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Male Orgasmic Disorder: A New Look at an Old Problem

INTRODUCTION

The past decades have seen remarkable progress in the diagnosis and treatment of male

sexual dysfunctions. Behavioral techniques, medication and other therapies have

provided significant relief for men complaining of erectile dysfunction, premature

ejaculation and even diminished desire. One vexing problem, which remains stubbornly

without a proven intervention, is what DSM jargon currently refers to as Male Orgasmic

Disorder (MOD).

It is of more than passing interest that sexual health professionals have yet to

agree on a diagnostic term to describe men who rarely if ever reach orgasm through

intercourse. This phenomenon has remained resistant to our attempts at understanding

and consequently our efforts to offer consistently effective intervention. The relatively

small number of reported cases compounds the problem; we do not have a population of

sufficient size to allow for statistically valid studies. Further complicating our efforts at

resolution is the unfortunate myth that at the very least, men suffering from this condition

are highly prized as sexual partners, remaining erect indefinitely.

This article suggests an alternate understanding of the factors contributing to this

condition and offers a practice-tested treatment protocol based on this perspective. Not

included as a focus is orgasmic/ejaculatory disorder that results from illness, injury,

substance abuse or medication side effect.

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Understanding the issue

So what’s the problem? So he can’t come. Unless the focus of sexual intercourse is

procreation, we may be looking at the ultimate lover, one who can stay erect long enough

to bring his partner to multiple screaming orgasms and who creates no ejaculatory mess –

or so the myth and the media would have us believe.

Reality paints a more painful picture. Whether through his own eyes or the eyes

of others, this man does not live up to the most rudimentary expectations of being a man -

naturally fathering a child or feeling the intensity of orgasm. As Zilbergeld (1992) has

poignantly noted:

(men) learn from an early age that manhood is conditional rather than absolute …

Not making the team, not being willing to fight, not performing in bed, losing a

job – that’s all it takes and our man no longer believes he is a man.

From his partner’s point of view, the prolonged thrusting associated with MOD

can engender both physical and emotional distress. In addition to complaints of vaginal

bruising and chafing, women often report feeling guilty and responsible, fearing that they

have somehow failed to be sufficiently provocative, that his inability to reach orgasm

would disappear, if only she were more … something.

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Literature

It is of note that much of the existing literature regarding MOD consists of reviews of the

existing literature (e.g. Bettocchi et al, 2008; Kandeel et al, 2001; Lue et al, 2004;

McMahon et al, 2004; Mah & Binik, 2001; Munjack & Kanno, 1979; Ralph & Wylie,

2005; Waldinger & Schweitzer, 2005). In addition, the last paragraphs of many citations

end with a message similar to the following: “Further research on lifelong retarded

ejaculation is of the utmost importance … (Waldinger & Schweitzer, 2005, p. 8, see also

e.g. Heiman and Meston 1997; Jannini, Simonelli, & Lenzi, 2002). Underscoring the

current state of knowledge is the plethora of expressions employed to describe a lack of

ejaculatory response, including but not limited to ejaculatory incompetence, partner

anorgasmia, psychogenic-inhibited ejaculation and of course retarded or delayed

ejaculation.

The etiological focus has changed little over the past decades as indicated by the

following two citations written more than 40 years apart by respected authorities seeking

to offer plausible explanations:

"... a strict religious upbringing which engenders sexual guilt, intrapsychic

conflict deriving from an unresolved oedipal complex, strongly suppressed anger,

ambivalence toward his partner, the man's fear of abandonment by the woman or

a specific sexual calamity …"

(Kaplan, 1974, p. 327).

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"… cultural and religious beliefs, concurrent psychopathology such as

unconscious aggression and unexpected anger, insufficient sexual arousal, a

preference for masturbation over partnered sex, fear of inducing pregnancy, or

fear of sexually transmitted infections."

(Komisaruk, Beyer-Flores & Whipple, 2006, p.59).

Neither source offers research data or a cogent theoretical model to support these

contentions, as is true of most other attempts to understand this phenomenon. One

notable exception is an elegant, erudite article written by Bernard Apfelbaum (2000),

who suggests that MOD is caused by a failure of arousal. The author suggests a complex

treatment model, but other than a one-sentence mention of arousal and MOD by

Slowinski (2007), I have found no follow-up articles or critical evaluations that may have

appeared in the literature.

Wincze and Carey (2001) list sources, which provide estimates of the prevalence

of MOD, with a range of 0% to 39%, with most recent studies citing a figure not higher

than 3%. They conclude “ … there have been many methodological differences across

these studies, especially involving sampling … and, most importantly, the definition of

the disorder …” (p.48).

In a recent review done for the British Association of Sexual Health and HIV,

Richardson and Goldmeier (2006) conclude:

The definition of this condition does not appear to have reached consensus among

all therapists and researchers. There are few case reports and case-controlled

studies describing aetiological factors and associations; however well constructed,

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hypothesis testing trials for these factors have not been done. …the literature is

lacking in quality scientific evidence for the management of this condition…

(p.11).

AN ALTERNATE MODEL

In contrast to existing pathology models, I suggest that MOD is the result of a conflict

between two positive messages heard by most sexually active people, yet for these men,

unlike most of us, no resolution has been discovered. My thinking in this direction

derived from the men I have treated for MOD who, other than the distress engendered by

their inability to reach orgasm during intercourse, did not exhibit any other

symptomatology and did not report any overt etiological causal factors.

Almost from the moment infants begin to exert control over their bodies and

external environments, they receive messages of self-control – don’t touch a hot stove,

stay away from the edge, don’t eat that bug. As we move on in our lives, these messages

become ever more pervasive and determine our behaviors in myriad aspects of our daily

existence – don’t steal that apple, don’t cheat on a test, don’t touch that girl. In essence,

our lives would be chaotic if not impossible without the ability to count on the constant

self-control that represents a cornerstone of civilization.

Various theories have been suggested to explain how we incorporate self-control

as a dominant influence on our actions and interactions. From the perspective of internal

psychic processes, Freud’s concept of the development and function of the superego

provides a workable thesis. According to this perspective, our notions of right or wrong,
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of permissible or forbidden are internalized moral expectations based on messages from

parents and society. We tend to accede to the strictures of the superego because to do so

engenders feelings of pride, value and success and not to so may cause guilt and

punishment. The superego continually prods us to maintain control over our instinctive

drives, sex, of course, being a major focus.

Bandura’s (1977) Social Learning Theory offers a alternate but arguably

complementary perspective. He summarizes his model as follows:

Learning would be exceedingly laborious, not to mention hazardous, if people had

to rely solely on the effects of their own actions to inform them what to do.

Fortunately, most human behavior is learned observationally through modeling:

from observing others one forms an idea of how new behaviors are performed,

and on later occasions this coded information serves as a guide for action (p.22).

Bandura also emphasizes the relevance of motivation and the value of outcomes

as further influencing how we learn to conduct ourselves. Thus, if those around us

consistently teach and live the critical importance of self-control, it becomes a continual

stimulus for our behavioral decision-making.

In contrast, sex transmits a dramatically different message – let go.

Starting with lowering barriers by revealing oneself physically and emotionally and

moving on to the intense release of orgasm, the entire process is predicated on the
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pleasure of giving up control. An old rock n’ roll song expresses this point with simple

clarity:

I’m so excited, I just can’t hide it,

I’m about to lose control and I think I like it.

(Tonight’s the Night – The Pointer Sisters)

For the large majority of men, familial and societal messages encouraging sexual

activity provide sufficient rationalization for surrendering an element of self-control,

which otherwise may prevent that freedom experienced as orgasm. For others, however,

these demands remain contradictory; they cannot, by definition, exist simultaneously.

This group may well be aroused by their partners and have no difficulty with the stages

leading to penetration and thrusting. As ejaculatory inevitability approaches, however,

they lack that mechanism which allows for a comfortable, temporary transition from self-

control to release and then back again. The resulting syndrome – MOD – tends to

characterize the sexual responses of these men unless a suitable intervention becomes

available.

THE PROTOCOL

The following treatment protocol has been developed with an understanding that the two

values stances described above – control and release - are inherently positive and
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attempting to tamper with either of them may produce confusion and resistance. Instead,

the therapist seeks to create a physical sensation, which could best be described as

“controlled release.” The protocol makes use of a procedure to contract and release

pelvic musculature first proposed by Kegel (1948, 1952) and suggested by Zilbergeld

(1992) as a technique for enhancing orgasm. Here the procedure is modified for the

specific treatment of MOD.

1. The couple is asked to refrain from any sexual intercourse until the therapist

instructs otherwise; any other non-genital pleasurable touch is encouraged.

2. The client is given an explanation of the location and function of his PC muscle.

He is then asked to step into the bathroom, begin urinating and then stop mid-

stream, doing this twice, if possible. As he intentionally stops the urination, he is

asked to be aware of feeling himself tense the PC muscle.

3. The client is then instructed to tense and relax this muscle 20 times in succession

each day for a week, with the tension at this stage lasting 2 seconds and the

release 1 second. It is essential to clarify that this no longer has anything to do

with urination and can be done anytime, anywhere.

4. Depending upon the client’s level of comfort and cooperation, the periods of

tension and release should be gradually increased, with a goal of 10 seconds of

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tension and 3 seconds of release. Each increase should be practiced every day

for at least a week.

5. Once the client has reached a mutually agreed upon exercise end stage, the

couple is encouraged to recommence intercourse. Using the male-superior

position, he is instructed to thrust at a moderate pace and to start the PC muscle

exercise when he begins to feel any heightened level of excitement. The now

familiar relaxation of the tensed PC muscle allows for the release that unlocks his

orgasm. When this has worked, it has worked at this point.

CONCLUSION

So does this technique really provide a viable solution? My results suffer from the same

flaw as previous theories and models – insufficient numbers to reach statistical reliability.

I have suggested this protocol to four men, all of whom shared the following

characteristics: married less than two years, no indication of physical or emotional illness,

not currently taking medication and no history of sexual trauma. They all identified

themselves as religious, none had sexual experience prior to their wedding nights and all

were able to achieve erection and have intercourse. Two of the men completed the

sequence (4-6 weeks) and were able to ejaculate during intercourse, subsequently no

longer needing the Kegel exercises. Of these, one contacted me several months after

treatment termination, saying that the MOD had returned. He was advised to redo the

fifth step of the protocol, which restored his ability to ejaculate during intercourse.
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Of the other two men, one did not return after the first session and the

second found the Kegel exercises to be annoying and ended treatment. Should any

readers wish to use this intervention, I respectfully request their feedback; perhaps an

aggregate of outcomes can provide numbers sufficient for data analysis. Since July 2008,

the protocol has been sent to a number of therapists in response to their inquiries through

the AASECT on-line discussion forum as to treatment options for MOD. I subsequently

heard from only one of them, but her report was, and I quote “Wow!”
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Bettocchi, C., Verze, P., Palumbo, F., Arcaniolo, D. & Mirone, V. (2008). Ejaculatory

disorders: Pathophysiology and management. Nature Clinical Practice Urology,

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Connell, R.W. (1995). Masculinities. Cambridge, UK: Polity Press.

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