Tom
Tom, age sixty-two, was a retired firefighter. He first noticed erection problems when he masturbated. He went to a urologist and was diagnosed with prostate cancer. He had his prostate gland surgically removed, after which he was unable to have an erection or ejaculate, although he could still reach orgasm with stimulation. Tom was lucky because several medical options were available for his situation. He tried some of them and found that the best option for him seemed to be a hormone suppository called MUSE. The suppository is inserted into the urethral opening before the man wishes to engage in sexual activity. You’ll read about MUSE and other medical options in Chapter 24.
The cases of Tom and Larry illustrate something very important about erection problems: They aren’t necessarily caused by deep, dark secrets in your sexual past. In Larry’s case, he developed thought patterns that stood in the way of his getting erections. In Tom’s case, his erection problems were due to a serious medical condition.
chapter 8
Female Sexual Arousal Disorder
According to the DSM, female sexual arousal disorder (FSAD) is “the persistent or recurrent inability to attain, or to maintain until completion of the sexual activity, an adequate lubrication-swelling response of sexual excitement.” The older name for this problem was frigidity, a term that is rarely if ever used today because of its negative and sexist connotations.
Before the current DSM definition, there were two main criteria for diagnosing female sexual arousal disorder. One was failure to have the lubrication-swelling response, and the other was failure to feel a subjective sense of arousal or excitement. I believe this second criterion was a very important part of the definition of FSAD and I was sorry to see it taken out of the diagnostic manual. Here’s why. In men, the physical erection response and the psychological or subjective sense of feeling sexually aroused pretty much go together. For women, typically that’s not the case. Many different lines of research have shown that it’s possible for a woman to lubricate but not feel sexually aroused, and also that it’s possible for a woman to feel very sexually aroused but to experience very few lubrication- and swelling-related changes in the vaginal area. In fact, a woman can desire sexual intercourse very much, even beg for it, while knowing that she is not lubricating and that her vaginal opening is not expanding.
Another issue is that the DSM definition of women’s arousal problems says that a woman fails to have an “adequate” swelling and lubrication response, but it doesn’t define “adequate.” Does adequate mean any lubrication at all, or does it mean enough lubrication to last a woman through an act of intercourse of average length? In order for a woman to become psychologically sexually aroused, it’s not necessary for her to produce any lubrication at all. There are plenty of women who don’t lubricate naturally; they use an externally applied lubricant and become aroused enough to have orgasms.
In my clinical experience the most common form of FSAD was in women who reported that their clitoris engorged and their vagina lubricated, but they just didn’t feel turned on. It’s clear that sexual arousal is a much more psychological process for women than it is for men, and the current DSM definition fails to recognize this.
What’s Normal?
When a woman becomes sexually aroused, blood flows to her genitals, triggering a number of phenomena. Her clitoris, which contains erectile tissue just like the penis does, engorges with blood. Her inner and outer vaginal lips swell up and turn a darker shade of pink or red. Her vaginal opening expands. Most important, blood flowing into the middle layer of vaginal tissue forces fluid out through the vaginal walls. This is the source of most female lubrication. Although engorgement of a woman’s genitalia can be thought of as an “erection” of sorts, it’s very different from a man’s erection. A woman’s erection doesn’t just involve the clitoris. The whole area of her body called the vaginal sponge, or paraurethral sponge, swells up. The vaginal sponge encompasses the entire area surrounding the urethra. It includes the clitoris on the outside, the G-spot on the inside, and all the tissue in between. Normal, healthy women with no disease processes experience the lubrication-swelling response during REM sleep the same way men experience nighttime erections. And as with men, this response in women has nothing to do with dream content.
It’s normal for a woman to experience some degree of reflexive vaginal swelling if her genitals are touched, in a process that is similar to a reflexogenic erection in men. However, unfortunately there is about a thirty-year time lag between our understanding of male genital anatomy and physiology and our understanding of female genital anatomy and physiology. This means we still don’t fully understand the contributions of spinal cord reflexes and the brain to female arousal. We do know that women have a reflex arc that goes from the genitals to the sacral area of the spinal cord and back out to the genitals. Stimulation of the female genitals triggers this reflex and causes the clitoris and other genital tissues to swell and the vaginal walls to lubricate.
There is also no doubt that women can produce genital arousal from the brain. I have read research confirming that many women can experience genital swelling and lubrication without having their genitals touched—for example, while reading a sexy story or hearing their lover whisper something sexy in their ear. This psychological aspect of female arousal is so important that I think it’s a mistake for the DSM to ignore it.
There’s a wide range of what’s “normal” in terms of how women experience sexual arousal, both physically and psychologically. During sexual activity, some women experience very little overt genital sexual arousal but high levels of psychological arousal, and that’s normal for them. There are also huge differences in the amounts of lubrication women produce. Some women produce a lot and some women hardly lubricate at all, and, again, that’s normal for them.
Patterns of Female Sexual Arousal Disorder
In lifelong arousal problems, a woman has never experienced genital swelling or lubrication. In acquired arousal problems, a woman has experienced what she considered normal swelling and lubrication in the past but no longer does so. In generalized arousal problems, a woman fails to experience swelling or lubrication in any situation—not during sleep, masturbation, or any activities with a partner. In situational arousal problems, a woman may experience swelling and lubrication with masturbation but not with a partner; or with kissing, genital fondling, or oral sex but not with intercourse; or with one partner but not with another.
As I mentioned above, the most common complaint I’ve encountered regarding female arousal problems is that a woman swells and lubricates but doesn’t feel psychologically aroused. Another common complaint is for a woman to experience swelling and lubrication with oral sex but not with intercourse. Most women who become psychologically aroused but don’t lubricate very much usually don’t consider this a problem. Many choices of artificial lubricant are available that can remedy a lack of vaginal lubrication. I’ll discuss these in Chapter 26.
Physical Causes of Arousal Problems
Physical origins of female arousal problems are similar to the causes of men’s erection problems, with some additional ones unique to women. Cardiovascular problems can cause difficulty becoming aroused, because any problems with blood flow have the potential to affect the genitals. Diabetes and multiple sclerosis are huge causes of arousal problems in women. Another cause that is often overlooked is complication from pelvic surgery, such as hysterectomy or ovarian cyst removal. And cancer treatment that includes radiation of the pelvis can dry out the vaginal tissues.
Drugs, such as high blood pressure medications and ulcer medications, can cause difficulty with arousal. Over-the-counter weight loss supplements that contain stimulants can cause problems with lubrication, as can antihistamines. Nicotine and caffeine can restrict blood flow to the genitals, and illegal drugs such as barbiturates can cause problems with arousal.
Women undergo many more hormonal events throughout their lives than men do, including puberty, mont
hly menstruation cycles, potential multiple pregnancies and childbirths, breastfeeding, and menopause. It’s not unusual for women to report different abilities to become sexually aroused during the different stages of pregnancy. It’s also unrealistic to expect the same degree of lubrication and swelling throughout the lifespan. After menopause, the lack of estrogen can cause a woman’s vaginal tissues to dry out, which can cause problems with lubrication, resulting in painful intercourse.
Psychological Causes of Women’s Arousal Problems
Anxiety and depression can cause women to have problems becoming aroused, as can past sexual abuse or trauma. A woman’s lack of trust in her partner is another factor that can inhibit her arousal response. Perhaps some aspect of a woman’s partner is a psychological or physical turn-off. In addition, women often embrace a double standard for men’s and women’s sexual behavior. They may believe that “nice girls don’t do that”—that is, don’t lubricate or otherwise become turned on. Such a belief can cause mixed feelings about becoming excited and create a self-fulfilling prophecy in which a woman may fail to become aroused because she believes she can’t or won’t or shouldn’t. Many possible factors in a woman’s current sexual situation may cause her to have difficulty becoming aroused or may cause her arousal response to shut down when it reaches a certain level. She may be receiving sexual stimulation and find herself focusing on some kind of antiarousal cue, such as a basket of unwashed laundry, instead of on the pleasurable sensations.
The typical way in which men and women have sex may present arousal difficulties. The woman may not receive enough foreplay, such as kissing, genital fondling, or oral sex, before intercourse starts. The genital fondling she does receive may be done in a manner that’s typical of an X-rated movie rather than in a sensuous manner. Her partner may fail to pay enough attention to her A-spot, which as we saw in Chapter 2 is the vaginal area that’s responsible for most of a woman’s lubrication. He may fail to stimulate the clitoris enough, or he may stroke it too hard or too fast. Failing to use external lubrication if it’s needed or using condoms without lubrication can also cause arousal problems.
By far the biggest cause of women’s arousal problems is the lack of a history of self-touch. Many women begin to have sexual intercourse with male partners before they have learned to touch themselves or before they have experience with what pleases and arouses them from a genital standpoint. Any program to heal female arousal problems (such as the one described in Chapter 26) begins with self-touch.
Diagnosing women’s arousal problems is similar to diagnosing men’s erection problems. If you go to either a urologist or a gynecologist who specializes in women’s sexual problems, you’ll undergo a series of tests designed to measure genital blood flow, lubrication, and swelling. Sometimes these tests involve stimulating yourself while watching and/or reading sexually explicit materials. Some urologists, such as Jennifer Berman, M.D., author of For Women Only, use very sophisticated devices to measure genital blood flow and sensation. She uses probes to measure vaginal lubrication, a balloon device to measure the ability of the vagina to relax, heat and cold sensation measures of both the internal and external female genitals, and ultrasound to measure vaginal blood flow when a woman is sexually aroused. She also takes a comprehensive sex history to determine if a woman’s arousal problems might be psychological. This is clearly a very thorough approach to women’s arousal problems.
Sherri
Here’s a case history of a woman with arousal problems. Sherri, forty-two, was in serious trouble when she sought sex therapy. She was married, but she and her husband had not had sex for two years. She had been able to become aroused (and even reach orgasm) in the past, but her current problems dated from an extramarital affair she’d had three years previously. Her lover, who from her description clearly had sadistic tendencies, injured her vagina by inserting objects into it without lubrication. She needed surgery to correct the injuries.
It was obvious that Sherri’s problem with sexual arousal stemmed from several sources. In addition to the sexual trauma she had experienced, she was bored with her husband, who was rather mechanical about sexual activity and tended to prefer positions that were not very stimulating for Sherri. After her affair she went through a stage of apathy toward sexual activity, and when she and her husband tried to have sex, she found she couldn’t get aroused at all—she didn’t lubricate or feel any sense of excitement.
Fortunately, the sexual healing program worked for Sherri. She was afraid that she might have suffered some kind of permanent injury to her vagina, but that turned out not to be the case. Her psychological issues were shutting down her arousal, and when she worked through them she once again experienced the ability to become aroused.
chapter 9
Premature Ejaculation
Premature ejaculation is defined in the DSM as “persistent or recurrent ejaculation with minimal sexual stimulation before, on, or shortly after penetration and before the person wishes it.” This condition used to be called rapid ejaculation. A clinician working with a client who complains of this problem has to take into account factors that affect arousal, such as age, novelty of the sexual partner or situation, and recent frequency of sexual activity.
Like so many sexual problems, premature ejaculation can be a matter of degree. Some men ejaculate with no physical or sexual stimulation at all. Others ejaculate when a woman rubs against them. (This is probably a reflex ejaculation that occurs without the pleasurable feeling of orgasm.) Some men ejaculate upon being touched by a hand or mouth, and some ejaculate immediately upon penetration. It is very common to ejaculate a few seconds after penetration. Some men experience premature ejaculation the first time they are with a new partner. Others ejaculate quickly during a first episode of intercourse, but last much longer if they have intercourse again during the same sexual encounter. Premature ejaculation may occur with any type of stimulation, or it may be specific to the vagina during intercourse.
Lifelong premature ejaculation means that a man has ejaculated quickly ever since he first attempted sexual intercourse. In acquired premature ejaculation, a man lasted what would be considered a normal amount of time during intercourse in the past, but ejaculates quickly now. In generalized premature ejaculation, a man ejaculates quickly in every situation. In reality, this means he ejaculates quickly with every partner. Men don’t really complain about premature ejaculation when they masturbate because most men ejaculate more quickly with masturbation than they do with any partner activity. Generalized premature ejaculation also includes the understanding that a man ejaculates quickly with every type of partner activity, including manual stimulation, oral stimulation, and intercourse. In situational premature ejaculation, a man ejaculates quickly with one partner but not with others, or ejaculates quickly in some situations but not in others. Men with situational premature ejaculation tend to ejaculate more quickly when they are with partners they care more about or with whom they are more intimate. In this situation they experience more of a sense of psychological pressure and therefore more anxiety.
Confusion used to exist about the definition of premature ejaculation. Some authors tried to define it based on how long a man lasted during sexual intercourse before ejaculating. The problem was, nobody knew how short a time was too short. Back when the famous sex researcher Alfred Kinsey was conducting his research, the average man reported that he lasted about two to three minutes during intercourse before ejaculation. But what really constitutes a premature ejaculation? One minute? Thirty seconds? Attempts were made to define premature ejaculation by the number of thrusts a man was able to complete during intercourse before he ejaculated. This was problematic also, because not all thrusts are created equal. Some men tend to thrust with very short, fast strokes, and some men tend to thrust with longer strokes. Generally, a pattern of thrusting with short, fast strokes contributes to premature ejaculation.
Masters and Johnson believed that all sexual dysfunctions were couple prob
lems. Therefore, they tried to define premature ejaculation partially according to the woman’s response. I believe they said a man ejaculated too quickly if he didn’t last long enough for his female partner to have an orgasm half the number of times they had sexual intercourse. This is a very misleading definition, as a woman’s orgasmic response during intercourse is not dependent on how long intercourse lasts. It’s dependent on a number of other, more important factors, such as how aroused she was before intercourse started.
Currently, premature ejaculation is not defined by the amount of time a man lasts, the number of strokes he has, or whether or not his partner has an orgasm. It’s defined by the man’s personal sense of ejaculating too quickly, ejaculating before he wants to, or lacking control of his ejaculation.
What’s Normal?
The issue of what is normal in terms of ejaculatory control is a little trickier than trying to define how fast is too fast. Technically, male ejaculation and orgasm are reflexes, meaning they are involuntary reactions, and therefore nobody has control of his ejaculation. If you reach a certain critical level of genital stimulation, the ejaculation is going to happen no matter what, and it’s beyond your control. So many men have problems lasting as long as they want to that, in a sense, premature ejaculation is the norm.
Most men gain a rudimentary sense of ejaculation awareness in adolescence or young adulthood based on their experience with masturbation. They learn to back off the stimulation slightly to last longer and to speed it up to ejaculate more quickly. This trial-and-error learning process usually carries over when they start having intercourse with women. However, for some men this learning process doesn’t happen. You could make an analogy to swimming or riding a bicycle. Most people learn to swim when they’re kids. Some people don’t learn it, because maybe they didn’t have the opportunity to be around water. You can still learn to swim as an adult. You may never be as good a swimmer as someone who learned when they were young, but you can still swim. The same thing applies to riding a bicycle. Most people learn to ride a bicycle when they’re kids, but for some reason, maybe because their family couldn’t afford bicycles, some kids don’t learn this skill. You can still learn to ride a bicycle when you’re an adult; you just may be a less confident bicycle rider than you would have been if you had learned when you were a kid.
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