However, many couples don’t want to go down this path and would like to try something themselves. This is certainly worth doing, as it can produce good results and prevent premature ejaculation becoming a way of life. Here then are some basic preventive tips:

• If the man thinks the woman in any way contributes to the problem he should say so and the couple should talk it through. If he feels that he is trying to get back at her for some other dissatisfaction in life then they should talk it out and resolve the other problem in another way so that they don’t carry it over into sex.

• If the couple are having sex too infrequently so that he becomes ‘trigger-happy’ the answer is usually obvious. If more regular intercourse is not possible the man should masturbate every few days or his partner could masturbate him.

• Open display of the woman’s sexuality, including the sharing of her fantasies, helps many such men to start to see women as earthy sex-loving human beings instead of a sexless Madonna who should not be defiled. This sort of revelation alone can make a lot of difference.

• A very good and well-proven preventive is for the man to masturbate or get the woman to masturbate him (to orgasm) before intercourse. This defuses the situation and the man can later have a controllable orgasm to the pleasure of them both.

• Using a sheath can so reduce the level of sensation that the man receives from his penis that he can sometimes be totally cured of his problem.

• Weak anaesthetic creams or ointments work in the same way.

• Contracting the anus tightly at the end of each thrust helps some men gain control, as does penetrating deeply with the penis.

• Stop-start intercourse can also produce good results. In this the man makes love, but as soon as things begin to get too excited he stops thrusting and concentrates on the pattern of the wallpaper or counts the rings on the curtain rail, for example. Many women enjoy this teasing intercourse and it can help the man learn how to control his progress to ejaculation.

• A little alcohol can be a good preventive. It reduces the man’s anxiety about the act of intercourse (and he also has an excuse should things go badly).

• Here is an exercise for a woman to do with her partner, to help him learn to recognize the ‘almost there’ signs that his body produces and to be able to control them. This can be done by any caring couple who really want to succeed.

Set some time aside one evening and take the phone off the hook. Read something sexy or get in the mood in whatever way you choose. The woman should stimulate the man’s penis until it is fully erect. He then tells her when he feels he is about to climax, so that she can squeeze his penis very firmly (putting her finger and thumb on opposite sides of the rim at the base of the head), which will stop his erection in seconds.

Once he is limp she can start to re-stimulate him until he is erect again, whereupon she can squeeze him again. Continue this cycle until the woman can erect the man and collapse him at will for up to half an hour. At the end of this session she should masturbate him, or he should do so himself, so that he is not left ‘high and dry’.

Once you have practiced this for a few sessions you will be confident that he can control his ejaculations. In the next few sessions the woman can stimulate the man as before, but instead of squeezing his penis to stop the erection, she should leave his penis alone when he says he is about to climax, perhaps even getting him to do something else around the house. Repeat this procedure several times at one session. End with masturbating him as before.

The next stage involves the woman giving the man a really hard erection and then getting on top of him and gently putting his penis inside her. She should just sit on it without moving, getting him used to the feeling of being erect inside her and not ‘coming off. She should then move gently, and when he feels he is about to come off she either squeezes him with her fingers as before or lets him go down of his own accord.

Slowly, over several weeks the woman will be able to exert such control over the man’s penis that he will never come unless they both want him to. After such training most men can take over their own ejaculatory control and remain erect for half an hour or more inside their partner’s vagina, only coming when she is also ready.

*5/72/5*

Kaplan assumes that sexual dysfunctions have many causes and calls for an eclectic, equally multi-faceted approach. Depending upon whether the primary pathology is intrapsychic or interpersonal, the treatment will emphasize individual or dyadic in – will depend on the nature of the symptoms as well as on the skills and preferences of the therapist. This, of course, is true in any psychotherapeutic relationship. In practice, both intrapsychic and interpersonal factors are encountered in almost all cases.

Kaplan’s treatment does not ignore the total system, the ecology in which the patients’ functioning is integrated. No person or couple can escape the effects of a destructive family system; these ecological considerations are confronted and explored when they arise.

Theoretical flexibility extends not only to the treatment offered but also to the definition of the “patient.” Although it is traditional in sex therapy to define the patient as a couple, Kaplan feels this is not always appropriate, nor is it necessarily the best procedure. In particular, one type of sexual dysfunction has been addressed by the Kaplan method with only a single person without a partner as the “patient”; lack of orgasm in the female. Since the treatment of the anorgastic woman with or without a partner has the same initial goal – the attainment of orgasm through self-stimulation – the participation of a male is not essential. The step toward having orgasms with a partner and eventually during coitus may or may not require further clinical therapy with a male; whether to seek such therapy is the choice of the individual woman.

In addition to the patient without a partner, it is occasionally considered appropriate to see one member of a dyad alone for a number of sessions. A common situation is for the couple to have bilateral dysfunctions, for example, premature ejaculation or secondary impotence in the male and lack of desire or lack of orgasm in the female. In those cases, a typical treatment schedule would begin by seeing the couple together for one or two sessions, and then seeing the woman alone until she is able to have orgasms by herself through self-stimulation. At that point, work with both partners resumes until the couple has full sexual functioning. Individual sessions might also be indicated when one partner has a special sexual “secret” whose revelation to the other partner might have a deleterious effect on the overall relationship (Kaplan).

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The notion of sexuality which Freud developed in the Three Essays was more or less familiar in that it referred in the first instance to the erotic life of the individual. He also used the concept in a more general sense to include sensations and activities that might be described as sensual since they are sources of pleasure and gratification but might not otherwise be regarded as specifically sexual. In his analysis, Freud demonstrated the connection between such sensual behaviors and activities and levels of libidinal gratification connected with the phases of psychosexual development.

The earliest forms of sensual expression arise specifically in relation to bodily functions that are basically nonsexual, such as feeding and the control of bowel and bladder. Freud arranged these stages of psychosexual development into a succession of developmental phases, each building on and successively subsuming the attainments of the preceding phases. The phases he described were the oral phase, the anal phase, and the phallic phase. During these infantile and early childhood stages, erotic sensations arise from stimulation of the mucosal surfaces of particular body parts or body organs. In the oral phase, it is particularly the mucous membranes of the mouth, in the anal phase the mucous membranes of the anus, and finally in the phallic phase the mucosal surfaces of the external genitalia that provide the primary focus of erotic stimulation.

When the adult form of genital sexual integration is achieved, sexual activity is then dominated by the genital zone. Nonetheless, the capacity for sensual arousal and stimulation deriving from pre-genital or prephallic erotogenic zones retains a functional place in adult sexual activity, specifically expressing itself in preliminary mating activity or foreplay. When such zones are appropriately stimulated, preliminary gratification or forepleasure can be elicited which usually provides a form of preliminary excitation which leads to coitus. In normal sexual development when mature genital potency has been achieved, the sexual act achieves the full end-pleasure of orgasm.

In Freud’s analysis the erotic impulses coming from the pre-genital zones were described as component or part instincts. These part instincts can find their expression in love-making activities, in behaviors of kissing, anal stimulation, biting the love object, and the like. The activities of these component instincts may undergo displacement of various kinds so that different kinds of otherwise nonsexual activities become erotized-for example, the derivation of pleasure from looking at or being looked at by a love object. Ordinarily such component instincts are repressed or are expressed in some restrictive fashion in sexual activity such as varieties of foreplay. Such component instincts, however, may come to dominate the libidinal organization and result in various forms of perversion.

At the beginning of his psychosexual development, the young child is regarded as polymorphous-perverse in his sexual disposition. Sexuality and the forms of sexual gratification at this level are relatively undifferentiated and include all of the part instincts. As development progresses toward adult genital maturity, however, the part instincts become subordinated to the primacy of the genital region. In this context the part instincts normally serve as sources of preliminary excitation which lead toward full genital expression. According to this early theory, then, the failure to achieve genital primacy would result in various forms of psycho-pathology. If the libido became too firmly attached to one of the pre-genital erotogenic zones or if a particular part instinct came to predominate in the libidinal organization, forms of perversion such as exhibitionism or voyeurism would come to replace the normal act of sexual intercourse in the libidinal economy, such that orgastic satisfaction and end-pleasure would be derived from that activity rather than from the normal genital expression.

*209/187/5*

According to attribution theory, when a person performs in a fashion consistent with prior expectations, the outcome is attributed to a stable phenomenon, either of the individual or the situation, one which is enduring and consistent over time. However, when a person performs in a fashion inconsistent with prior expectations, the outcome is attributed to a variable phenomenon, either of the individual or of the situation, one which is unreliable and subject to change from one time to another. Since expectations of the likelihood of success on various tasks are sex-linked, if one adheres to an attribution framework, the consistency or inconsistency of a performance outcome with sex-role stereotypes should affect whether the causal attribution given for that outcome is stable or variable.

Following this reasoning, Deaux and Emswilier conducted an experiment in which subjects evaluated the identical performance of either a male or female on a “masculine” task. Although rated as equally successful, their success was explained quite differently. By both male and female subjects, a woman’s success was attributed to luck (variable phenomenon) rather than to ability; a man’s success was attributed to ability (stable phenomenon) rather than to luck. Explanations of causality were indeed strongly affected by the fit between the sex of actor and expectations of the task.

Feldman-Sumners and Kiesler also explored this issue. In two separate studies subjects had the opportunity to decide the extent to which each of four factors—ability, motivation, task difficulty, and luck—determined another’s performance. Again it was demonstrated that the success of women was attributed to a different cause than was the success of men. Subjects attributed greater motivation (variable phenomenon) to females for the identical performance as that of males, and at least in the case of male subjects, successful professional women were viewed as less capable and as having an easier task than their male counterparts did. These results, along with those from Deaux and Emswiller, were interpreted as supporting the idea that female success (an unexpected event) is most often causally explained by variable phenomena (motivation or luck), and male success (an expected event) is explained by a stable phenomenon (skill).

These studies and others as well (e.g., Feather and Simon) demonstrate that identical performances are not always explained as resulting from equal skill: women’s skill tends to be downgraded as compared to that attributed to men for the same performance. Attributional processes work to confirm the stereotypical conception of men and women. Even objective evidence of a woman’s competence does not necessarily counteract its effects.

Building on these findings, some have considered the possibility that the different causal attributions arising from sex differences provide the basis for sex discrimination within organizations (Terborg and Ilgen). The fact that sex biases the formation of causal attributions does not, by itself, establish the importance of attributional processes in mediating discriminatory behavior. Different attributions must be shown to result in differential allocation of organizational rewards.

In a recent study the relationship between causal attributions and reward allocation was directly tested (Heilman and Guzzo). Subjects, who were MBA students, decided about the appropriateness of various organizational rewards, a raise and a promotion, for those whose successful performance was thought to be because of luck, effort, task difficulty, or skill. They also indicated what their preferred personnel action, if any, would be. The types of causal explanations attributed to successful women were shown to deter from the degree to which organizational rewards were viewed as appropriate personnel actions and if a reward were indeed seen as fitting, to deter from the scope and magnitude of the reward viewed as preferable. It appears that even if they are both judged to be successful, the difference in explanations ordinarily made about the success of males and females can result in their differential treatment in work settings.

We now have considered the ways in which the presumed characteristics of women can create barriers to their career advancement. The normative aspects of sex stereotypes also can present grave problems for them.

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Because rape is defined as a special crime and a special issue in American culture, it is somewhat difficult to realize that this brutal attempt to engage persons sexually can be understood more generally as an extreme example of strategy in sexual encounter. One strategy similar to rape is the moetotolo (or moe dolo, mootoro) “sleep crawling,” or “night crawling” attempt at sexual intercourse reported in several Polynesian settings, as well as among the Cayapa of the lowland region of Ecuador.

Although each of these reports is somewhat different, Mead and several others depict “night crawling” generally as a rough and risky way to go about seeking sexual relations. The practice is to visit the female lover in her house at night, generally with a quorum of her kinspeople sleeping in the same room. Samoan boys will plan such an adventure to retaliate against girls who have stood them up or have chosen other boys over them. Moetotolo is not a delicate courtship maneuver, and Mead prefers to treat it as though it were out of the realm of proper courtship altogether, although such meetings occasionally are mutually satisfying. Girls can pretend that their lover’s presence was not sanctioned, should commotion awake parents, family, and dogs. Support for Mead’s conclusion that moetotolo is a “curious form of surreptitious rape” comes from Nukuoro, where Carroll found much of the “night crawling” attempted by drunken men and boys.

Ethnographic literature often refers to female strategy in sexual relationships, generally as a response to the constraints of domination. Dougherty reports that black women in the rural South are careful not to terminate a relationship with one man until they are certain of the sincerity and commitment of a new lover. Kgatla women will falsely pretend they are menstruating to ward off an unwelcome lover (Schapera). A Yanomam? woman who does not want to be bothered by her husband can tell him to take his drugs into the forest and chant to the forest spirits (Chagnon), which apparently works as a culturally standardized distancing mechanism. Dougherty and Gregor report that a wife will withdraw sexual and domestic services as a symbolic form of disappointment with the marital relationship.

In sexual approaches, both Mehinaku men and women manipulate kinship terminology to their advantage. A male will ask a female to have sex, but she may refuse, arguing that she is a “real” sister. Since cross-cousins are available for sexual encounters, Gregor finds that among the Mehinaku the attractive girls are usually cross-cousins and not sisters. The Tuareg are also reported to use their kinship domain to this same end.

Do the Mehinaku and the Tuareg violate the terms of their own kinship systems in order to make these sexual approaches? Or are we to understand these definitional strategems as part of a larger cultural system? The answer lies in how the Mehinaku and Tuareg themselves conceptualize relationships.

*134/187/5*

When compared with younger men, males fifty-five and older show decreases in the amount of precoital mucus secreted in the urethral canal. The source of this mucus is generally believed to be the Cowpers glands which become less active with age. The Kinsey self-report data showed relative amounts of mucus secreted by males at various ages. The average amount for males in their twenties and thirties was slightly more than three times as much as for men in their fifties and sixties. Although there were individual differences in the amounts of these secretions at every age, Kinsey suggested that the amount of mucus secreted was related to the intensity of erotic stimulation and that lowered secretions in older men represented increased thresholds for stimulation and declining arousal levels as well as glandular changes themselves. Older men generally have reduced amounts of ejaculate and the force of ejaculation as measured by expelled distance and subjective report is diminished (Masters and Johnson). Declining volume of ejaculate can be tied to declining secretory activity of reproductive accessory structures (primarily the prostate and seminal vesicles), but force of ejaculation is influenced by the changing character of penile contractions. Young males were observed to expel seminal fluid twelve to twenty-four inches from the urethral meatus; in men over fifty, the maximum distances were from six to twelve inches (Masters and Johnson). Instead of the usual recurrent, expulsive penile contractions which forcefully propel the ejaculate, older males tend to develop spastic contractions. Although contractions occur at the same intervals (0.8 seconds), older men have fewer of them and with protracted penile erection, ejaculate often “seeps out.” The viscosity of ejaculate from older males is generally lower than that found in younger men.

There are a number of behavioral changes in male sexual activity. Penile erection is typically slower for older men. For males under forty, ten seconds is the typical reaction time; young men can demonstrate full erection in from three to five seconds of sexual stimulation. The reaction time is doubled or tripled for men in their fifties and above (Masters and Johnson). Older men also show a decline in the number of ejaculations per fixed unit of time; the number of ejaculations declines from its peak in late adolescence (four to eight per day are not unusual) to an average of slightly less than two per week in the fifties to less than one per week in the sixties and thereafter (Kinsey). Kinsey reported that the number of males capable of multiejaculation decreased with age. In his sample, 15 to 20% of the sample reported the occurrence of multiple ejaculations in the teens. Only 3% of men in their sixties and older reported this behavior. The greatest proportional decline in Kinsey’s sample occurred in the late thirties and early forties.

The erectile refractory period following ejaculation increases progressively from minutes in the teens (Kaplan and Sager) to about a half hour in the thirties to eight to twenty-four hours in the fifties. Many males in their fifties and sixties experience paradoxical refractory periods in which loss of erection in protracted sexual encounters results in a wait of from twelve to twenty-four hours before erection can be attained again. This “refractory period” resembles that following ejaculation although ejaculation did not take place.

Penile erection under coital stimulation can be maintained longer by older men (Masters and Johnson). This age-related increase in latency to ejaculate may be a function of both previous coital experience and decreased sensitivity to erotic stimulation.

*98/187/5*

The implants come in several different lengths and widths, and the correct size will be determined when you’re opened up.

Once the implants are in place, they fit snugly inside the corpora cavernosa and don’t have to be sewn in place. The incisions are sewn shut, and the procedure is over. From start to finish, this type of operation routinely takes about an hour.

Recovery from this type of surgery is usually very uneventful. When you first check out the results, you’ll find yourself with a swollen penis. You may have a catheter in your bladder, and as anyone knows who’s had one, the sensation isn’t terribly pleasant. Once the catheter comes out (usually in about a day), you may feel a burning sensation when you urinate. The penis may temporarily turn purple from bruising about one day after the surgery.

Most men require some pain medication for several days, sometimes longer. You’ll want to take a week or more off from work, and in general, the whole genital area will be sore and tender. There’s a lot of variation in how much pain men feel during the recovery period; some men find themselves feeling pretty good in just a few days, others are in pain that requires medication for six weeks or so.

Often it will be difficult to bend the prosthesis in the first few weeks because of soreness and pain, even if it was designed to bend easily. (After surgery, it may take some types of implants

12 weeks or longer to bend easily and be easily concealed.) As time goes on, it becomes easier. Usually men are told to wait about 6 weeks before having intercourse. To be truthful, most men are not in the mood for love during the first few weeks of recovery, anyway.

*154\184\8*

Researchers have speculated that the high soy intake among the Chinese and Japanese is related to their corresponding low levels of heart disease. Other studies also suggest that soy removes LDL from the bloodstream, delivering it to the liver where it is broken down for excretion. The mechanism for this may be through the actions of substances known as phytoestrogens, a type of plant hormone akin to human estrogen. The result is artery protection from plaque build-up and protection from cancer.

A legume no bigger than a pea, soy is available in many varieties, including tofu (soy bean curd), and soy burgers, flour, milk, and tamari, a sauce. A high-protein, low-fat nutrient that can be substituted for meat, soy should be added to your diet. Just a few ounces a day can improve your health.

*122\183\8*

Almost every antihypertensive medication is linked to some form of sexual disorder, but some are more likely than others to cause specine problems. I often use diuretics, such as chlorthalidone and hydrochlorothiazide, as a first line of attack to lower blood pressure. In my practice, three quarters of the men taking these medications do not experience ED. However, for the quarter who do, I may prescribe an ACE (angiotensin-converting enzyme) inhibitor, such as Accupril or Vasotec, or possibly a calcium channel blocker, such as Norvasc or Procardia XL. I would tend to shy away from medications such as clonidine (Catapres), methyldopa (Aldomet), or reserpine (Hydropres). These drugs are known to have more significant ED effects.

Beta-blocker medications, which include atenolol (Tenormin), bi-soprolol (Ziac), metoprolol (Lopressor), nadolol (Corgard), propranolol (Inderal), and timolol (Blocadren) reduce the workload on the heart and, therefore, the arteries. I commonly prescribe these drugs for the treatment of a variety of cardiac problems, from coronary artery disease to hypertension. However, I’ve found that patients often complain of ED after using these drugs. If that’s the case, I’ll switch them to either a calcium channel blocker or an ACE inhibitor.

If a man has already developed ED due to an underlying medical condition, such as diabetes, or had instances of ED because of a diuretic medication he may have taken, then I will not recommend a beta-blocking drug as a first-line treatment or even as an alternative. Again, it’s the ACE medication or calcium channel blocker that I would prescribe. ACE inhibitors are one of the most commonly used classes of antihypertensives although, to date, no one is quite sure exactly how they work. It is suspected that they block an enzyme that is required for blood vessels to constrict. As a result, the vessels relax, which is favorable to erectile function. Of the heart medications, the ACE inhibitors—benazepril (Lotensin), captopril (Capoten), enalapril (Vasotec), fosinopril (Monopril), lisinopril (Zestril), quinapril (Accupril), and ramipril (Altace)—are least likely to create ED problems.

*93\183\8*

“I have to tell you,” he said, “the thought of beginning a new relationship is very scary to me. I could be wrong, but I strongly feel that a woman might think less of me if I just wanted sex all the time. I like sex as much as the next guy, but I want to be more than a walking erection.”

The pill worked beautifully for Jason—as soon as he found a woman he really liked and trusted.

The emotional issues in his case were:

• concern that his partner would want him just for sex

• a worry that he would, therefore, have to be in a constant state of arousal

Think about your own feelings concerning:

• erectile problems, and whether they were present at the beginning of a relationship

• the fear of losing control during sex

• whether the pill could bring you closer to your partner

• the potential sexual reaction of your partner

• the possibility that a restoration of sexual function could enhance—or threaten—your situation

• your concern about a partner’s response to your sexual overtures and techniques

• how sexually demanding your partner is

• sexual desire and what it means to you

• sensory pleasure, and your capacity for it

• the difference, if any, between your anticipated relationship and how it has turned out in reality

Seriously evaluate whether you and your partner are in agreement about using the oral medications. They can affect your life in many ways and you owe it to yourselves to address issues that concern you both.

*65\183\8*