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RESTORATION OF INTIMACY
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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