The most remarkable change in the treatment of sexual disorders in the past two decades has been the emergence of somatic treatments. In ear lier years, the only somatic interventions had been surgeries and topical applications. The surgeries included procedures such as insertion of a penile prosthesis and reconstruction of vulvar and vaginal tissue. Topical aids were vaginal lubricants and attempts, usually unsuccessful, to apply an anesthetic to the penis to retard premature ejaculation. In the past twenty years, however, the primary somatic treatment of male sexual dysfunction has been the use of oral medications such as Viagra, intracavernosal injections, and penile vacuum devices. The goal of the treatment is, obviously, to produce an erection capable of penetration. It is an organ- specific goal; there is no claim that the presence of an erection will make the man want to use it sexually—let alone that his partner will want to.

For women, the goal of somatic treatment is likewise directed toward improving the genital environment so that it can contain the penis and respond with pleasurable sensations rather than pain. Vaginal lubricants are sold over the counter and are widely used successfully. For women with hormone deficiencies due to surgery or for postmenopausal women, estradiol vaginal tablets improve lubrication and make the vaginal epithelium thicker. Exogenous androgen is also employed for androgen-deficient women (e.g., those who have had their ovaries removed) to increase sexual desire, but this remains a controversial treatment. A product called EROS-CTD serves as a suction device on the clitoris, improving clitoral engorgement and presumably the potential for vaginal lubrication, subjective arousal, and orgasm. At present, research is being conducted on vasoactive medications for sexual arousal in women, comparable to the Viagra-assisted arousal in men.

A full review of the somatic treatments of sexual dysfunctions and disorders is not the purpose here and is available elsewhere. Instead, I offer some comments on somatic treatments from the disease perspective in the context of a typical case.

■ Mark and Esther had been married for thirty-nine years. During the last ten years they had not had intercourse, because of Mark’s erectile dysfunction brought on by diabetes. The diabetes was well controlled in recent years, and Mark had felt guilty about not being able to have intercourse with Esther. In preparation for their fortieth wedding anniversary, Mark obtained a prescription for Viagra from his primary care doctor. He tested it privately and, with some manual simulation, obtained a full erection such as he had not experienced in years. He could not wait for their anniversary to surprise Esther. As might have been predicted by even a casual observer, the anniversary bedroom scene was not a happy one. Having taken the Viagra an hour before retiring, and with some minimal self-stimulation, Mark had a full erection. Esther had reconciled herself years ago to a marriage that was sensual but not sexual. She had not taken hormone replacement after menopause, because she had some medical concerns and, in any case, they weren’t having intercourse. Now here they were: forty years of marriage, ten years without intercourse, Mark with a full erection—and Esther with no psychological or physiological preparation for intercourse. Following some conversation, during which Mark lost the erection, they decided to try intercourse. After some time and stimulation, Mark was able to get an erection. It was difficult to penetrate Esther, and when he finally did it was quite painful for her. He withdrew immediately, with orgasm for neither. It was about two months before they felt able to seek help, so hurt and embarrassed were they about the failure of communication and the physical pain Mark had caused Esther. The work of the sexual therapy was to assist them to gradually integrate the use of Viagra into their sexual life. It necessitated a switch of focus from his penis to her arousal, both emotional and in terms of vaginal lubrication. After discussing the pros and cons with her internist, Esther began hormone replacement therapy, which made her “generally feel better.” Gradually, over a period of four months, the couple progressed in sensate focus therapy, from sensual rapprochement to sexual engagement to successful intercourse about every three weeks.

Integration

The somatic treatments, as briefly described above, offer women and men an opportunity to restore sexual function in situations where disease, surgery, aging, or even psychological factors have made it impossible. These treatments are widely prescribed by primary care physicians and by specialty physicians such as urologists and gynecologists, and many of the somatic treatments are available over the counter. Millions of people will try them; the challenge is whether or not the somatic treatments will be integrated into the sexual lives of those who use them. The case of Mark and Esther is patently a situation of non-integration in the introduction of Mark’s use of Viagra. Mark’s attention was too selffocused on the presence of an erection. He forgot that coming together sexually, for two people who care for and are committed to each other, entails more than an erect penis. He was probably totally ignorant of the possible condition of his wife’s postmenopausal vagina in the absence of hormone replacement.

Integration of somatic treatments of sexual dysfunction recognizes that the treatments are directed to the genital organs. Their effect is to make the genitals capable of responding sexually. The work of integration is to harmonize improvements in physiological functioning of the genitals with an emotional desire and readiness for the sexual activity. This integration does not require professional assistance for most couples— most can incorporate the somatic treatments into their sexual life through open communication with each other. But other couples, such as Mark and Esther, find themselves unable to use the somatic advances without professional assistance in the work of integration. The art of sexual therapy with such a couple is to provide assistance while being as unobtrusive and noninvasive of their sexual and intimate life as possible. Sexual therapy entails assisting couples to do the work of emotional, sensual, and sexual integration.