Importantly, pharmaceutical advertising and educational initiatives have altered the delivery of sexual medicine services, especially in the United States. Specifically, these changes in practice patterns resulted in PCPs becoming the principal healthcare providers for men who present with a primary complaint of ED, with urologists typically seeing the more recalcitrant cases. MHPs rarely are the initial treating clinicians anymore. This both helps and contributes to the problem of success and failure. The large number of PCPs treating ED has dramatically increased the number of patients seen, and the accessibility of medical treatment. Unfortunately, the history obtained by PCPs and urologists is frequently limited to an end-organ focus, and fails to reveal significant psychosocial barriers to successful restoration of sexual health. These obstacles or "resistance" represent a significant cause of noncompliance and nonresponse to treatment (2). These barriers manifest themselves in varying levels of complexity, which individually and/or collectively must be understood and managed for pharmaceutical treatment to be optimized (15,20).
Only recently, have physicians begun incorporating sex therapy concepts, and recognized that resistance to lovemaking is often emotional. Clearly, medical treatments alone are often insufficient, in helping couples resume a satisfying sexual life. There are a variety of bio-psychosocial obstacles to be recovered that contribute to treatment complexity. All of these variables impact compliance and sex lives substantially, in addition to the role of organic etiology (20). There are multiple sources of patient and partner psychological resistance, which may converge to sabotage treatment: (i) What is the mental status of both the patient and the partner and how will this impact treatment, regardless of the approach utilized? What is the nature and degree of patient and partner psychopathology (such as depression)? What are the attitudinal distortions causing unrealistic expectations, as well as endpoint performance anxiety? (ii) What is the nature of patient and partner readiness for treatment? When and how should treatment begin, and be introduced into the couple's sex life? What is his approach to treatment seeking? What should be the pacing of intimacy resumption? The average man with ED waits 2-3 years, before seeking assistance (21). By that time, a new sexual equilibrium has been established within the relationship, which may be resistant to the changes a sexual pharmaceutical introduces. Furthermore, although partner pressure is a primary driver for treatment seeking, some men who sought treatment at their partner's initiation do not necessarily confide in them about the treatment (21). (iii) What is their emotional and attitudinal readiness for change? The sexual history will provide information regarding premor-bid and current sexual desire. What is her motivation or desire for sex? What are her concerns regarding his safety? What are her belief systems regarding the treatment process which now enables coitus? Her compliance may be affected be her perception of the treatment being artificial or mechanical: "Is it the sildenafil, or me?" (iv) What is her health status (vaginal atrophy, etc.) and physical readiness for sex; her capacity for lubrication and need for stimulation, etc.? We know from the Massachusetts Male Aging Study that frequency of ED increases with age (22). We know that older men tend to have older, post-menopausal partners. Female partner's additional and sometimes complex medical needs are frequently not addressed in the brief evaluation interview, often conducted by the average physician. (v) What are the relevant contextual stressors in the patient and/or partner's current life, such as work, finances, parents, and children, etc.? (vi) What is the couple's overall quality and harmony of relationship? Interpersonal issues impact outcome through a variety of manifestations? Intimacy blocks and power struggles may cause failure. (vii) What are the patient and partner's sexual script? Overtime, incompatible sexual scripts, interest, and arousal patterns may predetermine SD. For instance, PDE-5s require stimulation, for the man to respond sexually; stimulation is frequently more than merely adequate friction. There are many divergent sexual scripts and a variety of unconventional patterns of sexual arousal (homosexuality, sadomasochism, etc.), which may sabotage arousal. Additionally, over time, there are reality-based alterations in a partner's sexual desirability, which may also affect both arousal and orgasmic response.
Although most of these barriers to success can be managed as part of the treatment, too few physicians are trained to do so (20,23). What is a model for this situation? These various sources of psychological resistance manifest themselves in a diverse manner, which Althof conceptualized as three "scenarios" of psychosocial complexity (15). Each level would lead to an alternative treatment plan. Importantly, this concept can be expanded to conceptualize treatment for all SD, and regardless of who provides care—they all would be CT.
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