ABSTRACT
Introduction: The False Dichotomy 14
Models for Treating Sexual Dysfunction 15
Sex Therapy 15
Medical Treatments for Erectile Dysfunction 17
New Sexual Pharmaceuticals: Success or Failure 18
Success of the New Treatments 18
Barriers to Treatment Success 18
Identifying Psychosocial Barriers to Success 19
Combination Therapy: The Road to Success 21
Combination Therapy: A Brief Relevant History 21
Combination Therapy for Sexual Dysfunction: Integrating
Sex Therapy and Sexual Pharmaceuticals 22
Combination Therapy Guidelines: Who, How, and When? 22
Categorizing Psychosocial Obstacles to Treatment 23
Sexual Dysfunction Treatment Guidelines 23
Sex Counseling Tips for Clinicians 24
The Focused Sex History 25
Patient Preference, Sexual Scripts, and Pharmaceutical Choice 27
Follow-up and Therapeutic Probe 29
Partner Issues 30
Cooperation vs. Attendance 30
Partner Consultation? 31
Weaning and Relapse Prevention 32
When to Refer? 33
Integration vs. Collaboration 33
Case Study: Roberto 34
Working Together: A Multidisciplinary Team Approach 35
Case Study: Jon and Linda 36
Summary and Conclusion 38
References 39
INTRODUCTION: THE FALSE DICHOTOMY
The 20th century marked huge strides in our knowledge of sexual disorders and
their treatments, however, advancements were followed by periods of reductio-
nistic thinking. Etiology was conceptualized dichotomously, first as psychogenic
and then organic. Early in the 20th century, Freud highlighted deep-seated
anxiety and internal conflict as the root of sexual problems experienced by
both men and women. By mid-century, Masters and Johnson (1) and then
Kaplan (2) designated “performance anxiety” as the primary culprit, while pro-
viding a nod to organic factors. Together, they catalyzed the emergence of sex
therapy, which relied on cognitive and behavioral prescriptions to improve
patient functioning. For the next two decades, a psychological sensibility domi-
nated discussions of the causes and cures of sexual dysfunctions (SDs). However,
during the late 1980s, there was a progressive shift toward surgical and predomi-
nantly pharmaceutical treatments for male erectile dysfunction (ED). By the
1990s, urologists had established hegemony, with the successful marketing of
various penile prostheses, as well as intracavernasal injections (ICI) and inter-
urethral insertion (IUI) systems [e.g., Caverject (Pharmacia, Teapak, NJ,
USA), Muse (Vivus, Mountainview, CA, USA)]. The monumentally successful
1998 sildenafil launch (Pfizer, New York, NY, USA) and its subsequent publicity
at the end of the 20th century symbolized the apex of biologic determinism. Most
physicians and most of the general public saw SD and its treatment solely in
organic terms.
