Why Not Just Do What Works? What’s the Catch? Part 1

If the squeeze technique, vaginal dilators, and sildenafil citrate work, why object? These treatments have been proven to be highly effective, at least short-term, in reducing or eliminating the symptoms of rapid ejaculation, vaginismus, and erectile dysfunction, respectively. A useful tool is just that— a fine thing to have available in our arsenals. Whether and when to use these tools are decisions to be made by clinicians and their clients.

It is a question of which approach this individual or couple will find most helpful in meeting his/her/their wishes. These wishes may well be for symptom reversal or control, in which case either brief, cognitive-behavioral treatment or medical intervention may fit the bill. However, if we present our patients with only these options, we may miss those who seek entirely different kinds of resolutions to their problems.

– Perhaps they want to refrain from intercourse, or to refrain from sex with their current partner(s);
– perhaps they prefer same-sex partners or a time of celibacy;
– perhaps they would prefer to be assertive enough to decline sexual intercourse verbally and directly rather than with their seemingly uncooperative bodies;
– perhaps they would prefer to focus on the dysfunctional relationship, in which case “normal” sexual functioning would constitute a betrayal of the self;
– or perhaps they want to use the symptom, regardless of its origins, as an opportunity for individual or interpersonal growth, to deepen the relationship, to heighten the chance for inner change, or to optimize sexual (or other) potential.

Not all patients would choose to avail themselves of these options. Some just want the symptom to go away. That choice deserves to be honored. But it is not much of a choice if it is the only possibility offered. We owe it to our patients to present them with more (and, for some, better) options. Increasingly, market-driven forces will make such a position difficult, although all the more crucial, to sustain.

The concern is that economic pressures from managed care have led to treatment decisions that are not necessarily in the best interests of clinicians and their patients. Patient welfare is not the priority in decision making. In medicine, this has resulted in increased out-patient surgery for major procedures, reduced hospital stays after surgery, and forcing women out of the hospital within 24 hours postpartum. Similar agendas with parallel consequences have surfaced in mental health care. Current controversies surround the possible over prescription of antidepressants to adults and Ritalin™ to children, without sufficient exploration of side effects or alternate treatment approaches. In the same fashion, the presence of expedient, efficient treatment modalities for the symptoms of sexual problems may provide a welcome weapon in our armamentarium. However, the economic pressures brought to bear upon us may ultimately make the most expedient solution appear the most attractive, rather than merely one option among many. Managed care often aims for the fastest route to symptom reversal or containment, even when the underlying problem remains unchanged.

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