“Performance” anxiety, indeed! That’s precisely the problem: thinking of sex as a performance, as something we are doing that is being scrutinized and evaluated by an audience. This performance mindset leads many men to be self-conscious, self-critical, worried, tense and anxious while being sexual. This in turns often results in bringing about the very problem they were worrying about in the first place: erectile dysfunction, premature ejaculation or difficultly experiencing orgasm.
These sexual problems can be caused by various medical conditions, or may even result from—or be made worse by—various medications you may taking. If you experience these problems frequently while being sexual with someone else, but seldom experience them while being sexual by yourself, then it is unlikely that a medical problem or medication is the principle cause. But if you are unsure, consult with your physician first for an assessment. In addition, there are medications available that can help with these sexual problems, although sometimes with side effects. In addition, these medications sometimes have the effect of reinforcing the tendency to focus on “performance” rather than pleasure, which keeps the problem alive.
Stage fright: vicious cycles & self-fulfilling prophecies
Evaluating our “performance” while we are performing typically results in hurting our performance. This vicious cycle occurs in all sorts of social anxiety: making social conversation, speaking in groups, performing on stage…or having sex.
Let’s take an example of a true performance in front of an audience: an actor (or other stage performer, public speaker or athlete). Certainly it makes sense that the actor wants to please the audience. But if the actor is monitoring and critiquing her performance while she is performing—and worrying about what the audience is thinking while she is acting—she is likely to perform less well due to distraction and self-consciousness.
The same is true for people making conversation…or making love: monitoring and evaluating how we think we are doing, and worrying about the other person is reacting to us, tends to have a negative impact on how well the conversation or the sex goes, and how much we and our partners enjoy it. Ironic, isn’t it?! We’re doing all this self-monitoring and self-evaluation in an effort to make things go better, but that strategy backfires badly on us!
Mindful focus: being in the moment, not in your head
The constructive alternative to self-monitoring is focusing our attention on the experience in the moment, and to to treat any self-evaluative and worrying thoughts as unimportant background noise. This is called mindfulness. For the actor, mindful focus means throwing herself utterly into the role, and saving evaluation until the performance is over. For the conversationalist, mindful focus means focusing with curiosity what is being said in the moment, and saying whatever comes to mind naturally, without scripting.
For the man being sexual, mindfulness means focusing our attention on any or all of the pleasurable sensations we are experiencing in the moment–touch, sight, sound, smell, taste—as well as focusing on any pleasant emotions we may be experiencing—excitement, affection, enjoyment. Mindfulness when being sexual also means distancing—defusing—from any evaluative or worrying thoughts and feelings we may be having, treating them like unimportant background noise.
Well, this takes a lot of practice! Some of us have become so used to self-evaluating and worrying while being sexual—and often before and after being sexual, too—that it’s unrealistic to expect us to suddenly be in the moment the next time we have sex. And if you wait until having sex to try to be mindfully focused, there’s a chance that you will start evaluating how well you are being in the moment—which will only worsen self-consciousness and self-criticism.
Cognitive-behavioral therapy (CBT) homework practice
1. Cognitive restructuring (attitude change): Identify your belief about the sexual problem you are having. Typically, it’s something like “My partner and I won’t enjoy sex if I don’t perform really well (don’t get erect or lose an erection, ejaculate too soon, or never have orgasm).” Then write down a constructive alternative attitude that you believe, at least intellectually, such as: “My partner and I can greatly enjoy being sexual together if I focus on the pleasant sensations, feelings and experiences we are having, regardless of what my penis is doing!” Creating a new attitude that is both helpful and believable may take some discussion first, with your sexual partner, with a trusted friend, or with a cognitive-behavioral therapist (CBT).
2. Practice mindful focus while masturbating: Read your constructive attitude (from #1) before masturbating. Breathe slowly and deeply. Mentally scan your entire body for areas of muscle tension, and loosen up one area at a time. Then bring up a vivid image in your mind of you being sexual, and perhaps romantic, with a partner. Focus on this image while slowly masturbating, as well as touching other areas of your body that please you. Leave yourself plenty of time; don’t rush it. Most importantly, focus on the pleasurable sensations—touch, sight, sound, smell and taste—and the pleasurable emotions—excitement, affection, enjoyment—that you are experiencing in your image or in your body.
Practice mindful focus on imagery while masturbating regularly, and vary the imagery when you do. Don’t limit your imagery to sex going the way you most prefer. It is important that some of the time you do imagery of enjoying the sexual experience even when you are not erect in your image, or when you ejaculate soon or not at all in your image (regardless of what your body is actually doing). Don’t stop because you imagine losing an erection or ejaculating. Instead, keep the imagery going, and focus on continuing to give and receive pleasure with no shame, embarrassment or sense of apology. While doing so, practice setting aside any self-critical or worrying thoughts and feelings you may be experiencing as background noise, and return your attention to the pleasurable sensations and emotions you are experiencing in your imagery and in your body.
If you have problems with premature ejaculation, pay close attention to the physical sensations as you very slowly masturbate, and learn to distinguish the building sensations that immediately precede the point of ejaculation. Learn to occasionally change your touch to less sensitive areas of your penis and testicles to gain greater control over the way your body is responding. (This is more effective than stopping touch all together so as not to reinforce all-or-nothing thinking about genital pleasure.) Don’t distract yourself in an effort to delay ejaculation. Instead, keep your attention on your sensations, and set aside any self-critical thoughts and feelings as background noise.
One last point: physical relaxation is important when being sexual. Tension and anxiety often lead to sexual functioning problems (erectile dysfunction, premature ejaculation, and lack of orgasm). So, right before doing the sexual imagery exercises, practice muscle relaxation and slow, deep breathing to relax your body. Then, during the imagery and masturbation, continue to relax whenever you notice tension, but keep returning your focus to the pleasurable sensations and emotions.
3. Practice mindful focus while being sensual with a partner: Have you practiced the imagery exercises enough that you have become quite adept at physical relaxation, mindful focus on pleasurable sensations and emotions, and setting aside unpleasant thoughts and feelings? It is now time to begin practicing with a partner. If it is possible, it is best to talk to your partner first about your working on overcoming this problem. Explain to her or him that it is important to go very slowly; to be mutually supportive and not pressure each other; and to focus on the whole experience of pleasure, not just intercourse. And silently recite your constructive attitude before each sexual practice session together.
Ideally, the initial few practice sessions would involve focusing on taking turns pleasuring each other with sensual, but non-genital touch all over one’s body, so that there is no pressure to get or maintain an erection. Each of you might take turns giving and receiving pleasure for 15 minutes or so. The receiver may give gentle, non-critical, non-pressuring directions as to what he or she likes and doesn’t like. While giving or receiving, focus your attention mindfully on the pleasurable sensations and emotions you are experiencing, and set aside self-critical or worrying thoughts as background noise. It doesn’t matter what your penis is or isn’t doing! Just keep returning your attention to the pleasure, and treat any distressing thoughts and emotions as background noise. And remember to relax: proceed slowly, breathe slowly and deeply, and loosen any muscle tension in your body.
Continue these practice sessions as you become gradually more sexual with your partner in later sessions. As always: relax, and focus on the pleasurable sensations and feelings, not on evaluating your poor penis’ performance! If it turns out you do not get or maintain an erection, or you ejaculate earlier than you want or not at all, then set aside any self-critical thoughts and feelings as background noise, and return to focusing on giving and receiving pleasure.
Ideally, talk openly with your partner between practice sessions about feelings you both are having in your sexual experiences together. Hopefully such conversations will help to reinforce your constructive attitude that being sexual can be enjoyable even when it doesn’t go perfectly, so long as you focus on the pleasure and not on self-evaluation and worry.
Here are two very useful self-help cognitive-behavioral therapy (CBT) books for sexual anxiety and sexual dysfunction. (Unfortunately, these otherwise excellent books ignore LGBT people. Still, the content is highly helpful regardless of sexual orientation or gender identity.)
Coping with Erectile Dysfunction, by Michael Metz, PhD and Barry McCarthy, PhD.
Coping with Premature Ejaculation, by Michael Metz, PhD and Barry McCarthy, PhD.
by Larry Cohen, LICSW
Cofounder and Chair, National Social Anxiety Center; Director, NSAC District of Columbia
How to Get Help for Social Anxiety
The National Social Anxiety Center is a national association of regional clinics with certified cognitive therapists specializing in social anxiety and anxiety-related problems. Currently, we have regional clinics in San Francisco, District of Columbia, Los Angeles, Pittsburgh, New York City, Chicago, Newport Beach / Orange County, Houston / Sugar Land, and St. Louis. Contact our national headquarters at (202) 656-8566 or visit our Regional Clinics contact page to find help in your local area or if your clinic is interested in applying for membership.