Mortal Limits

Biomedical ethicist Daniel Callahan wrote that, in our parent’s time, persons used to die of natural causes, but today we no longer have that luxury. Callahan was writing about the frenzied exercise of medicine to keep terminally ill patients alive, at great expense to survivors and soci ety. Commonly, family members and medical teams collude in the work of preventing death at all costs. Callahan commented that, in the medical culture shared by both doctors and patients, “natural causes” of death no longer exist; every death is treated as a preventable failure on the part of medicine.

The truth is, of course, that the body dies. Before death, gravity takes its toll on organs and tissues. What was taut and firm now points south. With aging, bodies get smaller, saggier, and weaker. For many, if not most persons, these hints of mortality are an insult. In response, Western culture is replete with strategies to counter this insult: elective plastic surgery, fat farms, and December-June marriages. The culture of youth is as vibrant as its television advertisements. The limits of mortality are denied. Against this denial of mortal limits, sex is a sign of life. And so it should be. It requires, as has been said repeatedly here, a minimum level of physiological health. In its procreative expression, sex promises future lives if not future life. But sex can also be used as a device to deny limits that, to borrow Callahan’s phrase, are “natural causes.” The loss or decline of sexual function is a hint of mortality. There is a distinct value judgment to be made about how attentive one should be to hints of mortality. If one takes the position, as I do, that hints of mortality are part and parcel of life that should be listened to, then one should listen to and accept the limits of sexual function without ceaseless somatic interventions. Employing somatic treatments over and over again to deny eventual mortality does little to enrich the sexual life of a couple. Indeed, it may do much to distract from an appreciation of their total life together during the time remaining to them.

The tragedy of September 11, 2001, gave rise to a cultural appreciation of the limits and fragility of life. Persons about to die called their dear ones on cell phones to express their love in their final minutes. Those of us who were survivors, like survivors everywhere, generally expressed in our grief a greater appreciation of “the important things of life” and an intention to “take time to do the really important things.” What made this possible was the terrible shout of mortality rising from the crashes of September 11. We heard our mortality and returned to our lives to live them more intentionally.

On a personal level, the many hints of mortality that an individual or couple receives can, and I suggest should, be used for the same purpose of living more intentionally. While somatic treatments for sexual dysfunction may be part of that living intentionally, they may also be part of a collusion to deny mortality at all costs.

SUMMARY

The disease perspective takes the somatic reality of sex seriously. It states that sex is, at its bedrock, a corporal event. To the extent that disease, injury, surgery, medication, and drugs compromise the physiological functioning of the body, to that same extent sexual functioning may be compromised. The clinician working to understand a sexual problem from the disease perspective evaluates the patient’s physical and psychological history as well as his or her family medical and psychological history. Although there may be many psychosocial factors that should be noted and treated in due course, the clinician employing the disease perspective wants to be sure that the body is working as well as it can. If somatic treatments will improve sexual functioning, the clinician informs the patient about them and assists in their integration. When the body signals that it has reached its highest level of sexual functioning given its limitations of disease or aging, the clinician understands that signal and turns to another perspective, the life story perspective, to assist the patient in heeding the meaning involved.

Disease

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.

The most remarkable change in the treatment of sexual disorders in the past two decades has been the emergence of somatic treatments. In ear lier years, the only somatic interventions had been surgeries and topical applications. The surgeries included procedures such as insertion of a penile prosthesis and reconstruction of vulvar and vaginal tissue. Topical aids were vaginal lubricants and attempts, usually unsuccessful, to apply an anesthetic to the penis to retard premature ejaculation. In the past twenty years, however, the primary somatic treatment of male sexual dysfunction has been the use of oral medications such as Viagra, intracavernosal injections, and penile vacuum devices. The goal of the treatment is, obviously, to produce an erection capable of penetration. It is an organ- specific goal; there is no claim that the presence of an erection will make the man want to use it sexually—let alone that his partner will want to.

For women, the goal of somatic treatment is likewise directed toward improving the genital environment so that it can contain the penis and respond with pleasurable sensations rather than pain. Vaginal lubricants are sold over the counter and are widely used successfully. For women with hormone deficiencies due to surgery or for postmenopausal women, estradiol vaginal tablets improve lubrication and make the vaginal epithelium thicker. Exogenous androgen is also employed for androgen-deficient women (e.g., those who have had their ovaries removed) to increase sexual desire, but this remains a controversial treatment. A product called EROS-CTD serves as a suction device on the clitoris, improving clitoral engorgement and presumably the potential for vaginal lubrication, subjective arousal, and orgasm. At present, research is being conducted on vasoactive medications for sexual arousal in women, comparable to the Viagra-assisted arousal in men.

A full review of the somatic treatments of sexual dysfunctions and disorders is not the purpose here and is available elsewhere. Instead, I offer some comments on somatic treatments from the disease perspective in the context of a typical case.

■ Mark and Esther had been married for thirty-nine years. During the last ten years they had not had intercourse, because of Mark’s erectile dysfunction brought on by diabetes. The diabetes was well controlled in recent years, and Mark had felt guilty about not being able to have intercourse with Esther. In preparation for their fortieth wedding anniversary, Mark obtained a prescription for Viagra from his primary care doctor. He tested it privately and, with some manual simulation, obtained a full erection such as he had not experienced in years. He could not wait for their anniversary to surprise Esther. As might have been predicted by even a casual observer, the anniversary bedroom scene was not a happy one. Having taken the Viagra an hour before retiring, and with some minimal self-stimulation, Mark had a full erection. Esther had reconciled herself years ago to a marriage that was sensual but not sexual. She had not taken hormone replacement after menopause, because she had some medical concerns and, in any case, they weren’t having intercourse. Now here they were: forty years of marriage, ten years without intercourse, Mark with a full erection—and Esther with no psychological or physiological preparation for intercourse. Following some conversation, during which Mark lost the erection, they decided to try intercourse. After some time and stimulation, Mark was able to get an erection. It was difficult to penetrate Esther, and when he finally did it was quite painful for her. He withdrew immediately, with orgasm for neither. It was about two months before they felt able to seek help, so hurt and embarrassed were they about the failure of communication and the physical pain Mark had caused Esther. The work of the sexual therapy was to assist them to gradually integrate the use of Viagra into their sexual life. It necessitated a switch of focus from his penis to her arousal, both emotional and in terms of vaginal lubrication. After discussing the pros and cons with her internist, Esther began hormone replacement therapy, which made her “generally feel better.” Gradually, over a period of four months, the couple progressed in sensate focus therapy, from sensual rapprochement to sexual engagement to successful intercourse about every three weeks.

Integration

The somatic treatments, as briefly described above, offer women and men an opportunity to restore sexual function in situations where disease, surgery, aging, or even psychological factors have made it impossible. These treatments are widely prescribed by primary care physicians and by specialty physicians such as urologists and gynecologists, and many of the somatic treatments are available over the counter. Millions of people will try them; the challenge is whether or not the somatic treatments will be integrated into the sexual lives of those who use them. The case of Mark and Esther is patently a situation of non-integration in the introduction of Mark’s use of Viagra. Mark’s attention was too selffocused on the presence of an erection. He forgot that coming together sexually, for two people who care for and are committed to each other, entails more than an erect penis. He was probably totally ignorant of the possible condition of his wife’s postmenopausal vagina in the absence of hormone replacement.

Integration of somatic treatments of sexual dysfunction recognizes that the treatments are directed to the genital organs. Their effect is to make the genitals capable of responding sexually. The work of integration is to harmonize improvements in physiological functioning of the genitals with an emotional desire and readiness for the sexual activity. This integration does not require professional assistance for most couples— most can incorporate the somatic treatments into their sexual life through open communication with each other. But other couples, such as Mark and Esther, find themselves unable to use the somatic advances without professional assistance in the work of integration. The art of sexual therapy with such a couple is to provide assistance while being as unobtrusive and noninvasive of their sexual and intimate life as possible. Sexual therapy entails assisting couples to do the work of emotional, sensual, and sexual integration.

The disease perspective makes sense ultimately when considered against a background of healthy function. Disease is an aberration of healthy cells or physiological functioning. Therefore, the disease perspective on problems of sex must also consider issues relating to the healthy body and sex.

From the viewpoint of physical health alone, sexual activity is exercise and as such is good for the general health of the body. Circulation is increased, muscles stretched, and endorphins released. But as with any exercise, the question may become one of quantity. In other words, is too much sex harmful to the body?

For men, there is a refractory period after ejaculation when a subsequent ejaculation is not possible. The refractory period gradually increases with aging, from minutes in a young man to several hours in an older man. This serves as a natural limit-setting mechanism. For women, dyspareunia—pain with intercourse—is a marker that the vaginal tissue is not prepared for more penetrative activity. The friction of the penis is not assuaged by vaginal lubrication and so pain occurs. Pain may also occur in women and men who manually stimulate their genitals to excess. Pain from abrasions, usually around the glans penis or clitoris, suggests that the skin of the glans is being damaged by too much sexual activity. But apart from the helpful signals of pain—in sexual organs or in other parts of the body (e.g., chest pain)—the effects of sexual activity on a healthy body are comparable to other forms of physical activity: sexual activity is good for the general health of the body.

From the viewpoint of psychological health and social adjustment, the question of too much sexual activity is usually relevant and, to be candid, controversial. Our culture is not one that likes limits—especially sexual limits or limits on what one can do with one’s body. From abortion to use of protective headgear for cyclists, any attempt to suggest, let alone legislate, limits on individual choice will be met with heated opposition.

Nevertheless, there is a point at which sexual activity can be detrimental to psychological health and social adjustment. The parallel with exercise is again helpful here. The norm to be used in addressing the question of whether a level of sexual activity is too much is whether the activity interferes with one’s psychological maturation or occupational or social functioning. Hours and hours spent in the gymnasium or in a sporting activity daily must detract from the development of other intellectual and interpersonal skills and relationships. Hours and hours thinking about, pursuing, and/or consummating sexual activity must also detract from the development of other intellectual and interpersonal skills and relationships. In this situation, then, too much sex (including thinking about sex) is not healthy for the whole person. I will have more to say about this when discussing the “overvalued idea” in the behavior perspective.

Can too little sexual activity hurt the body? There is no evidence that too little or no sexual activity does physical harm to the body. We know that during rapid eye movement (REM) sleep, individuals have a sexual response in terms of vaginal lubrication and erection. It is hypothesized that one of the functions of the lubrication and erection during sleep is oxygenation of the tissues involved. Nighttime sexual arousal may act as a preservative of the tissues necessary for sexual health. In the same self-regulatory manner, nocturnal emissions and ejaculations in men maintain a comfortable level of seminal fluid.

It is common wisdom that most physical activities have a “use it or lose it” factor. Muscles should be stretched; psychological resistance to physical inertia should be routinely surmounted. The same wisdom applies to sexual activity. Especially for postmenopausal women, the normal stretching of vaginal tissues during intercourse serves to preserve suppleness in the vaginal walls. For both men and women, sexual activity usually involves more than the genitals. Torso and limbs move, breathing increases, and the body is exercised. From a physical viewpoint alone, the “use it or lose it” wisdom does have application to sexual activity. Studies of the sexual activity of older persons repeatedly report that the greatest predictor of the level of sexual activity in older age is the amount of sexual activity during the individual’s younger years.