Counselling for male sexual problems is usually for erectile dysfunction (ED) or lack of libido. Both conditions reduce the quality of life for the men and their partners, plus they make natural conceptions challenging. Specialised “psychosexual therapy” is the recommendation, and because sex involves both partners, the partners of men with ED can play an essential role in managing and improving their sex life.
A multidisciplinary approach is generally recommended for men with ED, with a combination of medical treatment and psychological support, as this improves ED more than one option on its own. i It takes two to tango, and it’s strongly recommended that partners are actively involved in assessments and the choice of therapy, be it counselling or another option. ii
Counselling as a therapy usually involves cognitive and behavioural techniques that are aimed at:
- Reducing anxiety
- Challenging dysfunctional beliefs
- Increasing sexual stimulation
- Disrupting sexual avoidance
- Increasing intimacy and communication skills in the relationship
When the man is comfortable with the option, it works best when his partner is included in the assessment and treatment. Their involvement in deciding on agreements they make as partners is crucial if they’re to understand and support the man regarding possible treatment options. Without their involvement, it’s difficult for the man to create the intimate space that’s a core part of psychosexual homework.
Erectile dysfunction and mood
There’s a strong association between mood and erectile dysfunction (ED) and depression, and men with depression are more likely to have ED, and ED increases the risk of depression. When 18 to 25-year-old Swiss men screened for the military, 30% had ED, and the conditions they were also most likely to have were:
- Mood disorders
- Illegal drug use
- Shorter sexual lifespan
- High BMI and lack of fitness
When re-assessed over a year later, the only one still linked to ED was mood disorders. iii Other studies of young men confirm the role of depression in ED but also showed that anxiety plays a significant role and that ED is much less likely in men who had sex at a younger age.
This underlies the positive role sexual experience and confidence have in avoiding ED, as anxiety is often a factor that drives ED in the early stages of sexual life. Men tend to develop an unhealthy focus on erection quality and size, which negatively impacts the arousal state and the erection itself. Society is filled with body images, and many men worry about their physical (especially genital) image, to the point that this over-riding preoccupation prevents full engagement in sexual acts. Poor genital self-image is a significant cause of sexual anxiety and sexual dysfunction in young men, and a focus on genital image is more likely to become a considerable factor when:
- More porn is viewed
- The longer this image-based experience of sex lasts
Viewing porn shifts sexual experience from a physical to a conceptional/visual interaction, distorting the usual sexual engagement. The longer this lasts, the more entrenched this sexual experience becomes, which probably explains why men who have sexual experiences at younger ages are less prone to these issues.
The autonomic nervous system is crucial for erections; arousal involves the parasympathetic side (rest and relax), while ejaculation is controlled by the sympathetic side (fight and flight). Being too heavily in “fight and flight” mode makes it extremely difficult to maintain arousal and can trigger premature ejaculation.
Unhappy memories of previous sexual encounters can trigger anxiety, which in turn causes:
- Low sexual confidence
- Fear and avoidance of sexual contact
- Greater chance of further sexual failures
This is a vicious cycle that counselling is best placed to treat as the medications used for anxiety and depression cause significant problems of ED and lack of libido. iv
Relationships
Conflicts within couples are characterized by a broad spectrum of sexual symptoms, including severe ED and lower libido. However, it’s also possible that ED can cause relationship conflicts, and when men take Viagra (or similar PDE5I medication), it improves their partner’s sex lives and mood.
Combining counselling (cognitive behavioural sexual therapy (CBST) and 10mg of Levitra improves the long-term outcomes of couples far more than Levitra alone, and the women experienced better sexual function and satisfaction when vardenafil and CBST are combined. This suggests that counselling heals the couple more effectively and for longer than simply using medication focusing on ED. v
Counselling has a core role for many men with ED or lack of libido. It offers a safe place and therapeutic framework to address psychological issues connected to their sexual experience and improves the outcomes for men and their partners when they take medication.
ii Li, H., Gao, T. & Wang, R. The role of the sexual partner in managing erectile dysfunction. Nat Rev Urol 13, 168–177 (2016). https://doi.org/10.1038/nrurol.2015.315
iii Akre C, Berchtold A, Gmel G, et al. The evolution of sexual dysfunction in young men aged 18-25 years. J Adolesc Health 2014;55:736-43. 10.1016/j.jadohealth.2014.05.014
iv Corona G, Ricca V, Bandini E, et al. Selective serotonin reuptake inhibitor-induced sexual dysfunction. J Sex Med 2009;6:1259-69. 10.1111/j.1743-6109.2009.01248
v Rastrelli, Giulia, and Mario Maggi. “Erectile dysfunction in fit and healthy young men: psychological or pathological?.” Translational andrology and urology vol. 6,1 (2017): 79-90. doi:10.21037/tau.2016.09.06
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