The search for an effective, safe, easy to administer and painless
solution for the treatment of erectile dysfunction has been long
and difficult. All those found before citrate of sildenafil, although
effective in some way, act by themselves and the partner’s
presence is not required, in order to achieve erection there is
no need of stimulation nor sexual desire as with sildenafil.
For this reason, many women felt excluded from the process. And
that is why we always hear more about the dysfunctional patient
but little about his partner. The degree of her participation in
the production of the symptom, its maintenance and resolution results
essential in this kind of treatment.
MENTAL AND SEXUAL HEALTH
Besides the difficulties already found when having sexual relations,
this dysfunction presents severe consequences for mental health:
guilt, low self-esteem, aggressiveness, anxiety, and depression,
symptoms that partners frequently also show. Moreover, there are
marital conflicts and/or obstacles to establish interpersonal relationships.
Shame and guilt are mixed unrevealing bad moods and anxiety that
might jeopardize personal and work relationships.
The WHO considers sexual health an important part of individuals’
lives for their emotional as well as physical wellness.
Whether erectile dysfunction is psychological, (in this case, tends
to be abrupt and related to recent facts, achieves erections sometimes)
or due to organic causes (dysfunction appears gradual but continuously
for more than three months, no morning or during sleep erections
are present) the characteristic symptom is a change in the quality
of the erection: hardness, ability to maintain it, or both.
REACTIONS TO THE APPEARANCE OF ERECTILE DYSFUNCTION
During the first times that a dysfunction appears, women do not
complain much. They try to understand, be tolerant, and look for
alternative solutions such as oral or manual sex, or enjoying other
aspects as caresses and hugs. However, a great percentage of women,
especially after the problem has been extended for a long period
of time, may start directly avoiding or result in another dysfunction
(inhibited sexual desire, anorgasmia). In men, the first common
reaction is to mask, neglect, and hide the problem using different
• Simulate orgasms when the erection starts to decrease.
• Ejaculate promptly
• Fall asleep too early or too late.
• Stay up watching TV or working on PC.
• Avoid talking about the subject with his partner.
• Try with another woman.
THE STAGE OF DESIRE
Sexual desire is not automatic, moreover is the most complex and
vulnerable aspect of our sexual response. Generally, more than a
factor is required to create the sensation of desire and initiation
of excitation. The stage of desire, when sexually responding, starts
due to different stimulus that, if continued, will introduce us
in the stage of sexual excitation:
• Psychic fantasies
• Remembrance of past experiences.
• Visual stimulus
• Physical sensations (e.g. genital contact).
• Emotions and feelings (e.g. love).
It is also fair to say that the bedroom is not only a place for
love, but also where resentment, irritation and power are reflected.
That’s why the erectile response is often a good indication
of what is going on.
THE DYSFUNCTIONAL COUPLE
When Simon Campbell, English chemist that managed the team that
researched sildenafil for 14 years, was in Buenos Aires in 1998
he said “this new generation of drugs would help a lot of
couples to meet their sexuality again”.
We know that this drug may change the sexual dynamic and bond of
many couples. However, improving sexual performance may lead to
an unbalanced relationship- and even create a crisis- if the couple
has been structured on a dysfunctional axis. That’s why dyadic
therapeutic treatment is becoming essential. Sometimes, there are
hidden issues that the couple is not willing to face, such as:
• The husband asking his wife to leave her passive role
and play an active one by stimulating him when she is no longer
used to such role or does not wish to play it.
• Some men, after discovering their potentiality again,
have the fantasy of leaving their partners with whom sex did not
work, and start a new life.
The situations may vary depending on the different models of couples:
hetero- or homosexual relations, stable marriages, first encounters-
and the anxiety that that implies-, parallel relationships, engagements,
or one night stands.
Sildenafil (or Tadalafil or Vardenafil) places the patient in a
new position: this is a drug that can be taken secretly. If the
patient decides to hide it, a new serial of additional complications
starts: when to take it, what kind of relation it would have with
meals since we know that fat may delay its absorption up to 40%,
what kind of beverage to drink (much alcohol may result in an hipotensive
episode), what would happen if partners finds out. Also, he would
have to show his partner that his performance is getting no extra
help and besides, he would have to satisfy her.
Sometimes men do it with their partners and not with other women.
Eluding anxiety, guilt and difficulties to establish an emotional
compromise. But, on the other hand, with his wife there is no need
to pass the test. At worst, he fails because of his inhibited hostility,
and his wife acts uninterested and lacking stimulus; then, a prostitute
or friend would demands less and, with proper estimulation, he would
achieve and maintain his erection with no difficulty.
FEARS AND FANTASIES
We have detected certain fears and fantasies in couples before and
after taking the drug:
• Fear that he may die after taking the pill.
• Fear to infidelity and AIDS.
• Their partners may look for other women that ignore their
• May not be able to keep their partners desires and rhythm
since their sexual activity has increased.
• Men may feel young again and may look for a younger and
more attractive partner.
• Partner may became addicted to drug.
Some liberal and well-informed women ask their partners to take
the pill. But if they are very structured, they think that their
partners must have an erection at the sight of them. And when they
realize that the drug has had some effect that they weren’t
able to cause, envy and competition result and treatment is jeopardized.
SILDENAFIL AND SEXOLOGICAL TREATMENTS
Generally, those who have been treated with intra-cavernosum injections
and shift to sildenafil, feel relieved since they leave behind discomfort,
sometimes penis injuries and fear to priapism. Some others miss
the rigidity, which is greater, achieved with vasoactive drugs and
lack of need for estimulation.
In some cases, sildenafil is essential to achieve a second erection
and orgasm (not a simple task in the elderly). Non dysfunctional
male are taking it to improve their erectile response- this issue
was debated at the last APA Meeting, Washington, D.C. (1999).
Although the appearance of this drug sets an extraordinary advancement
in helping patients with E.D., we must keep in mind that the final
goal is not only about achieving rigid erections but also about
restoring deteriorated sexual functions.
In our clinical experience, we were able to observe that, in general,
the effects produced by the drug result in a greater bond of the
couple and in a richer and more creative sexuality.
Before sildenafil, we counted with sexual integrative psychotherapy
that helped to develop a more satisfying eroticism and to solve
conflicts of the bond dynamic of the dysfunctional couple. This
is so that patients who have been administered sildenafil by other
physicians, come to sexual consultation, wanting to work on the
problem because they understand that is much more than just a erectile
SILDENAFIL + SEXUAL THERAPIES
Developed by a team of physicians and psychologists specialized
in clinical sexology.
This type of therapy is short and focused, it is preferably to
work with both parts of a couple, but there are also techniques
to treat single people.
Anyway, this kind of sex therapy is compatible, complementary and
synergetic with sildenafil and other psychopharmacological treatments
that, as it is well known, many of them produce sexual dysfunctions.
* Nora S. Cavagna, psychologist and sexologist; ** Adrian A. Sapetti,
M.D., psychiatrist and sexologist
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Dysfunctions. Brunner Mazel, NY, 1974
-Leiblun S., Rosen R.: Couples Therapy for Erectil Disorders: conceptual
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Vol. 17, number 12, 1991
-Masters W., Johnson V., Kolodny R.: Heterosexuality. Harper Collins
Publishers, NY, 1994
-Pasini W. Intimidad. Editorial Paidós, Bs. As., 1992
-Sapetti A.: Los senderos masculinos del placer. Galerna, Bs. As.,
-Sapetti A., Kaplan M. V.: La sexualidad masculina, 4ta ed. Galerna,
Bs. As., 1992