“Wiener” Week: Adventures in the practice of a sex-literate therapist

By Susan Ansorge, PhD. I told my husband this morning that this week should have been called “Dick Week” at my practice. No one actually acted like a Dick, but it seemed EVERYONE was talking about them! It started with a middle-aged female client complaining about how trying to date men her age, she definitely encountered more men with erectile issues. She said “I told my friend and she said, ‘Dick problems are the worst!’”

It’s true that nobody would choose to have “Dick problems”, but I think a lot of therapists, particularly female ones, shy away from talking about sexual problems in general, and erectile problems in particular, because they don’t know how to deal with them. Given that, according to The Massachusetts Male Aging Study, 40% of males at age 40 and 70% at age 70, are affected to varying degrees, I thought it was a topic worth discussing. I’ll start with some examples of the topics that came “up” this week, and some ideas for managing them. I am not a Certified Sex Therapist, but I consider myself competent and literate in the area. Given that I seem to have a caseload of about 50% “Cisgender” males, mixed between gay and straight, including a men’s group, and I market myself as a therapist comfortable and experienced with sexual issues, I have my share of conversations about erectile functioning. I find that my male patients often feel relieved to talk about this topic with a female therapist, even if it takes a while for them to bring it up, or they are initially shy about answering my questions.

Anxiety

What are the two major requirements for healthy sexual functioning? Safety and Arousal. Now, this is not to say that danger is not a turn-on. For many people it is. But actual anxiety, rather than nervous excitement is an arousal killer. One of my male clients’ presenting complaints was anxiety about intimate relationships. He had avoided sex because of it for several years. We worked through several roots of his anxiety before he mentioned that the most proximal cause of his swearing off intimate relationships was erectile dysfunction due to a combination of anxiety and normal aging. The good news, is that by the time we got to really talking about his issues with ED, he had worked so much on his communication skills, that he was able to rattle off an extremely effective strategy for prepping his partner for this potential outcome, and for dealing with it if it occurred. Our relationship had developed so much that we were able to discuss the “ins and outs” of his ED with humor and candor that actually made it fun, rather than torturous for him.

Communication

What are the hallmarks of a positive outcome after an initial episode of Erectile Dysfunction? Good communication! If a partner is punitive or avoidant in dealing with their own feelings of rejection, disappointment, anger, etc., things don’t tend to go well. It’s important to strategize and ask one another how they want to proceed and what’s helpful when erectile fluctuations happen in the relationship. (Notice that terminology? It’s much less pathologizing!)

In addition to communication related to sex, it is important that communication be flowing well in general. It doesn’t take a sex therapist to know that anger and arousal don’t mix very well. Many couples’ sexual problems are very much linked to other issues in their relationship that go well beyond the bedroom. So, before or during the addressing of sexual issues, the other areas of conflict must be addressed. I don’t think that couples therapists should put off addressing sexual issues just because there are other major areas of conflict, but it is always a judgment call, whether there is the basic level of safety required to address an area as vulnerable as sexuality.

Persistence

Whether it’s within the sexual interlude, or within a short time after, “getting back on the horse” is very important. That’s why the idea of erectile fluctuation, rather than dysfunction appeals to me. There is no reason for an interlude to end just because a penis is being a little moody! I’ve had so many couples avoid sex because of fears of failure, which then puts that much more pressure on the sexual experience when it does happen. Yikes! Don’t do it! I mean, DO IT, more frequently, not less. I have been thinking of a metaphor with healthy eating. If you starve yourself, you will not tend to eat very healthily when you do eat. You will overeat, or have lost your appetite. Thus, there will be too much pressure on the interlude, or too little interest.

Pornography

This metaphor also applies to pornography use. If you eat overly sweet, salty or rich foods, healthier foods won’t be very appealing. Similarly, if a person watches very graphic pornography, which caters to their exact desires at all times, it may make regular sex with their partner seem boring in comparison. This is not to say that erotica and pornography has nothing to add to a couple’s sex life. Many couples find that adding “kink” to their sex lives, wakes up desire that may have been flagging, and erotica and porn can educate people on these topics. But a steady diet of unreal images has been shown to have an unhealthy effect on many people who use it compulsively (The Porn Trap by Maltz and Maltz is a good self-help book on this topic).

Medical Issues

Although we as therapists are usually charged with dealing with the psychological side of sexual functioning, it is important to address potential medical issues. A referral to a primary care physician or urologist is always a good first step, and can be reassuring to a client that he is OK medically. I had two medical issues emerge in therapy this week that were major impediments to erectile functioning. I felt like saying “you buried the lead!” to my clients who admitted to having avoided talking about them because they worried I might be squeamish. “Bring it on! I’m interested in hearing about it and interested in helping you, and we won’t get very far if I’m in the dark!”.

Although the problems I heard about this week were due to accidents and illness, some of the erectile problems that can be helped with medicine may be due to normal aging. It’s true that the little blue pill won’t fix you if you don’t have desire for your partner, or if you are furious with him or her, but I’ve seen it help when guys lose confidence because “it just doesn’t work like it used to”. I always encourage men to try and notice if there are factors that make them more likely to cause erectile issues (Tiredness, stress, etc), and reserve it’s use for those times so they don’t become dependent on it. That said, if it works with relatively few side effects, and the person can afford it, I don’t feel it’s beneficial to discourage it’s use.

That’s my little primer on Erectile Fluctuation from someone who gets to talk about it pretty frequently. If you have male clients, I encourage opening up the topic, because it’s not one that guys will tend to bring up themselves, unless it’s the primary issue. So, if you have your own internal barriers to the conversation, I encourage you to address them. ED is not fun, but talking about it doesn’t have to be fraught with misery and tension if you bring your humor and candor to the table!

Susan Ansorge, PhD is a psychologist in private practice, and has particular interest and expertise in working with issues related to sex and sexuality, relationships, and the challenges faced by academics and creatives. She works from an interpersonal relational orientation, integrating aspects of attachment theory, neurobiology, as well as behavioral interventions to enhance the treatment.

You may view her profile on Psychology Today at: Susan Ansorge, PhD.

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