Introduction

Sexology is defined as the study of sex and sexual relations and their evolutionary, physiological, developmental, and sociological aspects.¹ The problem of erectile dysfunction (ED) is addressed in sexology by integrating biological, psychological, and socioeducational aspects from the sexual health perspective of the person.

Traditionally, etiologic factors of ED have been classified as organic, psychogenic, or mixed. This way of classifying ED is relatively useful for organizing our intervention, although it is completely arbitrary. Strictly speaking, a penis that does not respond with an erection to an 'effective' stimulation may be a consequence of what we call organic factors. However, every ED problem is 'psycho-organic,' because it affects the man as a whole (both physically and psychologically) as well as his partner and the couple's relationship. Furthermore, there are socioeducational aspects that influence sexual behavior, which have considerable importance on how the sexual encounter is experienced. These are considerations that have led the World Health Organization (WHO) working group on sexual health to propose the generic term sexual problem rather than pathology to refer to ED and other sexual heath problems.²

Evaluation of ED in sexology

From the patient's first complaint of ED, the evaluation process is to identify the etiology of ED as precisely as possible, by making a differential diagnosis between organic and psychogenic causes. Determining the cause of ED will help to develop an effective therapy.³

Since the more general aspects of the interview are discussed in the core document, we will emphasize the aspects specific to intervention from a sexologic perspective.

Nonspecific clinical manifestations that may detect ED

The first element in the evaluation is to identify clinical manifestations of ED. A variety of psychosomatic disorders may be associated with ED, such as headache, nonspecific malaise, lumbalgia, gastrointestinal disturbances, stress, anxiety, and depression. These problems are frequent causes for repeated outpatient visits to primary care and/or psychological services. These symptoms may be presented by the man with ED, his partner, or both.

Patient and/or partner seeks medical attention for ED

When the man with ED, his partner, or both seek medical attention for ED, one of the key focuses of the interview should be to establish the diagnosis of this dysfunction.

It is a key point at this stage not to equate the reason for consultation (the complaint presented to us) with the diagnosis. Couples often transfer other conflicts to their sexual life, or the man may manifest erection problems when the primary cause is, for example, lack of desire or a problem with the partner. Other factors such as low sexual desire, premature ejaculation, delayed ejaculation, or partner dysfunctions such as hypoactive sexual desire, anorgasmia, and so on, may coexist. This is why it is essential to establish the primary diagnosis.⁴

Psychogenic factors

With respect to psychogenic causes of ED, one of the keys to sex therapy is consideration of temporal criteria.⁵ We can thus distinguish among the following:

• Predisposing psychogenic factors. The presence of these factors may facilitate the occurrence of ED. The most common factors are
  • Antisex messages during childhood;
  • Problematic family environment;
  • Inadequate sexual information;
  • False sexual beliefs;
  • Inadequate or traumatic first sexual experiences;
  • Early insecurity in sexual role;
  • Fear of commitment;
  • Fear of intimacy;
  • Anxious personality;
  • Low self-esteem.
• Precipitating psychogenic factors. The presence of these factors may result in ED. In addition, the combination of precipitating factors may aggravate the condition. The most common factors are:
  • General disturbance in relationship;
  • Partner sexual dysfunction;
  • Partner infidelity;
  • Demanding partner;
  • Unreasonable expectations;
  • Prior chance failure;
  • Traumatic sexual experience;
  • Reaction to organic causes;
  • Increased overall anxiety;
  • Depression.
• Perpetuating psychogenic factors. The presence of these factors contributes to ED as an automatic response to sexual stimulation. In any case, the psychogenic component is always present as a perpetuating factor of ED. The following may act as perpetuating factors because of their constant presence:
  • Fear of sexual relations, failure, lack of response, loss of erection, penetration, and so on;
  • Anxiety about the idea of having intercourse or actual intercourse;
  • Vulnerability of the man to his partner's attitude about ED;
  • Feelings of guilt;
  • Poor communication with partner;
  • Little foreplay;
  • Lack of perception of sexual sensations: disconnecting from excitation or even sexual desire by acting as a spectator during lovemaking (spectator role);
  • Insecurity that soon extends to other areas of the man's life.

Addressing the perpetuating factors through sexological support is fundamental because treatment of predisposing and precipitating psychogenic factors and organic causes alone may not be effective over the long term owing to the occurrence of relapses. To avoid relapses, it is essential to treat perpetuating psychogenic factors, which may become the only cause sustaining ED when the other factors have been resolved and the problem persists.

Differential diagnosis

It is vital to know the relevance of organic factors to perform sex therapy aimed at restoring erectile function. The patient interview remains the instrument that will provide us with these answers. ED is considered to be situational if:

• the absence or lack of erection does not occur at all times when the man has sexual relations, and/or
• an erection is achieved with masturbation, and/or
• if the man maintains sexual relations with more than one partner and ED occurs only with one or certain partners, and/or
• he has erections after dreams, on waking, and/or
• he has nocturnal erections (during rapid eye movement (REM) sleep phases).

In this case, unless the patient reports that he awakens on some occasions and this has been confirmed, we may need to resort to diagnostic tools such as the stamp (a strip of stamps that is placed around the penis at night—a break in the strip indicates an erection, although not quantifiable) or similar tests, polygraphic recordings of nocturnal penile tumescence, or Rigiscan.

If ED is situational, we should institute sex therapy, focusing on the psychogenic and relationship components that may be present. If we cannot rule out the presence of organic factors, we should treat ED along with the psychogenic factors that are always present.

If the man has a sexual desire disorder and this is our principal diagnosis, ED being simultaneous or secondary to inhibited sexual desire, we may need to conduct a more in-depth endocrinological assessment with a hormone profile (testosterone, prolactin (PRL), luteinizing hormone (LH) and thyroid hormones); a referral to the endocrinologist may then be appropriate. Typically, the specialist treats only the endocrine disease, and thus the patient or partner will continue to require simultaneous or subsequent sexual support, orientation, or therapy.

If the diagnosis is ED and there is no lack of sexual desire, we begin treatment with drugs (sildenafil, tadalafil, vardenafil, apomorphine, and so on). If these treatment options do not restore erections, we should consider referral to another specialist to further investigate diagnosis and treatment.

Treatment of ED in sexology

Sex therapy is a specialized form of psychotherapy. The essence of the therapeutic approach used in sexology is integration, which implies the use of both pharmacotherapy and psychotherapy. Psychotherapy integrates cognitive-behavioral and psychodynamic approaches.⁶

Depending on the basic training as a physician or psychologist and specialized training in sexology, the clinical sexologist (or sex therapist) will use a range of available resources.⁷ It should be noted that psychologist sexologists are not legally qualified to access the pharmacological or surgical resources intrinsic to medical training. On the other hand, physician sexologists often lack extensive training in psychotherapy, and therefore, their intervention in ED may be ineffective when it is due to deeper psychological causes.

Sex therapy for ED may be categorized as follows:

• Psychological intervention with the patient. Addressing predisposing, precipitating, and perpetuating factors through cognitive restructuring, insight therapy, or other interventional modalities according to the clinical orientation of the therapist.
• Intervention on the partner relationship (if required). Addressing relationship problems, improved communication, role conflicts, and so on.
• Intervention with the partner (if required). Subjective experience of problem, degree of involvement, sabotage mechanisms, and so on.

The prescription of tasks to be performed with the partner only is a basic resource in sex therapy. With regard to ED, the exercises performed in the privacy of the home (the patient alone or with his partner) aim, in keeping with the premises of systematic desensitization in vivo, to help them face the anxiogenic stimulus under the most favorable conditions and with the lowest degree of anxiety. The suggested exercises should also be specific for each patient, so that they result in an improvement in sexual performance and psychosexual well being.

Referral criteria for ED

When should patients with ED be referred to a sexologist?

1. When the professional (who is not a sex therapist) learns that there is a psychological and/or partner conflict that is the only, or a significant component, in the etiology of ED.
2. When, after treating the organic components underlying the lack of erection, the problem of ED does not improve. This is the referral route for general physicians and specialists.
3. When, after treating the psychological and/or psychopathological components presented in the man with ED, the problem of ED does not improve. This is the referral route for psychologists and psychiatrists who are not sexologists.

When and to whom should sexologists refer patients with ED?

As sexologists are a diverse group in terms of their basic training (physicians and/or psychologists), referral should be made based on these training differences.

Referral to the urologist/andrologist specialized in erectile function

By psychologist sexologists: It is essential to know the organic cause of the problem for referral to the appropriate specialist. In many cases, it is recommended to work cooperatively with the referral physician, to determine the sexological support required to alleviate the problem. Referral should be considered when

• the contribution of an organic factor to ED cannot be ruled out and psychological or relationship causes are not detected;
• after initiating treatment, the expected response is not obtained and not attributable to resistance to the treatment;
• drugs are required as a diagnostic tool for ED;
• drugs are required for treatment;
• surgery (prosthesis) is required for treatment.

It should be kept in mind that pharmacological and/or surgical treatment, although effective to achieve an erection, often does not resolve the problem of ED for the patient or partner. Therefore, pharmacological and/or surgical treatment should be combined with sex therapy to resolve the problem.

By physician sexologists: Based on their underlying medical specialty, as a general criterion, the patient should be referred to the urologist/andrologist specialized in ED who will

• perform a more in-depth diagnostic assessment if required, by conducting or coordinating a wide range of diagnostic tests such as intracavernous injection of vasoactive substances, echo-Doppler, nocturnal erection recording, cavernosometry–cavernosography, somatosensory evoked potentials, electromyography, penile biothesiometry, pudendal artery arteriography, and so on;
• apply or coordinate with other specialists the use of other therapeutic resources such as the sacral root stimulator, penile prostheses, and so on.

Referral to other specialists

By psychologist sexologists: When the use of psychoactive drugs is required in cases in which ED is accompanied by depressive states or anxiety, the patient should be referred for treatment. It is essential to consider that referral does not mean abandoning the patient but collaborating with other professionals to jointly perform the most effective intervention.

Conclusions

The appropriate treatment of ED, similar to other sexual health problems, requires the health professional to understand that he or she is treating a psychosomatic problem. ED often presents with some degree of psychological affectation and, frequently, organic alterations. This adds to the interference that ED causes in a relationship.

Sexology essentially contributes to the medical and psychological aspects of sexual health problems, and in this case, specifically to ED. The impact that ED has on the couple's relationship is also contemplated; with this in mind, sexual therapy often contains elements of couple therapy. Even if the man is not involved in a relationship, therapy works with the expectation that he soon will be.

The health professional, physician, or psychologist, with sexological training and perspective, is in a privileged position to assist the patient with ED and to coordinate the consultation process with other medical specialists, psychologists, or psychotherapists who are pertinent for successful treatment.

References

1. Greenwood Publishing Group. A Descriptive Dictionary and Atlas of Sexology. Greenwood Press: Westport, CT, USA, available at: http://info.greenwood.com/books/0313259/0313259437.html. Accessed November 25, 2003.
2. Promotion of sexual health. Recommendations for Action. Pan American Health Organization, World Health Organization, World Association for Sexology: Antigua Guatemala, Guatemala, 2000, pp 1–58.
3. Benet AE, Melman A. The epidemiology of erectile dysfunction. Urol Clin North Am 1995; 22: 699–709. | PubMed | ISI | ChemPort |
4. Guay AT et al. American Association of Clinical Endocrinologists medical guidelines for clinical practice for the evaluation and treatment of male sexual dysfunction: a couple's problem. Endocr Pract 2003; 9: 77–96. | PubMed |
5. Hawton K. Terapia Sexual. Ediciones Doyma: Barcelona, 1985.
6. Perelman MA. Sex coaching for physicians: combination treatment for patient and partner. Int J Impot Res 2003; 15(Suppl 5): S67–S74. | Article | PubMed |
7. Federción España de Sociedades de Sexología. Sexologia: Código Deontólogico. Federción España de Sociedades de Sexología: Valencia, 1996, p 20.