This section of the course will now look at specific issues facing males in the area of sexual functioning, suggest differing ways of considering these issues, and present various means for providing relief for client concerns.

In 1999, Laumann, Paik, and Rosen presented the following statistics on male sexual dysfunction in the United States:

Prevalence of male sexual problems:

• Climax too early: 30.7%
• Anxious about performance: 17.8%
• Lacked interest in sex: 14.7%
• Trouble maintaining or achieving erection: 10.2%
• Sex not pleasurable: 8.3%
• Unable to achieve orgasm: 7.8% (Laumann)

Male sexuality has frequently been addressed in ways that have ultimately been counterproductive in terms of adequate knowledge, communication, and relationships. Indeed, many men grow up thinking that they are supposed to know everything, but the methods by which they are supposed to be learning are unclear.
As sex educators of sons, a majority of fathers have not taken an active role. If sons learn any reliable information about sexuality in their families, this information comes largely from mothers. Fathers’ lack of role modeling from their fathers in how to talk about sex and their lack of experience in doing this teaching may play a large role in their failure to talk with their sons.


Sexuality Factoid

54% of men think about sex everyday or several times a day, 43% a few times per month or a few times per week, and 4% less than once a month

Source: Laumann, E., Gagnon, J.H., Michael, R.T., and Michaels, S. The Social Organization of Sexuality: Sexual Practices in the United States. 1994. Chicago: University of Chicago Press (Also reported in the companion volume, Michael et al, Sex in America: A Definitive Survey, 1994).

At least partly due to the lack of effective communication about sexuality, many myths about male sexuality have been perpetuated. Zilbergeld’s The New Male Sexuality Revised Edition (1999) is one of the most valuable resources available for healthcare clinicians, for sexuality educators, counselors, therapists, and for the general public. In addition to providing a wealth of very helpful information, it is written in a very readable, often humorous fashion. This book addresses 10 common myths about what many men have believed to be true.

Ten myths about sex:

1. In general, a man should not be seen to express certain emotions.
2. In sex, as elsewhere, it is performance that counts.
3. An erection is essential for a satisfying sexual experience.
4. All physical contact must lead to sex.
5. Sex equals intercourse.
6. Good sex must follow a linear progression of increasing excitement and terminate in orgasm.
7. Sex should be natural and spontaneous.
8. On the whole, the man must take charge of and orchestrate sex.
9. A man wants and is always ready for sex.
10. We no longer believe the above myths. (Zilbergeld)

In addition to the lack of information about sexuality many men receive while growing up, the typical model of male sexuality today is a model that the New View describes as “a penis-centered mythical performance model that privileges erectile and orgasmic function and downplays the issues of pleasure and intimacy”(Tiefer, 2006).

This model emphasizes organic causes of sexual function problems and has led to a fervent preoccupation with performance and the huge success of Viagra and other pharmaceuticals in remedying problems.

Frequently, medical professionals have perpetuated this focus by quickly prescribing drugs rather than investigating other issues that might be factors in causing or contributing to problems. The New View model presents a different perspective that challenges the prominence of this model, instead emphasizing the role of psychological, relational, and cultural factors in men’s sexuality:

“Asking whether or not erectile dysfunction is a problem for men may be inadequate to appreciate the extensive impact on men's sexuality and sense of self and may in fact close off the opportunity for further discussion of the issue. In focus groups, men did not identify erectile dysfunction as a problem that could be fixed. Rather, they saw it as a new change in their lives. Physicians need to probe beyond the mechanics of erectile function and ask questions about men's feelings about their sexual lives and relationships.”(Tiefer, 2006).

PENIS SIZE

A male therapist noted recently that although it is rarely discussed, men have significant and sometimes quite terrible issues about body image. One of the major concerns is related to penis size. Silverberg (2007) stated, “Penis size is determined entirely by factors out of our control. Yet penis size may be the single greatest cause of anxiety for men young and old.”

Men often grow up interacting in open locker rooms where they can see one another in various states of undress and nudity. Comparisons of penis size are frequently made, although almost always in silence. Unfortunately, the man doing the comparing is generally looking down at his own penis, and his own will likely appear smaller to him than the penis of another man who is beside him or across the room.

The Kinsey Institute data found that the length of the average man’s erect penis is between 5 and 7 inches and in general that smaller flaccid penises lengthen by a greater percentage than do larger flaccid penises. Consequently, erection is sometimes referred to as the “great equalizer.” The data also showed that the vast majority of men measure within the average genital size range and have a penis size that is more than adequate for sexual functioning (Reinisch, 1991).

Despite information about normal variations, penis size continues to be a concern with many men. The magnitude of these concerns is illustrated in the following clinical case.

Clinical Case

A couple in their forties came to a sex therapist with the following story:

They were at a football game and the husband became angry about the wife’s friendliness with a nearby male fan. The husband’s anger resulted in his insistence that they leave the game. On their way out of the stadium, the wife, who had also become angry, turned to her husband and blurted out, “I’m sick of you and your little dick.” Having made the remark, she was unable to take it back, and the husband became obsessed with the idea that his penis was indeed small.

His obsession grew to the point that he would go into work each day and announce to the office staff, “Little Dick is here.” He would tell the story to complete strangers and to the couple’s friends. He talked about it incessantly. The wife told him countless times that she had not meant it and that she had said it in anger, but he could not be persuaded.

He went to a male counselor who asked him to measure his penis. When he told the therapist the measurement, the therapist responded, “Well, that’s normal—it’s on the low end of normal, but it’s normal.” This response DID NOT HELP, and the man became even more obsessed. Finally he agreed to believe his wife if she would stand up in front of their church congregation and tell the story, say it was not true, and apologize. The wife was totally unwilling to do this.

None of the therapist’s attempts to explore what his penis size meant to him was successful, and the man finally said that he did not know if he would ever be able to reconcile his feelings and reactions and that he might have to divorce his wife. Most men are much less concerned than in this example, but experience does indicate that penis size is important to many men.

Note: This particular client had researched websites of physicians who purport to perform successful penis enlargement surgeries (phalloplasty). Although there are a number of websites that extol the benefits of such surgery, no clear evidence of the efficacy of these procedures has been found.

BODY IMAGE

Body image issues impact men as well as women, and it appears that men, both heterosexual and homosexual, are growing increasingly concerned about their appearance. According to a counseling website, in 1997, American men spent: $4 billion on exercise equipment and health club memberships, $3 billion on grooming aids and fragrances, and $800 million on hair transplants.

In 1996 they spent $500 million on male cosmetic surgery procedures, $300 million on procedures such as pectoral implants, chin surgery, and penis enlargement, and $200 million on procedures such as liposuction and rhinoplasty. In their quest for enhancing their body image, they may develop eating disorders and mental health issues, and put themselves at high risk for negative health consequences by taking anabolic steroids (Silva, 2006).

ERECTILE DYSFUNCTION (ED)

One of men’s major sexuality-related concerns has to do with erections and erection problems. Even the suggestion of a possible erection problem can cause anxiety, sometimes profound. Masters, Johnson, and Kolodny (1988) stated, “For most men in most societies, sexual adequacy is considered a yardstick for measuring personal adequacy. The man who does not “measure up” sexually is often embarrassed, confused, or depressed over his plight, which he regards as reflecting poorly on his manhood” (p. 462).

Sex therapists have said that Masters and Johnson once noted that for a man, an erection problem on only one occasion can be devastating, and nothing, except perhaps the loss of a job, can cause as much concern as a problem with erections. And yet, by the age of 40, 90% of men have had an erection problem on at least one occasion (McCarthy, 1981).

For many years mental health clinicians told patients that 80% of erection problems were psychological and 20% were physical, while urologists were saying that 80% were physical and only 20% psychological. Our updated information reveals that a large majority of erection problems, particularly in older men, do indeed have a physical cause or causes (Harvard Health Publications, 2004).

In younger men without concurrent medical, surgical, and disabling conditions, there is often a large psychological component. Studies show that 75% of erection problems in men under age 35 are "psychogenic," or caused by psychological factors. In men over age 50, the figure is 15% (St. John, 2003). Even in men whose erection problems are primarily physically based, psychological issues exert a powerful contributory influence on erection capability (Wincze & Carey, 1991).

Common causes of erection problems:

Physical Causes: (listed most to least prevalent)

1. Vascular Insufficiency (arteriosclerosis, hypertension, antihypertensive medication)
2. Diabetes Mellitus
3. Radical Surgeries (prostatectomies, colostomies, etc.)
4. Trauma (spinal cord injuries, etc.)
5. Side effects from alcohol and medications (tranquilizers, antidepressants, antihypertensives, etc. Drugs play a large role in many sexual problems, and medications can have a negative impact on each area of sexual expression. Even unsuspected, over-the-counter drugs can cause problems, e.g. Tagamet can cause erection problems in men and lubrication problems in women.
6. Low testosterone or cells' inability to use testosterone—the exact effect of low levels of testosterone on erection is not clear (Cornell Physicians, 2007a).

Psychological Causes:

1. Depression
2. Emotional conflict
3. Repressed anger
4. Traumatic experiences
5. Sex center not turned on
6. Thinking/Anxiety (J. LoPiccolo, personal communication, 1990).

PREMATURE EJACULATION

Premature ejaculation (PE), also known as rapid ejaculation (RE), is thought to be the most common male sexual problem, although its actual occurrence is unknown. Some believe that there may be under-reporting of this problem, as the medical community may have doubts about the effectiveness of available treatment options.

Currently it is presumed that the vast majority of men who would meet DSM IV-TR diagnostic criteria for PE are not being diagnosed or treated; or, in many cases, they are not even coming forward. Estimates as to its prevalence are that it may affect as many as 27-34% of men across all age ranges and an even greater number at some time in their lives. In contrast, erectile dysfunction (ED) is estimated to affect 10-12% of all men - who are usually older in age (Broderick, 2005).

Difficulties in talking about PE, adequately defining what is meant by PE, a shortage of standardized research, and lack of a broad range of effective treatment options have contributed to the lack of knowledge and understanding.

Sexuality Factoid

Males 30-44 report an average of 6-8 female sexual partners in their lifetime

Source: Mosher WD, Chandra A, Jones J. Sexual behavior and selected health measures: Men and women 15–44 years of age, United States, 2002. Advance data from vital and health statistics; no 362. Hyattsville, MD: National Center for Health Statistics. 2005.


Defining Premature Ejaculation

One of the problems encountered with premature ejaculation is how to define it. Today the DSM IV-TR defines premature ejaculation as: “persistent or recurrent ejaculation with minimal sexual stimulation before, on, or shortly after penetration and before the person wishes it, causing marked distress or interpersonal difficulty” (American Psychiatric Association, 2000).

Infrequent sexual activity can be associated with premature ejaculation, but generally this is quickly resolved with resumption of regular sexual activity. For premature ejaculation to be considered a condition, it has to be persistent and it has to cause distress.

Using a broad definition for premature ejaculation avoids specifying a precise duration for sexual activity and ejaculation, because the duration is variable and depends on many factors specific to the individuals engaging in intimate relations. Oftentimes premature ejaculation is labeled within the context of a specific relationship.

To illustrate this, a divorced physician involved in a new relationship was told by his current partner, “You sure come quick.” His response was, “I never knew there was any other way to do it.” Another man who had outlived two wives came for evaluation because his current partner told him he came too fast—he stated that neither of his wives had identified this as a problem.

The fact that female arousal and orgasm require more time than male arousal is being increasingly recognized, and this may result in increased recognition and definition of premature ejaculation as a problem.

Sexuality Factoid

It is estimated that approximately 29% of men experienced premature ejaculation and 8% of men experienced an inability to reach orgasm in a comprehensive survey performed in 1994.

Source: Laumann, E., Gagnon, J.H., Michael, R.T., and Michaels, S. The Social Organization of Sexuality: Sexual Practices in the United States. 1994. Chicago: University of Chicago Press


Causes of Premature Ejaculation

Historically, premature ejaculation has been considered a psychological disorder or a result of early experiences in which males are conditioned by societal pressures to reach climax in a short time because of fear of discovery as when masturbating as young people or during early sexual experiences "in the back seat of the car" or in other situations that necessitated a quick response. This pattern of rapid attainment of sexual release becomes conditioned and difficult to change in marital or other long-term relationships.

While the exact physiology remains unclear, PE is probably multifactorial, with an interaction of biological and psychological components.

1. Biological/Physical Components

Ejaculation is a very complex and coordinated muscular and neurological process, and serotonin is believed by many to be the primary neurotransmitter regulating this process. There is good evidence today that low serotonin in the central nervous system is related to the mechanism of rapid ejaculation (Sharlip, 2005).

In addition to the theory that changes in serotonin metabolism in the central nervous system may be responsible for the timing of ejaculation, a number of investigators have found differences in nerve conduction/latency times in men who experience PE compared with those who do not. The theory is that some men have hyperexcitability of the ejaculatory reflex or oversensitivity of their penis that prevents a delay of orgasm (Sharlip, 2005).

It may well be that ejaculatory latency, like other human variables, is distributed along a bell-shaped curve. In terms of the sexual response cycle, a man with PE has a very steep excitement phase, a short plateau, and an intense and rapid ejaculation or orgasm.

Foreskin status has not been tied to the presence or absence of PE or whether circumcision would be an effective therapy for premature ejaculation. There is conflicting information (Barada & McCullough, 2004).

2. Psychosocial/Relational Components

As mentioned earlier, there have been very good case reports of early sexual experiences as a potential causal factor in PE. Many teenagers report early sexual experiences in which they ejaculated rapidly as a result of the perceived need to finish quickly. Some men are able to learn the response of ejaculatory control over time, while others, because of their biological set point, lack of knowledge, or other factors, are unable to develop the control necessary for a satisfactory sexual experience.

Also, there are a variety of psychosocial, environmental, and contextual factors that likely play a role in rapid ejaculation, and the overlapping of physical and psychological factors is similar to what often happens with erectile dysfunction. For many men anxiety continues to be a major factor, and the partner’s expectations and reactions can contribute to performance anxiety.

For many women, a man’s staying power is not the “be all end all” of a satisfying sexual experience. Since most women do not orgasm through intercourse alone, how long he can last in intercourse is not necessarily the determining factor in her sexual satisfaction and this a relatively unimportant issue. On the other hand, stamina is very important to some women, not necessarily for orgasm, but for pleasure and intensity. Many women enjoy the feeling of containing the penis inside their vagina.
In these instances, the pressure for the male to control his ejaculations can become a major concern, particularly if the woman is continually outspoken and insisting that he “fix” the problem or if she contends that the problem must have something to do with her, e.g., she’s not attractive enough, not a good partner, he doesn’t care about her, etc. As in almost all sexual relationships, this comes down to the partners’ individual and blended desires and how they interact and collaborate with one another.


Clinical Case

The prevailing and pervasive myth that endless intercourse will produce the elusive female orgasm can result in unrealistic expectations, disappointment, and often finger pointing and blame or self-deprecation.

One therapist reported the following case:

“I just received a letter yesterday from a couple in their early twenties who are struggling because the young woman hadn't had an orgasm by oral or manual means, and when they began to have what she called ‘regular sex' the boyfriend was sure she would come. When she didn't, he lost interest in being sexual at all because he felt like a failure. There's no question that the issues are muddy as a riverbank, and people need so much more detailed, comprehensive information than they have. Remarkable that with all the books and advice columns people in our field write, the amount of misinformation and disinformation is still so rampant.”

Note: Rapid ejaculation is considered a bigger problem if the man frequently (or always) ejaculates outside the vagina before intromission.

Overlap between Premature Ejaculation and Erectile Dysfunction

PE and ED can coexist and overlap, and it is important for clinicians to recognize and differentiate between these conditions. Secondary PE can develop in men who overstimulate in an effort to attain or maintain an erection. Many men actually think they have an erection problem because they quickly attain an erection, they ejaculate, and the erection subsides.

In reality they are experiencing premature ejaculation. Obtaining an accurate history and a clear description of a typical sexual event will help to facilitate an accurate diagnosis. Treating a supposed erection problem that is actually a problem with rapid ejaculation will, in all likelihood, not correct the PE. However, the individual may have both problems (Barada & McCullough, 2004).


ERECTION, ORGASM, AND EJACULATION

Erection, orgasm, and ejaculation can occur independently from one another.

Ejaculation involves two phases:
1) emission—deposition of semen in the urethra and
2) ejection—actual ejaculation of the fluid from the urethral meatus, i.e. opening).

Orgasm is a separate sensual sensory event that has significant subjective variation.

Orgasm can occur without erection. Orgasm can also occur independently from ejaculation, although the two most frequently happen together. Following ejaculation, penile detumescence occurs, followed by a refractory period during which the man can not be restimulated. This refractory period lengthens with advancing age and repeated ejaculations (Link and Copeland, 2007).


RETROGRADE EJACULATION

Retrograde ejaculation involves a process by which the semen is propelled backward into the bladder instead of out of the urethra.

Causes of retrograde ejaculation include:
1) anatomic –this refers to the structure of the urethra either from birth or following surgery of the bladder neck.
2) neurologic –this refers to any disorders that may interfere with the ability of the bladder neck to close during ejaculation. This could occur in diabetes or surgeries of the peritoneal cavity that have affected nerves in the bladder neck.
3) pharmacologic –It is possible for certain medications to cause paralysis of the bladder neck (Cornell Physicians, 2007b).

Treatments for retrograde ejaculation depend on the cause. Those caused by structural problems are rarely curable. When nerve damage is involved, positive results are also more difficult to achieve. Medication induced problems may reverse themselves when the medication is discontinued (Mulhall et al., 2001).

MALE ORGASMIC DISORDER -- EJACULATORY INCOMPETENCE/INHIBITED/RETARDED/DELAYED EJACULATION

This condition involves the inability of the patient to ejaculate in a timely manner - typically within a 30 minute time period from the initiation of sexual stimulation. In severe cases there is an inability to ejaculate at all.

Causes of inhibited ejaculation include:

1) the use of the antidepressant SSRI medications (Prozac, Zoloft, Paxil, Luvox, Celexa)
2) sensory neurologic disorders affecting penile sensation - as may occur with diabetes)
3) psychological disorders, e.g., cultural and religious taboos, young men fearful of impregnating a partner, older men in early experiences following divorce or being widowed, and men with obsessive-compulsive disorder or performance anxiety (Mulhall et al., 2001).

Other psychosexual factors that may contribute to this problem are lower levels of relationship satisfaction, lower levels of self-reported subjective sexual arousal, greater levels of distress, and higher levels of health-related problems (Rowland et al., 2005).

Tension and anxiety can lock up the pubococcygeal muscle and prevent the ejaculatory reflex. For some men, no clear precipitating cause can be identified.

Treatments may include individual and couple therapy to address psychological/relationship issues. Practicing the use of Sensate Focus masturbation exercises while consciously relaxing the pubococcygeus muscle may also be helpful.

No specific pharmacologic strategy for treating inhibited ejaculation has been identified, although there are anecdotal reports of the use of bupropion (Wellbutrin), and pseudoephedrine (Sudafed).

Penile vibratory therapy has been reported as useful in some patients, generally those who have a delay in ejaculation as opposed to those who have a total failure to ejaculate. Reported success rates vary widely (Cornell Physicians, 2007b).


MALES AND PREGNANCY

The birth of a child may impact sexual desire in the spouse/male partner. For some men, witnessing a birth can be a traumatic event in terms of future sexual attraction toward the wife/partner. Also, a syndrome known as the Madonna-Prostitute or Madonna-Whore Syndrome may surface when a wife takes on the role of a mother.
This syndrome will not be expanded in this course. Additional information can be found at http://www.sex-lexis.com/Sex-Dictionary/prostitute-versus-madonna%20syndrome

It is important to realize that the birth of the child can stir up unhealed, subconscious issues in both partners. Males may be jealous of the attention shift to the infant or resentful of the fatigue the new mother has which takes her energy and interest away from sex.

Communication is vital for new parents so that they are able to retain their sexual intimacy as their new family develops.

The following pages are suitable for printing as a resource for Male Sexuality.

Male Sexuality
Resources for Professionals

Best Short Internet Resource

Gregoire, A. (1999). ABCs of sexual health: Male sexual problems. BMJ, 318: 245-247. Available at: http://bmj.bmjjournals.com/cgi/content/full/318/7178/245.

General Texts

Bancroft, J. (1989). Human Sexuality and its Problems, 3rd Edition. Edinburgh, Scotland, UK: Churchill-Livingstone.

Books for Patients

Castleman, M. (2004). Great Sex: A Man's Guide to the Secret Principles of Total-Body Sex. New York, NY: St. Martins Press.
Handy, R.Y. (1988). Male Sexuality and the Challenge of Healing Impotence. Buffalo, NY: Prometheus Books.
Zilbergeld, B. (1999). The New Male Sexuality, Revised. New York, NY: Bantam Books.

Masculinity and Manhood

Connell, R.W. (1995). Masculinities. Cambridge, UK: Polity Press.
Friedman, D.M. (2001). A Mind of Its Own: A Cultural History of the Penis. New York, NY: The Free Press.
Kimmel, M. S. (2000). The Gendered Society. New York, NY: Oxford University Press.
Kimmel, M.S., Hearn J., Connell R.W., (Eds). (2005). The Handbook of Studies on Men and Masculinities. Thousand Oaks, Calif: Sage Publications.
Levant, R. F., & Pollack W. S., (Eds). (1995). A New Psychology of Men. New York, NY: Basic Books.

Biomedical Perspectives on Men's Sexuality

Lue, T., Basson, R., & Rosen, R., (Eds). (2004). Sexual Medicine: Sexual Dysfunctions in Men and Women. Paris, France: Health Publications, Inc.

Psychological Perspectives on Men's Sexuality

Levant, R. F., & Brooks, G. R., (Eds). (1997). Men & Sex: New Psychological Perspectives. New York, NY: John Wiley & Sons.
Levine, S. B., Risen, C. B., & Althof, S. E., (Eds). (2003). Handbook of Clinical Sexuality for Mental Health Professionals. New York, NY: Brunner-Routledge.

Boys and Young Men

Frosh, S., Phoenix, A., & Pattman, R. (2002). Young Masculinities. Understanding Boys in Contemporary Society. Houndsville, UK: Palgrave.
Horne, A. M., & Kiselica, M. S., (Eds). (1999). Handbook of Counseling Boys and Adolescent Males: A Practitioner's Guide. Thousand Oaks, Calif: Sage Publications.

Older Men

Gott, M. (2005). Sexuality, Sexual Health and Ageing. Maidenhead, Berkshire, UK: Open University Press.
Schiavi, R. C. (1999). Aging and Male Sexuality. Cambridge, UK: Cambridge University Press.

Academic Journals

International Journal of Men's Health (2002-)
Journal of Men's Studies (1992-)
Men and Masculinities (formerly Masculinities, and before that Men's Studies Review, 1998-)
Psychology of Men & Masculinity (2000-)

Penile Implant Information

See the following websites for photos and descriptions of different types of implants:
http://www.thetransitionalmale.com/penileimplant
http://www.seekwellness.com/mensexuality/penimpl.htm

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