“Couples are wholes and not wholes, what agrees disagrees, the concordant is discordant. From all things one and from one all things.”
Heraclitus of Ephesus (540–480BC)
These words illustrate the complexity and necessity to consider a couple as a whole; nevertheless respecting each individual. There has been limited research on sexual dysfunction in the couple, and on the sexual functioning of one member of the couple influencing the libido of the partner.
Studies on Sexual Dysfunction
“Couples are wholes and not wholes, what agrees disagrees, the concordant is discordant. From all things one and from one all things.”
Heraclitus of Ephesus (540–480BC)
These words illustrate the complexity and necessity to consider a couple as a whole; nevertheless respecting each individual. There has been limited research on sexual dysfunction in the couple, and on the sexual functioning of one member of the couple influencing the libido of the partner.
Studies on Sexual Dysfunction
Traditionally, sexual dysfunction clinical research has focused on erectile dysfunction (ED), and on men’s experiences of ED and the improvements to their sexual function following treatment. More recently, research has begun to look at female sexual dysfunction, and the issue of ED and its treatment from the woman’s perspective has also been addressed. Some studies have assumed that ED is a shared sexual dysfunction that is distressing for men who experience the condition as well as for their partners,1-3 and have examined the adverse effects of ED on a female partner’s sexual functioning and sexual satisfaction.4-6 The Index of Sexual Life (ISL) questionnaire was developed and validated by Chevret et al. to measure a woman’s sexual satisfaction and desire in relation to her partner’s ED.2 Findings indicate that the partners of men with ED reported a significantly decreased sexual drive and sexual satisfaction compared with those women whose partners did not have ED.7 Studies that have explored female sexual dysfunction suggest that women partners of men with ED are themselves more likely to have sexual dysfunction or to cease sexual activity entirely.3,5,8,9 A study comparing the views of female partners of men with ED (organic and non-organic) found that dyspareunia and vaginismus were more common in female partners of men with non-organic ED.10 More recently, the sexual experience of female partners of men with ED has been examined, alongside a male study.11 Women reported engaging in sexual activity much less frequently after their partner developed ED in comparison with before. Moreover, significantly fewer women experienced sexual desire, arousal or orgasm ‘almost always’ or ‘most times’, and the majority of women reported dissatisfaction with their sexual relationship after their partner developed ED. Decreases in female sexual satisfaction and frequency of orgasm were related to the male partner’s self-reported severity of ED. The proportion of women who experienced sexual desire, arousal and orgasm ‘almost always’ or ‘most times’ was significantly higher in the group whose partners were currently using a phosphodiesterase type-5 (PDE-5) inhibitor. Moreover, a randomised study has been published concerning the quality of the sexual life of couples affected by ED using PDE-5 treatment, which showed that erectile function in men with ED, subjective arousal, lubrication, orgasm and satisfaction in untreated women partners and overall quality of sexual life improved together.12,13 ED management should therefore include both partners.
Initiating Discussion with the Patient and Involving the Partner
Regardless of the obstacles or impediments to the discussion, physicians involved in ED ought to try to address any sexual and relationship concerns that exist between patients and their partners. The immediate goal should be to initiate an in-office dialogue with the patient. Later, by including the patient’s partner in the treatment plan, the broader goal of enhancing or restoring patient/partner intimacy can become the primary focus to support and augment the effects of treatments. Of equal value and necessity is the involvement of the man’s partner in both the assessment and treatment processes. As many men hesitate to bring sexual problems to their physician’s attention, it is sometimes the partner who is the initial source of information about a man’s ED. This fact underscores the importance of interviewing both the patient and his partner. It is also difficult to identify and address all the etiologic and maintaining factors by speaking with only one of the partners. In obtaining a history from the respective partners, factors that contribute to ED can be identified as follows.
- Predisposing factors, e.g. restrictive upbringing, disturbed family relationships or traumatic early sexual experiences, which may make a man more susceptible to ED.
- Precipitating factors, e.g. dysfunction in the partner, discord in the relationship, depression or anxiety, which may have triggered the onset of the problem.
- Maintaining factors, e.g. performance anxiety, discord in the relationship, fear of intimacy, impaired self-image or poor communication, which maintain the problem.
For some couples, ED maintains an unspoken, but mutually preferred, ‘sexual equilibrium’, i.e. it serves a function within the relationship, such as regulating intimacy or allowing blame for marital failure to be shared. It also allows the couple to avoid facing concerns about the dissatisfaction of one or both partners with their sexual relations, such as when intercourse has become mechanical or boring. When such dynamics are in play, correcting the man’s ED will not result in sexual or relationship satisfaction. If anything, the couple will find some way to fail the treatment or minimise the success of the therapy. Even when pharmacological treatment of ED results in resumption of firm erections, relationship problems can thwart a successful outcome. It is therefore important that physicians take into account the significance and the complexity of the couple’s dynamics in the development of a treatment plan. Not only must physicians determine the onset and duration of ED, the events surrounding it, the frequency of attempted and successful intercourse and the complete inventory of sexual partners, but also do so within the context of a couple’s relationship.
Managing Erectile Dysfunction – a Multidisciplinary Approach
Data support a multidisciplinary approach to the treatment of ED.14 As noted earlier, with the availability of PDE-5 inhibitors for the treatment of ED, quality of life for both partners could be improved in prescribing such medications. However, it is not always possible to obtain these results in ‘real life’ due to the heterogeneity of couples and psychological resistance that interferes with the effectiveness of the intervention. Psychological counselling, use of therapies for anxiety reduction and desensitisation and cognitive behavioural intervention, etc. could be useful for restoring intimacy.
The Future
There is a need of specific enquiries to assess the impact of ED on female partners in terms of their own sexual attitudes and response to their partner’s ED. Only one of seven enquiries reviewed by Chevret et al. during development of the ISL questionnaire offered in-depth coverage of female sexual attitudes and behaviour. Efforts to understand female attitudes, experience of ED and beliefs have also been hampered by the difficulties of communication between men with ED and their female partners, as identified in the ‘Strike Up a Conversation’ study.1 Ideally, a perfect enquiry would assess the success of treatment and improvement in quality of life of the couple, but more interestingly would also permit the analysis of failures of a given therapy in helping to choose other therapies better adapted to patient and partner profile. Another point is to respect each individual in trying to restore a couple’s harmony, because in a couple there are three specific entities: the man, the woman and the couple. ■
