Common Sexual Concerns
Sexual concerns are common, and many people wait a long time before asking for help. Whether you are dealing with pain, changes in desire, erection or arousal changes, orgasm concerns, or something that is hard to put into words, you deserve thoughtful, respectful care.
At Rochester Center for Sexual Wellness, we care for adults of all genders in a confidential, open-minded, whole-person-centered setting. We know sexual concerns can be shaped by the body, relationships, stress, trauma, medications, medical conditions, life stage, and identity, so we take time to understand the full picture.
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
Sexual Arousal (Lubrication) Problems
A wide variety of issues can contribute to problems with arousal– from psychological and relational concerns to physical concerns. Are you having the sex you want to have? Are you able to communicate with your partner(s) about what feels good to you? Is it hard to keep your attention on satisfying sensations? Do you have vulva and vagina dryness due to menopause and low estrogen? Many medications can contribute to problems with arousal. And chronic medical illnesses such as diabetes, high cholesterol,hypothyroidism as well as cancer and its treatments can affect arousal. Childbirth, breastfeeding, and infertility treatments may also have an impact. We can help sort these reasons out and help you on your way to having more satisfying sex. We are also experts at helping couples manage and even thrive when sex is less satisfying.
Sexual Desire Concerns
“I want to want.”
“If I never had sex again, that would be fine.”
“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.”
If any of this sounds familiar, you are not alone. Low or changing sexual desire is one of the most common concerns people bring to us. It can be painful to feel like you’ve lost your “drive” or that you and a partner can’t get back to the way things used to be.
Many people try to fix this on their own with date nights, scheduling sex, or gentle touching exercises. Those ideas can help some couples, but if they were enough for you, you probably wouldn’t be reading this. There is still hope.
Desire is not a simple on/off switch in your brain. It’s more like a good feeling that emerges when many pieces—your body, your mind, your relationship, your stress level, your sense of safety—line up just enough. Medical issues, hormones, medications, past experiences, trauma, relationship patterns, and life changes (such as childbirth, illness, or menopause) can all affect desire.
Often what feels like a “me” problem is actually a “we” problem. Differences in desire can create tension, hurt feelings, and pressure on both the person wanting sex less and the person wanting sex more. Sex is often about much more than orgasm or release—it can be a way to feel close, to reduce anxiety, to feel desired, or to reassure yourself that a relationship is okay. Understanding what sex means to each of you is a key part of healing desire differences.
At Rochester Center for Sexual Wellness, we start with careful listening. For many people, the most helpful first step is couples or individual therapy with one of our certified sex therapists. Together, you’ll explore what has changed, what sex means to you, and what kind of intimate life you want to build going forward. Your therapist will outline a clear plan and, when it’s helpful, may recommend a medical evaluation.
Sometimes medical factors are part of the story: medications that decrease desire or arousal, low testosterone or other hormonal changes, or health conditions that affect mood, energy, or body comfort. When indicated, we can review your medications, order appropriate lab work, and discuss treatment options—including, in select cases, medications specifically used to support desire. For some people, adjusting a medication or addressing a hormonal concern can be a game changer, especially when combined with therapy and relational work.
Recommended Books:
Desire: An Inclusive Guide to Navigating Libido Differences in Relationships by Lauren Fogel Mersy PsyD and Jennifer Vencill PhD, ABPP
Magnificent Sex by Peggy Kleinplatz, PhD and A. Dana Menard
Getting the Sex You Want by Tammy Nelson, Ph.D.
Rekindling Desire by Barry and Emily McCarthy
Come As You Are by Emily Nagoski, Ph.D.
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 concerns around menopause
Many people notice changes in their sexual lives around perimenopause and menopause. You might have less interest in sex, need more time to feel aroused, or find that your body responds differently than it used to. Vaginal dryness, burning, or “tightness,” discomfort with penetration, changes in orgasm, sleep problems, mood shifts, hot flashes, and body image concerns can all affect how sex feels—and how you feel about yourself.
These changes are common, but that doesn’t mean you just have to put up with them. At Rochester Center for Sexual Wellness, we look at the whole picture: hormones, medications, medical conditions, stress, relationship dynamics, and what sex means to you at this stage of life. Together, we can talk about options such as vaginal moisturizers and lubricants, local or systemic hormone treatment when appropriate, pelvic floor physical therapy, sex therapy, and practical ways to stay (or become) sexually connected in ways that fit your body now.
Sexual Pain
Pain with sexual activity is common, but it is never something you “just have to live with.”
People often tell us things like:
-
“I brace myself every time because I’m expecting it to hurt.”
-
“It feels like hitting a wall.”
-
“The burning and soreness last long after sex is over.”
-
“I want to be close to my partner, but my body tenses up.”
Sexual pain can show up in many ways: pain with touch at the opening of the genitals, deeper pain with penetration, burning or rawness afterward, pain with arousal or orgasm, or pain that lingers for hours or days. It can also show up during medical exams or when using tampons, dilators, or toys.
However it shows up for you, your pain is real and it deserves careful attention.
Pain almost always has more than one cause. Muscles may be tightening to protect you, nerves may be extra sensitive after an injury, infection, surgery, childbirth, or trauma, and hormones or medications can change how tissues feel and respond. Past experiences, anxiety, or relationship stress can add another layer. None of this means the pain is “all in your head”—it means your body is doing its best to protect you, even if that protection no longer serves you.
At Rochester Center for Sexual Wellness, we take a gentle, step‑by‑step approach. We start by listening to your story: when the pain began, how it feels, what you’ve already tried, and what you most hope for. We will talk about both physical and emotional factors in a way that respects your pace and boundaries. An exam, if needed, is done slowly, with your consent at every step, and can be paused or stopped at any time.
Treatment plans are tailored to you and may include:
-
Education about how pain and the nervous system work
-
Topical or oral medications when appropriate
-
Hormonal treatment if needed
-
Pelvic floor physical therapy with providers who understand sexual pain
-
Gradual, body‑based exercises (such as dilator or touch work) at a pace you choose
-
Counseling or sex therapy to address fear, avoidance, relationship impact, or past trauma
Our goal is not simply to “get you through” sex. Our goal is to help you build comfort, safety, and choice in your body so that sexual or intimate touch can feel more like something you might want—now or in the future—rather than something you endure.
If you are experiencing sexual pain, you are not alone, and you are not “broken.” With the right support, many people are able to reduce their pain and find new ways of being intimate that feel possible, respectful, and more aligned with what they want.
Helpful books and other resources on this issue:
When Sex Hurts by Andrew Goldstein MD, Caroline Pukall PhD, and Irwin Goldstein MD
Heal Pelvic Pain by Amy Stein, DPT
Healing Painful Sex by Deborah Coady, MD & Nancy Fish, MSW, MPH
Persistent Genital Arousal Disorder
Persistent genital arousal disorder (PGAD) is an uncommon but very disturbing sexual concern. People with PGAD have unrelenting, unwanted, intrusive, spontaneous sensations in the genitals without thoughts of sexual desire or sexual interest. This was first described in 2001 and often is unreported as people may feel ashamed for having genital feelings that in other situations may feel like sexual arousal. PGAD is often associated with significant personal distress. There is hope– with a thorough evaluation and proper treatment, we are able to help decrease these sensations and the distress that accompanies them.
Difficulty with Orgasm
The lack of sexual climax (orgasm) is called anorgasmia. Many factors can contribute to this problem, including sexual inhibition, inexperience, or lack of knowledge of one’s own body. Psychological contributors to anorgasmia may include guilt, anxiety, or sexual shame. Not getting enough or the right kind of stimulation is an important cause of difficulty with orgasm. It’s also important to know that many drugs or medications and chronic diseases can also result in lack of orgasm- medical evaluation may be helpful in this case.
Helpful books and other resources on this issue:
Becoming Orgasmic by Julia Heiman (an oldie but a goodie)
Sex for One by Betty Dodson PhD
A Women’s Guide to Masturbation: Getting Off by Jayme Waxman
Are You Coming: A Vagina’s Owners Guide to Orgasms by Laura Hiddinga
Article about Orgasm Concerns from The Sexual Medicine Society of North America
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
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