In about 15 minutes I’m leaving my office to give a talk to urologists about what sex therapists can do for men with erectile dysfunction and other common–and not so common–problems, so I thought I’d jot a few thoughts about when to visit a urologist, and when to visit a sex therapist.

If you are under 35 and are in good health, have morning erections, or can get erect when you’re by your lonesome, then you probably want to visit a sex therapist.  If you are under 30 and have health problems or don’t have erections much, spontaneously or not, then see a urologist first.

If you are over 35, then your best first stop is an urologist, who can determine if you have “plumbing problems” or hormonal issues such as low testosterone.  You don’t want to skip this step, because erectile dysfunction (ED) can be caused by various illnesses, including multiple sclerosis, diabetes, pituitary disorders, etc.

Sex therapists are trained to rule out medical problems first.  There’s no point in engaging in “talk therapy” if the problem is your health.  On the other hand, if you have a health problem such as diabetes or need to take medication that affects your ability to have erections, then you probably have a psychological problem, too.  After all, who wouldn’t be a little depressed or even paralyzed at the thought of a change in your sexual health?

Once you have ruled out medical problems, or you are in great health, then you can contact a sex therapist.  If you don’t live in the SoCal area, you can look on the AASECT website to find a sex therapist near you.  A sex therapist can help you overcome obstacles that prevent you from enjoying sex, and also counsel you and your partner about how to incorporate medical interventions into your sexual script, as in the case of someone who is recovering from prostate surgery and needs medication, shots, or other form of treatment.

Hope that’s helpful!

Poking around for blog ideas, I found a very good article on the Telegraph website on “The Sexuality of Middle Aged Men” that I thought I’d share with you.  The article isn’t earthshaking; by now, with all of the ads for meds for erectile dysfunction, you pretty much know that ED is the most common male sexual problem, and that it’s okay to talk about it with your doctor.

But what about with your therapist?  Can a pill solve every sexual problem that men have?   If you’re a regular reader, you know that my answer is no, because a pill can’t give you a skill.  And that’s where I think sexual medicine made a left turn at Albuquerque instead of a right.  Here are some of the skills that men can learn from a sex therapist that they can’t get from a pill:

1. You can’t learn how to be a better lover by taking a pill.
2. You can’t learn what will make you more aroused now that you’re older and may need more sexual stimulation.
3. You can’t learn how to talk about sex and communicate with your partner.
4. You can’t explore other types of sexual experiences that don’t require an erection.
5. You won’t learn that it’s okay not to have an erection sometimes and that snuggling isn’t just for women.
6. You may not learn that ED means that you need to relax, to stop and smell the roses.
7. You may not discover that there is more to your sensual life than is going on with your penis.
8. Your partner may never know that you need more direct stimulation to have an erection.
9. You may always wonder whether or not you are psychologically dependent on medication to have an erection.
10. If the pills don’t work, you may not realize that you have other options, or that your problem is more psychological than physical.

ED medications are marvelous for men that have medical issues that cause their problem, such as recovery from prostate cancer.  Other treatments, too, such as injection therapy, can be helpful.  But I fear that too many men are taking medication that really don’t need it.  Psychotherapy ain’t cheap, true, but neither are meds if the cost is missing out on understanding yourself and your sexuality a little better.

Kind regards,

Dr. Stephanie Buehler

It’s a question I get asked often: Can a sex therapist really help us with our problem?  And, in how many sessions?

In a recent comment, a woman wondered if a man’s low sexual desire was really more about no longer finding their partner attractive, not even a little bit.  She also wondered if the problem could be fixed, and if so, how long it would take.

First, as to the problem itself, low sexual desire can indicate many things, including the presence of out-of-kilter hormones and other biological problems, like an enlarged pituitary gland.  Also, in a study of people with depression, about 70% reported that they had low sexual desire.  Low desire may also occur when a person is struggling with another sexual problem, such as erectile dysfunction or, in either sex, lack of orgasm.

Of course, low desire can also be indicative of a problem in the relationship.  The person with low desire may be angry and unable to express their anger appropriately, so they withhold sex.  They may find that their partner’s lovemaking technique leaves something to be desired.  Rather than communicate, they avoid sex or make excuses.

And yes, as the person who commented said, sometimes it means that the person is so turned off by their partner that they no longer want to have sex with them.  It could be (more…)

Over the past week, a number of articles on sexual abuse were drawn to my attention by various sexologists.  The first was about a TV special called “Hot for Teacher,” which features Mary Lou Letourneau, a married teacher who slept with her teenage student (whom she met when he was in second grade), for which she was imprisoned.  After she was released, and having been divorced by her first husband, she married the boy and had children with him.  The TV special suggests that since she married him, all must be fine, that there is nothing unique about her relationship with someone so young.

Next, my colleague and fellow sex therapist Stephen Braveman, MFT, was featured in an article in Rolling Stone on a teenage boy who was molested by his teacher.  Outwardly, the relationship may have appeared to be consensual and even condoned.  Deeper investigation, however, shows that the boy became extremely distressed over the relationship.  It affected his grades, his relationships with peers, and his mental health.

Finally, as I was casually researching topics today for both of my blogs, I happened across two more articles, one in the Star News and one on a NYC news website about female teachers molesting students.  Both the Rolling Stone article and this one have a similar theme, that there is a prevalent myth that boys are unaffected by sex with a woman in a position of authority.  In fact, it is because of this myth that many boys may not come forward if they have been bothered by a similar sexual experience.

Another myth is that boys cannot be coerced into sex.  But erection is an automatic response to stimulation; it doesn’t necessarily take consent (more…)

About one-third of the couples who come into our offices at The Buehler Institute have a complaint of low sex drive in the male partner, not the female.  Social myths make it hard to believe that there are so many men who have low libido.  Men are expected to “always think about sex,” ever ready to perform.

When men have a low sex drive, female partners often complain of being extremely confused and hurt.  They feel isolated and unloved.  They talk about a lack of intimacy in the relationship.  Sometimes they are even angry that the person with whom they most want to have sex is physically unavailable.

Why do some men lose their zest for sex?  One reason has to do with physical health, especially testosterone levels.  Most every man who has low drive should have their hormone levels tested, because one of the hallmarks of a low drive in men is low testosterone.

However, you can’t get too caught up on hormones.  There are men whose testosterone tests at low levels who still have a drive, and men with normal levels who don’t care to have sex.  So you need to look at other physical, psychological, and relationship issues as well.

For example, sometimes when a man is out of shape or overweight, he may not only feel more fatigued, but have poor body image.  It’s not just women who get hung up about lumps and bumps on their body.  Second, he may have a poor diet, leading to a lack of energy.  Or, he might not be getting adequate sleep.  Stress, too, can take its toll on a man’s physical and sexual well-being.

Another important physical aspect to be aware of is the effect of some medications on drive.  For example, antidepressants, while helpful, can cause sexual side effects.  This is another reason to check with one’s doctor when drive is low.

Psychologically, a man may have performance anxiety, pressuring himself to please his partner.  After awhile, sex becomes a drag to be avoided at all costs.  He may also have a mood disorder such as depression, which is causing him to shut down, isolate, or feel unable to enjoy things he once liked–including sex.

Relationally, a man may withhold sex when his feelings are hurt.  Men don’t much like to be criticized by day, then expected to perform sexually at night.  A man may also stop having sex when he is the one who is angry.

An additional reason in the “sad but true” department:  A man may stop having sex because he is gratifying himself with pornography, call girls, or having an affair.

Sometimes, there really is nothing wrong with a man’s drive.  The problem is just that the woman’s drive is naturally higher.  But again, because of the myths surrounding male sexuality, the woman with the higher drive may have difficulty believing that the cause of low drive is natural, not personal.

Just read an article by Dr. Batya Ludman in the Jerusalem Post, “Psychologically Speaking:  Sexless Marriage.“  What Dr. Ludman observes in Israel is not much different than what sex therapists in the States have also witnessed:  Many couples, whether by choice or by force, are in a sexless marriage.

Read the article to  understand all the reasons that a marriage loses all its potential juiciness.  In my practice, what I have also seen:

• Difficulty becoming sexual again after the birth of a child
• Difficulty being sexual while trying to conceive, with lingering effects
• Allowing childrearing to interfere with the couple’s relationship
• Husbands and wives not getting enough support when children have difficulties so that they can continue to function as a couple
• Giving up sex when it doesn’t go well because that’s easier than the embarrassment of talking about it
• Becoming ill or experiencing the effects of aging and determining that it is a signal to stop having sex
• Entering menopause (or for men, andropause) and not addressing issues of low drive

Couples needn’t continue on this path, even if it has been years since they have had sex.  But it does take a commitment of time and energy.  A sex therapist can help a couple discover the reasons they have not had sex, help them eliminate blame, and find ways to ease into creating a sex life anew.  In that case, a financial commitment is also required, but sex therapy is far less costly, emotionally and financially, than living in a barren marriage, or ending the marriage, whether through divorce or simply withdrawing emotionally.

WebMD carried this men’s health article on male masturbation that I thought I would share on this blog.  In general, masturbation is a healthy activity, except when it becomes compulsive (something that you feel you must do) or, as general thinking goes, takes away the quality or quantity of sex from a partnered relationship.  Also, masturbation can become problematic because a man can become used to his own technique, and find sex with a partner less satisfying.  Although the article doesn’t state it, masturbation for men can become overly focused on a singular body part.  As men age, more sensual exploration of one’s body can become important in becoming and sustaining arousal levels and erection.

Women readers might also want to read it to learn something about the male body and needs.

The Boston Globe delivers an article today on a problem that many people don’t realize: antidepressants can decrease or eliminate sexual desire and interfere with a person’s ability to have orgasm.

It’s a problem that’s more common than originally believed. Pharmaceutical companies testing their drugs before release have stated only about 3-5% of people in their trials had sexual side effects. But now that the drugs are in widespread use, it turns out the problem is also widespread: about 10 times that number actually have experienced sexual side effects.

What to do? Knowing this, one of the first things I do with clients who come in with mood disorders or anxiety and who have not yet been diagnosed is to educate them about the pros and cons of taking antidepressants. I also give them a reasonable option: Try eliminating symptoms of depression and anxiety without medication. For mild to moderate cases, psychotherapy alone has been shown to be effective. I let the client know that we can revisit the issue of medication if there doesn’t seem to be any improvement after 6 to 8 sessions of psychotherapy.

Second, for those patients with moderate depression, I counsel them about taking the smallest but most effective dose. I also tell them that if they notice a change in their sexual interest for the worse, or have delayed or no orgasm, then they need to speak to the prescriber and make a switch quickly. That’s because the side effects can become permanent. Although the number is very small, I have definitely had people in my office who went off medication, only to find orgasm still difficult to attain, even months and months later.

In a sex therapy practice, it is somewhat rare to have a client come to us with severe mood or anxiety problems that have not been previously diagnosed. Mostly, we see them when they are already on medication. Sometimes they come in with complaints that are related to their medication. Once they realize that is the case, some clients chose to try switching. Others, having tried multiple medications already to find one that works, decide that they will live with low desire or delayed orgasm rather than risking a mood disorder that interferes with their ability to function.

One thing is certain: Physicians needs to take more care about prescribing antidepressants to counsel their patients about possible sexual side effects, and to carefully consider referring people for psychotherapy for mild to moderate problems, rather than immediately reaching for the prescription pad.

Oprah.com features an in-depth article on men who were sexually abused as boys. No one is certain how many boys are molested, but the number is probably much higher than reported because boys are unlikely to report abuse; when it is reported, it has usually been discovered by someone else.

Men recovering from the effects of sexual abuse suffer as much as women–and maybe a little more. While we have had a few decades of women telling their stories of recovery, it is still relatively rare for men to openly admit or discuss their early negative experiences. Men fear that others will think they are gay if the abuser was male, and men also like to think that they can manage most anything on their own.

It appears that the priest abuse we’ve all been reading about over the past several years has blown the lid off of the existence of male sexual abuse. Having worked with men who have been abused by religious figures as well as men abused by close relatives, teachers, scout leaders, coaches, and strangers, I can tell you that men have real difficulty coping with sexual abuse.

Why see a sex therapist rather than a general therapist? For many men, sexual development is compromised, and sex with a partner, even a trusted one, can become problematic. As with women, there are many things that can trigger sexual problems later in life. Men can have performance problems and difficulty managing other emotions, such as intimacy and anger.

The Oprah article links to a list of signs that a man may have been sexually abused. If you are a woman who believes her husband may have been abused, but is unwilling to discuss it, please read the article and the signs. If you are a man, you can learn that you can heal yourself from the effects of sexual abuse by reading the article.

If you want help, please call us. We are experienced with working with men, and women, who want to heal from sexual abuse.

Recently an article appeared on the struggles that military couples have when the military person returns from duty. Many soldiers come back from war not just physically and emotionally scarred, but have sexual problems, too. The sexual concerns arise for many reasons, including effects from post traumatic stress disorder (PTSD), depression, and performance anxiety. Of course, physical problems, both large and small, can also make sexual function a challenge.

Having trained at the now defunct Marine base at El Toro, I can tell you that opening up a dialogue about this issue is a great idea. I don’t remember talking to military couples about their sex lives per se–as an intern, I don’t think anyone ever mentioned sex as an area that I should explore with clients–but issues did come up related to sexual intimacy.

I am a member of Operation Comfort which connects military personnel with therapists. If you are a military couple struggling with this issue, I invite you to contact us to see how we might be of service to you.