Although psychological factors have been primarily implicated in retarded ejaculation, we still do not really understand what causes this problem, which makes treatment difficult. In many cases, psychotherapy is used to help work through some of these issues as a part of treatment. One 43-year-old man shared with me his lifelong problem in reaching orgasm with his partner. He had been sexually abused as a child for many years by an uncle who was a few years older than he. During this abuse, the uncle tried to make him reach orgasm. However, the boy learned to withhold the orgasmic response, much to the dismay of the uncle. Later on in life, this pattern continued even though he was not consciously trying to do so.

To treat retarded ejaculation, the man is instructed to use situations in which he is able to achieve ejaculation to help him during those where he is not. For example, if a man can ejaculate during masturbation while fantasizing about being watched during sexual activity, he is told to use this fantasy while he is with his partner. Gradually, the man is asked to incorporate his partner into the sexual fantasy and to masturbate while with the partner. Finally, he is to allow the partner to masturbate him to orgasm. Retarded ejaculation can be very difficult to treat.

<"K PAIN DISORDERS

Genital pain disorders can occur at any stage of the sexual response cycle. Although pain disorders are more frequent in women, they also occur in men. DSM-IV-TR has two cat­egories of pain disorders, vaginismus (vadg-ih-NISS-muss), which occurs in women, and dyspareunia (diss-par-ROON-ee-uh), which can affect both men and women.

Vaginismus

Подпись: | pubococcygeus muscle A muscle that surrounds and supports the vagina. The pubococcygeus (pub-oh-cock-SIGH-gee-us) muscle surrounds the entrance to the vagina and controls the vaginal opening. Vaginismus involves involuntary contractions of this muscle, which can make penetration during sexual intercourse virtually impossi­ble. Forced penetration can be very difficult and may cause a woman severe pain. Vaginismus may be situation-specific, meaning that a woman may be able to allow pen­etration under certain circumstances but not in others (say, during a pelvic exam but not during sexual intercourse; LoPiccolo & Stock, 1986).

The muscle contractions that occur during vaginismus are in reaction to anticipated vaginal penetration. One woman had been in a relationship with her partner for more than 3 years, but they had never been able to engage in penile-vaginal intercourse be­cause she felt as if her vagina “was closed up” (Author’s files). Penetration of her vagina with her partner’s fingers was possible and enjoyable, but once penile penetration was at­tempted, her vagina closed off. She also shared that she had been forced to engage in sex with her stepfather for several years of her early life.

Vaginismus is common in women who have been sexually abused or raped, and it is often present along with other sexual difficulties such as sexual aversion and/or difficul­ties becoming aroused. Women who experience vaginismus often experience dyspareu- nia, or painful intercourse, as well (Heiman, 2002).