Combination Therapy for Sexual Dysfunction: Integrating Sex Therapy and Pharmacotherapy
Michael A. Perelman
The New York Presbyterian Hospital,
Weill Medical College of Cornell University, New York, NY, USA
INTRODUCTION: THE FALSE DICHOTOMY
The 20th century marked huge strides in our knowledge of sexual disorders and their treatments, however, advancements were followed by periods of reductio- nistic thinking. Etiology was conceptualized dichotomously, first as psychogenic and then organic. Early in the 20th century, Freud highlighted deep-seated anxiety and internal conflict as the root of sexual problems experienced by both men and women. By mid-century, Masters and Johnson (1) and then Kaplan (2) designated “performance anxiety” as the primary culprit, while pro- viding a nod to organic factors. Together, they catalyzed the emergence of sex therapy, which relied on cognitive and behavioral prescriptions to improve patient functioning. For the next two decades, a psychological sensibility domi- nated discussions of the causes and cures of sexual dysfunctions (SDs). However, during the late 1980s, there was a progressive shift toward surgical and predomi- nantly pharmaceutical treatments for male erectile dysfunction (ED). By the 1990s, urologists had established hegemony, with the successful marketing of various penile prostheses, as well as intracavernasal injections (ICI) and inter- urethral insertion (IUI) systems [e.g., Caverject (Pharmacia, Teapak, NJ, USA), Muse (Vivus, Mountainview, CA, USA)]. The monumentally successful 1998 sildenafil launch (Pfizer, New York, NY, USA) and its subsequent publicity at the end of the 20th century symbolized the apex of biologic determinism. Most physicians and most of the general public saw SD and its treatment solely in organic terms.
The new millennium finds us moving forward toward a more enlightened and sophisticated paradigm where the importance of both organic and psycho- genic factors is appreciated for their role in predisposing, precipitating, main- taining, and reversing SD. The pharmaceutical industry has developed other phosphodiasterase-5 inhibitor (PDE-5) based treatments for ED as evidenced by the successful 2003 launches of vardenafil (Bayer, New Haven, CT, USA and GSK, Philadelphia, PA, USA) and tadalafil (Lilly, Indianapolis, IN, USA and ICOS, Seattle, WA, USA). All three FDA-approved PDE-5 inhibitor compounds are selling well worldwide, and new pharmaceutical delivery systems for treating SD are in development. The FDA has approved EROS (UroMetrics, Inc., Anoka, MN, USA), a mechanical device, for the treatment of female SD (FSD). Indeed, multiple products (pharmaceutical, nutriceutical, and mechanical) are being introduced, or are in development, to treat a host of complaints under the market driven heading of “FSD.” Despite this juggernaut of pharmaceutical activity, a renewed sensitivity to psychosocial issues is emerging and a more balanced perspective is shaping our discussions of the understanding and treat- ment of male and female SD. These discussions are the focus of symposia at important international meetings (American Urological Association, World Health Organization, International Society for the Study of Women’s Sexual Health, etc.). Yet, they are underwritten (directly or indirectly) by the same pharmaceutical companies that develop and manufacture the drugs, which essen- tially catapulted a biologic medicalized view of SD onto the world stage, to the exclusion of psychosocial sensitivity. This rebalancing of perspective, reflected a growing consensus of thought, catalyzed by mental health professionals (MHPs). These MHPs have once again successfully advanced the obvious concept: psychosocial factors are also critical to the understanding of sexual function and dysfunction. Sexual pharmaceuticals can very frequently restore sexual capacity. Yet, rewarding sexual function is experienced only when psychosocial factors also support restored sexual activity. Medicine today emphasizes an evidence-based research. There is a seeming inherent tension between this concept and the qualitative “art and science” of psychotherapy (3). This chapter will attempt to bridge that gap by discussing combination treatments (CTs) for SD, where the use of sex therapy strategies and treatment are integrated with sexual pharmaceuticals. There is a synergy to this approach, which is not yet supported by empirical evidence, but is rapidly gaining adherents which over time will document its successful benefits. Although there has been an explosion of research regarding the efficacy of PDE-5s for ED in the last 5 years, there is no doubt in this author’s mind that combination therapy (CT) will be the treatment of choice for all SD, as new pharmaceuticals are developed for desire, arousal, and orgasm problems in both men and women. Yet, owing to the paucity of current data available for other sexual disorders, this chapter will primarily emphasize CT for ED.
MODELS FOR TREATING SEXUAL DYSFUNCTION Sex Therapy
Sex therapy theory and technique were derived from the pioneering works of both Masters and Johnson (1) and Kaplan (2). Initially Masters, a gynecologist, used an innovative 2 week, mixed-gender, co-therapy team, quasiresidential approach.
Sex therapy rapidly morphed into weekly sessions provided within a solo MHP’s office based practice. Treatment continued to emphasize “sensate focus exer- cises” and the reduction of performance anxiety. By the 1980s, sex therapy reflected a cognitive-behavioral theoretical bias, while typically utilizing Masters and Johnson variations, such as Kaplan’s, four phase model of human sexual response: desire, excitement, orgasm, and resolution (1,4,5). The models were not necessarily linear and causes could become effects. For instance, an ED might cause diminished desire. However, generally speaking, sex therapy was and is, the diagnosis and treatment of disruptions in any of these four phases and/or the sexual pain and muscular disorders. These dysfunctions occurred independent of each other, yet they frequently clustered.
Sex therapy was based on the development of a treatment plan conceptual-ized from the rapid assessment of the immediate and remote causes of SD while maintaining rapport with the patient (6,7). The sex therapist assigned structured erotic experiences carried out by the couple/individual in the privacy of their own homes. These exercises were designed to correct dysfunctional sexual beha- vior patterns, as well as positively altering cognitions regarding sexual attitudes and self-image. This “home play” modified the immediate causes of the sexual problem, allowing the individual to have mostly positive experiences and created a powerful momentum for successful treatment outcome. Interventions aimed at correcting or challenging maladaptive cognitions were incorporated into the treatment process (8). The individually tailored exercises acted as “thera- peutic probes” and were progressively adjusted until the individual or couple was gradually guided into fully functional sexual behavior (4,6). However, each dysfunction had its own cluster of immediate causes. Certain exercises were typi- cally used with a particular dysfunction. For example, almost all men with premature ejaculation (PE) were taught the “stop – start” technique, because failure to recognize and respond properly to sensations premonitory to orgasm, characterized that syndrome.
Patients might be single or coupled. The single patients were seen alone, but their new sexual partner might join them in treatment, once an ongoing relationship was formed. Couples were usually seen conjointly, however, during the evaluation phase of treatment, they were typically seen alone for at least one session of history taking. Other individual sessions were reserved for management of resistance where it may be more strategic to discuss the obstacles to success privately. To facilitate the success of this rapid approach, individuals/ couples at times needed to explore other aspects of their relationship and/or intrapsychic life. Nevertheless, establishing sexual harmony typically remained the primary focus. Despite the concrete goal orientation, the therapeutic context was humanistic, emphasizing good communication, intimate sharing, and mutual respect.
Sex therapy was an “efficacious” treatment for primary anorgasmia in women, some erectile failure in men, and was “probably efficacious” for secondary anorgasmia, … , vaginismus in women and PE in men (9). Clinical experience supported efficacy in treating hypoactive sexual desire, sexual aver- sions, dyspareunia, and delayed orgasm in men (9). Despite its potency, there were and are drawbacks to this approach, particularly from a cost-benefit stand- point. Although considered as a “brief treatment” within a mental health context, it typically required many appointments with a trained specialist and a high degree of motivation on the part of the patient. Historically, healthcare systems have discarded labor intensive, expensive approaches once “easier” and more rapid alternatives were available. Sex therapy receded as a treatment of choice during the 1990s, as medical and surgical approaches performed by urologists established hegemony over the treatment of ED, in particular. The pinnacle of this transition was reached during 1998, with the launch of sildenafil.
Medical Treatments for Erectile Dysfunction
The 1980s saw a progressive shift away from psychological treatments of SD to an emphasis on surgical and medical solutions for improving sexual health. Sim- ultaneously, there was a progressive shift within the medical community and public at large, towards viewing the etiology of SD as organic, rather than the psychogenic understanding emphasized by sex therapists. Use of improved soph- isticated diagnostic procedures, such as duplex sonography and cavernosograms (although not necessarily improving treatment) added credibility and imprimatur to the importance of organic pathogenesis (10). This was particularly true in the area of ED, where urologists established dominance, with the successful market- ing and use of various intracavernosal and intraurethral systems. Although highly touted by urologists, the treatment efficacy of these products was offset by their intrusiveness into the patient’s bodies and reduction in spontaneity, their patterns of use required.
Initially, there were few oral treatments for ED, being used by urologists, such as yohimbine based products, trazodone, and bupropion. They had only modest proerectile capability (11). Pharmaceutical companies were inspired to pursue oral treatments with the promise of less intrusiveness and even greater profits. The first visible evidence of fulfilling that promise was the sildenafil launch. Subsequent to Pfizer’s success, multiple companies simultaneously pursued clinical trials of easy-to-use treatments for male SD. Among others, these included additional PDE-5 type compounds and other oral treatments, such as ixense (TAP Holdings, Deerfield, IL, USA), and topically applied com- pounds (MacroChem, Lexington, MA, USA). Additionally, PT-141 (Palatin Technology, Cranbury, NJ, USA) is a nasally administered peptide that is under development, which is presumed to work through a central nervous system mechanism.
Currently, there are three highly efficacious PDE-5, FDA-approved treat-ments for ED: sildenafil, vardenafil, and tadalafil. Reviews of long-term extension studies and published accounts of use in clinical practice show that sil- denafil’s effectiveness was maintained with long-term treatment. “Significantly improved erectile function was demonstrated for sildenafil compared with placebo for all efficacy parameters analyzed (P , 0.02 to 0.0001), regardless of patient age, race, body mass index, ED etiology, ED severity, ED duration, or the presence of various co morbidities. Long-term effectiveness was assessed in three open-label extension studies (12).” Vardenafil (launched in 2003) “is a potent, selective PDE-5 inhibitor, which improved erectile function in a broad population of men with ED and in characteristically challenging-to-treat groups such as diabetic and post prostatectomy patients (13).” Tadalafil also launched in 2003, when taken, “as needed before sexual activity and without restrictions on food or alcohol intake, significantly improved erectile function. It allowed a substantial proportion of patients to achieve a normal IIEF erectile function domain score, exhibited a broad window of therapeutic responsiveness and was well tolerated in a representative population of patients with broad- spectrum erectile dysfunction (14).”
NEW SEXUAL PHARMACEUTICALS: SUCCESS OR FAILURE Success of the New Treatments The new PDE-5 inhibitors have resulted in more people being treated than ever, with high success rates. There is much greater awareness of sexual and psycho- sexual issues surrounding dysfunction, simultaneous with a reduction of the stigma previously associated with ED. Treatment is now conducted by an expanding number of helping professionals, primarily PCPs. Treating ED is now a billion-dollar business with millions of men treated and many helped.
Barriers to Treatment Success
Approximately 90% of men who seek assistance for ED are treated with PDE-5s, all of which are reasonably safe (15). All are completely contraindicated with concomitant nitrate use; with some additional warnings and/or contraindications attached to use of alpha-blockers. Generally, PDE-5 inhibitors are highly effec- tive, restoring erections in 70% of men, yet there is a growing body of evidence suggesting that the frequently quoted 20 – 50% drop-out rate for medical treat- ments is true for PDE-5 treatment as well (15). Why? The adverse event profile is excellent for all three PDE-5s, with few patients terminating treatment, because of adverse events. Of course, not all discontinuation of sexual pharma- ceuticals are due to failure or complications. There are some who tried the medications out of curiosity and never intended to continue using a PDE-5. There are some reported cases of men with psychogenic ED experiencing a “cure” after temporary use of a PDE-5 (16).
Reciprocally, some people will discontinue PDE-5 because of the severity of their ED. For these individuals, the pharmaceuticals simply do not work. Regardless of the mode of administration, a certain percentage of the population will not experience restored capacity, because the degree of organicity is so
profound as to overwhelm the salutary effects of the drug. In particular, some diabetics and radical prostatectomy survivors may need more powerful medical treatments.
Importantly, PDE-5 treatments do have significant psychosocial limitations and consequences which have created “born-again” roles for sex therapists, albeit more complex and sophisticated ones (17). Previously, many presumed that high discontinuation rates were due to the objectionable nature a specific treatment, such as self-injecting the penis. They thought that the introduction of efficacious and safe oral agents would decrease this high drop-out rate (18). However, there is great complexity to the barriers to success story. Although definitely improv- ing, the reported success rate, the ensuing publicity (following PDE-5 launches) still resulted in just a small percentage of people worldwide receiving pharma- ceutical therapy. ED treatment, even with its juggernaut of publicity and advertising has penetrated ,15% of the estimated market place. In fact, industry information suggested that a geometrically small number of individuals were actually successfully treated and satisfied repeat “customers” (19). Apparently, a limited number of men were treated and a large percentage of those who tried it, apparently discontinued rather abruptly (19). There was also a high relapse rate when medication was stopped. The model for all three PDE-5s, as well as ICI and IUI treatments for ED, was chronic pharmaceutical use in order to relieve symptoms. To date, very little was written about “weaning” patients from pharmaceuticals or effectively maintaining them on lower doses. Concepts of “weaning” and relapse prevention offer opportunities for MHPs (20).
Identifying Psychosocial Barriers to Success
Importantly, pharmaceutical advertising and educational initiatives have altered the delivery of sexual medicine services, especially in the United States. Specifi- cally, these changes in practice patterns resulted in PCPs becoming the principal healthcare providers for men who present with a primary complaint of ED, with urologists typically seeing the more recalcitrant cases. MHPs rarely are the initial treating clinicians anymore. This both helps and contributes to the problem of success and failure. The large number of PCPs treating ED has dramatically increased the number of patients seen, and the accessibility of medical treatment. Unfortunately, the history obtained by PCPs and urologists is frequently limited to an end-organ focus, and fails to reveal significant psychosocial barriers to suc- cessful restoration of sexual health. These obstacles or “resistance” represent a significant cause of noncompliance and nonresponse to treatment (2). These barriers manifest themselves in varying levels of complexity, which individually and/or collectively must be understood and managed for pharmaceutical treatment to be optimized (15,20).
Only recently, have physicians begun incorporating sex therapy concepts, and recognized that resistance to lovemaking is often emotional. Clearly, medical treatments alone are often insufficient, in helping couples resume a satisfying sexual life. There are a variety of bio-psychosocial obstacles to be recovered that contribute to treatment complexity. All of these variables impact compliance and sex lives substantially, in addition to the role of organic etiology (20). There are multiple sources of patient and partner psychological resistance, which may con- verge to sabotage treatment: (i) What is the mental status of both the patient and the partner and how will this impact treatment, regardless of the approach utilized? What is the nature and degree of patient and partner psychopathology (such as depression)? What are the attitudinal distortions causing unrealistic expectations, as well as endpoint performance anxiety? (ii) What is the nature of patient and partner readiness for treatment? When and how should treatment begin, and be introduced into the couple’s sex life? What is his approach to treat- ment seeking? What should be the pacing of intimacy resumption? The average man with ED waits 2 – 3 years, before seeking assistance (21). By that time, a new sexual equilibrium has been established within the relationship, which may be resistant to the changes a sexual pharmaceutical introduces. Furthermore, although partner pressure is a primary driver for treatment seeking, some men who sought treatment at their partner’s initiation do not necessarily confide in them about the treatment (21). (iii) What is their emotional and attitudinal readi- ness for change? The sexual history will provide information regarding premor- bid and current sexual desire. What is her motivation or desire for sex? What are her concerns regarding his safety? What are her belief systems regarding the treatment process which now enables coitus? Her compliance may be affected be her perception of the treatment being artificial or mechanical: “Is it the silde- nafil, or me?” (iv) What is her health status (vaginal atrophy, etc.) and physical readiness for sex; her capacity for lubrication and need for stimulation, etc.? We know from the Massachusetts Male Aging Study that frequency of ED increases with age (22). We know that older men tend to have older, post-menopausal part- ners. Female partner’s additional and sometimes complex medical needs are fre- quently not addressed in the brief evaluation interview, often conducted by the average physician. (v) What are the relevant contextual stressors in the patient and/or partner’s current life, such as work, finances, parents, and children, etc.? (vi) What is the couple’s overall quality and harmony of relationship? Inter- personal issues impact outcome through a variety of manifestations? Intimacy blocks and power struggles may cause failure. (vii) What are the patient and part- ner’s sexual script? Overtime, incompatible sexual scripts, interest, and arousal patterns may predetermine SD. For instance, PDE-5s require stimulation, for the man to respond sexually; stimulation is frequently more than merely adequate friction. There are many divergent sexual scripts and a variety of unconventional patterns of sexual arousal (homosexuality, sadomasochism, etc.), which may sabotage arousal. Additionally, over time, there are reality-based alterations in a partner’s sexual desirability, which may also affect both arousal and orgasmic response.
Although most of these barriers to success can be managed as part of the treatment, too few physicians are trained to do so (20,23). What is a model for this situation? These various sources of psychological resistance manifest them- selves in a diverse manner, which Althof conceptualized as three “scenarios” of psychosocial complexity (15). Each level would lead to an alternative treatment plan. Importantly, this concept can be expanded to conceptualize treatment for all SD, and regardless of who provides care—they all would be CT.
COMBINATION THERAPY: THE ROAD TO SUCCESS
Combining sexual pharmaceuticals and sex therapy is the “oral therapy” of choice to optimize treatment for all SDs. This is true for men with ED, PE, or retarded ejaculation (RE) and will also be true for FSD. Less medication is required when you modify immediate causes while appreciating other psy- chological obstacles (20). However, CT is by no means a new idea, and sexual medicine is not the first specialty utilizing a broad-spectrum approach to increase efficacy and satisfaction.
Combination Therapy: A Brief Relevant History
During the 1970s, psychiatrists and psychoanalysts argued, with analysts insist- ing that psycho-pharmaceuticals interfered with analysis. Today, mainstream psychiatry is characterized by a CT of psychotherapy and psychopharmacology. In the 1990s, psychiatrists finally integrated SSRIs synergistically with cognitive- behavior therapy to treat depression. Indeed such a model, frequently practiced in modified form by PCPs, probably dominates the treatment of depression today. There is an emerging literature demonstrating the benefit of combining both pharmacological and psychological treatments for a number of psychiatric conditions (24 – 26).
In urology and many medical specialties, CT usually referred to a, two or more drug regimen, such as the 2003, AUA guidelines for BPH (27). There already is a history of using CT in sexual medicine. In the 1990s, sex therapists worked with urologists combining either ICI or vacuum tumescence therapy. Turner et al. (28a) found that psychological counseling was necessary to augment a pharmaceutically induced erection, for a man with a psychogenic ED. Kaplan managed “resistance to ICI,” helping five couples find satisfaction with pharmaceutical restoration of potency (28b). Hartmann and Langer (29) integrated injection therapy and sexual counseling concluding that a combined approach was beneficial. Colson described the results of a study integrating cognitive-behavior therapy and ICI technique. Of their patients, 51% were still able to experience satisfactory sexual intercourse after discontinuing injection therapy (30). Lottman et al. (31), integrated short-term therapy with intracaver- nosal injections and counseling, improving erectile function and facilitating couples communication. Wylie et al. (32) reported a successful combining of “vacuum treatment” and couple’s therapy for primarily psychogenic ED patients using a group approach.
Multiple case reports have summarized the benefits of combining sexual phar- maceuticals with cognitive or behavioral treatments for ED (33 – 37). There were also multiple articles recommending the combination of medical and psychological approaches to the treatment of ED (15,20,32,38,39). Unfortunately, at this point there are no well-designed randomized control studies focused on integrated approaches to the treatment of SD. However, many are optimistic that the data sup- porting this approach will be forthcoming. An excellent summary of this material on CTs, primarily for ED, with a few FSD studies, can be found in Table 10 of the WHO
2nd Consultation on Erectile and Sexual Dysfunction, Psychological and Inter- personal Dimensions of Sexual Function and Dysfunction Committee report (40).
Combination Therapy for Sexual Dysfunction: Integrating
Sex Therapy and Sexual Pharmaceuticals
We know, clinically, that many PDE-5 nonresponders will be restored to sexual health through a CT integrating sex therapy and sexual pharmaceuticals. Yet how do we conceptualize such a model so that standard treatment algorithms could be stretched to incorporate this concept? The answer is twofold. We need a schema for understanding psychosocial obstacles (PSOs) to successful treatment, inte- grated into a model that executes that understanding.
Combination therapy is the therapeutic modality of choice for any SDs. Combination therapy refers to a concurrent or step-wise integration of psycho- logical and medical interventions. We have previously described developing adherence for this approach to ED, with enthusiasm growing within the FSD treatment community (36). Combination therapy is already being recommended for PE, and is likely to be recommended for the full range of ejaculatory disorders (41). Although desire disorders for men and women have a strong psychosocial cultural component, there is little doubt that sexual “desire” has biological under- pinnings and is likely to be distributed on the same bell-shaped distribution curve as other human characteristics. This simply means that all SDs have a bio- psychosocial basis and that treatment must incorporate medical and psychologi- cal dimensions. Without adequate desire, motivation, and realistic expectations, treatment outcome is likely to be disappointing and with high discontinuation rates. Medical interventions do not motivate the sexually reluctant patients or partners to try treatment, nor do they help overcome psychological obstacles to success. Reciprocally, it would constitute malpractice to only focus on psycho- logical factors to the exclusion of all possible organic etiology for an individual seeking assistance. Then, how can an ethical and motivated clinician proceed?
Combination Therapy Guidelines: Who, How, and When?
There are two alternative models for CT: both will likely be adopted within the framework of sexual medicine, by different clinicians. First, working alone, PCPs, urologists, psychiatrists, and eventually gynecologists will integrate sex counseling with their sexual pharmaceutical armamentarium to treat SD. “Sex
counseling” in this situation, is utilizing sex therapy strategies and techniques to overcome psychosocial resistance to sexual function and satisfaction (20). In a second model, the above clinicians will collaborate with nonphysician MHPs (sex therapists), resolving SD(s) through a coordinated multidisciplinary team approach to treatment. The clinical combinations will vary according to the presenting symptoms, as well as the varying expertise of these health care provi- ders. The utilization of these two different models will require three steps. (i) The clinician first consulted by the patient will consider their interest, training, and competence. (ii) The bio-psychosocial severity and complexity of the SD as a manifestation of both psychosocial and organic factors will be evaluated. (iii) The clinician in consideration of the two previous criteria, together with patient preference, will determine who initiates treatment, as well as, how and when to refer. The guidelines for managing the relative severity of the dysfunction will essentially be expanded, but continue to match the type of treatment algor- ithm described in “The Process of Care” and other step-change approaches (42).
Categorizing Psychosocial Obstacles to Treatment
Whether or not a physician works alone, as in the first model, or as part of a multi- disciplinary team, as in the second, will be partially determined by the psychoso- cial complexity of the case. This CT model adapts Althof and Lieblum’s “Proposed Integrated Model for Treating Erectile Dysfunction” (15,40). However, it must be emphasized that this author is advocating a CT model for all SD. The treating clinician would diagnose the patient(s) as suffering from mild, moderate, or severe PSOs to successful restoration of sexual function and satisfaction. This characterization would be based on an assessment of all the available information obtained during the evaluation. This would include an assessment of the issues/factors described in this chapter’s earlier section on “Psychosocial Barriers to Success.” This assessment would essentially include the psychosocial (cognitive, behavioral, cultural, and contextual) factors predisposing, precipitating, and maintaining the SD. This would be a dynamic diagnosis, continuously reevaluated as treatment progressed. The con- sulted clinician would continue treatment and/or make referrals on the basis of progress obtained. These PSOs are categorized as follows:
1. Mild PSOs: No significant or mild obstacles to successful medical treatment.
2. Moderate PSOs: Some significant obstacles to successful medical treatment.
3. Severe PSOs: Substantial to overwhelming obstacles to successful medical treatment.
Sexual Dysfunction Treatment Guidelines
Although no objective data determines the criteria for diagnosing these three PSO categories, they will become a useful heuristic device to help clinicians know
when to refer. For instance, “Severe” PSOs may require psychotherapeutic and/ or psychopharmacologic intervention prior to the initiation of treatment utilizing sexual pharmaceuticals in order to restore sexual functioning and satisfaction. Most nonmedical MHPs will collaborate with physicians to augment their own treatments, as sexual pharmaceuticals are likely to provide an ever-increasing role in MHP’s treatment strategies and armamentarium for SD (15,17,20,43). Additionally, this treatment matrix will provide a useful tool for sex therapist physicians (usually psychiatrists), when deciding whether to treat themselves, or seek collaborative assistance. The matrix determining who might treat is presented in Table 2.1.
The following discussion illustrates how Table 2.1 could be used in clinical practice. Clearly, a multidisciplinary team including a sex therapist and multiple medical specialists could attempt to treat almost every case. Although severe cases would usually require a greater number of office visits with lower success rates, than moderate or mild cases. However, a team is a very labor- intensive approach and frequently unrealistic, both economically and geographi- cally in terms of available expertise and manpower. However, in the first two cells, which reflect common scenarios in clinical practice, a physician who first evaluates a patient suffering from SD, could integrate sex counseling with their sexual pharmaceuticals, often resulting in a successful outcome.