Erectile Dysfunction: Integrating Couple Therapy, Sex Therapy, and Medical Treatment

This brief volume gives a good summary of the current status of both sex therapy in general and the treatment of erectile dysfunction in particular. Drs. Weeks and Gambescia, who both hold doctorates in psychology, have collaborated in writing a very readable book that combines seamlessly the medical treatment and the psychological treatment. The illness they are approaching is erectile dysfunction, a much more prevalent disease than we had expected.

They give startling figures for this problem: the prevalence rate for men who are 40 years of age is 39%, and it dramatically increases to 67% for men who are 70. Of course a very important development for this malady is that former Sen. Robert Dole had the courage to go public with his problem—particularly since it is a problem that occurs both psychologically and physically in various combinations.

The field is rapidly changing, led in particular by the discovery of the drug Viagra (sildenafil), which provides one more, usually quite acceptable, approach to the problem to add to the methods that are already in vogue. The advantage of these authors' approach is that it is “intersystemic,” meaning that every problem is viewed in terms of its individual, interactional, and intergenerational components. In addition, the individual component is seen as including both the medical and psychological factors. The authors also imply that almost every sexual problem of this sort involves all of these factors and that the most effective treatment approach is to be sophisticated in addressing them all.

Weeks and Gambescia mention the three most common methods of treating erectile dysfunction via medication: oral (Viagra), transurethral (MUSE), and injection (Caverject). Alprostadil is the medicine found in MUSE and Caverject. Other mechanical medical treatments such as vacuum pumps are mentioned but only briefly described.

The authors' contribution is primarily in the area of the psychological treatment of this problem, and they give very specific recommendations as to how to “reframe” the problem, develop a therapeutic alliance with the couple, and deal with the therapy in an incremental way. They comment on the common pitfalls encountered in dealing with couples and also the fundamental problems involved in doing sex therapy (of any type), including communication difficulties, differences in expectations, and dealing with unresolved anger and conflict.

There is a vast literature on sex therapy, including works by Masters and Johnson, Helen Singer Kaplan, and numerous other therapists. That is one of the few deficiencies in this slender volume: most of the references are to the senior author's own work rather than to other authors. This makes it somewhat repetitious and narrow.

References to Viagra and its use are scattered in many places in the book. The authors have been very sensitive in showing that its use is not invariably a simple positive response and that it affects all aspects of the relationship of the couple. For example, one woman had a negative reaction because she felt the drug changed her husband into “an animal.” Numerous clinical examples are given; these deal with the resistances of the couple rather than with total outcome. Most of these resistances are familiar to any psychotherapist, such as forgetting appointments, being late, not doing their “homework”. (the mutual sensate focus exercises that couples do that speed up the treatment).

I recommend this book heartily as a concise summary of where the field of sex therapy is in general and of current treatment of erectile dysfunction in particular. It requires some background in psychology, especially sexual psychology, as well as sophistication in the area of couple and family therapy. It is an excellent introduction to the topic for anyone who works in this field.