Call It What It Is: Biomedical-Psychosocial and Cultural

Sexual healthcare should embrace the term "Biomedical-Psychosocial and Cultural"

The time is well past due to change the common nomenclature used by sexual healthcare professionals from “biopsychosocial” to “biomedical-psychosocial and cultural.” The latter name describes our best approach to the understanding, diagnosis, and treatment of sexual disorders. While probably true for other health conditions as well, this commentary will limit itself to my own area of expertise. It is a fact and obvious that both the mind and body (mental and physical) are always involved in any sexual experience.

Yet, the model used by healthcare professionals to understand sexual disorders has been under sharp debate throughout the late twentieth century and even through today, vacillating between “biomedical” and “biopsychosocial.” In many respects, this has been a turf war between those who have been formally educated to emphasize the critical importance of psychosocial expertise and many physicians who lack that experience and do not share that viewpoint.  While the “biomedical” model of health and disease does continue to dominate much of current medical practice, that perspective is changing as reflected in the proposed changes to the World Health Organization, International Classification of Diseases, 11th Edition (2019).

Both sides of the debate have engaged in extreme accusations, including among others: ignorance regarding the nature of disease, misconstruing the absence of disease for health, ignorance of the “whole person;” as well as suggesting that the healthcare industry sidesteps responsibility for preventative medicine. These various points do have evidence and facts to support them. However, both camps become “dead wrong” when engaging in a one-sided focus which ignores the obvious fact that all of these factors have a role in every sexual disorder but varies in their proportionate contribution from person to person and moment to moment.

While each group has strong respected advocates, the situation is a classic example of science not catching up with common sense. Regrettably, such false dichotomies continue to be discussed amongst professionals, in academic institutions, and in mass media presentations, as evidenced with a Google search of all online documents. However, such a search merely displays the tip of the iceberg.

While much has been written beginning more than 50 years ago about what is wrong with the “medical model,” that “biomedical” model of health and disease does continue dominating much of current general healthcare practice. However, there has been much progress both within psychiatryand sexual medicine in particular that recognizes the importance of cognitive, behavioral, interpersonal and cultural factors. In fact, the term “biopsychosocial” has become a predominant one in the sexual medicine literature as any online “term” search of prominent journals shows.

Generally speaking, a “biopsychosocial model” is considered the current gold standard for understanding sexual health. While the process by which this viewpoint became dominant may be debated, the reality of it’s being widely embraced and globally accepted within the sex therapy and sexual medicine professions are beyond question.

However, as a sexual health community, we are at risk of “throwing out the baby with the bathwater” in deleting “biomedical” from our model’s lexicon and seemingly denying the value of the term. It just does not make sense to do so any longer. 

For instance, in 2012, Bitzer, Giraldi, and Pfaus offer an excellent article appearing in the Journal of Sexual Medicine that describes a semi-structured interview, based on a “Biopsychosocial Matrix” approach to the evaluation of Hypoactive Sexual Desire Disorder. Despite an entire section being devoted to the importance of recognizing biological and medical factors, which the authors identify as “biomedical” causes that underlie and/or impact the treatment of the sexual disorder, the overarching model guiding their view was consistently described as “biopsychosocial.” Given the explicit statements emphasizing the importance of also incorporating medical evaluation, why not title the article, “Semi-structured Interview, Using a Biomedical-Psychosocial and Cultural Matrix?” I reference this specific article not because it was of poor quality, but for the opposite reason: it is generally excellent! Yet, the authors adopted what has become an implicit global consensus in our field, that such multi-determined phenomena must be described as “biopsychosocial.” The examples of this overly limiting nomenclature are too pervasive to bother listing too many more of them in this commentary, but I will provide one additional example to highlight how universal and automatic the phrase “biopsychosocial” has become.

While writing a soon to be published chapter update for a preeminent sex therapy textbook series, I just received a comment from an editor asking me if I had made an error in describing my Sexual Tipping Point® theoretical model as a “Biomedical-Psychosocial & Cultural Model,” rather than the “conventionally accepted biopsychosocial model.” It was not an error. Instead, I was intentionally making an essential point. The medical treatments for many health conditions at high prevalence may both improve and/or cause sexual disorders. Therefore, any theory that attempts to promote an understanding of sexual disorders must (at least in part) incorporate “biomedical” in its name. A moniker that more fully and accurately describes the causes of sexual disorders and how they are most often actually treated on a global basis is a “Biomedical-Psychosocial and Cultural” model. Such an approach is well exemplified by the Sexual Tipping Point® Model where both medical and psychosocial treatments are specifically incorporated into its current illustrations as shown below. 


An STP Model explanation is found at mapedfund.org. Factors slide along the axes to indicate their polarity and valence.  Source: Used with permission of the MAP Education and Research Foundation a 501 (c)(3) public charity.


An STP Model explanation is found at mapedfund.org. Factors slide along the axes to indicate their polarity and valence.

Source: Used with permission of the MAP Education and Research Foundation a 501 (c)(3) public charity.

Why Is This Distinction A Meaningful One?

The reason this change in nomenclature is meaningful and required reflects the high prevalence that medical/surgical interventions both cause and also are used to treat sexual disorders. Besides the obvious role that biological factors play in the etiology of sexual disorders (aging, genetics, etc.), the medical and surgical interventions used to treat diseases, as well as the diseases themselves, often cause or exacerbate sexual problems. The range of disease with sexual sequela are well documented as are the side-effects of the medications and surgical interventions used to treat them.

One unfortunate consequence of many new scientific discoveries and innovations that have brought us miraculous life-saving drugs and technical surgical advances is an increased prevalence of sexual disorders.

Such scientific advances increase our life expectancy and allow us to live (ever longer), despite many of us suffering from chronic diseases such as diabetes, cancer, heart disease, etc. Even when the progressive deterioration of diabetes is delayed by drugs that enable excellent modulation of blood sugar levels, eventually diminished sexual capacity results.

Greater number of men and women than ever in history are able to live as cancer survivors for longer and longer amounts of time, but the medical/surgical treatments that enable that positive result frequently cause sexual difficulty in many if not most cases. Since the 1950’s legions of men and women around the world are relieved of psychological suffering through the use of antidepressants, antipsychotics, and anxiolytics, yet a large proportion of individuals on those medications report and/or experience sexual difficulties.

Despite the above, it is also axiomatic that there is always a psychosocial and cultural component to any sexual issue, disorder or dysfunction regardless of the degree its primary cause is organic.  

Besides being accurate, why is it also important for non-physician mental health professionals in particular to adopt the phrase “Biomedical-Psychosocial and Cultural?” Because as a group many of us fully understand the role that all these factors play. To avoid using the term “medical” for fearof our being disenfranchised, rather than embracing the term as a critical part of the whole, is to avoid the obvious reality and naively cede professional turf.

One does not need to be a physician to recognize the importance of medical/surgical factors. Nor does one need to be a prescriber of medications to understand and recognize both the positive and negative impact of such treatments. 

I recognize the importance and value many of the polemics articulating the risks associated with medicalization and pharmaceuticalization (The New View, 2019). However, acknowledging the obvious role that medical/surgical factors play in the etiology of sexual (and indeed other health-related complaints) does not diminish our role as providers, but merely increases the validity and reliability of our approaches to treatment.

Such knowledge as well as when to refer to medical colleagues is part of a growing recognition of the importance of embracing a transdisciplinary perspective to healthcare in general and the treatment of sexual disorders in particular (Perelman, 2016, 2018).

 It is reflective of a naïve tribalism and disingenuous to suggest that the “bio” in “biopsychosocial” fully incorporates diagnosis, disease manifestations, and the pharmacotherapy that today is the most common and often appropriate treatment for sexual disorders in the view of both physicians and the general public.

Most mental health professionals are more than aware of important biological determinants, including ones specific to disease and secondary effects of pharmaceuticals used to treat those diseases.

However, for many of them, there remains a convention of only referencing a biopsychosocial model and separating rather than integrating the medical components.

Even recent articles that discuss the variety of sexual sequela related to oral contraceptives use the term “biopsychosocial” variables when clearly discussing the consequences of medical intervention. 

There have been meaningful and significant psychological, medical and surgical advances over the last 50 years in our ability to successfully treat sexual disorders.

While the majority of those suffering sexual disorders were treated by psychodynamic and later behavioral treatments prior to the mid-1970s, formalized sex therapy became the dominant modality for the next 15 years.

However, by the mid-1980s and especially for men, increased diagnostic sophistication led to the widely held viewpoint within the medical community that the primary causes of sexual problems were “physical” and that medical and surgical interventions should predominate as the treatment of choice (Perelman, 1984).

This was the era of the development and deployment of penile prostheses and intraurethral injections/insertions. 

Unquestionably, the introduction of Viagra®in 1998 and subsequent drugs for men changed the landscape of how their sexual dysfunctions are treated across the globe.  

Furthermore, strong data exists that for the majority of individuals suffering from sexual disorders, the profession most likely to be consulted first is a physician who again is likely to offer medication first rather than beginning a trial course of sexual counseling alone.

At the turn of the century, the new millennium was a time when psychotherapist/sex therapists' anxiety was highest with concerns of being “shut out” from the treatment of disorders about which we knew so much. Clearly, psychosocial and cultural factors were not necessarily less important to the underlying etiology of sexual disorders as most physicians and pharmaceutical companies erroneously believed at that time.

However, the impact and success (especially within the USA which allows direct to the consumer advertising) of pharmaceutical advertising caused a shift in the public’s mind as to what caused sexual problems and what treating them first required. While the impact of such marketing has not yet manifest itself when referencing female sexual disorders, the approach to them too is highly likely to change progressively if not rapidly. It is not a stretch to suggest once TV commercials extolling the benefits of Addyi®and Vyleesi®, that there will be a dramatic increase in prescriptions both written and filled.

This is not to say that such pharmacotherapy is always effective in resolving the complaint. Indeed, there is an ever-growing body of evidence that pharmacotherapy without concurrently integrated sexual counseling is generally only 50% effective (Althof, 2002; McCarthy & McDonald, 2009; Perelman, 2014). Sex therapists and other mental health professionals along with physical therapists are of course often needed to accomplish a successful outcome (Perelman, 2019). 

It is high time for physicians and non-physicians alike to embrace, incorporate into our nomenclature, and promote to the public the phrase “Biomedical-psychosocial and Cultural” as the term that most accurately describes our current theoretical models for understanding, diagnosing and treating disorders of sexual response. 


References

Perelman, M.A. 2014 “History of Sexual Medicine,” In APA Handbook of Sexuality and Psychology, Vol. 2: Contextual Approaches, D. L. Tolman and L. M. Diamond (Editors-in-Chief), American Psychological Association. 

Perelman, M. A. (2018). Sex Coaching for Non-Sexologist Physicians: How to Use the Sexual Tipping Point Model, 15(12), 1667–1672.

Bitzer, J., Giraldi, A., & Pfaus, J. (2012). A Standardized Diagnostic Interview for Hypoactive Sexual Desire Disorder in Women: Standard Operating Procedure (SOP Part 2). Journal of Sexual Medicine. 

McCarthy, M., & McDonald, D. (2009). Psychobiosocial versus biomedical models of treatment: Semantics or substance. Sex Relat Ther, 24(30), 30–37.

Perelman, M. A. (2016). Introduction: Advocating for a Transdisciplinary Approach to the Management of Sexual Disorders. In L. I. Lipshultz, A. W. Pastuszak, A. Giraldi, A. T. Goldstein, & M. A. Perelman (Eds.), Management of Sexual Dysfunction in Men and Women(pp. 1–8). New York, NY: Springer New York. 

Perelman, M. A. (1984). Rehabilitative sex therapy for organic impotence. In T. Segraves & E. Haeberle (Eds.), Emerging Dimensions of Sexology(pp. 181–188). NY: Praeger Publishers. 

Althof, S. E. (2002). When an erection alone is not enough: biopsychosocial obstacles to lovemaking. Int J Impot Res, 14(S1), S99–S104. http://doi.org/10.1038/sj.ijir.3900799

World Health Organization. (2018). International statistical classification of diseases and related health problems (11th Revision). Retrieved from https://icd.who.int/browse11/l-m/en

The New View Campaign, http://www.newviewcampaign.org/, accessed 2019_06_28