Postgraduate Medical Journal (August 1971) 47, 562-571. Postgrad Med J: first published as 10.1136/pgmj.47.550.562 on 1 August 1971. Downloaded from

Sexual inadequacy in the male JOHN BANCROFT M.D., M.R.C.P., D.P.M. First Assistant, Department of Psychiatry, University of Oxford

Summary paper will confine itself to inadequate function in the The adequacy of sexual functioning in the male de- male. The main types of such inadequacy will be pends on a complex interaction between psycho- described, their incidence and factors affecting their logical, hormonal and neurophysiological factors. presentation to the physician considered, and pos- Disturbance of any one of these factors may lead to sible aetiological factors discussed. Finally methods sexual inadequacy. In the majority of cases no gross of treatment that are at present available and their abnormality is found but the absence of gross hor- reported results will be briefly reviewed. monal or neurophysiological abnormality does not necessarily imply a purely psychological cause. Indi- The range of sexual inadequacy in the male vidual variations in the pattern of response of the There are three aspects of a man's sexual per- autonomic nervous system or in the ability to learn formance which may be affected: the level of sexual control of autonomic responses such as erection or drive, erection and ejaculation. ejaculation may be sufficient to account for some cases Protected by copyright. of inadequacy and in others may increase the suscepti- Low sexual drive bility to psychological factors. Further research is Low sexual drive means a low level of sexual required to clarify these undoubtedly important arousability so that in the male sexual behaviour psychophysiological relationships. leading to coitus is less likely to be initiated. This is Treatment has been most successful when it has most likely to constitute a problem if a sexual partner taken into account both psychological and physio- with a higher level of sexual drive is involved. Sexual logical factors. The advances made by Masters & drive may be selectively lowered, e.g. the male who Johnson (1970) in this area have partly depended on has no sexual interest in his wife but does find other their earlier physiological and anatomical studies of women stimulating, or may be generally lowered. sexual response (Masters & Johnson, 1966). Such a person may simply complain of loss of It may be that in some cases the use of anxiety- interest but be able to perform adequately if the reducing drugs or androgens will be all that is required sexual act is initiated by his partner. In others how- but further work is required to identify such cases. ever the loss of interest is combined with a degree of

The placebo effects of such preparations should not be erectile or ejaculatory inadequacy. Low sexual drivehttp://pmj.bmj.com/ overlooked particularly as many cases of sexual may be 'primary', i.e. present since puberty, or inadequacy are based on lack of confidence or 'secondary', i.e. developing after a period of relative ignorance and require little more than good advice or normality. reassurance. Considerable advances in our understanding of Erectile inadequacy or impotence these problems have been made in the past 20 years This is the inability to produce or maintain an and techniques of endocrine, physiological and erection sufficient for satisfactory vaginal penetra- behavioural assessment are now available which tion and coitus. Erections may develop normally on October 2, 2021 by guest. should enable further progress to be made in the near until vaginal penetration is either attempted or future. merely contemplated, when failure occurs. In other cases the presence of a sexual partner will be SEXUAL inadequacy is the failure to achieve satis- sufficient to inhibit erection, though the man, when factory coitus. It is thus a problem affecting two alone, can produce erections normally. Occasionally people. The failure may lie with one partner more erections do not occur at any time, not even on than the other but it is unusual for the responsi- waking, but this is relatively rare. bility to be entirely one-sided. Erectile impotence may be 'primary', i.e. erection Having emphasized the 'dyadic' nature of sexual sufficient for coitus has never been achieved, or inadequacy, it is convenient to consider separately 'secondary', i.e. at some stage in the past satisfactory the ways in which each sex may be affected and this coitus has occurred. Sexual inadequacy in the male 563 Postgrad Med J: first published as 10.1136/pgmj.47.550.562 on 1 August 1971. Downloaded from Secondary impotence may be of 'acute onset', e.g. The role of the partner is particularly important following some psychologically traumatic event, or in determining the incidence of premature ejacula- of 'gradual onset', where it is associated with a tion. According to Kinsey and his co-workers gradual decline in sexual drive. Ejaculatory in- (Kinsey et al., 1948) approximately 75Y4 of all males adequacy is an important cause of secondary ejaculate within 2 min of vaginal entry and 'a not impotence, leading either to acute psychological inconsiderable number of males' in less than 1 min. trauma or when chronic to a more gradual onset of A social class factor was involved however. Males impotence. in lower socioeconomic groups would tend to ejaculate quickly and consider it the norm. Members Ejaculatory inadequacy of higher socio-economic groups were more inclined to delay ejaculation. The attitude of the female is The commonest problem in this category is clearly crucial. If women consider intercourse to be premature ejaculation. This has been arbitrarily de- primarily a source of pleasure for the male, then fined by Masters & Johnson (1970) as the inability rapid ejaculation will be accepted as normal by both to control ejaculation 'for a sufficient length of time partners. Such an attitude may have been more during vaginal containment to satisfy the partner on widespread in the past and may still be more at least 50Y. of their coital connections'. frequent in the lower socioeconomic groups. If the As with erectile impotence, premature ejaculation woman seeks orgasm herself then it becomes a prob- can be 'primary' or 'secondary' although it is a lem if the ejaculation is too rapid for the woman to problem that is usually at its worst early in a man's obtain satisfaction. Obviously the speed with which sexual career and is less often of late onset. It may the woman reaches orgasm is an important variable however occur in certain sexual situations and not also. others. Ejaculatory incompetence is certainly less common The other problem in this category is ejaculatory Protected by copyright. incompetence. In this case ejaculation is either than either erectile impotence or premature ejacula- seriously delayed or does not occur at all during tion. In Kinsey's series (Kinsey et al., 1948) it coitus. In the majority of cases ejaculation and was reported in six of the 4108 cases. It is not clear orgasm are affected jointly. As with erectile im- from this report however whether this refers to potence the problem may only arise during coitus, absence of ejaculation and orgasm in the presence of ejeculation occurring normally from other sources a partner or total absence. of penile stimulation such as mutual masturbation. Sexual drive or 'appetite' is a difficult concept to In other cases the presence of a sexual partner is all define. The nearest one can get to measuring it in the that is required to ensure failure. Occasionally male is to count the frequency of sexual outlets or ejaculation only occurs during the sleeping state. orgasms. Clearly there are a number of factors which Ejaculatory incompetence may also be either are likely to influence the level of such activity. The 'primary' or 'secondary' and has to be distinguished availability of an acceptable partner and culturally from so-called 'dry-run' orgasm in which orgasm determined taboos on alternative methods of outlets occurs but is not accompanied by ejaculation such as masturbation are two examples. The high & 1967). frequency may in some cases reflect a high level of http://pmj.bmj.com/ (Money Yankowitz, concern about sexual performance rather than a high level of 'appetite'. If one allows for such factors how- Incidence of sexual inadequacy ever there is still evidence of considerable individual In the study of males reported by Kinsey, variation in the frequency of sexual outlet. In Pomeroy & Martin (1948) the incidence of erectile Kinsey's males (Kinsey et al., 1948) the mean impotence increased steadily with age. It had occurred frequency for all subjects was 2-74 outlets/week. in 1.3O/ of their population by the age of 35. By the For those under 31, 2-9y. showed a frequency of age of 50 the proportion was 6-7%y, by 60 it was orgasm of once in 10 weeks or less. There was a on October 2, 2021 by guest. 18-4%y and by 75 it was 55%4. The proportion of steady increase in low-rating males after the age of these with primary impotence was apparently very 35 and age is obviously an important factor. small. In the older cases the impotence was usually In the three main series of cases reported in the associated with a decline in sexual interest. There are literature (Johnston, 1968; Cooper 1969a, b; additional factors which determine whether sexual Masters & Johnson, 1970) erectile impotence is the inadequacy is presented to the doctor and little is commonest problem, ejaculatory incompetence the known of the incidence in clinical practice. The in- least common. Secondary impotence is considerably fluence of the sexual partner is clearly important. more frequent than the primary form. A complaint of If the female also experiences declining sexual in- low sexual drive is not usually made although cer- terest then cessation of sexual activity may be tainly some patients do present in this way (Burnap accepted by both partners. & Golden, 1967). 564 John BancroJt Postgrad Med J: first published as 10.1136/pgmj.47.550.562 on 1 August 1971. Downloaded from

Possible aetiological factors in male sexual marked and less predictable in prepubertal cases inadequacy (Money, 1961). This is consistent with experimental In order to discuss aetiological factors the normal findings in cats (Lehrman, 1962). The late onset of mechanisms underlying maintenance of sexual drive. puberty in humans is also associated with a relatively erection and ejaculation will be briefly considered. low sexual drive thereafter (Kinsey et al., 1948). These will be looked at in terms of endocrine, neuro- Jt thus seems possible that the establishment of physiological and psychological factors, with par- normal adult levels of sexual drive depends on the ticular emphasis on the interaction between them. interaction between circulating androgens and be- haviour, and that this critical interaction takes place Sexual drive at the stage of puberty. Presumably in the normal As with appetite for food, sexual drive reflects a situation optimum hormonal and psychological (and complex interaction of psychological and physio- hence behavioural) factors coincide, thusrepresenting logical processes. The role of the central nervous a further 'critical period' of development. system in this respect however is even less well Psychological factors clearly play a crucial part. understood than in the case of hunger. Evidence Sexual drive will be heightened by an erotic stimulus from ablation and depth-electrode studies in animals whether external or internal (i.e. fantasy) and may and the effects of localized pathology and cerebral be inhibited by anxiety-provoking stimuli. How- surgery in man suggests that, as with other basic ever, if the necessary hormonal and metabolic state drives, the limbic system is involved, though the is not present purely psychological stimuli will be precise mechanisms remain unknown (Maclean, ineffective. That the interaction between sexual 1965). In the male the cerebral cortex is also in- behaviour and androgen levels is complex has been volved, at least in the process of discriminating be- further indicated by a recent finding that androgen tween sexual stimuli (Ford & Beach, 1952). levels increase after sexual activity (Ismail & Hark- The interaction of the endocrine system and cen- ness, 1967). This means that low levels of androgensProtected by copyright. tral nervous system has been clearly demonstrated may be the result as well as the cause of low levels of in the early development of gender differences in sexual drive. There is probably considerable indi- rodents and primates. The presence of androgens at vidual variation in this respect; in some individuals critical stages of foetal development determines sexual abstinence appears to heighten sexual drive, whether the brain thereafter behaves in a charac- in others it may be associated with reduction in teristically masculine or feminine way. This early sexual drive. The explanation of such differences is sensitization also determines the later response to not yet understood. circulating androgens. If a female rat brain in utero is Loss of sexual drive may be associated with a masculinized in this way, then later administration debilitating condition or starvation; it is a frequent of testosterone will provoke characteristic masculine though not invariable accompaniment of depressive sexual behaviour (Harris, 1964). A similar effect has illnesses. The mechanism in such cases is not under- been demonstrated in primates (Goy, 1968). stood. Disorders of the temporal lobe are not in- Puberty is associated with an increase in circulat- frequently associated with reduced sexual drive ing androgens due to the lessening of sensitivity of (Gastaut & Collomb, 1954; Johnson, 1965; Hierons http://pmj.bmj.com/ the hypothalamus to their inhibitory feed-back effect & Saunders, 1966). (Donovan, 1963). In the male, testosterone levels The role of endocrine dysfunction as a cause of reach their maximum early in adolescence when lowered sexual drive also remains obscure. Heller & sexual drive is probably at its height also. This may Myers (1944) described males with high levels of be partly due to the sensitizing effect that androgens gonadotrophins in late adult life suggesting testicular have on erectile mechanisms leading to frequent failure. This syndrome they labelled the 'male erections (i.e. increased target organ sensitivity) and climacteric' although emphasizing that it was not partly due to sensitization of the central nervous part of the normal aging process. Such men would on October 2, 2021 by guest. system to erotic stimuli. report loss of libido which was correctable by Males who have gonadal failure or undergo testosterone therapy, in contrast to men with so- castration before puberty are unlikely to experience called psychogenic impotence where gonadotrophin any significant level of sexual drive. Castration or levels were normal and there was no response to hypogonadism following puberty will result in androgens. Other reports of the relationship between marked reduction of sexual drive in the majority of androgen administration and the improvement in cases but not all, and the reduction may be gradual sexual drive or impotence were conflicting and over a year or more (Bremer, 1959). Replacement interest in the area was dropped mainly due to poor therapy with androgens will predictably restore assay methods. With recent techniques however sexual drive to its previous level in postpubertal interest has revived. A recent study of impotent hypogonadism or castration whilst its effects are less males reported by Cooper et al. (1970) found low Sexual inadequacy in the male 565 Postgrad Med J: first published as 10.1136/pgmj.47.550.562 on 1 August 1971. Downloaded from androgen levels in cases of so-called 'constitutional' The role of the endocrine system in erectile impotence compared with normal levels in 'psycho- mechanisms is not clear though androgens probably genic' cases. The 'constitutional' cases were charac- increase sensitivity to both reflexive and psychic terized by an insidious onset, with gradual loss of stimuli. This may account for the frequent occurrence sexual drive starting relatively late in men whose of erections to non-specific stimuli in prepubertal sexual drive had never been particularly high. The boys when androgens are starting to rise (Ramsey, aetiological distinction between 'constitutional' and 1943). The effect of testosterone on psychic erections 'psychogenic' requires justification however and as and sexual drive was clearly demonstrated in the case the authors point out the low androgen levels in the reported by Beumont et al. (1971). former group may have been the result rather than The relationship between psychological factors and the cause of their lower levels of sexual outlet. In erection is obviously of crucial importance. The contrast to Heller & Myers' 'male climacteric' group early over-simplified view that erection resulted these 'constitutional' cases did not apparently from parasympathetic stimulation and was inhibited benefit from exogenous androgens. by sympathetic stimulation led to the view that Administration ofoestrogens to males is frequently anxiety inhibited erection by means of the autonomic associated with a reduction in sexual drive, an effect arousal (or sympathetic activity) that accompanied often made use of in the treatment ofsexual offenders it. There is evidence in both animals and man (Golla & Hodge, 1949; Bierer & Van Someren, 1950; (Gantt, 1944; Ramsey, 1943; Bancroft, 1970) that Scott, 1964). The mechanism is not clear but may be erections may occur in situations which provoke due to an androgen-blocking effect of oestrogens. anxiety. The presence of anxiety therefore does not No systematic studies of such oestrogen effects have mean of erection. Recent been carried out but it seems probable that in some necessarily the inhibition it is sexual drive that is affected whilst in others sexual work (Maclean & Ploog, 1962; Bancroft & Mathews, 1971) has also shown that erection is not necessarily Protected by copyright. desire persists but erectile impotence prevails. accompanied by autonomic arousal and in some Similar libido-reducing effects have been reported individuals may be accompanied by a lowering of with the use of cyproterone, a specific anti-androgen autonomic arousal. Erection is therefore one of the (Laschet & Laschet, 1968) and also with several autonomic responses that may occur following tranquillizers, both phenothiazines (Bartholomew, erotic stimulation. Whether it is accompanied by 1968) and butyrophenones (Sterkmans & Geertz, other autonomic changes, or by central arousal or 1966). It is of interest that testosterone levels were subjective anxiety, and the pattern that these re- found to be low in some patients on chlorpromazine sponses show, depends upon the characteristics of studied by Ismail & Harkness (1967). the situation and the response characteristics of the individual involved (Bancroft, 1971). There will Penile erection and erectile impotence thus be considerable variation between individuals. It remains a possibility that for some individuals the Erections are of two main types, 'reflexive' and pattern of response will be fairly predictable from 'psychic'. 'Reflexive' erections depend on lower one occasion to the next (the concept of response- spinal pathways only. Stimulation of the erotogenic in http://pmj.bmj.com/ zones is sufficient to produce such responses. The specificity) whilst others the pattern will vary sensitivity of such pathways is controlled by inhi- according to the situation. bition from higher centres, as is demonstrated in On this theoretical basis the relationship between spinal man when release from such inhibition results anxiety and erection may be of at least four types. in a lowering of stimulus threshold. Firstly, anxiety and erection may co-exist; the indi- Psychic erections depend on mediating processes vidual approaches the situation in a way which leads in the central nervous system. They may occur in to both anxiety and erection. Secondly, anxiety and response to thoughts or fantasies or perceptions, the inhibition of erection may co-exist; appraisal of on October 2, 2021 by guest. particularly visual. the situation leads to both direct inhibition of erec- The neurological mechanisms involved in erection tion and anxiety. Thirdly, the presence of anxiety are not as straightforward as most physiology text- may interfere with the processes leading to erection, books would have us believe. Reflexive erections are e.g. erection often follows the production of erotic most probably mediated by cholinergic pathways fantasies and thoughts and anxiety may interfere with but psychic erections may depend partly on adrener- the production of such fantasies. (This mechanism gic mechanisms also (Bancroft, 1970). The central should not affect 'reflexive' erections.) Finally there pathways involved are not completely understood may be some individuals who require an optimum but MacLean & Ploog (1962) have mapped out areas level of autonomic arousal for erections to occur; of the limbic system of the monkey, stimulation of anxiety would tend to increase the arousal above its which leads to erection. optimum level. 566 John Bancroft Postgrad Med J: first published as 10.1136/pgmj.47.550.562 on 1 August 1971. 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The relationship is further complicated as the question remains to be answered with certainty. inhibition of erection may reduce anxiety by remov- Erection, however, is a response which can be sub- ing the threat of a sexual encounter or may increase jected to an unusual amount of control compared the anxiety by causing a 'fear of failure'. with other autonomic responses (Laws & Rubin, The psychological factors in the sexual situation 1969). This control may depend on a subtle inter- which lead to either anxiety or inhibition of erection action between awareness or 'feed-back' of erection are very variable. Early experiences may lead to a and the cognitive processes that precede it, awareness fear of heterosexual relationship in general or more of slight increases in erections serving to inform the specifically those involving women that the man subject that his cognitive processes are being effec- considers to be like his mother or 'respectable'. tive. In general, control of autonomic responses such Such anxiety is thought by many psychoanalysts to as heart rate or blood pressure can be learnt when stem from unresolved Oedipal problems though such 'feed-back' is available but such learning is why it occurs in some men and not in others is not fairly subtle (Bremer, Kleinman & Goesling, 1969; always clear. Other types of fears include phobias or Shapiro et al., 1969). In learning control of erections feelings of disgust towards female genitalia, fears of the process may possibly 'go wrong' if too much pregnancy, or fears of venereal disease. Ignorance attention is paid to 'feed-back'; the subject becoming and the anxiety that it generates is a frequent prob- preoccupied with his degree of erection thus inter- lem as is sexual inhibition stemming from a child- fering with rather than facilitating the cognitive hood in which sexual expression has been sup- processes leading to erection. Certainly it is an im- pressed and sex considered dirty. Sexual deviance portant feature in the treatment of erectile impo- such as homosexuality is frequently associated with tence to direct attention away from the erectile fear of heterosexual relationships. In many cases the process (Masters & Johnson, 1970). fear may have been an important factor contribut- ing to the development of the deviant pattern. In Emission and ejaculation Protected by copyright. others, however, the man, because of his deviant Emission of semen results from contraction of the interest, considers himself to be innately abnormal or smooth muscles of the vas deferens, mediated by the 'inverted' and hence incapable of normal hetero- sympathetic nervous system. Ejaculation then results sexual relationships. Such conviction will make him from rhythmic contractions of the ischio and bulbo- reluctant and fearful to attempt a heterosexual en- cavernosus muscles leading to spurts of semen. counter. This is mediated by cholinergic fibres of the para- A single episode of impotence due to such factors sympathetic sacral outflow. Emission can occur as alcoholic intoxication or some passing psycho- without ejaculation. Emission and ejaculation are logical trauma may initiate a continuing pattern of normally accompanied by orgasm in which variable impotence, further sexual situations becoming degrees of rhythmic contraction of other muscle threatening because of the possibility of failure. For groups may occur. many men impotence is one of the most traumatic Ismail & Harkness (1967) have suggested a types of failure they can experience. mechanism by which emission may serve to maintain

The tendency to inhibit erections is a characteristic normal levels of androgens. The importance of http://pmj.bmj.com/ which appears to make some individuals particularly androgens in facilitating orgasm and emission is less vulnerable to the effect of such sexual 'threats'. certain, however. The neurophysiological mecha- The severity of the impotence therefore is not nisms underlying orgasm are not understood and necessarily an indication ofthe severity ofthe psycho- central pathways have not been clearly demonstrated. logical problem or threat leading to it. Most writers At the spinal level, however, the degree of excitation have assumed in the past that impotence is a symp- in the spinal centres presumably reaches a threshold tom of a neurotic personality and sexual inadequacy beyond which there is a spread of activity or dis- has been shown to be common amongst neurotic in- charge through the sympathetic fibres resulting in on October 2, 2021 by guest. dividuals (Slater, 1945). The proportion of sexually emission. A spread of excitation through the spinal inadequate males who have neurotic personalities pathways may result in the climax of sensation and has varied in different reports (El-Senoussi, Coleman muscular activity which can either generalize very & Tauber, 1959; Cooper, 1968). Certainly in some widely through the body or be localized. The re- the neurosis is as much a result ofthe sexual problem lationship between the level of autonomic arousal as a cause, particularly when the sexual inadequacy and the production of orgasm remains uncertain. has been of early onset. On the other hand some It seems probable, however, that a state of high men cope with considerable psychological difficulties arousal, whether due to excitement or anxiety, faci- and sexual traumas without impotence adding to litates the emission process. their troubles. What then is the nature of such It is therefore more likely that the physiological psychophysiological vulnerability? This important states accompanying anxiety directly influence Sexual inadequacy in the male 567 Postgrad Med J: first published as 10.1136/pgmj.47.550.562 on 1 August 1971. Downloaded from emission rather than erection. Sexual excitement will purpose is to reduce anxiety which as a physiological have a similar effect except that the orgasm resulting state is assumed to inhibit performance. The argu- will be more intense and pleasurable. The ability to ment against this rationale in the case of erectile delay or control emission and ejaculation tends to impotence has been put forward above, the evidence increase with age. This is partly due to a reduction in suggesting that in many cases it is not anxiety per se novelty of the sexual partner so that less excitement but specific inhibition of erection that is responsible. is generated, but also some learning of control In the author's experience such drugs are only apparently takes place (Johnson, 1968). Premature occasionally of value and so far there has been no ejaculation may therefore be due either to anxiety systematic evaluation of their use. (regardless of the origins of that anxiety) or excite- The rationale for the use of anti-anxiety drugs in ment. Or, alternatively it may result from failure to the treatment of premature ejaculation is easier to learn control of ejaculation. As with erectile im- justify. Schapiro (1943) classified premature ejacula- potence, anxiety can occur as a consequence of tion cases into those associated with high arousal 'fear of failure' so that a vicious circle can arise, and due to high anxiety or excitement, and those without in fact secondary erectile impotence may also de- high arousal. In the former group he reported success velop later. with the use of sedatives. Once again, however, no In cases of ejaculatory incompetence erections systematic study has been carried out and the occur readily but in spite of normally adequate precise value of such drugs remains uncertain. The stimulation orgasm and ejaculation do not. It seems side-effects of some adrenergic blocking drugs such likely that psychological factors may play a more as mono-amine oxidase inhibitors or phenothiazines direct role in these cases than in the case of pre- in occasionally interfering with ejaculation in other- mature ejaculation (Masters & Johnson, 1970). wise sexually adequate males has led some workers to Extreme religious orthodoxy, marked sexual inhibi- recommend their use in treating premature ejacula- tions or some traumatic sexual incident are tion (Bennet, 1961). However, considering the haz- Protected by copyright. commonly found in such cases. The mechanism ards and side-effects of such drugs it is not yet here is, therefore, comparable with erectile impotence possible to justify their use for this purpose. in that specific inhibition occurs, but, in this case, At the present time, therefore, there is no certain of the orgasmic and ejaculatory rather than the evidence of the value of drugs in the treatment of erectile mechanisms. This inhibition may be part of male sexual inadequacy. the general inability to 'let oneself go' or to become sufficiently abandoned sexually to reach the thres- Hormonal treatment hold of sexual excitation necessary for orgasm and The effects ofmale hormones on sexual inadequacy ejaculation to occur, or it may stem from a more have already been referred to (Heller & Myers, 1944; specific need to avoid ejaculation itself. Cooper et al., 1970). Johnson (1968) reported twelve cases treated with testosterone and two improved. Treatment of sexual inadequacy in the male Success has been claimed for a mixture containing In a person complaining of sexual inadequacy, methyltestosterone, yohimbine, pemoline and strych- the possibility of a physical or psychiatric illness nine. Its superiority to placebo was reported in a http://pmj.bmj.com/ being the cause must be considered, as obviously double-blind study of forty-one cases (Bruhl & this will determine the appropriate treatment. In all Leslie, 1963). A further 2000 cases were reported with but a few cases, however, no such cause will be found. a substantial improvement rate (Margolis et al., The possibility that the sexual problem is being used 1967). Neither of these reports is convincing but they as a scapegoat for other difficulties, especially marital do suggest a possible effect which should be more ones, should also be considered. If this appears to be closely studied. At the moment, therefore, the use of the case, then treatment directed at the sexual prob- androgens in treating sexual inadequacy is also lem is unlikely to be helpful. Only after adequate uncertain and little is known of the hazards of long- on October 2, 2021 by guest. initial assessment should treatment therefore be term medication in such cases. started. Earlier methods of treatment have been reviewed Psychological treatment by Johnson (1968). At the present time treatment Methods of psychological treatment have ranged can be considered under three headings: (a) drugs; from full psychoanalysis to simple counselling or (b) hormones; and (c) psychological methods. reassurance. In Johnson's series (1968), seventy-five cases were Drug treatment followed up. Of these twenty-three (38%) refused or Two types of drug treatment have been advocated, were not offered treatment. Of this untreated group firstly the use of anti-anxiety drugs, and secondly the six (26%4) were improved at follow-up. Of the forty- use of drugs to delay ejaculation. In the first case the two treated patients seventeen (40Y/) were improved 568 John Bancroft Postgrad Med J: first published as 10.1136/pgmj.47.550.562 on 1 August 1971. Downloaded from or 'cured'. Various types of treatment were in- advised against in the early stages. By this means volved, however. Nineteen patients received some sexual arousal increased and permitted contact physical or drug treatment (e.g. testosterone, ECT, nearer and nearer to coitus. The patient was also or circumcision). Four (21 %) of this group improved. advised on alternative ways of satisfying his partner. The remaining twenty-three were treated by various They emphasised the importance of the partner's psychological methods. Of these thirteen (57Y%) were co-operation though they would not necessarily inter- improved or cured. The psychological methods view her themselves. Occasionally they found that therefore produced the best results, and of these the patient was so frightened of women that even methods joint marital counselling appeared to be being alone in their presence would provoke anxiety. most successful (of four couples treated in this way In such cases they would use systematic desensitiza- two were improved, two cured). The numbers re- tion ofimaginary sexual situations in the same way as ceiving each method were too small, however, to is used for treating phobias (Wolpe, 1958). draw any firm conclusions. The best results were with Friedman (1968) treated nineteen cases with secondary erectile impotence, primary disorders systematic desensitization in this way, except that responding generally less well and premature intravenous barbiturate was used as the anti- ejaculation responding poorly. anxiety agent rather than muscular relaxation. In Cooper's (1969a) series of fifty-seven patients Eight out of ten cases with erectile impotence were with erectile impotence or ejaculatory incompetence, cured; three out of six with premature ejaculation forty-nine were treated. Of these nineteen (390 O) were cured; and three cases of ejaculatory incom- were recovered or improved at follow-up. The best petence failed to respond. results were in those with acute onset of erectile The most impressive series, in results, numbers impotence; 88% of these did well. Of the cases of treated and technique is that reported by Masters erectile impotence with an insidious onset, usually at and Johnson (1970). The results are shown in Table 1. Protected by copyright. a later age, only 26% did well. Forty-six per cent of the cases of ejaculatory incompetence improved. TABLE 1. In a further thirty cases of premature ejaculation % improved Y. improved (Cooper 1969b) 43%o were improved, the best Diagnosis No. of at end of at results being in the 'acute onset' cases. cases treatment follow-up Cooper's method consisted of a combination of Primary relaxation training (in order that the patient could impotence 32 59 4 59-4 to relax sexual advice on Secondary learn during stimulation), impotence 213 80-2 69 1 producing optimum sexual stimulation from the Premature partner, sexual education for both partners, and ejaculation 186 98-8 97 3 superficial psychotherapy. Ejaculatory Apart from the obviously superior outcome of the incompetence 17 82-4 82-4 cases of acute onset, other variables which were associated with a favourable response were youth, The long-term stability of these results, which are duration of the disorder less than 2 years, a 'secon- based on a 5-year follow-up, is shown in all groupshttp://pmj.bmj.com/ dary disorder', heterosexual orientation, 'normal' except secondary impotence. These results are personality, and co-operation of the female partner generally superior, therefore, to those of other series, in treatment. but particularly in the case of premature ejaculation. Wolpe & Lazarus (1966) report the results of treat- With the exception of Tuthill (1955) most workers ment in thirty-one cases of male sexual inadequacy. have reported poor results with premature ejacula- Unfortunately they did not give details of the type tion (Hastings, 1963). of disorder involved. Twenty-one patients (67-7%) The treatment method of Masters & Johnson achieved entirely satisfactory sexual performance (1970) deserves closer attention, although for those on October 2, 2021 by guest. and a further six (19-4%) were improved. readers wanting to apply their techniques reference The rationale of their method was that sexual to the full report is essential. inadequacy resulted from anxiety in the sexual Patients in their study were treated for a set period situation and treatment, therefore, should aim at of 2 weeks. During this time they stayed in a nearby reducing the anxiety. In most cases Wolpe's prin- hotel attending the treatment centre each day. They ciple of reciprocal inhibition of anxiety was in- were thus a highly motivated group and predomi- volved though not by means of muscular relaxation nantly middle class. Some attempt to screen the but by using the presumed anxiety-inhibiting effect patients before accepting referral was made, in of sexual arousal. Thus the patient and his partner particular to exclude psychotic illness. would be instructed to indulge in sexual contact only Masters & Johnson stressed the necessity of con- as long as he was free from anxiety. Coitus was joint therapy, so much so that if males sought treat- Sexual inadequacy in the male 569 Postgrad Med J: first published as 10.1136/pgmj.47.550.562 on 1 August 1971. Downloaded from ment without a partner, surrogate partners were strongly between finger and thumb. This procedure supplied. In addition, they used a male and female was carried out repeatedly and eventually manual therapist in each case whose qualifications and train- stimulation gave way to intermittent vaginal entry ing were such that all aspects of treatment including again with the woman in the superior coital position. physical examination and investigation could be The 'squeeze' technique was continued, however, carried out by them. for several months until finally ejaculation could be The first 4 or 5 days of treatment were the same avoided without it. This technique has some simi- whatever the problem. The couple were told at the larities to the method described by Semans (1956) start to avoid any sexual contact until instructed for the treatment of premature ejaculation, although otherwise. The sessions on the first 2 days were spent in the latter case no squeezing was involved. in history-taking, each partner separately with the Semans' method, however, has never been systema- same sexed therapist. History-taking was thorough tically evaluated. enough to give the therapist a clear idea of the indi- In the case of ejaculatory incompetence emphasis vidual's 'sexual value system'-what his sexual was on vigorous penile stimulation by the partner attitudes were and what he accepted as normal or with the aid of a lubricating jelly. Once ejaculation desirable, in addition to a detailed account of past occurred with manual stimulation, the woman, again sexual experiences and present difficulties. in the superior coital position, stimulated her partner On the third day there was a 'round table dis- to ejaculate, inserting the penis into the vagina cussion' with both patients and both therapists in- before ejaculation occurred. Once ejaculation has volved. This was used to explain to each partner the occurred into the vagina an important psychological anxieties and difficulties of the other, to emphasize barrier is overcome and and thereafter the level of that 'fears of performance' act both in the female and inhibition appears to be lower so that vigorous male to block the reception of erotic stimuli in the stimulation becomes less necessary. Protected by copyright. sexual situation. Communication between the mar- Masters & Johnson found that undue religious ried pair, both verbally and later physically was orthodoxy and homosexual propensity both carried strongly encouraged. The 'spectator role' that a poor prognosis, regardless ofthe type ofinadequacy. sexually inadequate individuals adopt was also Although the above techniques involve several of discouraged; neither the male nor the female ob- the features of earlier methods, it must be concluded serving what is going on during the sexual act can that at the present time Masters & Johnson have fully respond to the erotic stimuli in the situation. evolved the most successful approach to the treat- On the third and fourth day the couple were in- ment of sexual inadequacy. This combines the assess- structed to concentrate on 'sensate focus' which ment and modification of relevant sexual attitudes means exploring each other's bodies to discover areas with directive counselling in sexual technique. and methods of tactile stimulation that are pleasur- Unfortunately their full method is relatively imprac- able. On the second of these days the genital areas ticable within the National Health Service, but when were included in this exploration, but throughout it their findings are considered together with those of was made very explicit that the release of sexual other workers, various points can be made which are tension through orgasm was not being sought. In of practical relevance to treatment. http://pmj.bmj.com/ many of their patients their abilities to respond to Treatment is most likely to be successful when (1) such stimulation had been largely overshadowed by both members of the marital unit or pair are pre- their preoccupation with performance and orgasmic pared to take part in treatment and each one release. accepts that he or she is involved in the problem. From the sixth day onwards, direction from the Ideally they should be prepared to leave their normal therapist was specifically related to the type of sexual routines for a short period. (2) The problem is of inadequacy involved. In the case of erectile impo- recent onset. (3) Satisfactory sexual performance tence, attention was directed away from the erectile has occurred in the past (i.e. the inadequacy is on October 2, 2021 by guest. process until erections occurred spontaneously The secondary). (4) The problem has developed 'acutely' pair were then encouraged to permit the erection to rather than slowly with a gradual loss of sexual come and go, thus demonstrating that the loss of interest. (5) There is no severe personality problem, erection is not irrevocable. This is an important undue religious orthodoxy or homosexual propen- psychological step. Following this the partner was sity in either partner. instructed in intermittent vaginal insertion adopting the superior coital position, until erection was The following points are of value in carrying out maintained. treatment. In treatment of premature ejaculation the partner (1) A specified number of treatment sessions is was instructed in penile stimulation just short of stated at the onset. The patients then know what to ejaculation at which point the penis was squeezed expect and improvement is more likely to occur in 570 John Bancroft Postgrad Med J: first published as 10.1136/pgmj.47.550.562 on 1 August 1971. Downloaded from the time available. For those cases who are likely to BREMER, J. (1959) Asexualization. MacMillan, New York. improve, ten to fifteen sessions should be sufficient. BREMER, J. KLEINMAN, R.A. & GOESLING, W.J. (1969) The effects of different exposures to augmented sensory feed- (2) Sessions should be close together so that back on the control of heart rate. Psychophysiology, 5, 510. patients can discuss difficulties as they arise. Once BRUHL, E.E. & LESLIE, C.H. (1963) Afrodex, double blind a week is the most practical. The extent to which the test in impotence. Medical Record and Annals, 56, 22. couple are prepared to organize their lives to fit in BURNAP, D.W. & GOLDEN, J.S. (1967) Sexual problems in is a good indication of medical practice. Journal of Medical Education, 42, 673. with the needs of treatment COOPER, A.J. (1968) 'Neurosis' and disorders of sexual their motivation. potency in the male. Journal of Psychosomatic Research, (3) Equal attention is paid to both partnersso there 12, 141. is no one patient. Full histories should be taken from COOPER, A.J. (1969a) Outpatient treatment of impotence. both, regardless of who has the presenting problem. Journal of Nervous and Mental Disease, 149, 360. given to the pair at the COOPER, A.J. (1969b) Clinical and therapeutic studies in (4) Clear instructions are premature ejaculation. Comprehensive Psychiatry, 10, 285. start to avoid intercourse or any attempt to achieve COOPER, A.J., ISMAIL, A.A.A., SMITH, C.G. & LORAINE, J.A. orgasm until instructed otherwise. It is helpful to (1970) Androgen function in 'psychogenic' and 'con- give these instructions to the pair jointly. stitutional' types of impotence. British Medical Journal, 3, (5) A careful search for any ignorance or mis- 17. understanding of sexual matters is made in both DONOVAN, B.T. (1963) The timing of puberty. Scientific Basis of Medicine Annual Review, 53. partners and the necessary information provided to EL-SENOUSSI, A., COLEMAN, D.R. & TAUBER, A.S. (1959) correct it. Factors in male impotence. Journal of Psychology, 48, 3. (6) Attention is paid to encouraging and facilitat- FORD, C.S. & BEACH, F.A. (1952) Patterns of Sexual Be- ing communication between the partners about haviour. Eyre and Spottiswoode, London. sexual responses and feelings. FRIEDMAN, D. (1968) The treatment of impotence by Brietal (7) Instructions are given to concentrate on enjoy- relaxation therapy. Behaviour Research and Therapy, 6, 257. Protected by copyright. ing mutual erotic stimulation with no orgasmic GANTT, H. (1944) The Experimental Basis of Neurotic release. The natural occurrence of erections and Behaviour. Hoeber, New York. orgasm when the individual permits erotic stimuli GASTAUT, H. & COLLOMB, J. (1954) Etude du comportement to act is explained and the futility of trying to force sexual chez les Epileptiques Psychomoteurs. Annales these responses is stressed. midico-psychologiques, 112, 657. GOLLA, F.L. & HODGE, S.R. (1949) Hormone treatment of (8) Instructions relevant to the specific problem are the sex offender. Lancet, i, 1006. given according to the methods of Masters & John- Goy, R.N. (1968) Organising effects of androgens on the son (1970). It is important that such techniques are behaviour of Rhesus monkeys. In: Endocrinology and discussed in considerable detail so that the therapist Behaviour (Ed. by R. P. Michael). Oxford University Press, feels confident that he knows what is taking place. Oxford. HARRIS, G.W. (1964) Sex hormones, brain development and It is easy to be misled by the glossing over of em- brain functions. Endocrinology, 75, 627. barrassing details and it should, in any case, be an HASTINGS, D.W. (1963) Impotence and Frigidity. Churchill, important aim of treatment that such details can be London. discussed without embarrassment. HELLER, C.G. & MYERS, G.B. (1944) The male climacteric:

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