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Once you’re comfortable with sexual pleasure that doesn’t involve intercourse, and with the experience of losing and regaining an erection, the therapist may suggest that you’re ready for intercourse. Often sex therapists recommend that the woman be on top, because this makes it easier for her to be the more active partner, Such an arrangement may help the man because he has less pressure to perform and can more easily relax and enjoy himself.

An important part of a sex therapy program is for each partner to be responsible for his or her own pleasure—and to communicate his or her feelings. Marvin and Caroline welcomed this change. Focusing on different ways to have sensual pleasure was a wonderful development. “This helped us take the emphasis away from intercourse,” she says. Initially, the ban on intercourse was difficult, but the process of going through the exercises provided an unexpected bonus for Caroline. She found herself learning to be more comfortable with enjoying sensual and sexual pleasures which did not involve intercourse. Like many of us, although she “knew” such behavior was okay, she had not quite accepted it emotionally. But having Marvin caress her for a period of time without any expectation of intercourse helped her overcome her inhibitions about “that kind” of touching.

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As you have seen throughout this book, a fulfilling sex life requires a lot more than a pill. There are any number of variables and conditions which can affect the attraction, as well as the performance, of two people, with one factor overriding all the rest. Without libido, the desire to bond physically with another person can be greatly diminished—or even lost. A constant presence throughout our lives, libido ebbs and flows as much as the tides. Springing from an intricate network of physiological and psychological components, libido varies from man to man. And, of course, from woman to woman.

Years of living with ED can have a profound and far-reaching effect on the libidos of both men and women. When sex is absent, often the desire to have it again is sacrificed as well. Yet, when sexual function is restored—as it can be with the new oral medications—libido doesn’t automatically jump-start in both partners equally, much less simultaneously. For many men, the desire to have sex is a logical extension of being functional again. For women, however, the reality can be very different.

Many women have told me so. Their husbands or companions, ecstatic with the return of their potency, exhibit an intense longing for sex. But often the women don’t. It’s not, they explained to me, because they don’t feel attractive or because they no longer have feelings for their partners. Rather, it’s because they have adapted to their situation, integrating the loss of sex into their daily lives. And, they confess, the idea of accessing those dormant feelings can be daunting.

Their reaction is totally understandable. The longer they have lived with men who have ED, the harder it can be for them to tap into their own sexuality. As you read in Chapter 6, there are many ways to heighten intimacy between partners. But where libido is involved, the approach is somewhat different. The best place to start is inside your head.

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Sexual well-being has always been an integral part of the overall health profile of my patients. It makes a lot of sense: if the body is sound, it is likely that sexual performance will be, too. And the reverse is true as well: if a man’s sexual health is compromised, then his body may be in jeopardy. Your first line of penile health defense is determined by three things: supplements, diet, and exercise. All three go a long way toward helping you avoid ED.

The lifestyle recommendations in my virility-enhancement program have more than one application. Not only will they help prevent and, in some cases, treat, ED, they will actually make you feel and look better. And they will not only improve your sexual function, they may also save your life.

Research has shown that optimal sexual health depends on certain lifestyle choices. All affect the body, the flow of blood, and delivery of a pivotal element: oxygen. Although there are several major physical causes of ED, each one has an impact on oxygen flow. They are hypertension, high cholesterol, diabetes, stress, smoking, alcohol consumption, and lack of exercise. Without sufficient oxygen supply to the penis, an erection won’t happen. That’s because decreased oxygenation of penile tissue can cause progressive fibrosis—a permanent thickening and stiffening of tissue—of the gland. With more fibrous tissue than muscle tissue in the penis, this can cause the penis to actually shrink in size. The crucial oxygen pipeline can be severely limited or blocked by all of the conditions listed above—and all of them can be controlled, improved, or even eliminated through lifestyle changes.

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There are men who don’t want to ever lose what they presently have. To that end, they are willing to do everything possible—including taking the pill. Their thinking goes like this: why shouldn’t a healthy man use it to make sure he won’t lose his own hard erection? This and other philosophical dilemmas raised by the pill are perplexing because they verge on areas where there are no clearly defined medical answers at this time. The oral erection drugs are so new that no one as yet has had enough experience to be able to say yes or no to their “off-label” use.

Should doctors give patients who are not suffering from ED—but who nonetheless want to maximize their peak performance in every way—access to these new medications? They have already demanded them. One of my patients, a forty-two-year-old man with no erection problems, was insistent. He stated categorically that he wanted to see if he could turn back the clock and regain the rocklike hardness he had when he was twenty. His rationale was direct. “If it’s available,” he said, “why shouldn’t I use it, as long as it won’t hurt me?”

In another significant turn of events, one of my female patients, a very attractive forty-one-year-old divorcee who had heard of the pills, wanted to know if she could get a prescription for them. “If they are all that I’ve heard they are, I want to keep them in the night table, next to the condoms.”

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Another patient who sought to enroll in the study was John, a fifty-eight-year-old maintenance crew supervisor who had recently undergone triple bypass surgery. For the five years prior to the operation, his heart disease had put a brake on his sexual relationship with Harriet, his wife. What was frustrating to both of them was that now that his heart was repaired, he still had ED. Harriet, who accompanied John to my office, put it this way: “We thought that the surgery would put the bad times behind us, that the pressures and stress of his illness would be gone. When we finally felt the time was right, John couldn’t respond, no matter what I tried. We both were disappointed. And, I’ll tell you the truth, I was a little angry, too. I want to be supportive and reassuring, but I’m having a really hard time. We fight a lot. I feel like no matter what medicine has to offer, nothing will help us.”

I wasn’t surprised to hear Harriet’s view. Being the partner of a man with ED is no easy matter. Many couples maintain a truce; either they won’t talk about the problem or they ignore it in the false belief that it doesn’t exist. Sadly, their self-induced silence not only distances them physically, but emotionally as well. Often, the relationship, already on shaky ground, disintegrates completely. And ED can foster doubt in the partner, as well.

As Harriet said, “I thought I knew what the trouble was after the operation. John just didn’t find me attractive anymore. Alter all, we’ve been married for twenty-five years and I’ve had three children. I don’t look like I did when we first got married. I thought that now that he had recovered his health, he wanted a younger, more vibrant woman at his side. On one level I was devastated but ironically, on another, I was kind of relieved. Now I wouldn’t have to feel rejected because we didn’t have to try to have sex. I looked elsewhere for comfort, and buried myself—like so many unhappy people do—in my work.”

John looked stunned as Harriet told her side of the ED story. “I never felt that way,” he said to her. “I thought you’d leave me because I was failing you.”

After consulting John’s cardiologist, I was able to reduce the dosage of some of his heart medications, which I felt were contributing to his erection problems. I also enrolled the couple in the Vasomax study.

While the 40 mg of Vasomax did them both a world of good, it was the foundation on which they could start to rebuild their torn relationship. John, who was so beaten down by years of erectile failure, needed to face the profound psychological damage that both he and Harriet had experienced. Harriet, in turn, could benefit by facing her anger and doubts. I suggested to them that they seek professional help. Happily, they took my advice and began seeing a therapist who specialized in marital issues.

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