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INTRODUCTION

This chapter offers primary care providers as well as specialists a paradigm for conceptualizing sexual response and sexual disorders (SDs), as well as an approach to easily and effectively evaluate and treat sexual disorders within a standard office practice. The Sexual Tipping Point (STP) Model is recommended for optimizing understanding, evaluating, and treating SDs, as well as providing guidance for follow-up, relapse prevention, and referral.34 This chapter is written from the perspective of a sex therapist and emphasizes the importance of integrating sexual counseling skills for physicians identifying as men’s health specialists (MHS) who treat SDs.

There are a number of reasons that physicians specializing in men’s health are likely to progressively see more and more patients who are suffering from sex-related complaints. Perhaps “aging” and the “media” are the 2 most predominant considerations. Advancing age, while not necessarily causative, is highly correlated with SDs. Both disease and their treatments (which are themselves highly correlated with aging) are key factors in causing SDs. The direct-to-consumer advertising by the pharmaceutical industry frequently prompts patient visits to physicians’ offices with the ubiquitous admonition, “Ask your doctor about….” Some of the most frequently broadcast advertisements today are for drugs specific to SDs.

WHY IT IS CRITICAL TO INTEGRATE SEXUAL COUNSELING

Every SD has a psychosocial and cultural component that if not causative, is certainly consequential. Regardless of the degree of organic etiology, SD is exacerbated by insufficient stimulation: an inadequate combination of subjective erotic thoughts, feelings, and the physical stimulation needed by a given individual to experience a desired sexual response. There is widespread recognition that simply restoring sexual function is often insufficient in helping patients or, especially couples, resume a satisfying sex life.1,2 That was not the consensus within the sexual medicine community at the time pharmaceuticals for erectile dysfunction (ED) first became widely available in 1998 with the launch of Viagra. The high discontinuation rates due to suboptimal responsiveness to phosphodiesterase 5 (PDE5) inhibitors helped raise greater recognition that the multifaceted etiology of SDs must be addressed.2–4 Following Viagra’s launch, close to 90% of men who sought medical assistance for ED were treated with PDE5 inhibitors alone, with very little additional counseling. Approximately 70% of these men reported improvement in quality of life, yet discontinuation rates appeared to approach 50%.5,6 Some men tried PDE5 inhibitors out of curiosity and never intended long-term use. Others discontinued ED treatments as a result of a lack of efficacy, a fear of side effects, cost, and overall poor health. Yet there is no question that psychosocial and cultural factors were also major considerations. Postmarketing surveys that queried both the patient and his partner indicated that “mental” factors, such as depression, loss of confidence, fear of failure, unrealistic expectations, and performance anxiety, affect treatment outcome. Over time, alterations in a partner’s sexual desirability also affect both arousal and orgasmic response. Perhaps the most important ...

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