Is Viagra enough? broadening the conceptual lens in sex therapy with (Heterosexual) men: a case report.

To the extent one equates male sexual satisfaction with unyielding erections and more enduring sexual performance, one cannot imagine a better historical era than one that offers the seemingly perfect medicinal answer to age-old male insecurities. Unfortunately, the medicinal "miracle" of sildenafil citrate is fraught with insidious hidden problems for many men. This article presents a clinical case that illustrates this matter and highlights the multiple levels of needed intervention. It addresses the benefits and hazards of therapy interventions that treat male body parts without exploring the broader social and relational contexts.

Keywords: masculinity, medicalization of sex, nonrelational sex, sex therapy, Viagra

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Based upon the enormous popularity, physiological safety, and proven effectiveness of sildenafil citrate (Viagra[TM]), (1) strong arguments can be made that this medication should be considered a modern miracle drug. Most recent estimates place the number of male users at more than 6 million, with drug companies hoping to boost usage to more than half of the 60 million men over age 40 (Tuller, 2004). Since its introduction in 1998, sildenafil citrate has proven to be quite effective and relatively free of once-feared side effects (BachDiello, 2003). There can be little doubt that this drug has radically altered treatment for male erectile dysfunction and seems to have provided the best answer yet to the "pursuit of the perfect penis" (Tiefer, 1986).

Despite its phenomenal impact upon the lives of many, this modern "wonder drug" has raised serious concerns among a variety of sexologists, psychologists, feminists, journalists, and others. These concerns are less about specific physiological properties of the medication itself and much more about its key role in a larger sex therapy industry that is often misguided and harmful.

For example, Tiefer (1986, 2001) views Viagra as only the latest development in a longstanding trend toward "medicalization" of sexuality, a pattern she describes as harming women both through omission and commission. She argues this trend commits harm to women through "sexuopharmacological" solutions to sexual problems, a pattern that leads to a "comical infinite regress" (2001, p. 39) of more and more medications and their subsequent side effects. Additionally, this reductionistic pattern of over-focusing upon the functioning of the genital organs also generates harm through omission. Here, Tiefer identifies the overvaluing of sexual performance and the almost complete lack of attention to "the relational aspects of sexual experience" (p. 39).

Kleinplatz (2004) comments that "the discourse in sex therapy is increasingly dominated by 'the language and imagery of machines in disrepair'" (p. 215). In her clinical work, she has observed that the "prevailing Viagra-super mindset" may produce rigid erections, but it also produces substantial problems for sexual partners through "reductionism, desensitization, alienation, fragmentation, and mechanization" (p. 215).

Other feminists (see Ellison, 2000; Irvine, 1990; Stock, 1988) have been sharply critical of many of the dominant values of the sex therapy field, for which Viagra is only the latest manifestation. As one reviews the criticisms of sex therapy as sexist, patriarchal, and phallocentric, one is tempted to assume that this matter is primarily of concern to women. Although feminist voices have been the leading edge of these critiques, there is a growing awareness of the need for re-thinking how dominant discourses of sexuality and sex therapy are also harmful to men (Brooks, 1995; Kimmel, 1991; Levant & Brooks, 1997; Zilbergeld, 1999). These authors challenge conventional assumptions that male sexuality is relatively straightforward and problem-free. They argue that many aspects of male sexual socialization are problematic and profoundly harmful to men's capacity for sensuality and interpersonal connection. Sex therapy, they believe, cannot be left to its customary focus on simply finding ways to create better erections. It must also examine the broader issues of the role of sexuality and intimacy in men's lives. This article will illustrate this crucial perspective by presenting a common clinical scenario that demonstrates the problems of conventional reductionistic sex therapy.

This clinical case has been particularly interesting to us because it unfolded in a manner reflecting successive levels of complexity, a pattern common in our work with men. Our therapy has more commonly been with heterosexual men in couple relationships, and this case is reflective of that trend. Although some of the issues, of course, would be different for work with gay or lesbian couples, many would be quite similar. In general, we have experienced men to be more comfortable presenting issues of biological functioning and less willing to see the connection between body and psyche. Even more disquieting for them is when we attempt to help them see the presenting problems in relational context, that is, to broaden the focus from individual to couples counseling. Finally, we have commonly found that most men benefit greatly when we are able to incorporate the widest conceptual lens, helping men see their problematic issues in the context of contemporary masculinity and their role in the culture of masculinity.

RANDALL C.: SEX THERAPY OR RESHAPING MASCULINITY?

Randall C. considered himself to have been a reasonably successful corporate executive, caring father, and generous contributor to his church and community. Entering his mid-50s, he was generally pleased with his physical health, although he was overweight, exercised less than he wished, occasionally drank too much, and sometimes slept erratically. Married to Rita since his early twenties, Randall believed his marriage was happier than most. Although he occasionally joked about the sexual boredom and "lackanookie" prevalent in long-term marriages, he privately realized the decline in marital sexual activity was partially related to his decreased sexual arousal, anxiety about the decreasing rigidity of his erections, and occasional bouts of impotence. Rita never complained, and they rarely discussed their diminishing level of sexual activity. Randall sensed Rita desired more affection and emotional connection, but he assured himself that loyalty and emotional security were far more important than "trying to screw like porno stars."

The situation in the household remained reasonably stable until Vicki, the youngest of their three children, left home to attend college. Randall coped with the situation with higher levels of work involvement, but Rita found this strategy unsatisfactory for herself, as she became irritable and more demanding of Randall's time and attention. Recognizing his sexual avoidance was being challenged, Randall decided to swing into action.

GETTING HELP: PHASE ONE--THE INTERNET

Consistent with the help-seeking pattern of most men (Courtenay, 2001; Good, Dell, & Mintz, 1989), Randall's first efforts to resolve his distress were those he thought would be the least likely to make him feel vulnerable and needy. Rather than admit his concerns to a "judgmental" professional, he pursued the most covert strategy by ordering Viagra over the Internet. (2) This plan seemed to have worked perfectly, as the medications arrived in a few days and had required minimal personal exposure. Even more gratifying, the first medication dosage was a huge success. He was amazed that within a brief period of time he could feel the blood rushing into his penis, producing the most glorious erection he had experienced in years. Overcome with a surge of masculine vitality, he enthusiastically went to work on "answering the call" of his sudden sexual urgency (by vigorously masturbating). Although he was somewhat disappointed that Rita would be unable to benefit from his marvelous new potency, he was convinced that the overall effect would be beneficial to their mutual lives.

Randall was stunned by the intensity of Rita's negative response to his surprise news. Perhaps he was thinking she would be aroused by his new vitality. Certainly, he thought, she would be appreciative of the considerable efforts he had made to bring her pleasure. Instead, she was disconcerted and unhappy, voicing incomprehensible complaints about "sharing," "dialogue," and (her favorite word) "communication." Covering his disappointment with indignant anger, Randall accused her of impossible bitchiness and stormed out of the bedroom. Although Rita made subsequent indirect efforts to discuss the issue, Randall never responded, and the matter returned to its previous quiescence.

GETTING HELP: PHASE TWO--INDIVIDUAL PSYCHOTHERAPY

Over the next several months, Randall realized he had become increasingly dissatisfied with his work, sullen with friends, and listless in all activities that had once been pleasurable. Feeling unable to discuss this with Rita, he decided it might finally be time to seek advice from Bob, a longtime friend and psychotherapist. Not surprisingly, Bob declined to see Randall, but he did refer him to another therapist. In his first individual therapy session, Randall was guarded and cautious, emphasizing his physical lethargy and general irritability. With some difficulty, he acknowledged he might be depressed and globally dissatisfied with many aspects of his life. In response to questions about his marriage and family life, he professed relative satisfaction and emphasized that he and Rita had a "functional" relationship.

As therapy progressed, Randall gradually acknowledged the "emptiness" he had begun to experience in his life, noting the lack of challenges in and enthusiasm for his job and usual recreations. He admitted the "empty nest" had unsettled him but insisted his children were the source of his greatest satisfaction (although he felt more distant from them than he would have liked). Eventually, he admitted his estrangement from Rita and his resentment of her criticisms of him. He was especially unhappy that she was impossible to satisfy, as she seemed to simultaneously want more sexual activity but carp at him when he made efforts to solve his sexual difficulties.

Randall's individual therapy seemed valuable in helping him recognize sources of his midlife distress but limited in its capacity to address unresolved marital issues. Recognizing this, Randall's therapist referred him to the first author for more focused couple's therapy.

GETTING HELP: PHASE THREE--COUPLE'S THERAPY

The referral of Randall and Rita seemed to be an ideal one. Each appeared to be motivated, sincere, and desirous of improving their relationship. Therapy progressed slowly at first, as each was cautious in changing their long-standing pattern of emotional avoidance and suppression of conflict. Nevertheless, since there had been many positive aspects to their relationship, they were able to incrementally move toward more open communication and discussion of mutual needs and disappointments. Eventually, however, therapy touched on their almost nonexistent sexual relationship, and tensions escalated to crisis levels. Rita had discovered Randall's recently developed habit of browsing Internet pornography sites and was both devastated and furious. Making matters worse, she had also discovered that Randall's Viagra medication was nearly gone, although they had not been sexually active in many months.

Couple's therapy, although previously productive, now seemed to reach an impasse. Rita threatened divorce, saying she was repulsed by the Web sites Randall had frequented and had no interest in living with a "pervert." Stung by Rita's rage and humiliated by the revelations, Randall appeared to shut down. Other than plaintive admissions that he couldn't comprehend his own behavior, he said little and began to find reasons to miss therapy appointments. Because he recognized the delicacy of the situation, the therapist suggested a sabbatical from couple's therapy and a move toward separate sessions for gender consciousness raising. This separate phase, during which Randall was seen more frequently, was explained as a time to help him examine and better articulate his complex beliefs about sexuality and relationships. Rita was seen occasionally for support and to avoid the perception of Randall as the exclusive focus of treatment.

SEEKING HELP: PHASE FOUR--SEXUALITY IN GENDER CONTEXT

As is often the case with men seeking help for relationship issues, Randall felt confused and disabled by Rita's anger and inarticulate in describing his inner experiences. Levant (2001) has described this situation as "normative male alexithymia," a condition common to many men whereby they are detached from their feelings and have a diminished capacity for intimate communication. Levant has described treatment for this condition as a necessary first step in psychotherapy with men. Brooks (1991) has observed that intensive marital therapy is frequently too overwhelming for many men and has argued for an initial treatment phase of gender consciousness raising (CR), either through all-male groups (Brooks, 1996) or through gender-informed individual therapy (Brooks, 1998). This consciousness-raising psychotherapy, similar to women's CR groups of the 1960s (Brodsky, 1973), helps men become more aware of the depth of their distress and view their pain in context of the pressures of the male role.

This therapy plan is especially critical when the client presentations include problems with sexual relationships, since male sexuality is one of the most gender-typed, most problematic, and most superficially discussed aspects of men's lives (Levant & Brooks, 1997). Levant and Brooks (1997) proposed the term "nonrelational sexuality" to characterize the normative pattern whereby young men are socialized to experience sex only as lust, without any requirements for relational intimacy or even for more than a minimal connection with the object of one's desires. In this mode of sexual experience, "targets of sexual desire are objectified and pursued instrumentally to meet a set of needs, which--in addition to the release of sexual tension--include receiving nurturance and affirming a sense of adequacy" (Levant & Brooks, 1997, p. 1).

Levant (1997) considers nonrelational sexuality in men to be an unfortunate outgrowth of male emotion socialization, during which "boys experience sharp limitations on the expression of caring/connection emotions" (p. 18). Levant notes this nonrelational pattern is worsened in adolescence when

   Boy's deficits in emotional empathy reinforce this self-involved
   objectification of girls by preventing boys from realizing how it
   might feel to the girls to be objects of their lust....  The
   long-suppressed caring/connection emotions get swept along in this
   turbulent stream, but well outside of awareness. As a result,
   sexuality for boys becomes, at the conscious level, unconnected
   and non-relational. (p. 19)

Brooks (1995) proposed the "Centerfold Syndrome" as a dysfunctional constellation of attitudes and behaviors representing a pervasive distortion in the way men are taught, and subsequently reinforced, to relate to women and sexuality. This conceptualization of problematic male sexuality encompasses five elements: (a) voyeurism; (b) objectification of women; (c) sex for masculinity validation; (d) trophyism; and (e) fear of true intimacy. Brooks observed that men's relationships with women are severely hampered by the centerfold syndrome and argued that couple relationships can be greatly improved by helping men enhance their capacity for sensuality and emotional intimacy. Before this can be accomplished, however, men must confront the destructive aspects of the centerfold syndrome and must make a commitment to change many of their sexual habits (Brooks, 2001, p. 64).

With these perspectives in mind, it became much easier to understand Randall's sexual difficulties and intervene in a compassionate manner. Randall relaxed noticeably when therapy dialogue shifted from focus on his "pathology" to a broader exploration of all men and their sexuality. Cautious at first, Randall soon became more enthusiastic in relating his early experiences with girl-watching, soft-core pornography, and jokes about "jacking-off" as the only cure for "blue balls." He described endless sessions with male friends comparing assets of "babes" and bragging about sexual conquests. He acknowledged a moderate degree of embarrassment about his fraternity exploits but insisted he had been far more mature after "sowing my wild oats" and marrying Rita.

Using this conversation as context, the therapist was better prepared to help Randall examine the sexual issues in his marriage. Randall admitted that sex with Rita was different, since he cared about her, both as his wife and mother of his children. He remembered he had initially been moderately attracted to her physical attributes but acknowledged that he had focused more on her nonphysical characteristics; for example, her character, her compassion, and her emotional sensitivity. Over the years, he had noted a deepening of their attachment to each other but had also experienced some discomfort with her changing appearance and a gradual decline in physical desire for her. Furthermore, he admitted that they had left many disagreements unresolved and frequently avoided intimate contact during extended periods of resentment. As the emotional distance increased, Randall found himself more desirous of sexual activity and more likely to privately masturbate. Over time, he found himself relying on masturbation for sexual release and somewhat avoidant of the "complexities" of actual sexual interaction with Rita. By the time Randall and Rita had entered therapy, Randall had developed a fairly strong and secret pornography habit and was rarely able to function sexually without visualization of the various naked women of his magazines and Web sites.

The tactical retreat from conjoint sessions and the move to individual consciousness-raising sessions allowed us to freely explore Randall's "secret" sex life and begin finding ways to shift into a healthier sexual relationship with Rita. In sessions that acknowledged the prevalence of pornography in men's lives, Randall felt freer and less inclined to experience shame for his habits. At the same time, these sessions challenged the popular myths about pornography as "harmless fun" and explored the multiple ways his pornography habits had harmed his sensuality and intimacy with Rita. With heightened sensitivity to these issues, Randall seemed better able to recognize the loneliness engendered by his solitary sexual activity, and he began to recognize emotional needs that had remained unmet.

FINAL PHASE--RE-INTEGRATION IN COUPLE'S THERAPY

With Randall more aware of his masculinity-based issues and better prepared to participate in therapy, conjoint sessions became far more productive. Although Rita had been seen periodically, whereas the primary focus had been on consciousness raising with Randall, careful efforts were made to re-incorporate her into therapy. We reviewed issues considered in Randall's sessions and encouraged Rita to re-express her dissatisfactions and describe her emotional pain. As each partner became more empathic toward the other, therapy became far more than a narrow discussion of their sex lives and became a venue for exploring their deepest hopes and fears, as well as their needs for intimacy and emotional connection.

CONCLUSION: ADOPTING THE BROADEST CONCEPTUAL LENS

There are several reasons why therapists need to avoid reductionistic sex therapy with men and adopt the broadest conceptual focus. First, men are strongly socialized to resist the patient role and avoid help-seeking whenever possible. When the overt issues are sexual, men are unusually reluctant to seek help for matters they see as very threatening to their worthiness as men. An approach that "normalizes" their problems is often exceptionally helpful. Second, in contrast to their women partners, most heterosexual men have spent very little time pondering the emotional pain in their lives and greatly benefit from time to "catch up" with a men's group or with a therapist who is thoroughly familiar with men's gender role strain. Finally, when one conceptualizes the presenting issue only as a problem of malfunctioning genitalia, major opportunities are lost for broad exploration of the immensely important area of male sexual socialization and sexual behavior. Despite the myths, this area is not problem-free and uncomplicated for men. Men badly need to discuss and examine this poorly understood area of their lives. Some troubled men may only need the physiological help they can get from Viagra. Many others, however, can gain considerably more if the opportunity is taken to examine the profound problems of nonrelational sexuality and to recognize the considerable advantages of a more compassionate, sensual, and intimate sexuality.

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NOTES

(1.) Although the client in this case report chose to utilize the most widely prescribed medication (sildenafil), it should be noted similar circumstances would prevail with tadalafil and vardenafil (see Jannini, Lenzi, & Wagner, 2003).

(2.) In this clinical case, the client chose to pursue self-prescription of a significant medication through the Internet and without careful and integrated control with a qualified medical professional. Of the many professionals who have raised great concern about this practice, one could consult the work of Eysenbach (1999) and Smith and Romanelli (2005).

Correspondence concerning this article should be directed to: Ronald F. Levant, Office of the Dean, The University of Akron, Akron, OH 44325. Electronic mail: [e-mail].

GARY R. BROOKS

Baylor University

Waco, TX

RONALD F. LEVANT

The University of Akron

Akron, OH