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Peter J. Fagan, Ph.D.,
Director of the Sexual Behavior Consultation Unit
The Johns Hopkins School of Medicine Hospital

Erectile dysfunction (ED) most often has a physical cause and today, thanks to Viagra and other non-oral treatments, the physiological aspects of ED can be treated successfully. However, without also addressing specific issues of intimacy between a couple, a critical component of a man's emotional and sexual life, these treatments will take that man only so far. Sex involves two people whose feelings must also be recognized. Many men often shy away from talking about their sex life in general, and ED in particular, for a variety of reasons, including embarrassment, frustration, even fear. When a sex life has problems, emotional estrangement can quickly occur. Dealing with the problem, in all its complexity, is the only way to assure that the problem is solved to the mutual satisfaction of both partners.

Without an emotional connection to your sexual partner, you won't develop the deep, satisfying awareness that defines great sex. For those of you who took your sex lives for granted prior to your cancer, this is a golden opportunity. Not only do you have available the means to restore your sexual function, but by talking to your partner about your sex life together you can also bring new emotional perspective to your relationship, creating a stronger, more resilient bond that will enhance your sexual experiences as well as those of your partner.

Facing the many psychological reverberations that ED causes in men and their partners after a prostate cancer procedure is a very important part of treating the condition successfully, which is why sexual counseling can play a critical role.

Q. What are the best ways to initiate change in one's sexual relationship?

A. Talking with your partner is the biggest step you can make since it's never easy to admit that your sexual relationship needs help. Modifying it takes work and time, but knowing those areas that are giving you and your partner trouble will make it easier. You always need to keep the lines of communication open. It's paramount that you speak frankly with your partner about your condition. Be honest about your feelings, sexual needs, and desires. If you both come to agree that counseling is the right course, your partner needs to be part of the process.

Q. When does someone need counseling?

A. When it starts to hurt too much emotionally, whether it be the man or his partner. The earlier a couple seeks counseling, and I like to see couples, the better the results will be. Most of the patients I see have had their surgery nine to 18 months before. In that period, the first nine months especially, the couple was being patient but then when the erections did not return as before, they began to get worried and wanted answers.

If you find that you cannot satisfactorily resolve your problems, I urge you and your partner to seek additional help. Hopefully, you will find that sexual counseling can be an effective way to strengthen and deepen a relationship while regaining lost pleasure.

Q. What type of medical professional should a couple seek?

A. If there is a department of sexual health connected with the psychiatry or urology department at a major teaching hospital, call and ask for a referral. If not, check your county medical society or state psychological association. You want a mental health professional who is experienced in sexual dysfunction and related disorders, and has treated post-surgical prostate patients or has had some experience with patients with a chronic illness.

Q. How long do you recommend that a couple stay in counseling?

A. For the uncomplicated post prostatectomy couple, with the strengths and weaknesses of most couples, I would estimate about two to three months of weekly sessions. I describe the therapy as an ongoing retreat, a period that will allow them to work closely together. It's a privileged time where they can step back, reassess, and see what they can do to make things better.

Q. What is the general emotional state of the male undergoing counseling?

A. The Hopkins prostate cancer patient already understands that the surgeon has three major goals, in the following order: stop the cancer, prevent incontinence, and spare sexual function. Patients are aware of this. The couple that has had minimal sexual activity will not be too traumatized at the loss of erection. However, if sex played a significant part of their relationship, it will be a much greater loss and require more counseling.

Q. What are your goals as a therapist?

A. What I hope will happen is the creation of as much intimacy and sexual expression as possible between the couple. Even if it is not possible to achieve sexual intercourse, it is still possible for sensual pleasuring to take place and I make this clear to the couple. If the man had previously thought that sexual intercourse was the end point in a sexual relationship, I invite him and his partner to now write new sexual scripts for themselves. This works to diminish sexual estrangement between the couple.

Q. Is it difficult for a man to review his sexual history with a therapist?

A. Most couples have difficulty talking to each other about their sexual life. Granted, they can talk about sex in general, for example, sex in the news, but when it comes down to the man and his partner, it's often a challenge to talk about their sexual wishes and concerns. Therefore, it really comes down to the level of comfort that's established by the therapist with the couple. "I'd like to get an understanding of how sex has been for both of you," is a typical non-threatening question asked of the couple in the first session. With each one answering in turn, an easy dialogue is created that should carry over for the rest of the meetings.

One of the things I ask couples soon after we've met for a few sessions is why they have intercourse. "Pretend I'm from Mars," I'll say. "Why do you humans do this sex thing?" Oftentimes, through this ensuing dialogue, the couple comes to realize that it's more than an erection, more than orgasm, that sexually attracts them to each other. I will ask the man and his partner to look inward and bring out into the open issues that may have been waiting beneath the surface. To make their bond stronger, to create a trusting atmosphere that will foster growth, to progress to a mutually-fulfilling relationship, the couple has to find out how each one really feels about sex. This can encompass everything from the meaning of sex in their relationship, and their reactions to utilizing ED therapies, to their degree of personal sexual satisfaction, identifying sexual problems, and anxieties related to intimate matters.

Q. If sex was a big part of a relationship, will the relationship be permanently broken if erections don't return?

A. Sex is frequently made to carry more of an emotional burden than it should. A therapist has to first see how the couple is handling the death threat imposed by the cancer. This means that the couple has to come to terms with what the cancer has done to their lives. Even though the prognosis is often good following a radical prostatectomy, 99.9 percent of the couples are still jarred by a cancer diagnosis. A woman has been forced to picture herself as a widow, while the man has had to come face to face with his mortality. A couple that comes in for treatment may be totally focused on their sexual life and don't typically say they're suffering from the angst of dealing with mortality. it must be recognized in order for true healing to take place. They then need to be able to find joy in their lives together again. They need to be grateful for the days, for the time that they have together, taking the baseline that is there in terms of intimacy, the emotional as well as sexual, and build on it to make it even better.

Q. How do you counsel the man who is devastated by his inability to get an erection?

A. If the man is really depressed about his inability to achieve an erection, then he will need special care. Treatment for this depression includes medication, counseling, or a combination of both. These treatments not only improve behavior and mood, they also reduce suffering and enhance quality of life.

Family and friends are usually the first to notice the changes in behavior and mood, and should encourage the man to seek the evaluation of a doctor or mental health professional when symptoms are severe or last for two weeks or longer. Some symptoms to look for include a persistent sad or 'empty' mood, loss of interest or pleasure in ordinary activities, fatigue or loss of usual energy, sleeping problems, including insomnia, early waking or oversleeping, loss of appetite or overeating, difficulty concentrating, remembering, or making decisions, and feelings of guilt, worthlessness or helplessness.

Q. Does the difficulty or inability in achieving an erection bring about a sexual reawakening in some men?

A. Yes, it does. Some men have been so intercourse-oriented that they never really understood the power of romance and what intimacy really meant for their partner. Without being able to have an erection or to sustain one as before, they soon come to realize that something as simple as a hug or gentle back rub or massage helps firm the intimate bond between the couple.

Q. What are the best ways to get back in synch sexually?

A. Synchronizing your sexual longings with those of another person will reward you over and over again. If you or your partner has a sex drive which has slackened off, you owe it to yourselves to find ways to build it up again. This has to be a joint venture; if one person is in the mood for sex and the other isn't, then there obviously is going to be a no-win situation. Finding that mutual connection takes time and thoughtfulness. One of the best, and mutually satisfying ways to rekindle a sex life is to rediscover the pleasures of touching. I make use of a structured program with couples called sensate focus therapy and find that it gradually leads to a sensual and sexual rapprochement over time.

Q. What are the basics of sensate focus exercises?

A. Sensate focus exercises, developed by two noted sex therapists, Drs. William Masters and Virginia Johnson, is a way to explore various parts of your body including your head, hair, face, ears, and neck; your chest, breast, nipples, abdomen; your back, buttocks, arms, underarms, hands, fingers, legs, feet and toes. Exploration can include using different kinds of touch with the hands, such as stroking, rubbing, and squeezing. You can also use different kinds of touch with your mouth, such as kissing, nipping with your teeth, or sucking.

The goal of these fun, sensate exercises is to emphasize intimacy and pleasure without pressuring anyone to have intercourse. Partners need to zero in on touching, one of the most powerful components of human sexuality. Using tactile communication, including kissing, caressing, and petting, just as you did in early courtship, will help you to reexplore sexual sensation and bond you together. Communicating with your partner through increased touching is one of the most effective means to expand intimacy and add vitality to a sexual relationship. Many couples find that giving each other a massage is a great way to enhance their mutual attraction as well as boost libido.

Q. What are some basic sensate focus exercises?

A. First, the couple needs to schedule time for each other. Plan blocks of time, within your regular schedule, when you are both relaxed and comfortable. Working as a team is paramount. By this, I mean that partners who share the goal of regaining sexual function are most likely to succeed. By working with your partner and therapist, you have the best chance of regaining complete sexual fulfillment.

Begin by setting the scene in a romantic manner - soft music, candlelight, complete privacy. Plan on not attempting intercourse but simply on exploring each other's bodies in a relaxed and pleasurable way. The initial focus exercise begins with both partners taking turns, each one being totally receptive for 15 minutes or so while the other explores, stimulates, and caresses all parts of the body except genital areas and breasts. If you like, lotions, powders, feathers, oils, and a vibrator may also be used. I ask my patients to come together for these exercises two to three times a week and then I want them to talk about their experiences in our next weekly session. This discussion helps them come to grips with the man's physical and emotional state as well as how the partner deals with it as well.

Q. Is it difficult to convince a resistant man to create new sexual scripts?

A. ED is really a couple's issue. It's a question of the couple being educated about various options and then, being respectful of their esthetics and values, having them understand that they are being given permission to broaden the sexual scripts, to have more variety than there might have been. The couple has to come to realize that it's this sensual pleasuring of each other that can preserve, restore, and enhance the intimacy between them.

Q. What have been the typical responses from patients after completing a full counseling session?

A. Uniformly, they are grateful for having done it because communication and intimacy have improved. How things actually work out sexually, depends on the pre-cancer sex baseline, how often and how satisfying sex used to be, and secondly, the effects of the surgery on their sexual performance. Even if there is not a return to baseline, I think most couples feel the counseling is extremely beneficial because it helps cement their intimacy and lets them come to terms with their new physical reality.

Peter J. Fagan, Ph.D., past President of the Society of Sex Therapy and Research, is currently the Director of the Sexual Behavior Consultation Unit at The Johns Hopkins School of Medicine Hospital. Dr. Fagan is also the associate editor of the Journal of Sex Education and Therapy. He lectures extensively on sexual intimacy issues.

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