Sexual Dysfunction: The Brain-Body Connection
How many clinicians can say that they include a comprehensive sexual history, including thorough inquiries about sexual dysfunction, in every new patient interview? Edited by Richard Balon, a leading expert in the field of sexual disorders, this volume addresses numerous aspects of sexual dysfunction that are of interest and importance for psychiatric clinicians striving to provide comprehensive patient care within a mind-body framework.
The first chapter provides a solid foundation for exploring sexual dysfunction. Research measures and clinical interviewing techniques are described in detail. Emphasis is placed on understanding both past and present sexual issues, with special attention to medical history, medications/drugs, psychiatric disorders, and relationship issues. The distinction between "dysfunction" and "difficulties" (the latter not associated with pathophysiology or psychopathology) is particularly helpful. A brief section about laboratory tests rounds out the evaluative process, and the division of tests into "recommended" and "optional" is useful.
Following chapters address a myriad of topics that may be seen in medical and psychiatric practices. The chapter on erectile dysfunction (ED) defines the problem, reminds clinicians that ED can signal medical and psychiatric disorders, addresses communication barriers, and lists modifiable risk factors, including obesity, cigarette smoking, illicit drug use, and alcohol use. Laboratory guidelines, information about physical examinations (which may be more useful for general practitioners or urologists than for psychiatric clinicians), and treatment options are also reviewed. The chapter on premature ejaculation (PE) includes pertinent background and diagnostic criteria. Four subtypes of PE are proposed (lifelong, acquired, natural variable, and premature-like ejaculatory dysfunction), and sections on neurobiology/ neurotransmitters and treatment round out this chapter.
As this volume continues, the sexual impact of physical illness, mental illness, and substance abuse are explored further. The chapter on medical issues impacting sexual dysfunction provides a particularly important review. Starting within a body system format, neurologic, endocrine, cardiovascular, and pelvic diseases are discussed. Additional medical conditions such as pregnancy, and specific illnesses, including prostate conditions and breast cancer, are also addressed. Finally, brief mention is made of (nonpsychotropic) medication-induced sexual dysfunction. The chapter on psychotropics and sexual dysfunction is especially well-written and informative. Medications are described by class (antidepressants, antipsychotics, mood stabilizers, anxiolytics) and by specific neurotransmitter characteristics. Treatment strategies are proposed, including psychotropic medication adjustments, augmentations, and specific sexual dysfunction agents. This chapter is written from a refreshing perspective, discussing treatment limitations, "debunking" common myths about treatments, and addressing the impact of pharmaceutically sponsored research studies. A chapter on imaging, an area of sexual disorders investigation largely unfamiliar to general psychiatric clinicians, adds a novel conclusion to this text.
This volume is not without limitations. As in many works on sexual dysfunction, emphasis is placed on male gender and heterosexuality. Paraphilias and issues of gender identity, all of which may have relevance to sexual dysfunction, are not addressed. Several chapters refer to the relative lack of sexual activity in the lives of chronically psychotic patients; this could lead practitioners to continue ignoring sexuality in this patient population. Finally, several tables in this work are fairly elementary and do not add as much to the written text as one would hope.
Limitations aside, this book is significant and relevant for several reasons. Firstly, medical practitioners in general, and psychiatrists in particular, often fail to discuss issues of sexuality and sexual dysfunction adequately with their patients. This modestly sized volume can provide practitioners with basic knowledge to start discussions with their patients about sexual function, and it may lead practitioners to more quickly evaluate, identify, and treat (or refer) when problems surface. Additionally, clinicians can use this book as a meaningful reference for sexual dysfunction evaluation strategies and research studies. In using this book to inform and guide practice, practitioners hopefully will feel more prepared to thoroughly inquire about sexual dysfunction, to select appropriate medications based on past and present sexual history, and to remain cognizant of the complex interplay of medical-psychiatric issues as they relate to sexual dysfunction.
Author affiliations: Case Western Reserve University School of Medicine, Cleveland, Ohio. Potential conflicts of interest: None reported.
© Copyright 2010 Physicians Postgraduate Press, Inc.