Diabetes and normal aging (menopause) are two real somatic conditions that affected Mark and Esther’s ability to function sexually. As such, the diabetes and postmenopausal conditions deserve to be the object of somatic treatment. Perhaps other, psychological interpretations might have been developed to understand their sexual problems. Mark might have been passive aggressive in not treating his erectile dysfunction sooner. Esther, as a consequence of her sense of rejection, might have refused hormone replacement treatment as a way of withholding herself as a potential sexual partner. And there certainly may have been numerous nonsexual marital tensions or differences that could serve as the focus of lengthy marital therapy. But Mark had diabetes and Esther had atrophic vaginal walls.

The disease perspective says that the clinician should first examine all the somatic conditions and diseases that might play a causal role before rushing on to a more psychological understanding of the sexual dysfunction. For the physician, this is professionally instinctive; for the nonphysician with a treatment quiver filled with psychological approaches and interpretations, ruling out diseases and somatic conditions is usually a skill deliberately learned. Nonphysician mental health providers must develop a level of knowledge about the diseases affecting sexual function that is superior to that of the educated layperson. They must also have a good working relationship with primary care physicians, urologists, and gynecologists, both for their own continuing education and for mutual patient referrals.

The Past Is Prologue

In the somatic treatment of sexual dysfunction, it is important to observe the limits posed by premorbid sexual function. “Past is prologue” in the sense that the baseline level of sexual function for the years preceding the onset of the disease is probably going to be the optimum level of functioning possible with the most successful of somatic treatments. A common medical phrase is “return to baseline”: the patient returns to the level of function (e.g., cardiac, pulmonary) that he or she had before a disease or critical event.
Mark and Esther will in all probability never have more interest in sex or more frequent sex than they did before the onset of Mark’s diabetes. While the “finding again” of each other sexually will undoubtedly enrich their marriage, after their second honeymoon their sexual life will probably settle into the baseline value they placed on sex twelve years ago. This is realistic, not pessimistic. It is a realism that is aided by the disease perspective, with its sensitivity to somatic limits posed by illnesses and injuries even though much of the baseline of sexual life is determined by factors other than somatic.

These nonsomatic factors make the return to baseline not merely a realistic compromise between ideals and reality but also a goal to strive for. After many decades, aging bodies and the ebbing of all novelty demand that the physiological drive for sex be supplemented by motivations of caring, sensuality, and need for intimacy. Helping couples to recall their baseline level of sexual life gives them a joint goal to aim for. Memory and imagination can be employed to picture the type of sexual life the future may hold for them. The clinician’s role is—to use the saying usually applied to parents—to give their patients both ground and wings: the ground of accepting the limitations imposed by somatic conditions; the wings of imagining new meanings and ways of coming together sexually.

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