Male orgasmic disorder

Definition

Male orgasmic disorder may be defined as a persistent or recurrent inability to achieve orgasm despite lengthy sexual contact or while participating in sexual intercourse.

The mental health professional's handbook, the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR), includes this disorder among the sexual dysfunctions , along with premature ejaculation , dyspareunia , and others.

Description

The individual affected by male orgasmic disorder is unable to experience an orgasm following a normal sexual excitement phase. The affected man may regularly experience delays in orgasm, or may be unable to experience orgasm altogether.

Normal orgasm

First, it is important to this discussion to understand the characteristics of a "normal" orgasm. The sensation of orgasm in the male includes emission followed by ejaculation. The term emission refers to a sensation of impending ejaculation produced by contractions of the prostate gland, seminal vesicles, and urethra accompanied by generalized muscular tension, perineal contractions, and involuntary pelvic thrusting. Orgasm is followed by a period of resolution characterized by feelings of well-being and generalized muscular relaxation. During this phase, men may be unable to respond to further sexual stimulation, erection, and orgasm for a variable period of time.

It is also important to distinguish orgasm from ejaculation, although in most instances they occur almost simultaneously. Orgasm is a peak emotional and physical experience, whereas ejaculation is simply a reflex action occurring at the lower portion of the spinal cord and resulting in ejection of semen. Some men have been able to recognize the separation of the two processes, enabling them to experience multiple orgasms without the occurrence of ejaculation. Once ejaculation takes place, a period of recovery time is required prior to a subsequent orgasm.

The sensation of orgasm differs between individuals, and individual orgasms may differ in the same person. All orgasms share certain characteristics in common including rhythmic body and pelvic contractions, elevation of the heart rate, systemic hypertension, hyperventilation, and muscle tension, followed by the sudden release of tension.

The physiological mechanism of normal orgasm

The cycle of sexual response is under the control of a balanced interplay between the two major nervous systems, the sympathetic and the parasympathetic. In general, the sympathetic nervous system prompts action whereas the parasympathetic system's main action is recovery and calming. In order for a penis to become erect, its smooth muscles are relaxed and it becomes congested with blood vessels. This process is mediated by a complex cascade of humoral, neurological and circulatory events in which the parasympathetic nervous system plays a key role. Orgasm and ejaculation and subsequent relaxation of the penis are predominantly functions of the sympathetic nervous system.

Thus, whereas emission is a balanced interplay between the parasympathetic and sympathetic nervous systems, orgasm and ejaculation are predominantly under the control of the sympathetic nervous system. The mechanisms of this system may be blocked by impaired function of the brain or of the hormonal, circulatory, and neurological systems. Additionally, certain medications may block these actions.

Abnormalities affecting the process of orgasm

Abnormalities in these processes may be "primary" or "secondary." Primary abnormalities are of lifelong duration with effective sexual performance never having been experienced. Secondary abnormalities are acquired after a period of normal function. If an orgasmic problem only occurs under a particular set of circumstances, or only with certain sexual partners, the condition is considered to be "situational" rather than "generalized" (occurring regardless of the circumstances or partner). The defect in sexual function may be total or partial.

The evidence strongly suggests that orgasm has more to do with the brain than with the body. Electrode stimulation of certain parts of the brain will produce sexual pleasure similar to that produced by physical stimulation. The fact that orgasm occurs during sleep is supportive of this concept.

Causes and symptoms

Causes

The cause of male orgasmic disorders may be organic (related to a condition in the body), but, in most cases, is of psychological origin. It is important for the physician to make every effort to find an underlying cause because the therapy and prognosis depend upon it. A detailed history (including an interview with the sexual partner, if feasible), a general physical examination, the performance of certain laboratory and, in some cases, special tests, are important in the investigation of the underlying cause of the male orgasmic disorder.

Organic causes of male orgasmic disorder include the following:

• Hypogonadism, in which the testes do not produce enough testosterone.
• Thyroid disorders (both hyperthyroidism—too much thyroid hormone— and hypothyroidism, or abnormally low levels of thyroid hormone).
• Pituitary conditions (Cushing's syndrome, excessive production of the hormone that induces lactation called prolactin).
• Diseases that affect the nervous system, such as strokes, multiple sclerosis, diabetic neuropathy, spinal cord injuries.
• Surgery affecting the prostate and other pelvic organs.
• Diseases of the penis.
• Substance abuse, including alcohol.
• Certain medications. Some of these medications include: the phenothiazines [antipsychotics such as chlorpromazine (Thorazine) or trifluoperazine (Stelazine)]; certain medications used to treat high blood pressure, including the thiazides [such as triamterene (Dyazide) or spironolactone (Aldactone)] and beta blockers [such as propranolol (Inderal)]; and the tricyclic antidepressants such as doxepin (Sinequan) and protriptyline (Vivactil).

The most common causes of the male orgasmic syndrome are psychological in nature. The responsible psychological mechanisms may be "intrinsic" (due to basic internal factors), or "extrinsic" (due to external or environmental factors).

Intrinsic psychological factors that may cause male orgasmic disorder include:

• depression
• feelings of guilt, anger, fear, low self-esteem, and anxiety
• fear of getting the partner pregnant or of contracting a sexually transmitted disease or HIV
• Extrinsic psychological factors that may cause male orgasmic disorder include:
• living under conditions that cause undue stress
• unsatisfactory relationship with sexual partner
• past history of traumatic sexual encounters such as sexual abuse, rape or incest
• having been raised in an atmosphere of strict sexual taboos

Environmental factors may interfere with sexual functioning. There may be no safe, private place in which the patient can exercise sexual activity or he may be too fatigued from other activities to participate sexually. The difficulties in striving for "safe sex" and the psychological effects and stresses that may result from homosexuality may also interfere with sexual function.

Symptoms

In order to be diagnosed with male orgasmic disorder, the following symptoms must be present according to the DSM-IV-TR :

• Persistent or recurrent delay in, or absence of, orgasm following a normal sexual excitement phase during sexual activity that the clinician judges to be adequate. The affected man's age is considered, as well.
• As with all of the sexual dysfunctions, the manual states that the dysfunction must cause the affected man "distress or interpersonal difficulty." According to the DSM-IV-TR, the orgasmic dysfunction cannot be better accounted for by another disorder (except another sexual disorder), and cannot be due exclusively to the direct effects of substance abuse, a medication, or a general medical condition. This entry, however, discusses the full scope of male orgasmic difficulties, and so discusses general medical conditions and medications as well as psychological factors.

In addition to specific symptoms involving sexual function (inability or delay in reaching orgasm after sufficient stimulation), most patients complain of anxiety, guilt, shame and frustration, and many develop bodily complaints on a psychological basis. Although sexual dysfunction usually occurs during sexual activity with a partner, the clinician should inquire about sexual function during masturbation. If problems occur during masturbation, the problem probably has nothing to do with the sexual partner.

The physician should differentiate male orgasmic disorder from other sexual disorders such as retarded or delayed ejaculation and retrograde ejaculation. In both of these conditions, orgasm occurs but is delayed or, in the case of retrograde ejaculation, occurs in a retrograde direction (into the bladder).

Demographics

Male orgasmic disorder is found in all races and ethnic groups. In the case of the lifelong type of the disorder, manifestations will occur around the age of puberty. In certain genetic hypogonadism disorders, such as Klinefelter's syndrome, certain bodily signs and symptoms may alert the physician. Similarly, in associated thyroid, testicular and pituitary abnormalities, there may be other manifestations of the underlying disorder. In the acquired type of male orgasmic disorder, the patient will have had the previous experience of normal sexual function. In these cases, it is usually a situational factor that precipitates the disorder.

Diagnosis

The diagnosis is usually readily made on the basis of the patient's history and the presence of the DSM-IVTR diagnostic criteria. Male orgasmic disorder may be part of a complex of sexual malfunctioning that may include erectile dysfunction , abnormalities in ejaculation (such as premature ejaculation or retrograde ejaculation), and hypoactive sexual desire disorder .

In order to differentiate between the various potential disorders, the physician may request laboratory tests and/or may perform further diagnostic evaluations. Blood plasma levels of testosterone are of help in diagnosing hypogonadism. A number of tests of thyroid, pituitary and adrenal function are available to diagnose hormonal abnormalities of those glands. A test for nocturnal penile erections may be performed to diagnose erectile dysfunction.

Treatments

If an extrinsic mechanism is discovered as the cause of the orgasmic disorder, steps should be taken to eliminate or ameliorate the problem. An example would be substance or alcohol abuse or the use of certain provocative medications. In the case of antihypertensives, for example, a number of equally effective agents are available if the one in current use is suspect. Therapy should be directed toward improvement of concurrent conditions such as diabetes that may be having an adverse effect on sexual function. Environmental factors that interfere with sexual activity should be corrected.

In the majority of cases, psychotherapy will be suggested even in those cases where psychological factors are secondary rather than the primary mechanism for the disorder. Such treatment should be rendered by therapists with special training in the disorders of sexual function and who can tactfully evaluate the sexual compatibility of the patient and his partner. Treatment usually requires the support of the sexual partner in improving both the psychological as well as the physical aspects of the problem. A step-wise program of partner stimulation of the patient to initially ejaculate outside the vagina, then at the vaginal labia, and finally inside the vagina may be helpful.

Prognosis

The prognosis of the patient with male orgasmic syndrome is dependent on whether the condition is lifelong or acquired and the condition's causes. Prognosis is best when it can be demonstrated that the condition is related to some extrinsic or environmental factor that can be corrected or ameliorated. The prognosis is also favorable in those cases that are due to a remedial organic condition such as a thyroid disorder or hypogonadism. The prognosis is guarded when the disorder is found to be secondary to a deep-seated and chronic psychological or actual psychiatric problem that, in itself, carries an unfavorable prognosis.

Prevention

There are no definitive steps that can be taken to prevent the onset of the male orgasmic disorder. Prompt recognition of the syndrome is important so that appropriate therapy can be attempted as early as possible. As with many chronic conditions, the longer the condition exists, the more difficult therapy becomes.

Resources

BOOKS

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th edition, text revised. Washington, DC: American Psychiatric Association,2000.

Lue, Tom F., F. Goldstein. "Impotence and Infertility." In Atlas of Clinical Urology. Volume 1. New York: Current Medicine, 1999.

Masters, William and Virginia Johnson. Masters and Johnson on Sex and Human Loving. New York: Little, Brown,1986.

Steidle, Christopher P., MD. The Impotence Source Book. Los Angeles: Howell House, 1998.

Ralph Myerson, M.D.

orgasm The term ‘orgasm’ — derived from ‘organ’, meaning to grow ripe, swell, or be lustful — is applied equally to the sexual climaxes of women and men. The medical lexicon distinguishes orgasm from ejaculation; the latter term specifically describes a sudden spurt of fluid released in response to sexual excitement. The distinction arises partly because there is some question about whether female orgasms may result in an ejaculation, and partly because males can experience orgasms without ejaculation. (Pre-adolescent males and some adult males can apparently reach orgasm without the emission of semen.)

Poets have long sung of the pleasures of orgasm. Perhaps the most common literary trope for orgasm is that which likens the experience to dying; orgasm became, for seventeenth-century poets, la petite morte. (The historian and philosopher Michel Foucault famously punned on this relationship between l'amour and la morte.) Thus, in Imperfect Enjoyment, even while bemoaning the problem of premature ejaculation, Etherege looked with pleasure on that moment ‘When, overjoyed with victory, I fall/Dead at the foot of the surrendered wall.’

Sexologists in this century have struggled to put the orgasmic experience into more precise, clinical terms. Probably the simplest description comes from Alfred Kinsey, the American human-sex researcher, who, in his classic 1948 study, Sexual Behavior in the Human Male, suggested that ‘the most important consequence of sexual orgasm is the abrupt release of the extreme tension which preceded the event and the rather sudden return to a normal or subnormal physiologic state after the event.’ Kinsey's description of orgasm in his 1953 Sexual Behavior in the Human Female was a bit more dramatic: ‘This explosive discharge of neuromuscular tensions at the peak of sexual response is what we identify as orgasm.’

In short, sexologists of today have only confirmed what the poets of yesteryear knew — that sexual climax and dying share some key physiological similarities, not the least of which is the occasional loss of consciousness. Wrote Kinsey, ‘Some, and perhaps most persons may become momentarily unconscious at the moment of orgasm, and some may remain unconscious or only vaguely aware of reality throughout the spasms or convulsions which follow orgasm.’ Pleasurable? Kinsey wondered, on noting the intensity of experience, so similar to epileptic fits and physiologic responses to electric shock. ‘In the most extreme types of sexual reaction, an individual who has experienced orgasm may double and throw his [or her] whole body into continuous and violent motion, arch his back, throw his hips, twist his head, thrust out his arms and legs, verbalize, moan, groan, or scream, in much the same way as a person who is suffering the extremes of torture.’ Kinsey could only conclude, ‘this makes it all the more amazing that most persons consider that sexual orgasm … provide[s] one of the most supreme of physical satisfactions.’

Satisfying indeed, but to what end? Two questions pervade two millennia of medical constructions of the orgasm: ‘Can you suffer from too few or too many?’ and: ‘What purpose does the female orgasm have?’

Aristotle worried that the wombs of over-stimulated women would become slippery and inhospitable to fetuses, but generally early anatomists were relatively unobsessed with questions of frequency. Humoral theories tended to require, for health, some periodic release of ‘seed’ (or at least a careful diet which would reduce production of the excitable stuff). Humoral theory held that semen was made up of phlegm — interestingly, the same stuff as the brain. (Upon opening, post-mortem, the head of a particularly lecherous fellow, an early-modern anatomist noted, without surprise, that there wasn't much brain left.) To relieve pressure, early-modern English medical texts recommended regular intercourse or even occasional episodes of masturbation. But too much activity was thought to risk the health or production of offspring, as well as one's own health.

The nineteenth century saw much bile spilled over the concern that people were excessively spending their energies on sexual gratification. Many Victorian physicians, enamoured of a conservation-of-energy approach to physiology, warned that frequent orgasms would only drain the life from the body and leave the other systems wanting. (A far less happy sex-and-death link.) This essentially constituted a new version of the old bodily-economy trope. Inventors designed devices to discourage erections (these tended to involve sharply-barbed clamps), and many physicians recommended clitorectomies for ‘hysterical’ women, particularly those who enjoyed too much sex or sex with other women. Even well into this century, versions of this dire belief — that one's bodily supply of energy could be squandered by sexual emissions — hung on. Most male athletes are familiar with the aphorism which prohibits ‘spending’ oneself before a match.

On the heels of the Victorians, Sigmund Freud invented new ways to worry about (or worry about worrying about) sexual gratification. Most infamous among feminists is Freud's belief that truly mature women achieve vaginal orgasms, not clitoral ones. Laqueur aptly notes that, ‘prior to 1905 [the publication of Freud's theory], no one thought that there was any other kind of female orgasm than the clitoral sort.’ In his Three Essays on the Theory of Sexuality, Freud argued that, while pre-pubescent girls might enjoy clitoral orgasms, clitoral stimulation in the adult woman was only meant to ‘[transmit] the excitation to the adjacent female sexual parts’, namely the vagina, ‘just as — to use a simile — pine shavings can be kindled in order to set a log of harder wood on fire.’ If a woman could not move her seat of excitation to her vagina, she would only wind up frigid. Meanwhile, Freud argued that the very transfer of excitation from clitoris to vagina over the course of a woman's maturation left her prone to hysteria.

Kinsey's studies did much to dispel the vaginal-orgasm dogma of Freud. Indeed, Kinsey, who saw vaginal orgasm as a ‘biological impossibility’, took Freud to task for leaving thousands of women in a well of frustration and shame. Masters and Johnson's 1966 tome, Human Sexual Response, and The Hite Report of 1976 confirmed Kinsey's findings: most women do not experience orgasms directly from intercourse, and female orgasms originate from stimulation of the clitoris. By the 1960s, so fascinated with orgasms had the populace become that the British writer Malcolm Muggeridge declared in 1966, ‘The orgasm has replaced the Cross as the focus of longing and fulfillment.’ Popular quasi-medical texts today offer clues about how to achieve more, better, and better-timed orgasms.

Freud's impetus towards vaginal stimulation did not die away after Kinsey, Masters and Johnson, and Hite. Sexologists continue to investigate the sensitivity of the vagina and the ability of certain women to achieve orgasm without direct clitoral stimulation. Reports of a ‘G spot’ — a zone of high sensitivity in the vagina — are yearly put forth and summarily condemned. ( Beverly Whipple and John Perry named the ‘G spot’ after the gynecologist Ernst Graefenberg.) Some researchers posit that stimulation of a vaginal ‘G spot’ can lead to ejaculation.

Perhaps because science has been mostly a male sport, few scientific minds have pondered the question of the purpose of the male orgasm, but many a man (and a few women) have contemplated the point of the female orgasm. Early anatomists, who presumed essential similarities between men's and women's bodies, figured that, if men's orgasms were needed for reproduction, so were women's. Thomas Laqueur, in his historical study of sex, imagined the logic of Hippocrates: ‘Like a flame that flares when wine is sprinkled on it, the woman's heat blazes most brilliantly when the male sperm is sprayed on it … She shivers. The womb seals itself. And the combined elements for a new life are safely contained within.’ Aristotle figured that, if a woman did not climax, she would not become pregnant. These ideas led to some curious (and ineffective) attempts at birth control.

Well into the early-modern period, the assumption stood firm that woman's well-timed orgasm was necessary to conception. Patricia Crawford has argued that, in early-modern England, this belief had both good and bad implications for women. On the one hand, men who wanted heirs would have worked harder for their partners' satisfaction. But ‘if a rape were followed by pregnancy, the law deemed it no rape because the woman had, by definition, enjoyed the encounter.’

Once it became clear that women's orgasms were in fact unnecessary for pregnancy, the question of their purpose attracted the attentions of evolutionists. (That women can have multiple, closely-timed orgasms particularly bothers certain theorists.) Sarah Blaffer Hardy, Randy Thornhill, and other sociobiologists have offered reasons for why the female orgasm might be (or have been) functionally adaptive in evolution — that is, why female orgasm would be conducive to a lineage's life. (Thus sociobiology tries to translate the female's petite morte into the species' grande vie.) Other evolutionists, like Stephen Jay Gould, have argued alternatively that female orgasms have no adaptive purpose — that they are just a pleasant side-effect of the fact that human males and females share embryological roots: the clitoris and the penis are embryological homologues, so it makes sense that the clitoris would be super-sensitive and able to be stimulated to climax. Gould has sensibly noted that many non-scientists really don't care all that much why orgasms exist.

Alice Dreger

Bibliography

Gould, S. J. (1987). Freudian slip. Natural History, 96, 14–21.
Laqueur, T. (1990). Making sex: body and gender from the Greeks to Freud. Harvard University Press, Cambridge, MA.
Porter, R. and Teich, M. (ed.) (1994). Sexual knowledge, sexual science: the history of attitudes to sexuality. Cambridge University Press, Cambridge.

ORGASM

Orgasm is the pleasure obtained at the culmination (end pleasure) of sexual activity; it differs from the preliminary pleasure of foreplay in that it corresponds to a relaxation rather than a rise in excitation. Freud takes up the commonly referred to link between orgasm and death (petite mort ) by analogy with the separation between the soma and the germen and, in some of the lower animal species, the death of the male. From a metapsychological viewpoint the momentary short-circuiting of Eros through the satisfaction obtained ensures Thanatos a degree of supremacy.

The question of female orgasm and its dissimulation for reasons of cultural propriety is discussed by Freud in the first manuscripts addressed to Fliess (1950a [1897-1902]) and in the Studies on Hysteria (1895d), where he notes that, during orgasm, thought disappears almost completely and this restriction of consciousness is very similar to the hypnoid state, or even a hysterical crisis. Some years later, in the Three Essays (1905d), referring to the observations of the pediatrician Lindner, he notes that the sensations of the satiated infant can lead to a motor reaction similar to orgasm if it does not lead to sleep. He also acknowledges that the orgasm associated with genital emission is inaccessible to the infant, whose masturbatory activity is incomplete, a perspective he associates with the infant's endless quest for sexual knowledge (1910c). It is interesting that among Freud's last works this same idea reappears:

"The ultimate ground of all intellectual inhibitions and all inhibitions of work seems to be the inhibition of masturbation in childhood. But perhaps it goes deeper; perhaps it is not its inhibition by external influences but its unsatisfying nature in itself. There is always something lacking for complete discharge and satisfaction—en attendant toujours quelquechose qui ne venait point [always waiting for something which never came]—and this missing part, the reaction of orgasm, manifests itself in equivalents in other spheres, in absences, outbreaks of laughing, weeping [. . .], and perhaps other ways.—Once again infantile sexuality has fixed a model in this." (1941f [1938], p. 300).

Freud didn't actually define orgasm as a psychic or affective phenomenon associated with, but somewhat distinct from, a somatic process, although he drew attention to its absence in discussions of the symptom of frigidity. Sándor Ferenczi (2000/1931), in describing masochistic orgasm, attempted to define normal orgasm as the "meeting of two tendencies to action. The love relationship apparently does not arise from subject A or from subject B but between the two of them." This definition of a hypothetical "normality" does not go as far as his description of masochistic orgasm during female rape: "The reaction," Ferenczi writes, "is primarily a shock, accompanied by the anxiety of death and disintegration, and only secondarily a plastic identification with the emotion of the sadist, a hallucinatory masculine identification" (p. 248).

The function of the orgasm played a central role in the work of Wilhelm Reich (1940/1968), illustrating that it is necessary to incorporate an "actual" neurosis into any psychoneurosis. Reich took up Freud's propositions concerning libidinal stasis and its conversion into anxiety. He defined "orgiastic power" as "the aptitude to achieve satisfaction matching the libidinal stasis of the moment." Moreover, according to Reich, while inhibition prevents the transference of sexual excitation to the sensorimotor system and the genital apparatus, the excitation remains compressed within the vasovagal system and produces the phenomena of vasomotor neurosis. Reich believed, however, that civilization and monogamous marriage do not allow orgasm to develop and fulfill its function. There is not only a biological perspective in Reich's work (bioenergy, orgone), but a moral and political vision as well: "The patient, previously moralistic in his ideology and perverse, lascivious and neurotic in reality, becomes free of this contradiction in himself; with his moralism he also loses his sexual anti-sociality and acquires a natural morality in the sex-economic sense" (1933/1946, p. 156).

Sophie de Mijolla-Mellor

See also: Adolescence; Anorexia nervosa; Dipsomania; Orgone; Partial drive; Perversion; Reich, Wilhelm.

Bibliography

Ferenczi, Sándor. (2000). On masochistic orgasm. In Final contributions to the problems and methods of psychoanalysis. (p. 248-49; Michael Balint, Ed; Eric Mosbacher, Trans.). London: Karnac Books. (Original work published 1931)

Freud, Sigmund. (1905d). Three essays on the theory of sexuality. SE, 7: 123-243.

——. (1941f [1938]). Findings, ideas, problems. SE, 23: 299-300.

Reich, Wilhelm. (1946). The mass psychology of fascism (T. P. Wolfe, Trans.). New York: Orgone Institute Press. (Original work published 1933)

——. (1968). The function of the orgasm: Sex-economic problems of biological energy (Theodore P. Wolfe, Trans.). London: Panther. (Original work published 1940)

Further Reading

Abraham, G. (2002). The psychodynamics of orgasm. International Journal of Psychoanalysis, 83, 325-338.

Eissler, Kurt R. (1977). Comments on penis envy and orgasm in women. Psychoanalytic Study of the Child, 32, 29-84.

or·gasm / ˈôrˌgazəm/ • n. a climax of sexual excitement, characterized by feelings of pleasure centered in the genitals and (in men) experienced as an accompaniment to ejaculation. • v. [intr.] experience an orgasm.

orgasm Physiological culmination of sexual stimulation, marked by general release of muscular tension and waves of contractions causing climactic spasms of vaginal muscles in the female and ejaculation (the release of semen) in the male.

orgasm The climax of sexual excitement in humans, which – in males – coincides with ejaculation. A sense of physiological and emotional release is accompanied by a feeling of extreme pleasure.

orgasm paroxysm of excitement. XVII. — F. orgasme or modL. orgasmus — Gr. orgasmós, f. orgân swell as with moisture, be excited.

orgasm (or-gazm) n. the climax of sexual excitement.

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