Some cases of erectile dysfunction and anorgasmia have a clear physiological basis. Erectile dysfunction is a fairly common symptom of diabetes, for example, and is sometimes the first symptom to make its appearance. Thus a test for diabetes should be part of the study of a client who is continuously impotent under all conditions. The erectile dysfunction may end when the diabetes is brought under control. Prescription drugs, excessive alcohol intake, and cigarette smoking also harm potency. Numerous men have reported an upsurge in sexual interest after they stop smoking. But in the vast majority of cases, it is quite easy to prove that the roots of erectile dysfunction are psychological. The hallmark of psychological erectile dysfunction is a man's inability to attain an erection under some circumstances - but to demonstrate full potency under others. He may be sexually quite capable during paid-for sex, for example, but not with his wife. Or he may be quite capable with his wife, but find himself impotent when attempting to consummate an extra-marital affair. He may attain erection during masturbation but not when he attempts sex with a woman.
There are many variations around this theme; but the diagnostic lesson is always the same: if a man is capable of attaining erection under any circumstances, whatever it may be, it follows logically that there is nothing wrong with his erectile apparatus, and that the roots of his problem are inherently psychological.
A few of the psychological causes for erectile dysfunction and anorgasmia are so common that general statements about them are possible.
It is common for the healthy young male at the outset of his sexual life to be troubled with temporary erectile dysfunction or premature ejaculation until he has gained experience. With the gathering of experience, the problem gradually diminishes and finally disappears. In effect, he has embarked on a period of self-training. Frequently the young man will have a firm erection just before and just after attempting intercourse but not during the attempt. If there is a ready explanation, it is most likely a feeling of ineptness, a fear of hurting the girl, an inability to reconcile the loved female with sexual passion, anxiety about performance, feelings of guilt or wrong-doing, a fear of pregnancy, or any combination of these.
For a while it may induce the "fear of failing" phenomenon. If the man has a few failures, he may come to have serious misgivings about his potency; subsequent sexual trials may be approached with a dread of failure. The determination to prove his masculinity, combined with inner doubts that he can, does not provide the ideal setting for sexual success.
Although there can be numerous emotional causes behind this phenomenon, the most frequent in my clinical experience has been deep-seated feelings of hostility and resentment towards his partner on the part of a moderately passive man. In this setting erectile dysfunction is a symptom of a troubled relationship, and the treatment focus has to be on the relationship and the relationship between the partners. Sexual withholding is a frequent hostile act in a disrupted relationship. It is a particularly powerful weapon against the husband or wife who has relatively high sexual drives and equally high moral or ethical bars to extra-marital contacts, masturbation, or other sexual outlets. This person is "trapped."
Mounting resentment and anger often result in symptoms ranging from insomnia, bitterness and irritability, and mild depression to psychosomatic disturbance. Often it gives rise to fantasized death wishes against the withholder, which in turn can produce feelings of guilt for entertaining such violent ideas. An interesting and tragic variation of this type was described as early as 1912 by Freud. As is characteristic of this group, the man loves his wife dearly and yet is impotent with her but not with certain other females. Freud pointed out that in the emotional development of the boy, the affectionate (love) feelings toward the female figure (mother) are much older than the sensual feelings of sexuality arising at puberty. If the newer sensual feelings become attached to incestuous fantasies, the result will always be total erectile dysfunction, Freud believed.
In other words, male sexual maturity requires that the older affectionate love feelings be freed from the forbidden (mother) and fused with the newer sensual feelings and that both then be attached to the new love object (relationship partner). Freud felt that the degree of fusion determined the degree of potency in the male. Referring to degrees of incomplete fusion, he said, "Where such men love, they have no desire and when they desire, they cannot love. They seek out objects (i.e., women) they need not love. As soon as the sexual object fulfils the condition of being degraded, sensual feeling can have free play."
This particular condition of erectile dysfunction is relatively common. In the face of an affectionate attachment to his wife, the husband is often capable of erections before and after the attempt. Genital union with her is forbidden by forces of which he is unaware. On the other hand, he is not at all impotent with downgraded women to whom he need form no affectionate attachment, for example, sex-workers. This condition - erectile dysfunction in the face of a love relation between husband and wife - is a cruel tragedy for both. It is almost the rule in these situations that the wife comes to feel that she does not have the power to arouse her husband and regards herself at fault. If it becomes known to her that her husband is potent with anyone else, it creates a condition beyond her understanding; nor does the husband understand it any better. Treatment of this kind of erectile dysfunction requires therapy.
In some situations the erection may disappear before orgasm and ejaculation due to various reasons. In its simplest form, it may occur because the vagina is too "loose" as a result of child bearing and does not furnish sufficient "grip" on the penis. (A relatively simple vaginal repair procedure can usually correct this condition.) At the psychological level, this type of erectile dysfunction may relate to feelings of guilt, fear of discovery, fear of pregnancy, and the like. For example, it is a common observation that the male, engaged in intercourse, may quickly lose his erection if he hears noises that indicate a possible invasion of privacy. Another cause of this type of failure occurs if the male feels that his partner is unresponsive and uninterested. A casual remark on the part of the wife during intercourse - for example about a household problem - often will cause erection to vanish by making the male aware that his wife's mind is elsewhere. Consistently, felt attitudes of this sort may cause a male either to cease making approaches to his wife, or to be impotent when he does.
When it is apparent that erectile dysfunction (and anorgasmia, too) is the symptom of a disturbed relationship between husband and wife, little if anything will be gained unless an attempt is made to treat this relationship by helping both partners towards a better adjustment to each other. Here, an attempt to treat one partner would be as futile as attempting to treat the pain of appendicitis without removing the appendix, the seat of the trouble.
By and large, anorgasmia is to the female what erectile
dysfunction is to the male; most of the things said about erectile dysfunction
are basically no different when applied to the female. In particular, it is
nonsense to look for a physiological cause of anorgasmia if it occurs under one
set of circumstances but not under others.
A wife, like a husband, may be non-orgasmic with a spouse but not with other partners
- or with another man but not with her husband. She may be non-orgasmic with men but
may attain orgasm with masturbation or during sexual dreaming, and so on. The
establishment of the circumstances under which a specific instance occurs is of
critical importance, and such questions as the following must therefore be
tactfully but precisely asked:
(1) Has the woman achieved orgasm? Under what circumstances ?
(2) Can she achieve orgasm by means of masturbation or not?
(3) Under what circumstances does she experience sexual arousal?
(4) Has she achieved orgasm with a sexual partner other than her husband?
(5) Does she notice sexual arousal in dreams or fantasy during the day? Upon reading erotic literature? On watching adult movies? Etc.
(6) Do arousal and orgasm occur under any other circumstances ?
(7) What are her usual responses during arousal and genital union?
In the event that an anorgasmic or frigid woman achieves arousal and orgasm under any of the circumstances mentioned, it follows that she possesses the physical potential for orgasmic response.
Typical is the case of the woman who before relationship was able to achieve orgasm fairly easily during masturbation but who has rarely, if ever, achieved orgasm with marital intercourse. Another fairly frequent pattern is demonstrated by the woman who had fairly consistent orgasmic response with her fiancée during their engagement, but who lost this ability in the months or years after relationship. This situation almost invariably points to non-sexual marital problems which have arisen between the partners subsequent to relationship.
The solution for such problems is clearly relationship counselling or psychotherapy or both. In its simplest terms, this means that the therapist and the client propose to explore together the psychological factors and attitudes that have entered into the formation of the symptoms. Intellectual understanding of the causes, although an essential first step, is not enough. After reaching an understanding of why he is impotent, for example, it still remains for the male client to tackle the larger task of applying this new-found knowledge to his feelings, attitudes, and conduct - a longer, harder job, and one which often involves knotty decisions.
TRAINING PROCEDURES
While I believe in psychotherapy, we must remember there are other types of treatment - even for conditions that are clearly psychological in origin.
A simple example is a training procedure that some women find helpful in overcoming anorgasmia. Its purpose is to lower the threshold of erotic response. The woman initiates her arousal pattern in her own home by reading stimulating literature or by some other arousing activity, and then proceeds to masturbate to the point of orgasm (even though at first this may require a prolonged period of stimulation). On the next occasion she repeats the procedure, attempting, by close concentration, to shorten the stimulus time to orgasm. Having accomplished the desired lowering of her threshold response by repeated sessions of self-stimulation, she may then enlist her husband's co-operation to accomplish the same end by having him masturbate her. The final step is the attempt, once mutual confidence has been established, to achieve the same result with intercourse. Once the desired response pattern has been achieved through this technique of progressive training, it apparently tends to remain stable. This training procedure appears to be of material help to some women suffering from anorgasmia even though the roots of the anorgasmia may lie far back in the psychological experiences of childhood.
By similar methods some women who have previously experienced only a single orgasm report the ability to "train" themselves to multiple orgasms, first by self-stimulation and subsequently by intercourse. As soon as clitoral sensitivity following the first orgasm has faded, the woman promptly resumes genital stimulation to the second orgasm, and so on.
Training has also helped in overcoming another barrier to sexual satisfaction in intercourse - a condition called vaginismus, which is a spasm of the muscles surrounding the vagina and its entrance. This is not a conscious female response but a reflex response - much like the tight blink of the eyelids at a threatening motion toward the eyes. There are many degrees of vaginismus, including an extremely painful spasm so tight that even the lubricated tip of the physician's finger cannot be introduced into the vagina. Regardless of the causes of vaginismus - at least some of them no doubt psychological - there is a very simple treatment. The woman is taught to dilate her own vaginal orifice gently and repeatedly, either with her fingers or with a lubricated cylinder.
A useful training procedure for men who experience premature ejaculation was reported in 1955 by Dr. James H. Semans of the Duke University School of Medicine. It is the most successful therapy known for overcoming this form of sexual inadequacy. In brief, the man (or his wife) stimulates the penis until the first warning feelings of impending orgasm are noticed. Every adult male is familiar with these sensations a few seconds before ejaculation starts. When the first sensation is noticed, stimulation of the penis is stopped immediately and abruptly. The sensation disappears and the ejaculation does not occur. The erection may or may not go down; it doesn't matter. Ten or fifteen minutes later the same procedure is repeated. Repetitions three or four times a night (or day) for three or four days running have proved highly successful in abolishing the premature ejaculation pattern. The client and his wife can be assured that no harm will result if the stimulation is not stopped quite in time so that ejaculation occurs; they simply wait until the man is able to have an erection again - perhaps a few hours later - and then try again.
A training procedure published for the treatment of erectile dysfunction - the inability of a man to achieve or to maintain an erection - can be found on the internet.
OBJECTIONS TO THE TRAINING PROCEDURES
Some readers as well - will be shocked at this seemingly superficial, do-it-yourself approach to such deep-seated conditions as anorgasmia and premature ejaculation. And there is some validity in the objections that can be raised to it. Let me review them briefly.
Perhaps, such a training procedure does not get to the root of the problem; it only succeeds in modifying behavior. One answer to this objection can best be stated: As a woman, would you rather be left frustrated and "hanging in the air" following sex, or orgasm during intercourse or climax during sex with your partner? As a man, would you rather ejaculate prematurely or have freed yourself of that particular problem?
But there is another answer of greater weight, both theoretically and practically. The typical adult who comes to psychotherapy is not suffering from one traumatic early experience from which all his subsequent problems stem directly. Rather, a series of emotional stresses evokes distressing symptoms, which in turn add to his emotional pressure, evoking further symptoms or further exacerbating his initial symptoms, and so on. The vicious cycle is familiar to every psychotherapist. Anorgasmia, erectile dysfunction, and premature ejaculation are three of the most crushing symptoms, producing the most widespread distress and contributing enormously to the viciousness of the cycle. Relieving these symptoms can thus be a significant contribution towards curing the basic problem.
Surely orgasm is one of the joys of life? The man or woman who learns to experience orgasm is to that extent better off than s/he was before. Helping a client to achieve orgasm - either through traditional psychotherapy, or through training procedures, or both - is a worthy goal of therapy, among many others. This is especially true if sexual problems are the presenting symptoms that brings the client to therapy, or if it turns out to be a central factor in the client's anxiety as the therapy proceeds.
PSYCHOTHERAPY AND TRAINING
A firm belief in the psychological origins of sexual inadequacy can go hand in hand with the acceptance of training procedures. The rationale for such procedures in treating conditions of psychological origin is identical with the rationale for psychotherapy. So, for example, the little girl who learned from her mother to reject and draw back from men can learn in psychotherapy to be more accepting. The little boy who learned in his relationship with his mother to be afraid of his own intense emotional responses to women can learn to be afraid no longer. During training procedures, similarly, a woman can learn that the approach of a man is not a threatening occasion for which vaginismus is the appropriate response; or a man who wants to enjoy normal intercourse can learn not to ejaculate prematurely. Both psychotherapy and training procedures are in effect learning procedures for the client, and both have their place as methods of approach for the therapist.
The relief of anorgasmia or premature ejaculation is a dramatic demonstration to the client of the effectiveness of the therapeutic relationship, and may thus open the door to deeper psychotherapy. Clients previously inaccessible may become not only accessible to psychotherapeutic procedures, but in some cases eager to tackle their other life problems in a therapeutic setting. Having once learned to experience orgasm during the training procedure, the client is freed to integrate it into his or her total response in the sexual relationship, and the relationship is itself thereby enriched and drained of much anxiety. It is not necessary to abandon the emotional rewards of a warm interpersonal relationship, or to sacrifice the values already imbedded in a relationship, or to abandon all the romance that bring a man and woman together in order to embark on a programme of training for sexual response. On the contrary, these and other values a man and woman share can in many cases be transfigured by the addition of this further opportunity for sharing.