How To Solve The Problem Of Male Anorgasmia

Treating retarded ejaculation (delayed ejaculation)

Cognitive-Behavioral Interventions

To some extent, cognitive- behavioral approaches like the ones put forward by McCarthy and McCarthy (1998) or Perelman (2001, 2004) have already combined a number of basic features of both the inhibition and the reframing concepts. From his analysis of a larger group of patients with delayed ejaculation, Perelman (2004) highlighted two factors as predisposing toward and/ or maintaining delayed ejaculation: high frequency idiosyncratic masturbatory patterns and a disparity between the man's inner world of erotic imagery and the actual sexuality with his partner. For overcoming this disparity, the man or, preferably, the couple is instructed to integrate masturbation fantasies into their sexual interactions, thus reducing guilt and increasing the likelihood of orgasm. Perelman recommends a simple technique for making the man aware of and eventually changing his problematic masturbatory style: the man is instructed to switch hands while masturbating. This immediately makes him more aware of exactly what types of and what intensity of stimulation he needs to become aroused and reach orgasm. The man is thus able to see that, if his own left hand could not produce an orgasm, it is no surprise that his partners have also failed.

In their refined treatment approach for delayed ejaculation patients, McCarthy and McCarthy (1998) employ a wide array of psychotherapeutic techniques. From a cognitive- behavioral vantage point, the basic therapeutic strategy is to identify inhibitions and fears and develop sexual scenarios and techniques to overcome them. While some can be mastered or modified so they no longer interfere with the erotic flow, others have to be accepted and worked around. The principal behavioral change strategies are to increase erotic stimulation and identify and use orgasm triggers. However, interventions targeting cognitions or changes in attitude are at least equally important. The man is encouraged to ask his partner for increased intimacy and eroticism. Cognitive-behavioral treatment strategies involve a three-part combination: (1) being an intimate sexual team, (2) comfort with pleasuring, and (3) increased erotic stimulation.

1. If the couple manages to work as an intimate team, the performance pressure on the man will be significantly reduced. Mutual involvement in the cycle of pleasuring is the key factor in the increased verbal and physical intimacy that can overcome inhibition and sexual isolation.

2. For those patients who automatically get erections, the erection may erroneously signify readiness for intercourse, even if the level of subjective arousal is too low. The major treatment strategy is to give support and permission to enjoy pleasure and view ejaculation as a natural culmination of arousal. It is a gradual process of encouraging the man to be direct in requesting stimulation and experiencing and savoring erotic feelings. By gaining confidence and being more "selfish," he will experience more intense levels of subjective sexual arousal culminating in orgasm.

3. The two key techniques are multiple stimulation and being aware of orgasm triggers. Examples of multiple stimulation include using fantasy during partner sex, testicle stimulation during intercourse, stimulating the partner's breast or anal area during intercourse. Orgasm triggers are highly individualistic and can be identified during masturbation. Depending on the individual case, the goal of intravaginal ejaculation must be approached in a stepwise manner. Patients are instructed not to initiate intercourse until they are highly aroused. Fantasies can be a bridge to heighten arousal.

Systemic approaches can add some effective components to the treatment repertoire for delayed ejaculation. In a systemic perspective there are no techniques or assignments but only "tools" that the therapist should have at his or her disposal.

Clarifying the Therapy Goals and the Client's Objectives

In considering the goals of therapy, clients should be asked to consider "what's at stake," that is, what are the consequences for each partner if the symptom disappears, and what are the consequences if it lingers. Subtle and latent fears are often connected to the elimination of the symptom: What would happen if the man was no longer sexually "handicapped" by his delayed ejaculation? Would he want to "catch up" on lost experience? Would he cheat on his partner? Addressing questions such these is not just important, but can also be very enlivening for the therapeutic process as it helps to develop and particularize future scenarios in a lively way and thus promotes change. The therapist needs to be aware of contradictory objectives from the couple and must not be swayed to adopt just one of the partners' positions on change.

Testing Possible Sexual Realities

For a sexual problem as stubborn and unyielding as delayed ejaculation, it is important that the therapist understand the couple's "erotic framework." Typically, couples wish to have their sexual problem removed by a "microsurgical procedure" that does not affect the foundations of the relationship or the personalities of the partners. An effective way of bringing the couple out of their cozy, but also insipid and boring comfort zone is to make their erotic scripts more fluent and dynamic. The gentle elucidation of their erotic dark area can enable both partners to develop their own sexual profile and to discover each other in a new way. In patients with delayed ejaculation, it is especially apparent that an exaggerated consideration for the partner serves as a way of veiling one's own lack of courage toward one's sexual fears. In some cases, traumatic experiences and emotional barriers would lead to a hesitancy to risk intimacy or to a loss of access to one's self. Changing the focus from the couple's interpersonal conflicts to each partner's intrapsychic conflicts and fears can be helpful.

The process of discovering possible erotic worlds will almost always lead to defensive reactions, fears, and the activation of unconscious guilt. In these phases it is important that the therapist adopt an emotional holding function to provide the couple with a safety net. The key question here should be: Which of your own (sexual) fears have been sheltered by your partner's sexual problems?

A very effective therapeutic tool in this context is the "Ideal sexual scenario" (ISS) described in detail by Clement (2004). It serves to make available to the therapeutic process the sexual profile and the already accessible erotic potential of both partners, as well as the unlived, or underlying potential that cannot be accessed by simple questions. For this approach, each partner is instructed to imagine being completely egoistic in sex, without having to be considerate of the other. Which script of an ideal sexual encounter trimmed to one's own individual needs would each partner create? This ideal scenario, containing ample detail and less concerned with feelings than concrete actions, should be written on a piece of paper and enclosed in an envelope. Initially one's partner does not find out what was written down. The envelope is brought to the next session, but it is up to each individual to open it or not. The exercise can also be extended in such a way that each partner is asked to write down what he or she imagines might be in the other's ISS.

Even more significant than the content of each ISS is the way each partner approaches this exercise, since it reveals the dramaturgy of sexuality in the relationship and its concealed fears. While some couples can not bear the "secret" of the envelopes, and, contrary to instruction, show each other the scenarios before the next session, other couples prefer never to open the envelopes at all. Still other couples compose an obviously rosy plot devoted to tenderness and mutuality and maintain that all possible needs are already satisfied by the present sexual relationship and that no "exotic" desires exist beyond them. According to our experience, the ISS provides abundant links to further therapeutic work and is particularly useful for the treatment of couples affected by delayed ejaculation.

TOWARD AN INTEGRATED TREATMENT OF delayed ejaculation

Lifelong or chronic delayed ejaculation remains one of the least prevalent and least understood of all the sexual disorders and confronts both researchers and clinicians with many unresolved problems. With respect to research issues, both neurobiological and psychological factors play a role in the etiology and pathogenesis of delayed ejaculation. However, much remains to be known about why men differ so dramatically in ejaculatory latency or why men capable of ejaculating with masturbation are unable to ejaculate intravaginally. Both the neurobiological vulnerability and the biographical, psychodynamic, or interpersonal factors responsible for this dysfunction need to be elucidated in future studies on larger samples. It should be noted that any neurobiological vulnerability may, in turn, be the result of psychological or environmental stress factors that negatively interfered with the development of the neural circuitries necessary for successful ejaculation in a specific phase of brain plasticity. Therefore, only an integration of psychosocial and neuroscientific research methods will pave the way to a better understanding of this disorder.

delayed ejaculation is certainly challenging to clinicians. The case history described in this chapter is typical of a complex multiple etiologic case of delayed ejaculation and illustrates the need for a multiple-modality treatment approach. Although ejaculation in male rats can be facilitated by certain compounds, it does not automatically follow that these drugs will have the same effect in patients with delayed ejaculation. Overall, treatment of delayed ejaculation should reflect an integrated approach combining pharmacotherapy and sex therapy and addressing medical, intrapsychic, and interpersonal contributions.

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