Michael A. Perelman1, 2, 3
(1)
Reproductive Medicine and Urology, Weill Medical College Cornell University, 70 East 77th Street, New York, NY 10075, USA
(2)
Human Sexuality Program, The New York Presbyterian Hospital, New York, NY, USA
(3)
MAP Education and Research Fund, New York, NY, USA
Michael A. PerelmanPsychiatry, Co-Director, Founder
Email: perelman@earthlink.net
Keywords
Sexual tipping point modelTransdisciplinary treatmentBiopsychosocial-behavioral and cultural modelSex therapyIntegrated treatment model
Two concepts were particularly important to me in developing this textbook: (1) a desire to cultivate a transdisciplinary sexual medicine perspective for the reader that emphasized integrating counseling with current and future medical/surgical approaches for the treatment of male and female sexual disorders and (2) emphasizing the need and benefit for the reader to use a biopsychosocial-behavioral and cultural lens when contemplating sexual response and sexual dysfunction.
When asked to coedit this volume, I was concerned about the need for yet another edited text about sexual disorders and their treatments. It was agreed that if we were to write a text for a truly multidisciplinary clinical audience, our editorial and author group would need to be diverse in terms of both gender and professions of origin. Through editorial discussions, a concept emerged of a book whose chapters would be written primarily by sexual medicine physicians and typically with additional commentary from those with a mental health background—often sex therapists. We believed such a dialectic would provide a unique contribution to the literature as well as support the emerging viewpoint that sexual medicine should share a transdisciplinary perspective which has characterized the most recent advances in many areas of medicine [1]. Such an approach goes beyond the multidisciplinary view, previously held by others as well as ourselves. Instead, transdisciplinarity speaks to the need for healthcare practitioners to exchange information in a manner that each contributing discipline and specialty begins to alter its own practices to share an integrated knowledge and achieve common scientific and clinical goals [2].
We hope the reader will develop insights and wisdom that transcends the information explicitly contained in the chapters and commentaries offered within this volume. Why and how? The dialogue between the mental health authors and the medical/surgical authors was often an implicit one. The reason for this was twofold. First, some of the commentaries were written to express the viewpoint of the mental health author in response to their perception of a physician’s/surgeon’s general approach to sexual problems today. These authors spoke about their view of the generic trends, rather than addressing a specific chapter author’s writing. Other commentaries were written to directly complement a specific chapter and commented on the work of a given author. Obtaining a thorough understanding of sexual medicine requires an understanding of the mind/body issues inherent within human experience in general and sex in particular. The purpose of this book was to evoke a dialogue within the mind of the reader about a more comprehensive perspective on how to view patient’s sexual disorders and concerns. In other words, the book is designed to teach an integrated treatment approach; yet our ultimate goal was to nurture for at least some of you a transdisciplinary perspective for the future of sexual medicine.
Of course, there is no reason to believe a single pathogenetic pathway to sexual disorders exists. Clarity of understanding requires that the clinician and researcher alike maintain a biopsychosocial-behavioral and cultural view of sexual response and dysfunction. Besides the obvious common sense appeal of such models, there is an ever-expanding body of empirically based quantitative and qualitative evidence supporting a multidimensional conceptualization, especially in the areas of treatment optimization, treatment adherence, and continuation of recommended therapies [3–26].
The reader may choose from a number of multidimensional models, but sexual medicine and sex therapy have recently been most influenced by various “dual-control models ” [27–36]. Earlier, Helen S. Kaplan brought to sex therapy and to sexual medicine the principles of multi-determinism and multilevel causality [32, 37]. However, in her last book The Sexual Desire Disorders , published in 1995, Kaplan foreshadowed the important work of Bancroft and colleagues [27] when she both described and illustrated dual-control elements of human sexual motivation and identified sexual “inciters” and “suppressors” to sexual desire dysregulation [31, 38]. She attributed her conceptualization to Kupferman [39] who had noted earlier that “all examples of physiological motivational control seem to involve dual effects—inhibitory and excitatory—which function together to adjust the system” (p. 751). Kaplan felt that control of sexual motivation was no exception and also operated on such a “ dual steering” principle (Fig. 1.1).
Fig. 1.1
Helen S. Kaplan’s (1995) Dual-control elements of human sexual motivation: a psychosomatic model. With permission from Kaplan HS, The Sexual Desire Disorders. Dysfunctional Regulation of Sexual Motivation. Brunner-Routledge (Taylor and Frances, London, 1995: p. 15
The seminal works of Bancroft and colleagues are the best known and researched of the various dual-control models [27]. Bancroft’s 1999 manuscript [27] and subsequent work with his Kinsey Institute colleagues (Graham, Heiman, Janssen, Sanders, etc.) have provided outstanding, erudite articulation of their dual-control theory, psychometrics, and comprehensive research for over 15 years [40–42]. In short, they postulate and attempt to demonstrate “that sexual response and associated arousal occurs in a particular individual, in a particular situation, and is ultimately determined by the balance between two systems in that individual’s brain, the sexual activation or excitation system and the sexual inhibition system, each of which has a neurobiological substrate” [27, p. 15].
Yet, from our perspective when contemplating the clinical need for understanding etiology, diagnosis, and treatment, we find the Sexual Tipping Point ® (STP) dual-control model particularly useful in its ability to illustrate both intra- and interindividual variability that characterizes sexual response and its disorders for both men and women (Fig. 1.2) [13].1
Fig. 1.2
A sequential key to the STP model. mapedfund.org provides a video explanation of the STP model as well as continuously updated images and other resources which are all available for free download by healthcare professionals
The Sexual Tipping Point® model easily illuminates the mind/body concept that mental factors can “turn you on” as well as “turn you off”; and the same is true of the physical factors. The Sexual Tipping Point® is the characteristic threshold for an expression of a given sexual response. Therefore, an individual’s Sexual Tipping Point® represents the cumulative impact of the interaction of their constitutionally established capacity to express a sexual response which is elicited by different types of stimulation as dynamically impacted by various psychosocial-behavioral and cultural factors. An individual’s threshold will vary somewhat from one sexual experience to another, based on the proportional effect of all the different factors that determine that tipping point at a particular moment in time. For instance, an individual suffering from a diminished sexual response (desire, arousal, orgasm) is illustrated by the cartoon in Fig. 1.3.
Fig. 1.3
STP illustrates diminished response. mapedfund.org provides a video explanation of the STP model as well as continuously updated images and other resources which are all available for free download by healthcare professionals
Besides illustrating all etiological permutations, including normal sexual balance, the Sexual Tipping Point® concept is particularly useful for modeling treatment and can easily be used to explain risks and benefits for patients with sexual disorders. The STP model can be used to teach patients where different treatment targets should be focused, depending on diagnosis of their etiological determinants. Typically expressed erroneous binary beliefs can be politely disabused, and the patient can be reassured that “no it is not all in your head” nor “all a physical problem.” Reciprocally, their partner can be assured it is “not all their fault!” Teaching the STP model to the patient and partner can reduce patient and partner despair and anger, while providing hope through a simple explanation of how the problem’s causes can be diagnosed, parsed, and “fixed.” In fact, the Sexual Tipping Point® also allows for modeling of a variety of future treatments, including medical or surgical interventions not yet discovered or proven such as novel pharmacotherapy, genetic engineering, or nanotechnology [35] (Perelman, 2011b). This is illustrated in Fig. 1.4.
Fig. 1.4
STP depicts integrated treatment with a future medical therapy unknown today. mapedfund.org provides a video explanation of the STP model as well as continuously updated images and other resources which are all available for free download by healthcare professionals
Indeed, all the biopsychosocial-behavioral and cultural models of sexual dysfunction provide a compelling argument for sexual medicine treatments that integrate sex counseling and medical and/or surgical treatments [43]. Our work is not just to alleviate our patient’s sexual symptom but when possible to improve their intimate relational lives. Restoration of lasting and satisfying sexual function requires a multifactorial understanding of all of the forces that created the problem, whether a solo physician or multidisciplinary team approach is applied. The healthcare professional that can accomplish an integrated treatment will offer the most optimized approach and the most elegant solution [43].2 Treatment formats vary according to the preference and expertise of healthcare providers and tend to incorporate three processes: (a) the clinician’s interest, training, and competence; (b) the biopsychosocial-behavioral and cultural severity of the sexual dysfunction; and (c) patient preference as to which healthcare professional they first choose to consult. Perelman [44] recommended that the degree of medical and psychosocial complexity determines whether a healthcare provider would work alone or as part of a multidisciplinary team. For instance, a physician working alone would assess all needed physical findings (examination, laboratory testing, etc.), as well as diagnose the patient as suffering from mild, moderate, or severe psychosocial obstacles to successful restoration of sexual function and satisfaction. In addition to the physical factors, the physician would attempt to identify the cognitive, behavioral, relational, and contextual cultural factors predisposing, precipitating, and maintaining the patient’s sexual dysfunction. The physician would either continue treatment or make a referral(s) on the basis of perceived complexity and the actual progress obtained [5, 43].
Each clinician needs to carefully evaluate his or her own competencies and interests when considering treatments for sexual dysfunction. Having a multidimensional understanding of sexual dysfunction does not mandate a multidisciplinary approach. Solo practitioners may question whether to collaborate with a multidisciplinary team or to provide an integrated treatment themselves. Regardless of which healthcare professional the patient consults first, he or she is entitled to receive optimized care. For many patients, neither sex therapy alone nor medical/surgical interventions alone are sufficient to facilitate lasting improvement and satisfaction for a patient or partner with sexual dysfunction. For those patients who have sexual dysfunction based on deep-seated psychosocial and emotional issues, the use of a simple single-agent pharmacologic therapeutic will not be sufficient. Furthermore, a patient who has physical issues related to age, illness, and so forth is extremely unlikely to be fully restored (versus helped to adapt) by sex counseling exclusively. Indeed, some primary care physicians as well as many specialists will not have the expertise to adequately diagnose psychological obstacles to success, independent of their willingness to treat these factors. Alternatively, most mental health practitioners are neither capable nor licensed to provide medical care to the full extent needed by the patient. And as in all areas of healthcare, professionals should appropriately refer their patients for adjunctive consultation as needed.
We hope medical research will one day bring us more and better treatments to help ameliorate the biological factors that underlie some people’s failure to function sexually in ways they would prefer. We believe the multidisciplinary perspective that emerged from an emphasis on the empirical success of combination treatments will be replaced by an integrated approach to sexual issues and dysfunctions by clinicians who will consult to these patients in the future. As that transdisciplinary view becomes more prevalent, we hope it will become the teaching model for all healthcare practitioners early in their training. In other words, we hope our readers will advance sexual medicine with an enlightened appreciation of etiology, diagnosis, and treatment based on a biopsychosocial-behavioral and cultural model. It is our hope that such sophistication will lead to an improved personalized sexual medicine benefitting both patient and practitioner alike. Our aspiration is for all healthcare practitioners to maintain a patient-centered holistic view of healing that integrates a variety of treatment approaches as needed whether for sexual dysfunction or any sexual concern. We hope this book provides a window on how this can be accomplished both now and in the future.
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Additional Reading
Barlow D. Causes of sexual dysfunction: the role of anxiety and cognitive interference. J Consult Clin Psychol. 1986;54(2):140–8.CrossRefPubMed
Bella A, Perelman M, Brant W, Lue T. Peyronie’s disease (CME). J Sex Med. 2007;4(6):1527–38.CrossRefPubMed
Hatzichristou D, Moysidis K, Apostolidis A, Bekos A, Tzortzis V, Hatzimouratidis K, Ioannidis E. Sildenafil failures may be due to inadequate patient instructions and follow-up: a study on 100 non-responders. Eur Urol 2005;47(4):518–22; discussion 522–13.
Jemtå L, Fugl-Meyer K, Öberg K. On intimacy, sexual activities and exposure to sexual abuse among children and adolescents with mobility impairment. Acta Paediatr. 2008;97:641–5.CrossRefPubMed
McCarthy B. Integrating Viagra into cognitive-behavioral couple’s sex therapy. J Sex Educ Ther. 1998;23:302–8.
Perelman M. Sex coaching for physicians: combination treatment for patient and partner. Int J Impot Res. 2003;15 Suppl 5:S67–74.CrossRefPubMed
Perelman M. A new combination treatment for premature ejaculation: a sex therapist’s perspective. J Sex Med. 2006;3(6):1004–12. doi:10.1111/j.1743-6109.2006.00238.x.CrossRefPubMed
Perelman M. Clinical application of CNS-acting agents in FSD. J Sex Med. 2007;4 Suppl 4:280–90. doi:10.1111/j.1743-6109.2007.00611.x.CrossRefPubMed
Perelman M. Guest editorial: female sexual dysfunction and the central nervous system. J Sex Med. 2007;4(s4):257–9.CrossRefPubMed
Footnotes
1
The STP model is a registered trademark of the MAP Education and Research Fund, a 501(c)(3) public charity. STP illustrations are available free from mapedfund.org.
2
Telemedicine through today’s Internet technologies offers the opportunity for inexpensive video conferencing of diverse experts across geographic boundaries, which will perhaps increase the productive interaction between disciplines. Such technology offers the potential of multispecialty referral or consultation being available for the patient or partner when required, independent of geography.