Category: Men’s Health

A typical history of an acute episode of alcohol consumption as an etiological factor in the onset of secondary impotence is classic in its structural content. The clinical picture is one of acute psychic trauma on a circumstantial basis, rather than the chronic psychosocial strain of years of steady attrition to the male ego as described in the case history for the premature ejaculator.

There has been a specific history of onset of symptoms of secondary impotence as a direct result of episodes of acute alcoholic intake in 35 men from a total of 213 men referred with a complaint of secondary impotence.

The onset of secondary impotence in an acute alcoholic episode is so well known that it almost beggars description. A composite example is that of a relatively “successful” male aged 35-55, college graduate, working in an area which gears productive demand more to mental than physical effort.

The perfect environmental situation for onset of secondary impotence is any occupational hazard where demands for high levels of psychosocial performance are irrevocably a part of the nine-to-five day and frequently carry over into an evening of professional socializing.

Alcohol Impotence

Mr. A is a man with a habit of alcohol before dinner, frequently a few glasses of wine with his meals, and possibly a whisky. Alcohol intake at lunch is an integral part of his business as well.

In short, consumption of alcohol has become a part of his life.

This man and his wife leave home one night for a party and alcohol is available in large quantity. Somewhere in the late evening, the party comes to an end. Mr. A has had entirely becomes tipsy and so his wife drives them home for safety’s consideration.

His wife retires to the bedroom, and with a sense of vague irritation, a combination of a sense of personal rejection and a residual of her social embarrassment, prepares for bed. Mr. A has stumble but with the aid of a strong banister and even stronger nightcap, manages to arrive at the bedroom door. Suddenly he felt that his wife is indeed fortunate tonight, for he is prepared sexually satisfied her.

Alcohol Hangover

It never occurs to him that all she wants to do is go to bed and avoid a quarrel at all costs. He jumped into the bed, moves to meet his imagined commitment, and nothing happens. He has simply had too much alcohol.

Dismayed and confused both by the fact that no erection develops and that his wife obviously has little or no interest in his gratuitous sexual contribution, he pauses to resolve this complex problem and immediately falls into deep, anesthetized slumber.

Next day, he is further traumatized by the symptoms of an acute hangover. He surfaces later in the day with the concept that things are not as they should be. The climate seems rather cool around the house. He can remember little of the prior evening’s festivities except his deeply imbedded conviction that things did not go well in the bedroom. He is not sure that all was bad but he also is quite convinced that all was not good.

Obviously he cannot discuss his problem with his wife, she probably would not speak to him at this time. So he putters and mutters throughout the evening and goes to bed early to escape. He sleeps restlessly only to face the new day with a vague sense of alarm, a passing sense of frustration, and a sure sense that all is not well in the household this Monday morning.

He pondered about it over a drink or two at lunch and another, and while contending with traffic on the way home from work, decides to check out this evening the little matter of sexual dysfunction, which he may or may not have imagined.

Sexual dysfunction within 48 hours!

If the history of this reaction sequence is taken accurately, it will be established that Mr. A does not check out the problem of sexual dysfunction within 48 hours of onset, as he had decided to do on his way home from work. He arrives home, finds the atmosphere still markedly frigid, makes more than his usual show of affection to the children, retires to the security of the cocktail hour, and goes to supper and to bed totally lacking in any communicative approach to his frustrated, irritated marital partner.

Tuesday morning, while brushing his teeth, Mr. A has a flash of concern about what may have gone wrong with his sexual functioning after the party night. He decides unequivocally to check the situation out tonight.

Instead of thinking of the problem occasionally, his concern for “checking this out” becomes of paramount importance. On the way to work and during the day, he does not think about what really did go wrong sexually because he does not know. Rather he worries constantly about what could have gone wrong.

Needless to say, there is resurgence of concern for sexual performance during the afternoon hours, regardless of how busy his schedule is.

Mr. A leaves the office in relatively good spirits, but thoroughly aware that “tonight’s the night.” He does have vague levels of concern, which suggest that a little relaxation is in order; so he stops at his favorite tavern for a couple of drinks and arrives home with a rosy glow to find not only a forgiving, but an anticipatory, wife, ready for the reestablishment of both verbal and sexual communication that a drink ‘or two together before dinner can bring.

Probably for the first time in his life, he approaches his bedroom on Tuesday night in a self-conscious “I’ll show her” attitude. Again there has been a little too much to drink-not as much as on Saturday night, but still a little too much.

And, of course, he does show her. He is so consumed with his conscious concern for effective sexual function (the onset of his fears of performance) that, aided by the depressant effect of a modest level of alcoholic intake (modest by his standards), he simply cannot “get the job done.”

When there is little or no immediate erective reaction during the usual sexual preliminaries, he tries desperately to force the situation-in turn, anticipating an erection, then wildly conscious of its abscence, and finally demanding that it occur. He is consciously trying to will sexual success, while subjectively watching for tumescence. So, of course, no erection.

While in an immediate state of panic, as lie sweats and strains for the weaponry of male sexual functioning, he simultaneously must contend with the added distraction of a frightened wife trying to console him in his failure and to assure him that the next night will be better for both of them.

Sexual Incompetence

Both approaches are equally traumatic from his point of view. He hates both her sympathy and blind support which only serve to underscore his “failure,” and reads into his wife’s assurances that probably he can do better “tomorrow” a suggestion that no longer can he be counted on to get the job done sexually when it matters “today.”

A horrible thought occurs to Mr. A. He may be developing some form of sexual incompetence. He has been faced with two examples of sexual dysfunction. He is not sure what happened the first time, but he is only too aware this night that nothing has happened. He has failed, miserably and completely, to conduct himself as a man.

He cannot attain or maintain an erection.

Further, Mr. A knows that his wife is equally distressed because she is frantically striving to gloss over this marital catastrophe. She has immediately cast herself in the role of the soothing, considerate partner who says, “Don’t worry dear, it could happen to anyone,” or “You’ve never done this before, so don’t worry about it, dear.”

In the small hours of the morning, physically exhausted and emotionally spent from contending with the emotional bath her husband’s sexual failure has occasioned, she changes her tune to “You’ve certainly been working too hard, you need a vacation,” or “How long has it been since you have had a physical checkup?” (Any of a hundred similar wifely remarks supposed to soothe, maintain, or support are interpreted by the panicked man as tacit admission of the tragedy they must face together: the progressive loss of his sexual functioning.)

From the moment of second erective failure,

72 hours after the first erection failure, this man may be impotent.

In no sense does this mean that in the future he will never achieve an erection quality sufficient for intromission.

Occasionally he may do so and most men do. It does mean, however, that any suggestion of wifely sexual demand either immediate in its specific physical intensity or pointing coyly to future sexual expectations may produce pressures of performances quite sufficient to reduce Mr. A to and maintain him in a totally no erective state.

In brief, fears of sexual performance have assumed full control of his psychosocial system.

Mr. A thinks about the situation constantly. He occasionally asks friends of similar age group how things are going, because, of course, any male so beleaguered with fears of sexual failure is infinitely desirous of blaming his lack of effective function on anything other than himself, and the aging process is a constantly available cultural scapegoat.

Sexual Approach

He finds himself in the position of the woman with a lifetime history of non orgasmic return who contends openly with concerns for the effectiveness of her own sexual performance and secretly faces the fear that in truth she is not a woman. In proper sequence he does as she has done so many times.

He develops ways and means to avoid sexual encounter.

He sits fascinated by a third-rate movie on television in order to avoid going to bed at the usual time with a wife who might possibly be interested in sexual expression. He fends off her sexual approaches and jumps at anything that avoids confrontation as a drowning man would at a straw.

His wife immediately notices his disinclination to meet the frequency of their semi established routine of sexual exposure. In due course she begins to wonder whether he has lost interest in her, if there is anyone else, or whether there is truth in his most recent assertion that he couldn’t care less about sex.

For reassurance that she is still physically attractive, the concerned wife begins to push for more frequent sexual encounters, the one approach that the self-pressured male dreads above all else.

Obviously, neither marital partner ever communicates his or her fears of performance or the depth of their concerns for the sexual dysfunction that has become of paramount importance in their lives. The subject either is not discussed, or, if mentioned even obliquely, is hastily buried in an avalanche of words or chilled by painfully obvious avoidance.

Sexual Anxiety

Within the next 3 months, Mr. A has to fail at erective attainment only another time or two before both husband and wife begin to panic.

She decides independently to avoid any continuity of sexual functioning, eliminate any expression of her sexual needs, and be available only should he express demand, because she also has developed fears of performance.

Her fears are not for herself, but for the effectiveness of her husband’s sexual functioning.

She goes to great lengths to negate anything that might be considered sexually stimulating, such as too-long kisses, handholding, body contact, caressing in any way. In so doing she makes each sexual encounter much more of a pressured performance and therefore, much less of a continuation of living sexually, but the thought never occur to her. All communication ceases.

Each individual keeps his own counsel or goes his own way. The mutual sexual stimulation in the continuity of physical exposure, in the simple physical touching, holding, or even verbalizing of affection, is almost totally withdrawn.

The lack of communication that starts in the bedroom rapidly spreads through all facets of marital exchange: children, finances, social orientation, mothers-in-law, whatever.

In short :
Sexual dysfunction in the marital bed, created initially by an acute stage of alcoholic ingestion, supplemented at the next outing by ah “I’ll show her” attitude and possibly a little too much to drink can destroy the very foundation of a marriage of 10 to 30 years duration.

As the male panics, the wife only adds to his insecurity by her inappropriate verbalization, intended to support and comfort but interpreted by her emotionally unstable husband as immeasurably destructive in subjective content.

The dramatic onset of secondary impotence following an in stance of excessive alcohol intake is only another example of the human male’s extreme sensitivity to fears of sexual performance.

In this particular situation, of course, the onset of fears of performance was of brief but dynamic duration as opposed to those in the preceding example of the premature ejaculator whose fears of performance developed slowly, stimulated by continued exposure to his wife’s verbal denunciation of his sexual functioning.

Discussed above are examples of combinations of psychological and circumstantial factors that contribute the highest percentage of etiological input to the development of secondary impotence. Continuing through the listing of major influences there remain environmental, physiological, and iatrogenic factors.

In the final analysis:
Regardless of listing category, secondary impotence is triggered by combinations of these etiological factors rather than by any single category with the obvious exception of psychosocial influence. Once onset of erective failure has been recorded, regardless of trigger mechanism, involved, the individual male’s interpretation of or reaction to functional failure must be dealt with on a psychogenic basis.

The etiological factors recorded above are little more than categorical conveniences. From his initial heterosexual performance through the continuum of his sexual expression, every man constantly assumes a cultural challenge to his potency.

How he reacts to these challenges may be influenced directly by his psychosocial system, but of particular import is the individual susceptibility of the man involved to the specific pressures of the sexual challenge and to the influences of his background.

When considering etiological influences that may predispose toward impotence, it always should be borne in mind that most men exposed to parallel psychosexual pressures and similar environmental damage shrug off these handicaps and live as sexually functional males.

It is the factor of susceptibility to negative psychosocial input that determines the onset of impotence. These concepts apply to primarily as well as secondarily impotent men.

When considering environmental background as an etiological factor in secondary impotence, the home, the church, and the formative years are at center focus.

What factors in or out of the home during the formative years tend to initiate insecurity in male sexual functioning?

The preeminent factor in environmental background reflecting sexual insecurity is a dominant imbalance in parental relationships dominant, that is, as opposed to happen stance, farcical, or even fantasized battles for family control.

Secondary, but still of major import is the factor of homosexuality, which is to be considered in the environmental category. In no sense does this placement connote professional opinion that homophile orientation is considered purely environmental in origin.

Since homosexual activity may have derogatory influence upon the effectiveness of heterosexual functioning, the subject must be presented in the etiological discussion. The disassociations developing from homophile orientation are considered in the environmental category only for listing convenience.

Impotence Male

There are innumerable classic examples in the literature of maternal dominance contributing to secondary impotence. Thirteen such instances reflecting maternal dominance have been referred to the Foundation for therapy. Since the picture is so classic, a composite history can be provided to protect anonymity without destroying categorical effectiveness.

Impotence In Young Man

Maternal dominance primarily depreciates the young male’s security in his masculinity and destroys confidence in his socio cultural role-playing by eliminating or at least delimiting the possibility of a strong male image.

When the father is relegated to the role of second-class citizen within family structuring, the teenage boy has no male example with which to identify other than that of a devalued, shadowy, sometimes even ludicrous male allowed access to the home but obviously subject to control of the dominant maternal figure.

Mr. B, 34 years old
was referred with his wife for treatment of secondary impotence. He could remember little in family structuring other than a totally dominant mother making all decisions, large or small, controlling family pursestrings, and dictating, directing, and destroying his father with harsh sarcasm.

He remembered the paternal role only as that of an insufficient paycheck, and of a man sitting quietly in the corner of the living room reading the evening newspaper.

When he reached midteens, the parental representative at school functions was always the maternal figure, for both the young male and his younger sister (two siblings only). The same situation applied to church attendance and, eventually, to all social functions. The family matured with the concept that only three people mattered.

Masturbatory onset was in the early teens with a frequency of two or three times a week during the teenage years. As would be expected in a maternally dominated environment, dating opportunity for the boy was delayed, in this case until the senior year in high school.

Through college there were rare commitments to female interchange, all of them of a purely social vein. The young man was insecure in most social relationships, particularly those having orientation to the male sex.

He had been forbidden participation in athletics by his mother for fear of injury. He rarely pursued male companionship, feeling himself alternatively totally insecure in, or intellectually superior to, the male peer group.

Premarital sex in youth
Finishing college, the young man, particularly interested in actuarial work, joined an insurance firm. Although mainly withdrawn from social relationships, at age 28 he met and within three months married a 27 year old divorcee with a 2 year old daughter.

The divorcee, a dominant personality in her own right, was the mirror image of his mother. The two women were, of course, instant, bitter, and irrevocable enemies. The marriage, accomplished in spite of his mother’s vehement objections, was a weekend justice-of-the-peace affair.

The sexual experience of the courtship had been overwhelming to the physiologically and psychologically virginal male. The uninitiated man literally was seduced by the experienced woman, who manipulated, fellated, and coitally ejaculated him within three weeks of their initial meeting.

The hectic pace of the premarital sexual experience continued for the first 18 months of the marriage, with Mr. B awed by and made increasingly anxious by his wife’s sexual demands.

Intercourse occurred at least once a day. Following the pattern established during the courtship, opportunities, techniques, positions, procedures, durations, and recurrences, in fact, all sexual expression in the marriage, was at his wife’s able direction.

For the first year of the marriage the wife thoroughly enjoyed overwhelming her fully cooperative but naive and insecure husband with the force and frequency of her sexual demands. As the marriage continued unwavering in the intensity of her insistence upon sexual and social dominance, his confidence in his facility for sexual functioning began to wane.

He sought excuses to avoid coital connection, yet when cornered tried valiantly to respond to her demands. Finally, there were three occasions when sudden demand for coital connection forced failure of erection for the satiated male. Her comments were harsh and destructive, and the sarcasm struck a familiar chord.

The fourth time he failed to satisfy her immediate sexual needs, his wife’s denunciations reminded him specifically of his mother and of her verbal attacks on his father. For the first time in his life he identified with the man sitting in a corner of the living room reading the newspaper, and within a month’s time he had withdrawn to a similarly recessive behavioral patterning within his own home.

Successful erection
There is only one subsequent recorded episode of erection sufficiently successful for intromission with his wife. Aside from this, the man was totally impotent and had been so for three years when seen in therapy.

On an occasion when his wife was out of town, he followed the time-honored response pattern of the secondarily impotent man. There was attempted sex with a prostitute to see whether he could function effectively with any other woman.

For the first time in several months there was a full erection, but when he attempted to mount, the concept of his mother’s disapproval of his behavior disturbed his fantasy of female conquest. He immediately lost and could not recover the erection. This was his only attempt at extramarital sexual functioning.

At onset of the program, couples were requested to devote three weeks of their time to the therapeutic program. This concept of time commitment was maintained for the first two years of this clinical research program.

Evaluation of sexual experience made clear that three weeks was simply too long for a couple’s comfortable commitment of time away from home and, from the stand point of therapy demand also was an unnecessarily extended period. Therefore, the outer limit of time demand became two weeks and has remained so for the last nine years.

An important clinical contribution to effective therapy in sexual dysfunction can be made by scheduling husband and wife partners on a continuum; all units in the acute phase of the treatment program are seen daily (seven days a week) during their two weeks in the foundation’s intensive educational program.

One of the therapeutic advantages inherent in the two-week phase of rapid education and/or symptom reversal is the isolation of the husband and wife partners from the demands of their everyday world.

Approximately 90 percent of all couples treated by the Foundation are referred from outside the St. Louis area. These people are regarded and treated as though they were guests. Every effort is made to insure their enjoyment of a “vacation” during time spent in the city.

Care is taken to familiarize them with the geographic area and supply up-to-date information regarding restaurants, areas of interest, amusement, educational potentials, etc.

Inevitably they rekindle, in part, their own communicative interests when there is no child crying, no secretary reminding of business commitments, or no relatives or friends inadvertently intruding. With this isolation from social demand, opportunity develops for closeness or a unity that almost always is missing between marital partners facing crises of sexual dysfunction.

This arbitrary social isolation certainly is an important factor supporting the effectiveness of the therapy program. Under these circumstances protected from outside pressures the marital partners frequently accept for the first time the Foundation’s basic premise that “there is no such thing as an uninvolved partner in any marriage distressed by a complaint of sexual inadequacy.”

Sexual Interest

Yet another advantage of the social-isolation factor is its effect upon the sexual interest of both marital partners. With the subject of sex exposed to daily consideration, sexual stimulation usually elevates rapidly and accrues to the total relationship. This specific psycho physiologieal support is indeed welcome to the cotherapists dealing with the blocking of sexual stimuli in individuals distressed by sexual inadequacy.

To help develop a level of sexual interest:
for the couple which is realistic to their life style, vacations from any form of specific sexual activity are declared for at least two 24-hour periods during the two weeks, in a system of timely checks and balances. However, daily consideration of sexual matters and social isolation continue to give maximum return to this facet of the psychotherapy.

It might be held as part of this therapeutic concept that patients must have the opportunity to make those mistakes which reveal factors contributing to their particular distress. This means of learning is particularly important in reversing sexual dysfunction. In this interest, the patients are told that the cotherapists are not interested in a report of perfect achievement when they are following directions in the privacy of their own bedroom. Article Sponsored Find something for everyone in our collection of colourful, bright and stylish socks. Buy individually or in bundles to add color to your drawer!

The cotherapists are interested in couple’s making their usual errors of reaction and interaction as they involve themselves in situations that provide opportunity for natural response to sexual stimuli. If the mistakes then are evaluated and explained in context, the educational process is infinitely less painful and more lasting. There are significant advantages in this technique.

When mistakes are made, they are examined impartially and explained objectively to the unit within 24 hours of their occurrence. Additionally, they are discussed within the context of the misunderstanding, misconceptions, or taboos that may have led to or influenced their occurrence initially.

There is yet another specific advantage in daily conferences. If the distressed unit waits a matter of days after mistakes are made before consulting authority, the fears engendered by their specific episode of inadequacy or mistake in performance increase daily in almost geometric progression. In such a situation, alienation between partners is a common occurrence. By the time the next opportunity for consultation arises, a great deal of the effectiveness of prior therapy may have been destroyed by the takeover of the fears.

Fears of performance do not wait a few days or a week until the next appointment; in the meantime, the couple, separately or together, must use their own methods of coping. Most often this will be withdrawal of sexual or total communication, which places them further away from altering the sexual distress than before therapy was initiated.

When patients do not make mistakes during their acute phase of treatment, the cotherapists arrange for them to do so. It is inevitably true that individuals learn more from their errors than from their ability to follow directions effectively on the first attempt.

If marital partners reverse their sexual dysfunction and fully understand, through comparison with episodes of failure, why and what made it possible for them to function effectively, the probability of reduplicating the success in the home environment is increased immeasurably.

As evidence of the advantage to the therapeutic program of the unit’s social isolation, those couples referred from the St. Louis area require three weeks to accomplish symptom reversal rather than the standard two weeks for those living outside the local area. It is difficult to isolate oneself from family demands and business concerns if treatment is being ear tied out in the environment in which the couple lives.

For this reason it has been found more effective to see patients referred from the St. Louis area on a daily basis for the first week, there after five times a week, and to assign a total of three weeks to accomplish reversal of symptomatology. Partners in sexually distressed marriages who cannot or do not isolate themselves from the social or professional concerns of the moment react more slowly, absorb less, and communicate at a much lower degree of efficiency than those advantaged by social retreat.

The Foundation’s request for two weeks’ withdrawal from daily demands, at first rather an overwhelming suggestion to most patients, pales into insignificance when compared to the isolation demands engendered by necessary hospitalization for acute surgical or medical problems. When the couple’s presenting complaint is one of sexual inadequacy, it should constantly be borne in mind that there is not only the equivalent of two distressed people but also an impaired marital relationship to be treated.

In therapeutic procedure involving the dual-sex teams, the control within the team rests primarily with the silent cotherapist during treatment sessions. The silent cotherapist is literally in charge of each therapeutic session. He or she, as the observer, is watching for and evaluating levels of patient receptivity to therapeutic concept and to the educative and directive material presented by the active cotherapist.

The silent cotherapist’s role is to define, if possible, degrees of understanding, acceptance, or rejection of material and to identify immediate areas of concern in either member of the dysfunctional couple.

The silent observer really acts as the coach of the team. As soon as it is apparent that there is need for a situational change of pace, that the individual subject under discussion can be presented in a different, possibly more acceptable or understandable manner, or that it requires further clarification, the roles reverse and the cotherapist functioning previously as the observer, fortified and advantaged with the salient features of patient reaction to the on going situation, becomes the active discussant.

The previous discussant then assumes the role of observer. And so roles change back and forth as indicated by patient responses or the immediate need for a particular sex-linked definition or explanation of material. Much of the patient’s reaction can be identified by the observer that cannot be immediately apparent to any individual therapist simultaneously attempting to direct therapy and to evaluate levels of patient receptivity.

In the finite cooperative interaction between mutually confident cotherapists in any dual-sex therapy team, the currently dominant partner influence at any particular time is not being exercised by the one that is talking, but by the one that is observing.

Inevitably any sexually dysfunctional couple has, as one of its fundamental handicaps, insecurity in any and all sexual matters.

How often have the sexual partners asked themselves if they are really “complete” as individuals?
Has their functional efficiency been diminished in stressful situations other than in bed?
How do their patterns of sexual response compare to those of their peers?
How can a particular sexual situation or any confrontation with material of sexual content be handled without awkwardness or embarrassment?

The cotherapists encounter a multiplicity of these problems to which they can respond by holding up a professional “mirror” and helping the marital partners understand what it reflects. With the non-judgemental mirror available, constructive criticism can be accepted in the same non-prejudiced, comfortable manner in which it must be presented.

With this educational technique of reflective teaching, the distressed couple can be encouraged to take that first step that ultimately presages success in therapy for sexual dysfunction. The step consists of putting sex back into its natural context.

Seemingly, many cultures and certainly many religions have risen and fallen on their interpretation or misinterpretation of one basic physiological fact. Sexual functioning is a natural physiological process, yet it has a unique facility that no other natural physiological process, such as respiratory, bladder, or bowel function, can imitate.

Sexual responsivity can be delayed indefinitely or functionally denied for a Iifetime. No other basic physiological process can claim such male ability of physical expression.

With the advantage of this unique characteristic, sexual functioning can be easily removed from its natural context as a basic physiological response. Everyone takes advantage of this characteristic every day as he rejects or defers untimely or inappropriate sexual stimuli in order to comply with the social requirements of the moment.

Religions have found dedicated support from those willing to sacrifice their functional physical expression of sexuality as a devotion to or an appeasement for their god or gods. If the natural physiological process of human sexual response did not encompass this completely unique adaptability, the sacrifice of denying one’s sexual functioning for a lifetime could never have been made.

But the individuals who involuntarily take sexual functioning further out of context than any other are those members of couples contending with inadequacy of sexual function. Through their fears of performance (the fear of failing sexually), their emotional and mental involvement in the sexual activity they share with their partner is essentially nonexistent.

The thought (an awareness of personally valued sexual stimuli) and the action are totally dissociated by reason of the individual’s involuntary assumption of a spectator’s role during active sexual participation.

It is the active responsibility of therapy team members to describe in detail the psychosocial background of performance fears and “spectator” roles. This explanation is best accomplished by the cotherapist of the same sex as that of the individual whose performance fears are to be discussed. Again, education is the basis for therapeutic success, and the dual-sex team can best present this information by following a sex-linked guideline.

Sexual Dysfunction Treatment

In any approach to a psycho-physiological process, treatment concepts vary measurably from school to school and, similarly, from individual therapist to individual therapist. The Reproductive Biology Research Foundation’s theoretical approaches to the treatment of men and women distressed by some form of sexual dysfunction have altered significantly and, hopefully, have matured measurably during the past 11 years. There are founded on a combination of 15 years of laboratory experimentation and 11 years of clinical trial and error.

Sexual Response

When the laboratory program for the investigation in human sexual functioning was designed in 1954, permission to constitute the program was granted upon a research premise which stated categorically that the greatest handicap to successful treatment of sexual inadequacy was a lack of reliable physiological information in the area of human sexual response.

It was presumed that definitive laboratory effort would develop material of clinical consequence. This material in turn could be used by professionals in the field to improve methodology of therapeutic approach to sexual inadequacy. On this premise, a clinic for the treatment of human sexual dysfunction was established at Washington University School of Medicine in 1959, approximately five years after the physiological investigation was begun. The clinical treatment program was transferred to the Reproductive Biology Research Foundation in 1964.

When any new area of clinical investigation is constituted, standards must be devised in the hope of establishing some means of control over clinical experimentation. And so it was with the new program designed to treat sexual dysfunction. Supported by almost five years of prior laboratory investigation, fundamental clinical principles were established at the onset of the therapeutic program. The original treatment concepts still exist, even more strongly constituted today. As expected, there were obvious theoretical misconceptions in some areas, so alterations in Foundation’s policy inevitably have developed with experience.

If there are to be dual-sex therapy teams, what roles do the individual cotherapists play? What guidelines do they follow? What therapeutic procedures ensue? What should be their qualifications as professionals in this sensitive, emotionally charged area? These are all pertinent questions, and, as would be expected, in some cases they are difficult to answer.

The major responsibility of each cotherapist assigned to a husband and wife problem is to evaluate in depth, translate for, and represent fairly the member of the distressed couple of the same sex. This concept should not be taken to suggest that verbal or directive interaction is limited to wife and female cotherapist or to husband and male cotherapist far from it. The interpreter role does not constitute the total contribution an individual cotherapist makes in accepting the major responsibility of sex-linked representation. The male cotherapist can provide much information pertaining to male-oriented sexual function for the wife of the distressed couple; and equally important, female-oriented material is best expressed by the female cotherapist for benefit of the husband.

Acute awareness of the two-to-one situation frequently develops when a sexually distressed couple sees a single counsellor for sexual dysfunction.

For example, if the therapist is male and there is criticism indicated for or direction to be given to the wife, the two-to-one opposition may become overpowering.

Who is to interpret for or explain to the wife matters of female sexual connotation? Where does she develop confidence in therapeutic material she cannot express her concepts adequately to the two males in the room?

Exactly the same problem occurs if the therapist is female and contending with a sexually dysfunctional couple. Who interprets for or to the husband?

Dual Sex Team

Avoids the potential therapeutic disadvantage of interpreting patient complaint on the basis of male or female bias. Experience has established a recognizable pattern in the various phases of response by a female patient to questioning by a male cotherapist.

As a rough rule of thumb, unless the distress is most intense, the wife can be expected to tell her male therapist first what she wants him to know; second, what she thinks he wants to know or can understand; and not until a third, ultimately persuasive attempt has been made can she consistently be relied upon to present material as it is or as it really appears to her. With the female cotherapist in the room, although the wife may be replying directly to interrogation of the male cotherapist.

During the first exposure to questioning she routinely is careful to present material as she sees it or as she believes it to be, for she knows she is being monitored by a member of her own sex. The inference, of course, is that “it takes one to know one.” The “presence” usually is quite sufficient to remove a major degree of persiflage from patient communication.

When the sexually dysfunctional male patient is interviewed by a female therapist, it is extremely difficult to elicit reliable material, for cultural influence inevitably will prevail. Many times the male tells it as he would like to believe it is, rather than as it is.

Sexual Dysfunction and Male Ego

His ego is indeed a fragile thing when viewed under the spotlight of untempered female interrogation. Not infrequently his performance fears, his anxieties, and his hostilities are magnified in the face of his concept of a prejudiced two-to-one relationship in therapy, when he presumes that his wife has the advantage of the therapist’s sexual identity.

The participation of both sexes contributes a “reality factor” to therapeutic procedure in yet another way. It lessens the need for enactment of social ritual designed to gain the attention of the opposite-sex therapist, an unnecessary diversion which often produces biased material in its effort to impress.

These hazards of interrogation and interpersonal misinterpretations can be bypassed through use of the dual-sex team. Certainly, during history-taking there is a session devoted to male cotherapist interrogation of the wife and female cotherapist interrogation of the husband, but in each instance within the method there is built-in protection to avoid the previously mentioned pitfalls.

First
The husband has had an extensive discussion with the male cotherapist the previous day (as has the wife with the female cotherapist); thus, the pattern for same-sex confrontation and information interchange has already been introduced, concomitantly establishing greater reliability of reporting.

Second
Both members of the sexually disturbed couple are aware that four persons are committed to a common therapeutic goal and that all parties will be brought together the next day for the roundtable discussion. Hence, any tendency of the patient to provide the cotherapist with inaccurate clinical material in the opposite-sex interrogative session usually is curbed in advance by the dual-sex team environment and the previously described progression of the treatment program.

Equal partner representation in a problem of sexual dysfunction is a particularly difficult concept to accept for those patients previously exposed to other forms of psychotherapy. When either partner has been accustomed to being the principal focus of therapy, he or she finds it strange indeed that neither partner holds this position. Rather it is their interpersonal relationship within the context of the marriage that is held in focus.

An additional fortunate therapeutic return from the presence of both sexes within the therapy team is in the area of clinical concern for transference. There always is transference from patient to therapist as a figure of authority. There is no desire to avoid this influence in the therapeutic program, but, beyond both patients’ and therapists’ need to establish the authority figure, every effort is made in the brief two-week acute phase of the therapy program to avoid development of a special affinity between either patient and either cotherapist .

Instead of generating emotional currents, especially those with sexual connotation, from one side of the desk to the other, the therapeutic team is intensely interested in stimulating the flow of emotional and sexual awareness between husband and wife and encourages this response at every opportunity.

For example, if the team were to observe the wife becoming intensely attentive to the male cotherapist, directing all questions to him, accepting or even prompting answers only from him, in short, replacing the husband with the cotherapist as the male figure of the moment. The team would take steps to counteract this distracting, potentially husband-alienating trend.

The male cotherapist would begin to direct questions only to the husband, and all material pertinent to the wife (even including basic information pertaining to male sexual response) would be presented by the female member of the team until it was obvious that the wife’s incipient tendency to establish special interpersonal communication with the male cotherapist had been counterbalanced by team intervention. Attempted recruitment of special rapport with the female cotherapist by the husband is handled in a similar manner.

To create further emotional trauma for either sexually insecure marital partner by encouraging or accepting such alignment, however deliberately or naively proffered, is not only professionally irresponsible, but also can be devastating to therapeutic results.

It cannot be emphasized too vigorously that the techniques of transference, so effective in attacking many of the major psychotherapeutic problems over the years, are not being criticized. The Foundation is entirely supportive of the proper usage of these techniques as effective therapeutic tools.

However, from the start of the clinical program, the Foundation has taken the specific position that the therapeutic techniques of transference have no place in the acute two-week attempt to reverse the symptoms of sexual dysfunction and establish, re-establish, or improve the channels of communication between husband and wife.

Anything that distracts from positive exchange between husband and wife during their time in therapy is the responsibility of the therapeutic team to identify and immediately nullify or negate.

Positive transference of sexual orientation can be and frequently is a severe deterrent to effective reconstitution of interpersonal communication for members of a couple, particularly when they are contending with a problem of sexual dysfunction.

Regardless of the particular form of sexual inadequacy with which both members of the couple are contending.

Fears of sexual performance are of major concern to both partners in the marital bed.

The impotent male’s fears of performance can be described in somewhat general terms. With each opportunity for sexual connection, the immediate and overpowering concern is whether or not he will be able to achieve an erection. Will he be capable of “performing” as a “normal” man? He is constantly concerned not only with achieving but also with maintaining an erection of quality sufficient for intromission

His fears of sexual performance are of such paramount import that in giving credence to or even directing overt attention to his fears, he is pulling sexual functioning completely out of context. Actually, the impotent man is gravely concerned about functional failure of a physical response which is not only naturally occurring, but in many phases involuntary in development.

To oversimplify, it is his concern which discourages the natural occurrence of erection. Attainment of an erection is something over which he has absolutely no voluntary control. No man can will, wish, or demand an erection, but he can relax and allow the sexual stimulation inherent in erotic involvement with his marital partner to activate his psycho-physiological responsivity. Many men contending with fears for sexual function have distorted this basic natural response pattern to such an extent that they literally break out in cold sweat as they approach sexual opportunity.

Impotence

Not only does the husband contend with fears of performance when impotence is the clinically presenting complaint, but the wife has her fears of performance as well. Her constant concern is that when her husband is given adequate opportunity for sexual expression, he will be unable to achieve and/or maintain an erection. She has grave fears for his ability to perform under the stress of the psychosocial pressure which both partners have unwittingly contrived to place upon this natural physical function.

Additionally, wives of impotent men are terrified that something they do will create anxiety, or embarrass, or anger their husbands. All of these crippling tensions in the marital relationship are gross evidence that two people are contending with sexual functioning unwittingly drawn completely out of context as a natural physical function by their fears of performance.

An exactly parallel situation can be a factor in female sexual inadequacy. Fifty years ago in this country the non orgasmic woman was led (or under the pressure of propriety, forced) to believe that sexual responsivity was not really her privilege. Sexual pleasure was considered an unnatural physical response pattern for women, and any admission of its occurrence was unseemly to say the least.

The popular magazines, with their constant consideration of the subject, have brought to the non orgasmic female a realization that in truth she is a naturally functional sexual entity.

Unfortunately they have also provided her with real fears of performance by depicting, often with questionable realism, the sexual goals of effectively responsive women.

Sexual Stimuli

Her frequently verbalized anxieties when she does not respond to the level of orgasm (at least a certain percentage of time) are: “What is wrong with me? Am I less than a woman? I certainly must be physically unappealing to my husband,” and so on. These grave self-doubts and usually groundless suspicions are translated into fears of performance.

It should be restated that fear of inadequacy is the greatest known deterrent to effective sexual functioning, simply because it so completely distracts’ the fearful individual from his or her natural responsivity by blocking reception of sexual stimuli either created by or reflected from the sexual partner.

Therapy concepts place major emphasis on the necessity for familiarizing the marital partner of a dysfunctional patient with details of the fear component. There must always be real awareness of the fears of performance by the marital partner attempting to support his or her mate in the distress of sexual inadequacy.

The husband of the non orgasmic woman may well have his own fears of performance. He worries about why he, as a sexually functional male, cannot give her the “gift” of response. Why is his wife non responsive to his sexual approaches? What really is wrong when he cannot satisfy her sexual needs?

The husband’s fear of performance when dealing with a non orgasmic wife reflects anxieties directed as much toward his own sexual prowess as to his wife’s inability to accomplish relief of sexual tensions. It is the influence of our culture, expressed in the demand that he “do something” in sexual performance, that gives the man responsibility for the woman’s sexual effectiveness as well as his own.

If his wife is non orgasmic, more times than not he worries about his inadequate performance rather than lending himself with personal pleasure to the mutual sexual involvement that would lead to release of his wife from her dysfunctional status. Together, these frightened people manage to take not only sexual functioning from its natural context, but also keep it in its unnaturally displaced state indefinitely.

One of the most effective ways to avoid emphasizing the patient’s fears of performance during any phase of the therapy program is to avoid all specific suggestion of goal oriented sexual performance to the couple.

Regardless of the length or the intensity of the psycho therapeutic procedures, at some point the therapist usually turns to his or her patient and suggests that the individual should be about ready for a successful attempt at sexual functioning, immediately the fears of performance flood the psyche of the individual placed so specifically on the spot to achieve success by this authoritative suggestion.

Rarely is this suggestion taken as an indication of potential readiness for sexual function, as intended, but usually is interpreted as a specific direction for sexual activity. If there is a professional suggestion that “tonight’s the night,” the individual feels that he has been told by constituted authority that he must go all the way from A to Z, from onset of sexual stimulation to successful completion.

In many instances, regardless of the duration or effectiveness of the psychotherapeutic program, the fears of performance created by this authoritative suggestion for end point achievement are of such magnitude that sensate input is blocked firmly, and there will be no effective sexual performance regardless of the degree of motivation.

Removal of such goal-oriented concept, in any form or application, is necessary to secure effective return of sexual function. This can be achieved by moving the interacting partners, not the dysfunctional individual, on a step-by-step basis to mutually desirable sexual involvement.

Sexual Discussion

Four way verbal exchange is maintained at an open, comfortable level during therapy. Communication is first developed across the desk between patients and cotherapists. Within a few days, verbal exchange is deliberately encouraged between patients.

The cotherapists are fully aware that their most important role in reversal of sexual dysfunction is that of catalyst to communication. Along with the opportunity to educate concomitantly exists the opportunity to encourage discussion between the marital partners wherein they can share and understand each other’s needs.

If the therapy team functions well, its catalytic role in marital communication, which initially is of utmost importance, becomes a factor of progressively decreasing importance over the two week period. If the catalytic role is well played, the marital partners will be communicating with increasing facility at termination of the acute phase of therapy; by then communication between the marital partners should be well established.

When considering intense pain elicited during coital functioning as opposed to vaginal aching or irritation, the therapist generally should look beyond the confines of the vaginal barrel for existent pathology involving the reproductive viscera.

Acute or chronic infections and endometriosis are pathological conditions involving the reproductive viscera; uterus, tubes, and ovaries that consistently may return a painful response as the female partner is sharing coital experience.

Although these two entities will be discussed separately, they do have in common similar physiological creation of painful response patterns during intercourse.

In both instances the response arises from peritoneal irritation resulting in local adhesions not only between folds of peritoneum but also involving tubes, ovaries, bowels, bladder, and omentum.

The combination of involuntary distention of the vaginal barrel created by female sex-tension increment and active male thrusting during coital connection places tension on relatively inelastic pelvic tissues stabilized by minor or even major degrees of fibrosis resulting from the infection or the endometriosis.

In short:
Any clinical condition that creates an untoward degree of rigidity of the soft tissues of the female pelvis, so that they do not move freely during sexual connection can return a painful response to the female partner involved.

Infections in the reproductive organs start with chronic involvement of the cervix (endocervicitis). By drainage through lymphatic channels, long-maintained endocervicitis can involve the basic supports of the uterus (Mackenrodt’s ligament) in a chronic inflammatory process. The resultant low-grade peritoneal irritation initiates painful stimuli when the cervix is moved in any direction, particularly by a thrusting penis.

The uterus itself can be involved with infection in the uterine cavity or endornetritis, or with a residual of infection throughout the muscular walls (myometritis) to such an extent that any pressure upon the organ is responded to with pain.

Retrograde involvement of the peritoneal covering of the uterus and its supports is quite sufficient to cause distress if the uterus is moved, either with involuntary elevation into the false pelvis with female sex-tension increment or during a male thrusting phase in coital connection.

Obviously there are many sources of infection of the oviducts (tubes). Any infections that originate in the cervix have opportunity to spread through the uterine cavity and into the tubal lumina.

The major infective agents are:
Gonococcus, streptococcus, staphylococcus, and coliform organisms. First infections in the tubal lumina frequently spill into the abdominal cavity, causing at least localized pelvic inflammation and at most generalized abdominal peritonitis.

Subsequently, as the acute stage of the infection subsides those areas involved in the infectious process remain open to the development of adhesions between loops of bowel, the omentum, and the pelvic viscera.

There even may be abscess formation involving the tubes and ovaries. In all these situations there is tension on and tightening of the peritoneum and rigid fixation of the pelvic soft-tissue structures to such an extent that vaginal distention and coital thrusting create a markedly painful response for the woman.

In no sense does this brief clinical description of pelvic inflammatory processes imply that whenever any woman acquires infection in the pelvic viscera she is committed thereafter to pain during coital connection.

With early and adequate medical care most pelvic infections do not create a residual of continuing pain with coital exposure. The degree of residual pelvic pain depends upon the severity of the occasional sequelae of the infectious process.

Where are the adhesions and how extensive are they? To what extent is natural expansion of the vaginal barrel restricted by filling of the cul-de-sac with an enlarged tube, by an ovary firmly adhered to the posterior wall of the broad ligament, or by a uterus held in severe third degree retroversion by adhesions? Any of these situations may create painful stimuli with penile thrusting.

There have been three cases referred as problems of dyspareunia in which individual women were involved in gang-rape experiences. In all three instances there were multiple coital connections, episodes of simultaneous rectal and vaginal mountings, and finally traumatic tearing of soft tissues of the pelvis associated with forceful introduction of foreign objects into the vagina.

Superficial and deep lacerations were sustained throughout the vaginal barrel and by other soft tissues of the pelvis. Included in the soft-tissue lacerations were those of the broad ligaments (in each case only one side was lacerated), but these lacerations were quite sufficient to produce severe symptoms of secondary dyspareunia.

For some years after the rape episodes each of the three women was presumed to be complaining of the subsequently acquired pain with intercourse as a residual of the psychological trauma associated with their raping.

The immediately necessary surgical repair to pelvic tissues had been conducted, but beyond the clinically obvious lacerations of vaginal barrel, bladder, and bowel, the remainder of the pelvic pathology understandably had not been described at the time of surgery.

Before gaining symptomatic relief by a second surgical procedure, these three women underwent a combined total of 21 years of markedly crippling dyspareunia, involving a total of five marriages.

The only way that broad-ligament lacerations can be handled effectively is by surgery. Operative findings are relatively constant: (1) The uterus usually is in third-degree retroversion and enlarged from chronic vasocongestion; (2) A significant amount of serous fluid (ranging from 20 to 60 ml in volume) arising from serous weeping developing in the broad-ligament tears is consistently found in the pelvis; (3) There may be unilateral or bilateral broad ligament and/or sacrouterine-ligament lacerations.

It is the inevitable increase in pelvic vasocongestion associated with sexual stimulation added to the already advanced state of chronic pelvic congestion in these traumatized women that can elicit a painful pelvic response.

Particularly does such a response arise when the chronically congested pelvic viscera are jostled by the vaginally encased thrusting penis.

It is not within the range of this textbook to describe the surgical procedures for repair of the traumatic tears of the uterine supports. The reader is referred to the bibliography for more definitive consideration. Subsequent to the definitive surgery, the symptoms of acquired dyspareunia, dysmenorrhea, and the sensations of extreme fatigue usually show marked improvement or may be completely alleviated.

These pelvic findings have been described in far more than usual detail for this type of text, primarily to alert examining physicians to the possibility of the broad-ligament laceration syndrome.

When these pelvic findings have been overlooked, the complaining woman frequently has been told by authority that the pain described with intercourse is due to her imagination. The intelligent woman bas grave difficulty accepting this suggestion. She knows unequivocally that coital activity particularly that of deep vaginal penetration is severely painful.

Actually, she finds that with vaginal acceptance of the full penile shaft, pain is almost inevitable.

Even if she has been orgasmic previously, it is rare that she accomplishes orgasmic release of her sexual tensions during intercourse after incurring broad-ligament lacerations, simply because she is always anxiously anticipating the onset of pain.

Any woman with acquired pelvic disability restraining her from the possibility of full sexual responsivity is frustrated. Without orgasmic release with coital connection there will be a marked residual of acute vasocongestion to provide further pelvic discomfort during a long, irritating resolution phase.

Probably the most frustrating factor of all is to have the acquired dyspareunia disbelieved by authority when the pain with penile thrusting is totally real to the woman involved. The vital question for the therapist to ask should be, “Did this pain with deep penile thrusting develop after a specific delivery?”

If the woman can identify a particular pregnancy subsequent to which the dyspareunia became a constant factor in her attempts at sexual expression, the concept of the broad-ligament-laceration syndrome should come to mind.

Many men complain:
Burning, itching, and irritation after coital connection with women contending with chronic or acute vaginal infections.

Not infrequently small blisters appear on the glans penis, particularly around the urethral outlet. If there are any abrasions on either the glans or shaft of the penis, secondary infection can occur in these local sites.

Irritative Penile Reaction

The same type of irritative penile reaction may develop from exposure to a non infectious vaginal environment as a response to the chemicals in contraceptive creams, jellies, foams, etc.

It may not be the female that responds in a sensitive manner to an intravaginal chemical contraceptive agent but rather her male partner. Sensitivity to intravaginal chemical contraceptives is seen quite frequently in the male and, if symptoms develop, contraceptive technique should be changed.

The same sort of irritative penile reaction can be elicited by a repetitive pattern of vaginal douching.

There are some douche preparations to which not the female but the male partner becomes sensitive.

Not infrequently, vesicles form on the glans penis. If these blisters rupture, the raw areas on the glans are quite painful, particularly during sexual connection.

Gonorrhea

In the actual process of ejaculation there are many situations that return painful stimuli to the involved male. If the individual has had gonorrhea there may be strictures (adhesions) throughout the length of the penile urethra, and attempts to urinate and/or to ejaculate may cause severe pain spreading throughout the penile urethra and radiating to the bladder and prostate.

Infection in the Bladder, Prostate, or the Seminal Vesicles

There may be the sensation of intense burning during and particularly in the first few minutes after ejaculation. Particularly if the offending agent has been the gonococcus, the pain with ejaculation sometimes is exquisite. Immediate medical attention should be given to any complaint of burning or itching during or immediately after the ejaculatory process.

Prostate and Ejaculation

There is a spastic reaction of the prostate gland seen in older men during the stage of ejaculatory inevitability. In this situation the prostate contracts spastically rather than in its regularly recurring contractile pattern, and the return can be one of very real pelvic pain and/or aching radiating to the inner aspects of the thighs or into the bladder and occasionally to the rectum.

This pathologic spastic contraction pattern can be treated effectively by providing a minimal amount of testosterone replacement therapy.

Care should be taken to evaluate the possibility of concurrent infection in the prostate. Occasionally, chronic prostatitis has caused significant degrees of pain during an ejaculatory process.

As a point in differential diagnosis, the painful response with prostatic infection is with the second, not the first, stage of the orgasmic experience, while that of prostatic spasm has just the reverse sequence. Careful questioning usually will establish specifically the timing in onset of the painful response and thus suggest a more definitive diagnosis.

Prostate

Benign hypertrophy of the prostate gland primarily and carcinoma of the prostate rarely may be responsible for onset of pain with the ejaculatory process. The pain is secondary (acquired) in character and radiates to bladder and rectum.

Usually confined to older age groups, onset of this type of dyspareunia should be investigated immediately by competent authority. This review of the major causes of dyspareunia has been primarily directed toward the female partner, for from her come by far the greater number of complaints of painful coital connection.

However, male dyspareunia no longer should be ignored by the medical and behavioral literature. The review of the etiology of male dyspareunia has not been exhaustive, nor is it within the province of this text to do so.

In concept, the entire chapter has been designed to suggest to cotherapists, faced daily with a myriad of problems focusing upon both male and female sexual dysfunction, that there are physiological as well as psychological causes for sexual inadequacy.

Combined pelvic and rectal examinations for the female and rectal examination for the male partner are a routine part of the total physical examination provided for both members of any marital unit referred to the Foundation for treatment of sexual dysfunction.

To attempt to define and to treat the basic elements of sexual dysfunction for either sex without including the opportunity for thorough physical examination and complete laboratory evaluations as an integral part of the patient’s diagnostic and therapeutic program is to do the individual and the marital unit a clinical disservice.