What You Can Change . . . And What You Can't*: The Complete Guide to Successful Self-Improvement (29 page)

Layer V: Sexual Performance: Correcting Sexual Dysfunction

Assume that the first four layers of your sexuality are in good working order: You have an identity, a fixed orientation, set preferences, and a clear sex role. You are with someone who fits with your desires and you are in an erotic situation. Tonight’s the night. What can go wrong now?

Plenty. Your sexual performance can falter. If you are a man, you might

• fail to maintain an erection
  (impotence)
  

• climax within the first few seconds
  (premature ejaculation)
  

If you are a woman, you might

• fail to get aroused
  (frigidity)
  

• not reach orgasm
  

These problems are called sexual
dysfunctions
. They are agonizing and quite common problems. Until twenty years ago, they were largely unsolvable: People endured them. Marriages were strained to the breaking point. Love soured. Self-loathing and deep depression ensued. When quiet desperation became unbearable, people sought therapy, which usually failed. But thanks to a major breakthrough, these problems are, today, for the most part, curable.

Adequate sexual performance is exactly parallel in men and women. It consists of two phases: arousal and orgasm. During female arousal, a woman feels excited. Her vagina lubricates and swells to just the size to “glove” a penis. Her clitoris erects. Her uterus enlarges. Her nipples swell. During male arousal, a man feels excited. The penis hardens (the blood vessels of the penis widen dramatically, blood flows in, and a set of valves close to block it from leaving).

Arousal is the natural prelude to orgasm. In men, after enough penile stimulation a plateau of orgasmic inevitability is reached. If no interruption occurs, semen is soon released
(emission)
and is immediately pumped out by a set of rhythmic (at o.8-second intervals) contractions by powerful muscles at the base of the penis
(ejaculation)
. This is accompanied by extremely intense, spasmodic pleasure. Orgasm in women is triggered by the clitoris and is then expressed by a series of rhythmic (you guessed it: o.8-second intervals) contractions of the muscles around the vagina. It is accompanied by ecstatic and rhapsodic feelings.

As we ponder the “unbridgeable” chasm between the sexes, I find it powerfully consoling to know that the underlying biology of sexual arousal and orgasm is completely parallel for men and women. He is probably feeling what you are feeling.

Men and women can break down at either phase, and where you break down defines your particular sexual dysfunction. Whatever the specific problem, it is always complicated by
spectatoring
. When things go wrong, or when you worry that things will go wrong, you start to watch your own lovemaking—from the outside. This gets in the way of losing yourself in the act, and so worsens the specific problem. Spectatoring creates additional anxiety, thereby starting a vicious circle. This is a clue as to what goes on in every sexual dysfunction. Arousal and orgasm are the result of biological systems that can get shut off by negative emotion. Anxiety, anger, and depression all interfere with arousal and orgasm, and spectatoring worsens all the sexual dysfunctions because it heightens anxiety.

If a woman is frightened or angry during sex, her arousal or her orgasm may be blocked. There are many commonplace sources. She may fear she will not reach orgasm, she may feel helpless and exploited, she may be ashamed of her excitement, she may expect physical pain during intercourse, she may fear pregnancy, she may find her partner unattractive, or she may think he is the wrong man. The sources of sexual blocking are parallel for men.

In the late 1960s, William Masters and Virginia Johnson invented
direct sexual therapy
for these then intractable problems. Their therapy was revolutionary, and it differs in three ways from the sex therapies that had gone before:

• It does not label you “neurotic” or otherwise deeply troubled because you are frigid or a premature ejaculator. Rather, it formulates the problem as local (my Layer V), not global.
  

• It treats the problem as the problem of a couple, not just of an individual: People are seen in pairs. (In some variations, if no partner shows up, there is a surrogate.)
  

• The couple directly practices sex with the advice and instructions of the therapist. Typically, you spend one or two weeks in daily therapy. Instruction occurs during the day, and then the couple retires to the privacy of a hotel to practice what is prescribed. They report their progress the next morning.
  

Direct sex therapy is not a do-it-yourself affair, and therapists can now be found in almost all major American population centers. Ask your prospective therapists if they use Masters and Johnson techniques. The treatment of all the dysfunctions is similar, so I will illustrate only one.

Cindy has never had an orgasm, and her marriage to Bob is starting to unravel. They travel to Philadelphia to work with two therapists at the Marriage Council. In the second session, Cindy is taught how to masturbate with a vibrator. Afterward, alone, she has her first orgasm. This builds her confidence and dissolves some of her fear of the unknown. Next, Bob is instructed to start participating
—
gradually. That night, he just watches Cindy climax. The following night, he holds the vibrator. The night after that, he touches her clitoris lightly with his lubricated finger while she masturbates. Cindy begins to spectate at this phase and is encouraged to have wild sexual fantasies to distract herself. That hurdle past, Cindy and Bob go on to
sensate focus,
a graduated sequence of reciprocal caresses in which giving and receiving is emphasized. This culminates in
nondemand
intercourse
—
intercourse with no expectation or pressure to have orgasm. Cindy has two orgasms during the first session of nondemand intercourse. Six years after therapy, Cindy almost always has orgasms during intercourse
.

Direct sexual therapy treats all of the major sexual dysfunctions, except for retarded ejaculation in men, with high success rates—70 to 95 percent. Once successful treatment is accomplished, not much relapse occurs.
³⁰

Conclusion

The idea of
depth
organizes our erotic life and affects how changeable it is. Sexual identity and sexual orientation are very deep and don’t change much, if at all. Sexual preference and sex role are of middling depth and, accordingly, change somewhat. Sexual dysfunction is a surface problem that with proper treatment can change readily. This is the beginning of a global theory, and what depth really means and how it applies across all of our lives is the topic of
chapter 15
.

I want to end here with the most common and least understood sexual problem. So ordinary is this problem, so likely are you to suffer from it, that it usually goes unnoticed. It doesn’t even have a name. The writer Robertson Davies dubs it
acedia.
³¹
Acedia used to be reckoned a sin, one of the seven deadly sins, in fact. Medieval theologians translated it as “sloth,” but it is not physical torpor that makes acedia so deadly. It is the torpor of the soul, the indifference that creeps up on us as we age and grow accustomed to those we love, that poisons so much of adult life.

As we fight our way out of the problems of adolescence and early adulthood, we often notice that the defeats and setbacks that troubled us in our youth are no longer as agonizing. This comes as welcome relief, but it has a cost. Whatever buffers us from the turmoil and pain of loss also buffers us from feeling joy. It is easy to mistake the indifference that creeps over us with age and experience for the growth of wisdom. Indifference is not wisdom. It is acedia.

The symptom of this condition that concerns me is the waning of sexual attraction that so commonly comes between lovers once they settle down with each other. The sad fact is that the passionate attraction that so consumed them when they first courted dies down as they get to know each other well. In time, it becomes an ember; often, an ash. Within a few years, the sexual passion goes out of most marriages, and many partners start to look elsewhere to rekindle this joyous side of life. This is easy to do with a new lover, but acedia will not be denied, and the whole cycle happens again. This is the stuff of much of modern divorce, and this is the sexual disorder you are most likely to experience. I call it a disorder because it meets the defining criterion of a disorder: like transsexuality or S-M or impotence, it grossly impairs sexual, affectionate relations between two people who used to have them.

Researchers and therapists have not seen fit to mount an attack on acedia. You will find it in no one’s nosology, on no foundation’s priority list of problems to solve, in no government mental health budget. It is consigned to the innards of women’s magazines and to trashy “how to keep your man” paperbacks. Acedia is looked upon with acceptance and indifference by those who might actually discover how it works and how to cure it.

It is acedia I wish to single out as the most painful, the most costly, the most mysterious, and the least understood of the sexual disorders. And therefore the most urgent.

12

Dieting: A Waist Is a Terrible
Thing to Mind

I
JUST HAD LUNCH
. A really classy buffet—twenty-two dollars for all I could eat—my nemesis. I can’t resist trying everything and then going back for more of the things that taste especially good. I realized after the very first plateful—shrimp, sashimi, and potato salad—that my stomach was full and I didn’t need any more. But I kept going back: a plate of the cold cuts, rolls and butter, then some more shrimp and some smoked salmon, then the hot dishes—duck and onions, and blackened chicken with sausage—and a token bit of vegetable. Then the salads (the avocado-and-bacon was great) and the fresh fruit. Then I topped it off with three desserts: the white chocolate mousse, the carrot cake, and the cherry pie.

How do I feel now? Stuffed, certainly. But fat, ugly, unhealthy, and ashamed as well.

I have been watching my weight and restricting my intake—except for an occasional binge like this—since I was twenty. I weighed about 175 pounds then, maybe 15 pounds over my official “ideal” weight (“big-boned and barrel-chested,” I told myself). I weigh 199 pounds now, thirty years later, about 25 pounds over the “ideal.” “I’ve had a sedentary adulthood: writing, doing research, seeing patients, teaching,” I tell myself, “and I only started exercising—a half-mile swim every day—last year.” I have tried about a dozen regimes—fasting, the “Beverly Hills Diet,” no carbohydrates, Metrecal for lunch, 1,200 calories a day, low fat, no lunch, no starches, skipping every other dinner. I lost 10 or 15 pounds on each in about a month.

I lied: I had to quit the Beverly Hills thing—all the pineapple and watermelon I could eat—because I got such bad diarrhea. The pounds always came back, though, and I have gained a net of about a pound a year—inexorably.

This is the most consistent failure in my life. It’s also a failure I can’t just put out of mind, like the failure to get rid of my slice at golf. There are too many reminders, every time I look in the mirror and every time I look at a tempting dish. In thirty years of dieting, this is what I’ve been trying to achieve:

• I want to be more attractive. I hate this two-inch spare tire.
  

• I want to stay healthy. My father had a stroke at just my age.
  

• I want to feel zestier. I am often tired and irritable.
  

• I want to feel that I am in control, not that I’m a grown man defeated by a carrot cake.
  

Pretty sound reasons. I think I should keep at it. Okay, no dinner tonight, only coffee (with saccharin) tomorrow morning, no dessert for the rest of the week.

Not so fast. I have spent the last few years reading the scientific literature, not the parade of best-selling diet books or the flood of women’s magazine articles on the latest way to slim down. The scientific findings look clear to me, but there is not yet a consensus. I am going to go out on a limb in this chapter, because I see so many signs all pointing in one direction. What I have concluded will, I believe, soon be the consensus of the scientists. The conclusions surprise me. They will probably surprise you, too, and they may change your life.

Here is what the picture looks like to me:
¹

• Dieting doesn’t work.
  

• Dieting may make overweight worse, not better.
  

• Dieting may be bad for health.
  

• Dieting may cause eating disorders—bulimia and anorexia.
  

Are You Overweight?

Here is an “ideal weight” chart. Are you above the “ideal” weight for your sex, height, and age? If so, you are “overweight.” What does this really mean? “Ideal” weight is arrived at simply. Four million people, now dead, who were insured by the major life-insurance companies of America were once weighed and had their height measured. At what weight on average do people of a given height turn out to live longest? That weight is called “ideal,” or “desirable.” Anything wrong with that?

You bet. The real use of the table, and the reason your doctor takes it seriously, is that an “ideal” weight implies that, on average, if you slim down to yours, you will live longer. This is the crucial claim. Lighter people indeed live longer, on average, than heavier people, but how much longer is hotly debated.