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