Input: Write about the presentation and assessment of low sexual desire in men, including the prevalence and contingencies, comorbidities, and risk factors. Discuss the difficulties in distinguishing between hypoactive sexual desire disorder (HSDD) and hidden sexual desire disorder, and the importance of a multidisciplinary approach in assessment and treatment. Include information on the various biomedical, cognitive-affective, relational, and sociocultural risk factors that may contribute to the development of sexual desire problems in men.

Response:
opportunity to evaluate broader domains of the sexual motivation construct, which takes into account the observation of wide individual differences in how desire is experienced and expressed.

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**CHAPTER 2**

Hidden Disorder/Hidden Desire

Presentations of Low Sexual Desire in Men

Marta Meana and Eric T. Steiner

**"L** ow sexual desire remains the most mysterious of all the male sexual dysfunctions." With that pronouncement, Meana and Steiner proceed to suggest that the mystery revolves around two common phenomena: low desire being hidden under erectile difficulties or presentaton of low desire hiding actual desire that is being met outside of sex with the primary partner, or simply suppressed. In combination with a lack of evidence-based treatment for male HSDD other than testosterone replacement in hypogonadal men, these hidden aspects make for a significant assessment and treatment challenge. Within a multidisciplinary framework, Meana and Steiner outline approaches to both types of low desire presentations, drawing from "the sex therapy arsenal of cognitive-affective-behavioral and relationship skills-building techniques efficacious with other sexual problems." They also warn against damaging stereotypes about the imperturbability of male sexual desire and urge us to all take a closer look.

**Marta Meana, PhD,** is Professor of Psychology and Dean of the Honors College, University of Nevada, Las Vegas. She was the President of the Society for Sex Therapy and Research from 2011 to 2013 and an associate editor of the Archives of Sexual Behavior from 2010 to 2012. She is the editor of Springers Focus on Sexuality Research book series and the author of over 70 peer-reviewed articles and book chapters.

**Eric T. Steiner, PhD,** is Assistant Professor of Psychology at National University in San Diego.

In Western culture and much of its academic literature, male sexual desire is assumed to be essentially uncomplicated: a simple biological urge seeking an outlet in a multilayered social world that can thwart its easy release. Sexual desire in women, on the other hand, is characterized as complex, requiring a long list of arousal contingencies, mostly psychosocial in nature. This polarization is typified by Baumeisters (2000) statement that "women are the creatures of meaning . . . and men are the creatures of biology" (pp. 368–369). Assumptions aside, we know very little about sexual desire in men. In contrast, the past decade has witnessed an explosion of research on the nature of female sexual desire. Fueled by concerns that the high prevalence of low desire in women signaled a problem with existing diagnostic criteria for hypoactive sexual desire disorder (HSDD), theorists and researchers sought to investigate the nuances of womens desire that were unaccounted for therein (Meana, 2010). This effort has expanded our view of female sexual desire, but there has not been a commensurate effort to investigate the sexual desire of men. Some assumptions die hard. Some end up being true.

That Friday morning, Maggie was delighted when Jason received a text canceling his 49

weekend meeting in Chicago. Although they had not had sex for over a year, Maggie enjoyed her time with Jason and hated when he had business over the weekend. She was sad that he had lost all sexual desire (by his account) but had come to accept it.

Both were in late middle age, and Maggie had finally decided that it shouldnt matter that much to her. She started unpacking his carry-on while he talked on the phone downstairs with his associate. Inside she found a box of condoms and Cialis.

Men presenting with low desire for sex as their primary complaint are not very common in clinical practice. Often coaxed into therapy by confused and hurt partners, some men reporting low sexual desire are actually fulfilling their desire in other ways (e.g., masturbation, extramarital affairs, Internet porn, paraphilias). In a considerable number of them, what presents as HSDD may actually be hidden sexual desire disorder.

Regardless, the scarce data available indicate that the reasons for low sexual desire (with a current partner or anyone else) often involve a complex interaction of biological, psychological, relational, and sociocultural forces.

**WHATS IN A NAME?: DEFINING SEXUAL DESIRE PROBLEMS**

Individual variation in the desire for sex is large, and one mans perceived low desire may be anothers high. Primarily subjective in nature, definitions of desire problems tend to be mostly tautological. Low desire is classified as a sexual dysfunction in the International Classification of Diseases (ICD-10; World Health Organization, 1992) and in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR; American Psychiatric Association, 2000).

There are three criteria for a diagnosis of HSDD in DSM-IV-TR (American Psychiatric Association, 2000). The first requires a deficiency or absence of sexual fantasy and desire for sexual activity. Arguably, the definition of the disorder is no more descriptive than its name. The second criterion requires that there be associated marked distress or interpersonal conflict. Although there is controversy as to whether the distress criterion is justified (Althof, 2001), the point is moot from a clinical perspective. Only individuals who are upset or whose partners are upset seek treatment. The third criterion stipulates that low desire not be better accounted for by a major psychiatric or medical condition, or by substance abuse. This criterion is also of questionable clinical utility, as medical problems do not preclude the involvement of psychorelational factors amenable to treatment.

The diagnosis of HSDD in DSM-IV-TR is further subtyped as lifelong or acquired, generalized or situational, and due to psychological factors or combined factors. The lifetime-onset subtype has face validity and can be useful in determining whether the onset of HSDD coincides with potentially related life or health changes that could be targeted for intervention. The other two subtypes are more problematic. It is hard to determine whether low desire is situational or generalized when individuals cannot escape their situation without unacceptable consequences (e.g., a man who has lost 50

desire for his wife but does not find it acceptable to test his desire under other circumstances—masturbation, pornography, or extramarital trysts). Finally, the causal subtype assumes the ability to distinguish psychological causes from physiological ones, a questionable assumption in many cases.

There have been no significant criteria changes for DSM-5 (American Psychiatric Association, 2013) diagnosis of HSDD in men. It is significant, however, that the diagnosis for men has been retained, whereas that for women has been merged with female sexual arousal and included in a new diagnosis called "sexual interest arousal disorder." This development is likely more reflective of the discrepancy in extant research for women and men than of gender differences in desire mechanisms.

**REPORTING LOW DESIRE: PREVALENCE AND ITS**

**CONTINGENCIES**

The number of men reporting episodes of low sexual desire is actually substantial; in many surveys it is the most prevalent male sexual complaint. A thoughtful review of epidemiological data, however, requires attention to four important specifiers: age and health complications, the distinction between sexual interest and sexual desire, symptom persistence, and associated distress. In summary, low sexual desire is more common in older men, with surveys that inquire about decreases in sexual interest rather than desire yielding significantly lower prevalence rates. Reports of low desire/interest also decrease as the persistence bar is raised (i.e., more men report low desire/interest lasting 1 month than 6 or more; lifelong lack of desire appears rare).

Finally, associated distress remains largely unknown in men.

Although prevalence rates for low desire across studies have ranged from 0 to 40%

depending on sample characteristics and methodology, recent reviews suggest a likely overall prevalence of low desire/interest in men between 15 and 25% (Brotto, 2010; Lewis et al., 2010). The extent to which the rates for low sexual desire/interest or decreases therein capture the prevalence of HSDD is unclear, though, as distress is rarely assessed. Perhaps this is a function of a sister assumption to the one about the imperturbability of male sexual desire—that a man with low desire must necessarily be distressed.

**LACK OF TREATMENT SEEKING: WHERE ARE ALL THOSE MEN**

**WITH LOW DESIRE?**

The aforementioned prevalence estimates should result in a higher number of consultations than most clinicians report. There are multiple reasons why men may not seek help for perceived low desire. Older men or those with health problems may consider low desire normal under the circumstances. Men may also be hesitant to 51

identify themselves as having a sexual dysfunction, as it impugns their masculinity in a culture that equates the latter with sexual virility. It is also possible that women are not as distressed as are men when partners experience a decrease in sexual desire, resulting in less interpersonal conflict and thus less urgency to seek help than when the woman is the partner lower in desire. The most likely explanation for the low rates of treatment seeking, however, is that men (and the research literature) are more focused on erections than on desire, despite the fact that erectile dysfunction (ED) may often be consequent to low desire. Research articles on erectile versus desire problems in men yield a 30:1 ratio.

**COMORBIDITIES: IS IT A PROBLEM OF AROUSAL OR DESIRE?**

**HIS OR THE PARTNERS?**

Sexual dysfunctions tend to co-occur (Fugl-Meyer & Fugl-Meyer, 2002), but clients generally present with the one they assume, accurately or not, to be primary. Despite the fact that both men and women find desire and arousal difficult to distinguish (Janssen, McBride, Yarber, Hill, & Butler, 2008), men are much more likely to present with arousal problems and women with desire concerns (e.g., Kedde, Donker, Leusink, & Kruijer, 2011). HSDD in men may thus often be hidden under ED, although there is very little data on comorbidity. One recent study, however, was successful in distinguishing HSDD in men independent of erectile dysfunction (DeRogatis et al., 2012).

Sexual dysfunctions in men also have a close association with mens perceptions of their partners function (Lewis et al., 2010). This association can work in at least one of two ways. The partners sexual dysfunction (e.g., pain with intercourse) can engender a loss of sexual desire in the man. Alternately, individuals with sexual difficulties can end up bonding as the dysfunction in one (e.g., HSDD in the man) happens to be

"compatible" with the sexual dysfunction in the other (e.g., avoidance of sex in the partner with dyspareunia). This type of interdependency highlights the importance of treating couples, rather than individuals, whenever possible.

After 5 weeks of cognitive-behavioral pain management treatment for dyspareunia, Kelly was elated to report that she and her husband, Rob, had had almost pain-free intercourse the night prior. Paradoxically, Rob was less than joyful, despite his apparently deep concern at the start of therapy about her inability to have intercourse. He later disclosed his fear that the near resolution of her problem would shine a spotlight on the fact that he did not really want to have sex very often.

**WHY LOW DESIRE?: RISK FACTORS IN THE DEVELOPMENT OF**

**SEXUAL DESIRE PROBLEMS**

52

The interaction of biomedical, cognitive-affective, relational, and sociocultural dimensions is likely in most HSDD presentations. The longer the problem has persisted, the less likely it is that targeting one dimension exclusively will resolve problems in the others. The HSDD may have an originating factor (e.g., hypogonadism), but it may also have an equally powerful maintaining one (e.g., relationship conflict). Thus the simultaneous consideration of all potential risk factors is recommended, while remembering that risk factors are not necessarily causes. There are men in whom many of the following risk factors do not result in HSDD.

**Biomedical Risk Factors**

**Age**

Although age is accompanied by physiological changes (e.g., decreases in testosterone), health problems (e.g., neurological, cardiovascular), and medications (e.g., antihypertensives) that are likely to affect sexual function, age is more than a physiological phenomenon. It is also psychological and cultural. Older men are clearly at higher risk for the development of HSDD, but age should be considered holistically, as there are aspects (e.g., attitudes) that may be amenable to cognitive-behavioral intervention.

**Hormones**

Research on androgen replacement (in hypogonadal men) and suppression (in men with prostate hyperplasia) indicates that the effect of testosterone (T) on sexual desire in men is often direct, indirect, and dose-dependent. The administration of T to hypogonadal men generally increases sexual desire; it also results in improvements in mood and energy, which can augment desire (Corona, Rastrelli, Forti, & Maggi, 2011; Khera et al., 2011). However, the relationship between T and sexual function exists only below a certain T threshold (Isidori et al., 2005). The sexual desire levels of men with normal androgen levels do not increase as a function of T administration. T replacement is thus unlikely to be helpful to eugonadal men presenting with low desire. Although no treatment is without risk, the data increasingly indicate that T replacement in hypogonadal men is relatively safe. Some suggest that men on T replacement should follow the same screening recommendations for prostate cancer as those not on T

replacement (Corona et al., 2011), whereas others recommend that prostate-specific antigen (PSA) be monitored in men over the age of 40 prior to T replacement and then 3, 6, and 12 months later with yearly screenings if no significant change is detected (Buvat et al., 2010). Rare though they are, chronic elevations of prolactin (PRL) have also been shown to have a negative impact on sexual desire in men, and, more important, they are associated with serious though treatable diseases (Buvat, 2003).

Hyperprolactinemia (HPRL) has been linked to pituitary tumors and a variety of 53

medications, including phenothiazines, tricyclic antidepressants, antiemetics, H2

blockers (for gastroesophageal reflux disease), and certain antihypertensives. High levels of estrogens and cortisol may also be associated with low desire in men, although these are rarely assessed in the first round of tests for what appears to be uncomplicated hypogonadism (Hackett, 2008; Kobori et al., 2009).

**Illnesses and Medications**

Illnesses that can affect sexual desire are legion, either as a function of pathophysiology or associated psychological effects. Renal failure, cardiovascular diseases, cancer, and substance dependence are among these, as are major depression or anxiety disorders. In addition, medications indicated for these problems can also have sexual side effects.

Most commonly associated with low desire are selective serotonin reuptake inhibitors (SSRIs), prescribed primarily for depression and anxiety (Clayton & Balon, 2009).

**Developmental and Cognitive-Affective Risk Factors**

Psychological factors have been found to be stronger correlates of sexual desire in men than biomedical ones (e.g., Corona et al., 2004). Negative early life experiences (including sexual abuse) can shape attitudes toward sexuality and reactions to sexual difficulties. Family-of-origin messages about sexuality can also leave their mark, not uncommonly in the form of shame (Carvalho & Nobre, 2011). Cognitive interference with desire may consist of complex schema about male sexuality and how it "should"

function, as well as more proximate distractions during sexual activity. Carvalho and Nobre (2011) found that lack of erotic thoughts during sex was statistically the strongest predictor of sexual desire in their sample of men. Attentional focus and performance anxiety have long been associated with low desire, although both may be more of an HSDD-maintaining factor than an originating one. Depressive and anxious mood undeniably interferes with desire in the majority of men, although a minority will engage in sexual activity to regulate negative moods (Bancroft et al., 2003). Most studies, however, show that men seeking help for sexual problems have higher levels of depression and anxiety and that depressed men recall the onset of their depression and desire problems to be approximately concurrent (Brotto, 2010).

**Relational Risk Factors**

Relationship factors feature prominently in men presenting with low desire in the context of a committed relationship (Corona et al., 2004). Lack of attraction to a partner is a difficult risk factor to target clinically. More amenable to intervention are low satisfaction with the quality of partnered sex or relationship conflict. Of particular relevance are lack of communication and intimacy, anger, hostility, dominance, and 54

control in either member of the couple. Desire is often used as currency in maladjusted relationships, making sex the battleground for any number of nonsexual conflicts.

Although noxious relationship dynamics are likely to result in sexual problems, the latter also occur in the context of healthy, loving relationships. It is common for desire to decrease over the length of a relationship, for sex to become routine over time, and for life stressors (e.g., parenting, work-related stress, conflicting schedules) to interfere with the vibrancy of sex (Sims & Meana, 2010). Fortunately, these risk factors are also amenable to intervention, and many long-term couples continue to desire each other and enjoy satisfying sex.

**Sociocultural Risk Factors**

Although most men are exposed to similar sociocultural risk factors, some may be particularly vulnerable to their negative effects. Male sexual socialization in contemporary Western culture sows the seeds for multiple problems by equating masculinity with sexual virility, depicting emotional expression as weak, and sexually objectifying women (Brooks & Elder, 2012). In addition, our culture offers unprecedented anonymous access to sexual stimuli (e.g., Internet pornography) that consist mostly of unrealistic depictions of sexual activity and idealized images of both male and female bodies. Masculinity ideology coupled with the persistent narrowing of what qualifies as sexually attractive provides fertile ground for vulnerable men to develop feelings of sexual inadequacy, to find their partners lacking, and to increasingly turn to sexual gratification that poses no aesthetic or interpersonal challenge.

**ASSESSMENT: IS IT HSDD OR HIDDEN SEXUAL DESIRE**

**DISORDER?**

The assessment of HSDD presentations is optimized by a multidisciplinary strategy that combines (1) medical workups to rule out biomedical factors; (2) medical, developmental, sexual, and relationship history taking; (3) a detailed description of the presenting problem; (4) investigation of comorbid dysfunctions in the man and his partner; (5) an evaluation of the clients current relationship and sexual dynamics therein; and (6) patience for the potential disclosure of sexual secrets (e.g., lack of attraction to partner, extradyadic sexual fulfillment, paraphilias, same-sex preference, gender identity conflict) long after the initial assessment (Levine, Hasan, & Boraz, 2009).

The disclosure of sexual secrets can be facilitated by interspersing couple sessions with individual ones, with clear rules about confidentiality.

In addition to the clinical interview, questionnaires can help assess and track treatment progress. The International Index of Erectile Function (IIEF; Rosen, Cappelleri, & Gendrano, 2002) is a validated measure that inquires about erectile function, orgasmic function, sexual desire, intercourse satisfaction, and overall 55

satisfaction. Comorbid sexual dysfunction in a female partner can be assessed with the Female Sexual Function Index (FSFI; Rosen et al., 2000), which yields scores on desire, arousal, lubrication, orgasm, satisfaction, and pain. The Golombok–Rust Inventory of Sexual Satisfaction (GRISS; Rust & Golombok, 2007) has male and female versions that assess the quality of a couples relationship, sexually and otherwise.

Depending on the medical history and a physician examination, laboratory tests may include fasting glucose and lipids, T (total and free), serum sex hormone-binding globulin, leutinizing hormone (LH), follicle-stimulating hormone (FSH), PRL, and thyroid function. Morning samples are preferred, as T is at its daytime high. Low T with high LH and FSH may indicate hypogonadism, whereas, if all three are low, a pituitary–

hypothalamic disturbance (e.g., pituitary tumor) requiring treatment other than T

replacement may be the culprit (Segraves & Balon, 2010).

Most cases that present as low desire will fall into one of four categories: (1) HSDD

with significant biomedical involvement (e.g., hypogonadism, hyperprolactinemia, medications); (2) HSDD without biomedical involvement; (3) lack of desire for sex with a current partner—sexual desire is being fulfilled otherwise (e.g., masturbation, pornography, extra-marital affairs); (4) lack of desire for sex with a current partner—

sexual desire is being suppressed. Teasing these apart can be difficult. Assessing readiness for change using motivational interviewing techniques (e.g, validating the clients reasons for being apprehensive about change, expressing empathy while pointing out discrepancies in the clients position, avoiding argumentation with client and demonstrating an understanding for resistance to change, and supporting self-efficacy while emphasizing that the client gets to choose what she or he wants with no judgment from the therapist) can indicate the presence of sexual secrets, uncover motivation discrepancies within the couple, and help align the pace of treatment to the clients stage of readiness (Miller & Rollnick, 2002).

**TREATMENT/MANAGEMENT APPROACHES**

The summary of recommendations from the 2009 International Consultation on Sexual Dysfunctions does not offer a differentiated treatment approach for the treatment of HSDD in men (Montorsi et al., 2010). An evidence-based approach to the specific management of sexual desire problems has to necessarily draw on the treatment outcome literature for comorbid dysfunctions (ED) and on nonspecific sex therapy research and clinical experience. As mentioned, there is likely to be a wide diversity in the type and number of influences on the desire of men presenting with HSDD or men in whom HSDD is comorbid with ED. Multidisciplinary assessment will determine the extent of the multidisciplinarity required in treatment, but it is likely that many men will require management on multiple fronts concurrently. Risk factors do not act on desire sequentially, thus their sequential targeting is unlikely to be as effective as a concurrent strategy.

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**Stage 1: Educate, Reduce Distress, Target Biomedical Influences** Most clients have little understanding of sexual function or ways in which physiology, psychology, relationships, and culture interact to affect it. In addition, there are persistent beliefs that can make men feel inadequate (e.g., they should always be ready for sex), as well as media- and pornography-propagated ideals (e.g., sex should be spontaneous) that are impossible to maintain (Zilbergeld, 1999). Education is the base from which to establish reasonable expectations, set realistic treatment goals, explore treatment options, and target cognitive distortions. Although some distress is necessary for client motivation, distress needs to be targeted early, as it interferes with desire and arousal. Instilling hope, normalizing, helping generate attainable goals focused on satisfaction rather than sexual frequency, and mediating the impact of the problem on the couples nonsexual relationship can be useful distress-reduction strategies. Targeting biomedical influences will require coordination and collaboration with the appropriate treatment team health professionals.

**Testosterone Replacement Therapy**

HSDD in men with low testosterone (as a function of age or hypogonadism) is highly responsive to testosterone treatment (Khera et al., 2011). Although there is no definitive level of normal testosterone, there is general agreement that men with morning total testosterone levels consistently below 8 nmol/L (2.3 ng/mL or 230 ng/dL) are likely to benefit from testosterone replacement therapy (TRT). Administering T to men with HSDD who have normal total T levels greater than 12 nmol/L (3.5 ng/mL or 350 ng/dL) will likely have no effect on desire. In men whose total testosterone levels fall between 8

and 12 nmol/L, measuring free T may be helpful, with a lower limit of 225 pmol/L (65

pg/mL) generally accepted (Buvat et al., 2010). Effects appear to be contingent on maintaining a relatively constant blood level of T, which is facilitated by transdermal delivery (gels, patches, subcutaneous pellets). Although these are generally well tolerated and have lower adverse effects than injections or oral delivery methods, a conservative strategy would be to monitor for hepatotoxic T levels and PSA periodically. Men who continue to have erectile problems despite a return of sexual desire after TRT can be considered for combined TRT and phosphodiesterase type 5 (PDE-5) inhibitor therapy (Khera et al., 2011).

**Treatment Involving Other Medical Conditions and/or Medications Affecting**

**Desire**

In cases of HPRL, treating the primary disorder (e.g., pituitary tumor) or replacing medication that increases PRL are the obvious strategies for the appropriate health professional. In cases of hypothyroidism, restoring thyroid function with medication has been shown to affect desire. If serotoninacting antidepressants are suspected to be 57

affecting desire, there are treatment options, including switching to antidepressants with fewer sexual side effects (e.g., nefazodone, mirtazapine, and bupropion) or reducing dosages (Segraves & Balon, 2010). For men with low T/hypogonadism and no psychosocial concerns, TRT may be sufficient to restore sexual desire and satisfaction.

Recent research showed that TRT also had beneficial effects on couples overall functioning (Conaglen & Conaglen, 2009). On the other hand, if low desire has been long-standing, it is likely to have left deleterious cognitive, affective, and relational traces that need addressing, even if the sex drive is restored.

**Stage 2: Cognitive-Affective-Behavioral Therapy**

Although there is precious little HSDD treatment outcome data for either men or women, there is evidence that treatment approaches combining cognitive, emotion-centered, and behavioral strategies, along with relationship skills building, may be effective in helping individuals and couples with difficulties, sexual and otherwise. There are also experienced sex therapists who claim success using any number or combination of the strategies that follow (e.g., Metz & McCarthy, 2010), ideally involving both members of the couple.

**Cognitive Refocusing**

Identifying and challenging maladaptive thoughts and restrictive sexual scripts that interfere with sexual desire and enjoyment is central. Men may present with an ideal of sex that neither they nor their partners are attaining, resulting in distressing thoughts about oneself, ones partner, and the relationship that can be inhibit desire and arousal.

The use of sexual imagery and fantasy are other cognitive strategies commonly reported in the sex therapy literature on desire and arousal. Cognitively refocusing clients on sexual stimuli, either before or during sex, can have significant positive effects. Sexual self-concept is another important cognitive schema that might require intervention in men who have lost a sense of their virility.

**Emotional Regulation**

Some men and/or their partners will present with high levels of negative emotion about his lack of sexual desire, whereas others will suppress emotion for fear of its effect on the relationship. Neither scenario is helpful to the management of the problem. Developing affective awareness is as important as the modulation of emotions. HSDD cases characterized by emotionally focused coping can result in anger, hostility, and mood disturbances that can entrench the desire difficulty. Helping clients and partners modulate emotional reactivity can reduce stress and help them progress through treatment. Acceptance strategies (such as mindfulness) can be useful in this regard, but 58

also in helping clients live with limitations that may not be within their control. Not all clients will be able to achieve the sexual function they wish they had or to achieve the desires of both partners equally. Learning to accept certain realities can have just as positive an impact as attempts to change what can be modified.

**Stimulus Control and Behavioral Activation**

By the time couples seek help for desire problems, their sexual interactions have often been disrupted on multiple levels. Sensate focus can act as the proverbial reset button that refocuses the couple on sensuality. Optimizing the timing and context of sexual interactions may seem obvious, but the literature shows that couples with busy lives tend to deprioritize sex and relegate it to contexts within which desire is likely to be low (e.g., at the end of the day when tired). In addition, couples with sexual problems are more likely to make timing errors, as frustration has set in and sexual demands can issue forth thoughtlessly or in anger. Expanding the sexual repertoire can also be helpful to couples whose sex has become mechanistic. The use of erotica can build desire, unless pornography use is one of the reasons underlying the low desire for a partner. Finally, healthy lifestyle changes may be helpful; of particular relevance are reducing stress, increasing exercise, smoking cessation, and decreasing alcohol use.

**Relationship Skills-Building**

Interventions range from targeting overall relational dynamics to specific directives for communication about sexual preferences. Relational conflict needs to be addressed first, as couples with low levels of trust and respect are unlikely to tolerate behavioral techniques to improve their sex life. Sound conflict resolution strategies revolve around taking responsibility rather than blaming, self-soothing rather than expecting ones partner to reduce ones anxiety, and taking ones ego out of the picture when considering a partners dilemma (Schnarch, 2003). Disrupting the demand–withdrawal pattern of relating commonly witnessed in the context of HSDD can also be transforming. One partner insists on having his or her "needs" met, and the other reacts to this insistence by withdrawing. The more the latter withdraws, the more the former demands, and vice versa. On a less macro level, increasing affection, reactivating romantic ways of interacting, and enhancing communication skills can all work to build desire.

**Can Hidden Sexual Desire Disorder Be Treated?**

The strategies in Stage 2 can be applied concurrently with the treatment of biomedical factors or singularly in cases with no biomedical involvement. Things get more complicated if what looked like HSDD is actually lack of sexual desire for the partner or 59


Input: Could not generate response.

Response:
type of sex possible with that partner. A categorical lack of attraction, or even aversion, to a partner is difficult to change, and attempts can be very painful and damaging to both the man and his partner. There are two alternatives in such cases: either the person who is no longer attracted to his or her partner can try to recover that attraction without making the partner go through humiliating hoops, or the painful truth needs to be exposed so that the couple can make a decision. When the mans sexual preferences and/or identity (e.g., paraphilias, gender identity conflict, preference for gender opposite of partner) cannot be encompassed within the existing relationship, a similar, sensitively implemented exposition needs to occur. In these cases, the therapist is likely to be managing the fallout from the disclosure of the hidden desire and helping the couple negotiate a new direction. One exception is infidelity, in which desire may be reinstated if the couple is willing and able to overcome the crisis.

**Treatment Summary**

In summary, there is very little evidence-based treatment for male HSDD other than the administration of T to hypogonadal men. Treatment strategies are gleaned from a body of primarily clinically informed sex therapy literature that points in certain directions.

First, assessment needs to be multidisciplinary so that treatment can be targeted concurrently at all implicated dimensions. Second, long-standing low desire is likely to have generated psychorelational problems not easily resolved by targeting the biomedical problem. Third, we have little choice but to treat nonbiomedical presentations of low desire with the sex therapy arsenal of cognitive-affective-behavioral and relationship skills-building techniques efficacious with other sexual problems.

Finally, some presentations of low sexual desire in men may not be HSDD at all but desire that is being fulfilled outside of sex with the current partner. Figure 2.1 presents an assessment and treatment choice algorithm as explicated in this chapter.

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**FIGURE 2.1.** **** Presentation of male HSDD treatment algorithm.

**CASE DISCUSSIONS**

**Case 1: The Hope and Hurt in Hidden Sexual Desire**

Fifty-year-old Brad was a successful corporate lawyer who had been married to 45-year-old Stacey for 20 years. They had two boys under the age of 10, and Stacey was primarily a stay-at-home mom, although she ran a small landscaping consultant business from their home on a part-time basis. Their relationship appeared to have deteriorated significantly in the past 2 years, and they rarely had sex (she could recall three times in the past year). Stacey did most of the talking during that first session, while Brad insisted that she was exaggerating and that "things arent that bad." She came across as angry, he as dismissive and annoyed by her. She had dragged him into therapy by threatening to leave if they did not do something to fix their relationship.

The marital conflict purportedly revolved around two issues, interpreted differently by each of them. Stacey complained about Brads lack of attentiveness to her and their 61

family life and about his lack of sexual desire for her. Brad complained that she was overly demanding and critical but conceded that he had in fact lost sexual desire in general. Brad seemed detached and self-involved, showing very little empathy for Staceys distress during sessions. He worked long hours and was an avid runner, insisting on covering a large number of miles every day. Between work and the near-obsessive running, very little time was left for Stacey and the boys. Stacey, on the other hand, seemed unable to express anything without a caustic, hypercritical tone and black-and-white judgments. In terms of sexual desire, both agreed that he had close to none, but he refused to consult a physician, as he said he was perfectly healthy and did not want "to mess with hormones." He also denied in an individual session that he was fulfilling his sexual desire in other ways, including masturbation, which he claimed not to have engaged in for months.

Given their high level of relationship conflict, therapy first focused on the relationship, as it was unlikely they would be able to tolerate sex-focused interventions.

With the goal of disrupting their maladaptive demand–withdrawal pattern, the therapy worked on shifting their focus from partner blame to personal responsibility for improving their own qualities as partners. Stacey committed herself to the effort and even signed up for anger-management classes at another venue. Brads behavior-change efforts were more modest, but he appeared relieved at Staceys diminished demands and calmer demeanor. There was definitely a marked improvement in their relationship. It was time to start addressing his lack of desire.

On the seventh session, Stacey came to therapy alone. She was distraught, and she was excited. They had just left a cinema the night prior when his cell phone rang, and something about the way he turned away from her to talk made her suspicious. Brad broke down and confessed to a 2-year affair with a 25-year-old law clerk, although he swore to end it and begged for forgiveness. She was deeply hurt but, paradoxically, excited to discover that he still had sexual desire that might be redirected toward her.

Brad returned to therapy the week after, and Stacey was curiously more focused on reigniting their sex life than on punishing him or dwelling on the affair. In her new language of differentiation, she claimed that "I am owning wanting to stay married to him even if he had an affair, so whats the point of beating him up? Its my choice." Brad appeared somewhat listless but less resistant to therapy than he had been.

Although the infidelity was processed intermittently, they both wanted to focus on their sexual interaction. The expression of affection, sensate focus, romantic activation, and an emphasis on quality time and communication became the primary interventions.

Although there was progress, Brad rarely initiated sex and appeared unenthusiastic during sexual encounters. His desire for Stacey was low. Slowly and painfully, she realized that he was no longer attracted to her and that, despite his fears about divorce and not living with his boys, their romance had ended. They decided to part ways.

Stacey remained in therapy for another eight sessions to process the damage to her sense of self and to plan her new life. Brad moved in with the law clerk.

**Comment**

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Working hard with a couple through relationship conflict and sexual dynamics only to discover in the end that one person is not attracted to the other is difficult for all involved. We all revel in the mystery of passion and chemical attraction until it results in a very hurt client, in a broken family, and in woefully ineffective therapeutic techniques rendered impotent by the inexplicability of desire. The case of Brad and Stacey reminds therapists that some problems of desire may not be amenable to intervention. On the other hand, cases such as these sometimes yield unexpected results. At the end of therapy, Stacey had become someone much more likely to make good relationship choices and much more likely to succeed in her next relationship. That was not the goal of therapy, but it was a welcome outcome.

**Case 2: Love, Desire, and the Prostate**

Fifty-four-year-old Charles and Betty had been married for 30 years and had 4 grown children and busy, fulfilling professional lives. Affluent and well known in the community for their charitable work, they were generally considered the perfect couple by all who knew them. The problem was that Charles and Betty had had an almost sexless marriage for the past 5 years, something that Betty had decided was no longer acceptable to her. Charles reluctantly agreed to engage in sex therapy for his lack of sexual desire.

Ten years earlier, Charles had been diagnosed with prostate cancer. Having had both parents die of cancer relatively young, the diagnosis had frightened Charles and sent him into an existential spin as he confronted his mortality. Although the prostate surgery had been successful at extracting the cancer, it had also left him with substantial erectile problems, in addition to a new sense of vulnerability. Papaverine injections made intercourse possible, but he hated injecting himself. Viagra worked but did not produce as rigid an erection as the injections and often left him with a serious headache.

Slowly, Charles had started to initiate sex with Betty less frequently and had become less receptive to her advances. By the time they came to therapy, he claimed to feel no sexual desire at all and seemed somewhat hurt at Bettys insistence on restarting their sex life.

Betty had been a trouper about the need for injections and Viagra. Neither bothered her, nor did the fact that the erections were never as rigid as they used to be. She felt perfectly comfortable working around all of that. What she could no longer tolerate was his lack of motivation to engage her sexually. The erectile complications and associated accoutrements were not about her; his not wanting to go to the trouble felt like it was.

An exploration of Charless affect revealed that he had been deeply hurt about Bettys attitude toward the prostate cancer and the impact it had had on his sexual functioning.

Charles had thought he might die, and Betty had treated the diagnosis as if it were "no more than a mosquito bite." This had made Charles feel unloved—she had not been there for him emotionally and, even worse, had made him feel like a baby for getting so worked up. When this was followed by Bettys annoyance at his squeamishness over the injections and his focus on his reduced rigidity, Charles was left feeling that Betty cared more about sex than about him. He had in the end lost sexual desire, but it wasnt 63

because he did not find Betty attractive. It was because he needed to feel loved by Betty to feel desire, and he needed to feel manly, which neither Bettys no-nonsense attitude nor his erectile dysfunction made him feel.

Treatment involved building mutual affective awareness, tweaking sexual scripts, and activating different behaviors. Charles and Betty needed to nondefensively hear what each had experienced concerning the cancer threat and subsequent sexual difficulties, as well as what each had intended by their behavior. Bettys nonchalance, though insensitive, was a testament to how much she desired Charles, complications and all.

Charless narrow sexual script about masculinity and idealized sex was also targeted for modification. Finally, therapy focused on expanding their sexual repertoire, making it less penetration/rigidity focused, with an emphasis on sensuality and intimacy. Charles and Betty started having sex again. Their satisfaction was evident in their reports and in the way they related to each other as the therapy was terminated.

**Comment**

For all we read about love and relationships being central to womens sexual desire, this case illustrates that mens desire can also be deeply affected by relational factors and sexual self-concept. As men age and their desire and erectile function become less automatic, there is a "feminization" of male sexual desire wherein love, intimacy, trust, and self-esteem become increasingly important desire and arousal contingencies. It may be useful to advise women who have always assumed their male partners desire to be imperturbable not to personalize changes that accompany age and health complications.

The case of Charles and Betty also illustrates the primacy of a strong relationship in the prognosis for male HSDD.

The presentation of two cases in which the man had to be talked into therapy for his desire difficulties in no way implies that men with desire difficulties are never motivated to seek help. It illustrates that one of the strongest motivations for men to seek help for desire difficulties is the distress of their partners, much as in the case of women with HSDD (Maserejian et al., 2010).

**CONCLUSIONS**

Low sexual desire remains the most mysterious of all the male sexual dysfunctions.

Rarely a presenting complaint in therapy, it is hard to know how many cases of low desire are hidden under ED complaints, which present primarily to physicians. Cases of PDE5 treatment-resistant ED may in fact be cases wherein desire was the primary problem. In addition, many presentations of male HSDD end up being cases wherein desire is actually intact but not viable within the clients current relationship and/or circumstances. All of this makes the assessment and therapy of male HSDD a tricky affair. The wisest approach is a multidisciplinary one that simultaneously leaves no 64

stone unturned in assessment and throughout therapy (e.g., consideration of a wide variety of desire inhibitors or of alternate sources of sexual fulfillment) while dropping stereotypes about male sexual desire being imperturbable. Much like female sexual desire, male sexual desire is also affected by perceptions of love and trust and safety, increasingly so as men age.

Research is sorely needed for our understanding of sexual desire in men and its disturbances. We know more about ejaculation variations than about the motivational state that drives men to seek out or avoid sexual activity. The focus on physiological arousal has blinded researchers, clinicians, and the public to the fact that desire is an important part of the erection story. Desire is undoubtedly more elusive than erections; it is a construct rather than a measurement of girth. The purely subjective assessment of desire, however, encompasses the complex biological, psychological, relational, and sociocultural universe that makes human sexuality more than a simple drive. We seem to have understood the wisdom of that multidimensionality in our considerations of female sexuality. Although the story may be significantly different for men, it is time that we bring mens sexual desire out from the mechanistic cold into the fold of human complexity.

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**CHAPTER 3**

Erectile Dysfunction

Integration of Medical and Psychological Approaches

Raymond C. Rosen, Martin M. Miner, and John P. Wincze

**B** eing unable to get or maintain an erection can have a devastating effect on a mans self-esteem, his relationship, and his overall quality of life. Although the introduction of the PDE5 inhibitors such as Viagra and Cialis have promised a quick and easy cure, the reality is somewhat different. Many men fail to make adequate use of the medication or discontinue its use altogether. This may be true because interpersonal and psychological factors, long thought to be the cornerstone of a diagnosis of erectile dysfunction (ED), are given little attention by family practitioners, who are now the main prescribers of PDE5 medication.

In this chapter, Rosen, Miner, and Wincze advocate for an integrated model of medical and psychosocial interventions with "psychological and sex therapy approaches strongly emphasized." They critically review the available evidence and suggest that an integrated treatment approach is potentially superior to unimodal psychological or biological therapies. Future therapeutic directions that await empirical validation include the potential integration of cardiovascular risk prevention, lifestyle modification, and couple therapy approaches into the treatment for ED. A comprehensive approach of this type is likely to improve treatment adherence and outcome.

**Raymond C. Rosen, PhD,** is former Co-Director (with Sandra R. Leiblum) of the Sex and Marital Therapy Center of Robert Wood Johnson Medical School and Rutgers University. He also served as Chief Psychologist and Director of the Human Sexuality Program at Robert Wood Johnson Medical School from 1998 to 2006. Dr. Rosen has served as cochair of the first and second International Consultation in Sexual Medicine and also coedited the second and third volumes of Principles and Practice of Sex Therapy. He has served as a senior consultant to the U.S.

Food and Drug Administration, the National Institutes of Health, other federal agencies, and to the pharmaceutical industry. Dr. Rosen has authored or edited nine books and more than 350 book chapters and peer-reviewed articles and has received multiple grants and awards. He is a member of several professional organizations and serves on the editorial boards of the Archives of Sexual Behavior, Journal of Sexual Medicine, Menopause, Journal of Mens Health and Gender, and the Annual Review of Sex Research. He is currently Chief Scientist at New England Research Institutes in Watertown, Massachusetts.

**Martin M. Miner, MD,** is Director of the Mens Health Center of The Miriam Hospital in Providence, Rhode Island, Clinical Associate Professor of Family Medicine and Urology at Warren Alpert Medical School of Brown University, and co-director of the Mens Health Center there. Active on several journal editorial boards, Dr. Miner also serves as a reviewer and has published extensively in the areas of erectile dysfunction, cardiovascular disease, benign prostatic hyperplasia, lower urinary tract symptoms, male sexuality, and hormone therapy for men. He has given numerous presentations in the United States and internationally, is active in several research studies on mens health, and is a consultant to the International Society of Sexual Medicine Consensus Panel.

**John P. Wincze, PhD,** is Associate Director of the Mens Health Center at The Miriam Hospital in Providence, Rhode Island, and Clinical Professor in the Department of Psychiatry and Human Behavior and in the Department of Psychology at Brown University. He has had more than 35 years of experience in the diagnosis and treatment of sexual problems and has published over 100 research papers, book chapters, and books in the area of sexual behavior. He has served as the head of the Psychology Licensing Board in the State of Rhode Island and is currently an Associate Editor of the Journal of Sex Research.

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ED is the signature male sexual dysfunction in contemporary society, which has been the focus of intensive scientific and public interest and intense commercial activity over the past two decades. Since the approval in the U.S. of sildenafil (Viagra) in 1998, more than 100 million men worldwide have received prescriptions for phosphodiesterose type 5 (PDE5) inhibitors, countless websites have been disseminated, and an unknown number of men worldwide have been seen by physicians, pharmacists, or other health providers for ED. Defined as the inability to achieve or maintain erection sufficient for sexual activity, ED occurs in approximately 10% of men under 35 years of age and up to 50% or more of men over 60 (Feldman, Goldstein, Hatzichristou, Krane, & McKinlay, 1994; Panser et al., 1995; Rosen et al., 2004). In addition to being age-related, ED is associated with a wide array of medical and psychological risk factors (Feldman et al., 1994; Panser et al., 1995; Hall et al., 2009; Kupelian, Araujo, Chiu, Rosen, & McKinlay, 2010). It can have negative, or even in some cases devastating, effects on self-esteem, quality of life, and the mans partner relationship. Recent epidemiological studies have highlighted the association between ED and the broader indices of cardiovascular health and psychological well-being, suggesting that ED may be a harbinger or early warning marker for cardiovascular disease (CVD) and depression (Araujo et al., 2010; Inman et al., 2009; Kostis, Jackson, Rosen, & the Second Princeton Consensus Panel, 2005). At the same time, the availability of safe and effective oral therapies has led to a historically unprecedented number of men seeking treatment in the past two decades, with largely unknown consequences, positive or negative.

Evidence from epidemiological studies supports at least five broad observations: 1. ED is highly prevalent in aging men, affecting approximately 50% of all men older than 60. For many men, ED manifests first in their 40s and 50s but increases markedly in both prevalence and severity after age 60.

2\. The degree of distress or bother associated with ED is inversely related to aging, as men older than 70 typically report a lesser degree of bother than their younger counterparts. This finding is consistent across studies. Consequently, distress and treatment seeking are usually higher in younger and middle-aged men and their

partners, who are more likely to seek treatment overall.

3\. The prevalence and incidence of ED are highly correlated with the presence of known risk factors and comorbidities. In particular, cardiovascular comorbidities (e.g., hypertension, hypercholesterolemia), diabetes mellitus, and the metabolic syndrome have all been associated with ED in multiple cross-sectional and longitudinal studies. Most recently, depression and lower urinary tract symptoms (LUTS) have been added to the list of significant medical comorbidities and risk factors.

4\. Lifestyle factors, including smoking, obesity, and exercise, are also significant predictors of ED.

5\. A complex and often interactive set of variables and determinants can lead to ED.

The following case vignette (Case 1) of a middle-aged man with ED and cardiovascular risk factors shows the interactive cycle of causes and consequences of ED

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in this man. The interaction of psychological causes in a younger man with ED is portrayed in Case 2 later in this chapter.

Case 1: ED in a 49-Year-Old Man

Bill K. was a 49-year-old, married stockbroker with a history of coronary artery disease and recent coronary bypass surgery. He had been married for the past 18

years and reported a satisfying sexual relationship with his wife for most of their relationship. The patient complained of increasing erection difficulties and loss of libido since undergoing coronary bypass surgery 2 years before. He was currently maintained on cholesterol-lowering and antihypertensive medications, in addition to intermittent use of benzodiazepines for anxiety. He reported increasing marital distress and was concerned that his wife might be having an affair with a colleague at work. The patient had experienced moderate success in achieving erection with sildenafil (100 mg) but had not attempted sexual intercourse with his wife for several months. His sexual desire was markedly reduced, and he noted that his wife was avoiding him sexually and emotionally. The patient felt anxious and helpless about his situation.

**ED AND THE LINK TO CVD**

Common risk factors for atherosclerosis are prevalent in patients with ED, and the risk of ED has been related to the number and severity of risk factors overall (Feldman et al., 1994; Bortolotti, Parazzini, Colli, & Landoni, 1997). In addition, the prevalence of ED is increased in patients with vascular comorbidities such as coronary artery disease (CAD; Solomon et al, 2003b; Kloner et al., 2003; Montorsi et al., 2003; Montorsi, Montorsi, & Schulman, 2003), diabetes (Bortolotti et al., 1997; Gazzaruso et al., 2004), cerebrovascular disease, hypertension, and peripheral arterial disease (Virag, Bouilly, & Frydman, 1985; Burchard et al., 2001). In fact, evidence is accumulating in favor of ED

being viewed as a vascular disorder (Thompson et al., 2005; Schouten et al., 2008) or incipient vascular disorder in the majority of clinical patients (Inman et al., 2009; Nehra, Jackson, Miner, Billups, Burnett, et al., 2012).

Additionally, ED and CVD share a similar pathogenic involvement of the nitric oxide pathway leading to impairment of endothelium-dependent vasodilatation (early phase) and structural vascular abnormalities (late phase; Azadzoi & Goldstein, 1992). Thus ED

may be considered as the clinical manifestation of a vascular disease affecting the penile circulation; likewise, angina pectoris is the clinical manifestation of a vascular disorder affecting coronary circulation.

**Is ED a More Potent Predictor of CVD in the Younger ( < Age 60) Male? **

The concept of an increased relative cardiovascular burden or risk within patients with 69

ED in the younger age group has been validated in a large Australian study, in which the incidence of atherosclerotic cardiovascular events in men less than 40 years of age with ED was shown to be more than seven times the incidence in a reference population representative of the general male population in Western Australia (Chew et al., 2010).

Thus ED may be a potential marker for silent cardiovascular risk in younger men (Miner, 2009) and minorities (Billups, Blank, Padma-Nathan, Katz, & Williams, 2005), whose risk may be underestimated by traditional CVD risk factors. Although ED had little relationship to development of incident cardiac events in men age 70 years and older, it was associated with a nearly 50-fold increase in the 10-year incidence in men 49

years and younger.

**DIAGNOSIS AND CLASSIFICATION OF ED**

Diagnosis of ED has historically been based on the self-reported ability of the man to achieve and maintain erection sufficient for sexual performance (Lue et al., 2004; Hatzichristou et al., 2004). The disorder is further classified as organic or psychogenic, based on the presence of specific organic factors, including vascular, hormonal, or neurogenic determinants. If these factors are present to a significant degree, and if the patients history is suggestive of a temporal association between onset of symptoms and the patients medical condition, an organic diagnosis is suggested. Psychogenic ED has traditionally been used as a diagnosis of exclusion, which may be given in the absence of specific organic factors.

According to the DSM-5 (American Psychiatric Association, 2013) definition of erectile disorder, at least one of three symptoms (1, marked difficulty obtaining an erection; 2, marked difficulty maintaining an erection; 3, marked decrease in erectile rigidity) must have been present for a minimum duration of approximately 6 months and be expected on all or almost all (approximately 75–100%) occasions of sexual activity.

The third symptom mentioned (decrease in erectile rigidity) is new and has been added to the definition. The rationale provided does not specifically justify the new rigidity criterion, although this has been shown in multiple studies to correlate positively with the ability to achieve or maintain erection sufficient for sexual performance. As previously, DSM-5 recommends that the disorder be specified as lifelong versus acquired or generalized versus situational.

Additionally, it is important to include the presence of other male sexual dysfunction in the diagnosis. For example, recent studies have suggested that up to 30% of men with ED also report symptoms of premature ejaculation (Fisher et al., 2004). Rapid or premature ejaculation may develop as a secondary response to psychogenic ED or may precede the erection difficulty in some cases. In either event, the diagnosis should reflect the presence of concomitant ejaculatory and erection difficulty. In older men, it is not uncommon for men with ED to report loss of orgasm and ejaculation, as well as decreased sexual desire (Rosen et al., 2004). Again, these concomitant or comorbid 70

symptoms of sexual dysfunction should be included in the differential diagnosis.

**ETIOLOGY AND ASSESSMENT: PATIENT EVALUATION IN THE**

**POST-VIAGRA ERA**

Along with new treatment approaches for ED, fundamental changes have occurred in the clinical assessment and evaluation of the disorder. Due in large part to the increasing management of ED by primary care physicians, in addition to the widespread use of PDE5 inhibitors, little attention is paid nowadays to taking detailed sexual histories or using specialized diagnostic testing (e.g. nocturnal penile tumescence, penile cavernosography). Medical or psychological testing for ED, once the mainstay of the diagnostic approach, is rarely used in most settings. Instead, focused symptom evaluation, along with the use of brief screening questionnaires, such as the International Index of Erectile Function (IIEF; Rosen et al., 2004), is the preferred approach in most primary care settings. In fact, self-report of sexual symptoms is the cornerstone of ED assessment at the present time (Hatzichristou et al., 2004). Although partner assessment is acknowledged as also important in most clinical guidelines and recommendations, partners are seldom included in the clinical evaluation in most medical settings. No studies have been performed on the relative contribution of partner involvement to ED treatment outcome, either.

Given the strong evidence of an association between ED and various medical risk factors (e.g., diabetes, coronary artery disease), recent guidelines have emphasized the importance of a comprehensive medical history and physical examination for all men with ED (Lue et al., 2004). The physical examination also provides an opportunity for patient education and reassurance regarding normal genital anatomy (Lue et al., 2004).

Selective laboratory testing is recommended in all cases. This includes investigation of the hypothalamic–pituitary–gonadal axis via assessment of androgenic status, particularly if sexual desire is reduced. There is disagreement about the relative value of the various testosterone assays, including total, free, and bioavailable testosterone (Qaseem et al., 2009). Standard serum chemistries, complete blood count (CBC), and lipid profiles may be of value and should be obtained if they were not performed in the past year. Finally, a serum prostate-specific antigen (PSA) test should be performed based on the patients age and relative risk status, and certainly if the clinician suspects hypogonadism.

Specialized diagnostic procedures, such as nocturnal penile tumescence and rigidity (NPTR) testing or other specialized vascular or neurological procedures, may play a role in selected cases. For example, these procedures may be of value in evaluating young patients with pelvic or penile trauma who may be candidates for reconstructive vascular surgery. Patients with complicated diabetes or other endocrinopathies may benefit from further endocrinological studies. Patients with a history of cardiac disease or significant cardiovascular risk factors should be evaluated for potential cardiac risk associated with sexual activity. Consensus guidelines have been established for evaluating cardiac risks 71

associated with sexual activity (DeBusk et al., 2000; Kostis et al., 2005) Results of the initial evaluation and specialized testing should be carefully reviewed with the patient and the patients partner, if possible, prior to initiating therapy.

Potentially modifiable risk factors, such as cigarette smoking or alcohol abuse, should be addressed. Prescription drugs such as antihypertensives or antidepressants may be implicated in the patients erectile difficulties and should be altered when medically indicated. Patients with specific endocrine deficiencies such as hypogonadism should be placed on hormone replacement therapy prior to initiation of direct therapies for ED.

Additionally, sexual problems in the partner, such as a lack of lubrication, hypoactive sexual desire, or dyspareunia (painful intercourse), should be addressed. Patients and partners should be fully informed about the range of treatment options available, and the risks and benefits associated with each should be addressed.

Beyond the standard approach for medical evaluation of ED (Lue et al., 2004), several authors have recommended a combined medical–psychological approach to evaluation in all cases (Weeks & Gambescia, 2000; Wincze & Carey, 2001). An integrated approach to assessment has also been proposed by Althof and colleagues (2005), based on their comprehensive review of psychological and interpersonal factors in ED. Included in their model are the need for assessment of (1) patient factors, such as performance anxiety or sexual inhibition; (2) partner issues, such as low self-esteem or sexual performance problems; (3) quality of the overall relationship; and (4) sexual and contextual variables, such as financial stresses and family dysfunction. Each of these different areas of involvement is illlustrated in the following case study:

Case 2: A High School Student Complains of ED

Carl, at age 16, came to his primary care physician (Miner) complaining of erectile dysfunction. He was accompanied by his mother, who explained to the physician that Carl was very distraught over his problem and desperately wanted help. Carl stated that he had never had sexual relations with a girl but he knew that he had an erection problem because he was not getting erections "like [his] friends talked about." Also, he denied having any morning or nighttime erections, and he stated that during masturbation his erections were not as hard as they should be, although he was achieving orgasm and ejaculation. He stated that he had strong sexual desire for girls and had engaged in "heavy petting" but did not get firm erections.

In order to rule out any possible organic etiology contributing to Carls erection problems, a number of tests were performed, including: hormone evaluation (total serum testosterone and bioavailable serum testosterone), doppler duplex ultrasound, and nocturnal penile tumescence (NPT). Carl was not taking any medications, and he was not being treated for any medical or psychological problems. All test results were in the normal range, and Carl was informed that his problem was most likely due to performance anxiety; he was referred to a clinical psychologist (Wincze). He was prescribed Cialis to help him when he got involved with another partner. It was explained that the Cialis could be used to help build his confidence but that it was not intended as a long-term solution.

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Carl was seen alone for the psychological evaluation. He denied any past sexual abuse or trauma, but he stated that there was considerable tension in his home due to conflicts between his parents, who were planning to divorce. He denied any suicidal plans, but he stated that if his problem did not improve, he did not want to go through life not able to function with a girl. He denied any same-sex attractions and stated that he had had a number of sexual experiences with girls but would not let them touch his penis because he was too fearful that he would not get an erection.

The phenomenon of "performance anxiety" was explained to Carl, and it was emphasized that this was a common occurrence for males and that males of all ages could experience sexual problems. Carl did not have a girlfriend at the time he was seen; so it was explained to Carl that he should not avoid going out with girls but that he should look for girls whose personalities seemed very "easygoing." Carl was a good-looking boy who was athletic, and he felt he would have no trouble meeting girls who might be interested in him. It was also suggested that he should not get involved sexually with a girl until he felt very comfortable with her. The therapy plan was to continue meeting with Carl for support, and he was also encouraged to call for an appointment when he had questions or when he met a new girlfriend.

Carl was seen 2 weeks after his initial appointment, but he then missed a follow-up appointment and stopped attending therapy. Two years later (at age 18) Carl contacted the clinic again and was again complaining of erectile dysfunction. He was accompanied to the clinic by his mother, and he wanted his mother to attend the therapy session with him. His mother, who is a professional educator, was very concerned about Carls frustration and anger over his problem. She explained that following his work-up 2 years previously, he had insisted on being brought to another physician for another evaluation. The results of this second evaluation also pointed to a psychogenic origin for Carls erection difficulties. Carl was discouraged and did not want further help until more recently. Following this initial input from Carls mother, she excused herself, and Carl was seen alone the remainder of the session.

Carl explained that he did have a steady girlfriend whom he had been going out with for over a year. They were sexual, and they were having intercourse. Carl said that his girlfriend was happy with their sexual relationship, but he felt his penis wasnt as hard as it should be and he did lose his erection on some occasions. He was very insistent that he had "tried everything" and "nothing worked." He did not want therapy; what he wanted was vasoactive injections. He had been given vasoactive injections as part of his medical work-up and he felt that this was the only solution.

Upon further questioning about what he felt might have caused the problem in the first place, he said, "I caused it myself by jelqing." He continued to explain that he felt that he had a small penis and he wanted to increase its size, so, he explored the Internet and found the "Jelqing" technique. In applying this technique to stretch his penis, he felt that he irreparably damaged his penis, which caused his erection difficulties. Following this disclosure, he agreed to continue in therapy to explore ways to address his problem.

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**Comment**

This case illustrates that extreme concern over erectile functioning can occur at any age.

Also, this case, as well as many more we have treated, illustrates the intensity with which an individual can hold onto a belief even in the face of contradicting evidence. In addition to the false belief about the etiology of his problem, Carl endorsed many other false beliefs about sexual functioning. He believed that a male should automatically obtain a full erection whenever he sees an attractive female, and he believed that a male should always be interested in sex.

When Carl initially came to the clinic for evaluation at age 16, he did not have a sexual partner. Because the therapy strategy to resolve an ED problem is greatly facilitated with the involvement of a supportive and informed partner, males presenting without partners are at a disadvantage. Nonetheless, even without a partner, specific issues and strategies can be addressed to better equip a male to resolve his problem. For example, addressing the following areas is helpful: common sexual misunderstandings, accurate and normative sexual information, performance anxiety, and selecting a compatible sexual partner.

In Carls case, he was harboring a belief that he found very shameful; namely, that he had caused irreparable damage to himself by practicing "jelqing." The doctors medical findings that there was nothing physically wrong with him were dismissed by Carl because "he knew what he had done to himself." His shame prevented him from sharing his secret with the doctors or with his mother. His shame and anxiety related to his sexual problem were no doubt exacerbated by his teenage insecurity and fear of peer ostracization if others should find out. When he finally revealed his secret, he put therapy in a position to address all of the issues contributing to his sexual problem.

**CURRENT MEDICAL MANAGEMENT OF ED**