I would like to begin by discussing a particular patient. He is a 24 year old male in a live in relationship with his girlfriend. They are to be married in a few months. They have been sexually active for the last 6 months. Everything was fine till last week. One Saturday night after attending a party, he tried having sex with his partner but could not. He tried the following morning and failed again. Tuesday evening, when his girl friend approached him in bed, he was in a state of panic. There was absolutely no erection. Now he finds that he is not able to concentrate on work. His sexual desire is suddenly low. He has been avoiding his girl friend after these events and not making advances towards her. He tells me when he thinks about sex, he is only able to think of the times he tried and failed and nothing else. He is only 24 and what does this mean? Is this the end of him?
What is his diagnosis? Well, he has performance anxiety. Performance anxiety is the fear of future sexual failures based on previous sexual failures. In sexual dysfunctions, performance anxiety remains a key factor which maintains these problems, especially sexual arousal. The self confidence of a man is shattered and this contributes to sexual avoidance. Performance anxiety brings into play an entity more commonly referred to as “spectatoring”. This basically means during sexual intercourse, the man or woman steps outside of the sexual act and monitors his or her own performance. As a result of this, focus on the pleasurable aspect of sex is reduced and this results in difficulty in maintaining sexual arousal which in turn leads to anxiety thereby contributing to this vicious cycle.
Performance anxiety may also be associated with having negative sexual schemas. One of these schemas may read like this. ”If you are a man your erection should always last till the end of intercourse”. The problem with these schemas is that it makes men search for cues that tell them that they may not be perfect and instead of looking at the erotic side, they end up questioning their own performance during the act. This for sure will lead to anxiety, distraction, loss of stimulation and end up in the man losing his erection.
How do we treat performance anxiety? The most important thing to recognize is that there is help out there and it should be sought. On no account self medication should be tried as psychosexual therapy alone has proven benefit in these patients. The therapist will focus on the cognitive schemas that impair sexual functioning and how they can be modified. The need for control in sex should be replaced by “giving oneself unconditionally” without any expectations. Sexual behavior should involve gravitation towards pleasing sensations and this is emphasized by self exploration in terms of massage. A man’s own erotic areas should be identified and masturbation techniques can be tweaked. These simple changes go a long way in reducing performance anxiety and helps build self confidence.
Sexual dysfunction is not all pharmacology. A pill will not always help. Personalised treatment based on proper assessment should be the order of the day.