Introduction The False Dichotomy

The 20th century marked huge strides in our knowledge of sexual disorders and their treatments, however, advancements were followed by periods of reductio-nistic thinking. Etiology was conceptualized dichotomously, first as psychogenic and then organic. Early in the 20th century, Freud highlighted deep-seated anxiety and internal conflict as the root of sexual problems experienced by both men and women. By mid-century, Masters and Johnson (1) and then Kaplan (2) designated "performance anxiety" as the primary culprit, while providing a nod to organic factors. Together, they catalyzed the emergence of sex therapy, which relied on cognitive and behavioral prescriptions to improve patient functioning. For the next two decades, a psychological sensibility dominated discussions of the causes and cures of sexual dysfunctions (SDs). However, during the late 1980s, there was a progressive shift toward surgical and predominantly pharmaceutical treatments for male erectile dysfunction (ED). By the 1990s, urologists had established hegemony, with the successful marketing of various penile prostheses, as well as intracavernasal injections (ICI) and inter-urethral insertion (IUI) systems [e.g., Caverject (Pharmacia, Teapak, NJ, USA), Muse (Vivus, Mountainview, CA, USA)]. The monumentally successful 1998 sildenafil launch (Pfizer, New York, NY, USA) and its subsequent publicity at the end of the 20th century symbolized the apex of biologic determinism. Most physicians and most of the general public saw SD and its treatment solely in organic terms.

The new millennium finds us moving forward toward a more enlightened and sophisticated paradigm where the importance of both organic and psycho-genic factors is appreciated for their role in predisposing, precipitating, maintaining, and reversing SD. The pharmaceutical industry has developed other phosphodiasterase-5 inhibitor (PDE-5) based treatments for ED as evidenced by the successful 2003 launches of vardenafil (Bayer, New Haven, CT, USA and

GSK, Philadelphia, PA, USA) and tadalafil (Lilly, Indianapolis, IN, USA and ICOS, Seattle, WA, USA). All three FDA-approved PDE-5 inhibitor compounds are selling well worldwide, and new pharmaceutical delivery systems for treating SD are in development. The FDA has approved EROS (UroMetrics, Inc., Anoka, MN, USA), a mechanical device, for the treatment of female SD (FSD). Indeed, multiple products (pharmaceutical, nutriceutical, and mechanical) are being introduced, or are in development, to treat a host of complaints under the market driven heading of "FSD." Despite this juggernaut of pharmaceutical activity, a renewed sensitivity to psychosocial issues is emerging and a more balanced perspective is shaping our discussions of the understanding and treatment of male and female SD. These discussions are the focus of symposia at important international meetings (American Urological Association, World Health Organization, International Society for the Study of Women's Sexual Health, etc.). Yet, they are underwritten (directly or indirectly) by the same pharmaceutical companies that develop and manufacture the drugs, which essentially catapulted a biologic medicalized view of SD onto the world stage, to the exclusion of psychosocial sensitivity. This rebalancing of perspective, reflected a growing consensus of thought, catalyzed by mental health professionals (MHPs). These MHPs have once again successfully advanced the obvious concept: psychosocial factors are also critical to the understanding of sexual function and dysfunction. Sexual pharmaceuticals can very frequently restore sexual capacity. Yet, rewarding sexual function is experienced only when psychosocial factors also support restored sexual activity. Medicine today emphasizes an evidence-based research. There is a seeming inherent tension between this concept and the qualitative "art and science" of psychotherapy (3). This chapter will attempt to bridge that gap by discussing combination treatments (CTs) for SD, where the use of sex therapy strategies and treatment are integrated with sexual pharmaceuticals. There is a synergy to this approach, which is not yet supported by empirical evidence, but is rapidly gaining adherents which over time will document its successful benefits. Although there has been an explosion of research regarding the efficacy of PDE-5s for ED in the last 5 years, there is no doubt in this author's mind that combination therapy (CT) will be the treatment of choice for all SD, as new pharmaceuticals are developed for desire, arousal, and orgasm problems in both men and women. Yet, owing to the paucity of current data available for other sexual disorders, this chapter will primarily emphasize CT for ED.

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