Book Review
Sexual Disorders
Perspectives on Diagnosis and Treatment. Peter J Fagan. Baltimore (MD): Johns Hopkins University Press; 2004. 151 p. US$19.95.
Reviewer
rating*: Excellent
Review by:Paul Fedoroff, MD
Ottawa, Ontario
In the interest of full disclosure, I first acknowledge that Dr Fagan was one of my esteemed teachers when I had the privilege and honour of working as a psychiatry resident and then fellow at Johns Hopkins. During those years, I had frequent contact with Dr Fagan and fondly recall the hours of spirited discussions we had about the ideas appearing in this book.
Like many landmark books, Sexual Disorders is at first glance deceptive. It is short and has a modest reference section. Its thesis is that people with sexual disorders require treatment from multiple perspectives—nothing too earth-shaking here.
Dr Fagan proceeds to describe 4 specific perspectives, with beautiful rigour. The disease perspective rests on the premise that patients with sexual disorders have a known or presumed pathophysiological abnormality. The dimensional perspective rests on the premise that troubled individuals all possess strengths and vulnerabilities that can be analyzed on continuous, as opposed to categorical, scales. The behavioural perspective rests on the premise that dysfunctional acts arise from preceding experience. The life-story perspective rests on the observation that people assign meaning to what they experience. Anyone familiar with biopsychosocial or sociopsychobiological formulations should be comfortable so far.
Next, Dr Fagan argues that specialists who assess or treat troubled individuals have not only the option but the obligation to employ all 4 perspectives both at the beginning and relentlessly throughout their work. This is not easy, and he recommends that specialists become expert in at least 2 of the 4 paradigms and consult, consult, consult. Frankly, to read a book by a world authority in such an exclusive area as sexual disorders, one that pays more than lip service to being multidisciplinary, is alone worth the price of the book.
Sexual Disorders goes further, discussing the strengths and weaknesses of each perspective, the difference between description and understanding(social constructionism and essentialism), and ways in which multiple perspectives can be simultaneously brought to bear on therapeutic impasses. The few graphics in the book are delightful in their simple summarization of the complex perspectives they define.
My only criticism of the book is to wish there were more. The Johns Hopkins Sexual Behaviors Consultation Clinic has a history that exemplifies the very paradigm shift the book espouses. Prior to 1979, the Clinic was world-famous for its work in sex reassignment surgery. However, the index of Sexual Disorders does not have a single reference to gender identity disorders (GIDs), to transsexualism, or to the highly influential investigators preceding and following the decision to abandon sex reassignment surgery at Johns Hopkins. This book makes only a passing reference to GIDs during a discussion of “over-valued ideas.”
I am also sorry the Forward by Professor Paul McHugh, former chair of the department, is so brief. His uncharacteristic pessimism about the area of psychiatry dealing with sexual disorders, in which, “despite past interest and effort, little fundamental service to patients has emerged,” invites dispute. But perhaps this highlights the greatest strength of Sexual Disorders. It encourages reevaluation of the way all clinicians work. It is not a manual for treating specific sexual problems, and it is not a comprehensive review of the literature. There are brief case reports but not much data: it is not a tome. Instead, it is a rallying cry for specialists from all disciplines to reexamine their ideas and practices with the aid of a model of Kuhnian proportions. This book encourages debate and argument. I predict Sexual Disorders will become a classic.
*Reviewer
Rating Scale/ Échelle d’évaluation du réviseur
Excellent / Excellent
Very Good / Très bon
Good / Bon
Fair / Passable
Not recommended / Pas recommandé
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