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Exploring the Interpretation of Medical Students of the Brief Sexual Attitudes Scale

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Title: Exploring the Interpretation of Medical Students of the Brief Sexual Attitudes Scale
Language: English
Authors: Williams, Bryana, Duda, Elizabeth (ORCID 0000-0001-8717-8167), Daniels, Keziah (ORCID 0000-0002-0166-0057), Schneider, Jason S. (ORCID 0000-0002-6265-0370)
Source: American Journal of Sexuality Education. 2022 17(3):304-319.
Availability: Taylor & Francis. Available from: Taylor & Francis, Ltd. 530 Walnut Street Suite 850, Philadelphia, PA 19106. Tel: 800-354-1420; Tel: 215-625-8900; Fax: 215-207-0050; Web site: http://www.tandf.co.uk/journals
Peer Reviewed: Y
Page Count: 16
Publication Date: 2022
Document Type: Journal Articles
Reports - Research
Education Level: Higher Education
Postsecondary Education
Descriptors: Sex Education, Health Services, Undergraduate Students, Medical Students, Physician Patient Relationship, Curriculum Design
DOI: 10.1080/15546128.2021.2016524
ISSN: 1554-6128
1554-6136
Abstract: Effectively addressing the sexual health concerns of patients is critical to supporting and improving overall health for individuals and communities. This study aimed to collect validity evidence for use of the Brief Sexual Attitudes Scale (BSAS) in a sexual health curriculum among undergraduate medical students. A qualitative thematic analysis was conducted with three focus groups of medical students. Early findings indicate the need to modify the current version of the instrument to make it more useful to learners. A modified BSAS survey could help students understand their own perspectives about sexuality and how their perspectives influence their ability to provide non-judgmental patient care.
Abstractor: As Provided
Entry Date: 2022
Accession Number: EJ1357250
Database: ERIC
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  Value: <anid>AN0157982688;[1h2p]01jul.22;2022Jul18.01:20;v2.2.500</anid> <title id="AN0157982688-1">Exploring the Interpretation of Medical Students of the Brief Sexual Attitudes Scale </title> <p>Effectively addressing the sexual health concerns of patients is critical to supporting and improving overall health for individuals and communities. This study aimed to collect validity evidence for use of the Brief Sexual Attitudes Scale (BSAS) in a sexual health curriculum among undergraduate medical students. A qualitative thematic analysis was conducted with three focus groups of medical students. Early findings indicate the need to modify the current version of the instrument to make it more useful to learners. A modified BSAS survey could help students understand their own perspectives about sexuality and how their perspectives influence their ability to provide non-judgmental patient care.</p> <p>Keywords: BSAS; medical student; curriculum; sexuality</p> <hd id="AN0157982688-2">Introduction</hd> <p>Sexuality is an integral part of health and wellness. It is incumbent on physicians to promote sexual health among other health promotion topics (Solursh et al., [<reflink idref="bib22" id="ref1">22</reflink>]). From the diagnostic and treatment perspective, sexual dysfunction is quite prevalent (Rosen, [<reflink idref="bib16" id="ref2">16</reflink>]). Sexually transmitted infections, such as the HIV epidemic, remain a critical issue for populations in the United States and globally (Prevention CfDCa, [<reflink idref="bib14" id="ref3">14</reflink>]). However, physicians are often reluctant to discuss issues related to sexuality and sexual health with their patients (Maurice & Bowman, [<reflink idref="bib8" id="ref4">8</reflink>]; O'Keefe & Tesar, [<reflink idref="bib12" id="ref5">12</reflink>]). This communication barrier renders invisible health issues considered important by patients and that prove relevant to public health. Douglas and Fenton note that a "more holistic and health-focused approach [to sexual health] ...can positively affect public health problems related to sexual behavior (Douglas & Fenton, [<reflink idref="bib3" id="ref6">3</reflink>]).</p> <p>When considering a curriculum for an individual educational program, it remains unclear what the optimal instructional methods are for undergraduate medical learners (Stayton, [<reflink idref="bib23" id="ref7">23</reflink>]; Thomas et al., [<reflink idref="bib24" id="ref8">24</reflink>]). Maurice reported that a learner's proficiency in taking a sexual history from patients was related to their sexual experience (Rosen, [<reflink idref="bib16" id="ref9">16</reflink>]). After educating learners, those students who believed a sexual history was relevant to the medical interview improved their sexual history-taking skills. Thus, it is arguable that a medical student's experiences, beliefs, or attitudes toward sexuality may influence learning and adoption of patient-centered skills.</p> <p>There is a need for evidence-based evaluation of sexuality curricula in medical education (Rubin et al., [<reflink idref="bib18" id="ref10">18</reflink>]; Solursh et al., [<reflink idref="bib22" id="ref11">22</reflink>]; Tucker et al., [<reflink idref="bib25" id="ref12">25</reflink>]). The sex knowledge and attitude test (SKAT) was developed, initially created in 1967, was developed to assess respondents' sexual knowledge, attitudes, and experiences (Miller & Lief, [<reflink idref="bib9" id="ref13">9</reflink>]). Miller and Lief created this scale in 1967 to measure participant attitudes in relation to four main categories: heterosexuality, sexual myths, masturbation, and abortion. A modified version of the scale, SKAT-A, was then developed to specifically assess how adolescent attitudes in these categories changed, if at all, after a sexual education curriculum was implemented. These actions emphasize the need for an appropriate tool to understand the impact of a sexual education curricula in a population, as well as the need for that assessment tool to be applicable to the population in question. In their original forms these instruments are not reflective of the breadth of gender and sexual diversity recognized in modern societies.</p> <p>Although, the SKAT/SKAT-A importantly highlights the need for tailoring a measurement tool toward the population being assessed, as an older tool widely used among medical students to inform their sexual health curriculum, the tool also highlights the decrease in the utility of a tool utility over time. Researchers have found that although the SKAT was beneficial in assessing medical student attitudes before and after the introduction of a sexual health curriculum, in an attempt to use a validated tool as is, specific objectives and understanding of new knowledge introduced following the creation of the tool could prove to be a limitation in the tool's utility (Weerakoon & Stiernborg, [<reflink idref="bib27" id="ref14">27</reflink>]). Thus, a tool inclusive of the aims of the curricula, informed by the current knowledge within the realm of sex, sexuality and sexual health, is critical</p> <p>The Brief Sexual Attitudes Scale (BSAS) is a 23-item instrument made up of four subscales: Permissiveness, Birth Control, Communion, and Instrumentality. Items are rated on a five-point Likert scale, ranging from strongly agree and strongly disagree. The Sexual Attitudes Scale (SAS) was developed in the late 1980s by Hendrick and Hendrick with the aim to assess multidimensional attitudes toward sex based on gender identity (Bailey et al., [<reflink idref="bib1" id="ref15">1</reflink>]). This husband-and-wife couple used the SAS to identify how gender orientation influenced an individual's attitudes toward their view of sex which they defined as one's "sexuality." The scale included 43 items that aimed to understand individual views about 4 subcategories of sexuality: casual sex (permissiveness), sex as normal human bodily function (instrumentality), sex as a means of deeper love (communion), lastly, views on sexual practices and sexual education (birth control) (Bailey et al., [<reflink idref="bib1" id="ref16">1</reflink>]). After the scale's original development, it was found to have utility in assessing population attitudes toward sexuality and influenced policies surrounding sexual health including the effectiveness of contraception methods. Later, an abbreviated form of the scale, BSAS, was developed to test the same parameters in a briefer and more efficient way (Hendrick et al., [<reflink idref="bib4" id="ref17">4</reflink>]). The shorter version, BSAS, is what is more widely used today as a means of assessing sexual attitudes.</p> <p>The BSAS was initially validated in 2006 utilizing studies of undergraduate college students as well as in two cohorts of psychology students (Hendrick et al., [<reflink idref="bib4" id="ref18">4</reflink>]; Kimberly et al., [<reflink idref="bib5" id="ref19">5</reflink>]). The authors utilized data from studies of the older, 43-item Sexual Attitudes Scale and prospective survey data ascertained with their modified version with the intent of demonstrating comparable psychometric performance. Previous research studies utilizing of the Sexual Attitudes Scale (SAS) compared the sexual attitudes of different populations, considering both gender and nationalities (Rubin et al., [<reflink idref="bib18" id="ref20">18</reflink>]). While validity evidence has been collected to determine how well the BSAS measures undergraduate students' sexual attitudes, similar validity evidence has not yet been collected in medical students.</p> <p>Besides BSAS and SKAT/SKAT-A, other more modern surveys have been used to evaluate sexual attitudes in medical students. One such example is, the Sexual Health Education for Professionals Scale (SHEPS) has previously been used to evaluate the impact of a sexuality curriculum on medical student learners (Ross et al., 2018). SHEPS was created to specifically assess student healthcare trainee's confidence in their ability to address sexual health in patients. The study emphasized the need not only for a sexual health curriculum but the need for a useful tool to measure its effectiveness in strengthening trainee sexual health management abilities. Of the various types of medical trainees, medical students represent an important population of learners who may have different and varying attitudes toward sexuality (Leiblum et al., [<reflink idref="bib6" id="ref21">6</reflink>]; Ross, [<reflink idref="bib17" id="ref22">17</reflink>]; Shindel & Parish, [<reflink idref="bib21" id="ref23">21</reflink>]). These attitudes in turn can affect how they counsel patients about their sexual health even when they possess the necessary and fundamental biological and clinical knowledge (Leiblum et al., 1993). Thus, an instrument that measures changes in student sexual attitudes throughout the course of intervention proves beneficial to student readiness to provide apt sexual healthcare.</p> <p>Given BSAS's use in the past to understand sexual attitudes, this tool provides a foundation toward understanding the best method of analyzing student sexual attitudes. A review of the literature demonstrates no previous investigation of the utility and appropriateness of the BSAS as an assessment tool for an undergraduate medical student population specifically. The purpose of this study is to, therefore, obtain initial, exploratory evidence to examine the utility of the BSAS and effectiveness of its application among undergraduate medical students.</p> <hd id="AN0157982688-3">Materials and methods</hd> <p></p> <hd id="AN0157982688-4">Study design</hd> <p>This is a qualitative, focus-group based investigation approved by the Emory University Institutional Review Board (IRB00111835). The study took place at Emory University School of Medicine with 1st year medical student participants. Focus group participants were recruited through E-mails to medical student class listservs. To maintain confidentiality and privacy, participants signed a consent waiver. Participants were not compensated monetarily for their participation, nor was participation linked to academic advancement. The study involved three focus groups occurring between June and August of 2019 with concurrent analysis between June 2019 and May 2020. The focus groups were conducted near the end of the academic year after students experienced two half-day learning sessions covering human sexuality and sexual health.</p> <hd id="AN0157982688-5">Data production</hd> <p>Three hour-long focus groups were attended by five to nine participants each (total 22 participants). The number of overall participants represented approximately 15% of the 1st year class at our institution. Gender and age demographics were collected with participants. No identifying information was collected, and names were de-identified in focus group transcripts. During each 60-minute focus group, a near-peer medical student member of the research team served as facilitator (i.e., 3rd year or 4th year medical student) using a "think aloud" technique to explore participants' understanding of selected items in the BSAS. The principal investigator, a member of the medical school faculty, was present at the session to take written notes. Participants were given a handout of the BSAS survey that included section headings and the 23 statements of the survey. Facilitators asked participants to share their understanding of these selected survey statements, thought by the authors to be representative of the overall instrument:</p> <p></p> <ulist> <item> "I do not need to be committed to a person to have sex with him/her."</item> <p></p> <item> "One-night stands are sometimes very enjoyable."</item> <p></p> <item> "Sex as a simple exchange of favors is okay if both people agree to it."</item> <p></p> <item> "Birth control is part of responsible sexuality."</item> <p></p> <item> "A sexual encounter between two people deeply in love is the ultimate human interaction."</item> <p></p> <item> "The main purpose of sex is to enjoy oneself."</item> </ulist> <p>The sessions were audio recorded to allow transcription and later analysis. Audio recordings were saved on the investigator's smartphone device, which was encrypted, and password protected. Transcription was completed immediately following the group sessions by a third-party provider.</p> <hd id="AN0157982688-6">Data analysis</hd> <p>Three of the authors (BW, ED, JSS), the faculty principal investigator and the two near-peer student facilitators, utilized inductive coding to describe underlying concepts that participants brought up in the focus groups (MacQueen et al., [<reflink idref="bib7" id="ref24">7</reflink>]; Namey et al., [<reflink idref="bib10" id="ref25">10</reflink>]). Initially, each member of the research team read the transcripts in their entirety, independently noting themes arising from the discussions in the focus groups. Next, the investigators met as a group to discuss findings, ultimately constructing a list of draft codes. The authors then utilized MAXQDA 2020 software to code the focus group transcripts (VERBI Software, [<reflink idref="bib26" id="ref26">26</reflink>]). The authors conducted their analysis independently. During the first cycle of coding, structural coding (Saldana, [<reflink idref="bib19" id="ref27">19</reflink>]) was used to create conceptual representations of topics generated during the three focus groups. The second cycle of coding used a combination of axial coding (Saldana, [<reflink idref="bib19" id="ref28">19</reflink>]), where emergent themes were linked together, and theoretical coding (Saldana, [<reflink idref="bib19" id="ref29">19</reflink>]) where more narrow codes were related to broader categories.</p> <p>After concluding individual work, the three participating authors met and resolved any coding disagreements by consensus and verified the applicability of the coding structure. This also allowed the investigators to conclude they had reached saturation where no additional codes were emerging. By the end of the data analysis process, the researchers agreed upon the following ten codes: Outdated Language, Missing Topics, Lack of Inclusion, Distracting Terminology, Methodological Concerns, Ambiguity, Relative Perspective, Challenges with Grammar, Influence of Personal Experience, and Implied Judgment. These codes were clustered into four themes: (<reflink idref="bib1" id="ref30">1</reflink>) Significant Change in Attitudes (<reflink idref="bib2" id="ref31">2</reflink>) Lack of Clarity (<reflink idref="bib3" id="ref32">3</reflink>) Assessment of Societal Norms versus Personal Practices (<reflink idref="bib4" id="ref33">4</reflink>) Survey Structure.</p> <hd id="AN0157982688-7">Results</hd> <p></p> <hd id="AN0157982688-8">Significant change in attitudes</hd> <p>This theme encompasses three codes: outdated language, missing topics and lack of inclusion. The participants described that the current language and perspectives around sexuality are quite different from when the survey was originally written. Medical students believe that attitudes have changed so drastically that the survey assesses outdated or irrelevant topics that are not consistent with how students currently understand sexuality. One person described the survey statements as reading "<emph>Like [an] old school Lifetime movie, yeah. Very conservative, yeah. Not matching the times whatsoever."</emph> Another person stated, <emph>"it just reads so dated...We need like a more updated [survey] that reflects like the culture that we live in today."</emph></p> <p>Participants noted that the sexual activities listed on the survey such as sex outside of marriage and "one-night stands" are more normative/mainstream in society today.</p> <p>Participants expressed frustration that the BSAS survey developed in 1987, does not reflect attitudes and perspectives around diverse sexual activities and identities (i.e., bondage, discipline submission and masochism (BDSM), homosexual activity, polyamory, gender-non-binary, etc.). A separate participant noted, <emph>"it's very centered on a relationship between a man and a woman... It's very nuclear family."</emph> Regarding the phrase, "Sex...is ok if both people agree to it," someone noted "<emph>[it] narrows down to two and that's not necessarily how people engage in sex."</emph> Participants also objected to the use of "him/her" to describe a partner, noting a need for a "<emph>gender-neutral premise</emph>."</p> <p>Generally, participants expressed a desire for the survey to reflect a broader range of sexual experiences. For example, in response to the statement "Birth control is part of responsible sexuality," an additional participant responded, "<emph>we are not taking into account sexual experiences between people that wouldn't get pregnant at all."</emph></p> <p>In addition to noting the outdated and limited scope of the language utilized in the survey, medical students identified missing or truncated topics that they value and deem worthy of further assessment. One person said, "<emph>I think ... a sexual attitudes survey would benefit from a STI centered question versus birth control"</emph> and someone else said "<emph>Birth control" is not implying safe sex from ...STIs."</emph> Regarding discussions of birth control, one person noted "<emph>Most people, at least women, might think of birth control as in hormonal birth control or IUD. I think it's more associated with those types of things, whereas other forms of contraceptives could also be used for birth control."</emph> Participants also felt that the survey would benefit from language that incorporated modern concepts of consent.</p> <hd id="AN0157982688-9">Lack of clarity</hd> <p>This theme encompasses two codes: distracting terminology and ambiguity. Overwhelmingly, medical students wanted more clear and specific instructions as to how they should answer questions. There was a consensus that explicit definitions of words like "sex," "birth control" would be helpful for medical students to accurately interpret what is being asked in the statements. The ambiguity of statements and terms led to significant confusion for participants such that disengagement from active completion of the survey was a risk.</p> <p>For some people, items were perceived as very straightforward, while others found the statements unclear. One example being the phrase, "the merging of two souls," a phrase found in one of the items not highlighted by the investigators. It was more uniformly understood by participants in contrast with "simple exchange of favors" that was a point of general contention and debate in several focus groups.</p> <p>Several participants described a lack of synchronicity in terms of what each word meant alone or combined with others in the statement. Participants brought up the idea that each word added to a statement has the possibility to clarify or confuse a sentence. Examples of a more straightforward statement would be "the main purpose of sex is to create offspring" that participants could agree to on a Likert scale. This particular cohort of medical students demonstrated a tendency to deeply contemplate the meaning behind questions in an effort to "get the right answer:"</p> <p>Because whenever you're trying to interpret what the writer is saying or trying to ... it becomes like you're trying to play a game and you're trying to, generally ... most of us are conditioned to be like, "I wanna get a 100% on this test." So, you're trying to answer it correctly.</p> <hd id="AN0157982688-10">Societal norms versus personal practices</hd> <p>This theme includes three codes: relative perspective, influence of personal experience and implied judgment. The students describe confusion around which perspective of belief is asked in the statement, the perspective of self versus general society. Participants questioned if they should be answering the statements based on their actual behaviors or based on ideal behaviors that people in general should practice.</p> <p>You could clarify, is it about asking...the person that you're talking to ...or is their perspective towards it for the general population, but not necessarily about themselves? And I think you can rewrite the question to make that clearer.</p> <p>The participants also mentioned the point that that being clear about answering the statements from a personal perspective or societal norm perspective would have broader implications. Not only would clarifying the perspective of the question make it easier for students to answer the question, but clarity would also make it easier for researchers to interpret the responses.</p> <p>Speaker 2: "How would you analyze data that people answered via different interpretations, that's not going to reflect their different attitude of text. That's going to just reflect how they interpreted differently, these questions? I don't think that's the purpose of this study."</p> <p>Speaker 4: "But there are, I guess... Would there be multiple people that interpret the same way? Even if it's for one question, three or four different interpretations. But there might be several people that thought ... X, so they chose that. People thought...Y so they chose this."</p> <p>The participants also brought up that terminology used on the BSAS survey, such as "one-night stand" may have different meanings and connotations to various respondents.</p> <p>Speaker 1: "This also seems to imply that the person that you're asking has had a one -night stand and would be able to comment on it, when that's not necessarily true either."</p> <p>Speaker 3: "Oh yeah, there should be like, in the Likert scale, just-"</p> <p>Speaker 2: "Does not apply ..."</p> <p>Speaker 3: "Yeah, does not apply."</p> <p>The phrase "loaded" statements was used multiple times by participants that conveyed a kind of implied judgment. Participants described strong feelings that many statements presented a "loaded question" with moral value attached to it. Phrases such as "responsible sexuality" were interpreted as being ambiguous or loaded with an implied value that many participants found difficult to interpret.</p> <p>I think if you read that statement, you would assume this was being written from like a heteronormative Judeo-Christian world view and I think if you were a person who didn't ascribe to those values, you might read the rest of the survey in a way that was judgmental. And I don't think that's what you're trying to get at in the survey.</p> <p>Participants also disliked statements that read as all-or-nothing, such as "Birth control is part of responsible sexuality." The medical students preferred answering questions that are written as "can be" rather than "always are." They also expressed concern about judging other people's sexual practices. They described that the survey as written suggests that people who don't use birth control are having irresponsible sex. In general, participants felt there was inconsistency in the survey statements between implied judgment of statements. The participants suggested statements be worded as a sexual activity "could be" something (enjoyable) rather than "should be" something (enjoyable).</p> <hd id="AN0157982688-11">Survey structure</hd> <p>Finally, this theme is composed of two codes: methodological concerns and challenges with grammar. Students described a desire for clearer instructions and open-ended questions. Medical students brought up several issues with the utility of having the survey at all. Some participants suggested having a "not applicable" option if a person has never experienced (one-night stand, any sexual activity).</p> <p>I just feel like it's such a complex topic that narrowing it down to a scale in terms of just wanting us to talk about these questions was difficult...I feel like this is always going to be a problem in medicine. Having a quantitative scale is very easy and very good for research purposes, but qualitative interviews can kind of elucidate some of these nuances a bit more, but also how do you implement results from a qualitative study into clinical practice? So, I think just from a meta point of view, it's hard to use a scale like this with such a nuanced topic that is always going to be changing in the future as well.</p> <p>Many participants felt that the organization of the questions on the BSAS survey was problematic. Several students suggested changing the order of questions so that all statements surrounding a certain topic, such as birth control, were not all grouped together. Participants also brought up the idea of re-wording the questions so that they could be randomized on the survey.</p> <p>So, I think that comes to a bigger problem, is that these questions would need to be written in a way that they can be interpreted without the context clues of other questions. And I think that some of these questions are not written in a way that they can stand alone.</p> <p>Participants described it as being easier to consider smaller, specific statements than broad statements that consider multiple concepts. Students described that the order of words or use of multiple concepts within a statement was confusing; a person could agree with part of a statement and disagree with another part.</p> <p>I figure it would make it easier to read or more straightforward if they were all written in the same way. So, like, sex is a pleasurable act, sex is meant for reproduction, sex is only between two people. Because then you can really kind of rapid fire, go through it quickly, and just agree or disagree with the statement. [The statement] "I do not need to be committed to a person to have sex with him/her." You're like, "Hmm." You have to really think about it.</p> <hd id="AN0157982688-12">Discussion</hd> <p>The genesis of this project was a need to evaluate the impact of a human sexuality curriculum for undergraduate medical students. The principal investigator was familiar with the Brief Sexual Attitudes Survey, and initially planned to utilize this instrument to assess the curriculum. However, the literature review demonstrated that the BSAS had not previously been utilized in our population of interest. Thus, our research team embarked on this effort to investigate the utility of the survey among medical students in assessing their own attitudes toward sexual behavior, sexuality, and sexual orientation. The results emphasize the critical point that various aspects of this tool make it ineffective at assessing the attitudes for these parameters specifically in a medical student population.</p> <p>In order to elicit an inclusive sexual history in a non-judgmental manner, learners must confront their own discomfort and attitudes about the topic of sexuality. An ideal curriculum would allow learners to explore the ways their internal beliefs influence outward biases toward patients, thereby affecting their medical practice (Papaharitou et al., [<reflink idref="bib13" id="ref34">13</reflink>]; Schulte & Kay, [<reflink idref="bib20" id="ref35">20</reflink>]). As part of the proposed competencies for sexual health education in North America, Bayer et al recommend that learners consider implicit bias associated with sexual health topics as part of patient care. An instrument that assesses attitudes of learners in an objective way would address this competency (Bayer et al., [<reflink idref="bib2" id="ref36">2</reflink>]). Medical education literature shows there is a need to create evidence-based evaluation tools for sexuality education curricula (Shindel & Parish, [<reflink idref="bib21" id="ref37">21</reflink>]; Tucker et al., [<reflink idref="bib25" id="ref38">25</reflink>]; Wiggers et al., [<reflink idref="bib28" id="ref39">28</reflink>]). A effectively designed curriculum would directly impact the attitudes of learners regarding the topic of human sexuality and behavior. An ideal evaluation tool would assess learners' attitudes about other's sexual practices that can influence patient care.</p> <p>The BSAS was designed to assess personal beliefs about the respondents' current sexual practices. The introductory paragraph for the BSAS asks respondents to answer based on their subjective individual experiences. Data gathered from our focus groups suggests that the survey indirectly assesses a respondent's attitudes about societal norms. Embedded within the items on the BSAS are value statements about what is seen as normal and abnormal sexual behavior. For the purposes of medical education, understanding attitudes about societal norms is more relevant to future health care professionals.</p> <p>An optimal instrument would be useful in evaluating medical student beliefs for two main reasons. First, using the BSAS provides a wealth of history in how the survey has been used in different populations. This history is useful in comparing previous findings to current research. Second, creating a new survey from scratch would be very time-consuming and labor-intensive.</p> <p>We recommend several modifications to the instrument for it to be used as an assessment tool for undergraduate medical curricula.</p> <p>A modified instrument for educational purposes should include:</p> <p></p> <ulist> <item> Expanding the behavior assessed in the survey to include consent for sexual activity, sexually transmitted infections (STI), and same-sex or same-gender sexual activity.</item> <p></p> <item> A major problem with using the BSAS with present day medical students is the narrow scope of sexual activities that are currently assessed on the survey (Kimberly et al., [<reflink idref="bib5" id="ref40">5</reflink>]). Yes, it is practically impossible for a single survey to be fully inclusive of the diversity of human sexual experience and increasing the domains and types of sexual practices assessed would make the survey unwieldy. However, the survey explicitly and implicitly inquires only about heterosexual activity, and this is an inherent deficiency of the BSAS. Increasingly, research has indicated the drastic need to increase undergraduate medical education for care of lesbian, gay, bisexual, and transgender/gender-fluid patients is documented by focus group participants as well as in other literature (Obedin-Maliver et al., [<reflink idref="bib11" id="ref41">11</reflink>]). Recommendations for survey revision include using gender inclusive pronouns, constructing item language to be inclusive of multiple partners (e.g., "for all parties involved"), and explicitly addressing STIs and pregnancy.</item> <p></p> <item> Use of inclusive and non-judgmental language.</item> <p></p> <item> An ideal survey would provide specific statements of sexual activities without alienating many participants (Rickards et al., [<reflink idref="bib15" id="ref42">15</reflink>]). Controversial or extreme statements can be useful in the survey as they accommodate discrimination in respondent attitudes. Neutral statements run the risk of having most participants answer in the middle of a Likert scale range. Optimally, items can be revised to evaluate attitudes about sexuality (e.g., "Sex should only be for procreation" or "Sex without emotional attachment") without implied judgment.</item> </ulist> <p>If you keep this on the survey, this would alienate people, but you will get some people and, I don't know, that's useful in and of itself. To see what kind of people you end up ... that respond very highly ... or that respond very positively this kind of ... section.</p> <p></p> <ulist> <item> A glossary of terms used in the instrument to avoid respondents utilizing their own interpretations.</item> <p></p> <item> Additionally, a sizable portion of the discussion captured in the focus groups reflected unclear instructions for the instrument. Notably, not all participants were confused by the same items. This suggests a lack of clarity of the questions and its influence on the utility of the survey as an effective analytical tool.</item> </ulist> <p>Just some general feedback to you, I think I would define sex at the top when you're reading it because just right at the bat, people can interpret sex a lot of different ways. Intercourse, oral sex, anal sex, do you want to include all of these in this survey or just a specific type of sex? So, I think just defining that at the beginning might be useful as well.</p> <p></p> <ulist> <item> A limited word count for survey items to avoid respondent confusion.</item> <p></p> <item> Participants can overthink lengthy statements with multiple embedded phrases or concepts. The instrument can be made easier to read by shortening the items to avoid distracting words.</item> </ulist> <hd id="AN0157982688-13">Limitations</hd> <p>Significant selection bias in this study comes from the demographics of the medical students who volunteered to participate in the focus groups. Many students tended to be more progressive in their views on sexuality; thus, we may be missing a wider range of perspectives in our study.</p> <p>Participants had a lot of discussion about the section headings that described certain constructs in the survey such as "permissiveness" and "communion." While discussions about these headings in the survey were useful to inspire dialogue among the participants, these headings led to diverging conversations. Since these section headers are not usually visible to people taking the survey, in future research using the BSAS survey we would suggest omitting these section headers from the survey given to participants.</p> <p>The faculty principal investigator was present during the small group sessions, and this may have influenced medical student participant responses with an assumption that answers should adhere to a norm based on the faculty member's work in sexual health and sexual health education. Students were regularly encouraged to be honest and give their personal views whether or not they themselves thought they were contrary. Having a near peer student serve as facilitator also mitigated the bias of the presence of the faculty investigator.</p> <hd id="AN0157982688-14">Conclusion</hd> <p>Past studies have determined that providers' personal perspectives about sexuality can influence their ability to provide impartial care. These personal views can negatively affect patient care and population health. Additionally, past studies indicate that a potential solution to this problem is a curriculum that educates undergraduate medical students about sexual health concerns reflective of their current patient population. Thus, a tool to accurately measure and describe changes in student attitudes toward sexuality is necessary. Our study has shown that an approach beyond BSAS, even in a modified form, is needed to effectively analyze how student perspectives about sexuality is influenced by the implementation of a sexual education curriculum.</p> <hd id="AN0157982688-15">Future directions</hd> <p></p> <ulist> <item> Addressing determined limitations of BSAS</item> <p></p> <item> A proposed next step includes utilizing individual interviews of the respondents in this study to further explore their understanding and interpretation of items on a modified BSAS. Individual or small group interviews can be done to assess the clarity, objectiveness, and representation of modern-day sexual health concerns/treatments of an updated instrument compared to the BSAS. Our study has found that one of the innate limitations of the BSAS is both the time period that it was created and validated as a tool for assessing sexual attitudes and, in alignment with that, also the specific population that it was created for. Tools such as SKAT/SKAT-A have highlighted the need to tailor a tool toward the population of interest and not the other way round. Our study has also highlighted that even when assessment tools are created for a specific population, the validity of that tool must be assessed over time because the population itself is dynamic. Thus, we must take great consideration of the necessary aspects of sexual health relevant to undergraduate medical students <emph>now</emph> as well as determining the general composition of this population at this time. Continuing this iterative process will allow comprehensive validation of the BSAS among medical students and can inform subsequent modifications of the survey.</item> <p></p> <item> Modification of the BSAS with the aid of modern assessment tool(s).</item> <p></p> <item> Our study primarily revealed the deficiencies in using BSAS to assess medical student attitudes toward sexual health. Another proposed next step includes investigating more modern surveys and determining how these address limitations of BSAS. The SHEPS tool was developed in the 2010s compared to BSAS with its origin in the 1980s. SHEPS is more focused on the knowledge that health care providers have about sexuality while the BSAS is more targeted to the general population (Miller & Lief, [<reflink idref="bib9" id="ref43">9</reflink>]). Furthermore, the SHEPS tool may be better than the BSAS at measuring the sexual attitudes of medical students given that this survey consists of distinct questions that assess sexual health communication skills, knowledge and attitudes around sexual health (Rubin et al., [<reflink idref="bib18" id="ref44">18</reflink>]). Thus, the SHEPS tool offers a prime comparison to what a modified version of the BSAS could be and more studies should be done to further investigate in what ways SHEPS addresses the limitations of BSAS.</item> </ulist> <hd id="AN0157982688-16">Acknowledgments</hd> <p>The authors would like to thank Drs. Ulemu Luhanga and Linda Lewin for their review of this manuscript and leadership of the Woodruff Health Educators Academy Fellowship in Educational Scholarship through which this project was developed. We are also grateful to Dr. Leigh Partington for her review and editing of the manuscript.</p> <hd id="AN0157982688-17">Disclosure statement</hd> <p>No potential conflict of interest was reported by the author(s).</p> <ref id="AN0157982688-18"> <title> References </title> <blist> <bibl id="bib1" idref="ref15" type="bt">1</bibl> <bibtext> Bailey, W. C., Hendrick, C., & Hendrick, S. S. (1987). Relation of sex and gender role to love, sexual attitudes, and self-esteem. Sex Roles, 16 (11–12), 637 – 648. https://doi.org/10.1007/BF00300378</bibtext> </blist> <blist> <bibl id="bib2" idref="ref31" type="bt">2</bibl> <bibtext> Bayer, C. R., Eckstrand, K. L., Knudson, G., Koehler, J., Leibowitz, S., Tsai, P., & Feldman, J. L. (2017). Sexual health competencies for undergraduate medical education in North America. 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  Data: Exploring the Interpretation of Medical Students of the Brief Sexual Attitudes Scale
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  Data: <searchLink fieldCode="AR" term="%22Williams%2C+Bryana%22">Williams, Bryana</searchLink><br /><searchLink fieldCode="AR" term="%22Duda%2C+Elizabeth%22">Duda, Elizabeth</searchLink> (ORCID <externalLink term="http://orcid.org/0000-0001-8717-8167">0000-0001-8717-8167</externalLink>)<br /><searchLink fieldCode="AR" term="%22Daniels%2C+Keziah%22">Daniels, Keziah</searchLink> (ORCID <externalLink term="http://orcid.org/0000-0002-0166-0057">0000-0002-0166-0057</externalLink>)<br /><searchLink fieldCode="AR" term="%22Schneider%2C+Jason+S%2E%22">Schneider, Jason S.</searchLink> (ORCID <externalLink term="http://orcid.org/0000-0002-6265-0370">0000-0002-6265-0370</externalLink>)
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  Data: <searchLink fieldCode="SO" term="%22American+Journal+of+Sexuality+Education%22"><i>American Journal of Sexuality Education</i></searchLink>. 2022 17(3):304-319.
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  Data: Taylor & Francis. Available from: Taylor & Francis, Ltd. 530 Walnut Street Suite 850, Philadelphia, PA 19106. Tel: 800-354-1420; Tel: 215-625-8900; Fax: 215-207-0050; Web site: http://www.tandf.co.uk/journals
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  Data: 16
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  Data: <searchLink fieldCode="DE" term="%22Sex+Education%22">Sex Education</searchLink><br /><searchLink fieldCode="DE" term="%22Health+Services%22">Health Services</searchLink><br /><searchLink fieldCode="DE" term="%22Undergraduate+Students%22">Undergraduate Students</searchLink><br /><searchLink fieldCode="DE" term="%22Medical+Students%22">Medical Students</searchLink><br /><searchLink fieldCode="DE" term="%22Physician+Patient+Relationship%22">Physician Patient Relationship</searchLink><br /><searchLink fieldCode="DE" term="%22Curriculum+Design%22">Curriculum Design</searchLink>
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  Data: 10.1080/15546128.2021.2016524
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  Data: 1554-6128<br />1554-6136
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  Data: Effectively addressing the sexual health concerns of patients is critical to supporting and improving overall health for individuals and communities. This study aimed to collect validity evidence for use of the Brief Sexual Attitudes Scale (BSAS) in a sexual health curriculum among undergraduate medical students. A qualitative thematic analysis was conducted with three focus groups of medical students. Early findings indicate the need to modify the current version of the instrument to make it more useful to learners. A modified BSAS survey could help students understand their own perspectives about sexuality and how their perspectives influence their ability to provide non-judgmental patient care.
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