Author: The Beauty Nation

Among the most distressing of the many factors in dyspareunia are the complaints of burning, itching, or aching in the vagina during or after intercourse. The existence of chronic vaginal irritation frequently robs women of their full freedom of sexual expresssion, for they are well aware that any specific coital connection may be severely irritative rather than highly stimulative.

Presuming adequate production of vaginal lubrication, rarely, if ever, does a woman complain of burning, itching, or aching during coition or describe these symptoms immediately after or even in a delayed postcoital time sequence without concomitant evidence of established pathology in the vaginal barrel.

This form of dyspareunia registered as a complaint by the female partner should have an important connotation to the cotherapist. This specific response pattern is not described by women who are subjectively impelled to register an excuse to avoid impending or threatened coital connection.

When women use the complaint of pain to avoid or delay the necessity for submitting to psycho genically unappealing coital experience, their most frequent complaint is one of severe pain with penile thrusting, “a hurting” deep in the pelvis.

When considering the complaints of burning, itching, or aching in the vagina, initially clinical concern is focused on infectious vaginal invaders. The primary sources of vaginal infection are coition and rectal contamination; secondary sources are manual contact, clothing material, insertion of foreign material, and functional disuse.

Support of and control of the acidity of the vaginal environment is the fundamental means of protection against the bacterial pathogens that can create symptoms of burning, itching or aching. The vagina naturally maintains a strongly acid environment as a protective mechanism against all forms of infectious invasion.

With an experimentally controlled environment, vaginal acidity has been established as varying clinically from pH 3.5 to pH 4.0. Thus, there is a rather wide margin for error in vaginal protection against concurrent infectious agents, for acidity must be sufficiently neutralized to raise the pH level to five or above, before bacterial invaders can flourish freely in the vaginal environment.

The one time that natural vaginal protection against infection breaks down is during the period of established menstrual flow. For many women vaginal acidity consistently registers in the neighborhood of pH 5 or above during menstrual flow, particularly if vaginal tampons are employed.

The neutralizing effect of blood serum constrained to the vaginal tract by retentive tampons directs vaginal acidity into pH 5 levels routinely. It is not surprising, then, that most vaginal infections either have clinical onset or flourish during menstrual flow.

Bacteria

The infective organisms most constantly encountered in vaginal infections, yet trichomonal and fungal forms of infection are seen frequently enough to provide additional causes for clinical concern. Probably the most persistent vaginal-tract invader in any woman’s lifespan are the coliform organisms (Strepto coccus faecalis, Escherichia coli, and the type of Streptococcus viridans), which are the basic contaminants of bowel environment.

From the point of view of patterns of sexual functioning alone, a persistent vaginitis, from which pathogenic organisms repeatedly are cultured in the adult, sexually functioning woman, should always make the therapist question the possibility of occasions of rectal intercourse.

A popular technique employed during rectal intercourse includes the expected format of initial rectal penetration during the excitement phase and repetitive thrusting during the plateau phase of the male sexual response cycle.

Infected Penis

But many men withdraw from the rectum and plunge the bacterially contaminated penis into the vaginal barrel just before or during the stage of ejaculatory inevitability, terminating the orgasmic phase of their sexual cycle by ejaculating intravaginally. Recurrent coliform vaginal infections that are resistant to treatment may have origin in this coital technique.

When rectal intercourse is practiced, the ejaculatory episode should be confined to the lumen of the bowel. There should never be penetration of both rectal and vaginal orifices during any single coital episode, if the woman wishes protection against the probability of recurrent vaginal infections.

If coliform vaginitis persists despite both adequate treatment and patient denial of rectal intercourse, a direct rectal examination frequently will solve the therapist’s diagnostic dilemma. If a woman is experiencing rectal intercourse with some regularity, there may be a specific involuntary reaction of the sphincter to the rectal examination.

When the examining finger is inserted, the response of the rectal sphincter at first will be one of slight to moderate spasm, following the expected reactive pattern of most men or women undergoing routine rectal examinations. But if the examining finger is retained rectally for a few seconds, the sphincter may relax quite rapidly in a completely involuntary manner, as opposed to the routine response pattern of continuing in spastic contraction for the duration of the examination.

If involuntary sphincter relaxation develops, this response pattern, while certainly not reliably diagnostic, should make the cotherapist skeptical of the patient’s denial of rectal coital episodes.

The involuntary sphincter relaxation develops because the retained examining finger stimulates a pleasurable response for those women enjoying regularity of rectal coital exposure as opposed to those finding rectal examinations subjectively objectionable and objectively painful.

Clinical note:
The same type of involuntary sphincter relaxation may develop in male homosexuals whose preferred pattern of sexual expression includes interest in regularity of rectal penetration. Again, the involuntary sphincter response pattern has been used by the Foundation’s professional staff as a clinical diagnostic aid when dealing with homosexual male patients employing the rectum as the means of providing ejaculatory release for sexual partner or partners.

When the cotherapist can be reasonably certain by both history and examination of some regularity of rectal intercourse, techniques to avoid vaginal contamination with fecal material should be discussed at length with the women involved.

Although the basic premise of the clinical advice is to avoid recurrent episodes of coliform vaginitis if possible, there is an accrued secondary effect of reducing dyspareunia during occasions of intravaginal coitus.

Uncircumcised Penis

When trichomonal vaginitis is suggested by direct inspection of the vaginal barrel and confirmed by adequately stained vaginal smear or hanging-drop preparation of the vaginal discharge, which may be profuse and irritating.

The husband also should be suspected of harboring the trichomonads, possibly beneath the foreskin if he is uncircumcised, but more frequently in the prostate gland, the seminal vesicles, or the urinary bladder.

If both husband and wife are not treated simultaneously for this particular distress, the infection may become a source of chronic dyspareunia, as it may be exchanged frequently between marital partners during repeated opportunity at coital connection.

It does little good to treat the wife for trichomonal vaginitis and then have her reinfected by her husband. And it obviously does little good to treat the husband individually and have him reinfected by his wife. With chronic trichomonal vaginitis there may be recurrent bouts of dyspareunia, particularly with coital connection of any significant duration.

Fungal vaginitis is seen clinically more and more frequently. Incidence of this particular infectious entity used to be primarily confined to the late spring, summer, and early fall months, but now such pathogens as Monilia and Candida albicans are encountered regularly throughout the year.

Chronic fungal infection creates a debilitating situation for the recipient woman. Burning and itching is intense and swelling and weeping of soft tissues are frequent complications. Coital connection is virtually impossible due to the pain involved when a fungal infection dominates in the vaginal environment.

Infections with antibiotics frequently will protect women from the complications of fungal vaginitis.

Curved Penis

Peyronie
A disease produced by induration and fibrosis of the corpora cavernosa of the penis and evidenced as an upward bowing of the penis, plus a gradually increasing angulation to the right or left of the midline, makes coital connection somewhat difficult, and in advanced stages, coition is virtually impossible.

There also may be pain attached to attempts at coital connection due to the unusual angulation of the penis creating resultant penile shaft strain, both with inserting and with thrusting experience.

Penile Chordee or Curved Penis

It is seen rarely in situations of penile trauma and only occasionally with neglected gonorrheal urethritis. Consultation has been requested by four men with severe penile chordee as a post traumatic residual.

In two instances the fully erect penis was struck sharply by an angry female partner. The remaining two men each described severe pain with a specific coital experience. During uninhibitedly responsive coital connection with the female partner in a superior position, the penis was lost to the vaginal barrel. In each case, the women tried to remount rapidly by sitting down firmly on the shaft of the penis.

The vaginal orifice was missed in the hurried insertive attempt and the full weight of the woman’s body sustained by the erect penis.

Each of the four men gave the remarkable verbal description that he felt or heard something snap. Shortly thereafter an obvious hematoma appeared on the anterior or posterior wall or lateral walls of the penile shaft.

Over a period of weeks, as the local hemorrhage was absorbed, fibrous adhesions developed and, with subsequent scar formation, there slowly developed a downward bowing and (in three cases) mild angulation of the penis.

Urologists state that due to the type of tissue involved in the penile trauma, there is little to offer in the way of clinical reprieve for men afflicted with these embarrassing erective angulations, Peyronie’s disease or chordee.

Attempts at surgical correction currently are of relatively little value and not infrequently make the situation worse. Any of these situations create responses of pain and tenderness during both masturbation and coital connection.

It always should be borne in mind that the erect penis can be traumatized by a sudden blow, by rapidly shifting coital position, by applying sudden angulation strain to the shaft, or from violent coital activity that places sudden weight or sudden pressure on the fully erect penis. The unfortunate residuals of such trauma have been described above.

Direct trauma of the penis occasioned by major accidents, war injuries, or direct physical attack sometimes requires that treatment for sexual dysfunction be patterned to include marked variation in the anatomical structuring of the penis. In anatomical deformity of the penis, the complaint of dyspareunia can be raised by either the male or female sexual partner.

Testicular Pain

Usually of the dull, aching variety, develops for some men who spend a significant amount of time in sexual play or in reading pornographic literature, concurrently maintaining erections for lengthy periods of time without ejaculating within the immediate present.

Frequent returns to excitement or even plateau-phase levels of sexual stimulation without ejaculatory relief of the accompanying testicular vasocongestion can cause an aching in either or both testes, particularly in younger men. Relief is immediate with ejaculation, which disperses the superficial and deep vasocongestion and returns the testicles to their normal size.

No permanent damage is occasioned by maintaining chronic testicular congestion for a period of days. Men with this syndrome of testicular pain occasioned by long-maintained sexual tension are in the minority.

Usually, the syndrome of involuntary testicular pain is relieved somewhat as the man ages.

There are painful reactions that develop during or shortly after coital connection that particularly reflect the influence of the vaginal environment. These situations are mentioned only in passing, but the therapist should keep in mind the fact that the basic pathology involved rests within the vaginal environment.

Sexual Interest

Yet another advantage of the social isolation factor is its effect upon the sexual interest of both marital partners. With the subject of sex exposed to daily consideration, sexual stimulation usually elevates rapidly and accrues to the total relationship. This specific psycho-physiological support is indeed welcome to the co-therapists dealing with the blocking of sexual stimuli in individuals distressed by sexual inadequacy.

To help develop a level of sexual interest: 

For the couple which is realistic to their lifestyle, vacations from any form of specific sexual activity are declared for at least two 24-hour periods during the two weeks, in a system of timely checks and balances. However, daily consideration of sexual matters and social isolation continue to give maximum return to this facet of psychotherapy.

It might be held as part of this therapeutic concept that patients must have the opportunity to make those mistakes that reveal factors contributing to their particular distress. This means of learning is particularly important in reversing sexual dysfunction. In this interest, the patients are told that the co-therapists are not interested in a report of perfect achievement when they are following directions in the privacy of their own bedroom.

The cotherapists are interested in couple’s making their usual errors of reaction and interaction as they involve themselves in situations that provide opportunity for natural response to sexual stimuli. If the mistakes then are evaluated and explained in context, the educational process is infinitely less painful and more lasting. There are significant advantages to this technique.

When mistakes are made, they are examined impartially and explained objectively to the unit within 24 hours of their occurrence. Additionally, they are discussed within the context of the misunderstanding, misconceptions, or taboos that may have led to or influenced their occurrence initially.

There is yet another specific advantage in daily conferences. If the distressed unit waits a matter of days after mistakes are made before consulting authority, the fears engendered by their specific episode of inadequacy or mistake in performance increase daily in almost geometric progression. In such a situation, alienation between partners is a common occurrence. By the time the next opportunity for consultation arises, a great deal of the effectiveness of prior therapy may have been destroyed by the takeover of the fears.

Fears of performance do not wait a few days or a week until the next appointment; in the meantime, the couple, separately or together, must use their own methods of coping. Most often this will be withdrawal of sexual or total communication, which places them further away from altering the sexual distress than before therapy was initiated.

When patients do not make mistakes during their acute phase of treatment, the cotherapists arrange for them to do so. It is inevitably true that individuals learn more from their errors than from their ability to follow directions effectively on the first attempt.

If marital partners reverse their sexual dysfunction and fully understand, through comparison with episodes of failure, why and what made it possible for them to function effectively, the probability of reduplicating the success in the home environment is increased immeasurably.

As evidence of the advantage to the therapeutic program of the unit’s social isolation, those couples referred from the St. Louis area require three weeks to accomplish symptom reversal rather than the standard two weeks for those living outside the local area. It is difficult to isolate oneself from family demands and business concerns if treatment is being ear tied out in the environment in which the couple lives.

For this reason, it has been found more effective to see patients referred from the St. Louis area on a daily basis for the first week, thereafter five times a week, and to assign a total of three weeks to accomplish the reversal of symptomatology. Partners in sexually distressed marriages who cannot or do not isolate themselves from the social or professional concerns of the moment react more slowly, absorb less, and communicate at a much lower degree of efficiency than those advantaged by social retreat.

The Foundation’s request for two weeks’ withdrawal from daily demands, at first rather an overwhelming suggestion to most patients, pales into insignificance when compared to the isolation demands engendered by necessary hospitalization for acute surgical or medical problems. When the couple’s presenting complaint is one of sexual inadequacy, it should constantly be borne in mind that there is not only the equivalent of two distressed people but also an impaired marital relationship to be treated.

Aside from direct infective agents, there are many other sources of burning, itching, or aching in the vaginal barrel that can produce chronic dyspareunia. Among those most frequently encountered are the sensitivity reactions associated with intravaginal chemical contraceptive materials.

Many women develop vaginal sensitivity to chemical factors included in contraceptive creams, jellies, suppositories, foams, or foam tablets. When persistent itching or burning is intense enough to engender the symptoms of dyspareunia during or shortly after intercourse, and when any of these above-mentioned intravaginal chemical contraceptive agents are employed routinely during coital connection, the possibility of sensitivity to the chemical agents should always be kept in mind.

There also are occasional irritations created by the rubber used in manufacturing both diaphragms and condoms. In a few women, the response of the vaginal mucosa to latex products is quite irritative in character.

When these contraceptive techniques are employed with regularity and chronic non-infectious irritation in the vagina causes obviously increasing dyspareunia, sensitivity to rubber products should be suspected. The sensitivity to rubber is quite infrequent but must be kept in mind in the differential diagnosis of non-infectious, irritative, vaginal dyspareunia.

Agents frequently most often responsible for making the vaginal mucosa sensitive to infective processes and emphasizing the potential irritation of maintained penile thrusting are the various douching preparations.

Many women feel they must douche after every coital exposure to maintain cleanliness. This is one of the most persistent and widespread misconceptions in the folklore of human sexual functioning. From a cleanliness point of view, there is not the slightest need for douching after intercourse.

The vagina returns to its natural protective pH value within 6 to 8 hours after seminal-fluid deposition. Repeated douching usually accomplishes only the untoward result of washing protective levels of residual acidity from the vagina.

Thereafter, secondary infection frequently develops from the elevated levels of pH usually found in the post-douching vaginal environment. Additionally, proprietary products used in douching can create reactive, chemical-type vaginitis of the same pattern as that stimulated by intravaginal chemical contraceptives.

Esthetically concerned women should be reassured by the authority that the simple expedient of external washing with soap and water is all that is necessary to maintain security from post-ejaculatory drainage and to avoid any suggestion of post-coital odor.

Forceful Penile Thrusting

There is another type of chronic vaginal irritation that should be highlighted. It frequently is seen associated with clinical complaints of dyspareunia and is described as senile vaginitis. Older women not supported by steroid protection techniques develop thin, atrophic mucosal surfaces in the vagina.

These tissue-paper-thin areas crack and bleed easily under duress of forceful or maintained penile thrusting. Many women in the 50 to 70 year age group complain of vaginal burning and irritation not only during but even for hours and occasionally days after coital exposure due to the atrophic condition of the mucosal lining of the vagina.

Sex Steroid

Aging women can be fully protected from these distressing symptoms by initiation of adequate sex steroid support. Although seen infrequently, yet in the same physiological category as senile vaginitis, is radiation reaction in the vagina. After local radiation for carcinoma, the vaginal barrel shrinks, the mucosa becomes atrophic, and dyspareunia usually develops not only from the atrophic mucosa but also on the basis of loss of vaginal wall elasticity and marked reduction of lubrication production.

Secondary Impotence

Definition of secondary impotence depends upon acceptance of the concept of primary impotence as expressed and discussed in primary impotence. Primary impotence arbitrarily has been defined as the inability to achieve and/or maintain an erection quality sufficient to accomplish coital connection.

If erection is established and then lost from real or imagined distractions related to the coital opportunity, the erection usually is dissipated without an accompanying ejaculatory response. If diagnosed as primarily impotent, a man not only evidences erective inadequacy during his initial coital encounter but the dysfunction also is present with every subsequent opportunity.

If a man is to be judged secondarily impotent, there must be the clinical landmark of at least one instance of successful intromission, either during the initial coital opportunity or in a later episode. The usual pattern of the secondarily impotent male is success with the initial coital opportunity and continued effective performance with the first fifty, hundred, or even thousand or more coital encounters.

Finally, an episode of failure at effective coital connection is recorded.

Secondary Impotence and Sex

The most distressing etiological influence upon any dysfunction in the cycle of male sexual inadequacy is a derogatory effect of consulted therapeutic opinion. Careless or incompetent professionals inadvertently may either initiate the symptoms of sexual dysfunction or, as is more frequently the case, amplify and perpetuate the clinical distress brought to professional attention.

There have been 27 cases in the total 213 units referred for treatment of secondary impotence that have been told at first consultation with selected authority for relief of symptoms that nothing could be done about their problem.

These cases are represented in all categories of etiological influence described previously in the chapter as prime initiators of the symptoms of secondary impotence. When the sexually incompetent male finally gathers his courage and reaches for the presumed security of authoritative consultation only to be told that nothing can be done about his problem, the psychogenic effect of this denial of salvation is devastating.

Of the 27 men denied hope of symptomatic relief by consultative authority, 21 individuals were so informed on their first and only visit to their local physician.

Among these 21 men, 11were told that the onset of symptoms of secondary impotence was concrete evidence of clinical progression of the aging process and that they and their wives would have to learn to adjust to the natural distress occasioned by the sexual dysfunction.

Among these 11 men the eldest was 68, the youngest 42, and the average age was 53 years. These men and their wives experienced an average of 28 months of sexual inadequacy before seeking further consultation.

In the 10 remaining instances of authoritative denial of hope of reprieve from symptoms of impotence, there were 4 instances of negation of clinical support by the consulted theologian; in 2 of these instances the men were informed that symptoms of impotence were in retribution for admitted adulterous behavior.

One of the husband and wife was informed by a clergyman that the symptoms of secondary impotence developed as a form of penance because this particular unit had mutually agreed that a pregnancy conceived prior to marriage should be terminated by an abortion.

Finally
One unit was assured that the symptoms of impotence would disappear if there were regularity in church attendance for at least one year. Two years later, despite fanatical attendance at all church functions, the symptoms of impotence continued unabated.

In each of the 6 remaining couples there were individual patterns of authoritative denial of hope of symptomatic relief. They ranged from the statement that “once a grown man has a homosexual experience, he always ends up impotent,” to the authoritative comment that “any man masturbating after he reaches the age of thirty can expect to become impotent.” The authorities consulted were psychologists, marriage counselor, and lay analyst.

The incidence of erective failure progressed rapidly after authoritative denial of support.

Sexual Disability

Male fears of performance were magnified and marriages were shaken and even disrupted by projection by the professional sources of a black future with full sexual disability.

This mutually traumatic experience for husband and wife could easily have been avoided had the consulted authority figure accepted the fundamental responsibility either by admitting lack of specific knowledge in this area or by acquiring some basic understanding of human sexual response, or at least by not confusing personal prejudice with professional medical or behavioral opinion.

In addition to the 27 cases in which the presenting symptoms of sexual dysfunction were amplified or perpetuated by consultative authority, there were 6 instances in which consultative authority was directly responsible for the onset of symptoms of secondary impotence.

The susceptibility of the human male to the power of suggestion with reference to his sexual prowess is almost unbelievable. Two classic histories defining iatrogenic influence as an etiological agent in onset of symptoms of secondary impotence provide adequate illustration of the concept.

Vaginal Penetration

A man in his early thirties married a girl in her mid twenties. Both had rather extensive premarital sexual experience. His was intercourse with multiple partners, hers was mutual manipulation to orgasm with multiple partners, but never vaginal penetration. She had retained her hymen for wedding night sacrifice.

However, the honeymoon was spent in repetitively unsuccessful attempts to consummate the marriage. The husband and wife felt that the difficulty was the intact hymen, so she consulted her physician for direction. She was told that it was simply a matter of relaxation, to take a drink or two before bedroom encounters.

By relieving her tensions with alcohol she should be able to respond effectively. The drinks were taken as ordered, but the result was not as anticipated.

The marriage continued in an unconsummated state for three years, with the wife’s basic distress (in retrospect) a well established state of vaginismus. Throughout the three-year period, the husband continued penetration attempts with effective erections at a frequency of at least two to three times a week.

There usually was mutual manipulation to orgasm, when coitus could not be accomplished.

As a second consultant, her religious adviser assured the couple that consummation would occur if the husband could accept the wife’s (and the adviser’s) religious commitment. The husband balked at this form of pressure.

Hymen

Finally, a gynecologist, third in the line of consultants, suggested that the difficulty was an impervious hymen. The wife immediately agreed to undergo minor surgery for removal of the hymen. It is not only the human male that is “delighted to find some concept of physical explanation for sexual dysfunction.

When the physician spoke with the husband after surgery, the husband was assured that all went well with the simple surgical procedure and that his wife was fine. The physician terminated his remarks to the husband with the statement, “Well, if you can’t have intercourse now, the fault is certainly yours.”

Obviously, surgical removal of the hymen will provide no relief from a state of vaginismus, so three weeks after surgery, when coital connection was initiated, penetration was still impossible.

For two weeks thereafter, attempts were made to consummate the marriage almost on a daily basis, but still without success. By the end of the second week both husband and wife noted that the penile erections were no longer full or well sustained.

The symptoms of impotence increased rapidly over the next few weeks. Three months after the hymenectomy, the husband was completely impotent. Both partners were now fully aware that the inability to consummate the marriage was certainly the husband’s fault alone, for so he had been told by authority.

The problem presented in therapy two-and-a-half years later by this husband and wife was not only the concern for the wife’s clinically established vaginismus but additionally the symptoms of secondary impotence that were totally consuming for the husband.

In another instance:
The husband and wife in a three-year marriage had been having intercourse approximately once a day. They were somewhat concerned about the frequency of coital exposure, since they had been assured by friends that this was a higher frequency than usual.

Personally delighted with the pleasures involved in this frequency of exposure, yet faced with the theoretical concerns raised by their friends, they did consult a professional. They were told that an ejaculatory frequency at the rate described would certainly wear out the male in very short order.

The professional further stated that he was quite surprised that the husband hadn’t already experienced difficulty with maintaining an erection. He suggested that they had better reduce their coital exposures to, at the most, twice a week in order to protect the husband against developing such a distress.

Finally, the psychologist expressed the hope that the husband and wife had sought consultation while there still was time for his suggested protective measures to work.

Sexual Response

The husband worried for 48 hours about this authoritative disclosure. When intercourse was attempted two nights after consultation, he did accomplish an erection, but erective attainment was quite slowed as compared to any previous sexual response pattern.

One night later there was even further difficulty in achieving an erection, and three days later the man was totally impotent to his wife’s sexual demands with the exception of six to eight times a year when coitus was accomplished with a partial erection. He continued impotent for seven years before seeking further consultation.

When duly constituted authority is consulted in any matter of sexual dysfunction, be the patient man or woman, the supplicant is hanging on his every word.

Extreme care must be taken to avoid untoward suggestion, chance remark, or direct misstatement. If the chosen consultant feels inadequate or too uninformed to respond objectively, there should be no hesitancy in denying the role of authority. There is no excuse for allowing personal prejudice, inadequate biophysical orientation, or psychosocial discomfort with sexual material to color therapeutic direction from duly constituted authority.

There are innumerable combinations of etiological influences that can and do initiate male sexual dysfunction, particularly that of secondary impotence. It is hoped that the survey of these agents in this chapter will serve not only as a categorical statement but also render information of value to duly constituted authority.

Secondary impotence is inevitably a debilitating syndrome. No man, or, for that matter, no husband and wife emerges unscathed after battle with the ego-destructive mechanisms so intimately associated with this basic form of sexual dysfunction.

There must be support, there must be relief, and there must be release for those embattled husband and wifes condemned by varieties of circumstance to contend with male sexual dysfunction. As emphasized earlier in this chapter, most men are influenced toward secondary impotence by manifold etiological factors.

Although case histories have been held didactically open and brief for teaching purposes, it must be understood that frequently there was a multiple choice of determining agents. Other professionals well might make a different assignment if given an opportunity to review the material.

For example
there remain 12 cases referred for treatment that could not be categorized from an etiological point of view. No dominant factor could be established among a multiplicity of influences despite in-depth questioning by Foundation personnel.

It must be emphasized that, regardless of the multiplicity of etiological influences which can contribute to incidence of secondary impotence, it is the untoward susceptibility of a specific man to these influences that ultimately leads to sexual inadequacy. It is this clinical state of susceptibility to etiologic influence about which so little is known.

A statistical evaluation of the returns from therapy of secondary impotence will be considered as an integral part of the chapter on treatment of impotence. Present concepts of treatment for secondary impotence have been joined with those of the current clinical approaches to primary impotence in a separate discussion devoted to these therapeutic considerations.

The most important fact of sexually transmitted diseases is they are not contracted by people who have only one partner.

At the Clinic

Some clinics which specialize in the diagnosis and treatment of sexual diseases are free. Others charge for their services. Some are walk-in; others require an appointment to be made first. Many women opt to visit a health clinic rather than a family physician. They prefer the anonymity of their surroundings. When the infection is cured, there is no record in the family files.

Some STDs are “notifiable.” By law, they must be reported to the local health authorities. This varies from area to area, and from time to time. Other STDs are anonymous; a number instead of a name is used. Still, other diseases are confidential; name, address, and telephone number are kept in secret files. Again, this varies with the area and the time.

Some STDs have more than one name. Others have their names changed as more is discovered about them. They then get placed in their own special category; they no longer belong to the group they were originally designated. In much the same way, therapies and medications vary from clinic to clinic and from time to time. Though this can seem confusing, it shows an increase in medical knowledge of the disease. Also, environmental conditions and the endemic nature of the infection in one particular area are taken into account.

In towns and cities, there are hotlines to call for advice, help, and information. There are telephone tapes which are useful too. In isolated areas, look for notices in public locales, such as town halls, libraries, and restrooms. Consult the phone book. Entries might be under V for venereal disease or $ for STD. Above all, avoid delay in seeking help.

High Risk Behaviors

High risk sexual behavior includes:

• Sex which is paid for.
• Constant change of heterosexual partners.
• Heterosexual anal sex which is unprotected.
• Sex with an intravenous drug user.
• “Tough” sex which causes lesions, bruises, bleeding.
• Male sex (anal homosexual intercourse).

AIDS is transmitted by the HIV virus in blood, semen, and vagina fluids. It can be passed in skin sores and genital lesions too tiny to be seen with the unaided eye. It is also passed from mother to child in breast milk. Infected blood and semen contain the highest concentration of the virus. Vagina fluids have a lesser concentration. HIV may be present in sweat, saliva, and tears, but the concentrations are usually too weak for there to be any risk.

STDs, however, pass in very low concentrations. One germ can be enough. Studies suggest that syphilis and herpes are significant risk factors in the transmission of HIV. The sores of either disease can be on the mouth or inside the rectum, as well as on the genitals. In women, HIV is linked with a history of genital warts. It seems likely that STDs, which disrupt epithelial (lining) tissue, are important factors in the transmission of HIV. An appropriate way to avoid infection is to avoid direct contact with a partner’s semen, blood, or sores anywhere on the skin. Condoms provide some protection.

Gonorrhea

Gonorrhea is a bacterial infection which affects one million people each year in the United States. It is believed a further one million cases each year go unreported, because the disease is asymptomatic in 10 to 15 percent of men, and in 50 to 80 percent of women. Of the women with mild symptoms, 40 to 60 percent ignore them, believing that they are due to some other minor problem. The cervix is the most common site of gonorrhea.

Symptoms appear 3 days to 2 weeks after sexual contact. There is a thick, yellowish discharge. The cervix looks red, with small bump-like pits which are erosions. The urine tract often becomes infected, with the classic symptoms of UTI: stinging pain, frequency, and urgency. The infection can spread, to Skene’s and Bartholin’s glands. With oral sex, gonorrhea can spread from the penis to the throat, with sore throat and swollen glands, or it is asymptomatic. Discharge from an infected vagina or anal sex can infect the rectum with itching anus and discharge.

Untreated gonorrhea can lead to pelvic inflammatory disease (PID). Some 1 to 3 percent of women develop “disseminated gonorrhea,’ which spreads throughout the system. It can cause arthritis and, in rare cases, heart disease. The infection can be passed to a baby during birth, causing serious infection and possible blindness. Therapy is by antibiotics. Protect the cervix.

Syphilis

The corkscrew shaped bacteria of syphilis penetrate the skin of the vulva and within 30 minutes reach the glands in the groin. Thirty-six hours after infection, the bacteria have doubled in number. They double again every 30 hours. It takes an average 3 weeks (10 to 50 days) for the first symptoms to appear. By then, there are countless bacteria in the blood stream.

The first symptom is a chancre, an ulcer which starts as a pimple and then develops into an open sore with a hard rim. It is painless and self-healing. Once the sore disappears, bacteria travel in the blood, rapidly multiplying. Second stage syphilis occurs 2 to 6 weeks later. The symptoms include a skin rash over the body, swollen glands, and a flu-like condition; but often the disease is asymptomatic. Syphilis continues to wreak its havoc in the vital organs. In later years, the tertiary (third) stage is devastating: heart and brain disorders, joint inflammation, and sometimes early death.

Only about 10 percent of women who get chancres notice them. They can be hidden in the folds of the labia, under the hood of the clitoris, inside the vagina or rectum, on the cervix itself. The bacteria enter through any tiny skin lesion. The sores can appear anywhere, the most usual places being the mouth, nostril, tongue, even the finger. Avoid sexual contact if sores appear on any skin parts. The same applies to a partner.

Antibiotics destroy the bacteria of syphilis. Regular blood tests are necessary for the next two years to check for lingering germs. Keep all follow-up appointments to ensure that the disease has finally gone. Syphilis is 3 times more common in men than women; it is rare in female homosexuals. It can be passed to the fetus after the 20th week of pregnancy, so a blood test for syphilis is now a routine part of prenatal care.

Anal Sex

Anal sex carries specific health risks for all lovers, be they heterosexual or homosexual. Faeces contain highly infectious matter. The walls of the rectum are only a few cells thick. They are not designed to resist the pressure of a thrusting penis. They tear easily, and microscopic bleeding occurs. If the penis is not washed immediately after anal sex, whatever germs are in the bowel are thrust directly into the vagina. Infected semen, blood, or faeces can then pass directly into the blood system. Repeated attacks of yeast overgrowth can also occur this way.

Whatever the moral stance, hygiene is top priority. The penis should not touch the vulva, nor should it ever enter the vagina straight from the bowel. Hands, particularly fingernails, are an added danger in anal sex. Wiping with a tissue is not enough. Penis, hands, mechanical toys, all must be thoroughly scrubbed. It is strongly recommended a condom be used during anal sex, and immediately discarded afterwards.

Oral Sex

Specific micro-organisms inhabit the mouth, just as they inhabit other body orifices (openings). They rarely cause problems within their natural ecology. If they are transmitted to other orifices, they can cause infection. One typical example is a harmless bacteria of the mouth which can come in contact with the penis. The germs enter the urinary tract, and cause male UTI.

The membranes which line the mouth are naturally subjected to tiny lesions. It has been estimated that there is gum bleeding after brushing the teeth in at least one-third of any given population. Small ulcers can be present at the sides of the mouth. The tongue can be sore for a variety of reasons. All these factors can make the mouth an “unsafe” place for sex.

Diseases known to be transmitted by oro-genital infection are: the herpes virus cold sore, yeast infections, AIDS, gonorrhoea of the throat, and syphilis chancre of the lips. At least two cases of AIDS have been contracted this way. It would seem unlikely that a woman would wish to kiss a partner with a sore on the mouth, or that she would perform oral sex on a penis with a “drip”. Yet all infections have an incubation period. There is a time lapse between contracting a disease and the appearance of symptoms. Incubation periods vary widely with different STDs; they can take years for AIDS. With a new partner, the incubation period must be taken into account.

In some cases, both partners are asymptomatic. There are no signs of disease to remind lovers that oral sex can be hazardous. Avoid direct mouth contact with semen. Where there is high risk sexual activity, one option is to completely avoid oro-genital sex. If this is unacceptable, wait until a new partner has been tested and is known to be infection-free.

Tricky Trichomonas

Trichomonas vaginalis, or trich, is caused by a one-celled protozoan which grows rapidly within the vagina. Some women have an immediate and painful reaction to trich. Many more have asymptomatic trich; it is often only found if there are tests for other problems. The symptoms include a thin, foamy discharge which is yellow, green, or grey; there is intense itching and soreness, especially if the vulva is scratched. Trich can infect the urinary tract, causing burning, urgency and frequency. No tiny, one-celled creature should be able to cause such misery. But it does.

Trich can be passed on damp material: towels, bathing suits, washcloths, and toilet seats. This is rare. In most cases, it is transmitted by direct sexual contact. Metronidazole in Flagyl destroys trich. It has side effects, and should not be taken if there is any risk of pregnancy. A partner must be treated. Eschew douches and tampons. Avoid a flare-up recurrence by following the same “cool and dry” regime as for yeast overgrowth.

Vaginitis

There are many other organisms that can attack the area. They come under the generic terms nonspecific vaginitis and vulvitis. Nonspecific refers to conditions in which the cause is uncertain. They may be due to sexual infection, or they may not. The symptoms are often the same as for yeast and trich, with a profuse, foul-smelling discharge, intense itching, soreness, and in some cases, severe pain. Again, like yeast and trich, none of these attacks seem to affect the cervix. Yet they can cause real misery, and greatly reduce the quality of life.

Have a test for diabetes or a prediabetes condition first. Check diet and general health; try to boost the immune system by getting more rest, more profound sleep. Many women are run down and exhausted without realizing how deeply tired they are. Once yeast and trich are ruled out, a course of antibiotics may be the answer, though yeast overgrowth may then have to be treated. If attacks of vaginitis or vulvitis do recur, be extra scrupulous with genital hygiene. Keep the entire area cool and dry.

Chlamydia

Chlamydia is the most common STD in the U.S. today, with as many as 4 million new cases each year. It causes about half the known cases of NGU (non-gonococcal urethritis) in men. It breeds on the cervix in women. The symptoms are often mild and frequently go unnoticed. They are the same symptoms as for gonorrhea and can be confused with it. However, they appear a little later, within 1 to 3 weeks of sexual contact. More rarely, Chlamydia can be passed by a hand infected with the discharge from parent to baby.

If left untreated, chlamydia can lead to PID and infertility. Tests involve taking swabs from the cervix and culturing a specimen. The antibiotic of choice is tetracycline. Protect the cervix.

Herpes

The first attack of the herpes virus is the most painful and takes the longest time to heal. Within 2 to 20 days after infection, there is a mild tingling or itching. This can be on the labia, clitoris, or vagina opening; more rarely on the vagina wall, the cervix, the buttocks, thighs, or anus. It develops into one or more watery, painful blisters in the next few days. There can be burning or pain on urination, with swollen lymph nodes in the groin. There is an increase in discharge, or a feeling of pressure in the pelvic area. In some cases, the entire body reacts with flu-like symptoms: fever, headache, and chills.

Ninety percent of women develop sores on the vagina and cervix during a first infection. The blisters burst quickly, and shed highly contagious viruses everywhere. The now-empty blisters turn into shallow ulcers, which can be painful. The ulcers form into crusts, which heal spontaneously within 1 to 5 weeks. Visit the physician as soon as the symptoms appear. At an early stage, diagnosis can be made by sight alone. Help can begin immediately, but a culture test is very expensive.

At least 5 types of herpes virus are known to affect humans. The Epstein Barr virus and-cytomegalovirus causes infectious mononucleosis, also known as glandular fever. The varicella virus causes chicken pox in children, and shingles in adults. There are 2 types of herpes simplex virus. HSV 1 causes cold sores on the lips or nose, also called fever blisters. HSV 2 causes genital ulcers, also called genital herpes.

By adulthood, most people have been infected with the cold sore virus, HSV 1. They develop antibodies against it, and only a few actually get cold sores. Fewer adults have HSV 2 antibodies because the virus is spread by sexual contact. The findings of a recent study suggest that 99 percent of prostitutes have HSV 2 antibodies in their blood, compared with 3 percent of nuns and 29 percent of women in a committed relationship.

About 50 percent of those with HSV 2 have no symptoms. The recent increase in genital herpes is thought to be partly due to this, and partly due to an increase in the practice of oro-genital sex. In some cases, both HSV 1 and HSV 2 cause genital herpes. If suffering from a cold sore, avoid kissing, and any facial or genital contact. This applies to a partner as well.

Not all HSV 2 die after a first attack. The virus coats itself in the person’s own protein substance and retreats along nerve endings to the base of the spine. Here it sets up a permanent home, staying inactive for varying lengths of time. When the virus becomes active again, it usually returns to the same place as the previous attack. Recurring outbreaks can be virulent and painful, or very mild. If mild, a woman may be unaware that she is shedding highly contagious germs.

HSV 2 is particularly dangerous for women. It is linked with cancer of the cervix, The virus can cause miscarriage in the first 3 months of pregnancy. If shed during birth, 1 in 2 babies will be infected. Two out of 3 of those infected babies will die. Half the others suffer brain damage, or visual defects. These horrors are now avoided by Caesarian birth. The baby is lifted from the uterus and thus avoids contact with the virus.

As yet, there is no drug to destroy the herpes virus. The drug acyclovir helps reduce the pain of an attack; it may even lessen the number of recurrences. One of the miserable factors of herpes is the permanent risk of passing on the disease. Some physicians believe that this is only during the active phase; others strongly disagree. An infected person cannot be free of this worry.

Genital Warts

Molluscum Contagiosum: There are two kinds of warts, simple and genital. Both can infect the genitals; it is crucial to recognize the difference. Simple warts are the kind which appears on the hands of children. They are small, dimpled papules, which look like spots with a drop of pearly fluid inside. They are highly contagious, as their Latin name shows. They can be transmitted to the genitals by self or partner from warts on the hands and elsewhere. The virus enters the skin through invisible lesions which occur during sexual activity. The warts appear some 30 days after contact. Attacks of simple warts on the genitals are rare, being most likely in the teens and 20 to 30 age group.

If the penis is infected with simple warts, some men try self therapy. This is not advisable for women. Simple warts can be painful if rubbed, otherwise a woman is unaware of them. They are not life-threatening, nor do untold damage, but they are highly contagious. Visit the physician or clinic. Therapy varies.

Human Papilloma Virus: HPV is specific to the genital area. It is transmitted by direct sexual contact. The warts appear 3 weeks to 3 months after contact, but the incubation time can be up to 8 months, even more. The warts can be single; usually, they grow in clusters like grapes. With their raised, bumpy tops, they look like miniature cauliflowers. They grow on the labia lips or anus, inside the vagina, or on the cervix. In many cases, they are asymptomatic, and the woman is unaware that she is infected.

The warts are painless, but easily irritated by rubbing, and sometimes they itch. If there has been anal contact, they can grow inside the rectum and around the anus. More rarely with oral contact, they infect the linings of the mouth. If the warts breed in colonies on the cervix, the disease may not be detected until a Pap smear is done. Women with HPV have a five times higher risk of cancer of the cervix.

Larger warts, especially on the cervix, maybe vaporized by laser therapy, but it is difficult to know if they have all been destroyed. The healing process takes 6 weeks. Repeat therapy is necessary if they flare up again; avoid losing patience as laser therapy usually works. Other therapies include burning the warts off by electric cautery, or freezing them with dry ice. The physician then snips them off. External warts can be painted with the drug podophyllin. It takes 3 or 4 weekly treatments for the warts to dry up and drop off.

HPV infection is also called condyloma. The prescription drug Condylox has just been made available for home treatment, which means that patients no longer need to have a physician apply the therapy. At least 56 different types of the virus have been identified.

Hepatitis

Hepatitis A and B are caused by virus infection of the liver. The virus breeds in waste matter from the bowel and is common where there is poor sanitation. It is passed in contaminated food and drink; less usually, by sexual contact; more rarely, by transfusions of infected blood. Hepatitis is on the increase, probably due to more foreign travel. When visiting areas with poor sanitation, observe strict personal hygiene. Drink bottled water, eschew ice cubes. Avoid anal and oral sexual contact.

The symptoms of both A and B are the same: fever, nausea, headache, fatigue, loss of appetite, and chills. Jaundice shows as a yellow tinge to the skin, fingernails, and whites of the eyes about a week later. Urine can be dark in colour; stools almost whitish. A few people are asymptomatic. With hepatitis A, the symptoms are mild. The defence system builds immunity to the virus, but it remains in the blood and can be transmitted.

The hepatitis B virus (HBV) produces severe symptoms, which start suddenly 1 to 6 months after contact. If liver damage is extensive, death occurs in 5 to 20 percent of cases. The B virus is transmitted in blood and blood products during sexual contact: semen, vagina secretions, saliva, and faeces are suspect. It is also passed by IV drug users sharing infected needles. The incidence of HBV is rising rapidly, perhaps due to more foreign travel and IV drug use. Male homosexuals, heterosexuals with multiple partners, travellers, and drug addicts are high risk groups.

AIDS

AIDS stands for Acquired Immune Deficiency Syndrome.

Acquired: it is passed on, but not inherited.
Immunodeficiency: the immune system grows weak and deficient.
Syndrome: a group of symptoms of which the cause is unknown.

However, it is now known that AIDS is caused by the human immunodeficiency virus (HIV). The word AIDS is still used to avoid confusion. The virus does not kill, but it damages the immune system, leaving the person vulnerable to rare infections and cancers which are life-threatening. If death occurs, it is not from AIDS, but from one of these opportunistic diseases.

HIV is transmitted in body fluids: blood, blood products, semen, vagina secretions, and breast milk. It does not appear to be easily transmitted in saliva.

The Future

Scientists using an experimental AIDS vaccine have succeeded in changing the way the body fights the AIDS virus. The discovery could open the door to new ways of treating the disease. By giving the vaccine to 30 men and women infected with HIV, researchers found that they were able to prompt the immune systems of most in the group into mounting a more sophisticated counterattack against the virus. It is too early to know if this response will help HIV-infected people to survive the ravages of the disease.

The study’s results counter the long-standing and pessimistic conviction of many AIDS researchers that there is little to be done to improve upon the immune system’s battle against the HIV virus.

New therapies such as the use of the antiviral drug AZT early in infection and inhaled pentamidine to prevent AIDS-caused pneumonia will delay the time when HIV infection develops into full-blown AIDS.

The subject of physiological influence on sexual inadequacy will be considered in this chapter because at least 95 percent of the time when physical disability affects male sexual response.

The symptoms are those of secondary impotence.

It is almost impossible to list the diversity of physical defects, metabolic dysfunctions, or medications that may influence onset of secondary impotence.

Below is a list of some of the physical influences that have been reported to have resulted in secondary impotence on at least one occasion. This listing does not imply that these physical influences have been demonstrated in male patients referred to the Foundation for sexual dysfunction.

The list has been culled from the literature and is presented only as a reminder that almost any physical dysfunction that reduces body economy below acceptable levels of metabolic efficiency can result in the onset of the symptoms of erective incompetence. Physical causes are:

Anatomic:
Congenital deformities, Testicular fibrosis, Hydrocele.

Cardio Respiratory:
Angina pectoris, Myocardial infarction, Emphysema, Rheumatic fever, Coronary insufficiency, pulmonary insufficiency.

Drug Ingestion:
Addictive drugs, Alcohol, Alpha-methyl-dopa, Amphetamines, Atropine, Chlordiazepoxide, Chlorprothixene, Guanethidine, Imipramine, Methantheline bromide, Monoamine oxidase inhibitors, Phenothiazines,Reserpine, Thioridazine, Nicotine (rare), Digitalis (rare).

Endocrine:
Acromegaly, Addison’s disease, Adrenal neoplasms (with or without Cushing’s syndrome).

Castration:
Chromophobe adenoma, Craniopharyngioma, Diabetes mellitus, Eunuchoidism (including Klinefelter’s syndrome), Feminizing interstitial-cell testicular tumors, Infantilism, Ingestion of female hormones (estrogen), Myxedema, Obesity, Thyrotoxicosis.

Genitourinary:
Perineal prostatectomy (frequently ), Prostatitis, Phimosis, Priapism, Suprapubic and transurethral prostatectomy (occasionally), Urethritis

Hematologic:
Hodgkin’s disease, Leukemia, acute and chronic, Pernicious anemia

Infectious:
Genital tuberculosis, Gonorrhea, Mumps

Neurologic:
Amyotrophic lateral sclerosis, Cord tumors or transaction, Electric shock therapy, Multiple sclerosis, Nutritional deficiencies, Parkinsonism, Peripheral neuropathies, Spina bifida, Sympathectomy, Tabes dorsalis, Temporal lobe lesions.

Vascular:
Aneurysm, Arteritis, Sclerosis, Thrombotic obstruction of aortic bifurcation.

While the above listing is of import, it must be emphasized in context that many of these conditions have been identified in individual case reports that are in many instances unsubstantiated by adequate patient evaluation.

True biophysical dominance in the etiology of impotence is not a frequent occurrence. In any reasonably representative clinical series, the incidence of primary physiological influence upon onset of secondary impotence is indeed of minor consideration.

Among the 213 men referred to the Foundation for treatment of secondary impotence, there have only been 7 cases in which physiological dysfunction overtly influenced the onset of the sexual inadequacy.

Impotence Drug

In the neurological group there has been one case of spinal-cord compression at the level of the eleventh and twelfth thoracic vertebrae subsequent to an automobile accident; this particular man did not accomplish erective success with therapy.

In the drug ingestion category, the influence of alcohol has been previously mentioned and is not included in this listing. There has been one case of the use of Reserpine for relief of hypertension that was referred without consideration of the possible influence this product might have had in the onset of secondary impotence.

Reversal of the impotence was possible after alteration of the patient’s medication. Eunuchoidism (Klinefelter’s syndrome) has been recorded in one instance of referral to the Foundation for treatment that was not successful. There also has been a case of acromegaly and one of advanced myxedema, both referred without prior authoritative association of onset of symptoms of secondary impotence with exacerbation of the disease.

In the first instance failure and in the second success marked therapeutic effort.

In two instances genitourinary surgical procedures have been responsible for onset of symptoms of secondary impotence. In one case a perineal prostatectomy was performed for carcinoma of the prostrate.

Technically, the prostatic capsule was necessarily removed during surgery, damaging the innervation that controls the erective process. This is the usual result of such surgery. As expected, treatment was unsuccessful.

Sexual Therapy

A basic premise of therapeutic approach originally introduced, and fully supported over the years by laboratory evidence, is the concept that there is no such thing as an uninvolved partner in any marriage in which there is some form of sexual inadequacy.

Therapeutic technique emphasizing a one-to-one patient-therapist relationship, effective in treatment of many other psychopathological entities, is grossly handicapped when dealing specifically with male or female sexual inadequacy if the sexually dysfunctional man or woman is married. Isolating a husband or wife in therapy from his or her partner not only denies the concept that both partners are involved in the sexual inadequacy with which their marital relationship is contending, but also ignores the fundamental fact that sexual response represents (either symbolically or in reality) interaction between people. The sexual partner ultimately is the crucial factor.

If treatment is directed separately toward the obviously dysfunctional partner in a marriage, the theoretically “uninvolved” partner may actually destroy or negate much therapeutic effort, initially from lack of knowledge and understanding and finally from frustration.

Sexual Response

If there is little or no information of sexual import, or for that matter, of total treatment progress reaches the wife of the impotent husband, she is in a sincere quandary as to the most effective means of dealing with the ongoing marital relationship while her husband is in therapy. She does not know when, or if, or how, or under what circumstances to make sexual advances, or whether she should make advances at all. Would it be better to be simply a “good wife,” available to her husband’s expression of sexual intent, or on occasion should she take the sexual initiative.

During actual sexual functioning should she maintain a completely passive, a somewhat active, or a mutually participating role? None of these questions, all of which inevitably arise in the mind of any intelligent woman contending with the multiple anxieties and the performance fears of an impotent husband, find answers in the inevitable communication void that develops between wife and husband when one is isolated as a participant in therapy.

Of course, an identical situation develops when the wife is non orgasmic and enters psychotherapy for constitution of effective sexual function. It is the husband that does not know when, or if, or how, or under what circumstances to approach her sexually.

If he approaches his wife in a physically demanding manner, she reasonably might accuse him of prejudicing therapeutic progress. If he delays or even restrains expression of his sexual interest, possibly looking for some signal that may or may not be forthcoming, or hoping for stone manner of behavioural guideline, he may be accused of having lost interest in or of having no real concern for his sexually handicapped wife.

Not infrequently he also is accused (probably with justification) of being a significant contributor to his wife’s sexual dysfunction. But if no professional effort is made to explain his mistakes or to educate him in the area of female sexual responsivity, how does he remove this continuing road block to his wife’s effective sexual function?

Methods of therapy using isolation techniques when approaching clinical problems of sexual dysfunction attempt to treat the sexually dysfunctional man or woman by ignoring half of the problem, the involved partner. These patient-isolation techniques have obliterated what little communication remained in the sexually inadequate couple at least as often as the techniques have returned effective sexual functioning to the distressed male or female partner.

It should be emphasized that the Foundation’s basic premise of therapy insists that, although both husband and wife in a sexually dysfunctional marriage are treated, the marital relationship is considered as the patient. Probably this concept is best expressed in the statement that sexual dysfunction is indeed a husband and wife problem, certainly never only a wife’s or only a husband’s personal concern.

Dual Sex Therapy

Definitive laboratory experience supports the concept that a more successful clinical approach to problems of sexual dysfunction can be made by dual-sex teams of therapists than by an individual male or female therapist.

Certainly, controlled laboratory experimentation in human sexual physiology has supported unequivocally the initial investigative premise that no man will ever fully understand woman’s sexual function or dysfunction. What he does learn, he learns by personal observation and exposure, repute, or report, but if he is at all objective he will never be secure in his concepts because he can never experience orgasm as a woman. The exact converse applies to any woman.

Since it soon became apparent in the laboratory that each investigator needed an interpreter to appreciate the sexual responsivity of the opposite sex, it was arbitrarily decided that the most theoretically effective approach to treatment of human sexual dysfunction was to include a member of each sex in a therapy team. This same premise applied in the clinical study provides husband and wife of a sexually dysfunctional couple each with a friend in court as well as an interpreter when participating in the program.

By repute, report, observation, and by personal exposure in and out of bed, she too learns to conceptualize male sexual functioning and dysfunctioning, but she will never fully understand the basics of male sexual responsivity, because she will never experience ejaculatory demand or seminal fluid release.

For example, it helps immeasurably for a distressed, relatively inarticulate, or emotionally unstable wife to have available a female cotherapist to interpret what she is saying and, far more important, even what she is attempting unsuccessfully to express to the uncomprehending husband and often to the male cotherapist as well.

Conversely, it is inevitably simpler for any wife to understand the concerns, the fears, the apprehensions, and the cultural pressures that beset the sexually inadequate man that is her husband when these grave concerns can be defined simply, effectively, and unapologetically to her by the male cotherapist. The Foundation’s therapeutic approach is based firmly upon a program of education for each member of the dysfunctional couple.

Multiple treatment sessions are devoted to explanations of sexual functioning with concentration on both psychological and physiological ramifications of sexual responsivity. Inevitably, the educational process is more effectively absorbed if the dual-sex therapy teams function as translators to make certain that no misunderstandings develop due to emotional or sexual language barriers.

A typical history of an acute episode of alcohol consumption as an etiological factor in the onset of secondary impotence is classic in its structural content. The clinical picture is one of acute psychic trauma on a circumstantial basis, rather than the chronic psychosocial strain of years of steady attrition to the male ego as described in the case history for the premature ejaculator.

There has been a specific history of onset of symptoms of secondary impotence as a direct result of episodes of acute alcoholic intake in 35 men from a total of 213 men referred with a complaint of secondary impotence.

The onset of secondary impotence in an acute alcoholic episode is so well known that it almost beggars description. A composite example is that of a relatively “successful” male aged 35-55, college graduate, working in an area which gears productive demand more to mental than physical effort.

The perfect environmental situation for onset of secondary impotence is any occupational hazard where demands for high levels of psychosocial performance are irrevocably a part of the nine-to-five day and frequently carry over into an evening of professional socializing.

Alcohol Impotence

Mr. A is a man with a habit of alcohol before dinner, frequently a few glasses of wine with his meals, and possibly a whisky. Alcohol intake at lunch is an integral part of his business as well.

In short, consumption of alcohol has become a part of his life.

This man and his wife leave home one night for a party and alcohol is available in large quantity. Somewhere in the late evening, the party comes to an end. Mr. A has had entirely becomes tipsy and so his wife drives them home for safety’s consideration.

His wife retires to the bedroom, and with a sense of vague irritation, a combination of a sense of personal rejection and a residual of her social embarrassment, prepares for bed. Mr. A has stumble but with the aid of a strong banister and even stronger nightcap, manages to arrive at the bedroom door. Suddenly he felt that his wife is indeed fortunate tonight, for he is prepared sexually satisfied her.

Alcohol Hangover

It never occurs to him that all she wants to do is go to bed and avoid a quarrel at all costs. He jumped into the bed, moves to meet his imagined commitment, and nothing happens. He has simply had too much alcohol.

Dismayed and confused both by the fact that no erection develops and that his wife obviously has little or no interest in his gratuitous sexual contribution, he pauses to resolve this complex problem and immediately falls into deep, anesthetized slumber.

Next day, he is further traumatized by the symptoms of an acute hangover. He surfaces later in the day with the concept that things are not as they should be. The climate seems rather cool around the house. He can remember little of the prior evening’s festivities except his deeply imbedded conviction that things did not go well in the bedroom. He is not sure that all was bad but he also is quite convinced that all was not good.

Obviously he cannot discuss his problem with his wife, she probably would not speak to him at this time. So he putters and mutters throughout the evening and goes to bed early to escape. He sleeps restlessly only to face the new day with a vague sense of alarm, a passing sense of frustration, and a sure sense that all is not well in the household this Monday morning.

He pondered about it over a drink or two at lunch and another, and while contending with traffic on the way home from work, decides to check out this evening the little matter of sexual dysfunction, which he may or may not have imagined.

Sexual dysfunction within 48 hours!

If the history of this reaction sequence is taken accurately, it will be established that Mr. A does not check out the problem of sexual dysfunction within 48 hours of onset, as he had decided to do on his way home from work. He arrives home, finds the atmosphere still markedly frigid, makes more than his usual show of affection to the children, retires to the security of the cocktail hour, and goes to supper and to bed totally lacking in any communicative approach to his frustrated, irritated marital partner.

Tuesday morning, while brushing his teeth, Mr. A has a flash of concern about what may have gone wrong with his sexual functioning after the party night. He decides unequivocally to check the situation out tonight.

Instead of thinking of the problem occasionally, his concern for “checking this out” becomes of paramount importance. On the way to work and during the day, he does not think about what really did go wrong sexually because he does not know. Rather he worries constantly about what could have gone wrong.

Needless to say, there is resurgence of concern for sexual performance during the afternoon hours, regardless of how busy his schedule is.

Mr. A leaves the office in relatively good spirits, but thoroughly aware that “tonight’s the night.” He does have vague levels of concern, which suggest that a little relaxation is in order; so he stops at his favorite tavern for a couple of drinks and arrives home with a rosy glow to find not only a forgiving, but an anticipatory, wife, ready for the reestablishment of both verbal and sexual communication that a drink ‘or two together before dinner can bring.

Probably for the first time in his life, he approaches his bedroom on Tuesday night in a self-conscious “I’ll show her” attitude. Again there has been a little too much to drink-not as much as on Saturday night, but still a little too much.

And, of course, he does show her. He is so consumed with his conscious concern for effective sexual function (the onset of his fears of performance) that, aided by the depressant effect of a modest level of alcoholic intake (modest by his standards), he simply cannot “get the job done.”

When there is little or no immediate erective reaction during the usual sexual preliminaries, he tries desperately to force the situation-in turn, anticipating an erection, then wildly conscious of its abscence, and finally demanding that it occur. He is consciously trying to will sexual success, while subjectively watching for tumescence. So, of course, no erection.

While in an immediate state of panic, as lie sweats and strains for the weaponry of male sexual functioning, he simultaneously must contend with the added distraction of a frightened wife trying to console him in his failure and to assure him that the next night will be better for both of them.

Sexual Incompetence

Both approaches are equally traumatic from his point of view. He hates both her sympathy and blind support which only serve to underscore his “failure,” and reads into his wife’s assurances that probably he can do better “tomorrow” a suggestion that no longer can he be counted on to get the job done sexually when it matters “today.”

A horrible thought occurs to Mr. A. He may be developing some form of sexual incompetence. He has been faced with two examples of sexual dysfunction. He is not sure what happened the first time, but he is only too aware this night that nothing has happened. He has failed, miserably and completely, to conduct himself as a man.

He cannot attain or maintain an erection.

Further, Mr. A knows that his wife is equally distressed because she is frantically striving to gloss over this marital catastrophe. She has immediately cast herself in the role of the soothing, considerate partner who says, “Don’t worry dear, it could happen to anyone,” or “You’ve never done this before, so don’t worry about it, dear.”

In the small hours of the morning, physically exhausted and emotionally spent from contending with the emotional bath her husband’s sexual failure has occasioned, she changes her tune to “You’ve certainly been working too hard, you need a vacation,” or “How long has it been since you have had a physical checkup?” (Any of a hundred similar wifely remarks supposed to soothe, maintain, or support are interpreted by the panicked man as tacit admission of the tragedy they must face together: the progressive loss of his sexual functioning.)

From the moment of second erective failure,

72 hours after the first erection failure, this man may be impotent.

In no sense does this mean that in the future he will never achieve an erection quality sufficient for intromission.

Occasionally he may do so and most men do. It does mean, however, that any suggestion of wifely sexual demand either immediate in its specific physical intensity or pointing coyly to future sexual expectations may produce pressures of performances quite sufficient to reduce Mr. A to and maintain him in a totally no erective state.

In brief, fears of sexual performance have assumed full control of his psychosocial system.

Mr. A thinks about the situation constantly. He occasionally asks friends of similar age group how things are going, because, of course, any male so beleaguered with fears of sexual failure is infinitely desirous of blaming his lack of effective function on anything other than himself, and the aging process is a constantly available cultural scapegoat.

Sexual Approach

He finds himself in the position of the woman with a lifetime history of non orgasmic return who contends openly with concerns for the effectiveness of her own sexual performance and secretly faces the fear that in truth she is not a woman. In proper sequence he does as she has done so many times.

He develops ways and means to avoid sexual encounter.

He sits fascinated by a third-rate movie on television in order to avoid going to bed at the usual time with a wife who might possibly be interested in sexual expression. He fends off her sexual approaches and jumps at anything that avoids confrontation as a drowning man would at a straw.

His wife immediately notices his disinclination to meet the frequency of their semi established routine of sexual exposure. In due course she begins to wonder whether he has lost interest in her, if there is anyone else, or whether there is truth in his most recent assertion that he couldn’t care less about sex.

For reassurance that she is still physically attractive, the concerned wife begins to push for more frequent sexual encounters, the one approach that the self-pressured male dreads above all else.

Obviously, neither marital partner ever communicates his or her fears of performance or the depth of their concerns for the sexual dysfunction that has become of paramount importance in their lives. The subject either is not discussed, or, if mentioned even obliquely, is hastily buried in an avalanche of words or chilled by painfully obvious avoidance.

Sexual Anxiety

Within the next 3 months, Mr. A has to fail at erective attainment only another time or two before both husband and wife begin to panic.

She decides independently to avoid any continuity of sexual functioning, eliminate any expression of her sexual needs, and be available only should he express demand, because she also has developed fears of performance.

Her fears are not for herself, but for the effectiveness of her husband’s sexual functioning.

She goes to great lengths to negate anything that might be considered sexually stimulating, such as too-long kisses, handholding, body contact, caressing in any way. In so doing she makes each sexual encounter much more of a pressured performance and therefore, much less of a continuation of living sexually, but the thought never occur to her. All communication ceases.

Each individual keeps his own counsel or goes his own way. The mutual sexual stimulation in the continuity of physical exposure, in the simple physical touching, holding, or even verbalizing of affection, is almost totally withdrawn.

The lack of communication that starts in the bedroom rapidly spreads through all facets of marital exchange: children, finances, social orientation, mothers-in-law, whatever.

In short :
Sexual dysfunction in the marital bed, created initially by an acute stage of alcoholic ingestion, supplemented at the next outing by ah “I’ll show her” attitude and possibly a little too much to drink can destroy the very foundation of a marriage of 10 to 30 years duration.

As the male panics, the wife only adds to his insecurity by her inappropriate verbalization, intended to support and comfort but interpreted by her emotionally unstable husband as immeasurably destructive in subjective content.

The dramatic onset of secondary impotence following an in stance of excessive alcohol intake is only another example of the human male’s extreme sensitivity to fears of sexual performance.

In this particular situation, of course, the onset of fears of performance was of brief but dynamic duration as opposed to those in the preceding example of the premature ejaculator whose fears of performance developed slowly, stimulated by continued exposure to his wife’s verbal denunciation of his sexual functioning.

Discussed above are examples of combinations of psychological and circumstantial factors that contribute the highest percentage of etiological input to the development of secondary impotence. Continuing through the listing of major influences there remain environmental, physiological, and iatrogenic factors.

In the final analysis:
Regardless of listing category, secondary impotence is triggered by combinations of these etiological factors rather than by any single category with the obvious exception of psychosocial influence. Once onset of erective failure has been recorded, regardless of trigger mechanism, involved, the individual male’s interpretation of or reaction to functional failure must be dealt with on a psychogenic basis.

The etiological factors recorded above are little more than categorical conveniences. From his initial heterosexual performance through the continuum of his sexual expression, every man constantly assumes a cultural challenge to his potency.

How he reacts to these challenges may be influenced directly by his psychosocial system, but of particular import is the individual susceptibility of the man involved to the specific pressures of the sexual challenge and to the influences of his background.

When considering etiological influences that may predispose toward impotence, it always should be borne in mind that most men exposed to parallel psychosexual pressures and similar environmental damage shrug off these handicaps and live as sexually functional males.

It is the factor of susceptibility to negative psychosocial input that determines the onset of impotence. These concepts apply to primarily as well as secondarily impotent men.

When considering environmental background as an etiological factor in secondary impotence, the home, the church, and the formative years are at center focus.

What factors in or out of the home during the formative years tend to initiate insecurity in male sexual functioning?

The preeminent factor in environmental background reflecting sexual insecurity is a dominant imbalance in parental relationships dominant, that is, as opposed to happen stance, farcical, or even fantasized battles for family control.

Secondary, but still of major import is the factor of homosexuality, which is to be considered in the environmental category. In no sense does this placement connote professional opinion that homophile orientation is considered purely environmental in origin.

Since homosexual activity may have derogatory influence upon the effectiveness of heterosexual functioning, the subject must be presented in the etiological discussion. The disassociations developing from homophile orientation are considered in the environmental category only for listing convenience.