AND CASE ILLUSTRATION. EVA LIBMAN .... The following case study provides clinical data favoring the .... response itself while others must learn to transfer.
1. Bchav. Ther. &Etp fsychiaf. Printed in Great Britain.
Vol. 15, No. 2, pp. 127-131,
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ooO5-7916/84$3.00+0.00 0 1984 Pergamon Press Ltd.
1984.
INCOMPETENCE: A THEORETICAL AND CASE ILLUSTRATION
FORMULATION
EVA LIBMAN and WILLIAM BRENDER Concordia University and Sir Mortimer B. Davis-Jewish General Hospital, Montreal, Quebec
ROSALIE BURSTEIN Sir Mortimer B. Davis-Jewish General Hospital, Montreal, Quebec
and SHEILAGH HODGINS University of Montreal, Quebec Summary-Three theoretical formulations of ejaculatory incompetence have been proposed in the literature. They include: (1) aversive conditioned inhibition of the ejaculatory reflex, (2) an “autosexual” orientation associated with discrepant levels in the cognitive and physiological dimensions of sexual arousal, and (3) a discriminative learning model. These three models are discussed in relation to their theoretical and therapeutic implications. Clinical data supporting the discriminative view is presented.
Ejaculatory incompetence (also termed retarded ejaculation and inhibited ejaculation) has been defined as “the persistent difficulty or inability to ejaculate, despite the presence of adequate sexual stimulation and erection” (Munjack and Kanno, 1979). The following range of cases can be included under this label: an inability to ejaculate during intercourse, but ease in achieving ejaculation with a partner outside of coitus (Masters and Johnson, 1970); difficulty in ejaculating through any form of stimulation by a partner, but no problem with masturbatory ejaculation; no experience of ejaculation under any conditions of deliberate stimulation (LoPiccolo and LoPiccolo, 1978). The last condition (general orgasmic difficulty) is relatively rare and the focus of this paper will be on the more commonly observed situation in which the orgasmic disorder is specific to the partner, and in particular to intravaginal stimulation. Munjack and Kanno (1979) reviewed the literature on retarded ejaculation and con-
cluded that there were almost no objective data related to etiology and treatment outcome and, to the present, this continues to be the case. Three basic theoretical formulations of ejaculatory incompetence can be distinguished in the sex therapy literature, each with different therapeutic implications. The first formulation is associated with the psychoanalytic model and postulates involuntary inhibition secondary to unconscious feelings of fear, anxiety, hostility and resentment associated with ejaculation (e.g. Ovesey and Meyers, 1968). Although psychoanalytic therapy and “sex therapy” would address the emotional disorder underlying the behavioral symptom, this paper will examine those techniques commonly known as “sex therapy”. Both Masters and Johnson (1970) and Kaplan (1974) present an etiological view related to the psychoanalytic model in that they propose the ejaculatory incompetence syndrome to be an involuntary and unconscious conditioned inhibition of the ejaculatory reflex; this inhibition is usually
Requests for reprints should be addressed to: Eva Libman, Sexual Dysfunction Service, Sir Mortimer B. Davis-Jewish General Hospital, 3755 C8te Ste-Catherine Road, Montreal, Quebec, Canada H3T lE2. 127
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initiated by having been paired either with a past aversive event and/or negative cognitions (e.g. guilt related to strict religious upbringing, conflicts about expressing anger, defenses of “holding back”, aggressive impulses). The therapeutic focus is on the extinction of this maladaptive response either by a process of gradual exposure to the problem situation or by the initiation of intense penile stimulation in order to “force” the ejaculatory response. The object of the treatment is to loosen the association of ejaculation with unconsciously anticipated negative consequences. A second model presented by Apfelbaum (1980) postulates that the ejaculatory incompetence syndrome, rather than being the behavioral manifestation of a conditioned inhibition or aversion, reflects the individual’s experience of self-stimulation as much more sexually arousing than stimulation by a partner. He categorizes such an individual as having an “autosexual” orientation. The idea that sexual orientation may be implicated in the etiology of the ejaculatory incompetence syndrome had been proposed previously by Cooper (1969) who observed that his sample of 13 males suffering from ejaculatory incompetence included four homosexuals, one fetishist and two autosexuals; all found heterosexual sex distasteful. Apfelbaum also claims that these males typically manifest an easily elicited and sustained erectile response in the interpersonal sexual context which does not accurately reflect their subjective experience and which consists of a lower level of erotic arousal than is necessary to allow for ejaculation. This model appears to the present authors to be based on the complex nature of the sexual arousal experience, which usually includes both a physiological and a cognitive component. Previous studies have demonstrated that one form of arousal may be present without the other (Heiman, 1977; Zuckerman, 1971) and the model suggests that the ejaculatory incompetence syndrome may be an example of a discrepancy between the two arousal dimensions. Apfelbaum does not, however, explicitly integrate this concept into his
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HODGINS
model. Neither does he present any systematic evidence for the “autosexual” construct as a stable, enduring preference, similar to heterosexual or homosexual preferences. Based on his own model Apfelbaum advocates a therapy which promotes insight for the male that he is not highly sexually aroused during interpersonal sexual activity, and encourages him to verbalize his resentment over his role as a “sexual work horse”. If, on the other hand, the important factor is the discrepancy between the two dimensions of arousal, an alternative therapeutic strategy would be to enhance the erotic value of the stimulus conditions when a partner is present to elicit a physical and cognitive level of arousal similar to that experienced with selfstimulation. The third position is formulated in terms of learning theory (e.g. LoPiccolo, Stewart and Watkins, 1972), and has been more precisely presented by Dow (1981), who postulates a discriminative learning model. Rather than having been associated with some negative event, Dow believes that orgasm has functioned primarily as a positive reinforcer for masturbation. Initial experiences of easily elicited sexual arousal and orgasm during solitary sexual activity with its particular stimulus conditions, has led to sexual response occurring more and more readily with masturbation rather than under the contrasting condition of sexual activity with a partner. In this discriminative conditioning model, self-stimulation becomes the preferred sexual activity, and orgasm becomes confined to its relatively narrow stimulus control. This formulation recognizes masturbation as a normal developmental phenomenon which in most cases leads to the facilitation of heterosexual activity. Failure to transfer the sexual response from the solitary to the interpersonal situation is due more to an incompatible masturbatory style than to a generalized “autosexual” preference. The therapeutic approach associated with this formulation would focus less on a desentization of anxiety, and more on the gradual transfer of orgasmic responsiveness from masturbation to the interpersonal
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setting. The therapist would attempt to design conditions to generalize the orgasmic response which is occurring reliably under one set of stimulus conditions (masturbation) to a graded series of changes in stimuli which approach those in sexual intercourse. There is little evidence in the literature to support or refute the hypotheses of anxiety avoidance, autosexual orientation and stimulus generalization, or even to suggest operation of some combination of these positions. What evidence there is has been largely anecdotal. The three models share some common features such as anticipatory anxiety, which is readily generated in the male subsequent to the experience of the problem. They also have in common the negative response which may be displayed by the partner. In addition, the actual therapeutic techniques derived from each position are likely to be similar. For example, all three approaches might encourage erotic fantasy, in one case as an effective distraction from anxiety-provoking cog&ions, in the second case to bring cognitive arousal up to the presumed level of physiological arousal, and in the third, to broaden the stimulus conditions in masturbation and thus facilitate transfer of the response to the interpersonal setting. There are a number of predictions each model might generate as evidence for or against its validity. In support of the aversive conditioning model, one could expect a large proportion of males with ejaculatory incompetence to report past aversive experiences and/or cognitions associated with interpersonal sexual activity. In addition, one would expect that the anticipated negative consequences which initially impaired only the ejaculatory reflex, would then spread backwards to other phases of the sexual response (the type of phenomena associated with development of a phobia) and ultimately significantly decrease sexual desire. Neither of these features predominate in the present syndrome. Consistent with both Apfelbaum’s and the discriminative learning model, one would predict that these males not only have developed a stable rate of
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masturbation to orgasm, but that this masturbation rate would remain stable prior to and throughout the duration of the problem (unlike erectile disorder, for example, which tends to decrease, or at least alter, sexual interest and activity). Case reports generally appear to confirm this expectation (Apfelbaum, 1980; Dow, 1981). The following case study provides clinical data favoring the discriminative learning view of ejaculatory incompetence in which the orgasmic response appears to be under the narrow stimulus control of masturbation rather than being affected by previous aversive conditioning of coital ejaculation.
METHOD Subjects A young couple, male 28, female 26, presented for treatment with a problem described by the husband as, “I cannot ejaculate during a sexual relationship”. The couple had been married -for 3% years. They-had an Smonth-old child conceived through artificial insemination. A significant factor in their seeking treatment appeared to have been their desire to have a second child “more naturally”. Results of a urological examination were normal. Neither husband nor wife had had previous psychological therapy. At the time of initial contact, the couple’s sexual repertoire consisted of intercourse 3-4 times a month. Foreplay included mutual manual genital stimulation and occasional oral-genital stimulation by the wife. Mrs. X was always orgasmic either manually or via intercourse while Mr. X was never orgasmic through any form of genital stimulation. Mr. X typically initiated the sexual contact, and always showered before and after. He was very much preoccupied with thoughts of his wife’s genitals and secretions being unclean, but nevertheless regularly caressed his wife genitally. Mr. X’s past history revealed that he had never experienced ejaculation intravaginally or through any other means of stimulation by a partner. He reported masturbating to ejaculation about 3 times a month, beginning in late adolescence and continuing at the same rate since that time.
Procedure A detailed sex questionnaire, the Eysenck Personality Inventory (EPI), and the Locke Wallace Marital Adjustment Scale, were administered during the assessment phase. Mrs. X’s inability to read English did not permit valid scoring of her test material. EPi scores for Mr. X were 10 on extraversion (E), 3 on neuroticism (N) and 4 on the lie scale (L). The elevated L score suggested that he was
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“faking good”, an interpretation which was in accord with clinical impression. His score on the Locke Wallace was 94, indicating that he was reasonably satisfied with his marriage. Throughout treatment both partners periodically complained of dissatisfaction with various aspects of the relationship, occasionally necessitating pauses in the treatment of the sexual difficulties and a focus on the content of the conflict as well as the couple’s destructive interactions during these periods. Nevertheless, the couple often completed assigned tasks in spite of concurrent relationship difficulties and this ability was likely a significant component of the successful outcome of this case. Similarly, the husband’s fastidiousness was noted, but since it did not cause sexual avoidance nor was it presented as a problem, it was not addressed in therapy. Following the information-gathering sessions, treatment began by homework assignments and non-genital and genital “pleasuring” with a goal of orgasm for Mrs. X and relaxation and attending to bodily sensations for Mr. X. It is noteworthy that at no time did he report sexual anxiety, therefore a homework assignment of erotic reading (Friday, 1974; Nin, 1978) before each encounter was included mainly to help generate and maintain sexual excitement in the interpersonal context. At the seventh therapy session, Mr. X reported that he had ejaculated during a sexual encounter with his wife the previous week while he was in the position which he habitually used for masturbation. At this point the therapist discovered that Mr. X’s sole masturbatory technique involved lying on his abdomen, his penis pointing downward, strong pressure on the penis with his palm and circular movements with his pelvis. It seemed reasonable to hypothesize that since his idiosyncratic style of masturbation was very different from penile contact which occurs with a sexual partner (i.e. penis pointing up and pelvic thrusting), this constituted one important reason for Mr. X’s previous failure to ejaculate in response to partner stimulation. Two programs based on this hypothesis were designed. One shaping procedure was aimed at teaching Mr. X. to masturbate in a position and with a motion similar to intercourse in an effort to associate ejaculation with these forms of stimulation. A concurrent fading procedure was aimed at gradually transferring control of the ejaculatory response from his unique masturbatory stimulation to the tactile stimulation available from his wife. This involved having him masturbate in his usual manner but at the point of orgasm turn on his side towards his wife. She would then manually stimulate his penis in a more conventional manner, first as he lay on his stomach and then on his side or back. The length of time Mr. X required to reach orgasm through selfstimulation followed by manual stimulation by his wife in the old position gradually diminished. When he was able to ejaculate reliably to his wife’s manual stimulation, he progressed to the next step which involved her initiating coitus from the female superior position. When he was able to ejaculate repeatedly intravaginally in the female superior position the couple began to use the male superior position with no difficulty. During the weeks following sessions 7-l 1 the couple worked on the steps of these two shaping programs. During weeks IO and 11 intravaginal ejaculation occurred 4 times. No further failure to ejaculate during intercourse was reported over the next 5 months-
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8 sessions-(although Mr. X did report a delay of several seconds between ejaculation and the pleasurable feelings of orgasm). He also continued to masturbate in the new way. At termination of treatment, Mrs. X was 7 months pregnant. A follow-up telephone interview 6 months after termination suggested that despite many life stresses, improvement had been maintained. Due to the wife’s having been out of town for 2 months, the birth of their baby and subsequent extended visits from relatives, there had been only three sexual encounters to report, two of which included intravaginal ejaculation. Telephone contact was made with Mrs. X 1 year after termination of therapy. Frequency of sexual contact had been similar to the rate before therapy (i.e. 2-4 times per month), Mr. X ejaculated intravaginally and on the rare occasion when he did “almost always”, not, his wife was easily able to stimulate him to orgasm manually.
DISCUSSION One cannot draw firm conclusions from the data of a single case study, however useful hypotheses are generated which may then be investigated under more rigorous experimental conditions. The case history revealed no evidence of aversive consequences or cognitions associated with past interpersonal sexual experiences. In addition, information gathered during the course of therapy suggested that the ejaculatory response had always been attached to an unusual and narrow set of tactile stimuli. These data are more consistent with a discriminative learning rather than an aversive conditioning model. Effective therapy involved stimulus generalization, the two aspects of which were (a) broadening the range of stimuli evoking sexual arousal and orgasm, and (b) successively approximating the masturbatory pattern to the interpersonal context. Of critical importance in the design of such a program was the acquisition of detailed information on the male selfstimulation pattern in masturbation. In general, treatment followed a sequence similar to that which is frequently applied to the case of a female complaining of secondary orgasmic dysfunction. The therapeutic emphasis traditionally has been on broadening the sexual repertoire and enhancing awareness of effective stimulus conditions for sexual arousal, first via a directed masturbation program (Lobitz and LoPiccolo, 1972) then by a gradual transfer
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of the acquired skills to the interpersonal coital situation, closely attending to the conditions the individual woman requires for sexual arousal. It is noteworthy that many secondary nonorgasmic women are reported to have a long history of masturbating in one very limited and coitally impractical way (McGovern, StewartMcMullen and LoPiccolo, 1978), an important feature both in the present case study as well as in the literature (Dow, 1981). The parallels strongly suggest that for males with interpersonal orgasmic problems, formulation of the problem and design of the therapy program in a manner similar to that for the secondary non-orgasmic female, would be an effective therapeutic strategy. A recent study has highlighted the variety of sexual response in the secondary orgasmic syndrome, suggesting that some women need to learn the orgasmic response itself while others must learn to transfer sexual responsiveness to the interpersonal setting (Libman, Fichten and Brender, 1984). It is likely that there are important variations in the nature of the problem within any single diagnostic category, and individual differences would similarly be found in the ejaculatory incompetence syndrome. The theoretical explanation why a particular male may experience difficulty transferring the sexual response from the almost universal initial experience of solitary sexual activity to subsequent interpersonal sex may lie in personality variables related to difficulty and ease in general interpersonal interactions (Eysenck, 1972). We are persuaded by Dow’s (1981) formulation and the presented case study that the discriminative learning model with its etiological and therapeutic implications is very useful. Within this framework, however, the complexity of the human sexual response must be taken into account. One can conceive of the sexual response as consisting of three phases (desire, arousal, orgasm) within which three dimensions may be identified (sensory, cognitive, affective). In the assessment of ejaculatory incompetence, a comprehensive classificatory scheme should be employed (e.g. Schover et al., 1982). This would include the global
or situational characteristics, the duration of the problem and the current or historical factors contributing to its maintenance, thereby permitting the location of a particular manifestation of inhibited ejaculation. Such a systematic descriptive scheme would provide the basis for the most effective treatment procedure. REFERENCES
Apfelbaum B. (1980) The diagnosis and treatment of -retarded ejaculation. In Princtples and Practice of Sex Therapy (Edited by Leiblum S. R. and Pervin L. A.). Guilford Press, New York. Cooper A. J. (1%9) A clinical study of “coital anxiety” in male potency disorders. J. Psychosom. Res. 13, 143-141. Dow M. G. T. (1981) Retarded ejaculation as a function of non-aversive conditioning and discrimination: A hypothesis. J. Sex & Marital Ther. 7.49-53. Eysenck H. J. (1972) Personality and sexual behavior. J. Psychosom. Res. 16,141-152. Friday N. (1974) My Secret Garden. Simon & Shuster, New York. Heiman J. R. (1977) A psychophysiological explanation of sexual arousal patterns in females and males. Psychophysiology 14,266214. Kaplan H. (1974) The New Sex Therapy. Brunner/Mazel, New York. Libman E., Fichten C. S. and Brender W. (1984) Prognostic factors and classification issues in the treatment of secondary orgasmic dysfunction. In Personality and Individual Differences 5, l-10. Lobitz W. C. and LoPiccolo J. (1972) New methods in the behavioral treatment of sexual dysfunction. J. Behav. Ther. & Exp. Psychiat. 3, 265-271. LoPiccolo J and LoPiccolo L. (1978) Handbook of Sex Therapy. Plenum Press, New York. LoPiccolo J., Stewart R. and Watkins B. (1972) Treatment of erectile failure and ejaculatory incompetence of homosexual etiology. J. Behav. Ther. & Exp. Psychiat. $233-236. McGovern K. B., Stewart-McMullen R. and LoPiccolo J. (1978) Secondary orgasmic dysfunction-I. Analysis and strategies for treatment. In Handbook of Sex Therapy (Edited by LoPiccolo J. and LoPiccolo L.). Plenum Press, New York. Masters W. H. and Johnson V. E. (1970) Human Sexual Inadequacy. Little, Brown, Boston: Munjack D. J. and Kamio P. H. (1979) Retarded eiaculation: Areview. ArchsSex. Behav. 8,‘139-150. Nin A. (1978) Delta of Venus. Bantam Books, New York. Ovesey L. and Meyers H. (1968) Retarded ejaculation: Psychodynamics and psychotherapy. Am. J. Psychother. 22.185-201. Schover L. R., Friedman J. M., Weiler S. J., Heiman J. R. and LoPiccolo J. (1982) Multiaxial problem-oriented system for sexual dysfunctions: An alternative to DSM III. Archs Gen. Psychiat. 39,614-619. Zuckerman M. (1971) Physiological measures of sexual arousal in the human. Psychol. Bull. 75,297-329.
