edited by R. Balon. Basel, Germany, Karger, 2008, 174 pp., $39.00.
Sexual behavior represents a complex interaction of biology and psychology. Over the past decades, the study of human sexuality has become multidisciplinary with urology, obstetrics, and gynecology as well as other disciplines providing biological assessment and treatment. Unfortunately, the field of psychiatry has become less involved and more disinterested. Psychiatry has a great deal to offer by integrating the biological, psychological, and sociocultural perspectives with our ability to provide integrated treatment. In Sexual Dysfunction: The Brain-Body Connection, this integrated perspective is missing, and, consequently, the book reads like a biological text.
It is important to note the title of the book, in which there is no mention of mind, emotions, or relational context. The Viagra Revolution occurred in 1998, and the medicalization of sex quickly followed. Lenore Tiefer (1) asked the question, “Is sex becoming more like digestion than dancing?” Tiefer led a campaign to raise awareness of the political aspects of the role of the pharmaceutical companies in the medicalization of sex.
Sexual Dysfunction: The Brain-Body Connection presents some of the new biological developments in some areas of sexual dysfunction. There are 10 chapters covering topics such as erectile dysfunction, management of hypoactive sexual desire disorder, and recent advances in the classification, neurobiology, and treatment of premature ejaculation. The book is heavily slanted toward male dysfunction and the use of pharmacological agents. Did you know that patients who report relational dysfunction are generally excluded from medication trials? A fact that you will not find in this book is that without concomitant psychological treatment, the drop-out rate for pharmacotherapy, in general, and erectile problems, in particular, is high and reported to be in the range of 40%–80% (2).
However, several biological facts reported in the book are noteworthy. The presence of erectile dysfunction is “a sentinel marker for several reversible conditions such as peripheral and coronary vascular disease, hypertension and diabetes” and “prompt investigation and intervention for cardiovascular risk factors is imperative” (p. 33). The Princeton Consensus group considers that “a man with erectile dysfunction and no cardiac symptoms is a cardiac patient unless proven otherwise” (p. 42). Also interesting to note is that a Mediterranean diet leads to an improvement in erectile function scores in patients with erectile dysfunction. Further, women with coronary artery disease also have statistically significant increases in sexual dysfunction.
There has been little focus or attention paid to female sexual dysfunction in this book and in the study of human sexuality in general. For example, there are no Food and Drug Administration-approved medications for the treatment of sexual problems in women. Chapter 2 discusses the recent challenges to the DSM-IV-TR criteria for sexual disorders, particularly the delineation of the differences between male and female sexual response cycles. The linear sequencing of desire, arousal, and orgasm is a model better suited to male sexuality. The female sexual response cycle is better described as circular, in which sexual desire and arousal phases overlap. Therefore, it is difficult to consider treatments for female sexual dysfunction when the basic mechanisms for the sexual response cycle are still relatively poorly understood and researched.
Leiblum (3) addressed the common clinical problems underlying sexual dysfunction and discussed how to integrate biological and psychological treatments. While Balon’s book is informative, I hope it does not give the impression that the current standard of care for the management of sexual dysfunction is purely biological. Although it is everyone’s fantasy that all ailments can be cured with a magic pill, most people on reflection will understand that problems of intimacy need to be addressed within the relationship. It is imperative that psychiatrists continue to evaluate patients and their partners together to assess sexual dysfunction in the context of their relationships. The treatment that follows will, therefore, more likely be comprehensive and have a greater likelihood of success.
1.Tiefer L: Sexual behaviour and its medicalisation: many (especially economic) forces promote medicalisation. BMJ 2002; 325:45
2.Brock G, McMahon C, Chen K, Costigan T, Shen W, Watkins V: Efficacy and safety of Tadalafil for treatment of erectile dysfunction: results of integrated analysis. J Urol 2002, 168:1332–1336
3.Leiblum S: Principles and Practice of Sex Therapy, 4th ed, New York, Guilford Press, 2007
The author reports no competing interests.
Book review accepted for publication October 2008 (doi: 10.1176/appi.ajp.2008.08091435).