Blocks and Freedoms in Sexual Life

A Handbook of Psychosexual Medicine

Ruth Skrine

• Publisher: CRC Press
• Year: 2019
• Print ISBN:
  9781138414945
• eBook ISBN:
  9781315348964
• Topic: Psychology
• Subtopic: Medical Theory, Practice & Reference
• Index: Psychology

Doctors increasingly recognize that sexual unhappiness has serious effects on the health of individuals and families. Sexual function depends on our bodies and our minds and sexual problems may present with physical symptoms. Using case histories the book describes the practice of psychosexual medicine and explores the skills used by doctors therapists and counsellors. A systematic and comprehensive examination of this field for the first time this book places psychosexual medicine in context with other therapies. For those working at all levels throughout primary care including doctors and nurses in general practice and in family planning clinics therapists and counsellors and for specialists in the fields of genito-urinary medicine gynaecology andrology and urology Blocks and Freedoms in Sexual Life is an essential reference and a tool for increasing the scope and effectiveness of their work.

Part I
Aspects of Doctoring

1

A psychosexual body/mind approach

Truth ... is a reality that exists in between two people seeking it... truth can be seen or glimpsed, not possessed.

Neville Symington¹

Sexual activity is dependent on both physical and emotional factors. The nerves, arteries and veins to the genital organs, not to mention the hormones throughout the body, need to be working adequately. At the same time, as anyone who has ever felt the stirring of sexual arousal within themselves will know, an almost limitless expanse of emotions can enhance or subdue arousal and sexual activity. Even to be able to masturbate with any degree of pleasure and satisfaction requires, for most individuals, appropriate physical stimulation combined with some particular thoughts and images that work in an erotic way for them.

This book is concerned with the search for some truths between the body and the mind. Since the time of Descartes these two aspects of man have been seen as separate. The ills of the two parts have been attended by different medical specialists, although general practitioners have always tried to care for the whole person. It is a difficult task, as the thinking processes of all of us have been channelled into the divide for so long that many doctors and patients still see an illness as 'real' or 'all in the mind'.

The term 'psychosexual medicine' is used by different people to describe different ways of working, each of which may have a different emphasis. In Britain since 1974 it has been used by the Institute of Psychosexual Medicine to describe an approach to sexual difficulties that attempts to take account of both sides of the Cartesian divide. The members of the Institute, originally mostly women doctors working in family planning clinics, and one psychoanalyst, Dr Tom Main, chose the term as a label for the skills they were trying to develop to help people who came to them with sexual problems.

The setting in which the term is used is important to the understanding of the viewpoint from which this book is written. It is based on my own clinical experience, and that of my colleagues in the Institute of Psychosexual Medicine, and is therefore enlightened and circumscribed by that experience. Any insights we have gained are based on our work with people who chose to bring their problem to a doctor, or other worker who deals with the body, and will therefore be different from those gained by, for example, a marriage guidance counsellor, psychoanalyst or priest, although there will, of course, be many overlapping areas. The skills and insights we have acquired are now used by doctors and others working in different settings, but their development at that particular time was at least in part an outcome of the contingency of the setting.

Most of our patients were not suffering from any illness, either physical or mental, but were healthy people who had come for contraceptive advice. Behind this overt request there were often anxieties and physical and emotional pains. We, the doctors and nurses, were freed from the pressure and responsibility of providing acute medical care, yet we were faced with distressed people for whom we felt we had little to offer. Our search for further training and understanding grew not from some particular interest in sexual matters (such interest was probably neither more nor less than that of any other group of people), but from the sense of hopelessness in the face of patients in need.

Now that most general practitioners are offering a comprehensive family planning service to their patients, it is in that setting that sexual difficulties are most often presented. This change is reflected by the sorts of doctor who are seeking further training with the Institute of Psychosexual Medicine. In 1988 two-thirds of the doctors in training worked in community medicine and one-third in general practice. In 1995 an equal number worked in general practice, the community and hospital medicine, mainly in gynaecology or genitourinary medicine. The presence of those working in hospitals is a sign of the increasing realization that sexual problems often present with physical complaints.

The method of training and study that we used, and that is still used, is based on the seminar method devised by Dr Michael Balint.² We were not provided with answers or theories, but with an opportunity to develop our skills. Thus for most of us the sense of not knowing what to do or how to help continued, but we gradually began to be able to tolerate such confusion with less despair.

Doctors are traditionally expected to have the answers or at least to be able to offer a view informed by knowledge and experience, and in many situations they can do just that. When it is a question of which antibiotic to use, or whether the patient needs to have an operation, such a view is worth canvassing and worthy of careful consideration. When the question is one of 'Should I leave my wife?' or 'Why have I gone off sex?', the doctor's view is not so useful because the answer lies within the person asking the question. Yet that person has not been able to find the answer alone and has chosen to come to a doctor for help. Often he has chosen a particular sort of doctor, a general practitioner whom he knows to be approachable about personal matters, a family planning or genitourinary doctor whose specialty implies an acceptance of sexual matters, or sometimes a newcomer or locum in a practice who has the advantage of being a stranger who need not be seen again. Help may be possible if the answer can be to allowed to 'emerge between' the patient and doctor during the consultation. Thus it has been necessary to develop some skills in working in a psychodynamic way, which is very different from the traditional role of the doctor as expert adviser or even caring counsellor and friend.

However, doctors have knowledge about and some responsibility for the bodies of their patients, and that cannot be ignored in their attempt to work differently with the patient's feelings. A simple example would be of a woman complaining that sex was painful. As in the case of headache, another very common but often baffling symptom, there may be many underlying causes, ranging from serious life-threatening disease such as a brain tumour to tension due to a row at home. Painful sex can be due to serious pelvic pathology, to an attack of thrush or to vaginal dryness from poor sexual technique, to name but a few possibilities. On the other hand, it may be due to emotional blocks to arousal. The doctor who develops psychodynamic skills but who wishes to remain someone who treats the whole person cannot forget his traditional physical doctoring, and it is this combination of emotional and physical interest and concern that provides the possibility of looking at the way in which the body and mind work together.

Such an approach is still far from common among doctors, and indeed often not expected or understood by those wanting help. Many men suffering from impotence will subject themselves to physical treatments, injections or operations, believing that their problem lies in their penis. Physical treatments of this kind can be very useful if there are serious physical disabilities causing the erectile difficulty. They can also have a powerful effect in combating anxiety, which is a major factor in all sexual problems, and in restoring confidence. Other men, however, have the sneaking feeling that perhaps that is not the whole story and look for other types of help.

Because sex is such a complicated activity, it can be difficult to begin to sort out the causes of problems, which may be partly physical and partly emotional. For example, we know that the mechanism of erection requires the veins of the penis to be able to retain the extra blood in it. Sometimes impotence can be caused by a venous leak, but the many complicated and deep emotions that are almost certain to be present in the person attached to that penis make a simple physical diagnosis fraught with difficulty. One might approach the problem by asking a back-to-front question. What degree of venous leak might be compatible with an erection adequate for intercourse in a sexually confident man in the presence of an interested woman whom he finds highly desirable and who makes him feel neither anxious, angry nor guilty? Such a question is, of course, impossible to answer, as those emotions can occur at all levels of the personality, including the deeply unconscious, and can never be completely understood or quantified.

The acceptance that we can never have complete answers or grasp the whole truth does not make the search a useless one. In my experience most patients are much more realistic about what doctors might be able to do for them than are the doctors themselves, who sometimes feel that they should be able to cure everyone of everything. I am not denying the hope that a magic answer can be found to a problem that is brought to doctors with differing degrees of urgency and pressure. 'You must do something doctor' does not necessarily mean that the patient believes you can, only that he wishes to impress on you the desperation of his case. If the desperation can be recognized in such a way that the person feels you are on his side, above all that you understand something of what it feels like to be him in his situation, it may be possible to begin to work together to search for a degree of understanding.

Case Study 1

Mr Abbot had seen many doctors to try to get help with his impotence of 8 years' standing. He had waited several months to see the psychosexual doctor and entered the room saying, 'Well, I hope you can help me because if I am not better in the next 6 months I am going to have a penile implant.' The doctor's heart sank, as it did not appear from the referral letter that Mr Abbot had any gross physical disease that might justify such a radical step. (The use of an implant requires the destruction of any natural erectile tissue that is present.)

Patient and doctor talked with difficulty about Mr Abbot's fury with all the doctors who had not helped him, including his feeling about having to wait so long for this appointment. Towards the end of the interview they were able to share something of his misery and despair at having lost a part of himself that was so precious.

As Mr Abbot left, the doctor asked whether he would like to come again, admitting that he did not have any magic and could not promise a cure in 6 months, or indeed at all, but that they could talk and try to understand it a bit together. The patient gave a charming smile and said he had not expected to be cured anyway, and yes, he would like to talk again.

The lack of sexual happiness, or at least 'good enough sex', which could be compared to Winnicott's 'good enough mothering',³ causes much suffering both to individuals and to families, and that suffering can be damaging to health. Doctors and health care workers should therefore be among those many groups of people (not least friends, neighbours and relatives) who give thought to the problems. It is the fruit of some of that thinking that I am trying to capture here.

In medicine the place to begin is usually with a consideration of aetiology, the causes of things. I have already indicated that the causes of sexual difficulties often lie in both the body and the mind. There are further ways of trying to understand the emotional side, which I have summarized in an abridged form in Table 1.1.

What we believe about aetiology will affect what help is offered and in what way people feel they want to be helped. I believe that all the views listed in the table have some validity. In Chapter 3 I will look briefly at ideas about the structure of the personality, and it will become clear that many of the basic facts of our sexuality are determined early in life. However, there is ample evidence to show that subsequent experiences can also have damaging or enhancing effects on that part of our lives. A behavioural view holds that early sexual experiences under less than ideal conditions, in the back of a car or behind the bicycle shed for example, can produce a conditioned response such as premature ejaculation. That may be the case, but as I will show in later chapters other deeper emotions can often underlie what appears to be a simple symptom.

There is a widespread belief that sex is always about the relationship between the couple, and some doctors insist on referring couples to a psychosexual clinic when individuals wish to come on their own. Such a belief seems to be a legacy of early behavioural sex therapy in which the method depended on both members of the couple being involved in the treatment. Of course, the relationship is a vital area for study, but it does not address the feelings that individuals have inside themselves and in relation to their own bodies.

Table 1.1 Aetiological views of sexual problems

Psychoanalytic

Behavioural

Sex as part of a relationship

Psychosexual: body/mind together

Table 1.2 Skills of psychosexual doctoring

Listening; patient-centred consultation

Giving advice appropriately

Using reassurance sparingly

Tolerating not knowing what to do

Psychosexual genital examination

Use of the doctor-patient relationship

As this book draws on the particular experiences of body/mind doctoring, I will not be dealing in detail with the other approaches listed. However, there is much overlap between them all, and we will not get anywhere near a realistic understanding if we stick rigidly to one aetiological belief. Where possible and where it seems appropriate, I will give reference to the other views.

Meanwhile I must return to my task of trying to explain what is meant by a psychosexual approach. One way of trying to convey a sense, a gut feeling, a taste of what such a view might be, is to describe the skills that doctors, nurses and others are working to develop in order to try to help (Table 1.2). Lists create artificially hard borders and boundaries, yet they can form a focus from which one can explore surrounding areas. The last two items in Table 1.2 are so important that I will devote a separate chapter to each of them. Here I will enlarge briefly on the other skills. The list is by no means comprehensive, and it includes aspects of the medical consultation that have been to some extent examined and analysed by other people. I have included these aspects in order to try to create a link with the sort of training and skills that are now being used in undergraduate and immediate postgraduate medical training.

Listening

If one tries to define listening, the meaning seems to become blurred and indistinct round the edges. At its simplest, we may know something has been said yet realize we have not heard the words. We may have to say, 'Could you repeat that? I didn't qui...

Table of contents

• Cover
• Title Page
• Copyright Page
• Contents
• Acknowledgements
• dedication
• Part I Aspects of Doctoring
• Part II Symptoms and Feelings
• Part III Making Connections
• Index