Sexual Concerns for Men*
Erectile Dysfunction
If you have a penis, you can have an erection. Even if treatments have failed in the past, there is a way! And while there are many ways to enjoy sex without an erection (truly!), we understand that erections are important to people with penises in a variety of ways. We understand and have helped many clients with this problem.
30 million Americans suffer from ED – from mild to severe. ED increases significantly with age. 40% of men by age 40 experience erectile dysfunction. However, it can occur at any age and we have treated many men in their twenties and thirties.
The foundation of ED treatment is a thorough evaluation of the many causes of ED. There are a variety of reasons for ED– problems with blood flow, with the nervous system, as well as anxiety and worry about “performance.” We can offer you a comprehensive picture of all the medical and therapy treatments for problems with erections. While we do not perform surgeries, procedures, or advanced testing for unusual causes of ED, we do collaborate with area urologists to make sure you get the best medical care to achieve your goals. Often urologists don’t get enough time with their patients to get down to the bottom of what may be getting in the way of erections– our comprehensive evaluation will set you on an effective course of treatment.
Helpful books and other resources on this issue:
The New Male Sexuality by Bernie Zilbergeld PhD
Coping with Erectile Dysfunction by Barry McCarthy PhD and Michael Metz PhD
What kind of ED do I have?
There are two main categories of ED and they overlap. Physiologic (sometimes called “organic”) ED means the penis is not biologically capable of maintaining and erection under most conditions – sleep, partner sex, self-stimulation (masturbation).
Psychogenic ED is when the mind gets in the way. The penis works but the brain works against it, and then the body makes it impossible to have an erection. Usually a person is worried about their performance: “Am I going to stay hard?” “Is my partner going to enjoy this sexual moment?” “Will I enjoy this?” People also worry about the consequence of being sexual “will I get caught masturbationg or watching porn?” “Will someone get pregnant or get a sexually transmitted infection?”
Many of the people we see have this problem – they can get an erection while asleep or masturbating but not with a partner. This is where sex therapy can be very helpful, sometimes with the assistance of medical treatments. You can see our “try this first” section, and more power to you if that is helpful enough! If not, give us a call.
Many people have some physical issues with getting and maintaining an erection. They can get hard under perfect conditions but the mind keeps worrying they will lose it – and of course, then you lose it. Sex therapy and medical treatment is overwhelmingly the best treatment here and we have many many satisfied clients.
Try this first.
1) If you can’t get an erection at all – and that means at night during sleep too – you need to see a doctor. Erections problems can be a sign of other health problems, so do not delay.
2) If you can get an erection at night or wake up with one, or can masturbate with and erection but cannot get an erection in partnered sex you can try relaxation and mindfulness. This is not easy. You need to get RID of your need to get hard. Your partner needs to be ok with you not getting hard. The harder you want to get hard, the harder it is to get hard. Sometimes it is really that simple – and frustrating!
3) Have all the sex you can have without an erection. Play and try new stuff. Receive oral sex when you are soft. Yes, you can orgasm without an erection. Great lovers who have magnificent sex often enjoy aspects of sex that have little to do with orgasm and erection.
Helpful books and other resources on this issue:
The New Male Sexuality by Bernie Zilbergeld PhD
Coping with Erectile Dysfunction by Barry McCarthy PhD and Michael Metz PhD
FrankTalk.org
Low Testosterone/Andropause
Low sex drive? Poor erections? Difficulty concentrating? No energy? Loss of Muscle Mass? These symptoms may all be linked to Low Testosterone. Go ahead and try this quiz (link to ADAM questionnaire — see below)
Low testosterone (Low T) can affect many areas of wellbeing– from sex drive to bone density, concentration, and erections. Treating Low T properly can have dramatic effects. To diagnose low T, you need a full evaluation including a lab evaluation. You need a doctor with experience to order the right labs, interpret them, and prescribe and monitor treatment within the context of your overall health.
Sexual medicine specialists keep up with the most up-to-date research and medical practice. In the past, there have been concerns about TRT (Testosterone Replacement Therapy) and cardiovascular health -and unfortunately some physicians are not familiar with the current overwhelming evidence that TRT can decrease cardiovascular problems, like heart attack and stroke. Also contrary to what you may have seen in the media, medical evidence now clearly shows that treating Low T with TRT does NOT increase your risk of prostate cancer or cardiovascular disease. In fact, studies correlate TRT with improved cardiovascular and overall health.
Even men as young as 30 suffer from Low T and that is why it is important to seek medical advice if you have poor erections and/or a big decrease in sexual desire.
If you are concerned about low testosterone, let’s talk!
PS Women can suffer from symptoms of low testosterone as well. See our section about low desire in the sexual concerns for women page.
Mohamed O, Freundlich RE, Dakik HK, et al. The quantitative ADAM questionnaire: a new tool in quantifying the severity of hypogonadism. International Journal of Impotence Research. 2010;22(1):20-24. doi:10.1038/ijir.2009.35. [PubMed]
Morley JE, et al. Validation of a screening questionnaire for androgen deficiency in aging males. Metabolism. 2000;49(9):1239-1242.
Sexual Desire Concerns
One of the most common complaints people come to us with is that they feel they have lost their drive and sexual interest. “If I never had sex again that would be fine.” “We just can’t get back to the way it used to be.” “Ever since we had this medical problem/child/crisis/change our sex life is gone.” “Everything else in our lives together is perfect – except sex.” Some have been told to have a date night, or schedule sex, or trying gentle touching exercises. If that was enough for you, then you would not be reading this! For many, these recommendations are just not enough. There is hope.
The best approach is to engage in couples counseling with one of our certified sex therapists. Based on that initial assessment, our therapists will advise you on the value of further evaluation with Dr. Kranz. If you prefer to deal with this on your own (because you have no partners or prefer to get help without including your partner) you can do that too. Often low desire is a ‘couple’ problem not a ‘me’ problem.
Our sex therapists will explain the process clearly to you, and make it easy to follow through. Typically, you will first meet the sex therapist as a couple, then each of you meets individually with the therapist, and then you meet a fourth time to discuss how treatment can help and give you a roadmap for progress.
At times, medical evaluation may be helpful right off the bat. We evaluate for medications that are decreasing desire or checking for low testosterone (even in women sometimes). When testosterone levels are low, testosterone therapy can be a game changer for low desire. So many things have to work in the body for desire to happen – it is not a switch inside your brain – but more like a really good feeling that happens when everything works out just right.
When we start seeing people in the office again we will offer a group therapy approach to this problem. Dr. Kranz and Mr. Rosen run an 8 week program specifically for couples with these problems. Sometimes people need to develop a whole new way to make sex satisfying. And sometimes there is a biological issue contributing to this problem. Mr. Rosen, Mr. Kelly and Ms. Barrett all see individuals and couples to do the deeper work to connect sexually.
Try this first.
Not sure you want to try sex or relationship counseling? We understand. Counseling costs money and takes time. Perhaps you are not sure you can share your issues with another person? Again, we understand. Undertaking counseling at the wrong time is not a good idea: you should feel ready and willing to engage. If you are not, here are some activities you can try right now.
Not enough sex with your partner or your partner wants too much sex from you:
Sex is often not about sexual release. Sex is often a method to create intimacy with your partner, or a way to reduce relationship anxiety, to get a physical release – both orgasm and relaxing touch, to ensure your partner stays with you, or a way to feel good about yourself (“I am wanted”). If you can first recognize what sex is for you and reflect on this that may take some of the urgency away for a higher drive partner and may be helpful information for a partner who wants less sex. You’ve learned to navigate difficult negotiations on so many other things in your relationship– housework, parenting, financial decisions– why should this issue be any different?
Here are a few things to remember:
Working together on how to get satisfaction as well as a better understanding of what sex means for each partner can help. Low desire partners often resent sex they don’t want. Coercion and guilt can damage a relationship further. Low desire partners should recognize that high desire partners often do not know how to talk about this. They may be doing the best they can to meet their needs. Listening to each other in a forgiving way can be helpful.*
Helpful books and other resources on this issue:
Getting the sex you want by Tammy Nelson, PhD
Rekindling Desire by Barry and Emily McCarthy
*whenever there are threats of violence or guilt tripping, force or coercion people should think about safety first.
Premature Ejaculation
The most common sexual problem in men is not what many think. More men complain that they ejaculate and orgasm too quickly than any other sexual problem for people with a penis. 20-30% of men across the globe suffer from early ejaculation (also called premature ejaculation or PE).
There are 4 main kinds of early ejaculation:
- Lifelong — this is when ejaculation/orgasm occurs within 1 minute of penetration and this has been the case throughout a person’s life. This is often best treated with a combination of medication and behavioral changes.
- Acquired — this is when ejaculation/orgasm change over time to occur in less than 3 minutes of penetration.
- Variable or Subjective — this is when ejaculation/orgasm occurs in a shorter time than desired and this is causing significant distress. The treatment for this is often therapy and behavioral changes.
We can help with all of these problems. A combination of sex counseling and affordable medications relieves the vast majority– providing more satisfying sexual experiences.
If you have already tried counseling for PE and it has not been helpful, or you know you have lifelong PE, then you should get to Dr. Kranz as soon as you can. One of our sex therapists will do an initial evaluation to collect all the data to make sure a medical evaluation is right for you, and then you will see our doctor.
If you have variable or subjective PE or acquired this later in life, sex counseling may be effective on its own. We find great results with treatment, even for people who have tried over and over in the past to get help!
Try this first.
This is the most common sexual problem for people with penises. Often people have this life long – that is during both masturbation and partnered sex they have orgasm very shortly (less than 1 minute) after anything that is arousing. Forget self-help: see a medical provider. Medication is often more appropriate for these folks, and we have a variety of easy to use treatments. Our client satisfaction for this is quite high.
If you developed this later in life, it may be more responsive to self-help. It is hard and easy at the same time. You must figure out how you respond to sexual stimulation and slow things down in your head and your body. Never try to avoid orgasm… Simply start with very slow gentle touch and notice how you respond. Begin to notice when things build, when is the ‘point of inevitability’, and relax relax relax. If you are trying to keep an erection AND not orgasm too quickly you are working against yourself. Trying to stay hard requires feeling aroused and relaxed and worrying may either make your erection go away or make you orgasm more quickly. Let go of trying to stay hard and let go of trying not to orgasm. Yes, that is hard to do. But if you focus every day on feeling sexual pleasure, not fighting it, letting what happens happen, relaxing and enjoying, not caring if you are hard or not, you may just get there.
Coping with premature ejaculation by Barry McCarthy PhD and Michael Metz PhD
The New Male Sexuality by Bernie Zilbergeld PhD
Delayed Ejaculation
Delayed Ejaculation, when orgasm and ejaculation take significantly longer than desired (and sometimes no orgasm), can be caused by a wide variety of physical and psychological concerns. If you are concerned about this issue, a combined approach of medical evaluation and management and sex therapy can be very useful.
Nervous system and hormonal problems (like diabetes) as well as spine issues, and prostate disease can contribute to this problem. Additionally, many medications can inhibit orgasm– from antidepressants to medications for pain or seizures. Alcohol use and some recreational drugs may also delay orgasm.
Additionally, psychological issues such as relationship concerns, feeling performance pressure, fatigue, guilt and shame, and mental health concerns can make orgasm hard to attain. Sometimes a person becomes conditioned to a particular style of self-stimulation and it is necessary to become accustomed to other kinds of stimulation. Also, some people simply have needs for higher levels of physical stimulation to have orgasm– their orgasm “threshold” is simply what it is! And pressure to orgasm, either from your own self or from a partner, will only make things harder.
Try this first.
This concern is more common for people with penises than you would think! Sometimes, it has to do with commonly prescribed medications. Rarely, it can be because of some medical issues. If it happens in every situation whether it’s solo sex or partnered sex, then don’t stop here, come see us!
If it happens only with partnered sex and not with solo sex, then it may be related to the kind of stimulation to which your body has become accustomed. Dr. Stephen Snyder describes this well in his blog. Here’s the great news– for most people working on self-acceptance, increasing one’s ability to concentrate on relaxation and pleasure rather than the goal of orgasm, and expanding the kinds of arousing sensations your body experiences, this can change!
A good book to try: The New Male Sexuality by Bernie Zilbergeld PhD
These are just some of the most common sexual concerns we hear about. There are a wide variety of other sexual concerns — changes in genital sensation, post orgasmic illness syndrome, sexual concerns due to peyronie’s, long term sexual effects of medications, orgasmic headaches, orgasm without enjoyment (anhedonic orgasm), the list goes on and on. If you are concerned about any aspect of your sexual experience, call us, we can help.
*We recognize that gender is a complicated and evolving topic. Often people with penises are men, but sometimes they are not. Often people with vulvas and vaginas are women, and sometimes they are not. Truly, we are all more alike than different. Language continues to be complicated in this area. Please note we care for clients where they are and respect the language each client chooses for their gender, their parts, and their identity.