Machon Hasharon - English

Rehabilitation of sexual functioning in a chronic mental health patient

Written by 


(A lecture given at an International Conference on Sex Therapy and Rehabilitation - 1998)


Dr. Mark Roitman


The case I will present now is interesting because of diagnostic and treatment challenges that arouse during a total of eight months (30 sessions) of therapy.


Michael is a 50 years old man. With his childish face, shy smile, and thick black hair, he looks much younger than his age. He lives with his elderly parents and a younger sister.


His mother was hospitalized in a psychiatric hospital about 30 years ago and diagnosed both as Heibephrenic Schizophrenia and Reactive Depression, which means that we don't have her exact psychiatric diagnosis.


His younger sister was hospitalized several times in different psychiatric hospitals. She is diagnosed as Chronic Schizophrenic. Michael describes her as very shy, unable to contact with people or leave home alone. However at home she cleans and cooks compulsively.


Michael's father is a retired clerk and Michael describes him as a very nervous and a "heavy customer character" suspicious man. The family leads a very isolated life style, with no one ever entering their home.


Michael himself developed as a shy suspicious boy with very few friends. He used to study for long hours and had good grades, especially in mathematics. He graduated high school and entered an engineering school.


During a reserve service at the army, in the age of 20, he had his first psychotic breakdown and was hospitalized. During 13 years between 1967 till 1980 he was hospitalized in four psychiatric hospitals for at least eight times. The clinical pictures as described in the release letters - vary from catatonic, paranoid, to depressive states. And the diagnosis varies from Hebephrenic Schizophrenia to Reactive Depression, which means that the diagnosis is unclear.


During the hospitalizations and between them, he expressed paranoid thought against his father and against his physicians. He made two serious suicidal attempts by trying to hang himself and tried to cut his penis.


Despite the hospitalizations he managed accomplish his BA in mathematics with excellence. He tried several jobs but was fired after a short time because of slowness and mistakes he made. His longest job (3 years) was as a receptionist in a public outpatient clinic.


After his last hospitalization, in 1980 he never worked again, and lived on social security pension. During his hospitalization and till his arrival to our clinic he received different doses of antipsychotic, antiparkinsonic and antidepressant medications. At the time of his first visit he received Clorpromasin 100gr / day.


All of these years he used to get up late and to get his breakfast in bed, served by his sister. His only duty at home was to take his sister for walks and to the doctor. Once a week they went together to a coffee shop or to MacDonald's. Every once in a while Michael would visit his married university friend. Most of his time at home he used to watch television or to read newspapers.


His sexual life consisted of masturbation about twice a week. He always masturbated by standing in the bathroom and soaping his genitals. He never masturbated in a lying position in bed because of the fear to be overheard by other members of his family, especially by his sister, for whom he believed it would be disastrous because of her shyness and fear of any expression of sexuality.


His only experience with a woman was a single unsuccessful visit to a prostitute in the Red Lights district during his visit to Amsterdam, many years ago.


On his first visit to the clinic, he looked well groomed, a little bit shy and childish. He was a little bit anxious, and had difficulty to listen patiently. His pattern was to cut me in the middle of the sentence when sensitive topics were touched. When hearing my Russian accent he started telling old Soviet jokes and slogans.


However there were no signs of psychotic or mood disorders. His judgment was not impaired and he seemed well informed about political, social and financial matters.


However there was something strange in him. He looked like a person from another historical epoch. His reason for coming to the clinic was his wish to learn to function sexually. His plan was to find a woman friend through a matching agency and he wanted to gain some experience before entering a real relationship.


He expressed fear and suspicion of women by stating that all women want the same thing, namely to marry him and then get hold of his money and possessions.


The first stage of the treatment included meeting the surrogate outside the clinic, developing social skills, keeping a conversation, functioning as a partner in a restaurant and during a visit to a museum.


He formed a good, although in some ways childish relationship with the surrogate. The next stage was a very slow work on "Sensate Focus". Michael advanced enthusiastically, he watched with interest video materials, asked many questions.


In the sessions with the surrogate he performed well sensual massage but mostly enjoyed being taken care of, caressed, massaged, and washed. Both Michael and the surrogate reported a pleasurable atmosphere, good humor and spontaneous erections.


The next stage was mutual masturbation. Michael learned well to excite and masturbate his partner, but was unable to reach an orgasm except in a standing position when his genitals were soaped.


After a few disappointments in reaching orgasm in positions other than that, he started having problem achieving erections. It was impossible to teach him to put a condom because a condom would slide off his soaped penis. He was reluctant to masturbate differently at home and reported reduction in desire to do it at all.


At this stage he became suspicious of me and of the treatment. He expressed suspicion that our only goal was to rid him of his money. The surrogate that was new in the clinic and was eager to succeed, also turned with claims to me: You are the doctor. Is there no drug or injection that will give him a good erection? If you don't know any send him to another doctor". It was obvious that the whole process reached a crisis.



My consideration at this stage was as follows:


1) The physical examination at the beginning of treatment showed no medical problems.


2) Laboratory findings: Prolactin and total Testosterone levels were normal.


3) The patient masturbated and reached orgasms with no problem previous to the crisis.



4) The patient reached erection during the "Sensate Focus" state of the treatment.


5) There was a little possibility that the dose of 50 mg of Cloropromasin interfered with his erection and ejaculation.



6) It was dangerous to reduce farther his antipsychotic medication, especially when he became belligerent and suspicious.
At this point of treatment the surrogate had to cancel 3-4 sessions because of medical problems of her own, leaving Michael and me in doubts concerning the continuation of treatment.



The situation was ideal for acting out, and it didn't take long for Michael to act. He didn't appear for the session with me and cancelled the payment for his last appointment.


He arranged a visit to a private urologist, not the one connected with the clinic.



The laboratory tests showed slightly elevated levels of Prolactin and slightly lowed levels of Testosterone. (On the initial examination the levels were normal). The NPT test showed 5 erections during an 8 hours sleep lasting from 8 to 31 minutes. The tumescence was good, and the Rigidity - good at the base of the penis and weak at the distal end. The conclusion was - clear inefficiency of rigidity at the distal end of the penis. The Urologist prescribed Tesophalmed Forte (A combination of Yohimbin with Strichnine) and Xatral - a drug for the possible enlargement of Prostate Gland.


In the session that followed four weeks of disconnection Michael looked relaxed. He told me: "You see, I told you that my problem was physical and not psychological".


He was ready to go on with the surrogate therapy. Seeing Michael relaxed and in good spirit as he was, I decided to take the risk and take him completely off the Clorpromasine that has a potential of elevating prolactin levels. This same session I recommended him to quit taking Antihypertension drug that was prescribed to him by his family doctor since his blood pressure was normal during continuous measurements for several months.


The renewal of sessions with surrogate was very successful. Michael had good erections, learned to put a condom. Very soon he made penetration and achieved orgasm in different positions.


His spirit was high and one day he started a course in C++ - an advanced computer language. In a few months parallel to his progress with the surrogate he finished the course with excellence and began looking for a real job in programming.


After a few disappointments in the interviews he decided not to reveal his real life story and invented a cover story. It is now three months that he successfully works in a computer company with a very good salary.


Meanwhile his progress with the surrogate was amazing. He became familiar with the missionary position, woman on top position, woman on four position, sitting position. He even managed to orgasm twice with an interval of twenty minutes. The surrogate couldn't stop praising him. He had strong erections even before taking his pants off.


A question remained: was his success a result of the medication he received from the urologist or quitting Clorpromasine or the Antihypertension drug. Or was it a placebo effect or a function of advancement in surrogate therapy.


At this stage I decided to take him gradually off Tesopalmed Forte. He used to take two tablets daily morning and evening. Not wanting to destroy the placebo effect if it was one, I used the technique of disorientation originally used in hypnosis. I ordered him for a week to take off one pill in the evening every other day. The next week, to take off the pill in the morning every other day - at the days he took the pill in the evening. The week that followed, I advised him to stop taking the pill in the evening, and the next week - to stop taking the pill at all.


All those weeks his sexual function continued to improve. In the middle of the process of taking him off the drugs, when already sure of successful termination of the treatment, I asked Michael what were his plans after the termination. I was sure of receiving a mature and reasonable answer.


Instead Michael told me that all women want the same thing - to marry him and get hold of his money. He told me that he trusts no one. It is obvious that he can't leave his sister alone after his parent's death and no woman will agree to live together with his sister. His sister also will never agree to let him live with another woman.


His next passage was that the treatment is very expensive and he decided to stop it now. All reasoning trials, that he had only two - three sessions left and it made no sense to leave with medication while he can get rid of them completely, did not help.


In the last minutes I tried to explain to him that his investment in treatment was probably the best investment in his life. For the first time in 50 years he has a real job with a very good salary, for the first time he discovered himself as a virile man, able to satisfy a woman and enjoy sex himself. For the first time in 30 years he was off all the medications. All my explanations and pleads for no avail.


While he was already at the door I uttered: "You are a heavy customer", those same words that he used to describe his father. Michael hesitated, then smiled, turned around and said: "let's arrange an appointment". This was the second crisis in the treatment. The next session Michael told me that when I said: "You are a heavy customer" - he understood that he is suspicious as his father. "Not that my father is wrong, but I decided to give it a chance."




The case I presented here is interesting because of complexity of problems and challenges it posed upon the therapeutic team. We see here a chronic mental patient with severe psychopathology in the family, symbiotic relationships with his mentally ill sister, suspiciousness as a symptom, a character trait and family strategy, variety of medical problems and all this in one 50 years old virgin man.


We see in this presentation how surrogate sex therapy can be used as a powerful lever in rehabilitation process of an otherwise hopeless case.


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