Psychiatrist's Specialty Finds Him on Rarely Trodden Path

Although psychiatrists have a long history of discussing sexual themes in psychotherapy, relatively few actually specialize in helping patients with sexual problems (see Original article: Psychiatry and Sexual Medicine). An exception is Canadian psychiatrist Ronald Stevenson, M.D.

Certainly it's a delicate mission, the tall, sandy-haired, laid-back clinician recently acknowledged in an interview in his Vancouver, British Columbia, office. “It means talking with people about things they may have never spoken with anyone about before, even their own partners.”

Stevenson was born in 1949 in the Okanagan Valley of southern British Columbia, a terrain of breathtaking beauty and challenging outdoor adventures. He lived there until age 12, when his family moved to Calgary, Alberta. That's where he spent his adolescence and in 1975 where he received his medical degree. After that he returned to British Columbia, but this time to Vancouver for his family practice residency, which lasted until 1977.

It was during his residency that he took an elective course in what then was called “sexual medicine.” “The reason, to be honest, is that it sounded intriguing and quite different from anything else [that was] offered,” he said. “But I was immediately fascinated by it. It required both medical knowledge and an awareness of relationship psychology as well as a sensitivity and comfort in exploring highly personal themes.”

So from 1981 to 1990, Stevenson, as a family physician, joined a specialized sexual medicine clinic in Vancouver.

“But I also came to realize that the problems I was most interested in helping patients with were a lot more complicated than I had the training to deal with,” he explained. “So I decided to undertake a psychiatry residency as well, from 1990 to 1994.” Then in 1994, after he had become a psychiatrist, he decided to practice sexual medicine from both perspectives in Vancouver.

“I've known Ron for decades,” said Michael Myers, M.D., a former Vancouver psychiatrist who now works in New York and is a member of the Psychiatric News Editorial Advisory Board. “We used to work in the same hospital when he was a family physician specializing in sexual medicine.... I was running a couples clinic there and would refer couples to him.... He is very highly regarded as someone who is very balanced and very good at what he does.”

Today Stevenson works in a clinic in Vancouver that is devoted exclusively to helping people with sexual-dysfunction problems. The clinic is staffed not just by Stevenson, but also by other psychiatrists and specialists with expertise in sexual medicine. It is part of a publicly funded health care organization called Vancouver Coastal Health, which in turn provides a wide range of medical services to people throughout British Columbia. Stevenson and his clinic colleagues accept only patients who have been referred by other physicians.

Initially patients, who are usually accompanied by their partners, might find it difficult to discuss their sexual concerns, Stevenson said, but he tries to be reassuring and supportive to put them at ease. Usually they become comfortable discussing their sex lives with him rather quickly and more so over a series of visits.

What soon follows is the challenge of diagnosis—determining whether sexual problems are predominantly physiological or psychological or a complicated mixture of both. This is no small task, he explained, since“ sex is never entirely physical or entirely psychological. Physical disorders can have emotional or psychological consequences, and emotional or psychological problems can manifest themselves in physical ways. Our perspective here is a very biopsychosocial one. We don't just look at the psychological or physical manifestations, we always look at both.”

After he has determined the cause or causes of a patient's sexual problems, he works up a treatment plan. The mainstay psychological treatment is cognitive-behavioral therapy such as “sex therapy” and sometimes more intensive insight-oriented psychotherapy. Relationship or couples counseling is often used as well. The physiological treatments can run the gamut from erectile-dysfunction medications to hormone supplements to antidepressants. More often than not, psychological and physiological treatments are combined.

Treatment Options in Arsenal

“Any sexual problem can cause great suffering, but in some ways, erectile dysfunction is the best of the sexual dysfunctions to have because there are a number of treatment options,” Stevenson explained.“ The new oral medications Cialis, Levitra, and Viagra have revolutionized its treatment, and if they aren't sufficient, there are a number of other options that can be tried as well. Moreover, if hormone tests reveal that a patient has an abnormally low level of testosterone, testosterone supplements might be in order. And if medical illnesses—say, diabetes, multiple sclerosis, Parkinson's disease, or spinal cord injury—contribute to the dysfunction, we address those issues as well.”

Stevenson also treats men with premature ejaculation, he said. “I had a fellow recently in his 50s who had suffered from lifelong premature ejaculation, but who decided that he finally wanted to do something about it. I saw him with his wife. Cognitive-behavioral therapy combined with a small amount of antidepressant to suppress his sexual response just a little solved his premature ejaculation problem. He and his wife were delighted.”

Unfortunately drugs for erectile dysfunction are generally not useful when women have orgasm problems, Stevenson said. Nonetheless he can often assist them by “helping them learn about their bodies and how to focus more intently on pleasurable sensations of the moment, thereby improving their sexual response. And in some cases, I can help them with postsurgical or postmenopausal issues that bear on their problem, and, as with men, sometimes hormonal supplements are indicated and can be helpful.”

Disinterest the Biggest Challenge

The toughest sexual-dysfunction problem to treat in either men or women is sexual disinterest, Stevenson reported, “because it is often related to very broad psychological issues such as trust, control, and self-esteem as well as to overall mental, physical, and interpersonal/relationship health—all those things that feed into one's sexual interest. So, motivation by the patient to address those issues psychologically becomes extremely important.”

Stevenson also tries to help older couples cope with their sexual difficulties. Erectile-dysfunction problems are more prevalent as men age and experience other health problems. “We see men here in their 70s and even their 80s who are keen on sex and being sexually active, and we are often able to be of some help to them with a combination of counseling, medication, or devices that facilitate erection,” he said.

Also, he pointed out, “I try to help men and women understand that sexual responses don't happen as quickly as people get older, that not all senior erectile problems can be corrected with medications, and that it can be equally important to explore ways of [sexually] pleasing each other that don't involve intercourse. True, for some older couples, such information entails a major adjustment in their perspective, but inevitably changes in our bodies and our response capacities are part of the realities that we all have to adjust to as we grow older.”

He continued, “People sometimes disparage sexual problems, and sexuality can be a rich source of material for humorists. But, in fact, sex is a pretty fundamental part of a full and healthy life. So in terms of quality-of-life issues, it is tremendously important, and for me, it's extremely rewarding to be able to help people with their sexual difficulties.” ▪