Male masturbation habits and sexual dysfunctions (2016)

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COMMENTS: Top European sexologist warns that porn use is associated with ED and inability to ejaculate during sex. The author of this new paper is French psychiatrist Robert Porto MD, the current president of the European Federation of Sexology. The paper revolves around Dr. Porto's clinical experience with 35 men who had developed (otherwise unexplained) erectile dysfunction and/or anorgasmia, and his therapeutic approach to helping them. A quarter of his patients were addicted to porn, and the paper's abstract points to internet porn as a primary cause of the problems. (Keep in mind that masturbation [pornfree] does not cause chronic ED, and experts never cite it as a cause of ED.)

The main article is in French, but the abstract is in French and English.

Excerpts from the paper:

Intro: Harmless and even helpful in his usual form widely practiced, masturbation in its excessive and pre-eminent form, generally associated today to pornographic addiction, is too often overlooked in the clinical assessment of sexual dysfunction it can induce.

Results: Initial results for these patients, after treatment to “unlearn” their masturbatory habits and their often associated addiction to pornography, are encouraging and promising. A reduction in symptoms was obtained in 19 patients out of 35. The dysfunctions regressed and these patients were able to enjoy satisfactory sexual activity.

Conclusion: Addictive masturbation, often accompanied by a dependency on cyber-pornography, has been seen to play a role in the etiology of certain types of erectile dysfunction or coital anejaculation. It is important to systematically identify the presence of these habits rather than conduct a diagnosis by elimination, in order to include habit-breaking deconditioning techniques in managing these dysfunctions


Sexologies (2016)

R. Porto

48, boulevard Rodocanachi, 13008 Marseille, France

Available online 16 August 2016

Summary

Introduction.

After a long period of relative tolerance, masturbation was demonized and suppressed the eighteenth and nineteenth centuries, before being restored in the twentieth century and trivialized and even valued in recent decades as a result of sexual liberation, the advent of scientific sexology, and the development of media and the internet. Harmless and even helpful in the usual form widely practiced, masturbation in its excessive and pre-eminent form, generally associated today with pornographic addiction, is too often overlooked in the clinical assessment of sexual dysfunction it can induce.

Aim.

The aim of this article is to shed light on the role of idiosyncratic masturbation patterns in the onset of two male sexual dysfunctions; firstly, erectile dysfunction (ED), and secondly, coital anejaculation (CA), and to encourage physicians to include masturbation patterns in their sexological investigations with a patient.

Method.

Based on the very rare publications on the subject and his clinical experience of 35 cases, the author describes the mechanism of this conditioning and suggests some therapeutic solutions.

Results.

Initial results for these patients, after treatment to ‘‘unlearn’’ their masturbatory habits and their often associated addiction to pornography, are encouraging and promising. A reduction in symptoms was obtained in 19 patients out of 35. The dysfunctions regressed and these patients were able to enjoy satisfactory sexual activity. They are still being followed-up at longer intervals, or have been encouraged to come back in the event of recurrence of the disorder. These results show some potential efficacy and should now be confirmed by further controlled clinical studies.

Discussion.

The patients in our sample were not seeking help for masturbation addiction, but for their ED or CA. Addiction to masturbation and its idiosyncratic style are never mentioned spontaneously by these patients. In the first cases, in the absence of other significant factors that could be causing the dysfunction, the masturbation problem was uncovered during further interviews with the subject in more depth. For subsequent cases, this experience led us to investigate the subject’s masturbation patterns right from the initial assessment.

Conclusion.

Addictive masturbation, often accompanied by a dependency on cyber-pornography, has been seen to play a role in the etiology of certain types of erectile dysfunction or coital anejaculation. It is important to systematically identify the presence of these habits rather than conduct a diagnosis by elimination, in order to include habit-breaking deconditioning techniques in managing these dysfunctions.

[Paper]

There is no definite truth in science, just knowledge available at a given point in time. Pr Patrick Gaudray

The term Masturbation comes from the Latin manus (hand) or Greek mazea (penis) and turbare Latin (disrupt) (Dally, 1975).

Masturbation, sometimes called unfairly by onanism following an erroneous assimilation to biblical lack of Onan has long been condemned by morality and religion. In the eighteenth century, for decades, the auto-eroticism became unhealthy and even harmful especially under the influenceTissot (1760).

In the twentieth century, with the evolution of morals and development epidemiological surveys, we see it is a practice extremely widespread : 94% men (Kinsey et al., 1948), 63% (Nazareth et al. 2003), 73% (Gerressu, 2008); with a variation according to Age: 25-30 years of 2/3, ½ of the forties, 1/3 sixties (Herbenick et al., 2010). Regular practice would cover 40.3 % of men (Bajos et al., 2008), figures that is found in another French inquiry (Brenot, 2011) when added subjects who masturbate at least one once daily (11.1%) and those who do so at least once per week (31.4%).

Masturbation in its usual practice is more than liberalized nowadays and even recognized as having useful functions in connection with the evolution of customs: it facilitates the psychosexual development by awakening the sensations genital and this in both sexes (Carvalheira and Leal, 2013), can help with sexuality of the couple, can serve as a contraceptive method, be used an outlet for lonely and handicapped, is a prevention STDs, sexual offenses, and adultery when frequency of different desires in the couple... Inadequate erections during masturbation would be a predictive marker cardiovascular disease (Rastrelli et al., 2013). It also has diagnostic properties, for example to identify organic ED (Corona et al., 2010). It has also therapeutic applications in the treatment of orgasmic dysfunction (LoPiccolo and Lobitz, 1972). All these are additional arguments for taking into account masturbation habits the sexological evaluation.

On the other hand, there is a misuse of masturbation, as is the case for all sexual activity, when practiced for non-sexual reasons (a tranquilizer or as sleep inducer example).

However, a habitual or excessive use may cause disadvantages that we do not consider enough.

Note that in this regard, it is not ejaculation, the usual conclusion of auto-eroticism, which is harmful in itself, but the conditioning of the subject to a specific stimulation mode too far away from sensations felt during vaginal penetration.

Specific terms of masturbation

Although manual stimulation of the penis or by sliding the foreskin, either by direct friction or pressure on the glans (whether the subject is circumcised or not) is not the sole technique, it remains the most widespread. Other autoerotic habits are varied and limited only by the imagination of man and the progress of technology: They range from rubbing on a pillow or mattress to various vibratory devices, via stimulation anal, self-fellatio (which requires high flexibility and / or long penis) or the pseudo-erotic hanging (sometimes fatal !).

Added to this are the special features of the contact: full hand or two fingers, exclusively on the brake, by pinching, torsion, the force of the compression, the fast pace or slow, and of course the repetitive, often with reading vision or erotic-pornographic material. Furthermore, the subject can quickly seek ejaculatory pleasure or delay orgasm indefinitely by stopping before.

Autoerotic habits are too often forgotten during the evaluation of patients consulting for sexual dysfunction.

Some authors report a significant prevalence excessive masturbation in a wide range of dysfunction sex (Gerressu et al., 2008).

Of 596 men in heterosexual couples with sexual desire declined for the partner, 67 % reported masturbation usual common with pornography (Carvalheira et al. 2015).

The first description that identifies the relationship between style and idiosyncratic masturbatory and sexual dysfunction often returns Perelman (1994), who based on 75 cases of delayed ejaculation (RE) collected in five years, estimated that the high frequency masturbation (30% of its sample masturbated at least once a day) was highly correlated with ER (Perelman, 2004). More recently Gila Bronner (2014) stressed the importance of this question about 4 cases.

Let us understand that it is not ejaculation itself that is in question but rather habitual, repetitive, addictive penile stimulation. And of course, it is not a question of setting a frequency standard as to what disrupts the sexual functioning as this varies across subjects. The conditioning we speak of involves individual habits unique to everyone, including frequency, and equally dependent on the personality.

Some authors refer to compulsive masturbation (Coleman, 2011); this concerns cases where the motivation is to reduce anxiety as subjects who cannot fall asleep without masturbating or those who do it when they are stressed.

Others speak of impulsive behavior when motivation is the pursuit of pleasure; the latter being generally present in any sexual activity, we say therefore more likely that this is an impulse control disorder (Barth and Kinder, 1987).

There is talk of addiction to behaviors more or less uncontrolled, repetitive, which can be triggered by internal or external factors, which the subject finds hard to resist even when he is aware of their effects negative, and upon which he becomes dependent.

To stay at the clinic level, we find this conditioning, this dependence, via interrogation of patients consulting for DE [erectile dysfunction] or anejaculation coital, if one thinks to ask. In the absence of other causes, we can therefore assign to masturbatory conditioning the causal hypothesis of these dysfunctions. Frequent employment of cyber pornography during these masturbatory practices has other disadvantages: enabling users to avoid the risk of real relations, the illusion of social relationships, lack of empathy and especially the deficit in contact with others. The repetitive use of Internet porn alters the virtual psyche and the user makes do without the
more "dangerous" relational reality.

Risk factors

Originally this uncontrolled sexual behavior, was mentioned a pathology of attachment, narcissistic flaw, a disorder of emotion regulation, early trauma (and Seedall Butler, 2006; Seedall and Butler, 2008). It is often found in these subjects, at least in the initial timeline of their conditioning, a shyness, an emotional immaturity, fear of women, ignorance of their history and parental desires.

Pathophysiology

We will only consider the links between addictive masturbation and two male sexual dysfunctions : ED and anorgasmia coital [inability to ejaculate during intercourse]. Certain masturbatory habits seem to account for the emergence of an ED or coital based anejaculation via two processes that are superimposed:

• conditioning via repetition;
• the specific, idiosyncratic, means of self-stimulation.

The frequent practice of masturbation enhanced by orgasmic pleasure induces activation of certain brain circuits (the reward circuit) (Benedetti, 2014; Porto, 2014). This auto-erotic addictive activity creates an imprint in the brain circuitry of excitement, and autoerotism can become dominant thus making sexual intimacy with a partner difficult. These subjects eventually experience serious difficulties in obtaining an erection with their partner (ED) because they are conditioned to manual stimulation of the penis (without waiting for a "desire erection"), stimulation which gradually becomes indispensable to become erect.

Also, the almost universal association of masturbation with pornography (contextual reinforcement) makes recourse to the latter a necessity, making spontaneous erection impossible in terms of regular intimacy.

Similarly, conditioning the ejaculation trigger to special digital stimulation,
unique to each, renders ineffective the intravaginal sensations and induces coital anorgasmia in some subjects. This repetitive behavior in a specific context strengthens and becomes more automatic, pleasure playing the role of reward, and the process becomes addictive by a sort of neo-circuit habit/illness in the learning mechanisms.

But fortunately brain neuroplasticity allows deconditioning of a number of these patients.

Support

Psychological approach

Before any therapeutic approach, it is appropriate to give the patient a minimum of narcissistic consideration; renarcissisation is part of his support.

Helping the patient identify and employ his defense mechanisms appears more effective than a drastic ban. Deconditioning involves using the instinctual dynamic of the subject; introduce speech where there are only images, put words to describing feelings, identify the image (he could not embody?) the subject discovers, to ensure that the virtual no longer makes the screen real. We must seek and improve the subject’s skills of reworking and symbolizing and reintroduce the narrative dimension, helping the patient to open to another and enact his word.

Behavioral approach

Erectile Dysfunction by conditioning to 'passive masturbation"

We designate with this term subjects who do not wait for their excitement to bring about an erection, but cause it manually and seek frantically for ejaculation, so that erection becomes something so "useless", that it eventually disappears. This is often the case in intensive addiction to masturbation since adolescence, which causes the subject to stimulate even a soft penis in a compulsive search for orgasm.

It follows that in circumstances coital erection fails or only happens by self-masturbation.

Deconditioning passive masturbation calls for not stimulating at all in the usual manner, that is to say where the genital is passive and only the hand moves to cause (or not!) the erection and trigger orgasm. This is not to say a ban on self-stimulation but rather to allow only what we have called "active masturbation" (Porto, 2014). The patient must first be erect, either by spontaneous desire or by erotic imagination, and penetrate a steady, lubricated hand back and forth, in an imitation of coitus, while engaging in fantasy of sexual intercourse with a vagina. It is a program of systematic repetition for several weeks which can cause dishabituation.

Anejaculation coital orgasm by masturbatory conditioning

Adepts of self-stimulation, over years of intensive idiosyncratic masturbation, habituate themselves to difficulty during penetration.

They are unsettled by the difference in genital sensations experienced during intercourse, which are insufficient (pressure, speed and intensity are not the same).

One can also experience a psycho-emotional excitation failure, fantasies during intercourse being different.

The key to diagnosis is identifying the circumstances in which the subject may ejaculate.

These subjects often report "more excitement and pleasure by masturbation than sex" (Perelman, 2009).

On the other hand, "ejaculatory performance anxiety" about these issues can interfere with stimulating genital feelings and can divert their attention from psycho-erotic signals that normally trigger their ejaculation (Apfelbaum, 2000; Perelman, 1994, 2005).

We leave aside the example of some users of PDE 5 [sexual enhancement drugs] who get erections even when they do not feel, before and during coitus, enough psycho-erotic excitement to ejaculate... as they take their erection for sexual desire indicator while the effect is only a pharmacological vaso-congestive effect not always adequate for desire!

In summary, a high frequency of idiosyncratic masturbation with a disparity between fantasies and coitus promotes the onset of erection and ejaculation difficulties.

Deconditioning of these patients includes the following phases.

The masturbatory style of the subject must change. He must approach as much as possible the conditions imitating coital penetration always followed by intravaginal ejaculation once it is triggered manually.

It is therefore necessary to abandon any "passive masturbation" and to exclusively practice the "active masturbation" described above. In addition, the patient is encouraged to facilitate his orgasm using a higher excitation level via psychosexual fantasies present during masturbation.
All sexual intercourse should end with intravaginal ejaculation. To relearn, one must thus:

  • stop vaginal intercourse (eg. when the partner is willing);
  • cause ejaculation by masturbation;
  • then enter immediately to have ejaculation always take place in the vagina.

Practice the bridge maneuver with the collaboration of the partner. The "bridge maneuver" consists of associating the triggering stimulus with the less effective stimulation, in such a manner that once the conditioning is achieved, a sole stimulation will suffice to trigger. In practice, the patient, or better his partner, manually grips the penis while he performs all intravaginal movements. Gradually, one will stop manual stimulation earlier and earlier to possibly do without it totally.

Our sample

We collected 35 cases of addiction to passive masturbation (that is to say the manual self-stimulation of the penis, usually flaccid in the beginning, and high frequency), mean age 41.8 years, 19 to 64 years. The habit masturbatory lasted adolescence, at a frequency from multi-weekly (1) or daily (21), to multi-daily (7), twice daily (2), three times by day (3) and even five times per day (1).

Ten subjects had coital anejaculation, 25 subjects had erectile dysfunction. Of these, 5 cases showed both dysfunctions, 8 were also addicted to pornography and 8 also complained a significant decrease of libido. Biopsychosocial-Relational assessment did not find other potentially significant etiological factors, we chose addiction to masturbation and style as main targets of the cure, also treating possible pornographic addiction and resulting conjugopathy when that was the case. The duration of the treatment spread between 4 months for those who have been diligent and more a year for those who are discouraged and have stopped many times. Reversal requires one to three years.

Nineteen patients were dis-habituated from their conditioning, 3 are in progress, 13 have given up or disappeared from view.

Conclusion

Recall that historically it was necessary to fight for a long time to reemphasize the role of the mind in sexuality and how it was necessary to preach such that the psychological etiology would not be eliminated from diagnosis in sexology.

Since its inception, the AIUS never changed the affirmation of this thrust. Now, major international scientific societies in our discipline have rehabilitated psychogenic causes of sexual dysfunction integrating them into their recommendations.

If frequency of masturbation and it’s not uncommon persistence in a sometimes addictive form in partnered adults with partner were taken into account, it’s possible role in some sexual dysfunctions would not be so often neglected. The etiological role of masturbatory habits with respect to erectile dysfunction and coital anorgasmia should be studied systematically and should not be a diagnosis of exclusion, even if our approach requires a multidisciplinary assessment of our patients.

Declaration of interests

The author claims to have no interest links.

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