The role of the partner in the treatment of erectile dysfunction
In the International Journal of impotence research (2002), 14, Supplement 1, Dr A Riley of the Human Sexuality Group, University of Central Lancashire, analyses the role of the man's partner in erectile dysfunction and its treatment. International Journal Of Impotence Research
He starts by making the observation that although advances in pharmacological and other treatment methods for erectile dysfunction have allowed erectile function to be re-established in the majority of men who have this problem, there is a considerable difference between re-establishing a man's ability to have an erection and ensuring that there is a sexual relationship with a partner which is satisfactory and satisfying.
These are of course different objectives, and when a man's sexual relationship with his partner is not addressed during the treatment of ED, it is entirely possible that the man may represent as a treatment failure or indeed withdraw himself from treatment in its entirety.
Riley makes the observation that any therapy which focuses exclusively on the penis as the dysfunctional element is flawed because ED can result from problems in the relationship with the partner, or indeed with the partner's behavior.
He sets out to analyze the role of the partner in all aspects of a man's erectile dysfunction.
There is of course no such thing as a partner who is not involved in any case of sexual dysfunction. The partner's involvement may range from some role in the etiology and maintenance of a sexual dysfunction to having some kind of investment in a relationship with a partner who has a sexual dysfunction.
And while it is well-known that interviewing the sexual partner is important in both the diagnostic and therapeutic processes, this is still not a universal practice. Indeed, the introduction of Viagra has tended to mean that ED is regarded as a male medical problem, which in turn leads to treatment of a man in isolation from his partner.
Furthermore, many clinics do not invite partners, and even if they do men may not bring them along during the treatment sessions.
The partner's role in the development and maintenance of erectile dysfunction
Overcoming sexual dysfunction and allowing the sex to flourish within a relationship requires positive feedback from both partners to each other, and new and stimulating sexual behavior.
Without such feedback and novelty, either one or both partners in a relationship may lose interest in sex, which can cause all kinds of sexual impairment in the other, including erectile dysfunction. In one study, the female partners of men who were seeking treatment for sexual dysfunction were revealed to have a significantly lower sex drive and a narrower range of sexual activities than women who were not in this position.
In the case of an older men a lack of interest from his partner may mean that he experiences erectile dysfunction simply because he does not receive enough penile stimulation.
In other studies, too, there have also been significant indications of sexual difficulties in the female partners of men with erectile dysfunction.
These problems include orgasmic problems, vaginismus, dyspareunia, and lack of sexual drive. However, it's fascinating that in less than 10% of the cases were these female sexual dysfunction found to precede the onset of the man's erectile dysfunction.
The implication, of course, is that these problems actually maintained the erectile dysfunction rather than just causing it. By contrast, there have been other studies which indicate that sexual dysfunctions in the female were commonly present before the onset of erectile dysfunction in men.
This appears to occur more often when the ED has a psychological origin rather than an organic origin.
We know that erectile dysfunction is multifactorial, and that both physical psychological and behavioral factors all combine either to cause it all to maintain it once it has developed.
It follows that to be successful, any treatment methodology must identify all the different factors which are affecting a man's erectile function. Indeed, this is probably essential to help the man re-establish a satisfactory sexual relationship.
Even if he's given Viagra it is quite possible for doctors to identify physical and organic conditions which are associated with his erectile dysfunction and treat these conditions individually; the problem is that this does not necessarily indicate that these factors are causing the erectile dysfunction, rather than simply maintaining it.
In the most extreme case, for example, a man with diabetes may have ED as a consequence of vascular or neurological issues caused by diabetes; equally he may have erectile dysfunction that is completely unrelated to his diabetes.
And of course the difficulty arises in that talking to only one of the partners does not enable the rapid analysis of the man's problem; the best practice is to interview the two partners separately and then to see them together to identify and resolve discrepancies in their individual accounts of the dysfunction and the relationship.
According to Riley, the three sets of factors that must be identified when the clinician is taking a history from both partners are as follows: (1) those that have made the man more likely to develop erectile dysfunction, (2) those factors that are responsible for triggering his erectile dysfunction, and (3) the factors that are responsible for maintaining the erectile dysfunction.
The partner's role in the treatment and prognosis of erectile dysfunction
Involving both partners seems to increase a man's compliance with treatment for erectile dysfunction, but clearly this is only possible if both partners are in attendance at the initial and subsequent consultations.
Having both partners attend the clinic is useful because it allows them both to learn about the treatment and how it is to be applied. This is particularly marked in the use of intracavernosal injection therapy, where a significant proportion of women refuse to co-operate with the man's treatment unless it is explained in detail to them.
An interesting observation that has emerged in the study of erectile dysfunction is that about twice as many men with erectile dysfunction consider sexual intercourse to be very important than do their partners.
The underlying subtext here is that if a woman is actually not very interested in sexual intercourse then she may not be willing to assist a man in carrying out the full treatment methodology for erectile dysfunction.
This reluctance may manifest in various ways including reluctance to take part in the treatment methodology, provide stimulation, provide feedback, or spend time practicing the exercises prescribed.
Furthermore a woman needs to have a motivating factor to enable her to take part, and, as already indicated, it's inevitable that from time to time a man and his partner will have different objectives for the outcome of treatment.
It seems that a man with erectile dysfunction is likely to want an erection sufficient for intercourse (but unfortunately a majority of women apparently find foreplay more satisfying than intercourse).
Evidently, unless a woman is going to achieve some kind of sexual satisfaction from the treatment methodology she may be reluctant to assist her partner, and may even sabotage his treatment.
Riley observes that many women wish to be involved in their partner's treatment. When the use of Viagra generates an erection a woman may express resentment because she has not been involved in any physical or sexual interaction, and regards the process as unnatural.
Research shows that these objections are dissipated somewhat when the partner is encouraged to take an active role in some aspect of treatment, even something as apparently insignificant as opening the packet or, in the case of intracavernosal injection, giving the injection.
Following the onset of erectile dysfunction most men manifest fear of failure, fear of initiating sexual behavior, and put some psychological and/or physical distance between them and their partners in the relationship.
So it's not uncommon for the woman to feel guilty and rejected, and it's not uncommon for the man to avoid intimate contact for prolonged periods of time before seeking treatment for his erectile dysfunction.
In one case, a couple had avoided intimate behavior avoided for 15 years, and it's likely this is not uncommon. In such cases, it's not enough just to offer Viagra because simply having an erection will not necessarily bring a couple into a renewed sexual relationship.
When a female partner has sexual problems of her own these may prevent the re-establishment of intimacy in sexual activity. Several research studies have demonstrated that there is indeed a relationship between the quality of a couple's general relationship and their communication skills and the successful outcome of treatment. Wiley has observed that a high dropout rate from couple therapy for erectile dysfunction is associated with poor relationship quality as reported by the male client.
Clearly problems like this need to be identified before treatment of erectile dysfunction with the use of Viagra is initiated. Furthermore, among couples where the men were approaching or in midlife, many had not actually had sexual intercourse for many years; a significant proportion of these women showed evidence of urogenital atrophy. It follows that these women would need treatment before successful intercourse could be resumed.
The partner's role in assessing the outcome of treatment
All therapists who have interviewed sexual partners will be aware that there can be massive discrepancies between the accounts offered by individual partners.
For one thing, this is because - as we've already mentioned - for the man are the most important measure of outcome is having an erection sufficient to allow intercourse, while the female partner may judge success based on the success of emotional relationship.
For example, Salonia demonstrated that whereas Viagra provided a high level of satisfaction among men who displayed vascular genetic erectile dysfunction, a significantly smaller number of their female partners appeared to be satisfied with this treatment.
And in addition 75% of the partners who were not satisfied with the outcome of treatment strategies had some sexual dysfunction of their own, such as low sexual drive and lack of sexual arousal.
Riley's conclusion, therefore, is that in all cases of erectile dysfunction, health care professionals need to ensure that they have recognized the role of the partner and are prepared to see those partners and offer therapy and advice about their sexual behavior. The ideal situation for this would be a multidisciplinary clinic where psychologists, sex therapists, urologists and other experts could work together.
Erectile dysfunction is a problem that affects not just a man but those around him.
And it seems to be especially common for relationship problems and sexual conflict to occur in female partners of men with erectile dysfunction, either as a contributing or causative factor. These issues can negatively affect the treatment process and prognosis of recovery. Unless a partner with these issues is assessed along with the male patient, the treatment will be compromised.
International Journal of Impotence Research
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