Because male orgasmic disorder is relatively rare, little systematic data are available regarding the outcome of psychotherapeutic treatment. The few studies that are available all suffer from small sample size, ranging from 1 to 10 patients. One review of the results of psychotherapy concluded that “the outcome is rather poor” (Dekker 1993). Given that the majority of male orgasmic disorder cases seen in practice probably involve some medical or pharmacological problem, the poor outcome may reflect inadequate medical screening or lack of a combined psychotherapeutic-physiological approach to treatment.
The standard psychotherapeutic treatment strategy for inhibited orgasm involves eliminating performance anxiety and ensuring adequate levels of physical stimulation. In this approach, the couple is instructed to caress the penis manually (and, if acceptable to the couple, orally) until erection is attained, but to cease stimulation whenever arousal is approaching the point of impending orgasm. This paradoxical instruction reduces goal-focused anxiety about performance and allows the man to enjoy the sexual pleasure provided by this caressing. Elements from the treatment program originally developed for inorgasmic women, including sexual activities that trigger orgasm and having the patient role-play an exaggerated orgasm, are also prescribed (Heiman and LoPiccolo 1988; LoPiccolo 1994). Once orgasm is occurring reliably with manual or oral stimulation, the same procedure is used during intravaginal intercourse.
The most common cases of inhibited male orgasm now arise out of medication use, often to treat depression within this population of patients. Those most frequently experiencing this side effect are those taking SRI antidepressants that do not also block the 5-hydroxytryptamine type 2 (HT2) receptor (Ashton et al. 1997; Montejo-Gonzalez et al. 1997). There are five strategies to limit this side effect. Patients can wait for accommodation to this side effect to occur, although one study of 97 patients followed up to 38 months revealed that this was achieved in only 9.8% of patients (Ashton and Rosen 1998a). Another strategy would be to switch to an antidepressant with less likelihood of sexual dysfunction, although this may also put the patient at risk for relapse or alternative side effects. Drug holiday has been proposed and may be helpful for some well-informed patients but also may encourage noncompliance or lead to serotonin withdrawal syndrome (Rothschild 1995). A fourth strategy would be dosage reduction, but this, too, could lead to relapse if a prior unsuccessful dose is prescribed. Finally, an increasingly common strategy is to augment with a pharmacological antidote. Reports of successful use of these agents are accumulating without a clearly superior recommendation that can, as yet, be made. Strongest evidence for triumph in reversing SRI-induced sexual dysfunction appears to be for yohimbine at 5.4 mg three times a day (Ashton et al. 1997; Hollander and McCarley 1992; Jacobsen 1992). Other antidotes that appear promising include amantadine (Ashton et al. 1997; Balogh et al. 1992; Shrivastava et al. 1995), cyproheptadine (Ashton et al. 1997; Feder 1991; McCormick et al. 1990; Segraves 1993), stimulants (Bartlik et al. 1995), bupropion (Ashton and Rosen 1998b; Labbate and Pollack 1994), buspirone (Landen et al. 1999; Norden 1994), and sildenafil (Ashton 1999; Ashton and Bennett 1999; Nurnberg et al. 1999).
For patients with physiological or pharmacological impairment, increased stimulation of scrotal, perineal, and anal areas is useful in facilitating orgasm. Most effective is the use of an anal insertion probe, which can be either a vibratory device or one that carries a mild electric current; indeed, this type of anal stimulation is the only effective treatment for severely neurologically impaired patients (LoPiccolo 1994; Murphy and Lipshultz 1988).
Case Management Tactics
For a patient with lifelong and global inhibited orgasm, treatment should begin with the patient learning to masturbate (Hawton 1985). If, as is more typically the case, the man can reach orgasm through masturbation or through manual or oral stimulation by his partner, treatment begins with his partner manually stimulating the penis. Intercourse itself is forbidden, as this activity has been associated with goal-directed (and often frantic) attempts to reach orgasm. The patients are instructed that the goal is not to produce orgasm for the man; rather, orgasm is initially prohibited during this manual stimulation of the penis. The man’s mental attitude should be one of enjoying the sensations of arousal without attempting to reach orgasm. If he feels he is getting close to orgasm, he is to discontinue stimulation and relax. When he is less aroused, he can resume stimulation. This procedure differs from the pause procedure used in treatment of premature ejaculation in that the man is allowed to let his arousal build much higher, until he is on the verge of orgasm, before pausing. In addition, the session does not end with the man allowing himself to have orgasm after several pauses in the manual stimulation. Instead, the session ends after perhaps 15-30 minutes of stimulation, without any orgasm at all. After a few sessions of this sort of stimulation, it is hoped that the man is unable to prevent himself from having an orgasm during the stimulation. At this point, the therapeutic instructions will be modified to permit orgasm during some, but not all sessions, and only when the patient feels that the orgasm is going to happen despite his not making any attempts to reach orgasm.
For patients who enter treatment able to masturbate to orgasm while alone but unable to reach orgasm in the presence of a partner, the previously described program is modified. These men may be inhibited about displaying the emotional expression and loss of control associated with orgasm. For such men, an early assignment is for them to role-play a grossly exaggerated orgasm with their partner present. This role-playing can occur during the man’s own masturbation or his partner’s manual stimulation of his penis. To further disinhibit them, the partner may be asked to first role-play a grossly exaggerated orgasm, or, if this is in the partner’s sexual repertoire, to potentiate an actual orgasm and be especially unrestrained and out of control. If fear of loss of control or fear of his partner’s reaction is a factor in preventing orgasm, the exaggerated role-play procedure is very effective. Having acted out something much more extreme than a real orgasm, the man is no longer embarrassed or inhibited to let his partner see him have a real orgasm.
As orgasm becomes reliably established during the partner’s manual stimulation, the couple’s sexual repertoire can be expanded. Oral stimulation, if acceptable to the couple, may be tried next. When intercourse is allowed, the sequence of passive containment - partner thrusting, male thrusting, and finally mutual thrusting - is followed. At each step, attempts to reach orgasm are initially forbidden, then allowed only after the patient finds orgasm occurring spontaneously. Although this program to reduce performance anxiety works moderately well with men who have no physiological or pharmacological factors involved in their problem, such men are rarely seen in current practice. For the majority of men seen with male orgasmic disorder not caused by a medically or pharmacologically induced impairment, techniques for increasing the intensity of stimulation they receive are indicated, rather than a simple focus on reducing performance anxiety. At a behavioral level, teaching these men to use the orgasm triggers originally developed for inorgasmic women (Heiman and LoPiccolo 1988) is useful to some degree.
Orgasm triggers are physiological events that tend to occur spontaneously and involuntarily when a person has orgasm. With experience, many people come to perform the orgasm triggers voluntarily when they are highly aroused, both to initiate their orgasm and to heighten its intensity. Orgasm triggers include arching the foot and pointing the toes, tensing the thigh muscles, contracting the pubococcygeal muscle and bearing down in the pelvis, caressing and squeezing the scrotum against the perineum, holding the breath in a Valsalva maneuver (i.e., attempting to exhale against a closed glottis), and throwing the head back to displace the glottis. However, telling a patient to perform all of these maneuvers at once to trigger an orgasm would certainly interfere with arousal and would lead to a performance-oriented spectator role! To avoid this negative effect, orgasm triggers are introduced sequentially over a few sessions, with each one described as a way to heighten pleasure and not initiate orgasm.
For men with severe physiological or pharmacological compromise of their orgasmic capacity, anal stimulation may be the most effective orgasm trigger of all. The therapist should make clear to such patients that anal stimulation does not indicate any homosexual orientation (a common misperception). It should be explained that a reflex arc exists for orgasm through anal stimulation. The therapist might also tell patients that because endangered species such as the gorilla often will not mate naturally in captivity, zoos use anal stimulation of the anesthetized male gorilla to obtain semen for artificial insemination. Emphasizing the reflex nature of orgasm in response to anal stimulation leads to good acceptance of this procedure in medically compromised patients.
Typically, the couple is encouraged to explore anal stimulation while in the shower, to eliminate any concerns about cleanliness. Often, stimulation of the perineal region and the surface of the anus is all that is required to trigger orgasm. Other couples may go on to insertion of a finger or use of an anal vibrator. Although vibration applied to the penis is not particularly effective for men with inhibited orgasm (Hawton 1985), anal vibration is very effective. Many couples come to regularly include anal stimulation as a natural part of their lovemaking, thus enabling the man to reach orgasm during intercourse.
In summary, it appears that if the clinician is sensitive to issues of underlying hypoactive sexual desire and also attends to medical or pharmacological impairments, the prognosis for treatment of male orgasmic disorder may be reasonably positive.
Revision date: June 20, 2011
Last revised: by Dave R. Roger, M.D.