The Voluntary Control of Genital Response, Arousal, & Orgasm
Donald S. Strassberg
Department of Psychology, University of Utah
It is unlikely that the issue of control of sexual arousal represents much of a problem for
any organism other than humans. Getting aroused too quickly or to the “wrong” targets probably
does not represent a common challenge for most other species. For most organisms, sexual
arousal (including the physiological correlates of this arousal) and ejaculation/orgasm occur
largely without conscious attempts to exert any control over these processes. Among humans,
however, the story is often rather different. Experience, both direct and indirect, along with our
cognitive capacities allow for the enhancement as well as the interference with otherwise innate
sexual responsivity. Thus, the targets of our arousal are more varied than in other species, as
well as our capacities to consciously enrich or detract from our sexual pleasure via a variety of
cognitive and behavioral mechanisms.
While assessing this capacity for voluntary control of our sexual arousal has both
theoretical and clinical value, it also represents significant methodological challenges. Our usual
methods of assessment, involving questioning our research participants or clients, still has
substantial value, but they are complicated by the nature of sexual arousal. What exactly are the
best questions to ask? How accurate are men and women in assessing their current and past
sexual arousal? When might they be inclined to misrepresent such evaluations, either to us or to
themselves? Can genital plethysmography help to avoid the methodological complications of
relying on self-reports? If so, how shall we handle the frequently reported lack of consistency
between self-reports and plethysmographic assessment of arousal, particularly among women
and under some conditions more than others? How much do we need to worry about someone’s
ability to misrepresent his or her plethysmographically assessed sexual arousal? Such questions
represent more than just methodological challenges. More importantly, they speak to the very
essence of what we mean by sexual arousal, including attempts to control it.
As a clinical science, human sexology has included the study and treatment of a variety
of conditions in which our capacity to exert some degree of voluntary control over our sexual
arousal has been the focus. The study of, and attempts to treat, these “conditions” has added to
the applied value of our discipline, increased our understanding of the psychophysiology of
sexual arousal, and identified how much we still need to learn in this area. Among the clinical
areas in which control of sexual arousal has been studied, rapid (or premature) ejaculation and
so-called “inappropriate” targets of arousal (e.g., same-sex adults, prepubescent children) are
particularly often described and discussed. Those of us who have studied these clinical
phenomenon have come to appreciate (1) how difficult it can be to conduct methodologically
sound, ecologically valid research in these areas, as well as (2) how much we have yet to learn
about the psychosocial and physiological mechanisms that underlie the “normal” processes of
sexual arousal and orgasm. Simply put, assessment of change in sexual arousal as a function of
voluntary control strategies includes all the problems associated with measuring arousal, and
then some.
The vast majority of research on attempts to control the sexual arousal process (herein
taken to mean arousal and orgasm) has been conducted on men. This is primarily a function of
the facts that the clinical phenomenon at issue (i.e., rapid ejaculation and “inappropriate” targets
of arousal) are assumed to be more often male than female problems. One could argue that there
are, in fact, clinical phenomenon associated arousal control that impact women as (or more)
often than they do men. For example, one might take the position that female hypoactive sexual
desire or female orgasmic dysfunction represent disorders that are associated with the “control”
of sexual arousal. That is, some have argued that many of the instances of these female sexual
disorders are a consequence of involuntary (or otherwise unconscious) cognitive “control”
mechanisms (e.g., Kaplan, 1974).
While the above argument is a reasonable one, this paper will focus primarily on those
instances in which sexological scientists and clinicians have looked specifically at circumstances
where individuals (primarily males) have attempted to use cognitive and behavioral techniques in
order to control either the timing or direction of the sexual arousal process.
The Nature and Treatment of Rapid (“Premature”) Ejaculation
Rapid ejaculation, while often described as the most common male dysfunction (e.g.,
Spector & Carey, 1990), impacting as many a third of men, has proven to be more difficult to
assess and define than one might expect. Most operational definitions described in the research
literature rely on self-reports of such phenomenon as (1) time from penetration to orgasm, (2)
degree of satisfaction with time to orgasm, (3) number of penile thrusts till orgasm, and (4) sense
of control over the occurrence of orgasm during sexual stimulation. These measures involve a
great deal of subjectivity, or even guesswork, yet they form the basis of most of our evidence
regarding the nature of the dysfunction and the efficacy of various treatment approaches. Some
researchers have gone beyond such self-reports and included partner evaluations (e.g.,
Strassberg, de Gouveia Brazao, Rowland, Tan, & Slob, 1999), objective timing of orgasmic
latency (e.g., Strassberg, Mahoney, Shaugaard, & Hale, 1990), or penile plethysmography (e.g.,
Strassberg, et al., 1999).
Among the various self-report indices of orgasmic latency, many researchers seem to
agree that, while all of these features of the condition are defensible (although not always highly
correlated), the self-perceived sense of control over the occurrence of orgasm during sex is a
particularly important element. There is evidence, for example, that perceived sense of control is
the feature most closely associated with sexual satisfaction (Grenier & Byers, 1997).
There are many reasons why a man would prefer to have substantial control over the
timing of his orgasm. Perhaps the most important of such reasons is the desire (for both his
partner’s sake and his own) to be able to engage in intercourse long enough so that his female
partner has the greatest opportunity to reach her orgasm during the act. Yet, because intercourse
appears to be a generally more efficient technique for men to reach orgasm than for women,
many men (including many non-rapid ejaculators) will have difficulty engaging in intercourse
long enough for their partner to climax at or before the time that they do. For rapid ejaculators,
this can be a particular challenge since their average time to orgasm during intercourse can be
two or three minutes, or less!
Many men, therefore, have learned a variety of cognitive and behavioral techniques by
which to prolong their sexual arousal without reaching orgasm. The cognitive techniques usually
involves some sort of distraction, attempting to focus their attention on something other than the
psychological state or physical sensations associated with their current sexual interaction, while
behavioral techniques include slowing down thrusting, withdrawal, condom use, and ejaculating
prior to intercourse (e.g.,Grenier & Byers, 1997). While there is little direct empirical evidence
of the effectiveness of such distraction during intercourse, the virtual universality of the use of
the technique, and extensive anecdotal data, suggest that it probably is of some value to at least a
significant number of men, both rapid ejaculators and otherwise. But even when effective, its
use may come at a price. In effect, men delay orgasm during intercourse by interfering with their
attention to the sensations that make the act so pleasurable. Imagining one’s partner as
unattractive or STD-infected, doing math problems or thinking about one’s hated boss or
financial woes might well help to prolong the sexual act, but it does so at the cost of the pleasure
of the act itself. Just what it is that one has now managed to prolong?
Cognitive distraction is not the only way men have learned to control their sexual arousal
prior to orgasm. Simply slowing or stopping thrusting, penile withdrawal, changing intercourse
positions, thrusting in a “circular motion,” or the use of one or more condoms are all selfreported to prolong intercourse (e.g., Grenier & Byers, 1997).
Masters and Johnson (1970), Kaplan (1974), and other have popularized the squeeze
(Semens, 1956) and stop-start techniques as treatments for clinical levels of rapid ejaculation. In
most cases, this includes men who report reaching orgasm either while attempting vaginal
penetration or within 2 - 3 minutes of intercourse. There is substantial clinical and research data
attesting to the efficacy of these techniques, at least in the short-term. Obviously, these
techniques are designed, at least in part, to prolong intercourse by helping the man to repeatedly
reduce penile sensations below the orgasmic threshold. These therapy-related techniques are
essentially variants of some of the procedures, described above, followed by so many “normal”
men in trying to prolong their sexual arousal (e.g., Grenier & Byers, 1997).
Whether stop-start, squeeze, and related procedures lengthen intercourse simply because
of the delays they introduce (i.e., by slowing down or stopping intercourse), or whether they
actually change the orgasmic threshold (i.e., the absolute amount of physical stimulation
someone can sustain without reaching orgasm) remains unclear. While this distinction may be
important for scientists, it is probably less critical to men who are trying to lengthen the period of
intercourse and to their partners. As long as they continue to stop active thrusting, or at least
slow it down, the reduction is stimulation experienced by the man will allow them to lengthen
the time during which they engage in coitus.
Other clinical procedures for treating serious rapid ejaculation also rely on reducing the
level of physical stimulation experienced by the man during intercourse, and are identical (or
similar) to techniques many men seem to learn on their own. These include (1) experimenting
with different intercourse positions towards finding one that may produce less stimulation (e.g.,
female superior or side-by-side positions) (2) using one (or more) condoms, or (3) using a
desensitizing cream. As mentioned above, one must weigh the relative costs and benefits
associated with the lengthening of intercourse while reducing arousal during the process. This is
especially true for the last two of these three techniques.
The newest, and most controversial, of the techniques used clinically in the treatment of
serious rapid ejaculation is the use of medication. For many years, psychiatrists and others
prescribing psychoactive medications noted that, in many instance, the drug interfered with some
aspect of the patient’s sexual functioning, usually reducing their ability to obtain or maintain an
erection, or to achieve orgasm. In particular, the SSRI class of anti-depressants (e.g., Prosac)
were notorious for lengthening the time it took a man to reach orgasm, in many cases preventing
him from doing so (e.g., Rosen, Lane, & Menza, 1999).
A number of clinical reports began to appear in which a clinician described success in
using an anti-depressant medication to treat rapid ejaculation; using one man’s unwanted drug
side effect as another’s very much desired therapeutic effect. These case reports were eventually
followed by sophisticated, double-blind, placebo-controlled studies in which the efficacy of antidepressants (e.g., clomiprimane) in treating rapid ejaculation was clearly demonstrated (e.g.,
Strassberg, et al., 1999).
What makes the use of psychoactive drugs in the treatment of rapid ejaculation
controversial is not the issue of efficacy. These drugs clearly reduce the level of arousal men
experience with sexual stimulation, and consequently allows rapid ejaculators to last longer
during intercourse and to feel more in control of their arousal in the process (Strassberg, et al.,
1999). The controversy centers around the use of any medication in treating sexual dysfunctions,
i.e., the medicalizing of sexual functioning (Tiefer, 1994). The debate (Strassberg, 1994) over
the validity of such concerns is beyond the scope of this paper.
Other controversies in this area concerns the very nature of rapid (premature) ejaculation.
There seems little doubt that there is a subgroup of men who are less able to tolerate significant
levels of physical genital stimulation than most other men, and who also tend to report less
control over the onset of their orgasm and less sexual satisfaction (Strassberg, Kelly, Carrol, &
Kircher, 1987). How many such men there are depends on one’s definitions of normal and
premature ejaculation. What remains unclear and debated is (1) whether rapid (premature)
ejaculators actually experience less control over their orgasm than other men, and (2) the
etiology of rapid ejaculation.
There is little doubt that rapid ejaculators report lower levels of control over the onset of
their orgasms than other men (e.g., Rowland, Cooper, Slob, & Houtsmuller, 1997; Strassberg et
al., 1999). What remains unclear is if this is simply a perceptive side-effect of reaching orgasm
so quickly. That is, many men (perhaps most men) report that they wish they could last longer
during intercourse (e.g., Grenier & Byers, 1997). If these men have substantially more genuine
control over their level of arousal than rapid ejaculators, why aren’t they able to prolong
intercourse as long as they’d like, or at least longer than they currently can? The higher (relative
to rapid ejaculators) levels of control these men report may not represent greater (than rapid
ejaculators) control, but just the perception of greater control owing to their higher arousal
threshold and therefore their ability to last longer during intercourse.
Yet one more debate associated with premature ejaculation and the presumed arousal
control deficiency it represents concerns the etiology of the condition. Masters and Johnson
(1970) believed that the condition was the result of early ejaculatory experiences in which
reaching a quick orgasm was of value (e.g., to avoid being interrupted by an adult while
masturbating or during early attempts at intercourse). The primary flaw in this argument is that
concerns about interruption during early sexual experiences are so ubiquitous that it is unlikely
that such experiences would be far more characteristic of any one group than others. In contrast,
Kaplan (1974) argued that premature ejaculators were, for psychological reasons, less able than
others to recognize the physical sensations that indicated one was dangerously close to reaching
orgasm. As a result, these men could not work to control their level of arousal (e.g., through
slowing down thrusting) until it was too late. However, there is compelling evidence that rapid
ejaculators are no less able than others to assess their level of sexual (Strassberg et al., 1987).
A number of other theories have been put forth over the years explaining rapid
ejaculation as the consequence of a variety of intra- and interpersonal psychological problems,
including unresolved oedipal conflicts, anger, passive-aggressiveness, and too little sex.
However, there is little (if any) empirical support for any of these hypotheses. In contrast, it has
long been my position that, for most men, the amount of physical genital stimulation they can
tolerate before reaching orgasm is primarily a physiologically determined threshold, one that
they have exhibited since puberty across virtually all types of genital stimulation (Strassberg,
1994). Why not assume that the orgasmic reflex, like most other human reflexes (e.g., the gag
reflex or the patella reflex) is normally distributed in terms of the amount of stimulation required
to trigger it. Men on the low side of this distribution would represent those we refer to as rapid or
premature ejaculators, while men at the other end of the distribution would represent those
currently diagnosed as having an orgasm phase disorder (previously termed retarded ejaculation).
Consistent with this hypothesis is the fact that in most clinically significant cases of rapid
ejaculation, men report that they’ve always had the problem, across both time and partners.
Further, these men have been demonstrated to reach orgasm more quickly than normal controls
even in masturbation (Strassberg, Mahoney, Shaugaard, & Hale, 1990).
Irrespective of the etiology of rapid ejaculation, it is clear that men who obviously fit the
diagnosis reach orgasm with very little physical stimulation (I once treated a man for whom the
act of removing his underwear was sufficient) and (perhaps as a result) experience little control
over their level of arousal during sexual acts (e.g., Rowland, Strassberg, de Gouveia Brazao,
&Slob, 2000). As mentioned above, even men whose orgasmic latency during intercourse is
average (or even above) often express the desire to have greater control of their arousal so as to
last longer. One of reasons reported (anecdotally) by some men without erectile dysfunction for
using Viagra is that the drug allows them to maintain an erection for at least a short time
following orgasm/ejaculation. Clearly, the issue of control of arousal is a significant one for
many men., not just those who meet diagnostic criteria for rapid ejaculation.
Control of Sexual Arousal: Other Populations
In addition of rapid ejaculators, there are several other groups of (predominantly) men for
whom the issue of control of sexual has had significant clinical relevance and has also been the
target of substantial research. There are several groups of men, and some women, who are so
bothered by (or have been made to feel so uncomfortable about) the primary target of their
sexual interest that they have explored for (or been otherwise subjected to) interventions
designed to help (or make) them control their arousal by (1) decreasing it to their current target,
and (2) increasing it towards some other target. The two most common examples of such efforts
involve those with a same-sex orientation (or variations thereof), and pedophiles. Readers
should understand that the inclusion of these two categories in the same part of this paper is, in
no way, meant to equate these phenomenon.
Sexual Orientation. Much attention has been paid to the issue of the flexibility (or
malleability) of sexual orientation. Some men and women (the numbers of which are unknown,
but estimated to be much higher for men) seek help, or are “strongly encouraged” by others to
seek help, to change the adult target of their sexual/romantic interest. These are virtually always
same-sex oriented individuals. Among sexual scientists and clinicians, there is a substantial
range of opinions regarding how likely, or even possible, such changes are. These opinions are
often closely tied with theories regarding the development and clinical normalcy of same-sex
orientations. There is not sufficient room in this paper to consider the many etiological theories
that have been offered in this area or to review the research evidence that has been offered for
each. Rather, we will focus on the anecdotal and research evidence that speaks to the issue of
control of arousal: Specifically, the degree of success achieved by those who have tried to
become less aroused to same-sex targets and more aroused to opposite-sex targets.
Unfortunately, the nature of this issue and other factors have resulted in there being
virtually no well designed and controlled experimental study of change in sexual orientation.
There are certainly reports of individuals who say they have changed orientation (e.g., Diamond,
2000; Kinnish & Strassberg, 2002), and many others where attempts at change have met with
little, if any, success. The evaluation of successful change in orientation is complicated by the
very nature of sexual orientation. What should we be measuring; sexual behavior, romantic
attraction, sexual fantasy, all three, or something else? A recent study by Kinnish and Strassberg
(2002) demonstrated that change, when it occurs, along any one of these dimensions is often
unrelated to change along the others. Must change occur across all such dimensions to be
considered successful? Irrespective of which or how many of these dimensions must reflect
change is the issue of how much change must occur to consider it meaningful (e.g., is one point
on a seven-point Kinsey scale sufficient)? Further, how long much any change be evidenced
before we consider it stable? Some say that self-reports of change are insufficient, arguing that
genital plethysmography is necessary for “true change” in orientation to be demonstrated.
With methodological complexities such as this, it is not surprising that there is far from a
consensus among researchers and clinicians regarding how common significant change in sexual
orientation really is. It seems fair to say that even those most convinced of the possibility of
change in sexual orientation and the data they use in support of this belief suggest that such
change, especially for men who early in life recognize a strong and exclusive same-sex
attraction, is, at best, very difficult (e.g., Haldeman, 1994). Over the years, gay men have been
lectured to, preached to, electrically shocked and made to feel guilty, sick, or doomed. Still,
exerting sufficient control over the target of their sexual arousal has frequently proven illusive.
While some have changed their behavior, most have found it very difficult (bordering on
impossible) to substantially change the sex of those who fill their fantasies and are the objects of
their sexual desires. One suspects that such a change would be no less difficult for exclusively
heterosexual individuals. At this point, it seems fair to conclude that control of arousal, at least
when it concerns the sex of the target of that arousal, is generally very difficult to control. How
difficult, and for whom remain open questions that will, among other things, require that a
greater agreement is reached regarding the empirical evidence needed to demonstrate such
change.
Pedophilia. The issue of control of sexual arousal becomes relevant in the assessment and
treatment of men who sexually offend against children. Despite the importance of accurately
assessing the target of sexual interest among child molesters, it is often difficult to obtain owing
to the frequent efforts of many offenders to misrepresent (both to themselves and others) their
deviant response patterns. The introduction of penile plethysmography provided the first
objective measure of sexual arousal (Simon & Schouten, 1991), one that was not dependent on
the honest self-report of the offender. However, even this “objective” measure of arousal is not
without its limitations. Because male erectile structures are enervated by the autonomic nervous
system, the prevailing view for many years was that the penile erection was a totally involuntary
response. However, the presence of neural pathways leading to and from higher brain centers
suggests that, like some other autonomically-mediated responses (e.g., eye blinking), penile
tumescense may also be under some degree of voluntary control.
Research on the validity of plethysmography in distinguishing pedophiles from nonpedophiles has yielded mixed results (e.g., Barbaree & Marshall, 1989; Rice & Harris, 1991;
Simon & Schouten, 1991; Wormith, 1986). In general, the research results suggests that,
when used with cooperative adult males who have no motive for misrepresenting the targets of
their sexual arousal, penile plethysmography (PPG) can yield reasonably accurate assessments
that correlate substantially and significantly with self-reports and external behavior (Strassberg et
al., 1987). However, the data is also suggest that (1) many men (one third or more) are able to at
inhibit (by as much as 50%) their plethysmographically assessed sexual arousal in a laboratory
setting, even when attention to the stimuli is assured, and (2) some (but substantially fewer) men
are able to generate, to a very modest degree, partial arousal in the absence of any external erotic
stimulus (e.g., Hatch, 1981; Mahoney & Strassberg, 1991; Quinsey & Carrigan, 1978).
The degree of incentive one has to dissimulate (i.e., control) their PPG-assessed arousal
seems unrelated to their ability to do so (McAnulty & Adams, 1991; Mahoney & Strassberg,
1991). However, several variables have been found to impact such dissimulation efforts. For
example, experience with the procedure (Freund, Watson, & Rienzo, 1988) and the type of
stimulus material (Card & Farrall, 1990; Golde & Strassberg, 2000; Malcolm, Davidson, &
Marshall) used (e.g., audio vs. visual stimuli) has been shown to impact a man’s ability to control
his arousal (primarily through suppression of arousal towards preferred stimuli) so as to
misrepresent the true nature of what “turns him on.” Further, many men find it increasingly
difficult to suppress arousal the longer they are attempting to do so, resulting in PPG traces that
often start low but then increase over time (Mahoney & Strassberg, 1991).
When experimental participants have been questioned about the techniques they used
when attempting to suppress their arousal (i.e., their penile response), most describe either trying
to avoid perceiving the target stimulus (e.g., looking away whenever possible) or
employing competing imagery or cognitions (Mahoney & Strassberg, 1991). These strategies
are similar to those reported by “normal” men who are attempting to exert greater voluntary
control over their arousal so as to lengthen intercourse (Grenier & Byers, 1997). It becomes
important, therefore, that researchers and clinicians assessing someone via the plethysmograph
attempt to insure that the individual is attending to the stimuli throughout the procedure and have
methods for assessing such attending.
Even when men are successful in suppressing their PPG-assessed arousal to
“undesirable” targets (e.g., children), the meaning of this “success” remains unclear. That is,
does their success in getting less erect when exposed to “undesirable” targets in any way reflect
their ability to control the sexual desirability of such targets outside of the assessment setting, or
their likelihood of acting on such feelings? Are they really controlling their arousal or just their
erections...or are these the same thing? There are those who argue that being able to control
one’s erections in the presence of certain stimuli indicates that an individual has learned to
control his arousal and can therefore, if motivated to do so, reduce his likelihood of acting on
that arousal because it is now being effectively suppressed. Yet research evidence suggests that
pretreatment plethysmographic assessment is more predictive of reoffending among pedophilic
sex offenders than is their post-treatment assessment. This raises some interesting questions
concerning the meaning of changes in plethysmographic assessment of arousal.
A second way in which the issue of control of sexual arousal impacts the clinical
population of pedophiles is in the area of changing the targets of their sexual arousal. That is,
most sex offender treatment programs attempt to encourage, motivate, threaten, or otherwise
convince pedophiles to becomes less sexually interested in children and more sexually interested
in adults. Among the behavioral techniques that have been used in the service of such change
are orgasmic reconditioning, aversion therapy, covert sensitization, and masturbatory satiation.
While there is substantial anecdotal evidence of at least the sporadic effectiveness of each of
these approaches (e.g., Foote & Laws, 1981), there is little persuasive empirical support for any.
These are the same techniques that have been used over the years in an attempt to change
homosexuals into heterosexuals, again with little empirical support of their effectiveness.
The interventions with perhaps the most demonstrated effectiveness in reducing a
pedophile’s sexual interest in prepubescent children are chemical and surgical castration.
Reducing the availability of testosterone to a pedophile frequently appears to significantly reduce
his experience of sexual attraction towards children. Of course, it does nothing to increase his
sexual attraction towards more appropriate targets...it essentially renders him asexual or
hyposexual. This hormone-induced “control” of his deviant sexual arousal, of course, lasts only
as long as his testosterone remains lowered.
Summary
Sex researchers and clinicians have long recognized the value of accurately assessing the
direction and strength of one’s sexual arousal. We’ve learned, however, that as simple and
straight forward as the construct of arousal might first appear, it’s evaluation is actually quite
complicated and frequently very difficult. This is certainly the case where the object of the
assessment is to evaluate the degree to which an individual is able to control some aspect of his
or her sexual arousal.
Several examples have been offered here of relatively common clinical circumstances in
which people’s (usually men’s) ability to control the level or target of their sexual arousal has
been studied. Many of the evaluative complications associated with such assessment are
described. It seems clear that, in part because of the complications associated with arousal
assessment, many basic questions regarding the control of sexual arousal far from resolved. It is
equally clear that the difficulties associated with assessing the effectiveness of arousal control
are much the same as those impacting virtually all other areas of research and practice where
accurate assessment of sexual arousal is important.