Patient Preference Sexual Scripts and Pharmaceutical Choice

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Patients suffering from SD, first express preference when they choose to seek help from a MHP vs. a nonpsychiatric physician. Most MHPs (having ruled out organic etiology) will initially proceed with sex therapy in cases where psy-chogenic etiology is paramount. For many of these patients, sex therapy will be effective in and of itself. For others, the MHP will facilitate incorporating sexual pharmaceuticals into the treatment process, to help "bypass" or overcome PSOs. The use of sexual pharmaceuticals for these patients may be a temporary recommendation, until a more pro-sexual equilibrium is established for the patient and partner. Reciprocally, pharmacotherapy may be either continuously or intermittently integrated with other attitudinal and behavioral changes necessary for a successful sexual and emotional experience. This will vary based on patient and partner pathologies interacting with the progressive organicity, often secondary to aging. Understanding relapse prevention requires consideration of these issues and factors (16,20,48). How these issues are currently managed by MHPs is illuminated within this chapter's Case Studies.

Owing to multiple factors including the organization of health care delivery, attitudinal beliefs, and pharmaceutical advertising; the majority of patients suffering from ED (when they do seek treatment) are likely to consult their PCP or a nonpsychiatric physician specialist (21). Although a few select physicians (primarily multiskilled psychiatrists) will provide sexual counseling as an exclusive modality when appropriate, most nonpsychiatric physicians will initiate treatment with a PDE-5 regardless of etiology. All three PDE-5s are used worldwide and are now FDA approved in the USA. All have good success rates! Simple cases do respond well to oral agents, with proper advice on pill use, expectation management, and a cooperative sex partner. However, physicians should offer patients choices, especially those who are pharma-ceutically naive. Providing an unbiased, fair-balanced description of treatment options, including pharmaceutical benefits on the basis of the pharmacokinetics, efficacy studies, and the physician's own patients' experience will result in the patient attributing greater importance to the physician's opinion. Incorporating patient preference provides important guidance and will enhance healer/patient relations, minimize PSOs, and improve compliance. Preliminary comparator data, abstracted from the 2003 European Society of Sexual Medicine, suggested, patient preferences reflected, key marketing messages of the respective pharmaceutical companies (49). Prescribing physicians might take advantage of that hypothesis to increase efficacy. If safety and long-term side effects are the primary concern, sildenafil has the oldest/longest database (12). If, pressed by questions regarding hardness of erection; in vitro selectivity may or may not translate to clinical reality, yet some patients believe vardenafil provides the best quality erection with the least side-effect (13). What is the physician's experience with their own patients?

By taking a sex history and evaluating the premorbid sexual script (what used to work sexually), a skillful clinician may make an educated guess, as to which pharmaceutical to first prescribe. This transcends, "try it, you'll like it." Knowledge of pharmacokinetics (onset, duration of action, etc.) and sexual script analysis helps optimize treatment, by improving probability of initially selecting the right prescription. Many physicians initiated treatment with sildena-fil and will continue to do so. However, psychosocial factors and previous sexual scripts, may suggest a different drug on the basis of pharmacokinetic profile. Partner issues help determine correct pharmaceutical selection on the basis of analysis of the couple's premorbid sexual script and relationship dynamics. Understanding the couples "sexual script" can help the physician fine tune pharmaceutical selection, leading to better orgasm and sexual satisfaction, not merely improved erection (50). Sexual script in this situation refers to style and process of the couple's premorbid sex life (51). For those fortunate enough to have had a good premorbid sex-life, dosing instructions should focus on returning to previously successful sexual scripts—as if medication was not a necessary part of the process. This maximizes patient likelihood of getting adequate stimulation in a manner likely to be comfortable and conducive to partner sensitivities. Awareness of within individual differences improves the quality of recommendations made for that person or couple's sexual recovery. Differences between individuals in sexual style (sex script analysis) can determine which medication might be used by a couple effectively, with less change required in their "normal" sexual interactions. For instance, some couples mutually presume that the man is "in charge" and should initiate and seduce like he used to. As he is planning the sexual encounter, sildenafil or vardenafil might be good choices. However, tadalafil may be preferable, if a more spontaneous response to an externally evoked situation is desired.

Fitting the right medication on the basis of pharmacokinetics to the individual/couple will increase efficacy, satisfaction, compliance, and improve continuation rates. Rather than changing the couples' sexual style to fit the treatment, try to fit the right medication to the couple (50). A sensitive clinician may be tempted to facilitate a relationship of greater egalitarian and psychological balance. However, a symbiotic relationship with decades of history must be respected. For the most part, clients are seeking restoration of sexual function not a

"make over," defined and reflecting a "politically correct" professional bias. Success requires consumer sensitivity. For instance a "rejection sensitive" woman may function as the couple's sexual "gatekeeper," yet may never initiate sex. She may require him to respond to explicit initiations or her implicit initiations through signs of sexual receptivity (leg touching in bed, a subtle caress). The astute clinician might ask "Couldn't these merely be signs of partner affection and not subtle sexual initiation?" Yes. However, for such a women, his willingness and ability to be sexual, is experienced positively even if she declines sex. She needs to feel both affirmed and in control. They agree that she is the gatekeeper and she may encourage sexuality, or limit the process to affection. Yet, his initiation is an important aspect of their sexual script and relationship equilibrium. By serving as a source of affirmation for her, it reduces the noxious (toxic) manifestations of her insecurity and rejection sensitivity. They both expect that she will decline some initiations. Yet, if he is only willing and able to initiate once dosed, then sildenafil or vardenafil is a poorer choice. For their relationship, multiple initiations are required, and pre-dosing with longer acting tadalafil may be a better choice. Harmony will be restored and satisfaction will increase. Two to three doses of tadalafil weekly, for a month, might be useful for such men who are essentially "on-call" in order to initially facilitate their capacity. As confidence and capacity improves and predictability increases, dosing could be titrated down or the pharmaceutical even weaned away. If the previous sex script was weekend sex, then a Friday night dose may be sufficient. If he has become resistant to her "controlling domination," then a referral for couples counseling would be appropriate. Although the suggestion of referral may be enough to compel him to try the drug, given the reaction many men have to MHPs. The physician simply makes an educated guess regarding pharmaceutical selection. Follow-up may indicate greater PSO complexity. Then, the case would be better managed utilizing a multi-disciplinary integrated approach, with a sex therapist working collaboratively with the prescribing physician. Later in this chapter, this multidisciplinary method is illustrated with the case of Jon and Linda.

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