Sexual Disorders
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Sexual Disorders Document Transcript

  • 1. 1 Sexual Disorders & Treatments Popular culture leads us to believe that everyone is always ready, willing, and able to have sex; however, at any time throughout our lives the sexual fires may be slow to ignite. Your sexual well-being is intimately connected to your emotional and physical health. Sexual dysfunction, a problem with sexual desire, arousal, or satisfaction, often coincides with other health problems. Without an understanding of the cause of a sexual problem it is difficult to provide effective treatment. Sexual dysfunction can contribute to personal and interpersonal stress; treatment is essential to identifying (or ruling out) significant medical or psychological problems. A disorder caused by an organic disease requires different treatment than a sexual problem resulting from relationship conflict. While it is difficult to separate cause and effect, sexual health and overall happiness are closely linked. A recent report in the Journal of the American Medical Association found that 43 percent of American women and 31 percent of men ages 18 to 59 said they suffered from one or more sexual problems (Laumann, Paik, & Rosen, 1999) Men with erectile dysfunction were more than four times as likely to be unhappy than men without this problem, while women who had difficulty becoming sexually aroused were five times more likely to be dissatisfied with their lives than other women (Laumann, Paik, & Rosen, 1999). In contrast to what the clothing industry would have us believe, sex is not an alluring undergarment that can be put on and taken off; it is an integral part of life as a whole. The American Psychiatric Association (1994) places sexual disorders into four categories: disorders of sexual desire, disorders of sexual arousal, orgasmic disorders, and sexual pain disorders. But don’t put yourself into one of these boxes just yet. Anyone can experience any of these on occasion. It is important to distinguish between a rare or occasional problem, which is normal, and a frequent or chronic problem, one that occurs consistently over a long time period. Who hasn’t had a time when you (or your partner) would really just as soon watch television as have sex? Not every sexual experience is worthy of poetic rapture. In order to be considered a sexual dysfunction, the symptoms must be persistent and pervasive and the problem must cause the individual personal distress. If your partner is unhappy with the frequency of sex in your relationship but you are not, by definition you do not have a sexual dysfunction. There are two types of dysfunctions: primary and secondary. A person who has never had satisfactory sexual relations suffers from primary sexual dysfunction, while one who has had successful sexual relations at some time but is currently having chronic difficulty suffers from secondary sexual dysfunction. It is not always easy to distinguish those who have a sexual dysfunction from those who don’t. As one researcher states, “Just as everyone able to complete the sexual response cycle isn’t having great sex, everyone with a sexual dysfunction isn’t having lousy sex” (Schnarch, 1991, p. xiv). Another way of categorizing sexual dysfunction is as lifelong vs acquired (learned), or global (generalized) vs specific (situational). Classifications of Sexual Dysfunction Lifelong The dysfunction has always been present Acquired At some point, the person was ableo to function without the problem Situational The dysfunction occurs in some situations but not in others Generalized The problem occurs regardless of the situation At one time it was thought that most sexual disorders resulted from psychological problems. There has been a general trend in Western culture to blame psychosocial factors for sexual problems, especially those experienced by women (Davis, 1998). We now know that sexual dysfunction may have any of a number of causes: biological, in- terpersonal, emotional, cultural, or any combination of these. Researchers in England recently investigated the association of sexual problems with social, physiological, and psychological problems in 789 men and 979 women ages 18 to 75 years (Dunn, Croft, & Hackett, 1999). Results indicated that sexual problems were most commonly associated with self-reported physical problems in men and with psychological and social problems in women. The difference between the genders is no accident. As we discuss throughout this book, many theorists believe that male sexuality tends to be more closely linked to biological factors, and female sexuality depends more on the social and interpersonal context.
  • 2. 2 Treatment for sexual dysfunction may be medical, psychological, or a combination of the two. Medical therapies include various approaches such as hormone therapy, prescription medication, and surgery. Psychological treatment includes behavioral models as well as psychodynamic or talk therapy. A review of four professional journals (the Journal of Sex Education and Therapy, the Journal of Sex & Marital Therapy, the Journal of Sex Research, and Archives of Sexual Behavior) found that the medical model has become the dominant treatment for male sexual dysfunctions (Winton, 2001). You might be wondering why this chapter is included in the section of our text on physical needs rather than under social or emotional needs. As with most aspects of our sexuality, there are multiple dimensions to any sexual disorder. Sometimes the problem is purely a medical one, or it might be solely a relationship problem or only related to an individual’s emotional distress. Sometimes the problem might be related to all of your basic needs. You might have a health problem and at the same time feel unfulfilled in your relationship because it conflicts with your sexual values and cognitive beliefs. Some people may feel societal pressure to perform sexually. These real or imagined pressures may result in a fear of performing that ultimately produces a sexual dysfunction We include sexual dysfunction as a physical need, because that is where most therapists start when evaluating a client; any underlying physical problem is ruled out before exploring other possibilities. DISORDERS OF SEXUAL DESIRE Sexual desire, or libido, runs along a continuum. For some, having sex once a day is not enough; for others, sex once a year is too often. Sexual desire in the same individual can also vary, from day to day or over the years. It’s not unusual for us to compare ourselves to others to see how our sex lives measure up. But little is known about what constitutes normal sexual desire or how sexual desire may differ between men and women. Moreover, there are no established criteria by which to measure sexual desire. Since we lack scientific data, we must rely on information from clinical observation and statistical surveys. “Normal” may simply be what is usual or typical for you. Stress, fatigue, and general health can affect your level of sexual desire, as can more serious medical conditions, relationship problems, and emotional difficulties. Being too tired one night is not a problem; the problem occurs when there is an unsatisfactory change in the overall pattern of sexual desire. Sexual desire disorders are the most common reason couples seek sex therapy. However, those seeking help often mistake a lack of sexual desire for a problem of sexual arousal, such as erectile dysfunction, or an orgasmic disorder. Sex therapists report that nearly half of all clients are diagnosed with sexual desire disorders (Reinisch, 1991). The most common health-related causes of decreased sexual desire are depression, stress, side effects of drugs, and changes in hormonal levels, especially testosterone. Any disruption of the brain or central nervous system, such as that experienced in a stroke, can affect the biological mechanisms necessary for experiencing sexual desire (Reinisch, 1991). In the past, disorders of sexual desire were considered to belong to psychology not medicine. Although we are learning that endocrine fluctuations and neural activity of the brain affect sexual desire, the influence these neurological and biochemical systems exert is uncertain. Today you are as likely to be treated for a sexual desire disorder by your physician as by a mental-health professional. Hypoactive Sexual Desire Hypoactive sexual desire is the technical term for a lack of interest in sex (APA, 1994). It may include an absence of sexual fantasies or thoughts as well as a lack of interest in sexual activity. Women with hypoactive sexual desire have in the past been referred to as being “frigid.” This pejorative term, rarely used to describe men with low libido, unfairly placed blame squarely on the woman rather than exploring the sociocultural, emotional, and physical factors that might contribute to her low libido. Almost everyone has periods in life when they have little or no interest in sex. As with other sexual difficulties, hypoactive sexual desire can be a chronic or episodic problem. For some people, a low level of desire affects all sexual interactions; in others, it is specific to one partner, situation, or sexual activity. A temporary change in sexual desire is usually due to a specific stressor and generally is not considered to be a serious sexual problem. There are different degrees of hypoactive sexual desire. Some individuals may not initiate sex, but they enjoy sexual relations when their partners come on to them. Others may avoid genital sex but enjoy other types of physical
  • 3. 3 affection. And there are those individuals whose loss of sexual interest is so pervasive that any form of physical affection is repellent. Biological factors such as the changes associated with menopause, nerve damage, diabetes, heart disease, smoking, and obesity are all possible roots of a problem with sexual desire. Reduced or deficient ovarian function resulting in decreased androgen levels may also affect libido. Medications, including antidepressants and certain drugs for birth control, baldness, and high blood pressure, can inhibit libido. Hormones have a significant effect on our sexual desire; the normal hormonal fluctuations that occur with aging (a decrease in estrogen and testosterone) can result in decreased sex drive. Psychological factors have a tremendous effect on libido. These include stress, depression, past sexual abuse, poor body image, and a history of unsatisfactory relationships. Hypoactive sexual desire can be related to conscious or unconscious negative thoughts and feelings about sex formed by cultural upbringing or past sexual abuse. When activated by sexual thoughts, fantasies, or emotions, the sexual pleasure centers of the brain create physical sexual excitement. However, the process cannot occur if sexual desire messages are overridden by other emotions or shut down by other brain centers. For example, if a person associates pain with sexual intercourse, the need to avoid pain takes priority over seeking pleasure. Individuals with sexual desire problems often perceive danger where there is none and shut down sexual feelings in situations that are, in reality, safe (Knopf & Seiler, 1990). While individuals may be fully aware of this process and able to identify the source of their difficulties, more commonly, these desires are unconsciously suppressed. Depression and sexual desire problems often coexist. To complicate things further, antidepressant medications can induce sexual problems or make them worse, creating a vicious circle. Your attitude toward sex can also be a physical expression of problems in the relationship. If you’re angry hurt or bored with your partner, it is likely to spill over into the bedroom. It is sometimes difficult to determine which comes first, a bad relationship or a bad sex life. As indicated earlier, hypoactive sexual desire, like all sexual dysfunctions, is diagnosed only if it is a problem for the individual, not if it only upsets the individual’s partner. Differences in sexual desire between the partners in a relationship are not uncommon. Because one partner doesn’t want sex as often or at the same time as his or her partner doesn’t necessarily mean that the less-interested partner has a hypoactive sexual desire disorder. Some people are content with a low libido and others only have sex “to pacify or silence the complaints of their disgruntled partners” (Schover & Leiblum, 1994, p.18). However, most of those who have hypoactive sexual desire want to enjoy sexual feelings but find that they are unable to do so. The desire to enjoy sex is key to treatment of hypoactive sexual desire, the topic of the next section. Treatment for Hypoactive Sexual Desire Once dismissed as an intractable psychological problem or an inevitable result of menopause, hypoactive sexual desire is now getting increased attention from researchers and the medical establishment. However, barring any biological cause, sexual desire disorders maybe the category of sexual problem that is most difficult to treat (Hawton, Catalan, & Fagg, 1991; LoPiccolo & Friedman, 1988). Insight-oriented psychotherapy, in which a client talks with a therapist to heighten self-awareness, can help reveal and resolve deep-seated psychological conflicts that inhibit sexual desire. Some therapists believe this type of psychotherapy to be especially helpful in the treatment of low sexual desire. Behavior therapy, which focuses on modifying behavior and may include self-stimulation exercises combined with erotic fantasies, may sometimes be recommended for clients experiencing hypoactive sexual desire (LoPiccolo & Friedman, 1988). When low sexual desire is linked to depression, treatment with antidepressant medication or psychotherapy may be helpful. However, as already noted, antidepressants themselves have the potential to cause sexual dysfunction; as a matter of fact, nearly all antidepressants approved for use in the United States have a negative effect on sexual function (Sussman, 1999). Some studies have reported that between 35 and 75 percent of patients taking selective serotonin reuptake inhibitors (SSRIs), such as Prozac and Zoloft, reported sexual dysfunction as a side effect. The most frequent sexual side effects reported are delayed ejaculation, absent or delayed orgasm, and sexual desire and arousal problems (Rosen, Lane, & Menza, 1999). Many women who choose hormone replacement therapy during and after menopause receive only estrogen. However, the levels of testosterone and other androgens also diminish in menopausal women. Although it is known that testosterone plays a key role in sexual desire for both men and women, it is not routinely included in hormone replacement regimes. Studies have shown that women who received estrogen and testosterone feel much better sexually than those who receive only estrogen (Kauntitz, 1997; Sherwin, 1997). A study published in the New England Journal of Medicine (Shifren et al., 2000) found that the use of an experimental testosterone skin patch
  • 4. 4 could improve sexual well-being in women who have had a hysterectomy, so-called surgically menopausal women. However, testosterone is still controversial and some health-care professionals are reluctant to prescribe it because of earlier studies showing that, in high doses, testosterone has masculinizing side effects like increased hair growth and deepening of the voice. It also can cause weight gain and acne. More serious side effects of high doses include increased cholesterol levels and the risk of liver and heart disease. However, the doses currently recommended are so low that side effects are virtually nonexistent. Testosterone also may be given to younger women who take birth control pills or who have other conditions leading to a lower-than-normal testosterone level (Warnock et al., 1997). Because low sexual desire has both physical and psychological causes, it only makes sense that a mind-body approach would provide optimal treatment possibilities. Medications or hormone treatment might be supplemented and complemented by psychotherapy that may specifically focus on sexual problems or more generally on emotions and relationship problems. Sexual Aversion Low sexual desire that includes fear, disgust, and avoidance of sexual activity is considered sexual aversion (Kaplan, 1987, 1995). Even the thought of sexual contact may result in extreme anxiety and include physiological symptoms such a rapid heartbeat, nausea, dizziness, and trembling. Those who develop fearful reactions to sex may have a history of physical or sexual abuse or a severely rigid or punitive upbringing. Others may have health concerns, real or imagined, resulting in an aversion to sexual intimacy. Treatment tar Sexual Aversion According to Masters and Johnson, the key to treating sexual aversion is empowerment. The person experiencing sexual aversion is temporarily put in control of any situation involving physical intimacy (Masters et al., 1987). A series of sensate focus exercises is used to allow the person to develop comfort with his or her own body, tolerate mild anxiety, and gradually increase the level of sexual contact. See the section later in this chapter on Sex Therapy for more on how sensate focus exercises are used to treat sexual disorders. Compulsive Sexual Behavior So far we have discussed problems with inadequate sexual desire. There is also a disorder involving excessive sexual desire or behavior, called compulsive sexual behavior. The problem is, who decides what is excessive and how much sex is too much? There is no agreement among professionals about the definition, diagnosis, treatment, or even the terminology to describe this behavior, and the American Psychiatric Association does not recognize it as a legitimate psychiatric disorder. Although it is not a medically recognized sexual disorder, because of the widespread interest and concern with compulsive sexual behavior, we feel it is important to include a discussion of it in this section. The various terms used reflect not only the confusion about this problem but also different values, attitudes, and theoretical orientations. In the past, the pejorative term nymphomania was used to describe women with a higher level of sexual desire than was deemed to be appropriate, and satyriasis was used for men. These terms have since been discarded, but there is still no consensus regarding a label; you may also hear the terms sexual addiction, hypersexuality, sexual impulsivity, and sexual dependence used to describe this disorder. The term sexual addiction first became popularized in 1983 with the publication of Patrick Carnes’ book Out of the Shadows: Understanding SexualAddiction. Carnes argued that there are a large number of people whose craving for the “high” of sex is out of control to the degree that it can legitimately be considered a true addiction. Rather than enjoying sex as a pleasurable activity, the sex addict relies on sex for comfort, nurturing, or stress relief. Several researchers believe that compulsive sexual behavior is a valid and serious sexual disorder in which obsessive sex can lead to a dependency similar to that caused by alcohol and drugs. Others think that the problem has more in common with compulsive behaviors such as eating or gambling or impulse disorders such as kleptomania. Some see the label of sexual addiction as a means of pathologizing illegal sexual behavior (Rinehart & McCabe, 1998), for example, using sexual addiction as an explanation for rape. Others think that it is simply an excuse for being irresponsible. Sexual addiction may be related to a biochemical abnormality. Individuals become hooked on the pleasurable neurochemical changes that take place in the body during sexual behavior. Liebowitz (1983) has found that many so-called “relationship-junkies” (those who go from one sexual relationship to the next) suffer from a craving for the brain chemical PEA. In an experimental study, subjects were given antidepressants to boost levels of PEA and other
  • 5. 5 natural amphetamines. After this treatment, they no longer craved the PEA high and could make more considered choices in sexual activity. Sabelli, Carlson-Sabelli, and Javaid (1990) reached similar conclusions in their study: 33 happily attached people were all found to have high levels of PEA, while a couple going through a divorce had low PEA levels. Other researchers have also concluded that those who have low levels of PEA are more likely to pursue sexual variety and excitement (Sostek & Wyatt, 1981; Weiss, 1987). Those who do not believe that compulsive sexual behavior is a disorder criticize it as a fad diagnosis with no scientific basis. Calling conventional sexual behaviors taken to an extreme an addiction negates personal responsibility for behavior; so-called addicts may seek to excuse their behavior behind the shield of an uncontrollable disease (Konner, 1990). Historically there is a long tradition of pathologizing behavior that some might find distasteful; these behaviors have included masturbation, oral sex, homosexuality, and extramarital sex. Behaviors that conflict with your value system may be problematic, but that does not mean that the person is “sick.” Treatment for Compulsive Sexual Behavior Since sexual addiction is not a medically recognized diagnosis, there is no standard treatment protocol and few empirical evaluations of the efficacy of treatment (Gold & Heffner, 1999). Typically treatment may include the combination of drugs used for other compulsive disorders or antidepressant medications, a 12-step program such as Sex Addicts Anonymous, behavior therapy to control compulsivity, or treatment of underlying emotional problems such as depression or anxiety. DISORDERS OF SEXUAL AROUSAL Sexual dysfunction may occur at any point of the sexual response cycle, but most typically it involves difficulties related to sexual arousal or orgasm, thus the term sexual arousal disorder. Erectile Dysfunction Erectile dysfunction (ED) is a persistent inability to sustain an erection sufficient to complete sexual activity (APA, 1994). Difficulty in becoming erect or maintaining an erection is caused by a failure of the blood to flow into and engorge the erectile tissues of the penis to make it firm and erect. You may have heard this condition referred to as impotence. Because this term is imprecise and implies personal failure or a challenge to masculinity, experts prefer to use the term erectile dysfunction. This emphasizes the medical aspect of the problem and more clearly defines its role in male sexual function. Erectile dysfunction can be classified into one of two categories. Men with lifelong erectile dysfunction have had this disorder throughout their lives. As implied by its name, acquired erectile dysfunction occurs after a period of normal functioning. It is not uncommon for a healthy man of any age occasionally to experience erectile problems. This occasional problem may be caused by a number of factors, including fatigue, stress, alcohol consumption, or a short-term illness. However, chronic erectile dysfunction should be evaluated and treated quickly. More than 50 percent of men ages 40 to 70 (that’s 10 to 30 million in the U.S. alone!) experience some degree of erectile dysfunction, and the prevalence increases dramatically with age. Contrary to popular belief, most chronic problems are not psychological; rather they are indicators of a physical problem that requires prompt medical attention. Physical factors that can affect a man’s ability to have and sustain an erection in-elude diabetes, vascular disease, high blood pressure, and various neurological disorders. It is thought that about 25 percent of all erection problems are caused by alcohol, illicit drugs, or prescription drugs given to treat other conditions (Leary, 1992). It is believed that a lack of the chemical nitric oxide may play an important role in many cases of erectile dysfunction. When the penis is flaccid, the arteries that carry blood to the penis are clamped tightly so they carry little oxygenated blood. As a matter of fact, the relaxed penis contains less oxygen than any other organ of the human body. During sexual stimulation, the brain sends a signal to nerves in the smooth muscles of the penile arteries to produce nitric oxide. The nitric oxide relaxes the clamped arterial muscles and allows blood to flow into the penis. Anything that deprives the penis of oxygen—vascular disease, lack of exercise, sleep deprivation, smoking, diabetes, sexual abstinence, or physical injuries—can contribute to erection difficulties (Blakeslee, 1993). Men who have vascular problems may not get enough blood flowing to the penis. In such cases the nerves that make nitric oxide are malnourished and erections are either absent or partial. Erectile problems occur in 50 percent of men who have undergone coronary bypass surgery. Many drugs that are used to treat heart disease interfere with
  • 6. 6 blood flow, with similar effects. Nerve damage resulting from prostate surgery or some hormone imbalances can also cause erectile dysfunction (Blakeslee, 1993). Diabetes can damage blood vessels and nerves needed for erections; in more than 50 percent of men diagnosed with diabetes, the first signs of the illness are decreasing firmness of erections (Reinisch, 1991). Men with heart disease who smoke have a sevenfold increase in erectile dysfunction (Manning, 199Th). Treatment for Erectile Dysfunction Treatment for erectile dysfunction differs based on whether the disorder has a physical or psychological basis. Physically sound men usually have erections for approximately 3 hours each night during rapid eye movement (REM) sleep. If a man’s erectile dysfunction has a physical cause, he will not have these overnight erections. The nocturnal penile tumescence (NPT) test can be performed in a sleep laboratory to measure erection patterns during sleep. A device something like a blood pressure cuff is placed around the man’s penis before he falls asleep. As an erection develops, the swelling and enlargement of the penis create pressure, which is recorded to identify when erections occur. This information is compared to the man’s simultaneous brain wave pattern to see if erections occur when a man is experiencing REM sleep. A cheap and easy substitute for the NPT test can be performed at home with postage stamps (that’s right, postage stamps!). Before going to sleep, the man attaches postage stamps from a perforated roll to his penis by moistening them and pressing them in a snug circle around the base. (Leave them attached to each other in the perforated roll.) If his penis becomes erect during the night, the increased size of the penis will separate the stamps at the perforations and detach them from his penis, indicating that the physical functioning of the penis is still intact and pointing to a psychological source of the erectile difficulty. In contrast, if the penis does not have the normal erections during sleep, the roll of stamps will remain snug around the penis. (Please note that this test does not work with the new self-adhesive rolls of stamps issued by the Post Office, which are not connected to each other like those on a traditional perforated roll.) Another diagnostic tool is the snap gauge, a device equipped with three bands that is fitted around the shaft of a man’s penis at bedtime. Each band is of a different tensile strength so that an increased degree of penile enlargement is required to break each ring. Minor swelling will break only the first ring, further swelling will break the second ring, but only a fully rigid erection will rupture the third ring. The snap gauge has the advantage of being relatively inexpensive and does provide limited information about erective capability. It does not, however, provide any information on the nature and extent of REM sleep or the frequency and duration of nocturnal erections. A single, brief erection would break all three rings, but might not be adequate for intercourse. The Rigi-Scan is a newer device calibrated to provide information on penile rigidity as well as tumescence (swelling). The Rigi-Scan is actually a small computer that can be easily slipped into a pocket in a Velcro cuff that fits easily around a man’s thigh. Connected to the computer are flexible wires linked with two soft cloth-covered loops. One loop is affixed to the tip of the penis and the other to the base. During the night, the Rigi-Scan computer records the number and vigor of the man’s erections. He returns the device to his doctor, who gets a computer printout for analysis. Although many physicians still rely on these tests, especially the NPT, others question whether involuntary erections at night are related to the waking erections of sexual intercourse. Another approach requires a two-stage study (Wincze et al., 1988). The standard NPT test is done and, on another day, penile tumescence is measured as the man views a series of videotapes depicting oral and genital sex followed by a sexually neutral file, usually a travelogue. In addition to the measurement of penile tumescence, subjects are asked to indicate how aroused they were by either film. A substantial number of men who had spontaneous nocturnal erections and described the erotic tapes as arousing did not have an erection when viewing the tape. Possibly these men have a subtle malfunction in the system responsible for activating erections. Once the basis for erectile dysfunction has been established, a course of treatment must be selected. Probably no medication since the birth control pill has generated more publicity than sildenafil citrate, known better by the trade name given to it by the Pfizer Corporation, Viagra. Since its approval by the FDA in 1998, the demand for Viagra has been unprecedented. It was estimated that as many as 10,000 prescriptions per day were being written shortly after it became available (Handy, 1998). As you learned in the previous section, when a man is sexually stimulated, his brain sends signals to the nerves surrounding the penis that release nitric oxide. The release of nitric oxide causes the penis to make the chemical cyclic guanosine monophosphate (cyclic GMP). Cyclic GMP is the gatekeeper that widens blood vessels in the penis, allowing blood to gush in and causing the penis to become erect. In order to avoid potential embarrassment, another chemical in the body, phosphodiesterase type 5 (PDE5), destroys cyclic GMP once the fun is over. While
  • 7. 7 PDE5 is always present in the penis, cyclic GMP is produced only during arousal. Men with erectile dysfunction may not produce enough cyclic GMP to overtake the PDES. Viagra works by blocking PDE5 and boosts the effect of cyclic GMP in the penis by slowing down its chemical degradation, allowing cyclic GMP to overtake PDE5 and causing an erection. In clinical trials Pfizer reported that Viagra had the remarkable success rate of 60 to 80 percent depending on the dosage. A 1998 report in the New England Journal of Medicine concluded that Viagra is an effective and well- tolerated treatment for men with erectile dysfunction (Goldstein et al., 1998). However, don’t rush out to buy it just yet. The erectile tissue in the penis has a finite number of receptors for cyclic GMP. This means that men with adequate levels of cyclic GMP have their receptors filled already and won’t experience any response to the drug. In other words, men who can have an erection naturally probably won’t benefit from Viagra. Viagra is effective, but it isn’t a magic cure; some patience is required. Physicians recommend taking Viagra an hour before having sex. After the hour, don’t expect an instant reaction; desire, attraction, or stimulation are still required to achieve erection. As with any medication, there are possible side effects. Patients with heart conditions such as clogging of the arteries, and especially those taking blood-pressure-lowering nitrate drugs cannot safely take Viagra. The FDA has reported over 100 deaths of men taking Viagra, of whom 70 percent had risk factors for cardiovascular or cerebrovascular disease. About a third of men experience one or more side effects, including headaches, flushing, indigestion, stuffy nose, and temporary changes in visual perception of color (seeing blue) or brightness (Arora & Melilli, 1999). Viagra has had some unexpected effects on some relationships. There are reports that some women are less than thrilled when their partners’ sexual functioning is restored (Nordheimer, 1998). Women who have their own medical problems or are content with a relationship that does not include sexual intercourse may be disturbed by living with a mate who is suddenly sexually active. This may contribute to another difficulty—infidelity. One woman sued Pfizer, claiming her 10-year common law marriage fell apart after her 70-year-old partner began taking Viagra. She claimed that the company should warn consumers that the drug could be hazardous to marriages. Recall that Pfizer reported the success rate for Viagra at 60 to 80 percent; this means that it does not work for everyone. The highest failure rate is among men who have had radical prostate surgery and those with long-standing insulin-dependent diabetes. There are a number of other treatments available to treat erectile dysfunction. Among these are penile injections, which involve injecting one’s penis with a hypodermic needle, a treatment obviously not for the squeamish. Phentolamine (an alpha-blocker), papaverine (a smooth-muscle relaxer), and alprostadil (a prostaglandin) are all effective chemical injections. These chemicals overcome neurologic signals that normally keep the penis flaccid and help encourage the release of intrapenile chemicals like nitric oxide to increase blood flow into the corpora cavernosa. A noninvasive alternative is a vacuum constriction device that helps men achieve erection through vacuum pressure. A cylinder is held over the penis and connected to a hand operated vacuum pump. The vacuum increases the flow of blood into the penis, inducing an erection. If none of these methods is effective, some physicians may recommend a penile implant, a prosthetic device to restore erectile capability. There are a number of different types of implants available today. The Scott prosthesis, a multicomponent silicone inflatable penile prosthesis (IPP) was first used in 1973. A tube from a fluid reservoir im- planted in the lower abdomen is connected to a bulb in the scrotum. The penis remains in a normal flaccid state until intercourse is desired. Pumping the scrotal bulb to transfer the fluid from the reservoir to the penile implant creates the erection. Another type of implant, the Small-Carrion prosthesis, is inserted in the penile corpora cavernosa and provides a perpetual erection. The Jonas prosthesis is a semimalleable device that depends on a network of internal silver wires to allow for some degree of flexibility. The OmniPhase and DuraPhase implants have internal cables that allow the device to bend to a flaccid state when not in use. The Finney prosthesis is hinged and converts from flaccid to rigid state by locking the hinge in place. The newer Hydroflex and FlexiElate, which have internal fluid systems and are designed as self-contained penile prostheses, transform a flaccid penis to an erect state by manipulation of a valve implanted in the tip of the penis. In 1989 (the pre-Viagra days), an estimated 27,400 penile implants were performed (Spark, 2000). Surgical implants have become less popular, not only because of the success of Viagra, but also because of the cost, surgical complications, mechanical malfunctions, and fears that the silicone material could be harmful (Blakeslee, 1993). Because any existing natural erectile capacity is destroyed by implant surgery, it is recommended for use only in cases where all other treatment possibilities have been unsuccessful. Counseling and sex therapy are sometimes effective in helping men with erectile dysfunction, especially if there are psychological factors involved. Sex therapy promotes education and symptom relief as well as personal and couples counseling to explore interpersonal and relationship issues that can contribute to sexual dysfunction.
  • 8. 8 Female Sexual Arousal Disorder Female sexual arousal disorder occurs when a woman is unable to attain or maintain adequate vaginal lubrication until completion of sexual activity (APA, 1994). Disorders of female sexual arousal often accompany other sexual disorders such as orgasmic disorders (see following section) and hypoactive sexual desire disorders (Segraves & Segraves, 1993). Symptoms include a lack of vaginal lubrication; decreased clitoral and labial sensation; decreased clitoral and labial engorgement; or a lack of vaginal lengthening, dilation, and arousal. Unfortunately, there has been very little research involving problems of female sexual arousal. However, some of the knowledge gained from studies of male physiology may be applicable to women. Oxygen deprivation of the clitoris may result in sexual problems in women, just as oxygen deprivation of the penis causes dysfunction in men. Adequate arousal in females depends on both physical and psychological factors. Reduced vaginal lubrication may be due to a low level of estrogen, certain vaginal infections, diseases, medications, drugs, or alcohol. A subjective feeling of arousal may occur without lubrication and vaginal expansion in postmenopausal women (Leiblum et al., 1983), nursing women, or those who have undergone treatment for pelvic cancer (Schover, Evans, & Von Eschenbach, 1987). The more common psychological bases of female sexual arousal disorder include feelings of guilt, a deep-seated anger toward a partner, a history of sexual trauma, anxiety, and ineffective stimulation by the partner (Morokoff, 1993). Treatment tar Female Sexual Arousal Disorder The medical and financial success of Viagra has led researchers to investigate the possibility that the drug might also be helpful to women with sexual arousal disorders. Like the penis, the clitoris becomes engorged with blood during sexual arousal. Viagra appears to work the same way in women as it does in men, leading to increased blood flow to the vagina, clitoris, and labia causing engorgement of these tissues, enhanced sensation and increased vaginal lubrication. However, Viagra will not be approved for women until the completion of clinical trials, which are now ongoing in the United States. Researchers caution that while it may work for some women, women who have the combined problems of sexual desire disorder and sexual arousal disorder would most likely not benefit from Viagra. Any treatment for a sexual dysfunction in women or men should begin with a medical examination to rule out the contribution of medical problems to the difficulty. Once physical problems have been ruled out, treatment focuses on reducing and eliminating any anxiety that inhibits the natural reflexes involved in the arousal process. In therapy, clients learn that they cannot will themselves to an aroused state and that they do not need to perform to become sexually aroused. ORGASMIC DISORDERS Orgasmic disorders include difficulty or inability to reach orgasm after sufficient sexual stimulation and arousal, or any difficulty or delay in the timing of orgasm. The former are more common in women, and the latter are more common in men. Who determines whether a man ejaculates prematurely? How fast is too fast? Must a woman experience an orgasm during every sexual encounter? Perhaps the best way to approach this issue is consensus; if neither partner is dissatisfied then there probably isn’t a problem. Premature Ejaculatoin There is as much disagreement among the experts as to what constitutes premature ejaculation as there is among the parties involved. Masters, Johnson, and Kolodny (1994) state that a man ejaculates prematurely if his partner isn’t orgasmic in at least half of their coital episodes, while Kaplan (1974) suggests that it occurs when a man does not have voluntary control over when he ejaculates. The American Psychiatric Association (1994) defines premature ejaculation as “persistent or recurrent ejaculation with minimal sexual stimulation before or shortly after penetration and before the person wishes it” (p. 511). Certainly, ejaculation can be considered premature if it occurs prior to penetration. In this text we define premature ejaculation as a sexual dysfunction in which ejaculation occurs so rapidly that it interferes with the couple’s sexual satisfaction. Some therapists prefer the term rapid or early ejaculation because of the implication that the term premature connotes. Men with this problem are not underdeveloped, immature, or any less masculine than other men. While the condition is sometimes associated with young, sexually inexperienced men, it can occur in men of all ages and backgrounds.
  • 9. 9 There is no definitive physical or psychological explanation for premature ejaculation. Medical problems such as abnormalities of the prostate gland or inflammation of the genitals rarely are involved although occasionally unusually high nerve sensitivity around the opening of the penile glands and frenulum can lead to premature ejacula- tion. There is a physiological point of no return; recall that in the second stage of the male orgasmic phase, once the external sphincter muscle relaxes to allow the passage of semen into the penis, ejaculation will occur automatically. Contrary to popular myth, premature ejaculation is not caused by excessive masturbation. Inattention to the sensory signals that indicate ejaculation is about to occur is the most common cause of premature ejaculation. Since most boys have their first ejaculatory experience as a result of either a wet dream or masturbation, it is not surprising that they have no reason to adjust the tempo of their earliest sexual encounters in order to accommodate a partner. This conditioning of rapid ejaculation is fostered by both private masturbatory experiences (in which speedy responsiveness may be a necessity in order not to be caught in the act by family members) and early sexual encounters in which noncoital sex play also places a premium on swift ejaculation where discovery also may be an issue (Master, Johnson, & Kolodny, 1994). One study indicated that a long history of using withdrawal as a method of contraception might condition rapid responsiveness (Pierson & D’Antonio, 1974). Anxiety can play a role in rapid ejaculation, although it may be unclear whether this is the cause or an effect of the problem. Anxiety triggers electrical and chemical changes in the nervous system that may accelerate the ejaculatory reflex; at the same time, performance anxiety (which will be discussed in Chapter 16) may heighten the loss of ejaculatory control. A vicious cycle can develop; the more anxious a man becomes, the less ejaculatory control he may have. Treatment for Premature Ejaculation The basis of current therapy for rapid ejaculation is to enable men to tolerate progressively more intense sexual stimulation, to alleviate their concerns about sexual performance, and to help them concentrate on pleasure rather than ejaculatory control (Levine, 1992). There are various techniques to help a man focus his attention on the buildup of erotic sensation in his body as he approaches orgasm. The Stop-Start Technique A therapy often recommended for men troubled by premature ejaculation is based on the stop-start technique first developed by urologist James Semans (1956). The stop-start technique is designed to prolong sensations before orgasm, thereby giving the man the chance to experience and control his ejaculatory reflex The man’s partner is instructed to stimulate his penis orally or manually until he feels he is about to have an orgasm. Stimulation is then stopped until the pre-ejaculatory sensations subside. During each session the couple repeats the stop-start procedure several times and then allows ejaculation to occur on the last cycle. This exercise is repeated once a day for 15 to 30 minutes. As the man’s ejaculatory control improves, the couple progresses to genital-to-genital contact with the man’s partner sitting astride him so that the man can relax his body. The man puts his penis in his partner’s vagina and lies quietly for a few moments before beginning slow movements. Couples are encouraged not to think of this as intercourse but instead to look at it as an extension of the touching that has occurred during previous sessions. When the man begins to feel close to orgasm, they stop and relax. The stop-start technique is continued as the man progressively increases ejaculatory control. The Squeeze Technique The squeeze technique is another method of treating premature ejaculation. When the man feels that ejaculation is about to occur, his partner places the middle and index fingers on the front of the penis, below the head of the penis or at the base, with the thumb on the back side, and squeezes his penis for about 4 sec- onds. Considerable pressure can be applied without causing pain on the erect penis. While some men may ejaculate while their partner is applying the squeeze technique or shortly after, this usually does not happen after a few sessions. The couple is instructed to use the technique during a minimum of three different sessions within a day or two of each other. Eventually, continuing to use the squeeze technique, the couple proceeds to the female superior position, with insertion of the penis in the vagina and slow thrusting. The woman dismounts and squeezes every 1 to 2 minutes before the couple moves on to more vigorous thrusting and ejaculation. Masters, Johnson, and Kolodny (1994) claim that a 5-year follow-up of 196 couples who came to their institute for 2 weeks of treatment for premature ejaculation demonstrated a 98 percent success rate using the squeeze technique. The man can use both the stop-start technique and the squeeze technique alone during masturbation; the gains made can then be transferred to sexual activity with a partner.
  • 10. 10 Drug Treatment Some researchers have reported successful treatment for premature ejaculation using small doses of drugs normally prescribed for depression or obsessive behavior (Waldinger et al., 1998). In several cases, men who had ejaculated within seconds to a minute or two of beginning intercourse were able to delay ejaculation for 20 minutes or longer (Petit, 1994). In one study, men receiving clomipramine reported a significantly greater sense of control over their orgasm while on the drug (Strassberg et al., 1999). Male Orgasmic Disorder For some men the problem is not that they ejaculate too soon, but that they are not able to ejaculate at all. Men who are able to have erections but cannot ejaculate may suffer from male orgasmic disorder, a condition also known as ejaculatory incompetence, or delayed, inhibited, or retarded ejaculation. Approximately 4 to 9 percent of men suffer from an inability to ejaculate during sexual intercourse (Spector & Carey, 1990). Some may be able to ejaculate by masturbating or by oral sex, but cannot climax during coital activity (Munjack & Kanno, 1979). A related disorder, in which there is seepage of semen without orgasmic sensations, is known as partial ejaculatory incompetence (Kaplan, 1974). Treatment for Male Orgasmic Disorder Physical causes of ejaculatory incompetence include multiple sclerosis, neurological damage that interferes with neural control of ejaculation, and drug side effects. Helen Singer Kaplan (1974) suggests a psychological cause: Some men with this disorder may be unconsciously “holding back” their ejaculate from their partners because of underlying hostility or resentment. Masters and Johnson (1970) discovered a possible cultural basis; they found that men with delayed ejaculation frequently had strict religious backgrounds that may have left a residue of unresolved guilt about sex. Emotional factors, such as fear of pregnancy, may also play a role. As with other sexual dysfunctions, men with retarded ejaculation often attempt to resolve the problem by “trying harder,” which as you might guess only compounds the problem. Once medical causes have been ruled out, treatment of underlying psychological factors is undertaken. Female Orgasmic Disorder The terms anorgasmia and female orgasmic disorder refer to the inability of women to experience orgasm. According to the American Psychiatric Association (1994), the condition is diagnosed when there is a persistent or recurrent delay in, or absence of, orgasm following a normal sexual excitement phase. The prevalence of women who suffer from orgasmic dysfunction is estimated to be 5 to 10 percent (Spector & Carey, 1990). Some women who are anorgasmic may be extremely dissatisfied and depressed about the absence of orgasms during sexual activity. Others may experience arousal and lubrication, and enjoy their sexual relationships, in which case there is no cause for concern. About 5 percent of the cases of orgasmic dysfunction in women are the result of organic causes (Masters, Johnson, & Kolodny, 1985). Such causes include chronic illnesses such as diabetes, hormone deficiencies, alcoholism, pelvic infections, or other conditions that cause damage to the pelvic nerves. Anorgasmia can also have a psychological basis. One is a psychological link between sex and problematic past experiences. Anorgasmia can also serve as a defense against an anxiety-producing situation (Levine, 1992). However, the most common cause of female orgasmic disorder may be the persistent belief that sex equals inter- course. Most women do not experience orgasm without adequate stimulation of the clitoris. It is extremely rare for women to experience rapid female orgasm, the female equivalent of premature ejaculation. Some women do report that they have orgasms too quickly before their partners and then are not interested in further stimulation. However, since women are more capable of having multiple orgasms, rapid orgasm may not necessarily be a problem for the individual or the couple. Treatment for Female Orgasmic Disorder During the Victorian era, physicians diagnosed a broad range of women’s problems as due to hysteria, an affliction that was thought to be linked to the female sex organs. To treat hysteria, physicians routinely used “pelvic massage,” essentially manually stimulating the women to orgasm. Given the Victorian reticence about sexuality it is quite plausible that these visits constituted the only source of orgasms for some Victorian women. Such treatments may
  • 11. 11 have encouraged women to make and keep regular appointments with their physicians, but the physicians themselves did not seem to have been fond of this part of their duties. To spare their own fingers the exertions of pelvic massage, physicians eagerly adopted the vibrator when it was invented in 1883, and it became one of the standard medical tools for several decades (Maines, 2000). Today vibrators usually are battery operated but early models were steam powered. Neither the diagnosis of hysteria nor the treatment of female patients with vibrator- induced orgasms is part of mainstream medical practice today. Anorgasmic women need to be reassured that orgasm is possible but that it is not always essential to a satisfying sex life. They must also become comfortable with the idea that they are responsible for their own orgasms and accept the clitoris as a sexual organ. A willingness to learn to stimulate themselves or teach their partners to stimulate them is also essential to successful treatment. With knowledge of and comfort with clitoral stimulation, it is highly likely that anorgasmic women will respond to treatment. Some couples find that the coital alignment technique (sometimes called “the new and improved missionary position,” is most effective for female orgasm. More than a position, the coital alignment technique is a coordinated movement in which the male lies on top of his partner with his head next to hers. The woman wraps her legs around her partner with her feet resting on his calves. The man positions himself so that the base of his erect penis pushes up against his partner’s clitoris and begins a subtle, rocking movement. As the woman pushes up on the top of her partner’s penile shaft, he resists with less force than she pushes. Then, as he pushes down against her clitoris, she resists with less force than he pushes. The rocking, vibrating movement of this technique (rather than the standard friction of thrusting in other coital positions) may stimulate female orgasm. Many therapists recommend learning to masturbate to orgasm as one of the most effective techniques for treating anorgasmia. Masturbation increases body awareness through self-exploration and self-stimulation. Therapists also may recommend sensate focus exercises or have more general suggestions for increasing comfort with one’s own body and learning what kinds of thoughts, touches, and sensations are most stimulating and pleasurable. In May 2000 the Eros-CTD (clitoral therapy device) became the first treatment for female orgasmic disorder approved by the FDA. In essence the clitoral therapy device is a small pump with a tiny plastic cup attachment that fits over the clitoris and surrounding tissue. It provides gentle suction, simulating the sucking effect of oral sex and stimulating blood flow to the vaginal area. After a woman is able to experience orgasms through mechanical or self-stimulation, she may proceed to experiencing orgasm with her partner. A variety of activities may be recommended, including masturbating in the presence of a partner and placing her hand over her partner’s hand when the partner stimulates her manually. Once the couple proceeds to intercourse, many women find that they must experiment with positions to find those that provide the most effective clitoral stimulation. The female superior position is often suggested because it allows the woman freedom of movement and control of her genital sensations. Using this position the woman is better able to experience the most pleasurable sensations, and to sustain them longer through deliberately slow thrusting, thus avoiding rapid orgasm by the male. As we have stated previously, some women may be unable to climax through intercourse alone. Oral or manual stimulation prior to intercourse, manual stimulation during intercourse by the woman or her partner, or the use of a vibrator during intercourse are options that can allow a woman to experience orgasm during intercourse. SEXUAL PAIN DISORDERS Sometimes sex is not just unsatisfying, it is actually painful. Although sexual stimulation triggers the pain, the primary cause of sexual pain disorders can be physically or psychologically based. Priapism Priapism refers to a condition in which a man experiences a continued erection that will not subside. This can be extremely painful. Because priapism can lead to damage of the penis’s vascular system to the point where erectile ability is permanently destroyed, the man must seek immediate medical assistance. Priapism is a potential negative side effect of several commonly prescribed medications, and drug-related causes are implicated in 15 to 36 percent of cases (‘Weiner & Lowe, 1998). Typically, priapism is due to a failure in the mechanism that frees the blood trapped in an erect penis. It also can be the symptom of a severe physiological problem such as spinal cord disease or leukemia.
  • 12. 12 Treatment for Priapism Priapism is a medical emergency and requires immediate intervention. An erection that persists beyond 6 hours deprives the penis of adequate oxygen. Treatment of priapism usually requires the infusion of chemicals. Often this treatment alone allows blood to drain from the penis. For those men whose priapism remains even after medical treatment, surgery is required. Dyspareunia Dyspareunia, genital pain during intercourse, is classified as a sexual dysfunction. However, since sexual and urological functions are closely related anatomically, hormonally, and psychologically, some scientists argue that it would be more accurate to describe dyspareunia as a pain syndrome (Meana et al., 1997). Dyspareunia is more commonly diagnosed in women, but some men also suffer from this disorder. The foreskin of uncircumcised men may be so tight that sexual arousal is painful. Inadequate hygiene of the foreskin may result in infection that can cause irritation of the glans. Infections of the penis, foreskin, testes, urethra, or the prostate can cause men discomfort or extreme pain during sexual activity. Other possible causes are an allergic reaction to a spermicidal cream, foam, condom, or diaphragm. Anything that disrupts the secretion of vaginal lubrication during sexual arousal can result in vaginal dryness, the most common cause of female pain during intercourse. There are many factors that can cause insufficient lubrication, including inadequate stimulation prior to intercourse, changes in a woman’s hormone levels caused by menopause or breast-feeding, and medications such as antihistamines. Some women find that using a lubricated condom or water-soluble lubricant is helpful. Postmenopausal women may consider hormone replacement therapy to alleviate vaginal dryness. Treatment for Dyspareunia Pain felt at or near the entrance to the vagina may be the result of a vaginal or urinary tract infection or can be related to scarring from an episiotomy during childbirth. Spermicides, feminine hygiene products, and tight clothing also can create soreness. Feeling pain deep inside the vagina or in the lower abdomen during intercourse may be a sign of endometriosis, pelvic inflammatory disease, or other reproductive tract disorders. Medical research has found that some women are allergic to their partners’ seminal fluid. Known by the two- dollar term human seminal plasma hypersensitivity, the condition was first described in 1958. A 1997 study found that 12 percent of patients examined by allergists met the diagnostic criteria for an allergy to seminal fluid (Bern- stein et al., 1997). Symptoms include wheezing, itching and hives all over the body, chest tightness, vomiting, or diarrhea. Severe reactions include loss of consciousness or complete circulatory collapse. Nearly all the research on dyspareunia concerns vaginal intercourse but some investigators are examining the frequency and severity of anodyspareunia, pain in same-sex anal intercourse. One study found that approximately 12 percent of gay men found anal sex too painful to continue. Factors associated with a greater amount of pain were anxiety, depth and rate of thrusting, and discomfort with their homosexuality (Rosser et al., 1998). Vaginisumus Vaginismus is the recurrent or persistent involuntary contraction of the muscles surrounding the outer third of the vagina when vaginal penetration is attempted. The vaginal muscles clamp down, making penetration painful and sometimes even impossible. A woman may suffer from this disorder throughout her life or suddenly develop vaginismus in response to a sexual trauma or a medical condition. Some researchers question if the diagnostic emphasis should be placed on fear or resistance to penetration rather than on pain or distress (Ng, 1999; Reissing et al., 1999). Treatment for Vaginismus Once a medical problem is ruled out, treatment typically takes a behavioral approach. Relaxation and body awareness exercises such as sensate focus exercises are recommended. Once a woman becomes more relaxed, the next step is insertion of finger or a narrow vaginal dilator. After relaxing her vagina with a finger or dilator inside, she is instructed to consciously contract and relax the vaginal muscles. The woman controls the pace of treatment at all times. She progresses to wider dilators or more fingers. When the woman is able to tolerate insertion and
  • 13. 13 containment of a dilator or number of fingers approximately equivalent in diameter to a penis, her partner may join her. Her partner begins by inserting a finger into her vagina. After her partner can insert several fingers without the woman experiencing an involuntary muscle spasm, the couple may then attempt relaxed, nondemand coitus at the woman’s pace (LoPiccolo & Stock, 1986). Sensate Focus Exercises Sensate focus exercises are a form of therapy designed to help couples respond erotically with all areas of the body without the pressure to “perform.” Masters and Johnson developed the concept in 1970. Although the technique was created to treat a variety of sexual problems, couples not experiencing problems can also use sensate focus exercises to enhance their sexual relationships. The original Masters and Johnson techniques were developed for couples who were willing to devote 2 weeks to an intensive daily sexual therapy program. While there is more flexibility for therapists using this therapy today, certain ground rules are fundamental. Couples must agree to establish a moratorium on sexual intercourse during the treatment period. They must have no extramarital affairs during the course of therapy and the use of alcohol, mood-altering drugs, or nonprescription medications is prohibited. Both partners must agree to set apart a specific time of the day to do individual homework assignments. The couple must agree to set aside any disagreements or grievances, and they must be explicit in telling each other what does and does not stimulate them. In the first sensate focus exercise, which consists solely of touching, partners take turns exploring one another’s bodies while following some essential guidelines. The person who will be doing the touching takes some time to create a comfortable atmosphere— perhaps turning off the phone, lighting candles, and playing soft music. The couple disrobes and the toucher begins to explore his or her partner’s body in a nonsexual way, without the goal of pleasing or arousing the partner (although that may well happen). Intercourse and the touching of breasts and genitals are prohibited. Instead, the toucher focuses on his or her own pleasure by experiencing the texture, form, and temperature of the partner’s body. The person being touched remains quiet except when any touch is uncomfortable. Next, the partners switch roles, following the same guidelines. In Step 2 the couple explores all parts of the body manually or orally, but exclude the breasts and genitals. The partners are encouraged to take turns so that both can find ways to relax and arouse each other. Manual or oral stim- ulation of the breasts is allowed in Step 3, and in Step 4 the women is encourage to caress the man’s penis and scrotum. The goal is not to achieve erection or orgasm but to create an atmosphere for a pleasurable experience. Step 5 is the manual caressing of the genitals to bring both partners to orgasm. During this step, if there is concern about premature ejaculation, the woman is instructed in the “squeeze” or “start-stop” exercise to delay ejaculation. Intercourse is allowed in Step 6, but the goal is simply vaginal penetration. Only a minimum amount of thrusting is permitted, and it is advised that the man lie on his back with the woman on top. Step 7 is an extension of Step 6, with prolonged thrusting to orgasm with the woman on top. Step 8 allows intercourse with the man on top. From: Human Sexuality, by Baumeister, Miracle, and Miracle. 2003. pages 101 – 107, 111-124.