priority, clinicians, who typically have limited time to evaluate patients, will be hesitant to commit the necessary time and resources to STD prevention. This may be reinforced by clinicians' discomfort in dealing with the issues related to their patients' sexuality. Clinicians may not feel that dealing with sexuality is their responsibility. For example, while some consider sexuality to be within the physicians' province, medical training continues to reflect the predominant opinion of society that sexual health issues are private issues; therefore, such training has ignored sexuality (Lief and Karlen, 1976). As further discussed in Chapter 5, medical students learn little beyond the anatomy and physiology of the sexual reproductive system; they are not trained to deal with patients' sexual problems, and many feel uncomfortable with their lack of preparation (Merrill et al., 1990). Moreover, every clinician has biases, beliefs, and preferences related to sexuality, based on his or her own experiences and judgment, that should be recognized.

Health care professionals may subconsciously rebuke those whose sexuality differs from their own and provide services in a superficial or judgmental manner. Clinicians need to develop an awareness of their values in order to avoid unwittingly imposing them on patients or letting their values affect clinical judgment and management (Lief and Karlen, 1976; AMA, Council on Scientific Affairs, 1996). The individual's comfort level with sexuality influences the interaction between the health care professional and patient, and between the health educator and student, in subtle ways that are not always readily perceivable (Woods, 1979). This points to the need for educational and training efforts that will facilitate open and clear discussions of sex and sexuality between health care professionals and their patients (Woods, 1979; Hogan, 1980; Lewis and Freeman, 1987; Poorman and Albrecht, 1987).

Impact on Community Activism

The stigma associated with STDs hinders public discourse and, as a result, community activism for STDs other than HIV infection. Because having an STD is still socially unacceptable, there are few if any patient-based constituent groups who advocate publicly or lobby for STD-related programs. In contrast, persons with cancer and other common diseases have successfully advocated for additional funding for their causes. There also has been good advocacy for HIV infection. In considering why there is a difference in how HIV infection and other STDs are publicly viewed, the committee speculates that the following factors may help explain the disparity: (a) the stakes are higher for HIV infection than other STDs since it is a fatal disease, (b) the HIV epidemic initially spread within an organized and largely educated community (gay men) with a substantial social support network and infrastructure, and (c) HIV infection occurred among and was publicly acknowledged by highly visible opinion leaders such as persons in the arts and entertainment industry.

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