Rekindling Desire. Chapter 4. The new man: overcoming sexual dysfunction.

Do desire problems cause sexual dysfunction, or does sexual dysfunction cause desire problems? For the great majority of males, the causation is clear,sexual dysfunction results in desire problems. The main male sexual dysfunctions are premature ejaculation, erectile dysfunction, and ejaculatory inhibition. For males, sexual desire problems are almost always secondary. In other words, he once had desire, but it is now inhibited, low, or nonexistent. The destructive cycle is anticipatory anxiety, performance anxiety resulting in dysfunctional sex, and sexual avoidance due to embarrassment and failure.

There is a second pattern,variant sexual arousal. This can involve compulsive masturbation (often accompanied by use of “900” numbers, online sex, or pornography), a paraphiliac arousal pattern, or an issue of sexual orientation. These subvert desire for marital sex.

Males learn that desire, arousal, and orgasm are easy and automatic. Most males masturbate by age 16, usually beginning between ages 10 and 14. The combination of masturbation and the fact that masculinity and sexuality are so closely tied reinforces sexual desire for the adolescent and young adult. These experiences are valuable, but pose vulnerabilities with dysfunction and aging. Ease and quantity of sex are not solid foundations for sexual desire. For example, an 18-year-old ejaculates, has a short latency period before he is receptive to sexual stimulation, and then can have another orgasm. Is this the best measure of sexual satisfaction? The easy, automatic, autonomous quantity approach to sex sets the stage for sexual dysfunction as he ages.

By their mid-30s or early 40s most men find that arousal is no longer autonomous; they need partner involvement and stimulation. About one in three men finds this transition difficult and develops arousal (erection) problems. Valuing quantity, rather than sexual quality, is self-defeating. The focus on performance, rather than on pleasure, makes him vulnerable to dysfunction. The worst sexual learning is that autonomy is better than intimacy. Over time, especially in marriage, intimacy is a key bridge to maintaining sexual desire. The prescription for sexual desire is integrating intimacy, nondemand pleasuring, and erotic scenarios and techniques. Male sexual socialization emphasizes only the erotic component.

A common male fear (which becomes a self-fulfilling prophecy) is that if he reduces self-confidence and goal-orientation, he will begin a “slippery slope” of becoming sexually self-conscious and lose erectile confidence. In other words, the cycle of positive anticipation, enjoying intercourse, and frequent sex will disappear, replaced by anticipatory anxiety, anxious and failed intercourse, and sexual avoidance. What accounts for this self-defeating cycle? Self-consciousness and performance anxiety.

Sex is an active, involved, participatory activity,not a spectator sport. The couple enjoys the erotic flow, in which each spouse’s desire, receptivity, and responsivity enhances the other’s. This is the basis of the “give to get” pleasuring guideline. At its core, sexuality involves giving and receiving pleasure-oriented touching. The spouse being “turned on” is a turn on for him.

Sexual desire is integrated into the relationship, not something “on the side.” Each persons arousal plays off and enhances the other’s arousal. Distraction and selfconsciousness break the erotic flow. When sex becomes a pass,fail performance, this creates conditions for sexual inhibition and failure.

The answer to the anticipatory and performance anxiety cycle is not a return to the youthful pattern of easy autonomous erections. Once sensitized to sexual difficulty, a man cannot pretend it did not happen and resume automatic functioning. By the time he seeks help, the anxiety/failure pattern has become well-established, resulting in secondary inhibited sexual desire.

Sex is now a source of anxiety, frustration, and angst, rather than of pleasure and satisfaction.

Sexual anxiety and avoidance are stigmatizing because sexuality is viewed as a measure of masculinity. The performance myth is that “A real man can have sex with any woman, any time, any place.” You and your penis are human, not a perfect performance machine. How can you challenge this trap? Key strategies are establishing positive, realistic sexual expectations; viewing your spouse as your intimate friend; enjoying nondemand pleasuring; allowing pleasuring to flow into erotic scenarios and techniques; enjoying your own and your spouse’s arousal; viewing intercourse as a special erotic experience, not a performance test; letting arousal naturally flow to orgasm; and enjoying afterplay. At its essence sexuality is about intimacy and pleasure, not pressure and performance. Desire and satisfaction are more important than arousal and orgasm. Sex is more than the penis, intercourse, and ejaculation. You can learn to value intimacy and partner involvement, rather than automatic, autonomous functioning. Sexuality is about sharing pleasure and eroticism. Males have been socialized to function in a sexually autonomous manner and only turn to the spouse when there is a problem. This is the model of pornography. The man becomes turned on by external stimuli, not by intimate, interactive sexuality. Being open to her stimulation and arousal is key to regaining erectile comfort and confidence.

These concepts are particularly valuable for desire, arousal, and ejaculatory inhibition, less so for the most common male problem, premature ejaculation. Even with that problem, it is crucial to view the woman as your intimate friend who helps you learn ejaculatory control.

premature ejaculation.

Most males begin their sexual lives as premature ejaculators. As they gain comfort and experience, most men develop ejaculatory control. However, 3 in 10 adult males experience early ejaculation.

The average time for intercourse from intromission to ejaculation is 2 to 7 minutes. Contrary to male braggadocio, most males ejaculate in less than ten minutes.

Some define premature ejaculation in terms of time (a minute after intromission), some in terms of activity (fewer than 20 strokes), and some in terms of whether the woman is orgasmic during intercourse (an extremely poor criterion because a significant number of women are orgasmic with nonintercourse sex, but not during intercourse). A rea-sonable approach is that if the couple is making good use of nongenital and genital pleasuring and the man’s ejaculation is earlier than both partners wish and interferes with pleasure, then they can benefit by improving ejaculatory control. Learning ejaculatory control will enhance sexual pleasure for the man, as well as for the couple.

Enhanced pleasure facilitates sexual desire.

Premature ejaculation is usually a primary dysfunction, although some men (especially when sex is infrequent or tension-filled) develop secondary premature ejaculation. The two most common male strategies make the problem worse. The first is using “do it yourself’ techniques to reduce arousal. These include the man biting his lip, wearing two condoms, or thinking of the money he owes. The outcome of distraction techniques is reduced sexual arousal, not greater ejaculatory control. He risks creating an erectile dysfunction. The second strategy is to replace quantity for quality. This means having a second intercourse as quickly as possible. Second orgasms are usually less satisfying for the man, and the woman is more likely to feel like a sex object than a loved spouse. This negatively impacts the sexual relationship, desire decreases because of low satisfaction.

Learning ejaculatory control is a three-phase process. First, identify the point of ejaculatory inevitability, after which ejaculation is no longer voluntary. Second, use the stop-start technique as you approach the point of ejaculatory inevitability.

The man signals his partner to stop stimulation as he approaches the point of inevitability. Stimulation stops for 30 to 60 seconds until he no longer feels the urge to ejaculate. The couple then resumes stimulation. This enhances awareness while maintaining arousal. Both phases are practiced with manual stimulation and involve communicating to the spouse when to stop stimulation.

The third phase involves ejaculatory control with intercourse. The couple practices intercourse in the female-on-top position, using slow, long stroking (controlled by the woman). She stops stroking as he approaches the point of ejaculatory inevitability. As control increases, slow down stroking, rather than stopping. The couple experiments with intercourse positions, types of stroking, and rhythm of stroking. The hardest situation for ejaculatory control is with the man on top, with short, rapid thrusting.

Some men prefer to utilize medication to improve ejaculatory control. Anti-depressant medications can help to delay ejaculation. Some men prefer to take daily small doses; others take a moderate dose 4 hours before intercourse. The problem is that when the medication is stopped, premature ejaculation returns (a rebound effect),sometimes more severely. For most men, the recommended technique is to practice the ejaculatory control exercises while taking medication and then gradually phase out the medication.

Learning ejaculatory control is a couple task, requiring time, practice, and feedback. Ejaculatory control is not about the man performing to a standard or proving that he can “give” her an orgasm during intercourse. The focus is on mutually satisfying, pleasure-oriented intercourse.

A common mistake is for sex to end at the man’s ejaculation.

Many women enjoy manual or rubbing stimulation after intercourse,either for orgasm or to share closeness. Afterplay is the most neglected phase of sexuality. Yet it very much affects the couples (especially the woman’s) sense of satisfaction.

Learning ejaculatory control is like learning any skill. It is a gradual process, requiring practice, feedback, and working as an intimate team.

erectile dysfunction.

Far too much of a man’s self-esteem and sense of masculinity are tied to his penis. Erectile dysfunction (commonly called “impotence” or “not getting it up”) is a major male fear. A well-hidden fact is that by age 40, about 90 percent of men have experienced (at least once) a problem with obtaining or maintaining an erection adequate for intercourse. By age 50, over half of males report mild to moderate erectile difficulty. So a man’s major fear is, in fact, an almost universal experience. Men are notorious liars and braggarts about sexual prowess. They deny sexual doubts, questions, or difficulties. The myth-based performance criterion of “A real man is able and willing to have sex with any woman, at any time, in any situation” puts tremendous pressure on the man, especially on his penis.

For men under 40 most erectile problems are caused by psychological or relationship problems, rather than by physical or medical factors. Physical vulnerabilities do increase with age.

Common physical causes include alcohol abuse, smoking, drug abuse, side effects of medications (especially hypertension and psychiatric medications), spinal conditions, prostate surgery, chronic illness, poorly controlled diabetes, and vascular insufficiency. Common psychological and relational causes are anticipatory anxiety, performance anxiety, distraction, self-consciousness, viewing intercourse as a pass,fail test, a reluctance to request partner stimulation, and anger at the spouse.

If an erection problem does not remit within 6 months, the man (and couple) becomes trapped in the cycle of anticipatory anxiety performance failure, and avoidance. No matter what started the problem (alcohol, side effect of medication, fatigue, alienation, depression, anger, or trying to force sex), this self-perpetuating anxiety cycle maintains erectile dysfunction.

The hormonal, vascular, and neurological systems must be functional for adequate erectile response. With aging, beginning in the mid-30s, there is a gradual decline in the efficacy of these systems. That is why there are few professional athletes at age 40; the body is a less efficient performance machine. Testosterone affects sexual desire, which indirectly affects erectile functioning.

An erection involves increased blood flow to the penis (vasocongestion), which fills the tissues and increases the size of the penis. As arousal builds, rigidity (hardness) increases,a neurological response. These systems remain functional, but are no longer at optimal efficiency Psychological, relational, and erotic factors become crucial for erectile response.

Erection is vulnerable to distraction and anxiety. Intimacy, nondemand pleasuring, and erotic stimulation matter more. A 50-year-old man is not the easy automatic, autonomous, sexual machine he was at 20. Sexual response is less predictable. Both spouses can accept sexual variability and flexibility while maintaining positive sexual feelings and expectations.

If you have questions about physical or medical aspects of your sexual functioning, the doctor to consult is either a urologist or a sexual medicine specialist. Although not considered a male sex doctor, the urologist functions much the way a gynecologist does for women. Be sure the urologist is interested in doing a comprehensive assessment, not simply in promoting Viagra, penile injections, external pumps, or surgery.

The most important assessment question is whether the man is able to get erections during self-stimulation, with partner manual or oral stimulation, during sleep, or on awakening. If so, it is likely that the physical factors are functional, although operating less efficiently, especially after age 50. Anxiety, distraction, fatigue, and negative emotions are major factors interfering with sexual functioning. Psychological factors of comfort, involvement, intimacy, and openness are necessary to regain erectile confidence. These include communication with and trust of the spouse, being turned on by her arousal, being open to her stimulation, and making sexual requests. Erotic factors, especially penile stimulation, her guiding intromission, awareness of personal and couple turn-ons, and enjoying orgasm with nonintercourse sex are crucial. If the couple chooses to use medical interventions such as Viagra, injections, or external pumps, the partners have to communicate about how to integrate these into their lovemaking style.

Guidelines for treatment of erectile dysfunction emphasize intimacy, nondemand pleasuring, erotic scenarios and techniques, and positive, realistic expectations. As with other sexual problems, seeking the counsel of a sex therapist is superior to working on your own.

The foundation for regaining erectile comfort and confidence is non-genital and genital pleasuring. A crucial technique is that the man (and woman) become comfortable with the waxing and waning of erections. Men are used to going to intercourse and orgasm on a first erection, so when an erection fades, they panic.

The man is afraid that the sexual opportunity is lost. In fact, continued involvement and erotic stimulation ensures that the erection will wax again. The process of waxing and waning of an erection can occur two to five times in a 45-minute pleasuring session. The next step is to be orgasmic at least twice while erect during nonintercourse sex (manual, oral, or rubbing stimulation).

This increases awareness and comfort with the interplay between subjective and objective arousal. During the free flow of penile stimulation (without switching to intercourse), the man can reach orgasm. Subjective arousal (feeling turned on) usually precedes objective arousal (becoming erect). Without the worry of intercourse failure, arousal and orgasm flow. The next step is to play with the penis around the vagina to desensitize performance anxiety and give the woman practice at stimulating and guiding the penis. She decides when to transition to intercourse, what position to use, and guides intromission. During intercourse, the couple is encouraged to use multiple stimulation (he touching her breasts, she stroking his testicles, kissing, fantasizing), which builds eroticism and heightens arousal.

Since 1998, an increasing number of men are using Viagra to improve erectile functioning. Viagra is the first user-friendly medical intervention; men take a pill approximately an hour before initiating sex. Viagra has two advantages: First, it is a vasodilator that enhances blood flow to the penis and allows the erection to maintain. Second, it serves as a positive psychological stimulus to reduce performance anxiety. The partners need to be comfortable and open in integrating Viagra into their intimacy, pleasuring, eroticism style.

Men who overcome erectile dysfunction do not go back to easy, automatic erections. They are aware, better lovers who have comfort and confidence with erections and appreciate variable, flexible sexual experiences. Approximately 85 percent of their sexual experiences flow into intercourse, another 5 to 10 percent involve nonintercourse sex to orgasm, and 5 to 10 percent are sensual experiences. Mediocre or disappointing sexual experiences (5–15 percent) are accepted. Neither the man nor the spouse overreacts. If sex gets off track, it is seen as a lapse, not a relapse. Men (and couples) who can shrug off or laugh about disappointing or unsuccessful sexual experiences are in a solid position to maintain erectile comfort and confidence.

ejaculatory inhibition.

This is the least known male sexual dysfunction. The old terms retarded ejaculation or ejaculatory incompetence had a negative, put-down connotation. Ejaculatory inhibition or male orgasmic disorder refers to the man wanting to reach orgasm, but his sexual response is blocked (inhibited). The most severe form, primary ejaculatory inhibition (inability to ejaculate by any means), is very rare. Among young men, the most common manifestation is the inability to ejaculate during intercourse, although they do during masturbation (and usually with manual or oral stimulation). This can continue for years, not being addressed until the couple wants to become pregnant.

Ejaculatory inhibition is most common in the intermittent form, affecting as many as 15 percent of men, especially after age 50.

Difficulty in ejaculating stems from a range of inhibitions,the inability to let go, beginning intercourse at low levels of arousal, not being comfortable requesting additional erotic stimulation, fear or ambivalence about pregnancy, or feeling sexually guilty or fearful.

Some males reach orgasm with a very narrow type of stimulation,rubbing against bedsheets, a fetish arousal pattern, or self-stimulation with partner present. They feel inhibited during intimate, interactive sex. Sex is a cooperative, sharing experience between two people who are actively involved in giving and receiving pleasure. With ejaculatory inhibition, this process is blocked. Rather than orgasm being the natural culmination of arousal, it becomes an anxiety-provoking goal the man fails to achieve.

As with other sexual dysfunctions, ejaculatory inhibition is best viewed as a couple issue. The couple,not just the man,has to increase involvement and erotic stimulation, which allows arousal to naturally flow to orgasm. You cannot will or force an orgasm, the key is to increase arousal, especially subjective feelings of being involved and turned on. Erections (objective arousal) can occur at low levels of subjective arousal, so the woman mistakenly believes that the man is highly aroused. A common inhibition is feeling shy about requesting additional erotic stimulation. Males with ejaculatory inhibition can have intercourse for half an hour, an hour, or longer. Those suffering from early ejaculation or couples worrying about erectile performance envy these men.

What nonsense! This type of intercourse is mechanical (and sometimes aversive), not pleasure-oriented. Involvement and arousal do not increase. Intercourse is more to service the partner than to give and receive pleasure.

Two techniques facilitate orgasm,multiple stimulation and using orgasm triggers. A guideline is not to initiate intercourse until the man’s subjective arousal is at least a “6,” and preferably a “8.” Another is to request erotic stimulation to increase arousal ,this can involve fellatio while he moves rhythmically, and she strokes his buttocks or testicles, or combining kissing and manual stimulation. Requesting erotic stimulation during intercourse enhances involvement and arousal. Why should multiple stimulation cease when intercourse begins? Erotic stimulation involves giving, as well as receiving, stimulation. You can switch intercourse positions. She does testicle or buttock stimulation, while he gives breast or clitoral stimulation. He verbalizes sexy feelings, fantasizes, or tells erotic stories.

Orgasm triggers are idiosyncratic. One of the best ways to identify orgasm triggers is to tune into the touches, thoughts, fantasies, and movements you utilize during masturbation right before the point of ejaculatory inevitability. You can transfer these to partner sex. Orgasm triggers include verbalizing or making sounds, moving your body, focusing on a fantasy, giving stimulation, watching the partner, and doing rhythmic thrusting.

Use orgasm triggers to move from high arousal to letting go and coming.

sexual dysfunction and inhibited sexual desire.

Sexual dysfunction often results in secondary inhibited sexual desire. Sex is no longer an anticipated pleasure. It becomes a source of disappointment and frustration. Sex is something to be feared and avoided. This is exacerbated when the man employs “do it yourself” techniques, such as using two condoms or a desensitizing cream for ejaculatory control; using a “cock ring” or doing an injection for erection problems without telling the spouse; or buying a herb or potion that is supposed to force ejaculation. These either do nothing or cause more severe sexual or relationship problems. Sex is a “team sport.” You need to communicate and work as an intimate team to resolve the problem. Focus on rebuilding a comfortable, functional couple sexual style. It is a gradual process, not a miracle cure. Engaging in couple sex therapy is more successful than trying it alone. There is a positive reciprocal relationship between sexual pleasure and sexual desire. Inhibited desire and performance anxiety subvert pleasure for both spouses.

variant sexual arousal.

Approximately 2 to 5 percent of males have a variant arousal pattern. The most common types are fetish arousal, cross-dressing, using “900” numbers with a speciality in “kinky” fantasies, cybersex, and sadomasochistic behavior. A second type is a “noxious paraphilia,” involving a sexual arousal pattern that is abusive and illegal. This includes exhibitionism, voyeurism, frotteurism, obscene phone calls, and pedophilia.

The variant arousal is very narrow, but very powerful. It combines high eroticism with high shame, a poisonous combination. It is quite difficult, and usually impossible, to transfer variant arousal to couple sex. Premaritally and early in the marriage the man might be functional, but over time he develops inhibited sexual desire. There is low desire for intimate, interactive sex. Sexual desire is trapped in the narrow dead end of variant arousal.

This problem absolutely requires clinical intervention.

Typically, the man is in denial or minimizes the impact of the variant arousal. He is intent on keeping this secret from his spouse, especially a noxious paraphilia. The secret is exposed when he is arrested or loses his job,a major crisis for the man and the marriage. Preventative intervention is preferable to crisis management. This problem will not be resolved unless addressed therapeutically.

Let us consider the more serious problem first, the noxious paraphilia. This is both illegal and harmful to others. The pattern develops in childhood or early adolescence and is reinforced by thousands of experiences of masturbating to images of deviant arousal. It is best thought of as a compulsive, addictive behavior that serves as the man’s “secret sexual world.” He distorts reality by thinking it is okay and does not harm others. Couple sex cannot compete with this distorted fantasy and secret world.

Fetishism, cross-dressing, masturbating to pornography, going to massage parlors or prostitutes, and telephone or online sex do not involve illegal activity (in most American cities) or harm to others. However, they are very impactful on the marriage, subverting couple intimacy. The woman feels relieved when the problem is revealed because she has blamed herself or felt “crazy.” Rather than feeling involved and turned on during partner sex, the man tries to shut her off and to focus on the variant fantasies.

Most men, and many women, use fantasies as a bridge to desire and arousal, a healthy form of erotic stimulation. However, variant fantasies serve as a wall to block out the partner. Intimacy is a victim of variant sexual arousal.

The therapeutic strategy is a one-two combination of the male confronting and stopping the variant arousal pattern and the couple developing an intimate, interactive sexual style. The woman is not responsible for changing the man’s variant arousal; he is. It is a joint responsibility to develop a comfortable, functional couple sexual style.

sexual orientation issues.

Sexual orientation issues are extremely disruptive to the man and a major threat to the marriage. This type of issue is a powerful secret he tries to hide from his wife. Emotionally and sexually, he is leading a double life.

Sometime in their lives (most often in adolescence or early adult-hood), approximately one of four men has a sexual experience with another man. Sexual fantasies or experiences with men do not mean the person is homosexual. Sexual orientation means an emotional and sexual commitment to a woman (heterosexual) or a man (homosexual). In clinical practice, Barry has seen a range of situations, from someone who is clearly gay and uses the marriage as a convenient cover; to a man who is aroused by being fellated in an anonymous encounter, but is not emotionally or sexually attracted to men; to men who are passive in anal intercourse (the most dangerous behavior for HIV/AIDS); to men who obsess about and are afraid of being homosexual, yet are clearly heterosexual; to men who use sex with males as a way to get back at the spouse. In cases where the husbands orientation is homosexual, trying to convert him to heterosexuality for the sake of the marriage or children is self-defeating. Most of these marriages will end in divorce, and that is for the best. Trying to pretend about a desire that is nonexistent is in no one’s interest.

Because of emotional closeness, concern for children, convenience, or any combination of these, some couples choose to stay in a no-sex marriage (often with one or both people having affairs).

These decisions are best made in the context of couple or individual therapy.

Where the male is ambivalent about sexual orientation, the treatment of choice is individual therapy, with couple therapy occurring concurrently or sequentially. Sexual orientation is a major life commitment. Although it is possible to be sexual with both men and women, this does not mean the persons orientation is bisexual. If bisexuality is defined as equal emotional and sexual commitment to both sexes, the number of true bisexuals is small.

To rebuild desire, the man’s sexual commitment must be heterosexual. He cannot pretend or try to convert to save the marriage.

Exercise,confronting male sexual problems.

This exercise has two components. The man honestly and objectively examines past and present sexual functioning in regard to premature ejaculation, erectile problems, and ejaculatory inhibition. Is sex functional or dysfunctional? How does this affect sexual desire? The man should not blame the spouse, but take responsibility for his sexual attitudes, behavior, and feelings.

The second component is sharing understandings with the spouse. The man proposes a strategy to address the sexual problems, whether through individual therapy, marital therapy, sex therapy, or a self-help approach. He should be clear about how he plans to change and what he needs from his spouse.

If there is a problem with a variant arousal pattern or sexual orientation, this exercise might cause it to surface for the first time.

It has been the man’s shameful secret. He needs to confront this, rather than to deny or minimize. Is he open to change? Is he willing to seek therapy? Does this problem mean the marriage is not viable? Is he motivated to maintain the marriage and resolve the problem? What is a healthy role for the wife?

In sharing information about sexual dysfunction or other sexual problems, the wife has an opportunity to present her perceptions and feelings and to add a helpful perspective. She can suggest alternative ways to approach the problem or support his proposed strategy. She clarifies what she is willing to do, as well as her limits.

How can she be an active, intimate team member in confronting the sexual problem and revitalizing marital sexuality?

Doug and alicia.

Doug and Alicia fell into the traditional trap, where he wanted to ignore or minimize the sexual problem and she wanted to cure it for him. When this did not happen, Alicia became angry and Doug’s worst critic. Doug married Alicia at 27, making jokes that he finally got caught. In reality, he was glad to be married and looked forward to a secure marriage.

Although Doug had engaged in sex with over 20 women, he never discussed the problem of premature ejaculation. He focused on sexual quantity rather than quality, lasting longer the second time. Alicia had not raised the issue of early ejaculation, either.

Alicia had had fewer premarital partners, but the relationships lasted longer. In her experience, ejaculatory control usually improved after some months. She naively hoped this would happen with Doug.

The “magic of romantic love/passionate sex” lasted 8 months, ending 4 months before marriage. Doug and Alicia admitted that the qual-ity of their premarital sex was not high, but fondly remembered it as a very special time.

Romantic love fades even among the most loving, sexually functional couples. Unless romantic love is replaced by mature intimacy, the sexual relationship is vulnerable. Three months before marriage, Doug threatened to call it off because Alicia was saying no to sex with increasing frequency. Rather than deal with the issues of sexual desire and premature ejaculation, Alicia tried to placate Doug. This proved disastrous for both. Alicia felt sexually anxious and pressured. Increasingly, she resented Doug, feeling more alienated and less aroused. Alicia’s desire and orgasms decreased. Doug felt it was on his shoulders to keep sex alive, and his focus was frequency.

A year and a half into the marriage, the problem of premature ejaculation was raised, this time with more vehemence and less empathy. After a frustrating experience, Alicia accused Doug of being uncaring and sexually selfish. He was shocked and offended and counterattacked by calling her a “frigid bitch.” Alicia saw him as mean and she withdrew. Impulsive sexual fights in bed are volatile and counterproductive.

Doug decided that he would show her by achieving ejaculatory control on his own. He used as his resource an advertisement in a men’s magazine, offering a desensitizing cream with a money-back guarantee. All it did was irritate his penis. Doug then consulted a male sex clinic that prescribed a low dose of antidepressant medication (Prozac, the miracle drug). He did not tell Alicia about this, but was pleased that his ejaculatory control improved. When Alicia found the medication, she was very concerned about Doug’s depression. This made him so self-conscious, he threw out the pills. Premature ejaculation returned with a vengeance. Medication can help with ejaculatory control, but is not a miracle cure. If incorporated into a couples ejaculatory control program, medication can be a valuable resource. However, if done alone, especially if kept secret from the spouse, it is likely to backfire and cause sexual alienation and inhibited desire.

Doug’s strategy had been to do it himself, reduce excitement, and prove something to Alicia. Unfortunately, he wound up with a worse problem,erectile anxiety. He inserted as soon as he became hard, ejaculated at or right after intromission, and blamed it on Alicia’s sexual disinterest. This is an example of the iatrogenic effect of focusing on sexual performance; it creates a more severe sexual problem. It was not long before Doug and Alicia were avoiding not only intercourse but affectionate touch. They were stuck in the cycle of emotional alienation, inhibited desire, avoidance, and a low-sex marriage.

It was Alicia who challenged the cycle by suggesting couple sex therapy. Alicia had been in individual therapy as a college student and benefited from 2 years of group therapy as an adult. Doug was distrustful of general psychotherapy, but open to the idea of sex therapy.

Regaining comfort and confidence with arousal and erection was the initial therapeutic focus. Doug began to treat Alicia as an intimate friend and to share sexual concerns and anxieties, as well as sexual requests. Alicia was a willing and supportive sexual friend. Pleasuring exercises made Alicia feel very good, and her sexual enthusiasm transferred to Doug. This is the usual pattern ,women find sex therapy concepts and techniques easier to accept than men. Intimacy and nondemand pleasuring greatly enhanced Alicia’s sexual anticipation and desire. Her openness and desire increased Doug’s involvement and arousal. With manual and oral stimulation, Doug was surprised at how quickly his confidence with erections returned. Sex was no longer a race toward erection, intercourse, and ejaculation. Slowing down the process, while increasing erotic stimulation, improved ejaculatory control.

A breakthrough occurred when they began the stop-start technique. Alicia used manual stimulation, and when Doug approached the point of ejaculatory inevitability, he signaled her to stop. They did this for 10 to 12 minutes. They openly communicated and enjoyed erotic feelings. Although Alicia found it less fun after the first week, they knew they could master ejaculatory control if they worked together. Being intimate friends, where each spouse’s arousal enhances the other’s, was particularly valuable. Doug was not performing for Alicia; they were sharing pleasure and eroticism.

For the transition to intercourse, Alicia guided intromission. She began with slow, long thrusting. They used the stop-start technique before and during intercourse. What worked even better was changing the type and rhythm of coital thrusting. Alicia could be orgasmic with both intercourse and nonintercourse stimulation. Doug particularly enjoyed Alicia being orgasmic during intercourse. Doug was learning ejaculatory control not for Alicia to have orgasms during intercourse, but to make the sexual experience comfortable, pleasurable, erotic, and satisfying for both.

male functioning and sexual desire.

The male (and the couple) can enjoy the process of desire, arousal, orgasm, and satisfaction. A sign of healthy male sexuality is replacing unrealistic demands to be a perfectly performing sexual machine with a mutual pleasure orientation. Adolescent and young adult sexual experiences take place in a double standard context, which ultimately undermines male sexuality, especially after age 40 and in marriage. Easy, automatic, autonomous sexual functioning can transition into valuing intimate, interactive, variable, and flexible sexuality. Arousal or orgasmic dysfunction is a sign that this transition has been unsuccessful. The stage is set for a collapse into inhibited sexual desire and avoidance. Male inhibited desire is more likely than are female desire problems to lead to a no-sex marriage. Male sexual problems are harder to treat, interfere more with intercourse, and are more disruptive to the marriage.

Male sexual dysfunction is best conceptualized and treated as a couple problem,the wife’s role as the intimate sexual friend is crucial. It is a one-two combination. He takes responsibility for changing his sexual attitudes, behavior, and feelings. They work together to develop a comfortable, functional, and flexible couple sexual style. This will inoculate the man and the couple against a no-sex or low-sex marriage with his aging and the aging of the marriage.

closing thoughts.

Male sexual dysfunction usually precedes inhibited sexual desire.

The man feels embarrassed and humiliated because he cannot meet the rigid performance demands he grew up with. He retreats into blaming of self, blaming of spouse, and sexual avoidance. The key to change is to adopt a broad, flexible, pleasure-oriented approach to sexuality. The couple is an intimate team that develops a comfortable, satisfying sexual style. The man’s trying on his own is likely to be iatrogenic and to cause more serious marital and sexual problems. Couple sex therapy facilitates the change process. When the problem is a secret,involving sexual variations or orientation,therapy is vital.