The male can not obtain or maintain an erection satisfactory to him for the purposes of heterosexual intercourse.

The following are the three classifications of impotence on the basis of etiology:

a. Organic disease causing impotence (anatomic abnormality; neuralgic disease, systemic disease; trauma, either accidental or surgical; and hormonal deficiency);

b. Chemical or medical impotence (drugs of a narcotic or sedative nature, morphine, alcohol, and medicines like anti-hypertensives, etc):

c. Psychological impotence.

However, what is most interesting is that of two men with exactly the same organic problem, one may have impotence problems and the other none at all.

Despite the large number of known organic causes, most authorities seem to agree that most of the causes of impotence stem from psychological reasons. One point that most agree upon is that anxiety or fear seems to play an important role. Learning interpretations generally see impotence problems as the result of conditioned anxiety, and treatment is largely aimed at reducing the anxiety associated by the approach to sexual intercourse.

Treatment for impotence includes psychoanalytic therapy, rational - emotive therapy, hypnosis, mechanical means such as splints and artificial phalluses, poetic “hypnograms”, post hypnotic suggestions and long - terms psychotherapy.

Learning oriented approaches usually use graded sexual responses in the actual sexual situation, if some sexual arousal is reported, or systematic desensitization if no arousal is present. Salter (1961) has reported success in using a combination of assertive training, and blended imagining. Wolpin (1969) has reported good results with his technique of guided imagining.

Cautela describes successful results by using covert negative reinforcement. His impotent client was asked to imagine and aversive scene, such as his boss yelling at him, and then he was immediately switched to a scene in which he was lying in bed naked and relaxed next to his wife. More recent treatment has been based on a broad spectrum coverage, such as the combined use of thought stopping, systematic desensitization, and sexual assertion.

Problems in this area usually being with some precipitating events such as the following: fatigue, preoccupation, jet lag, overdrinking, criticism by a partner, being bored with a partner, having a non - attractive partner, worry over to early ejaculation, fear of disease or pregnancy, guilt over masturbation, homosexual responses or unfaithfulness, pr anxiety associated with expected performance either by the partner or the client himself. Whatever the precipitating event, it is the male’s reaction to it that will most likely affect subsequent performance. He begins to doubt his “manhood” and he becomes anxious through the self - labeling process. He will approach his next sexual encounter with a great deal of anxiety and worry commonly called “fear of performance,” which also effectively blocks his normal arousal system and thus results in another failure. Once this chain starts to function, it can be quite difficult to break.

Occasionally, such problems result from direct training instead of anxiety chaining. It is important to know whether the client ever experiences erections and under what circumstances (e.g., fantasy stimulation, tactile stimulation, alone, with partner, etc.)

Treatment from a learning point of view is usually directed at reducing or eliminating the anxiety that is associated with the approach to sexual paradoxical intention or successive approximation principles.

The following treatment suggestions are divided into three categories: suggestions to the (1) male alone, (2) the female alone, and (3) the couple. The man should be encouraged to have his partner come in with him; and, the woman similarly. When the couples comes in together and they are willing to cooperate with the treatment suggestions, there is always a higher probability that they will achieve their goals. However in Pakistan it is rare for the wife to come, the man usually comes alone.

(a) Suggestions to the male

Letting the client know that he is not alone and that most men are sometimes unable to have an erection at some point in their lives, can do much to reassure the client.

It is further suggested that the client be asked to inform his partner of what he has learned and what he has been asked to try so as to enlist her cooperation and patience.

The initial suggestion that may be given is redirection of attention, that an erect penis is not particularly necessary for mutual sexual gratification, and this may encourage the client to explore other options. The clinician can further remind him that he still has his hands, fingers, legs, arms, mouth, lips, and tongue and that any one or combination of them may be very stimulating to his partner, possibly to the point of orgasm. In this way his natural arousal system may begin to function again and he may obtain an erection. However, caution should be given to him that he should not necessarily “use” his erection, should it happen, as there is always another time.

An alternate suggestion is one called suffering. He is asked to engage in whatever behaviour that he and his partner desire, and at some point when he is feeling comfortable and perhaps aroused to some degree, he or his partner literally “stuff” his penis into the vagina. There is no goal, other than pleasurable sensation for both. If he should “happen” to find that he has an erection, certainly enjoy the experience but that is not the main point of the suggestion and he is not to continue further if he feels the least bit anxious about his erection. The third suggestion is graded sexual response. He is told to engage in mutual sexual gratification with his partner, as often as possible, in whatever way that he and his partner would like, up o the point where he experiences his first sign of anxiety. At that point he is to stop. They can relax, cuddle, share a drink together, take a shower together whatever they would like. Then, start again.

Or, when he experiences the first sign of anxiety he is to stop whatever he is doing or about o do and return to an earlier point where no anxiety was present. There is no reason that his partner cannot experience orgasm through whatever means they feel comfortable, as long as they both desire it. He is instructed to gradually keep trying to extend his sessions past the point where he was before. But he is always to sop when his anxiety signal begins, remembering, there is always another day.

For self stimulation he has to involve himself in whatever activity or stimulation that has been arousing to him. This may involve attending motion pictures, reading books, using pictures, or fantasies. Whatever he finds arousing he is given “permission” to use, and at the same time he is to actually stimulate himself in the way that brings on the most pleasurable feelings. It may be help to suggest to him that rather than use his dominant hand in self - stimulation he is to use his non - dominant hand. In other words, if he regularly uses his right hand for self - stimulation, he is asked to start using his left hand, or vice versa. Many clients report highly positive results because this provides a “different” penile sensation and that the penis feels much larger than it ever has before.

Assuming that a level of 40% erection is reached, then henceforth, he is to use whatever fantasy or visual aid that he likes, and he is to stimulate in the way that he finds most arousing, but he is not to experience orgasm unless he obtains and erection of 40% or better. If, at a particular session he is unable to reach 40% and he becomes fatigued or bored, he is to stop, remembering that there is always the next time. Gradually, by following these successive approximation procedures, he may eventually reach a full erection with such self - stimulation.

For the client who has no difficulty with erections through self - stimulation, or for the client who has now learned to obtain them, it is suggested that he start systematically to use fantasies during such self -stimulation that involve him having a firm erection while engaging in sexual behaviour with a partner.

When the client is able to become involved with a partner, then the suggestions given previously for men with partners may also be given to him. Conversely, where appropriate, these suggestions can also be given to men already involved with partners.

(b) Suggestions to the female

In the case of fear of performance of her husband the female client may be advised to deliberately try to stimulate him in different situations, besides formal sexual intercourse, e.g. while driving a car, or sitting for dinner or watching a movie etc. she should be encouraged to continue to engage in regular sexual activity with him without any expectation of performance on his part, other than to just share some pleasurable activity together. She may also be given some other suggestions, like in a partial erection, if the penis is pushed downward, pressure and stimulation are increased and the erection becomes more firm. Stimulation of the base of the penis also puts pressure on the major blood vessels to retain blood. In the woman underneath position, raising the level of the vagina with pillows or pads beneath the woman may be initially helpful. The woman on top position is also helpful, for it allows insertion and a firmer vaginal hold even on a partial erection. In this way she can provide most of the initial movement stimulation. Other positions that may be helpful in promoting erection are the sitting position with rear entry to the vagina, side by side, the face to rear positions, or the woman on her back and drawing her knees up before parting her legs.

(c) Suggestions to the couple

The treatment of sexual impotence (Masters & Johnson Method)

The treatment of impotence will be outlined according to the number of sessions conducted with the patients and his marital partner. In the following format the sessions may not automatically follow each other, for if it is felt that the husband and wife have not mastered and enjoyed a session, it should be repeated as often as necessary. Thus the treatment duration will be different for different couples. For best results husband and wife should be residing in a hotel or a hospital but if this is not possible they may attend the out patient clinic daily or as often as they can come. In newly married couples, wives are seen only once or twice or not at all as they cannot leave the house repeatedly, without arousing concern in the family.

Session No 1

(a) History:- (i) Psychiatric (ii) Sexual

History taking involves more than the standard psychiatric interview. Basically it comprises of a detailed inventory of sexual attitudes and experiences in all phases of life, alongwith similar data of the marital partner and their mutual psychological and sexual interaction. The sexual history questionnaire is included at the end of this monograph.

(b) Examination:- (i) General (ii) Genital

After a complete physical examination, the genitals are also examined, for the satisfaction of the patient as well as to rule out any local pathology, for it seems most patients have a mistaken feeling that their genitals are either not fully developed or they have been deformed by masturbation and other sexual use. In the vast majority of the cases the genitals are absolutely normal and the patients should be informed of this in an emphatic manner, in order to alleviate all anxiety about this matter.

Session No. 2

Sex Counseling

The couple is told that the cause of sexual problems is mutually shared and the treatment of these problems can only be brought about my mutual efforts and co-operation. Attempts are made to resolve misunderstanding and conflict between he husband and wife, if any, and to create an atmosphere of understanding, love and Affection.

The anatomy and physiology of the male and the female sex organs is demonstrated to them through explanation and use of pictures. Then it is pointed out to them that sex is pleasurable and that sex between husband and wife is considered equivalent to worship by Islam. They are also encouraged to express their feelings about sex to each other, as well as to the therapists, including feeling of pleasure in sex.

Session No. 3

Then they are both instructed in the sexual exercise called “sensate focus” by Masters and Johnson. The husband and wife should be completely relaxed in their bedroom and completely naked. The husband is instructed to fondle, massage and otherwise rub with his hands the body of his wife in order to give her maximum pleasure. In this session the breast and the genitals are not touched. This session should be continued as long as it is pleasurable for both the partners, which a maximum of about half an hour.

After that the wife is to perform the same pleasuring to her husband but the genitals are not touched. The husband and wife are to guide each other verbally and non-verbally as to the parts of the body and methods of touching that give the most pleasure.

The couple should use their favourite perfume, and the bed room should also be properly decorated, in order to increase the sexual and sensate stimulation.

Session No 4

The experience and feelings of the previous session are discussed. If that session was not enjoyed by both it is repeated otherwise the partners are now allowed to touch the genitals and breast in addition to the whole body. In order to facilitate the stimulation of the penis by the wife it is suggested that she apply a little olive oil for that purpose. The husband and wife are now encouraged to have a good look at the sexual anatomy of their partner, specially the husband, who is asked to have a close look at his wife’s genitals, so that no more doubt about the exact structure linger in his mind. Husband and wife must also guide the stroking hand of their partner and indicate directly the parts of the body and the type of stroking that gives the maximum pleasure, specially in the area of the genitals.

Session No. 5

Experience and feelings of the previous session are discussed. If the couple enjoyed that session then this session is advised however, whenever this session is practiced, it must always be preceded by session No. 4 as given above.

It is pointed out to both husband and wife that erection cannot be voluntarily caused. When stroking of the body, specially the penis, automatically leads to erection, it is suggested that the marital unit enjoy this return to erective prowess by experimenting with the erective reactions. This is called the “teasing technique” and this includes manipulative play to cause an erection, cessation of the play to allow a period of distraction for the male wit consequent loss of erection, then return to play and resurgence of erective attainment. This should be continued for about half an hour, in a slow non-demanding fashion.

Session No. 6

Repeat session No. 4 and session No. 5. Then the husband should lie down on his back and the wife should sit on top of him in such a position that her knees are at or below the husband’s nipple line and then she should initiate penile play and the teasing procedure. However, if a full erection is obtained, she should insert the penis wit her own hand into her vagina. Even during the insertion into the vagina, she should continue active manual manipulation of the penile shaft. Both husband and wife should quietly enjoy the pleasure of penile containment in the vagina. No trusting movement should be made by either partner and the position should be maintained for as long as it is enjoyable to both partners.

Session No. 7

Repeat session 4, 5 and 6. However, when the penis is inside the vagina, the wife is asked to move slowly up and down on the shaft of the penis. Then she in turn should remain without movement and the husband is encouraged to thrust slowly, concentrating on the sensate pleasure to be derived from the feelings of vaginal containment and warmth, and the sensation engendered by his wife’s lubrication. This should also be continued as long as desired by both the partners.

Session No. 8

Repeat session 4, 5, 6 and 7. Hen both partners are encouraged to move to simultaneous pelvic pleasuring, feeling, and thinking, concentrating only on the sensations involved in this mutuality of their sexual stimulation. There must not be concern for satisfying the wife or forcing ejaculation by the husband. When the end point of sexual functioning comes during coition, it should be by chance, involuntarily, naturally and mutually rewarding, but never by direction.

Conclusion

Usually when he couple come in for the next session, they somewhat seephisly report that they did not quite follow instructions. The first session is generally reported as initially embarrassing, then fun, and finally arousing. By the second or third session the male is usually experiencing full erections and having a difficult time refraining from genital intercourse. Many times they are so happy about the situation that they say “to hell with the instructions” and go ahead.

For those few cases where the couple managed to refrain from genital intercourse but now request it, the clinician can suggest that they continue on the same program for one more week unless the male has an “overpowering urge” to have genital relations, and if he does, he may go ahea