Dr. Kris Case: Understanding Your Sexual Response Cycle Can Help

Sometimes what helps a patient most is not medicine, but understanding their own body. In this case I drew the cycle on a sheet of paper for him, and watched his face change from worried to relieved.

Background

He was a man in his early 40s who came in looking anxious. He explained that recently, when having sex with his wife, he could get an erection at first, but after a while it gradually faded until he couldn't continue, and he never reached orgasm. He was stressed, felt very guilty towards his wife, and thought he was "past it".

What I found

I assessed two areas separately.

The physical side

• I checked his blood pressure, glucose and lipids, and asked about his regular medicines, because some, such as antidepressants, can make orgasm difficult (read: antidepressants and sex).
• I asked about morning erections and reaching orgasm during masturbation, both of which were still normal.
• There were no signs of a disease that clearly explained the symptoms.

The psychological and relationship side

• Work had been very heavy at the time, and he was sleeping little.
• He tended to rush into penetration because he was afraid that if he took too long he would "go soft", which made him even more anxious.
• During sex he was constantly checking whether he was hard enough. In sexology this is called spectatoring: becoming an observer of yourself instead of being present with the sensations.

Care

I explained the sexual response cycle as described by Masters and Johnson:

1. Excitement. Touch, kissing and atmosphere make the body begin to respond.
2. Plateau. Sensation builds steadily and needs continuous, unhurried stimulation.
3. Orgasm. A release, both physical and emotional.
4. Resolution. The body returns to its resting state. This is a good time for cuddling and talking.

I added Rosemary Basson's model, which says that for many people desire does not always come first. Sometimes closeness and feeling safe come first, and desire follows.

In this case the problem began at stages 1–2, because stress and rushing meant his body never settled into a steady "rhythm". What we agreed on was:

• Giving more time to foreplay and closeness.
• Creating a relaxed atmosphere, and not having sex after a very exhausting day.
• Lowering expectations, with no goal that every time must end in penetration or orgasm.
• Practising sensate focus with his wife, and training himself to bring his attention back to touch instead of watching himself (read: mindful sex).
• A follow-up appointment, with the understanding that if things didn't improve we would consider further treatment, such as erection medicine as assessed by the doctor.

A few weeks later he came back smiling, saying that the closeness with his wife was back to how it had been in the early days, and his anxiety had dropped a lot.

1. 1
   ArousalTouch, atmosphere; the body begins to respond
2. 2
   PlateauSensations keep building; needs continuity
3. 3
   OrgasmRelease of body and mind
4. 4
   ResolutionBack to baseline; time for cuddling and talking

If stress or rush enters early, the curve never reaches the plateau. This is where this case was stuck.

1. 1
   Close, safeStarts with feeling good, not always with desire
2. 2
   Open to touchAllowing stimulation without pressure
3. 3
   ArousalBody and mind begin to respond
4. 4
   DesireWanting follows arousal
5. 5
   SatisfactionPhysical and emotional; makes you want closeness again

Based on Basson R. (2000); explains the many people whose desire doesn't always come first.

What I learned

• The body is not a switch. Arousal needs time and a sense of safety.
• Performance anxiety creates its own cycle. The more you fear losing your erection, the more likely it is to go.
• Check the body before concluding it is psychological, because losing an erection partway through can also be an early sign of vascular ED, and not reaching orgasm may be delayed ejaculation with other causes.
• Understanding yourself and your partner is treatment. Accurate sexual knowledge genuinely reduces guilt.

If you are going through the same thing

Try reading Stress, relaxation and erections and ED: causes and treatment, especially if symptoms have lasted more than 3 months or are starting to affect your relationship. At Dr. Kris Clinic, I check both the physical and psychological sides, and offer consultations individually or as a couple, at the clinic and online, including in English.