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BackTable / Urology / Podcast / Transcript #130
Podcast Transcript: Exploring Psychogenic Aspects of Erectile Dysfunction
with Mark Goldberg, LCMFT, CST
This week on BackTable Urology, Dr. Jose Silva invites Mark Goldberg, a certified sex therapist, to discuss psychogenic erectile dysfunction and his role as a sex therapist for patients and couples. You can read the full transcript below and listen to this episode here on BackTable.com.
Table of Contents
(1) The Role of Sex Therapy in Erectile Dysfunction
(2) First Steps for Erectile Dysfunction Patients
(3) Exploring Erectile Dysfunction in Otherwise Healthy Individuals
(4) Mental Health’s Role in Erectile Dysfunction
(5) Overlap of Stress and Erectile Dysfunction
(6) Unraveling Performance Anxiety and Therapy Timeline
(7) Premature Ejaculation Issues
(8) Balancing Overexcitation & Ejaculatory Control
(9) Physical & Psychological Factors Causing Anorgasmia
(10) Couples Therapy for Sexual Dysfunction
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[Dr. Jose Silva]
Hello, everyone, and welcome back to BackTable Urology Podcast, your source for all things urology. You can find all previous episodes of our podcast on iTunes, Spotify, and at backtable.com. This is José Silva, your host this week, and we have an interesting guest today. We have Mark Goldberg. Mark is a certified sex therapist. He has advanced training in cognitive behavior therapy from the Beck Institute. He is also a certified emotionally focused couples therapist. He is the host of the Erectile Dysfunction Radio Podcast. Welcome to Backtable, Mark.
[Mark Goldberg]
Thank you very much for having me.
(1) The Role of Sex Therapy in Erectile Dysfunction
[Dr. Jose Silva]
In the past, we have had previous episodes that we focused mainly on the mechanical aspect or things that we can do, surgical or pills, to treat ED. Definitely, the psychogenic part of the ED is sometimes difficult to talk about or really, personally myself, most of the time, I don't have time for that. Maybe 5, 10 minutes and then, "Hey, you need to talk to somebody else." I can see, even younger guys, although it doesn't matter the age, but maybe younger guys, but really, that they need somebody to talk to.
Sometimes you can see that it is either stress. It's a lot of emotional aspect. Sometimes they start thinking about they have one episode and then it is going to happen again. That's what we're going to talk about, that other part of the erectile dysfunction tree or logistic that we go with the patient. Let's talk about you, Mark. Tell us, what does a sexual therapist do?
[Mark Goldberg]
That's a great question. Sex therapist, at the base, is a mental health therapist. Certainly, here in the United States, mental health therapist is licensed. It means they've completed at least a master's level of education in psychology, professional counseling, marriage and family therapy, social work, et cetera, and they have completed requisite licensing requirements in their state. That's the starting point for any sex therapist is that they are a therapist who is trained to treat mental health conditions.
Sex therapists have additional training. If they're certified, they've been through a multi-year certification process where they have gained expertise in sexual issues and the mind's role in those sexual issues. Somebody like myself, I particularly focus on sexual dysfunction, so a lot of my work is focused on both the relational aspects and, also, the individual psychological aspects that contribute to sexual dysfunction. In particular, I focus on ED and the ejaculatory disorders.
[Dr. Jose Silva]
Do you have an office? I went to your website. I know you do trials also. Tell us about your practice right now.
[Mark Goldberg]
My practice is made up of myself and there's a couple other clinicians here with me. I do both in-person and telehealth. I'd say that, currently, I'm seeing, probably, about 70% of my patients are telehealth and about 30% are coming in person. Primarily couples, but also some individuals do come in person.
[Dr. Jose Silva]
In terms of that patient that comes with ED, do you know beforehand that the patient is coming for ED, or they just show up and then you start talking about, hey, what was the problem? How does that work?
[Mark Goldberg]
That's a great question. For the most part, we do know in advance that somebody is coming to talk about ED. It does come up a lot. In other words, the way I got into this work in the first place was that I was working with couples and the conversation around sexual dysfunction would start to come up in the office, so it really doesn't always present immediately. Sometimes people come in to talk about anxiety, depression, relationship issues, and then the conversation around erectile dysfunction may emerge a number of sessions in when they're feeling comfortable to talk about it.
(2) First Steps for Erectile Dysfunction Patients
[Dr. Jose Silva]
I want to talk about the couples aspect at some point later in the episode but let's start with that individual person. That is usually the ones that we see in the office. What do you talk about on your first visit?
[Mark Goldberg]
On the first visit, it's usually a lot of assessment questions. The starting point of any therapy process is, really, establishing rapport. When a patient comes in or when a- I call them clients. -when a client comes in, and they're coming, really, under the context of a sexual dysfunction, it's really important that we normalize the challenges that they're going through, that we establish a comfortable environment, that we ask questions, we make sure that we're asking permission about getting involved in different aspects of their life, because we're doing this very quickly.
Oftentimes, unfolds in the first 10 to 15 minutes, we're already talking about sexual function challenges. Generally speaking, in my practice, it's rare that somebody is seeing us without having been to at least a primary care physician, if not a urologist, before coming in. It does happen from time to time, but we do our utmost that we can to ensure that somebody has been medically cleared.
To that end, we generally are just doing a basic check-in on the medical front in terms of what has been done, who they've spoken with, if there was any testing done, any medication. We're asking about that, but we don't consider ourselves to be the first line for medical assessment or what not. We just want to make sure that, however they got to us, they've had proper medical checkings. That usually is the first piece of the assessment.
We then will go through a much more broad-- We call a psychosocial assessment. We want to understand who this person is, what their backdrop is, relationship status, how long the problem's been going on. We also want to assess just where the problem is taking place. How often? Is it just with a partner? Is it happening when they're on their own? Times of day, specific triggers.
We try to be as quick and as thorough as we can to try to see what are the specific conditions where erectile dysfunction seems to be present or seems to be more exacerbated or whatnot. We will also ask questions about general mental health, and we may, if it's relevant, get into topics pertaining to family of origin as well.
(3) Exploring Erectile Dysfunction in Otherwise Healthy Individuals
[Dr. Jose Silva]
I guess you encounter this all the time, but how do you approach that patient that is asking why? I'm healthy, I do exercise, I'm still having this issue. How do you give them expectations or what to, but mainly that why? How do you answer that?
[Mark Goldberg]
First of all is we normalize the frustrations around that. A lot of times, the patients that we see, they really are doing everything that they're supposed to be doing. They're healthy, they're not smoking. I get a lot of calls, emails, to that effect, and it becomes very puzzling. You're 27 years old in very good health, and you're having erection issues. What I explain to the people that I work with is as follows.
I think some of the thinking that erectile dysfunction is somehow a psychological process or a medical process is a little bit misleading because I think erections, in general, are both a psychological and a physical process when everything is working. For most men, once they are above a certain age, once they're out of their teenage years and their hormone levels have come into some kind of balance, they're generally not getting erections without some stimulation.
In other words, the mind has to be in a place where it is receptive, where the context makes sense, to be getting an erection in the first place. We just normalize the psychology or the role of the mind as part of a healthy erection process. That doesn't mean that there aren't physiological realities that may because a man to get an erection even when he's not necessarily thinking about anything or particularly stimulated, but as men age, that certainly becomes much more of how the erection process works.
We try to, again, normalize that the mind is involved and active. Then we talk about things that can distract the mind, or things that can trigger anxiety, or if there isn't enough stimulation, and if the mind is not engaged in the process, the erection process doesn't really get started as per its normal natural path.
(4) Mental Health’s Role in Erectile Dysfunction
[Dr. Jose Silva]
Sometimes when, you mentioned that 27-year-old guy, and we as urologists maybe say, "Hey, maybe it's mental." When you use that word, they're assuming that you're telling that he's crazy or extreme things like that. I say, "Hey, it might be just stress or something else." Sometimes they say, "Hey, I don't feel stressed." How do you divide that patient into different categories or if there are different categories?
[Mark Goldberg]
That's a fantastic question. What I divide this between is that there's something called mental illness, and there's something called mental health, and every human being has a mental health profile. A lot of times what we're talking about, even with psychogenic ED, has a lot more to do with mental health than it does with mental illness. People of all walks of life are going to experience elements of depression, elements of anxiety, performance anxiety, and none of that necessarily warrants a bona fide mental health diagnosis or a mental illness diagnosis, but it's part of the mental health profile that we all walk around with.
I know that, for myself, I have some days where it's just a tougher day, or I'm feeling anxious. That's part of my mental health profile. It doesn't necessarily mean I have a diagnosis. I think explaining to patients and to clients the difference between mental illness and mental health is really helpful for them to understand that our mental health has to be in a pretty decent place for us to be getting reliable erections.
(5) Overlap of Stress and Erectile Dysfunction
[Dr. Jose Silva]
Yes, like you mentioned, I have patients, I'm sure them as well, that they say, "Hey, during the week, I'm working, having good erections. Then I go on vacation, I start having spontaneous erections, good sex with my wife or my partner," whatever. How do you explain to the patient, hey, you need time to recharge?
[Mark Goldberg]
It really depends on the patient. For some patients, they really want a solution, or like being able to have better erections during the week, or they want to be able to do this when they're not on vacation. For other patients, they just feel relief understanding what is going on, understanding that the stress is actually having an impact. For some of them, they're actually okay, their relationships are okay to have sex on the weekends or when there's an opportunity.
It's just a matter of helping them just come to an understanding or come to terms with the reality that if you have a very stressful work life or what not, that can have an impact on erection, so it really depends, also, on what each client's goals or what each patient's goals are.
[Dr. Jose Silva]
You mentioned that patient that wants immediate relief. Do you offer some immediate relief, or you go to a urologist and get some pills? What do you tell that patient?
[Mark Goldberg]
If a patient is insistent on immediate release, I let them know that there are medical interventions that probably can provide more immediate relief. I do think that, sometimes, even the mental stress of not having that immediate relief sometimes warrants a medical intervention just to help this person be able to be in a much more calm and healthy state of mind.
I do not offer immediate relief because the mind is very tricky, very complex in many ways, and I think there's enough snake oil out there in the erectile dysfunction space and, generally, in the sexual function space that I don't think it's doing patients a service to offer them some kind of immediate, "We'll have you fixed within the hour." That being said, younger patients do tend to see results pretty quickly, even from the psychogenic process. I think that has to do with just their physically more fit bodies are just better positioned to be able to make those kinds of changes, but no, we don't offer anything immediate.
[Dr. Jose Silva]
That patient that says, okay, I'm going to work with you, let's start a process, what are your recommendations for that patient? Let's say most patients that I see that might be psychogenic is usually overwork, working two jobs, or working shifts at night, during the day they sleep. How do you tell them, hey, you need to change the way you function on a daily basis?
[Mark Goldberg]
That's a great question. I think with the patient base that I see that tends to be, let's say, a more rare presentation that it is a single factor event that's driving it. It tends to be more complex where there also is-- There's work stress, but it's also spilling over into the relationship. It tends to actually be a bit of a more complex picture. Sometimes it's as easy as saying, "Well, you need to cut back on work," and the response to that is, "That's just not possible."
Okay, so now we're on to those next steps where we have to work within the confines of this person's reality. A lot of times, there's enough factors that, I think, can be addressed both in terms of a person's relationship, their own internal psychology, that they can both maintain a challenging lifestyle and still be able to carve out space to decompress and have enough mental bandwidth to be able to have the kind of sexual function that they want.
(6) Unraveling Performance Anxiety and Therapy Timeline
[Dr. Jose Silva]
I want to talk about specific conditions. For example, performance anxiety. What do you tell the patient that say, hey, everything is good, I'm having good erections, but then when I'm about to penetrate, the penis becomes flaccid? What do you tell the patient?
[Mark Goldberg]
Performance anxiety is a very complex experience, and it's hard to simplify it down into some advice. That's where it goes back to when performance anxiety is present, it really needs to be assessed because performance anxiety can present in different ways for different people. For some people, performance anxiety is stemming from fear of perceived or real criticism from a partner, and they really want to avoid that.
For other people, performance anxiety is stemming from how they're assessing themselves, and they're totally not willing to hear anything that their partner is saying. Even if their partner is perfectly okay with it, the partner's not feeling like there's any negative impact, they're really very much assessing their own performance. It's really key to understand that performance anxiety is not a one-size-fits-all experience, and it really needs to be looked at as the unique thoughts and feelings that come with different manifestations of performance anxiety that will be contextually relevant to each patient.
[Dr. Jose Silva]
That's a good point that you're making, and that will lead to my other question in terms of premature ejaculation. For example, like you mentioned, the expectations. Some patients come to the office and they stay like half an hour. For them, it's premature ejaculation, so stand up and get out of the office. When that patient goes to your office, in terms of going back to the expectations, do you know, more or less, how many sessions it's going to take for somebody to get better, or it's just you go session by session?
[Mark Goldberg]
I've probably answered this question three times today on various phone calls from prospective patients. The way I approach this is I tell patients that it's very difficult to know. Generally speaking, again, the younger a patient is, certainly when it comes to erectile dysfunction as an example, the younger the patient is, the quicker the expectation is that we will see movement.
Now, again, that's a blanket statement, and I realize that cannot apply to everybody, but as people age, the physical body becomes, I think, a lot more relevant and the mind, I think, has become a lot more concrete, so the work tends to be a lot longer. What I aim for, and I tell people it's just an aim, what I aim for is that we should see some directional indicators within about four to six sessions. I know it sounds like a lot relative to appointments or visits with a urologist, in the therapy world, that certainly is not a very high number. Again, what we're looking for is to have a sense of what is going on and to be able to see some indicator that we're in the right direction.
[Dr. Jose Silva]
Most of the patients that you see, are-- You've been seeing them alone or do them in combination with a urologist?
[Mark Goldberg]
Almost exclusively in combination with at least a medical professional, preferably a urologist, but each person is in a bit of a different circumstance.
[Dr. Jose Silva]
Do you sometimes see patients that you need to tell, "Hey, you need to see a urologist because this is not just psychogenic"?
[Mark Goldberg]
All the time. What I remind my listeners on my podcast and all my patients is that erectile dysfunction and sexual dysfunction in general is a medical condition. It's impacted by psychology, but it is a medical condition. Even when I am fairly confident that it is psychogenic, I'm very much aware that there can be some more rare conditions that need to be assessed and need to be under medical care, so I look at erectile dysfunction as a medical condition that can be caused by and heavily impacted by psychogenic factors.
Everybody sees a medical professional, preferably before they come to see me, but secondarily, if they haven't, they're given a referral to do that in conjunction with the therapy. The other interesting thing, I think, towards this question is that a lot of times I will be working with somebody who's been medically cleared but something will emerge in the conversations that they didn't necessarily disclose to a urologist because there wasn't enough time, or they didn't think it was relevant, that may indicate something, maybe along the lines of say, of a venous leak, but they weren't really clear with the doctor in the first go-round, so I may send them back to the urologist and coordinate based on what comes out in the sessions.
(7) Premature Ejaculation Issues
[Dr. Jose Silva]
I wanted to ask you about premature ejaculation. Do you see patients, a lot of patients, like this?
[Mark Goldberg]
A fair amount, yes.
[Dr. Jose Silva]
Again, I guess, also, frustration can continue if the patient just overthinks it and it will continue to happen. Can you walk us through one of your sessions with this patient, with that patient like that?
[Mark Goldberg]
Premature ejaculation, there's different ways to categorize it, but again, a lot of this really depends on what the circumstances are. The big differentiators that we're looking for are if it's lifelong or if it's an acquired PE. We also want to know if it is situational or if it's across the board. When it's lifelong and it's across the board, I'm more hesitant these days to approach that as a psychosexual therapy to try to treat the underlying condition.
That's where therapy much more is supportive. It's helping to find alternative ways to engage in sexual activity that can be satisfying, but I think it's a lot more difficult to treat lifelong non-situational PE. When somebody comes in and it's much more situational, let's say it's only happening with a partner, so again, the two general areas that we're looking at are over-excitation with premature ejaculation as well as an anxiety, like a performance anxiety.
While these seem to work in opposite directions where anxiety does not sound like it's very exciting and over-excitation sounds like it's very hard to contain oneself, there is, certainly, an overlap both from a neurological and a psychological perspective between the excitation and the anxiety areas of the brain and those thought patterns, and we see a similar type of thing going on. That would be one of the areas that we're looking to understand for the patient.
Generally speaking, PE, like other forms of sexual dysfunction, is addressed with both-- Again, I'm a CBT therapist, so I look at it both from a cognitive but also from a behavioral standpoint, so the way I like to work is, as we are getting into the cognitive work, we also want to assign certain behavioral interventions so we can assess how progress is going. Also, helping men to learn ejaculatory control.
(8) Balancing Overexcitation & Ejaculatory Control
[Dr. Jose Silva]
Let's talk about the overexcitation. What does a patient can do about that?
[Mark Goldberg]
That's a great question. Overexcitation can have both a physical and, also, a psychological manifestation. On the physical side, there is very little that we can do on the psychological end. As I'm sure you're aware, and anybody listening to this podcast are aware, there are delay sprays, there's also some off-label use of medications that could help to decrease sensitivity or decrease the ejaculatory side of things.
From a psychological standpoint, there are a number of things that can be done. What I have found is what seems to be most effective is to be aware of what are the factors that lead to excitation and working with oneself or one's partner to try to -- Again, I don't like the idea of limiting pleasure or trying to cap sexual pleasure for the sake of extending performance, but I think working with a partner to be, maybe, a little bit more strategic about that when they bring in those more stimulating elements to the sexual experience.
There are ways to, I guess, gain more control over that psychological stimulation. That's one of the approaches. The other approach is to help desensitize a person to those stimulating factors both from a cognitive and, also, from an exposure standpoint.
[Dr. Jose Silva]
Is that like thinking of something else?
[Mark Goldberg]
That's more of a distraction type of thing. I know that some people use those. I'm not, as a therapist, I'm just not a big fan of distraction. I think being present in a sexual experience is something that I value both as a therapist and as a person, so I want to try to work within those confines so that a person is really there with themselves and with their partner.
[Dr. Jose Silva]
You mentioned distraction. What's the difference between distraction and detraction?
[Mark Goldberg]
In the erection space, what it probably means is like detraction from stimulation.
[Dr. Jose Silva]
Okay.
[Mark Goldberg]
If you wanted like a difference, there may be-- Distraction may be like I'm not paying attention to the experience, or I'm thinking about other things. Detraction may be that I find certain things stimulating and when other things are brought into the experience or are not brought into the experience, it detracts or it erodes the kind of stimulation that I would need to maintain my erection.
[Dr. Jose Silva]
I see that pa-- Sometimes it can be a change of position. The male partner that is the one that I see in the office sometimes feels different and, maybe, the change of position, they can have a decrease in the erection or there is some flaccidity. You mentioned, also, the con-- The ejaculatory control. How do you tell the patients to control that?
[Mark Goldberg]
If I could tell them to control it that would make my job a lot easier. [laughs]
[Dr. Jose Silva]
Okay. [chuckles]
[Mark Goldberg]
Ejaculatory control, I think, again, goes back to both the cognitive and behavioral components. Generally speaking, when I'm working with somebody with premature ejaculation, we want to help that person learn ejaculatory control on their own. Part of that is recognizing when they're approaching or reaching ejaculatory inevitability and being able to really become familiar with that sensation, understanding what brings them towards ejaculatory inevitability, and being able to back off of that sensation.
Where it gets a little bit more complicated is partner sexual activity. Again, this ties back into the performance component. Not even performance anxiety, but the performance elements of sexual activity. A lot of men are able to gain ejaculatory control when they're on their own because they can slow down the tempo, they can slow down the friction, they can control certain aspects.
Even when their partners are okay with them doing that in a partnered setting, a lot of men don't feel comfortable to actually slow down or detract from the experience that they believe they should be having or delivering to a partner, so gaining ejaculatory control with a partner tends to be a little bit more challenging.
[Dr. Jose Silva]
Are there any exercises that the patient can do for-- To be able to get some control?
[Mark Goldberg]
There are a number of behavioral interventions. There's the stop-start method, there's the squeeze method. There's various methods out there that do work to varying degrees. What I do try to encourage, though, is that people should go through a proper assessment to determine if these exercises are going to be applicable, if it really makes sense. There's a lot of people who will find this, it's published information on the internet, and without a proper assessment, will go ahead and try to engage in these exercises not understanding the backdrop, not understanding their own psychology, and a lot of times, it just ends up not working.
(9) Physical & Psychological Factors Causing Anorgasmia
[Dr. Jose Silva]
What about the opposite? That patient that is having anorgasmia?
[Mark Goldberg]
Anorgasmia or not just like delayed ejaculation, but not ejaculating at all?
[Dr. Jose Silva]
Yes, or they get tired at some point because they haven't ejaculated yet, or their partner says, "Hey, get off."
[Mark Goldberg]
Yes. This, I think, is one of the harder or more challenging sexual dysfunction conditions to treat both from a psychological, but also, from what I understand, from a medical standpoint. I find it a little bit challenging because it's very difficult to assess if it's a physical stimulation or a psychological issue. There are certain factors that I think sometimes can be enlightening where I've seen very interesting presentations of delayed ejaculation or an ejaculation have been around a unwanted pregnancy or a fear of an unwanted pregnancy. It's like a telltale sign of there being like a psychogenic or a real psychological factor.
Generally speaking, we try to assess if a man can ejaculate, obviously, on their own, but there is a difference between masturbation and like a penetrative sex experience that, again, it's very difficult sometimes to assess if it is a physical stimulation issue or if it is psychological. There are historical theories about men wanting to withhold from their partners and whatnot. I think those have limited applications, certainly based on how we are structured in our relationships in 2023, but it's important to be aware that there definitely are other ways to think about this from a psychological perspective.
[Dr. Jose Silva]
Exactly. Mark, another question that I have, patients that, for example, let's say a patient is a diabetes patient, for some reason, that patient is not a candidate for IPPs or any other intervention that, unfortunately, he's going to have to leave without being able to have erections. Let's say that a patient that, for some reason, is-- I saw a patient like that today. Multiple cardiac conditions that, unfortunately, they're poor candidate for sex.
Definitely, I can give, even if I put an IPP or an inflatable device on the patient, definitely, that patient is not going to be able to have sex because of the cardiac conditions. That patient was his partner so he was asking, "What are my options?" The guy clearly, while he was talking to me, was gasping. A guy that, just by walking, gets very fatigued or has multiple conditions, how do you approach this guy?
[Mark Goldberg]
It's a great question. I like the case that you're describing because he himself sounds like he's very limited. His options are going to be very limited. Why I think the role of a therapist, and certainly, a sex therapist, is to help this couple adjust to a new reality. Sex is a conduit for intimacy and for connection for a lot of these people and when that gets lost, unfortunately--
This can really apply to any type of person who experiences a sexual function challenge. That intimate connection starts to dwindle because the couple does not know how to adjust and does not know how to continue to engage with one another. In this case where this sounds like this gentleman is winded, like he really-- Like he's got to be careful about even exerting himself in any significant way.
Even like the incorporation of a device or a toy to be able to provide stimulation without having to overly exert and learning how to incorporate that and building some sort of intimacy around that is where a therapist would be able to be helpful. Obviously, we cannot psychologically treat the respiratory issues that are going on or the cardiac issues that are going on, but medical issues does not mean that a person does not crave and want that intimate connection, and a lot of times, there are ways to facilitate that.
[Dr. Jose Silva]
Yes, we always talk about the patient that we help or we can help, but what about the patient that sometimes there's nothing that we can do or offer to that patient? I'm glad that you mentioned that there are things that you as a therapist can talk about toys, other things, so at least that emotional and mental health is still there at least somehow.
[Mark Goldberg]
I would just also add to that there are many instances that I've heard of in my office where a sexual function challenge actually opens the door to deeper intimacy because a couple's forced to communicate about things that they never really spoke about. It was just almost automated. They had their routine and they went through that, and it forces them to really talk about their intimate life.
Certainly, for men with female partners, a lot of times when an erection is inhibited, it actually brings more into focus some of the other areas of their sexual life and sexual encounters that can actually be much more to the benefit of the female partner. A lot of times that only really comes to light in the face of erectile dysfunction.
(10) Couples Therapy for Sexual Dysfunction
[Dr. Jose Silva]
Mark, when do you tell a client, hey, bring your partner into the therapy? When does that happen?
[Mark Goldberg]
That's a great question. I want to be careful with how I answer this because it's an evolving approach for me. Initially, because I was trained as a couple's therapist, I would treat people experiencing sexual dysfunction in a couples context. I think what I have found over the years of doing this work and what works best for me is to default to an individual assessment and an individual approach because, a lot of times, I think what's going on is very much paradigmatic.
In other words, it's very much up inside of a man's head. It doesn't mean the relationship isn't having an impact, but a lot of times, because there's a lot of shame, there's a lot of things that people don't want to say in front of their partner, proper assessment and a proper approach are sometimes hard to develop when the partner is present. I like to make sure that part is done individually and, once we've made that assessment and if it really seems there's something specific to the relationship, we would then look to bring a partner in.
I would say I'm doing that less and less as part of the treatment over the years that I've been doing that work. Most men will bring their partner in at some point. I want to be clear about that. It's not like we're not including the partners in the treatment, but they're there to be much more part of the solution as opposed to viewing the dysfunction as stemming from something problematic in the relationship.
[Dr. Jose Silva]
In your practice, do you see, usually, more females, more women than men?
[Mark Goldberg]
As my practice has expanded, I think we're getting closer to a 50-50. I, as a clinician, I see more individual men than women. It's just because my area of expertise is a lot more around male sexual dysfunction. I also see a lot of couples as well, so I interact with plenty of women in the therapy setting, but on the dysfunction side, I primarily see men.
[Dr. Jose Silva]
On the dysfunction side, mainly men.
[Mark Goldberg]
Yes. In my practice, we treat both, and there's a number of clinicians that are specifically focused on female sexuality and female sexual function.
[Dr. Jose Silva]
Just out of curiosity, at least in your practice, are the expectations the same between men and women or what are the expectations? Do you see more false expectations from men compared to women?
[Mark Goldberg]
That is a fascinating question. I see it more in men, but it's probably because I'm seeing more men. I think men have higher expectations of themselves. I think it'd be fair to say I think women oftentimes feel like they are not living up to the bar a lot more. I know that's a subtle difference, but I think I see a lot more of that with women.
[Dr. Jose Silva]
In men, most of-- They always say, maybe at least these 60, 70-year-old guys, that when they were younger they had a 13-inch-- Everybody had a 12-inch, 13-inch penis. Now it's less than half. I say, "Okay, sure you did." I don't treat women in the office for sexual dysfunction, so I just wanted to see what you had to say about that. Anything else you want to add?
[Mark Goldberg]
The one thing I would add is, for any urologists who are out there, understand that I really respect how limited the time is in the office. In many practices, I know that sometimes it's just 10 or 15 minutes, but I think being able to just have that conversation, certainly, when it seems like there is a real relationship issue or a psychological issue going on, I think to be able just to have that even a minute conversation to normalize this, to let the patient know that it's not a mental illness, it's not something where it's all up in your head, it's not because your psychology is off or there's something fundamentally wrong.
We all have mental health, and sometimes our mental health is not as balanced as we want it to be, or we are pretty mentally healthy, and we get performance anxiety, and this is a normal part of being human. I think being able to have that conversation, I think, will help these patients get from the urologist's office to be able to talk to somebody. I just want to make sure that we emphasize that point.
[Dr. Jose Silva]
That is a great message, and I will definitely use that. You mentioned the difference between mental illness or mental health, I'm going to steal that one. Mark, I want to talk about the Erectile Dysfunction Radio Podcast. When did you start doing that?
[Mark Goldberg]
We launched the podcast in September of 2020.
[Dr. Jose Silva]
During COVID?
[Mark Goldberg]
During COVID, yes.
[Dr. Jose Silva]
Good.
[Mark Goldberg]
Let's say there was nothing else to do, but there was plenty to do. We launched in September of 2020. We were initially doing it weekly. Over the years of doing, it became a lot. I host the podcast. Then things have grown in my practice, and my schedule has gotten busier, so we have shift the podcast to a once every other week episode. If anybody is interested in listening, we try to touch on as many areas pertaining to sexual function challenges both from the experiential, the psychological, relational, medical. We've been having a couple PTs on recently to bring their perspective as well.
[Dr. Jose Silva]
Mark, you mentioned that you do telehealth. It doesn't matter what state you're in. You see anybody?
[Mark Goldberg]
That's, also, a very tricky evolving questions. At the time of this recording, there are a number of clinicians in the practice who can see people for proper therapy services in other states. Outside of the United States is actually a lot easier than it is to see people across state lines. There are a number of processes in place that will allow therapists to work in multiple states, and we will certainly be a part of that as that comes online towards the end of 2023, the beginning of 2024.
In the interim, we do offer coaching across state lines where-- The distinction we draw with that is what we can't do is we can't treat any diagnosed mental health condition across state lines, but we can provide the same educational pieces that we bring and the same assessment skills. If we find that somebody has a bona fide mental health diagnosis, we will help them with a referral in their state.
[Dr. Jose Silva]
Sounds good. Where are you at? Where's the office?
[Mark Goldberg]
Practice is located in Maryland.
[Dr. Jose Silva]
For the audience that have-- This is practicing in the Maryland area, you have Mark Goldberg there.
[Mark Goldberg]
Yes.
[Dr. Jose Silva]
Mark, again, thanks for being in BackTable. I really enjoyed this podcast.
[Mark Goldberg]
Thank you very much for having me.
[music]
[Dr. Aditya Bagrodia]
Thank you so much for listening. If you haven't already, make sure to subscribe, rate the podcast five stars, and share with a friend.
[Dr. Jose Silva]
If you have any questions or comments, DM us @_backtable on Instagram, LinkedIn, or Twitter.
Podcast Contributors
Mark Goldberg, LCMFT, CST
Mark Goldberg is a couples and sex therapist at the Center for Intimacy, Connection and Change in Washington, D.C.
Dr. Jose Silva
Dr. Jose Silva is a board certified urologist practicing in Central Florida.
Cite This Podcast
BackTable, LLC (Producer). (2023, October 23). Ep. 130 – Exploring Psychogenic Aspects of Erectile Dysfunction [Audio podcast]. Retrieved from https://www.backtable.com
Disclaimer: The Materials available on BackTable.com are for informational and educational purposes only and are not a substitute for the professional judgment of a healthcare professional in diagnosing and treating patients. The opinions expressed by participants of the BackTable Podcast belong solely to the participants, and do not necessarily reflect the views of BackTable.
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