SEXUAL CHALLENGES FOR MEN WITH ERECTILE AND ORGASMIC FUNCTIONING
Michael has been experiencing problems with erection for the last eight years. He and his wife have also not had sex in several years, their conflict is high, and he expresses that he rarely even thinks about sex.
Eduardo and his wife have been experiencing problems in their sexuality for a number of years. Eduardo has a long history of using pornography and masturbation. After much healing in their relationship, he continues to have issues with achieving and maintaining his erection.
Russ and his wife engaged in sex therapy and had some amazing results in their marriage and their intimacy, yet he still remains unable to reach orgasm, though he maintains his erection throughout sexual stimulation.
Davante shares that he always ejaculates within thirty seconds to one minute after entering his wife. He expresses that he thinks about this quite a lot before they have sex and is watching the clock while they are together sexually. Both he and his wife have a lot of frustration with this, though they feel that every other area of their relationship is going well.
Stewart has been unable to get an erection for over five years. He also has had severe back pain that resulted in several back surgeries. Though he initially tried a number of different prescribed medications, none helped his erectile difficulties. Over time, Stewart began to withdraw from all sexual contact with his wife, which has led to increased conflict in their relationship.
If you have experienced similar challenges as the men in the examples above, you are not alone. Many men experience a number of different challenges with erection, ejaculation, and orgasm. Men may feel they have a problem gaining or maintaining an erection. They may feel they ejaculate too soon. They may also have been unable to orgasm or ejaculate, even though they maintain their erection throughout sensual and sexual stimulation. There are countless books, research studies, and a number of different treatments available through the centuries for issues with erection and ejaculation. One thing that is important to note medically is that erectile difficulties in particular may be one of the early signs of heart trouble or other medical problems, hence the importance of making a medical appointment for an assessment. Having challenges with erection, ejaculation, or orgasm can sometimes point to other underlying physiological, psychological, and emotional issues. So let’s examine some of these issues and how they affect the marital sexual relationship.
Erectile Difficulties
Some men, when their penis does not stay erect, have few concerns. They accept that their penis fluctuates between erect and flaccid and that things may go better sexually another time. However, for other men, regularly having a difficult time becoming erect, maintaining erection, or reaching orgasm is very challenging. The official diagnosis of Erectile Dysfunction is the experience and distress over difficulty obtaining or maintaining erection or a marked decrease in the rigidity of erection during sexual stimulation 75–100 percent of the time.1 Especially during foreplay and sexual intercourse, men may become concerned about losing their erection or the strength of their erection, and this can cause a number of feelings including embarrassment, discouragement, frustration, anxiety, or loss. It can be particularly difficult if their wife responds in any manner that is negative—either by expressing disappointment outwardly or with silence; making negative, derogatory remarks; making comparisons with other partners; or wondering if their husband is not attracted to them or may be getting their needs met elsewhere. Some men disengage from sexuality altogether due to issues with and feelings about their loss of erection.
It is important to understand a few things about erection. It is common for the penis to regularly fluctuate between differing levels of erection during sexual stimulation. Men’s penises also fluctuate between erection and flaccidity several times during sleep, thereby bringing in oxygen and maintaining health in the penile tissues. Testing this using a penile plethysmograph, or by merely using a roll of stamps at night (search erection self-test on the Internet), are some of the ways in which a doctor, or a concerned male, might begin to discern if the penis is showing signs of healthy functioning during sleep or if there are any complicating physiological factors that need to be addressed.
Erection can be elicited by direct touch to the genitals. This leads to an automatic, reflexive response controlled by the lower spine, much like the knee-jerk reaction you get when the doctor taps your knee with a reflex hammer during a physical examination. Erection can also be induced by nerve stimuli from the brain caused by thoughts, images, touch, sounds, and emotions. These various forms of nerve impulses (genital and brain) combine synergistically to increase blood flow into the penis and restrict blood flow out of the penis, causing erection.
Because men (and women as well) are not always aware of how normal it is to experience fluctuations in erection during sexual stimulation, any sign of the loss of erection may create high anxiety or frustration, which in turn can—in a complicated loop with the brain—cause a further loss of erection. The term generally used for this in the literature and in the field of sexual treatment is performance anxiety. There are, however, many different factors that affect levels of anxiety and levels of erectile functioning. As certain authors explain, “The causes of ED are frequently multifactorial, with psychological, neurological, endocrinological, vascular, traumatic, and iatrogenic components described.”2 What does that mean? That means that erection can be affected by what you think and feel, by blood flow, by trauma or accidents, by illness, by things going on in your brain (thoughts, hormones and chemicals, communication between neurons), and by how your brain—overseeing the control of nerves and hormones—interacts and communicates with the rest of your body. In particular, other physiological, psychological, and relational issues can affect erectile problems (see table below).
ISSUES THAT AFFECT ERECTILE PROBLEMS
Physiological Factors |
Psychological Factors |
Relationship Factors |
Poor eating habits, lack of exercise, and poor sleeping patterns |
Anxiety and Fear |
Unresolved resentments |
Biological issues: vascular issues, surgeries, high levels of fat in the blood |
Depression |
Relational injuries |
Illness: diabetes, high blood pressure, cancer, surgery |
Distractions |
Sexual demands |
Smoking, alcohol, illegal drugs |
Perfectionism |
High conflict or avoidance |
Prescribed medications (antidepressants and blood pressure medications) |
Low self-esteem and negative body image |
Lack of intimacy, trust, or safety |
Treatment for these issues—either in pastoral counseling, professional therapy, or sexual medicine—can result in an improvement of erectile functioning. However, for some couples, the concern about erection is relieved when they come to a correct understanding of the normal fluctuations in penile erection.
Premature Ejaculation
Though premature ejaculation is a concern for many men, the actual diagnosis may not apply to many who describe themselves in those terms. Before you read on, ask yourself how many minutes of direct stimulation to the penis you think the typical male experiences before they ejaculate. No peeking ahead. What number are you saying in your head? Now read the following paragraph.
The typical male ejaculates after two to five minutes of direct stimulation. The actual diagnosis for Premature Ejaculation is given if someone ejaculates before one minute of beginning sexual intercourse (DSM-5). Though most men who believe they have premature ejaculation might not actually qualify for the diagnosis, they may still feel like they ejaculate sooner than they wish to, before they are able to thoroughly enjoy sexual intercourse or sexual stimulation as they would like.
Some men do not experience any worry over the length of time before they ejaculate. Others experience a moderate or high amount of anxiety and frustration when they feel like they cannot extend the amount of time before orgasm. For those men, working through these challenges may include learning to feel satisfied with a typical period of sexual stimulation. Others may decide to pursue treatment to prolong the time before ejaculation. For some couples, however, it is not the husband that is as concerned about the length of time that he lasts. Some wives express a significant amount of frustration as well. Wives may feel that their husband cannot last long enough, cannot remain hard long enough, in order to bring them to orgasm during vaginal intercourse.
Most women, in order to reach orgasm, need between twenty to thirty minutes of stimulation to their genitals. With most men taking between two to five minutes during vaginal intercourse to reach orgasm, this becomes a bit of a mathematical problem. If the goal is for her to reach orgasm during vaginal intercourse, and she needs twenty to thirty minutes, but he can only last two to five, then … Hmmm …. As mentioned, the reality is that only 30 percent of women are able to orgasm from vaginal intercourse. This may be due to the distance between the vagina and the clitoris, and the lack of enough stimulation to the clitoris. It may also be that a male cannot sustain erection without going to orgasm for the twenty to thirty minutes of stimulation that she needs to reach orgasm. Most women experience orgasm through stimulation by their partner’s hands, fingers, tongue, or lips or with the use of a vibrator. For men who feel they are experiencing premature ejaculation, and whose wives may feel frustrated, understanding and accepting these normal discrepancies can go a long way toward relieving the anxiety around ejaculating too soon.
Another factor that affects the frustration levels couples feel about premature ejaculation is that the media (in movies, books, magazines, and TV) predominately portrays couples as having their orgasms at the same time. While that might make for dramatic screen time, it is not most people’s reality. Magazines and websites make simultaneous orgasms seem like the ultimate peak sexual experience. These kinds of expectations can put pressure on the poor penis that can cause all kinds of havoc. It can also lead someone to feel cheated and disappointed with their sex life. It may be necessary to reclaim reality and ditch the dream of simultaneous, dramatic, Hollywood-style, concurrent orgasms. It may help for a husband and wife to learn to recognize any automatic negative thoughts that cascade through their minds when they begin to engage sexually or when it feels like something is going wrong … again. This may be the time to learn how to take those negative thoughts captive (2 Corinthians 10:5) and examine them, perhaps replacing them with more accepting and understanding thoughts. We would recommend the book Enduring Desire, and particularly the exercise entitled The Sexual Self-Talk Quiz, to learn how to manage these negative thoughts.
Delayed Ejaculation
Delayed ejaculation is considered an orgasmic disorder for men, and is one of the less common sexual difficulties men experience. A Delayed Ejaculation diagnosis includes the experience of a marked length of time maintaining erection during normal, exciting sexual stimulation that may or may not end with an ejaculation/orgasm (DSM-5).3 The length of time that is considered problematic is not specified in diagnostic manuals. For some men and their partners, the amount of time and physical effort attempting to reach orgasm may become exhausting and frustrating, especially if the end result is not a sexual release. This can cause both a husband and his wife to begin avoiding sexual time together.
When ejaculation becomes a problem, men can feel insecure, anxious, and sexually incompetent. A husband may become self-conscious and wonder if his wife is getting frustrated or bored. Some men may keep a mental count of how long it is taking them to reach orgasm and think to themselves, “Why is this taking so long?” A wife may feel anxiety as well, interpreting the inability to reach orgasm to mean her husband is either not attracted to her or that she is not a good lover. This can, of course, be particularly anxiety ridden if a couple is trying to conceive, which may add an extra measure of stress to what should be a pleasurable time together. There are other factors during sexual activity that could also affect delayed ejaculation. Some men with a history of frequent masturbation have expressed that—during sexual intercourse, oral sex, or hand stimulation given by their spouse—they are not able to achieve the level of firm stimulation their penis has become conditioned to receiving by their own hand. Other men share that they become over-focused and anxious about bringing pleasure to their wives, to the point that they have a difficult time releasing themselves to experience their own pleasure. Just as with erectile disorder and rapid ejaculation, anxiety levels about not reaching orgasm may play a significant part. There can also be a number of medical and psychological factors. Depression, traumatic experiences, spinal injuries, surgeries, age, lower testosterone, antidepressants and antipsychotic medications, alcohol, and heroin have all been connected to delayed ejaculation.4 The section and exercises below give practical approaches to dealing with orgasm issues for men.
Treatment
Erectile Difficulties. A primary question men and their partners often have is how they can overcome erectile problems. Treatment can include pastoral counseling, bibliotherapy (reading a book), sexual medicine care, psychotherapy, sex therapy, holistic care, or lifestyle changes. As we mentioned earlier, for some couples, the level of anxiety connected to erectile difficulties lowers just by learning how normal it is for the penis to fluctuate in the level of erection during sexual interactions. Other couples will benefit from working on their overall intimacy, learning how to have conflict in a way that brings them closer, and exploring how to enjoy touch and sensuality more. This might include discovering the negative thoughts a couple may have about erectile problems and replacing them with more accepting thoughts. Some may also benefit from traditional sex therapy techniques to aid in reaching and maintaining erection, such as the stop/start method or the squeeze technique (explained below). Sexual medicine care may include the use of PDE5 inhibitors (such as Viagra, Cialis, or Levitra), suppositories placed into the urethra at the tip of the penis (i.e., MUSE), vacuum pumps, injections into the penis (intracavernosal injections), hormonal treatments, or vascular or surgical treatment. Some men begin eating healthier, start exercising and losing weight, or stop smoking or drinking. Others benefit from holistic remedies (i.e., herbs and supplements) or acupuncture. For the majority of couples, a combination of these different interventions has led to more satisfying erectile functioning. When men are willing to communicate openly about these issues with their wives, it can bring about greater understanding and enjoyable times exploring solutions.
Premature Ejaculation. For those who decide they want to pursue achieving a longer time of arousal before ejaculation, there are a number of treatments available, though they vary in effectiveness. There are penis-numbing creams available over-the-counter. For some men, numbing agents lower the penis’ level of sensitivity to stimulation in order to lengthen the time before ejaculation occurs. Antidepressant medications, specifically SSRIs (i.e., Dapoxetine), have also been prescribed to treat rapid ejaculation since one of the side effects of antidepressant medication is delayed ejaculation. Sex therapists also coach men to use the two techniques explained below—the stop-start technique and the squeeze technique—to delay ejaculatory inevitability. Some men learn to modulate their level of sexual excitement by varying their muscle tension and breathing. Couples can do these various techniques together and make it a part of their sexual play. Having sex more frequently may also result in a longer time before ejaculation. For some men, using Viagra, Levitra, or Cialis takes the concern off the penis (knowing it will maintain erection) and thereby lengthens the amount of time before they orgasm. It is recommended that engaging in any of these techniques would benefit from professional direction.
Delayed Ejaculation. Many of the treatments described for erectile dysfunction and premature ejaculation are also used for delayed ejaculation. Learning to enjoy sexual intimacy and erotic touch, as mentioned in the chapters on sensual and sexual touch, may be beneficial. Finding ways to lower anxiety around sexual interactions might be important. See Sexual Exercise 3 below. It is also important to check with your medical doctor about the side effects of some of the medications you may be taking. Keep in mind that the timing of when medications are taken can also have some effect on sexual functioning. Taking a medication in the morning after having sexual intercourse the evening before (rather than taking it at night) may increase the ability to reach orgasm. These kinds of medical choices should only be done under medical care, but this does indicate the wide array of different factors that could be influencing your sexual functioning.
So What Happened?
What happened for Michael? He and his wife came to see Jennifer for sex therapy. They were experiencing high conflict and high disconnection. That was the primary focus of the first part of therapy. As they became more connected and learned to work through their disagreements in a way that brought them closer, the work on touch and affection and sensual and sexual touch progressed. Michael chose to pursue a prescription for Viagra. By the end of therapy, he and his wife felt closer than they ever had in their marriage, and he had been successful maintaining erection and achieving orgasm both with and without Viagra, though he did feel that the intensity of orgasm was higher when he used a medication. Both he and his wife began to experience exciting and mutual sexual fulfillment and pleasurable orgasms.
What happened with Eduardo and his wife? Like other Christian couples who have pursued sex therapy, some work and repair was done with the impact of pornography and masturbation on their sexual relationship. Eduardo got involved in support groups and Bible studies to strengthen his purity. Working through pain and broken trust were the focus of early treatment. As these foundations improved, both Eduardo and his wife learned to be less reactive around his erectile challenges, and they grew in how they talked about it openly, including how they wanted to involve medication. They were able to accept the reality of intermittent loss of erection and came to enjoy being together sexually, sometimes with the use of medications and other times without—even when sexual stimulation did not always end in an orgasm. The release of the tension around whether he was able to maintain an erection did allow both of them to enjoy their sexual life to a much greater degree.
And how are Russ and his wife? After participating in what they felt was successful sex therapy that had resulted in high sexual satisfaction, Russ was still not able to orgasm, though he remained erect during stimulation. He had earlier not been open to seeking help from a sexual medicine specialist. This was revisited in a follow-up appointment, and he made plans to go. Before attending his scheduled sexual medicine appointment, his primary doctor, in full support of that decision, did recommend that perhaps they first try changing his anti-depressant medication. Russ began to experience full orgasm from that point on. What a victory!
What about Davante, who’d been experiencing lifelong premature ejaculation? Actually, Davante wasn’t worried or bothered by it and neither was his wife. Their main concern ended up being that his wife felt very pressured by him to have frequent sex while she herself was not receiving pleasure in their sexual relationship. Davante and his wife improved tremendously in genuinely expressing how they felt about their relationship, including sexuality, and in listening with a sincere desire to understand. As they focused on that, their overall sexual relationship improved tremendously, including his wife’s sexual pleasure, and they were able to talk openly about frequency and sexual preferences. Davante did notice that as the level of tension in their relationship lowered—as his wife began to enjoy sex more, and as their frequency increased—the length of time before he ejaculated increased somewhat.
And how is Stewart doing? Stewart and his wife Margaret decided to engage in therapy to deal with the problems in their marriage and to address the sexual issues. Treatment initially consisted of dealing with conflict and increasing marital closeness. As their relationship improved, Stewart decided to see a sexual medicine specialist. Evaluation tests found venous leakage that would not be responsive to treatment using PDE5 inhibitors such as Viagra. Stewart was prescribed intracavernosal injections. The use of the injections was then incorporated into the process of therapy. Before beginning to use the injections, Stewart and Margaret had begun having increasingly enjoyable sexual time together, where each experienced sexual pleasure and Margaret reached orgasm. The work Stewart and Margaret had done on loving communication in their marriage aided tremendously in how they talked and worked together to incorporate the use of the injections into their lovemaking. With thoughtful use over several occasions, Stewart was able to maintain erection and reach orgasm without triggering his back pain. This was a wonderful addition to an already greatly improved marital sexual relationship.
EXERCISES
Sexual Exercises 1: For Premature Ejaculation (PE)
To prolong the length of time before ejaculation, try the techniques below. It is important that each of you read through the whole process and that both of you feel positive about engaging in this. One of the challenges in using these kinds of interventions is learning to talk about them and to get help about any feelings of frustration. Keep a spirit of curiosity, learning what your body finds enjoyable.
This should be a time of sexual fun and exploration that is intertwined with a lot of other play and pleasure. Research on these techniques has shown some success, though the most important goal would be the loving connection between you as you explore. Surround these exercises with a lot of fun sensual and sexual touch.
1) Squeeze: As your wife stimulates you to erection, before you reach the point-of-no-return (ejaculatory inevitability), ask your wife to place her thumb and forefinger around the head of your penis and squeeze until the urge to ejaculate recedes. Return to receiving stimulation and to other sexual play. Again, when you reach high stimulation, ask your wife to squeeze. Integrate all this within other sexual play.
2) Quiet Enjoyment: As your penis enters your wife’s vagina, do not thrust. Gently enter and rest. Quietly enjoy the sensation of being enveloped within your wife. Gently thrust one time and then rest. Continue until you have done this several times. When you desire to, go ahead and thrust to orgasm.
Sexual Exercise 2: For Premature Ejaculation (Stop/Start)
1) In the midst of sensual and sexual play, ask your wife to begin manually stimulating your penis. When you are at a medium level of excitement and erection, ask her to stop. Engage in other sensual and sexual touch and allow your erection to recede. Begin manual stimulation again, having her stop whenever you reach the medium level and allow the erection to again recede. Through this process, you can learn to reach and enjoy erection and then allow erection to recede without any pressure to continue to ejaculation and orgasm.
2) Do the same process described above during intercourse. As you enter your wife, begin thrusting; when you reach a medium level of excitement, stop, withdraw, and allow the erection to recede while continuing to enjoy other sensual and sexual touch. Then start again, entering and repeating the same process.
3) Do steps 1 and 2 several times without proceeding to orgasm. After spending several times together learning to accept and enjoy the ebb and flow of erection as described above, without the pressure of orgasm, engage in the same process until you decide to continue to orgasm. Be aware that the pressure of wanting to last longer before orgasm may increase your anxiety. Talk about this together and find ways to breathe through and accept the anxiety, while still continuing to play.
4) Medication version: Under a doctor’s recommendation, try out a medication such as Viagra, Cialis, or Levitra. Do the exercises as described above, exploring your bodily and penile response to sensual and sexual touch when it is influenced by the medication. Continue to orgasm.
5) After you have finished playing while doing one of these versions, lay with each other afterwards and have a conversation about your feelings regarding the different things you explored and experienced. Compliment one another on what you enjoyed receiving and giving. Tell your spouse in what ways they are a good lover.
Sexual Exercise 3: For Erectile Dysfunction - The Sensual to Sexual Survey
This exercise is very similar to the exercise in the Sensual Touch chapter. The survey provides an avenue to discovering both what is pleasurable and arousing in sexual touch. It also gives men an opportunity to learn to enjoy sexual touch without being inhibited by anxiety about erection. Read the directions below completely before beginning. This exercise is done unclothed. All three levels of this exercise are for exploring sexual touch without leading to orgasm.
1) First enjoy a time of pleasuring your wife. Because bringing a wife sexual pleasure is very arousing for most men, take plenty of time to explore what is arousing to her. While you touch and caress your wife, notice how your own body responds and pay attention to what is arousing to you as you continue to bring her pleasure. If your penis responds with an erection, relax and allow the arousal to ebb and flow.
2) Level 3: The “surveyor,” the wife, now gently touches various places all over the parts of her husband’s body that would be considered Erogenous Zone 3: the legs, arms, back, shoulders, hands, head, etc.
3) The husband then, in response to her touch, communicates, using numbers (from zero to ten), the level to which the sensation is arousing. For instance, saying “zero” would indicate a neutral response. Saying “three” would indicate that you enjoy that touch somewhat. Saying “seven” communicates that you like it quite a bit. Saying “ten” is like saying, “Oh yes! That is great!”
4) Husbands: As you receive touch from your wife, let yourself enjoy the sensations, allowing erection to build and subside. If you begin to feel anxiety about whether your penis is becoming erect or staying erect, notice your anxiety and go ahead and breathe through the anxiety. Then allow yourself to return to focusing on the pleasure of your wife’s touch.
5) Level 2: The wife then, with the same light touch, begins to explore various places of her husband’s body that would be considered Erogenous Zone 2: the sensual parts of the body such as the inner thighs, the buttocks, the small of the back, the neck, the ears, the inner arms, the stomach, etc.
6) The husband again communicates, using numbers, the level to which the sensation is arousing.
7) Husbands: As mentioned above, let yourself enjoy the sensations. If you become tense or anxious about your erection, breathe through it. Do not try to force the anxiety away. Just breathe through it. Then return to paying attention to the pleasure of your wife’s sensual touch.
8) Level 1: With her husband lying on his back, the wife then begins to lightly touch the genital areas of her husband’s body that would be considered Erogenous Zone 1, including the nipples, testicles, anus, perineum, shaft and head of the penis.
9) The husband again communicates, using numbers, the level to which the sensation is arousing. Once again, notice the ebb and flow of your erection. Notice your penis become erect and notice the erection subside without trying to maintain the erection. Relax while taking note of what type of genital touch is particularly arousing.
10) Throughout the exercise, the wife can explore using different types of touch with varying levels of firmness. Make sure to pay close attention so that you can have a clear map in your head of your partner’s body, and especially his responses to genital touch.
11) After some time of genital pleasuring, allow your erection to subside. Lie together after the survey, warmly holding each other, sharing about your experience, and expressing encouraging and loving words of appreciation.
Sexual Exercise 4: Prompt and Reflection
* This prompt and reflection exercise gives you a chance to share and reflect the concerns, worries, and fears that are attached to the challenges you are having with sexual functioning. Each of the sentence prompts below are about challenges you have with sexual functioning. As explained before, take the same sitting position in two chairs facing each other, holding each other’s hands, looking at each other as you speak. Decide who will start first. Whoever goes first begins with the first prompt and finishes the sentence. The spouse reflects. Then the spouse who is second begins with the first prompt and their spouse reflects. Do this for each prompt.
1) “One thing I have been discouraged about is …”
2) “Something that scares me is …”
3) “I have been embarrassed that …”
4) “I am hopeful that …”
5) “Something I’ve wondered if you’ve thought is …”
6) “In order to work on/deal with this, I’ve wondered if you’d be willing to …”
7) “I have wondered if you have felt ______________ about this problem”
8) “I worry that you might …”
9) “I worry about …”
10) “Something you do that can make this challenge more difficult is …”
11) “Something you’ve done that has helped me is …”
After doing all of the above prompts, ask each other:
12) “Is there anything I’ve said that you want to ask me about or have me explain?”
Sexual Exercise 5: Thoughts, Feelings, and Communication about Sexual Expectations
For both premature ejaculation and erectile dysfunction, purchase Metz and McCarthy’s Enduring Desire. In the chapter Your Expectations and Sexual Satisfaction, find the page containing Realistic, Constructive Cognitions and do the Self-talk Quiz. Together, read through each pair of responses and discuss your thoughts about each sentence.