Male Sexual Dysfunction: Pharmacology vs. Mental Health

Moshe Rozdzial, PhD

Urologists estimate that about 30 million American men suffer from some form of erectile dysfunction, and many clinicians believe that number is rising. Viagra, the pharmacological treatment for impotence, went on the market in April of 1998. Pfizer, Inc., its manufacturer, rates its success as high as 80 percent. Men are expected to find the drug far more desirable than the penile implants, vacuum pumps, and injections and other standard medical treatments for impotence. While talk therapy was once regarded as the first line of treatment, impotence now appears to be cured by simply popping a pill.

Once thought to be a largely psychological problem, erectile dysfunction experts have since discovered that diseases such as diabetes (Karacan, et al., 1978) or hypertension, or the drugs used to treat them, are often the cause of erectile dysfunction. Maintenance of erections has also recently been attributed to platelet accumulation in the penile venous system which impedes outflow of the blood (Rodrigues et. al., 1998.), explaining why individuals on blood thinners may have difficulty maintaining erections.

Erectile dysfunction is often assumed to be a natural result of the aging process, to be tolerated along with other conditions associated with aging. Karacan, et al., (1975) showed that nocturnal penile tumescence (NPT) occurs consistently in a healthy male population, that its expression is significantly affected by age, and that it is related to stage of psychosexual development. Although there is great individual variability, testosterone levels decline with age. Testosterone deficiency has been correlated with various maladies including depression, anxiety, irritability, insomnia, weakness, diminished libido, impotence, poor memory, reduced muscle and bone mass, and diminished sexual body hair (Sternbach, 1998). This assumption may not be entirely correct. For the elderly and for others, erectile dysfunction may also occur as a result of specific illnesses or of medical treatment for certain illnesses, resulting in fear, loss of image and self-confidence, and depression.

Causes contributing to erectile dysfunction can be broadly classified into two categories: organic and psychological. In reality, while the majority of patients with erectile dysfunction are thought to demonstrate an organic component, psychological aspects of self-confidence, anxiety, and partner communication and conflict are often important contributing factors.

The advent of Viagra signals an age of a lack of deeper understanding or commitment to dealing with the psychogenic aspects of male impotence. Male sexual performance or behavior has been relegated to a pharmacological/medical construct rather than to the cognitive/psychological model. In this regard the symptoms rather than the underlying issues of impotence are to be treated, continuing the maladaptive masculine view in our culture that men don't have to deal with the emotional contexts of their lives, but rather, relegated to a problem-solving, band-aid approach based on the medical model of health care. Indeed, Pfizer’s own clinical-trial data on Viagra shows that it is most effective for milder forms of erectil problems, such as those that are anxiety-based, and less effective for the more severe forms.

New and better pharmacological treatments has made impotence the domain of urologists and pharmaceutical companies, at the expense of mental health providers, precluding the assessment process on the psycogenic basis of male impotence. With a quick-fix, men may be more reluctant to come to therapy to deal with the issues of their impotence.

This society increasingly tells men that they can conquer age and age related health problems. From hair loss to body weight, the media projects an ever-youthful image for men to embrace. Even now, men do not perceive erectile dysfunction as a normal part of aging and seek to identify means by which they may return to their previous level and range of sexual activities. Such levels, expectations, and desires for future sexual interactions are also important aspects of the clinical evaluation of patients presenting with a chief complaint of erectile dysfunction.

In men of all ages, erectile failure may diminish willingness to initiate sexual relationships because of fear of inadequate sexual performance or rejection. Because males, especially older males, are particularly sensitive to the social support of intimate relationships, withdrawal from these relationships, because of such fears, may have a negative effect on their overall health.

Instead of teaching men new skills that they can use to overcome performance anxiety, and age related issues, the new pharmacology makes men dependent on a pill. This dependence may even delineate a new form of addiction: psychological rather than physical. The convergence of the quick-fix society, with the medical model of prescribing, combined with pressure by managed care to treat all maladies with medication, plus the financial rewards of the drug market, will only escalate this pharmacological bent. Although it is possible that use of new drugs could contribute to the public’s increasing awareness of the interplay between physical and psychological factors, between mind and body, it is also possible that the promise of an easy drug solution for sexual dysfunction will be yet another addition to this country’s intractable chemical dependency problem (Newman, 1998).

The concern is that the phychological causes of male sexual dysfunction, such as anxiety or depression, will not be assessed as components of the dysfunction. Even as the suspected medical causes for impotence are screened, patients will still need help to deal with the shame, embarrassment, and the relationship problems that can accompany their impairment, whether organically based or not. Indeed, clinical disturbances in sexual interest and activity often reported by depressed persons are associated with objective changes in sexual neurophysiology (Thase, et al, 1987).

Although new and better technology is being developed to diagnose and treat organically based erectile dysfunction, none precludes psychological treatment as an adjunct, if not integral part of the treatment. Like many medical problems, physical factors that contribute to impotence are often behaviorally based, and will not be "cured" by the blue pill. Smoking, poor diet, and lack of exercise all can lead to the vascular problems or diseases that can result in impotence. Alcohol, which has long been known to inhibit sexual response ability, while increasing disinhibition, has been correlated with erectile dysfunction (Dong, Wroblewska and Myers, 1995.). Alcohol is probably the greatest single cause of secondary erectile dysfunction.

Viagra can't make a man forget the fear he feels during intercourse. It doesn't change all the past experience of erectile dysfunction and performance anxiety. It just takes care of the mechanics of having sex. The bad feelings, poor self-esteem, and relationship problems remain. If you had poor coping skills or poor relationship skills before taking medication, you are still going to have poor skills after (Grohol, 1998). Thus, even medically based factors in impotence can create problems between sexual partners that can only be addressed psychologically.

Other causes of male impotency often involve psychological issues, including things such as past relationship hurts, abuse, and a host of other factors. Masters and Johnson, proposed that the main cause of impotence is simply fear, regardless of why or under what circumstances the male fails to achieve or maintain an erection the first time, the greatest cause of continued sexual dysfunction thereafter is his fear of nonperformance. Those who have had an instance of failure due, let's say, to fatigue or excessive alcohol intake, and do not attach special significance to it, rarely develop this fear. But those who elevate an occasional failure out of context and dwell on it retrospectively can go on to develop severe cases of secondary impotence (Grohol, 1998).

People expect too much from medications alone. Medications work best when they are a part of a larger, comprehensive treatment approach to these complex problems. In the age of Viagra, relationship based therapy is still very important, maybe even more than before. The man’s psychological reaction to the medical disorder and the problems it can cause in the relationship remain. Society dictates a pursuit of the perfect penis, which focuses more on the man, rather than the couple. Impotence treatment, by centering specifically on a man’s ability to engage in intercourse, seems to ignore other aspects of sexuality and slights the partner's satisfaction in a sexual relationship. Addressing only the genital component of sexual dysfunction doesn’t always guarantee great satisfaction (Sleek, 1998). 

Rather than creating more discussion and expression around the issues of sexuality, as implicitly stated in the media, male sexual dysfunction may be further driven into the closet. Men are already reluctant to talk about their own erectile dysfunction issues because impotence and erectile dysfunction represent a challenge to male and masculine identity. The social pressure on men is to be sexually virile. Men’s exaggerated expectations about their own sexual performance, combined with the increasing life expectancy, pose a critical juncture to the therapeutic approach to male sexual dysfunction in the age of Viagra.

References

Dong, Q.S., Wroblewska, B., & Myers, A.K. (1995). Inhibitory effect of alcohol on cyclic GMP accumulation in human platelets. Thrombosis Research. 80(2) 143-151.

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Karacan, I, Salis, PJ , Ware, JC , Dervent, B, Williams, RL, Scott, FB, Attia, SL, and Beutler, LE (1978). Nocturnal penile tumescence and diagnosis in diabetic impotence. Am J Psychiatry, 135:191-197.

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Rodrigues, M., O'Grady, J., Stackl, W., Granegger, S. & Sinzinger, H. (1998). Accumulation of platelets as a key mechanism of human erection. Thrombosis Research. 15;91(2) 53-56.

Sleek, S. (1998). Is impotence only a biological problem? APA Monitor 29(6).

Sternbach, H. (1998). Age-Associated Testosterone Decline in Men. Am J Psychiatry 1998; 155: 1310-1318

Thase, ME, Reynolds 3d, CF, Glanz, LM, Jennings, JR, Sewitch, DE, Kupfer DJ, and Frank, E. (1987). Nocturnal penile tumescence in depressed men. Am J Psychiatry 144:89-92.