However evidence has emerged to challenge the salience of this model. The challenges come from a methodologically diverse array of medical and social science studies that emphasize the central role of psychological, relational, and cultural factors in men's sexual expectations and satisfactions and downplay the importance of a universal model of sexual function and satisfaction. The challenges also come from critics concerned about the pharmaceutical industry's overweening role in the medicalization of sexual problems through its influence on sex research, guidelines development, professional education, journal publication practices, and possible "disease-mongering."Clinicians interested in a more independent and inclusive approach to understanding, assessing, and treating men's sexual problems can turn to one first developed in 2000 for women by a group of clinicians, sex therapists, and social scientists, called "The New View."
Since the 1970s, an emerging interdisciplinary field of knowledge known as "men's studies" has urged scholars in all fields to understand issues concerning men within the context of "what it means to be a man in a particular historical or cultural social setting." This quote, from a 2-volume encyclopedia on Men and Masculinities, scarcely does justice to the importance of understanding men's sexual problems within their social context. As Tepper, a leading expert on sexuality and disability writes, "What boys learn about sex and manhood becomes a critical treatment concern when they reach adulthood and are faced with sexual dysfunction."
Many authors have described that what boys around the world learn about sex and manhood constitutes some variation on a penis-centered mythical performance model that privileges erectile and orgasmic function and downplays issues of pleasure and intimacy. "We can hardly talk about sex without referring to it as a performance," says Apfelbaum. As Zilbergeld and Connell have discussed, impairment in erectile or orgasmic function profoundly threatens a man's gender identity because
[men] learn from an early age that manhood is conditional rather than absolute... Not making the team, not being willing to fight, not performing in bed, losing a job -- that's all it takes and our man no longer believes that he's a man.
And:
[the] constitution of masculinity through bodily performance means that gender is vulnerable when the performance cannot be sustained.
The loss or diminution of erectile or orgasmic abilities can easily constitute a serious identity crisis; although that is not to say that a crisis cannot also be an opportunity. Several recent studies have shown that some, but not all, men react to the threat to sexual function posed by illness by maintaining their masculinity. That is, they cope "like a man" and deal with the situation by adapting, experimenting, and changing practices. The way sexuality, sexual norms, and sexual satisfaction are defined and dealt with by health professionals plays a large role in either helping men cope with problems or, often unwittingly, in converting social norms into clinical standards and thereby exacerbating suffering. "Negative attitudes and misguided beliefs about sexual potential take their toll on sexual self-esteem [and may] make sexual relationships seem pointless."
Understanding and helping men with sexual problems is best achieved through appreciating how specific and contextualized men's sexual lives really are.
The expectations that create the standard script have been narrowly construed as the foreplay mental set and a preoccupation with erections and orgasm... which makes it appear to be the task of therapy to modify [pathogenic interferences] rather than [to modify] the... sex itself.
Treatment Prior to 1998
Until the 20th century, men's sexual problems were dealt with by herbs, ceremonies, incantations, exorcisms, physiotherapy (eg, ointments, baths, exercises), prayer, pilgrimage, external prostheses, and dramatic surgeries, the list id almost unemdimg. Interventions combined psychic and somatic elements that involved complex and culturally specific sexual meanings. Group witness and support were often involved. The outcomes, however, are largely unknown.
Throughout the first two thirds of the 20th century, a range of talk-therapies Psychoanalysis,Psychotherapy were developed to deal with human problems, including problems with sexual relations.
Table 1. Talk Therapies for Sexual Problems
| Individual Therapies |
| • Psychoanalysis |
| • Psychotherapy |
| • Behavior therapy |
| • Cognitive behavior therapy |
| Group psychotherapies |
| • Insight-oriented group psychotherapy |
| • Couples group therapy |
| • Support groups |
| • Humanistic group psychotherapy (eg, sensitivity training, encounter groups, gestalt therapy) |
| • Structured psycho-education groups |
| Family therapies |
| Couples therapies (Conjoint approaches) |
| • Sex therapy |
| • Marital and relationship therapy |
Individual, group, family, and couples talk-therapy approaches emerged from research on trauma, conflict, psychosexual development, conditioning and learning, behavioral change, and interpersonal processes. These approaches directed sexual treatment away from aggressive physical interventions, such as genital surgeries and massive hormones, towards self-understanding, interpersonal skills, empathy, and personal change. Many popular books stressed the importance of resolving neurotic conflicts and educational gaps in order to solve erectile and ejaculatory problems.
In some individual therapies the primary vehicles of insight and behavior change came from the healing potential of the therapist-patient relationship; in others, the benefits came from carefully chosen and thoroughly discussed psycho-educational homework assignments. Schools of psychotherapy competed throughout the century, sometimes criticizing each other's fundamental assumptions and sometimes looking for common ground.
Group therapies emerged in the 1920s to deal with sexual issues such as body image and interpersonal trust.[24] Postwar, group approaches to sexual problems diversified as a result of the human potential movement in the 1960s and involved modalities such as sensitivity training, encounter groups, gestalt therapy, and bodywork.[25]
Couples and family therapies were developed in the 1950s and 1960s. They identified the family/couple system, rather than the individual, as "the patient" and the locus of intervention. The crucial but counterintuitive notion that symptoms often maintain the homeostasis of the relationship is at the heart of both understanding and intervention on the systemic level (eg, see LoPiccolo and Friedman[26]). The thoughtlessness of medical efforts at "simply" removing such symptoms, as with a surgical strike, is reiterated in systems texts.
Masters and Johnson[27] formalized some of the individual behavioral and educational interventions into a widely publicized couple treatment format and inaugurated a wave of psychiatry-department-based sex therapy clinics that embraced group, couple, and individual formats, but their approach ignored the systems theory approaches developing in family therapy and family medicine.[28,29] Sex therapy clinics thrived in the 1970s and 1980s but were in decline by 1990 as a result of the growth of biological psychiatry and the medicalization of sexual problems.
Somatic therapies for men's sexual problems remained in the shadows prior to the 1980s, as they had little to offer but experimental surgeries and penile prostheses for impotence.[30-32] In 1978, a group of physicians convened in New York to discuss new research in the physiology of erection.[33] They instituted regular meetings that evolved into the International Society for Impotence Research (ISIR) in 1982.* In the 1980s, urologists claimed authority over the new area of sexual medicine, noting "the emergence of the urologist as the primary coordinator of care for the patient with sexual dysfunction, whether the cause of that dysfunction is an organic, a psychogenic, or as sometimes occurs, a combination one."[34]
In 1983, at the American Urological Association convention, Giles Brindley, a British physiologist and physician, injected his penis with phenoxybenzamine just before his lecture and displayed his erection to the astonished audience.[35] This legendary event inaugurated an active era of intracavernosal injection treatments, although the first drug was not actually approved by the US FDA until 1997.[33,36] Also in 1983 came the patenting of a widely advertised vacuum device for erections. (Earlier models had been patented, but either not distributed or sold in sex stores.[37])
The biological buzz fit with the general molecular Zeitgeist. By 1988, the main health reporters in The New York Times[38,39] and Time[40] magazine were promoting the new physiology and treatments for impotence. And, in 1989, a major New England Journal of Medicine review of the field was authored by urologists, with only 2 paragraphs in 11 pages devoted to nonsomatic issues.[41]
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