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Reprint from: Nordisk Sexologi 1995;/3:193-211

Sexological Training for Health Professionals

by Erwin J. Haeberle

Sexological Training for Health Professionals

Erwin J. Haeberle


Within the last few years, a number of academic training programs in sexology have sprung up in Europe, a fact that has gone largely unnoticed in established academic circles and even among the European sexologists themselves.

The Robert Koch Institute has conducted a survey of these programs and has collected the various, now existing, Czech, Polish, Belgian, British, French, Italian, and Spanish curricula and graduation requirements in a brochure "Sexology in Europe«.

As the collections shows, there are two basic types of training programs: 1. Training in medical sexology and 2. in non-medical sexology. The latter can be divided again into two groups: 1. Nonmedical sex therapy, and 2. sex education.

In view of the rapid process of European integration, leading to a mutual recognition of academic degrees, the paper will discuss the common elements in all of these programs as well as the discrepancies. It will then also make a few suggestions as to the next practical steps to be taken.

In recent years, the demand has been raised that most health professionals should have some basic scientific knowledge about human sexual behavior. That is to say, physicians and psychotherapists, nurses, hospital administrators, marriage and family counselors, family planing officials, community health workers and even epidemiologists should receive at least some sexological training.

This demand is the result of several historical processes which converged early in our century in Europe and later in the USA, and which, among other things, produced a new special science of sexuality. This science was at first a private, rather marginal enterprise, and even today it is still marginalized in our universities, but, in some indirect fashion, it has nevertheless had some surprisingly strong influence on modern social and political thinking. In any case, it is useful to cast a brief glance backward to the beginnings.

There were, I believe, three importart milestones on the way to the present situation:

1. The initial concept of sexology as an interdisciplinary scientific enterprise in Europe before WW I,

2. the acceptance of sexology as an academic field of study in the USA after WW II, and

3. the definition and promotion of sexual health by the World Health Organization since 1975.

1. Beginnings in Europe

The concept of sexology as a science in its own right was first proposed in 1907 by the Berlin dermatologist Iwan Bloch. His ideas were quickly embraced by interested colleagues in the same city, especially Magnus Hirschfeld, who, in 1908, edited the first »Journal of Sexology«, in 1913 co-founded the first »Medical Society for Sexology and Eugenics«, in 1919, founded the first »Institute for Sexology« in Berlin and, in 1921, also in Berlin, convened the first »International Conference on Sexual Reform on a Sexological Basis«.

Both Bloch and Hirschfeld believed that the traditional medical approach to sexual questions was too narrow and had to be broadened. Only a combination of methods taken from both the natural and social sciences could do justice to the complex bio-psycho-social phenomenon of human sexual behavior, and therefore they sought the collaboration of experts in a great variety of fields, such as medicine, biochemistry, psychology, ethnology, history, pedagogy, criminology, jurisprudence, philology, literary studies and art history. Some larger disciplines like sociology, economics and political science were still evolving or moving toward full academic acceptance at the time, and this is also true for some medical and biochemical subspecialties like endocrinology and genetics. In any case, all of these and many others were immediately enlisted in the enormous enterprise of investigating human sexuality. This investigation, in turn, had an openly stated goal: Providing ammunition in the fight for sexual reform. Hirschfeld's motto perfectly summarizes the common cause: »Per scientiam ad justitiam!«, through science toward justice! The early sexological journals, handbooks and congresses reflected this interdisciplinary philosophy. Indeed, Hirschfeld's institute, although medically dominated, welcomed and, in some cases, supported or endorsed historical and sociological studies and educational films. It also offered various forms of psychological counseling for both individuals and couples. Finally, it offered a so-called »milieu therapy« for homosexuals who, in Hirschfeld's opinion, were not sick, but who simply had to learn to accept themselves. Thus, they could no longer be called patients in the traditional sense, but were actually clients using a non-medical therapeutic service.

It is not widely known that Hirschfeld's private institute also served as a training school for two Czech physicians, Prof. Pecirka and Prof. Hynie, who planned to open a new sexological institute at the university in Prague. The former died prematurely, but the latter succeeded. The Prague institute is, in fact, the oldest surviving sexological institute in the world.

While these early sexological institutes were founded and run by physicians, and while their main purpose was to serve patients and clients with sexual problems, they also engaged in original research and devoted much energy to training professionals and educating the public. In other words, the three main branches of sexology - sex research, sex therapy and sex education were fully developed and blossoming before the triumph of Nazism and the following World War II brought the first promising phase of sexological growth to an end.

2. Developments in the USA

When the biologist Alfred C. Kinsey founded his Institute for Sex Research in 1947 at Indiana University, he did so without employing any physicians. Instead, his regular collaborators came from non-medical fields, such as anthropology, psychology, and sociology. Nevertheless, Kinsey amassed an enormous collection of sexological material from all related fields and invited serious scholars from all possible backgrounds, for example historians of art and literature, to take advantage of the institute. Unfortunately, because of the sudden loss of its financial support, Kinsey's institute was unable to sustain its growth, and the most promising interdisciplinary developments had to be curtailed. It also did not offer any formal training in sexology. Still, at least in the summer months it conducted continuing education courses for interested women and men from all over the country. It was only in 1976 that a formal, non-medical graduate school of sexology was established in San Francisco, which, to this day, awards state-approved doctoral and Master's degrees. Its Academic Dean was, for may years, Wardell B. Pomeroy, Kinsey's closest collaborator. At the present time, there are two more American universities (New York University and the University of Pennsylvania) with nonmedical sexological programs. They award degrees in sex education. In addition, a small number of universities now also offer programs in »Gay Studies«.

3.The WHO Report of 1975

Twenty years ago, in the spring of 1975, the World Health Organization (WHO) issued its Report Education and Treatment in Human Sexuality: The Training of Health Professionals. This report offered the following definition of sexual health:Sexual health is the integration of the somatic, emotional, intellectual, and social aspects of sexual being, in ways that are positively enriching and that enhance personality, communication, and love. (1)

This definition has, on occasion, been criticized as naive and ideological, and there is no doubt, that it reflects the professed moral values of the educated middle classes in Western industrialized societies. In that sense, the WHO definition cannot claim universal validity. However, in the present pragmatic context, there is no need to join this philosophical discussion. In any case, the text listed the following three basic elements of sexual health:

1. a capacity to enjoy and control sexual and reproductive behaviour in accordance with a social and personal ethic,

2. freedom from fear, shame, guilt, false beliefe, and other psychological factors inhibiting sexual response and impairing sexual relationships,

3. freedom from organic disorders, diseases, and deficiencies that interfere with sexual and reproductive functions«.

Following this detailed definition, the Report then logically arrived at conclusions about the meaning of sexual health care:

»Thus the notion of sexual health implies a positive approach to human sexuality, and the purposes of sexual health care should be the enhancement of life and personal relationships and not merely counselling and care related to procreation or sexually transmitted diseases.«

This, in turn, also defined the role of professionals in promoting or restoring sexual health, and from the clarification of this role again followed recommendations for professional training. In short, the WHO Report was the first international blueprint for the organization of sexology in the service of Public Health.

As a matter of fact, some of the WHO recommendations have since been followed in a number of countries, at least up to a point. For example, the WHO had called for the establishment of regional sexological resource centers:

»Country and regional resource centers should be established to provide consultation and assistance in programmes of training, production of educational materials, research, and therapy related to sexuality.«

These centers, it was hoped, would help in creating a standard terminology along with international professional standards. Indeed, they were expected to cooperate to the point of organizing an international institute.

The WHO Report realized that this would also require the development of sexology as a field of study in its own right:

»Depending on local conditions, human sexuality should be encouraged to develop as an autonomous discipline in the education and training of health professionals and to become a recognized component of general health services, particularly family health.«

These two proposals, that for resource centers and that for sexology as a special field of study, have indeed been put into practice in a number of countries.

4. First General Survey

In 1993, thanks to a printing subsidy by the Wellcome Foundation, Rolf Gindorf and I were able to publish for the DGSS a world-wide survey of sexological institutions, programs and organizations under the title »Sexology Today - A Brief Introduction«. Several thousand copies of this free booklet were distributed at the International AIDS Conference in Berlin to participants from many countries. Among other things, it contained international samplers of academic and professional standards in sexology, and it reprinted the WHO Report of 1975. (2)

In the meantime, of course, the booklet urgently needs updating and expanding. By now we have received many more relevant addresses as well as a number of new curricula and standards. All of these should be made available to all sexologists in order to facilitate communication and to spare many of them the trouble of »reinventing the wheel«.

Indeed, it is remarkable how broad a consensus has already been achieved. As our survey showed, most sexologists in most countries today agree about the content of sexological training, about the academic and professional levels to be reached, and about the need to train both medical and non-medical sexologists. In short, the suggestions of the WHO Report have been followed at least in some instances and have stood up remarkably well.

5. European Survey by the Robert Koch Institute

With the creation, in 1994, of an Archive of Sexology at the Robert Koch Institute in Berlin, it finally became possible to put our survey program on a more permanent basis. As a first step, we have now tried to assess the status quo of European sexology in a separate brochure entitled »Sexology in Europe: A Directory of Institutions, Organizations, Resource Centers, Training Programs, and Scientific Journals«. (3)

International Surveys of Sexology
World-wide 1993Europe 1995

This publication convincingly illustrates several developments:

There is a considerable and still growing number of sexological institutions and organizations in Europe, although their distribution among the various countries is quite uneven. Many of them keep in contact with each other as members of a European Federation of Sexology, which, in 1992 held its first congress in Taormina, in 1994 its second in Copenhagen, and which, in March 1996, will organize its third congress in Marseille.

There is quite a number of sexological resource centers in various European countries. Some are part of governmental agencies, others are private. Some offer their services free of charge, others ask for small or large fees. Some are open to the public, others restricted to members. Some have only a few selected materials, others have enormous collections. In short, as of now, the general picture is varied indeed.

Nevertheless, the fact that so many sources of sexological information should exist at all, comes as a welcome surprise. Uncoordinated as they are, their very existence is proof enough that they fill a need for many social groups. Professionals as well as the general public are increasingly interested in questions of sexual health, and, in response to this interest, a great variety of initiatives have been and are being taken. Obviously, in the long run, it would be very helpful if many or at least some of these resource centers could form a network in order to maximize each other's strengths. If, for example they could pool their catalogues and transform them into a central data base, the combined resources could be made easily and instantly accessible to very large numbers of people through Internet or by CD-ROM.

As all of these centers know from their own experience, sexological information is regularly - and all too often unsuccessfully - being sought by a great variety of interested parties: Students and professors from all disciplines journalists in both print and electronic media, government agencies, non-governmental organizations, professional associations and private citizens.

At the moment, this enormous need cannot easily be satisfied. Therefore, sooner or later, it will be necessary to avoid duplication and to make more efficient use of the available resources, especially since funding is becoming increasingly scarce everywhere. Our survey of European resource centers may serve as a starting point for the long-overdue process of informational integration. It will undoubtedly produce great benefits for the promotion of Public Health in Europe.

Even more impressive is another development in sexology: There is now a number of academic and professional training programs.

Apart from a few older examples, this has been a rather recent phenomenon. Moreover, such new programs are now being created at an accelerating pace. Of the countries inside the European Union, especially France, Italy, Spain and Great Britain are becoming very active, while the German-speaking countries have fallen far behind. A middle position is being occupied by Belgium and Sweden.

Because of the continuing progress of European integration, however, this asymmetrical development cannot long be ignored. There is no question, for example, that sooner or later legitimate academic degrees in any one of the EU member countries will also be recognized in all all of the other countries. Add to this the free personal and professional movement within the EU, and you have a situation that cries out for immediate attention.

As our survey shows, there are now many different academic and professional degrees being awarded. Some of these are officially recognized by governments and/or other universities, some are fighting for such recognition, and still others are recognized only by various professional organizations. The content of the programs also varies greatly, although there seems to be a general consensus about some canon of basic knowledge. Generally speaking, however, the present programs can be divided into three major groups:

Training in sexual medicine or medical sex therapy, - training in the non-medical psychotherapy of sexual problems, - training in sex education.

Needless to say, this does not exhaust the list of possible sexological training programs (there should at least also be some special training for sex researchers), but our present survey has found only the three kinds of training mentioned above.

It seems safe to predict that, at least within the European Union, both the now existing and all future training programs will have to be brought into agreement with each other. Some form of standardization, at least of the degree requirements, seems unavoidable in the long run. Indeed, some sexological core curriculum will have to be agreed upon in order to facilitate the general acceptance of sexology as a legitimate field of study.

This development will be greatly accelerated by the present rapid spread of computer technology. Once certain basic courses can be made available through Internet or on CD-ROM, some universities will undoubtedly take advantage of this new teaching tool and offer certain smaller or larger segments of their curriculum to long-distance students. This will greatly reduce the time students spend on location. In short: Sexological training will, at least in part, become both cheaper and more widely accessible.

This, in turn, will broaden the academic spectrum within sexology. Even medical schools which now offer nothing more than continuing education in medical sex therapy, will begin to see the merits of a more comprehensive program. After all, there is also an enormous potential market for courses in sex education and non-medical psychotherapy. Such additional curricula, on the other hand, must contain courses on sexual anatomy, physiology, STD's, and other medical matters. Therefore, sheer economic expediency will produce more and more interdisciplinary, integrated schools, departments, or programs of sexology.

In view of all this, it seems prudent to intensify the communication between all interested parties. A strict separation between medical and non-medical sexology is a luxury we cannot afford much longer. Undoubtedly, the former requires especially high standards and therefore must remain restricted to physicians, psychiatrists and paramedical personnel. However, it is important to remember that most actual human sexual behavior is neither sick nor criminal. Nevertheless, it needs to be studied all the more, and therefore a broadbased non-medical sexology is absolutely necessary, both for its own sake and as a corrective for a too narrowly defined medical perspective. In fact, the number of potential non-medical students of sexology is vastly greater than that of medical students can ever be. Sexological knowledge is increasingly useful to a wide variety of professionals: Educators, psychologists, lawyers, criminologists, sociologists, social workers, drug counselors, epidemiologists demographers, ethnologists, historians, journalists, and theologians, to name just a few. It follows, then, that sexological research and teaching institutions ideally should be truly interdisciplinary enterprises open to all serious students.

Let me be very clear about this: We would all make a very serious mistake, if we were to contend ourselves with the rapid progress of medical sexology. Sex is not a disease, and the study of sex must not be restricted to the study of its dysfunctions. Just as geology cannot be restricted to the study of earthquakes and vulcanic eruptions, just as history cannot be restricted to the study of wars and revolutions, and just as economics cannot be restricted to the study of bankruptcies and stock market crashes, sexology cannot be restricted to the study of sexual disease and crime. Any such restriction would be not only shortsighted, but fundamentally unscientific. Indeed, sooner or later it would cut medical sexology off from the very sources of its success, would isolate it from the rest of the scientific community and finally turn it into an obsolete, esoteric and harmful kind of quackery. Society would lose patience with it, and its well-deserved demise would then also threaten all other sexological specialties.

I am not talking about a vague and distant danger here. Indeed, as the history of psychiatry and sex therapy amply illustrates, the clinical treatment of real and alleged behavior problems always runs the risk of becoming too rigid, too strict, too orthodox, too sure of itself. Very often, clinicians have not only been unhelpful, but positively destructive. Instead of alleviating problems, they have created new ones. Instead of helping patients they have produced victims. Examples abound, from the medical persecution of masturbators and the oppression of sexually vigorous women to the stigmatization of homosexuals and the psychiatric torture of transvestites and other gender non-conformists. If, over the last century, sex therapy has succeeded again and again in climbing out of the trap of self-indulgent dogmatism, it was only because it was wise enough to correct its own professional myopia, to broaden its perspective and to listen to colleagues from other disciplines, such as biologists, sociologists, ethnologists, historians and philosophers.

Even today, sex therapy is not yet free of unscientific or rather prescientific concepts, unquestioned false assumptions, misleading terms and other ideological ballast. The recent, repeated revisions of American and other diagnostic manuals indicate that the awareness of these problems is growing, but the process of revising and updating must continue, and the necessary dialogue between different sexological specialties in both the natural and the social sciences must therefore be institutionalized. Obviously, the best way of doing this is the creation of truly interdisciplinary Institutes of Sexology. Experience has shown, however, that these have the best chance to grow if they are not part of a medical school. On the contrary, it is in the best interest of all sexologists, including medical sexologists, if such institutes are independent or tied to non-medical programs.

It is to be hoped that European universities will soon recognize all of this and draw the inescapable conclusions. In any case, the processes of European integration and the fast advancing computer technology are now making many traditional academic approaches obsolete. For sexology, however, a hitherto marginalized science, these recent developments are a boon. The already existing programs, taken together, form a very promising basis for a consensus and rapid progress as a result of mutual support.

Finally, looking at the European scientific journals in sexology, it is striking that most of them are still devoted to medical and therapeutic aspects of sex. This has not always been so.

True, the first scientific journal devoted entirely to sexual questions was published 1896 in Italy: »Archivio delle psicopatie sessuali«, edited by the psychiatrist Pasquale Penta. However, three years later, in 1899, the Berlin physician Magnus Hirschfeld began publishing his »Jahrbuch für sexuelle Zwischenstufen« (Yearbook for Intermediate Sexual Stages), which championed the cause of homosexual emancipation. Accordingly, the Yearbook presented mostly biological, legal, political, historical, literary, sociological and ethnological articles along with medical and psychological case histories. It was also Hirschfeld, who, in 1908, published the first »Zeitschrift für Sexualwissenschaft« (Journal for Sexology) which lasted only for one year but was refounded in 1914 by Iwan Bloch and Albert Eulenburg. Eventually edited by Max Marcuse, it appeared regularly until 1932, when the growing threat of Nazism forced it to cease publication. Again, this journal covered an enormous spectrum of scientific and scholarly approaches, from dermatology and gynecology to psychoanalysis, history, anthropology, law, literature and art. There is no doubt that, during the 18 years of its life, it was the leading periodical in the field. Hitler's rise to power and the following Second World War, however, destroyed the work of our sexological pioneers all over Europe.

It was only in 1948 that the Australian-born physician Norman Haire began to publish »The Journal of Sex Education« in London. He had been a close friend of Hirschfeld's and was, in fact, one of the last survivors of the pre-war generation of sexologists. In the meantime, a considerably number of sexological journals has newly appeared, and new one are constantly being added. In their totality they are a strong testimony to the increasing vitality of our field.

However, the preponderance of therapeutic journals in Europe is worrisome. This is in contrast to American sexological journals, which, taken together, show a much wider spectrum of approaches: They represent not only clinical disciplines, but embrace many other research interests. There is no compelling reason, why, in sexology, the social or cultural sciences should be left to Americans. Indeed, European sexologists should take up the challenge and publish their own journals of the history, economy and sociology of sex, sexual politics and sex education.

6. First Outline of the Field

In the meantime, the American Board of Sexology has produced an »Outline of Sexology«, i.e. a summary of present sexological knowledge in all related fields from sexual medicine to sex education. This is done by means of an ingenious system of critical, annotated bibliographical references, all contained in a booklet not larger or thicker than our own brochure »Sexology in Europe«. (4) This outline already serves as a core curriculum for candidates who want to receive a diploma and join the American Board as diplomates. They have to pass a written examination based on the outline in addition to completing 220 hours in clinical sexology.

First Outline of Sexology
Outline prepared by the ABS 1993

It remains to be seen, if the American outline is ever made available electronically either on Internet or on CD-ROM. It would certainly be an excellent teaching tool that could be used world-wide. In the meantime, one could distribute this outline gratis in printed form at sexological congresses, provided, one finds a sponsor. As a matter of fact, such a sponsor could hardly find a more potent vehicle for his advertising than the free distribution of a twovolume set: »Sexology in Europe« and »An Outline of Sexology«.

Both of these works, of course, need adaptation in other countries, constant revision and periodic updating, and therefore their ideal medium is an electronic one. Still, at the present time and for the next two ore three years a printed set could do wonders for the field. It could provide the ignition for a rapid and spectacular take-off of sexology in Europe. No other tool can hope to be as effective in furthering a professional consensus, setting internationally recognized standards or providing so much sexological information so quickly to so many. However, this information will not reach all those who need it, if it is not provided free. That is to say, the package cannot be a commercial product. Indeed, it must be delivered at no cost whatsoever to anyone who is interested in it.

7. Toward a European Core Curriculum

By recommending the existing American outline, I do not mean to suggest that it should simply be adopted wholesale. For us Europeans, it cannot be more than a starting point. What should be adopted is its underlying idea and its ingenious structure.

In order to arrive at a core curriculum - some basic course every student of human sexuality should take - the entire field of sexology with all of its contributing sciences - from biology to sociology, from psychology to archeology and literary criticism, from ethnonology to history, from civil and criminal law to economics - should be divided into special areas of concern, with these subdivided again into ever smaller curriculum units. These units, in turn should be divided into practical learning modules dealing with specific questions. For each of the hundreds of these questions, a brief answer and three or four scientific references should be provided. The references should be chosen in such a way that, in combination, they provide the necessary detailed information according to the latest generally accepted scientific research findings. In other words, the proposed outline is nothing more than a key to current research.

The mere description of such a project makes us aware of the difficulties involved. Traditionally, of course, such keys were provided by textbooks, and indeed, there already exist a number of such textbooks in sexology. However, in the future, both less and more than a classic textbook will be required. Less because there will be no need for lengthy explanatory texts once the originai references have been read, and more, because the full text of these references must be made available and their inclusion or removal must the the result of constant monitoring and continous updating.

Obviously, then, the whole project of a European core curriculum cries out for some electronic format. Perhaps one could begin by linking several university programs and independent researchers by Internet and then assign certain subject areas to certain participants. Once each participant has completed the assignment and produced the short answers together with the references, all the different contributions can be pooled to produce an acceptable general outline. If there are contradictions, objections, or suggestions, the necessary corrections or amendments can be discussed directly on-line. In the end, one should be able to arrive at an outline on which everyone can agree. Whether this outline is then presented, on whole or in part, on the Internet itself, on CD-ROM, or periodically in printed form, is of secondary importance.

I do not want to underestimate the problems of the interdisciplinary dialogue required here, but I do not believe them to be unsurmountable. After all there are already many sexological textbooks on the market showing vast areas of agreement, and the Sex Information and Education Council of the United States (SIECUS) has, for years, published widely acclaimed annotated bibliographies on various sexological topics. Moreover, as mentioned earlier, a complete sexological outline already exists that can be used as a starting point.

The biggest problem will arise within one particular subsection of the proposed core curriculum: that for medical sexology and non-medical sex therapy. There are still conceptional and terminological problems in both of these areas, where obsolete and confusing terms are still very widely used, and where different therapeutic schools strongly disagree with each other. Therefore, what often seems to be nothing more than an argument about words, is in fact almost always a dispute about substance. Definitions largely determine if anything or what and how and by whom should be done about a perceived sexual problem. For example, there are still arguments whether the human sexual response should be divided into two, three, four or more phases and what consequences these divisions and their scientific names have for cause of feminism. Sexologists disagree about whether »impotence«, »erectile dysfunction« or »lack of tumescence« is the more suitable term, whether socalled male ejaculation problems are not better described as problems of orgasm or still better as problems with the timing of orgasm, whether - in the interest of gender equality - corresponding or even identical terms should be used for both male and female sexual dysfunctions, whether there really is such a thing as a »desire phase disorder« and whether it should be treated, whether it is meaningful to speak of »sexual addiction«, or whether the terms »perversion« and »paraphilia« reflect some objective insight or are both equally ideological and unscientific. These are just a few hints at the present, still ongoing debate. Indeed, there is hardly a term in clinical sexology that cannot and has not been criticized by non-medical sexologists. It will take a long time establish some common ground large enough to build a common academic house.

Another problem is bound to arise with the debate between biologists and sociologists of human sexual behavior. At the present time, this perennial debate takes the form of heated arguments between the so-called essentialists and constructionists of sexual orientation. For example, while the essentialists continue to compare the hormones, brain structures and genes of presumed »homosexuals« and »heterosexuals« in order to find the cause of their different erotic inclinations, the constructionists ridicule them as naive and unscientific, because the vast spectrum of human sexual orientations does not allow the world to be »divided into sheep and goats«.

According to the constructionists, »homosexuals« as special group of people do not exist, and thus the essentialists are studying an arbitrarily created, entirely artificial class of people, indeed, nothing more than a figment of their own imagination. Therefore, the constructionists have abandoned the very terms »homosexual« and »homosexuality« as descriptions of individuals and their condition. They may now speak of same-sex erotic behavior, but without any implication that it characterizes a particular type of person.

Obviously, any dialogue between these scientific camps is difficult. At the moment, they are mostly talking past each other. However, just as in the earlier example of sex therapy, I believe a workable consensus about a sexological core curriculum and its terminology can be reached, if all participants keep an open mind. This does not mean that all scientific differences will be resolved, but it means that they can be stated in a generally comprehensible and acceptable way. In fact, the growing need for a core curriculum for all sexologists can and will, to the benefit of all disputants, accelerate this process of clarification.

8. Improving Sexual Attitudes in Health Workers

I personally worry about something else: Sexologists have, from the beginning, done much good, but, on occasion, they have also acted as agents of oppression. In many cases, they did not do this consciously or deliberately. Often, they even acted in good faith, because they failed to examine their own silent, but false assumptions. This uncritical attitude toward their own professional dogma was able to persist in many cases, because they had little or no personal experience of the vast spectrum of actual human sexual behavior. Kept ignorant in childhood and well-protected during adolescence, they had, as college students, neither the time nor the opportunity to meet sexual nonconformists of any kind. When they took their first job as physicians or clinical psychologists, they remained unaware of the sexual subcultures surrounding them, and when they married and had children, their new responsibilities cost them the last chance to catch a glimpse of hidden sexual realities. Even the patients or clients they saw, with all their sexual problems, were not able to enlarge their narrow field of vision. On the contrary, they merely reeinforced the prejudice that all non-conformist behavior is sick.

Let me illustrate my point with a personal experience: In the 1980's I taught seminars at the annual training conference for medical sexology in Heidelberg and thus became well known among the participants, many of whom came back year after year. In the eight or ninth year, leading a group session on AIDS prevention, I was suddenly interrupted by an elderly, distinguished-looking participant who exclaimed: »We are really wasting our time here. For years you have been telling us about sexual minorities - homosexuals, bisexuals, fetishists, sadomasochists, transvestites, transsexuals and all the rest -, but in my over 30-year practice as a physician I have never seen any of these people. Not a single one! So, please, let us concentrate on the real world!«

When I assured him that he had, in fact, seen hundreds, even thousands of such people, and that he simply had not recognized them, he remained unconvinced. After all, he knew his patients, and I did not. It was simply too late for this man at the end of his career to recognize that all his life he had sent out a strong signal to all patients entering his office that he expected them to be 'normal', and therefore none of them dared to challenge his presumption. He had blinded himself to their actual sexual behavior, and they, in turn sensed very clearly that he would not understand and therefore could not help them. Thus, both parties suffered: The doctor, because he missed the chance to learn something about the real world he lived in. Instead, he fell victim to an illusion and did not see the forest for the trees. His patients suffered, because they did not receive the support they needed and which he might have given them. Unfortunately, there are still too many of these well-meaning, but ignorant »authorities« trying to help people with their sexual lives. Some of them even call themselves sexologists.

The problem was well recognized by the WHO in its report of 1975, which demanded a rational sexual attitude on the part of health workers. They should understand and deal rationally with their own sexual problems, and, they should also »be aware of and accept the wide range of of variation in sexual behavior«. The report emphasized:

»Health workers at all levels share the same beliefs, myths, and superstitions that exist in the society to which they belong, and they may themselves have unresolved sexual problems. Their training generally does little to dispell these attitudes, because of the current emphasis on curative rather than preventive services; for example, physicians are better prepared to cope with pain and disease than with the establishment of pleasure and sexual well-being. The attitudes of health workers can present an important obstacle to their effective functioning ... in the field of sexuality, and it is not surprising that they are often reluctant to become involved in this area. This reluctance may be manifested in an unconscious denial of the sexuality of their patients or a mechanical and impersonal approach .... To the extent that people with sexual problems look to health professionals for guidance and advice, punitive or negative attitudes, careless statements, and inappropriate methods regarding sexual matters may seriously damage the patient's sense of value of his or her own personal sexual life.« (5)

The report therefore concluded:

»There is a need to change the existing attitudes towards human sexuality among the general public, as well as among health and other personnel who are responsible for sex education and sex counseling... The development of positive attitudes towards sexuality ... should be a primary goal of education and training activities.« (6)

Following this advice, all sexological training programs, whether academic or professional, must therefore take care to improve attitudes as well as to impart knowledge. That is to say, in addition to a theoretical core curriculum and a minimum of practica they must require and provide a basic training unit in attitude change.

Some clinical training programs now in existence are trying to meet this requirement by establishing so-called Balint groups or similar regular meetings in which the participants discuss not only their patients and clients, but also their own reactions to them. Such focussed group meetings are extremely valuable, but, by themselves, they are not enough.

In the United States, many training programs have therefore introduced special courses designed to change attitudes in a more comprehensive way.

These SAR (Sexual Attitude Restructuring) courses were pioneered by the Institute for Advanced Study of Human Sexuality in San Francisco, where I taught for many years, and where, although on indefinite leave, I still hold a faculty position.

Original Outline of the SAR Course
English edition 1975 French edition 1977

The Institute requires all of its students and new faculty members to take this course, which is given once or twice a year. Strictly speaking, it does not resemble any course in the traditional sense, but is rather an intensive eight-day interactive group process, during which the participants are exposed to all conceivable kinds of human sexual behavior. This is done by all available teaching methods: Lectures, discussions, exercises, field trips, personal encounters with sexual minorities, film, and video. For example, the participants, regardless of their own sexual orientation may all march in the city's Gay Freedom Day Parade, visit a sadomasochistic brothel, a nudist camp or a »swingers club«. Needless to say, they all go to these places not as customers, but merely as visitors who listen to the prostitutes, nudists and swingers explaining their activities and answering questions. Followers of unusual sexual tastes also appear as lecturers in the classroom and give live demonstrations. In addition, the participants are asked to view, without interruption, many hours of old and new, commercial and private »pornographic« films of every genre. Sometimes, a dozen such films are shown simultaneously on one giant screen. Transsexuals and transvestites may act as group leaders and only gradually reveal themselves to their group. Moreover, toward the end of the course, the participants organize a cross-gender party, i.e. all women appear dressed as men and all men dressed as women, and both act out their assumed new gender roles during the entire evening. Throughout the well-structured course, there are repeated interruptions for breathing and relaxation exercises, for small group discusions, individual meetings with course leaders and meals taken together. The cumulative effect of all of this over time, combined with the dynamics of the group process, does indeed lead to a reduction in anxieties and a restructuring of sexual attitudes in the direction of greater tolerance. This has been confirmed again and again, because, as is customary in the US, the participants have evaluated every course and each time have given it the highest marks. This alone would perhaps still prove little, if the Institute did not also know that many times, early in the course, participants complain bitterly, indeed, rebell and threaten to leave, asking for a return of their money. Curiously enough, not one of them has ever left, and, at the completion of the course, some want to stay much longer. They have to be »talked down« and made to understand that the assignment is over and other courses have to begin.

Naturally, this successful program of attitude change was soon imitated far and wide, although sometimes in such reduced and streamlined form that it hardly deserved the name SAR. Still, some medical schools and professional organizations produced at least some useful results with three-day weekend SARs, and for a number of years these were very popular all over the country. Curiously enough, with the arrival of AIDS, the SAR courses, instead of expanding, were gradually cut back for financial reasons, and today our San Francisco Institute is again their main organizer.

In Europe, however, SAR courses have never been seriously tried, apart from some half-hearted and soon abandoned attempts in France and Great Britain a number of years ago. For most European sexologists they would still be new and probably very effective. It may therefore be worth some consideration whether one should develop a European SAR course. I should point out, however, that it would require a great deal of preparation, consultation and cooperation, and the necessary audiovisual materials would not be cheap.

Furthermore, traditional classrooms, auditoriums and conference rooms are unsuited for the course, and thus different locations would have to be found.

In one form or another, however, sexual attitude change must become part of all sexological training of health professionals. Perhaps there are new avenues that could be explored, new teaching techniques that could be tried, new media that could be employed. Today, I have simply given practical examples of what has already worked in the past. Other ideas may work equally well. Only one thing is certain: Scientific knowledge and professional skills alone are not enough to make truly effective health workers in the area of human sexuality. Ways must be found to force them to confront their own sexual attitudes, preferences, prejudices, preconceptions and problems. Only after having successfully dealt with these will they be justified in approaching those of others.

9. An American Model

On the way to our own standardized European training program, let me refer one last time to our Institute in San Francisco which, I believe, from its beginning, has been one of the most innovative graduate schools not only in sexology, but in any academic field.

We realized very early on that most, indeed, eventually all of our students would be mid-career professionals, i.e. physicians, nurses, social workers, drug counselors, clinical psychologists, college professors in various disciplines, Catholic priests and Protestant ministers from all over the country and, indeed, foreign countries, who were already established and working successfully in their jobs, but who wanted some additional qualification, because they had to deal with various sexual problems in their clientele. Almost none of them was able to leave the job to become a full-time student on location in San Francisco, but all of them could manage to attend classes once in a while for a few weeks at a time.

The Institute therefore introduced a trimester system. During each trimester, three months could be spent at home, reading the scientific literature, doing book reports, working on mandatory research projects, studying the student handbook, and viewing videotapes of previous lectures. Only every fourth month required personal attendance, because all new lectures, seminars, workshops and practica were concentrated in that one month. Sometimes special arrangements could be made outside of San Francisco for very advanced students conducting supervised therapy, because a few adjunct faculty members resided in other states of the US. In the end, of course, all had to pass the same oral and written examinations in San Francisco.

This system worked (and still works) remarkably well, because the Institute had taken a step that was revolutionary at the time: From the very first day of teaching, it videotaped all lectures and seminars, including those given by guest lecturers, thus becoming the best documented institution of higher learning in history. Over the years, many hundreds, perhaps thousands of teaching hours were captured on video and could be cross-referenced, excerpted or combined for individual viewing according to the specific needs or interests of each student. With a simple push of the button, students could watch Wardell B. Pomeroy taking a sex history and teaching in great detail how to do it, they could watch prominent sex therapists like Lonnie Barbach, Leah Schaefer, Marilyn Fithian, Albert Ellis, Bernie Zilbergeld, Jack Annon, Bernard Apfelbaum, William Hartman and many others explain the principles of their work. They could watch sex researchers like Sandra Bem, Anke Ehrhardt, Shere Hite, Pepper Schwartz, Evelyn Hooker, John Gagnon, William Simon, Allan Bell, Ira Reiss, John Money, Milton Diamond, C. A. Tripp, Martin Weinberg, Laud Humphreys, Edward Brecher and Leonard Rosenblum discuss their research methods and results. They could watch great sex educators like Mary Calderone, Michael Carrera, Sol Gordon and Lester Kirkendall talk about their pedagogic approaches. They could watch famous writers like Glenway Wescott, Sam Steward, Allen Ginsberg, Robert Rimmer, Randy Shilts, John Rechy and Gore Vidal talk about the sexual aspects of their novels, poems, essays or reports. In addition, they could watch many other important women and men talking about their aims, accomplishments and concerns, from the leader of a union for prostitutes to the chief of police, from a producer of porno movies to a collector of erotic books, from the director of the San Francisco Health Department to a television talk show host. In short, a widely available, and relatively simple technical innovation - the video camera - within a short period of time paid enormous academic dividends.

First of all, it enabled the Institute to individualize its training to a much greater extent than before. Second, it both justified and improved the long-distance phase of the training. Third, on location in San Francisco, it provided a valuable historical resource, documenting the course of American sexology during the 1970s, 1980s, and 1990s. In addition, the Institute produced a considerable number of therapeutic films as well sexual documentaries, i.e. films without script or direction, documenting a great variety of sexual behavior patterns from young individuals and couples to lesbians and gay men to the aged and the handicapped. The Institute further acquired vast collections of commercial "porno" movies, magazines and photos. Much of this audiovisual material is now being transferred to a new medium which allows the user to preserve several hours of film on one small casette not larger than the common audio casette or a cigarette pack (HI 8 casette).

All of this was done before the current electronic revolution which now opens up entirely new horizons for all of us. Learning from the model in San Francisco, we Europeans should, from the very beginning, take full advantage of the new technical possibilities. We should not only pool and sift all of our now available teaching materials, but also make then directly accessible by personal computer. This should include audiovisual material and selected full texts as well as study guides, questionnaires, various tests and true or false examinations.

Unfortunately, experience, even in the US, has shown that the traditional universities are too slow and inflexible for innovations of this kind. I therefore see only three possibilities of quick advancement for our cause: private industry, local or national governmental initiative or supranational sponsorship.

Private industry in the form of publishing houses and media conglomerates will undoubtedly become active very soon or has already become active. For example, the Italian publisher Giunti has, with financing provided by the EU been working for some time on an interactive computer program of sex education for teenagers. Once completed, it will be offered simultaneously in all major European languages. Having solved the technical problems involved, Ginnti will then be ready to move on to a similar product of continuing education for health professionals. The only undecided questions are whether any existing training program will cooperate in this venture and whether it will have any suitable teaching materials to contribute.

Theoretically, the cooperation could go very far. For example, a publisher could take the lead and contract a number of existing academic programs to supply the content in return for royalties while supplying the finished software (perhaps even the hardware) in return for a profit. This, by the way, has always been the prevailing pattern in the world of textbook publishing. However, it is also possible that a university program takes the lead and, by giving out licences, subcontracts various publishers and hardware providers, thus securing for itself a stronger, more independent position. Unfortunately, at present, there is no sexological institution or program in Europe with enough of a profile to make this second outcome likely. The situation could change only if several programs were to act together or even succeeded in creating a standard European core curriculum approved, let us say, by the European Federation of Sexology. The eventual distribution of influence is hard to predict, especially since there is a larger trend in the world of media, to gather book and journal publishing, software and telecommunication, including television, together in monopolistic mega-companies. In the end, the profit motive may win out over the scientific habit of self-criticism and the search for truth.

To me it seems certain, however, that many traditional academic structures will fall by the wayside. To take one glaring example: Germany was the birthplace of sexology, but the Nazis deliberately destroyed it, and today, fifty years after the end of WW II, there is no academic degree program in sexology in any German-speaking country. Even so, thanks to European Union, it will soon be possible for students in Berlin, Vienna and Zurich to acquire sexological diplomas, Master's and Doctor's degrees recognized in all member countries, including their own. Today, only the language barrier is holding them back. However, it can safely be predicted that, within a few years, whole courses or even whole programs will become accessible in English or in many other translations through the personal computer. This will enable universities outside of Austria, Germany and Switzerland to offer some of their training directly to students in those countries. After all, a long-distance university in Madrid already offers a sexological Master's degree to students all over Spain. Following this model, universities in Sicily, on the French Riviera and on the Canary Islands may very well become the most popular. They will be able to enroll students all over Europe by offering them the opportunity to stay right where they are most of the time, and to »go on location« only for a few weeks per year. Thus, the students could study, at their own pace, in Hamburg, Glasgow or Stockholm, and only during the cold winter months, they would have to take a vacation in the sunshine for some practica and for examinations. I do not think these are idle fantasies, because the universities of Catania, Aix-Marseille and La Laguna, Teneriffa already have well-recognized sexological training programs. True, at the moment they require the students' attendance throughout, and they may still do so for most of their courses in the future. Nevertheless, once they begin to see the unique opportunity provided to them by their geographical location, they may not want to refuse forever what could turn into a considerable income. Therefore, to return to my example, I no longer believe that the German, Austrian and Swiss universities have or even should have a chance to play a major role in European sexology. They have ignored all international developments, including the WHO report of 1975, and have simply slept through the establishment of the training programs among their neighbors. The same is more or less true for Finland, Ireland, the Netherlands, Denmark, Portugal and Greece. It does not matter in any case, since future students from all of these countries will be able to profit from opportunities represented by the four magic letters EU and PC.

10. A Call to Action

As the secretary general of the European Federation of Sexology, I believe that we now have the proper forum for discussing and deciding all of these issues. Next March we will hold our third conference in Marseille, and until then we should prepare some plan of action.

We will have to see how many of us can be linked electronically in order to facilitate communication, how many of us can form special work groups or committees meeting regularly or irregularly in various European cities. We will also have to explore how we can make our voices heard in the various European institutions and sources for funding, where, until now, we are still being largely ignored. Indeed, we must establish a continuous working relationship with the WHO Regional Office for Europe, which has hardly taken note of us.

The Archive for Sexology in Berlin will continue its world-wide survey of sexological institutions, organizations, curricula and standards, hoping to be able to present the results two years from now. In June 1997 the next World Congress of Sexology will be held in Valencia, Spain. It would be very desirable if, by that time, European sexologists could present a more or less united front, if we could have agreed on a common core curriculum, and if, along with it, we could have produced some suitable common teaching materials in several European languages.

I firmly believe that we can no longer advance our cause on a national level, but must seek each other's support for a larger European effort. We have a lot to offer to our colleagues on other continents, who can offer us much in return. The time is ripe. Let us seize the moment!


1. World Health Organization (WHO), Education and Training in Human Sexuality: The Training of Health Professionals Technical Report Series Nr. 572, Geneva 1975. Reprinted in:

2. Haeberle, Erwin J. and Gindorf, Rolf (eds), Sexology Today: A Brief Inroduction, DGSS, Düsseldorf 1993

3. Haeberle, Erwin J. and Simons, Wolfgang 6. ibid (eds), Sexology in Europe: A Directory of Institutions, Organizations, Resource Centers, Training Programs, and Scientific Journals, RKI-Heft 3/1995, Robert Koch-lnstitut, Berlin 1995

4. The American Board of Sexology, An Outline of Sexology, Washington, D.C., 1993

5. See 2 supra p. 45

6. ibid.

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