Sex Through a Looking Glass
Date: February 1, 2010
To psychologist Chris Kraft, Ph.D., having a patient complain of low sexual desire is like telling the family physician,“Doctor, I’ve got a headache.” It’s a sign to pull out a variety of lenses, each one magnifying a layer of self.
If the medicine of sex differs from other Hopkins psychiatric specialties, it’s because sexuality itself crackles with a cultural and emotional charge. But aside from having a deep awareness of that fact, psychologist Kraft and fellow clinicians with the Sexual Behaviors Consultation Unit (SBCU) employ the same diagnostic approach. And that’s a strength.
“We rely heavily on the Perspectives,” Kraft says of the seminal textbook, The Perspectives of Psychiatry, by Hopkins psychiatrists Paul McHugh and Phillip Slavney. It gives an orderly view of patients from four platforms, seeing where they stand medically, for example, or how they handle what life’s dealt them.
Kraft, SBCU director Fred Berlin, M.D., co-clinical director Kate Thomas and colleagues evaluate local and international clients who come with a whole Crayola box of sexuality issues. Some patients are troubled by the kinds of sexual problems that resemble addictions. Others may have gender-identity concerns. But most SBCU consultations—some 75 a year—are for couples with sexual problems. And there, Kraft says, the Perspectives’ lenses fairly snap into place.
A common scenario is of a professional couple, both in their late 40s: The long hours that “Husband” spends competing with the young buck attorneys in his office for clients preclude exercise. He’s grown paunchy and sensitive about it. “Wife” works hard as well, but with the kids now in college, she’s turned a sibyl’s eye on the couple’s sex life: There isn’t any. The two live essentially separate lives in their home.
Wife initiates the SBCU visit. I love him but we don’t do anything. Is it his hormones? During an initial separate interview, Husband says, I dearly love my wife but I just don’t see us together that way. The spark is gone. A wide-reaching joint interview follows, then clinicians request hormonal and other blood work, psychological tests and psychiatric screening. Kraft suspects mild depression in both. And he also has Husband referred to a cardiovascular specialist.
It happens that the problem is neither hormonal nor depressive nor a wifely lack of “zing.” It’s circulatory and relational. Husband’s potency is lessened by a hypertension drug his doctor prescribed and he’s humiliated. Wife, not understanding, is resentful. Each explains the problem in unrealistic ways. Wife is sure she’s grown undesirable; for Husband, it’s that he’s old and incapable. They avoid sex altogether by sidestepping anything that might lead there—even holding hands. “It’s not uncommon to have these crossovers from the physical to the emotional to the relational,” says Kraft. He’s seen similar effects in patients on SSRI depression medication or in women following hysterectomy. Problems post-prostatectomy can also masquerade as low desire.
What’s next for the couple? “When we give feedback,” says Kraft, “we break it down into Perspectives and put it into a hierarchy we think most relevant.” In this case, staff began with the medical issue, but in two successive visits, worked into the couple’s relationship history, their self-esteem and body-image concerns. Both were counseled on normal role and physiology changes with age. They were given homework—structured activities that lead to intimacy.
“We’re not content,” says Kraft, “unless couples walk out of here happier, wiser and with a plan.”
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