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Sexual Performance Anxiety
By: Ken Rosenberg, MD & Robert J. Filewich, PhD
Millions of American men suffer with sexual performance anxiety. Below, clinical psychologist Dr. Robert J. Filewich, a specialist in anxiety disorders, and psychiatrist Dr. Ken Rosenberg, an expert in sexual disorders, give you the low down on how to keep it up.
Q: What is performance anxiety?
ROBERT J. FILEWICH, PhD: Performance anxiety, in sexual terms and with sexual problems, is when a person has an anticipation of some sort of problem occurring in the sexual act. As a consequence, they develop a sense of anxiety, which translates into an inability to become erect or an inability to have sex for a certain duration before they achieve orgasm, or premature ejaculation.
Q: Why does it happen?
KEN ROSENBERG, MD: We were not made to be anxious and have sex at the same time. When we're anxious, we're not ready to have intercourse. Our plumbing does not work when we become anxious, and therefore when we're extremely anxious we just can't perform very well sexually. ROBERT J. FILEWICH, PhD: And the anxiety is usually fear-based. It's the fear of being rejected, fear of disappointing a partner.
Q: How does performance anxiety manifest itself?
ROBERT J. FILEWICH, PhD: There are a few ways it can happen. You can get erect, and as you're about to have sex, you lose your erection, or maybe you're actually in the process of having intercourse and you lose the erection, or perhaps you don't get erect at all. Usually what happens is that the person is focusing on the orgasm, and not really focusing on all the rest of what goes on in the sexual encounter. As therapists, we try to get the person to focus more on the relationship and the sensory experiences that they're having as opposed to the final goal - focus on the process rather than the product.
Q: Are women also subject to performance anxiety?
KEN ROSENBERG, MD: Of course. It is not often called performance anxiety for women. It more characteristically is called anorgasmia, or the inability to have an orgasm, or vaginismus, the inability to allow the penis -- or the finger, for that matter -- to enter the vagina because a woman is so anxious that her vaginal muscles are contracting. So for women, anxiety certainly plays a role, and behavioral techniques and medicines and couples therapy and all sorts of therapies could be of enormous benefit for women as well as for men.
Q: What are some treatments for performance anxiety in men?
ROBERT J. FILEWICH, PhD: There are a multitude of different treatments. One of the treatments that was developed some time ago by Masters and Johnson is what is known as a sensate focus technique. Through a series of four stages, a person begins to learn to stop focusing on the orgasm, and stop worrying about whether or not he or she can provide the partner with the opportunity to achieve orgasm, and start focusing more on what the sensory stimulation is like, what it feels like to actually enjoy being stimulated. They learn to enjoy the ways in which they can pleasure each other, and it takes the focus off of what's happening at the end. So you'll start off with a stage where you'll keep your clothes on, and you'll actually just go ahead and touch each other and communicate with each other. Once you're doing that for a while and you're comfortable with that, you'll move to the second stage.
The idea is that if you're with your partner a good number of times without the expectation of orgasm, then the whole experience now starts to take on a completely different flavor. You're now realizing that there's so much more that's going on in terms of you and your partner than orgasm, and orgasm becomes less important. When it becomes less important, you're not going to be thinking about performance. You're going to be thinking about other things, and you're going to actually enjoy the experience, which will result in arousal.
KEN ROSENBERG, MD: In fact, the first homework assignment that we give our patients is, "You can't even have an orgasm. Erection is not the goal." You encourage the person to avoid thinking about that.
We even encourage them to think of it as a violation of their homework assignment to have an orgasm. So with that pressure gone, hopefully they begin to enjoy sex and not worry if they are going to have an orgasm.
ROBERT J. FILEWICH, PhD: At that point they'll move to the second stage where they'll be caressing and touching and communicating without clothes. The third stage is actually being inside your partner but not thrusting, and the last stage is actually thrusting. But the focus is on the sensations. That's why they call it "sensate focus."
Q: Some men are concerned that they're unable to have an orgasm during oral sex. Does this constitute performance anxiety?
KEN ROSENBERG, MD: Some people are just built that way. If oral sex is your thing, that's great; if it's not your thing, that's okay, too. There could be any number of reasons. It could be because they're very anxious. It could be because they have some psychological fear that the woman will devour their penis.
ROBERT J. FILEWICH, PhD: But communication is the most important thing. A woman may feel that because she can't give him an orgasm orally, that there's something wrong with her. He just may not have the certain sensory nerve endings that accommodate it, so it could be a physical thing for him. Then the issue between that couple becomes, "Is this a problem, and why is it a problem, and how can the two of you as a couple compromise and deal with this because he's not into it and you're into it." That's a really infrequent problem, by the way.
Q: Some men have the opposite problem with oral sex. They ejaculate too soon. What can be done about that?
ROBERT J. FILEWICH, PhD: Lots of different things. They can use medication to inhibit sexual response to avoid premature ejaculation. There is a technique called the squeeze and stop technique where you actually use your own body as a biofeedback device. You can learn the point of no return so that you don't get to it until you want to get to it. The partner could masturbate before sex so that he or she is very, very sexually aroused as well, and they can still achieve orgasm together.
KEN ROSENBERG, MD: Premature ejaculation happens a lot for men who have extremely high testosterone levels or are extremely sexual, and one of the things that you say to such a patient is, "I understand it's a problem, but understand, you're a very macho guy. You have a high sex drive," and that sort of helps, then, as well.
Q: How does Viagra work?
KEN ROSENBERG, MD: Viagra is the drug of choice for erectile dysfunction. It doesn't work to give you an erection, it just keeps the blood in the penis once it's there. You need to take it a half hour to an hour before you're going to have intercourse, because it has to get to your penis. You have to wait for certain metabolic things to happen, and then you also need to be stimulated. Once you're stimulated, what Viagra does very nicely -- it works about 80 percent of the time -- is to keep the blood in the penis, so it really keeps the hydraulic system going, and enables people to last longer and have second erections.
KEN ROSENBERG, MD: But I think it's important to say that Viagra has side effects and it's not something to be taken lightly. It's not something to order over the Internet. You need a doctor to prescribe it, and I would say you need an educated doctor to make sure you don't have any cardiac side effects, because it can be a dangerous drug if taken incorrectly.
Q: Where do people seek help for performance anxiety or sexual dysfunction?
ROBERT J. FILEWICH, PhD: They should go to a certified sex psychologist or psychiatrist who has had experience in this particular area. Make sure that they are well referred and qualified. There is a danger of seeing someone who isn't very well-educated or trained in the area, as they can give you some misinformation that actually might be harmful.