Treatment Principles, Strategies, and Techniques Specific to Men
In Chapter 2 of this text, Diagnosis of Sexual Disorders, we reviewed the diagnostic criteria for the seven sexual disorders listed in the DSM-5 (American Psychiatric Association 2013). In this chapter, we focus on Male Sexual Disorders and techniques used to treat them: (1) Male Hypoactive Sexual Desire Disorder, (2) Erectile Disorder, (3) Delayed Ejaculation, and (4) Premature Ejaculation.
Treating Male Hypoactive Sexual Desire Disorder
In contrast to predominant beliefs about male sexuality, it is surprising that from 15 to 25% of adult males report little or no desire for sex (Meana & Steiner, 2014). A wide range of etiological factors affect the sex drive in men; internalized stress and relational conflict are the most common. Acquired, situational Hypoactive Sexual Desire Disorder (HSDD) is generally considered to be the most common subtype (Brotto and Heiman, 2007). Less common but still significant are situations in which the man has sexual desire but not for his committed sexual partner because of a sexual secret, such as preference for masturbation over partnered sex, partiality for erotic activities such as fetishes, engaging in extradyadic sex with affair partners or prostitutes, an inclination for pornography accompanied by masturbation (Meana & Steiner, 2014), a history of sexual trauma that has not been addressed, or conflict about sexual orientation (Dosch, Rochat, Ghisletta, Favez, & Van der Linden, 2016).
HSDD is generally regarded as one of the most difficult to treat of all the sexual disorders since a confluence of factors, rather than one factor, contribute to the lack of desire. The treatment for Male HSDD depends upon the etiology of the disorder.
Identifying Physical Issues in the Man
In cases of acquired HSDD, it is necessary to have a medical evaluation to rule out organic etiologies and medication side effects that wouldcontribute to the man feeling disinterested in sex. Additionally, testosterone deficiency has been associated with lowered sex drive, but the connection is complex and often mediated by relationship and environmental factors (Raisanen, Chadwick, Michalak, & van Anders, 2018).
Uncovering Additional Sexual or Psychological Problems
It is always essential to uncover and treat sexual disorders that are co-morbid with HSDD such as premature ejaculation (PE), erectile disorder (ED) or sexual dysfunction in the partner. Anxiety, depression, or other mental health issues can adversely affect sexual desire. Also, an avoidant or dismissive attachment style might contribute to engaging in sex outside of the primary intimate relationship (Dosch et al. 2016).
Even when the problem primarily resides in the man, these etiologic factors can be addressed using the conjoint format. In fact, the partner can be helped to experience empathy rather than pessimism about the couple’s lack of sex. Some partners might respond negatively such as getting angry or expressing that “no other man ever found me unattractive,” thus exacerbating his problem. Partners may gradually be guided to see how other sexual disorders may have contributed to and maintained the HSDD in the male partner. Finally, they can work with the therapist to create cognitive, behavioral, mindfulness-based, and psycho-educationally driven remedies.
Reducing Response Anxiety
Response anxiety is a commonly used term referring to the subjective preoccupation about not feeling enough or any desire in sexual contexts (see Weeks & Gambescia, 2002). A common negative thought initiating a response anxiety scenario might be that the man should feel more desire than he feels, feel it more often, or even all the time. The couple can be educated about what response anxiety is, normalize its occurrence, what it does to diminish desire, and contribute to the recursive nature of the anxiety. The therapist gives the man permission to feel only the desire he feels and not to try to force feeling more than what he is ready to do. The more the man tries to force desire, the less likely he is to experience it.
Conducting Cognitive Work
One of the major factors in lack of desire is having negative thoughts about sexuality and experiencing distracting thoughts during sex. The therapist will want to employ cognitive techniques such as thought stopping and thought substitution in conjoint or individual sessions. Any and all negative cognitions about desire and/or sex with the partner should be identified and worked through using Cognitive Behavioral Therapy. Cognitive changes could be directed toward automatic unfounded, unrealistic, irrational, or distorted thoughts. The overall strategy is to develop cognitions that both counter the negative thoughts and develop positive sexual thoughts about the self, partner, and the relationship. Focusing on positive reasons for having sex (creating intimacy, expressing positive feelings) has been found to increase sexual desire (Muise, Boudreau, & Rosen, 2017).
