Sexual and Relationship Therapy Vol 18, No.

4, November 2003

Male psychogenic sexual dysfunction: the role of masturbation

JOSIE LIPSITH1, DAMIAN MCCANN2 & DAVID GOLDMEIER1
1 2

Jane Wadsworth Sexual Function Clinic, St. Marys Hospital, Praed Street, London Department of Child and Adolescent Psychiatry, Edgware Community Hospital, Edgware, Middlesex, UK

ABSTRACT

The role of masturbation in male psychogenic sexual dysfunction (MPSD) has been neglected by researchers and practitioners; this qualitative study explores that link through individual interviews with a clinic population by using grounded theory as a methodological approach and analytical style. Although a preference for functional sex with a partner was expressed by participants, our data suggest that masturbation dependence develops as a result of their sexual response having become conditional on a discrete set of behaviours, and is reinforced by cognitive components displaying different characteristics during masturbation and partner sex. The interrelation of both cognitive and behavioural components of sexual response is explored, and a theoretical model presented. Proposals for further study are suggested, and recommendations made for expansion of the formulation and treatment planning for MPSD.

Introduction It is generally accepted that human sexual function is made up of a complex interaction of physiological, psychosocial, and behavioural components that can be affected by the relationship with a partner in whom similar interactions take place (Kaplan, 1974; Bancroft, 1983; Hawton, 1987; Riley, 1998). Sexual difculties can arise from a disturbance in any of these components, but, as Riley suggests (1998: 229), It is surprising how little we know about the aetiology of many frequently occurring sexual symptoms. With the availability of effective physical treatments, particularly for erectile dysfunction (ED), there has been a polarization in the treatment of SD; many now want a quick x to restore physiological function. Whilst pharmacological treatments often succeed in restoring erections, clinical experience (Basson, 1998) has demonstrated that the use of new drug treatments in men to restore physiological
Correspondence to: Josie Lipsith, Jane Wadsworth Sexual Function Clinic, St Marys Hospital, Praed Street, London, UK; Email: josie.lipsith@virgin.net ISSN 14681994 print/ISSN 1468-1479 online/03/040447-25 # British Association for Sexual and Relationship Therapy DOI: 10.1080/1468199031000099442

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function alone may upset the patients psychological equilibrium, or the behavioural dynamics of their relationship, since these treatments do not address the underlying causes of the problem. Indeed Altof (1999) suggests current treatments often fail because they do not capture the complexity of the dysfunction. This study was undertaken to understand the aetiology of male erectile and orgasmic difculties. Clinical experience has led us to question if there may be some link between such difculties and an individuals masturbatory pattern. Research has suggested that many people masturbate (Lauman et al., 1994; Johnson et al., 1990). Yet, of all the sexual practices, it remains one that few discuss and about which little research is undertaken. Although orthodox religions and early medical writings (Tissot, 1741) regard masturbation as anything from a sin to a cause of illness, most current authorities have come to view the practice as a normal part of sexual development and a healthy sexual outlet (Davidson, 1984). More recently attitudes towards masturbation have been liberalized; the threat of the HIV virus, and the development of feminist movements, have contributed to the concept of sexual self-sufciency and a greater acceptance of masturbation as an acceptable, and in some cases preferred, form of sexual release. Perelman (1994) reports on his experience in clinical practice, suggesting that masturbatory frequency and technique are often implicated in difculties in male sexual desire, erection and ejaculation. He underlines the clinical importance of obtaining a detailed sexual status from patients who present with a sexual difculty, including specic details about masturbation, which he suggests provide rich diagnostic information. As part of their formulation, sex therapists (Kaplan, 1974; Hawton, 1987) routinely ask whether an individual masturbates and explore attitudes and feelings towards masturbation. Sank (1998) suggests practitioner embarrassment may have prevented asking how a patient masturbates. Several suggestions as to the part played by masturbation in the formulation of male PSD are available in the literature. Slosarz (1992) considers the consequences and inuence of adolescent masturbation on later heterosexual relationships. Based on clinical experiments and observations of patients experiencing sexual dysfunction, Slosarz (ibid) suggests that, in the case of normal development of human sexuality, the passage from autoerotic to heterosexual behaviour follows three main phases: (1) masturbation; (2) heterosexual contacts accompanied by masturbation, and (3) heterosexual contacts with or without sporadic masturbation. Slosarz (1992: 276) suggests masturbation xation, dened as a process which develops over many years, whereby masturbation is the dominant form of an individuals sexuality even when normal sexual contacts are possible, breaks this natural development at the rst or second phase, and difculty is then experienced in developing mature sexual partnerships in the nal phase. In his study on Retarded Ejaculation (RE), Dow (1981) suggests a discriminative learning model proposing that orgasm, having become a positive reinforcement associated with masturbation, may play a central role in the development of RE. Dow recognizes masturbation as a normal developmental phenomenon, but suggests that incompatible masturbatory style results in failure to transfer the sexual response to interpersonal relationships; orgasm becomes much more likely under the discrete stimulus

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conditions of masturbation. Rather than a discriminative learning model, Apfelbaum (1980) suggests that the presence of RE demonstrates an auto-sexual orientation, reecting the individuals experience of masturbation as much more arousing than stimulation by a partner. Sank (1998) reported on a previously unrecorded pattern of what he describes as atypical masturbation presenting as orgasmic or erectile disorder in four clinical cases. Sank believes that the idiosyncratic style of masturbation, distinguished by daily practice in a prone position over a number of years, contributed to his patients disorder. He suggests that, whilst literature is available to teach women how to masturbate (Barbach, 1974; Heiman et al., 1976), the absence of male-orientated literature may have contributed to their difculty, suggesting that for some men it is not the inability to masturbate, but the inability to do so correctly that results in problems of erectile functioning and orgasm. Sanks observations seem to support a discriminative learning model (Dow, 1981), and as many sex therapists, including Hawton (1987) and Kaplan (1974), use masturbatory programmes as part of their treatment package, this may have implications for treatment. Failure to establish precisely how an individual masturbates may result in the reinforcement of behaviour that is difcult to replicate during sex with a partner. The role of self-masturbation in relation to conditioning sexual response has been largely ignored by learning theorists in preference for an association with aversive contingencies (Masters & Johnson, 1970). Aetiological theories are not mutually exclusive, but from a behavioural standpoint are relevant to effective treatment. Whilst anecdotal and clinical evidence seem to be in line with our own clinical ndings, there has been no disciplined inquiry conducted into the link between masturbation and sexual dysfunction. This study uses grounded theory as a strategy and analytical style to describe and explain the individuals experience of masturbation and sexual dysfunction, to explore connections between the two, and generates theories that may help to understand MPSD.

Methodology Sampling and procedure This study was undertaken at St. Marys Hospital, Paddington: Local Research Ethics Committee approval was obtained. A purposive sample, that is a sample in which the process being studied is likely to occur, consisting of 10 male heterosexual participants experiencing psychogenic erectile or orgasmic difculties, was recruited. Those offered entry to the study were patients attending the sexual function clinic, for whom a medical examination had excluded physical causes for their dysfunction: the rst 10 participants agreeing to take part were interviewed. Eight participants had erectile difculties (ED) and the remaining two orgasmic difculties (RE). A clinical diagnosis had been made by the referring consultant and was conrmed by the participants themselves. Participants took part in one semi-structured interview, usually arranged on the day of their clinic appointment in order to minimize inconvenience. The interviews, lasting between 60 75 minutes, were tape recorded and later transcribed. Condentiality and

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anonymity were conrmed, and participants were assured that recording could be stopped at any time. All stages of the process have been documented. The interview schedule was based on the standard assessment suggested by Hawton (1987) and conducted as suggested by Pomeroy et al. (1982). Methodological considerations, particularly those concerned with veracity and recall, adopted in the construction and implementation of the questionnaire were consistent with those used by Johnson et al. (1990). The interview schedule was used as a guide and participants were encouraged to express their own views: a list of probe questions was used to explore areas of specic interest to this study. The manner in which the interviews were conducted, and the format of the interview, gradually progressing from questions concerning health to more sensitive areas, attempted to minimize any feelings of embarrassment or discomfort that participants may have experienced. Immediately following the interview participants were given the opportunity to reect, and all were offered a follow-up session to discuss anything arising from the interview. As part of the holistic approach to treatment at St. Marys, most participants have been offered, where appropriate, psychosexual therapy as part of their treatment. Demographic information Of the 10 male participants interviewed, nine self-dened as being of heterosexual orientation; the remaining participant described himself as having a lifelong confusion about his sexuality but with a wish for, and experience of, only heterosexual relationships. His uncertainty was compounded by his experience of sexual dysfunction, which he felt conrmed a tendency to homosexuality, a phenomenon recognized by Carey et al. (1993). Ages of the participants ranged from 30 67. All the participants were sexually active. Four participants have one regular partner, the remaining six had no partner at the time of the interview. Four participants are divorced, ve are single and one was married. The highest educational qualication of each participant was recorded: two participants had no qualications, one had GCEs, three had rst degrees and four had completed post-graduate courses. Participants self-classication, on the basis of ethnicity, is: eight white English, Scottish or Welsh; one Indian; one white other. On the basis of nationality, selfclassication was: British 9, Greek 1. Demographic information has been recorded (Table I). Evaluating the study Reexivity i.e. trying to understand how we as researchers impact upon what is being studied, has been a central concern of this study. The documentation of procedures and transparency in communicating the research process will enable others to evaluate the work. To improve validity, this study has adopted a more critical approach (Silverman, 2000) when considering data and to achieve objectivity follows Poppers (1959)

TABLE I. Demographic table Name: (assumed) Age Sexuality Marital Status Current Sexual Relationship Religion Degree of Religious Observance Highest Qualication Occupation (based on ISCO 88) Dysfunction Frequency of masturbation (per week) 1 Bob 54 H M 1RP GO NO D 214 ISD + ED Currently 0 2 Jim 46 H D 1RP CE NO D 123 RE 3 3 John 45 H D NP RC QO D 214 RE 2 4 Derek 53 U D NP None GCE 341 ED 7 5 Bill 33 H D 1RP None None 121 ED once every 46 weeks 6 David 67 H S NP Z VO PG 241 ED 3 7 Don 34 H S 1RP None PG 241 ED 3 8 Peter 30 H S NP RC NO PG 242 ED 10 9 Paul 58 H S NP RC QO None 712 ED 30 10 Jack 39 H S NP None PG 241 ED 5

Male psychogenic sexual dysfunction

Demographic Table Key: H - heterosexual U - confused about sexuality M - married D - divorced S - single RP - regular partner NP - no partner CE - Church of England RC - Roman Catholic

Z - Zoroastrian GO - Greek Orthodox NO - not observant QO - quite observant VO - very observant D - Degree PG - Post Graduate ISD - Insufcient sexual desire ED - Erectile dysfunction RE - Retarded ejaculation

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proposal of a critical rationalism which is achieved by challenging assumed relations between phenomena, and accepting as objective knowledge only that which cannot be refuted, at least at the present time. The use of grounded theory analysis has allowed the constant comparison of provisional hypotheses from one case to another, ensuring that data are minutely examined, thus adhering to Poppers (ibid) critical method. Analysis This analysis focuses on the development of those categories relevant in understanding the aetiology of sexual dysfunction (SD), and the part played by masturbation. Based on 10 semi-structured interviews, from analysis consistent with the grounded theory paradigm (Strauss & Corbin 1998), two core categories began to emerge indicating that, for these participants, components of anxiety (cognitive interference) and learning theory (masturbatory behaviour) were repeated in their histories (Fig. 1). The development of the substantive and theoretical codes within the two core categories considered below might prove helpful in understanding the ndings from this study, which suggest a dependence on masturbation and an inability to experience the same levels of arousal during sex with a partner. Each illustration used during the following analysis has been selected because it best represents the participants experience of that particular phenomenon. The data provided information on participants own experiences of heterosexual and masturbatory behaviour; ndings suggest that although each of the participants had experienced difculties during sex with their partners, no such difculties were experienced during masturbation. The experience of sex with a partner was understood to be different from masturbation, and whilst acknowledging their sexual difculties, all participants expressed a preference for sex with a partner that worked; it was felt that this provided a more complete experience, although masturbation was seen as the preferred alternative to sexual encounters with a partner that ended in disaster. Masturbation produces easier and more reliable orgasms. Don explains:

FIG. 1. Thematic plan of codes which emerged during data analysis.

Male psychogenic sexual dysfunction D: I wouldnt want it to be like that, but thats how it is. Cognitive interference

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Anxiety has long been considered to play a signicant role in the development and maintenance of SD, although evidence for this has been based on purely clinical inference and not empirical data: more recently, experimental studies have been undertaken (Barlow, 1986). Anxiety is seen as a construct (Lang, 1968; Barlow & Mavissakalian, 1981) in which separate response systems, cognitive, physiological and behavioural, exist and may not be perfectly correlated. The physiological reaction to anxiety may enhance sexual response in an additive way as both share many common elements, for example increased blood pressure and heart rate (Zillman, 1983), whereas the cognitive component of anxiety, for example performance related negative cognitions (Masters & Johnson, 1970), appears to have a different effect. Clinicians (Kaplan, 1974; Hawton et al., 1989) agree that several types of cognitive activities have a marked effect on sexual arousal and therefore may play an important part in the development and maintenance of SD. In this study all participants experienced negative cognitions during sexual relationships with a partner; the analysis emphasizes the signicance of participants experience of negative automatic thoughts and the inuence of participants dysfunctional attitudes, beliefs and expectations. Automatic thoughts Automatic thoughts associated with performance demands and the anticipation of failure were associated with a negative sexual response in all participants. Early in the analytic process, during open coding, categories emerged reecting participants experiences of a variety of phenomena supporting traditional beliefs that performance anxiety was present in all those experiencing sexual dysfunction. Jack spoke of his fears in new or short-term relationships, using the term performance anxiety: I: When you say performance anxiety, what can you elaborate on that? J: Well yeah, just thinking, you know were going home now, umm you know, I want to have sex, will I be able to get an erection, keep it, will I be able to give them an orgasm, sort of thing, could I then be able to have an orgasm myself? Jim put it more simply: J: Oh my god, here we go again. Im bound to have the same old problem. Once failure had been experienced, the anticipation of failure was a concern for all participants. John describes his sexual difculty (RE) as being a bit like a disability or a missing tooth: J: Its always there nagging you, will it happen, will it not happen?

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Further sampling to explore this cycle of failure was guided by theoretical understanding: the relevance of negative cognitions and their ability to distract from the sexual experience was acknowledged (Spence, 1991). As the interviews continued, questioning became more focused on specic thoughts during sexual activity, and their impact on sexual performance. The presence of performance anxiety appeared to prevent or interrupt arousal in most (9) participants. Systems theory recognizes the signicant role played by relationship difculties in the genesis of sexual problems, Kaplan (1974) refers to erotically destructive interactions and suggests that dysfunction is a result of an association of arousal with negative contingencies such as conict and disharmony, and whilst some participants have spoken of the impact of such difculties, evidence from this study seems to support a cognitive distraction model (Barlow, 1986). This can be seen in Jims story, as he describes how his initial sexual attraction to his partner has become diffused by both sexual and general relationship difculties: I: Do you nd your partner sexually attractive? J: Umm, yes I think so. It becomes overlaid with all sorts of other things. Umm if I just sort of if one could take away all the other stuff thats going on, then yes I probably would, I did, I do. I: What other stuff is around? What gets in the way of you seeing that? J: I think weve had, er, the arguments weve had, the, I think she does has and does get quite angry and distraught if she feels thwarted in getting her climax (by his loss of erection) and it can be quite not aggressive as such but shes angry, very angry (laughs). His partners emphasis on performance has further affected Jims ability to satisfy her. He describes a conict caused by a discontinuity between how they both like to make love, and how focusing on his partners satisfaction affects his level of erotic arousal: J: There are some quite specic things she likes and doesnt like. Umm that can take a while, and as Ive said, by the time shes done Ive sometimes lost interest or just tired. Pressure also comes from participants themselves, who tend to judge themselves on the basis of their performance. The participants (2) who experienced RE reported concern about an absence of arousal during sexual encounters; combined with general sexual anxieties, these men were expecting themselves to function sexually with women they found unattractive, or towards whom they had negative feelings. Derek spoke of his partner in a 5-year relationship: D: I dont think Id ever, even in the rst instance, found her that sexually attractive . . . sex with her was quite boring. Despite the presence of erections, those who experience retarded ejaculation (RE) feel little desire or arousal Apfelbaum (2000: 209) refers to automatic erections, a

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phenomenon experienced by Derek who often found himself having to perform when he didnt feel like it, just to please his partner. He recalls occasions: D: . . . when I could have not gone to see her, but I did go to see her, and she always wanted sex, and I remember thinking Oh god, I couldve not come round here. I could have avoided this. Masters and Johnson (1970: 10) discussed distraction as an inhibitor of potency, calling it spectatoring. Feeling detached from the sexual experience, or monitoring their own performance, was another common theme amongst participants in this study. David describes himself as being a bit like a policeman in relation to health issues and condom use: D: Youre thinking about the usual, you know, health problems, or pregnancy or X the unknown . . . youre too busy thinking about the world, yourself, the United Nations instead of enjoying yourself. Concern over condom use, safe sex, particularly with new partners, and the ability to maintain an erection were present for all participants not in regular relationships. Condoms were seen as necessary but their use was often abandoned when loss of erection threatened. Several participants referred to the numbing of penile sensations during sex with a condom. Sex without condoms provided greater stimulation but increased risk of sexually transmitted diseases and consequently increased anxiety in sexual situations. Don tries to describe his actual thoughts when he is with a partner: D: I must have safe sex. Oh you know, Im losing my erection, Ill have to take the condom off. Oh damn Ill have unsafe sex, . Participants experienced negative automatic thoughts, generally related to performance concerns, prior to or during dysfunctional sexual encounters with a partner.

Dysfunctional attitudes and beliefs Schnarch (1981) suggests that attitudes and beliefs, the styles of thinking or biases used in the interpretation of information, tend to inuence the content of cognitive activity: people cause their own reactions by the way they evaluate events. More specically, Hawton et al. (1989) suggests that automatic thoughts are the result of dysfunctional sexual attitudes gained through lifes experiences: indeed, generalizations about sexual aspects of themselves based on past experiences appeared to inuence participants current behaviour, which seems to support the model of sexual self schemas developed by Anderson et al. (1999), and is demonstrated by Don: D: Its almost as if your mind is trained to look on the negative side rather than the positive side because so many things have gone wrong.

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Evidence of just such a negative affective response (Abrahamson et al., 1985) in sexual situations resulting from the expectation of failure and perceived inadequate responding was displayed by Jack; he felt traumatized by his own sexual performance, and avoided watching erotic videos or television programmes as it stresses me out thinking about it. More than half of the participants (7) had experienced emotional difculties, or a generally low affect during adolescence: it may be that, for some, negative affect predates the onset of their sexual dysfunction, and may have contributed to the avoidance of erotic cues, facilitating some sort of cognitive interference by focusing on non-erotic cues. Don describes how he felt so bad because he failed every time. Negative feelings caused discomfort which resulted in either a continued dysfunctional response or the avoidance of all situations in which he might be expected to perform sexually: D: I thought I wouldnt do it again and the more I liked the person the more painful it was for me because . . . because I really wanted a particular person and I couldnt make that move. . There seemed to be a relationship between cognitive and physiological processes: most participants found that attitudes and beliefs, relating to the current situation, triggered a negative thought process which resulted in a change of mood (affect), and consequent diminished physiological (sexual) response.

Feelings of inadequacy are exacerbated by a limited sex education: for the majority of participants, during adolescence, most learning was obtained from friends and consisted of innuendoes and rumours. Sex was described as a mystery and nding out about sex was, for John, a bit like being a detective, whilst Derek recalls his mother and aunts making comments like: D: He knows it all. Theres nothing he dont know, and I used to sit there thinking, well actually I dont know anything. It seems that, for most of these participants, this early confusion over sexual matters is maintained. Peter explained: P: When I think back on things and even at the point Im at now, err . . . the common thread seems to be my naivety about sex. Feelings of inadequacy seem to co-exist with performance fears: for many of the participants, lack of experience and partner expectations reinforced those feeling. Participants have also been inuenced by societys attitude. John explains how pressured he feels when he is expected to know what he is doing sexually: J: Youve really been put on the spot. It seems maybe its just the system but everybody seems, you know, like in a job, oh well youve got some years of experience, come in and do the job now.

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The expectations that men should know all about sex certainly beyond 18 has increased Peters fears. Here he describes the embarrassment he experiences in a sexual situation: P: . . . the problem also if youre 29 . . . its very embarrassing the fact that youve not had sex, and so you dont want to do anything that will give it away. Sexual knowledge and experience are seen by Peter as age related components of masculinity, as Zilbergeld (1999: 11) suggests: societys attitudes have encouraged faking, lying and feeling inadequate. Maladapted thoughts and beliefs were reected throughout the interviews. By exploring the participants automatic thoughts, the silent internal dialogue that they engage in, and gaining an understanding of participants attitudes and beliefs, their style of thinking or biases used when interpreting information, a better understanding of participants cognitive processes and sexual response could be achieved. It is beyond the scope of this study to undertake an analysis of all the data relevant to cognitive interference, rather the aim has been to draw attention to its signicance in this population. This section of the analysis traces the development of the core category of cognitive interference and suggests the preliminary hypothesis that cognitive interference distracted these participants from being able to experience high levels of erotic arousal during sexual activity with a partner. No such distraction was experienced during masturbation. Sildendal (a cognitive distraction by-passer) Until recently sex therapy was the preferred treatment for psychogenic erectile difculties. The advent of new drugs polarized treatment and many now want immediate solutions, whilst acknowledging its effectiveness for some, recognising how to maximize sildendals benet and integrate it into combined treatment programmes is less well understood. The data from this study suggests sildendal may also have a psychological benet. Some participants found that using sildendal provided reliable erections which in effect allowed them to bypass cognitive distractions (performance concerns) and focus on enjoyment. Don describes his experience when using sildenal as being like swimming with armbands adding: youve got condence there, he continues: D: Viagra, its amazing sort of drug and how you feel, and you think its going to work anyway (laughs). I mean I just get on and enjoy it. Although sildenal did not provide consistent results for all participants (7), the study found that, for some (3) participants, sildenal increases condence, removes the fear of failure and allows them to focus on enjoyment, as one participant describes: Its a hand holding exercise.

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Masturbatory behaviour The negative history surrounding masturbation (Patton, 1986) may account for participants experience: its condemnation by Judeo-Christian religions (Bullough, 1976) and medical opinion (Tissot, 1758) has restricted open discussion and education (Michael et al., 1994) and left behind a confused and conicted heritage. This was reected in participants rst awareness of masturbation, most often through selfdiscovery or peer mimicry; certainly Nobody ever ever talked about what they got up to, recalled John. Participants found societys attitudes towards masturbation were reected in their early learning, the only reference to masturbation being that expressed by peers. Don explains how playground talk was so negative: wanker was used as a term of abuse, and after his rst masturbatory experience he recalls thinking, God Im a wanker now as well! The most widespread of sexual activities during youth is masturbation (Patton, 1986) and therefore societys attitude to it may determine the outlook of the individual towards all sexual expressions. The data in this study suggest that participants attitudes and beliefs affect their perceptions (Zilbergeld, 1999) and impact on their sexual response. There is some evidence in these interviews to support research ndings (Davidson et al., 1985) that there is a link between religious observance and the experience of guilt feelings associated with masturbation. Paul jokes about his fears concerning masturbation: P: I was Catholic werent I? I was waiting for the hairs to grow on me palm! The data supports suggestions that religious observance produces guilt feelings but does not reduce the frequency of masturbation. Paul describes the conict he experiences: P: Every time I go over to church on Sunday I dont feel right. Although most (6) of the participants said they experienced some guilt, it did not alter their behaviour. Through experiential knowledge and discussion, early negative attitudes towards masturbation appeared to become accommodated within participants belief system, and most (6) participants now nd they can enjoy erotic pleasure without rebound guilt (Spence, 1991). Masturbation seemed to be accepted by all as a legitimate way of expressing sexuality, particularly when there was no other outlet. For example, Paul rationalizes his decision to masturbate, despite his religious beliefs, by explaining his difculty in nding a partner: P: I was never going to be no bandit with the women, and so I got to (masturbate). (Pause). That was the only outlet (Pause) I still had the feelings.

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Whilst there are some data in this study to support the substitute outlet theory (Michael et al., 1994: 159), that masturbation is a substitute for partner sex, the interviews suggest that those with active sexual relationships also masturbate at a similar rate. It seems that, for these participants, masturbation is regarded as another component of sexuality making up total sexual expression, whilst also providing a stress free way of having sex, as the following illustration demonstrates. Released from the pressure to satisfy a partner, during masturbation Bob can focus on his own pleasure: I: You mentioned earlier about masturbation being just as good (as the real thing) B: It was just as good . . . It was just as good yes. I: So the orgasms were just as good. P: Yes. Sometimes better. I: What made it better. P: Because when you close your eyes and you fantasise, it can do anything you want, you see anything you want to see, and do whatever you want to do, and they do whatever you think. In contrast to performance pressures and expectations experienced during sex with a partner, self-masturbation offers most participants (8) a private experience in which the goal of personal pleasure is central. . Analysis of the data suggested that in self-masturbation, with its particular conditions, sexual response occurred more readily than during sex with a partner.

Experiential knowledge and theoretical sensitivity inuenced the selection of the most salient components of masturbatory behaviour which would form the core of the emerging theory: they are presented here in an attempt to demonstrate the level of integration achieved. Frequency of masturbation The interviews provided a detailed account of each participants experience of masturbation from adolescence to the present. Most of the participants (8) had practised masturbation throughout their lives and its practice continued during relationships. A period of celibacy, from 2 5 years duration, during which masturbation was the only means of orgasmic release, preceded the onset of secondary sexual dysfunctions in ve of the participants. For the remaining ve participants, whose sexual dysfunctions were of primary origin, a history of short-term relationships with limited partner contact was presented. Participants (9) indicated that their rate of masturbation remained constant throughout their adult life, affected only by bouts of heavy drinking, when achieving erection would be difcult, or during relationships, when the rate of masturbation

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would sometimes be reduced to accommodate partner sex whilst maintaining the overall level of orgasmic release. Kinseys et al. (1948) data suggest that the frequency of masturbation depends on the availability of alternative sexual outlets. Data from this study suggest that, whilst this is so for some participants, men in relationships appear to include masturbation as part of their sexual repertoire. As Bob said: B: While I was married I would masturbate as well. Its, it wasnt as if I felt . . . it is just as good as the real thing. For others (6), rather than sexual alternatives not being available, participants seemed to avoid sexual situations and their attendant failure, in favour of successful selfmasturbation. As Derek says: D: Ive been in situations in the past where I know somebody has been interested in having sex with us at least a couple of times, and Ive just not got involved, and I think its because I have a sort of fear of failure of it. Jim does not avoid sexual situations with his partner, but masturbates in addition to partner sex. He prefers contact with his partner but feels: J: It is easier to produce an orgasm on your own, the specic physical side of it, and certainly I feel the way my partner likes to make love initially mitigates against that. The actual frequency of masturbation varied between participants (Fig. 1), individual differences in personality and lifestyle may be responsible but with a small sample it was difcult to determine any pattern: what perhaps was more relevant was the effect of each individuals masturbatory behaviour on their sexual performance. Often sex therapists will advise clients to reduce masturbatory frequency if it is thought to be excessive in an attempt to prime the pump (Apfelbaum, 2000) in cases of RE, or to increase sexual tension in clients with erectile difculties. In certain instances participants (2) themselves had regulated the frequency of their own masturbation, fearing that it was affecting their ability to maintain an erection during sex with a partner. Peter, who masturbated on average probably never more than twice a day, recalls: P: Id been in a situation, and I hadnt got, um, an erection. I remember thinking that it might have been because Id masturbated this morning . . . so I got into a habit, which I dont follow now, in case I met someone at the weekend I wouldnt masturbate between Wednesday onwards. For many participants the interview had provided a unique opportunity to view their sexual behaviour overall, but more signicantly to think and talk about masturbation; an

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area of their sexuality that is intensely private. The opportunity to reect back on the interview demonstrated the level of understanding of their own difculty. Participants themselves had begun to question whether there may be a link between masturbation and the difculties they were experiencing, as in Jacks case: I: Did you ever think when you were younger that masturbation would harm you in any way? J: I do masturbate so much Im wondering you know . . . Ive never heard of masturbation being bad, but I just wondered like if you only ever have sort of masturbation for years and years and no, no intercourse . . . whether it could have any effect . . . Jim wonders whether reliance on masturbation and erotica during the 2 year period of celibacy preceding the onset of his problem has contributed to its cause: J: . . . that two year period I was masturbating while I wasnt in a regular relationship, umm and perhaps there were more images on television, so it wasnt you had to buy a magazine or its just more available. It seems that these participants are considering the conditions in which their dysfunction developed. . The data showed that for each of these participants, masturbation had been practised regularly over many years. As Paul says:

P: Ive done it so much its a wonder it aint wore out! Technique Most of the participants, when asked how they masturbated, said: oh the usual way, meaning that they used their hand to stimulate their penis. Further questioning revealed more specic descriptions of preferences for a certain kind of touch, or rmness of grip, stimulation of the shaft only, or the shaft and the glans, a degree of foreskin retraction or not, pressure at the base, or around the coronal ridge, backwards and forwards caressing or movement in one direction, with or without stimulation of the testicles, or anus, or nipples. Theoretical sampling (Silverman, 2000) conrmed what had become clear during the interviews, both to the interviewer and the participants, that each had their own idiosyncratic style (Sank, 1998) no matter how uniform it rst appeared. Orgasm and ejaculation have become conditional to a particular touch, and like most (9) participants, Jim nds it easier to achieve orgasm during masturbation rather than sex with a partner: J: Im more sensitive to the way I do it. I: Why do you think that is?

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J: Umm, I suppose years of practice! (Laughs) I: (Laughing). You know what you like? J: And I think theres a, just some actual mechanics of it, umm being at the right angle. I think producing the intensity of feeling in the penis, you can get the grip right, and the friction right, whatever. With intercourse it depends on such a lot of variables. Following the initial discovery period at the onset of puberty, all participants acknowledged that their masturbatory style had become habituated, changing little over the years. Trained to respond to their own hand, participants experienced difculty reaching orgasm during either masturbation by a partner, or during intercourse. In the following example Jacks use of its refers to the kind of touch he needs; partners have difculty reproducing it: J: You know its quite specic, its got to get the foreskin at the top. If its down at the root of the penis, thats slightly stimulating, and will keep me erect, but I couldnt reach ejaculation that way . . . but its got to be the working over of the foreskin, kind of moving over the head of the penis. The majority of participants (7) are able to experience orgasm more readily during masturbation than in an interpersonal situation. Participants masturbatory styles are not contingent with stimulation received during vaginal intercourse: orgasmic response has become conned to the specic conditions of masturbation, and transfer to partner sex presents difculties. As Dons experience during vaginal intercourse demonstrates: D: I need that certain kind of stimulation and sometimes if shes too wet I dont get that stimulation, and somehow its difcult for me to retain the erection. I: Does that differ from when you masturbate? D: If you masturbate youve got complete control, and you know what makes you feel good. . Orgasm becomes conditional upon the narrow stimulus of the individuals masturbatory style.

Frequency and style of masturbation are two conditions that Peter considers may be responsible for his difculties. He feels his reliance, between the ages of 16 and 26, on a regimen of twice daily masturbation using his normal procedure, may have made it difcult to adapt his sexual response to a partner. He explains: P: I think its possible because Ive spent so long a period without sexual activity and just lazily masturbating, that my thing . . . that when Im actually in a position, when Im in an embrace or close to penetration with a girl that its too far removed from my normal procedure, from the way I normally masturbate.

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In studies on retarded ejaculation, Apfelbaum (2000) suggests that a key diagnostic sign is that only the patients own touch is erotically arousing and his basic sexual orientation is therefore autosexual. Whilst most (7) participants in this study, irrespective of dysfunction, were more readily orgasmic during masturbation, all participants express a preference for functional heterosexual relationships rather than expressing an auto-sexual orientation. . Participants have become masturbation-dependent in the absence of functional partner sex either prior to or subsequent from the onset of sexual dysfunction.

Some (5) participants reported being able to ejaculate on a accid penis. It is not unusual to encounter men who experience this difculty and although referred to in the literature as something older men may experience (Perelman, 1994), no explanations are given as to its cause. Some understanding may be gained from Peters experience. Peters fantasies of a seduction process arouse him, producing erection and orgasm but, he explains, they take time so when he feels lazy he takes short cuts, not bothering to imagine the whole scenario just ashes; he experiences difculty getting an erection on these occasions, but by using intense friction he manages to keep it going even if he is only semi-erect and experiences orgasm on a accid penis. It appears in this situation that the increased penile stimulation compensates for the reduced level of erotic arousal, suggesting physical and cognitive processes are in operation. Two-component models have been considered previously: Weiss (1972) proposed the dual innervation model of two parallel physiological processes operating in unison, the difference in the current study being that both physiological and cognitive aspects seem to be involved. The complex nature of the sexual arousal experience has been acknowledged (Barlow, 1986; Spence, 1991) to include both physiological and cognitive components. Earlier studies (Zuckerman, 1971; Heiman et al., 1976) suggest that one form of arousal may be present without the other, as illustrated in Peters case, in which it appears that during masturbation, increased friction compensates for reduced erotic arousal, and that the total arousal (combined physical and cognitive stimulation) is sufcient to produce orgasm (Fig. 2). Fantasy and erotica Fantasy, in the form of visual imagery, is an important means of enhancing sexual arousal (Heiman et al., 1976) and accompanies masturbation for most of the participants. The ability to fantasise varied: Paul has always lived in a land of dreams whereas Sam has great difculty visualizing clear fantasies that produce arousal. Attitudes and beliefs seem to impact on the ability or desire to fantasize or masturbate. For Sam, having a partner is seen as an integral part of masculinity; masturbating to release tension makes him feel less of a man: S: Well if I had a partner then I wouldnt be concerned about it; whether Im manly or unmanly.

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FIG. 2. Model showing the two interactive parallel processes (cognitive and physical) that determine physiological changes during sexual response ( + / 7 indicates positive or negative inuence).

Fantasies were based on episodes the participants had experienced, or would like to experience, involving women they found sexually attractive whom they knew, had met or worked with. John explains how his fantasies develop: J: Well the fantasies just evolve, you know it starts with the germ of an idea, you know like I feel sexy and then I let the imagination run, and it develops into mystical fantasies of memories and dreams. Although inspiration could develop from their own experience, most participants used visual or literary erotica to enhance their fantasies and increase arousal. Jim, who is not good at mental visualizations, explains how his arousal is enhanced by erotica during masturbation: J: I mean quite often there are times when Im stimulating myself theres some sort of aid; watching a TV programme, reading a magazine, something like that.

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Some participants suggest that spontaneous arousal diminishes with age, and other forms of erotica are needed to produce the same response; as Bob explains: B: Sometimes the excitement of being with other people is enough, but as the years go by you need a book, or you see a lm, or you have one of those dirty magazines, so you close your eyes and you fantasize about these things. The effectiveness of erotic stimuli in creating sexual arousal has been noted by Gillan (1977). The use of erotica by these participants was restricted to masturbation in the main. Jim is aware of a heightened level of arousal during masturbation as compared to sex with his partner. Exploring why this might be so, Jim considers whether the pressure to please his partner might be responsible: I: Im just wondering whats happening in your mind at the time if its different from when youre on your own. J: It is different. Umm. Im not sure if the difference is worrying if shes okay. Umm, its different in as much as perhaps theres not its not there just isnt the lm or book there. During sex with his partner, Jim fails to achieve levels of erotic arousal sufcient to trigger orgasm, during masturbation the use of erotica signicantly increases levels of erotic arousal and orgasm is achieved. . Fantasy and erotica increased erotic arousal and were used freely during masturbation but its use was restricted during sex with a partner.

Many participants could not imagine masturbating without the use of fantasy or erotica, and many recognized the need progressively to extend fantasies (Slosarz, 1992) in an attempt to maintain levels of arousal and prevent boredom. Jack describes how he has become desensitized to his own fantasies: J: Latterly in the last ve, ten years, I, I, Id be hard pushed to get stimulated enough by any fantasy that I might create myself. Based on erotica, Jacks fantasies have become highly stylised; scenarios involving women with a specic body type in particular forms of stimulation. The reality of Jacks situation and partners is very different, and fails to match his ideal created on the basis of porno perception (Slosarz, 1992); the real partner may not be erotically arousing enough. Paul compares the progressive extension of his fantasies to his need for progressively stronger erotica to produce the same response: P: You get bored, its like those blue movies; youve got to get stronger and stronger stuff all the time, to cheer yourself up.

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By changing the content, Pauls fantasies retain their erotic impact; despite masturbating several times a day, he explains: P: You cant keep doing the same thing, you get bored with one scenario and so youve got to (change) which I was always good at cause . . . I always lived in a land of dreams. . The use of fantasy enhances erotic arousal in both masturbation and partner sex. The use of extended fantasies enhances erotic arousal during masturbation but may have a negative impact on erotic arousal during sex with a partner. The fantasized encounter is/can not be reproduced in real life.

For some participants, fantasies focus more on their own performance, enhancing their condence as performers: Wagman (1967) refers to these as self-aggrandising scenarios. Paul explains how different he appears in his fantasies: P: Im never actually me, Im always a super me, you know? Ive got a better, bigger dick . . . Im a bit more good looking . . . they dont dream of criticising me cause they think Im wonderful. Although fantasies generally focused on the visual impact and consequent arousal they created, they also served as an opportunity to role-play successful scenarios. Don imagines a camera focusing on his partners face: D: Its the pleasure thats being gained from what Im doing . . . if youre seeing this pleasurable thing then it makes you feel great. Im doing something right, its giving me a bit of condence here. Don knows his anxieties can trigger a negative thought process: success fantasies boost his condence. Fantasies concerned with positive cognitions appear to impact positively on his sexual performance. This critical analysis of participants experiences during both masturbation and partner sex has demonstrated the presence of a dysfunctional sexual response during sex with a partner, and a functional sexual response during masturbation. Two interrelated theories emerged and are summarized here: . During partner sex, dysfunctional participants focus on non-relevant cognitions; cognitive interference distracts from the ability to focus on erotic cues. Sensate awareness is impaired and the sexual response cycle is interrupted resulting in sexual dysfunction. In the absence of functional partner sex, these participants have become masturbation dependant. Sexual response has become conditional; learning theory does not postulate specic conditions, it merely identies conditions of acquisition of the behaviour. This study has highlighted frequency and technique of masturbation, and the ability to focus on task relevant cognitions

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(supported by the use of fantasy and erotica during masturbation), as such conditional factors.

Discussion The aim of this study was to gain a better understanding of male sexual dysfunction and the part played by masturbation. Findings suggest that all of the participants had experienced difculties during sex with a partner but no such difculties were experienced during masturbation. In effect, this study had a built-in control and comparisons could be made between participants functional sexual response during masturbation and dysfunctional response with a partner. In previous studies consideration has only been given to either dysfunctional or functional sexual behaviour with a partner; acknowledgement of the functional (masturbatory) component of the dysfunctional individuals sexual response may have implications for treatment Useful hypotheses have been generated by this work although rm conclusions cannot be drawn from one small study. Two interconnected theories emerged; rstly although expressing a preference for functional sex with a partner, masturbation dependence seemed to develop as a result of the sexual response having become conditional on a discrete set of stimuli, notably technique and frequency, which are then difcult to reproduce with a partner. Theoretical formulations of the aetiology of SD (Libman et al., 1984; Sank, 1998), together with this study, support a discriminative learning model in which orgasmic response appears to be under the narrow stimulus control of masturbation. Secondly this conditional response appears to be further reinforced by a cognitive component displaying different characteristics during masturbation and partner sex. In sexual situations involving a partner, participants appeared to focus on negative non task-relevant stimuli which are, generally, performance related concerns, which appear automatically prior to and during sexual relationships. These automatic thoughts seem to develop as a result of interpretations which participants make of their current situation based on their existing attitudes and beliefs generated by past experience and learning (Schnarch, 1981). The resulting mood experienced by participants appears to trigger physiological changes which inhibit sexual response (Leiblum & Rosen, 1991). Conversely, during masturbation, participants focus on positive task-relevant stimuli enhanced by fantasy and erotica: physiological changes resulting from a more positive mood appear to facilitate sexual response. This interplay of inuences that inhibit or facilitate arousal is played out at a physiological level; Fig. 2 presents a simplied hypothetical diagrammatic representation of the interrelated nature of cognitive, physiological and behavioural components of SD suggested by this study. These ndings seem to be in line with both Bassons Model of Sexual Arousal (1988: 215), which has attempted to provide an organizing construct broad enough to encompass the complexity of factors that make up sexual function and dysfunction, and Barlows Theoretical Model of Sexual Dysfunction (1986: 146), which has been instrumental in delineating cognitive factors related to erectile dysfunction. However, although clinicians (McCarthy, 1998; Rosen et al., 1994) have

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acknowledged the multi-causal nature of SD, little empirical study has been undertaken; and theories and consequently treatments are mostly based on experimental studies and anecdotal reports. Application to clinical practice Masturbation is acknowledged as a normal process (Bancroft, 1985; Michael, 1994); in this study failure to transfer the sexual response from a solitary to an interpersonal situation appears to be caused by both an idiosyncratic and incompatible masturbatory style (Sank, 1998) and an idiosyncratic cognitive component (Beck, 1964), a negative sexual schema, activated only during sexual encounters with a partner which then prevents participants from experiencing erotic cues. This study has highlighted the relevance of detailed questioning in two main areas; behaviour and cognitions. Firstly details of the specic nature of masturbatory frequency, technique and accompanying erotica and fantasy provided an understanding of how the individuals sexual response has become conditional on a narrow set of stimuli; such conditioning appears to exacerbate difculties during sex with a partner. It is acknowledged that as part of their formulation, practitioners routinely ask whether an individual masturbates: this study suggests that also asking precisely how the individuals idiosyncratic masturbatory style has developed provides relevant information. Secondly comparisons between participants responses to questions concerning specic thoughts prior to, during, and following both sexual encounters and masturbation provide an understanding of those cognitive and affective processes which accompany their sexual response. Comparisons made between the individuals imagined or ideal script (Gagnon et al., 1982; Gagnon, 1990) experienced during masturbation, and the performative or overt script with a partner may highlight dysfunctional cognitions and behaviour which may ultimately be helpful in the formulation of the individual treatment programme. Although it is beyond the scope of this article to recommend treatment programmes, some strategies are suggested on the basis of current ndings whilst recognizing that the formulation and treatment of all sexual problems is specically tailored to the individual. Treatments for sexual dysfunctions have historically been developed based on the concept in which anxiety are the most signicant factor in the development and maintenance of sexual dysfunction (Wolpe, 1958; Masters & Johnson, 1970), even though evidence for this view was purely hypothetical. Treatment became directive, focusing on anxiety reduction in a sexual context, involving methods like Sensate Focus (Masters & Johnson, 1970). More recent research has suggested a multidimensional concept of sexual dysfunction (Rosen et al., 1994; Basson, 1998); in particular, cognitive theory (Beck, 1964) has been applied to SD, and there has been an increasing focus on cognitions as aetiological and maintaining factors in SD and related issues (LoPiccolo, 1992). Whilst cognitive-based treatment models such as those proposed by Basson (1998) or Rosen et al. (1994) are indicated by the current study, in men in whom assessment reveals functional cognitive structures (that is those men who are not distracted by negative cognitions and are able to experience erotic stimuli), an alternative approach may be incorporating the couples individual sexual scripts

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(Anderson et al., 1999) into the couples sexual style; assuming there are no serious relationship difculties, the dysfunctional man may benet greatly simply from showing his partner how he likes to be handled. Further research Further exploratory qualitative and quantitative study, using functional and dysfunctional participants, to develop the theories concerning the behavioural and cognitive components of sexual dysfunction generated by this research may help to understand the aetiology, and inuence the formulation and treatment of orgasmic and erectile difculties. As masturbation, recognized in this study as the functional component of the dysfunctional individuals sexual response, is regarded as an almost universal experience (Patton, 1986), further study may explain why some men experience difculties in transferring functional sexual response to an interpersonal situation. By including men whose sexual dysfunctions are thought to have a mainly organic aetiology further study may indicate whether the inuence of the cognitive and behavioural components identied in this study are present before, or after, onset of the dysfunction, thus helping to identify risk factors. Concluding thoughts Whilst recognizing that aetiological theories are not mutually exclusive, the link between therapy, theory and research in the literature appears to be fragmented; organizing structures which represent the interrelated nature of the determinants of SD may be a pre-requisite to formulating effective treatments which produce lasting improvements. Findings from this study suggest clinical research and treatment should echo Bobs understanding: B: The mind and the caressing . . . its a kind of process, mechanism. The one ts into the other. They sort of control each other.

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Contributors JOSIE LIPSITH, MSc, Psychosexual Therapist DAMIAN MCCANN MSc, Principal Family and Systemic Therapist DAVID GOLDMEIER, MD, FRCP, Clinical Lead and Consultant in Sexual Medicine