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A clinical study of “coital anxiety” in male potency disorders
Journal of Psychosomatic Research, Vol. 13, pp. 143 to 147. Pergamon Press, 1969. Printed in Northern Ireland
A CLINICAL STUDY OF "COITAL ANXIETY" IN MALE POTENCY DISORDERS ALAN J. COOPER* (Received 27 September 1968)
MANY authorities of widely different psychiatric schools from the psychoanalytic, to the behavioral, cite anxiety as being the most important cause of male potency disorders, Fenichel [1], Stekel [2], Vanderveldt and Odenwald [3], Gutheil [4], Allen [5], Stafford-Clark [6], Rachman [7], Wolpe [8], respectively, to mention only a representative sample. In a previous study, however, the author was unablc to demonstrate any statistical association between "anxiety" (or "neurosis") as measured by (a) a standard psychological test (The N.S.Q.--Scheier and Cattell [9]) or (b) as judged clinically and "psychogenic" potency disorders (Cooper [10]). The author concluded that "neurosis" or neurotic tendencies may be associated only rarely with "psychogcnic potency disorders". Another possible interpretation of this seeming paradox might be that standard psychological tests, although helpful in confirming and quantifying clinical neuroses, in general, may be inappropriate and even misleading in the case of psychogenic potency disorders. Accordingly as a working tool, the author set out to develop and define a psychosomatic concept of "coital anxiety" and to examine its clinical relevance and usefulness, especially as a prognostic pointer in male potency disorders. AIMS OF THE PRESENT
INVESTIGATION
The main objectives were as follows: (1) To define and examine (a) quantitatively and (b) qualitatively, coital anxiety in a group of patients who presented in a psychiatric clinic with "psychogenic" potency disorders, and (2) to undertake a statistical examination to identify relationships between "coital anxiety" and the response to treatment. MATERIALS AND METHOD 49 patients satisfied the selection criteria of (a) presenting with a primary disorder of potency, (viz., cases which would generally be considered by most authorities to be psychogenic, but excluding those secondary to psychoses, drugs, endocrinopathies, or other "medical conditions", etc.). The typcs of disorder, the mean ages, and the mean duration of the disorder is seen in Table 1, and (b) attending for a minimum of 20 fortnightly treatment sessions during one year. The treatment of these cascs which consisted of an optimum combination of (a) training in deep muscular relaxation, (b) provision, as far as possible of optimum sexual stimulation for the male by the female, (c) sex education, and (d) psychotherapy, has been fully described elsewhere (Cooper [11]); it will not be reiterated here.
Method of assessing coital anxiety "Coital anxiety" was defined as anxiety related temporarily to the act of coitus, (either imagined or actual) or sexual overtures and stimulations (imagined or actual) short of intercourse, but which * From the Dept. of Psychiatry, Edinburgh University. Present address: University of Missouri School of Medicine, Missouri Institute of Psychiatry, 5400 Arsenal Street, St. Louis, Missouri 63139. Reprint requests should be addressed to North Wing, Royal Edinburgh Hospital, Morningside Terrace, Edinburgh 10, Scotland. 143
144
ALAN J. COOPER
the male subject believed at the time would culminate in a coital attempt, but not to other life situations or events. Each subject at referral was asked to rate himself (currently) accordingly to the following 4 point psychosomatic scale. (1) Marked anxiety was when an individual experienced somatic (at least two of the following: sweating, trembling, muscular tension, headaches, palpitations, and any other bodily symptoms clearly related temporally to coital attempts, either imagined or actual), as well as subjective feelings of anxiety which were recognized as being severe. (2) Moderate anxiety consisted of one of the above mentioned somatic manifestations together with subjective feelings of moderate degree. (3) Mild anxiety was rated when subjective feelings only were present; which although recognizable by a subject as anxiety, had been mild in intensity. (4) No anxiety. TABLE 1. DISTRIBUTION OF PATIENTS AT REFERRAL ACCORDING TO CLINICAL TYPE OF DISORDER
No.
~
Mean age at referral (yr)
Acute impotence Insidious impotence Impotentia ejaculandi Premature ejaculation
7 19 13 10
14-1 38'9 26-5 20.5
25-3 35.1 34 28.3
19-30 23-49 20-42 23-30
1 '9 7"1 5-8 1.31"
Totals
49
100K
31-8
19-49
4.8
Type of disorder*
Range (yr)
Mean duration of disorder (yr)
Range (yr) 9 mos-2-5 2-15 1-11 ---
(Impotentia ejaculandi = delayed or absent ejaculation in the presence of normal erection.) * Since sometimes more than one type of disorder had coexisted in any one individual, at the same time, patients were classified according to the type of disorder which had predominated in the year prior to referral. 1"Generally, premature ejaculation had only become recognized as a "medical problem" following marriage, although in many cases it was clear that it had existed since adolescence. In an attempt to evalue the possible aetiological significance of anxiety, each subject was asked to assign himself to one of the following categories according to that point in time when he became "'consciously aware" of anxiety during coitus. "Early onset" coital anxiety refers to anxiety which developed in close ten-_poral relationship (viz., just prior to, at the time of, or closely following) the first or an early failure. "Late onset" coital anxiety refers to anxiety which developed months or years after the onset of the potency disorder. Patients were only so classified if they were absolutely certain of the time relationships. RESULTS AND DISCUSSION (I) Levels of coital anxiety The distribution of patients according to the self rating of coital anxiety and the type of clinical presentation is seen in Table 2. For comparison, Table 2 also shows the previously published data for the same series of "anxiety" as measured by the N.S.Q. and as judged clinically as a frank neuroses (Cooper [11]). (2) Analysis of the main causes of coital anxiety Table 3 shows the frequency distribution of "consciously aware" specific anxieties experienced and recognized during coital activity; "fear of failure" which was the most frequently mentioned (36 cases) coital anxiety correlated significantly with (a) a fear of being seen by their spouses as sexually inferior (mentioned 20 times--43"5 per cent), (b) a fear of being ridiculed on account of this, (mentioned 19 times--40 per cent) and (d) a fear that their penises were too small (mentioned 7 times--15.2 per cent). (3) Temporal relationship of coital anxiety to onset of disorder Table 4 shows (a) the relationship of "coital anxiety" to the time of onset of the potency disorder, (b) the type of clinical presentation at referral, and (c) the outcome of treatment.
A clinical study of "coital anxiety" in male potency disorders
145
TABLE 2.
D I S T R I B U T I O N OF PATIENTS A C C O R D I N G TO SELF RATING OF " C O I T A L A N X I E T Y " AND PREVIOUSLY REPORTED ( C O O P E R [ I 0 ] ) DATA OF ANXIETY AS MEASURED BY THE N.S.Q. AND JUDGED CLINICALLY
Self rating of coital anxiety
NSQ Anx. score No. ~ n = 49
No.
~ n = 49
Marked anx. Moderate anx. Mild anx.
25 15 6
51 '0 Suggested ------sten > 8 30"6 Suggested ~ sten 8 12-3 Suggested ------sten 7
11 4 4
22.4 8'15 8'15
Totals
46
93"9 ~
19
38"7 ~
Clinical diagnosis of neurosis* No. ~ n = 49 6 (5 anx. states, 1 obsessional neurosis)
12.2
12"2
* Psychoneuroses was diagnosed if a patient had definite symptoms of (a) anxiety, (b) obsessional behaviour, (c) hysterical conversion or dissociation, or (d) depressed mood sufficiently severe to impair work or social capacity. TABLE 3. SPECIFIC ANXIETIES* MOST FREQUENTLY ASSOCIATED WITH COITAL ATTEMPTS Specific anxiety
Number of times mentioned
n = 46
26
56"3
20 19 11 7 7 5 3
43'5 40.0 24"0 15-2 15.2 11.0 6.7
Fear of failure Fear of being seen by wife as sexually inferior Fear of ridicule (from wife) Fear of pregnancy Anxiety over size of genitals Fear of physical disease Pervasive anxiety (no specific cause) Fear of detection
* Table 3 refers to manifest anxieties experienced by the patient during coital attempts. Only anxieties specifically and spontaneously (sometimes with a minimum of prompting) mentioned by the patient, were included. No attempt was made either to "interpret" the statements, or to unearth fears that may have been "unconscious". The majority of the patients complained of three or more specific anxieties. TABLE 4.
RELATIONSHIP OF COITAL ANXIETY TO ( a ) THE TIME OF ONSET OF THE POTENCY DISORDER, (b) THE TYPE OF CLINICAL PRESENTATION, AND (C) THE OUTCOME OF THERAPY
Relationship of coital anx. to onset of potency disorder
Type of clinical presentation
No.
~
Early onset coital anxiety
13
26.5
6 ac. imp., 5 prem. ejac. 2 imp. ejac.
Late onset coital anxiety Uncertain
24
49.0
12
24.5
16 insid, imp., 3 prem. ejac., 5 imp. ejac. 3 insid, imp., 2 prem. eiac., 1 ac. imp., 6 imp. ejac.
Totals
49
100 ~
49
ac. imp. = acute impotence imp. ejac. = impotentia ejaculandi prem. ejac. = premature ejaculation insid, imp. = insidious impotence
Outcome of treatment "Early onset" significantly better outcome than "late onset" (Fisher Test)/7 < 0-05
146
ALAN J. COOPER
The present findings of 94 per cent who experienced some degree of recognizable anxiety during coitus is in marked contrast to the previously reported data (for the same series) of 39 per cent anxious on the N.S.Q. (sten > 7) and only 12 per cent who presented clinically with a frank psychoneuroses (Table 2); this figure of 94 per cent is consistent with the many experts who cite anxiety as being seen in association with potency disorders in the great majority of cases (Stekel [2]; Allen [5]; Wolpe [8], etc.). The breakdown of specific anxieties experienced and recognized is set out in Table 3. The most significant single finding "fear of failure" was often part of a generalized feeling of inadequacy; the sexual component often appeared to be just one facet of this wider personality deficiency; many of these men had anticipated problems in handling an adult heterosexual relationship even prior to marriage, which in some cases had been approached with apprehension. The majority had limited premarital experience and were generally naive sexually; many had deliberately avoided sexual contact with females fearing confirmation of their misgivings. Seven subjects mentioned a "fear of physical disease" as a factor impairing their potency. Three unmarried patients were anxious of contracting venereal disease; whilst 4 married subjects who rationalized their potency disorders as due to "organic damage" through masturbation, etc. sustained during adolescence, were fearful in case repeated intercourse produced additional "damage" and an exacerbation of their impotence. Gutheil [4] felt that such irrational fears could often be traced to official publications, which directed at susceptible and suggestible, sexually ignorant youths, could seriously threaten their adult potency. Gutheil quoted The United States Public Health Service Bulletin (1937) and the Boy Scout Manual (1945) which exhorted the youth to avoid "wasting the vital fluid" (masturbation); they imply dire consequences to the nonconforming. Three single men, who out of necessity had conducted their sexual activities mainly out of doors, expressed anxiety, which was realistically related to being detected during coital attempts. In respect of the outcome of treatment, there was no relationship statistically between either the quantitative self rating of anxiety or the specific anxieties most frequently mentioned and the therapeutic response. The former was somewhat surprising to the present author who expected on a priori ground to confirm Rachman's [7] assertion that highly anxious impotents did worse in treatment (behavior therapy) than mildly or non-anxious subjects. On clinical scrutiny, however, the temporal relationship of anxiety to the onset of the potency disorder seemed to have a greater influence on the therapeutic response than anxiety levels. This clinical observation was corroborated statistically (Table 4 p < 0.05) with patients in the "early onset" coital anxiety group doing significantly better in therapy than those in which coital anxiety had been a late development. Detailed examination of the clinical histories suggested an interpretation of this finding: Although the incidence of coital anxiety was high, only in a comparatively few cases (14 per cent--all acute onset impotence) could it be confidently indicted as a specific cause. Most of these patients previously chaste and usually sexually inexperienced had developed considerable apprehension prior to, and in anticipation of a first or early intercourse. Their situation had often been exacerbated by a partner who was herself inexperienced and chaste. The usual developmental pattern in these cases was that following an initial failure, a subsequent attempt often made hurriedly, or in a panic, had also failed, or at best had been only partially successful. The additional anxiety engendered had
A clinical study of "coital anxiety" in male potency disorders
147
p r o d u c e d further loss o f confidence and had seemingly consolidated the d i s o r d e r - an inhibitory vicious circle of anxiety had been created and was strengthened by each fresh failure. Despite their failures, however, the acute onset patients were clearly "potentially" sexually responsive,--they were all indulging f r o m time to time in self masturbation to orgasm and ejaculation with g o o d erections; all had experienced spontaneous erections to erotic stimuli, such as sexually attractive females, suggestive films and literature, and sexual fantasies. M o r n i n g erections, on awakening were also c o m m o n . The m o s t striking feature o f these patients was their obvious capacity to respond erotically. It seemed that coital anxiety in this group might be the consequence o f an incapacity to transform a powerful emotional desire for intercourse into successful physical union. This view gains some support f r o m previous w o r k by the author, which showed a significant relationship between the level o f coital anxiety and the strength o f sex drive, subjects with stronger drives experiencing higher levels o f anxiety during coital activity (Cooper [10]). In contrast, in insidious impotence and impotentia ejaculandi, in which there had been a progressive decline in sexual interest and performance over m o n t h s or years, the most consistent finding was sexual indifference or apathy. In these patients, anxiety had more often developed and become maximal m o n t h s or years after the potency disorder had become established; it seemed to be the consequence of, rather than the cause of this disorder. Clinical investigation suggested that coital anxiety was often the result o f castigation or complaint by a frustrated, u n h a p p y spouse, who had suffered her husband's deficiency over months or years. It was this sudden, often bitter and traumatic confrontation rather than his physical failure per se, that seemed responsible for the anxiety. Indeed, in those males who had not been castigated, anxiety was minimal or absent. SUMMARY (1) A psychosomatic concept of "coital anxiety" is defined. Its usefulness as a clinical entity is examined in 49 patients who presented in a psychiatric clinic with a primary disorder of sexual potency. (2) The findings (94 per cent rated as anxious) in contradiction to a report published previously by the author, using conventional clinical examination and a standard psychometric scale (N.S.Q.), support the widely held view that anxiety is seen in the majority of cases of male potency disorders. (3) An examination of the temporal relationship of the coital anxiety to the onset of the potency disorder, suggested 2 main categories, viz., "early onset" (developing just prior to, at the time of, or shortly after) and "late onset (developing months or years later); the findings suggested early onset anxiety was in large measure causal, whilst "late onset" was consequential. Early onset patients had a significantly better outcome in therapy (p < 0.05) than late onset patients.
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.
REFERENCES FENICHELO. Collected Papers: First Series, Norton, New York (1953). STEKELW. Impotence in the Male, Liveright, New York (1927). VANDERVELOTJ. H. and ODENWALOR. D. Psychiatry and Catholicism (1952). GtrrHEm E. H. Sexual dysfunctions in men. In American Handbook of Psychiatry (edited by ARIETI,S.), Basic Books, New York (1959). ALLENC. ,4 Textbook of Psychosexual Disorders, Oxford University Press, London (1962). STAFFORD-CLARKD. The aetiology and treatment of impotence. Practitioner 172, 397 (1954). RACHMANS. Sexual disorders and behaviour therapy. Am. J. Psychiat. 118, 235 (1961). WOLPEJ. Psychotherapy by Reciprocal Inhibition, Stanford University Press, Stanford (1958). SCHEIERI. H. and CAT'rELLR. A. Handbook for the Neuroticism Scale Questionnaire (1961). COOPERA. J. Neurosis and disorders of sexual potency in the male. J. Psychosom. Res. 12, 141 (1968). COOPERA. J. Unpublished M.D. Thesis, University of Bristol (1967).
A CLINICAL STUDY OF "COITAL ANXIETY" IN MALE POTENCY DISORDERS ALAN J. COOPER* (Received 27 September 1968)
MANY authorities of widely different psychiatric schools from the psychoanalytic, to the behavioral, cite anxiety as being the most important cause of male potency disorders, Fenichel [1], Stekel [2], Vanderveldt and Odenwald [3], Gutheil [4], Allen [5], Stafford-Clark [6], Rachman [7], Wolpe [8], respectively, to mention only a representative sample. In a previous study, however, the author was unablc to demonstrate any statistical association between "anxiety" (or "neurosis") as measured by (a) a standard psychological test (The N.S.Q.--Scheier and Cattell [9]) or (b) as judged clinically and "psychogenic" potency disorders (Cooper [10]). The author concluded that "neurosis" or neurotic tendencies may be associated only rarely with "psychogcnic potency disorders". Another possible interpretation of this seeming paradox might be that standard psychological tests, although helpful in confirming and quantifying clinical neuroses, in general, may be inappropriate and even misleading in the case of psychogenic potency disorders. Accordingly as a working tool, the author set out to develop and define a psychosomatic concept of "coital anxiety" and to examine its clinical relevance and usefulness, especially as a prognostic pointer in male potency disorders. AIMS OF THE PRESENT
INVESTIGATION
The main objectives were as follows: (1) To define and examine (a) quantitatively and (b) qualitatively, coital anxiety in a group of patients who presented in a psychiatric clinic with "psychogenic" potency disorders, and (2) to undertake a statistical examination to identify relationships between "coital anxiety" and the response to treatment. MATERIALS AND METHOD 49 patients satisfied the selection criteria of (a) presenting with a primary disorder of potency, (viz., cases which would generally be considered by most authorities to be psychogenic, but excluding those secondary to psychoses, drugs, endocrinopathies, or other "medical conditions", etc.). The typcs of disorder, the mean ages, and the mean duration of the disorder is seen in Table 1, and (b) attending for a minimum of 20 fortnightly treatment sessions during one year. The treatment of these cascs which consisted of an optimum combination of (a) training in deep muscular relaxation, (b) provision, as far as possible of optimum sexual stimulation for the male by the female, (c) sex education, and (d) psychotherapy, has been fully described elsewhere (Cooper [11]); it will not be reiterated here.
Method of assessing coital anxiety "Coital anxiety" was defined as anxiety related temporarily to the act of coitus, (either imagined or actual) or sexual overtures and stimulations (imagined or actual) short of intercourse, but which * From the Dept. of Psychiatry, Edinburgh University. Present address: University of Missouri School of Medicine, Missouri Institute of Psychiatry, 5400 Arsenal Street, St. Louis, Missouri 63139. Reprint requests should be addressed to North Wing, Royal Edinburgh Hospital, Morningside Terrace, Edinburgh 10, Scotland. 143
144
ALAN J. COOPER
the male subject believed at the time would culminate in a coital attempt, but not to other life situations or events. Each subject at referral was asked to rate himself (currently) accordingly to the following 4 point psychosomatic scale. (1) Marked anxiety was when an individual experienced somatic (at least two of the following: sweating, trembling, muscular tension, headaches, palpitations, and any other bodily symptoms clearly related temporally to coital attempts, either imagined or actual), as well as subjective feelings of anxiety which were recognized as being severe. (2) Moderate anxiety consisted of one of the above mentioned somatic manifestations together with subjective feelings of moderate degree. (3) Mild anxiety was rated when subjective feelings only were present; which although recognizable by a subject as anxiety, had been mild in intensity. (4) No anxiety. TABLE 1. DISTRIBUTION OF PATIENTS AT REFERRAL ACCORDING TO CLINICAL TYPE OF DISORDER
No.
~
Mean age at referral (yr)
Acute impotence Insidious impotence Impotentia ejaculandi Premature ejaculation
7 19 13 10
14-1 38'9 26-5 20.5
25-3 35.1 34 28.3
19-30 23-49 20-42 23-30
1 '9 7"1 5-8 1.31"
Totals
49
100K
31-8
19-49
4.8
Type of disorder*
Range (yr)
Mean duration of disorder (yr)
Range (yr) 9 mos-2-5 2-15 1-11 ---
(Impotentia ejaculandi = delayed or absent ejaculation in the presence of normal erection.) * Since sometimes more than one type of disorder had coexisted in any one individual, at the same time, patients were classified according to the type of disorder which had predominated in the year prior to referral. 1"Generally, premature ejaculation had only become recognized as a "medical problem" following marriage, although in many cases it was clear that it had existed since adolescence. In an attempt to evalue the possible aetiological significance of anxiety, each subject was asked to assign himself to one of the following categories according to that point in time when he became "'consciously aware" of anxiety during coitus. "Early onset" coital anxiety refers to anxiety which developed in close ten-_poral relationship (viz., just prior to, at the time of, or closely following) the first or an early failure. "Late onset" coital anxiety refers to anxiety which developed months or years after the onset of the potency disorder. Patients were only so classified if they were absolutely certain of the time relationships. RESULTS AND DISCUSSION (I) Levels of coital anxiety The distribution of patients according to the self rating of coital anxiety and the type of clinical presentation is seen in Table 2. For comparison, Table 2 also shows the previously published data for the same series of "anxiety" as measured by the N.S.Q. and as judged clinically as a frank neuroses (Cooper [11]). (2) Analysis of the main causes of coital anxiety Table 3 shows the frequency distribution of "consciously aware" specific anxieties experienced and recognized during coital activity; "fear of failure" which was the most frequently mentioned (36 cases) coital anxiety correlated significantly with (a) a fear of being seen by their spouses as sexually inferior (mentioned 20 times--43"5 per cent), (b) a fear of being ridiculed on account of this, (mentioned 19 times--40 per cent) and (d) a fear that their penises were too small (mentioned 7 times--15.2 per cent). (3) Temporal relationship of coital anxiety to onset of disorder Table 4 shows (a) the relationship of "coital anxiety" to the time of onset of the potency disorder, (b) the type of clinical presentation at referral, and (c) the outcome of treatment.
A clinical study of "coital anxiety" in male potency disorders
145
TABLE 2.
D I S T R I B U T I O N OF PATIENTS A C C O R D I N G TO SELF RATING OF " C O I T A L A N X I E T Y " AND PREVIOUSLY REPORTED ( C O O P E R [ I 0 ] ) DATA OF ANXIETY AS MEASURED BY THE N.S.Q. AND JUDGED CLINICALLY
Self rating of coital anxiety
NSQ Anx. score No. ~ n = 49
No.
~ n = 49
Marked anx. Moderate anx. Mild anx.
25 15 6
51 '0 Suggested ------sten > 8 30"6 Suggested ~ sten 8 12-3 Suggested ------sten 7
11 4 4
22.4 8'15 8'15
Totals
46
93"9 ~
19
38"7 ~
Clinical diagnosis of neurosis* No. ~ n = 49 6 (5 anx. states, 1 obsessional neurosis)
12.2
12"2
* Psychoneuroses was diagnosed if a patient had definite symptoms of (a) anxiety, (b) obsessional behaviour, (c) hysterical conversion or dissociation, or (d) depressed mood sufficiently severe to impair work or social capacity. TABLE 3. SPECIFIC ANXIETIES* MOST FREQUENTLY ASSOCIATED WITH COITAL ATTEMPTS Specific anxiety
Number of times mentioned
n = 46
26
56"3
20 19 11 7 7 5 3
43'5 40.0 24"0 15-2 15.2 11.0 6.7
Fear of failure Fear of being seen by wife as sexually inferior Fear of ridicule (from wife) Fear of pregnancy Anxiety over size of genitals Fear of physical disease Pervasive anxiety (no specific cause) Fear of detection
* Table 3 refers to manifest anxieties experienced by the patient during coital attempts. Only anxieties specifically and spontaneously (sometimes with a minimum of prompting) mentioned by the patient, were included. No attempt was made either to "interpret" the statements, or to unearth fears that may have been "unconscious". The majority of the patients complained of three or more specific anxieties. TABLE 4.
RELATIONSHIP OF COITAL ANXIETY TO ( a ) THE TIME OF ONSET OF THE POTENCY DISORDER, (b) THE TYPE OF CLINICAL PRESENTATION, AND (C) THE OUTCOME OF THERAPY
Relationship of coital anx. to onset of potency disorder
Type of clinical presentation
No.
~
Early onset coital anxiety
13
26.5
6 ac. imp., 5 prem. ejac. 2 imp. ejac.
Late onset coital anxiety Uncertain
24
49.0
12
24.5
16 insid, imp., 3 prem. ejac., 5 imp. ejac. 3 insid, imp., 2 prem. eiac., 1 ac. imp., 6 imp. ejac.
Totals
49
100 ~
49
ac. imp. = acute impotence imp. ejac. = impotentia ejaculandi prem. ejac. = premature ejaculation insid, imp. = insidious impotence
Outcome of treatment "Early onset" significantly better outcome than "late onset" (Fisher Test)/7 < 0-05
146
ALAN J. COOPER
The present findings of 94 per cent who experienced some degree of recognizable anxiety during coitus is in marked contrast to the previously reported data (for the same series) of 39 per cent anxious on the N.S.Q. (sten > 7) and only 12 per cent who presented clinically with a frank psychoneuroses (Table 2); this figure of 94 per cent is consistent with the many experts who cite anxiety as being seen in association with potency disorders in the great majority of cases (Stekel [2]; Allen [5]; Wolpe [8], etc.). The breakdown of specific anxieties experienced and recognized is set out in Table 3. The most significant single finding "fear of failure" was often part of a generalized feeling of inadequacy; the sexual component often appeared to be just one facet of this wider personality deficiency; many of these men had anticipated problems in handling an adult heterosexual relationship even prior to marriage, which in some cases had been approached with apprehension. The majority had limited premarital experience and were generally naive sexually; many had deliberately avoided sexual contact with females fearing confirmation of their misgivings. Seven subjects mentioned a "fear of physical disease" as a factor impairing their potency. Three unmarried patients were anxious of contracting venereal disease; whilst 4 married subjects who rationalized their potency disorders as due to "organic damage" through masturbation, etc. sustained during adolescence, were fearful in case repeated intercourse produced additional "damage" and an exacerbation of their impotence. Gutheil [4] felt that such irrational fears could often be traced to official publications, which directed at susceptible and suggestible, sexually ignorant youths, could seriously threaten their adult potency. Gutheil quoted The United States Public Health Service Bulletin (1937) and the Boy Scout Manual (1945) which exhorted the youth to avoid "wasting the vital fluid" (masturbation); they imply dire consequences to the nonconforming. Three single men, who out of necessity had conducted their sexual activities mainly out of doors, expressed anxiety, which was realistically related to being detected during coital attempts. In respect of the outcome of treatment, there was no relationship statistically between either the quantitative self rating of anxiety or the specific anxieties most frequently mentioned and the therapeutic response. The former was somewhat surprising to the present author who expected on a priori ground to confirm Rachman's [7] assertion that highly anxious impotents did worse in treatment (behavior therapy) than mildly or non-anxious subjects. On clinical scrutiny, however, the temporal relationship of anxiety to the onset of the potency disorder seemed to have a greater influence on the therapeutic response than anxiety levels. This clinical observation was corroborated statistically (Table 4 p < 0.05) with patients in the "early onset" coital anxiety group doing significantly better in therapy than those in which coital anxiety had been a late development. Detailed examination of the clinical histories suggested an interpretation of this finding: Although the incidence of coital anxiety was high, only in a comparatively few cases (14 per cent--all acute onset impotence) could it be confidently indicted as a specific cause. Most of these patients previously chaste and usually sexually inexperienced had developed considerable apprehension prior to, and in anticipation of a first or early intercourse. Their situation had often been exacerbated by a partner who was herself inexperienced and chaste. The usual developmental pattern in these cases was that following an initial failure, a subsequent attempt often made hurriedly, or in a panic, had also failed, or at best had been only partially successful. The additional anxiety engendered had
A clinical study of "coital anxiety" in male potency disorders
147
p r o d u c e d further loss o f confidence and had seemingly consolidated the d i s o r d e r - an inhibitory vicious circle of anxiety had been created and was strengthened by each fresh failure. Despite their failures, however, the acute onset patients were clearly "potentially" sexually responsive,--they were all indulging f r o m time to time in self masturbation to orgasm and ejaculation with g o o d erections; all had experienced spontaneous erections to erotic stimuli, such as sexually attractive females, suggestive films and literature, and sexual fantasies. M o r n i n g erections, on awakening were also c o m m o n . The m o s t striking feature o f these patients was their obvious capacity to respond erotically. It seemed that coital anxiety in this group might be the consequence o f an incapacity to transform a powerful emotional desire for intercourse into successful physical union. This view gains some support f r o m previous w o r k by the author, which showed a significant relationship between the level o f coital anxiety and the strength o f sex drive, subjects with stronger drives experiencing higher levels o f anxiety during coital activity (Cooper [10]). In contrast, in insidious impotence and impotentia ejaculandi, in which there had been a progressive decline in sexual interest and performance over m o n t h s or years, the most consistent finding was sexual indifference or apathy. In these patients, anxiety had more often developed and become maximal m o n t h s or years after the potency disorder had become established; it seemed to be the consequence of, rather than the cause of this disorder. Clinical investigation suggested that coital anxiety was often the result o f castigation or complaint by a frustrated, u n h a p p y spouse, who had suffered her husband's deficiency over months or years. It was this sudden, often bitter and traumatic confrontation rather than his physical failure per se, that seemed responsible for the anxiety. Indeed, in those males who had not been castigated, anxiety was minimal or absent. SUMMARY (1) A psychosomatic concept of "coital anxiety" is defined. Its usefulness as a clinical entity is examined in 49 patients who presented in a psychiatric clinic with a primary disorder of sexual potency. (2) The findings (94 per cent rated as anxious) in contradiction to a report published previously by the author, using conventional clinical examination and a standard psychometric scale (N.S.Q.), support the widely held view that anxiety is seen in the majority of cases of male potency disorders. (3) An examination of the temporal relationship of the coital anxiety to the onset of the potency disorder, suggested 2 main categories, viz., "early onset" (developing just prior to, at the time of, or shortly after) and "late onset (developing months or years later); the findings suggested early onset anxiety was in large measure causal, whilst "late onset" was consequential. Early onset patients had a significantly better outcome in therapy (p < 0.05) than late onset patients.
1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.
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