When An Erection Alone Is Not Enough!
More about the complex causes of erection problems - and how treatment for erectile dysfunction may not always be straightforward (and why Viagra may fail to work)

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Obstacles to making love - when an erection alone is not enough

He introduces this article by making the observation that although it is easy enough to give a man a firm erection, getting him to "make use of it" on a regular basis in a sexual relationship is not quite as straightforward. Dropout rates for any treatment for erectile dysfunction, including Viagra, have been found to fall within a range of 20 to 50%. Bear in mind that this dropout rate is from a group of men for whom treatment has been successful. Clearly, understanding what promotes this dropout will be helpful in improving treatment.

Simplistically, it appears that psychological resistance of some kind on the part of the men, their partners, or both, contributes to the cessation of treatment for erectile dysfunction. Factors implicated include: (1) the length of time that a couple have not had sex before treatment was available; (2) the man's attitude to resuming sexual relationship with his partner; (3) a man's expectations of how treatment will change his sex life; (4) his partner's willingness and ability, both physically and emotionally, to recommence a sexual relationship; (5) how each partner views the impact of the medical intervention that allows them to start having sex again; (6) the quality of their relationship outside the sexual arena; and (7) any abnormalities or variations from the norm in the sexual arousal process for the man.

We know no single treatment for erection problems works for everybody, and not every patient is equally able to absorb the nuances and complexities of different treatment strategies. It's possible, therefore, that some of the unexplained discontinuation of treatment is due to a man not having enough information to confidently embark on the treatment, or because he fears there will be an unexpected and serious consequence of the treatment for erectile dysfunction.

A simple example of the education that is sometimes necessary to ensure that treatment is effective is the insight that men may not be advised that Viagra works best when taken on an empty stomach and requires between three quarters of an hour and an hour before it has its maximum effect. Equally many men do not know that the efficiency of the drug actually improves with continued administration up to the eighth dose. It's also possible that some men consider Viagra to be unsafe.

Because of this, Althof makes the observation that the best way of analyzing the cessation of treatment is to take the problem from a broad view, from a biopsychosocial perspective. Evidently, the cessation of treatment is the end result of a process which involved a man making a decision about seeking treatment, and attending a clinic with or without his partner. In this situation, it is often the case that a clinician will prescribe an effective remedy for erectile dysfunction (perhaps Viagra) and then consider that the situation is resolved. However, this approach does not consider any emotional or psychological aspects arising from the treatment strategy or the man's relationship.

For example, he may be consumed with performance anxiety, or depressed, or he may have unrealistic expectations of sex. Or he may have an unconventional sexual arousal process which includes sadomasochism,  transvestism or some other paraphilia. His partner's health or lack of interest in sex may preclude the resumption of lovemaking, or the quality of their relationship may be such that sex simply does not resume.

There are other factors which may be personal to either member of a couple or both of them, such as their sexual script(s) or the length of time for which they have been sexually continent, which also preclude resumption of intercourse. And finally, they may be experiencing stress with finance, children, family, or work pressure, any of which can get in the way of resumption of sex.

A typical profile of a man with erectile dysfunction

Evidently the goal of this behavior is to avoid any embarrassment or failure during sexual activity, but the outcome is that the couple's lovemaking frequency slowly dwindles to about once a month, then it becomes even less frequent, and then stops altogether. He loses his sexual desire, and becomes involved with distractions such as his work, television, the children, or volunteering. It's not only intercourse that disappears - any kind of affectionate touch or anything else that may be perceived by his partner as a suggestion that he is feeling sexually attracted to her is also absent form the couple's interaction with each other. The man's partner begins to wonder if she is still attractive, whether he still loves her, or whether he's having an affair. Her experience of him may be that he is slightly depressed, preoccupied, irritable or defensive; and she may collude with him in avoiding sex so that the pain of feeling rejected is lessened, or the pressure to have sex is avoided.

While some men do actually come for treatment for erectile dysfunction at the request of their partner, others seek treatment without notifying their partner of what they're doing. And in these cases a man may come back from his consultation with a prescription for Viagra, which results in him sporting an erection that he presents to his partner totally unexpectedly. In response to this his partner may feel a mixture of surprise and anger and some anxiety about what is expected of her and whether or not his erection will last. He will also be experiencing anxiety about his ability to engage in sexual activity. It's important to realize that in these circumstances a woman may feel as if she has been betrayed because the man's erection is not a response to her attractiveness, but merely to the response to the medication. It is further possible that she may not be able to lubricate or to become aroused adequately, either because of the difficulties that his actions have caused, or because she has simply moved into a menopausal stage of her life where her old expectations of her experiences during sexual activity are no longer valid.

With this background, clearly sex may not be particularly rewarding, and the motivation to try again maybe reduced - perhaps to zero. A man can summarize what happened by telling his doctor that the Viagra "did not work". It requires careful investigation by a practiced clinician to discover the level of fear and anxiety and other emotions that have arisen in the years when the couple were celibate, and to recognize also that the couple will now probably need help in restoring full sexual function to their relationship.

Although this thumbnail summary of information about erection problems encapsulates the major reasons why a man may discontinue treatment for erectile dysfunction, it does not cover cases where an unconventional pattern of sexual arousal or lack of sexual desire plays a part. (Men may hide these aspects of their sexual life because of fear of humiliation or embarrassment.) Since Viagra is not an aphrodisiac it will not induce an erection when there is a lack of sexual desire.

Althof claims that an integrated treatment approach which combines psychological therapy and pharmacological therapy is superior to an approach which involves either aspect of treatment alone. This has certainly been demonstrated in the treatment of depression, but at the time of writing -- 2002 -- there had been no controlled studies of therapy for erectile dysfunction which had looked at whether or not such a combined approach would be more  successful. Although it seems logical to assume that this would in fact the case, Althof makes the point that designing suitable research project to investigate these issues is rather challenging. He refers to a report of an uncontrolled, combined treatment study involving only 57 men given both Viagra and psychotherapy.

Although the mean age of the patients was 53, the age range was from 21 to 75 years with the erectile dysfunction having existed for between one month and a rather amazing 38 years, with a mean of eight years. 78% of this limited sample had experienced psychotherapy for an average duration of two years. The doctors assessed the origin of the erectile dysfunction as being psychogenic in 52% of the men, organic in 22% of the men, of mixed origin in 22% of the men; the remaining 3% of men had erection problems of uncertain origin. All the men received both Viagra and psychotherapy, and were seen at intervals ranging from weekly to every two months. The dose of Viagra was altered so that the chance of the men being able to accomplish intercourse successfully was as high as possible, and the men were evaluated five weeks into treatment and again at 10 weeks after they had received the first prescription for Viagra. Although the results of this study were limited and did not involve qualitative data, the responses of the men to the treatment did provide some qualitative data which was classified into one of seven categories, four of which indicated success, and three of which were variations of failure.

The success of ED treatment with Viagra

S2 The next best category of success was drug dependent success which was defined as requiring Viagra in every case to be able to have satisfactory sexual intercourse. Without Viagra, sex was not possible.

S3, the third category of success, was defined as drug dependent success with the development of a new sexual symptom. This meant that although sexual intercourse had been possible, either the man or his partner subsequently developed either some kind of dysfunction around desire, arousal, and orgasm or a symptom of pain on attempting intercourse.

S4, the lowest level of success was defined as improvement without intercourse, where a man who developed an erection which was firm enough to have sexual intercourse also experienced some kind of psychological resistance that stopped intercourse from happening.

As far as failure was concerned, the first category of failure, F1, was transient and sustainable improvement. This was used to refer to men who regularly obtained a firm erection from the use of Viagra and for whom intercourse was in fact possible on occasion. However, the erection was not valued enough by the couple for them to engage in sexual intercourse regularly, or they developed sexual aversion or some other symptom which precluded the possibility of sex altogether.

F2, the second category of failure was termed resistance failure and was applied to men or their partners who were simply not able to accept the drug as part of a treatment regime. And lastly, pharmacologic failure described a group who after dose adjustments and education about the method by which the drug should be used, simply did not have any improvement in erectile ability.

So what were the outcomes of this study in coping with erectile dysfunction, erection problems and impotence?

It was found that the Viagra combined with psychotherapy improved erections in two thirds of the men (this includes the success categories S1 - S4 and the first failure category F1). The first three success categories comprised 55% of the sample and they were able to have successful sexual intercourse. Among the whole sample 52% had ideal outcomes, that is to say, they fell in success categories S1 and S2, and they were able to have intercourse regularly with out any new sexual symptoms developing. Of 30 men who had been diagnosed with psychogenic erectile dysfunction 73% developed improved erections and 53% were having successful intercourse.

In summary, Althof observes that the difference between the ideal outcome (a combination of categories S1 and S2) at the first and second follow-up sessions was an indication of the extent to which biopsychosocial factors can contribute to a man and/or his partner discontinuing a safe and effective treatment. These figures are in fact 52% and 43% respectively.

Use of Viagra as a therapeutic probe

Masters and Johnson developed the technique of sensate focus as a way to help both men and women overcome performance anxiety associated with sexual intercourse. However, it was quickly discovered that not all patients responded in the same way because psychological resistances of one kind or another interfered with the effectiveness of this treatment strategy. After this was known, the purpose of sensate focus was adapted, and a move made towards using it as a therapeutic probe, a system to flush out and recognize psychological resistances which would then be amenable to psychotherapeutic treatment.

Althof draws a comparison between Viagra and sensate focus, suggesting that they have much in common. For example, Viagra may facilitate the development of an erection but not enable intercourse: in other words, it can be seen as a therapeutic probe which actually uncovers hidden reasons why a man or his partner (or the couple together) do not continue to use an effective treatment. His proposed model of treatment is that the doctor, having prescribed Viagra, will subsequently enquire how well it worked in the creation of an erection, what the couple learned from this, and whether or not sex was successful.

This approach will enable both doctor and patient to explore the reasons why the patient is reluctant to use his erection for intercourse, whether or not either of the couple is depressed, and whether there is an emotional or physical block to the resumption of lovemaking. This might include a high level of anger, resentment, or disappointment in the relationship. It's often the case that one or other of the couple prefers an asexual equilibrium, or that the woman believes the man is responding to the drug rather than to her.

In either case, sexual psychotherapy is an approach which can explain and reduce the resistances so that the couple can cultivate a romantic atmosphere within the relationship, and open lines of communication that both physically and psychologically enable them to accept the concept of resuming sexual activity. They may also need help to accept the inevitable changes which occur with age: the menopause, disability, illness, other sexual issues, or indeed the opening out of previously unacknowledged sexual variations. It's certainly true that if these psychological impediments to intercourse are not addressed, even the best medical efforts will probably not work very well.

The combined treatment approach to erectile dysfunction in the future

Althof concludes his paper by stating that doctors require a means of assessing what a man or couple actually need before they can obtain the goal of treatment, because success is no longer simply able to be defined as a rapid and sustained erection.

In fact, Viagra clearly works well in restoring erectile capacity in simple cases where nothing more than a prescription and advice on how to use the drug are required. But the problem is that many cases of erectile dysfunction are not so straightforward. The ability to have sex and obtaining sexual pleasure from intercourse are by no means assured with Viagra alone in many cases. In these situations, as already mentioned, Viagra can function as a therapeutic probe which is useful in uncovering issues for the man, his partner, the couple, and the context of their relationship.

In summary Althof lists these factors as likely to adversely affect the chances of successful resumption of sex: any issues of poorly managed or unresolved anger, control and power issues, contempt and disappointment. When these emotional or psychological factors are complicated by the prolonged absence of sex from a relationship there certainly needs to be a psychological approach to treatment in addition to the pharmacological.

Furthermore, unrealistic expectations may surface: a man may believe that with his erection restored, sex will be more frequent or that he will feel more lovable and successful in life. If these expectations are not fulfilled, a man rarely says "I had unrealistic expectations"; he usually says that the "treatment with Viagra did not work".

Remember also that Viagra requires a man to have sexual desire for his partner and any lack of sexual arousal will prevent him developing an erection. This is not true of vacuum pump therapy, use of a penile prosthesis, or intracavernosal injection. Viagra, buy contrast, only allows an erection to develop when the man is aroused by his partner.

When Viagra is used as therapeutic probe the things which may be uncovered can be challenging. They may include the fact that a married man is secretly attracted to other men, that a man has no sexual desire for his partner, or that he has unusual or unconventional patterns of sexual arousal such as sadomasochism. All of these arousal patterns will interfere with the achievement and sustaining of an erection, and Viagra cannot be expected to overcome them. Althof concludes his article by expressing the hope that combined treatments will become the rule rather than the exception, and by suggesting that treatment strategies need to be developed to determine were whether a couple requires no psychological intervention, pharmacological intervention alone, or combined pharmacological and therapeutic intervention. Clearly the implication of this is that a combined treatment for erectile dysfunction and biopsychosocial issues will require the involvement of both medical practitioners and psychosexual therapists.

References

1 Turner L et a]. A 12-month comparison of the effectiveness of two treatments for erectile dysfunction: self-injection versus external vacuum devices. Urology 1992; 39: 139-144.

2 Sidi A, Pratap R, Chen K. Patient acceptance of and satisfaction with vasoactive intracavernous pharmacotherapy for impotence. J Urol 1988; 140: 293-294. 3 Hatzichristou D. Sildenafil citrate: lessons from 3 years of clinical experience. Int J Impot Res 2001, 14 (Suppl 1): S43 -S52.

4 Keller MB et a]. A comparison of nefazodone, the cognitive behavioral analysis system of psychotherapy, and their combination for the treatment of chronic depression. New Engl J Med 2000; 342: 1462-1470.

5 Baum N, Randrup E, Junot D, Hass S. Prostaglandin E, versus sex therapy in the management of psychogenic erectile dysfunction. Int J Impot Res 2000; 12: 191 - 194.

6 Pallas J, Levine S, Althof S, Risen C. A study using Viagra in a mental health setting. J Sex Marital Ther 2000; 26: 41 - 50

7 Masters W, Johnson V. Human Sexual Inadequacy. Little Brown: Boston, 1970.

8 Rosen R- Medical and psychological interventions for erectile dysfunction: toward a combined treatment approach. In: Lieblum S, Rosen R (eds). Principles and Practice of Sex Therapy.. Update for 2000. Guilford Press: New York, 2000, pp 276 - 295.

9 Althof S. New roles for mental health clinicians in the treatment of erectile dysfunction. J Sex Educ Ther 1998; 229-231.

Other pages on this website about erection problems, erectile dysfunction and impotence

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