Memo to Docs (and Patients): Less Viagra, Please

As a sex therapist, I see men every week who don’t get erect when they want to.

They often describe themselves as having ED or erectile dysfunction. I say, “So, you don’t get erect when you want to. Let’s call it that.” Conceptualizing their situation as ED is frequently part of the problem. They think their penis is suffering some pathology; more often, the pathology is in their expectations.

By calling the problem what it is—“you don’t get erect when you want to”—we continually focus on the two-sided nature of the problem:
* the penis—“you don’t get erect”
* the expectation—“when you want to”

So, rather than “fixing” their “ED,” I ask these men lots and lots of questions—increasingly personal and detailed as the hour proceeds. More than half the time, we discover that their uncooperative penis is actually behaving in an understandable, fairly reasonable way. For some men, that single hour changes everything, and they need not return. More commonly, we meet for a series of sessions in which we discuss sexuality, gender, personal history, and whatever else seems relevant—always in detail, always clarifying what something means to this particular individual.

Occasionally Viagra (or its cousins, Cialis and Levitra) looks like a good approach. But many of these men have already tried it. Some are currently using it.

Sometimes Viagra is part of the problem—it reinforces the idea that there’s something wrong with their penis, which the Viagra is supposed to fix. But if there isn’t a problem with the penis, Viagra can’t fix it.

In America, you need a physician’s prescription to get Viagra. (You can use the internet, of course, but you have no idea what you’re getting.) Unfortunately, doctors don’t necessarily have the time to find out why someone might not be getting erect when he wants to. That is, a doc may not be able to help a guy find out that he doesn’t have ED—that his penis is simply responding reasonably to one or more situations that undermine erection.

Assuming he’s physically healthy, why might a man have trouble getting erect when he wants to? Here are just some of the reasons:

* He isn’t being touched the way he likes (or touched at all)
* He isn’t sober when starting sex
* He’s angry at his partner
* His partner is angry at him
* He isn’t attracted to his partner (for whatever the reason)
* His partner isn’t really interested (and may have perfectly good reasons for this)
* He believes he has to have intercourse until his partner climaxes (which his partner may or may not demand)
* He fears the tears or argument that almost always ensues after he doesn’t get erect
* He’s in physical pain, or fears triggering physical pain
* He doesn’t expect to enjoy the sex he usually has

Under conditions like these, a healthy penis will have difficulty becoming or staying erect. That’s not a dysfunction, any more than a car has a dysfunction when it won’t run on Gatorade instead of gasoline.

Of course, I don’t see a random sample of men with erection problems. Many concerned men see a physician first, who may diagnose diabetes, cardiovascular problems, medication-related issues, even depression. Or after ruling out such physical factors, the doc may send the patient to me.

I also see a lot of men who’d rather go to a sex therapist than a physician. Or who figure that they’re unhappy about sex, so they should see a sex therapist.

Still, I shake my head at the number of men who go to a doc, complain about their erections, and leave the doc’s office 10 minutes later with a prescription for Viagra. The doc didn’t have time to ask “Does your partner want more sex? Do you like the way your partner kisses? Do you two know how to enjoy sex without intercourse?” Viagra can’t fix any of these.

Eight weeks later, problem still not solved, these guys call me.

Of course the problem’s not solved; the problem isn’t their penis. That’s when we start with “So, you don’t get erect when you want to. Let’s call it that.”

There’s an important place for Viagra in modern medicine. But for too many men and too many couples, it isn’t part of the solution. It’s part of the problem.

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