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The sex doctors will see you now

Next week in San Diego, Dr. Irwin Goldstein will open the doors of the nation’s first holistic, hospital-based sexual medicine center. San Diego Sexual Medicine will draw upon multidisciplinary fields to diagnose and treat the sexual complaints of patients, says Goldstein.

Next week in San Diego, Dr. Irwin Goldstein will open the doors of the nation’s first holistic, hospital-based sexual medicine center. San Diego Sexual Medicine will draw upon multidisciplinary fields to diagnose and treat the sexual complaints of patients, says Goldstein.

This could be a revolution in the treatment of sexual complaints. Or, others argue, it could be another step toward inventing disease to serve a pharmaceutical industry bent on creating expensive drugs to fix what isn’t really broken.

The need for some way for the medical community to better address sexual concerns was made clear during a presentation by Dr. Sandra Carson, an ob-gyn at Brown University and the editor of the journal Sexuality, Reproduction and Menopause. Carson practically begged the assembled doctors, mostly ob-gyns, to pay some attention to their patients’ sex lives.

Yes, doctors don’t have time to engage in lengthy discussions and to take sexual histories. Yes, doctors don’t like even broaching the topic, and neither do patients. But please, she said, try.

Talking freely about sex is a problem for many, she says. “This can be for lots of reasons. Patients can have issues about their own sexuality and sometimes doctors are reticent to impose on that reticence.”

Dr. John P. Mulhall, the director of the sexual medicine program at Memorial Sloan Kettering Cancer Center in New York City suggests another reason why doctors are reluctant.

“The average student gets about two hours of sexual medicine in med school,” he says. The fact is, many doctors feel unqualified to talk sex.

So where do you go if you don’t feel like having sex anymore, but wish you did? Or if you like sex but can’t seem to have a orgasm?

Traditionally, primary care physicians would refer a patient to a urologist or ob-gyn, but this may not address the complexities of sexual experience which could require intervention from psychology, endocrinology, neurology or other disciplines.

'A couples' issue'
For Goldstein, addressing sexuality with just such a multidisciplinary approach has been a longtime dream.

Goldstein set up a sexual medicine center at Boston University to conduct basic research, treat patients and mentor new doctors (Mulhall among them). He also authored and co-authored a raft of scientific papers, including the 1998 New England Journal of Medicine report on a new drug called Viagra. The center received hundreds of calls, mostly from women, asking if they should take the drug.

“So we did the most logical thing. We were a clinic studying male sexual health and diagnosing men, so we sent (women) to their gynecologists and every one of them came back saying, ‘The gynecologist suggests we come back to your clinic.’ So we said, this is a couples’ issue. How can you only treat one gender? It makes no sense.”

That was when he realized there was a need for an integrated sexual medicine program center to treat both men and women.

Goldstein began implementing his vision of a multidisciplinary approach for both men and women but says he was hung up by internal politics.

Goldstein retired from Boston University and left the sexual medicine center in 2005 and has spent the last two years traveling the country trying to convince a university to make his dream come true. Finally, San Diego’s Alvarado Hospital and the University of California, San Diego, combined to set up San Diego Sexual Medicine in Alvarado facilities and give Goldstein an appointment as a clinical professor of surgery at UCSD. The doctors at Alvarado will have specialized sexual medicine training in addition to their own areas of expertise.

Sexual medicine as a subspecialty
In addition to treating patients at Alvarado, Goldstein hopes to beef up the training hours medical students get in sexual medicine and to draw upon academic experts there. Ultimately, Goldstein wants the American Medical Association to recognize sexual medicine as a certifiable subspecialty such as family medicine or sports medicine.

That’s already happened in Europe, where the European Academy of Sexual Medicine recently began issuing recognized accreditation, a development Goldstein calls “a huge breakthrough for our field.”

Goldstein’s view that different medical specialties should work together has been boosted recently by the evidence that erectile dysfunction in men is often a sign of blooming cardiovascular disease.

Patients coming to Goldstein’s clinic would first see a psychologist or sex therapist who will take a complete psychosocial, medical and sexual history. Then the patient will be examined by the appropriate professionals and any indicated tests conducted. Goldstein hopes to include sexual partners whenever possible because, he argues, “sex is about partners. It is about couples.” Finally any treatments, whether surgery, drugs, physical therapy or psychological counseling, will commence and patients educated about necessary lifestyle changes.

Real problem or disease mongering?
New York University psychologist Leonore Tiefer, among others, has been a longtime critic of such interventions. She believes, as the title of her 2005 article states, that “dyspareunia [pain with intercourse] is the only valid sexual dysfunction and certainly the only important one.” Tiefer has argued that orgasms and desire aren’t very important and that “the creation and promotion of female sexual dysfunction (FSD) is a textbook case of disease mongering by the pharmaceutical industry and by other agents of medicalization.”

We have been deluded into wanting more and better sexual experiences, she says. “People fed a myth that sex is ‘natural’ — that is, a matter of automatic and unlearned biological function — at the same time as they expect high levels of performance and enduring pleasure, are likely to look for simple solutions. This sets the stage for disease mongering, a process that encourages the conversion of socially created anxiety into medical diagnoses suitable for pharmacological treatment.”

Sloan Kettering’s Mulhall vehemently disagrees.

Sexual medicine clinics like the ones Goldstein envisions “are absolutely necessary,” he says. “If a 75-year-old man can’t have an erection and wants one, or a sexually active 75-year-old woman wants to be sexually active but has no vaginal lubrication, why are we not treating them?”

Mulhall’s comment reminds me of a conference I attended at which Tiefer spoke. She discussed the medicalization of menopause and decried the efforts to “cure” it, saying that an absence of desire could be a very good thing, natural and not to be regretted.

After her talk, a middle-aged woman tentatively raised her hand, drew it back down and then raised it again with great determination. When the moderator called on her, the woman stood up and said, “But I liked sex!” columnist and Glamour magazine contributing editor Brian Alexander’s book, “America Unzipped: In Search of Sex and Satisfaction,” will be published Jan. 15 by Crown/Harmony Books.