We know, clinically, that many PDE-5 nonresponders will be restored to sexual health through a CT integrating sex therapy and sexual pharmaceuticals. Yet how do we conceptualize such a model so that standard treatment algorithms could be stretched to incorporate this concept? The answer is twofold. We need a schema for understanding psychosocial obstacles (PSOs) to successful treatment, integrated into a model that executes that understanding.

Combination therapy is the therapeutic modality of choice for any SDs. Combination therapy refers to a concurrent or step-wise integration of psychological and medical interventions. We have previously described developing adherence for this approach to erectile dysfunction, with enthusiasm growing within the FSD treatment community. Combination therapy is already being recommended for PE, and is likely to be recommended for the full range of ejaculatory disorders. Although desire disorders for men and women have a strong psychosocial cultural component, there is little doubt that sexual "desire" has biological underpinnings and is likely to be distributed on the same bell-shaped distribution curve as other human characteristics. This simply means that all SDs have a biopsychosocial basis and that treatment must incorporate medical and psychological dimensions. Without adequate desire, motivation, and realistic expectations, treatment outcome is likely to be disappointing and with high discontinuation rates. Medical interventions do not motivate the sexually reluctant patients or partners to try treatment, nor do they help overcome psychological obstacles to success. Reciprocally, it would constitute malpractice to only focus on psychological factors to the exclusion of all possible organic etiology for an individual seeking assistance. Then, how can an ethical and motivated clinician proceed?

Combination Therapy Guidelines: Who, How, and When?

There are two alternative models for CT: both will likely be adopted within the framework of sexual medicine, by different clinicians. First, working alone, PCPs, urologists, psychiatrists, and eventually gynecologists will integrate sex counseling with their sexual pharmaceutical armamentarium to treat SD. "Sex counseling" in this situation, is utilizing sex therapy strategies and techniques to overcome psychosocial resistance to sexual function and satisfaction. In a second model, the above clinicians will collaborate with nonphysician MHPs (sex therapists), resolving SD(s) through a coordinated multidisciplinary team approach to treatment. The clinical combinations will vary according to the presenting symptoms, as well as the varying expertise of these health care providers. The utilization of these two different models will require three steps. (i) The clinician first consulted by the patient will consider their interest, training, and competence. (ii) The bio-psychosocial severity and complexity of the SD as a manifestation of both psychosocial and organic factors will be evaluated. (iii) The clinician in consideration of the two previous criteria, together with patient preference, will determine who initiates treatment, as well as, how and when to refer. The guidelines for managing the relative severity of the dysfunction will essentially be expanded, but continue to match the type of treatment algorithm described in "The Process of Care" and other step-change approaches.