Erectile Dysfunction impacts relationships & couples don’t know how to talk about it & don’t have enough information about it, so today is all about correcting this problem. Just a few statistics: In 2018 the National Institute of Health estimated that ED affects about 1/3 of men. In 2019 there was a global review that said the prevalence of ED ranges from 3%-76.5% One patient out of 4 is a young man under 40 according to research in the Journal Sexual Medicine published in 2013. The Cleveland Clinic reports 1in 10 men will experience ED in their lifetime. The LAST STAT only 25% of Men with ED receive treatment.
Let’s define ED:
Erectile dysfunction (ED) is a condition in which you are unable to get or keep an erection firm enough for satisfactory sexual intercourse. ED can be a short-term or long-term problem. Of course certain blood pressure medications, alcohol or a disease like diabetes can contribute to ED.
ED is a complex condition affected by physical, psychological, &and relationship issues—and it’s a problem shared by both a man and his partner
Today my guest is Dr. Barry McCarthy, Professor Emeritus at American University who has written countless books on sex including Coping With Erectile Dysfunction with Michael Metz & presented workshops all over the world, two which I was lucky enough to attend in Pittsburgh. So glad you were willing to join me today.
So my first question to you would be what would you like to add to my introduction about ED?
McCarthy: Well, the most important thing that I would like your listeners to understand, is that for the great majority of men. Again, that is not all men, but the great majority of men, they learned to be sexual in adolescents in young adulthood, in an autonomous manner. And what I mean by that, is again, easy spontaneous erection and go to intercourse and orgasm, and they don’t need anything from their partner.
They want the partner to be involved and to enjoy it, but they don’t need anything from their partner. And then the problem is that men define that as normal sexuality, autonomous sex, and what happens to the great majority of men.
They always want to make the point that nothing holds for everybody. Sexuality is incredibly complex, but for the great majority of men, sometime between age 35 and age 55, they have a sensitizing erectile experience, where they don’t get an erection sufficient for intercourse.
Now in a healthy way, what will happen with that man is it will be a wakeup call that he can’t take erections and sex for granted, and that he needs to be more aware of his partner and his own emotional and her sexual needs. And he actually becomes a better lover after a sensitizing experience, but for a significant minority of men, they develop an anxiety, anticipatory and performance anxiety, and they think of their erection as an individual pass, fail test for sex.
And the major mistake that the man makes is that he rushes to intercourse as soon as he gets an erection. And that’s why males by in large have failed with Viagra. Viagra has actually caused more non-sexual marriages and relationships and anything else in history, since 1998, not because it’s not a good drug, it is a good drug.
And though we can talk about why for many men, Cialis is a better drug, but that what happens is as soon as he gets an initial erection and the way to understand it, arousal as being both subject to an objective, objective is how form your erection is, subject is how turned on you feel.
So you often get an erection that’s subjective arousal at four or five, but you’re so much better off waiting until your subjective arousal is seven or eight before transition to intercourse. And what happens with anxious men, is as soon as they get an erection, they rushed to intercourse because they’re afraid of losing the erection.
So what you want in a positive way, realistic positive way, is you want the man to anticipate sex, to enjoy sex as a pleasurable experience, to engage in giving and receiving arousing in erotic stimulation.
And Hampion transitioned to intercourse when his subjective arousal ideally would be an eight, seven at the least, and then enjoy giving multiple stimulation receiving both before intercourse and during intercourse. Now here’s the core concept, the true core concept that comes from my colleague, Mike Metz and Michael received first author coping with erectile dysfunction.
You see Michael introduced the concept of good enough sex and good enough sex is a couple concept focused on senior partners, your intimate neurotic ally and sharing pleasure, and in a good enough sex model, 85% of encounters will flow from comfort to pleasure, to arousal, to eroticism, to erotic flow, to intercourse and orgasm.
But when it doesn’t flow, rather than apologizing or panicking, which is incredibly anti-fibrotic and really is destructive, what you want to do is you want to turn towards your partner and say, is there going to be an intercourse night, but let’s make an essential night or neurotic night? That’s what allows men to stay sexual in their sixty, seventies and eighties.
Rhoda: Yes, that makes a lot of sense. It really does. I was reviewing a handout from your workshop, because I did save them. And I wanted to include this for my listeners, that in a 45-minute pleasuring session, erection will wax and wane two to three times. There seems to be a lot of myths about sex and male performance.
McCarthy: There are a tremendous number of myths. And it’s reinforced in the culture, it’s reinforced in sexual medicine, but it’s especially reinforced by porn. What porn is, is an erotic fantasy dimension.
It has nothing to do with real life man and real life couple sex, but in porn sex, the message is, you always have a totally reliable hard erection. And that is intimidating. It is not empowering and motivating.
It is intimidating for men, and the message of porn is you are not a good enough, man. You don’t have a big enough erection, strong enough erection. You’re you are not erotic enough and your partner is not erotic enough, you’re second class sexual citizen.
Rhoda: Yeah, that sounds right to me.
McCarthy: Talk about unrealistic performance demands. When you associate sex and erections with performance, you’re halfway there to developing erectile dysfunction. You know, one of the things that most people do not know, and then actually very surprised about both clinicians and the public, is that when couples stop being sexual, politically correct thing, is they are there to a joint decision or it’s a woman’s decision because she has low desire.
But reality is in over 90% of the situations. It is the man’s choice. Not because he wants to stop having sex, but because he’s lost his confidence and erections and intercourse, he says to himself, I don’t want to start something I can’t finish.
So he avoids, I mean, when you think about what is the core pattern with male sexual avoidance, it’s high anticipatory anxiety, tense sex that is performance oriented, and then his feeling of frustration, feeling of embarrassment and ultimately, it’s avoidance, that’s kind of saying, sex is more embarrassing and difficult for me than it’s pleasurable. I don’t want to be sexual. He usually doesn’t tell his partner; he conveys it non-verbally.
Sometimes he blames her, which is really unfair, but that’s the pattern. Totally the opposite of good enough sex. When we asked the man to turn toward his partner as his intimate and erotic friend or intimate neurotic ally, many men think of women as their intimate friend, but not the erotic friend.
Rhoda: Wow. Yeah. That’s right. How can a partner go about bringing up ED without stepping all over the pride of the partner with the problem?
McCarthy: Well, ideally the best time to talk sex for a couple, is the day before being sexual. When you’re out on a walk or sitting over a cup of tea or a glass of wine on the porch and when they talk, they honestly say to each other, we can do better than this. We can have more comfort and more pleasure in our sexual relationship. I want you to think of me as your ally. We want to be an intimate sexual team.
Rather, you don’t have to perform for me at all, but I do want to share pleasure and neuroticism with you, by the way, the worst time to talk sex is when you’re nude in bed after negative experience, people say, and especially if they’re drinking, they save things that they take back the next morning when the harm has been done, where the man says to the woman.
I thought you were new Pittsburgh woman, but you’re the same old woman and I never would have married you if I knew who you were, or the woman says to the man, if you can’t keep it up, why do you bother to stay alone?
Now they take it back the next day and say, I didn’t mean to hurt you, but the damage has done. You don’t talk sex in the nude, in bed after a negative experience. It’s really a poison.
Rhoda: Yeah. That makes a lot of sense too. Is ED connected to what’s missing in a relationship and they’re not able to talk about it in your experience. How often is this the case? Does male silence contribute to ED?
McCarthy: Yes. Male silence or male shame dramatically contributes to ED. And the way it contributes is he has this belief that the essence of sex is intercourse and only intercourse. And it’s the most valuable thing that they talk about as a couple, they read about it as a couple, but the major thing is they implement it as a couple, is to redefine what you mean by sex.
That includes central playful and erotic scenarios in addition to intercourse. And they can say to each other, let’s be sexual tonight in a playful way, or let’s be sexual tonight in erotic, non-intercourse way. Well, let’s just have a central date and really enjoy being central with each other.
So it doesn’t become intercourse or nothing, it’s the intercourse or nothing is an individual pass fail test that caused the such destructive of patterns, and then ED becomes much more common. You really become caught in that destructive cycle rather than, and this understanding that… let’s say, you have a couple of mid-forties, mid-fifties.
And where the man of the couple and most men by the mid-forties and mid-fifties are taking a medication with us, a cholesterol medication, a blood pressure medication, diabetic medication, some other kind of medication. One of the things I say to men is you are not sexual in your forties and fifties, like you were in your teens, in your twenties.
And that’s an important message, but the other important messages that we need to use all of our resources, psychologically relationally bio medically to rebuild our erectile comfort and confidence.
But the major thing that we do is that we redefined sexuality as certainly intercourse. You want to be pro-erection and pro-intercourse for sure, but the sex has more than erection in intercourse.
So for example, it really helps if the woman is in sexual cheerleader and buys into the good enough sex males and often women do, because it’s so congruent with their sexual lived experiences, males find it harder, because they get no support from doctors, from ads, not from their male peers, males lie to each other about sex. They really do brag and lie to each other and they never admit to any vulnerabilities.
So you’re going to get more support from your partner than you’re going to get from your doctor or your male friends, or you’re going to get from the media, or from the drug company. Now the major reason that males fail with the pro-erection medications and I’m by the way, often encourage my male clients to use pro-erection medication, because it has two functions. It doesn’t give you an erection.
That’s a myth. But what it does do is once you’re subjectively aroused, it allows you to maintain your erection. Basically what the pro-erection medications do is it enhances, the relaxation in your penis.
So more blood flows to your penis and maintains your penis. And the second thing is, this has another effect and that it reduces anticipatory and performance anxiety. As long as you are aware that the medication cannot be a standalone intervention, that’s true.
Any other erectile medical intervention, you can’t use it as a standalone. It needs to be part of your psychological relational and sexual and biomedical resources. You know one of the best ways to getting men to stop smoking?
Rhoda: What?
McCarthy: Is to say to them, smoking is really bad for your penis.
Rhoda: It’s true.
McCarthy: Anything that’s bad for your vascular system, is bad for your penis. And smoking is one of the best examples, the same thing with alcohol. So, you know, one of the things that nobody ever says to men, especially men with alcohol and drug problems, is when you stop drinking and when you stop using drugs.
But what I mean by drugs, is illegal drugs. It’s not unusual, the majority of men develop sexual problems. And the reason they do that is that they’re used to being sexual in an altered state. They haven’t been sexual in a sober state for 10, 20 years.
And I say to them, it’s going to take you three to six months to learn to be sexual in a sober state, but give yourself the time to do that and turn towards your partner, as somebody to share intimacy with, somebody who shared man demand pleasuring with, somebody to share erotic scenarios and techniques with.
That’s the mantra for healthy sex, balance, intimacy, pleasuring, and eroticism, and with good enough sex realistic expectations. This idea that the man says, sex is a pass fail test. That’s a killer, for ED. Can I tell you a story?
Rhoda: Absolutely. I’m totally listening to everything you’re saying. It’s great.
McCarthy: When I was a young psychologist in my early thirties, I went to a two-day workshop with William masters, kind of the grandfather sexuality. And at the coffee break at the second day, I finally got up the courage to walk up to him.
And I walked up to him with this article that somebody else had written about erectile dysfunction. And I asked him, what did he think about the article and the approach, you know, master was a wonderful human being, but he was a very blunt man.
And he looked at the article and says, that’s lousy science. And he actually tossed it in the wastepaper basket and he hit the wastepaper basket. And then he turned to me and he said, do you know for sure, how you can be sure that a man is cured of erectile dysfunction? I was thinking, this was like the God of the sex therapy spirit speaking to me as a 30-year-old, when I said, tell me.
And he said, whether it happens once every 10 times, once a month or once a year, when you don’t have an erection sufficient for intercourse and you don’t panic, you know, you’re cured. That is incredibly wise advice. You lie to men, when you say to them, you will get totally reliable predictable erections, like you did in your teens and twenties. That is not the right goal. The right goal is good enough sex of really enjoying a sexual experience with your intimate neurotic partner and focusing on sharing pleasure.
And most of the time that’s going to flow to intercourse. When it doesn’t, no panicking, no apologizing. It’s poisonous, turn to your partner and say, let’s make this essential day, let’s make this an erotic day. Let’s have a good time sexual. It’s not about performance. It’s about enjoying ourselves.
Rhoda: Yes. And I’m always saying to people, you know, sex is about pleasure, you know, and there’s a range to that. That’s wonderful. So I think you’ve already covered this, a primary prevention of ED which you just talked about in your story, is not focusing on the performance and allowing it to be about pleasure. But I did want to mention your book that you wrote with your wife Emily, contemporary male sexuality.
McCarthy: It’s our newest book, came out in December 30th actually.
Rhoda: Is there anything you want to say about it in particular?
McCarthy: Well, the major thing I want to say about it, it is a pro male, pro couple, pro sexuality book. It confronts issues like toxic male sexuality, but it is basically saying to the man, you can enjoy yourself and your sexuality and accept yourself in the sexuality much better than in traditional male sexual socialization, in traditional male sexual socialization, the notion was, it’s all about individual performance and intercourses of pass fail test, that does not enhance male sexuality or couple’s sexuality. And I think the notion is a real man does not need anything from his partner.
The truth is, a real man, a wise man, his going to be sexual throughout his life, turns toward his partner, not toward a medication. He really… you know, couples who stay sexual. Let me give you the good news first, couples who stay sexual in their sixties, seventies, and eighties, they report more satisfaction with their sexual relationship than couples in their thirties and forties.
And it’s partly because, you know, I have, again, a true story of a client. They didn’t come to me for sex problem. This lovely couple, who were in their early seventies. And they started as a sexual couple when he was 18 and she was 16, I think. So they had been a sexual couple for over 50 years.
And the woman said to the man, I like being sexual with you so much better in our sixties and seventies than I did in our teen years, that actually hurt his feelings at first. But then she said to him, being honest, and let’s be honest with each other, back in our teens, in our twenties, you had shown up erections.
You didn’t need anything from me. Now in your sixties and seventies, you have grown up erections. I feel really a part of the sexual experience. We need each other in a way that we didn’t even 20 years ago, and we really can celebrate that.
But I often say to my male clients, there’s two lines. And I don’t mean to make this overly simplistic, but I say to my male clients, you can be a traditional man, and traditional men stopped being sexual in their fifties and sixties, or you can be a wise man, and you can be sexual in your sixties, seventies, and eighties.
I also say to them that the more you turn towards your partner, doesn’t mean you can’t use pro-erection medications or even penile injections, but you need your partners, your intimate, neurotic friend, you were being sexual with her rather than performing for her. And that’s a whole different mindset for men. And it’s a very powerful, positive mindset for men and for couples. And it says, at its essence, sexism intimate team sport, it is not an individual performance test.
Rhoda: Yes. Do you want to say something about Viagra and Cialis?
McCarthy: Right. So, you know, when Viagra and Cialis came on the market, there was really enthusiastic. Nobody would have predicted the true, incredibly high dropout rates, but I blame the drug companies for that. The drug companies were interested in making money and selling prescriptions, selling drugs, rather than I’m being helpful.
So both medications are actually very effective. The average person who takes Viagra or Cialis, has successful intercourse, 65, 85% of the time, which is great. Not bad, that’s a very positive, realistic, but it’s not what the man wants. It’s not what the ad’s promise. When I say, if I were practicing in Pittsburgh, by the way, you have a wonderful city.
Rhoda: Thanks.
McCarthy: If I was practicing in Pittsburgh, I would say nobody in Pittsburgh gets the results that you see in the advertisements. And the reason that I think for so many folks, Cialis is a better medication than Viagra, is that Viagra, it’s easier to integrate Cialis into your couple of sexual stuff. And that’s the key issue rather than expecting the medicine to do it all.
You’ve got to integrate a new couple of sexual stents. So men who are procrastinators or men who like structure, will often do better with Viagra, because you have this hour to four-hour window of opportunity to be sexual. Most couples prefer Cialis because it gives you a 30 minute, 30-hour window of opportunity.
And many people prefer taking a daily, low dose of Cialis. It’s like taking a daily, low dose of aspirin before going to sleep at night. So it allows you to be sexual whenever you want to be sexual. But the key element of being sexual is that the drug can’t be a standalone and do it all, you got to feel subjectively arouse.
So for example, males or couples who choose to do penile injections, and again, the way to think about it, is the more invasive the medical intervention, the more effective as it getting a predictable erection, but the harder it is to integrate it into your couple of sexual stent.
So for couples who would prefer to do penile injections, what I say to them is you got to make a decision, you want to play before the injection, or do you want to get the injection having erection and then playing section? And then the second question is, who should do the injection?
Should man do it, or the woman do it. Again, it’s your comfort level, but what actually happens in most couples, it’s the woman who chooses to do the injection because the man feels better about that, than feel so self-conscious. And secondly, they play before doing the injection usual. So they’re feeling subjectively into it, and this is going to be a good sexual experience.
Rhoda: Okay. I wanted to ask you about testosterone tests, because in all the years I’ve been working, I really only had one person and he who that it totally benefited. And he was an avid bicycle rider, like every day. Is it a good idea?
McCarthy: Well, the testosterone is a really good example of overuse of medication, that way too many men are taking testosterone, where they shouldn’t be and don’t need to be, and it has negative side effects. So one of the things that I tell people to do, is don’t go to a urologist.
Don’t go to… or maybe I’d rather you go to your internist than a urologist, but the person I really would encourage you to go to, is an endocrinologist who has a sub-specialty in male sexual function or hormonal function, for males who… and this is also true for females, by the way, if you have no testosterone at all, testosterone enhancement is very valuable, but for most people, their testosterone levels are in the normal range.
So again, you’re asking the medicine to do it all. It’s certainly true of these over the common medication that I see in the TV ads, especially the ads for sports events. It really is scientifically, totally unacceptable, but it’s about making money.
The one advantage is that it can have a placebo effect. The disadvantage is it can have… the biggest problems with over testosterone, is you get irritable and interferes with your sleep, it’s not good for your physical body. So go to an endocrinologist with a sub-specialty in male hormonal function. That’s my suggestion.
Rhoda: Okay. Why is there so much resistance by men, unwilling to ask their doctors or if they do, and I’ve had a lot of women come in and talk to me about this, their husbands or spouses or partners go in, ask the doctor and never fill the prescription or fill their prescription and never use it?
McCarthy: Or use it twice and then drop it?
Rhoda: Yes.
McCarthy: Let me give you… and again, this way too idealistic, but let me give you the best resolution here. And that is, have the couple who has a couple, go in to see the internist or the urologist. It’ll bring out the best in the physician. They won’t just give you a medication and not try to talk to you. If you go as a couple, they’re much more likely to talk to you as a couple, and physicians do not like sex problems.
They want to be helpful, but they’re not well-trained and they feel uncomfortable that they’re crossing a boundary. They’re going to be more comfortable if you go as a couple, and you say to the physician, we’re not asking for sex therapy from you or a magic pill from you.
We’re asking how to be a better diabetic patient or how to be a better cancer patient or a better multiple sclerosis patient, or a better breast cancer, whatever, or prostate cancer patient with less sexual negative impacts. You know, one of the wisest decisions that men make after prostate cancer is they resume being sexual.
The majority of men do not resume being sexual after prostate cancer, they say to themselves and to their spouse or their partner. Let’s wait two years, so I can regain my nerves and to have reliable erections.
You never going to get that. The name of the game is to accept the new normal after prostate cancer and the new normal, you’re not going to have as predictable and rigid erection. And in the new normal, you’re going to have orgasms, but you will not ejaculate out through your penis.
You’ll have an orgasm and your ejaculate will go into your bladder. So you want to get used to the new normal, enjoy the new normal and say, we’re going to be a sexual couple and together we’re going to move into a shared pleasure and enjoy sex after prostate cancer.
And we’re going to feel proud that we’ve done that, rather than compare it to the way it was in my twenties or before prostate cancer. Now can I tell you, so we don’t forget about this? The single most important sexual exercise for a couple dealing with erectile dysfunction?
Rhoda: Absolutely.
McCarthy: And you know, Michael Metz before he died, he probably did it with over 2000 males and I probably have done it with around 1500 men and neither of us ever did it with a man who enjoyed the exercise. It really was not fun, but it was crucial. And that was what’s called a wax and wane of erection exercise.
And what happens with that, is that you allow the man to get an erection in any way he can. And as soon as he’s erect, you stop stimulation. If you stop stimulation, your erection will wane. It’s the normal physiological function.
And then go back to sexual or playful touch. And again, sexual and playful. It is sexual and very different than affection, and if you’re mindful and relaxed and into receiving, as well as touching your partner, you will get a second erection, allow that second erection to wane again, don’t go to orgasm until your third erection. Nobody likes it.
The woman doesn’t like it, either you should, but what it is, it’s an anti-panic experience, that it allows you to understand your penis and how and why it waxes and wanes, that what you’re trying to help the couple build is a sense of erectile self-efficacy, which means you have very different ways of really enjoying yourself sexually and using your resources. And when it doesn’t work that night, you have positive ways for sharing pleasure and eroticism. So, you know, again, you can read about it.
You can talk about it, whether with your partner or in a therapist office, but the real learning occurs when you implement it, when you really get comfortable with your penis and the fact that it can wax and wane, where you get comfortable with your penis and say, I don’t need a super erection like I see in porn videos to feel erotic and good about myself as a sexual man.
Again, it sounds so easy when you do it on a podcast. It really is a hard learning, because the culture, male friends, the medical industry negate that learning, but that is the learning we talk about in contemporary men’s sexuality. And it does prevent erectile dysfunction for the great majority of people. Let me tell you another story.
Rhoda: Yes, do.
McCarthy: You know; I did a presentation about 20-minute presentation in Milan Italy for the European society for sexual medicine. I was the only American, there were four people on the panel. I was the only American, the only non-urologist and the only one talking about good enough sex.
And it was like speaking a different language, because the other three presenters who were very nice people and I’m sure very good urologist technical. They said whether it takes a thousand euros or a hundred thousand euros, my job as a urologist is to give you the strongest erection you can possibly have.
That is not your job as a urologist, your job as a urologist is to try to help him integrate intimacy, pleasuring, and eroticism, integrate good understanding and feelings about his penis and broaden his definition of what sexuality is. But that is not typically the way male friends, male urologist, or others approach it.
Rhoda: Yeah, that’s right. It’s true. There’s so much important information that you’re sharing. I really appreciate it. Do you have any other final thoughts that we haven’t covered that will help my audience understand ED and what to do about it? Anything else?
McCarthy: Do you have a lot of females in your audience?
Rhoda: Yes.
McCarthy: Okay. So let me say to the women in the audience, it is not your responsibility for him to get an erection, and he’s not going to have any trouble with erection doesn’t mean he doesn’t find you attractive. So there’s two extremes you want to avoid as a woman.
The one extreme is a sympathy extreme, where you say to him, don’t worry about it. I don’t care about your erection; intercourse doesn’t matter to me. All I care about is affection and intimacy. That is well intentioned, but it is an anti-sexual sympathy. Empathy is enormously helpful.
Sympathy is negating, the man feels put down or less of a man because of the sympathy. And then the other extreme is the extreme that says, if you love me, or if you really were turned on by me, you would have an easy automatic erection and she’s adding to his sense of isolation and demand.
What is the important thing I think that happens with the woman? Is what she says to her partner. I like being sexual with you. I liked sharing intimacy, pleasure and eroticism with you. I want you to stay present with me and I want to be your ally in integrating whatever we’re going to be doing in our sexual relationship.
But she also says to him, if this is true, I want you to learn to piggyback your arousal and my arousal. It is arousing for me to give and receive pleasure when we’re in erotic touching. I want you to not be turned off or intimidated by my arousal.
Instead, I want you to be open to in turned on by my arousal, and you can piggyback your arousal and mine. And by the way, that’s the major thing that encourages people to be sexual in their sixties, seventies and eighties. So throw that last one in.
Rhoda: That’s terrific, really. I’m so glad you came to the podcast today. I think it’s so important to get information out there for people. There are so many misunderstandings and myths that are created.
