One of the unfortunate carryovers from the classical model has been a glibness about symptoms, a rush to judgment, as it were. A quickness to come up with an explanation, without getting into the details of a symptom. This also is a common sense error. A man has an erection problem and we panic. What can be the cause? Unconscious homosexuality? Castration fear? Too much masturbation? An inhibition of aggression? Poor diet and shallow breathing? The answer as we now know is none of the above. These answers are all glibness and no substance.
But even now, when we are all calmer and more reasonable, we have yet to even notice, much less think about the still-mysterious details of sexual response. For example, how is it that some women are as quickly orgasmic during penetration as a premature ejaculating man, and may even, like such men, be on guard against it? They are not necessarily even relaxed, and may even have trouble coming any other way. They also may not necessarily enjoy it. They are part of a small subgroup of women who are so easily orgasmic that they never or rarely make any effort to come. They may be easily multiply orgasmic. My observation is that these women cannot be distinguished on the basis of feelings about their partner, or about men, or about their bodies, or masturbatory habits, identity conflicts, sexual sophistication, or anything else I have been able to think of.
If you compare them with a larger group, women who have never experienced orgasm, you don’t see consistent differences—at least not in an individual practice. What is needed is a large scale survey, first to get the incidences and then to select interviewees.
Some women are reliably orgasmic in one way or another, seemingly entirely independently of how tense or relaxed they are. Others, the majority, can never be orgasmic if they are tense. Sometimes the more reliably orgasmic women are clearly in more control of what goes on with the partner, and sometimes they just have some kind of system—like a variety of clitoral rubbing. But this is not necessarily the case. Sometimes they do it by breathing (focusing) techniques, but I think they have to be women in this category to begin with for this to work.
Another mystery is the clinically observable fact that if you consider the incidence of pre-pubescent masturbation, it looks like girls outnumber boys, although the overall incidence is low. Of course, after puberty there is no contest, but the big contrast is between women who begin masturbating as early as five or six, and most women, who never masturbate. And as I just noted, they are not more orgasmic in partner sex.
Then there is that mysterious difference between women who are only orgasmic in partner sex and women who are only orgasmic alone. Of the latter group are women who are only orgasmic in dreams. And then there are the women who G-spot ejaculate, sometimes copiously. And teenage girls who can have spontaneous orgasms at a Beatle gig (a dated reference, I know, but for some reason I have never seen this phenomenon mentioned about the previous decade’s Frank Sinatra frenzies, or about the Stones, or any subsequent group—another mystery not likely to be solved).
And there are those women whose sexuality is closely associated with their cycles and women who perceive little or no such effect.
I could go on, but this should make my point that there still is a lot to learn about sexual response, if we ever turn our attention to the details.
Male response is less variable then female but nevertheless there are plenty of mysteries remaining. For starters, no one has studied the variations in erectile dysfunction (ED). Perhaps because of having seen hundreds of men with this symptom (see Conceptual Bio) in pre-Viagra days, I developed a highly informal taxonomy.
Men who easily got erections but then lost them on penetration or during it or before it, seemed often to be men who had ED because of an inability to adjust to life-cycle change. As young men they enjoyed sex as an ego trip, but as they got older that appealed less, but they were unable to develop a less autonomous turn on. Men who had trouble getting erections at all were likely to be reacting to turned-off partners, but had too much performance anxiety to notice this. Men who were unable to have erections at the beginning of relationships looked like they suffered from shyness, and men who only could have erections in the beginning of relationships seemed especially vulnerable to feeling sex was obligatory. Men who always had erections when expected but never were very hard, although hard enough for penetration I could not explain. Men who could never regain an erection once lost are likely either to be more depressed about it than men who lose erections easily, or to have a style that precludes partner assistance. Some men will say that they could never lose an erection after penetration, whereas others are more likely to lose it at that point. Some men regain an erection by stroking themselves; others get nothing out of stroking themselves. For that difference I have no explanation.
But then no one in the field is helping. For a time I hoped someone would ask me to write a chapter on ED so I could at least have an excuse to take the time to work on it myself. This worked wonders for me when I was assigned a chapter on retarded ejaculation for Principle and Practice of Sex Therapy. Different clinicians were assigned different symptoms, and I was given that one because of a comment I made about it at a conference. The comment addressed another mystery, what I came to call autonomous erections. Here is how I would put that phenomenon now. My crude estimates are that about a third of men get erections very quickly and they are sustained. I noticed that this is particularly true of retarded ejaculators and that’s why I mentioned it in this connection. They are not even that excited. Their erections may even feel numb, which is why they are orgasmic only with difficulty. Premature ejaculators also are likely to have quick erections, although some also have ED (retarded ejaculators never do).
Men who are accustomed to quick erections come to expect them to be so reliable that even one experience will make them think they are over the hill or have ED. They may just stop having sex from then on, hard though that may be to believe. I have actually had men come in saying that they have ED and are desperate. “How long have you has this problem?” “Since last Monday.”
Nothing I can detect distinguishes these men from another third, whose erection potential is closely tied to the mood and degree of connectedness in the moment. For them to not have an erection is simply a non-event, and it takes quite a few such experiences before they think they have a problem. (The remaining third are not clearly one way or the other.)
For some men erections are so facile that they dread physical exams. One man said how mortified he was in the hospital when being washed in bed by a nurse, since he was unable to avoid having strong erections. Obviously, for other men, having erections while mortified is unimaginable. Nurses will deal with this by flicking a finger against the coronal ridge. For some men even this does not always work. One body-work therapist said that she had never seen one particular man without an erection, and this was a long-term case (he was RE and the case was described at length in my chapter on RE).
Some men have relatively intense orgasms with an extended refractory period in which they find any touching of the penis painful. Others have less intense orgasms and such mild refractory periods that they do not even lose their erections and can go right on thrusting so uninterruptedly that their partner may not even know they came.
Try out all your favorite interpretations against this tapestry of symptom pictures.
Obviously, there must be some neurohormonal substrates here, but even that is a vexed area. For example, we now hear that 90 percent or more of ED is organic, but what no one that I have read mentions is that this includes all ED, not just subclinical conditions. But everyone automatically assumes that it refers to the men who walk into your office. It actually includes ED from resulting massive trauma, severe neurological difficulties, diabetes, MS, obesity, etc. If you factor those obvious cases out and think only of men who have no concurrent organic impairment, the figure drops steeply. You hear from various sources that 70 percent of men experience ED at some time. This does refer to men with no diagnosable organic impairment. How many of these men actually have a subclinical condition, like vascular insufficiency or venous outflow problems? Ten percent would be too high a figure in my population, but—keeping in mind the myriad pictures I just drew, it is more than conceivable that predispositions are organic. In other words, just as some men could never possibly be PE, under any circumstances, as for example, men with RE, and some men could never be RE, as for example, men with PE, and some men could never have ED, as I just described, so men—and women—vary in their susceptibility to the psychological conditions that generate symptoms.