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THE CASE
A 52-year-old man requested medicine to help him with erectile dysfunction. After obtaining a medical history and performing a physical exam, the family physician (FP) asked for more details about the patient’s situation. He reported that his wife, who had recently seen the same FP for counseling related to her frustrations with her husband, was uninterested in sex. He then added that he was having an affair with a 32-year-old female co-worker and wanted to improve his sexual function.
He admitted to feeling guilty about this situation and was conflicted about whether to end the affair. He also stated that since the affair, his insomnia had worsened, he was drinking more alcohol, and he was having migraine headaches. As the FP for both patients, and with the knowledge that the wife was worried about possible infidelity, the physician felt some level of conflict about the situation. The following is a discussion of the issues that this patient encounter raised.
DISCUSSION
Issues related to infidelity are common to both men and women. They are also common in same-sex relationships; in general, however, lesbian couples have fewer outside partners, whereas gay men are more likely to seek variety by having multiple partners.1
It is widely understood that successfully committed couples spend quality time together, emphasize each other’s strengths, show respect, accept influence, and nurture their friendship. However, many couples experience infidelity at some time in the course of their marriage. It is difficult to put an exact estimate on rates of infidelity due to problems with research methodology, inaccurate reporting, and a lack of agreement on a definition for infidelity.2 General categories of infidelity include emotional only, sexual only, and combined sexual and emotional infidelity.3,4 In terms of sexual infidelity, one study found that 25% of married men and 15% of married women admitted to having had extramarital sex at least once during their relationship.5 However, other studies suggest that women are closing the “sexual infidelity” gap and engaging in sexual affairs at a similar rate to men.6 There are websites that, in fact, have made it easier for married individuals to engage in affairs.
Reasons for infidelity. Men and women often have different motives in engaging in infidelity. In general, men’s motivations are more often related to sexual dissatisfaction and women’s to emotional dissatisfaction.7,8 However, infidelity may not always be the result of marital unhappiness.
Some studies suggest that the presence of opportunity may override the positive aspects of a relationship.9 Opportunity is heightened in the work environment, as reflected by the finding that 50% of infidelity occurs in the office.10 Research suggests that all relationships may be vulnerable to infidelity if the right opportunities present themselves.11
In general, health care providers are encouraged to use caution in generalizing about infidelity, as the subject is extremely complex, nuanced, and difficult to measure with exactitude.12
Continue to: The impact of infidelity
The impact of infidelity on couples varies due to factors such as the pre-morbid health of the marriage,13 the depth of involvement with the affair partner,14 and pre-existing attitudes about infidelity.13
Infidelity is a common cause of divorce in America. However, in a sample, Schneider et al15 found that despite initial threats to leave the marriage after infidelity, less than one-quarter of partners divorced. Other studies have found that disclosure of the infidelity and a commitment to work on the marriage may be an essential component of healing.16
Emotionally focused couples therapy, with its emphasis on attachment and bonding, may hold promise for helping couples successfully work through the trauma brought on by extramarital relationships.17 Psychologist and infidelity researcher Shirley Glass found that of the two-thirds of couples who chose to stay together after an affair, 80% of them reported a better marriage after treatment.11
Initial steps to take, and questions to ask
Both male and female patients need to feel comfortable surfacing sexual concerns with their clinicians. In this case, the concerns of the husband are interwoven with broader marital issues, which are the source of emotional and psychosomatic distress. His decision regarding his affair carried with it potentially life-altering consequences for his wife, 3 children, and affair partner and her family. It also raised ethical issues for the FP, who was providing care to both the husband and the wife. Appropriate care requires that a physician in this situation
- demonstrate a nonjudgmental approach
- clarify personal ethics in response to patient behaviors
- maintain confidentiality
- apply an ethical framework to resolve value dilemmas
- avoid actions that would be harmful to patients.
Interviewing can help to elicit information that may be clarifying not only to the physician but also to the patient. When interviewing a patient such as the one in this case, it would be wise to ask:
- How long has the affair been going on?
- Why is the patient engaging in the affair?
- Is abuse (emotional or physical) a factor in the marriage?
- Does the patient still have feelings for their spouse? Does the patient want to work on the marriage?
- Has the patient talked to a friend or therapist about the situation?
- Would the patient be willing to talk to a therapist?
Continue to: Ethical and legal considerations
Ethical and legal considerations
Some therapists espouse the view that being “neutral” in the presence of an affair is as much a value judgment as taking one side or the other. In the presence of emotional or physical abuse, it might indeed be best to support a marital separation. However, in other situations when there are young children involved and the patient is undecided about what to do, the FP can discuss the pros and cons of working on a marriage that suffers from more treatable types of disrepair (ie, stress, disconnection, repetitive arguments).
Provision of care. If the patient is unwilling to end the affair, the physician needs to decide whether they feel ethically at ease with prescribing sexually enhancing performance medication, given that the patient’s wife is also a patient. A physician in this situation might feel that they are betraying the wife by providing such medications to the husband. In such cases, it might be appropriate to refer the husband to a colleague.
In all cases of infidelity, however, it is wise to discuss safe-sex practices in order to limit the risk of transmitting a sexually transmitted infection (STI) to the spouse (or affair partner) and offer testing for STIs.
Confidentiality. Despite feelings the physician might have about betraying the wife’s trust by providing the performance-enhancing medicine to the husband, there is very little justification for revealing the affair to the wife. In general, confidentiality can only be broken if there is a high level of imminent danger associated with nondisclosure. The physician needs to realize the serious legal implications of breaking confidentiality in this situation, as such disclosure may prompt the initiation of divorce proceedings.
Real-world recommendations
Check your own biases. Infidelity can trigger a whole host of emotional reactions in physicians based on their own personal and professional history. It is important to be aware of such emotions and if sufficiently triggered, discuss the case with a colleague.
Continue to: Encourage bibliotherapy and marriage therapy
Encourage bibliotherapy and marriage therapy. The conversation might go something like this:
“I would recommend you do some reading about infidelity. If you are interested in working on your marriage, you might want to consider a couples counselor who can help you. Research shows that while such counseling can help couples work through infidelity, disclosure needs to occur as part of that process. Research also indicates that about two-thirds of marriages stay together after the revelation of an affair and that such couples can experience healing if they commit to a therapeutic process. If you are unsure how you want to proceed, it might be helpful for you to explore your situation with an individual therapist. What would you like to do next?”
There are also written resources that the patient might find helpful; see “3 bibliotherapy resources for infidelity” for recommendations.
SIDEBAR
3 bibliotherapy resources for infidelity
Not ‘Just Friends’: Protect Your Relationship from Infidelity and Heal the Trauma of Betrayal (Shirley Glass)
After the Affair: Healing the Pain and Rebuilding Trust When a Partner Has Betrayed You (Janice Abrams-Spring)
How Can I Forgive You: The Courage to Forgive, the Freedom Not To (Janice Abrams-Spring)
Referral to an individual or marriage counselor is warranted if the patient wants to work through the issues alone or with their partner. Disclosure of infidelity may not always be necessary for successful reconciliation if the affair has ended. A marriage therapist to whom you refer needs to be competent in working with infidelity.
Our patient. At the completion of the initial consultation—and after a discussion focused on the issues described, including encouragement to seek counseling—the FP acceded to the patient’s request for sexual performance-enhancing medication.
Continue to: The patient returned a few months...
The patient returned a few months later. His wife had found texts between him and his affair partner and told the patient that they had to enter into couples therapy or she was going to file for divorce. The patient told his physician that he had ended the extramarital relationship and was working on his marriage with a qualified marriage therapist; however, he felt lingering feelings of loss, discomfort in the workplace, and confusion about his choices. The physician was supportive and encouraged him to share these feelings, if possible, with an individual therapist or to find a friend who could listen while being supportive of his marriage. The physician also offered his services as a sounding board.
A year later, the patient had found another job and was still working on his marriage.
THE TAKEAWAY
This case underscores the importance of some basic health care tenets. It reminds us that maintaining patient confidentiality is paramount, and that nonjudgmental interviewing can help us to help our patients navigate challenging situations. The particulars of this case also highlight the importance of referring patients out for individual or marriage counseling and making a referral to a colleague when a situation makes us feel as if we are betraying a patient’s trust.
CORRESPONDENCE
David C. Slawson, MD, 2001 Vail Avenue, Suite 400B, Mercy Medical Plaza, Charlotte, NC 28207; [email protected]
1. Blumstein P, Schwartz P. American Couples: Money, Work, Sex. William Morrow; 1983.
2. Blow A, Hartnett K. Infidelity in committed relationships I: a methodological review. J Marital Fam Ther. 2005;31:183-216. doi: 10.1111/j.1752-0606.2005.tb01555.x
3. Glass S, Wright TL. Sex differences in type of extramarital involvement and marital dissatisfaction. Sex Roles. 1985;12:1101-1120.
4. Thompson AP. Emotional and sexual components of extramarital relations. J Marriage Fam. 1984;46:35-42. doi: 10.2307/351861
5. Laumann EO, Gagnon JH, Michael RT, et al. The Social Organization of Sexuality: Sexual Practices in the United States. University of Chicago Press; 1994.
6. Oliver MB, Hyde JS. Gender differences in sexuality: a meta-analysis. Psychol Bull. 1993;114:29-51. doi: 10.1037/0033-2909.114.1.29
7. Glass SP, Wright TL. Justifications for extramarital relationships: the association between attitudes, behaviors, and gender. J Sex Res. 1992;29:361-387. doi: 10.1080/00224499209551654
8. Spanier GB, Margolis RL. Marital separation and extramarital sexual behavior. J Sex Res. 1983;19:23-48.
9. Atkins DC, Baucom DH, Jacobson NS. Understanding infidelity: correlates in a national random sample. J Fam Psychol. 2001;15:735-749. doi: 10.1037//0893-3200.15.4.735
10. Treas J, Giesen D. Sexual infidelity among married and cohabitating Americans. J Marriage Fam. 2000;62:48-60. doi: 10.1111/j.1741-3737.2000.00048.x
11. Glass SP. Not ‘Just Friends’: Protect Your Relationship From Infidelity and Heal the Trauma of Betrayal. Free Press; 2002.
12. Blow A, Hartnet K. Infidelity in committed relationships II: a substantive review. J Marital Fam Ther. 2005;31:2. doi: 10.1111/j.1752-0606.2005.tb01556.x
13. Buunk B. Conditions that promote breakups as a consequence of extradyadic involvements. J Soc Clin Psychol. 1987;5:271-284. doi: 10.1521/jscp.1987.5.3.271
14. Charn IW, Parnass S. The impact of extramarital relationships on the continuation of marriages. J Sex Marital Therapy. 1995;21:100-115. doi: 10.1080/00926239508404389
15. Schneider JP, Irons RR, Corley MD. Disclosure of extramarital sexual activities by sexually exploitative professionals and other persons with addictive or compulsive sexual disorders. J Sex Edu Therapy. 1999;24:277-287. doi: 10.1080/01614576.1999.11074316
16. Atkins DC, Eldridge KA, Baucom DH, et al. Infidelity and behavioral couple therapy: optimism in the face of betrayal. J Consult Clin Psychol. 2005;73:144-150. doi: 10.1037/0022-006X.73.1.144
17. Johnson SM, Makinen J, Millikin J. Attachment injuries in couple relationships: a new perspective on impasses in emotionally focused marital therapy. J Marital Fam Therapy. 2001;27:145-155. doi: 10.1111/j.1752-0606.2001.tb01152.x
THE CASE
A 52-year-old man requested medicine to help him with erectile dysfunction. After obtaining a medical history and performing a physical exam, the family physician (FP) asked for more details about the patient’s situation. He reported that his wife, who had recently seen the same FP for counseling related to her frustrations with her husband, was uninterested in sex. He then added that he was having an affair with a 32-year-old female co-worker and wanted to improve his sexual function.
He admitted to feeling guilty about this situation and was conflicted about whether to end the affair. He also stated that since the affair, his insomnia had worsened, he was drinking more alcohol, and he was having migraine headaches. As the FP for both patients, and with the knowledge that the wife was worried about possible infidelity, the physician felt some level of conflict about the situation. The following is a discussion of the issues that this patient encounter raised.
DISCUSSION
Issues related to infidelity are common to both men and women. They are also common in same-sex relationships; in general, however, lesbian couples have fewer outside partners, whereas gay men are more likely to seek variety by having multiple partners.1
It is widely understood that successfully committed couples spend quality time together, emphasize each other’s strengths, show respect, accept influence, and nurture their friendship. However, many couples experience infidelity at some time in the course of their marriage. It is difficult to put an exact estimate on rates of infidelity due to problems with research methodology, inaccurate reporting, and a lack of agreement on a definition for infidelity.2 General categories of infidelity include emotional only, sexual only, and combined sexual and emotional infidelity.3,4 In terms of sexual infidelity, one study found that 25% of married men and 15% of married women admitted to having had extramarital sex at least once during their relationship.5 However, other studies suggest that women are closing the “sexual infidelity” gap and engaging in sexual affairs at a similar rate to men.6 There are websites that, in fact, have made it easier for married individuals to engage in affairs.
Reasons for infidelity. Men and women often have different motives in engaging in infidelity. In general, men’s motivations are more often related to sexual dissatisfaction and women’s to emotional dissatisfaction.7,8 However, infidelity may not always be the result of marital unhappiness.
Some studies suggest that the presence of opportunity may override the positive aspects of a relationship.9 Opportunity is heightened in the work environment, as reflected by the finding that 50% of infidelity occurs in the office.10 Research suggests that all relationships may be vulnerable to infidelity if the right opportunities present themselves.11
In general, health care providers are encouraged to use caution in generalizing about infidelity, as the subject is extremely complex, nuanced, and difficult to measure with exactitude.12
Continue to: The impact of infidelity
The impact of infidelity on couples varies due to factors such as the pre-morbid health of the marriage,13 the depth of involvement with the affair partner,14 and pre-existing attitudes about infidelity.13
Infidelity is a common cause of divorce in America. However, in a sample, Schneider et al15 found that despite initial threats to leave the marriage after infidelity, less than one-quarter of partners divorced. Other studies have found that disclosure of the infidelity and a commitment to work on the marriage may be an essential component of healing.16
Emotionally focused couples therapy, with its emphasis on attachment and bonding, may hold promise for helping couples successfully work through the trauma brought on by extramarital relationships.17 Psychologist and infidelity researcher Shirley Glass found that of the two-thirds of couples who chose to stay together after an affair, 80% of them reported a better marriage after treatment.11
Initial steps to take, and questions to ask
Both male and female patients need to feel comfortable surfacing sexual concerns with their clinicians. In this case, the concerns of the husband are interwoven with broader marital issues, which are the source of emotional and psychosomatic distress. His decision regarding his affair carried with it potentially life-altering consequences for his wife, 3 children, and affair partner and her family. It also raised ethical issues for the FP, who was providing care to both the husband and the wife. Appropriate care requires that a physician in this situation
- demonstrate a nonjudgmental approach
- clarify personal ethics in response to patient behaviors
- maintain confidentiality
- apply an ethical framework to resolve value dilemmas
- avoid actions that would be harmful to patients.
Interviewing can help to elicit information that may be clarifying not only to the physician but also to the patient. When interviewing a patient such as the one in this case, it would be wise to ask:
- How long has the affair been going on?
- Why is the patient engaging in the affair?
- Is abuse (emotional or physical) a factor in the marriage?
- Does the patient still have feelings for their spouse? Does the patient want to work on the marriage?
- Has the patient talked to a friend or therapist about the situation?
- Would the patient be willing to talk to a therapist?
Continue to: Ethical and legal considerations
Ethical and legal considerations
Some therapists espouse the view that being “neutral” in the presence of an affair is as much a value judgment as taking one side or the other. In the presence of emotional or physical abuse, it might indeed be best to support a marital separation. However, in other situations when there are young children involved and the patient is undecided about what to do, the FP can discuss the pros and cons of working on a marriage that suffers from more treatable types of disrepair (ie, stress, disconnection, repetitive arguments).
Provision of care. If the patient is unwilling to end the affair, the physician needs to decide whether they feel ethically at ease with prescribing sexually enhancing performance medication, given that the patient’s wife is also a patient. A physician in this situation might feel that they are betraying the wife by providing such medications to the husband. In such cases, it might be appropriate to refer the husband to a colleague.
In all cases of infidelity, however, it is wise to discuss safe-sex practices in order to limit the risk of transmitting a sexually transmitted infection (STI) to the spouse (or affair partner) and offer testing for STIs.
Confidentiality. Despite feelings the physician might have about betraying the wife’s trust by providing the performance-enhancing medicine to the husband, there is very little justification for revealing the affair to the wife. In general, confidentiality can only be broken if there is a high level of imminent danger associated with nondisclosure. The physician needs to realize the serious legal implications of breaking confidentiality in this situation, as such disclosure may prompt the initiation of divorce proceedings.
Real-world recommendations
Check your own biases. Infidelity can trigger a whole host of emotional reactions in physicians based on their own personal and professional history. It is important to be aware of such emotions and if sufficiently triggered, discuss the case with a colleague.
Continue to: Encourage bibliotherapy and marriage therapy
Encourage bibliotherapy and marriage therapy. The conversation might go something like this:
“I would recommend you do some reading about infidelity. If you are interested in working on your marriage, you might want to consider a couples counselor who can help you. Research shows that while such counseling can help couples work through infidelity, disclosure needs to occur as part of that process. Research also indicates that about two-thirds of marriages stay together after the revelation of an affair and that such couples can experience healing if they commit to a therapeutic process. If you are unsure how you want to proceed, it might be helpful for you to explore your situation with an individual therapist. What would you like to do next?”
There are also written resources that the patient might find helpful; see “3 bibliotherapy resources for infidelity” for recommendations.
SIDEBAR
3 bibliotherapy resources for infidelity
Not ‘Just Friends’: Protect Your Relationship from Infidelity and Heal the Trauma of Betrayal (Shirley Glass)
After the Affair: Healing the Pain and Rebuilding Trust When a Partner Has Betrayed You (Janice Abrams-Spring)
How Can I Forgive You: The Courage to Forgive, the Freedom Not To (Janice Abrams-Spring)
Referral to an individual or marriage counselor is warranted if the patient wants to work through the issues alone or with their partner. Disclosure of infidelity may not always be necessary for successful reconciliation if the affair has ended. A marriage therapist to whom you refer needs to be competent in working with infidelity.
Our patient. At the completion of the initial consultation—and after a discussion focused on the issues described, including encouragement to seek counseling—the FP acceded to the patient’s request for sexual performance-enhancing medication.
Continue to: The patient returned a few months...
The patient returned a few months later. His wife had found texts between him and his affair partner and told the patient that they had to enter into couples therapy or she was going to file for divorce. The patient told his physician that he had ended the extramarital relationship and was working on his marriage with a qualified marriage therapist; however, he felt lingering feelings of loss, discomfort in the workplace, and confusion about his choices. The physician was supportive and encouraged him to share these feelings, if possible, with an individual therapist or to find a friend who could listen while being supportive of his marriage. The physician also offered his services as a sounding board.
A year later, the patient had found another job and was still working on his marriage.
THE TAKEAWAY
This case underscores the importance of some basic health care tenets. It reminds us that maintaining patient confidentiality is paramount, and that nonjudgmental interviewing can help us to help our patients navigate challenging situations. The particulars of this case also highlight the importance of referring patients out for individual or marriage counseling and making a referral to a colleague when a situation makes us feel as if we are betraying a patient’s trust.
CORRESPONDENCE
David C. Slawson, MD, 2001 Vail Avenue, Suite 400B, Mercy Medical Plaza, Charlotte, NC 28207; [email protected]
THE CASE
A 52-year-old man requested medicine to help him with erectile dysfunction. After obtaining a medical history and performing a physical exam, the family physician (FP) asked for more details about the patient’s situation. He reported that his wife, who had recently seen the same FP for counseling related to her frustrations with her husband, was uninterested in sex. He then added that he was having an affair with a 32-year-old female co-worker and wanted to improve his sexual function.
He admitted to feeling guilty about this situation and was conflicted about whether to end the affair. He also stated that since the affair, his insomnia had worsened, he was drinking more alcohol, and he was having migraine headaches. As the FP for both patients, and with the knowledge that the wife was worried about possible infidelity, the physician felt some level of conflict about the situation. The following is a discussion of the issues that this patient encounter raised.
DISCUSSION
Issues related to infidelity are common to both men and women. They are also common in same-sex relationships; in general, however, lesbian couples have fewer outside partners, whereas gay men are more likely to seek variety by having multiple partners.1
It is widely understood that successfully committed couples spend quality time together, emphasize each other’s strengths, show respect, accept influence, and nurture their friendship. However, many couples experience infidelity at some time in the course of their marriage. It is difficult to put an exact estimate on rates of infidelity due to problems with research methodology, inaccurate reporting, and a lack of agreement on a definition for infidelity.2 General categories of infidelity include emotional only, sexual only, and combined sexual and emotional infidelity.3,4 In terms of sexual infidelity, one study found that 25% of married men and 15% of married women admitted to having had extramarital sex at least once during their relationship.5 However, other studies suggest that women are closing the “sexual infidelity” gap and engaging in sexual affairs at a similar rate to men.6 There are websites that, in fact, have made it easier for married individuals to engage in affairs.
Reasons for infidelity. Men and women often have different motives in engaging in infidelity. In general, men’s motivations are more often related to sexual dissatisfaction and women’s to emotional dissatisfaction.7,8 However, infidelity may not always be the result of marital unhappiness.
Some studies suggest that the presence of opportunity may override the positive aspects of a relationship.9 Opportunity is heightened in the work environment, as reflected by the finding that 50% of infidelity occurs in the office.10 Research suggests that all relationships may be vulnerable to infidelity if the right opportunities present themselves.11
In general, health care providers are encouraged to use caution in generalizing about infidelity, as the subject is extremely complex, nuanced, and difficult to measure with exactitude.12
Continue to: The impact of infidelity
The impact of infidelity on couples varies due to factors such as the pre-morbid health of the marriage,13 the depth of involvement with the affair partner,14 and pre-existing attitudes about infidelity.13
Infidelity is a common cause of divorce in America. However, in a sample, Schneider et al15 found that despite initial threats to leave the marriage after infidelity, less than one-quarter of partners divorced. Other studies have found that disclosure of the infidelity and a commitment to work on the marriage may be an essential component of healing.16
Emotionally focused couples therapy, with its emphasis on attachment and bonding, may hold promise for helping couples successfully work through the trauma brought on by extramarital relationships.17 Psychologist and infidelity researcher Shirley Glass found that of the two-thirds of couples who chose to stay together after an affair, 80% of them reported a better marriage after treatment.11
Initial steps to take, and questions to ask
Both male and female patients need to feel comfortable surfacing sexual concerns with their clinicians. In this case, the concerns of the husband are interwoven with broader marital issues, which are the source of emotional and psychosomatic distress. His decision regarding his affair carried with it potentially life-altering consequences for his wife, 3 children, and affair partner and her family. It also raised ethical issues for the FP, who was providing care to both the husband and the wife. Appropriate care requires that a physician in this situation
- demonstrate a nonjudgmental approach
- clarify personal ethics in response to patient behaviors
- maintain confidentiality
- apply an ethical framework to resolve value dilemmas
- avoid actions that would be harmful to patients.
Interviewing can help to elicit information that may be clarifying not only to the physician but also to the patient. When interviewing a patient such as the one in this case, it would be wise to ask:
- How long has the affair been going on?
- Why is the patient engaging in the affair?
- Is abuse (emotional or physical) a factor in the marriage?
- Does the patient still have feelings for their spouse? Does the patient want to work on the marriage?
- Has the patient talked to a friend or therapist about the situation?
- Would the patient be willing to talk to a therapist?
Continue to: Ethical and legal considerations
Ethical and legal considerations
Some therapists espouse the view that being “neutral” in the presence of an affair is as much a value judgment as taking one side or the other. In the presence of emotional or physical abuse, it might indeed be best to support a marital separation. However, in other situations when there are young children involved and the patient is undecided about what to do, the FP can discuss the pros and cons of working on a marriage that suffers from more treatable types of disrepair (ie, stress, disconnection, repetitive arguments).
Provision of care. If the patient is unwilling to end the affair, the physician needs to decide whether they feel ethically at ease with prescribing sexually enhancing performance medication, given that the patient’s wife is also a patient. A physician in this situation might feel that they are betraying the wife by providing such medications to the husband. In such cases, it might be appropriate to refer the husband to a colleague.
In all cases of infidelity, however, it is wise to discuss safe-sex practices in order to limit the risk of transmitting a sexually transmitted infection (STI) to the spouse (or affair partner) and offer testing for STIs.
Confidentiality. Despite feelings the physician might have about betraying the wife’s trust by providing the performance-enhancing medicine to the husband, there is very little justification for revealing the affair to the wife. In general, confidentiality can only be broken if there is a high level of imminent danger associated with nondisclosure. The physician needs to realize the serious legal implications of breaking confidentiality in this situation, as such disclosure may prompt the initiation of divorce proceedings.
Real-world recommendations
Check your own biases. Infidelity can trigger a whole host of emotional reactions in physicians based on their own personal and professional history. It is important to be aware of such emotions and if sufficiently triggered, discuss the case with a colleague.
Continue to: Encourage bibliotherapy and marriage therapy
Encourage bibliotherapy and marriage therapy. The conversation might go something like this:
“I would recommend you do some reading about infidelity. If you are interested in working on your marriage, you might want to consider a couples counselor who can help you. Research shows that while such counseling can help couples work through infidelity, disclosure needs to occur as part of that process. Research also indicates that about two-thirds of marriages stay together after the revelation of an affair and that such couples can experience healing if they commit to a therapeutic process. If you are unsure how you want to proceed, it might be helpful for you to explore your situation with an individual therapist. What would you like to do next?”
There are also written resources that the patient might find helpful; see “3 bibliotherapy resources for infidelity” for recommendations.
SIDEBAR
3 bibliotherapy resources for infidelity
Not ‘Just Friends’: Protect Your Relationship from Infidelity and Heal the Trauma of Betrayal (Shirley Glass)
After the Affair: Healing the Pain and Rebuilding Trust When a Partner Has Betrayed You (Janice Abrams-Spring)
How Can I Forgive You: The Courage to Forgive, the Freedom Not To (Janice Abrams-Spring)
Referral to an individual or marriage counselor is warranted if the patient wants to work through the issues alone or with their partner. Disclosure of infidelity may not always be necessary for successful reconciliation if the affair has ended. A marriage therapist to whom you refer needs to be competent in working with infidelity.
Our patient. At the completion of the initial consultation—and after a discussion focused on the issues described, including encouragement to seek counseling—the FP acceded to the patient’s request for sexual performance-enhancing medication.
Continue to: The patient returned a few months...
The patient returned a few months later. His wife had found texts between him and his affair partner and told the patient that they had to enter into couples therapy or she was going to file for divorce. The patient told his physician that he had ended the extramarital relationship and was working on his marriage with a qualified marriage therapist; however, he felt lingering feelings of loss, discomfort in the workplace, and confusion about his choices. The physician was supportive and encouraged him to share these feelings, if possible, with an individual therapist or to find a friend who could listen while being supportive of his marriage. The physician also offered his services as a sounding board.
A year later, the patient had found another job and was still working on his marriage.
THE TAKEAWAY
This case underscores the importance of some basic health care tenets. It reminds us that maintaining patient confidentiality is paramount, and that nonjudgmental interviewing can help us to help our patients navigate challenging situations. The particulars of this case also highlight the importance of referring patients out for individual or marriage counseling and making a referral to a colleague when a situation makes us feel as if we are betraying a patient’s trust.
CORRESPONDENCE
David C. Slawson, MD, 2001 Vail Avenue, Suite 400B, Mercy Medical Plaza, Charlotte, NC 28207; [email protected]
1. Blumstein P, Schwartz P. American Couples: Money, Work, Sex. William Morrow; 1983.
2. Blow A, Hartnett K. Infidelity in committed relationships I: a methodological review. J Marital Fam Ther. 2005;31:183-216. doi: 10.1111/j.1752-0606.2005.tb01555.x
3. Glass S, Wright TL. Sex differences in type of extramarital involvement and marital dissatisfaction. Sex Roles. 1985;12:1101-1120.
4. Thompson AP. Emotional and sexual components of extramarital relations. J Marriage Fam. 1984;46:35-42. doi: 10.2307/351861
5. Laumann EO, Gagnon JH, Michael RT, et al. The Social Organization of Sexuality: Sexual Practices in the United States. University of Chicago Press; 1994.
6. Oliver MB, Hyde JS. Gender differences in sexuality: a meta-analysis. Psychol Bull. 1993;114:29-51. doi: 10.1037/0033-2909.114.1.29
7. Glass SP, Wright TL. Justifications for extramarital relationships: the association between attitudes, behaviors, and gender. J Sex Res. 1992;29:361-387. doi: 10.1080/00224499209551654
8. Spanier GB, Margolis RL. Marital separation and extramarital sexual behavior. J Sex Res. 1983;19:23-48.
9. Atkins DC, Baucom DH, Jacobson NS. Understanding infidelity: correlates in a national random sample. J Fam Psychol. 2001;15:735-749. doi: 10.1037//0893-3200.15.4.735
10. Treas J, Giesen D. Sexual infidelity among married and cohabitating Americans. J Marriage Fam. 2000;62:48-60. doi: 10.1111/j.1741-3737.2000.00048.x
11. Glass SP. Not ‘Just Friends’: Protect Your Relationship From Infidelity and Heal the Trauma of Betrayal. Free Press; 2002.
12. Blow A, Hartnet K. Infidelity in committed relationships II: a substantive review. J Marital Fam Ther. 2005;31:2. doi: 10.1111/j.1752-0606.2005.tb01556.x
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