Obstacles to making love

Erectile Dysfunction and Delayed Ejaculation

We should now take a brief look at erectile dysfunction, for the benefit of those men for whom that challenge  is associated with Delayed Ejaculation.

Stanley Althof of the Department of Urological Psychology, Case Western Reserve University School of Medicine, Ohio, has written an article in the International Journal of Impotence Research about research into the biopsychosocial obstacles to making love when a man is being treated for erection problems.

He introduces this article by making the observation that  it is easy enough for a man to develop a man a firm erection. However, 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 a man continuing with treatment for erectile dysfunctio(or not). The factors implicated include in ending treatment 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. Here’s a video on the subject:

Video – erectile dysfunction

It’s possible, therefore, that sometimes treatment never even starts because a man does not have enough confidence to embark on the treatment, Perhaps some men fear there will be some unexpected and disturbing s consequences if they accept treatment. Like, for example, having to resume sexual intercourse with their partner: treatment can disturb a comfortable status quo..

A simple example of the education that is sometimes necessary is that many men do not know that the efficiency of drugs like Viagra actually improves the more you take it, at least up to the eighth dose. 

Because of this, Althof makes the observation that the best way of analyzing why men stop treatment is to take the problem from a broad view, from a biopsychosocial perspective. 

In this situation, a clinician will often 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.

Also, a man’s partner’s ill-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. For example, their sexual script(s) or the length of time for which they have been sexually continent. Or, 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

Althof presents a profile of a typical patient who presents for treatment of erectile dysfunction dysfunction at his own clinic. This summarized character is a 54-year-old married man who has actually delayed seeking help for two years. During this period he may have developed feelings of inadequacy, resentment, depression, and possibly performance anxiety.

Typically, he will have developed behavioral strategies which allow him to avoid confronting his sexual situation: he may have begun to go to bed before or after his partner, and he will provide plausible excuses as to why he cannot make love, for example being “too old” or “too tired”. Another possibility is that he may experience shame due to not being able to delay ejaculation.

Evidently the goal of this behavior is to avoid any embarrassment or failure during sexual activity. This will be especially true if the man is experiencing delayed ejaculation. However, the outcome is that the couple’s lovemaking frequency slowly dwindles. Maybe it declines to 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 may also absent from the couple’s interaction with each other.

Video – how romance fades – the sex starved relationship

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.

He may 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. This may be because of the difficulties that his actions have caused, or because she has simply moved into a menopausal stage of her life and her attitude to sex has changed.

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.

This summary of information about erection problems describes some reasons why a man may discontinue treatment for erectile dysfunction. However, 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.  

Although it seems logical to assume 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.