By Jim Duffy
After Hopkins halted its infamous sex-change surgeries, the national hoopla disappeared. The low-profile Sexual Behaviours Unit, however, continues to lead the way in this unusual specialty.
With a swoop of his left hand, Fagan invites the youth to take a seat next to him. Only after the boy settles into the burgundy plastic chair does the group sit back down. They’ve already been briefed by the resident who’s done the initial evaluation of this case on this autumn Friday afternoon.
Several weeks earlier, 17-year-old David* had been confronted by his parents with a stash of homosexual pornography they had discovered in his room. In response to his mother’s distraught questioning, the boy had announced that he was gay. In fact, David never has had a serious girlfriend, but he does hang out with a small group of close friends, composed of both boys and girls. The youth’s parents hope this evaluation will help answer deeply emotional questions for them raised by the recent incidents: Is their son engaging in risky sexual interactions? Is his homosexual orientation set in stone? Or is this just a variation of an ordinary adolescent identity crisis?
Responding to gentle questions from Fagan, the boy’s voice trembles noticeably and his right leg shakes violently. David tries over and over to stop the shaking—first crossing his legs, then using both hands to hold his right leg, and then tucking it under his left leg—but nothing works.
“I notice your leg shaking a little,” Fagan says at one point. “Are you a little scared to be here today?”
David breaks into a crooked smile: “I’m a lot scared,” he blurts out.
The medicine of sex is different
The medicine of sex isn’t like other specialties, though that’s not because it’s practiced differently. You’ll hear as much talk in the Sexual Behaviors Consultation Unit about diagnoses, new drugs, promising treatments and recent research as you would in any other department at Hopkins. No, what makes the medicine of sex unique is its emotional landscape. Simply put, sex is one sensitive topic—and not just to troubled teenage boys.
Even here at the brink of the millennium, sex packs a punch powerful enough to stagger the whole country. Think gay rights. Think Viagra. Think Bill and Monica. That sex can still so rattle America isn’t something that surprises the faculty in the Sexual Behaviors Unit; they daily confront the devastating effect on individuals and families of problems ranging from simple dysfunctions like impotence to complex disorders like pedophilia.
“There are all sorts of meanings that people put on their sexual lives,” points out Julia Strand, Ph.D., a clinical psychologist and assistant director of the unit. “People just don’t regard this part of themselves like they do their respiratory lives.”
Sex is different. And so, therefore, is the medicine of sex—in ways that apply to institutions as well as individuals. “Sex in the most commonsensical nature of that word has never in my opinion been a comfortable topic at The Johns Hopkins School of Medicine,” says Chester Schmidt, M.D., associate director of the 27-year-old unit and one of its founders. “I suspect that lots of folks, even some who know Hopkins pretty well, are going to pick up this magazine and see what this article’s about and say to themselves, ‘What are they talking about? There isn’t any sex at Hopkins anymore.’”
And yet, Hopkins operates one of the nation’s oldest and most respected sexual behaviors clinics, with a reputation for outstanding research and clinical expertise. Two of its members played key roles in determining which sexual disorders would appear in DSM-IV (the Diagnostic and Statistical Manual of Mental Disorders—Fourth Edition). Its therapists hold faculty status, and medical students and psychiatry residents rotating through the unit are put through educational regimens in the medicine of sex that may be the most extensive offered by any academic medical center.
The unit’s patients fall roughly into two categories. Well over half are strikingly normal in other ways, but experience some “garden-variety sexual dysfunction.” Erectile difficulties and premature ejaculation are the most typical in men; low desire and orgasmic difficulties are common complaints among women. Many patients are referred by local family doctors, gynecologists or urologists. So common are the problems they suffer from that as many as one in three men are estimated to be grappling with problems of premature ejaculation, according to recent estimates. Problems of low desire and lack of satisfaction among women are also considered rampant.
A second, smaller category of the sex unit’s patients suffers from serious “disorders,” like gender dysphoria—the technical diagnostic term for people who think they’re trapped in the body of the wrong sex—and paraphilias such as transvestitism and pedophilia. These people, according to Paul Costa, Ph.D., an expert in personality assessments, “are more problem-prone as well.” Besides their sexual conflicts, they have a tendency toward high levels of anxiety, hostility and neuroticism.
Stick with the science
It’s Friday afternoon again, the one day of the week when therapists from the unit’s offices at Hopkins’ suburban outpatient center at Green Spring Station meet on the East Baltimore campus with psychiatrists, psychologists and other therapists from all over the Baltimore-Washington area who form the unit’s faculty. They’re here to evaluate patients and talk about their discipline with third-year psychiatry residents on a required six-month rotation in the unit.
Sandwich bags, napkins and potato chips now clutter the table in Meyer 165, where five residents and Fagan have gathered over lunch to hear psychiatrist Thomas Wise, M.D., the unit’s director of research and chief of psychiatry at Fairfax Hospital in Virginia, speak on the biology of sex. Wise has a mere 45 minutes to cover the endocrine, nervous and vascular systems; hence, that rat-a-tat-tat delivery of citations, statistics and observations. A bag of Pepperidge Farm cookies is making the rounds by the time Wise launches into a discussion of a rare condition in which yawning causes sudden ejaculation in men. A resident stops taking notes to speculate that the problem might prove rough during a boring lecture.
Spend even a little time observing the unit’s faculty in action and it’s easy to understand why all of them happily volunteer that Friday is their favorite day of the week. Informal exchanges with residents are collegial, often light-hearted. More formal discussions about diagnoses and treatments tend to be spirited and refreshingly egalitarian.
If there is anything approaching an orthodoxy on display during these sessions, it’s reflected in an oft-repeated mantra that’s pure Hopkins: “Stick with the science.” This insistence on the primacy of rock-solid research results is especially important in the field of sexual medicine, which long has been a comparatively low priority in research funding and medical education.
This week’s lecture by Wise is a good example. The psychiatrist puts as much emphasis on what is unknown about the biology of sex as on what is known and stresses the points where recent research is at odds with medical practices. Some doctors, for example, still administer testosterone to treat basic sexual dysfunctions, Wise warns, despite the fact that “again and again, the data suggest that testosterone is good for desire but not for function.” Wise is just starting to address the vascular system when administrative coordinator Beverly Levine waves a batch of folders indicating it’s time for the residents to head off to interview patients.
For the next couple of hours, these psychiatrists-in-training will use precise methods to conduct individual question-and-answer sessions with patients whose sexual problems run the gamut. All will use the same overall approach in interviewing their patient, no matter the symptoms. It’s a variation of the “four-perspective model” outlined in The Perspectives of Psychiatry, the landmark 1983 book by Paul R. McHugh, M.D., who’s directed the Department of Psychiatry here for 23 years, and Phillip R. Slavney, Hopkins’ director of general Hospital psychiatry (see sidebar). By viewing patients through a succession of lenses, each reflecting a different theoretical viewpoint, the approach discourages blind adherence to any particular school of thought.
“Residents see a real cross section of what people are reading about in the newspapers,” Fagan says. “They’re seeing sex offenders. They’re seeing little kids, 4- and 5-year-old boys who want to be mommies. They’re seeing your common sexual dysfunction issues, some of them in problematic marriages and some in stable ones.”
A woman who's repulsed by sex
It’s 4 p.m. by the time 15 members of the unit gather in a Hospital conference room to learn which of the afternoon’s patients has been selected for this week’s case conference. The resident, who has already interviewed the patient, takes a seat at the front, beside Schmidt, who will question the patient in front of the group.
The resident describes what he’s learned so far: The patient they will meet is a married woman in her late 30s with two young children. She’s worried that her marriage might be in trouble, because she refuses to have intercourse with her husband. She hasn’t asked her husband to accompany her to this appointment, because talking about intercourse in front of him would be too difficult.
The resident summarizes the woman’s middle-class background, then focuses on her problem. Her husband is the only sexual partner she’s ever had, but since the earliest days of their relationship, she has engaged in sexual intercourse with him only when she wanted to conceive. Intercourse has never been pleasurable for her, and she experiences it with considerable distress. She acknowledges having sexual fantasies that don’t involve her husband. She seems bright, and articulate, but the NEO-PI, a personality-assessment inventory developed by Costa, indicates that she is anxious and self-conscious.
The resident leaves the room and returns with the patient. She looks younger than expected, with shoulder-length hair held by a ribbon, and clothes that seem perhaps a bit too girlish. Responding very softly to Schmidt’s questions, she states with certainty that she loves her husband, but avoids any affectionate gesture that could lead to intercourse. Even the thought of intercourse makes her want to escape. With the patient’s permission, Schmidt invites questions from the observing staff.
Yula Ponticas, Ph.D., a clinical psychologist who’s been with the unit for more than a decade, asks the patient if she is comfortable undressing in front of her husband. She is not. Do she and her husband ordinarily go to bed at the same time? They do not.
After the patient leaves the room, the staff quickly agrees on a working DSM-IV diagnosis—Sexual Aversion Disorder. They propose a two-part treatment: The first involves systematic desensitization, a behavioral intervention that’s proven effective with many phobias. During therapy sessions, this woman, for instance, would identify anxiety-producing situations (such as undressing in front of her husband) and work on relaxation techniques that can help her become comfortable with sexual intimacy with her husband. The second part of treatment would focus on psychotherapy addressing the patient’s thoughts and feelings about her own sexuality. Because Ponticas is a specialist in Sexual Aversion Disorder, she will be the recommended therapist.
All told, the case conference—presentation, interview and discussion—takes just over an hour. “I’ve been coming here for 10 or 11 years now,” Costa remarks later. “What I always find so amazing is how much gets done in that hour. These guys are perhaps the best in the world at zeroing in on exactly the right thing.”
The Hopkins sex clinic got started back in 1971, when Schmidt, who was treating a couple of patients grappling with sexual problems, consulted with psychoanalyst Jon Meyer, M.D., and other colleagues specializing in classical Freudian analysis. The group agreed that while analysis was useful, it didn’t help resolve sex problems. At just about the same moment, Masters and Johnson’s landmark research put them on the covers of Time and Newsweek, and the onset of the sexual revolution in the late ’60s sparked a wave of activism. Thus was born the Sexual Behaviors Consultation Unit.
Soon after that low-key beginning, the unit found itself in the midst of a national brouhaha over one of the field’s most controversial topics—gender reassignment surgery. Hopkins’ involvement with the procedure dated to 1960, when surgeons removed both breasts from a woman who wanted to become male. Then, during the ’70s, John Money, Ph.D., now an emeritus faculty member, developed an international reputation for his pioneering studies identifying the condition of transsexualism. A Hopkins committee began to screen applicants for gender reassignment surgery, and the unit began seeing candidates through the lengthy preparation process.
Controversy over sex-change surgery at Hopkins raged, both in the media and inside the institution. “This was taking place at a very conservative place and in a highly charged atmosphere,” Schmidt recalls. “It’s pretty rough surgery; some people consider it mutilating. And, of course, the scientific side of it is pretty damn weak.”
Finally, in 1979, the unit’s then-director, Meyer, published a study questioning certain benefits of the surgery that helped convince the Hopkins hierarchy to eliminate its sex reassignment program entirely. But that early foray into gender reassignment here has maintained a long media shelf life. Before a recent case conference, Strand passed around a copy of a New Yorker essay containing a sex-change joke punctuated with a reference to Hopkins; it was published last May, nearly two decades after the Hospital last performed such surgery.
To psychiatrist Wise, who’s been with the sex unit since 1974, its strength lies in a set of practices poles away from the New Yorker portrayal. Not being “buffeted about” by all the societal changes of the ’70s, ’80s and ’90s on issues like gender dysphoria is one of the qualities that makes this group stand out, he says. Without looking beyond mainstream America, the unit’s been able to see thousands of men and women through deep sexual conflicts.
Viagra - A drug of choice
A final fall Friday afternoon case conference focusing on an old problem, but with a new twist—Viagra—is a case in point. A couple in their 50s, married for 25 years, has been referred by the husband’s internist, who has prescribed Viagra for his difficulties with erection. An initial trial produced an erection sufficient for penetration, but the husband has subsequently declined to use the Viagra for intercourse. This puzzles his internist and frustrates his wife.
The case history reveals that both partners were longtime heavy drinkers but stopped using alcohol eight years ago. The couple is attractive and socially adept and surprisingly at ease in front of this group. The husband clearly dates the onset of his erectile problems to three and a half years ago. After that, he avoided intercourse and, eventually, any sexual interaction with his wife. The wife complains that after the two stopped drinking there wasn’t much expression of affection in the marriage, but for the last three years, her husband even has pulled away from her affectionate gestures. They both are uncertain how to reopen a sexual relationship now that erectile function is restored.
Staff discussion settles on a recommendation for couple’s therapy that would include sensate focus exercises. This sequence of behavioral drills, originally developed by Masters and Johnson, provides for progressively more intimate physical encounters—moving over the course of several weeks from simple, non-sexual touching to full intercourse. The method, practiced at home, offers a structure for repairing and reclaiming shared sexuality. The results are discussed with a therapist.
The mix of counseling and medication—Viagra—that will be used to help this couple is typical of today’s approach to sex problems. Whereas treatment strategies once were heavily dominated by talking therapy, they now often employ pharmaceutical options too. Some antidepressants, for instance, can be prescribed for patients whose sex drives may have proven problematic or even criminal, and Viagra is now the drug of choice for common erectile problems. “No matter how many jokes you hear on talk radio,” Strand volunteers, “this medication is a wonderful addition.” The field has changed enormously since the unit began, Schmidt says. And it’s going to change still more. “As the scientific base of human sexuality becomes enriched, and the brain chemistry and the genetics are better understood, this is becoming more like the other fields in medicine. That’s very much to the good, in my opinion. The more interventions you have in your bag of tricks, the more patients you can help.”
* The cases presented in this article are composites.