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Four perspectives on sex problems

Therapists in the Sexual Behaviors Consultation Unit use one standard approach to assess every patient. It’s the “four-perspective model” developed for general psychiatry by Paul R. McHugh, M.D., the venerable director of Hopkins’ Department of Psychiatry, and Philip Slavney, director of general Hospital psychiatry. In a recent article in the Canadian Journal of Human Sexuality, unit director Peter Fagan presented the approach as a model for the field. Here are the four perspectives:

· The Disease Perspective. This approach reminds us that sexuality has to do with the body. The clinician searches for biological symptoms and reasons for the problem. One clear benefit of this perspective can be demonstrated in the fact that not so long ago, most cases of erectile dysfunction in men and vulvar pain in women were thought to be of psychogenic origin; today, most are attributed to physical causes.

· The Dimensional Perspective. Here, the patient’s behavior is viewed through various statistical lenses. It makes a difference from a clinical perspective, for instance, to know whether a couple married 25 years is having intercourse three times a day or three times a year. Personality assessments can give insight into how sexual problems might affect a patient’s attitudes and behaviors. Intelligence measures can help determine the best treatment option.

· The Behavioral Perspective. This approach is especially important in cases of unwanted or dangerous practices like pedophilia or bestiality. The therapist examines motivations driving patients’ behaviors and then—much as in treatments for eating disorders—seeks to identify “triggers” and embark on treatments designed to avoid or eliminate those motivations.

· The Life Story Perspective. This lens looks at the meanings patients place on their sexual behaviors. Inquiries from therapists frequently operate at the border between the conscious and unconscious and lead to treatments that help rebuild patients’ “inner stories” in constructive ways.

In sum, says Fagan, “The great plus of the four-perspective model is the way it invites input from different schools of thought—the psychopharmacologist’s medications, the psychologist’s self-report inventories, the behaviorist’s schedule of reinforcement, and the Freudian analyst’s input.”

—JD


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