Psychosomatics 46:280-281, June 2005
© 2005 The Academy of Psychosomatic Medicine
Sexual Disorders: Perspectives on Diagnosis and Treatment
By Peter J. Fagan, Ph.D., Baltimore, The Johns Hopkins University Press, 2003, 176 pages, $40.00 (hardcover), 2003, 176 pages, $18.95 (paperback), ISBN 0-8018-7526-9 (hardcover), ISBN 0-8018-7527-7 (paperback)
Glen O. Gabbard, M.D.
Sexual disorders do not lend themselves easily to a dispassionate, systematic evaluation. They are flashpoints for moralizing, contempt, and irrationality. The profession of psychiatry has long struggled with how to classify and label these problematic human behaviors. It is impossible to think about paraphilias without being influenced by personal biases and cultural norms about which forms of sexuality are considered outside the mainstream.
In this context, this new volume by Peter Fagan is a breath of fresh air for the field. Building on the work of McHugh and Slavney, the author brings multiple perspectives to the understanding of sexual disorders. These include the perspectives of disease, dimension, behavior, and life story. This broad-based approach allows for medical differential diagnosis, considerations of personality, evaluation of specific behaviors, and the psychotherapeutic perspective of idiosyncratic meanings and fantasies based on the specifics of a life story like none other. This systematic approach to sexual disorders fits neatly within the biopsychosocial model of psychiatry and therefore captures the person as well as the illness.
Fagan lays out these four perspectives in a prose style that is admirably clear and lucid. He uses remarkably little jargon, and the scientific discourse is liberally sprinkled with clinical examples that persuasively illustrate the points he wishes to make.
As the author discusses each dimension, he argues that some perspectives are particularly useful for understanding particular aspects of human sexuality. For example, the dimensional perspective reflects the complexity of sexual orientation. Fagan emphasizes that for a substantial number of people, there may be attractions to partners of the same gender, even though there is no self-identification as gay or bisexual. The "either/or" categories of straight or gay may not do justice to understanding the specific individual struggling with sexuality.
In the chapter on the life story perspective, the author stresses how specific developmental events may take on special significance in one’s sexual identity and sexual preferences. The narrative of any one individual with a paraphilia tends to humanize that individual in a way that makes treatment planning more individualized and that diminishes negative countertransferences that interfere with the psychotherapist’s capacity to empathize. Films such as The Woodsman and Lolita are often troubling to audiences because they refuse to approach subjects like pedophilia generically. Instead, they consider the individual idiosyncracies in the life narratives of the protagonists in such a way that the audience is forced to understand and not simply condemn. Nowhere is this emphasis more important than in the clinical setting.
In the masterful final chapter, Fagan integrates the four dimensions in a way that is clinically useful to clinicians at all levels of experience and education. This book deserves a place on the shelves of students as well as veteran clinicians who thought they had a thorough understanding of sexual disorders and no longer required new perspectives to enlighten them. I feel certain that all readers will be richly rewarded by spending time with this first-rate contribution to the literature.
FOOTNOTES
Dr. Gabbard is the Brown Foundation Chair of Psychoanalysis, Professor of Psychiatry, and Director, Baylor Psychiatry Clinic, Baylor College of Medicine Houston, Tex.
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