Male sexual dysfunctions, including erectile dysfunction, hypoactive sexual desire disorder, premature ejaculation, and delayed ejaculation, are a complex amalgam of interrelated biological, psychological, and contextual variables that can combine to produce distressing symptoms both for the male diagnosed with the dysfunction and for his partner. This article describes the assessment process for identifying the psychological concerns associated with the man’s sexual complaint, and presents a stepwise algorithm for treating mild to moderate psychosocial issues. Physicians’ awareness of psychological and interpersonal issues will help them better manage patients’ ongoing medical treatment and limit discontinuation of efficacious therapies.
Male sexual dysfunctions, including erectile dysfunction (ED), hypoactive sexual desire disorder (HSDD), premature ejaculation (PE), and delayed ejaculation (DE), are a complex amalgam of interrelated biological, psychological, and contextual variables that can combine to produce distressing symptoms both for the male diagnosed with the dysfunction and for his partner. In some instances psychological factors may precipitate a man’s sexual dysfunction or further worsen and complicate the sexual dysfunction.
This article describes the assessment process for identifying the psychological concerns associated with a man’s sexual complaint and presents a stepwise algorithm for treating them. Physicians’ awareness of the psychological and interpersonal issues will help them better manage patients’ ongoing medical treatment and limit discontinuation of efficacious therapies. Other articles in this issue address the medical aspects of the evaluation and treatment of male sexual dysfunction. The authors recommend that clinicians use a biopsychosocial model, which allows the provider to capture the ever-changing blend of biological, psychological, relational, and contextual factors that interact to precipitate and maintain the dysfunction. Biological influences include illness, medication, surgery, and lifestyle factors (eg, obesity). The psychological/interpersonal aspects include the preexisting psychological life of the man, the psychological impact the dysfunction has on the man independent of his sexual life, and the impact the dysfunction has on the couple’s sexual and nonsexual life. A careful assessment will delineate all the factors—medical, psychological, interpersonal, and contextual—that contribute to the onset and maintenance of the sexual dysfunction.
Evaluation
Psychosexual evaluation goes beyond traditional psychological assessment to examine the patient’s or couple’s sexual history, current sexual practices, relationship quality and history, emotional health, and contextual factors (eg, young children, chronic illness, financial concerns, cultural beliefs, and so forth) currently influencing their lives. The patient’s developmental history is examined for influences on current functioning (eg, sexual or physical abuse) or the impact of a serious medical illness. Assessment of all the relevant medical and biological factors is necessary to understand the genesis and maintenance of the current difficulty.
The manner in which questions are presented is especially significant because patients usually have an unsophisticated view of their dysfunction and the impact it has on their lives. Patients are also often unaware of the relationship between this symptom and multiple disease processes and/or the relationship to their psychological and interpersonal issues. However, by following this method of logical and empathic questioning, the patient often gains a fresh perspective on the multiple issues that may be related to his dysfunction.
Although the partner does not often participate in the initial assessment meeting, clinicians should be aware that partner perspectives are frequently illuminating. When present, partners can provide important insight about the sexual and psychological dynamics of the relationship, and can become an important ally for both patient and clinician in a successful treatment intervention.
The assessment outline that follows is meant to guide the clinician from a first-person standpoint. The outline is not meant to impede on or supplant an individual clinician’s personal style or technique.
Begin by asking the patient, “What brought you in to see me?” Or, if the clinician is aware that the patient’s visit concerns a sexual problem, ask him to clarify the nature of the problem.
Clarify the Sexual Problem
Even though the patient has self-diagnosed the sexual problem, determine whether he is experiencing ED, HSDD, PE, DE, or more than one dysfunction. Patients may mislabel their sexual conditions; for instance, some men describe PE as ED. If the patient acknowledges multiple sexual issues, take a separate history for each dysfunction.
Ascertain the Onset and Course of the Sexual Dysfunction
Once the type of sexual problem has been clarified, use the following questions to distinguish between lifelong or acquired type, and what factors precipitate and maintain the dysfunction:
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When did the patient first notice the symptoms of the specific sexual dysfunction?
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Was the onset sudden or gradual?
If the onset was sudden, look for temporally related precipitants (eg, starting a new medication or being laid off from a job)
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What has the course of the sexual dysfunction been? In other words, has it gotten better or worse over time?
Delineate what led to improvement
Delineate what led to worsening.
Current Experience
At this point, attempt to further clarify the dysfunction by asking the patient (and partner if applicable) to recount, in as much detail as possible, a recent sexual experience. During the patient’s recollections, probe him for what he was thinking and feeling at the time. For example, did he wish to avoid lovemaking so that he would not embarrass himself? Did he have little confidence in his ability to achieve an erection? Did he feel angry toward his partner? Was he afraid of his partner’s possible contempt? How did his partner respond if the patient lost his erection during lovemaking?
Use this kind of questioning to identify the degree of performance anxiety, lack of confidence, distractibility, and attraction to the partner.
Treatment Avoidance
Before moving on to any intervention, assess the patient’s risk for early discontinuation of treatment. In other words, if you find that the sexual dysfunction has been present for more than 6 months prior to the current evaluation, ask the patient why he did not come in sooner. The answer(s) to this question may be predictive of issues related to early discontinuation of treatment. For example, patients may have avoided treatment if such avoidance helped maintain the quality of a relationship with a depressed or sexually unwilling partner.
In addition to ascertaining the reasons for possible delayed evaluation, it is equally important to find out what has motivated the patient to come in now. Again, some patients are motivated by partner pressure or concern.
Previous Treatment for Sexual Dysfunction
Determine if the patient has previously sought treatment for any sexual dysfunction. If this is the case, ascertain what type of treatment the patient received. For example, previous treatments may have focused solely on a psychological treatment while neglecting biomedical factors. In addition, by reviewing the patient’s previous treatment experience, the clinician may gain insight about treatment avoidance not covered by the previous section. In other words, such additional questioning may reveal barriers that could inhibit, or completely disrupt, the current treatment. Such barriers may include unrealistic treatment expectations or genital pain in partners.
Partner Response
A partner’s response to the patient’s sexual dysfunction can greatly affect the success of treatment. Clinicians should determine the following:
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Does the partner miss sexual intimacy?
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Is the partner angry or frustrated over the patient’s avoidance of treatment?
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Is the partner pleased that sexual intercourse is no longer a part of the relationship?
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Is the partner a willing and supportive partner in the patient’s treatment?
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Does the partner suffer from low desire?
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Does the partner suffer from genital pain?
Clinicians may need to discuss the use of lubrication, noncoital sexual behavior, or hormone replacement therapy as an adjunct to intercourse.
Lifestyle Factors
Assessment of lifestyle factors is also an important part of the evaluation of sexual dysfunction. Factors such as cigarette smoking, excessive consumption of alcohol, and substance abuse have all been associated with diminished ED. In addition, the sexual willingness of partners may be diminished in the face of a patient’s obesity, smoking, or alcohol consumption.
Nonsexual Relationships with a Partner
To restore intimacy between a patient and his partner, obstacles that may have arisen during the asexual months or years prior to evaluation must be overcome. On average, patients wait until 3 to 6 years after the sexual dysfunction symptoms appear before seeking treatment. The majority of men with sexual problems tend not to seek evaluation or treatment. During this protracted period of asexuality, both the frequency of sexual activity and other expressions of intimacy (like hand-holding, touching, and so forth) are greatly diminished. This situation occurs because men wish to avoid embarrassment and tend to withdraw emotionally. Some partners misinterpret the man’s avoidance to mean that he is involved with another partner or no longer finds her attractive, which may cause her to withdraw as well. Research has identified issues of trust, infidelity, sex-role demands, and power struggles as interpersonal problems in partner relationships of those with ED. For clinicians to help patients and partners overcome these issues, they must ascertain the dynamics and solidarity of the partner relationship. Regardless of the partner’s presence at the evaluation, clinicians should determine:
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The patient’s satisfaction with his current partner relationship(s)
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The patient’s sexual function in previous relationships
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The impact of the sexual dysfunction on the current relationship
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If any struggles over power, control, intimacy, or finances exist between the patient and his partner
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The partner’s level of sexual desire and overall sexual function
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The partner’s mental health
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If there are any other current stressors on the relationship (children, finances, and so forth).
Vocational Life/Patient Occupation
A patient’s work-related stress or concern about financial well-being may contribute to or maintain the sexual dysfunction. Clinicians should be aware that patients are often intuitive about the impact of work-related stress on physical symptoms such as a headache or stomachache. However, they are often psychologically naïve about the impact of work-related stress on sexual function.
Major Stress and/or Stress Management
Exposure to acute and chronic stress can also contribute to the sexual dysfunction. Common examples of life stressors include bankruptcy, children with addiction, ill parents or other family members, and diagnosis of a serious health problem in the patient or his partner.
Mental Health History
Mental health disorders, like depression, have been associated with ED and HSDD as both a precipitating and maintaining factor. Mental health disorders have also been identified as an inhibitor of successful psychological treatment. In addition, other psychological concerns such as performance anxiety, distractibility, and negative expectations can exacerbate sexual dysfunction. Clinicians can assess a patient’s mental health by asking about:
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Performance Anxiety
Distractibility
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Depression
Mood
Sleep
Appetite
Decreases in energy
Outlook on the future
Suicidal ideation
Libido
Prior or family history of depression
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Generalized Anxiety Disorder
Shortness of breath
Racing heart
Decreased concentration
Nervousness or agitation
Sleep disturbance
Excessive or unrealistic fears
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Obsessional Traits
Excessive focus or preoccupation with sexual function.
Related posts:
Penile Rehabilitation After Prostate Cancer Treatment: Outcomes and Practical Algorithm
Testosterone and Prostate Cancer: What are the Risks for Middle-Aged Men?
Erectile Dysfunction and Depression: Screening and Treatment
Priapism: New Concepts in Medical and Surgical Management
Testosterone Deficiency and Risk Factors in the Metabolic Syndrome: Implications for Erectile Dysfunction
Peyronie’s Disease: Review of Nonsurgical Treatment Options
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