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How well is the multidisciplinary model working?

The classical approach to sexual dysfunction has traditionally followed a divergent paradigm. If an organic, physiologically based etiology was identified and could be addressed medically, the practitioner most likely involved in treatment would be a medical health provider, such as a physician, nurse practitioner, physician assistant, or pelvic floor physical therapist. If no organic cause was identified, the patient would leave the office with a referral to a mental health provider with the implicit (or even explicit) message that the problem is primarily “in your head.” This “either/or” mentality continues to pit medical vs. mental health practitioners against one another in the battle of “whose patient is this?” Case discussions at multidisciplinary conferences are a predictable forum for participants to offer their often unidimensional perspectives. The case of a healthy young man with erectile dysfunction (ED), for example, can become the battleground over the significance of the insufficiently tumescent penis. To the physicians, the meaning is physiological; it may be a potential marker for heart disease, and anyways, why subject the client to talk therapy when a phosphodiesterase type 5 inhibitor can easily solve the problem? To sex therapists, however, blood flow is secondary to context, and ED may have psychological or sociological significance. Is this an unconsummated marriage in a traditional society where the man, with little or no prior experience, is expected to perform on his wedding night with his equally anxious or possibly vaginistic bride? What role does anxiety play in this man’s life? What is the meaning of pleasure and why does he have difficulty achieving it? A paradigm shift has occurred, in theory at least, as the multifactorial nature of sexual problems has become better appreciated, in part due to publications in The Journal of Sexual Medicine ( JSM ) [1]. This is particularly true in the area of women’s sexual health [2]. The biopsychosocial model of women’s sexual function posits that physiological and organic factors, together with emotional wellbeing, mood, social and cultural influences, and relationship context, all play a role in sexual function. Practically, however, this model continues to be problematic as medical practitioners deal with the “physical part” while mental health practitioners address the psyche. Too often, the woman’s “issues” are compartmentalized in treatment, leaving the woman feeling fragmented and her treatment, unintegrated. We can look at sexual pain disorders to exemplify this problem. Sexual pain disorders are understood to have multifactorial components. While research has focused on physiological mechanisms, cognitive and affective factors are recognized to have an important role [3]. Higher catasrophizing, fear of pain, hypervigilance, and lower self-efficacy have all been associated with increased intercourse pain intensity [4]. Traditional biopsychosocial conceptualizations of vaginismus and dyspareunia compartmentalize the treatment by designating the physiological aspects to physicians, and the psychosocial aspects including anxiety and aversion, to mental health professionals including psychotherapists and sex therapists. In this algorithm, treatment of the pelvic floor muscles (the physical manifestation of the emotionally anxious state) is designated to physiotherapists. This design is problematic for many reasons. In the physiotherapy clinical setting, for example, fear avoidance and anxiety are significant characteristics of the patient’s response, which mirrors their experience in sexual intercourse. Treatment, which attends to pelvic floor dysfunction without addressing the patient’s emotional experience of vulnerability and fear or the meaning of penetration in her sexual and nonsexual life, or the dynamics of her relationship may not only fail to help but may also cause additional harm. The physiotherapist may be perceived as one other coercive voice in her life. Addressing the patient’s anxiety and vulnerability later in the comfort and nonjudgmental psychotherapy office replaces the physiotherapy room as the safe and containing place. As a pelvic floor physiotherapist, I struggled with my limitations in a multidisciplinary model that attributed to me only the woman’s pelvic floor. While physiotherapists know how to deal with pain avoidance, the treatment model is based on cognitive and behavioral motivation (“you can 2957