The evaluation of sexual problems almost invariably requires some attention to marital or other sexual relationships. Counseling that focuses primarily on these relationships has been designated marital counseling. Instead of the usual medical relationship, which emphasizes the individual patient, marital counseling involves both partners, although each may be seen separately at times.
The specific nature of the counseling depends upon the complaints or upon the time of life of the couple. The main requisite is a willingness for physicians to set aside time for this kind of undertaking and to develop an interest in the functional health of patients beyond the specific issues raised by disease. The stresses and transitions in the early years of a marriage should be appreciated as well as the pressures exerted by children. In later years, job problems and conflicts over roles may emerge, followed by development of the “empty nest” syndrome, menopausal and midlife issues, and the male-depressive syndrome as horizons close in and the realities of aging appear.
Most marital problems are not due to sexual difficulties, although sexual problems may be the leading edge, especially in the climate where sexual adjustment is so widely publicized. Sexual satisfaction is dependent on the broader aspects of the relationship between partners and on mental and physical health. The alert physician should probe to these deeper levels during marriage counseling. In this sense, counseling about sexual problems is dependent upon the successful outcome of marriage counseling. Early in the approach the motivation of both partners should be assessed. If one partner is determined to break up the marriage, the counseling may consist of communicating this information to the other partner and perhaps advising legal assistance. On the other hand, apparent determination to seek divorce by either partner needs to be evaluated because it may mask depression, a paranoid reaction, or a hidden problem that is being avoided by flight, such as shame over an affair, fear, illness, or personal failure.
In marital counseling, as with other medical counseling, it is well to avoid giving direct advice about interpersonal relationships. By defining the problem, the physician may enable the patient to arrive at a decision on a course of action. By taking sides in family conflicts or by espousing an ethical position, physicians can inadvertently introduce their own biases or allow themselves to be manipulated by one of the marital partners.