I recently saw a middle-aged couple in our clinic who typically had sex no more than once every two months. When they did have sex, it was rarely satisfying to either partner. The wife, who had made the clinic appointment, complained that her husband seemed disinterested in sex and would go out of his way to avoid having sex with her. She would confront him about this, which inevitably led to an argument, after which they wouldn't speak to each other for days. The wife was not sure she wanted to continue living like this and was considering divorce.
The husband admitted that he had become less excited about having sex with his wife but that he had reasons for his declining interest. According to him, she had put on weight, nagged him incessantly, and refused oral sex of any kind. He described their sex life as very "plain vanilla," and implied it didn't excite him any longer. Added to the mix was the fact that the husband suffered from moderate Peyronie's disease, an inflammatory condition in which plaque or hardened scar tissue forms beneath the skin of the penis, leading to painful erections and a curvature of the erect penis. Though this disease didn't incapacitate him sexually, he sometimes had problems achieving or maintaining an erection. His concern and continuous monitoring or "spectatoring" of his own sexual performance only made things worse. He had been prescribed Cialis for his condition but, according to him, it gave him "about an 80 percent erection." He used the medication intermittently and without telling his wife, who wasn't always in the mood at the times he decided to take it.
In this case, although the chief complaint was sexual abstinence, the problem went much deeper. First, this was a seriously troubled relationship that provided a very negative context for their lovemaking. Second, the man had to be reassured that there were no new effective treatments for his Peyronie's disease; he was going to have to do the best he could with Cialis. He was instructed to use the drug regularly and to tell his wife his schedule for using it. Sex therapy was prescribed to deal with his spectatoring and her narrow sexual repertoire.
What started out as a single, simple complaint was found to have biological, psychological, and relationship components.