Most of the clinicians involved in the treatment and/or research of sexual dysfunctions/disorders are probably not very satisfied with the current nomenclature, which is mostly unidimensional and not including all nuances and aspects of sexual problems. The nomenclature does not deal with psychological, relational, and situational factors of human sexuality. Some of these issues, especially the ones related to female sexuality, are discussed in more detail in several chapters of this book (see for instance the Chapters 3 and 6).
A 26-year-old male who complains being distressed because ejaculating within 30-60 sec after penetration during sex with his wife, but reports no rapid ejaculation while masturbating technically meets the diagnostic criteria for premature ejaculation. Nevertheless, the diagnosis of premature ejaculation does not fully describe the scope and psychology of his sexual dysfunction. The same could be implied in the case of 67-year-old married male who started to compulsively masturbate about 2 years ago. He thinks about other men being around at times while masturbating, or at times he masturbates just "without any thoughts," in various places, for example, while driving. Is his diagnosis sexual disorder not otherwise specified? Or obsessive-compulsive disorder? Do these diagnoses-labels help the clinician in any way?
The recent diagnostic system, paraphrasing Winston Churchill, is probably the worst diagnostic system except for all those that have been tried. It certainly could be improved. Recently, Fagan (47) proposed a systematic way in which clinician organize the mass of information about sex. We discuss it in more details for two reasons—it clearly demonstrates that human sexuality, as other areas, requires a more complex and sophisticated descriptive/diagnostic system, and it illustrates one of probably many possible approaches.
Fagan suggests using the system of four perspectives, or four different ways to view a clinical case, which was originally developed by McHugh and Slavney (48) for all psychiatric disorders. He believes that these four perspectives are a more complex way of viewing clinical information and then communicating that information to clinicians, colleagues, and the individual with the clinical problem or disorder.
These four perspectives are:
1. The disease perspective
2. The dimension perspective
3. The behavior perspective
The disease perspective is categorical, the patient either has or does not have the disease. As Fagan (47) points out, this is the foundation of the medical model, but not the entire story. This perspective turns to physiology, anatomy, and medicine to learn about patient's sexual problem.
The dimension perspective focuses on measurement (dimensional gradation and quantification). Examples of the objects of measurements are intelligence quotient, behavioral patterns, mood, or personality traits.
The behavior perspective focuses on the behavior of an individual who is goal directed, or teleological. Fagan explains that the behavior perspective is to cognitive-behavioral clinician what the disease perspective is to physician.
Finally, the life story perspective is what "most people associate with psychotherapy." It relies on the narrative told by the patient to give some meaning and direction to their life.
Fagan emphasizes that "no single perspective is, in itself, more valuable than any other," and each perspective can contribute to the formulation. His proposal helps, in part, to deal with several issues. First, human sexuality is much more complicated than just achieving reliable erection and, as noted, the medical diagnosis does not include psychological, relational, and other factors. Second, not all sexually disordered behavior has a psychiatric diagnosis. Third, sexual diagnosis is an alternate and developing construct. Fourth, sexual diagnosis does not imply causality.
Fagan suggests that one should select the primary perspective that "best fits the patient and then integrate the other perspectives into the formulation and treatment to make use of the additional contributions they may provide." He also emphasizes that perspectives are conjunctive and not disjunctive.
Fagan feels that using the four perspectives is more helpful in delineating sexual problems/dysfunctions/disorders and conceptualizing their treatment. Many will probably find this proposal too complex or not complex enough, overly inclusive or not inclusive enough, not practical enough or too practical. However, we feel that it is an interesting and thoughtful proposal, which may further stimulate and help the debate about the diagnostic issues in the area of sexual dysfunctions/disorders.
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How to increase your staying power to extend your pleasure-and hers. There are many techniques, exercises and even devices, aids, and drugs to help you last longer in the bedroom. However, in most cases, the main reason most guys don't last long is due to what's going on in their minds, not their bodies.