But none of this precludes psychological treatment as an adjunct, if not integral part of the protocol, psychologists say. Like many medical problems, physical factors that contribute to impotence are often behaviorally based. Smoking, poor diet and lack of exercise all can lead to the vascular problems or diseases that can result in impotence.

And, even medically based factors in impotence can create problems between sexual partners that only psychologists can address.

'Relational therapy is still very important - maybe even more than before,' Ackerman says. 'Even if you fix the penis, you still have the man's psychological reaction to the medical disorder and the problems it can cause in the relationship.'

Many physicians agree with Ackerman's contention. For example, Boston University urologist Irwin Goldstein, MD, in a recent interview published in Urology Times (Vol. 25, No. 10), says he supports the National Institutes of Health standard that 'everybody with impotence needs a psychological evaluation,' conducted by a psychologist.

The technical solution

Many mental health experts lament the medicalization of sexuality as unwarranted and unfair. Tiefer says society's 'pursuit of the perfect penis' focuses more on the man, rather than the couple. Impotence treatment, by centering specifically on a man's ability to engage in intercourse, seems to ignore other aspects of sexuality and slights the woman's satisfaction in a sexual relationship, she says. And it reflects the societal pressure on men to be sexually virile, a standard that can often create performance anxiety in men, she says.

Addressing only the genital component of sexual dysfunction doesn't always guarantee great satisfaction among patients, says David Rowland, PhD, a psychology professor at Valparaiso University and senior associate at Johns Hopkins University. Just because the parts work doesn't mean the men, or their partners, are enjoying sex again, he says.

And the miracle medical cures may not be as miraculous as they sound, notes Leslie R. Schover, PhD, of the Cleveland Clinic Foundation. She notes that Pfizer's own clinical-trial data on Viagra shows that it is most effective for milder forms of erectile problems - such as those that are anxiety-based - and less effective for the more severe forms.

'Viagra is a threat to sex therapy precisely because it is a drug designed to take our 'best customers,'' she says. 'Instead of teaching them new skills that they can use to overcome performance anxiety, it makes them dependent on a pill that costs $10 a pop.'

The most effective treatment for men's sexual dysfunction, Ackerman says, is through closer collaboration between psychologists and urologists. Psychologists who treat men with sexual problems need to better sell their clinical abilities to urologists, Ackerman adds. Health psychologists offer skilled assessment and therapeutic techniques that can not only help urologists pinpoint any psychological or behavioral factors in a patient's sexual dysfunction, but can also help design a treatment plan and aid the patient in complying with the regimen, he says.

'The opportunities for psychologists are plentiful,' he says, 'and they've expanded significantly beyond the role of providing sex therapy.'

This article is from the American Psychological Association.

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