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Mental Disorders

by Peter J. Fagan
Johns Hopkins University Press, 2004
Review by Christian Perring, Ph.D. on Jun 1st 2005

Sexual Disorders

In Sexual Disorders, Peter Fagan applies the approach to psychiatry proposed by McHugh and Slavney in their profoundly important book The Perspectives of Psychiatry to the area of sexual problems. It is a short book with just 137 pages of main text, and so it does not attempt to provide an exhaustive categorization of the sexual difficulties people face and how to treat them. Rather, it provides a schematic approach illustrated with some cases. After the Introduction, the chapters address the disease perspective, the dimension perspective, problematic behaviors, the treatment of sexual disorders in the behavior perspective, and finally the life story perspective. The book finishes with a chapter on how to integrate the different perspectives.

McHugh and Slavney's perspectives approach can be seen as a thoughtful way to implement something like Engel's biopsychosocial model, which is generally presented without attention to how different levels of description fit together or whether different concepts are compatible with each other. Yet the perspectives approach is also very broad, and it is not necessarily clear how it might be applied in particular cases. Thus, Fagan's book on sexual disorders can be seen, surprisingly, as a contribution to theoretical psychiatry and even philosophy of psychiatry, in paying more careful attention to how different perspectives on sexual disorders should be understood, and how they can be melded together to create a comprehensive multi-dimensional view of people in order to provide the best treatment possible.

One of the frequent criticisms of the biopsychosocial model is that it insists that one must always consider human problems using a conjunction of biological, psychological, and social theories, even when this is not appropriate. Fagan's use of the perspectives approach shows that it does not suffer from the same failing: while it can be useful to consider all possible perspectives, often it is not necessary to do so. One can use just one or two perspectives in understanding and treating a patient, and clinical judgment helps the health professional to determine which perspectives are most appropriate. For example, one patient Ralph, a 45-year-old man with a twenty-year marriage, reported lowered sex drive. Although the clinician considered several possible diagnoses, tests showed very low testosterone and elevated prolactin levels, and subsequently an MRI showed a non-malignant neoplasm on Ralph's pituitary gland. He was treated with regimen of bromocriptine and he recovered, with his life returning to normal. Here the disease perspective was most appropriate and the patient's life history and personality were largely irrelevant. In other cases, the patient's problems are closely connected with his or her life history and feelings about sex. In these cases, treatment may involve some combination of medications, behavior therapy and psychodynamic exploration.

While the disease perspective is relatively straightforward, it is harder to separate out the dimension perspective, the behavior perspective and the life story perspective. Dimensions are closely linked to personality or character traits. They are referred to as dimensions rather than personality traits because of the belief in gradations in these traits, and even the potential quantification of them. This is different from a categorical approach, which simply asserts that a person has or lacks a particular trait. For example, George is a widower who has started a romantic relationship with a woman, but suffered from erectile dysfunction. He is given a personality inventory, and he scores high in Extraversion, Agreeableness, and Conscientiousness. After talking about his problems with a therapist for about two months, George's sexual problem dissipated. Although Fagan's discussion is speculative, he suggests that the difficulty was related to George's Conscientiousness, even George denied any sense of guilt about betraying his dead wife. Obviously, in a case such as this, the life story and the personality are intricately woven together, and it makes little sense to insist on a strict separation of them. It is also clear that the disease perspective is largely irrelevant.

For those such as myself who know little about the medical and scientific psychological literature on sex and sexual problems, Sexual Disorders provides a very helpful way to understand the relations between the profusions of approaches one finds there. It also provides an introduction to some of the main approaches in treating sexual disorders, written in clear language with a minimum of jargon. Finally, it may provide those concerned with the conceptual coherence of the biopsychosocial model with a way to combine the different levels of understanding in a methodologically sound way while resisting the dogmatic reductionism of advocates of biological, psychodynamic or social theories on their own. Being a short work written by a clinician, the book is unlikely to provide philosophical solutions to deep problems about the unity of knowledge, but it nevertheless could provide very helpful illustrations for those who are grappling with those problems.





2005 Christian Perring. All rights reserved. 


Christian Perring, Ph.D., is Academic Chair of the Arts & Humanities Division and Chair of the Philosophy Department at Dowling College, Long Island. He is also editor of Metapsychology Online Review.  His main research is on philosophical issues in medicine, psychiatry and psychology.