A Pole comes to a sexologist
Dr. Andrzej Depko, M.D., on what problems modern people face in their bedrooms and how a specialist can help them.
Paul Walewski: -Is there more medicine or psychotherapy in a sexologist's office?.
Dr. n. med. Andrzej Depko:.
- At the moment, unfortunately, more and more medicine.
Why unfortunately?.
Because many patients may be disappointed. If we conducted a street poll about what sexology is, most would answer that it is a variation of psychotherapy. And many people who come to a sexologist's office expect to meet a psychotherapist there.
There is something to it, after all, our main sex organ is the brain, and sexual reactions are governed by emotions..
Although this was only proven in the second half of the 20th century, but already the roots of sexology were connected with medicine - with psychiatry and neurology, which were supposed to help explain the background of various abnormalities.
I would also prefer not to talk about deviancy this time. In Poland, too often sexologists are seen as charlatans who seek to justify people who violate moral norms. This is not the case, after all.
I sometimes have the impression that living in a 21st century postmodern society, we are still mentally stuck in a time when sex was sinful and shameful. Meanwhile, the world has changed and the perception of sexologists should change as well. To understand this evolution, I invite you to take a short trip to the past.
Abstinence, training or beet juice
If we are to return to an era in which even enlightened doctors linked masturbation to brain desiccation, nerve paralysis and blindness, perhaps it is a waste of time?
For many years, sexology had no diagnostic or therapeutic tools. The primary method of treatment was to recommend sexual abstinence: save up so you have for later. It wasn't until the research of William Masters and Virginia Johnson that a sheen of light was shed on the physiology of sexual response, but it was already the second half of the 20th century when people started going to the moon.
But we still had to wait for convenient drugs that revolutionized the treatment of many disorders.
Until the mid-1990s, there was a belief that 80 percent of sexual problems had a psychogenic source. Lack of erection was attempted to be treated with training - for example, proper positioning of a woman in a gynecological position on the edge of a table or bed was supposed to help place a flaccid member in the vagina. Other ways were not known. In the early 1980s, treatment of impotence with injections into the penile corpora cavernosa began, but we had to wait for the aforementioned revolution until 1998, when Viagra hit the market. Then sexology began to change its face, research descended to the level of electrophysiology, cell biochemistry. And just as in the public perception electrolux is synonymous with a vacuum cleaner, and sports shoes are sneakers, Viagra became a symbol of a new view of sexology.
And have patients' attitudes toward sexologists changed?
With this I would not exaggerate. Sexology in Poland has become a field for conscious and rich people, because only such can afford to visit a private office. The appearance of Viagra on the market, followed by other drugs effective in treating impotence, hasn't quite opened up Poles to talk about intimate problems. Most still prefer to support themselves with supplements on their own, instead of going to a doctor for a diagnosis and specifics that have a proven effect. My observations show that the average delay in starting proper treatment is 2 years in Poland. There was a patient with me recently who was treated for six months with a psychologist for premature ejaculation, regularly drinking the beet juice he ordered.
I've always heard that a pill alone can't take care of everything. And you believe in these pills so much?
What I mean is the correct diagnosis. She determines the choice of the appropriate method of treatment. Sexuality is strongly connected with the psyche, but the causes of problems in intimate life usually have an organic-psychic background. Therefore, first of all, it is necessary to exclude or confirm the organic background of sexual disorder, that is, to check whether we are dealing with a disease or psychogenic disorder. It is an all too common mistake to start psychotherapy with an organic etiology. The patient goes to psychotherapy for half a year with no results, when in the meantime his underlying disease worsens and exacerbates his sexual troubles. And finally he hears that he is not cooperating with the therapist. Since everyone started talking about Viagra, the fair sex has been relieved to hear that the withering of sex life has not occurred in their relationships due to a loss of attraction, but is behind, for example, a partner's undiagnosed atherosclerosis or diabetes.
Diabetologist, cardiologist, or maybe a urologist
Is it the lack of erection that is the most common problem patients come to sexologists with?
The most common is premature ejaculation, followed by decreased libido and in third place erectile dysfunction. In women: decreased libido, orgasmic disorders and experiencing pain during intercourse.
Not long ago, the first pill for ladies to treat frigidity was registered in the US. For now, however, the main help may probably be psychotherapy?
Well, that's exactly what it is, too. We should treat sexuality in the context of the health of the whole body. Disorders that appear in this sphere are most often only a symptom, not an underlying disease. That's why it often happens that a young woman comes in concerned about a decline in libido, and does not know that it is influenced by poorly chosen birth control pills. The same is true of depression, to which women are much more predisposed than men. Depression, by altering neurotransmitter levels in the brain, adversely affects the sexual sphere. But quite a few mood-enhancing drugs unfortunately pacify sexuality. So a vicious cycle emerges: a woman comes out of her depression, but nothing works for her in sex, she doesn't desire her partner, which again feeds the depression, because she feels incomplete.
How to break out of this circle?
All it takes is a better choice of medication. A psychiatrist and a sexologist should work closely together in such a case. There are more such examples. Patients referred by cardiologists, neurologists, urologists, diabetologists come to us. In turn, I turn to doctors in these specialties for consultation.
To psychologists as well?
Yes, although a master's degree in psychology does not automatically predispose anyone to engage in sexological counseling. If a psychologist wishes to obtain the title of clinical sexologist, he or she must pass a state certification exam organized by the Polish Society of Sexology, and before that complete the appropriate training. Of course, no prescription pharmaceuticals can be prescribed by sexologists, but they often use, for example, cognitive-behavioral therapy. Some physicians sexologists do not want to parley with psychotherapeutic methods and - recognizing the psychogenic background of disorders - immediately refer to psychologists. Psychiatrists sexologists probably find it easiest to reconcile one with the other.
Prescription or support
What problems reported by patients require a psychological approach rather than a prescription?
If a patient is given a prescription before leaving the office, this does not at all mean that the sexologist did not provide psychological support throughout the visit. An empathetic, open approach is inherent in our specialty, as we touch an extremely sensitive sphere of life. Such a visit must last a minimum of 30-45 minutes, which distinguishes us from other doctors.
Please reveal how this works in practice?
To begin with, I let the patient speak in an unstructured, spontaneous way: what ails him, since when, how much. Once he directs us to the area of his problems, the interview can be structured by asking specific questions, such as: when, in what order the symptoms began to appear. On a daily basis, we do not pay attention to certain warning signs. And the reasons for emerging ailments, such as lack of readiness for intercourse, you sometimes need to look for two years earlier: in a change of job, habits, some stressful event. Or maybe the man started taking medication for hypertension - they also pacify the sex drive? I then order diagnostic tests, usually hormonal. And patients come back with the result, wondering: how did you know, because it wouldn't have occurred to me.
Is there also an examination in the sexologist's office, in other words, can you touch the genitals or see them?
According to the law, sexologists are allowed to conduct such an examination if there are reasons for it. This is included in the scope of specialization. There are many gynecological sexologists whose offices, for obvious reasons, are better equipped for this. At my place there is no gynecological chair - so if necessary, I refer the patient to an experienced specialist.
And when a couple sits down in front of you, do you ask the question: how do you do it?
But they don't have to show anything! They describe emotions, satisfaction, most often, by the way, they complain about the lack of it. A frank conversation is enough. Sexologists do not deal with voyeurism.
Does everyone diagnose and treat on their own, or do you have to conform to guidelines and standards?
We don't have to undergo supervisions, like race psychotherapists, if we don't do therapeutic psychotherapy. But the well-described rules of conduct regarding history taking, examination, diagnosis and treatment apply. All this is done to make contact with the patient as professional as possible.
Solo or two
Are Poles still ashamed of visiting a sexologist?
Yes, they feel intimidated. I'm not surprised, because, after all, the conversation is about completely different things than with an internist or cardiologist.
How do you give them courage?
It's actually too late for me to do that. Defusing this landmine lies with the media, which should change Poles' attitudes toward sex. Two curses hang over Polish sexuality: sin and duty. The space between these poles is narrow, like a path leading into dense thickets. Sex in Poland has never been glorified, such as in Taoism, where by being inscribed in the religious system it is ennobled and people are advised to have a successful sex life. In our country, self-appointed defenders of morality, for whom the hedonistic role of sex is an evil deserving of condemnation, tell us that we practice it like animals, since its essential acceptable function is the conception of new life. As a sexologist, I say the opposite: those who tell us to associate sex exclusively with reproduction reduce it to the level of animals. They are the ones who copulate during heat to prolong the species. They don't have sex for its bonding essence - we don't need to make love just for procreation!
Who is easier to convince, men or women?
Gender does not play a role here. It's more a matter of personality - introverts are certainly harder to open up than extroverts. It's not uncommon for patients to think that just telling half or a third of the truth about themselves is enough for a diagnosis to be made. They are afraid that they will confess secrets from their intimate lives to me, such as some of their unusual sexual behaviors, and I will judge them negatively. And these behaviors can induce a variety of symptoms.
Does the sexologist often intuitively guess certain things, although the patient tries to conceal them from him?
Of course, that's why the interview must be collected as thoroughly as possible. There are men who do not rise to the occasion with their wives because they realize erotic fantasies in escort agencies. Others have erectile dysfunction only when they can't realize their own sexuality. For example, when they are transvestites - with classic intercourse they lack the stimulus of a female disguise. Even if I prescribe a viagrope-like drug, it won't help, because the right arousal will be missing.
Surely, there are times when both partners need to be therapized?
In sexology, it's not that we give the patient medication and when he's cured, he only goes back to bed - it has to be done simultaneously! A man came to me with a problem of premature ejaculation. I treated him with mediocre success. In the end, he admitted that his treatment was not helped by his wife, who was irritable and avoided close-ups. Since the partner doesn't want to have regular intercourse with such a man, all the treatment is for naught. I asked the lady for an interview. I guessed that some problem lay with her. I did not insist that she reveal it. She finally admitted that she had once been raped, which she hid from her husband. A huge trauma remained in her. It was in her best interest for her husband to continue to have premature ejaculation and give her peace of mind.
Do patients come to the office more often alone or with female partners?
Forty percent of visits are couples, 60 percent come solo. But even in these cases, I often recognize that it would be important to have a partner or partner present at the next visit. And this is an important diagnostic signal as to whether the invited spouse will come or not. Some people use a variety of tricks - for example, a husband tells his wife: "Something is wrong with me, but the doctor also wants to talk to you. After all, if I had a stomach ulcer, they would also want to instruct you on what to eat and what not to eat." Unfortunately, there are still situations when a partner declares: you have a problem, not me, so get cured and only then will we return to the bedroom together.
And will it succeed on its own?
Sometimes they don't. I treated a patient who suffered from painful vaginal cramps just before and during intercourse, although she was very open to sexual intercourse. She and her boyfriend had planned the date of their sexual initiation according to the rules of the art: a cozy lodge, champagne, candles, tenderness. But the partner, with his anxious approach, kept causing her stress, asking her if nothing hurt and if she was ready. Without working through such behavior on his part at the next visit, there was no way to help this woman. Pharmacology had nothing to do here, only psychological influence.
Was one meeting enough?
Several. You need to take a close look at whether it's just an interaction stemming from the current relationship or the result of past experiences, sometimes painful, related to sexual harassment, for example. A typical situation: she is harboring nightmares from the past that are uncomfortable with sex, and he is frustrated with his ineptitude and has no idea how to please the woman. The more repressive the partners' approach to their own sexuality, the less they get out of it. People who place sexuality in the realm of taboo and sin have more trouble experiencing strong raptures.
Internet or bedroom, however
Many men confuse impotence with a decline in libido, or weakened drive.
And in this case, again, pills will not help. We work for a decrease in libido all our lives: overwork, overtiredness, stress. If someone overexploits the nervous system because he has become a corporate rat who has to live in tension and competition, this is not without its impact on the reduced readiness for sexual life. A structure called the hypothalamus is located in the brain, where the nervous system communicates with the endocrine system. A chronic state of tension triggers changes in hormone levels: for example, prolactin secretion increases, which lowers testosterone secretion, and consequently extinguishes sexual desire.
This biochemistry of love strips sex of its beauty and mystery. In the end, isn't feeling the most important thing, and it should be the job of sexologists to make the lost aware of this?
Often it turns out that the reasons lie in emotional problems, lack of self-acceptance, family conflicts. Men have begun, out of fear, to seek fulfillment on the Internet, to avoid entering the bedroom, where their over-demanding wives are waiting for them. In sex, it's not enough to stomp your foot to demand something. I am here to teach people not only to live in harmony with each other, but also to be able to express their desires.
DISCUSS
PAWEŁ WALEWSKI.
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