Is Impotence Only a Biological Problem?

male sexual problems

Viagra doesn't preclude psychologists' integral role in the treatment of sexual dysfunction.

Urologists are inundated with inquiries about it. The news media is treating it as the hottest since Prozac.

Viagra, the pharmacological treatment for impotence, went on the market about 2 years ago amid a torrent of publicity. Its manufacturer, Pfizer, Inc., pegs the success rates as high as 80 percent. Men are expected to find the drug far more palatable than the penile implants, vacuum pumps, injections and other standard medical treatments for impotence.

Such is the way that the treatment of impotence is changing. Once thought to be a largely psychological problem, experts have since discovered that diseases such as diabetes or hypertension-or the drugs used to treat them-are often the cause of erectile dysfunction. And while talk therapy was once regarded as the first line of treatment, impotence now appears to be cured by simply popping a pill.

So where does that leave psychologists who have built careers as sex therapists? Has impotence become the domain of urologists and pharmaceutical companies, at the expense of mental health providers?

Practitioners have a variety of answers to those questions. Some say they play an integral, albeit altered role in the treatment of impotence, even in cases of physiological causes. They still conduct psychological screenings to make sure some mental problem, such as anxiety or depression, isn't behind the dysfunction. They work closely with urologists to help patients understand the suspected medical causes for their inability to perform. And they still need to help patients deal with the shame and embarrassment-and the relationship problems-that can accompany their impairment, whether it's organically based or not.

'The current approaches reflect an application of the biopsycho-social paradigm,' says Stewart Cooper, PhD, a Valparaiso University psychology professor who directs the school's counseling center and teaches a course in marital and sex therapy. 'It's a blending of the urological and endrocinological examination, the use of pharmacology and psychotherapy, to resolve issues surrounding sexuality and sexual performance.'

Others worry that medicine has focused on fixing the 'hydraulics' of male sexual dysfunction, at the expense of the personal and relationship problems that so often result in impotence. Leonore Tiefer, PhD, clinical associate professor of psychiatry at Albert Einstein College of Medicine, says the medical field has exaggerated the prevalence of physiologically based erectile disorders, and that organicity is not usually the cause.

'Many people say that unknown percentage of men have organic problems and 100 percent have psychological problems,' she says. 'The point is that they coexist.'

Increasing prevalence?

Urologists estimate that about 30 million American men suffer from erectile dysfunction, and many clinicians believe that number is rising. They say that trend stems from several factors:

- Men's high or exaggerated expectations about their sexual performance.

- The increasing life expectancy, which hikes the population of men who encounter age-related barriers to their erectile functioning. (Studies show that the prevalence of erectile dysfunction triples between the ages of 40 and 70.)

- New and better technology that can be used to diagnose and treat organically based impotence.

'It was once thought to be a largely psychogenic problem,' says Mark Ackerman, PhD, director of health psychology at the VA Medical Center in Atlanta and an assistant professor at the Emory University School of Medicine. 'But recent advances in diagnosis have confirmed that organic factors, such as diabetes or hypertension, confer significant independent risk for erectile dysfunction. The field of medicine now has more tools, like Doppler ultrasound that looks at penile vascular blood flow. The pendulum has now swung in the other direction. Urologists can devote whole practices to the treatment of erectile dysfunction.'

Many psychologists agree that they need to understand the biological risk factors - such as hormonal abnormalities, vascular disorders and neurological problems - that can contribute to impotence.

'I've found I need to have familiarity with fields like urology, endocrinology and geriatrics,' say Rodney Torigoe, PhD, lead psychologist at the U.S. Department of Veterans Affairs (VA) offices in Honolulu. 'Those are things you don't learn in psychology training.'

But none of this precludes psychological treatment as an adjunct, if not integral part of the protocol, psychologists say. Like many medical problems, physical factors that contribute to impotence are often behaviorally based. Smoking, poor diet and lack of exercise all can lead to the vascular problems or diseases that can result in impotence.

And, even medically based factors in impotence can create problems between sexual partners that only psychologists can address.

'Relational therapy is still very important - maybe even more than before,' Ackerman says. 'Even if you fix the penis, you still have the man's psychological reaction to the medical disorder and the problems it can cause in the relationship.'

Many physicians agree with Ackerman's contention. For example, Boston University urologist Irwin Goldstein, MD, in a recent interview published in Urology Times (Vol. 25, No. 10), says he supports the National Institutes of Health standard that 'everybody with impotence needs a psychological evaluation,' conducted by a psychologist.

The technical solution

Many mental health experts lament the medicalization of sexuality as unwarranted and unfair. Tiefer says society's 'pursuit of the perfect penis' 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 woman's satisfaction in a sexual relationship, she says. And it reflects the societal pressure on men to be sexually virile, a standard that can often create performance anxiety in men, she says.

Addressing only the genital component of sexual dysfunction doesn't always guarantee great satisfaction among patients, says David Rowland, PhD, a psychology professor at Valparaiso University and senior associate at Johns Hopkins University. Just because the parts work doesn't mean the men, or their partners, are enjoying sex again, he says.

And the miracle medical cures may not be as miraculous as they sound, notes Leslie R. Schover, PhD, of the Cleveland Clinic Foundation. She notes that Pfizer's own clinical-trial data on Viagra shows that it is most effective for milder forms of erectile problems - such as those that are anxiety-based - and less effective for the more severe forms.

'Viagra is a threat to sex therapy precisely because it is a drug designed to take our 'best customers,'' she says. 'Instead of teaching them new skills that they can use to overcome performance anxiety, it makes them dependent on a pill that costs $10 a pop.'

The most effective treatment for men's sexual dysfunction, Ackerman says, is through closer collaboration between psychologists and urologists. Psychologists who treat men with sexual problems need to better sell their clinical abilities to urologists, Ackerman adds. Health psychologists offer skilled assessment and therapeutic techniques that can not only help urologists pinpoint any psychological or behavioral factors in a patient's sexual dysfunction, but can also help design a treatment plan and aid the patient in complying with the regimen, he says.

'The opportunities for psychologists are plentiful,' he says, 'and they've expanded significantly beyond the role of providing sex therapy.'

This article is from the American Psychological Association.

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