Taboos in Treating Men's Sexual, Erectile, and Mental Health

November 19 is International Men's Day, a day to celebrate men and focus on issues specific to men, including their physical, mental, and sexual well-being. On average, cis-gender men in the United States die five years earlier than their cis-gender female counterparts. According to Harvard Health, there are multiple reasons for this:

• Men generally work more dangerous jobs.
• Men die by suicide at higher rates than women.
• Men are less socially connected than women.
• Men generally avoid doctors more often than women do.

Hannah Farrimond, a sociology researcher based in the U.K., describes this avoidance of medical help as a way for men to feel more masculine and in control. In a 2012 study, she reports that her subjects felt as though not seeking out help from anyone else was their way of acting responsibly and maintaining their masculinity. By taking matters into their own hands instead of relying on a medical professional, they feel stronger and more capable.

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It is often very difficult for men to pull down the facade of strength and masculinity when dealing with their physical health, but things really compound when we talk about men’s mental and sexual health. An extensive 2018 literature review of 49 studies, published in The Journal of Sexual Medicine, addressed the nexus between erectile dysfunction (ED) and depression in men. The findings suggested that men with ED are significantly more likely to experience depressive symptoms than those without ED. While the review found this link, it remains unclear which is the cause and which is the effect.

From a behavioral model perspective, the authors state that “patients with depression tend to engage in negative thought and are less confident, which results in performance anxiety that further reduces erectile function.” On the other hand, the “biological model postulates that depression affects the hypothalamic pituitary adrenocortical (HPA) axis, leading to excess catecholamine production, which in turn leads to poor cavernosal muscle relaxation and ED.”

In clinical practice, therapists find that when men’s sexual prowess and mental strength are called into question, many report feeling emasculated as a result of societal pressures instilled in them from early ages. They commonly begin to avoid all intimate touch or even verbal expression that might be interpreted as a sexual initiation by a partner.

Societal expectations for men to be tough, competitive, emotionally stoic, and the primary breadwinners can cause them to neglect preventive health measures, especially when it comes to mental and sexual health.

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While the tie between depression and ED is apparent, our society still makes working through these issues even more difficult. Therapists should understand how to have clear, honest, and compassionate discussions with their male clients surrounding sexual wellness. Since studies and sexual therapy clinical observations support the biopsychosocial-sexual connection between ED and depression, therapists not only need to be able to screen their male clients' mental health, but they also need more training and a greater sense of comfort in asking them about their sexual health and functioning. General therapists might need to learn more about how complex and varied each client's or couple's challenges can be. It’s important that clinicians treat ED as a multifactorial condition that often requires a multidisciplinary team approach, which might include:

• urologists
• sex therapists
• pelvic floor physical therapists
• oncologists

While PDE5 inhibitors (like Cialis and Viagra) and other medical interventions treat symptoms of ED, medical providers often forget the importance of the psychosocial-sexual-spiritual component of sexual wellness. Researchers at the European Society of Sexual Medicine published a 2021 report stating that there is “increasing evidence that psychological treatments of ED can improve medical treatments, the patient's adherence to treatment, and the quality of the sexual relationship.” Since many general therapists aren’t trained in sexual health issues, and specifically in male sexual disorders, they might find it intimidating to ask detailed questions regarding ED symptoms including; timing, frequency, how full an erection is, and the history of the disorder. If general therapists obtain more sexual health information while also becoming more comfortable asking these questions, they can support their male clients through the stigmatized barriers that society has put up around sexual expression while inviting them to seek out medical care and treatment for the biological aspects of their symptoms, leading to an emotionally healthier and more fulfilling sex life. Therapists may also provide the encouragement their clients need to seek out a urologist or a cardiologist because many research studies have shown that early signs of ED can be red flags warning of future cardiovascular disease.

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In order for therapists’ male clients to feel empowered emotionally, physically, and sexually, clinicians must obtain more education on how to assess for sexuality-related issues and disorders that may feel taboo to bring up or had previously not been part of their training and education. Encouraging male clients in psychotherapy to express more of their sexual health and psychological challenges is key to men gaining the medical and emotional treatment they need. By expanding their training and becoming biopsychosocial-sexual and spiritually clinicians, psychotherapists can help their male clients overcome the stigmas society has ingrained in them. Well-trained therapists can then offer them guidance and support to seek out appropriate medical professionals who will not only help them to improve their mental health but also provide targeted treatment for sexuality- and sexual-health-related disorders, preventing potentially serious medical problems down the line.