Sexual Therapy in the Age of Pharmacotherapy

In 1994, Schover and Leiblum decried the stagnation of sex therapy.

They chided clinicians for failing to develop new, innovative sex therapy

techniques. Their “call to arms” coincided with the evolving medicaliza-

tion of sexual problems for men and women.

At that time, intracavernosal injection (Althof et al., 1987), intramus-

cular apomorphine (Segraves, Bari, Segraves, & Spirnak, 1991) and vac-

uum pump therapy (Turner et al., 1990) were proliferating as medical

treatments for erectile dysfunction (ED), including those men with psy-

chogenic ED. The use of selective serotonergic reuptake inhibitors

(SSRIs) was eclipsing sex therapy as the treatment of choice for prema-

ture ejaculation (PE; McMahon et al., 2004). Hormone replacement

therapy (HRT) was being advocated for women to alleviate the nonsex-

ual and sexual symptoms of the menopausal transition, and testos-

terone was being recommended by some to treat female hypoactive

sexual desire disorder (HSDD) (Buster et al., 2005; Sherwin & Gelfand,

1985). There were voices of dissension, complaint, and warning that the

Sexual Therapy in the Age of

Pharmacotherapy

Stanley E. Althof

Case Western Reserve University School of Medical School

Center for Marital and Sexual Health of South Florida

Combining medical and psychological interventions for individuals or couples

with sexual dysfunction offers an alternative approach to therapy that

enhances efficacy, treatment and relational satisfaction, and decreases

patient discontinuation. By combining the power of both and changing the

way we deliver psychological care, patients may, in the long-term, derive

greater benefit. I review the literature on combined therapy and propose one

paradigm for combined therapy. This paradigm serves only as a model to be

improved upon or extensively modified. Such combined treatment models

must be conceptually sound and be subjected to reproducibility and sophisti-

cated analysis.

Key Words: combination therapy, erectile dysfunction, pharmacotherapy

and psychotherapy of male sexual problems, premature ejaculation.

Stanley E. Althof, PhD, is a Professor of Psychology at Case Western Reserve Univer-

sity School of Medical School and Executive Director of the Center for Marital and Sexual

Health of South Florida, West Palm Beach, Florida. Correspondence concerning this arti-

cle should be directed to Stanley Althof, Center for Marital and Sexual Health of South

Florida, 1515 N. Flagler Drive, Suite 540, West Palm Beach, FL 33401.

(stanley[email protected])

2 S. ALTHOF

field of sex therapy was being corrupted and co-opted by the populariza-

tion of the emerging medical treatments for sexual dysfunction. Note

this was all still pre-Viagra (Tiefer, 1995)!

The treatment landscape forever changed in 1998 after sildenafil

(Viagra™) was approved by the Food and Drug Administration (FDA)

as the first phosphodiesterase type 5 inhibitor (PDE5i) for the treat-

ment of ED. Five years later, two other PDE5is, tadalafil (Cialis™) and

vardenafil (Levitra™), also received FDA approval. Currently, over 90%

of men with ED are treated with PDE5is.

With the ever expanding role of approved and “off label” pharma-

cotherapy for male and female sexual dysfunction, the predisposing, pre-

cipitating, maintaining, and contextual factors linked to the dysfunction

were often disregarded (Althof, et al., 2005; Hawton, & Catalan, 1986).

Sexual dysfunctions were reframed as medical problems that reliably

responded to medical solutions. This framework was driven by the clever

marketing strategies of the pharmaceutical industry, physicians with

insufficient time or interest to grasp the larger picture, and patients who

longed for effortless and immediate solutions to complicated life prob-

lems. What surprised many, however, was the large percentage of

patients who discontinued pharmacotherapy, a phenomenon not easily

explained by the robust efficacy and safety of these interventions.

Combined medical and psychological intervention may be one possi-

ble solution to the excessive discontinuation rate. Such innovative treat-

ment offers patients the opportunity to overcome the psychosocial

obstacles that interfere with them effectively utilizing medical treat-

ments for their sexual dysfunction.

The Disconnect Between Efficacy and Continuing

Pharmacotherapy

Chronic administration of clomipramine or SSRI’s for rapid ejacula-

tion increases intravaginal ejaculatory latency time (IELT) six to eight

fold (Waldinger, Zwinderman, Schweitzer, & Olivier, 2004). As-needed

dosing tends to increase IELT by 3 to 4 fold (Pryor et al., 2006). Yet, in

spite of this impressive delay, over the long-term, men tend to become

disenchanted with pharmacotherapy and discontinue treatment. What

contributes to this discontinuation phenomenon?

Similarly, over 60% of men discontinued intracavernosal injection or

vacuum tumescense therapy (Turner et al., 1992). Discontinuation was

attributed to the objectionable nature of the treatment, for example,

having to inject the penis or the use of an artificial means to generate

erection. Indeed, these were large hurdles for men/couples to overcome.

It was, however, surprising, that when PDE5is, with their ease of use,

SEXUAL THERAPY AND PHARMACOTHERAPY 3

excellent efficacy and safety were introduced that the dropout rate was

over 50% (Althof, 2002)!

Schiavi (1999) noted that in aging males, sexual functioning and sat-

isfaction are influenced more by psychological and relational factors

than vascular, neurological, or hormonal concerns. Age causes the vas-

cular, neurological, and hormonal systems to function less efficiently.

Thus, the relational and psychological influences become more promi-

nent. Could these factors influence the dropout rate?

The answer to all these questions lies in the complex inter-relation-

ship between efficacy, treatment satisfaction, adverse events, insurance

concerns and, cost, and the powerful but often silent multiple psychoso-

cial factors. Medical therapy alone does not address these important

issues. Combination therapy provides a venue where the psychosocial

factors can be identified, acknowledged, and addressed while patients

simultaneously make use of a variety of efficacious medical treatments

for sexual dysfunction.

In this paper, I focus on combined treatment for male sexual dysfunc-

tion. To date, there is no approved pharmacotherapy for female sexual

dysfunction in the United States and the data for “off label’ testosterone

creams and gels for women are incomplete. Although there are inte-

grated/combined treatments for female pain disorders, a comprehensive

review of those issues is beyond the scope of this paper (Basson et al.,

2004).

Conceptual Paradigms

Prior to the 1980s sexual dysfunction was conceptualized in binary

terms—it was either psychogenic or organic. When fewer treatment

options were available, this paradigm simplified treatment planning.

Over time it became clear that the binary model alone was insufficient

to explain the multidetermined, multifaceted intricate underpinnings of

male and female sexual function.

The biopsychosocial model gained prominence in the mid-1980s. The

integration of biological and psychological predisposing, precipitating,

maintaining, and contextual factors and their impact on treatment

responsiveness offered a more inclusive and sophisticated understand-

ing of patients’ sexual problems. Such an interactive model conceptual-

izes the psychological and biological factors as additive and interactive

(Althof & Seftel, 1999, Levine, 1992; LoPiccolo, 1992; Schnarf, 1990;

Tiefer & Melman, 1989) and captures the ever changing influences of

biology and psychological life. Regardless of the precipitating causes,

over time, changes in both domains occurred. Such a model emphasizes

the psychological impact that the dysfunction has upon the individual,

4 S. ALTHOF

and the couple’s sexual equilibrium, and the fluctuating influence of

medication, lifestyle, and disease. The model also explains the failure of

treatments for biological problems, which ignored the psychological con-

tributions. What follows is a case vignette illustrating the complex

interaction between medical and psychological variables.

Following the diagnosis of prostate cancer, Harold, age 55, underwent a

radical prostatectomy that left him with unreliable erectile function. His

treating urologist tried him on a PDE5i without success and then offered

him intercavernosal injection. The injections resulted in firm erections

sufficient for intercourse.

I saw Harold and his wife Judy, age 50, 4 years later. They had never

resumed lovemaking, not because of his ED, but because she had discov-

ered his infidelity 6 months after he underwent surgery. Now, both felt

ready to rekindle their romantic and sexual life. Their situation is even

more complicated. All during their 20-year marriage, Harold had episodi-

cally suffered from psychogenic ED. Lovemaking focused on his erectile

capacity, not their mutual pleasure. Judy felt Harold was inattentive to

her needs, and he felt she did not understand his embarrassment, humili-

ation, and long-standing dysthymia, which he attributed to the ED.

A simple medical intervention, which provided Harold with a reliable

erection, could not overcome the myriad of psychosocial obstacles. This

case illustrates the need for combined treatment.

The interactive model fractionated with the introduction of the oral

ED agents. Cause and effect, treatment and response, were again nar-

rowly perceived through the biomedical lens. Patients and clinicians

alike naively hoped that psychosocial issues would yield to the robust

efficacy of these compounds.

The limited long-term success of pharmacotherapy shifted the pendu-

lum back toward the interactive biopsychosocial model. Such a model

leads us to consider combination therapy, in which pharmacotherapy

and psychological intervention are provided to the patient and/or couple

in either a stepwise or simultaneous manner. Perhaps combined ther-

apy was one of the novel sex therapy innovations anticipated by Schover

and Leiblum in 1994.

Learning From Related Fields

In a provocative article entitled, “Moving Behavioral Medicine to the

Front Line: “A Model for the Integration of Behavioral and Medical Ser-

vices in Primary Care,” Pruitt, Klapow, Epping-Jordan, and Dressel-

haus (1998) exhorted mental health clinicians to expand beyond their

present models and roles of care-giving. They wrote, “The time is right

to integrate behavioral medicine concepts into primary care and expand

SEXUAL THERAPY AND PHARMACOTHERAPY 5

the role of psychologists in the broader health care arena” (p. 230).

In a scholarly commentary consistent with the interactive biopsy-

chosocial model, Sobel (1995) observed that

Thoughts, feelings, and moods can have a significant effect on the onset of

some diseases, the course of many, and the management of nearly all.

Even in those patients with organic medical disorders, functional health

status is strongly influenced by mood, coping skills, and social support, yet

the predominant approach in medicine is to treat people with physical and

chemical treatments that neglect the mental, emotional, and behavioral

dimensions of illness. This critical mismatch between the psychosocial

health needs of people and the usual medical response leads to frustra-

tion, ineffectiveness, and wasted health care resources. There is emerging

evidence that empowering patients and addressing their psychosocial

needs can be health and cost effective. By helping patients manage not

just their disease but also common underlying needs for psychosocial sup-

port, coping skills, and sense of control, health outcomes can be signifi-

cantly improved in a cost-effective manner. Rather than targeting specific

diseases or behavioral risk factors, these psychosocial interventions may

operate by influencing underlying, shared determinants of health such as

attitudes, beliefs, and moods that predispose toward health in general.

Although the health care system cannot be expected to address all the

psychosocial needs of people, clinical interventions can be brought into

better alignment with the emerging evidence on shared psychosocial

determinants of health by providing services that address psychosocial

needs and improve adaptation to illness. (p. 234)

Behavioral health specialists interface with patient care delivery in

unconventional ways that go beyond the traditional method of seeing

patients in their offices for psychotherapy. For instance, mental health

clinicians may offer onsite consultation to the treating physician without

ever seeing the patient. They advise him/her on treatment strategies,

which are implemented by the primary care clinician. Alternatively, they

may train medical professionals, such as nurse practitioners or physician

assistants to assess psychosocial issues and provide care. Or, the mental

health professional might engage patients onsite for consultation or treat

them in short- or long-term group, individual, or conjoint treatment in

their office. Such stratification of services enables psychologists and

physicians to target behavioral medicine resources to patients with the

greatest needs. Many patients can benefit from low-intensity interven-

tions, whereas more expensive individual treatment is reserved only for

those patients who require more in-depth care.

Case Vignette

Bob is a 54-year-old married man who comes to his primary care

physician requesting treatment of his ED. He suffers from Type II dia-

6 S. ALTHOF

betes, hypertension, and obesity and requires five medications for his

medical problems. Bob reports having poor morning erections and weak

erections with masturbation and foreplay. Intercourse has not been pos-

sible for 8 months. He has no ejaculatory difficulties but his sexual

interest has decreased.

In this case it is likely that the predisposing and precipitating factors

for the erectile dysfunction are entirely medical, namely, diabetes,

hypertension, and possibly his medications. However, his mood, atti-

tude, motivation to resume a sexual life, level of performance anxiety,

preoccupation with the symptom, expectations and fears of treatment,

quality of his interpersonal relationship, degree of his partner’s interest

in resuming a sexual life, her health status, the couple’s interval of

abstinence, life stresses, and coping skills could all conceivably worsen

the symptom and interfere with responsiveness and continuation of

treatment. Simply giving Bob a PDE5i without considering the impact

and interaction of all the biopsychosocial issues may be insufficient to

overcome the amalgam of medical and psychosocial obstacles. Unfortu-

nately, because of limitations of time, interest, and education all too

often the psychosocial features are overlooked.

It is also possible that the PDE5i would not be efficacious in restoring

erectile reliability even if there were no psychosocial obstacles. The dis-

ease process itself might have progressed too far to be remedied by

PDE5is. However, it is also possible that psychosocial issues interfere

with the man or couple making use of an efficacious intervention.

In either case, the man (or couple) returns to the clinician’s office and

states, “Doctor, it didn’t work.” Clinicians assume this phrase means the

medication was not effective in restoring erectile reliability. In response

they tend to increase the dose of the medication, switch medications, or

suggest alternative medical ED options, such as intercavernosal injec-

tion, vacuum pumps, or MUSE. They do not clarify the meaning of the

phrase “it didn’t work.” It might mean exactly what they thought.

However, it might also mean any of the following: I was afraid of

another failure; I thought I would leave well enough alone; I no longer

find my partner attractive; my partner was not cooperative; it was

painful for her; or I thought it would fix the problems in our marriage.

Obviously dose titration or alternative medical interventions would not

address these disguised psychosocial concerns. Combination therapy

simultaneously or in a stepwise fashion might both improve long-term

treatment satisfaction and psychosocial outcomes.

Combination Therapy

Combination therapy, alternatively called coaching or integrated

SEXUAL THERAPY AND PHARMACOTHERAPY 7

therapy, is not a novel concept. It has been successfully employed in the

treatment of depression, schizophrenia, and posttraumatic stress disor-

der (Keller et al., 2000; Nathan & Gorman, 2002). It is also an impor-

tant aspect of treatment for diabetes and breast cancer because

psychosocial support is a crucial component of care giving.

Although the idea of combination therapy sounds intuitively correct,

there remain several unanswered questions. Most important, what is an

evidenced-based or proven conceptual framework guiding treatment

decisions? Practically speaking, how are the resources allocated—who

delivers the care, where is the intervention done, are the medical and

psychological treatments concomitant or stepwise?

From experience we know that the traditional referral of patients

from a primary care, urological, or gynecological physician to a sex ther-

apist is fraught with difficulties. For a variety of reasons (stigma, cost,

insurance issues, lack of motivation, etc.) patients rarely follow through.

The rule of thumb is that only 10% of referrals present for a first visit

with sexual specialist.

Additionally, sex therapists are a rare commodity. Although large

cities generally are fortunate to have this resource available, there are

insufficient numbers of trained clinicians to provide care to those in

need in smaller cities or rural areas. Also, there is the issue of time and

cost. Many patients are not willing to pay “out of pocket” for these ser-

vices and/or cannot commit to once weekly treatment over a period of

several months. One solution to the problem of resource availability,

time, and money would be to offer the initial services at the site of the

primary care or specialty physician.

Onsite intervention would allow more individuals to have access to

sexual health education and intervention. In a “one-stop shopping”

model, patients could see the physician and the person designated to do

the psychosocial intervention (this may or may not be one and the same

person). This places less burden on the patient and could possibly result

in a cost savings for them as well. To take a lesson from the behavioral

medicine interventions, this would require sexual experts to train

physicians and other health care workers in assessment, education, and

rudimentary psychological intervention. The conceptual model would

guide these caregivers to recognize when more intensive psychological

treatment is required and to appropriately refer.

Combined treatment paradigms challenge traditional sex therapy

practices. Are we willing to train other professionals to provide some of

the care, are we willing to leave the comfort of our offices and provide

onsite assessment/intervention? Or, in the future, will we witness the

establishment of comprehensive sexual treatment centers that include

8 S. ALTHOF

specialists from several disciplines (Levine, 1989)?

Review of Combined Therapy Treatment Efforts

Several articles have described combined treatments for men with

ED. No combined interventions have been reported for PE, delayed ejac-

ulation, or female desire, arousal, or orgasm difficulties.

Psychological interventions combined with the use of sildenafil have

been evaluated in two articles. In the first Melnik and Abdo (2005) ran-

domly assigned men with psychogenic ED to one of three experimental

groups. In Group 1, participants received 6 months of theme-based psy-

chotherapy plus sildenafil 50mgs; in Group 2, they received only 50 mgs

of sildenafil; in Group 3, they received only theme-based sexual counsel-

ing. At the end of 6 months, compared to baseline, all three groups

demonstrated significant improvement in posttreatment International

Index of Erectile Function (IIEF) scores. However, utilizing the criterion

of normalization of IIEF scores (EF domain ≥26), only the combined and

psychotherapy only groups demonstrated statistically significant

improvement.

The authors explained the results in terms of psychotherapy encour-

aging patients to understand the emotional component of their condi-

tion, helping them to strengthen their commitment to the change

process, to become more deeply involved, and to benefit from treatment.

Psychotherapy also promoted more realistic and positive sexual expec-

tations instead of expecting automatic, autonomous erections.

In the second article Phelps, Jain, and Monga (2004) highlighted the

value of a one-session psychoeducational intervention. The authors com-

pared two groups of men: The first received combined treatment with

one session of psychoeducational intervention and sildenafil, and the

second received only sildenafil. Those in the psychoeducational plus

sildenafil group received one 60 to 90 min session of counseling, which

included information about sexual function, clarified their treatment

expectations, and gave them communication exercises and references

for self-help books. After 24 weeks of treatment, there were no differ-

ences in the IIEF scores between the two groups: Both demonstrated

significant improvement. However, the treatment satisfaction scores for

the psychoeducational intervention group were significantly higher

than the sildenafil-only group.

Three articles have addressed combined treatment with intercaver-

nosal injection therapy (ICI). Lottman, Hendriks, Vruggnik, and Meule-

man (1998) compared a small group of men receiving ICI plus three

sessions of counseling at weeks 0, 6, and 12, with a larger cohort of men

receiving ICI without counseling. During the trial dosing phase, there

SEXUAL THERAPY AND PHARMACOTHERAPY 9

were no differences in discontinuation patterns. From the trial dosing

phase forward until the 6-month follow up, no additional patients dis-

continued treatment in the combined therapy group. In contrast, the

discontinuation rate after the trial dosing phase in the ICI-only group

was 60%. Patients reported that counseling increased their knowledge

about factors contributing to erectile dysfunction and improved their

ability to communicate about their sexual interest and desires. Through

counseling they felt more comfortable talking about feelings and

thoughts concerning sexual problems.

Hartmann and Langer (1993) described an integrated treatment pro-

gram involving injection therapy and sex counseling. They concluded

that a combined approach was more beneficial to men with primarily

psychogenic ED and that improvement could occur only in the absence

of partner problems or premature ejaculation.

In a more recent study, Titta, Tavolini, Dal Moro, Cisternino, and

Pierfrancesco. (2006) reported on a group of non-nerve sparring radical

retropubic prostatectomy and cystectomy patients receiving ICI who

were randomized into two groups. The first group received ICI plus sex-

ual counseling, while the second group received only ICI. Patients were

followed for 18 months after initiating ICI. Over the course of the 18

months all men also received a trial of sildenafil. In these patients,

there were no differences between the groups on baseline IIEF or post-

surgery scores. At the 3-month and 18-month follow-up, compared to

the ICI only group, the counseling plus ICI group achieved significantly

higher erectile function, desire, orgasm, and satisfaction scores. Addi-

tionally, the counseling plus ICI group manifested a lower discontinua-

tion rate and were able to achieve good quality erections with lower

does of medication. Finally, more men in the sexual counseling group

responded to sildenafil than subjects in the ICI-only group.

Combined treatment utilizing vacuum tumescence therapy and coun-

seling was reported by Wylie, Hallam-Jones, and Walters (2003) who ran-

domized 45 patients with primarily psychogenic ED into two groups. The

first group participated only in couples therapy, whereas the second was

instructed in the use of a vacuum device while simultaneously receiving

couples therapy. Improvement was reported by 84% of the combined

group but by only 60% of the therapy-only group. The authors suggested

that early combination treatment of couples therapy and a physical treat-

ment, such as a vacuum device, may lead to a more beneficial response

than psychotherapy alone. They also highlighted the importance of

demonstrating potential benefits from a physical intervention early in

therapy and suggested that delaying the demonstration of such benefits

to the patient may have a negative impact on treatment outcome.

10 S. ALTHOF

These studies all suggest that combining medical and psychological

treatments for ED improves the physical outcome and promotes greater

treatment satisfaction and decreased discontinuation rates than med-

ical treatment groups alone. The benefits of the psychological interven-

tion appear to be educational and aspirational in terms of treatment

expectations, improving sexual confidence by demonstrating early on

that reliable erections are possible with medical intervention, and

improving communication between partners.

Psychological and Relational Responses to Pharmacotherapy

The introduction of pharmacotherapy alters the sexual script of most

men/couples utilizing these treatments (McCarthy & Fucito, 2005). Usual

patterns of lovemaking may be disrupted to accommodate the use of phar-

macotherapy, for example, when lovemaking occurs, who initiates, and so

on, with some couples being more flexible in their routines than others.

The duration of a medication’s window of opportunity may influence the

sexual script as well (Dunn, Althof, & Perelman, 2006). Specifically, silde-

nafil’s and vardenafil’s erectile facilitating effects last between 4 and 10 hr;

tadalafil’s duration can be up to 36 hr. For some men, use of a shorter act-

ing agent increases the pressure to perform within the window of opportu-

nity. Extended duration medications may allow for more spontaneity,

repairing sexual mishaps, creating more opportunities for the partner to

initiate, and less focusing on the clock for both partners.

Until sexual confidence is restored, men may focus more on the qual-

ity of their erections than on deriving pleasure from the experience or

pleasing their partners. Some partners may resent men using medica-

tions to assist with arousal, believing they are responding only to the

drug effects and not to them. Other partners fear that the medication

may harm the man and carefully monitor his physical reactions rather

than focusing on their own sensations or pleasure.

Additionally, administration of a pharmacological agent functions as

a “therapeutic probe,” uncovering patient and partner, interpersonal,

and contextual issues that can conspire to interfere with the stated goal

of resuming lovemaking. For example, when relationships are problem-

atic, any of the following motives by one or both partners may interfere

with the successful resumption of lovemaking: poorly managed or unre-

solved anger, power and control issues, and contempt and disappoint-

ment. These concerns, complicated by prolonged sexual abstinence,

need to be addressed before or during the pharmacological treatment

intervention to achieve the stated goal. The following vignette illus-

trates how a medical intervention can significantly and, in this case,

negatively alter the couple’s equilibrium.

SEXUAL THERAPY AND PHARMACOTHERAPY 11

Richard Friedman (2006), a psychoanalyst, writes about his patient, Dan,

age 53, who although in excellent health and free of sexual dysfunction

asked him for Viagra™ to “jazz up” his marital sexual life. Dr. Friedman

inquired whether his wife was complaining; she wasn’t. Dan ultimately

obtained a prescription for Viagra™ from his internist and nothing was

mentioned in therapy for several months.

Then Dan reported that for the first time in his married life that he and

his wife were fighting over their sexual life. Dan had become more sexu-

ally demanding, which was not well received by her. Additionally, Dan

sought to convince his wife that she should find a medical intervention so

that she too could be more sexual.

Dr. Friedman writes, “What Dan had not realized was that his newfound

sexual vigor had changed his relationship with his wife. She was perfectly

happy with her affectionate, laid-back, middle-aged husband; she had no

desire for a sexual athlete as a partner at this point in her life. Viagra™ had

become an intruder in their intimate life. Dan was loath to give up his new

vigor. If he couldn’t get her a remedy, he just hoped that with time his wife

would adjust to her rejuvenated husband. Dead wrong. His exhausted wife

finally lost her patience and told him that he had to stop the Viagra™ if he

cared about their marriage” (Friedman, New York Times, August 22, 2006).

In the end Dan did not renew his prescription for the drug.

Another obstacle to successful use of a pharmacological agent focuses

on the unrealistic expectations that patients may have. For instance,

some men believe that “with my restored erection, lovemaking will be

more frequent” or “I will feel more lovable and successful in life.” When

these expectations are not realized, demoralization results and patients

discontinue treatment.

Finally, disguised or hidden (conventional and unconventional) sex-

ual arousal patterns may be the cause of pharmacotherapy failure.

PDE5is require the man to desire his partner, and a lack of sexual

arousal for his partner is likely to prevent any erectile response. Exam-

ples of disguised or hidden conventional and unconventional arousal

patterns can include the married man who is secretly attracted to men,

the man who has no sexual desire for his partner, and the man who can-

not acknowledge his unconventional patterns of arousal, such as to

young children or to sadomasochistic situations. Any of these arousal

patterns are likely to interfere with the man’s achieving or sustaining

his genital response to his conventional partner. Pharmacotherapy

alone cannot be expected to overcome these psychosocial obstacles.

Conceptual Paradigm for Combined Therapy

To date there are no evidence-based or accepted models for conduct-

ing combination therapy. Clinicians who advocate for its use stress the

12 S. ALTHOF

multidimensional nature of sexual dysfunction and the myriad ways

that psychosocial issues can interfere with the success and utilization of

pharmacological treatment (Althof, 1998, 2003; Perelman, 2001, in

press; Rosen & Leiblum, 1995).

One proposed conceptual model of combined therapy is based upon

the level of psychosocial complexity of the individual and/or couple

(Althof, 2003). Psychosocial complexity refers to the contextual features

of the individual or couple. It includes such factors as the length of time

the couple has been sexually abstinent, the quality of the interpersonal

relationship, the motivation of each partner to resume lovemaking, the

presence of serious psychiatric psychopathology, and so on. The clinician

categorizes the couple as having (a) no or insignificant barriers prevent-

ing use of the medical intervention, (b) mild to moderate barriers, or (c)

profound psychological/interpersonal difficulties that will render med-

ical intervention relatively ineffective.

Individuals or couples who are classified as having no or insignificant

barriers to utilizing medical treatments generally have a good to excel-

lent relationship. Although the male has premature ejaculation or erec-

tile dysfunction, they continue to be affectionate and respectful to one

another. The partner’s disappointment is well managed, and she is sup-

portive of his seeking help. One or both partners have realistic expecta-

tions for treatment, and they value their return to a satisfying sexual

life. In such ideal circumstances, and if the sexual dysfunction is mild to

moderate in severity, pharmacotherapy most likely will ameliorate the

sexual symptoms. Such couples require nothing more than a medical

prescription and practical suggestions as to how to maximize the treat-

ment’s effect.

However, the most frequently encountered clinical situation is the

second scenario in which individuals/couples are judged as having “mild

to moderate psychosocial barriers.” These patients have been sexually

abstinent for an extended period of time. Expressions of affection have

dwindled. At least one person is mildly depressed and uncertain of how

to re-initiate or repair their sexual life. Brief, directed coaching is often

helpful in improving this couple’s sexual life. Coaching refers to offering

the patients guidance, suggestions, and techniques for overcoming their

resistance or inhibitions.

One such technique discussed by Perelman (in press) refers to teach-

ing a man with severe premature ejaculation to recognize the premoni-

tory sensations associated with the point of ejaculatory inevitability, as

men who ejaculate rapidly are frequently unaware of these sensations.

The delay induced by the medication allows men to linger in less

intensely aroused states and to recognize the signals of impending

SEXUAL THERAPY AND PHARMACOTHERAPY 13

orgasm. This important lesson can be practiced while on medication,

and over time it may be possible to decrease the dose or discontinue the

medication while the man continues to gain proficiency with his new

found skill in modulating arousal.

Suggestions for increasing emotional intimacy or planning a roman-

tic evening prior to initiating sexual behavior can help dislodge the

asexual equilibrium that might be present in these “second scenario”

cases. Addressing one or both partners’ depression, attending to perfor-

mance anxiety, or inquiring about any physical obstacles, such as vagi-

nal dryness, that might diminish the quality of their sexual experiences

will likely prove helpful.

It is relatively easy to recognize individuals/couples in the third sce-

nario, that is, those with profound psychological or interpersonal diffi-

culties (or both). Medication alone is likely to be ineffective with these

patients. Common patient obstacles include poorly managed or unre-

solved anger, power and control issues, abandonment concerns, broken

attachments, substance abuse, serious depression, contempt, and disap-

pointment. These psychological states, complicated by prolonged sexual

abstinence, must be addressed prior to or during the pharmacological

treatment intervention in order for the couple to benefit from medical

interventions and to achieve emotional satisfaction from sex. Although

these suggestions may appear time consuming to the busy clinician,

some or all of the above suggestions can be implemented onsite by

trained personnel.

Additionally, referral to a mental health clinician can occur at any

point but will likely be required with the man/couples who fall into the

profound psychosocial complexity category. Traditional interventions

addressing the serious issues that interfere with the man or couple’s life

can then be offered in the clinician’s office.

Finally, McCarthy, and Fucito (2005) advise incorporating a relapse

prevention plan into combined therapy. Setting follow-up appointments,

planning brief phone contacts, or providing patients with handouts

describing relapse prevention techniques are simple, brief, and often

very helpful additions to combination therapy.

Proposed Research Agenda

Although the idea of combined therapy for sexual dysfunction may

seem intuitively correct, the field requires solid evidence-based research

supporting its efficacy. Health care providers must be able to clearly

answer the following set of questions: What are the characteristics of

patients most likely to benefit from combined treatment, and con-

versely, which patients do not require such intervention? When should

14 S. ALTHOF

the intervention be initiated? By whom? What is the ideal duration and

form of such an intervention? How can relapse prevention be success-

fully implemented? What is the guiding model(s) for combined treat-

ment? And how do we train professionals to administer this

intervention?

In the end, health-care providers and therapists must be able to

demonstrate that combined treatment has greater efficacy at symptom

improvement than either medical treatment or psychological treatment

alone. Additionally, combined treatment should result in a lower discon-

tinuation rate over the long-term and greater treatment, sexual and

relational, satisfaction. While the studies reviewed herein are encourag-

ing, more research needs to be generated to support, modify or dismiss

the usefulness of this intervention.

Conclusion

Preliminary evidence suggests that combined medical and psycholog-

ical treatment results in improved efficacy of the medical interventions,

decreased discontinuation rates, and enhanced treatment and sexual

satisfaction. Providing combined treatment to patients challenges ther-

apists to move beyond traditional postures and paradigms and to work

with, rather than in opposition to, or independent of, medical providers.

Although one paradigm is offered in this manuscript, it serves only

as a model to be improved upon or extensively modified. Such combined

treatment models must be conceptually sound and subjected to repro-

ducibility and sophisticated analysis. Combination therapy, if proven

useful, may be one answer to Schover and Leiblum’s (1994) challenge to

develop fresh and innovative treatments for sexual problems. In the

future, pharmaceutical interventions for female sexual dysfunction

(FSD) will likely be approved. Clinicians should stand ready to consider

combined therapy for FSD and to test models and interventions for

these problems. As the field develops, paradigms and techniques of com-

bined therapy will hopefully evolve and become the future standard of

care for treating male and female sexual dysfunction.

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