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2004 May/June (1)

Friday, 02 January 2009 11:24

Beyond Viagra

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Beyond Viagra

Why the Promise of Cure Far Exceeds the Reality

by Barry McCarthy

At 52, Alex was worried about the state of his penis. He missed the easy, automatic erections he once had and sometimes was mortified by his inability to be hard enough to engage in intercourse. With every such "failure," he felt his sexual confidence waning. Alex was sold by the Viagra ads on TV and went to his internist, who was more than willing to give him a free sample of pills.

The first three times Alex took Viagra, it worked as promised. "Whew," Alex thought, glad he hadn't raised this touchy issue with Lorraine, his wife of 28 years. He felt he shouldn't have to talk about sex; he'd always been a take-charge kind of guy, who certainly had never had any problems on this issue, thank you very much.

But the fourth time Alex took Viagra, he got an erection and was able to insert, but he promptly began to lose his erection and felt very panicky. Lorraine tried to restimulate him, but Alex pushed her away. This wasn't supposed to happen. How could the "miracle drug" not work for him? It had to be Lorraine's fault.

The Truth About Erections

Adolescent and young-adult men learn that erections are easy, automatic, and most important,  autonomous. They can experience desire, arousal, and orgasm without help, or even active cooperation, from their partners. Alex subscribed to the common belief about male sexual performance on demand: "A real man is able to have sex with any woman, any time, any place."


The Viagra media blitz both feeds and amplifies this male performance standard. The blue pill, the ads suggest, will restore to you the automatic, autonomous, rock-hard erections of your twenties. But even for successful Viagra users, 20 to 35 percent of the time, the drug doesn't work. More striking still, the estimated dropout rate for Viagra within a year is between 40 to 80 percent of users. This is caused by unrealistic expectations of returning the man to 100-percent guaranteed erections. Medication cannot be a stand-alone intervention. As with so many one-shot, simplistic solutions to human emotional problems, the promise of cure far exceeds the reality.

The real news

behind the Viagra sensation is what it says about men's misunderstanding of their own sexuality as they age. Young men can and often do get erections quite suddenly and unexpectedly, simply when a good-looking body swims into view or a sexual fantasy wafts through their brains. They don't need the stimulus of physical touch to become aroused. Middle-aged men expect the libido of young studs long past the time when their bodies can keep up the pretense.

Contrary to media myths, movies, and male braggadocio, sex is seldom 100-percent successful, especially as men age. The most important fact for our sex-saturated society to accept is that 5 to 15 percent of all sexual experiences among well-functioning couples are dissatisfying or dysfunctional. In other words, contrary to the cultural myth of ecstasy all the time as the norm, almost all happy, sexually fulfilled couples experience lousy sex occasionally.


Unfortunately, men who haven't gotten beyond the equation of sex = erection = intercourse become more vulnerable to sexual dysfunction as they age. Often, like Alex, they're only one or two flagging erections away from feelings of sexual inadequacy. Indeed, for men, the largest factor causing inhibited sexual desire is fear of erectile failure. By a certain age, men need to learn what most women already know: good, satisfying, pleasurable sex, particularly in midlife and beyond, is more a matter of intimate teamwork than of physical hydraulics.

Once "the machine" fails to function a few times as it always has, confidence in the normal cycle of positive anticipation, satisfying sex, and a regular rhythm of sexual contact is lost. Instead, a new, more pernicious, cycle takes its place: anticipatory anxiety, tense and failed intercourse performance, embarrassment, and sexual avoidance. The man becomes an anxious, self-conscious, sexual spectator, the worried and passive observer of his penis--a state of mind that's the very antithesis of eroticism.

Developing Teamwork

It was at this juncture--post-Viagra failure--that Alex and Lorraine, at Lorraine's insistence, came to see me, a couples therapist with a subspecialty in sex therapy.  As often occurs, Lorraine was more enthusiastic about addressing the sexual problem than Alex. He felt embarrassed, ashamed, and demoralized. In the first session, I normalized both the erectile dysfunction (ED) and his experience with Viagra.

Alex was used to being the expert, not the one seeking help, especially from Lorraine. Yet Lorraine was more than willing to help resolve this problem, as long as Alex didn't blame her for the ED. She enjoyed sex and wanted it to be a part of their lives. She missed not just intercourse, but the whole range of sensual, playful, and erotic experiences that went with it. At the end of this session, I gave them a chapter from Rekindling Desire , which I wrote with my wife, Emily, to reinforce the need for them to work together in the face of a common enemy: inhibited sexual desire and performance anxiety.


After the initial couples session, I see each person for one individual sexual-history session to tell his/her story of their psychological and sexual life. Then we have a couple-feedback session.

From those sessions, I developed a therapeutic plan aimed at revitalizing desire and helping Alex regain confidence in his erections. Alex needed to stop seeing sex as a competitive performance--in which Lorraine's existence and sexual feelings were almost incidental--and begin approaching his wife as his dearest, most intimate, friend, with whom he could share pleasure, eroticism, and arousal.

Alex had always felt that he shouldn't have to have his penis stimulated by Lorraine--his erection should be sufficient unto itself. I told him he'd need to be open to her penile stimulation. Even more potentially alarming for a man who so valued his own sexual self-sufficiency, Alex needed to learn to piggyback his arousal on Lorraine's arousal. Alex began to learn that it was both normal and manly to use the "give-to-get" pleasuring guideline, so that the more responsive and aroused she was, the more aroused he became. This was good news for Lorraine, who'd been afraid to let herself get too aroused for fear Alex would feel even more pressured to perform. I pointed out that a woman's arousal can be a major aphrodisiac for the man. The key to achieving change was Alex's willingness to try new ways of thinking about and experiencing sexuality, and Lorraine's enthusiasm for renewed intimacy and eroticism.

I asked Alex to tell Lorraine the emotional, physical, sexual, and interpersonal factors he found most attractive about her. Then he was to make one to three requests--not demands--that would make her more attractive to him. The next day, they were to switch roles, and Lorraine would do the same with Alex.


Alex told Lorraine that he appreciated her spunkiness, her interest in working with him to revitalize their sexual life, her work skills, her help in caring for his mother when she was dying, and her staying in good physical shape and carrying herself in an attractive manner. Making requests was harder for Alex. His three requests were to give penile stimulation before he had to ask for it, to be sexually receptive and responsive, and to not talk about sexual problems when in bed. Lorraine enthusiastically agreed to them.

Lorraine wrote out the characteristics she found attractive about Alex. Alex had developed such a negative sexual self-esteem, it was difficult to accept Lorraine's genuine compliments. From this exercise, Alex realized how contingent on performance his sexual self-esteem was.

Alex was surprised by Lorraine's first request--to remember her birthday and plan something special--but was quite willing to do this. The two sexual requests that followed--that Alex shower before a sexual encounter so that oral sex would be more inviting and that he not apologize if they didn't have intercourse, but to just hold her--were more difficult for him. Alex realized with surprise that he had no idea that these three issues bothered Lorraine. But as he thought about it, they really were pretty easy requests to fulfill. At this stage, both Alex and Lorraine felt more positive and hopeful, realizing this wasn't an adversarial process; they could be on the same intimate team.

Lorraine had previously only achieved orgasm occasionally during intercourse. I suggested they refrain temporarily from having intercourse, and encouraged them to explore erotic stimulation to orgasm. She reported that she enjoyed the pleasuring exercises she and Alex were trying and found it considerably easier to reach orgasm, and they were more intense and satisfying than those she'd experienced during intercourse. Alex was ambivalent about these developments. He was glad that he could please Lorraine sexually, but afraid that she might not enjoy intercourse as much as he. I assured Alex (and Lorraine reinforced this) that intercourse would continue to be an integral part of their sexual relationship. The problem wasn't intercourse, but Alex's pass-fail approach to it. The goal of therapy was, in part, to help him realize that there was more to making love than successful intercourse.


Alex was enjoying the pleasuring exercises, especially the comfort exercise, in which they engaged in playful (mixing nongenital and genital) touch in the living room with music on but no talking. The hardest thing for Alex to accept was that instead of being the Lone Ranger, he enjoyed and even needed Lorraine's stimulation.

The most helpful exercise was the "wax and wane erection" experience. When Lorraine stopped manually or orally stimulating him, Alex's penis would become somewhat flaccid. While this sent him into a panic at first, after coaching in therapy, he let himself simply relax and allow Lorraine to begin stimulating him again until his erection came back. The realization that relaxation was a more powerful erection enhancer than force of will was itself reassuring.

We reintroduced intercourse into Alex's and Lorraine's sex life at the sixth therapy session. I emphasized that intercourse wasn't the preeminent goal of sex, but a natural (though not inevitable) extension of the pleasuring/erotic play/arousal process. The experience now was far different from their previous pattern of foreplay before intercourse, in which Alex paid less attention either to Lorraine or to his own erotic sensation than he did to the problematic state of his penis. Once Alex accepted that Lorraine's arousal could be an aphrodisiac, he let go and was involved with the erotic flow, piggybacking his arousal on how sexually excited, aroused, and orgasmic she was. Lorraine's being highly aroused with Alex's stimulation was a powerful erotic stimulant.


Bridges to Desire

An important component in sex therapy is helping couples do what I call "building bridges to sexual desire--his, hers, and theirs." Bridges to desire means discovering individual cues, places, and scenarios that are sexually inviting for one or both partners. Alex was so used to the idea that the signal that he wanted sex was his erection that the concept of planning sexual dates or consciously inviting sexual encounters was foreign to him. Lorraine took the lead in setting the mood to be sexual. She compared making a sexual date to preparing to attend a play you really want to see: you plan for it, you set aside time to do it, you look forward to it, and, chances are, you enjoy actually doing it.

One of Lorraine's favorite "bridges to desire" was to shower with Alex and have a lit, scented candle in their bedroom. Alex's favorite bridge to desire was cuddling on the couch and becoming more and more turned on before moving into the bedroom. The bridge to desire they both enjoyed the most was a weekend away, especially to a romantic B&B with access to hiking trails. The different environment was a major desire cue for Alex. He liked variety and new challenges in other aspects of his life, and came to understand that was true sexually as well.

Now Alex was beginning to gain a more realistic sense of middle-aged sexual expectations. In one of our last sessions, Alex announced proudly that, a few nights previously, they'd not been able to finish intercourse but, for the first time in his life, he felt okay about it. He comfortably laughed it off and went to sleep cradling Lorraine in his arms. He and Lorraine were enjoying a broader sexual repertoire, and he valued a richer, deeper sexuality, even if it didn't always lead to intercourse.

Couples who are comfortable with their sexuality can genuinely value erotic play that leads to high arousal and orgasm for one or both partners, as well as sensual scenarios--mutual massage or close cuddling--that allow warm, loving, physical encounters without involving arousal or orgasm. Sharing intimacy, pleasure, and eroticism makes sexuality more human and genuine. The man who accepts and values a variable, flexible approach to sexuality in his fifties will inoculate himself and his marriage from sexual problems in his sixties, seventies, and beyond.


This isn't to say that medical interventions to facilitate erections and intercourse shouldn't be used. There are times when men are so anxious that they can't relax, even with coaching. Until the process of allowing their erections to wax and wane comes more naturally, Viagra can be used and integrated with pleasuring exercises as a backup resource. But these medications will only work--in the sense of contributing to a richer, more satisfying sex life--if a man values sharing intimacy and eroticism in both intercourse and nonintercourse sexuality.

The man who has a more spacious, healthy understanding of sex knows that it involves two people, not two sets of sex organs (with his clearly the most important). Sexuality is as varied as human interaction in general, encompassing many daily, intimate moments of tenderness, sensuality, pleasure, and mutual teamwork with a beloved mate and friend, not just the culminating drama of intercourse. Real-life, adult sex isn't a kid's game--it can be really well played only by men who've gained some wisdom and experience about the world and themselves, even if their penises are no longer the envy of the locker room.

Case Commentary

By David Treadway

While it may not be true that men's brains reside in their penises, their fascination with their own performance in the bedroom often gets in the way of the shared experience of sexuality with their partners. One woman in my practice said it very succinctly to her husband: "I feel like you're more involved with your thing than you are with me."


Barry McCarthy's discussion of his excellent work with Alex and Lorraine gets to the heart of the matter. Middle-aged men who are naturally losing some of their performance abilities may be drawn to some quick pharmacological fix, but, ultimately, they need to learn that sexuality isn't about performance. In fact, boys of all ages need to learn this message. As women become freer to express their own sexuality, performance anxiety in men is skyrocketing, and even college men are having more instances of erectile dysfunction.


Both men and women need to understand that men's preoccupation with their sexual performance isn't simply about testosterone and narcissism. Boys still are being socialized in latency to master and deny their neediness, vulnerability, and insecurities. When they go through puberty, all those socially unacceptable and repressed feelings suddenly assert themselves relentlessly below the belt. The tender feelings that little boys have are transformed into the insatiable demands of the ever-present erection. Thus the often voracious sexuality that drives boys and men, frequently experienced by women as impersonal and hurtful, is really an expression of the same yearnings that women bring to relationships: the desire to be seen for who one truly is; the wish to love and be loved without shame.

In teaching Lorraine and Alex how to truly make love with each other, McCarthy is really helping them risk being vulnerable, needy, and insecure together. Alex's fear of Lorraine's disapproval or disappointment and his reluctance to discuss these things with his wife are the real issues. Unfortunately, many men still presume that they're supposed to be skillful sexual partners without ever consulting their partners. Why does it take over a million sperm to fertilize just one egg? None of them will stop and ask for directions.

I confess that Alex and Lorraine's willingness to take direction in the couples therapy and do their therapy homework did give me a case of client envy. My clients frequently have difficulty doing their therapeutic homework, particularly in situations involving sexual intimacy. It would have been useful in this case if McCarthy had added a little more discussion about how Alex, who'd been very private and unilateral in his approach to sexuality, became such a willing participant in the exercises, both with Lorraine and in discussions in front of the therapist. Clearly, McCarthy joined with Alex very skillfully, and I wanted to see a little more how he did that. Unlike the doctors in white coats measuring blood flow with electrodes and prescribing medications, McCarthy is practicing sex therapy based on a strong therapeutic connection that's based on healing the couple's relationship. The case is a helpful demonstration of the limits of pharmacological solutions. Ultimately, it's not Viagra: it's the vitality of relationship that makes a difference in the bedroom.

Despite all the obvious distinctions between men and women, our hearts share the same fears and yearnings. Learning how to hold each other's hearts tenderly is the art of lovemaking.


Barry McCarthy, Ph.D., is a professor of psychology at American University and practices at the Washington Psychological Center. He's the coauthor of Rekindling Desire: A Step-By-Step Program To Help Revitalize Sex . Address: AU Psychology, 321 Asbury Building South, Suite 321, 4400 Massachusetts Avenue, N.W., Washington, DC 20016. E-mails to the author may be sent to

David Treadway, Ph.D., is director of the Treadway Training Institute in Weston, Massachusetts. He's the author of Before It's Too Late: Working with Substance Abuse in the Family and Dead Reckoning: A Therapist Confronts His Own Grief . Address: 228 Boston Post Road, Weston, MA 02493. E-mails to the author may be sent to

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