Almost every healthy man experiences episodes of ED at some point in his life; however, these are usually short-lived and related to specific circumstances such as exhaustion, lack of sleep, stress, life difficulties, or temporary conflicts in romantic relationships. Erectile difficulties usually resolve once the underlying issue is addressed and do not require medical intervention. However, if ED persists for an extended period (i.e., several months), this indicates a need for intervention due to the possibility of underlying medical factors (undiagnosed illnesses, inappropriate treatment) or the entrenchment of adverse psychological mechanisms (fear of intercourse, deterioration of the relationship).
Placing psychological intervention between medical methods and immediately after popular oral medications is a deliberate choice. It aims to highlight the role of psychological intervention in the treatment of men with ED. Therapy should, in fact, be integrated. In the predominant group of patients with ED caused by comorbid somatic diseases, medications, or surgery, psychological factors are often observed in the form of fear of sexual intercourse, avoidance of intimacy, and excessive focus on physiological responses. A specific “vicious cycle” mechanism arises, and coexisting psychological difficulties often reduce the effectiveness of the medications used.
The author’s experience treating many patients with somatogenic ED shows that adding a simplified psychological intervention—in the form of psychoeducation, learning to control anxiety reactions, focusing on the pleasure of sex and the relationship with one’s partner significantly improves treatment outcomes, including cooperation regarding pharmacotherapy. Psychological intervention is the method of choice for psychogenic ED; however, in this group of patients, short-term use of pharmacotherapy can also be very effective, primarily due to the rapid “overcoming” of difficulties and increased patient self-confidence. On the other hand, in this group of patients, oral medications may prove ineffective as monotherapy due to significant stimulation of the sympathetic nervous system triggered by an anxiety reaction during sexual intercourse.
The goal of psychosexual therapy is, among other things, to address the complex predisposing, triggering, maintaining, and contextual factors responsible for the occurrence of sexual dysfunction. Among the most important are early sexual trauma and adverse past sexual experiences, restrictive upbringing and lack of sex education, lack of sexual experience, difficulties in building intimacy, relationship problems, susceptibility to stress, and in particular “performance anxiety” accompanying sexual intercourse, as well as adverse life circumstances (professional and financial problems, relationship breakdown, etc.) (Althof et al., 2006) The cognitive-behavioral model emphasizes a triad of factors shaping susceptibility to sexual dysfunction: dysfunctional beliefs about sexuality, a deficit of positive emotional states, and an excess of negative emotional states as personality traits. (Nobre, 2010)
Psychological interventions may include psychodynamic, cognitive, cognitive-behavioral therapy (CBT), integrative, or the increasingly popular mindfulness approaches. Currently, the most evidence for the effectiveness of psychological intervention in treating men with ED pertains to CBT. The primary techniques in the treatment of sexual dysfunction include behavioral training (e.g., sensate focus, stimulus control), sexual skills training, and cognitive restructuring. A detailed discussion of these can be found in studies on psychosexual therapy.
