SEXUALITY & SEX THERAPY: Part II
WHEN THERE is SEXUAL DYSFUNCTION
by Edward A. Dreyfus, Ph.D.
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
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.
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 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
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.
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."
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.
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
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
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 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:
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.
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.
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
- 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
Read Dr. Dreyfus' next article on this topic:
Sexuality and Aging
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.
He offers individual psychotherapy to adolescents and adults, divorce mediation,
couples counseling, group therapy, and career and vocational counseling and
assessment.His book, Someone Right For You, is available in the Amazing
Dr. Dreyfus can be reached at: (310) 208-5700.