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CASE STORY
IMPOTENCE, also known as erectile dysfunction (ED), is the inability to achieve and sustain an erection sufficient for sexual intercourse. ED is the most common male sexual disorder, affecting some 30 million males in this country.
Occasional failure to achieve an erection, whether as a result of too many drinks, stress, being extremely tired, or lack of desire, is not unusual for men at any age. Recurring difficulty achieving and sustaining an erection is another matter, and is generally the result of ongoing physical problems rather than temporary, situational conditions. Failure to achieve erection less than 20% of the time is not unusual and treatment is rarely needed. More than 50% of the time indicates a problem that will worsen without appropriate treatment.
ED is not necessarily a normal part of aging. Some men never develop ED, but the odds of being affected by it increase with age. Older men may need more stimulation to achieve erection, penis sensitivity may diminish, and orgasms may not be as strong, but older men should still be able to get and sustain an erection and enjoy a satisfying sex life.
ED is caused by physical and psychological factors and often by a mixture of both. The most common physical causes of ED are:
- Diseases that affect blood flow: hardening of the arteries, hypertension, high cholesterol
- Diabetes
- Nerve and brain diseases: strokes, multiple sclerosis, Alzheimer’s disease, Parkinson’s disease, and spinal cord injuries
- Injury to the penis
- Chronic illness
- Some medications, including certain drugs for the treatment of depression and high blood pressure
- Some treatments including radiation treatment for prostate cancer
- Peyronie’s disease
- Tobacco, alcohol and recreational drug use
Psychological factors are estimated to be responsible for 10% to 20% of all cases of ED, often as a secondary reaction to physical causes. Psychological causes may include:
- Stress
- Depression
- Performance anxiety
- Low self-esteem
- Guilt
- Relationship conflicts
- Poor sexual communication
- Indifference
The good news is that ED can be successfully treated. If you are experiencing problems with erections, consult a physician to determine if ED is present. If it is, once its cause is identified, treatment plans can be made. There are many ways ED can be treated, including oral medications, sex therapy, penile injections and surgery.
Sex therapy is usually helpful in conjunction with any of the treatments you and your doctor choose. ED takes more than a physical toll; it also takes an emotional toll. It is common for men with ED to feel anger, frustration, or lack of confidence. It can also have emotional impact on the partner: feeling undesirable, feeling responsible for “fixing it” and feeling frustrated are common partner reactions to ED.
Depression medication, performance anxiety and treatment for prostate cancer are common causes of ED.
JOSE: Impotence due to Depression Medication
A thin, gaunt, but attractive 40-year old Hispanic, Jose, arrived at my office with tears in his eyes. He felt severely depressed. He wasn’t sleeping well, he had lost 25 pounds in the last three months, he found himself crying throughout the day, he was having difficulty concentrating at work, and he lacked motivation for even previously pleasurable activities.
Jose’s divorce from his 15-year marriage was final three months before his first visit to my office. When he separated from his wife four months before the divorce, he wasn’t depressed. He had moved to a friend’s apartment and was dating. Once the divorce was final, the reality of what had happened hit him. He missed his wife, his 11-year old daughter, and his home. He tried to reconcile with his ex-wife, but she refused to discuss reconciliation. Her rejection plunged him into deep depression.
His wife, Maria, 39-years old and also Hispanic, told him she loved him but didn’t think she could forgive him and take him back. She asked for the divorce when she found out he was having an affair.
Jose explained that emotional distance had grown between him and Maria in the last couple of years. They were no longer sleeping together when he met a divorced woman, a few years older than he, who found him attractive and paid attention to him. The affair ensued. He continued to see this woman during the separation and after the divorce. He enjoyed her and found sex exciting with her. Soon after the divorce, he realized he did not love her. He broke off the relationship in hopes that he could reconcile with his ex-wife.
Because of the severe symptoms of his depression, at the end of our first session I asked Jose to see his physician for evaluation for antidepressant medication. He was reluctant at first because he feared he would become addicted to the medication and because he felt he should be able to fight depression on his own. I explained that antidepressants are not addictive and that willpower has nothing to do with overcoming depression. He agreed to speak to his physician and we set a date for our next appointment.
When he returned, Jose reported he had been prescribed Zoloft, an antidepressant medication. He had taken it for a week and voiced doubts that the medication was helping. I encouraged him to be patient and explained that many antidepressants take 4 to 6 weeks to be fully effective. He agreed to continue taking the medication.
He also expressed a glimmer of hope that his ex-wife would consider a possible reconciliation. The previous Sunday they met at church and sat and prayed together. She agreed to see him again.
During the next two sessions, Jose reported feeling better: he had no more crying spells, he was sleeping better, he was regaining his appetite, and he was functioning more effectively at work. He was dating his ex-wife and felt hopeful about reconciling.
Six weeks after our first session, Jose announced he was spending nights with his wife and she had suggested he move back home. He was pleased but anxious. He was uncertain about the terms of his return. They were no longer married. The house was hers now. I suggested he discuss his anxiety with her and set up terms for their reconciliation.
When we met again, Jose had moved back home. But he was very worried. Hesitantly, he confessed that he was losing his erections with his wife. He had never experienced this problem before. He feared Maria would feel he didn’t want her and that this would cause them to separate again.
Though there were many possible emotional reasons for his ED, this problem didn’t surface until he started taking Zoloft. This is not unusual; one of the side effects of many antidepressants is impotence. Since Jose was doing so well managing his depression with
Zoloft, discontinuing the medication was unwise. I suggested he discuss the problem with his prescribing physician. He did. At our next session, Jose confided his doctor had prescribed Viagra, an oral medication for the treatment of ED. He tried it and it worked, but he had reservations about using Viagra. He felt it took spontaneity out of sexual relations and it worried him that Maria would feel he didn’t want her.
We discussed how he could inform Maria about the side effects of Zoloft and how he could reassure her of his feelings for her. I also explained to him that Viagra is no magic bullet. He would still need some stimulation to achieve an erection; it could take from 30 minutes to a couple of hours after taking it for it to work; it is best taken on an empty stomach for quicker results; it wouldn’t necessarily create firmer or longer lasting erections than he used to have; it wouldn’t inspire desire; and it wouldn’t bridge any emotional distance between him and Maria. Discussing these issues openly with her would help her understand so she would not take his impotence personally.
Jose said he would discuss his fears and feelings with her.
At this point in counseling, Jose had achieved his goal of managing his depression. He was no longer crying, he was sleeping through the night, his appetite returned (he had gained 3 pounds), and he was able to concentrate at work. He had also succeeded in reconciling with his ex-wife. We terminated this phase of counseling with the recommendation that he and Maria participate in couples counseling to ensure that their reconciliation would be permanent.
SEXPERT’S COMMENTS
In Jose’s case, counseling revolved mostly around:
- Education about depression
- Education about depression medication
- Side effects of antidepressants
- Education about Viagra
Since Jose hadn’t experienced depression prior to this time, he wasn’t familiar with the symptoms of depression. He felt that as a man, he should be able to control his moods. Not being able to do so made him feel weak, helpless, unmanly. When he learned that brain electrochemical functions were related to depression, not manliness, he viewed his symptoms from a different perspective.
His misconceptions about antidepressant medication also had to be addressed:
- Antidepressants are not addictive
- Antidepressants are prescribed only for as long as needed
- Antidepressants generally take 4 to 6 weeks to be fully effective
- Antidepressants have to be taken exactly as prescribed
Jose was also unaware of the possible sexual side effects of many antidepressants, including Zoloft: decrease in desire, problems with erections, and problems reaching orgasms. Counseling and Viagra reassured him that he hadn’t lost his ability to have satisfying sex.
Viagra gave him confidence to participate in sexual relations again without the haunting fear of “failure to perform”. But he needed more information on the use and limitations of Viagra:
- Viagra is most effective when taken on an empty stomach as fatty meals delay absorption of the drug
- Sexual stimulation is necessary to achieve erection
- Viagra doesn’t give firmer, longer erections than he would generally experience
- Viagra doesn’t bridge emotional distance between partners
Though we had successfully dealt with his depression and impotence, Jose still had the challenge of dealing with his broken marriage. He and Maria still had to face the issues which distanced them initially and which led to their separation and divorce.
SUMMARY
Erectile dysfunction, ED, is the most common sexual disorder affecting men.
It is estimated that about 1 in 10 adult males suffer from ED on a long-term basis.
ED is not considered normal at any age.
If you experience problems with erections, consult a physician who can perform tests to determine the cause of the problem.
Depression and antidepressant medication can lead to ED.
Whether the cause of ED is physical or psychological, or a mixture of both, Viagra has become the treatment of choice for men with ED who are not on nitrates medication for heart disease.
ED has emotional impact on both sex partners.
Counseling can be a helpful adjunct to physical treatments for ED.
If you feel that you need more counseling for your difficulties than was offered
in the case story, you may contact me
about your specific problem via email
counseling or telephone counseling.
THANK YOU FOR YOUR INTEREST IN SEXPERT COUNSELOR.
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