Stress, Sex and Side-effects: Why I routinely talk to men about their penis

I’m excited to introduce James Spiers as the first guest writer on Notaguru.blog. James is a LIT in Sheffield IAPT and trainee Counselling Psychologist at York St John University who speaks passionately about LIT wellbeing and has been a generous friend to this blog since it started. You can find him on Twitter @JamesDspiers. He’s written about a crucial subject and a thank you box of chocolates is on it’s way to him!

Stress, Sex and Side-effects

When I say stress, I am in fact referring to the psychological and physical effects of emotional distress. The increased prevalence of people accessing primary care services for help with their psychological wellbeing has normalised both discussion about emotional health as well as talking about antidepressant medication.

For most people, Selective Serotonin Re-uptake Inhibitors (SSRI’s) are well tolerated and people experience little disruption from taking the medication. The research also suggests that combined with evidence based psychological treatment, the outlook for recovery from stress is good. Unless someone has a specific health condition that could be complicated by medication, people are mostly told about the common side-effects such as; dry mouth, nausea and a temporary increase in the symptoms of anxiety and depression. All of which are likely to settle after a few weeks.  Less talked about, but definitely more physically disruptive are the possible side-effects specific to men. 

The NHS lists the side effects of SSRIs with sexual problems at the bottom of the list
https://www.nhs.uk/conditions/ssri-antidepressants/side-effects/

Language matters

Erectile dysfunction and inhibited ejaculation can be side-effects of both emotional distress and anti-depressant medication in men of all ages.  However, in my clinical experience it is rarely discussed in either the GP or IAPT consulting rooms. Perhaps this is due to the very time-limited nature of primary care appointments, the possibility that it may put most men off taking medication, or simply to avoid embarrassment on behalf of both the client and the clinician.  Either way, we really do need to become better at talking about it. 

In my role as a Low Intensity Therapist (LIT), I typically see an equal number of men as I do women, mostly aged 20-40.  In the demographic I work in, many have encountered adverse childhood experiences, and through no fault of their own have had very little opportunity for a comprehensive education. Sometimes people refer to me as “posh” because I wear an NHS badge and sit in a consultation room in a GP surgery. My personal view of myself is far from “posh” (quite the opposite), but talking about “erectile dysfunction and inhibited ejaculation” or even “libido” or “sexual problems” is generally meaningless if this is not a part of the person’s day to day language. 

“sometimes men can have problems having sex – that may not affect you, but if it does I want you know that it’s ok to talk about it”

Considering that we work in human services, often with people who are vulnerable, scared, ashamed or stuck, we need to be able to communicate at a human level.  For example, I would find it really odd if a GP told me about a client they were referring who was “partaking in the consumption of Tetrahydrocannabinol”.  Even the most well-spoken of the medical profession will afford themselves the humanness of talking about “weed”or “spliffs”. 

So why do we dance around the topic of stress and anti-depressant medication “stopping you getting a hard-on and being able to cum”?  For the most part, this can be the lightbulb moment that diffuses a significant amount of distress for many of the men that I see clinically, and for some it has literally been life-saving. 

About 2 years ago, I was working with a young guy in his early 20’s.  We were at session 5 of his depression treatment and whilst he had been engaging well and had more or less achieved all of his goals for treatment, his scores on the measures of depression and anxiety were not shifting. He was also starting to experience increased hopelessness and had recently thought about hanging himself.  We recapped his initial problem statement and used the session to re-assess his situation, what had I missed?  After some degree of probing around his social circumstances (these can often be volatile in the demographic I work in), he finally confessed that after a recent confrontation, his girlfriend was threatening to leave him. 

As a LIT, we are hard-wired not to delve and open a can of worms we cannot close in a short appointment.  But it felt clinically relevant (I had nowhere else to go with his assessment) so I asked him “why is that”?  After some pauses and uncomfortable shifting in his seat, he confessed; “my cock is broken and she thinks I’m cheating on her”!  In a nut shell, having started SSRI’s around the same time he started his treatment with me, he began having temporary problems with erections, this had quickly led to performance anxiety.  He was avoiding sexual contact with his girlfriend and she had become distant, worried that he was cheating on her.  At no point had anyone mentioned to him that this was a common side effect of both emotional distress and the medication he was taking to treat it.

Talking for their lives

There was a knock on effect from this appointment for me as a clinician.  Firstly, I started to routinely talk about the specific side-effects that affect men (how I introduce this varies depending on who I am working with).  Often they will simply say “nah, not happened to me mate” and it’s then business as usual.  But for many of the men I have seen for assessment, this has opened an important line of communication that has led to valuable knowledge being shared.  For several men (including one just this week), it’s had such an impact that it reduced them to tears when they realise it is temporary and can be (generally) easily remedied.

The other major difference I’ve seen over the past 2 years is that a few of the GP’s I work with, regularly refer (medically fit) men to me at the surgery when they have come to talk about problems with erections.  Whilst there will be the odd case where this requires specialist psycho-sexual services, the majority of the time, they are scoring high on the measures of both anxiety and depression.  With some good psychological education and a plan around increased physical activity, they are generally back to firing on all cylinders within a relatively short amount of time.  Essentially, this is IAPT’s text book patient group, not to mention that sex is a good motivator for most humans.

why do we dance around the topic of stress and anti-depressant medication “stopping you getting a hard-on and being able to cum”?  For the most part, this can be the lightbulb moment that diffuses a significant amount of distress for many of the men that I see clinically, and for some it has literally been life-saving. 

Generally, I deliver the education on stress and medications in the same way I would with any client, but always directly address the issue of erections when working with men; “sometimes men can have problems having sex – that may not affect you, but if it does I want you know that it’s ok to talk about it”.  I then gauge how much more information is required or how direct my language needs to be depending on how they respond. 

Over the past 2 years I’ve been really surprised at the vast amount of men where they’ve been dealing with the worry about sexual function in silence, because they were too embarrassed to talk to anyone about it. I’ve also been alarmed at how frequent this has been a contributory factor in their depression/low esteem. 

A person-centred approach to healthcare consists of working with the whole person; the psychological, social and the biological. Talking about something that feels ‘taboo’ is pretty familiar to most LIT’s, we often hear the most personal aspects of people’s lives, so why should easily treatable sexual problems be any different? When we consider the rise in suicides in young men, we need to get better at talking about this stuff and is for this very reason why I routinely talk to men about their penis.

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