This article was downloaded by: [Central Michigan University] On: 22 December 2014, At: 08:19 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
Journal of Sex & Marital Therapy Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/usmt20
Psychological Treatment of Erectile Dysfunction in Men Without Partners: Outcome Results and a New Direction Barry Reynolds
a
a
Human Relations Center , University of Southern California , 1002 West 3oth Street, Los Angeles, CA, 90089-1591 Published online: 14 Jan 2008.
To cite this article: Barry Reynolds (1991) Psychological Treatment of Erectile Dysfunction in Men Without Partners: Outcome Results and a New Direction, Journal of Sex & Marital Therapy, 17:2, 136-146, DOI: 10.1080/00926239108404955 To link to this article: http://dx.doi.org/10.1080/00926239108404955
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
Psychological Treatment of Erectile Dysfunction in Men Without Partners: Outcome Results and a New Direction Downloaded by [Central Michigan University] at 08:19 22 December 2014
HARRY REYNOLDS
Studies concerning the psycholopal treatment of erectile dysfunction in men without partners are reviewed. A significant majority of single men experience improved erectile functioning following surrogate-assistetl or men’s group therapy. However, the expense and unresolved legal status of surrogate therapy and lopstical problem i n forming m&’s groups limit the availability of these treatments. “Personal Polenticil” is a new audio cassette d j u n c t for individual therapy. To appoximate n men’s group experience, “Personal Potential” itxludes discussions by former clients, didactic pesentcztions, communication roleplays, arid sexual and social homework assi,pments. Routine attention to Communication problems in men without partners muy also increase patient satisfaction with intracavernosal vasodilator self-infections, penile implants, or vacuum constriction devices. Early proponents of sex therapy maintained that the treatment of erectile dysfunction ideally involves the participation of both the man and his partner in This emphasis o n couples therapy may have led to an initial absence of controlled studies concerning the treatment o f men who d o not have sexual partners. In fact, many university-based sex therapy centers initially refused treatment or merely provided nonspecific counseling to men without partner^.^ T h e consequences of a relative absence of empirically tested treatments for men without partners are substantial. Due t o an increasing divorce rate, the delaying of marriage, and a slowed place of remarriage,6 the percentage of adult males who are single, separated, divorced, or widowed climbed from 26% in 1970’ to 42% in 1990.8 T h e absolute number of unmarried men more than doubled t o nearly 38 million during the same Although incidence and prevalence figures for erectile dysfunction in unmarried men arc unavailable, extrapolation from surveys of’ married couples”’” and men across age groups”.” suggests that Barry Reynolds, Ph.I).. IS Executive Director. Human Relations Cqnter. L‘niversity of Southern Caliloriiia. 1002 West 36th Street. Los Angelrs. (;A 90089- 1591.
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as many as 5 million unmarried men may experience erection problems. T h e likelihood of erectile dysfunction might even be greater for inexperienced single men or recently separated, divorced, or widowed men than for men in stable relationships. An increase in erectile d sfunction as a presenting problem has been observed for adolescents1! and college students.14 T h e absence of a partner has been cited by patients as a reason for noncompliance with the recommendation for sex therapyI5 and premature termination of sex therapy.16 Without specific therapy alternatives for men without partners, many men might receive insufficient, inappropriate, or unnecessary medical, surgical, or psychological interventions.” Fortunately, there has been some progress in the empirical evaluation o f treatment for men without partners since the 1970s. ‘The present paper includes a review of published outcome studies concerning the psychological treatment of erectile dysfunction in men who d o not have sexual partners at the onset of treatment. Following this review, a new treatment direction will be discussed. REVIEW OF TREATMENT MODELS A N D OUTCOME RESULTS
Surrogate Partner Therupy Masters and Johnson’ provided the first report of surrogate partner therapy for men without partners. Masters and Johnson trained women volunteers to be the man’s sexual partner during “sensate focus” sessions. T h e male patient and his surrogate partner might practice a sequence of sex therapy exercises that range from nongenital caressing to sexual intercourse. T h e surrogate partner did not attend counseling sessions but did consult with the supervising cotherapist team regarding treatment progress. Masters and Johnson reported outcome results for 28 men who received surrogate-assisted treatment. Nineteen men were diagnosed as having “primary impotence” (no history of attaining and maintaining sufficient erection during sexual intercourse), and nine men experienced “secondary impotence” (some history of successful intercourse). Masters and Johnson reported a “failure rate” of 37% for primary impotence and 22% for secondary impotence. These failure rates did not differ appreciably from the rates reported for men who were treated with their natural partners. Apfelbaum18 described an intensive, two- to three-week program in which patients received daily “body-work” sessions with a trained paraprofessional, followed by discussion sessions that were also attended by a cotherapist professional. Body-work sessions involved a progressive sequence of nongenital touching, genital stimulation, and intercourse experiences. Apfelbaum reported combined outcome data for a variety of sexual dysfunctions. Of 407 patients, 119 (29%) were rated by the cotherapists as “completely successful,” 172 (40%) were “largely successful,’’86 (2 1%)
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were “moderately successful,” 27 (7%) experienced “no change,” and 3 ( 1 5%) were “worse.” Apfelbaum did not provide separate data for erectile dysfunction. D a ~ wcombined ’~ surrogate-assisted therapy with client-centered, behavioral, insight, and cognitive techniques applied by the surrogate o r supervising psychotherapist in separate, weekly sessions. This treatment also included bibliotherapy, educational audio- and videotapes, and homework assignments pertaining to social skills, assertion, or masturbation practices. Dauw reported outcome results for 489 heterosexual clients, including 55 men with primary erectile dysfunction and 256 men with secondary erectile dysfunction. Ninety-five percent of the men were professionals or business executives. Treatment success was defined as the ability to maintain an erection until orgasm during more than 75% of coital attempts. Outcome was assessed by the surrogate’s report during treatment and by client report three months after treatment. Dauw reported a 98% success rate for primary impotence and a 85% success rate for secondary impotence. Only men who maintained gains at follow-up were judged as treatment successes. ’I’hese studies suggest that surrogate-assisted therapy can be an effective treatment for men without partners. However, because of the hazy legal status of a treatment that involves sexual interaction for a fee, the surrogate approach has not been evaluated at university-based treatment centers. For example, no published studies have included control groups or comparison treatments. T h e availability of surrogate therapy has been limited to private practice settings, where clients must afford fees for both surrogate and supervising therapist. Furthermore, surrogate therapy is only available in major population centers. One practitioner survey indicated that fewer than 2% of sex therapy clients receive surrogate therapy.20These factors have prompted the development and evaluation of alternative treatments for men without partners. Men’s Group Therapy
Several studies have evaluated structured men’s group treatment.” -“In these studies, groups of five to eight men met with two therapists for 8 to 2 1 weekly sessions. Some studies included a male-female cotherapist team,?I.zJ others included female paraprofessionals for communication roleplays,‘* and one study included both female-male cotherapists and additional paraprofessional^.^^ T h e group formats included educational presentations, group discussion, and homework exercises. T h e presentations and discussions concerned gender role stereotypes, sexual dysfunction, social and sexual communication, and sensual or sexual activities for new relationships. T h e groups also included less structured discussion concerning patient histories and current relationship experiences. Many of the groups included roleplay exercises for developing dating and communication
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skills. Some groups included bibliotherapy, films, o r videotapes pertaining to masturbation, sensate focus, or exercises for overcoming erectile dysfunction. Sexual homework. assignments included individually administered sensate focus experiences and directed masturbation sequences. T h e results of these studies suggest that structured men’s group therapy can be an effective multifaceted treatment. Among the early studies, ZiIbergeld2’ reported that two-thirds of his group members had “completely achieved their goals by the end of therapy.” Zilbergeld did not provide more precise outcome data. Lobitz and Baker2‘ found that the frequency of erection difficulties and scores on a Goals for Sex Therapy questionnaire were significantly improved following treatment. T h e frequency of erection difficulties was further reduced at a 4- to 9-month follow-up. Six of nine clients (67%)showed “noticeable improvement.” Price, Reynolds, Cohen, Anderson, and S ~ h o c h e provided t~~ the first men’s group study that included a no-treatment control group. Twentyone men with secondary erectile dysfunction were assigned to men’s groups or to a waiting list. Men’s group clients reported significantly greater improvement than did waiting-list clients on measures of sexual self-esteem and attitudes related to erectile functioning at both posttreatment and six-week follow-up. There was also a significant difference between treated and untreated clients in subjective satisfnction with changes in erectile functioning. T h e actual frequency of erection difficulties also declined for men’s group participants. However, this improvement just failed t o reach statistical significance (.05 < p < . l o ) when men’s group clients were compared to waiting-list clients. T h e 14 men who had been treated in men’s groups were then reevaluated at a six-month follow-up. T h e subjective treatment gains were maintained at this second follow-up. Ten of the 14 men (71%) reported improvement in erectile functioning. In comparison with pretreatment levels, men’s group participants reported significant increases in sexual self-image, estimates of partner satisfaction, pleasurable reactions to a partner’s sexual initiation, and the frequency of male orgasm during intercourse. In contrast, the average frequency of erection difficulties only declined from 64% of sexual encounters at pretest to 47% of encounters at the six-month follow-up; this difference just failed to reach statistical significance ( p = .06). T h e Price et al.‘3 data can reasonably support opposing viewpoints regarding the value of men’s groups. A possible negative interpretation is that men’s groups produce much larger changes in feelings and attitudes than in erectile functioning. A positive interpretation is that large changes in erectile functioning are not required for a successful outcome. In discussing their results, Price et al. noted that the group participants whose erectile functioning did not improve had typically maintained a pattern of minimal dating and avoidance of open communication with occasional artners. Therefore, Reynolds, Cohen, Schochet, Price, and Anderson‘ conducted a second study in which substantial dating skills training was added to the treatment format. Homework assignments
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now emphasized communication skills, such as initiating conversations, meeting potential partners, having time-limited dates, disclosing sexual concerns, suggesting sexual alternatives, and sharing sexual preferences. In addition, Reynolds et al. invited female therapist trainees to several sessions to practice communication roleplays with the men. This combination of sex therapy and dating skills training resulted in a significantly reduced frequency of erection difficulties and social anxiety for 11 men with secondary erectile dysfunction. These improvements were maintained at a six-month follow-up. Of 10 men who completed the followup, nine (90%) reported increased satisfaction with erectile functioning. T h e previous studies concerned men’s group treatment of erectile dysfunction in heterosexual men. Everaerd, Dekker, Dronkers, van dcr Khee, Staffeleu, a n d W i ~ e l i u s ’reported ~ on the treatment of sexual dysfunction in homosexual, heterosexual, and bisexual men who participated in men’s groups of mixed sexual orientation. This study is also unique because outcome data were reported concerning sexual functioning d u r i n g masturbation, as well as during encounters with partners. Everaerd et al.’s clients included 21 men, 15 of whom experienced erectile dysfunction. Everaerd et al. reported significant improvements o n measures concerning social anxiety, the rejection of restrictive sex morals, a n d the allowance of psychosexual stimulation. Nine of 13 men (69%)with erectile dysfunction n o longer experienced erection problems d u r i n g masturbation (two other men did not have erection problems d u r i n g masturbation at treatment onset). At a two-month follow-u , six of the 15 men (40%) reported a “complete cure,” three men (‘LO?!) reported “no or only slight improvement,” and the remaining six men (40%) reported n o new sexual interaction with a partner. Separate outcome data were not presented for men with different sexual orientations. Further scrutiny of the data for individual clients reveals that the six men who experienced a cure with partners were previously able to attain erections during masturbation at thc onset of or following treatment; n o clients with continuing erectile dysfunction during masturbation experienced a cure with partners. This suggests that intact erectile functioning d u r i n g masturbation can be of prognostic value and may also be an early therapeutic goal. Auerbach a n d Kilmann“ compared group systematic desensitization with a n attention-placebo control condition in the treatment of 16 men with secondary erectile dysfunction. Men in the desensitization g r o u p received 15 sessions of relaxation training plus exposure to a composite hierarchy of anxiety-arousing images. Men in the attention-placebo g r o u p received relaxation training alone. Both groups were instructed to practice daily relaxation. T h e desensitization clients reported a n improvement of over 40% in the frequency of succcssful intercourse, while t h e control clients reported a 3% improvement. These differences were maintained at a three-month follow-up. Scrutiny of the results for individual clients suggests that single men improved to the same extent as married men. Althou h reasonably well-controlled studies have provided evidence for the ef ectiveness o f men’s group treatment, there are several logistical
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problems with the application of men's groups in the typical therapy ~ e t t i n g . ~Many ' therapists d o not have access to a sufficient number of clients who are willing and able to attend a men's group at any one time. Furthermore, paraprofessionals for group roleplays are usually unavailable or cost prohibitive. Less than 5% of individual sex therapy clients are treated in groups.2oThese factors have prompted the continuing development of individual treatments for erectile dysfunction.
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I ndiv idua1 Therapy -1'he men's group results indicate that dating skills training is often a necessary ingredient in the treatment of men without partners. Stravynski2Rprovided an individual case report that suggests that interpersonal skills training, without sex therapy, may be a sufficient treatment for some men. Stravynski's client was a 54-ycar-old engineer with erectile dysfunction, rapid ejaculation, deficient social skills, and severe heterosexual anxiety. Stravynski's treatment included prolonged exposure in vivo and social skills training. T h e client was instructed to invite women to pubs or cafes and eventually to his home while pursuing conversation and without making sexual overtures. T h e client was also trained in positive social behaviors, such as initiating contact, showing interest, expressing pleasant emotions, expressing empathy, and initiating further contact. N o specific treatment suggestions were made regarding sexual dysfunction. During treatment, Stravynski's client reported an increased frequency of the targeted social behaviors, accompanied by reduced anxiety. An occurrence of successful sexual intercourse occurred after six weeks of treatment and was maintained at a twice-weekly level throughout a sixmonth follow-up. Changes in the social behaviors were also maintained. 13 unmarried men with a combination of sexual K u r ~ v i l l atreated ~~ reeducation, guided imagery, and directed masturbation homework. Nine men reported full erections during masturbation and imagery training, and four additional men reported partial to full erections during at least half of the masturbation sessions. A two-year follow-up of 11 clients revealed continued improvement in seven men (64%); five of the 1 1 men had married. Csillag3" conducted a comparison group study in which subjects received biofeedback of erection changes. Six men with erectile dysfunction and six nonpatient volunteers received 16 sessions of erectile biofeedback training. T h e improvement in erection response in the laboratory declined for the nonpatient group but increased for the patient group. Five o f the patients reported improved erectile functioning outside of the laboratory. However, only one of two men without partners reported improvement. Reynoldss' conducted a control group evaluation of erectile biofeedback training for 30 men with erectile dysfunction. Thirteen of the men did not have partners. In the laboratory, men who received segments of erotic film contingent on erection increases showed greater erectile
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response when instructed to facilitate erection in the absence of feedback than did men who received film segments o n a noncontingent basis. However, treatment and control groups did not differ in the amount of clinical improvement revealed at a one-month follow-up. Overall, 17 of 26 clients (65%)reported some improvement in erectile functioning, but only seven men (27%) reported considerable or complete improvement. Separate outcome results were not reported for the men without partners. Reynolds concluded that the therapeutic effectiveness of erectile biofeedback remains undemonstrated. H e speculated that the positive results obtained by Csillag"' may have been d u e to repeated exposure to erotic stimuli. I t could be argued that biofeedback of penile erection might actually increase performance anxiety by focusing attention o n erection. Less direct feedback concerning nongenital responses (e.g., finger temperature, muscle tension) might provide a better treatment for anxiety associated with erectile dysfunction. Cionini and Giovannoni3' provided a single case report in which erectile dysfunction was treated with biofeedback of frontalis muscle tension. However, Reynolds3' found that heart rate, finger temperature, a n d respiration rate did not significantly correlate with erection changes during biofeedback training. Hypnosis has been suggested as a treatment possibility for men without partners.33 Hypnotherapy techniques have included guided sexual imagery combined with posthypnotic suggestions of effortless erection a n d sensual focus,34 suggestions of association between penile rigidity and induced limb catalepsy or arm l e ~ i t a t i o n- 3, 6~ indirect ~ suggestions involving sports metaphors,37 and imagery training concerning positive selfstatements or dating a n d sexual interaction.3' Crasilneck provided outcome results for a large sample of consecutive patients treated with h y p n ~ s i s . "In ~ *the ~ ~final series of 100 patients, 87% of the men at a 12-month follow-up "werc relatively free of impotency with only occasional loss of erection" after a n average of 10 treatment sessions. However, 75% of Crasilneck's patients were married, and separate outcome results were not reported for men without partners. N o published studies of hypnotherapy for erectile dysfunction have included control groups or more objective measures of treatment outcome. However, imagery training has been included as one of several treatment components in controlled evaluations of men's groups.2"*24 Summary of Outcome Studies Outcome studies have provided evidence for the effectiveness of a variety of psychotherapeutic approaches to erectile dysfunction in men without partners. Studies of surrogate therapy, men's group treatment, and several individual therapies have reported improvement rates that range from 40% to over 90%. A number of factors make comparisons among these treatment approaches particularly difficult: First of all, patients in these studies differ
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in age, socioeconomic status, and psychiatric diagnoses. Since these characteristics are associated with treatment comparisons between studies are risky. Second, the treatment models that are described as “surrogate-assisted sex therapy” or “structured men’s group treatment” actually involve many overlapping treatment components, such as directed masturbation, social skills training, roleplays, cognitive techniques, emotional disclosure practice, and imagery training. Finally, the studies differ markedly in such design features as the duration of treatment, measures of outcome, and length of follow-up. While these considerations limit comparisons between treatments, research involving a sufficient sample, reasonable follow-up, and/or control groups suggests that a significant majority of men without partners report improved erectile functioning following surrogate-assisted or men’s g r o u p therapy. Men’s group research indicates that dating skills training may be necessary for treatment succcss, while case study evidence suggests that relationship skills training may be sufficient for some men. Individual therapy formats contain many of the same procedures as g r o u p treatment, but there are n o published control group evaluations of individual treatments that are specifically designed for men without partners. T h e r e are also n o studies that directly compare individual with g r o u p therapy for single men. Well-controlled studies have cast some doubt o n the effectiveness of erectile biofeedback training as a standalone treatment, but further evaluation of biofeedback as a treatment adjunct is warranted. Studies of hypnosis provide claims of substantial success, but these studies suffer from the absence of control groups or independent outcome assessment. A NEW TREATMENT DIRECTION T h e limited availability of surrogate-assisted and men’s group sex therapy has prompted the development of new treatment approaches that are more readily available in the more typical context of weekly individual therapy. O n e such approach is described here. Personal Potential3g is an audio cassette adjunct, developed by this author, that is designed for single men with erectile dysfunction, premature ejaculation, limited sexual experience, or sexual relationship anxiety. Personal Potential consists of 16 45-minute tapes, along with printed summaries a n d homework assignments. At the conclusion of each therapy session, the therapist assigns the appropriate tape and printed homework. A major benefit of a men’s group is that each man can learn that h e is not alone in his experience of sexual d i f f i c ~ l t i e sO . ~n~the Personal Potential tapes, five former clients discuss personal backgrounds, the experiences that led them to treatment, and their experiences in overcoming dysfunction. T h e tape format is also similar to a men’s group session. Each tape begins with a didactic presentation or a discussion with one of the former clients. T h e didactic presentations focus o n a variety of topics concerning the causes and treatment of sexual dysfunction. T h e middle portion of
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each tape includes roleplay examples for developing communication, relationship, a n d sexual skills. T h e tape concludes with a review of the sexual a n d social homework. T h e combination of components contained in Personal Potential has been shown to be effective when administered in men's group therapy.2".24T h e author is currently collecting outcome data from consecutive clients who are using the tape program while receiving individual therapy. Future studies will compare the effectiveness of Personal Potential procedures that are administered in individual, men's group, or self-help formats. T h e emergence of sex therapy procedures that are specific for men without partners highlights the potential benefits of greater interdisciplinary cooperation in the medical and psychological treatment of erectile men can be taught self-injection of intrad y s f u n c t i ~ n . ~For ' ' ~ example, ~ cavernosal vasodilator medication^,^^ but this method may be of limited value for single men who lack the interpersonal skills for establishing intimate relationships or for effectively communicating with new partners about self-injection. T h e regular evaluation and treatment of social a n d communication deficits in men without partners might also increase both the use a n d effectiveness of penile implants44and vacuum constriction device^."^ REFERENCES 1. Masters W H , Johnson VE: Human sexual inadequacy. Boston, Little, Brown, 1970. 2. Kaplan HS: The new sex tlrrrapy Actziv treatment of sexual dysfunctions. New York, Rrunner/Mazel. 1974. 3. H a r t m a n WE, Fithian MA: Treatment of sexual dysfunction: A biopsychosocial approach. Long Beach,
Journal of Sex & Marital Therapy Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/usmt20
Psychological Treatment of Erectile Dysfunction in Men Without Partners: Outcome Results and a New Direction Barry Reynolds
a
a
Human Relations Center , University of Southern California , 1002 West 3oth Street, Los Angeles, CA, 90089-1591 Published online: 14 Jan 2008.
To cite this article: Barry Reynolds (1991) Psychological Treatment of Erectile Dysfunction in Men Without Partners: Outcome Results and a New Direction, Journal of Sex & Marital Therapy, 17:2, 136-146, DOI: 10.1080/00926239108404955 To link to this article: http://dx.doi.org/10.1080/00926239108404955
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
Psychological Treatment of Erectile Dysfunction in Men Without Partners: Outcome Results and a New Direction Downloaded by [Central Michigan University] at 08:19 22 December 2014
HARRY REYNOLDS
Studies concerning the psycholopal treatment of erectile dysfunction in men without partners are reviewed. A significant majority of single men experience improved erectile functioning following surrogate-assistetl or men’s group therapy. However, the expense and unresolved legal status of surrogate therapy and lopstical problem i n forming m&’s groups limit the availability of these treatments. “Personal Polenticil” is a new audio cassette d j u n c t for individual therapy. To appoximate n men’s group experience, “Personal Potential” itxludes discussions by former clients, didactic pesentcztions, communication roleplays, arid sexual and social homework assi,pments. Routine attention to Communication problems in men without partners muy also increase patient satisfaction with intracavernosal vasodilator self-infections, penile implants, or vacuum constriction devices. Early proponents of sex therapy maintained that the treatment of erectile dysfunction ideally involves the participation of both the man and his partner in This emphasis o n couples therapy may have led to an initial absence of controlled studies concerning the treatment o f men who d o not have sexual partners. In fact, many university-based sex therapy centers initially refused treatment or merely provided nonspecific counseling to men without partner^.^ T h e consequences of a relative absence of empirically tested treatments for men without partners are substantial. Due t o an increasing divorce rate, the delaying of marriage, and a slowed place of remarriage,6 the percentage of adult males who are single, separated, divorced, or widowed climbed from 26% in 1970’ to 42% in 1990.8 T h e absolute number of unmarried men more than doubled t o nearly 38 million during the same Although incidence and prevalence figures for erectile dysfunction in unmarried men arc unavailable, extrapolation from surveys of’ married couples”’” and men across age groups”.” suggests that Barry Reynolds, Ph.I).. IS Executive Director. Human Relations Cqnter. L‘niversity of Southern Caliloriiia. 1002 West 36th Street. Los Angelrs. (;A 90089- 1591.
Journal of Sex 8c Marital Therapy, Vol. 17, No. 2, Summer 1991 0Brunner/Mazel, Inc.
136
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as many as 5 million unmarried men may experience erection problems. T h e likelihood of erectile dysfunction might even be greater for inexperienced single men or recently separated, divorced, or widowed men than for men in stable relationships. An increase in erectile d sfunction as a presenting problem has been observed for adolescents1! and college students.14 T h e absence of a partner has been cited by patients as a reason for noncompliance with the recommendation for sex therapyI5 and premature termination of sex therapy.16 Without specific therapy alternatives for men without partners, many men might receive insufficient, inappropriate, or unnecessary medical, surgical, or psychological interventions.” Fortunately, there has been some progress in the empirical evaluation o f treatment for men without partners since the 1970s. ‘The present paper includes a review of published outcome studies concerning the psychological treatment of erectile dysfunction in men who d o not have sexual partners at the onset of treatment. Following this review, a new treatment direction will be discussed. REVIEW OF TREATMENT MODELS A N D OUTCOME RESULTS
Surrogate Partner Therupy Masters and Johnson’ provided the first report of surrogate partner therapy for men without partners. Masters and Johnson trained women volunteers to be the man’s sexual partner during “sensate focus” sessions. T h e male patient and his surrogate partner might practice a sequence of sex therapy exercises that range from nongenital caressing to sexual intercourse. T h e surrogate partner did not attend counseling sessions but did consult with the supervising cotherapist team regarding treatment progress. Masters and Johnson reported outcome results for 28 men who received surrogate-assisted treatment. Nineteen men were diagnosed as having “primary impotence” (no history of attaining and maintaining sufficient erection during sexual intercourse), and nine men experienced “secondary impotence” (some history of successful intercourse). Masters and Johnson reported a “failure rate” of 37% for primary impotence and 22% for secondary impotence. These failure rates did not differ appreciably from the rates reported for men who were treated with their natural partners. Apfelbaum18 described an intensive, two- to three-week program in which patients received daily “body-work” sessions with a trained paraprofessional, followed by discussion sessions that were also attended by a cotherapist professional. Body-work sessions involved a progressive sequence of nongenital touching, genital stimulation, and intercourse experiences. Apfelbaum reported combined outcome data for a variety of sexual dysfunctions. Of 407 patients, 119 (29%) were rated by the cotherapists as “completely successful,” 172 (40%) were “largely successful,’’86 (2 1%)
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were “moderately successful,” 27 (7%) experienced “no change,” and 3 ( 1 5%) were “worse.” Apfelbaum did not provide separate data for erectile dysfunction. D a ~ wcombined ’~ surrogate-assisted therapy with client-centered, behavioral, insight, and cognitive techniques applied by the surrogate o r supervising psychotherapist in separate, weekly sessions. This treatment also included bibliotherapy, educational audio- and videotapes, and homework assignments pertaining to social skills, assertion, or masturbation practices. Dauw reported outcome results for 489 heterosexual clients, including 55 men with primary erectile dysfunction and 256 men with secondary erectile dysfunction. Ninety-five percent of the men were professionals or business executives. Treatment success was defined as the ability to maintain an erection until orgasm during more than 75% of coital attempts. Outcome was assessed by the surrogate’s report during treatment and by client report three months after treatment. Dauw reported a 98% success rate for primary impotence and a 85% success rate for secondary impotence. Only men who maintained gains at follow-up were judged as treatment successes. ’I’hese studies suggest that surrogate-assisted therapy can be an effective treatment for men without partners. However, because of the hazy legal status of a treatment that involves sexual interaction for a fee, the surrogate approach has not been evaluated at university-based treatment centers. For example, no published studies have included control groups or comparison treatments. T h e availability of surrogate therapy has been limited to private practice settings, where clients must afford fees for both surrogate and supervising therapist. Furthermore, surrogate therapy is only available in major population centers. One practitioner survey indicated that fewer than 2% of sex therapy clients receive surrogate therapy.20These factors have prompted the development and evaluation of alternative treatments for men without partners. Men’s Group Therapy
Several studies have evaluated structured men’s group treatment.” -“In these studies, groups of five to eight men met with two therapists for 8 to 2 1 weekly sessions. Some studies included a male-female cotherapist team,?I.zJ others included female paraprofessionals for communication roleplays,‘* and one study included both female-male cotherapists and additional paraprofessional^.^^ T h e group formats included educational presentations, group discussion, and homework exercises. T h e presentations and discussions concerned gender role stereotypes, sexual dysfunction, social and sexual communication, and sensual or sexual activities for new relationships. T h e groups also included less structured discussion concerning patient histories and current relationship experiences. Many of the groups included roleplay exercises for developing dating and communication
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skills. Some groups included bibliotherapy, films, o r videotapes pertaining to masturbation, sensate focus, or exercises for overcoming erectile dysfunction. Sexual homework. assignments included individually administered sensate focus experiences and directed masturbation sequences. T h e results of these studies suggest that structured men’s group therapy can be an effective multifaceted treatment. Among the early studies, ZiIbergeld2’ reported that two-thirds of his group members had “completely achieved their goals by the end of therapy.” Zilbergeld did not provide more precise outcome data. Lobitz and Baker2‘ found that the frequency of erection difficulties and scores on a Goals for Sex Therapy questionnaire were significantly improved following treatment. T h e frequency of erection difficulties was further reduced at a 4- to 9-month follow-up. Six of nine clients (67%)showed “noticeable improvement.” Price, Reynolds, Cohen, Anderson, and S ~ h o c h e provided t~~ the first men’s group study that included a no-treatment control group. Twentyone men with secondary erectile dysfunction were assigned to men’s groups or to a waiting list. Men’s group clients reported significantly greater improvement than did waiting-list clients on measures of sexual self-esteem and attitudes related to erectile functioning at both posttreatment and six-week follow-up. There was also a significant difference between treated and untreated clients in subjective satisfnction with changes in erectile functioning. T h e actual frequency of erection difficulties also declined for men’s group participants. However, this improvement just failed t o reach statistical significance (.05 < p < . l o ) when men’s group clients were compared to waiting-list clients. T h e 14 men who had been treated in men’s groups were then reevaluated at a six-month follow-up. T h e subjective treatment gains were maintained at this second follow-up. Ten of the 14 men (71%) reported improvement in erectile functioning. In comparison with pretreatment levels, men’s group participants reported significant increases in sexual self-image, estimates of partner satisfaction, pleasurable reactions to a partner’s sexual initiation, and the frequency of male orgasm during intercourse. In contrast, the average frequency of erection difficulties only declined from 64% of sexual encounters at pretest to 47% of encounters at the six-month follow-up; this difference just failed to reach statistical significance ( p = .06). T h e Price et al.‘3 data can reasonably support opposing viewpoints regarding the value of men’s groups. A possible negative interpretation is that men’s groups produce much larger changes in feelings and attitudes than in erectile functioning. A positive interpretation is that large changes in erectile functioning are not required for a successful outcome. In discussing their results, Price et al. noted that the group participants whose erectile functioning did not improve had typically maintained a pattern of minimal dating and avoidance of open communication with occasional artners. Therefore, Reynolds, Cohen, Schochet, Price, and Anderson‘ conducted a second study in which substantial dating skills training was added to the treatment format. Homework assignments
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now emphasized communication skills, such as initiating conversations, meeting potential partners, having time-limited dates, disclosing sexual concerns, suggesting sexual alternatives, and sharing sexual preferences. In addition, Reynolds et al. invited female therapist trainees to several sessions to practice communication roleplays with the men. This combination of sex therapy and dating skills training resulted in a significantly reduced frequency of erection difficulties and social anxiety for 11 men with secondary erectile dysfunction. These improvements were maintained at a six-month follow-up. Of 10 men who completed the followup, nine (90%) reported increased satisfaction with erectile functioning. T h e previous studies concerned men’s group treatment of erectile dysfunction in heterosexual men. Everaerd, Dekker, Dronkers, van dcr Khee, Staffeleu, a n d W i ~ e l i u s ’reported ~ on the treatment of sexual dysfunction in homosexual, heterosexual, and bisexual men who participated in men’s groups of mixed sexual orientation. This study is also unique because outcome data were reported concerning sexual functioning d u r i n g masturbation, as well as during encounters with partners. Everaerd et al.’s clients included 21 men, 15 of whom experienced erectile dysfunction. Everaerd et al. reported significant improvements o n measures concerning social anxiety, the rejection of restrictive sex morals, a n d the allowance of psychosexual stimulation. Nine of 13 men (69%)with erectile dysfunction n o longer experienced erection problems d u r i n g masturbation (two other men did not have erection problems d u r i n g masturbation at treatment onset). At a two-month follow-u , six of the 15 men (40%) reported a “complete cure,” three men (‘LO?!) reported “no or only slight improvement,” and the remaining six men (40%) reported n o new sexual interaction with a partner. Separate outcome data were not presented for men with different sexual orientations. Further scrutiny of the data for individual clients reveals that the six men who experienced a cure with partners were previously able to attain erections during masturbation at thc onset of or following treatment; n o clients with continuing erectile dysfunction during masturbation experienced a cure with partners. This suggests that intact erectile functioning d u r i n g masturbation can be of prognostic value and may also be an early therapeutic goal. Auerbach a n d Kilmann“ compared group systematic desensitization with a n attention-placebo control condition in the treatment of 16 men with secondary erectile dysfunction. Men in the desensitization g r o u p received 15 sessions of relaxation training plus exposure to a composite hierarchy of anxiety-arousing images. Men in the attention-placebo g r o u p received relaxation training alone. Both groups were instructed to practice daily relaxation. T h e desensitization clients reported a n improvement of over 40% in the frequency of succcssful intercourse, while t h e control clients reported a 3% improvement. These differences were maintained at a three-month follow-up. Scrutiny of the results for individual clients suggests that single men improved to the same extent as married men. Althou h reasonably well-controlled studies have provided evidence for the ef ectiveness o f men’s group treatment, there are several logistical
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problems with the application of men's groups in the typical therapy ~ e t t i n g . ~Many ' therapists d o not have access to a sufficient number of clients who are willing and able to attend a men's group at any one time. Furthermore, paraprofessionals for group roleplays are usually unavailable or cost prohibitive. Less than 5% of individual sex therapy clients are treated in groups.2oThese factors have prompted the continuing development of individual treatments for erectile dysfunction.
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I ndiv idua1 Therapy -1'he men's group results indicate that dating skills training is often a necessary ingredient in the treatment of men without partners. Stravynski2Rprovided an individual case report that suggests that interpersonal skills training, without sex therapy, may be a sufficient treatment for some men. Stravynski's client was a 54-ycar-old engineer with erectile dysfunction, rapid ejaculation, deficient social skills, and severe heterosexual anxiety. Stravynski's treatment included prolonged exposure in vivo and social skills training. T h e client was instructed to invite women to pubs or cafes and eventually to his home while pursuing conversation and without making sexual overtures. T h e client was also trained in positive social behaviors, such as initiating contact, showing interest, expressing pleasant emotions, expressing empathy, and initiating further contact. N o specific treatment suggestions were made regarding sexual dysfunction. During treatment, Stravynski's client reported an increased frequency of the targeted social behaviors, accompanied by reduced anxiety. An occurrence of successful sexual intercourse occurred after six weeks of treatment and was maintained at a twice-weekly level throughout a sixmonth follow-up. Changes in the social behaviors were also maintained. 13 unmarried men with a combination of sexual K u r ~ v i l l atreated ~~ reeducation, guided imagery, and directed masturbation homework. Nine men reported full erections during masturbation and imagery training, and four additional men reported partial to full erections during at least half of the masturbation sessions. A two-year follow-up of 11 clients revealed continued improvement in seven men (64%); five of the 1 1 men had married. Csillag3" conducted a comparison group study in which subjects received biofeedback of erection changes. Six men with erectile dysfunction and six nonpatient volunteers received 16 sessions of erectile biofeedback training. T h e improvement in erection response in the laboratory declined for the nonpatient group but increased for the patient group. Five o f the patients reported improved erectile functioning outside of the laboratory. However, only one of two men without partners reported improvement. Reynoldss' conducted a control group evaluation of erectile biofeedback training for 30 men with erectile dysfunction. Thirteen of the men did not have partners. In the laboratory, men who received segments of erotic film contingent on erection increases showed greater erectile
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response when instructed to facilitate erection in the absence of feedback than did men who received film segments o n a noncontingent basis. However, treatment and control groups did not differ in the amount of clinical improvement revealed at a one-month follow-up. Overall, 17 of 26 clients (65%)reported some improvement in erectile functioning, but only seven men (27%) reported considerable or complete improvement. Separate outcome results were not reported for the men without partners. Reynolds concluded that the therapeutic effectiveness of erectile biofeedback remains undemonstrated. H e speculated that the positive results obtained by Csillag"' may have been d u e to repeated exposure to erotic stimuli. I t could be argued that biofeedback of penile erection might actually increase performance anxiety by focusing attention o n erection. Less direct feedback concerning nongenital responses (e.g., finger temperature, muscle tension) might provide a better treatment for anxiety associated with erectile dysfunction. Cionini and Giovannoni3' provided a single case report in which erectile dysfunction was treated with biofeedback of frontalis muscle tension. However, Reynolds3' found that heart rate, finger temperature, a n d respiration rate did not significantly correlate with erection changes during biofeedback training. Hypnosis has been suggested as a treatment possibility for men without partners.33 Hypnotherapy techniques have included guided sexual imagery combined with posthypnotic suggestions of effortless erection a n d sensual focus,34 suggestions of association between penile rigidity and induced limb catalepsy or arm l e ~ i t a t i o n- 3, 6~ indirect ~ suggestions involving sports metaphors,37 and imagery training concerning positive selfstatements or dating a n d sexual interaction.3' Crasilneck provided outcome results for a large sample of consecutive patients treated with h y p n ~ s i s . "In ~ *the ~ ~final series of 100 patients, 87% of the men at a 12-month follow-up "werc relatively free of impotency with only occasional loss of erection" after a n average of 10 treatment sessions. However, 75% of Crasilneck's patients were married, and separate outcome results were not reported for men without partners. N o published studies of hypnotherapy for erectile dysfunction have included control groups or more objective measures of treatment outcome. However, imagery training has been included as one of several treatment components in controlled evaluations of men's groups.2"*24 Summary of Outcome Studies Outcome studies have provided evidence for the effectiveness of a variety of psychotherapeutic approaches to erectile dysfunction in men without partners. Studies of surrogate therapy, men's group treatment, and several individual therapies have reported improvement rates that range from 40% to over 90%. A number of factors make comparisons among these treatment approaches particularly difficult: First of all, patients in these studies differ
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in age, socioeconomic status, and psychiatric diagnoses. Since these characteristics are associated with treatment comparisons between studies are risky. Second, the treatment models that are described as “surrogate-assisted sex therapy” or “structured men’s group treatment” actually involve many overlapping treatment components, such as directed masturbation, social skills training, roleplays, cognitive techniques, emotional disclosure practice, and imagery training. Finally, the studies differ markedly in such design features as the duration of treatment, measures of outcome, and length of follow-up. While these considerations limit comparisons between treatments, research involving a sufficient sample, reasonable follow-up, and/or control groups suggests that a significant majority of men without partners report improved erectile functioning following surrogate-assisted or men’s g r o u p therapy. Men’s group research indicates that dating skills training may be necessary for treatment succcss, while case study evidence suggests that relationship skills training may be sufficient for some men. Individual therapy formats contain many of the same procedures as g r o u p treatment, but there are n o published control group evaluations of individual treatments that are specifically designed for men without partners. T h e r e are also n o studies that directly compare individual with g r o u p therapy for single men. Well-controlled studies have cast some doubt o n the effectiveness of erectile biofeedback training as a standalone treatment, but further evaluation of biofeedback as a treatment adjunct is warranted. Studies of hypnosis provide claims of substantial success, but these studies suffer from the absence of control groups or independent outcome assessment. A NEW TREATMENT DIRECTION T h e limited availability of surrogate-assisted and men’s group sex therapy has prompted the development of new treatment approaches that are more readily available in the more typical context of weekly individual therapy. O n e such approach is described here. Personal Potential3g is an audio cassette adjunct, developed by this author, that is designed for single men with erectile dysfunction, premature ejaculation, limited sexual experience, or sexual relationship anxiety. Personal Potential consists of 16 45-minute tapes, along with printed summaries a n d homework assignments. At the conclusion of each therapy session, the therapist assigns the appropriate tape and printed homework. A major benefit of a men’s group is that each man can learn that h e is not alone in his experience of sexual d i f f i c ~ l t i e sO . ~n~the Personal Potential tapes, five former clients discuss personal backgrounds, the experiences that led them to treatment, and their experiences in overcoming dysfunction. T h e tape format is also similar to a men’s group session. Each tape begins with a didactic presentation or a discussion with one of the former clients. T h e didactic presentations focus o n a variety of topics concerning the causes and treatment of sexual dysfunction. T h e middle portion of
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each tape includes roleplay examples for developing communication, relationship, a n d sexual skills. T h e tape concludes with a review of the sexual a n d social homework. T h e combination of components contained in Personal Potential has been shown to be effective when administered in men's group therapy.2".24T h e author is currently collecting outcome data from consecutive clients who are using the tape program while receiving individual therapy. Future studies will compare the effectiveness of Personal Potential procedures that are administered in individual, men's group, or self-help formats. T h e emergence of sex therapy procedures that are specific for men without partners highlights the potential benefits of greater interdisciplinary cooperation in the medical and psychological treatment of erectile men can be taught self-injection of intrad y s f u n c t i ~ n . ~For ' ' ~ example, ~ cavernosal vasodilator medication^,^^ but this method may be of limited value for single men who lack the interpersonal skills for establishing intimate relationships or for effectively communicating with new partners about self-injection. T h e regular evaluation and treatment of social a n d communication deficits in men without partners might also increase both the use a n d effectiveness of penile implants44and vacuum constriction device^."^ REFERENCES 1. Masters W H , Johnson VE: Human sexual inadequacy. Boston, Little, Brown, 1970. 2. Kaplan HS: The new sex tlrrrapy Actziv treatment of sexual dysfunctions. New York, Rrunner/Mazel. 1974. 3. H a r t m a n WE, Fithian MA: Treatment of sexual dysfunction: A biopsychosocial approach. Long Beach,
