Because it is made up of glandular tissue, the prostate is highly susceptible to cancer. Many cases of prostate cancer are readily curable, but, unfortunately, many of the treatments for it can have a serious effect on a man’s sex life. For example, if a man has his prostate gland surgically removed due to cancer, some of the nerves that trigger erection may be damaged, causing him to be unable to have an erection. Furthermore, a man whose prostate gland has been removed will probably be unable to ejaculate (although he will probably still be able to have an orgasm). Even the other treatments for prostate cancer, such as chemotherapy and radiation, can affect a man’s ability to have an erection and ejaculate. The good news is that many medical solutions are available to help men who have erection difficulties due to prostate problems. You’ll read about these in Chapter 24.
Two other potential problems with the male genitals can cause sexual problems: phimosis and Peyronie’s disease. When boys are born, a flap of skin called the foreskin covers the head of the penis. In many cultures the foreskin is surgically removed in an operation called circumcision. In uncircumcised boys and men, sometimes the foreskin is too tight and can’t be retracted behind the head of the penis for urination; this condition is called phimosis. When a boy with phimosis reaches puberty and his penis enlarges in size, erections can be painful; he may need to undergo circumcision to allow for pain-free erections.
In Peyronie’s disease the erectile tissue develops sections of calcified plaque, which cause the penis to bend in one direction. (Hardly any man’s penis is perfectly straight. Most normal penises curve to one side or the other.) If there is only one small plaque, it can be removed to straighten the penis. More than one plaque can cause quite a bit of pain and can limit a man’s ability to have an erection. Peyronie’s disease can result from injury to the penis, or it can occur for no apparent reason in older men.
Female Sexual Anatomy and Physiology
The term vulva refers to the female external genitals (see Figure 2). The vulva includes the clitoris, the inner and outer vaginal lips, and the vaginal opening. A girl’s clitoris grows from the same embryonic tissue as a boy’s penis. Like the penis, the clitoris has a head, shaft, and hood. It contains two rather than three cylinders of erectile tissue. When a woman receives stimulation, blood flows to the clitoris and to the inner and outer vaginal lips, causing them to swell. A failure of this normal arousal response is called female sexual arousal disorder.
When female babies are born, a membrane called the hymen partially covers the vaginal opening. Injuries can tear the hymen, but sometimes it remains intact until the first time a woman has sexual intercourse. A medical condition called imperforate hymen can cause either vaginismus or sexual pain; the condition occurs when the hymen is too fibrous and doesn’t tear during intercourse. Sometimes it has to be surgically removed.
Figure 2. Female external sexual anatomy
Like men, women have a pubococcygeus muscle that supports the pelvic organs. The PC muscle is very critical to female sexuality. It is the muscle that spasms when a woman has an orgasm. Having a weak or out-of-shape PC muscle can cause a woman to experience difficulty reaching orgasm. At the opposite end of the spectrum, anxiety that causes an uncontrollable spasm of the PC muscle and prevents penetration results in the condition known as vaginismus.
The inner female genitals include the vagina, the cervix, the uterus, the fallopian tubes, and the ovaries (see Figure 3 on the next page). The vagina is the tubular sex organ that is used both for sexual intercourse and as the birth canal. It therefore must be very muscular. The vaginal canal has muscular ridges called rugae that run along its walls. If you looked inside a vagina, you would see that the walls have a striped or corrugated appearance. When a woman receives stimulation, blood flow to the vaginal walls causes them to lubricate. If this does not happen, a woman has arousal problems.
Several areas inside the vagina are sensitive enough that stimulating them can often lead to orgasm. The anterior fornix, or A-spot, located on the upper front wall of the vagina, is one such spot. It is believed to be responsible for most of a woman’s vaginal lubrication. The Gräfenberg spot, or G-spot, is located on the front wall of the vagina behind the pubic bone. Stimulation of the G-spot causes some women to release a great deal of fluid. This is called female ejaculation. Some women enjoy stimulation of the cervix, which is the opening to the uterus. Positioned near the cervix is the end of the vagina, called the cul de sac. When a woman becomes intensely aroused, the muscles that support her uterus tighten and cause the uterus to lift up, exposing the cul de sac. Many women report that penetration into the cul de sac is intensely pleasurable.
Figure 3. Female internal sexual anatomy
Speaking of orgasm, there are many areas on a woman’s body that can trigger one. In fact, some women can have orgasms without even being touched. In the genital area, the sites that most commonly trigger orgasm are the clitoris, the PC muscle, the G-spot, the cervix, and the cul de sac. Some theorists think in terms of two types of female orgasm: clitoral and vaginal. A clitoral orgasm is one that results from stimulation of the external genitals, and a vaginal orgasm is one that results from stimulation of the internal genitals. Sometimes a clitoral orgasm is called a vulval orgasm and a vaginal orgasm is called a uterine orgasm. There’s also such a thing as a blended orgasm, which occurs when a woman has an orgasm while receiving stimulation both inside the vagina and on the clitoris.
The ovaries are the female reproductive organs. In addition, they produce hormones, including the hormone testosterone, which is essential for sexual desire, even in women. The adrenal glands, which lie atop the kidneys, also produce some testosterone. If a woman has glandular problems that cause her body to produce insufficient amounts of testosterone, her sex drive will suffer.
The fallopian tubes convey eggs into the uterus, and if an egg is fertilized, the uterus carries the developing embryo. The fallopian tubes and the uterus don’t really have any direct bearing on sexual dysfunctions, although surgery to remove the uterus and/or ovaries can result in unintended nerve damage or problems with blood flow. Both of these could affect a woman’s ability to become aroused.
There are many health problems involving the genitals that can affect a woman’s sex life, especially in terms of pain during intercourse. I cover many of these issues in Chapter 13, on sexual pain.
Intersex Conditions
About one in two thousand children are born in the United States each year with genitalia that are ambiguous enough to create problems accurately identifying the child as male or female. Medical conditions that cause ambiguous genitalia are called intersex conditions. There are many types of intersex conditions—in fact, too many to list here. Intersex conditions can result from problems with chromosomes, prenatal hormones, or internal or external organs.
An example of an intersex condition that affects some men is Klinefelter’s syndrome, in which a boy is born with an extra X (female) chromosome. If the condition is recognized before puberty, it can be treated with hormones. But if a man has this problem in adulthood, it can cause an abnormally small penis and lack of sex drive.
An intersex condition that can affect women is called congenital adrenal hyperplasia (CAH). In CAH, a female embryo is exposed to male hormones before birth. When the baby girl is born, her clitoris is so enlarged that it could be mistaken for a penis.
In terms of sexual healing, some intersex conditions affect sexual functioning and some do not. You can see that Klinefelter’s syndrome would affect sexual functioning, but CAH would not (although it would almost certainly affect body image). Although this book is not directed specifically toward people with intersex conditions, I believe it can be of use to many such individuals.
The Sexual Response Cycle
In the 1960s, sexologists William Masters and Virginia Johnson conducted research that involved volunteer subjects visiting their laboratory and agreeing to have recording devices attached to their bodies. The devices re
corded things like respiration rate, blood pressure, and even genital blood flow. Some people came into the laboratory alone, and some came in as couples. The single people were instructed to masturbate and the couples to have sexual intercourse. As the volunteers became sexually stimulated, often all the way to orgasm, Masters and Johnson monitored the changes in their bodies. The result of these studies was the first clinically defined model of the sexual response cycle, which is the series of physiological changes that occur in the human body as it becomes aroused and reaches orgasm.
The sexual response cycle has four stages: excitement, plateau, orgasm, and resolution (see Figure 4). I’ll briefly summarize the physiological changes that happen in men and women as they go through each stage.
In the excitement phase, men get a partial or full erection, and their scrotum and testes swell and move closer to the body. Women also experience blood flow to the genitals, including the clitoris, inner and outer lips, and vagina. Blood flow to the vagina causes vaginal lubrication. In both sexes, blood pressure, respiration, and heart rate start to rise. Both men and women may experience nipple erection and the “sex flush”: redness on the chest, face, and neck.
The plateau phase occurs when a person reaches a high level of arousal and stays there for a while. On a scale of 1 to 10, with 10 being orgasm, the plateau phase would correspond to about a level 8. Men experience a very strong erection during the plateau phase. Due to blood flow to the penis, the head of the penis may turn a dark color. The scrotum and testes continue to move close to the body. The Cowper’s glands, which are located at the base of the penis, may secrete a couple of drops of clear fluid that appear at the tip of the penis.
In the plateau phase, women may experience engorgement of the areolas of their breasts. The inner third of the vagina may tighten and grip the penis. The muscles that support the uterus contract and cause the uterus to lift up. This opens the back area of the vagina, the cul de sac. The Bartholin’s glands, located under the skin of the inner vaginal lips, may secrete a couple of drops of lubrication. A woman may experience “sex skin,” which occurs when the inner lips of the vagina turn a very dark color due to blood flow.
Figure 4. Masters and Johnson’s human sexual response cycle
In both sexes, blood pressure, respiration, and heart rate continue to rise and then plateau at a high level. Both men and women may continue to experience the sex flush, as well as muscle spasms in the hands, feet, or face.
As stimulation continues, a person may enter the orgasm phase. Orgasm occurs when blood flow and muscle tension reach a peak in the genitals. It is a reflex that dissipates the blood flow and muscle tension. Masters and Johnson judged that a woman had had an orgasm if her PC muscle spasmed rhythmically and her heart rate reached a peak. They judged that a man had had an orgasm if his PC muscle spasmed rhythmically, his heart rate reached a peak, and he ejaculated. In fact, however, in a man, orgasm and ejaculation are not exactly the same thing. Ejaculation is the localized genital response in which semen leaves the penis. Orgasm is a full-body or systemic response that includes changes in blood flow, muscle tension, and the brain. The distinction between ejaculation and orgasm is important for treating male orgasm disorder, as I’ll explain in Chapter 10.
When you have an orgasm, muscles in your body contract, especially in the genital area, although many people also experience muscle spasms in their legs, arms, and face. For most people, the mental experience of orgasm runs anywhere from a pleasant feeling to intense pleasure or an almost altered state of consciousness. When you reach high levels of arousal and then have an orgasm, your brain secretes endorphins, which are chemicals that kill pain and cause pleasure. After orgasm, most people experience a sense of closeness or intimacy with their partner.
During the resolution phase, the body returns to its normal, unaroused state. The man loses his erection, and blood leaves the female genitals. Many men experience a refractory period, during which they are unresponsive to sexual stimulation for some time after ejaculation and orgasm.
The sexual response cycle has its problems and critics. It has been augmented over the years. For example, in the 1970s Helen Singer Kaplan added a desire phase to the beginning of the cycle. She theorized that some kind of motivational factor must be present in order for stimulation and excitement to take place.
The significance of all this for sexual healing is that Masters and Johnson’s sexual response cycle has been highly influential in how we view and treat sexual problems. The sexual dysfunctions I briefly described in Chapter 1 are usually grouped according to the sexual response cycle. For example, sexual aversion disorder and low sexual desire are problems with the desire phase; male erectile disorder and female sexual arousal disorder are problems with the excitement phase; and premature ejaculation, male orgasm disorder, and female orgasm disorder are problems with the orgasm phase. (The sexual pain disorders are not grouped according to the sexual response cycle. They fall at different phases for different people.)
Earlier in this chapter, I described sexual problems in terms of what anatomical structures or physiological functions they involve. Another way of looking at sexual problems is to use Masters and Johnson’s sexual response cycle as a guide. I described Masters and Johnson’s plateau phase as about a level 8 on a 1-to-10 scale. The program in Sexual Healing uses two different 1-to-10 scales: a physical arousal scale, which measures either a man’s erection or a woman’s lubrication/swelling response, and a subjective psychological or emotional arousal scale, which measures perceived closeness to orgasm. This system is a good one for healing many of the problems you’ll read about in this book.
For now, let’s take a closer look at anxiety. As I pointed out in Chapter 1, anxiety is a contributing factor in all of the sexual problems addressed in this book. The next chapter introduces some simple and effective strategies for reducing anxiety during sexual activity.
chapter 3
Dealing with Anxiety
Many of the sexual dysfunctions are affected by anxiety. Before you read in detail about the different sexual problems and before you try any exercises, I would like to give you some ideas for how to deal with any performance pressure or anxiety you might feel.
In our society, we tend to view sexuality—and much else—as a performance. We wonder constantly if we could “do it better.” We also tend to think of a sexual problem as something “missing.” In fact, if you experience problems with your sexuality, you probably need to subtract stress or anxiety rather than add props such as X-rated videotapes, exotic clothing, or other erotica to your sexual encounters.
How to reduce and eventually eliminate sexual anxiety is one of the most important things you can learn from this book. The sensate-focus exercises (which, if you remember from Chapter 1, are touching and bonding exercises you do with your partner) are designed to teach you, step-by-step, how to identify and deal with anxiety during the course of a sexual encounter. If you have been experiencing sexual anxiety for a long time, even the earliest and most basic sensate-focus exercises may make you anxious. Do not blame yourself for this. Even fairly mild levels of anxiety take time and practice to overcome completely as you work to undo the results of years of fearful reactions to sexual encounters.
Remember, though, that the exercises will not help you if you remain anxious while you do them. You will do yourself more harm than good if you attempt to disguise your anxiety just to get through an exercise. It is extremely important that you stop any exercise that makes you anxious; if you continue, you will only reinforce your fear.
The Physiology of Anxiety
What is anxiety? It is a mind-body phenomenon that occurs because of the way our nervous system is set up. (I’m sorry that the explanation is about to get a bit technical, but I hope it will help to demystify anxiety for you.) The body’s nervous system allows all of the parts of the body to communicate with each other. At its most basic level, the nervous system includes the brain and spinal cord. This is called
the central nervous system. In addition to the central nervous system, we have the peripheral nervous system, which includes all the nerves that go from the spinal cord to the rest of the limbs and organs.
The peripheral nervous system has two parts: the skeletal nervous system and the autonomic nervous system. Sometimes the skeletal nervous system is called the voluntary nervous system and the autonomic nervous system is called the involuntary nervous system. The skeletal nervous system provides nerves to limbs like your arms and legs. We call it the voluntary nervous system because your ability to activate these nerves and move your limbs is under your control.
The autonomic nervous system provides nerves to your internal organs, such as your heart, diaphragm, intestines, stomach, and genitals. We generally do not have much control, if any, over the responses of these organs. Their activities are largely reflexive. The presence of food in the stomach, for example, triggers a series of reflexes that cause digestion. We can’t make it stop or cause it to happen any faster. The same thing is true of the genitals. A touch on the penis can trigger a reflexive erection, or a touch to the opening of the vagina can trigger reflexive vaginal lubrication.
The autonomic nervous system has two divisions—the sympathetic nervous system (the SNS) and the parasympathetic nervous system (the PNS). The function of the SNS is to expend energy rapidly. It is responsible for initiating the stress response (also known as the fight-or-flight mechanism). The SNS functions when you are faced with a major threat to your safety. When your SNS is activated (which happens within a split second), your eyes dilate, your heart pounds, and blood rushes away from the center of your body toward your limbs so you can fight or run away. The action of the PNS is the opposite. Its function is to conserve energy for use at a later time. The PNS is active when you are asleep, digesting, or just resting. Many sexual phenomena are functions of the PNS. For example, the early stages of erection and arousal occur when the PNS is active. The activity of the PNS is also called the relaxation response.
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