Sex is an integral part of an intimate relationship and forms the basis for a couple’s shared love and respect, but many people cannot fully enjoy these pleasures. A sexually dysfunctional man, for example, may lack the desire or self-confidence to participate in sexual activity. He may not be able to focus his attention on arousal activities. He may ejaculate prematurely, or lose his erection before his sexual partner is sexually satisfied, or he may develop and maintain an erection for a long time but without being able to reach orgasm or ejaculate.
Other men with sexual dysfunction may find that they cannot achieve an erection of sufficient rigidity for intercourse—or cannot get an erection at all. They may be too anxious during the sexual act. They may be ignorant of various sexual techniques. They may not indulge in adequate or proper foreplay and lack adequate sexual stimulation. They may not experience appropriate or enjoyable mental or emotional attitudes as they become sexually aroused.
Sexual dysfunction can destroy a marital or other sexual relationship. Understanding this affliction, how it affects the sufferer’s and others’ lives, and how the sufferer can free himself or herself is essential for the maintenance and preservation of any current or future sexual relationship.
Consider a scandal that rocked American society in 1937. Some readers may still remember the stunning beauty of movie star Jean Harlow, the first Hollywood “sex goddess.” At the age of 21, she married 40-year-old producer Paul Bern, but their wedding night proved disastrous when she realized that Bern was “underendowed” and probably impotent. Her agent later reported that Harlow was then beaten ferociously with a cane by her humiliated husband, sustaining several broken bones. Perhaps Bern had believed that by marrying a young woman with tremendous sex appeal, he could overcome his sexual inadequacy—and when this failed, he became violent and inflicted physical punishment on her. Despite the couple’s public reconciliation and manifestations of affection, their relationship was in shambles. When Bern once tried to impress her by “wearing a contraption designed to make the most of his meager assets she felt disgusted.” Two months after their wedding, Bern committed suicide by shooting himself in the head, leaving a note: “Dearest dear: Unfortunately this is the only way to make good the frightful wrong I have done you and to wipe my frightful humiliation. I love you. Paul” (Blundell N 1994,137). This particularly dramatic example illustrates the potentially devastating effects of sexual dysfunction on the individual and the couple.
It is often said that a man can stoically confront wars, hurricanes, tornados, earthquakes, diseases, and other tragedies with great courage and determination, but when he can’t function sexually as he wishes, he may feel devastated, depressed, anxious, distressed, guilty, angry, and physically diminished. When the fire dies out in a relationship because of a man’s sexual dysfunction, he may not realize that his partner also has a personal involvement with the problem—even to the point of developing his or her own sexual disorder(s).
According to a recent study carried out at the University of Edinburgh, among all factors, sexual dysfunction was rated the number one cause of marital problems. Sex constitutes the flame that lights up marital life with its scintillating luster and bonds the couple together in love, complicity, and affection, and its loss may have a devastating effect on both people. They may elect to ignore the problem or to face it and find a solution. How can the sexually dysfunctional man and his partner best understand their situation and go about resolving it?
A popular joke reflects the not-so-funny frustration of a man having sexual difficulties: “What is the difference between anxiety and panic?” Answer: “Anxiety is the first time you cannot have it the second time—panic is the second time you cannot have it the first time.”
A man with erectile or other sexual dysfunction may wallow in the pits of hell and may lose his self-esteem, self-confidence, and pride. He may experience painful frustration; a sense of the loss of his much-valued virility and manhood; and increased vulnerability to emotional, marital, familial, professional, and social difficulties. The radiant spring of his life may change to a cold, gloomy winter. He may shun any sex-related subject in normal conversation, and even with his physician, for fear of embarrassment. He may accuse his wife or partner of being the primary cause of his problem or deny its occurrence and refuse to discuss it or seek medical help. Within the relationship, the vital ingredients of intimacy, romanticism, love, and respect can gradually dwindle or be washed away by feelings of suspicion, blame, anger, repulsion, and even hatred. Physical and mental quality of life may be greatly reduced for the affected male and for the couple, subjecting them to significant emotional and psychological disturbances.
Fortunately, those feelings are not manifested by all men suffering from sexual dysfunction. Some of them may admit their problem and seek advice for any number of reasons. They may be motivated by a genuine desire to resume adequate sexual functioning, or they may be primarily worried about their physical health and only interested in ruling out any serious disease possibly underlying the dysfunction. They may seek professional help at the insistence of their partners, whether to please them, for reassurance, or for other psychological reasons. They may simply wish to regain their sense of manhood. But surprisingly, the majority of men with sexual dysfunction seem simply to accept their condition and refuse any medical help, with less than 12% of them attempting any safe, successful medical treatment for their distressing condition.
Contrary to false popular beliefs, sexual intercourse remains an important part of life for elderly people. About 30% to 70% of folks over 60 still engage in sexual relationships, with about 40% of men in their seventies having sex once a week (Braun M et al. 2000). According to several surveys by M. Perelman et al. (2005) of men aged 50-70, sex was rated by 13% as very important, by 29% as important, and by 41% as occasionally enjoyable; only 17% stated that they could live without it. Most of the men surveyed agreed that sexual dysfunction caused them and their partners great sadness and that it was important to assess their capabilities to perform sexually. Half reported that they would “do almost anything to cure their [erectile dysfunction].” Men in the United States and the United Kingdom were the most motivated to seek medical advice and find a cure (Perelman M et al. 2005).
In another study from the Netherlands on 1,481 men over the age of 18, the global prevalence of erectile dysfunction (ED) was 14.2%. Of those men, 67.3% were bothered by their condition, 68.7% either ignored it or accepted it as a natural phenomenon related to such things as their age, and 85.3% wanted help. Unfortunately, only 10.4% of the afflicted men received any medical care for their condition (de Boer BJ et al. 2005). Nevertheless, these findings underscore the importance of sex at any age for men’s well-being and quality of life.
Furthermore, several studies have demonstrated a positive correlation between successful sex and good general health, happiness, healthy relationships, intimacy, increased quality of life, decreased symptoms of depression, and positive self-image (Sadovsky R, Mulhall JP 2003). Physical and mental health, sexual intimacy, everyday interactions with women, sexual fantasy life, and men’s perception of their masculinity are deeply affected by sexual disturbances, and sexually dysfunctional men have a higher incidence of anxiety and depression (Latini DM et al. 2002). ED’s psychological impact may lead to reduced physical and emotional satisfaction, decreased general happiness, a decline in physical and mental health, and disturbed sexual and other personal relationships—all of which could be corrected with the resumption of normal sexual functioning (Seidman SN, Roose SP 2001).
It is important for sexual partners to be aware of the various psychological reactions that men with ED or other sexual dysfunctions may go through, so that they are better able to understand and sympathize. A man’s reaction to his erectile failure is often devastation and humiliation. He may lose his confidence in his abilities and adequacy as a man. His self-esteem, ego, and selfworth may be crushed, and this may pave the way to depression, bringing with it additional stress and hostility toward himself and his partner. Beyond his sex life, his ED may impair not only his mental attitude, but also his professional and social relationships.
When suddenly confronted with a man’s sexual problem, his partner’s first reaction might be to ignore it, believing that it is only temporary and due to such causes as fatigue, illness, stress, alcohol, or perhaps an argument. If the problem persists, the partner starts to worry; everyone generally likes to have his or her world in order and may be inclined to search deeper for a reason for any dysfunction. “Is he having an affair? Doesn’t he love me any more?” These thoughts are a common reaction. Partners of sexually dysfunctional men may become angry and resentful, feeling rejected and frustrated. It is not unusual for them to experience their own loss of self-respect and self-esteem and to question their own self-worth.
As the problem persists, partners often become increasingly concerned about its causes and possible consequences. They may attribute the dysfunction to an affair or a lack of desire or love on the man’s part, or blame themselves. These ideas stir up further reactions of disappointment, insecurity, and distrust. Partners may conclude that they have failed in their relationship or marriage and wonder whether it will last. Tormented by these thoughts and feelings, they may behave as if in a state of defeat. They may decide to go back to ignoring it and hope for its spontaneous resolution. They may be too embarrassed to discuss it, or they may have tried to bring it up with the sufferer but to no avail. At this point, some people may become content with the situation, and even be relieved to give up sex.
Alternatively, partners of sexually dysfunctional men may start looking for information, sympathy, reassurance, understanding, and the best way to solve the problem. They may wonder about where to seek help, whom to trust, and whether it is possible to resolve the situation independently. They may talk about it with friends, clergymen, close relatives, or physicians; they may read about it or tune in to a TV program on the subject. Learning that the sexual dysfunction may be caused by a medical condition or disease can, unfortunately, increase their anxiety and agitation, potentially complicating the problem and further straining the relationship.
When people lack the correct information about a problem, they may feel that the problem is monstrous or incurable. Fear, hopelessness, and desperation may overcome rational thought and appropriate behaviors. Partners of sexually dysfunctional men may react to their mates in an unpredictable manner—perhaps avoiding sex, or demanding it persistently, or trying different ways to attract him—or they may decide to play an active role in seeking professional help. Some of them may develop their own sexual disturbances, which may improve following the successful treatment of their male partners.
One positive aspect of all the turmoil surrounding a man’s sexual dysfunction may be a smart decision on his and his partner’s part to seek professional help. This means that both people have acknowledged the problem and are motivated to solve it to save their relationship. Let me review some important facts as a starting place for seeking assistance and treatment.
First of all, they should both realize that for most men, erectile ability is synonymous to virility and manhood, and its loss may be one of the most devastating and humiliating experiences they may suffer. A few men with ED may even undergo surgical insertion of penile prostheses, without necessarily even using them for intercourse after surgery, simply to be satisfied that they are “men” again.
When a man has ED, his sexual partner is also affected by the dysfunction and may develop sexual problems as well. According to a study at Loyola University’s Sex Clinic, 52% of female partners of men with ED developed their own sexual problems after the onset of their partners’ disorder (Renshaw DC 1981). The partner’s reaction may be one of loneliness, isolation, doubt, rejection, and guilt. It is important for the couple to engage in cognitive restructuring to alleviate these negative emotions and solve the problem appropriately.
The partner should not feel guilty or totally responsible for the sufferer’s sexual dysfunction. She or he should concentrate instead on being supportive and finding a solution, rather then being obsessed with the problem or trying to solve it alone. Both people must accept that no cure is possible until the man honestly acknowledges his problem and is willing to discuss it with his partner and seek medical help. His partner should feel compassion for his frustrations and should also realize that any lack of expressed emotions or manifestations of love, even his irritability and rejection of sexual advances, are probably results of his ED.
By being fully informed and enlightened about sexual dysfunctions, the partner can take an active role in seeking help and encouraging the afflicted man to seek medical advice early on. A sexual problem may be the first manifestation of a serious disease that should be diagnosed and treated promptly to prevent dangerous, or even fatal, consequences. In the meantime, the sufferer should keep in mind that his partner may still nurture a strong desire for him, and that it may be possible to have an orgasm and ejaculate without an erection. The couple should still engage in nonintercourse sexual activities that minimize any performance pressure and continue to manifest plenty of love, warmth, and respect toward each other.
Unfortunately, some people are totally unconcerned by their partners’ sexual dysfunction and disinterested in participating in its management. Many may even prefer the situation as it is, for various reasons, including lack of sexual pleasure with their husbands, lack of interest in sex, satisfaction with an extramarital relationship, or refusal of all current artificial therapeutic methods that minimize their role in the sexual act. If either person in a relationship affected by ED resists assistance, it may be advisable for the other person to participate in a support group or seek the help of a sex therapist.
Clearly ED and other sexual dysfunctions have an impact on both individuals involved. Talking about the afflicted man’s feelings can stir up some difficult emotions in his partner: sorrow for him, perhaps self-pity as well, or frustration, depression, anxiety, or failure as a lover. The couple must remember that the problem affects them both and that they may have similar feelings of inefficacy, sadness, and low self-esteem. These feelings, which are normal and to be expected under the circumstances, can be transient, disappearing following the dysfunction’s successful treatment. There are, however, cases in which these emotional sequelae linger beyond the resolution of the sexual problem and may need to be addressed via self-help psychology or professional counseling.
In many cases of ED, a man may feel aroused, excited, and ready for sex, but, when it comes to implementing his desire, his penis fails him. Evaluation and identification of any sexual dysfunction—ED, ejaculatory disorders, low libido, and others—is, of course, the first step on the road to successful treatment. As noted in chapter 5, ED may be due to various physical or psychological factors, or both.
Physical causes include aging (though ED is not an inevitable consequence of growing old); cardiovascular disease or ischemic heart disease; diabetes or other hormonal, vascular, or neurologic disease; hypertension and/or high cholesterol; lower urinary tract symptoms secondary to benign prostatic hyperplasia; chronic renal failure; pelvic injury (especially to the pelvic nerves); chronic alcoholism, drug abuse, or heavy smoking; obesity; and certain medications such as some of the antihypertensives, antidepressants, antipsychotics, female hormones, muscle-building steroids, and peptic ulcer drugs. ED may also occur following certain surgical procedures or result from chemotherapy or radiation therapy. (Physical causes of ED are detailed in chapter 7.)
The numerous psychological causes of ED include anxiety, stress, depression, Oedipal issues, fear, guilt, and various psychological inhibitions. Any of these can be activated by sexual excitement, which results in erectile difficulties because such psychogenic signals can inhibit the activation of the parasympathetic nerves and increase the activity of sympathetic nerves, leading to constriction of the penile arteries and therefore penile flaccidity. Marital discord, lack of communication, financial trouble, adultery, the practice of heterosexual sex by a homosexual man, physical repulsion, poor hygiene, and even rudeness may play major roles in ED’s onset. Other psychological roots can be found in the ED sufferer’s upbringing, experience of severe sanctions against sexual expression, erroneous beliefs about sex, and fear of failure and rejection by the sexual partner. A particular factor in many cases is the man’s inability to abandon himself to a sexual experience; during sex, he may be obsessed with the quality of his performance or act as a spectator rather than an active participant. (Psychological factors are detailed in chapter 8.)
The next obvious question is, what can be done about it? Whether the ED is organic, psychogenic, or a combination of the two, most cases can be treated successfully, regardless of the man’s age and underlying disease(s)—provided that he is willing and eager to be treated, is fit physically to engage in sex, and does not suffer from severe cardiovascular or other conditions that preclude engaging in sex.
Physical conditions contributing to ED necessitate a thorough medical workup for diagnosis (chapter 9) and treatment (chapters 10 through 14). When ED is due to physical causes, it can be treated with oral drugs, vacuum devices, intracorporeal injections, intraurethral inserts, vascular surgery, or the insertion of a penile prosthesis. But it should be noted that in a substantial number of cases, behavioral changes such as smoking cessation, daily exercise, treating obesity, lowering serum cholesterol, curing alcohol and drug addiction, and substituting or changing medications by the treating specialist may restore the man’s erectile ability without the need for any further therapy.
When ED is caused by psychological factors, treatment varies from behavioral and psychoanalytic therapy to sexual and marital therapy. Several psychological tactics to relieve performance anxiety; modify behavior; improve sexual communication between partners; acquire sexual skills; and eliminate taboos, misconceptions, and negative attitudes toward sex are employed (see chapter 14). Full cooperation of the couple is required for successful treatment.
A man’s willingness to undergo treatment for a sexual problem should be seen as a special demonstration of his love, to which his partner should respond in the most loving and caring way. A couple’s mutually positive and supportive attitude, based on complete understanding of the various aspects of sexual functioning and its disturbances and on a genuine desire to resume a fulfilling sex life, will affect the ultimate outcome. It is always preferable for both partners to discuss the preferred mode of treatment before its application to avoid any dissatisfaction or inhibition from its subsequent use and to gauge expectations against practicality.
Some partners of sexually dysfunctional men may feel uncomfortable with or even reject certain forms of therapy for ED, perhaps feeling that the erections created by these methods do not represent the God-given, natural erectile process based on a genuine physical and mental attraction. They may feel that they have lost their role in eliciting their partners’ erections, depriving them of the pleasure of feeling desired and attractive. They may come to see the sex act under these circumstances as tainted and unnatural. Others worry about the possible medical side effects of the therapeutic methods on the man’s health and well-being, or on their own. Some women, for instance, are concerned about the possibility of damaging the penile implant or being injured by the plastic ring used with the vacuum device.
Women who have never been truly interested in sex may abhor the idea of their partner recovering full potency, having more desire, and/or prolonging his erections. They may not be able to cope with his rejuvenated sexual capability, or they may worry (rightly or wrongly) that it will lead him to seek sexual pleasure with others. Some women seem quite satisfied with their partner’s ED, perhaps because it enables them to avoid sex, instill feelings of guilt in their partner, control him physically and emotionally, or enjoy the role of a suffering victim.
There are certainly other factors for female dissatisfaction with their partners’ renewed sexual vigor, such as financial/reproductive considerations, myths regarding the unimportance of sex in older age, or fear of betrayal. It is, however, very fortunate that many women are fully understanding, caring, and willing to participate actively in their partners’ therapy and recovery and fully support the man’s eagerness to regain his sexual ability so they can resume a happy, fulfilling sex life.
In conclusion, I must emphasize that optimal sexual functioning does not imply only a firm, erect penis, but must be viewed within a broader picture of shared love, intimacy, respect, physical and mental attraction, strong relationship dynamics, privacy, motivation, receptivity for sex, absence of performance anxiety or guilt or anger, and proper sexual communication. Any psychiatric, interrelational, emotional, marital, professional, and social disturbances must be effectively addressed to individualize treatment and optimize its outcome.
Do you suspect that you might have erectile or other sexual dysfunction? You may be one of the 30 million American men suffering from ED. If so,
Having an erectile or other sexual dysfunction, however, does not mean that you cannot and should not continue to show love, warmth, and respect for your partner—and receive it as well. To the extent that you are both willing, you can continue to engage in nonintercourse activities. Your partner may still have strong sexual desires and needs, despite your lack of erectile ability. Most men can continue to have an orgasm and ejaculate without an erection.
If you are experiencing sexual difficulties, seek help from a medical expert, who will be able to diagnose the problem correctly and recommend the best treatment for you. Contrary to some misconceptions shared by some laypeople and some nonexpert physicians, ED can be cured in many cases, sometimes simply by the discontinuation of certain medications (or other drugs), smoking cessation, exercise, weight loss, male hormone supplementation, surgical repair of a ruptured lumbar disk, or microsurgical arterial shunting for traumatic occlusion of the arteries providing blood to the penis.
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