When Sex Therapy Fails

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Deepak is a nice enough guy—mid-30s, Silicon Valley software engineer, married three years to Nikki, a researcher. They had both come here from India for graduate school, and stayed afterwards. He was referred to me by a well-known urologist at Stanford Medical Center.

One of my specialties is Deepak’s exact complaint: unreliable erections. And after three sessions, I’m pretty sure he’ll be disappointed with the results of our work.

That’s because we still disagree on what his problem actually is. As he put it, “I go to have sex, and sometimes I get hard, but other times I don’t. The urologist at Stanford said you could help me.” While of course I understand his frustration, I told him it didn’t mean he and his wife couldn’t have sex. “Yes, I know we can do other things,” he said, “But they’re not real sex. My wife doesn’t get full satisfaction from them.”

It turned out that she didn’t get “full satisfaction” from these alternatives to intercourse because she believed that she was causing his erection difficulties. “She says that if she were more beautiful, I wouldn’t have this problem,” Deepak said. Did he agree? “No, the problem is me—I’m not powerful enough in sex. Sometimes I’m weak.”

EXPECTATIONS & INTERPRETATIONS

I tried to describe how their expectations and interpretations were driving their frustrating experiences—which was my definition of his (and their) problem. He kept saying he understood, but then would say “but…” and reiterate their beliefs.

I explained the way arousal works: the nervous system sends messages to the blood vessels to engorge the genitalia. But you need the right circumstances: someone has to interpret some stimulation as sexual—a touch, a smell, a visual image. And they have to maintain that focus on arousing stimuli. However, the nervous system can carry other messages simultaneously, which can cancel out the sexual messages. Those would include guilt, shame, anxiety, anger, feeling alone or misunderstood.

Again, Deepak said he understood, and then told me why this wasn’t helpful.

I asked if their parents were pressuring them to have grandchildren. “Of course,” he said. I asked if they wanted kids, but the question didn’t quite make sense. “This is how Indian families work,” he said. “We will have children. We must.”

Since he became erect about half the time they wanted to have sex, I asked him to compare: put all the sex that was designed to conceive (given her ovulation schedule) in one group, and all the other sex when they knew they couldn’t conceive in a second group. In general, were his erections more similar between the two groups, or more different?

They were more different, he said. “Let me guess,” I said. “Your erections are more reliable in the second group of sexual encounters, right?” He was impressed by my awesome predictive powers. The connection between the pressure of conception and his wobbly erection hadn’t occurred to them.

ERECTION VS ANTI-ERECTION MESSAGES

“This is what I mean about the nervous system carrying two messages at once,” I said. “You kiss her, she touches your penis, and you want sex. That ordinarily leads to erection. But when you two are desperate to conceive, you feel pressure, shame, and fear that you’ll fail. In your nervous system, that second message creates communication noise that interferes with the sexual message. Then your penis isn’t driven to become erect. Quite the contrary, actually.”

Pretty clear, I thought.

Not clear enough, it seems.

“Yes, but what’s wrong that so many times we can’t have sex?” Deepak asked plaintively. “She’s ready, but I can’t. Or worse, she’s ready and I say I’m too tired, or have to work, because I’m afraid if I say yes I’ll fail again. I can’t stop worrying that I’ll fail.”

The poor guy—trapped in a prison of his own making (yes, culturally appropriate, but still…). And every session, multiple times, he would ask me, sometimes tearfully, “What should I do?”

I taught him about breathing exercises to relax when he felt pressured. I taught him visualizations for when he obsessed on failure. I encouraged him to see sex as play rather than a project, to see his wife as a partner rather than a critic, to see pleasure as the goal rather than conception.

It just didn’t stick.

ONE MORE APPROACH

OK, one more approach. “What do you two do when you lose your erection when you want to have intercourse?” I asked, confident that I knew the answer.

He answered in some generalities, and I asked for specifics. Minute-by-minute specifics. As I expected, erectile disappointment was followed by apologies, excuses, each of them blaming themselves, and the occasional quarrel. It wasn’t just the month-by-month hassle from their parents he wanted to avoid. It was the more immediate ugly scene after “failing” that he wanted to avoid. There was pressure everywhere he turned.

“When you don’t get an erection, does she still love you?” Of course she did. “And does she say she’ll want sex with you again soon?” Of course she did. “And do you sleep in the same bed after this disappointment?” Yes they did. “And do you feel confident that soon you will see her body again, and you will be able to touch her and smell her?” Yes, he was.

“Then,” I said gently, “When you don’t get an erection, it sounds like you could celebrate your sexual connection, rather than turning it into a failure. In your twenties, before you married (they were both virgins at their wedding), wouldn’t such a situation seem like heaven—hugging and kissing a lovely nude woman who said she loved you? Even agreeing that you’d be doing it again soon? And then going to sleep together?”

A nice image. But Deepak didn’t find it comforting. “What should I do?” he asked again. So I gave it my last shot. “Take three months off from trying to conceive,” I said. “You deserve 90 days of no-pressure, no-fail sex. As we’ve seen, you’re way more likely to get erections when you aren’t trying to conceive. And tell both sets of parents—‘we’re taking a break from creating a child, and we’ll be back at it next spring.’”

Alas. The parents wouldn’t go for it, he said, and it shouldn’t be necessary. But most of all, he said, in three months, he’d be back in the same spot—failing to get erect when they resumed trying for a child. I briefly explained that he wouldn’t be in the same spot, because he wouldn’t be the same person after three months of no-pressure, no-fail sex.

Alas, not helpful. I wasn’t surprised.

I think next session will be our last. I don’t want to waste his money, or reinforce the idea that he’s damaged goods. And so he will be disappointed with the results of our work.

And I will, too.
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Like your Sexual Intelligence much shorter? See www.instagram.com/DoctorMartyKlein
Like short videos about sex? See www.youtube.com/@Marty_Klein/videos

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