
and your partner} communicate about sexual issues?," "what is {your}
masturbatory behaviour?", and "how do {you} meet {your} needs for intimacy?"
while the second, from a dermatology exam, asked, "how frequently per
month {do you have} intercourse?,"how frequently do you masturbate?" and
"how is {your partner's} sexual functioning?"  Because dermatology deals
with a patient's skin and hence his appearance, which very much influences
his sexuality, and the article from which the latter questions were taken
purported to teach its readers how to take a sexual history, Nancy found
"appalling" the manner in which the patients were attacked by demands
for "numbers of times" rather than treated as individuals with needs as
the first questionnaire did.  She described an incident she had witnessed
in the operating room where a male patient required urgent shortening
of the tunica albuginea to relieve torsion of the testes.  The patient
requested very neat stitches as he was a striptease dancer and "jokes
flew around the room, where everyone else but the attendant was female."
The resident surgeon after unsuccessfully quizzing the patient asked the
attendant what the odd mark was on the patient's penis and was told
"a human bite, of course." Turning to the patient, she asked, "How
did you get that on your penis?' and he replied, 'Dear, you don't ask
"what's that," you ask, "who bit you?"'  The important thing in talking about
the patient's sexual history, Nancy concluded, was not to reveal one's
bias or judgment, but rather to be bold and to provoke an open discussion.


     (                 )pointed out that although that guideline worked in
dealing with experienced but closed patients, igt might not work, for
example, with inexperienced adolescents.  "If one followed Mitchell's 
instructions and asked, 'when did you first masturbate?' of a young boy
who hadn't yet masturbated, he might feel humiliated, afraid or forced to 
lie."  It was difficult in some situations,(               ) suggested,
to know whether to be bold or tentative.  

     (                )a greed and said that over the summer a similar 
question had arisen with young male diabetics.  It's a fact that male 
diabetics become impotent as the disease progresses, so when does one 
break it to a severely afflicted young patient?  A 15-year-old struggling
with the normal throes of adolescence and with diabetes in addition, 
probably would not be able to handle the knowledge. Yet the 'rule' of
'5 years after the onset of the disease' seems simple enough in the
classroom.(              ) suggested that one ought certainly to get an
idea of the patient's sexual life first before broaching the subject
of impotence, but that the problem remained of how to discuss sex with
a young patient.  Should one wait until the patient brought up the 
subject?  Steven Denlinger commented, "If I were to lose erectile func-
tion in a few years, I'd certainly want to know about it as soon as
possible."(                   ) added that it one said nothing, in
the case of a well-documented disease like diabetes, the patient would
most likely read or hear about the facts elsewhere, but noted that 
"he may not come back to discuss them with you, but instead just get
depressed."  Alan Green suggested that it was the physician's obligation
to give the patient the possible outcomes whether or not he might learn 
elsewhere, but Allan Hobson qualified the remark saying there could be
no absolute rule -- one could never, categorically, tell each patient all
aspects of his disease and prognosis; :some patients want to know, others
make it clear they do not want to know, and some you know would over-
react in terror at the bad news."  The same problem also occurs in
choosing when to tell a patient he has a terminal illness. "My guideline,
in part, " Allan said, "is to move as far as I can before encountering
defensive or phobic anxiety."


     Much of the art of medicine is in learning when to say what, agreed
Alan Green.  As another example, he raised the problem of giving a prognosis
to a patient with multiple sclerosis, a disease which varies widely in its
progression.  A patient may experience two or three isolated bouts in a
lifetime or he may be confined to a wheel chair within three years of the
diagnosis. "Should one give him hope by giving only the first prognosis, or
should one explain the whole continuum of possibilities?"

     In reply(                        )
 reiterated Allan Hobson's point, saying 
that what one told a patient must depend on his particular history, both
inside and out of the medical relationship.  He related a personal story.
"I once had a psychiatric patient who developed neurological symptons
and was hospitalized while I was away.  When I returned, I was faced with
chossing the best method to break the news of a multiple sclerosis diagnosis
to him.  I conferred with the neurologist and we both agreed that it was his 
duty to deliver the diagnosis, but only if I could join my patient immediately
afterwards to assess his reaction and offer him support."  The patient closed
his ears to the worst in his prognosis and confided to Steve that he was
afraid to go out into the world after having battled a psychiatric illness for
15 years, only to be struck down by a physical one.  He would rather never 
recover from his psychiatric illness, he said.  On the other hand, his family,
who were involved in the ongoing psychotherapy, wanted to know specific 
answers, to know all possible outcomes.  In dealing with the neurologist, the
patient, and the patient's family, with their different levels of attitudes
and authority, (                   ) had to make difficult decisions for which 
there were no hard and fast rules, only feelings to play by.

     Steven Denlinger marveled at the seeming smoothness of (              )'s
experience in pooling resources to cope with the patient's crisis.  "When I 
worked in the cardiac unit at the Brigham," he said,"I was required to trans-
cribe verbatim my interviews with patients and then to discuss them line-
by-line with my supervisor, to decide whether I had said the right thing at
the right time."  In other specialties and at higher levels, did such instruc-
tive scrutiny of one's techniques take place? 

     In one's residency,(                   ) replied, such scrutiny did
take place, but later, one simply had to learn by experience.  One must
accept one's mistakes and like a comedian who makes a bad joke know how to turn
bad to good and when not to repeat oneself.

     "Such comfort as I've developed," emphasized Allan Hobson,"has come from
patients, not other doctors.  They show you how far to go, if you try to
keep in touch with your own feelings -- a difficult task since M.D.s are not
supposed to have feelings.  Patients themselves are not as fragile as we
think; they have their own resources, and they might some burdens easier
than we do?"

     The remarkable but simple thought that the patients might not simply be
helpless subjects but rather helpful colleagues took hold and cheered the
group.  Some recalled illustrative instances: Once (                  ) worked 
as an orderly at the bottom of the hierarchy in a hospital, performing tasks
considered unpleasant or improper for female staff. , one of which was
euphemistically called "to finish a bath."  He would wash the genitalita of
bedridden men after the female nurses had bathed their other parts.  Once while
doing so for a young quadriplagic, he was embarrassed to see his patient's
penis erect.  Immediately however, the young man perceived (             )'s
feelings and said "don't worry about that; it happens all the time."

     Another time he gave an enema to an elderly man who was ready and
anxious to leave the hospital.  He could detect (              )'s discomfort 
and being both patient and religious, began to pray audibly not only for
himself, but also for (                )).  "I suspect that a lot of
patients we'll work with will be veteran," concluded (                 ),"and
will be willing to give of their experience and knowledge."

     Steven Denlinger recalled a similar example from an article on medical
ethics by Steve Hoffman in the Alumni Bulletin a few years ago.  The author
described learning arterial punctures on an elderly woman, unsuccessfully 
jabbing her arm again and again.  She responded by shouting to a passing 
attendant, 'This medical student really knows his stuff,' because  in prac-
ticing on her, he had made her feel a comrade in his learning and healing.

     The discussion had gradually come to pinpoint the conventional roles
of physician and patient as much of the source of unease in delicate
clinical situations.  In fact, the group realized,a  simple way to deal with
tensions or fears was to loosen the physician's garb when it became too
restrictive, and to reveal the underlying human engagement.  Using one's
feelings as guides rather than repressing them was often the way to the
most humane, therapeutic solution in a difficult clinical problem, Allan 
Hobson had said.  Yet the roles must also be maintained enough to impose
responsibility and control, the group concluded in the remainder of the
discussion.

     (                      drew on the new sense of sensitivity and relief by
asking whether it was acceptable to simply admit one's feelings, such as
to say:"I'm a bit new at this -- my hands may be a bit cold."  Steven 
Denlinger echoed her, saying he'd thought about that question for the last two
years.

     Allan Hobson encouraged the students to do so; "no matter how much exper-
ience one has," he said,"one should never expect to be perfectly confident.
When, in certain situations, I am forced to make a tentative approach to a
patient's problem, I always begin by confessing, 'I'm not certain this is
correct...' and only then offer my opinion."

     But(                  )    raised the possibility that in some delicate
examinations, for example, a pelvic, one's admission of inexpertise might
instead make the patient more uncomfortable.

      Allan replied that there was a difference in being comfortable or
uncomfortable about one's own discomfort.  "If I accept my discomfort in a
normal situation and state it without spreading anxiety and panic, and
instead elicit my patient's alliance and cooperation, then I make him 
feel better.  If I spill out my anxiety, without having thought it through, 
then I make him feel worse."

     It wasn't always so easy to admit one was still a student and not yet
fully qualified, said Clare Bloom.  Often when accompanying a clinical tutor
she would be introduced to a patient as 'Dr. Bloom.' a title she would then
be forced to challenge if she wished to alleviate her inexpertise by
explaining that she was not a doctor, and in fact, learning from the
patient himself.

     Steven Denlinger commented that in the previous years some of the I.C.M.
students had been angered by just such authority from the attending physicians;
particukarky when after having been touted as doctors, the students might
worry they wouldn't know an 'ear from an elbow' on the physical exam.  They
had suggested that students be given a unique and distinctive garb for 
immediate identification in the hospital.  A variety of eager suggestions arose\n from the group.

     Many patients, said (                   ), would easily recognize medical
students simply by their behaviour and attitudes.  She related her story of 
working in a hospital where she did not perform physical examinations on 
patients but discussed with them details of theor personal lives such as
impotence caused by illness.  Sometimes she would feel compelled to remind 
patients that she was only a medical student and they would usually reply, "Oh,
I know, that's the only reason I was talking to you."

     "What do you think that meant?" asked Allan Hobson.

     "That they were hostile to doctors," replied (                  ).

     She further explained that because she was there to learn how people
cope with illness, she had more time to spend with them, and never imposed
a schedule on them.  They undoubtedly felt freer and more willing to open
up to her and help her.

     Alan Green agreed that as a student one has a very special relationship
with the patient.  "As a student, you aren't ultimately responsible for the
care of someone's illness and therefore his attitude toward you will be 
different, more tolerant, understanding, and sympathetic than toward his
doctor."

     If, on the contrary, the patient's attitude were obnoxious or offensive,
there would be nothing wrong in confronting him, concluded the group.  
(                     ) confessed that a "tough guy" making rude comments
would unnerve her more than a patient with an erection.   Allan Hobson said
that in this new situation there were again no absolute rules on how to
handle it, but that one had to be sensitive to the motivation between the
patient's behaviour.  Alan Green said, "If you're a psychotherapist, talk
about it."  Nancy emphasized that one oughtn't feel there is such "holiness"
about the examination room that one couldn't say straight to the patient, 
when the situation has gone too far,"Either you cooperate, or I won't be able 
to help you."


      "Not all medical students belong to William James Seminars; where do
most learn what we've taught ourselves tonight?" asked (                   )
Nancy related an experience, again from her summer's work, which revealed that
some doctors never learn.  She observed a physician performing the Doppler
technique on an elderely man to determine the patency of the dorsal arteries
and veins of his penis.  After half an hour of the operation, the patient,
very upset, asked what was wrong and the physician merely shrugged him off.
Nancy interpreted his inability to discuss sexual dysfunction with the patient
as an unwillingness to venture into an area where he knew little, but she
emphasized that even without all the answers, a doctor must know how to deal
with a patient's fears.

     Is the necessary emotional and sexual education ever taught in a formal
curriculum?  Students mentioned courses in sexual dysfunction, human
reproductive pathophysiology, and human sexuality, which dealt largely
with the physical aspects of sexuality.  In  the introductory psychiatry
course, however, Alan Green said psychological aspects such as the demystifi-
cation of the doctor's task in treating sexual problems were probed and
 afilm of several downright funny but appalling scenes between doctors and
patients was used to illustrate the points madein lecture.

    (                )  described the reaction his class in the second year
of medical shool had had to an explicit film on homosexuality: silence. 
The instructors abruptly ended the class, the last of the course, and
departed.  During the film it was clear that some strong emotional responses
had been elicited from the audience but afterwards there was no discussion 
whatsoever.

    (                 )'s story prompted (              ) to describe the most
popular course in his undergraduate school, which explored human sexuality
through films and discussions.  "The small discussion groups saved the course,"
said (                      ) "I compare my medical school education with what
I learned then, which gave me much better education in sexuality and I feel
for those people who don't get it here."

     "Society in general expects us to be much better trained in sexuality
than we are," nancy said.  "Society expects us to be the ones who are
knowledgable and comfortable and who take the initiative.  We cannot wait
for the patients to become so uncomfortable that they must confront the 
issue."  Her words again pointed to the role that physicians are expected
to play, but here to its necessary and beneficial aspects.  A physician
who does not live up to the responsibility of his role can experience
no relief in playing it down, only failure.

     Two reactions from the group summarized the conclusions that had been 
steadily illuminated.  (                ) said that the acceptance of
his role as physician had come to him as a revelation; that it gave him 
strength and made the responsibility it required him to shoulder seem reasonable and bearable.  Yet at the same time, he knew that he should always fall
back on his feelings as the best guide to what was happening.

     The feeling of the group towards the concerns they had expressed was 
reflected in (              ) 's exclamation, "I feel better, just
having talked about them."






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