Sexual Disorders Perspectives on Diagnosis and Treatment
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To my wife, Gail Lambers
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CONTENTS
Foreword, by Paul R. McHugh, M.D. ix
Acknowledgments xiii
1. Introduction to the Perspectives on Sexual Disorders 1
2. Sex and the Disease Perspective 19
3. Sex and the Dimension Perspective 41
4. Sex and the Behavior Perspective: Problematic Behaviors 63
5. Treatment of Sexual Disorders in the Behavior Perspective 86
6. Sex and the Life Story Perspective: The Question of Meaning 100
7. Integrating the Perspectives 119
References 139
Index 147
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FOREWORD
Books on sexual pathology by psychologists and psychiatrists line library
shelves. But I am repeatedly struck by how little most of these books
teach about the specific character of the sexual difficulties patients bring
to doctors. Many preach the same sermon: “You think you have a sexual
problem but actually some deeper psychic conflict of yours has expressed
itself as a sexual symptom.” This “root cause” explanation draws atten-
tion away from the particular maladaptive conditions—holding out the
promise that they are phenomena more like fever or cough that fade
away as the more fundamental matters (i.e., the “root causes”) are ad-
dressed.
This logical but in practice ineffective approach to maladaptions, in-
cluding sexual ones, was challenged and eventually refuted as a thera-
peutic procedure by Alcoholics Anonymous (AA) in the 1930s. Then
psychiatrists regularly sought some provocation or “root cause” for ex-
cessive drinking but often failed to help their alcoholic patients. AA pro-
claimed that alcoholism and its explanation were actually one and the
same. Alcoholic persons will seldom recover by searching for some hid-
den provocative cause but will mend if they identify themselves as “al-
coholics” vulnerable to losing control when drinking and therefore ex-
ert all their powers (and seek help from others) to stop drinking—“just
for a day.”
Actually there is no mystery behind the success of AA’s approach. Al-
coholism does have provocations or “roots,” but drinking can quickly
become a habit sustained by its rewarding consequences. By then, the
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foreword
provocations have faded in significance. Only a direct and systematic at-
tack on alcohol consumption itself will help the alcoholic person recover.
Learning from this example, therapists should look at every other mal-
adaptive activity directly, see it often as its own explanation, note espe-
cially how it has become a way of life for the patient, and then work dili-
gently to discern what can be done to stop it. This idea certainly applies
to sexual disorders. A sexual problem is first and foremost a sexual prob-
lem, not another problem in disguise. It follows, therefore, that those
who would help a patient with a sexual problem must learn about the
sexual problem “in itself,” not as a symptom of something else.
Sexual Disorders teaches this message. In writing this book, Dr. Fagan
has drawn on his experience directing the Sexual Behaviors Consultation
Unit at Johns Hopkins, where patients suffering serious maladaptive
sexual difficulties are investigated and treated. There Dr. Fagan came to
see different classes of sexual problems whose different natures entailed
different prognoses and treatments. This book distills his observations
on this subject.
Dr. Fagan generously suggests that our book, The Perspectives of Psy-
chiatry ( Johns Hopkins University Press, 1998), helped him find a co-
herent structure from which to speak about the different kinds of sexual
disorders. For this, I have a colleague’s gratitude. But more to the point,
I have learned much from Dr. Fagan. For example, with his help I can see
how a sexual problem that emerges in the midst of a psychiatric disease
such as bipolar disorder–manic type differs in treatment and prognosis
from a paraphilic disorder emerging in an individual with an excitement-
seeking, extraverted temperament. Thus, explanation and example emerge
from his varied experiences in the clinic.
Perhaps existing treatises on sexual maladaptions promote the “root
cause” approach because they believe it encourages nonjudgmental prac-
tices with patients, given its assumption of common human vulnerabil-
ities and fellow feelings. This kindly intended idea expresses itself in the
motto: “There but for the grace of God go I.” But differentiating the sex-
ual disorders according to their natures as Dr. Fagan does here protects
equally well against the judgmental condemnation that is so adverse to
a treatment alliance. It empathetically acknowledges the distressing
diminution of choice provoked by the hungers that drive these tenden-
cies. But it does more than identify and commiserate with the character
of the lost freedom. It differentiates the fundamental natures of the dif-
ferent sexual maladaptions even as it describes the therapeutic approaches
suitable to correct them. This stance of description, differentiation, and
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foreword
therapeutics also suggests appropriate paths for research into these dis-
orders.
A crucial moral prevails here: we should scrutinize sexual disorders for
themselves just as we scrutinize addictive disorders, eating disorders, and
sleep disorders for themselves. As a result, our powers of understanding
and treatment will increase. We need not fear that we will drift either to-
ward reflexive condemnation that disrupts any therapeutic opportunity
or into callous license that ignores the patient’s need to regain the free-
dom lost to intemperate habit and dominating preoccupations.
I expect this book to become a model of its kind and ultimately bring
clarity to an arena of psychiatry where, despite past interest and effort,
little fundamental service to patients has emerged.
Paul R. McHugh, M.D.
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ACKNOWLEDGMENTS
This book is the product of nearly two decades of collaboration with
friends and colleagues at the Johns Hopkins University School of Med-
icine. I am grateful primarily to the persons with whom I have been priv-
ileged to work in the Sexual Behaviors Consultation Unit (SBCU) for
twenty years. Chester Schmidt has given steady leadership to the SBCU
since the early 1970s; he is always ready to identify questions raised by
the clinical cases and to pose challenges for further research. It is impos-
sible for anyone to be around Tom Wise, with his intellect and enthusi-
asm, and not be curious about the phenomenology of human sexuality
and to pursue that curiosity in a rationally cohesive fashion. Julia Strand,
when with us in the SBCU, was a partner in wondering about the com-
plexities of the human psyche and the remarkable manner in which sex-
ual behavior expresses this complexity. These three colleagues have been
central to the development of my thought as reflected in this book.
In addition to the central roles played by Chet, Tom, and Julia, the
SBCU has benefited from the presence of two leaders in the field of psy-
chological measurement. Paul Costa is not only an international expert
in personality but also, more importantly, a friend and colleague who
generously collaborates with and teaches us. For more than thirty years,
Len Derogatis has been the preeminent psychometrician in human sex-
uality. He was a mentor in my clinical psychology internship in the early
1980s and has been a professional colleague since then.
Others in the SBCU fostered the work of the unit and my ability to
grow in an understanding of the various perspectives on human sexual-
xiv
acknowledgments
ity. They are Emile Bendit, Lois Blum, David Cowie, Ellen Halle, Linda
Hellman, Van King, Chris Kraft, Dinah Miller, Yula Ponticas, Mark
Reader, Linda Rogers, Lex Smith, Bob Ward, and Debbie Weaver. A spe-
cial thanks to Cindy Osborne and Steve Johnson, who, as associate di-
rectors of my two “day jobs,” provided the coverage necessary to give me
the time to write the book.
For the past ten years I have organized the human sexuality curricu-
lum for the first- and second-year medical students at Johns Hopkins—
an eighteen-hour curriculum, generous by current medical school stan-
dards. This task has permitted me to be updated annually in the genetic
and biological, medical, and psychosocial aspects of human sexuality by
a wonderful interdepartmental faculty. Among the Hopkins faculty, I am
grateful to Greg Ball, Lisa Beasley, Fred Berlin, Bud Burnett, Adrian
Dobs, Leslie Heinberg, Alain Joffe, Jeremy Nathans, Bill Reiner, Court-
land Robinson, Leon Rosenberg, and Julie Van Rooyen. In addition,
Mike Plaut, of the University of Maryland School of Medicine, Sandy
Lee, of Northern Virginia Family Services, and David Rowland, of Val-
paraiso University, generously traveled to Hopkins to teach us. Annu-
ally, the medical student lecturers taught the medical students well, and,
in doing so, they taught this faculty member.
Over the past two decades, many persons have helped me think about
what has emerged as the contents of this book, sometimes with a care-
fully designed research presentation at meetings of the Society for Sex
Therapy and Research or the International Academy of Sex Research, at
other times with a very brief comment made in passing. For their help in
thinking about human sexuality and, in many cases, their enlightening
presentations and publications, I especially thank Richard Friedman,
Julia Heiman, Sandra Leiblum, Derek Polonsky, Ray Rosen, David
Scharff, Raul Schiavi, Pat Schreiner-Engel, Taylor Segraves, Leonore
Teifer, Ken Zucker, and the trio from Cleveland: Stan Althof, Steve
Levine, and Candace Risen.
Others, professionally outside the field of human sexuality, were help-
ful at various stages in the writing of this book. For their comments and,
most often, answers to my questions I am very grateful. I thank Andy
Cherlin, Charles Curran, Hank Giedzinski, and Jennifer Haythornth-
waite.
I am especially grateful to those who made helpful comments on pre-
liminary drafts of the book: Tom Wise, Chet Schmidt, Melinda Fitting,
and Julia Strand. Matt McDonald’s encouragement was priceless.
I am grateful to the patients who entrusted to me and to all of us in
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acknowledgments
the Sexual Behaviors Consultation Unit their sexual problems and con-
cerns. Health, mental health, and sexual health are collaborative works
of those who seek assistance and those who attempt to help. But the di-
rection of the beneficence is not one way. I have been helped and taught
by my patients, and I am grateful for the life wisdom they have provided.
The cases described in this book are composites of those who have shared
their life story as partners in achieving mental and sexual health. No one
should be recognizable, even to himself or herself. The human condition
is universal.
The graphic art of Jackie Schaffer has contributed to the understand-
ing of the perspectives and how they might be integrated. I thank my ed-
itor at the Johns Hopkins University Press, Wendy Harris, whose quiet
and consistent nudges were just what was needed.
I am, of course, very indebted to the work of Paul McHugh and
Phillip Slavney in their Perspectives in Psychiatry. Without Perspectives and
Paul’s personal support, this book would not have been written.
While I am grateful to all the above and many others for their contri-
butions to my thinking and to this book, all limitations and any errors
contained herein are my responsibility.
Last, and most important, I thank my wife, Gail Lambers, for her pro-
tection of the time and space I needed to write this book and for the lov-
ing support that makes such work possible.
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SEXUAL DISORDERS
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