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A Man’s Sexual Identity and
Sexuality Over Time: The Goals of
Sex Therapy and Medical
Management.
Dorota Niedziela M.A.
Clinical Sexologist
The West Island Sexual Dysfunction Clinic
Sexuality is a complex interaction of biology, culture,
developmental, and current intra and interpersonal
psychology.
Sociocultural
factors
Organic
factors
Relationship
factors
Corporal
factors
Sexual
Identity
Behavioral
factors
Psychological
factors
Cognitive
factors
SOCIOCULTURAL FACTORS
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Social environment (standards) is shaping and reinforcing male sexual
expression.
Contemporary masculinity is rooted in a “performance script” that all to
often males are not even in touch with a language of vulnerability that
would enable them to seek early treatment for erectile dysfunction.
Traditional competitive masculine culture norms render many men
incapable of admitting any weaknesses.
Many of males are postponing treatment seeking for a year or more.
No matter how dysfunctional it may seem, these norms for many men are
essence of an evolving process of masculine gender identity formation, the
questioning of which carries many inherent psychological risks—not the
least of which is admission of any weaknesses or inadequacy whatsoever—
because of fears that such an admission might be interpreted by others as a
sign of failure.
COGNITIVE and PSYCHOLOGICAL FACTORS
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The inability to connect with women sexually as well as the knowledge that
they had lost their sexual capabilities in getting and/or maintaining the
erection led men to feel as if they had lost their manhood.
In other words, the feelings that one might not be able to “pull it off”, led
men not only to doubt their sexual ability, but also provoked questions
about their masculinity.
Both the fear of embarrassment and the changes in the ways in which men
imagined their interactions with a partner led them to question their own
identity as a man in the same ways in which they had defined themselves
prior to having erectile problems.
Sexuality is seem here as a substantial part of what defines an individual as
a “man” and men who lost sexual function are finding themselves
challenged to redefine themselves in our society.
COGNITIVE and PSYCHOLOGICAL FACTORS
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Even sexual fantasies are affected by they erectile dysfunction.
The men became nostalgic when they described how they once enjoyed
thinking about sex, now a lost pastime. They no longer enjoyed sexual
feelings in response to seeing an attractive woman.
A profound sense of loss associated with a loss of a fantasy life in which
they were able to imagine themselves as potential sexual partner is
identified with an individual suffering from ED. They no longer gain
pleasure in fantasizing about a sexual encounter.
Any sexual experience is view as a source of stress and anxiety and
depressive symptoms are well documented in scientific literature.
Despite the loss of erection, sexuality remained part of their lives, and the
ways in which men thought about themselves as sexual beings required
redefinition and reinforcement of they masculine identity and sexuality.
COGNITIVE and PSYCHOLOGICAL FACTORS

Exact information about:
 Sexuality:
four phase model of sexual response, anatomy,
physiology, etc……
 By age forty, 90 % of males experience at least one erectile
failure. This is a normal occurrence, not a sign of ED.
 In a 45-minute pleasuring session, erections will wax and
wane 2 to 5 times. Subsequent erections, coitus, and orgasm
are quite satisfying.
 Sexual myths and believes may influence sexual behavior in
negative way: “male machine, ready to have intercourse at
any time, with any woman, in any situation”……..
 Attitudes, self-thoughts and fantasies affect arousal. The key
is “sex and pleasure” not “sex and performance”.
BEHAVIORAL and RELATIONSHIP FACTORS
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Physical intimacy with a wife or a partner is no longer a comfortable and
familiar experience.
Men feel apprehensive about intimate contact, fearing that it might lead to
an awkward and embarrassing performance.
Diminished confidence and ability to perform sexually is pushing males in
avoiding a sexual intimacy and finding ways to retreat from the interaction
before the possibility of a sexual encounter is raised.
Men also described changes in the ways in which they related to women
outside of their intimate relationships. They are more aware of the absence
of erection, the element of sexuality that had once characterized many of
their interaction with women.
Now they experienced social interaction in a new way, defining themselves
and those interactions as nonsexual. They non longer actively pursuing
sexual relationships in every encounter with a woman.
BEHAVIORAL and RELATIONSHIP FACTORS

A detailed sex history of current and past sexual behavior assist in
understanding and identifying the “immediate cause”; the actual
behavior and/or cognition causing or contributing to the sexual
disorder:
 Erotic
experiences carried out by the couple/individual in the privacy
of their own homes.
 PDE-5s require stimulation for the men to respond sexually: there are
many divergent sexual scripts and a variety of unconventional patterns
of sexual arousal (homosexuality, fetishism, passivity, etc.).
 Couple sexual dynamic: a woman may function as the couple’s
“gatekeeper”. She may require the partner to respond to explicit
initiations through different signs of sexual receptivity. However, they
both expect that she will decline some initiation: encourage sexuality
or limit the process of affection (she needs to feel both affirmed and in
control).
BEHAVIORAL and RELATIONSHIP FACTORS
 Yet,
if he is only willing and able to initiate once dosed, then
sildenafil or vardenafil is a poorer choice. For this relationship,
multiple initiations are required, and predosing with longer acting
tadalafil is a much better choice.
 If the previous sex script was weekend sex, then a Friday night dose
may be sufficient.
 Evaluation of the level of partner cooperation and support: the
sexual dysfunction is “a couple problem” not just the identified
patient’s problem.
 Fitting the right medication to the individual/couple will increase
efficacy, satisfaction, compliance, and improve continuation rates.
 Rather than changing the couple’s sexual style to fit the treatment,
try to fit the right medication/treatment to the couple.
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Erotic communication and seduction skills.
ORGANIC FACTORS
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Erectile problems can be caused by wide variety of factors:
 Side
effects of medication: depression…. Physicians must adjust
dose or combine with other drugs to ameliorate the problem.
 Vascular and neurological deficits.
 Hormonal deficiency.
 Chronic diseases or injury.
– As men age, the hormonal, vascular and neurological systems become
less efficient.
– As women age, she also is at risk for arousal phase disorders, painful
intercourse: hormonal deficiency, vaginal atrophy and dryness……
– Men postpone treatment seeking. By that time, a new sexual equilibrium
has been established within the relationship, which may be resistant to
the changes a sexual pharmaceutical introduces.
– The couple need to integrate PDE-5 inhibitors into their lovemaking
style (preliminaries).
CORPORAL FACTORS
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“Body-Brain” or “Brain-Body”: any emotion is carry out through body
language. On the other hand, modifying body posture (body laws) will influence
the level of emotion as well as your cognitions (perceptions).
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3 Elements ( body laws) to look for in sexuality:
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Muscular tensions: a lot - little
Rhythm: fast - slow
Space:
 exterior space: movements
 interior space: breathing: thoracic, diaphragm or
abdominal.
Masturbatory style:
Mechanical
Mechanical
 Archaic
Archaic
 Mechanical-Archaic
Mechanical-Archaic
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In Wave: the release of
upper and lower body
Case example, Pierre
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66- year- old male, in relationship for 10 years.
Andropause, low libido and “soft erection”
PDE-5 inhibitor works when used during masturbation
sessions but does not work with partner - absent of genital
stimulation, sexual scripts and partner very conservative.
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Normal DRE, PSA low
Adam Score 10/10 positive
Generalized anxiety.
Fear of failure, inadequacy, negative evaluation.
Important muscular tensions, upper lung breathing restricted
movement and rhythm - rigid body.
Case example, Pierre
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Bio-T low 1.8 (N=2.3-14)
Androgel recommended
Penile Doppler : venous leakage bilaterally
Maintain use of PDE-5 inhibitor during and after the sex
therapy.
 sexual anxieties,  self-esteem.
Improve communication skills.
Introduce upper and lower release of the body, increase
body mobility and physical sensations.
Enhance sexual scripts: adding new elements, increasing
sexual intimacy.
Case example, Luc
Medical evaluation:
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57- year- old male, single, dates young women.
Good general health.
Morning erection.
Masturbation, rigidity 10/10
On PDE-5 inhibitor : Viagra, but works only 50 % of the time
with partner.
Libido down.
Bio-available Testosterone normal, Thyroid normal.
Penile Doppler normal.
Case example, Luc
Psychosexual evaluation:
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Obsessive behavior, negative anticipation.
Sexual scripts: performative scripts: restricted, repetitive with little
satisfaction. The focus is on sexual performance and
constant search for feed-back.
cognitive scripts: absence of sexual thoughts to
maintain an erection.
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Myths: “ A man is always interested in and ready for sex”, “ A real man
performs in sex”, “A man should be able to make the earth move for his
partner, or at the very least knock her socks off”………
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Disconnected from lower body, sexual energy.
Case example, Luc
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1-2 session: Evaluation: functional analysis, objectives and treatment plan
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3 session: Patient education:
 Understand how the erection works.
 Understand four phase model of human sexual response and study,
or compare to what the patient experiences in his sexuality.
 Identify life stressors, obstacles to lovemaking.
 Masturbation I
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4 session:
~Study sexual myths: advantages and disadvantages,
limitations.
~Create a realistic expectations and new definition
of sexuality: performance – pleasure.
~Masturbation II
Case example, Luc
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5 session: Pleasure: focus on body and physical sensations, pleasure of
being touched, 5 senses. Self-centered – looking for
feed-back.
Introduction of lower release of the body: rocking of
the pelvis.
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6-7-8 session:
– Study each sexual script to compare the influence of sexual
stimulating thoughts and negative anticipation, context….
– Introduction of abdominal breathing.
– Reinforce rocking of the pelvis, play with rhythms and
muscular tensions.
– Maintain use of Cialis through learning process.
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9 session: Relapse prevention, schedule the follow-up session.
Case example, Martin and Sonia
Evaluation:
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44-year-old male, 41-year-old female.
Married for 9 months. Since, wife wishes to conceive:
 Performs less since pressure to conceive.
 Viagra used when she is ovulating: works only 70% of the
time, difficulty ejaculating 50 % of the time: switch to
Cialis.
 Anxiety , both feed on each other anxiety : upper lung
breathing, restricted body movement and rhythm causing
muscular tensions.
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Sexual scripts: narrow and restricted with little satisfaction for either
partner: he only use 2 positions other wise ED. She would
like to expend their lovemaking.
Case example, Martin and Sonia
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Very limited sexual experience: 1st coitus at 27 years old, limited
masturbation ( “good boys their don’t masturbate” ), negative thinking
/anti-fantasy.
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Unrealistic expectations / Multiple sexual myths: “ A good lover
should………”.
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He is very sensitive to rejection, abandonment: constant search
for emotional connection, approval and emotional fusion, don’t express his
needs and desires: disconnected from lower body and sexual energy.
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Relational pattern: saviour-victim creates self-misery and
discomfort for personal growth, absence of clear sense of self
in close proximity.
Case example, Martin and Sonia
Treatment:
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1 step: Patient/Partner education: sexuality and fertility, sexual desire
/desire to have a child/desire for emotional fusion – see the changes in
sexual scripts; did arousal vary during manual, oral and coital stimulation ?
Realistic expectations: been a good lover, myths, unrelenting standards.
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2 step: Anxiety/Stress management:
 Decreased muscular tensions by changing breathing: abdominal.
 Counterthinking: S-I-E-B, triple-column technique, creating more
realistic, positive and sexually stimulating thoughts.
 Talking to yourself: what thought just went through my head; does
that thought actually make sense; is there any evidence to support
that thought and how do I know that thought to be true ?
Case example, Martin and Sonia
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3 step:
Self-esteem/self-confidence:
 Fantasy
is helpful to eroticize both the experience and the partner:
erotic fantasy, active participant; slowly integrate the partner in the
fantasy.
 Masturbation I,II,III with fantasy.
 Assertive walk: modifying body language by owning upper and
lower body; B-B-B-B.
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4 step: Relational pattern: family of origin, understand how/why
the past is paying out in the present relationship: advantages-disadvantages:
less intimacy and anxiety tolerance, etc.
 Differentiation: clear sense of self, self-regulate our own anxiety
and self-soothe hurts, non-reactivity to anxiety of significant
person, ability to tolerate discomfort for growth…..
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5 step: Learn new sexual skills to improve lovemaking:
 Focusing/spreading sexual energy: rocking of the pelvis/shoulders.
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Playing with 3 groups of muscles involved in sexual excitement: MT
Sexual repertoire : add new elements.
Case example, Paul
Evaluation:
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34-year-old-male.
Married for 6 years, one child, wife wishes to conceive.
Religion : misconception of sexuality, guilt .
Masturbatory style: Archaic: never full erection and no ejaculation.
Fantasies: dominant fetish component, total absence of coitus.
Restricted attraction codes: breasts, legs.
Sexual script: limited to breasts sucking for 10-15 minutes or rubbing
partner legs with his penis. Incapacity to ejaculate inside the vagina / ED
just before penetration. No pleasure associate with coitus and absence of
physical sensations.
Case example, Paul
Treatment:
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1step: Sexual education:
– Understand sexual development: different stages, four phase
model of human sexual response……
– Understand different factors that may influence sexual
behavior: religion, family values, cognitions, perceptions,
fantasies……
– Fetish: origin, causes, limitations……
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2step:
Modify and change masturbatory style:
– Introduce different positions.
– Use of hand: play with pressure, rhythm, movement.
– Full erection and ejaculation.
Case example, Paul
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3step: Fantasies:
– Introduce new elements within existing fantasies: other body
parts to expend attraction codes.
– Create a total new fantasy: active with full erection and
penetration ( inside the vagina).
– Integrate the partner in a fantasy.
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4 step: Combine a new masturbatory style with a new fantasy
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5 step: Extend sexual scripts / sexual behaviors.
Conclusion
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Sexual functioning certainly declines with age but sexuality remains a
significant aspect of men’s lives well into their older years.
For men, their sense of themselves as sexual beings remains important.
Therefore, erectile problems affect men in both their intimate and
nonintimate lives, including how they see themselves as sexual beings.
Different domains of quality of life related to men’s sexuality are alter:
1. Men’s perceptions of their masculinity
2. Everyday interactions with women
3. Sexual imagining and fantasy life
4. The qualities of sexual intimacy
Physicians dealing with sexual dysfunctions must consider the
psychological and behavioral aspects of their patient’s diagnosis and
management, as well as organic causes and risk factors.
Conclusion
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Effective treatments for ED are available, but re-establishing erectile
function does not necessarily re-establish a satisfying sexual relationship of
the couple or individual.
A sexual performance is not the same as the emotional impact of erectile
dysfunction. Since sexuality remains an important aspect of men’s live,
men with ED may find themselves re-evaluating their sexuality, possibly
discovering themselves to be on new footing with respect to the women in
their lives.
Erectile dysfunction may precipitate an “identity dilemma” for men:
changes in how men see themselves as sexual beings and as men in our
society.
Physicians need to appreciate the increasingly complex psychosocial issues
that men attribute to their erectile dysfunction.
Conclusion
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In counseling men, physicians may need to probe beyond the mechanics of
erectile function, and ask questions about men’s feelings about their sexual
lives and relationships.
When men reveal that they no longer can get a “hard-on”, it is up to
physicians to create an opportunity for men to discuss the impact of this
upon their lives.
Restoration of lasting and satisfying sexual life requires a multidimensional
understanding of all of the forces that created the problem, whether a solo
physician or multidisciplinary team approach is used.
Each clinician needs to carefully evaluate their own competence and
interests when considering the treatment of a person’s sexual dysfunction,
so that regardless of the modality used, the patient receives optimized care.
Conclusion
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Both the urological and psychological communities came to recognize and
appreciate a new paradigm reflecting the interaction of both psychological
and organic factors within a larger social context when treating erectile
dysfunction.
A movement within the field of ED toward an integration of sex therapy
and pharmacotherapy is identified more and more.
The primary care physicians and urologists began incorporating sex therapy
(sex therapy referral) with sexual pharmaceuticals to increase the
effectiveness of their treatments for sexual dysfunction.
By combining disciplines and therapeutic approaches, one is more likely to
improve sexual desire, arousal, penile tumescence and sexual satisfaction,
and return the patient to a normal organic and psychological state.