Referral of Impotent Patients to a Sexual Dysfunction Clinic

Transcription

1 Archives ofsexualbehavior, Vol. 11, No. 6, 1982 Referral of mpotent Patients to a Sexual Dysfunction Clinic R. T. Segraves, M.D., Ph.D., 1,5 H. W. Schoenberg, M.D., 2 C. K. Zarins, M.D., 2 J. Knopf, M.A., 3 and P. Camic, M.A., 4 The referral pattern of impotent men from a urology clinic to a sexual dysfunction clinic was investigated. Only 62% of referred patients made such recommended appointments. Of the patients for whom sex therapy was recommended, only 32% accepted this recommendation. Of those accepting a recommendation for treatment, 57% prematurely terminated treatment against medical advice. The implications of this for referring physicians and alternative treatment approaches are discussed. KEY WORDS: erectile dysfunction; impotence; sexuality; male sexuality. NTRODUCTON t is now widely known that sexual dysfunction is quite common in the general population (Frank et al., 1978). Similarly, surveys have indicated that patient complaints of a sexual nature are not infrequent in many medical subspecialties, especially family practice, obstetrics-gynecology, and internal medicine (Burnap and Golden, 1967). n response to this increasing awareness of the number of,patients seeking help from 1Department of Psychiatry, University of Chicago Hospitals and Clinics, 950 East 59th Street, Chicago, llinois Department of Surgery, University of Chicago Hospitals and Clinics, 950 East 59th Street, Chicago, llinois Sexual Dysfunction Clinic, University of Chicago Hospitals and Clinics, 950 East 59th Street, Chicago,.llinois Psychology ntern, ~To whom correspondence should be addressed /82/ $03,00/ Plenum Publishing Corporation

2 522 Segraves, Schoenberg, Zarins, Knopf, and Camic physicians for sexual disorders, most medical school curricula now include basic instruction in sexual physiology and counseling (Lief and Karlen, 1976). However, several educators have questioned whether this rudimentary training is sufficient (Golden and Liston, 1972). Certainly many physicians feel that the treatment of sexual and marital difficulties is out of their area of expertise and is not a particularly productive use of their specialized training. Many physicians, outside of the specialties of psychiatry and family practice, might well feel that their role is to recognize the presence of a disorder, attempt to diagnose its probable etiology, and make a referral to an appropriate specialist. France et al. (1978) reported that only 10% of.patients with mixed psychiatric disturbances completed a recommended medical referral to a mental health center. Because of the sensitive nature of sexual disorders, one might expect that referrals to a sexual dysfunction clinic would be similarly difficult. The purpose of this report is to examine the referral of impotent men from a nonpsychiatric physician to a sexual dysfunction clinic. METHOD For the past 18 months, the authors have been involved in a collaborative treatment project concerning men with complaints of erectile dysfunction. The initial diagnostic evaluation involved physical examination, penile blood pressure monitoring, psychological testing, and a 2-hour psychiatric evaluation. During this time period, all patients seen in urology by one of the authors (HWS) were referred to psychiatry for further evaluation. Patients suspected or known to have organic causes for their erectile dysfunction were referred as well as cases presumed to be psychogenic. During this time period demographic and treatment information on all referred patients was maintained. Approximately 6-9 months after the referral, all patients were contacted by telephone by one of the authors (PC). This contact consisted of a structured interview concerning whether the problem still persisted, their feelings about seeing a psychiatrist, whether they had desired more information about the sexual dysfunction clinic at the time of referral, and their attitude toward the referring urologist. Patients who had not completed the recommended referral were asked if they had sought help elsewhere and whether they still wished to seek treatment for their sexual difficulty. The interviewer had not been involved in the psychiatric evaluation of these patients and possessed demographic data only concerning these patients. Attitudinal responses were rated by the interviewer.

3 Referral of mpotent Patients to a Sexual Dysfunction Clinic 523 RESULTS General Seventy-six impotent men were referred to the sexual dysfunction clinic by the urology service during this time period. Of the referred patients, 38 7o did not contact the clinic as recommended. For the reader's convenience, the referral flow pattern is outlined in Fig Patients Referred To Psychiatry By Urology ] 47 Contacted Psychiatry 20 Organic or Uncertain Etiology 4 Spontaneous Remis s ions i Penile Prosthesis For Psychogenic mpotence Psychotherapy Reconmended for 22 Patients 15 Refused Therapy 4 Prematurely Terminated Therapy 2 Still in Therapy i Successful Outcome Fig. 1. Summary of referral process. 29 Did Not Make Appointments in Psychiatry 6 Therapy Elsewhere 3 Spontaneous Remissions 4 Unreachable 16 Still Symptomatic on Follow-up Of 16 Patients Still Symptomatic, 13 Still Refused Psychiatric Appointments

4 524 Segraves, Schoenberg, Zarins, Knopf, and Camic Demographic Data on the Complete and ncomplete Referrals The two groups were remarkably similar in age, marital status, and race. The group of patients not completing the referral to psychiatry had an average age of (SD = 14.95) and was 48% white. The marital status breakdown for this group was as follows: married, 52%; divorced, 15%; single, 33%. The group of patients completing the referral to the sexual dysfunction clinic was similar on these variables. This group had an average age of (SD = 11.98), was 51% white, and had the following marital status grouping: married, 51%; divorced, 21%; single, 17 %; widowed, 10%. The group completing the referral to psychiatry tended to be more educated and to have higher status occupations. However, these differences examined separately were not statistically significant. When socioeconomic status was derived using the two-factor index of social position (Hollingshead and Redlich, 1958), the group of impotent men completing the initial referral to psychiatry was significantly more often of a higher socioeconomic grouping. These data are represented in Table. The group of men completing the referral to psychiatry had been impotent for a longer duration than the group not completing the referral. This difference was significant at the < 0.05 level of confidence. This information is contained in Table. nterview Data During the telephone survey, men who had completed the referral and those who had not were asked to discuss their reactions at the time Table. Demographic Data ncomplete referral Complete referral Duration of problem" N X (years) SD Social class b'c 2 (7 70) 7 (15O7o) 3 (11 70) 8 (15 70) 0 11 (23%) V 16 (59 70) 18 (38 70) V 6 (22 70) 3 (6%) ap < 0.05, t = bp < 0.05,x 2 = c Social class data incomplete on two patients.

5 Referral of mpotent Patients to a Sexual Dysfunction Clinic 525 that a psychiatric referral was made and to discuss their feelings about the urologist making the referral. There was no difference between the two groups in feelings about the urologist or in feelings about a psychiatric referral. Similarly, the two groups were not statistically different in the numbers who had desired a fuller explanation of the type of service rendered by the psychiatry clinic. Follow-up Data on the ncomplete Referral Group During the telephone survey, it was discovered that 6 men (21 /0) had sought sexual counseling elsewhere on their own and were still in psychiatric treatment. t was of note that 3 men (10%) reported spontaneous remission of their symptoms without seeking counseling or further medical assistance. There were 4 men who were unreachable for follow-up. Of the remaining 16 men, 13 (81%) declined an opportunity to schedule an appointment in the sexual dysfunction clinic with the telephone survey person. Follow-up Data on the Completed Referral Group n this groflp, 12 men were felt to have organic causes for impotence, and 11 have received penile prosthesis implantation to date. Eight men had impotence of undetermined origin and are still being investigated. Of 27 men who were felt to have impotence of psychogenic origin, 4 (15%) reported spontaneous remission of their symptoms after consultation with the urologist and prior to completing the interview with psychiatry. One psychogenic case of impotence who had a treatment failure in previous sex therapy and over 3½ years of psychoanalytically oriented marital therapy in another institution received penile prosthesis surgery. For the remaining 22 men, brief behavioral sex therapy was recommended- 15 (68%) declined this recommendation, and 4 (18 70) dropped out of therapy before completing six sessions of outpatient psychotherapy. To date, only 3 of the 22 men (14%) have stayed in behavioral sex therapy for more than 6 sessions. One of these cases is currently potent. DSCUSSON Referral of symptomatic patients to a sexual dysfunction clinic was rarely successful in this series. A large number of patients refused to schedule even initial appointments with the clinic. Of those men scheduling appointments in psychiatry, the majority refused the recommended

6 526 Segraves, Schoenberg, Zarins, Knopf, and Camic psychiatric therapy, brief symptom-oriented conjoint sex therapy. Of the small number of men entering behavioral sex therapy, the majority of these cases prematurely terminated therapy against medical advice. A small number of men not contacting the sexual dysfunction clinic did seek psychiatric help elsewhere. However, in most of these cases, the psychiatric help sought was not behavioral sex therapy. The explanation of our rather abysmal failure to refer and successfully engage impotent men in sex therapy is unclear. The group of men contacting the sexual dysfunction clinic were similar to the men not making the referral in most aspects except duration of the complaint and socioeconomic status. Why men with more long-standing complaints were more likely to make at least initial psychiatric appointments is not obvious to the authors. Various alternative explanations could be offered for the low rate of successful referral. Previous research suggests that completion of referral to psychiatric settings is more often successful when the referring physician takes the initiative in establishing contact with the referral source (Wilder et al., 1977). n this series, the referring urologist always made contact with the sexual dysfunction clinic concerning referrals. Similarly, the method of making the referral does not appear to be a factor in explaining the low rate of complete referrals. The group of patients contacting the sexual dysfunction clinic did not differ from those not contacting the clinic in terms of their attitude toward the referring urologist or in their desire for further information about sex therapy at the time of referral. During the telephone survey, various men mentioned that they were reluctant to come to the sexual dysfunction clinic because of the clinic's policy of requirng wives also to be seen. t is of note that most of the men coming for an initial appointment in psychiatry did not bring their wives as instructed. Similarly, reluctance to involve wives or any interested sexual partner in treatment was a frequent reason given for declining therapy. Other investigators (Schrom et al., 1979) have reported similar findings in this regard. Another possible reason for the failure of the referral process may have been sociocultural attitudes aginst being patients in psychiatry. This was frequently denied in the telephone survey, but the telephone interviewer identified himself as connected with the sexual dysfunction clinic. Clinically, most of these men preferred to see themselves as having medical rather than psychiatric problems and preferred organic solutions. One patient who was sexually quite active with a mistress but impotent with his wife strongly desired an inflatable penile prosthesis. Although acknowledging that his problem was undoubtedly psychogenic, he stated quite firmly that surgery was preferable to 12 sessions of conjoint marital therapy!

7 Referral of mpotent Patients to a Sexual Dysfunction Clinic 527 The large number of men refusing to enter psychotherapy after making an initial appointment with the sexual dysfunction clinic could be attributable to lack of expertise among the psychiatric personnel. This does not appear to be a complete explanation. Of the urologyreferred patients, 68% refused further psychiatric contact after the initial interview. During this same time period, the sexual dysfunction clinic interviewed 41 self-referred patients. n the self-referred group, only 28 7o declined further psychiatric treatment. This suggests that attitudinal variables in the patients may be partially responsible for our findings. t appears clear that the majority of these patients preferred to view their problems as organic and preferred treatment from a nonpsychiatric physician. The spontaneous remission rate of 9% in men with erection problems after brief contact with the urologist could be hypothesized to attest to the power of the nonspychiatric physician-patient relationship. Reversal of symptoms occurred in some men without intervention other than medical examination and interview by a nonpsychiatric physian. Recent research (Ansari, 1976) has indicated that complaints of impotence are often responsive to simple reassurance by authority figures. Perhaps the popularity of current behavioral sex therapy programs (Kaplan, 1974; Segraves, 1978) has deflected our interest from the powerful effect of simple reassurance by the nonpsychiatric physician. This project has several practical implications for physicians referring patients to sexual dysfunction clinics. Clearly, the referring physician should not assume that making a referral of a patient to a sexual dysfunction clinic has resolved the problem. Our evidence suggests that many patients simply do not successfully make such referrals. Our experience also suggests that the Masters and Johnson (1970) model of conjoint sex therapy, which was developed on a highly selected group of patients (Segraves, 1980), may not be appropriate for many cases of impotence presenting to nonpsychiatric physicians. n this regard, alternative treatment approaches need to be considered. For our population, attempts to treat the male patient without his spouse appear indicated. Some investigators (Zilbergeld, 1975) suggest that such treatment techniques may be effective when conjoint sex therapy is not possible. One wonders if these patients had been offered sexual counseling in the urology clinic rather than in psychiatry whether compliance with therapy would have increased. f the psychiatrist-therapist were more closely identified with the nonpsychiatric physician in the patient's mind, psychiatric counseling may have been more palatable. n conclusion, studies reporting high success rates using behavioral sex therapy appear to be based on very select subsamples of impotent men. One needs to use extreme caution in generalizing these findings to the general population of impotent men (Wright et al., 1977). The authors

8 528 Segraves, Schoenberg, Zarins, Knopf, and Camic are unaware of other investigations of referral patterns to sex dysfunction clinics. Hopefully, others will investigate this process to see if our findings are aberrant. REFERENCES Ansari, J. M. A. (1976). mpotence prognosis, a controlled study. Brit. J. Psychiat. 128: Burnap, D. W., and Golden, J. S. (1967). Sexual problems in medical practice. J. Med. Educ. 42: France, R. D., Weddington, W. W., and Houpt, J. L. (1978). Referral of patients from primary care physicians to a community mental health center. J. Nerv. Merit. Dis. 166: Frank, E., Anderson, C., and Rubinstein, D. (1978). Frequency of sexual dysfunction in normal couples. New Engl. Med. 299: Golden, J. S., and Liston, E. H. (1972). Medical sex education: The world of illusion and the practical realities. J. Med. Educ. 47: Hollingshead, A. B., and Redlich, F. C. (1958). Social Class and Mental llness. John Wiley, New York. Kaplan, H. S. (1974). The New Sex Therapy. Brunner/Mazel, New York. Lief, H. T., and Karlen, A. (1976). Sex Education in Medicine. Spectrum Publications, New York. Masters, W. H., and Johnson, V. E. (1970). Human Sexual nadequacy. Little, Brown, Boston. Schrom, S. H., Lief, H.., and Wein, A. J. (1979). Clinical profile of experience with 130 consecutive cases of impotent ment. Urologia 13: ; Segraves, R. T. (1978). Treatment of sexual dysfunction. Compre. Ther. 4: Segraves, R. T. (1980). Female sexual inhibition: Behavioral treatment. n Daitzman, R. J. (ed.), Clinical Behavior Therapy and Behavior Modification, Garland Press, New York. Wilder, J. F., Plutchnik, R., and Conte, H. R. (1977). Compliance with psychiatric emergency room referrals. Arch. Gen. Psychiat. 34: Wright, J., Perreault, R., and Mathieu, M. (1977). The treatment of sexual dysfunction. Arch. Gen. Psychiat. 34: Zilbergeld, B. (1975). Group treatment of sexual dysfunction in men without partners. J. Sex. Marital Ther. 1: