The concept is a simple one with a long history; sometimes, two heads are better than one. Treatment may require a multidisciplinary team in cases of severe dysfunction, and may be recalcitrant to success even under this ideal circumstance. There are many models for working together. Team approaches and composition will vary according to clinician specialty training, interest, and geographic resources. Although some expert physicians work alone, other PCPs, urologists, and gynecologists have set up "in house" multidisciplinary teams where nurses, physician associates, and master's level MHPs provide the sex counseling. This approach has obvious advantages and disadvantages. In cases of more severe PSOs, the patient(s) will be "referred out" for psychopharmacology, cognitive-behavioral therapy, and marital therapy in various permutations, provided by doctoral level MHPs (55-57). However, typically a clinician refers within their own academic institution, or within their own professional referral network—a kind of "virtual" multidisciplinary team. Endocrine, gynecologic, or urologic referrals for the patient or partner may be required, and would usually be readily available. However, MHPs trained in sex therapy will experience the greatest number of new opportunities for interdisciplinary participation to enhance and optimize patient response to sexual pharmaceuticals. Identifying psychological factors does not necessarily mean that nonpsychiatric physicians must treat them. If not inclined to counsel, or, if uncomfortable, these physicians should consider referring or working conjointly with a sex therapist. All clinicians should be encouraged to practice to their own comfort level. Indeed, some PCP will not have the expertise to adequately diagnose PSOs, independent of their ability or willingness to treat these factors. Awareness of their own limitations will appropriately prompt these physicians to refer their patients for adjunctive consultation. Physicians who prescribe PDE-5s and future sexual pharmaceuticals may need adjunctive assistance, referring to sex therapists, because of their own psychological sophistication or due noncompliance on their patient's part. Whether the referral is physician or patient initiated, sex therapists are ready to effectively assist in educating the patient about maximizing their response to the sexual situation. They are able to help re-motivate people who have failed initial medical treatments, as well as helping patients to adjust to "second and third line" interventions. They help make patients receptive to trying again. Sex therapists are also equipped to help resolve the intrapsychic and interpersonal blocks (resistance) to restoring sexual health (20,42). Some clinicians are uncomfortable discussing sex, and many important issues remain unexplored because of clinician anxiety and time constraints. Sex therapists can manage event and process based developmental factors, which predisposed the patient to manifest the SD. They are trained to manage the most difficult cases involving process-based trauma that are replicated in the current relationship. Sex therapists working adjunctively with the PCP, urologist, or gynecologist could provide all the previously discussed sex counseling, as well as managing PSOs with greater therapeutic depth. Sex therapists can enhance hope, facilitate optimism and maximize placebo response. There can be an increased individualization of treatment format, by fine-tuning therapeutic suggestions, as well as improving response to medication by optimizing timing and titration of dose. Sex therapists have a sophisticated appreciation of predisposing (constitutional and prior life experience), precipitating factors triggering dysfunction, and factors maintaining SD. Finally, sex therapists are skilled in using cognitive-behavioral techniques for relapse prevention. All of these issues impact potential and capacity for successful restoration of sexual health. Delineating all permutations, of multidisciplinary team approaches likely to be utilized for the next decade, is beyond the scope of this chapter. However, a useful glimpse of this process is provided in the following case, where this author collaborated with a PCP, a urologist, and a psycho-pharmacologist, in a "virtual" multidisciplinary team approach to CT.
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