Psychosexual issues: a caring providers manual.

Sexual Disorders: Perspectives on Diagnosis and Treatment. By Peter J. Fagan. Baltimore, MD: The Johns Hopkins University Press, 2003, 151 pages. Paper, $18.95: hardcover, $40.00.

Reviewed by Joshua Grossman, M.D., F.A.C.P., East Tennessee State University, 1005 Melrose Avenue, Johnson City, TN 37601-2605: e-mail: zjbg2@ imail.etsu.edu.

   "The iron tongue of midnight hath struck twelve. Lovers to bed"
   (from A Midsummer Night's Dream by Sir William Shakespeare).

And there we may have it. The stereotype--perhaps our stereotype--that those who are forever young and forever in love (as we all may yearn to be) will uniformly make straightaway to bed, vigorously engaging in psychosexual activities through the night, each and every night, without ever so much as a whisper or a whimper of psychosexual dysfunction. In our 20th century, when psychosexual dysfunctions were first openly admitted, of course it seemed reasonable to begin our search for a resolution. Dare we wonder, even before the sildenafil (Viagra) era, if our perpetual search for perfection in both our anatomic structures and our psychosexual functions is somehow akin to the medieval search for the occult and cryptic Holy Grail (Bass. 1994: Brown, 2003)?

Now, in our 21st century, Peter J. Fagan, Associate Professor of Clinical Psychology at the Johns Hopkins University School of Medicine, presents four perspectives for organizing our thinking in the approach to a psychosexual dysfunction:

1. The disease perspective defined as "what the patient has." This perspective forms the foundation of the medical model.

2. The dimension perspective defined as "what the patient is." This perspective includes behavior patterns and the assessment of intellectual functioning.

3. The behavior perspective defined as "what the patient does." This perspective focuses on the consequences of problematic behaviors.

4. The life story perspective defined as "what the patient encounters and gives meaning to." This perspective is the one most closely associated with psychotherapy.

Fagan presents a case-based discussion of each perspective. For example, with regard to the disease perspective we are introduced to "Frank," who presented with agitation and diaphoresis (sweating). These symptoms led directly to the resolution of his premature ejaculation when his medical issue of hyperthyroidism was properly diagnosed and treated. Then we are introduced to "Ralph," whose presentation with sexual disinterest was associated with a low serum testosterone level and an elevated pituitary prolactin level. Ralph's psychosexual interest and activity were restored when he was provided with bromocriptine to treat the benign hyperfunctioning adenoma of his pituitary gland.

To illustrate the dimension perspective we are introduced to "George and Millie," a loving couple whose marriage of 43 years ended when Millie died of cancer. When George met "Grace," he was initially unable to achieve an erection, until with therapy he was able to resolve his ambivalence about becoming sexual with any woman other than his wife.

With regard to the behavior perspective, we meet "John," married for 24 years with recent life stressors including the death of his father, his mother's forced placement in a nursing home, and his daughter's remission following cancer treatment. John. having engaged in masturbation in his work cubicle while accessing bondage and dominance web sites, is now required to have a psychological assessment as a condition of his continued employment.

With regard to the life story perspective, we encounter "Harriet," who, having had her hands slapped by her mother at age 6 for masturbating, now experiences genital pain during sexual intercourse with her husband.

Fagan would probably concur that deeply ingrained sexual problems may well be ego-syntonic because they fulfill certain psychological needs (Gabbard, 2000). In this regard, Fagan underscores the quintessential goal of "sensual rapprochement" in the case of "Mark," who after 40 years of marriage (the last 10 of which had been without sexual intercourse due to his diabetes-induced impotence) trotted much like an eager young stallion into the bedroom one evening, surprising his wife "Esther" with his sildenafil-induced full erection. The result was painful intercourse for Esther and orgasm for neither spouse. Pursuant to 4 months of therapy, Mark and Esther learned to enjoy each other through talking, listening, walking, reading, and massage, leading to reasonably regular and mutually satisfying psychosexual intercourse.

This readable text will be of considerable value to healthcare providers who endeavor to provide care to patients presenting psychosexual problems. I plan to keep this valuable text on my desk for ready reference in treating patients and in teaching students.

REFERENCES

Bass. B. A. (1994). In further pursuit of the perfect penis: The comprehensive urology center and the medicalization of male sexual dysfunction. Journal of Sex & Marital Therapy, 20. 318-320.

Brown. D. (2003). The Da Vinci code. New York: Doubleday.

Gabbard. G. O. (2000). Psychodynamic psychiatry in clinical practice (3rd ed.). Washington. DC: American Psychiatric Press.