Premature Obituary? Commentary on Rowland's Article

Sex therapists may be excused these days if they have the urge to repeat Mark Twain's famous line, “Reports of my death are exaggerated.” Rowland (2007) asks whether “medical solutions to sexual problems will make sexological care obsolete.” He predicts the “eventual demise of the nonmedical sex specialist.” Similarly, Binik and Meana (2007), highly respected researchers and clinicians in the field of sexual disorders ask, “Does sex therapy have a future?.” They point out the lack of an underlying theoretical framework, unique set of techniques, or clear empirical support for treatment outcomes. They even question the validity of the label “sex therapy.”

Clinicians and researchers in the field of sexual disorders, will appropriately ask, “What is happening to our field?” In his article, Rowland offers a very useful, if somewhat hyperbolic, challenge to the field of sexology, more specifically, the field of treatment of sexual dysfunctions. Overall, he presents a balanced critique of the benefits and problems of the medical approach to sexual problems. More importantly, he also offers valuable suggestions for ways that behavioral sexologists can shape the future of the field, both scientifically and clinically.

His underlying point is that the medical model requires a change in our approach to sexual problems. Unfortunately, there has been much unproductive debate pitting the medical model against the biopsychosocial model. While this debate has continued for years, it has heated up in the past 10 years as medical interventions have shown more promise in the treatment of common sexual dysfunctions. Worthwhile critiques have identified the limitations of a narrowly medical approach to sexuality (e.g. Tiefer, 1996). Much of the debate, however, has been superfluous, since most specialists in the field understand that an integrative approach is the only rational and comprehensive view of such a complex phenomenon.

Having said this, the dilemma remains that medical research, more specifically pharmaceutical research, dominates the field currently, due to its considerable financial resources, which, in turn, attract the intellectual resources of sexuality researchers. Clinical trials are also much easier to do with a medication than with a psychological treatment, even a manualized treatment intervention. Medical treatment outcome research is seductive. It is relatively straightforward and it pays well. Rather than dismissing the valuable work that is created by such research, a more productive alternative would be to seek public and private funding for outcome research for psychological treatments. Unfortunately, this is not easy to come by. Even beyond the usual squeamishness of public agencies to fund sex research, recently conservative groups (e.g., the Traditional Values Coalition) have targeted a number of researchers, particularly at the Kinsey Institute and attacked their funding. (Bancroft, 2004).

Rowland argues that erectile dysfunction (ED) drugs “ensured easy, economic, and efficacious treatment options for men with either (or both) pathophysiologically or psychologically based erectile dysfunction.” Unfortunately, this is an overstatement. Medical interventions certainly do help many patients, especially men with ED, but only some, and often in limited ways. We know that about half of prescriptions for Viagra™ are not renewed. Frequently men (or their partners) present with the desire to wean themselves off of oral medications. Their effectiveness with more complex problems, especially the most common problems of desire disorders, has been found to be equivocal. Witness efforts to use PDE-5i for women with sexual dysfunctions.

In talking to primary care physicians, I have taken to making the rather provocative statement that “Viagra is not a cure.” The goal is to help them understand the complexity of the sexual response and sexual relationships. To these physicians, the most common first contact for sexual problems, the point is not difficult to understand. They can quickly see that medications are often not adequate to solve the underlying psychological or interpersonal issues that may be behind the presenting sexual complaint. They say, however, that they feel at a loss as to how to help such patients and their partners in the brief time allotted to them. They are more than ready to look for help with such patients from nonmedical specialists in sexual problems. For the most part, they are happy to collaborate in an integrative treatment approach.

One of the most important ways that clinical sexologists can enhance the quality of care for their patients is to reach out to physicians working with these problems, not just the specialists, such as urologists and gynecologists, but especially to the front line clinicians. Conversely, healthcare professionals need to better appreciate psychological (e.g., behavioral, interpersonal, and mental) factors in sexual disorder. Mental health professionals need to become comfortable in working with medical providers and integrating their work with medical treatments. Both need to rely more on empirical research to demonstrate treatment efficacy and efficiency.

Rowland argues that the study of sexual problems has become medicalized and the discipline has been redefined as “sexual medicine.” This field has focused on sexual dysfunctions up until now. He suggests, however, that the disease model will be applied to other sexual problems in the future, such as gender identity disorders and paraphilias. There is little evidence for this currently and it seems unlikely to occur, given that both of these areas are good examples of the integration of medical and psychological interventions. For example, in the area of gender dysphoria, the multi-disciplinary professional organization of clinicians and researchers in the field (the World Professional Association for Transgender Health, formerly HBIGDA) has created standards of care for the treatment of gender dysphoria that explicitly identify the complementarity of medical and psychological interventions. Outcome research has supported such integration (Carroll, 2007). In the field of paraphilias and sexual offenses too, there is a long history of integrating biological, usually psychiatric, interventions and psychological, especially cognitive-behavioral interventions (e.g., Abel, Osborn, Anthony, & Gardos, 1992).

Rowland argues that, given the developments in the biological understanding of sexual response and the dramatic increase in the use of sexual pharmaceuticals, our field has evolved into that of “sexual medicine.” On this point, Rowland overstates the case. Sexual medicine can't replace the previous labels of sexology, sex therapy, or even sexual health. Sexual medicine can only properly apply to a subspecialty in the field of medicine. Progress in the field of sexual disorders has been the result of the contributions many disciplines beyond medicine, including psychology, physical therapy, anthropology, and social work. For example, recent empirical work on the understanding and treatment of sexual pain disorders emphasizes the role of medical interventions (surgery and medications), psychophysiological interventions (physical therapy), and psychological interventions, including cognitive-behavioral strategies, as well as the standard sex therapy approach of working with the couple (Binik, Bergeron, & Khalife, 2007).

The perspectives of biology and psychology have to be better integrated in the realm of research into sexual disorders as well. Rowland's own work in the area of premature ejaculation is a very good example of how this integration can lead to both better theory and better treatment (Rowland & Koos, 1997). This more comprehensive perspective on research and theory is already a widely accepted view of where the field should be headed.

One of the suggestions offered by Rowland for the improvement in “sexological health care” is integrated treatment, specifically the integration of psychological treatments with medical treatment. Fortunately, the field of sex therapy can point to a long history of such integration beginning with Masters and Johnson's (1970) earliest theoretical and clinical work, following by the important contributions of Helen Singer Kaplan (1974) and continuing to the present. Indeed a major focus of the past 10 years has been to offer various models of how medical and psychological interventions can be integrated to increase effectiveness (e.g. Althof, 2006; Perelman, 2006; Rosen, 2000).

The common themes in these approaches include:

1. appreciation of the heterogeneity of disorders;

2. a comprehensive view of etiology that considers the full range of biological, individual, interpersonal, and cultural factors;

3. appreciation of how the disorder impacts psychological well-being, as well as how psychological well-being impacts sexual function;

4. assessment of the relative “psychosocial complexity” involved in the problem;

5. the important role of the partner in understanding and treating sexual problems;

6. a flexible treatment approach that can incorporate medial interventions into the solution.

While there is a small amount of research that demonstrates the value of such an integrative approach, especially for ED, more research is required to better establish its efficacy (Althof, 2006).

Rowland points out the relative lack of empirical evidence for most of the established treatments of sexual problems. Here again, he may be overly negative. Heiman and Meston's review (1997) of empirically validated treatment for sexual dysfunction offers support for some of the long-standing approaches to these disorders. Using the criteria of the American Psychological Association (APA)'s Task Force on empirically validated treatments, they found that psychological treatments were “well established” for primary anorgasmia in women, and erectile disorder in men. They also argued that research supported psychological treatments as “probably efficacious” for secondary anorgasmia (inhibited orgasm) and premature ejaculation. Ten years later I believe that we can add to this list of treatments that have shown effectiveness, notably integrative treatments for sexual pain disorders (Binik, Bergeron, and Khalife, 2007).

Other research has supported the efficacy of common psychological approaches to sexual problems, such as working with the couple, homework assignments, bibliotherapy, and group treatment models (Hawton, 1992). They, like Rowland, point out the paucity of recent behavioral research on psychological treatments for sexual dysfunction and the methodological problems that continue to plague such research.

Ultimately we don't have to make an either/or decision regarding medical and psychosocial interventions. It would be considered inadequate for a primary care physician, upon diagnosing hypertension, to only recommend medication without suggesting behavioral lifestyle changes to address diet and exercise. While they may not provide this education and intervention for the patient (and his/her partner), they usually refer him or her to those who do. Likewise, every patient in a medical setting that presents with sexual dysfunction should be handed a referral to a specialist in sexual disorders whether this is a health or mental healthcare provider.

We don't need to reinvent the wheel, but we do need to improve on it and provide evidence to an increasingly skeptical medical system that it works. Rowland's article is most useful when he lays out recommendations in two areas: the clinical setting and the research agenda. First, he offers several good examples of how the sexual dysfunction specialist can offer integrated treatments that are likely to add significantly to a medical approach. To this we should add the importance of educating medical care providers, especially primary care physicians, about the importance of psychological factors in diagnosing and treating sexual problems.

While Rowland predicts the demise of the nonmedical sex specialist (i.e., the sex therapist), he also notes that clinical sexologists have much to offer to patients and to medical providers through their understanding of systemic factors in sexuality and their sensitivity to process issues in the delivery of treatment for sexual problems, especially the importance of relationship.

Rowland also offers very useful and concrete suggestions on ways that sexologists can enhance the empirical and theoretical bases of clinical treatment. To his suggestions, I would add the recommendation of developing strategies to evaluate the effectiveness of current treatment of sexual problems as they are applied in the real-world, i.e., actual clinical practice. While the clinical trial and the manualized treatment approach are valuable they have serious limitations with regard to generalizability. They also miss the inevitable integration and adaptability that are required for good clinical care. As Rowland would acknowledge, however, these more sophisticated research approaches are more difficult than the standard drug trial. Further, pharmaceutical companies are unlikely to support such research, even though they are beginning to accept that that their measures of outcome are limited.

Rowland argues that the “window of opportunity” for increased involvement in the field of sexual disorders will be closed within a few years. His call to action and specific recommendations are well founded, though his pessimism is not. We, i.e., the field of sex therapy, have been integrating the body and the mind for 40 years and we will continue to do so, even as the myopic gaze of the popular Zeitgeist continues to swing between the two. We should, however, be challenged by Rowland and others to demonstrate the effectiveness of our work.