It has such a varied etiology that a formalized frequency table for professional consideration is contraindicated at this time. Yet significant consideration must be devoted to dominant sources from which the fears of performance common to all forms of male sexual dysfunction can and do develop.
Every man is influenced to a major degree by his sexual value system, which reflects directly the input from his psychosocial background.
Over the centuries the single constant etiological source of all forms of male sexual dysfunction has been the level of cultural demand for effectiveness of male sexual performance. The cultural concept that the male partner must accept full responsibility for establishing successful coital connection has placed upon everyman the psychological burden for the coital process and has released every woman from any suggestion of similar responsibility for its success.
If anatomical anomalies such as vaginal agenesis or an imperforate hymen are exempted and the psychological dysfunction of vaginismus is discounted, it could be said provocatively that there has never been an impotent woman.
Woman need only make herself physically available to accomplish coital connection or even to propagate the race. Legions of women conceive and raise families without ever experiencing orgasm and carry coition to the point of male, ejaculation with little physical effort and no personal, reactive involvement.
During coition woman has only to lie still to be physically potent. While this role of total passivity is no longer an acceptable psychological approach to sexual encounter in view of current cultural demand for active female participation, it is still an irrevocable physiological fact that woman need only lie still to be potent.
Any biophysical or psychosocial influence that can interfere with the male partner's ability to achieve and to maintain an erection can cast a shadow of conscious doubt upon the effectiveness of his coital performance, and, in due course, upon his concept of the state of his masculinity.
Once a shadow of doubt has been cast, even though based only on a single unsatisfactory sexual performance after years of effective functioning, a man may become anxious about his theoretical potential for future coital connection. With the first doubt raised by any failed attempt at sexual connection in the past comes the first tinge of fear for the effectiveness of any sexual performance in the future.
There are a number of theoretical factors and a combination of psychological, circumstantial, environmental, physiological, or even iatrogenic factors that can raise the specter of the fear of performance in the always susceptible mind of the male in our culture, be he 14 or 84 years of age.
It should come as no surprise that in the referred population of sexually dysfunctional men, by far the most frequent potentiator of secondary impotence is the existence of a prior state of premature ejaculation, and that the second most frequent factor in onset of secondary impotence can be directly related to a specific incident of acute ingestion of alcohol or to a pattern of excessive alcohol intake per se.
Of course, both the factors of premature ejaculation and alcoholism accomplish their unfortunate purpose in the onset of impotence through engendering fears of performance.
In premature ejaculation
The fears of performance usually develop as the result of a slow but steady process of attrition spanning a period of years and are purely psychosocial in origin. In alcoholism the fears of performance usually develop rapidly, almost without warning, as the immediate result of untoward psychic trauma on circumstantial bases.
By reason of the diverse patterns of clinical onset as well as the marked variation in their rapidity of development, these two major etiological factors will be considered in some detail, with the discussion amplified by representative case histories.
An established pattern of premature ejaculation prior to the onset of the symptoms of secondary impotence has been recorded in 63 of the total 213 men evaluated and treated for secondary impotence in the past 11 years. The premature ejaculation tendencies usually have been established for a significant period of time (generally a matter of years) before the symptoms of secondary impotence develop.
The fact that the prior existence of a pattern of premature ejaculation often leads to secondary impotence is yet another reason for clinical confusion in the textual listing of the premature ejaculator as an impotent male. There is no established percentage of premature ejaculators who progress to secondary impotence.
While the number is of considerable moment, this by no means suggests that a majority of premature ejaculators become secondarily impotent. A composite history typical of the sequential pattern of secondary impotence developing in a man distressed by prior symptoms of premature ejaculation is presented in detail.
Typically, the man is married, with some college education. Married in his mid-twenties, he usually is well into his thirties or even mid forties before onset of the symptoms of secondary impotence forces him to seek professional support.
Sexual dysfunction (premature ejaculation) has existed throughout the marriage. This man has had a moderate degree of sexual experience before marriage with, perhaps, three to five other partners, and has the typical premature ejaculator's history of having been conditioned in a rapid ejaculatory pattern during his first coital opportunities.
If authority has been approached in the interest of learning ejaculatory control, the results of such consultation have been essentially negligible in terms of improved sexual function. Professional relief of the psychosexual tensions created for the marital union by the continued existence of this form of sexual dysfunction rarely is sought until the youngest of any children of the marriage is at least of school age.
By this time the female partner has little tolerance for the situation. She no longer can contend with the frustrations inherent in a relatively constant state of sexual excitation, occasional, if ever, release of her sexual tensions, and rare, if ever, male consideration of her unresolved sexual demands.
Over the years of the marriage (ten to twenty), the issue of the husband's rapid ejaculatory termination of their coital encounters has been raised repetitively.
The wife's complaint was initially registered quietly, even questioningly; in time, complainingly or accusingly; and finally, demandingly, shrewishly, or contemptuously, as her personality and the immediate levels of her sexual frustration dictated.
The male partner, rarely made aware of the inadequacy of his sexual performances during premarital sexual experience, and frequently totally insensitive to his wife's levels of sexual frustration during the early years of marriage, finally accepts the repetitively hammered concept that the dysfunctional state of their marital sexual status is "his fault" and, consequently, that he must "do something."
And so he tries. As described in premature ejaculation, he bites his lips; thinks of work at the office; plans tomorrow's activities; constricts the rectal sphincter; counts backwards from one hundred.
In short, does everything to distract himself from his partner's obvious demands for sexual fulfillment during coital connection. Insofar as possible, he consciously turns off both the functional and the subjective projections of his wife's sexual demands in order to reduce the input of his sexual stimuli.
For instance whenever his wife reaches that level of sexual tension that finds her responding to sexually oriented stimuli almost involuntarily (a high-plateau tension level), the physically obvious state of her sexual demand drives her husband rapidly toward ejaculation. The beleaguered premature ejaculator, trying for control, employs any or all of the subjectively distracting tactics described above.
Thus, as much as possible, he not only denies the objective demand for his ejaculatory response inherent in his wife's pelvic thrusting, but also attempts to deny generally the subjective feeling of vaginal containment and specifically the constrictive containment of the penis by her engorged orgasmic platform.
Insofar as possible, he compulsively negates the obvious commitment of her entire body to the elevated levels of her sexual demand. Whether or not this man ever acquires nominal physiological control of his premature ejaculatory tendencies by employing his diversionary tactics, one half of the mutually stimulative cycle that exists between sexually responsive men and women certainly has been dulled or even totally obviated.
This conscious dulling or even negating of input from his wife's physical expressions of sexual demand is his first unintentional step toward secondary impotence.
There is marked individual variation in the particular moment at which the wife's repetitively verbalized complaints of inadequacy of ejaculatory control were extrapolated by the husband into a conscious concern for "inadequacy of sexual performance." Once the premature ejaculator develops any in depth concept that he is sexually inadequate, he is ripe for psychosocial distraction during any sexual encounter.
While his wife continues to berate his premature ejaculatory tendencies as "his sexual failure," as "not getting the job done," as "being totally uninterested in her sexual release," or as "evidence of his purely selfish interests," the reasonably intelligent male frequently develops a protean concern for the total of his sexual prowess.
Once a premature ejaculator questions the adequacy of his sexual performance, not only does he worry about ejaculatory control, but he also moves toward over concentration on the problem of satisfying his wife. While over concentrating in an attempt to force effective sexual control, he subjectively blocks full sensate input of the stimulative effect of his wife's sexual demand.
Frequently, the pressured male resorts to a time honored female dodge: that of developing excuses for avoiding sexual activity. He claims he is tired not feeling well or has important work to do the next day.
He displays little interest in sexual encounter simply because he knows the result of any attempted sexual connection will probably be traumatic at best physical release for him but not satisfaction for his wife, and at worst a disaster of argument Or vituperation.
There is further blocking of the inherent biophysical stimulation derived from the consistent level of mutual sexual awareness that prevails between sexually adjusted marital partners and a depreciation of the importance of mutual communication within the security of the marital bed.
Finally, the turning point. The wife pushes for sexual encounter on an occasion when the husband is emotionally distracted, physically tired, and certainly frustrated with his sexual failures. In a naturally self-protective sequence, he is totally uninterested in sexual encounter. When the husband is approached sexually by his demanding partner, there is little in the way of an erective response.
For the first time the man fears that he is dealing with a sexual dysfunction of infinitely more gravity than the performance inadequacy of his premature ejaculatory pattern. Once this man, previously sensitized to fears of sexual performance by his wife's repetitively verbalized rejection of his rapid ejaculatory tendencies, fails at erection, fears of performance multiply almost geometrically, and his effectiveness as a sexually functional male diminishes with parallel rapidity.