Sex Coaching for Physicians: Combination Treatment for Patient and Partner

Home , Sex therapy, Treating (dating)

International Journal of Impotence Research (2003) 15, Suppl 5, S67–S74 & 2003 Nature Publishing Group All rights reserved 0955-9930/03 $25.00 www.nature.com/ijir Sex coaching for physicians: combination treatment for patient and partner

MA Perelman1*

1New York Weill Cornell Medical Center, New York, USA

Physicians dealing with sexual dysfunction (SD) must consider the psychological and behavioral aspects of their patient’s diagnosis and management, as well as organic causes and risk factors. Integrating sex therapy and other psychological techniques into their office practice will improve effectiveness in treating SD. This presentation provides information about the psychological forces of patient and partner resistance, which impact patient compliance and sex lives beyond organic illness and mere performance anxiety. Four key areas are reviewed: (1) ‘Sex coaching for physicians’ uses the ‘Cornell Model’ for conceptualizing and treating SD. A 5-min ‘sex status,’ manages ‘time crunch’ by rapidly identifying common causes of sexual dysfunction (insufficient stimulation, depression, etc). (2) Augmenting pharmacotherapy with sex therapy when treating erectile dysfunction (ED) specifically, or SD generally is stressed. Sex therapy is useful as a monotherapy or an adjunctive treatment and is often the ‘combination therapy’ of choice when treating SD. The following therapeutic integrations are highlighted: modifying patient’s initial expectations; sexual pharmaceuticals use as a therapeutic probe; ‘follow-up’ to manage noncompliance and improve outcome; relapse prevention. (3) Issues specific to the role of the partner of the ED patient are described. The physician must appreciate the role of couple’s issues in causing and/or exacerbating the ED and the impact of the ED on the patient/partner relationship. Successful treatment requires a supportive available sexual partner, yet partner cooperation may be independent of partner attendance during the office visit. Preliminary data from a survey of SMSNA members practice patterns, regarding partner issues, is presented and discussed. The importance of evoking partner support and cooperation independent of actual attendance during office visits is emphasized. (4) Finally, the need for more patient and partner educational materials to assist the physician in overcoming a patient/partner’s emotional barriers to sexual success in a time efficient manner are discussed. International Journal of Impotence Research (2003) 15, Suppl 5, S67–S74. doi:10.1038/sj.ijir.3901075

Keywords: combination therapy; sexual dysfunction; sex therapy; erectile dysfunction; partner issues; follow-up; relapse prevention

Introduction sex lives beyond organic illness and mere performance anxiety. There were four key areas of focus: A. ‘Sex coaching for physicians’ used the ‘Cornell Physicians dealing with sexual dysfunction (SD) Model’ for conceptualizing and treating SD. A 5-min must consider the psychological and behavioral ‘sex status,’ managed ‘time crunch’ by rapidly aspects of their patient’s diagnosis and management, identifying common causes of sexual dysfunction as well as organic causes and risk factors. Integrating (insufficient stimulation, depression, etc). 1,2 sex therapy and other psychological techniques into B. Augmenting pharmacotherapy with sex ther- their office practice will improve effectiveness in apy when treating erectile dysfunction (ED) specifi- treating SD. This presentation provided information cally, or SD generally was stressed. Sex therapy is about the psychological forces of patient and partner useful as a monotherapy or an adjunctive treatment resistance, which impact patient compliance and and is often the ‘combination therapy’ of choice when treating SD. The following therapeutic integrations were highlighted: modifying patient’s initial expectations; using sexual pharmaceuticals as a *Correspondence: MA Perelman, Co-Director, Human therapeutic probe; using ‘follow-up’ to manage Sexuality Program, Clinical Associate Professor of Psy- noncompliance and improve outcome; relapse pre- chiatry, Reproductive Medicine & Urology, The New York 2–4 Presbyterian Hospital, Weill Medical College of Cornell vention strategies. University, 70 East 77th Street, Suite 1C, New York, NY C. Issues specific to the role of the partner of the 10021, USA. ED patient were described. The physician must E-mail: [email protected] appreciate the role of couple’s issues in causing and/ Sex coaching for physicians MA Perelman S68 or exacerbating the ED and the impact of the ED on couple/individual in the privacy of their own the patient/partner relationship. Successful treat- homes. These exercises were designed to correct ment required a supportive available sexual partner, dysfunctional sexual behavior patterns as well as yet partner cooperation may be independent of positively altering cognitions regarding sexual atti- partner attendance during the office visit. Prelimin- tudes and self-image. This ‘home play’ modified the ary data from a survey of SMSNA members practice immediate causes of the sexual problem, allowing patterns, regarding partner issues, was presented the individual to have mostly positive experiences and discussed. The importance of evoking partner creating a powerful momentum for a successful support and cooperation independent of actual treatment outcome. The individually tailored ex- attendance during office visits was emphasized. ercises acted as therapeutic probes and were D. Finally, the need for more patient and partner progressively adjusted until the individual or educational materials to assist the physician, in couple was gradually guided into fully functional overcoming a patient/partner’s emotional barriers to sexual behavior.2,3 sexual success in a time efficient manner was discussed. Do physicians ask? Sex coaching for physicians The sexual dysfunctions each manifest a cluster of critical symptoms that point the way towards key Incorporating sex therapy and other psychological questions which must be asked, and indicate which techniques into office practice improved effective- questions will not be as immediately important. The ness in treating SD. Our ‘Cornell Model’ of sex most important information can be obtained in a therapy was based on the development of a treat- reasonable amount of time; physicians must discuss ment plan conceptualized from the rapid assess- sex with their patients. Numerous CME programs ment of the immediate and remote causes of sexual have addressed the problem of encouraging physi- dysfunction while maintaining rapport with the cians to both initiate and discuss sexual issues by patient.1,2 This sex therapy approach integrated the emphasizing the importance of ED as a biological work of Masters and Johnson as well as Helen marker of disease among other reasons. Physicians Kaplan, using a four-phase model of human sexual were taught to ‘bring up sex’ directly or use segue response: desire, excitement, orgasm and resolu- techniques.8–10 tion.3,5,6 Sex therapy is the diagnosis and treatment Many physicians learned about the statistically of disruptions in any of these four-phases and/or the significant increase in the incidence of depression sexual pain disorders. These dysfunctions occur in men with SD. Treatment of SD may improve mild independent of each other, yet they frequently reactive depression, while depressive symptoms cluster. Personal distress and the impact of these might alter response to therapy of SD.11 A physi- dysfunctions on quality of life, is an important cian’s history taking must parse out this ‘chicken or diagnostic consideration and has become a signifi- egg problem:’ Is SD causing depression or, is cant issue in sex research. depression and its treatment (eg, SSRIs), causing the SD? The value of direct questioning about sex became especially clear here. If physicians did not Sex therapy overview ask, the patients may not tell. When asked direct questions, SSRI patients reported an increase, from 14 to 58%, in the incidence of SD versus sponta- Sex therapy is an ‘efficacious’ treatment for primary neous report. True incidence was probably under- anorgasmia in women, some erectile failure in men, estimated as PDR data were based on patient and is ‘probably efficacious’ for secondary anorgas- spontaneous report. To manage adverse effects of mia y vaginismus in women and premature medication, physicians learned to adjust dose or, ejaculation in men.7 Clinical experience supports combine with other drugs, to ameliorate the pro- efficacy in treating hypoactive sexual desire, sexual blem.12 For instance, many might reduce the SSRI aversions, dyspareunia and delayed orgasm in men. and supplement with buproprion or try sildenafil as Despite its potency, sex therapy receded as a a possible adjunct. While intrapenile injections or a treatment of choice during the 1990s as medical ‘combination approach’ might be effective, sex and surgical approaches performed by urologists therapy enhanced all these strategies. established hegemony over the treatment of ED, in Sex status: A ‘sex status’ or focused sex history is particular. the sex therapists most important tool. Both sex Sex therapy is an amalgam of individual and therapists and physicians have used the ‘sex status couple’s therapy specifically focused upon improv- exam,’ becoming ‘sex detectives,’ who juxtaposed ing sexual functioning. The sex therapist assigned detailed questions about the patient’s current structured erotic experiences carried out by the and past sexual history or status to unveil an

International Journal of Impotence Research Sex coaching for physicians MA Perelman S69 understanding of the causes of dysfunction and non- whether a reflection of performance anxiety or compliance.2 A good ‘sex status’ assessed all current partner anger, was also a significant contributor. Of sexual behavior and capacity. The interview was course, the physician initiating the discussion of sex rich in detail, providing a virtual ‘video image,’ with the patient, in a mutually comfortable manner, clarifying all aspects of the individual’s behavior, transcended the importance of which question was feelings and cognitions regarding their sexuality. asked. The most important diagnostic tool we have in The physician followed-up, with focused, open- understanding behavior is a clear and detailed ended questions to obtain a mental ‘video picture.’ description. A flood of useful material emerged Inquiries were made about desire, fantasy, frequency when actively and directly evoked.2 of sex, effects of drugs and alcohol. Did arousal vary A comprehensive ‘sex status’ critically assists in during manual, oral and coital stimulation? What understanding and identifying the ‘immediate was the masturbation style, technique and fre- cause’ F the actual behavior and/or cognition quency? Idiosyncratic masturbation was a frequent causing or contributing to the sexual disorder. hidden cause of ED, as well as Delayed/Inhibited Armed with this information, a diagnosis could be Ejaculation (IE).14 The physician became implicitly made and a treatment plan formulated. However, aware of the patient’s sexual script and expectations, such detailed examination of current sexual beha- leading to more precise and improved recommenda- vior will also be of great utility to other health tions and management of patient expectations. For professionals. These sexual details provide impor- instance, a physician would improve outcome, by tant diagnostic leads. Significantly, the sexual briefly clarifying whether a patient was better off information evoked in history taking will help practicing with masturbation, or reintroducing sex anticipate non compliance with medical and surgi- with a partner? A recently divorced man, who was cal interventions. The ‘Cornell Model’ heuristically using condoms for the first time in years, was used immediate, intermediate and remote causal probably better off masturbating with a condom layering to help determine timing and depth level of rather than attempting sex with his partner, the first intervention. Modifying immediate psychological time he tried a new sex pharmaceutical. factors results in less medication being needed for men and women, regardless of their specific SD. The similarity to the previous decades’ integration of SSRIs with behavior therapy to treat depression Time crunch should be apparent. Sex therapist’s interventions are exercises and interpretations. In general, physicians ‘Time crunch’ can be managed, even if the patient will intervene with pharmacotherapy and brief ‘sex introduced the issue of SD as the physician reached coaching,’ which addresses ‘immediate causes’ for the door, or if earlier questions unleashed a (insufficient stimulation) directly, intermediate is- delayed torrent of information and emotion. There sues (eg, partner) indirectly, and rarely focuses on was no need to despair, as there were four steps deeper (eg, sex abuse) issues. Physicians manage available to effectively manage ‘time crunch.’ First, current obstacles to sexual success, which typically the physician showed concern, and listened for are both organic and psychogenic in nature. In fact, 1 min to whatever the patient was saying. Second, when deeper psychological issues are the primary the availability of help and hope was emphasized. problem, it is usually time for referral.13 Third, the physician sympathetically shared their A ‘sex status’ could become the physicians’ most time limitations, while empathizing with the im- important tool in evaluating SD, as it is most portance of the topic and the necessity of adequate consistent with the ‘review of systems’ common to evaluation. Fourth, a new appointment (follow-up) all aspects of medicine. The ‘sex status,’ gives to focus on the sex issue was scheduled. In physicians critical information in less than 5 min. this manner, the physician remained on schedule, The ‘sex status’ allows the physician to initiate while the patient was reassured, by both therapy with the least invasive method available; the physician’s concern and the availability of literally an ‘oral therapy.’ For this author, one 2 forthcoming help. question helps pin down many of the immediate and remote causes: ‘tell me about your last sexual experience?’ Common immediate causes of SD are quickly evoked by the patient’s response. The Sex coaching: the right ‘combination most important cause of SD is lack of adequate therapy’ friction and/or erotic fantasy, in other words, insufficient stimulation. Sex is fantasy and friction, mediated by frequency. To function sexually, people Sex coaching or integrating sex therapy and phar- need sexy thoughts, not only adequate friction. macotherapy could be the physician’s ‘combination While fatigue may be the most common cause of therapy’ of choice, because it more effectively SD in our culture, negative thinking/antifantasy, managed noncompliance. Since sildenafil’s launch

International Journal of Impotence Research Sex coaching for physicians MA Perelman S70 in 1998, primary care physicians (PCP) and urolo- ciated with life stressors and other psychological gists began incorporating sex therapy techniques issues: loss of partner, partner’s attitude, etc. These with sexual pharmaceuticals to increase the effec- are important issues in differentiating treatment tiveness of their treatments for sexual dysfunction. If non-responders from ‘biochemical failures,’ in order psychological issues did not spontaneously im- to enhance success rates. Early failures can be prove, the initial success of the sildenafil interven- reframed into learning experiences and eventual tion was disrupted. Then, a combination approach success.10–20 was required and the patient often benefited from a sex therapy referral. Physicians were often right in their diagnosis, but patients did not follow direc- Partner issues tions. These were noncompliance issues. Sex therapists helped by reframing and readjusting unrealistic expectations. Many physicians have Regaining potency, does not necessarily translate integrated these sex-coaching techniques into their into the couple resuming sexual intercourse. Psy- office practices. Both the urological and psycholo- chological issues may render the best treatments gical communities came to recognize and appreciate ineffective. PDE5 inhibitor discontinuation or fail- a new paradigm reflecting the interaction of both ure rates of 20–40% are not due to adverse events. psychological and organic factors within a larger Resistance to lovemaking is often emotional and the social context when treating SD.6 A movement most common ‘mid-level’ psychological causes of within the field of ED toward an integration of sex SD are relationship factors.2,4,13,16,18,23 There is a therapy and pharmacotherapy was articulated by need for partner education, counseling and/or both by urologists and by psychologists.14–22 referral: when the partner’s comfort with pharmacotherapy is too adversely effected by a concern for his safety; if compliance is adversely affected by a Follow-up perception of the treatment being too ‘artificial or mechanicalyis it me or the Viagra;’ if her own capacity and readiness for sex is physiologically Discussions of follow-up most vividly illustrated the impaired for any of a multiplicity of rea- importance of integrating sex therapy and pharma- sons.4,9,12,13,18 It is easy to extrapolate from the cotherapy. Barada and Hatzichristou led the way for MMAS findings of increased ED frequency and urologists in placing tremendous emphasis on severity with aging, that many aged men have older patient education (eg, food/alcohol effect), partner partners, who are also at risk for arousal phase involvement and follow-up.20–22 Patient education disorders.24 Finally, she may not be psychologically about the proper use of sildenafil was crucial to ready for sex. Since many men postpone treatment treatment effectiveness. seeking for a year or more, the couple’s sexual Most physicians initiated ED treatment using equilibrium may require a professional recalibrating sildenafil, which is the only currently approved the pace of intimacy resumption.25 PDE 5 inhibitor. Nonetheless, treatment was also a Both Hatzichristou and Barada have pointed out ‘therapeutic probe.’3,4 Initial failures examined at the amenability to brief counseling in the physi- follow-up reveal critical information. The pharma- cian’s office, of many immediate causes of ED.20–22 ceutical acted as a therapeutic probe, illuminating Still the most common mid-level relationship the cause of failure or nonresponse. Retaking a quick causes may present considerable difficulty for the ‘sex status’ provides a convenient model for mana- physician treating ED within the context of a ging follow-up. Physicians can increase their suc- typically brief office visit. How might this challenge cess by scheduling follow-up the first day they be met? The complexity of this conundrum can be prescribe. As with any therapy, follow-up is essen- reduced or resolved. The physician’s challenge is tial to ensure an optimal treatment outcome. not necessarily requiring an office visit with the Components of the follow-up visit include monitor- partner, as many CME programs have advo- ing side effects, assessing success and considering cated.8,9,12 Instead, the emphasis should be on whether an alteration in dose or treatment is needed. evaluating the level of partner cooperation and Providing ongoing education to patients and their support. partners is useful, as well as involving them in Urologist’s and PCP’s extreme success in treating treatment decisions whenever possible. A continu- ED has led many to disdain sex therapy’s considering dialogue with your patients is critical to ably more modest outcome research. Yet, there are facilitate success and prevent relapse. There are many useful lessons from sex therapy to apply to numerous psychological issues to consider which urology and medical practice. One of the most evoke noncompliance: fear of complications; reac- important areas of interest to physicians, which tions to changes associated with aging; reactions to can be learned from sex therapy, revolves around the chronic diseases or injury; changes associated with partner issue. Since Masters and Johnson (1970), sex medications; alcohol, and smoking; changes asso- therapists have recognized that sexual dysfunction

International Journal of Impotence Research Sex coaching for physicians MA Perelman S71 is a ‘couples problem,’ not just the identified conjointly. Was this bad practice and should they patient’s problem.6 However, almost equally long feel guilty? No! There were a number of good ago, myself and others noted that the key partner reasons for not having a conjoint visit, as long as treatment issue was supportive cooperation, inde- the importance of partner issues in treatment pendent of actual attendance during the office visit.5 success was understood. Indeed many urologists Back in the 1970s and 1980s sex therapists argued reflected thoughtfully, on the burden of the treater to about ‘treatment format.’ While Masters and John- not invade the privacy, beyond what was freely son used a daily 2-week residential conjoint model, accepted by the patient. Urologists noted that the most sex therapists today see outpatients individu- men saw the ED as their problem, and were not ally and/or conjointly in weekly or biweekly interested in involving their partner. These urolo- sessions. Generally speaking, encourage partner gists gently encouraged partner attendance, but attendance with married couples, allowing assess- appropriately did not require it. So why are ment and counseling for both. However, the issue is pharmaceutical ED treatments so effective? Does never forced. Treatment format is a psychotherapeu- these data suggest that partner issues do not impact tic issue and rapport is never sabotaged. While outcome? No, but it does support the thesis that conjoint consultation is a good policy, it is not ‘partner cooperation’ is even more important than always the right choice! A man in a new dating ‘partner attendance.’ Why are physicians successful relationship is probably better off seeing his thera- even when not seeing partners? Sex pharmaceuti- pist or physician alone, than stressing a new cals plus sex counseling and education work for relationship by insisting on a conjoint visit. many people, if the partner was cooperative in the While CME courses recommended that patient– first place. Fortunately, many partners of both men partner–physician dialogue was best enhanced and women are cooperative, which partially ac- through patient/partner education during conjoint counts for the high success rates of medical and visits, there was anecdotal evidence that physicians surgical interventions. were not regularly meeting with partners of ED Indeed, most of the cooperation goes unexplored. patients. Do physicians meet with partners? In order The cooperation is assumed, based on post hoc to investigate this issue, the assistance of the leading knowledge of success. Importantly, many women American urologists in the field of ED were enlisted, were cooperating with their partners, or facilitating by surveying the membership of the Sexual Medi- sexual activity, independent of their knowledge of cine Society of North America. In advance of this the use of a sexual aid or pharmaceutical. In presentation, approximately 200 members received other words, ‘we did what we used to do and it an e-mail (via the ‘EDNET’ List Serve) requesting worked!’ ED patients, characterized partners, they complete a 15-item survey, prescreened by an whose attendance might not be required, as suppor- expert panel of their members. In all, 44 urologists tive, encouraging and cooperative, These character- responded. A 20% response rate for an Internet istics were sometimes implicit rather than survey is high, but this is not a representative manifest. They were willing and capable of being sample. The data should be viewed as suggestive sexual. They had a willingness to allow sex to only. Complete methodology, results and discussion improve progressively, rather than requiring all of this survey will be reported in a later article. improvement to be immediate and perfect. They However, some important and interesting highlights were supportive of reasonable professional recom- were noted. mendations. They explicitly understand that sexual The results pointed to a striking disparity between pharmaceuticals are useful aids to restoring their sex physician attitude and actual practice. An over- life, not chemical competition for their partner’s whelming 79% of the responding urologists con- affection. They were less concerned that a sexual sidered partner cooperation with ED treatment pharmaceutical would result in a partner’s sexual ‘important,’ regardless of whether the partner actu- ‘acting out.’ ally attended sessions or not? A total of 21% of the Clinical experience showed us many of these responding urologists saw three of the ‘partners’, of patients had good outcomes even if the partners their last five ED patients, during the initial visit. never attended an office visit. However, good Tellingly, 39% of the responding urologists only saw becomes better by evaluating, understanding and one partner or less, of their last five ED patients. treating key partner issues. The physician must Nine percent never saw a partner at all! Nor was differentiate the complaining, sabotaging partner, there any contact by phone, e-mail or other means from the encouraging, supportive one, as both may between doctor and partners for 90% of the pressure the ED patient to seek help. Obviously, the responding urologists. One might speculate that most pleasant, supportive, cooperative partners the urologists were treating only unpartnered pa- would rarely be discouraged from attending office tients. Yet, in reality, the vast majority of patients visits with the ‘ED patient.’ Ironically, these same were married or coupled. patients would probably have successful outcomes Clearly, office behavior and attitude did not even if their partners never attended an office visit. align, as many urologists were seeing few couples Their partners were less likely to be resistant to the

International Journal of Impotence Research Sex coaching for physicians MA Perelman S72 restoration of sexual health, and indeed many Patient and partner education: consumer of them were the treatment seeking ‘drivers’ in education materials the first place.25 The existence of large numbers of cooperative, supportive women who themselves have partners with mild to severe ED account Recently, more professional society meetings have for much of the success of many ED patients recognized the importance of ‘partner participation’ who see their physicians alone, for evaluation in their educational programs.4,24–27 Yet, many and subsequent pharmacotherapy. Many of urologists were not necessarily motivated or suc- these partners were never seen by the treating cessful in obtaining partner attendance. Further- physician, nor was their attendance necessary for more, actual partner attendance during the office success. visits was not always a necessary aspect of success- The patient–partner–physician dialogue is best ful treatment of the man with ED. We have examined enhanced through patient/partner education. Part- these issues with an eye towards a different ner attendance during the office visit would allow hypothesis. Specifically, that supportive partner for such education. Yet, physicians do not regularly cooperation is the key therapeutic contributor to meet with partners of ED patients. Earlier we success and that actual participation, although discussed why such meetings might not be neces- usually reflecting cooperation, is not always necessary at all. Additionally, although working with sary and may even be contraindicated. All these couples was often recommended: sometimes there factors point to the importance of industry develop- was no partner; sometimes the current sexual ing partner education, as well as patient educational partner was not the spouse, raising legal, social materials for physician use. and moral sequella.9,12 The reality and cost/benefit The variety of different issues surrounding office of partner participation is a legitimate issue for both attendance of partners of ED patients highlights the the couple and the physician, and not always a importance of partner education materials being manifestation of resistance. Finally, the patient’s available for the ED patient. Whenever possible we desire for his partner’s attendance may be mitigated want to empower these ‘impotent’ men to educate by a variety of intrapsychic and interpersonal their partners, by providing them with knowledge factors, which, at least initially, must be respected and tools. It is, of course, critical that the ‘partner’ and heeded. never ‘hear’ a message of ‘blame’ for the problem. There are other solutions. When evaluation or These are suggestions for enhancement, not fault- follow-up reveals significant relationship issues, finding. The education materials should be available counseling the men alone may help, but interacting in a variety of different media, to allow for different with the partner will often increase success rates. If learning styles. This information needs to be the partner refuses to attend, or the patient is disseminated to the public at large, and not only unwilling or reluctant to encourage them; seek targeted for the physician’s office. Advertising and contact with the partner by telephone. Ask to be public relations could be directed toward educating called, or for permission to call the partner. Most the partner on how to improve their intimate life. partners find it difficult to resist speaking ‘just This could be as simple as normalizing a woman’s once,’ about ‘potential goals’ or ‘what’s wrong with age-related changes, with suggestions for using their spouse.’ The contact provides opportunity for supplemental lubrication. Other material would empathy and potential engagement in the treatment tastefully explain a man’s need to feel sexual and process, which may minimize resistance and im- be touched sexually for a sexual pharmaceutical to prove outcome further. This effective approach be effective. could be modified depending on the physician’s This patient/partner-based approach would result interest and time constraints. in greater success rates, with minimal extra physi- Physicians should counsel partners when neces- cian time required. Early sex therapy discussed the sary and possible. They need to be a resource; benefit of education, permission giving and brief treating with medication, counseling and educa- counseling. During the 1970s and 1980s this was tional materials. Education needs to be a greater part frequently all that was necessary, to successfully of ED practice, whether provided by the doctor and/ alter the sexual equilibrium necessary to restore or physician extenders. One urologist reported using sexual health for some dysfunctional individuals. his own 10-min ED education video, sent home with Over time, this information became part of the each patient. Given his unusual motivation and cultural backdrop and therapists complained, ‘cases effort, not surprisingly he scored the highest in are more difficult and complex.’ Similar to sex partner attendance of any urologist surveyed. Many therapy in the 1970s, sexual pharmacology is in its urologists and PCPs are neither motivated, nor have infancy. Success rates can be enhanced through the time to develop and implement such an patient–partner–physician education, which will approach. However, if treatment success rates are reduce the frequency of noncompliance, partner to be boosted even higher, then partner issues must resistance and minimize symptomatic relapse. Or- be addressed in some other manner. ganic and psychological factors causing sexual

International Journal of Impotence Research Sex coaching for physicians MA Perelman S73 dysfunction, and noncompliance with treatment, again. Sex therapists are also equipped to help are on a multilayered continuum. While some resolve the intrapsychic and interpersonal blocks to partners will require direct professional interven- restoring sexual health. Finally, sex therapists are tion, many others could benefit from obtaining skilled in using cognitive-behavioral techniques for critical information from the ED patient and/or relapse prevention.28 multiple media formats both private and public. An important caveat to this discussion involves situations where partner attendance during the Conclusion office visit is probable. Partners of patients suffering life-threatening situations (eg, cancer, heart attack, stroke) are likely to meet with the treating physician. It is certainly important to for physicians to discuss While the initial concern is potential death, quality sexual health with their patients. Techniques and of life issues will certainly emerge as a focus options are available for integrating sex therapy and sometime during the treatment or recovery process. pharmacotherapy into routine office practice of both The treating physician has ample opportunity to urologists and PCPs. Incorporating sex coaching will provide important sex coaching and/or an appro- enhance physician’s relationships with their pa- priate referral. The existence of better patient– tients and increase their success in improving their partner educational tools would, of course, only patient’s sexual health. enhance these efforts. While meeting with partners of patients may be desirable, there are alternative options for enhan- cing a man’s sexual functioning. In particular, more Referral patient and partner educational materials are needed for the physicians ‘tool box’ to assist him or her in overcoming a patient/partner’s emotional If the partner’s support for successful resolution of barriers to sexual success in a time efficient manner. the ED is not present, then active steps must be New questions will arise about when, where, and taken to evoke it. Frequently, brief counseling by the how, to use these materials. There will be new physician of the ED patient is sufficient. Yet, a medical and surgical treatments in the future. Sex conjoint referral for adjunctive treatment to a sex therapists have a role in this dialogue and sex therapist and/or gynecologic or endocrine referral therapy complements all of these approaches. This for the partner may also be required. Of course the author is optimistic, for our future, using an more problematic the relationship, the more pro- integrated, sexual pharmaceutical, and sex therapy found the marital strife, the less likely that patient– approach to facilitate treatment and minimize partner sex education will be able to successfully relapse. augment treatment in and of itself. Inevitably, a referral would be required, albeit not necessarily accepted successfully. Acknowledgements Identifying psychological factors does not necessarily mean the physician must treat them. If not inclined to counsel, or, if uncomfortable, the The author wishes to acknowledge Doctors Culley physician may consider referring or working con- Carson, Marc Gittelman, Larry Levine, Ron Lewis, jointly with a sex therapist. The physician should be John Mulhall, Ridwan Shabsigh, Ira Sharlip and encouraged to practice to his or her own comfort Ralph Swindle for their encouragement and assis- level. PDE5 inhibitors are extremely effective drugs, tance in reviewing drafts of the survey distributed to but they do have limitations.23 Some of these the SMSNA. This survey was partially supported by limitations created a ‘born-again’ role for sex an unrestricted educational grant from Lilly/ICOS. therapists, although a more complex and sophisti- cated one. Physicians who prescribed sildenafil and wanted adjunctive assistance, referred to sex thera- References pists because of their own psychological sophistica- tion or because of noncompliance on the part of their patient.13 1 Perelman MA. Commentary: pharmacological agents for ED & Whether the referral is physician or patient the human sexual response cycle. J Sex Marital Ther 1998; 24: 309 – 312. initiated, sex therapists are ready to effectively 2 Perelman MA. The urologist and cognitive behavioral sex assist in educating the patient about maximizing therapy. Contemp Urol 1994; 6: 27 – 33. his or her response to the sexual situation. They are 3 Kaplan HS, Perelman MA. The physician and the treatment of able to help physicians remotivate people who have sexual dysfunction. In: Usdin G, Lewis J (eds). Psychiatry in General Medical Practice. McGraw-Hill: New York, NY, 1979. failed initial medical treatments, as well as helping 4 Althof S. ‘When an erection alone is not enough: biopsycho- patients to adjust to second and third line interven- social obstacles to lovemaking.’ Int J Impot Res 2002; 14 19 tions. They help make patients receptive to trying (Supp. 1): S99 – S104.

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