The Sexual Performance Perfection Industry

The year was 1998 and reports of the medical breakthrough were being trumpeted throughout the media. On radio and television and in articles in all the major news magazines the message was the same:

Take one little blue pill and it’s as though you are eighteen years old again. Just one pill and all your sexual fears and inadequacies will disappear and be replaced with the joy and bliss of wonderful, exhilarating, spontaneous sex.

And because they wanted you to associate their pill with the strength and vigor you had during your honeymoon in Niagara Falls, Pfizer Pharmaceuticals named their new product Viagra.

Sound too good to be true? It is. That’s because in my thirty-five years as a clinical psychologist treating individuals and couples experiencing marital, relationship, or sexual distress, I have met surprisingly few men (or women) who remember their early sexual encounters as “blissful, wonderful, or exhilarating.” Instead they often remember them as filled with awkwardness and anxiety.

Those who place their hope for sexual bliss in Viagra will often agree that their early sexual experiences might not have always been great. But what they tell me is that although they don’t want to return to the ignorance and awkwardness of their youth, they do want to be able to function or perform as they did years earlier.

However, it is, in fact, the emphasis upon performance that is the basis for most sexual problems. It is the belief that “good sex requires expert performance and high standards of physical achievement” or that “men are always ready, willing, and eager for sex” that produces the very problems for which men and women will then come to my office for help.

The truth is that good sex has little or nothing to do with performance, and not much to do with erections, intercourse, or even orgasms. The fact is that good sex depends, not upon what is between our legs, but rather upon what is between our ears. In short, it is my assertion that whatever it is we mean by “good sex” is more likely to occur if it takes place in the context of a safe, non-competitive, and non-performance-oriented setting.

On the other hand, the definition of “good sex” as put forth by the “medical-surgical-pharmaceutical industrial complex,” among whom are the people who develop and sell products such as Viagra, goes something like this: “Good sex happens when a man inserts his rock-hard penis into a woman’s appropriately lubricated vagina and moves it around in there for a suitable amount of time. Under ideal circumstances this should continue until the man and the woman experience orgasm at exactly the same time.”

Judging from the amount of money being spent on developing medical interventions designed to make this definition of sex a reality for every American man and woman, this field of biotechnology research could be described as the research and development component of what I have coined the “sexual performance perfection industry.” This industry’s definition of good sex changes the basic nature of a sexual encounter from one of intimacy and pleasure to one of achievement and performance. In addition, these often unattainable standards of performance are guaranteed to make most of us feel like failures.

This attempt by the sexual performance perfection industry to restrict the definition of sex to “performance” and “intercourse” is not simply a benign, self-serving error by a few ill-informed researchers. The definition of sex, put forth by an industry in which Viagra is held out to the world as nothing less than the miracle medical breakthrough of the century, represents a phallocentric, sexist, and iatrogenic orientation to human sexuality. “Iatrogenic” refers to a treatment approach that itself causes or exacerbates the very problems it purports to be treating.

David Schnarch in his book Constructing the Sexual Crucible, makes a distinction that is relevant in this context. He writes that most couples are perfectly willing to settle for what might be called “workable” sex—sex in which men and women function just well enough to be able to have intercourse. He contrasts this with what he calls “wall-socket” sex, which he defines as the energy of “erotic connection comparable to one of sticking a finger in an electrical outlet.” Interestingly, Schnarch writes that wall socket sex does not “involve sticking anything into any body orifice; it occurs in the context of nongenital touch.”

It is this kind of workable sex—sex that requires little or no passion but allows us to keep our sexual “batting average” intact—that the medical establishment is now trying to sell us. In fact, couples coming to me for treatment are often quite willing to settle for little or no passion in their sexual lives in exchange for being able to say that they are a “normal” couple able to make sexual contact 2.5 times per week.

The mantra of the sexual performance perfection industry seems to go something like this: “Passion? That’s not important. Sexual intimacy? That’s a thing of the past. It’s performance that counts. All you need to do is take this little blue pill an hour before sex and you, too, will be able to make sex work for you. Take that pill every other day, at ten dollars a pill, and you, too, will be able to have that same predictable, reliable [albeit somewhat boring] kind of encounter. And did we mention that if the blue pill doesn’t work for you, then we can supply you with a vacuum device to allow you to pump up your penis, or a hypodermic syringe filled with aprostadil or papaverine to allow you to ‘inject up’ your penis, or even a surgical implant that will allow you to have a surgically enhanced, always-ready-and-willing-to-perform penis?”

The message communicated by this pervasive medicalization of male sexuality is a message guaranteed to provide a steady supply of new customers for the products of the sexual performance perfection industry. It is a message of fear and inadequacy. It tells us that we don’t measure up and that we will never measure up unless we become regular customers of the industry’s products.

But the truth is that the reason so many individuals experience disappointing sex has nothing to do with “plumbing”—at least not for the overwhelming majority of men or women. The problem with sex is not anything that a pump, an injection, a surgical implant, or even a blue pill can do anything about.The problem with sex is ignorance, anxiety, and our inability to communicate openly and honestly with our sex partners.

This was brought home to me recently during an initial consultation I was conducting with an unmarried 28 year-old man complaining of erectile dysfunction. At some point during that first interview, I asked this individual how he goes about telling each of his new sexual partners about his sexual concerns. My question was greeted with a look of horror. His nonverbal expression was of someone thinking to himself,

“I must be in the wrong office. Does this person really think I am going tohumiliate myself by actually telling some strange woman about my sexual insecurities? Heck, it took me three and a half years to get up the courage to call a psychologist. This guy must be nuts if he thinks I’m going to share my personal sexual history with some woman I will probably never see again.”

Of course the patient said none of that to me–at least not at first. Instead he said that he hasn’t said anything to any of the fifteen or twenty women with whom he had attempted intercourse. He simply hopes for the best, but invariably winds up being disappointed with the encounter. He then typically makes up some sort of excuse for his behavior–“I’m too tired or I’ve had too much to drink”—and then makes sure that he never sees the woman again. My guess is that his partner is probably thinking to herself, “I guess I just don’t turn him on.” That is followed by some variation on the following: “Of course I don’t turn him on. I’m just too fat (or) I’m just too skinny, (or) I’m just too flat-chested (or) I’m just not sexy enough. It can’t be his problem. It must be mine.” And when he never calls her again, she becomes even more certain of her theory.

Men such as this patient typically believe that engaging in sexual intercourse requires less intimacy and less openness than the intimacy required to share with a partner their sexual concerns. When questioned about this idea, these men typically answer that although they would attempt to have intercourse with virtually any willing partner, they would only be willing to communicate their sexual concerns with someone with whom they had, or were willing to have, a long-term relationship. And they never see the irony in that. They don’t realize that sex—at least the kind of sex that is going to ameliorate their sexual dysfunction—absolutely requiresthat they share their concerns with their partner.

It should be clear that these men do not want good sex. They don’t want satisfying sex. And they certainly don’t want “wall-socket” sex. What these men want—or at least are more than willing to settle for—is “workable” sex. That is, they want sex that allows them to get through the encounter with a minimum of shame, embarrassment, and humiliation. In fact, what they are asking for is the “sexual perfection industry” model of sex. Or as one patient once said to me, “I don’t want much. I just want a penis that gets hard on command.” And in fact, the medical establishment has, not coincidentally, set as its goal nothing less than this very same standard.

Parenthetically, it interesting to observe that the data on the causes of erectile dysfunction have changed over the years in direct proportion to the availability of treatment. Thus, when physicians had at their disposal few techniques or medical interventions to treat erection difficulties, it was widely reported in the medical literature (as well as in the media) that over 90% of all men presenting with erection concerns were experiencing what was then called psychogenic impotence. As the availability of medical, surgical, and pharmacological treatments has increased, so have the estimates of the organic causes of erection difficulties. Now it is not uncommon to read that at least 90% of all male sexual dysfunctions have an organic or medical cause.

To be fair, it should be noted that the fluctuating percentages of organic versus psychogenic dysfunction are partly a result of the differing settings in which the data are obtained. Research indicates that more than 45% of men evaluated in hospital-based urology departments are diagnosed with organic disorders. On the other hand, of the approximately 250 men I have treated over the years for erection or ejaculatory disturbances, fewer than 2% have had any detectable contributing medical condition—this in spite of the fact that I refer all of my patients to a urologist before beginning them on a psychotherapeutic treatment regimen.

These apparently contradictory findings are the result of a frequently overlooked experimental design flaw observed in studies in which individuals select their own provider when seeking treatment for a problem. For example, men with serious medical conditions such as diabetes, an illness associated with erectile dysfunction in as many as 50% of afflicted men, are likely to refer themselves to a physician rather than to a psychological practitioner. On the other hand, men who suspect that their “plumbing” is working just fine (for example, individuals having no difficulty with erections during masturbation) are likely to find their way to the office of a psychologist or other mental health professional. Calculating the psychogenic versus organic etiology of such disorders becomes virtually impossible with such non-random assignment of patients.

Nonetheless, the physician’s involvement in the diagnosis and treatment of male sexual dysfunction has been hailed by the medical establishment as well as by the popular press as an appropriate counterbalance to what had been described as the inflated claims of therapists concerning the ability of psychotherapy to treat these problems. It has been argued that these men should first be evaluated medically to rule out any neurological, physiological, hormonal, vascular, or other biochemical cause before beginning a regimen of expensive psychological treatment for erectile dysfunction. I should note at this point that in spite of the fact that for over 20 years the time-limited psychological treatment of sexual dysfunction has been shown to be both effective as well as inexpensive, psychotherapy is nonetheless often portrayed inaccurately in the media as an expensive, long-term process.

However, with the advent of the new, highly publicized, “comprehensive urology and impotence centers,” it appears that the pendulum has swung to the other extreme. Individuals will often spend weeks and thousands of dollars undergoing unnecessary medical tests to rule out any and all medical conditions. Sadly, even when all tests prove negative, many individuals are still offered medical solutions to what are more likely to be psychologically maintained problems. It is not uncommon for me to treat organically intact individuals who were first offered surgical or pharmacological treatments for their psychogenic sexual disturbances.

Certainly nothing written here is meant to demean the value of uncovering and treating those genuine medical conditions that can affect sexual functioning. However, it is my observation that some of my medical colleagues have become too zealous in the “medicalizing” of male sexuality. Among the consequences of this medicalization is the increasing risk of obscuring the more basic cause of most sexual problems—mainly theunrealistic sexual demands and expectations with which both men and women have been indoctrinated. These expectations are implicit within the harmful sexual myths that our culture has adopted. Among the most damaging of these myths is the notion that sex is a serious, competitive, task-oriented performance with “rigid” requirements for success or failure. This belief—in contrast to a more flexible definition of sex that emphasizes the unpredictable, relaxing, pleasurable, and intimate nature of the experience—is likely to produce significant sexual discomfort.

The current “sexual perfection” strategy seems to be, “First evaluate these men biologically and only after ruling out all possible medical causes and only after utilizing any and all surgical, pharmacological, or medical treatments should we then have them evaluated by a psychologist.” However, it is clear that many disorders of sexual functioning can be best diagnosed and treated by psychologists and other appropriately trained mental health providers rather than by physicians.

Lest I leave the reader with the wrong impression, I want to emphasize that my physician colleagues have an important role to play in the diagnosis and treatment of male (and female) sexual dysfunction. However, unless we recognize the deleterious implications of the current environment which encourages us to see all sexual concerns through the lens of the sexual performance perfection industry, medical intervention will, unfortunately, continue to be the preferred solution to a problem that is quite frequently nonmedical in nature.