Better Sex: Overcoming Common Problems in Sexual Relationships

9/19/2021

Better Man Clinics 

Most guys are always curious about how they are “doing” when it comes to their sexual relationships.  What is a reasonable way for men to evaluate their sexual relationship both from their own perspective and that of their partner?  Can you offer them a type of “scorecard” through which to evaluate themselves?

Kimberly Resnick Anderson, LCSW 

The problem is that the concept of a “scorecard” is inherently flawed. The scorecard is steeped in stereotypes and unrealistic expectations, and hundreds of years of notions about male sexual performance that are unhelpful. I just want to put that out there. If men use the scorecard that is available to them, they’re going to feel insecure, they’re going to wonder if their penis is big enough, they’re going to wonder if they have good enough technique, they’re going to wonder if their erection is hard enough, they’re going to wonder if they’re pleasing their partner. And as I’ve come to believe more and more over the past 30 years, these things are relevant variables, but certainly not primary variables.

There is a lot of misinformation out there that perpetuates insecurity. One of my primary missions is to give people a more realistic view as well as permission and encouragement to celebrate their sexual story, whatever that may be. And even if there is a sexual dysfunction, or some other complaint in some phase of sexual response, or some component of sexual identity, I encourage my patients to really make peace with whatever that may be.  These days, we live in a great time in terms of Sexual Medicine innovations. But if it has to do with gender, or orientation, or a kink or something, I really do encourage them to just accept who they are and celebrate that, regardless of what it is.

Better Man Clinics 

What about men that are concerned about their partner’s satisfaction with the sexual relationship? What can they do to better understand their partner’s perception of the relationship?

Kimberly Resnick Anderson, LCSW 

This gets complicated when a patient comes in with concerns about their partner, and the partner is not present. There’s only so much I can do because we all see through our own lens, we all have our own biases, we all have our own insecurities. In this scenario, I ask the man several questions:  What are you wondering?  what are you assuming? What is it that you think might be happening for your partner? And why do you feel that way? And then sometimes as they elaborate, right there, there’s things I can do to be helpful. I can reframe, I can offer a little tidbit around some piece of sexual education, I can dispel a myth. Men sometimes wonder if their partners are faking orgasm, which is a big thing that a lot of men come and talk to me about. A lot of men come and talk to me about a discrepancy in desire where they have a higher interest in sex and their partner has lower interest, I also hear the opposite – where men have low libido and their partner, whether it be a male or a female partner, is wanting more sex. I see a lot of men who are only able to maintain an erection and have an orgasm if they’re masturbating and/or watching porn.  That has become a requirement so they are not able to ejaculate, for example, inside their partner during intercourse. So men have a lot of worries when it comes to sexual relationships, a lot of concerns, and a lot of “Can I trust my partner to tell me the truth.” And with that comes a lot of resentment. I see a lot of angry men and a lot of angry women when it comes to sex. That resentment has to be acknowledged and processed before anything else.

Better Man Clinics 

Let’s dive into a couple of those scenarios that you brought up. If a man comes to you with concerns about a low sex drive, a lower interest in sex than that of their partner, what can you do to solve that problem?

Kimberly Resnick Anderson, LCSW 

This would be a great opportunity to do some education with that patient around the phases of sexual response. I would explain the difference between desire, arousal, orgasm, and satisfaction. Those are the phases of sexual response. Both men and women experience each phase, but we experience them differently and sometimes in not the same order.  So, first, I want to confirm that he’s talking about libido or desire, and not arousal, because those get confused a lot. If I can then confirm that he is talking about his desire, then I will ask a lot of questions to see if I can quickly point to an organic problem. I’m not a physician, but I’ve been working closely with physicians for 30 years so I know what the primary suspects are that might undermine libido in a man. So I ask questions like, “are you taking any medications? Do you have any vascular problems? Are you diabetic?”  I would ask about heart issues. I would also ask about depression, anxiety, or even performance anxiety. It could be that they’re no longer attracted sexually attracted to their partner. I go through a series of these questions to determine if their complaint is what’s called primary versus secondary. We also refer to that as lifelong versus acquired. So, if he says, “I just don’t have interest”, I want to find out, is this a change from their baseline?  Is this an acquired problem where he had interest up until time x and then since time x they have noticed a change, or has this change been gradual? Or has this been a lifelong awareness that he has never been as “horny” as his guy friends.  Then I want to determine if the problem is what is called global versus situational. And that has to do with the context. Some men might say, ”I’m really not hot for my wife, but I’m extremely hot for my lover”.  The other thing I want to assess (if I can) is if it’s a psychological problem or an organic problem. If I have any doubt or concern that there might be an underlying undiagnosed medical condition, I’m going to call a Urologist or other physician.  Sometimes I am pretty confident that the problem is psychological but I still send the patient to a Urologist to rule out any potential organic problems.  That way we can make sure everything is fine medically, and then we can tackle this the problem from a psychosocial perspective.

Better Man Clinics 

A lot of guys have what they think or what people tell them is maybe excessive desire. How do you judge when desire can be truly described as excessive? And what can guys do about that?

Kimberly Resnick Anderson, LCSW 

I’ve worked for a very long time with men who have what I would call compulsive sexual interest or compulsive sexual behavior.  We now use the term auto control sexual behavior.  You may hear the term sex addiction. It’s not a term I like to use, although it’s a popular term. And this gets tricky because men tend to pathologize themselves, and they tend to be pathologized by their partners and society as well because we live in a negative sex shaming culture. There’s an inherent little piece of distress for everyone around their sexuality. Some men who are preoccupied with sex or are distracted by sexual energy, often can’t focus on their work and can’t sleep, because they’re looking at porn. They can’t get through the workday without masturbating in the men’s room.  Sometimes they’re unable to drive in their car without pulling over and masturbating or masturbating while they’re driving. And they need a what’s called a TSL.  Total sexual outlet is a term that we use in terms of how many orgasms do they need per day, for example, and it’s not like there’s a magic number. I have treated men who masturbate 10 to 12 times a day. I’ve treated men who needed to be hospitalized because they were so rough with their penis that it was bleeding. I treated a neurosurgeon who was excusing himself from open brain surgery to masturbate because he couldn’t go more than three hours without having to orgasm. I think we all would agree that that’s compulsive.

Better Man Clinics 

It sounds like that’s a situation in which sex isn’t part of your life, it basically becomes your life.

Kimberly Resnick Anderson, LCSW

Yes. It impairs their ability to sleep, work, and function.

Better Man Clinics 

Most guys think about excessive sex as a positive. But these examples you describe certainly are disturbing and can really destroy somebody’s life. And I am sure that sometimes or a lot of times it’s unwanted.

Kimberly Resnick Anderson, LCSW 

Some guys lean in and they love it. And they wouldn’t trade it. I ask them, “If I could wave a magic wand and your compulsive sexual energy would just evaporate would you want me to?” Plenty of guys say no, but plenty say yes. They feel like slaves by the preoccupation and the perseverative component to it. They feel burdened and they would love it if I could turn the volume down. And there are ways to do that.

Better Man Clinics 

On a high level, can you just explain what are those methods to “turn down the volume?” I mean, you don’t have to go into the details. But like on a high level, how do you manage the situation where someone’s life is taken over by this compulsion, this desire? How do you turn that around for someone?

Kimberly Resnick Anderson, LCSW 

Well, it’s a multifaceted approach. Psychotherapy can help to really understand the role of sex in their life. What are they trying to accomplish? What is the backstory, what I call their sexual story? That would be my role. The doctor’s role would be to prescribe a medication, such as an SSRI, which has sexual side effects, which we actually use strategically, to turn down the volume on sexually compulsive energy. If you give someone an SSRI medication like Zoloft or Paxil or Celexa, it’s going to make it more difficult for him to have an orgasm and ejaculate. We actually use that medication intentionally to make it harder for a man to get to that orgasm phase, so that it’s more frustrating, much more work much more of an investment. And because it’s not as easy as it was, oftentimes that can be a deterrent to the compulsive sexual behavior.  If it’s really compulsive and especially if there’s a criminal component to it (like sexual assault), we even use Depo Provera, which is a female hormone. That is a form of chemical castration. Another option is a high dose of an SSRI and psychotherapy and a 12 step group. It has been shown that a group format is pretty successful, because you’re talking with other men who struggle with similar problems. There’s often a lot of overlap and so they can be a community and support each other.

Better Man Clinics 

What do you do when the desire of the man is simply not in line with that of his partner?

Kimberly Resnick Anderson, LCSW 

That’s basically my bread and butter. I have a new couple that is coming in for the first time and it’s either that they have a discrepant interest in sex, or he’s looking at too much porn, or there is the fallout of infidelity.  The discrepancy in desire is one of the primary presenting complaints. I’ll take a comprehensive sexual history from each to assess both the positive and negative influences that shaped their sexual identity. That can go back to pre-puberty.  I certainly spent a lot of time talking about puberty and what that was like and how they felt compared to their peers. Did they feel normal? Did they feel abnormal? I will assess whether there could be an organic component as we discussed.  I will try to get a sense of the dynamic between the two of them and see if sex is maybe being used as a currency or, you know, as a form of power or control. And then I just try to remind them that they got married for a reason, or they’re living together, or coupling for a reason. And then I have a little talk on how healthy and protective sex is both physically and emotionally and psychologically. Often there’s resentment, which can be a barrier. But, sometimes, people just have different appetites.  Like, you may like steak, and I may like lobster. Or you may like steak a lot. And I may like steak a little bit. So there needs to be a lot of negotiation and compromise, an attempt to nurture empathy for the partner and to appreciate their point of view. Sometimes I try to bring the lower partner up, sometimes I try to bring the higher partner down. But, often, it’s a compromise and negotiation. We explore parameters and expectations, and we set up what’s going to happen ahead of time – a kind of “pre-gaming.” There is a lot that can be done, but it’s hard work for sure.

Better Man Clinics 

One of the things that you mentioned, which is becoming more and more of an issue now is pornography. I was listening to another podcast where somebody had mentioned that adults in the US are probably having less sex than they’ve ever had in history. A big reason that they mentioned was pornography.  The amount of pornography that is being watched, mostly by the men, is rising astronomically higher, and that pornography is creating expectations that can very rarely be satisfied in real life. And that creates a disinterest in men from reality because they enjoy what they’re seeing on the internet or on movies much more than what they experience in real life.  As a result, they are just not as interested in actual sex in the real world and develop sexual dysfunction as a result. How do you overcome that?

Kimberly Resnick Anderson, LCSW  34:51

Yeah, that’s another chunk of my bread and butter.  Indeed, men who watch porn are becoming immune to what is referred to in the biz as “vanilla sex” which is what we might say is conventional sex or traditional sex. And the thing about porn is that there’s so much to see. It’s so accessible. There is an endless supply. There so much more and more perverse pornography available. I mean, we’ve got rape porn, torture porn, bestiality porn etc.  Men are becoming desensitized to so called vanilla sex. The novelty of the porn boosts dopamine. Dopamine is the foot on the gas of the sexual car. Anything new and different or unusual is going to give you that hit of dopamine. That is the pleasure center or the reward center in the brain- think like chocolate cake or heroin or whatever it is that someone might be addicted to. It is not going to feel as exciting to have vanilla sex with your partner after watching three hours of porn.  I’m not anti porn by any means. I just want to state that, for the record, I think porn can be used responsibly and in a healthy way, individually and for couples. But it is definitely changing the way that our younger generation think about sex because they’re seeing things and their brains are getting wired in a certain way. When sex is not as exciting in real life, a lot of men either can’t get erect, can’t maintain an erection, or can’t ejaculate. They are not getting to that point of what’s called ejaculatory inevitability, or what I say is a point of no return. They’re just not excited enough. And it’s causing extreme damage in in relationships. It is a very common reason why couples come and see me. Men will also come individually and say, “you know, I’m addicted to porn. I can’t get aroused with my partner, I can only masturbate.” That is porn induced erectile dysfunction,

Better Man Clinics 

In that situation of porn causing sexual dysfunction, is the solution to wean them off of the porn or to allow them to somehow still enjoy “vanilla sex” while still maintaining their porn habit?

Kimberly Resnick Anderson, LCSW 

Great question. The answer is a combination of things. I try to eroticize vanilla sex, because vanilla sex can be hot sex if you have the right components.  The consistent thing I hear from men is that they really appreciate an enthusiastic partner.  They want to be with someone who’s having a good time, who’s expressing that pleasure and is sexually responsive to them. So a lot of men would say, “if I could get my partner to loosen up or if I could get my partner to be willing to do certain things or if I could get my partner to be more open, I wouldn’t need the porn.” Some men want to stop the porn altogether. For some men, the partner doesn’t want them to have porn. So then there’s a lot of exploration and negotiation. I don’t have a problem with men having a rich and diverse and varied erotic arousal template, I think it’s healthy. I just like to broaden it. If there’s only one pathway or two pathways to sexual gratification, then that person is going to have a limited experience,

Better Man Clinics 

Another situation you probably see a lot is that, as relationships mature, the excitement goes by the wayside and with that the desire goes by the wayside from one or both partners because sex becomes routine and the spark is no longer there.  How do you help couples with that issue?

Kimberly Resnick Anderson, LCSW 

I help them with novelty. You know, intimacy, emotional intimacy can fuel erotic response and creativity, and humor and playfulness. I have some tricks in my bag that I bring out for couples to help them stay spicy in their sexual life. Another thing I treat a lot of people for, which is becoming more and more common, is a sexless marriage or sexless relationships.  Couples come in, and they’ll say, “we haven’t had sex in six months, or six years or 26 years.” I’ve actually had couples come to me that have been together for decades and haven’t had sex in decades.  They will say “we want to get back on that sexual horse.”  I help them reclaim that sexual energy.

Better Man Clinics

Guys often don’t feel comfortable talking about what they ate for lunch, much less about problems with a sexual relationship.  How do you advise men to broach the subject of sexual issues with their partners?

Kimberly Resnick Anderson, LCSW 

We are not taught to talk about our sexual feelings or sexual experiences. In fact, we’re taught not to. The messaging from a very young age is that sex is taboo and that sex is dirty. So why would we comfortably discuss something that’s taboo and dirty? It is just a setup for people to not go there. So I kind of do a reprogramming with people. And I facilitate those conversations. First of all, I might help them get in touch with their own sexual preferences, fantasies, expectations.  Then I help to facilitate a dialogue between them and their partner.  I’ve developed a clinical protocol called the comfort inducing sexuality dialogue that people can read about on my website which explains why it’s important to share with your partner. It has been life changing for some of my couples to have these conversations in my office with my facilitation. And it’s incredible what a conversation can do.

Better Man Clinics 

How do you differentiate which men have psychogenic erectile dysfunction caused by some of the psychological issues we have discussed from those guys that truly have organic erectile dysfunction and potentially need treatment with medications such as Viagra (assuming they have no contraindications to taking these medications)?

Kimberly Resnick Anderson, LCSW 

First, I would want to know whether the problem is new or if it is lifelong? I want to know is this situational or global?  If a man has an acquired erectile dysfunction, if it came on suddenly, that’s very different than if he has always struggled with erections.  If someone can’t get an erection with his wife, but can with his girlfriend (or boyfriend), that tells me that it’s unlikely to be organic – because its situational and contextual.  In contrast, if a man says that they can never get an erection and don’t wake up with an erection, and don’t get an erection during masturbation, that tells me that they likely have organic erectile dysfunction.

Better Man Clinics 

What is your approach to solving psychogenic erectile dysfunction that is psychological and only occurs in certain situations and in certain contexts?

Kimberly Resnick Anderson, LCSW 

First, I have to get a lot of information: family history, sexual history, current health status, current mental health status, current relationship status, former relationship dynamics, current relationship dynamics, notions about sex stereotypes etc.  I try to determine if there is resentment towards a partner or if they have guilt? Are they cheating on their partner?  There is just a lot of data to collect. It is my job to take all that data, all of those different strings, and weave it into a tapestry.  After synthesizing all of that data, I can then tell the patient what I think might be going on. I’ll make interpretations. I’ll reframe things. I’ll do some psychologic education.

Better Man Clinics

If I’m understanding you correctly, you are trying to take in a ton of data to understand the psychological framework of that individual and, in so doing, you’re trying to find the root psychological cause for erectile dysfunction that occurs in that particular situation or context.  Is that correct?

Kimberly Resnick Anderson, LCSW 

Yes, the cause or causes. There is often a multitude of potential causes.

Better Man Clinics 

Is it safe to say that men with psychogenic erectile dysfunction should not be focusing on pills like Viagra or Cialis because their problem is psychological rather than organic?

Kimberly Resnick Anderson, LCSW 

Yes, but with one caveat. Medication like Viagra or Cialis doesn’t care if you have psychogenic or organic erectile dysfunction. They draw blood into the pelvic region. They are going to be a vasodilator (dilate blood vessels) regardless of the cause of erectile dysfunction. Sometimes even men with psychogenic erectile dysfunction can get erections simply by taking a medication like Viagra or Cialis. And if that works, and that gets them where they need to be, then that’s fine. I wouldn’t categorically rule out these medications for men with psychogenic erectile dysfunction, because sometimes it’s a confidence issue. If they can just get a couple of successful sexual encounters under their belt, then maybe they won’t need it anymore. I just want to be clear that I don’t see Viagra as indicated exclusively in organic situations.

Better Man Clinics 

That being said, if a man has psychogenic erectile dysfunction and is using Viagra to treat it as opposed to getting to the root cause, won’t he just get dependent on the medication?

Kimberly Resnick Anderson, LCSW 

Yes, absolutely.  I would never encourage someone with psychogenic erectile dysfunction to use Viagra alone in lieu of psychotherapy or sex therapy. But the thing is, the medical doctors are writing these prescriptions like candy, right? They’re not screening their patients to tease out if there may be a psychogenic component. They are just giving them prescriptions. As a result, the guys do get dependent on it. They don’t ever understand what’s going on. And they really don’t need it because there is no underlying vascular or medical problem. And then they end up seeing me five years later and they’re worse off.

Better Man Clinics 

Right, you don’t want to forget the real problem. Some guys have organic erectile dysfunction and take Viagra and Levitra, which help them get an erection. But the whole process gets into their head so that, even though they’re able to perform, the performance anxiety they have developed makes the sexual experience just miserable. I’m sure you’ve dealt with that. How do you counsel them? How do you get them over that situation?

Kimberly Resnick Anderson, LCSW 

That’s why we need to talk and not just “do.” These problems have legacies. Maybe the dynamic between the couple went off track during the period of erectile dysfunction and, even though it’s better now, there’s still some lingering bad feeling or insecurity. A lot of times Viagra works, and men still discontinue it because good erections don’t solve bad relationships. Sometimes, men may be excited about the erection they can achieve with Viagra but their partners are so frustrated with the relationship that they are not receptive to sex. There should buy-in from the partner if the man is going to introduce Viagra or other medications into the sexual relationship. One thing that research has shown is that involving the partner from the beginning is very protective in terms of efficacy and satisfaction.

Better Man Clinics 

A quick word of caution -for those guys that are thinking about Levitra, Viagra, Cialis or, frankly, any of the other medications that we were mentioning here, you should talk to a doctor or health care practitioner before trying these medications.  These medications can be dangerous and can have significant side effects.  Sometimes they can even be life threatening. You need to have an appropriate health care professional guide you with these medications and not just borrow them from a buddy or try to buy them online. That could be an unmitigated disaster