Physical or Psychological?

Erection problems can be mainly physical (but almost always with a psychological component because of how men feel about a malfunctioning penis), mainly or totally psychological, or a mixture of the two. While it is helpful to determine what the main cause or contributor is, the nature of the problem does not necessarily dictate the treatment. For example, many men have had penile implants or used other medical treatments despite the lack of evidence that medical problems were causing their erection difficulties. They either preferred a medical solution or were not informed of the option of sex therapy.

On the other hand, there are cases where the problem was clearly physical but the patient didn’t want a medical solution and chose sex therapy. Just because there is some physical involvement does not mean that you need medical treatment. There may be, for instance, decreased blood flow to the penis because of arterial blockage; but if the blockage is slight, you may be able to have usable erections provided you are rested and not anxious. With a few sessions of sex therapy, you and your partner may be able to arrange your sexual activity so that your penis usually functions acceptably. And, occasionally, we get a miracle.

One man, close to seventy, had definite physical reasons for his erection problem, but had already had open-heart surgery and wouldn’t even consider more surgery. At that time, other medical options such as vacuum devices and penile injections were not in widespread use. His urologist advised him that sex therapy couldn’t help but referred him to me when the patient insisted. After talking to the man and reading the urological report, I wasn’t hopeful of being able to help, which I told him. But he wanted to give it a try anyway. We did, and much to everyone’s surprise, he was functioning very well after only five sessions.

I do not pretend that this outcome is the rule with men who have a physical basis for their erection problems. It isn’t. But the fact that it did happen in such an extreme case, and has happened in other, less extreme cases, means there is some hope for those who don’t want surgery or other medical treatments. It also offers an option for those who are willing to have surgery or use other medical alternatives but prefer not to. They can try a brief course of sex therapy to see whether it will be enough.

And, of course, there are cases in which sex therapy cannot help and medical treatment is necessary.

A man I saw almost two decades ago had a strong bias against physicians and medicine. Although his penis didn’t get stiff or even full under any circumstances, he refused to believe the reason might be physical. Every time he got involved with a woman, the two of them would go to a sex therapist. I was the fourth therapist he tried and, sure enough, he failed with me as well. Only after our absolute failure and continued badgering from me for months was he willing to visit a urologist. A few tests revealed that the problem was indeed medically based. Soon thereafter he had a penile implant inserted and his sex life improved considerably. What is sad is that he could have had a functioning penis five years earlier and saved himself considerable time, money, and energy.

DRUG THERAPY FOR ERECTILE DYSFUNCTION

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