Richard Balon

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Department of Psychiatry and Behavioral Neuroscience, Wayne State University, Detroit, Michigan, USA

In the last decades of the 20th century, major changes have occurred in our understanding, conceptualization, and treatment of sexual problems. Much of this change was heralded in by the development of oral therapies for the treatment of erectile disorders, the off-label usage of serotonergic antidepressants to treat rapid ejaculation, the increasingly common use of unapproved use of androgens

Evolution of Current Treatment Approaches

Epidemiology of Sexual Dysfunction


Evolving Models

Medicalization of Sexuality



to increase libido in women with hypoactive sexual desire disorder, and the combined use of anti-androgens and serotonergic antidepressants to treat paraphilias. The wide spread usage of effective biological therapies for sexual disorders has contributed to the increasing emphasis on biological models concerning etiology, often to the neglect of psychological factors. In the 1960s, it was commonly assumed that most sexual problems were psychogenic in etiology (1). However, the advent of effective biological therapies has shifted the focus to organic causes of erectile dysfunction (2). These changes in assumed etiology have had profound effects on treatment and conceptualization of the origins of sexual disorders. Many patients who used to be treated by behavioral therapy are now being treated pharmacologically. The rapid development of biological models of therapy has brought valuable help to many individuals who previously had minimal treatment choices. However, a number of factors including the large number of men who dont refill sildenafil prescriptions indicate that pharmacotherapy alone may not always be sufficient (3). To date, there is insufficient data to indicate when pharmacotherapy alone, psychotherapy alone, or combined therapy is indicated for most of the sexual disorders.

A comparable situation in general psychiatry exists in the treatment of depression and obsessive-compulsive disorders. In each of these conditions, both pharmacological and psychological treatment approaches have been shown to be effective, and the most efficient clinicians select and combine therapies for the individual patient (4-7). Our experience in treating depression and obsessive-compulsive disorders may provide useful models for the treatment of sexual disorders. An example of an useful model is the study comparing nefazodone to cognitive-behavioral analysis system of psychotherapy to the combination of these two modalities (8). Although the monotherapies were efficacious, they were not significantly different from each other. However, the combination of the two modalities was significantly better than either monother-apy. Actually, the combination resulted in a highest ever treatment response rate in clinical trials of chronic major depression. As Heiman (9) pointed out, the implications for treatment of sexual dysfunction are compelling, though we need to clarify which medications and psychological therapies might be compared and combined.

The rest of this chapter will briefly summarize the history of the development of treatment for sexual problems and the recent knowledge about the epidemiology of sexual dysfunction, and discuss problems with current nomenclature.

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