A book review by Michele O’Mara, PhD

Weeks, Gerald R and Nancy Gambescia (2000). Erectile Dysfunction: Integrating Couple Therapy, Sex Therapy, and Medical Treatment. New York, NY: W.W. Norton Company, Inc.

Thirty-nine percent of 40 year old men and sixty-seven percent of men who are 70 experience erectile dysfunction (ED).   While there are many books available today on the topic of erectile dysfunction, Weeks and Gambescia have separated themselves from the pack by presenting “an integrated approach that examines both the organic and psychological factors contributing to erectile dysfunction (ix).” In a book directed specifically to clinicians and physicians, rather than the actual man who is experiencing ED, this book reveals itself as a clearly charted, no-nonsense, guide for professionals who wish to offer hope and relief for the man experiencing ED.   What appeals to me most about this program is that the target of this treatment is not just him; this program addresses his relationship at large which inadvertently slowly takes the focus off of him, and eventually narrows in on the relationship itself.

By introducing the DSM-IV early in the book, the authors establish the difference between psychological ED and organic or medically-based ED. Because the client is actually the couple, not just the man, the authors note that they “frequently find that the couple is struggling with at least two distinct but interrelated problems.” When research suggests that 48% of women have difficulty getting sexually excited, 33% have difficulty maintaining excitement, and 46% were unable to have an orgasm, it stands to reason that the partners of men with ED might also be a part of the problem and the solution.

Getting a man into treatment is the first step. According to the authors there are plenty of reasons he may be hesitant, not the least of which is actually finding a provider that offers such help. As seems to be the case in all books related to sex, there is a good deal of myth-busting that must occur just to level the playing field to the facts. The authors have come up with 18 common misconceptions that serve as a great resource for educating the client. Among my favorite of these is the myth that “Every time a man has an erection, he must have sex” (11). The authors reassure their clients that, “a man can sustain an erection and choose not to have an orgasm without risking physical or psychological damage” (11).

After explaining the physiology of an erection, and the role of the central nervous system, the vascular system and the hormonal system, the reader is primed to learn about the medical influences on erectile dysfunction. Starting with age-related issues, the authors note that “the most important factor in the age-related decrease in sexual desire is the reduction in the production of testosterone…beginning about the age 40” (19). With age also comes a longer refractory period. Later in the book we learn that some men misdiagnose these natural changes in their sexual behavior as a problem, thus activating a psychological anxiety around performance that exacerbates an otherwise natural decline in desire and performance.

The author’s take great care to educate the reader about the various medical assessments involved in the diagnosis of a ED. Included is a review of the physical examination, the lab tests and electrocardiogram, the rectal exam, sleep monitoring to determine nocturnal penile tumescence (NPT), penile blood pressure, urology tests, neurological testing of the penis, as well as others. A generous amount of information is also provided about the various medical treatments available for men with ED, ranging from the penile implants which were introduced in 1966 to the ever common Viagra that introduced in 1998.

Not surprisingly one of the largest chapters in the book is on the psychological aspects of ED. Performance anxiety, or the excessive concern over attaining and sustaining erections (42), is the leading symptom of erectile dysfunction. Also of concern are good ole life stressors which may include:   divorce, relationship difficulties, addictions, depression, affairs, inability to problem solve or deal with conflicts, unresolved childhood abuse, or even negative cultural messages. Another concern is the presence of other sexual dysfunctions. For example, according to Masters and Johnson (1970) 50% of the men who experienced erectile problems were premature ejaculators (45).

Chapters four and five offer the provider a concrete place to start treatment: the initial phone call. The authors literally walk the provider through the necessary steps involved in assessing the psychological risk factors, including the questions to ask and the importance of taking control of the conversation by asking questions in a direct manner.   In a similar fashion, the book outlines the steps involved in the initial session, offering strategies to establish therapeutic rapport. Therapy is, by nature, an experience in vulnerability if one chooses to self-disclose, and it strikes me that the authors make a very good point when they highlight the importance of the first call as a starting place for treatment. There is no way to ease into the issues when you are seeking help for an erectile dysfunction. The request itself immediately renders the client vulnerable before he has a chance to assess the safety of the provider and his feeling of confidence in the process.

Thus it also makes sense that much of the initial process is about tending to the client’s need to feel safe, to feel reassured, and to be given a sense of hope that this can, and will, get better. One of the strategies the authors favor is that of reframing. The reframe is how the therapist is able to control the structure of the session, and literally crafts the stage on which this problem will be defined, and the solution will be found. The reframe is the process of teaching the clients to think about the problem differently (70).

Once clients begin to discuss the actual sexual problems it is important to determine if the man is describing an erectile dysfunction or if instead there is a desire problem. Similar to Cervanka’s message in her book, “In the Mood.” You can’t fix what isn’t broken, so you must first determine where the breakdown is.   Key questions to help determine this are offered, and the authors suggest that “answers to two important questions about nocturnal erections and masturbation can give you reliable indicators” (72). These questions relate to whether or not he awakens from sleep with an erection and the tumescence of that erection if so, and whether or not he has erectile problems when masturbating (72).  The answers to these questions serve as a sort of litmus test. When functional erections occur in sleep or while masturbating it is no longer deemed a medical concern.

With whole chapter dedicated to the basic techniques used with couples, my greatest criticism is the absence of information about imago therapy, a personal favorite when it comes to working with couples. The use of education (bibliotherapy), and a well-considered list of book suggestions, combined with some cognitive and behavioral strategies, are all solid approaches to any couple.   The best part, though, is the attention given to the sensate focus exercises initially developed by Masters and Johnsons.

Once the assessments are made, the rapport is built, and the couple is stable enough to do the work, Weeks and Gambescia suggest that it is time to use get to the heart of this treatment. The authors introduce sensate focus in a very user-friendly format, including the purposes behind this strategy. Particularly helpful is the emphasis on how to follow-up with the clients once their homework is given, and the importance of doing so. The authors indicate that, “tracking this aspect of treatment requires great consistency on the part of the therapist” (133).

In some cases, the authors literally provide scripts for how to communicate the homework to the clients, which is a useful tool for the novice therapist who may not yet be confident in doing so.   The clients are encouraged to identify where they would be most comfortable beginning a sensual experience. While I understand the value in having couples participate in this, it seems to contradict the otherwise directive nature of the therapeutic process so far. It seems that a key part of this program is in the hand-holding, in reassurance that “this is the path to recovery,” and fostering the confidence of clients that they are going to experience success, and that we know how to lead them there.

An alternative to how they approach this could be to create a check list for each partner to complete, without the other seeing, that indicates where he or she is most comfortable touching. Then the therapist takes these and decides from this where to direct the clients to start (using the lowest common denominator as the deciding factor).

The next step, sensate focus-II, is also clever in that the goal is to help the man now achieve an erection, but this goal is to never be stated – which makes sense, so that performance anxiety does not return.   The final step is the most interesting and offers me the greatest insight to the treatment, and that is the strategy of teaching him to actually lose his erection. While counter-intuitive at first, this makes perfect sense in that the authors are encouraging psychological strength here, rather than physical achievement.

Also of note is the importance of working with couples who do have medically induced erectile dysfunction. Because the medically-based dysfunction can initiate a psychological dysfunction it is wise to intervene at any point – to be sure he stays on the right course from the start, or to get the couple back on course if they find themselves exacerbating their dysfunction with the addition of psychological stressors.

After reading this book by Weeks and Gambescia, it seems reasonable that a skilled clinician with a solid understanding of the sexual response cycle, the physiology of an erection, and experience working with couples, could successfully implement their treatment protocol. It is noted that finding a local urologist to enlist in the care of patients with ED is also important, so perhaps this legwork is important to do first. However, the nuts and bolts of treatment are described with great care, and offer very detailed roadmaps to anyone interested in providing this type of service.

The book is very well written and organized. The authors set out to provide a guide for other clinicians and medical professionals interested in the care of men experiencing erectile dysfunction and they seemed to have hit the nail on the head with this book. Except for possible updates to assessment technologies and medical treatments, this book offers a timeless approach to the treatment of erectile dysfunction.   Any clinician who provides care for men with ED can benefit from this book, even if their role is not to provide psychological interventions. Understanding the bigger picture, the relational picture, of erectile dysfunction is invaluable and seems to be a key ingredient to their successful interventions.

While the jury is still out whether or not I will be actively promoting myself as a clinician for men with ED, I am happy to add this book to my bookshelf. Because the statistics of men who experience ED are so high, I am certain that I find myself face to face with couples who are dealing with this issue, and thanks to this book I will have a much better sense of how to proceed.