On Performance-Anxiety Anxiety

The ego-analytic model is the how-you-handle-it model. The idea is that sex problems (and other problems as well) are caused, not—as we usually assume—by anxiety, anger, or depression, but by how the person handles these feelings.

Many impotent men have some hatred of women, and it seems to many clinicians that this must be one cause of impotence. (I use the old, awful term “impotence” here advisedly, because it expresses the way the man with ED feels and even still is seen by many people in the West and by all people in non-western societies. The appropriate term is, of course, erectile dysfunction, or ED.) But many of our greatest sexual virtuosos have hated women. The difference is that they are good haters. The impotent men are poor haters. The poor hater expresses his anger with a limp penis. The good hater expresses his anger with an erect penis.

The good hater feels entitled to his anger. That’s an ego analytic word. If you feel entitled to your anger, then it is not undermining. It can even be strengthening.

Many impotent men are depressed, and it is obvious to all clinicians that depression is one cause of impotence. As sex therapists, we get the impression that when a man gets depressed his erections reflect it. Two years ago I did a quick survey of five analytic therapists I know. I asked them to list the men they had seen in the past year whom they thought of as depressed, and they came up with 23 men. Then I asked them how many of these men mentioned having any erection problems. The total number was zero.

Many depressed men get relief from sex. They need it more and may even get more out of it. I once had a patient who suffered severe and immobilizing depressions. He was a psychiatrist and he believed that it was sex that kept him out of the hospital. When he did develop a dysfunction, he was not concerned about the dysfunction as such, just about having to be hospitalized. The object of sex for him was reassurance and support, not performance. But the vast majority of men are vulnerable to male-role expectations; that is, sex gets defined as a performance and is a test of virility. This is the object of sex and so a man has to be up for it. Then being depressed is a threat and then he cannot “perform.”

Helen Kaplan (1979, 35f) is the only sex therapist who has noted that many men experience performance anxiety and have no erection problems. She also had an explanation for this, an explanation very different from mine. Here is how she put it:

The mere thought, “maybe I won’t have an erection tonight,” need not be associated with anxiety of sufficient intensity to drain the penis of blood. In the secure person who has a good relationship, such a thought will not produce impotence, but when there is deeper unrecognized anxiety about sex, unconsciously he needs to avoid a successful performance.

Kaplan maintained that these men have an “active role in evoking the anxiety-provoking thoughts which result in impotence,” although they are not consciously aware of it. In other words, her conclusion was that performance anxiety causes impotence only in those men who unconsciously wish to be impotent. (Notice how she unquestioningly reinforces the idea that sexual response is a performance and it can succeed or fail.)

I find no evidence to support Kaplan’s interpretation, but she does deserve credit for pointing out that performance anxiety alone is not enough to cause impotence. I think that the critical missing factor is performance-anxiety anxiety—the anxiety about having performance anxiety. The problem, as I see it, is that the impotent man is threatened by his performance anxiety. He thinks he should not be anxious. He does not think that anybody else is anxious in sex. It really scares him. He then tries to act as if everything is OK. If he is not anxious about feeling anxious it is not compounded, and therefore can be relieved in the ordinary course of events (see “Vignettes“).

One way performance anxiety gets compounded is by telling people that the purpose of sex is enjoyment, not performing. Many sex therapists and most other kinds of therapists, and all therapeutically untrained physicians are prone to scold people for being worried about performing sexually, to tell them that sex is natural. They should be telling people that sex is natural and so is being worried about it.

That at least avoids intensifying the anxiety about worrying about performing, although it does not relieve it.

The men who are vulnerable to performance anxiety do not feel entitled to have any feelings that might interfere with sexual performance. They have to act as if everything is OK. You could even say that that is the cause of their problem. Our solution is to help them to stop acting as if everything is OK.

We developed this solution in our work with that most difficult of all sexual relationships, that between a male patient and a female body-work therapist in individual bodywork sex therapy (Apfelbaum, 1984), our modification of approaches to sex therapy using surrogate partners—what Martin Williams called “a naturalistic laboratory for sex research” (1978).

Many people have a romanticized vision of the surrogate-patient relationship (Apfelbaum 1977). They imagine a serene, seductive, and confident woman who will just soothe away the patient’s performance worries. They imagine someone who is immune to the effect of the patient’s anxieties, anxieties that are intense to begin with, and that are further intensified by the pressures of the therapy itself.

For the patient, the therapy often seems to be his last chance. He has mobilized all his resources for this last effort. At considerable expense, he has traveled to our center and he now has two weeks to show whether he has the real stuff (as he sees it). He is to meet with a woman not of his own choosing, an expert in front of whom he is afraid he will appear as a humiliating failure.

Typically, this is just too much to bypass by the usual distraction techniques: sensate focus, the Hartman and Fithian caresses (popular among surrogates), or the Kaplan technique of having the man conjure up a favorite masturbatory fantasy. The alternative of gradual desensitization would fare no better in the hothouse climate of a two-week time limited therapy.

The ego analytic approach is to change the patient’s relationship to his anxiety. The first thing we do is to break it down into its components and the next thing is to train the man to share these experiences at the moment that they are happening in the body work. For a given patient, performance anxiety may break down into the following components: a feeling of urgency (often expressed nonverbally through pelvic motions and pubococcygeal, PC, muscle contractions); the feeling that he should not be anxious, that we expect him to be enjoying this “nondemand” relationship, and that any other man would be; feeling like a loser; feeling hopeless; being afraid of disappointing the bodywork therapist, of her getting irritated or bored.

Once we have separated out these worries, we then put them into simple statements. For example:

Now I’m feeling urgent.
I’m afraid I’m disappointing you.
I feel like I should be enjoying this more.
This doesn’t seem to be getting anywhere.
I’m afraid this isn’t going to work.

or even a simple statement like: “I’m feeling uncomfortable.

These are examples of not fighting off—and being alone with—moment-
to-moment doubts. The patient practices reporting these experiences during the body work and finds, to his surprise, that such reports are often accompanied by blips of erotic feeling. In the process, he learns to pay attention to these small signs of arousal and to differentiate them from anxiety.

It could be said that we are just using another kind of distraction technique. Instead of concentrating on performance, the patient is kept busy noticing and reporting his experiences. But we find that the statements have to be accurate or they do not work. At one point, the patient may say, “I’m feeling urgent,” and experience a burst of arousal. At another point, when he is feeling hopeless, he may experiment with saying he feels urgent and nothing happens.

One hidden effect is the impact of this kind of reporting on the body-work therapist. A man who in his initial response to the body work had been largely silent, withdrawn, and preoccupied is transformed into an involved and interacting partner. Instead of desperately trying to act as if everything is OK and trying to reassure the bodywork therapist that he is not worried, denying his all-too-obvious tension, he is taking her into his confidence. This relieves the pressure on her to act like everything is OK, and to not puncture his denials. She now has something to respond to and this, in turn, makes him feel responded to.

A brief transcript may help to visualize this process. Since we rarely record body-work sessions, we have few such transcripts available. This one is of particular interest because of the unusual severity of the symptom. This 42-year-old Alaskan construction worker had primary ED (“impotence”), meaning that he was still a virgin, although he was sexually experienced, had had multiple partners and a previous eight-year marriage. He had been through a course of couple sex therapy with his then-wife at another center, but had still not been able to sustain an erection sufficient for penetration. The previous therapists reported that he had demonstrated “massive performance anxiety.” His was a longer than average case for us, requiring 17 sessions over a three-week period.

On the transcript the patient is expressive, even chatty, but this is an artifact of the therapy. Initially he was quite reserved and taciturn, especially about personal matters, although he was bright and otherwise articulate in a homespun way. He prided himself on enduring conditions of extreme hardship without complaint.

This transcript is from Day Twelve and covers a three and one-half minute time span. There is full nudity, the patient is supine, and the body-work therapist is sitting next to him doing genital stroking, using a lubricant. The patient is holding a list of 18 statements that had been developed in previous sessions. The words in italics are those that he took from the list. As can be seen, he felt free to break up these sentences as he went along, rearranging and interpolating.

At first the patient’s tone is flat, and it is clear that he is reading and ruminating [P = patient; BT = Bodywork Therapist].

P: I feel like I’m, I’m still partially cut-off or ignoring something, you know, ignoring part of it or something.

BT: Hmm. I wonder if it could be on the list. I just don’t, I don’t know what it would be.

P: Kind of, kind of out of touch, a little bit, not like when I’m into a real gripping worry. I already mentioned that barrier feeling. I don’t know if I feel that now or not. I don’t think so. I feel kind of urgent, kind of preoccupied too. I wish you could help me get out of this mood. I don’t really like this mood. I don’t know if I feel shy or embarrassed—maybe that is the feeling in there—that I’m in this mood, or helpless too, you know. A mixture.

BT: Mm-hm.

P: [his tone now becomes more animated.] This mood that I’m kinda in seems irrational, you know. I’m kinda, I’m afraid to ask for anything, but uh—it’s just because I don’t know where I’m at, in a mood or my feelings or something, you know I’m—It feels like I’m waiting for some kind of reassurance or something—or something that makes me feel different or, you know, I’m waiting. I don’t know.

The BT reported that he had a full erection at this point. It began appearing when he read the lines: I’m afraid to ask for anything, I don’t know where I’m at, and It feels like I’m waiting for some kind of reassurance. In the past, this would have been the point at which he was silently straining to produce an erection, or trying to cover his impending failure by telling his partner how much he was enjoying everything she was doing.

Next, in what follows, as he is about to lose his erection as a consequence of internal struggles with his worry about losing it, he sustains his aroused state by noticing and sharing this worry.

BT: Uh-huh.

P: I’m starting to feel more though, so it must be something that—but now I get afraid I’ll do something wrong [I’m afraid I might do something wrong], you know. I’m starting to feel turned on and feel good and now I’m worried that something will wreck it [this mood]. I want to get more turned on, but I don’t know what to do.
[Long pause.] Yeah, that’s the feeling that keeps coming through. I feel like I should be doing something, but I’m afraid that I might do something wrong that will turn me off. I feel like I should do something to stay turned on.

BT: Hmm.

P: Maybe something with you or, you know, or—or the way I’m looking at my feelings or something. But I’m feeling more turned on and this seemed to do it. This seemed to—just going through there seemed to do something there.

By the end of treatment the patient was experiencing full erections lasting 30 minutes or more and had no difficulty with penetration. He also reported no difficulty on one, two, and five year follow-ups. His first post-therapy sex partner was his ex-wife. He said that she expressed so much relief at his being expressive rather than silent in sex that he found this to be highly reinforcing.

However, it is not our expectation that any of his post-therapy sexual encounters would much resemble this protocol. We expect that the ways of responding to his anxiety which he learned in the therapy will be internalized. We also expect that he now will be likely to share his worries, but it generally requires very little of that to reduce the tension level for both him and his partner.


It looks as if the BT isn’t doing much. What does it take to say, “Uh-huh,” and “Hmm?” Answer: a lot. It’s informed restraint. The natural response is to say, “Just relax; there’s nothing to worry about.” But the patient already thinks there is nothing to worry about. That’s what performance-anxiety anxiety is. You feel anxious and you tell yourself not to, like that’s crazy—here you are, finally with a patient and understanding woman. So this is your final, make-or-break chance. If you feel anxious now, you must really be crazy. That’s what I mean about the hothouse climate. It’s a pressure cooker just because it is not supposed to be. But it also gave us the opportunity to show the patient how to cope with his anxiety.

Other people’s anxiety makes us anxious, and so the natural reaction to tell them to stop being anxious—to relax—which usually makes them more anxious. This urge to be reassuring requires training to suppress. However it might be intended, it is typically for the giver, since in contradicting the patient’s feelings it creates an added pressure. Now the patient experiences another performance demand, to not feel anxious.

Now what is really going on here? It hardly seems natural for the patient to be consulting a list while being stimulated and it’s the last thing one would expect to see in a surrogate-patient scene. What this is about is that there are two ways of turning-on sexually. One is through connecting—hardly a new idea, but one whose implications are difficult to grasp. What this man is doing is connecting; he is having a moment of intimacy. The other way of turning on is through bypassing, that is, through disconnecting, as it were. This is the kind of turn on everyone expects. It is done by focusing on sensation and on imaging—on bodies—and for many people that is automatic, although this kind of turn on is usually not that passionate (connecting is required to generate passion) and it also is brittle, creating the bubble-bursting experience when the trance is interrupted.

The bypassing experience is the source of Kaplan’s theory. If you are a good, automatic byapsser, then turning on seems almost unavoidable. If that is your experience, it looks as if someone who has difficulty turning on or staying turned on must really not want to. Kaplan’s sex therapy consisted of urging people to bypass through fantasy. If they could not manage to do it—and especially if they could not work up the motivation—she apparently could only believe that they must be resisting, that they unconsciously really did not want to “succeed.” She would treat them accordingly, which meant heavy treatment pressure, just the opposite of the Masters and Johnson approach and that illustrated here.

Many can be helped by Kaplan’s no-nonsense insistence on narrowing attention to fantasy and to sensation (she even referred to her therapy as a no-nonsense approach), especially if their problem is guilt about ignoring their partner, but it can be fairly arduous, is a poor model for sexuality (sex as work and as objectifying), and seldom succeeds with desire problems (for perhaps obvious reasons). Our own ego analytic approach (counterbypassing) more easily accommodates people who experience sexual difficulties since they are unable or unwilling to bypass, or have lost that ability or can mange it only fitfully.

A way to put these two ways of turning on into perspective is to think of them as representing two capacities that work as a complementary series. One is the capacity to treat your partner as a body—to objectify him or her. The other is the capacity to connect with your partner. The better you are at one, the better you are at the other.

Our approach is not to be confused with that of “surrogate partners” now in independent practice. As was true for Kaplan, they rely exclusively on bypassing. The focus is on shutting out your partner as a distraction, on narrowing rather than broadening awareness. They are not trained to focus on the relationship, which would be difficult in any case for the solo practitioner.

The particular therapeutic modality exemplified here, individual bodywork sex therapy, is no longer available, but what we learned from it is applied to couples, as well as being a core influence on our thinking. The best examples of its application to couple sex therapy can be found in “An ego-analytic perspective on desire disorders,” in Sexual Desire Disorders, S. Leiblum & L. Rosen (Eds). Guilford Press, 1988 (75-104) and “What The Sex Therapies Tells us About Sex,” in New Directions in Sex Therapy, P. Kleindiest (Ed), Brunner-Routledge, 2001 (5-28), as well as in “Masters and Johnson revisited: A case of desire disparity,” in Case Studies in Sex Therapy, R.C. Rosen & S.R. Leiblum (Eds), Guilford, 1995 (23-45). For a more thoroughgoing example of individual bodywork sex therapy, see “Retarded ejaculation: A much-misunderstood syndrome,” in Principles and Practice of Sex Therapy (3rd Ed), S. R. Lieblum & R. C. Rosen (Eds), Guilford, 2000 (205-241). For a series of short case vignettes, see Apfelbaum (1984).


Apfelbaum, B. The myth of the surrogate. Journal of Sex Research, 1977, 13:238-49.
Apfelbaum, B. Individual body-work sex therapy: Five case examples. Journal of Sex Research, 1984 (20) 44-70.
Kaplan, H. S. Disorders of Sexual Desire. NY: Brunner/Mazel, 1979.
Williams, M. H. Individual sec therapy. In J. LoPiccolo & L. LoPiccolo (Eds.), Handbook of Sex Therapy, 1978 (477-483). NY: Plenum Press.


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