Erectile Difficulty

Two kinds of erectile difficulty have been identified. A man who has never been able to achieve an erection for intercourse suffers from primary difficulty. A man who has a history of successful erection for intercourse but during a particular period cannot achieve an erection has secondary difficulty. Secondary difficulty is much more common and can be treated more successfully.

Many men experience single instances of erectile failure at some time or another. Fatigue, anxiety, poor health, medication or alcohol may all be responsible. Erectile difficulty should not be considered a significant problem unless it occurs consistently or long enough to cause real stress to the couple or to the man himself.

Erection is an automatic process, a reflex, and therefore not under the man’s control. When a man suffers from erectile difficulty, the extra blood that should flow into the penis and engorge it fails to do so even though the man is excited and stimulated.

The causes of erectile difficulty can be physical, psychological or both. These are some of the more common causes:

Physical (organic) factors

• injury to the spinal cord
• diseases such as diabetes and multiple sclerosis
• effects of drugs like alcohol, heroin and some prescribed drugs
• surgery, such as a prostate cancer operation
• insufficient male hormone.

Psychological factors

• anger with a partner or other relationship problems causing conflict
• religious belief that sex is sinful, evil, dirty
• fear of castration if sex is attempted
• boredom with sex
• anxiety about not doing well in sex
• unsuccessful previous sexual experiences
• guilt or conflict arising from homosexual experiences.

In the late 1960s, when sex therapy was beginning to become a full health-specialty, it was believed that very small percentages of erectile difficulty could be attributed to physical factors.

However, research and work with patients suggests that many more men have organic reasons for erectile difficulty than was previously thought, and although psychological factors remain as the likelier causes of impotence, careful medical evaluation must go along with psychological work. Research is still under way to determine the full extent of possible physical causes of erectile difficulty.

Masters and Johnson developed a rapid and successful approach to dealing with erectile failure. Subsequently their concept has been varied and elaborated on by others. In outline, Masters and Johnson’s approach is to reduce the fear of failure, to direct the couple in therapeutic exercises while at the same time encouraging the development of effective couple communication, and helping reduce any irrational anxiety about sexual expression either of the partners may have. Masters and Johnson achieved quite high success rates for secondary failure and somewhat less for primary failure. Other therapists report similar success rates. Sometimes success occurs within weeks, but frequently it takes months.

Much depends on the willingness of the couple to be open to the therapy, and the extent of complicating personal and relationship issues that must be worked through. Other therapists have made their own additions and refinements to the basic Masters and Johnson program. Dr Helen Kaplan, for example, utilizes psychoanalytic concepts, drug therapy and behavioral therapy as well when they are appropriate.

A Review Of Scientific Research In This Area

There’s an article in the June 2008 Journal of Sexual Medicine about the effectiveness of psychological treatment for erectile dysfunction. Tamara Melnik and her colleagues from the University of São Paulo analyzed 11 randomized, controlled trials of various treatments for erectile dysfunction, including psychological interventions, oral drugs, vacuum devices, local injection, or other forms of therapy.

Before we go into the details, it’s worth observing that they concluded that there was indeed evidence that group therapy improves erectile dysfunction. Even more effective was the combination of psychotherapy and Viagra. This backs up the fact that it’s common nowadays for treatment of all sexual disorders to center on an interdisciplinary approach which combines psychological, sociological and medical treatment.

And erectile dysfunction, which is a very common condition, being associated with aging as well as common risk factors such as high blood pressure, obesity, dyslipidemia, and pelvic surgery, is clearly a good candidate for this form of therapy. Indeed, a recent research has demonstrated clearly that psychological factors are involved, either alone, or in combination with factors of physical origin, in the vast majority of cases of ED.

However, despite this, research into the effectiveness of psychological interventions is rather limited. Nowhere is this more true than in the field of sexual behavior. It appears that medical research, often funded by the pharmaceutical companies, is the predominant area of research into erectile dysfunction. It’s certainly true erectile dysfunction has been medicalized to a huge extent in recent years: this is quite understandable, because of the advent of Viagra, which is an easy drug to take and highly efficient in a large proportion of cases.

However, Viagra is not effective for all men, and in cases of persistent inability to attain and maintain an erection hard enough for satisfactory sex, psychogenic factors are apparently often responsible for failure to improve.  These factors can be divided into three groups: 1) factors which bear on the situation immediately – such as performance anxiety;  2) responses to recent life events which occurred prior to the episode of erectile dysfunction, and 3) developmental vulnerabilities from childhood and early mid or late adolescence.

There’s plenty of evidence that depression, loss of self-esteem, high anxiety, and various other psychological factors play a major role in the etiology of erectile dysfunction. Indeed, a psychogenic etiology is suspected to be at the root of these issues in about 40% of men.

We all know that Viagra has played a massive advance in pharmacological treatment of erection problems, but there has been much less research and work done on either the effect of psychotherapy for psychogenic ED, or the possible benefits of a combination of treatments including drug therapy and psychotherapy. Nor has there been any research done into the relative effectiveness of various techniques of psychological therapy.

Currently the most common treatments in this area of sexual dysfunction are oral drug therapy, intra-cavernosal injection, and vacuum devices. However no comparison has really been done on the effectiveness of treatment with psychological and behavioral therapy.

By means of meta-analysis of randomized controlled trials, the authors of the paper referred to in this article investigated the effectiveness of various forms of psychotherapy for ED. The various studies were selected for meta-review on the basis that the men in the original investigation had a diagnosis of ED based on the diagnostic and statistical manual DSM-IV, and they also needed to be older than 18 years (coming from any ethnic group or nationality).

Existing comorbidities were regarded as irrelevant, as was the pre-trial use of any medication (except for phosphodiesterase five inhibitors). Factors which rendered studies ineligible for the meta review included conducting original research on men with genital deformity, or the inclusion of any kind of primary sexual disorder which was not related to erection issues (such as, for example, hypoactive sexual disorder), hypogonadism and major psychiatric disorders.

The primary outcome of investigations into the various treatment methods measured change in erection issues by use of validated questionnaires such as the international index of erectile function (IIEF), as well as changes in the number of men in any treatment group who were unable to perform sexual intercourse.

The studies that were chosen for meta-review were subjected to quality assessment. To be selected for the meta-review, the study had to be randomized with low rates of attrition, and avoid unsatisfactory investigational procedures such as avoiding detection bias.

In the case of dichotomous data including clinical improvement, and remission, and dropouts, the relative risks were assessed at the 95% level of confidence based on the fixed effects model, with use of the random effects model when heterogeneity was present, and also according to an intention to treat analysis. The number needed to treat was another factor presented for statistically significant results at the probability of less than .1 level.

Heterogeneity was assessed by the Chi Square test and was assumed to be present when the significance level was lower than 0.1 (10% confidence level). In cases of significant heterogeneity, the investigators attempted to explain any differences on the basis of the clinical characteristics of the studies which were included in the meta-review.

All in all 11 trials were investigated, which covered 398 men and a mean age of 47.4 years. In all cases the existing severity of erection issues at the start of the trial was estimated; the most common duration of any kind of erection issue was at least 3 to 6 months.

The authors investigated various models of psychotherapy which had been used to address the issues of erectile dysfunction in the studies concerned and grouped them into the following categories:

1 RET (rational emotive therapy). This involves basic elements of both behavioral therapy and cognitive therapy using challenges to negative thought processes and dysfunctional beliefs to facilitate change. The subject will be asked to engage in collaborative hypothesis testing, along with various behavioral tasks and training in skills designed to shift the perspective and beliefs that sustain the ED. In addition, anxiety reduction, problem solving, and self control, along with script assessment and modification in skills and relationship issues such as conflict resolution are all adjuncts to the basic process.

2 Sexual group therapy. This was a special kind of therapy developed specifically for erection issues, a kind of group therapy which emphasizes the connection between any erection issue and the interpersonal experiences which a man is undergoing. It was based upon social skills training, reduction of anxiety around sexual situations, provision of education and information that the man may have been lacking about male sexuality, skills in communication, and on-demand pleasuring, together with permission to engage in masturbation or other forms of self pleasuring.

3 A variation of Masters and Johnson therapy based on the belief that sexual dysfunction can have many causes and one way of dealing with these in an efficient manner is to combine education, counseling and various forms of homework assignments.

4 The use of workshops focused on the dissemination of information about psychological and various physiological alterations that can occur in the human sexual response over time.

5 Systematic desensitization – which is a form of behavior therapy used to treat various forms of sexual dysfunction on the basis of deep muscle relaxation being used to ameliorate anxiety.

As mentioned before, there were 11 studies which were included in this review, and these merited eight comparisons between therapies.

Group Psychotherapy In The Treatment of Erectile Dysfunction

Group psychotherapy did indeed demonstrate a statistically significant improvement for men with erectile issues when compared with the control group.

And, six months later, when the men were followed up, there was also a continuing improvement in that the number of men who had persistent ED was significantly reduced over the control group. It transpired that six weeks of biweekly rational emotive therapy sessions produced a significant improvement in all men who received the treatment, an improvement which was maintained after 6 to 9 months.

Sex group therapy

Various studies on men who presented with erection issues have been reviewed in the meta-review to which we refer. In one case, treatment with two hour group sessions once a week offered by a man and woman working in partnership produced improvements in all clients. This group therapy involved various treatment methodologies, including group discussion around issues and progress, the presentation of didactic information, homework assignments, provision of information, various techniques for increasing intimacy and erotic involvement with partner, and communication skills.

Six months after treatment 10 out of the 14 men in the study reported improvement in satisfaction around their level of ability to sustain erection compared to their condition before the treatment

In another study, three group treatment formats were tried on 20 men with secondary ED. These included communication techniques training, training in sexual techniques, and a combination of these treatments.

Analysis of the results showed that the group who experienced active intervention did improve with a 95% rate of response to sexual therapy, and many of these men were able to successfully engage in intercourse: indeed, the success rate of sex group therapy appeared higher than the success rate of rational emotive therapy, or systematic desensitization, or the modified form of Masters and Johnson therapy.