Integrating Sildenafil and Sex Therapy: Unconsummated Marriage Secondary to Erectile Dysfunction and Retarded Ejaculation

Abstract

Steve, a married, 25-year-old, orthodox Jewish man was referred by his psychiatrist for sex therapy following 3 years of unconsummated marriage. The psychiatrist was treating Steve for depression, anxiety, and intrusive violent obsessive thoughts with psychoactive medications, including paroxetine (Paxil) and buspirone (BuSpar). The patient described erectile dysfunction (ED) and retarded ejaculation (RE). The couple's child (age 2) was conceived through artificial insemination with semen provided by the patient via masturbation. At the time of referral, Steve's spouse Susan (23 years old) was taking fertility drugs and artificial insemination was planned again. The couple was treated previously by a sex therapist, improving Susan's orgasmic capacity, but the marriage remained unconsummated. Unbeknownst to the previous therapist, the patient was secretly masturbating in an idiosyncratic and compulsive manner—a frequent cause of RE. Alteration of Steve's masturbation style and frequency was a necessary, but insufficient, intervention of this current treatment. Steve began obtaining erections and achieved penetration with his spouse, but remained coitally anorgasmic. Alternative formats (individual/conjoint) were required to strategically manage the treatment process. Successful therapy required maintaining rapport and congruence with the referring psychiatrist who continued pharmacotherapy using different psychoactive agents. Management of fertility issues, artificial insemination, pregnancy, the birth of a second child, and Jewish ritual law further complicated the therapy. Additionally, sildenafil (Viagra) was used to augment the cognitive-behavioral sex therapy, resulting in a more robust and powerful treatment. Eventually the couple consummated their marriage, and Steve was able to ejaculate intravaginally on a regular basis.