Helen Kaplan "Sex Therapy" New prospects for pleasure for loving couples
What should you expect?
Let's take a look at how your body naturally changes over the years. These changes are completely expected and predictable, so they should not surprise or upset you. You will need more immediate stimulation. One of the things to consider when you're in your forties is that spontaneous erections will no longer occur as quickly and easily as they did in your youth or twenties. Back then, just the thought of sex, the sight of your naked partner (hereinafter, the term “partner” implies a woman or a man), or even just sexual fantasies could make your penis shoot upward in a matter of seconds. Now this won't happen. With age, all physiological systems of the body slow down, including the one responsible for erection.
Without a doubt, you will find it increasingly difficult to achieve an erection just by thinking about sex or looking at your sexual partner. You will need direct physical stimulation of your penis.
But maybe that's not such a bad thing. And this does not mean that your erections will soon stop completely or that you should give up sex. You just need your partner's help. It turns out that it is very important to have an understanding and loving person nearby. Your loved one will help stimulate your penis with her hands, mouth, breasts or other parts of her body and will bring more intimacy, sensuality and variety into the process of your love, which, in turn, will surely open a new chapter of your sex life.
Men over forty often require direct physical stimulation. In the past, his erections occurred spontaneously. The partner rarely touched her husband's penis, and he did not feel the need to do so. Now he is gradually losing spontaneous erections, which previously occurred on demand. But he still continues to wait for her, believing that without this there is no need to bother his partner. Thus, their sexual encounters become increasingly rare as he waits a week, two weeks, a month for his spontaneous erection, which will never come again. As a result, such a man comes to the appointment, declaring that he has become impotent.
It is important to understand that you do not have to wait for an erection alone. Your partner will help you achieve arousal. You will be able to overcome your age limitations and begin to love each other at any time when you both wish.
Your erections won't be as hard anymore
The second change to keep in mind is that your erections will lose that steely hardness they had when you were younger. Nevertheless, this is quite enough for you to have full sexual intercourse and receive mutual pleasure and satisfaction.
Hardness, for the most part, serves only cosmetic purposes. Your penis, even if it is not as hard as before, can still do its job very well. And your partner's pleasure depends more on how skillfully you use your body and your penis, rather than on the degree of its hardness.
Your need for orgasm will decrease significantly
Many men after forty are worried that they cannot ejaculate with the same readiness and ease to which they are accustomed, mistakenly believing this to be an early sign of impotence. Unfortunately, instead of enjoying their sexual experience, they allow themselves to become sad and depressed. The need for ejaculation decreases over the years. At the same time, the frequency of sexual intercourse may remain almost the same, so it is understandable that some of them occur without orgasm.
Masters and Johnson (American sexologists) claim that for most men after sixty, one or two orgasms per week are enough. Therefore, some go to ‘reduce the number of sexual contacts, believing that each of them must certainly end in ejaculation. But if sexual intercourse ends with orgasm only once a week, this is not a reason to refuse the pleasure of making love two or three times more often. You just have to accept the situation and learn to enjoy sex, which does not necessarily lead to orgasm.
If you force yourself to ejaculate even at those moments when your body does not want it at all, your efforts may ultimately lead to the loss of an erection, which, of course, can hardly be called a successful result. Instead of an enjoyable sexual experience, you risk developing anxiety and uncertainty, worrying whether you will be able to achieve orgasm next time. And if at some point you really don't succeed, you will develop a fear of future sexual encounters.
You can often hear from male patients that by not achieving ejaculation, they are letting their partners down. A woman may feel like she's doing something wrong if her partner doesn't orgasm, that he no longer finds her attractive, or that he's sleeping with someone else.
Remember that after forty it is completely normal to go without an orgasm from time to time, it is quite easy to get used to. Sexual intercourse can be a very pleasurable, sensual and erotic experience, whether you ejaculate or not. You don't have to reach orgasm every time you make love, and you certainly can't force yourself to do it. Just warn your partner that you may not have an orgasm so that she doesn't feel guilty about you. Having sex without the tedious task of ejaculating will add a new dimension to your relationship, making it more enjoyable for both of you and allowing you to enjoy long, leisurely intercourse.
The process lasts longer, but there is more joy
Now that you are less focused on achieving ejaculation quickly, you are more likely to enjoy longer intercourse. This will be very pleasurable for your partner, as women often require longer stimulation to achieve full arousal and orgasm. She will appreciate your sexual stamina, which gives you both the opportunity to make love longer and get more pleasure from it.
Don't rush for your next erection
After orgasm there is always a period called refractory, during which it is impossible to achieve a new erection. At this time, your penis is resting and is not able to respond even to strong stimulation.
When you're twenty years old, the time between orgasm and the next erection is measured in minutes. By the age of thirty, this period usually drags on for about twenty minutes and by forty it reaches one to two hours. At sixty, you may have to wait a full day or even longer before you can achieve an erection again.
This need for rest largely depends on your level of arousal. In an overly sexually charged situation, the refractory period is often shortened, and you will be ready to continue more quickly.
Here, as in many other cases, awareness of the changes that occur during the aging process plays a key role. If too little time has passed since ejaculation and you are already trying to get aroused again, then it will naturally be difficult for you to achieve a good erection. If such a failure comes as a surprise to you and your partner, then you both cannot avoid worry, annoyance and disappointment.
And when, after waiting a few days and giving yourself a good rest, you decide to try again, the anxiety that arose due to the previous failure will remind you of itself and, of course, will not contribute to a good erection. In other words, you can scare yourself to the point of developing an episode of temporary impotence.
There is a simple way to avoid unpleasant consequences, and it is to listen to the messages of your body. So, for example, if you do not get a new erection simply because too little time has passed since your last ejaculation, do not try to forcefully speed up this process. You may decide that it's better to wait until next time, or you may enjoy making love without an erection, caressing each other with your mouth or hands. It's important to understand that you can use manual or oral stimulation to please your partner and help her reach orgasm. And then, when your body is sufficiently rested and ready to love again, you will begin with a clear intention and full of enthusiasm. Remember also that if you abstain from ejaculation, then you most likely will not need a long recovery period. Therefore, if your erection fades before you have time to achieve orgasm, do not be discouraged: your penis will soon be able to regain its hardness.
Other changes
There is something else that a man begins to notice in himself after forty. For example, at the moment of ejaculation, semen is not ejected as quickly as in youth. The fact is that the muscles responsible for this process are no longer as strong as before. But overall, this shouldn't affect your orgasmic pleasure in any way. After all, ejaculation is not a race.
When you were young, you may have had the sensation of impending ejaculation, several seconds ahead of your actual orgasm. This phenomenon is called the “feeling of the inevitability of ejaculation”, since it is known that, having passed this point, it is no longer possible to resist orgasm. As you age, you will begin to notice that in time this sensation is getting closer and closer to the beginning of orgasm and almost merges with it.
You may also have noticed that your erections go away much faster after orgasm now than when you were younger. This is also one of the inevitable changes of age, and it also should not affect your ability to have fun.
Why are these changes happening?
Where do these changes come from and why do they gradually begin to manifest themselves after forty years? Why does the need for ejaculation decrease over the years and, conversely, the need for penis stimulation increases? Why is your erection losing its former hardness?
The reasons for these phenomena are quite complex. Getting an erection, which you always thought was such a simple matter - you see your girlfriend naked, think about sex and your penis rises up - is actually a very complex process. It requires precise interactions between different parts of your body. First, it is the brain, where erotic thoughts and fantasies are born. The second is the erectile reflex, which consists of the transmission of nerve impulses that arise during direct stimulation of the penis.
The nervous system, in turn, activates a third mechanism, the action of which is manifested in the form of a series of coordinated reactions of the blood vessels. In this case, the system of arterial vessels must deliver the required amount of blood to the penis, while the outflow of blood from it is partially blocked. All this allows blood to pool in special areas of your penis and produces an effect similar to inflating a long, thin balloon. Your penis becomes engorged, hardens and becomes ready for sexual intercourse.
How does all this happen? It may sound like a technical description, but it's still worth reading to learn how to understand what problems you may have and how to properly deal with them.
Sexual stimulation—whether it comes from erotic thoughts and fantasies or direct physical stimulation—causes a flood of nerve impulses that release a chemical called nitric oxide*. Nitric oxide, in turn, causes the formation of another chemical that causes the smooth muscle in the special parts of your penis - the corpora cavernosa - to relax, allowing blood to fill them, similar to the way long balloons are inflated. As the corpus cavernosum fills with blood, it begins to compress the veins that drain blood from the penis. This traps it inside the corpora cavernosa and thus maintains the penis in an erect state.
The erection continues until the smooth muscles of the cavernous bodies contract again. At the same time, the blood in them is expelled, and the venous vessels open and drain its excess from the penis.
This entire process is controlled by testosterone, the male sex hormone, the presence of which in the blood in the right quantity ensures the launch of the erection mechanism, and also largely determines sexual desire and arousal.
What could go wrong?
The operation of the erection mechanism under ideal conditions is described above. However, the problem is that over the years this complex system gradually wears out. The reflex mechanism no longer works so clearly, there is a tendency to increase blood pressure and atherosclerosis of blood vessels, including those arteries that are responsible for the blood supply to your penis. As a result, less blood flows to it, which is also less enriched with oxygen, which, in turn, is reflected in the delayed onset of erection.
Smooth muscles, thanks to which the blood supply to the cavernous bodies is regulated, are also susceptible to the development of the atherosclerotic process and the formation of plaques and thickenings. As a result of such changes, the smooth muscles become not as elastic as before, and these sections cannot be completely filled with blood, and therefore completely block the venous outflow. In this case, the blood is able to partially leave the cavernous bodies.
This results in your penis requiring longer stimulation, but it no longer achieves the same hardness and becomes less erect. And the whole process as a whole becomes less predictable and stable.
Another problem can be anxiety, which causes the smooth muscles to spasm, allowing blood to flow freely from your penis. Therefore, if you start to worry about your erection, then you are actually working against yourself, since, on the one hand, you stop your sexual fantasies, which contribute to the production of nitric oxide, and on the other hand, the anxiety itself leads to a faster loss of erection.
In this case, you may notice, you just need to stop worrying. But the trouble is, if you know that your erections are becoming an increasingly fragile and unstable process, it's hard to stop thinking about them. This concern can develop into anxiety, which in turn will turn a good erection into something flaccid and shapeless.
And finally, with each passing decade, the level of testosterone in your blood decreases. At thirty it is produced less than at twenty, and at fifty less than at forty. This results in a less frequent occurrence of desire and a lesser need for orgasm. Apparently, there are other factors influencing this process. One of these factors is the banal habituation of partners to each other, the reluctance or inability to change their habits, to bring something new into their relationship.
Conclusion
As the entire erection mechanism loses its former sharpness of reaction, you gradually begin to notice the changes described earlier: a slowdown in erection, its greater dependence on external stimulation, and loss of its former hardness. But although the system responsible for producing an erection is becoming increasingly fragile and increasingly in need of outside help, remember that for the most part it remains quite effective and efficient even if you are in your sixties, seventies, and so on.
In some men, however, this mechanism fails, and then they develop real impotence, characterized by a persistent inability to achieve an erection. Why is this happening?
Let's start with the fact that with age, more serious disorders in the erection mechanism may occur. Diseases such as diabetes often cause damage to the nerve endings responsible for maintaining the erectile reflex. This process is negatively affected by various conditions, which often cause a deterioration in the blood supply to your penis. The latter include hypertension, atherosclerosis, as well as the already mentioned diabetes mellitus.
Lack of testosterone also plays a significant role in many male problems. It's important to note here that while testosterone levels decline to some degree with age in every man, some develop severe testosterone deficiency.
Other external factors that can negatively affect an aging man's already unstable erection include excessive alcohol consumption, smoking, and certain medications. The lack of certain substances entering the body with food also plays a certain role. In addition, certain diseases and painful conditions and, more importantly, anxiety and tension can, individually or in various combinations, block the mechanism of erection.
Why can sex be better after forty?
When you were young, the dominant theme of your sex life was the need to ejaculate. An erection occurred quickly, and this practically did not require resorting to physical stimulation; you were always ready to immediately engage in intimate intimacy. And while you may have been proud of your sexual prowess back then, fast-paced intercourse with hasty ejaculation is still not what most women need, who usually take longer to become sexually aroused. Unfortunately, when dealing with young people, a woman often has to deal with manifestations of impatience, self-centeredness, and reluctance to spend additional time on arousing her.
Ejaculation, from a female point of view, is only the final chord of love play, while prolonged sensual caresses constitute its main and most valuable part. As you age, you will find that you, too, prefer a fulfilling love relationship that brings great pleasure to both you and your partner.
The middle years are, in many ways, a great time for sexual relationships. By this point, you already have considerable experience, and you have had enough time to best explore your partner's needs. You no longer want to ejaculate quickly at any cost; you are already less focused on your penis and more attentive to the entire spectrum of mental and physical experiences. Thus, both the soul and body of a mature man are better prepared to receive sexual pleasure together.
The love of a mature man brings more trust and reciprocity into relationships for the following reason. The erection of a young man represents a certain primordial given. Women's participation in this process is less obvious. A relationship with an older man provides a woman with the opportunity to take a much more active role. She will be happy to notice how significant her help was in helping you achieve an erection. Understanding that she did this, literally with her own hands, will give her a sense of power, sharing and complicity in your sexual relationship, which she previously was largely deprived of.
Of course, you may be embarrassed by this dependence on physical stimulation, but do not attribute it to a decrease in your masculine prowess. These are actually natural age-related changes that you both can benefit from.
Firstly, you will experience many wonderful moments when your partner will excite you in all available ways. Secondly, you yourself have the time and opportunity to caress her for your own pleasure, without the internal need to rush to ejaculate. And finally, your partner will have a lot of fun caressing and arousing you, as well as helping you achieve an erection and orgasm.
The essence of the pathology is a conditioned reaction to the insertion of the penis or a reaction that occurs on the threshold of the expected introitus. The conditioned reaction leads to a pronounced muscle spasm. The development of a conditioned reaction can be facilitated by any source of pain that a woman associates with introitus. Vaginismus occurs as a result of violence, physical or psychological trauma, associated with conscious and unconscious fear and/or guilt. Sometimes the source of brutal violence is not clearly identified.
Vaginismus should be distinguished from physical defects of the vagina (for example, aplasia, agenesis), as well as from ischroitus phobias. The diagnosis of vaginismus is made with a complete sexological examination.
Treatment strategy
Treatment mainly comes down to suppressing the conditioned reflex vaginal reaction. This is achieved by introducing objects that are constantly increasing in size into the vaginal opening against the background of a relaxed and calm psychophysiological state of the patient. When the patient can accept objects the size of a phallus, the outcome of treatment is considered positive.
This extremely simple treatment plan is complicated by the fact that most cases of vaginismus are accompanied by additional phobias.
18. A woman inserts a finger into her vagina
19. A woman inserts a catheter into the vagina
20. A man inserts a finger into the vagina
This extremely simple treatment plan is complicated by the fact that most cases of vaginismus are accompanied by additional phobic symptoms of a mental component, such as coitophobia and fear of vaginal penetration. These manifestations of phobias must be eliminated even before changing the conditioned reflex (vaginismus itself) phase of treatment.
There are many techniques to help eliminate introitus phobias. These include analytical techniques for interpreting unconscious manifestations that enhance irrational fear; support and encouragement, orientation towards experiencing fears and a confrontational attempt at introitus at the time of experiencing phobias; behavioral techniques of desensitization and hypnosis. I typically use a combination of analytical and supportive techniques. I am trying to establish the source of trauma that caused vaginismus, and also find out the picture of the patient’s emotional states and reactions to various manifestations of the disorder. Then, from etiology and pathogenesis, a rapid transition is made to the current manifestations of the disorder and an attempt is made to support the patient in constructive and rational attempts to overcome a certain barrier. There are also behavioral approaches to treating the disorder that give good results.
Desensitization or introitus is carried out in vivo only after a significant weakening of existing fears and overcoming the ambivalent attitude of women towards sexual intercourse, that is, after a relatively successful resolution of the psychological conflict. To open the conditioned reflex connections characteristic of vaginismus, clinicians recommend using a variety of physical objects inserted into the vagina. Glass catheters, rubber devices and tampons are used. Given the conditioned reflex nature of the disease, the texture of the objects used does not seem to matter. I suggest that the patient use her finger or her husband's finger, as this is more emotionally acceptable. In this case, resistance from patients is less likely than in the case of the use of physical objects.
Treatment procedure
The patient is instructed to use a speculum in which she must observe the vaginal opening when performing the prescribed appointments. At first, tasks are completed alone. She is asked to place her index finger on the vaginal opening, then insert the tip of the finger into the vagina, observing this in the mirror and assessing the internal sensations arising from this action.
These sensations and their meaning are analyzed during subsequent therapy sessions. During these sessions, dreams and fantasies that the patient has recently experienced are further discussed. 3ix" may be useful for identifying and resolving negative unconscious motives, which in some cases contribute to the fixation of a conditioned reflex.
If the patient has successfully inserted the tip of her index finger, next time she is asked to insert the entire finger. Then two fingers. Sometimes she is instructed to insert a tampon without removing the tampon and leave it in the vagina for a few hours or until she can fully adjust to the sensations associated with it. The therapist can consolidate the process of “opening” conditioned reflex connections, warning the patient about possible unpleasant sensations, tense states, but not about pain that may occur when a certain object is inserted into the vagina.
As a result, neither anxiety nor tension increases. On the contrary, if a woman is able to tolerate unusual sensations for some time, they, as a rule, weaken and she reacts normally to introitus.
After the woman has mastered these procedures and responds normally to the insertion of fingers and/or a tampon, her husband joins the procedure. He is asked to examine her vaginal opening in full light. Then he performs all the same operations that were previously performed by the patient. First he inserts the tip of his index finger. After this, the woman, controlling her husband’s hand and completely controlling its movement, allows the entire finger to be inserted.
At first, the man must keep it motionless inside. The next stage is a slow, careful movement of the finger back and forth, then the same with two fingers. During this time, the woman must be constantly assured that there will be no attempt at penile insertion. If the husband becomes aroused during this love play, the couple is encouraged to engage in sexual activity that allows the spouse to achieve extravaginal orgasm.
The moment of the first introitus is very important. The spouses give their consent to this act in advance. The husband lubricates the erect penis and performs introitus, which is controlled and directed by the wife. He leaves the penis in the vagina for a few minutes without further movement, then removes it. In this case, spouses can (at their discretion) also use extravaginal forms of sexual activity.
With repeated introitus, gentle slow friction of the penis and the woman's response movements very often lead to orgasm.
21. A man inserts an object into the vagina
Reactions
Some women tolerate desensitization relatively easily, while others experience increased emotional stress. Tension and anxiety arise in anticipation of phallic penetration and increase in anticipation of this action. After coitus, a sharp decrease in anxiety is observed.
As a rule, a favorable treatment outcome is achieved if a married couple undergoes a full course of sex therapy treatment. Extremely diverse manifestations are observed in the sexual behavior of partners after introitus has become possible. It may come as a surprise to many that women suffering from vaginismus are highly excitable and easily achieve orgasm with clitoral stimulation.
Most women retain these abilities after achieving coitus. Some adapt quite quickly to the achievement and state of coital orgasm. For these categories of patients, no further treatment is required. In other cases, successful resolution of vaginismus reveals other sexual disorders in women and/or disorders of the erectile phase or ejaculation in men. In this case, the course of treatment continues with the use of additional methods and techniques of sex therapy.
IMPOTENCE - DISORDER OF ERECTION FUNCTION
Erection is a neurovascular reflex, the manifestations of which are associated with hormonal supply, anatomical mechanisms (the functioning of the spinal centers and vascular apparatus), as well as with the work of specific neuroreceptors. Violation of any of the listed components leads to a disorder of the physiological component of potency. But even with the integrity of the anatomical and physiological substrate of erection, there is a special “sensitivity” of the erectile component to the destructive effects of unconscious conflicts and, in general, to emotional influences. If a man has sexual intercourse with emotional instability and psychological conflicts, his erection reflex can easily be disrupted*.
In the past, it was generally accepted that psychogenically caused impotence was the “product” of a strong neurotic conflict. According to psychoanalysis, unconscious fear of pain (castration), associated with an unresolved Oedipus complex, is the main cause of psychogenically caused impotence. Not so long ago, factors of “paired” influence** began to be identified in the etiology of impotence. A hypothesis was proposed that unconscious dysgamy in love and marital relationships, manifested, in particular, in the struggle for power, disappointments in life together and in mutual infantile transferences (transfers), can all lead to erectile disorders.
22. A woman excites a clothed man
Obviously, the cause of impotence can be both unconscious intrapsychic conflicts and conflicts of “pair interaction”. The manifestation of these conflicts is more likely in a psychologically unprotected person who is preparing to engage in sexual intercourse. However, many of the cases observed in our clinical practice are not associated with deep pathogenic factors, and the emotionally destructive factors of impotence, as a rule, are easily removable. Such emotional factors include fear of “flaws” in one’s sexual activities, fear of being rejected by a woman, expectation of impotence due to an unsuccessful episode in the past; over-concern associated with the need to satisfy a woman; culturally imposed feelings of guilt about sexual pleasure.
These anxieties and deep-rooted fears can manifest themselves in men during sexual intercourse, leading to refusal of sexual activity. Complete dedication in sex, freedom from anxiety and protective suppression of anxious states are prerequisites for a normal erection.
Treatment of potency disorders associated with these “simple” psychopathogenic factors has a favorable prognosis during sex therapy correction. Sex therapy seeks, through the means available in its arsenal, to humanize the relationships of partners, to demystify and ease the anxiety that interferes with normal marital relationships.
Treatment strategy
The basic sequence of stages of a short active course of treatment for erectile dysfunction is as follows:
1) erotic pleasure without erection,
2) erection without orgasm,
3) extravaginal erection,
4) intromission without orgasm, 5) coitus.
Each case of impotence should be examined individually in order to determine what exactly causes anxiety and defense during sexual activity. Based on the data obtained, a restructuring of the sexual situation is carried out, allowing to reduce the impact of negative factors. Some sex therapists do not carry out such restructuring, taking into account individual characteristics, but routinely proceed to sensual focusing exercises I and II. There is a strong logical rationale for this approach, as these exercises do much to reduce the anxiety level of the “standard” patient. Prohibition of orgasm or intercourse reduces the manifestations of anxiety, and the therapist in this case proceeds from the idea of replacing the goals of sexual action: the goal of “giving pleasure” replaces the goal of “sexually expressing and showing oneself in the best light.” The obligatory condition for such a change in roles in the partners’ activity relieves the psychological pressure experienced by a man who is usually obliged to actively respond to the sexual manifestations of his wife. As a rule, a man gets an involuntary erection when performing sensual focusing II. The erection is unstable: it appears and then weakens. As a result, the couple receives an extremely useful lesson for themselves, and the therapist, judging by how the patients react to the exercise, draws important conclusions and observations for himself.
1) If an erection occurs in a serene, relaxed state, it means that the spouse’s “apparatus” is in normal “working condition.”
2) If an erection disappears from time to time, this does not mean that it disappears completely. She will appear again - for the necessary stimulation. The appearance and weakening of an erection is generally normal for long periods of sex, and only at a very young age can it last for a very long time.
"Compression"
Sometimes, in order to confront an anxious man with the feeling of loss and restoration of an erection, we use the “compression” technique, first proposed by W. Masters and V. Johnson (see Fig. 38).
After the man has an erection, his wife squeezes the penis slightly below the head. This is done with enough force to reduce the erection. Usually such an effort does not cause pain - the erection reflexively decreases by 30-50%. An erection lost in this way is usually quickly restored in response to gentle touch. A few repetitions of this exercise are usually enough to overcome the fear of losing potency.
Stimulation options
We often begin with Sensory Focusing Exercises I and II, but this beginning is not necessary. For some men, prolonged foreplay causes sexual repression. When the sexological history reveals certain situations of increased potency in a man, we begin therapy with these situations. It is known that some men with potency problems achieve a good erection in a situation where they engage in foreplay without taking off their clothes. In these cases, the man is not allowed intercourse, but the wife is asked to begin stimulating his penis through clothing. A little later she unzips his trousers and makes love to his penis. The man remains in his pants.
We also take into account the increased level of androgens in the morning and the associated morning erection. If a man notices regular morning erections upon waking, we prescribe Sensual Focusing Exercises II in the early morning.
It is sometimes suggested to use petroleum jelly as a lubricant. The wife applies the cream to the penis and stimulates it, or the man himself performs the stimulation in the presence of his wife. This sensual and exciting method in rare cases does not lead to an erection.
Oral stimulation is often used at this stage of treatment. For many men, this is the most exciting way. Naturally, it is used with the consent of the wife, if the idea of oral sex does not disgust her.
During stimulation, regardless of the form in which it occurs, a man receives an installation that allows him to get rid of obsessive self-control and the feeling of being in the role of a “spectator,” that is, he is prohibited from constantly observing whether he has an erection, and if he does. , then “how hard it is.”
If the noted techniques do not relieve a man from a state of anxiety, he is recommended to evoke vivid erotic fantasies during stimulation. Distraction from anxiety or obsessive defenses (self-observation or the feeling of being a spectator) through erotic fantasies is extremely important during sex therapy. Erotic fantasies are an ideal defense against anxiety, allowing for increased sexual response. The content of fantasies should be discussed with the utmost sensitivity. Spouses often react with emotional tension to their own erotic fantasies and/or to the fantasies of their partners. They experience guilt and shame, and fear that the content of fantasies is “abnormal and indicates illness.” They feel jealous and/or guilty when they see something alien or stranger during sexual intercourse when they “should” be honest in their relationships.
If such sentiments are rooted in the psychopathology of a given couple, then an open discussion of the partners’ erotic fantasies easily eliminates the feeling of guilt in each of the spouses and gives them a feeling of closeness, intimacy and erotic pleasure.
23. A couple excites each other, the woman is not completely undressed
24. A woman excites a man orally
25. A woman manually excites a man using Vaseline
26. Woman on top - stimulates a man’s erect penis
Often, however, we are faced with a delicate area of heightened and difficult to overcome experiences. The insecure spouse essentially reacts with feelings of paranoid jealousy when she learns that her husband is being “visited” by a stranger while he is making love to her. Reactions of this kind must be addressed at deeper levels of the subconscious, beyond symptomatic, limited treatment. A painful reaction to a partner’s fantasies requires a special approach to overcoming the patient’s suspiciousness and low self-esteem of his personality. Such therapeutic correction of a woman’s feelings and attitudes allows her to normally perceive the features of her husband’s inner erotic world.
Reactions
A regimen of intense erotic stimulation, combined with a lack of special sexual commitment from partners, usually leads to an erection within a few days. Some men are annoyed by the setting that prohibits ejaculation during this period of time. A number of men, however, do not achieve the expected sexual response to these procedures. These cases of impotence are most likely associated with intrapsychic and/or marital pathogenic factors, and short sex therapy sessions, as a rule, do not lead to a positive outcome. If a man does not respond to behavioral prescriptions prescribed to achieve an erection without orgasm, then the prognosis for sex therapy is negative.
Extravaginal orgasm
After a man has gained confidence in his potency, he moves on to procedures of manual and/or oral stimulation. This procedure is exactly similar to the techniques described earlier. The only difference is that the man is given complete freedom in case he wishes to ejaculate.
The wives of some impotent husbands are unable or unwilling to achieve orgasm solely through clitoral stimulation. This requirement puts a lot of pressure on the man, who views erection as an essential obligation to satisfy his wife. In this case, the sex therapeutic effect is focused on the spouse. We convince her to accept extravaginal coitus as an alternative form of pleasure. This attempt often requires long psychotherapeutic efforts. But this approach is extremely important, since this removes the burden of his obligations and the imposed need to perform certain actions from the man.
27. Woman on top - inserts penis into vagina
As a result, he can please his wife manually or orally and at the same time voluntarily control his actions. It no longer depends on the erectile capabilities of the penis, voluntary control over which cannot be achieved. Her fear of being rejected, which arises in the absence of her husband's potency, disappears. He, in turn, does not experience a similar fear, since he is able to bring her to orgasm with the help of caresses and he does not have the need to “prove” his love for his wife and confirm with the help of an erection that he is a “real” man.
Intromission without orgasm
Before true coitus with orgasm, vaginal continence exercises are recommended. The married couple will be instructed to engage in lovemaking in a manner that has previously allowed the husband to achieve an erection. When the erection becomes persistent, the man performs short-term intromission. He can make several copulatory movements, but he should not reach a coital orgasm. The orgasm occurs extravaginally, as before, that is, after he has removed the penis from the vagina. In these cases, the man must control intromission, that is, he inserts and removes the penis when he has the appropriate urge. In other cases, a man experiences less anxiety and is more aroused when his wife “controls” his penis. In the position on top, she plays with his penis until she gets a good erection. She then guides the penis into the vagina. She makes several body movements, after which she takes out her penis and continues erotic games again. The procedure can be repeated several times. And in this case, ejaculation must be extravaginal.
Coitus
Initially, the sensations that arise during coitus can cause a certain state of anxiety - which is why it is necessary to organize the sexual activity so structurally at this stage in order to activate encouraging and supporting stimuli.
The man is usually given a "time out". He is recommended to engage in erotic games of the type that were described in the section “Intromission without orgasm.” He is informed that he can ejaculate intravaginally if he has the urge to do so. In the absence of such a desire or if he has doubts about his ability to act actively, he should remove the penis from the vagina and then ejaculate or not try to achieve it at all.
In the presence of his wife, whose feelings and moods are especially important, he is advised to feel “selfish.” In order to act actively, he must completely surrender to emotions and sensations, excluding at this particular moment concern for his partner. His “selfishness” is temporary, since if she is dissatisfied with the manifestation of this involuntary pleasure, the man can “bring” her to orgasm using the clitoral method after he himself has experienced orgasm.
The man receives an instruction to remember erotic fantasies. He is advised to use the rhythm that suits him best and gives him pleasure, regardless of the particular position or sexual method. All these techniques are temporary, and the need for them disappears as the reliability and stability of sexual relations is restored. But if in the future a man experiences any fleeting anxiety that has a bad effect on his potency, he can help himself, that is, use the techniques that he learned from sex therapy.
Reactions
The rapid restoration of potency, as well as the restoration of any other sexual function, is accompanied by a feeling of relief and joy. However, in the case where the disappeared symptom was associated with unconscious defense processes, the patient may experience anxiety, anxiety or depression after the restoration of any lost function. It should be noted that the wife may experience even stronger emotional experiences in response to her husband's newfound potency. She may experience mixed feelings and be completely confused.
Some women experience joy at their husband's improvement, which is expressed both in their actions and in words. However, it happens that women are extremely alarmed by the new situation. They express their anxiety verbally, or show it in a depressed, agitated mood. There are times when a woman’s internal conflict comes out into open action and she unconsciously puts barriers to the successful healing of her husband.
The boycott of treatment and restoration of normal sexual activity of the husband sometimes takes various sophisticated forms. This may be expressed in a sudden loss of attention, warmth and support to your husband or in fleeting critical notes about his behavior. Such moods of the spouse, as a rule, become noticeable during therapeutic sessions. A woman's supportive attitude may suddenly give way to increasing withdrawal or demandingness. The wife's resistance can become quite obvious. She may feel apprehensive, depressed, may begin to drink heavily and/or complain about the nature of the prescribed exercises (“They are boring, mechanical in nature”). The wife may openly criticize or indulge in riotous fun. In one case from our practice, the wife started an affair just at the moment when the husband achieved normal, stable erections.
The sources of negative reactions towards your spouse are often unconscious hostility towards him and, what is much more common, the fear of losing your husband when he acquires potency and activity. Some wives psychologically contribute to their spouses' erectile dysfunction. Such women carry a deep-seated sense of insecurity. On an unconscious level, they think: “I’m not very attractive. He stays with me only because he is dependent on me, and I have come to terms with his impotence. If he becomes active, he will leave me and find another woman - a beautiful and suitable woman for him.” Such unconscious fears can lead to the wife’s boycott of the treatment process, which can be expressed both covertly and openly. Sex therapy cannot be perfect until it is possible to adequately eliminate the noted, sometimes barely noticeable, destructive manifestations in the behavior of partners. If the spouse senses an impending threat to her happiness and well-being, it is impossible to achieve a stable restoration of potency. Until it is possible to resolve the psychological conflict or, at least, achieve emotional stability in the relationship between the spouses, there will always be a possibility of relapse of sexual disorder.
SLOW EJACULATION
Delayed ejaculation is an involuntary suppression of a man’s orgasmic reflex. Physiologically, this condition is similar to a disorder of orgasmic function in a woman. A man with this disorder is able to experience sexual arousal and have good potency, but even with full stimulation he exhibits a disturbance in the ejaculation reflex. Strict self-control, that is, the complete absence of ejaculation, even during masturbation, is rare. This fact is encouraging, since cases of this kind are difficult to treat. Milder forms of delayed ejaculation are relatively common, and sex therapy has a good prognosis for cure. In moderate (in terms of severity) forms, a man achieves ejaculation alone through masturbation. Men suffering from mild forms of retention can achieve orgasm in the presence of their partner, but only in response to manual and/or oral stimulation. They can't do it intravaginally. A number of mild forms of disorders are situational and require the usual prolongation of coitus to achieve ejaculation.
In the pathogenesis of delayed ejaculation, processes similar to those that occur with constipation, hysterical swallowing disorders and difficulty urinating are observed. Defecation, swallowing, urination and ejaculation are autonomic reflexes that are normally subject to voluntary control. In the case when a person is in a state of passion, or as a result of the dominant influence of a psychological conflict, an involuntary defensive reaction occurs that suppresses one or another reflex. A strong defensive reaction leads to overcontrol, that is, to the inability to weaken reflex inhibition at the subcortical level.
Apparently, the source of unconscious conflict and/or the sources of an emotionally aggravated state are not specific. In other words, it seems impossible to identify such a specific psychodynamic connection, which in one case would be characteristic of delayed ejaculation, and in the other - of impotence. The same forms of unconscious castration fears and anxiety, as well as fears of fulfilling obligations towards a partner, can lead in one case to erectile dysfunction, and in another to delayed ejaculation. The conflicts may be the same, while the forms of protection may be different. When ejaculation is delayed, there is unconscious inhibition associated with excessive control. This control allows a man to avoid experiencing anxiety, whereas in the case of impotence, increasing arousal leads to loss of control: anxiety grows like an avalanche and leads to impotence.
The main goal of a brief sex therapy intervention is to distract a man from the need for excessive control in order to release inhibited reflex manifestations. Often this strategy gives very good results. In some cases, it is necessary, at least partially, to resolve and rebuild the conflict situation so that the patient allows himself to be distracted. For such patients, important factors of anxiety and suppressed defense against anxiety are relationships with a partner. Unconscious conflicts in the relationship between spouses require serious resolution even before the patient can calmly and without difficulty enjoy orgasm.
Treatment strategy
Treatment of delayed ejaculation is based on two main therapeutic principles*:
1) progressive desensitization of intravaganal ejaculation, carried out in vivo (i.e. desensitization in the presence of a partner);
2) stimulation accompanied by distraction.
Progressive desensitization
Most patients with delayed ejaculation can achieve normal ejaculation under certain conditions. The main treatment strategy is to adapt the ejaculatory reflex to the conditions of coitus. The structuring of procedures is carried out taking into account this strategy. Specific behavioral prescriptions vary depending on the individual.
28. A man masturbates while sitting with his back to a woman
29. A man masturbates while hugging a woman
30. A woman masturbates, a man’s hand rests on her arm.
For example, a patient is capable of ejaculation only when he is alone and his wife has left home. He can achieve orgasm through masturbation, while imagining how a stranger excites him orally. If he has intercourse with his wife, he receives pleasure, has a persistent erection, satisfies his wife, but does not achieve orgasm, even if coitus continues for an hour. The erection gradually fades, and he falls asleep.
This situation is openly discussed with both partners. The first instruction in this case may be as follows. The man masturbates alone, behind closed doors, experiencing his usual fantasies, but the wife remains in the house, in the most remote room. If the man achieves orgasm, the procedure is repeated a few days later, but this time the wife is already in the next room. Then everything repeats again, but the wife is present in the same room with her husband. The next stage: they have sexual intercourse, and the husband goes to the bathroom to masturbate until orgasm. This sequence of events allows us to establish a connection between heterosexual intercourse and orgasm. The turning point in therapy occurs when the patient's wife manually (using Vaseline is recommended) arouses her husband to orgasm. He is invited to experience his usual fantasies at this moment. These fantasies can be kept to yourself or discussed openly with your wife during sexual activity. (The use of fantasy constitutes another important principle of treatment - distraction from obsessive control and introspection during stimulation).
Once the patient has experienced orgasm after being aroused by his wife, further masturbation alone is prohibited. Now he can only ejaculate in the presence or participation of his wife. The next stage of therapy is the “transfer” of ejaculation into the vagina.
After a man achieves a sustained orgasm as a result of manual stimulation, the “male bridge” technique is used. A woman uses Vaseline to stimulate her husband's penis manually and stimulates him until he has an orgasm. After this, the man inserts the penis into the vagina and makes copulatory movements, while the woman stimulates his penis with her hand. In Fig. 32 and 33 show poses in which it is possible and convenient to perform this technique.
Thus, a combination of manual stimulation with penile insertion and coital movements is obtained, while the wife continues manual stimulation. During coitus, he always informs his wife about the moment of approaching orgasm so that she can remove her hand and he can make several movements leading to the onset of true orgasm. The position in which a woman keeps her legs tightly clenched during intercourse (Fig. 34) increases the force of friction and may be useful at this stage of treatment.
Stimulation and distraction
The basic principle of treating patients with delayed ejaculation, as well as women with suppressed orgasm, is a combination of intense stimulation and distraction from suppressed arousal. It was previously noted that internal experiences of erotic fantasies during genital stimulation are an excellent means of “disinhibiting” the reflex. However, some patients require more complete and complete distraction because they are unable to “get lost” in the inner world of their fantasies and images. In this case, I recommend erotic literature or viewing erotic paintings during stimulation. So, for example, one woman experienced her first orgasm under the influence of an erotic novel, while she used a vibrator for stimulation.
Partially delayed ejaculation
Difficulties in conducting sex therapy
Sex therapy in its intensive form with daily consultations provides the therapist with a lot of information that allows a deeper understanding of the dynamics of marital interpersonal and sexual relationships. Registration of the progress of individual sessions allows you to carefully analyze the influence on the course of sexual therapy of various factors that may contribute to the fixation of the disorder and negatively affect the course of treatment. In some cases, this makes it possible to overcome them and achieve a positive result when it seemed impossible to carry out further training. We have made an attempt to classify these factors and give brief casuistic illustrations of some observations, including cases in which the main disturbance was in the man, and cases in which the disorder was only in the woman.
In men, such difficulties are more common when treating erectile dysfunction. For simple premature ejaculation, treatment usually proceeds smoothly. In case of erectile dysfunction, 4 critical phases can be distinguished, which are determined by the experiences and reactions of a man, and 4 types of negative factors that arise when his partner behaves incorrectly. In sexual therapy for frigidity and anorgasmia, 10 factors can be identified that negatively affect the course of therapy or its results.
1. Critical phases that occur during exercise in case of erectile dysfunction
Phase when starting tasks. The first critical phase for some men occurs during the period of independent training, when, despite repeated instructions, he fails to fully concentrate on the stimulation; he is constantly preoccupied with controlling his erection and worrying about his partner's unsatisfied arousal.
R., 41 years old, technician, married for 16 years, wife 34 years old, employee. They had good family relationships. 4 years ago he experienced premature ejaculation, which was associated with long breaks in sexual relations between spouses, depending on a number of external conditions. The wife was energetic, quick-tempered, and immediately actively showed her dissatisfaction. This caused the husband a feeling of inferiority, to which he was predisposed before (he believed that he had a small penis, etc.). During further sexual intercourse, he became afraid. This led to the appearance and fixation of erectile dysfunction followed by a depressive reaction. The husband was hospitalized, and the wife, who was unable to leave the children with anyone, came to the department in the evening and stayed overnight.
After the introductory session, the spouses were advised to provide mutual tactile stimulation; the husband was not supposed to control the degree of erection, sexual intercourse was prohibited. When assessing the completion of the task, the wife reported that the husband was unable to get rid of control over the degree of sexual arousal and became nervous during love play. She had the impression that he was always preoccupied with something, instead of completely surrendering to tactile sensations. The husband reported that he constantly thought that his wife would become agitated and unsatisfied, that she would have a headache, etc. At times, he controlled the degree of erection with his hand and noticed with alarm that it had become weak and unstable. This was observed during further classes. Only after the 4th consultation was it possible to convince the patient that while sexual intercourse should not be carried out, an erection is completely useless. And even if it appears, he must suppress it. Ultimately, the husband lost control of the degree of erection, and the wife reported that with her sitting on top, they had successful intercourse and both achieved orgasm
Phase related to the penetration problem. Another critical phase for some partners is penetration. While with manual stimulation of the penis the erection is sufficient and stable, when the penis approaches the woman’s genitals it is suppressed. First, partners should be advised to make contact between the penis and the vulva, even with a slight erection, so that the partner can stimulate the clitoris with the penis. In this case, it is necessary to pay special attention to the fact that it is more convenient to carry out such stimulation for both partners with a non-erect penis. This eliminates the “obligatory” nature of the situation for the man: he gets rid of the need to achieve an erection. When a sufficient erection is achieved, it is recommended that the partner distract the man with a conversation and, without any preparation, in a sitting position on top, insert the penis into the vagina. This unexpected penetration is usually successful.
Unstable erection phase. In some cases, after successful penetration, men are unable to fully stabilize an adequate sexual response. Sometimes the erection is sufficient for penetration and sexual intercourse, in other cases it is insufficient or disappears during penetration or during sexual intercourse,
L., a 30-year-old engineer, suffered from primary impotence. After 3 classes on weekends, I gradually managed to induce an erection and perform sexual intercourse with my wife sitting on top. Further attempts to perform sexual intercourse were again unsuccessful and when repeating the first sessions, the erection could not be stabilized. After further consultation, the spouses reported that in approximately half of the attempts the erection was sufficient for sexual intercourse, but after 1–5 minutes it weakened, which did not allow orgasm to be achieved. Spouses receive sexual satisfaction through extracoital stimulation.
Relapse of disorders after completion of treatment. The fourth critical phase may be the end of therapy, when the man loses the support of the doctor, and the partner couple loses a sense of responsibility for completing the appropriate tasks that were given to the partners during the course of treatment. More often this happens when a man does not have sufficient desire and persistence to pay the necessary attention to a long love game.
The couple M., a 46-year-old driver, and I., a 36-year-old cleaner, were sent for treatment for sexual disharmony from a marital consultation. My husband's erection in most cases was insufficient for immission, and even if immission was possible, the erection disappeared already at the first frictions. Since the wife was excited at the same time, but did not achieve orgasm, she began to avoid intimate relationships. Both were in their second marriage. The wife divorced her first husband because he suffered from alcoholism, and the first wife left her husband because of his sexual incompetence.
The wife showed great patience during the lessons and was gentle and caring towards her husband. With the help of continuous 5-10-minute manual or oral stimulation of the penis, she managed to induce a sufficient erection in her husband, which, with continued exercise, allowed sexual intercourse. By the end of the classes, sexual intercourse lasted more than 15 minutes with two breaks or slowdowns.
The couple were discharged from the department completely reassured. Unfortunately, when we collected follow-up information 2 years later, my wife said that “it all ended when I came home.” She wrote: “The husband sits in front of the TV until the end of the program and makes no attempt. I do not like it. Leaving you home, we felt uplifted, it seemed to us that you had rejuvenated us. Now the husband plays the role of an old man. He had kidney inflammation and is worried about his health. None of us say “let’s go to class” anymore.”
2. Incorrect behavior of a partner in case of erectile dysfunction in a man
Tendency to humiliate a partner. A woman's sexual dissatisfaction during sex and anger at her partner due to various external circumstances can lead to her tendency to humiliate her partner, which causes further destabilization of his sexual function.
The spouses R. and X. (the story is given below), after the husband’s erection had normalized and the ability to have sexual intercourse had been restored, at the beginning of the 2nd week of treatment, tense relationships arose due to family problems associated with their growing son. After this, during the next lesson, my husband’s erection worsened again. The wife, who by this time had become aroused and felt disappointed, irritably and energetically demanded that her husband “calm down” and continued the stimulation further. This had a negative impact on erection, and therefore the wife began to reproach her husband for being “nervous,” “sweating a lot,” and irritably ended the love games.
The family conflict worsened, the wife was angry with her husband and during love play again reproached him for his nervousness, which again exacerbated the husband’s sense of inferiority. When the wife saw that her husband was sad, she began to question whether he had any feelings of guilt towards her. In a moment of weakness, her husband admitted to her that some time ago he hugged an employee at work. Irritated by sexual dissatisfaction and her husband’s confession, the wife believed that the cause of all misfortunes was her husband’s adventure. She began to reproach and ridicule her husband and did not want to cooperate in the treatment process. During the next consultation, she called her husband “poor guy” and “weak” and it was clear that she was trying to humiliate him as much as possible, taking advantage of the slight vulnerability of his sexual function.
At this point the class had to be interrupted. Fortunately, the wife had to leave for short training courses, which led to regression of negative emotions and after the wife returned home, the classes were continued and the spouses’ sexual relations were normal 5 weeks after the end of the classes. According to follow-up information obtained about a year later, intimate relationships remained good.
In the above case, the wife’s incorrect behavior was due to the presence of significant sexual reactivity and the inability to achieve a vaginal type of orgasm. Current family problems caused the wife's aggressive behavior towards her husband, which led to a temporary cessation of classes.
Fear of losing husband's addiction. In the case that we present, during the successful sessions, the wife began to fear that her husband, who was largely dependent on her when he had impotence, might meet another, more attractive woman after recovery. This led to her behavior interfering with classes.
L., a 48-year-old miner, for 10 years noted the presence of erectile dysfunction during sexual intercourse while maintaining an erection in the morning and during masturbation. After exercising for 5 days with the wife performing manual stimulation of the penis (which the wife initially resisted), the erection became sufficient. On the day when the wife, according to the recommendation, was supposed to insert the penis into the vagina while sitting on top, she began to worry and began to reproach her husband for not kissing her the previous evening before going to bed. In the conversation, she insisted that she did not want to interrupt her studies, but at the same time she made it clear to her husband that it would cost her a lot of effort. This led to suppression of my husband's erection.
There was a need to interrupt classes, explain to my wife the wrong nature of her behavior and ask her to change it. She explained her actions by saying that she was worried about what would happen when her husband recovered?
After a few days, we managed to convince the patient and the classes began all over again. Within a week, immission was achieved, and the following week successful sexual intercourse was performed 3 times. Six months later, the wife reported that, despite (or due to) the fact that her husband’s erection was still insufficient, their marital relationship was very harmonious.
A woman’s lack of motivation to prolong her marriage. Sometimes there is no motivation on the part of the wife to cure her husband, due not to the anxiety that after his recovery she will lose him, but, on the contrary, to the fact that she herself will want to divorce him. After all, his impotence can be a good excuse for divorce. Therefore, the wife plays the role according to the principle “look how hard I tried.” She agrees to cooperate in the treatment process, but does it mechanically. In fact, it is desirable for her to confirm the presence of impotence in her husband, and not to eliminate it.
Mutual criticism and accusations. Sometimes a stereotype of mutual negative reaction is established between partners, which is very persistent. Each partner is always ready to be offended by the other or accuse him of something.
R.M.'s spouses had a stereotype of mutual humiliation and accusation. Upon admission to the medical ward, the husband was active, extroverted, eloquent and witty. He joked with women and they liked him, which worried his wife. When the wife was absent, the husband was calm, but in her presence he became tense. In his presence, the wife spoke critically about him, the husband, in turn, offended her with his statements, often in a far from delicate way, for example, he mocked her fatness. It is clear that this stereotype of mutual accusation and humiliation was transferred to sexual relations. During classes on the very first night, such a reaction occurred. In the morning, the husband wanted to carry out tactile stimulation, but the wife told him that the instructions for its implementation were given in the evening, not in the morning, and that she did not feel well. Her husband accused her of being uncooperative and disturbing the class atmosphere. Already when, after 2 weeks, the spouses had improved the technique of sexual intercourse, the wife told her husband that the orgasm that she had achieved earlier (in the presence of impotence) with the help of oral stimulation was more pleasant. In response, the husband stated that it was more pleasant for him to have sexual intercourse with one pleasant employee than with his “nasty fat wife.”
3. Difficulties in treating frigidity and anorgasmia
Excessive shyness and inhibitions. This factor is often found in women suffering from anorgasmia. It is especially pronounced at the beginning of the course of treatment and gradually decreases as classes progress.
Patient A. at first could not undress during classes and remained in her underwear. Later, when she achieved sexual arousal during tactile stimulation, she allowed her husband to undress her. Another patient reported to the doctor that she felt guilty when she was undressed or during tactile stimulation. After several lessons, nudity and activity during love games became a matter of course for these women.
Prejudices regarding clitoral stimulation. Studying the excitability of the clitoris in women with anorgasmia and identifying the possibility of achieving orgasm with stimulation of the clitoris is necessarily included in the training program. As experience shows, a significant number of women achieve orgasm with both direct and indirect stimulation of the clitoris. In some cases, anorgasmia is a consequence of insufficient stimulation of the clitoris during intercourse. Some women prohibited manual stimulation of the clitoral area due to the fact that it did not fit with ideas about “correct sexual intercourse.”
I. considers the satisfaction achieved by manual stimulation to be unworthy: “the only true satisfaction comes from sexual intercourse.” N. remains in a state of tension after achieving orgasm caused by clitoral stimulation. Therefore, she believes that she needs “long-term, high-quality sexual intercourse” to achieve sexual satisfaction. We assume this at first because some women who are capable of experiencing orgasm with both clitoral and vaginal stimulation show certain differences between these types of orgasm, preferring the first or second of them (Hite, 1976]. Subsequently, classes were conducted aimed at achieving delay in the onset of ejaculation in her husband.After she managed to prolong sexual intercourse to 20 minutes, N. herself realized that even with a longer duration of sexual intercourse, she would not be able to achieve orgasm without stimulation of the clitoris.
Ya, a 41-year-old employee, married for 20 years, did not experience orgasm. She knows that she is aroused by clitoral stimulation, but forbids her husband to use it. During class, she very reluctantly agreed to this, pushed her husband’s hand away, and demanded that the lights be turned off. When she stopped resisting the stimulation, after 10 minutes she had the first orgasm in her life. Subsequently, they learned to use manual stimulation of the clitoris during sexual intercourse.
Excessive impatience (desire) when trying to achieve sexual arousal. A woman’s activity, her cooperation, and not passive waiting are an important condition for achieving sexual arousal and orgasm during training. However, this activity should not be aimed at achieving sexual arousal and orgasm at any cost as the sole or main goal. Under such circumstances, a situation may arise similar to that which arises when a man strives to achieve an erection by force of will: exactly what he is “chasing” for eludes him. Arousal and orgasm should occur as a spontaneous automatic reaction caused by effective stimulation in the presence of appropriate psychological factors, which include emotional relaxation during stimulation, and for a woman it is also important to have a good understanding with her partner.
Already during the first lessons, 35-year-old spouses D. and K. achieved mutual orgasm, but during the next lesson the wife again had a desire to definitely achieve orgasm. After manual stimulation and insertion of the penis into the vagina, she became only partially aroused, but, contrary to her expectations, the arousal did not further increase, as it had the previous evening. She tried hard to cooperate, but as a result of this, her sexual arousal decreased more and more; Irritation and hostility towards my husband arose. Her husband delicately suggested that she start over. But she set herself the goal of achieving orgasm “at any cost”, increased stimulation and friction, but it was all in vain. She began to fear that everything would return to its previous state. The briefing was aimed at eliminating the tension that had arisen. I had to return to the first lessons, when only tactile stimulation was carried out without attempts to have sexual intercourse and achieve orgasm. Subsequently, sexual activity and sensations spontaneously increased and the partners achieved mutual orgasm, which was more intense than ever before.
Lack of concentration on your feelings. During classes, complete concentration on your feelings and experiences is required. When a woman fails to concentrate during sexual intercourse or is distracted by other thoughts, sexual arousal, as a rule, does not increase. Sometimes, in connection with this, it is necessary to increase the ability to concentrate autogenic training.
M., a 21-year-old patient, suffered from secondary anorgasmia. During classes, she was unable to concentrate on her sensations and, with tactile stimulation provided by her husband, she became bored and yawned. It was necessary to conduct several classes using auto-training. During further sessions, the husband patiently provided tactile stimulation without attempts to perform sexual intercourse, which the wife usually resisted. A week later, after sufficient concentration, the wife became sexually aroused and wanted to have sexual intercourse, during which she achieved orgasm.
Habit of resisting your partner. Some women who are less sexually excitable or women with anorgasmia have a recorded reaction of resistance that occurs when their husband attempts to have sexual intimacy. In some cases, the husband can overcome this reaction by continuing to patiently pay attention to his wife; in other cases, such persistence, on the contrary, strengthens the reaction of resistance. This often causes irritation and anger in emotionally unstable men.
G., when her husband tried to conduct tactile stimulation, asked to postpone the lesson to the next day. The husband was disappointed and was very standoffish towards his wife for the next day. This did not allow the wife to properly tune in to a successful course of study in the evening and instead, a quarrel arose between the spouses. During the next consultation, the spouses reported that this behavior was stereotypical and was often observed at home. This led to long breaks in their sexual relationship.
Anxiety and reluctance as a life position. Sometimes a woman’s negative attitude towards sex is associated with her general negative life position, a tendency towards pessimism, and anxiety. Therefore, such women should first undergo systematic psychotherapy, since otherwise the persistence of a positive result after sexual activity is low.
Patient B., despite the fact that she agreed with the need for sexual therapy, was very reluctant to accept the doctor’s instructions, as if she was doing him a favor. During sexual activities she remained passive and was disappointed if something did not work out for her. The husband's behavior was calm, he used effective stimulation of the clitoris and this led to the onset of quite strong sexual arousal in his wife. However, she always commented negatively on the progress of the classes: there was excitement, but very weak; the excitement was strong, she did not reach orgasm; there was an orgasm, but “it wasn’t right,” etc. The course of sexual therapy was affected by her general position in life: she did not see joy in anything, what was pleasant for other people evoked negative feelings in her. Her life position corresponded, in the terminology of the Berne Questionnaire, to a position like “I feel bad, you feel bad.”
Feeling of mechanicalness of training sessions. We encountered this feeling more often among romantically educated women who adhered to spontaneity in sexual relationships. They found it difficult to perform sexual tasks that were “planned.” These arguments should be accepted without reservation during consultations, emphasizing the validity of the requirement that sexual activity be classified as a sensual relationship, a manifestation of love, respect and admiration, and its function be considered as an expression of spontaneous attention, love, inspiration and attraction. At the same time, it should be explained that since orgasm did not occur “spontaneously” during long-term intimate relationships, you should first learn the basic rules and techniques of sexual intercourse during classes, fix the necessary skills with mechanical exercise, and then you can succumb to your spontaneous sensations and focus on emotions . A comparison is made with dance: first one should learn the basic figures through mechanical training, and then one can enjoy the dance without paying attention to its technique. This problem can usually be easily resolved during training.
Fatigue and satiety during daily activities. Our experience shows that there are women for whom well-run sexual activity leads to its further intensification (orgasm causes a desire to achieve a new orgasm), while other women, after normal sexual activity with rapid achievement of satisfaction, need a certain period of time in order to so that their attraction and ability to respond sexually is restored. Therefore, the continuation of intimate relationships before the resumption of sexual desire leads to a feeling of satiety, and sometimes to resistance. Therefore, classes with women of this type should be carried out with breaks of at least one day or on weekends. According to our data, daily sexual activity for two weeks with 2-3 breaks was not painful for the majority of those women who avoided intimate relationships at home or limited them to a minimum.
Constant quarrels with your partner. Quarrels with a partner during the day reduce the ability of some women with anorgasmia to cooperate during activities. Many women cannot quickly get rid of a bad mood in this regard and transfer their negative emotions to the situation of classes, which deprives them of the necessary favorable atmosphere. Classes, despite correctly conducted stimulation, do not cause sexual arousal, since negative emotions and feelings of tension block it. Therefore, the partner’s tactics should be to avoid conflicts and praise the partner (according to the principle: “if you want honey, don’t turn the hive over”). It is also necessary to develop the ability of partners to conduct so-called constructive disputes, which make it possible to immediately eliminate the tension that has arisen and achieve final rapprochement.
Relationship problems with husband. One should distinguish between minor conflicts or shortcomings in mutual communication between spouses, which do not interfere with sexual activities, and deeper disagreements, which are caused by a feeling of indifference or hostility towards a partner or sensual attraction to another man. This reduces motivation to achieve and sustainably improve sexual relationships.
A. Acceptance of obligations only under the influence of doctor's instructions. The patient cooperates only after receiving the task. She does this because the task is new to her or because she wants to do a favor for the doctor. When the supervised sessions end, she considers herself free from her obligations and her sexual activity quickly returns to its original level.
Patient B. showed considerable persistence during classes. In most cases, on her own initiative, she participated in classes 2 times a day. All problems between spouses during classes moved away and, despite the previous reluctance to show any sexual activity With husband and the presence of anorgasmia, after a series of sessions with combined stimulation of the clitoris and vagina, the woman began to achieve orgasm. However, after returning home, she again began to avoid intimate relationships and resisted her husband.
Patient A., also under the influence of the doctor’s instructions, overcame her aversion to sexual intercourse and began to behave actively during it. However, after returning home she became passive again. Her husband explained this in the follow-up questionnaire by saying that “during treatment, she had to describe her behavior in a diary and that’s why she tried so hard.” But at home she had no motives, she was not happy with her husband and did not want to try “for his sake.”
b. Increased negative attitude towards a partner during classes under the influence of the requirement for active participation in sexual intercourse. Some women with anorgasmia, who lack a positive attitude towards their spouse, sometimes give in to his desires, but do not show any sensual participation in sexual intercourse. At the same time, activities aimed at eliminating anorgasmia require the woman’s active participation in them, her desire to experience, to prolong love play and be active during tactile contact with her partner. In cases where hostility towards a partner was deep and hitherto hidden, demands to be sexually active can make it obvious.
Patient B., a 30-year-old employee, has no children, married her husband after he took her virginity. She doesn’t respect her husband, considers him stupider than herself, and even though her parents support her, she dominates him. Sexual relations between them have been disrupted from the very beginning of marriage; sexual intercourse occurs no more than once a month, and then under pressure from the partner. Shy and sexually naive. I would like to have a child, I am being treated for infertility, but I did not tell the gynecologist about the rare frequency of sexual intercourse. First, it was necessary to overcome her excessive shyness with the help of autogenic training and systematic desensitization. The results were positive. Gradually, she began to experience sexual arousal with sexual imagination and a feeling of warmth in the lower abdomen when appropriately suggested. When her husband was involved in the classes, she began to vomit and react with resistance. One day she tried to participate in the classes, and the next day she resisted it. She stated that during classes she goes against her inner feelings that she could be sexually active, but not with her husband. A few days later, she stopped classes and told her husband that she felt deep hostility towards him and proposed a divorce.
V. The desire to prove that sexual relations cannot be established by any means. This desire was most often observed in women who are attracted to another man and want to prove to themselves or their spouse that existing sexual disorders are very persistent and cannot be eliminated with the help of special classes. These women also play the game of “look how hard I try” with the subtext of “but it’s not working.” Often this is necessary to justify a divorce from a husband in order to relieve feelings of guilt.
Patient E., after being married for 23 years, met a divorced, older man with whom she maintains a romantic relationship with a subtle spiritual understanding. Has two children. Considers her husband to be rude, vulgar, insensitive. She was dissatisfied with her marriage and never experienced orgasm. I tried to leave my husband, but the children did not want to leave their father. Under the influence of group therapy, she wanted to try to establish a sexual relationship with her husband, which, given her husband’s pronounced sexual desire and her reluctance to have sexual intercourse, was a constant source of conflict. Her motivation for engaging in sexual activities was ambivalent from the very beginning. She is sexually excitable, but whenever orgasm approaches, she suppresses sexual arousal so that her husband does not know about the positive effect of the treatment. She was afraid that this would not allow her to renew her relationship with the man who attracted her, a potential lover, with whom she constantly dreams of intimacy. After the end of treatment, she stopped maintaining an intimate relationship with her husband and, with her constant refusals, provoked his aggressive behavior, and then used this as an excuse for refusing further sexual intercourse. Her husband forces her to have sexual intercourse, which suppresses her sexual arousal. The wife decides to divorce her husband. Her sexual activity is restored when communicating with her lover, with whom she feels happy.
G. Overwhelming feelings of resentment about the past.
Patient Yu had a joyless childhood; she grew up in a poor family as the eleventh child out of twelve children. At the age of 11 she was raped, and at the age of 13 she attempted suicide. At the age of 19, at the insistence of her parents, she got married. The husband was older than her and the relationship between them did not work out. After some time, she left him and got divorced. She has been living with another husband for two years and has two children with him. I used to experience an orgasm during intercourse with him, but lately I haven’t. Her partner is a primitive, rude person who abuses alcohol, but provides well for the family financially. The husband is interested in continuing sexual intercourse with his wife, but the wife wanted to maintain a relationship with her husband only because of the children. Despite her initial consent, she kept interrupting the treatment she started. She played the role of an offended, insulted woman. During group sessions, I expressed old grievances to my partner. It was not possible to establish proper communication between the partners and the classes were interrupted.
4. Combination of sexual and marital disharmony
Often, when conducting sex therapy, we encountered cases where sexual and non-sexual problems were combined to such an extent and mutually potentiated each other that they created a vicious circle. The question arises: where can we break this circle? Is it possible to try to eliminate both negative factors? We will try to illustrate this problem and examine in detail several typical examples.
Negative influence of relationships on the course of classes.
Spouses M. and N. were referred from the sexological clinic. The husband is 30 years old, he is a cultural worker, the wife is 27 years old, a high school student. They had a 5 year old son. The wife was previously hospitalized in another psychiatric department due to the presence of neurotic complaints of a hysterical type. Psychiatrists saw their cause in prolonged sexual dissatisfaction. The husband had relatively premature ejaculation with the duration of sexual intercourse being about 3 minutes. This prevented the wife from achieving orgasm and caused tension between them. They have been living together for 6 years. At first, the wife hid the presence of sexual dissatisfaction, but later, as neurotic disorders intensified, she began to express her displeasure to her husband. This caused him a feeling of inferiority and secondary erectile dysfunction. Thus, the woman had anorgasmia, and the husband had impotence, and these disorders were mutually determined.
The wife's clinical picture was based on severe neurasthenic disorders, anorexia, tearfulness, elements of depression, feelings of inferiority, anhedonia with suicidal thoughts. The husband was an introverted person, with mild neurotic signs of the neurasthenic circle (insomnia, headaches, irritability, mild depression), which intensified six months ago due to family disagreements and the appearance of poor adaptation to his work.
Progress of treatment. The couple was hospitalized in the therapeutic department for 3 weeks for the purpose of sexual therapy.
The stay in the department showed that N. is a cheerful and sociable woman, dances well and shows spontaneous activity in communication in the absence of her husband. In the presence of her husband she becomes withdrawn or, conversely, overly sociable, which irritates him. His face acquired a critical expression, the spouses mentally and physically moved away from each other, tension grew between them. During sexual activity, it turned out that N. not only could not, but also did not want to achieve sexual satisfaction with her husband. She did everything for that. so that the classes are unsuccessful. A more detailed analysis revealed that at the age of 17 she was deceived by the man she loved. Since then, she has subconsciously taken revenge on other men, including her husband. This generalized reaction was irrational. She understood that she had all the conditions for everything to be calm in the family. At the end of the treatment, she said: “I have a well-mannered child, my husband has a good profession, I can study. I have everything for a quiet life." She formulated the reason for her inadequate reaction as follows: “I failed to take revenge on my first husband, who deceived me and ran away. I took revenge on others, and thereby harmed myself. Now I myself understand that my husband suffers from impotence because of me.”
The conflict between the spouses was resolved during group psychotherapeutic sessions, where they mutually accused each other of intransigence and unwillingness to correct their behavior. The husband drew his wife's attention to the theatricality and hysteria of her behavior, and the wife told him that he was overly controlling and discussing her behavior, that he was overly jealous.
The partners spent a very long time and unproductively sorting out an old conflict during psychodrama, when the wife came home late in the evening from a friendly party and did not know how to more advantageously explain her late arrival to her husband. The husband appealed to the other men in the group, arguing that his wife’s behavior was ridiculous. The wife objected, saying that she would have explained everything to him then if he had not behaved too critically towards her before.
In the department, M. tried to have an advantage over his wife, did not pay attention to her, did not show interest or tenderness in her, remained tense, and N. reacted with stubbornness. The couple took offense at each other at every evening in the department, for which they were criticized during group psychotherapy sessions.
When they were not analyzed during group psychotherapy. correct relationship, we decided to use the method of constructive dispute. However, it took almost incredible effort for the spouses to accept the conditions of this method.
When they argued, they could not stop, and it was difficult for them to admit their own mistakes or praise each other. Repeated sessions at a later stage of treatment also did not lead to complete reconciliation. Only under “pressure” from the other members of the group did the spouses come to a common opinion at least about what was wrong in their relationship.
Sexual activities were carried out according to our instructions in the afternoon and evening and were initially unsuccessful. However, at the end of the week some progress was achieved.
During a session with tactile stimulation and concentrating on his sensations, the husband noticed that his wife could not completely relax and concentrate. First, she should have been taught to concentrate using autogenic training. On the 4th day, during manual stimulation of the clitoris in the recommended position, the wife had an orgasm, but she believed that this type of orgasm did not give her complete sexual satisfaction and was less valuable, which was associated with her childhood ideas: she was raised in a conservative Catholic family , where masturbation was considered a sin.
On the 5th evening, the spouses did not complete the tasks because they had been arguing all night. On the 6th day, N., according to the lesson plan, stimulated her husband’s penis. Using the compression technique and constant stimulation, a good erection without ejaculation was maintained for 20 minutes. During further classes, immission was carried out and with minor frictional movements of the wife in a sitting position on top, they learned to prolong sexual intercourse. The wife became more active, but she was unable to achieve orgasm. The husband immediately developed a tendency to weaken his erection due to a relapse of anxiety due to his inability to achieve successful sexual intercourse.
Conflicts and tensions between spouses that accumulated throughout the day were then transferred to the period of classes.
During the class, despite manual stimulation of the penis, a sufficient erection did not occur, which again led to a conflict between the spouses; the wife irritably reproached her husband and did not follow the instructions for conducting the class, which was indicated to her by her husband.
At this stage, on the 8th day of classes, it became clear that it was necessary to improve the relationship between partners with the help of group therapy, which would require long-term group psychotherapy with all its phases (increasing tension, identifying and correcting previous forms of behavior, etc.). P.). However, this would lead to the cessation of sexual activities that require an atmosphere of goodwill, consent and good humor. Our doubts about achieving both goals grew within three weeks. We also thought about stopping sex therapy to work on our interpersonal problems. But then the couple would not be able to resume classes. Therefore, it was decided to continue the classes and pay special attention to creating calm, smooth relationships between partners without a deep analysis of the psychological reasons leading to disharmony.
On the 10th day, the couple conducted classes according to plan. A sufficient erection occurred within 20 minutes, without using the compression technique. Despite the fact that the wife was unable to achieve orgasm during intercourse while sitting on top, she felt satisfied. On the 11th day, the wife was active during the session, but did not achieve sufficient arousal and realized that vaginal stimulation was not enough for her, even if her husband could provide it for a long time, and that she needed additional stimulation of the clitoris. The orgasm came as a result of stimulation of the clitoris, and she endured it without previous negative experiences. On the 14th day, orgasm occurred in both partners - the husband at the end of sexual intercourse, and the wife during subsequent manual stimulation.
At the 15th lesson, the partners tried to achieve synchronization of the onset of orgasm. The husband, in a lateral forward position with the penis inserted into the vagina, performed 15 minutes of manual stimulation, after which his wife had an orgasm, and he himself achieved orgasm with subsequent rapid frictions.
After two weeks of training, the spouses achieved that during prolonged sexual intercourse in combination with manual stimulation, first the wife had an orgasm, and then the husband ejaculated. Over the next week, the husband became able to perform sexual intercourse (with interruptions and slower frictions) for more than 15 minutes, and the wife began to have an orgasm with the insertion of the penis and stimulation of the clitoris much faster than before (not after 20, but after 7 minutes). ). The wife was able to achieve orgasm faster with combined vaginal-clitoral stimulation than her husband. Both became calm and their relationship improved.
Catamnesis. 4 months after the course of treatment, in follow-up questionnaires, the spouses indicated that their sexual relationship was normal (no problems with erection or ejaculation; in most cases they achieved mutual satisfaction). However, after a year, they indicated that their marital and sexual relationships were disorganized. The wife believes that sexual relations have become the same as before treatment, and the husband believes that they are still somewhat better than they were before treatment. He wrote that at first, despite the normalization of sexual relations, there was no normalization of emotional relationships. The wife perceived her husband as a partner only in sexual terms. She reacted to all life difficulties (illness of a child, financial difficulties, conflicts with others, etc.) with an outburst of crying and was unable to overcome them calmly. She perceived all these “blows” of fate as malicious, directed specifically against her. She was more worried about her studies than about her child, which was in conflict with her husband’s ideas about motherhood. The child was neurotic due to the lack of affection and care from the mother, which caused concern to the husband. And although their sexual relationship has improved, he is not happy about it. It became difficult for him to fall asleep, he suffered from headaches, fatigue, and depression.
The wife reported that outwardly everything was going well with them, like ideal spouses. She has so many different concerns that she has no time to deal with this issue. She achieves sexual satisfaction only through masturbation or otherwise, in a relatively short time (5–8 minutes). She doesn’t want to write about this in detail, she doesn’t even want to think, because if she does this, she can no longer study or work. The husband knows nothing about this. His wife suspects that he has found another woman to stop tormenting his frigid wife. All this has an extremely negative effect on her, as she has lost faith in herself.
This example shows that within 3 weeks you can effectively help partners establish sexual relationships, but you cannot teach them how to live. Ultimately, family disharmony leads to disruption of sexual relationships.
Interdependence of interpersonal and sexual relationships. The case described above, despite individual characteristics, is largely typical of the category of unsuccessfully treated partner couples, a category where there are insoluble deep problems in interpersonal relationships. This is a negative example of the interaction of partners, their complex negative or ambivalent relationships, caused by negative experiences in the past and fixation of the incorrect nature of the relationship. In these cases, during treatment, the desire for harmonious relationships in classes is often incompatible with the desire to normalize relationships, resolve conflicts and eliminate tension between partners. In all these cases, during the course of treatment, we reached a phase when it was necessary to decide whether to continue the activities, which were complicated by the growth, actualization and consolidation of interpersonal contradictions in the mind, or to interrupt them, focusing primarily on the normalization of marital relations. In terms of time and taking into account the main purpose of the classes (the patients were directed specifically to sexual therapy and expect it), we, as a rule, tried to speed up the classes and limit the influence of interpersonal issues to a minimum. Our main emphasis was on the fact that these problems can be discussed in daytime group classes, but never in the evening. We recommended that the psychotherapy group on the department should not analyze the conflict in depth; We tried to explain to our partners the need for greater flexibility in the implementation of their intentions and in emotional relationships (one must be able to clearly separate the time devoted to conflict analysis from the time intended for spiritual harmony and sex).
Sexual and interpersonal problems create a vicious circle in such partners, mutually reinforcing each other. It is generally believed that interpersonal problems should be resolved first. However, we tried to solve sexual problems first, hoping that their successful solution would create the preconditions for resolving interpersonal conflicts. We recommended continuing the classes, explaining that first you can learn to successfully perform sexual intercourse and have positive sexual experiences, and then you can think about whether the spouses want to continue living together, improving mutual understanding and emotional relationships.
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