Sexuality and Sex Therapy: Part 2
When There Is Sexual Dysfunction

cont. from part 1

Bob became increasingly embarrassed as he talked about his problem with premature ejaculation. He claimed that can only 'last' for two minutes and felt that he was not much of a man. His 'problem' has kept him from dating.

Sally was beside herself with fear as she harshly castigated herself for not being able to achieve orgasm. She feared she would lose her husband because of her 'condition.'

Most sexual dysfunction occurs because of faulty beliefs and attitudes about sexuality, poor habits, ignorance, and early experiences. There are some sexual dysfunctions that are precipitated by physiological, biological, or chemical factors. However, all physiological dysfunctions have a psychological component. When men are unable to obtain or maintain an erection, whether from physiological or psychological causes, they feel inferior, less manly. When a woman is unable to reach orgasm she feels less feminine. Therefore, in all cases of sexual dysfunction it is necessary to attend to the psychological aspects of the difficulty and what it means to the individual.

Physiological factors. Some of the more common non-psychological precipitants of sexual dysfunction include hormonal imbalance, medications, neurological impairment, substance abuse (even nicotine dependence can cause erectile dysfunction), alcohol dependency, physiological disorders, and even vitamin deficiency. Certain illnesses and medications can have side effects that affect sexual functioning including impotence and increased or decreased libido.

Many people prefer to think of only a medical approach to sexual dysfunction, since it is more acceptable to one's self-image to believe that there is an organic basis for the dysfunction. Even in those instances when there is a recognizable medical condition affecting sexual functioning, the psychological component cannot be overlooked. We all have varying psychological reactions to physical illness or impairment. This psychological reaction can exacerbate the physical problem. This is especially true for infertility problems. Most people who have difficulty conceiving a child choose to investigate the medical aspects to the exclusion of the psychological aspects. Yet we all know of many cases where a couple after years of frequenting the fertility clinics to no avail, finally decide to adopt a child only to conceive a few months afterward. This can suggest that psychological factors were at play.

Psychological factors. Most sexual dysfunctions have a psychosocial etiology. Dr. Helen Singer Kaplan states, "In a general sense we see the immediate causes of the sexual dysfunctions as arising from an anti-erotic environment created by the couple which is destructive to the sexuality of one or both. An ambiance of openness and trust allows the partners to abandon themselves fully to the erotic experience."

She lists four specific sources of anxiety and defenses against full sexual enjoyment: 1) Avoidance of or failure to engage in sexual behavior which is exciting and stimulating to both partners. 2) Fear of failure, exacerbated by pressure to perform, and overconcern about pleasing one's partner rooted in fears of rejection. 3) A tendency to erect defenses against erotic pleasure. 4) Failure to communicate openly and without guilt and defensiveness about feelings, wishes and responses. Psychological reactions to traumatic events also affect sexual functioning. For example, child molestation, rape, abuse all can contribute to later sexual dysfunction.

Common Sexual Dysfunctions

The following are the most common forms of sexual dysfunction. They are all treatable with a high probability of success.

Male Dysfunctions

Inhibited Sexual Desire.

Inhibited sexual desire or response refers to the lack of desire for erotic sexual contact. In almost all cases when there is a lack of sexual desire, the underlying causes are psychological in nature. Avoidance of sexual contact because of fears of rejection, failure, criticism, feelings of embarrassment or awkwardness, body image concerns, performance anxiety, anger towards a partner or women in general, lack of attraction towards a partner, all play a part in reducing or eliminating the sexual response. Most men are too uncomfortable to talk to their partner or anyone else about these issues, preferring to simply avoid sex or attribute their lack of sexual appetite to stress, worries, etc. Some of these men have a very active fantasy life and prefer the solitude of masturbation to the intimacy of sexual relations.

Premature Ejaculation.

Premature ejaculation is the most common dysfunction and it is the easiest to treat. Masters and Johnson define premature ejaculation as the inability to delay ejaculation long enough for the woman to orgasm fifty percent of the time. (If the woman is not able to have an orgasm for reasons other than the rapid ejaculation of her partner, this definition does not apply.) Other therapists define premature ejaculation as the inability to delay ejaculation for thirty-seconds to a minute after the penis enters the vagina.

For the most part, premature ejaculation most often occurs as a function of a learned response. Early sexual experiences were often hurried in nature. Even masturbatory activity had to be hurried for fear of being caught. From youth onward men have trained themselves to be more concerned with the end result and their own pleasure rather than with the sexual process and their partner. The object of sex for most of these men, was and often continues to be, ejaculating as quickly as possible. This rapid ejaculating pattern can easily become a way of life after even only a few episodes. It then begins to create a pattern of anxiety in the male each time he engages in coitus thus increasing the probability of it occurring. Fearful of displeasing their partner and feeling inadequate as a function of it, men often would rather avoid sex rather than experience the humiliation and discomfort.

Retarded Ejaculation or Ejaculatory Incompetence.

Ejaculatory incompetence is the opposite of premature ejaculation and refers to the inability to ejaculate inside the vagina. Men with this difficulty may be able to maintain an erection for 30 minutes to an hour, but because of psychological concerns about ejaculating inside a woman, they are not able to achieve orgasm. Usually they do not experience sexual intercourse as satisfying. One of the reasons this dysfunction goes undetected is because the male's partner is satisfied and often is able to achieve several orgasms as a function of the man's inability to ejaculate. Most of the men who suffer from retarded ejaculation can readily achieve orgasm through masturbation or in some cases through felatio. Many factors contribute to this condition, some of which are religious restrictions, fear of impregnating, and lack of physical interest or active dislike for the female partner. In addition such psychological factors as ambivalence toward one's partner, suppressed anger, fear of abandonment, or obsessional preoccupation also play a significant role in developing retarded ejaculation.

Primary Secondary Erectile Dysfunction.

Primary erectile dysfunction refers to a man who has never been able to maintain an erection for purposes of intercourse either with a female or a male, vaginally or rectally. In secondary impotence a man cannot maintain or perhaps even get an erection, but has succeeded at having either vaginal or rectal intercourse at least one time in his life. The occasional failure to get an erection is not to be confused with secondary impotence. Familial, societal, and intrapsychic factors contribute to primary impotence. Some of the more common influences are (1) performance anxiety, (2) a seductive relationship with a mother, (3) religious beliefs in sex as a sin, (4) traumatic initial failure, (5) anger toward women, and (6) fear of impregnating a woman.

Female Sexual Dysfunctions

General Dysfunction.

These dysfunctions, according to noted sexologist, Dr. Helen Singer Kaplan, "are characterized by an inhibition in the general arousal aspect of the sexual response. On a psychological level there is a lack of erotic feelings." Manifested by lack of lubrication, her vagina does not expand, and "there is no formation of an orgasmic platform. She may also be inorgasmic. In other words, these women manifest a universal sexual inhibition which varies in intensity."

Orgastic Dysfunction.

The most common sexual complaint of women involves the specific inhibition of orgasm. Orgastic dysfunction refers solely to the impairment of the orgastic component of the female sexual response and not arousal in general. Nonorgastic women can become sexually aroused and in fact enjoy most other aspects of sexual arousal. Inhibition and guilt about masturbation, discomfort with one's body, and difficulty giving up control, contribute to orgastic dysfunction. With a combination of education and practice, most women can be taught to achieve orgasm.

Vaginismus.

This relatively rare sexual disorder is characterized by a conditioned spasm of the vaginal entrance. The vagina involuntarily closes down tight whenever entry is attempted, precluding sexual intercourse. Otherwise, vaginismic women are often sexually responsive and orgastic with clitoral stimulation. Similar attitudes to those found in impotent males are often found in these women. Religious taboos, physical assault, repressed or controlled anger, and a history of painful intercourse all contribute to this dysfunction.

Sexual Anesthesia.

Some women complain that they have no feelings on sexual stimulation, although they can enjoy the closeness and comfort of physical contact. Clitoral stimulation does not evoke erotic feelings though they do feel a sensation of being touched. Dr. Kaplan believes that sexual anesthesia is not a true sexual dysfunction, but rather represents a neurotic disturbance and should be treated through psychotherapy rather than sex therapy.

As with sexual dysfunctions in men, the female dysfunctions also have to be understood from a social, familial and psychological perspective. Attitudes, values, childhood experiences, adult trauma, all contribute to the sexual response in women. The attitudes and values of her partners, as well as their sexual technique, play a major role in the sexual response as well. An inept or mysogynistic lover can significantly affect the female response. Since a woman often does not want to "damage the male ego," she will try to accommodate her responsiveness to him often sacrificing her satisfaction in the process. She then builds up a secondary inhibition to sexual arousal in order to avoid the frustration accompanying an unsatisfying sexual experience. This inhibition or accommodation then becomes a habituated conditioned response.

Inhibited sexual desire.

As indicated above, inhibited sexual desire is almost always caused by psychological factors (some medications cause a reduction in sexual desire). Since women in our society are often more concerned with intimately connecting to their partner (as compared to men who are more often phallocentric and more concerned with orgasm), women become more sensitive to the psychological climate. When women feel that they are being used, exploited, misunderstood, rejected, unappreciated, and unattractive, their sexual desire will often be affected. Unexpressed anger and hurt can lead to depression, which affects desire. Sometimes these emotions are expressed in passive-aggressive ways, sexual withdrawal being one manifestation. Sexuality, especially for women, is more than a form of pleasure and release; it is a form of communication.

Sex Therapy

Sex therapy provides information and counseling on all aspects of human sexuality, including enhancing sexual pleasure, improving sexual technique, and learning about contraception and venereal diseases. Sex therapy is used in the treatment of all of the dysfunctions discussed earlier. In many cases treatment is relatively short, requiring specific techniques, homework, and practice. In some cases, the underlying issues are more complicated. They may require an exploration into historical and psychological factors, both conscious and unconscious, that are contributing to the dysfunction. However there is a very high probability of success, even in those cases, if people are motivated, cooperative, and willing to learn.

Unfortunately, most people would rather live with a sexual dysfunction and a less than satisfying sexual life than seek help. The embarrassment they feel in discussing their sex life with a professional is too great. There are others who have adjusted to their sex life and despite the fact that their spouse might be unhappy, they refuse to seek help. When these people hear that their spouse is unhappy about their sex life, they experience it as a criticism, become defensive, and often become either hurt or angry, rather than open themselves up to exploration with a sex therapist.

Four common causes of sexual dysfunction:

1. Stress.
   Often unidentified, stress can produce temporary sexual dysfunction which can become permanent. Unfortunately, people often consider sexuality such a private matter that they are reluctant to discuss it with others. Even those who have had sexual difficulties as a consequence of disease or surgery, have difficulty seeking sex therapy to facilitate adjustment to the dysfunction. Many men prefer to needlessly avoid sex altogether rather than seek professional help. Their pride gets in the way of sexual satisfaction.

2. Attitude.
   One of the most significant contributing factors in sexual dysfunction is your attitude toward the dysfunction. If you view it as a diminishing your self-worth and reflecting negatively on your overall value as a human being, sex therapy will take a little longer since we first have to overcome these initial feelings.

3. Motivation.
   Another contributing factor is your motivation and that of your spouse or partner. Your partner's cooperation, participation, and support can accelerate the process and in many cases is essential for effective treatment. Remember, when one member of the dance team is impaired, the team is impaired. Sex therapy, like sex itself, is a cooperative venture.

4. Performance anxiety.
   This is frequently a prime cause of sexual dysfunction. People become so preoccupied with their sexual performance or the performance of their partner, that they lose sight of the process. Enjoying the pleasure involved in being together, the pleasure of human touch, and the process of love making ought to be the primary focus. Many individuals are more concerned with their "reviews" than they are with whether they are enjoying themselves.

Many sexual problems aren't just about sex. Usually, there are some relationship issues that need to be worked out. That's where relational and sex therapy come together.

Dr. Edward A. Dreyfus is a Clinical Psychologist, Marriage, Family, Child Therapist, and Sex Therapist. Dr. Dreyfus has been providing psychological services in the Los Angeles-Santa Monica area for over 30 years. His book, Someone Right For You is available here.

Last updated: 8/05

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