Nora S. Cavagna*, Adrián A. Sapetti, M.D.**


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.


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.


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 excuses:

• 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.


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.


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.


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 dysfunctional past.
• 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.


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 symptom.


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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-Sapetti A.: Los senderos masculinos del placer. Galerna, Bs. As., 2009

-Sapetti A., Kaplan M. V.: La sexualidad masculina, 4ta ed. Galerna, Bs. As., 1992