Sexual anxiety - lack of erection, premature ejaculation, and delayed ejaculation

Third, there's an idea created by the tabloid press and magazines, and indeed popular culture in general, that "real men" can satisfy a woman on demand every time she wants sex. So if you don't live up to this image of maleness as presented in popular culture, once again you're less of a man, aren't you? The paradox is most women define manliness by virtues other than the hardness of a guy's penis: strength, tenderness, consistency, compassion, clarity and directness being just some of these qualities.

The simple fact is that this fear of inadequacy or performance anxiety is the greatest emotional problem in effective sexual functioning. (There are some other, physical, reasons for not getting hard, like diabetes damaging the nerve cells and cholesterol narrowing the arteries of the penis.) The way it works is this: you feel anxious, and you detach from what's happening. Instead of being right there, in the experience, it's almost as if you're watching it, evaluating and observing it with a critical eye. Fear of failure crowds out the sensual pleasure you could be getting from sex, and without any sense of sexual pleasure or arousal, your anxiety grows, your erection can't happen, and you then get into a cycle of negative expectation ("I'll never be hard again, so I won't even try to have sex...")

Sexual performance anxiety can make you want to avoid all sexual encounters, it can cause a reduction in your self-esteem, it will certainly produce disharmony in your relationship, and of course it causes sexual dysfunction. When a man has this problem, he usually spends so much time thinking about it that he is much less engaged in the process itself - he has, effectively, removed himself from the situation and disconnected from his partner. Naturally this makes the failure he fears even more likely. As the anxious man worries about how it is possible for him to be sexual responsive to his partner, he tends to focus on the smaller details of the lovemaking - so much so that any kind of enjoyment of the bigger picture is diminished. Sex that starts from this emotional position isn't likely to be very satisfying for either partner.

And of course, anticipation of what will happen next time produces more anxiety, which will be stronger if there was a failure to perform adequately (i.e. get an erection) last time. This tends to make a man want to reduce his sexual encounters to a minimum - usually zero, in fact, which will probably make his woman think he is rejecting her. It is important for a woman to understand that this is much more about him feeling in control and avoiding guilt than rejecting her.

From recent times right back to the 1950's, sex therapists helped their clients overcome performance anxiety with a technique called Sensate Focus, a process about getting back in touch with yourself - quite literally. It means losing the pressure of the expectations around sex by agreeing with your partner that for a couple of weeks, you'll enjoy touching and caressing, but you quite definitely won't be sexual. This allows the partners to recapture the sensuous experience of touching each other without any suggestion of sexual expectations, and to overcome any fear of intimacy that may have developed after an erection didn't appear on demand. The partners take turns to give and receive touch, focusing on being right there in the moment, not emotionally detached and watching what's happening from some higher psychological viewpoint.

More recently, though, sexual therapists have seen the advent of Viagra and other drug-related answers to the problems of performance anxiety. I believe Viagra can be a great help in cases of loss of confidence, since it promotes an erection and allows a guy to get his confidence back. There's more to curing performance anxiety than taking Viagra, though. For one thing, every man has bouts of sexual anxiety at some point in his sex life without finding his penis subsequently wilting every time he has sex. To cut a long story short, therapists now believe that the lack of erection may be telling its owner something important. Sexual therapists report that a flaccid penis seems very often to be associated with five major life changes: a relationship that's going off track, divorce or separation, death of a spouse or partner, employment problems, and poor health. The last four are obvious, but the first one may be significant - if you're with a partner and none of the other factors apply, and you're not tired or stressed, maybe the message your penis is giving you is that your relationship is past its sell-by date.

In some cases the relationship never reached its best-before date; in fact it should never have been a relationship at all. A colleague who works with teenagers finds boys of 15 or 16 coming to him saying "I was with a girl I really liked, and I was really turned on, but when we started to have sex I just couldn't get it up". He thinks many of these guys should still be playing with their skateboards; they're just too young to be having sex, or deep down they know they don't like the girl they're with. In short, he says, you can try and fool yourself, but the penis never lies.

Another thing you might care to keep in mind is that focusing too much on your partner (as opposed to focusing on your own pleasure) can be bad for your sexual performance. You have to have a certain amount of selfishness to get highly aroused, and if you're highly aroused your partner will be too. Spending too much time thinking about her will not help you; so if you're having erectile problems, you might want to be a bit more selfish in getting your needs met.

Premature ejaculation

An ignominious problem, indeed, for many of the same reasons that I mentioned above - pressure on men to perform, social expectations, and fear of failure. This time,  even though you have an erection, you ejaculate far too early for either you or your partner to be really satisfied. Often the problem is fear or anxiety.

But coming too quickly isn't just caused by anxiety, of course. Among young men, premature ejaculation is so common that it can be considered normal. There are basically two methods to use at home for curing your tendency to ejaculate quickly, both of which depend on lessening your sensitivity to sexual stimulation. In the first, you get aroused by masturbation, then when you feel you are about to come, you stop stimulating yourself and wait until your arousal has dropped. In the other, your partner gives you a firm squeeze just underneath the coronal rim of your glans till you're less excited. It's not a method I recommend, as it is simply rather unpleasant.

Failing that, go to your doctor and ask him if he knows about anti-depressants and ejaculation. That's not because premature ejaculation will make you depressed, though it may do, but because SRI drugs given out for depression slow down the sexual responses. He might be willing to help you if he's fully informed about how the drugs can help.

Delayed ejaculation - or inability to ejaculate at all

This might sound delightful to you, especially if you're a premature ejaculator, but to a man who can't ejaculate during sex it's not a bonus in any way at all. This is anorgasmia, the inability to reach orgasm.

Like everything about human sexuality, it isn't a simple problem. For one thing, it's several problems which look similar. But for some men, the problem only occurs with their long-term partner; if they have an affair, they can come normally. For others, the problem is not partner-specific. Generally, sexual therapists think that there's a big emotional aspect to this, of which the man concerned is often very unaware. It comes down to his attitude to women in general or his partner in particular.

Men in this position often seem compelled to try and satisfy their partner, even when they don't experience her presence or touch as sexy or stimulating. It's about a reversal of priorities, a belief in the man's psyche that his partner's pleasure is more important than his own, or a sense that he has a duty to please her at all costs. He may resent doing so, or feeling so driven, but he still seeks to please her at the expense of his own pleasure. In essence, his penis is no longer his own: it somehow has no sexual function other than to satisfy his partner.

Diagnostic and Differential Diagnostic Aspects

The evaluation of psychological factors in patients with delayed ejaculation does not substantially differ from the usual diagnostic procedures established for sexual dysfunctions. The symptomatology must be clarified by means of a detailed sexual history, preferably with inclusion of the partner, which forms the basis of a proper diagnostic classification including the usual formal criteria like lifelong versus acquired, and situational versus global.

The main goal of the diagnostic assessment is to determine the conditions under which orgasms are possible or impossible for the individual patient. As usual, the level of immediate, here-and-now causative factors should be explored first, through a detailed analysis of the patient's thoughts and feelings during sexual encounters. Important aspects include:

What are his "start conditions"? Does he experience enormous pressure to succeed right from the beginning or does this pressure emerge later during intercourse?

What is his degree of spectatoring?

What is the relationship between subjective sexual arousal and penile erection?

Does he want and receive sexual stimulation from his partner?

Are there sexual fantasies and can they be used without feelings of guilt?

Can the patient monitor his own feelings and emotions during the sexual contact with his partner or is he totally focused on satisfying her?

Does he have the feeling that his partner becomes frustrated, bored, or annoyed during prolonged intercourse or that she is doing it just for his sake" (mercy sex)?

Are there apprehensions in connection with the experience of orgasm/ejaculation or with the loss of control of which the patient is aware?

Can the partner achieve a coital orgasm, and if so, how quickly? Does the patient continue intercourse after his partner's orgasm?

Another focal point to be addressed during the evaluation process relates to how the patient masturbates. Again, the inner processes, the masturbatory technique, and especially the erotic imagery involved should be explored. Are there sexual fantasies (possibly paraphilic) about which the patient feels conflicted and which he tries to suppress?

Examination at the level of immediate causes is followed by an evaluation of more deep-rooted intrapsychic or dyadic variables. Given the low degree of specificity of these factors, the clinician should consider the above-mentioned categories and scrutinize them in a comprehensive manner. It should be determined if feelings of anger or hostility toward the partner can be identified or if they should be interpreted as a sign of more fundamental conflicts. In most cases, hypotheses can be derived from sexual history, which may then be assessed more closely by targeted questioning. However, these psychodynamically complex issues, predominantly unconscious to the patient, often are revealed only in the course of a longer therapeutic process. Therefore, the investigator should not try to enforce rapid clarification.

In terms of differential diagnosis, delayed ejaculation causes no particular problems. Attention should be paid to differentiating delayed ejaculation from erectile dysfunction, since some men lose their erection and don't ejaculate and may regard this as ejaculatory inability. As with all sexual dysfunctions, it should be determined if DE is secondary to a psychiatric illness (depression, anxiety disorder, obsessive-compulsive disorder) or is caused by drugs or medication.