For those individuals where cost is less of a factor in determining decision-making, consultation with a qualified sex therapist offers a potentially more elegant solution, than merely experiencing a trial of sexual pharmaceuticals, when confronted with SD. Yet, it would be unnecessary to subject everyone to a complex evaluation by a sex therapist in advance of a sexual pharmaceutical prescription and brief counseling by a PCP. In part, patients will seek the treatment they want and prefer. Some will seek herbal supplements purchased on the Internet, whereas others will choose a consultation with a MHP specializing in sex therapy. However, if only due to pharmaceutical advertising, most patients will first consult with a physician who will hopefully possess sex counseling expertise, as well as a prescription pad. This physician would adjust treatment according to the individual and couple's history, sexual script, and intra and interpersonal dynamics.
All clinicians want to optimize the patient's response to appropriate medical intervention. However, it is equally important to not collude with the patient's unrealistic expectations of either his or her own idealized capacities, or an idealization of the treating clinician's abilities. These fantasies are based on ignorance and may reflect unresolved psychological concerns. There are situations when it is appropriate to either make a referral within a team approach or to decline to treat a patient. Significant, process based, developmental predisposing factors, usually speak to the need for resolution of psychic wounds prior to the introduction of the sexual pharmaceutical. A man with ED or RE who avoids sex with his intrusive, domineering spouse, is even less likely to successfully utilize a sexual pharmaceutical; if his idiosyncratic and hidden masturbation pattern, emerged in response to a critical intrusive mother (35). The more determinants of SD are driven by developmental processes, the more likely the patient will benefit from sex therapy in addition to pharmacotherapy. There are situations when it is appropriate to postpone treating the patient for the SD, until psy-chotherapeutic consultation is able to assist the individual in developing a more reality-based view. Although sometimes this can be done simultaneously, other times, treatment for SD must be postponed.
Sexuality is a complex interaction of biology, culture, developmental, and current intra and interpersonal psychology. A bio-psychosocial model of SD provides a compelling argument for CT integrating sex therapy and sexual pharmaceuticals. Restoration of lasting and satisfying sexual function requires a multidimensional understanding of all of the forces that created the problem, whether a solo physician or multidisciplinary team approach is used. Each clinician needs to carefully evaluate their own competence and interests when considering the treatment of a person's SD, so that regardless of the modality used, the patient receives optimized care. For the most part, neither sex therapy nor medical/surgical interventions alone are sufficient to facilitate lasting improvement and satisfaction for a patient or partner suffering from SD. There will be new medical and surgical treatments in the future. Sex therapists and sex therapy will complement all of these approaches. This author is optimistic, for a future, which uses CT, integrating sexual pharmaceuticals and sex therapy, for the resolution of SD and the restoration of sexual function and satisfaction.
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