Normal Variation and Clinical Dysfunction · Clinical Exercise

Three Questions, One Gate

Three questions organise the first clinical conversation about any sexual concern, and the answers route the presentation rather than diagnose it. Six presentations to route, and the two places this reasoning most often fails.

What this exercise practises

Deciding where a presentation goes before deciding what it is called. Normalisation, a relational frame, or a full diagnostic assessment, and recognising which of the three questions settled it.

Two of the six presentations are the under-recognition error waiting to happen, and in both the client has already done the dismissing.

Estimated time to complete this exercise: 20 minutes

1Six routes
2Whose distress
3The gap
4Close

Before you begin

How this one works

Three questions organise the first clinical conversation about any sexual concern, and the answers route the presentation to one of three places rather than to a diagnosis.
Part 1 gives you six presentations to route. Two of them resolve at the first question and never reach the other two. Two of them are the under-recognition error waiting to happen.
Parts 2 and 3 are single questions about the two places this reasoning most often fails: whose distress is being assessed, and what the operative question is when a couple arrives with a gap.
Nothing is graded and nothing is recorded. Reloading starts it again.

Over-pathologisation and under-recognition are equally consequential errors, and a clinician who guards against only one of them will reliably commit the other. The question is never simply whether this is normal. It is what is actually happening, whether it causes genuine personal distress, and whether it is a departure from this person's own baseline.

References

  1. American Psychiatric Association. (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787
  2. Bancroft, J., & Janssen, E. (2000). The dual control model of male sexual response: A theoretical approach to centrally mediated erectile dysfunction. Neuroscience & Biobehavioral Reviews, 24(5), 571–579. https://doi.org/10.1016/S0149-7634(00)00024-5
  3. Basson, R. (2001). Using a different model for female sexual response to address women’s problematic low sexual desire. Journal of Sex & Marital Therapy, 27(5), 395–403. https://doi.org/10.1080/713846827
  4. Brotto, L. A. (2010). The DSM diagnostic criteria for hypoactive sexual desire disorder in women. Archives of Sexual Behavior, 39(2), 221–239. https://doi.org/10.1007/s10508-009-9543-1
  5. Chivers, M. L., Seto, M. C., Lalumiére, M. L., Laan, E., & Grimbos, T. (2010). Agreement of self-reported and genital measures of sexual arousal in men and women: A meta-analysis. Archives of Sexual Behavior, 39(1), 5–56. https://doi.org/10.1007/s10508-009-9556-9