Sexual difficulties

Sexual difficulties: why trying to control makes it worse

Almost all sexual difficulties share one counterintuitive feature: the harder you try to govern the response, the less the response arrives.

Arousal, erection, desire, orgasm are not voluntary actions. They're responses that occur when attention is elsewhere — on the person in front of you, on what you're doing. The moment attention moves onto whether it's working, the response stops.

That's where the cycle almost always begins. One occasion goes badly. The next time you arrive already alert, checking. The checking occupies exactly the mental space the response would need. It goes badly again — and now there's evidence.

Sexual performance anxiety

This is the most common form, and it describes the mechanism best.

Intimacy becomes an exam. There's an expected result, there's someone assessing — often only in your own head — and there's the fear of not measuring up. Under those conditions the body does what it would do in any situation read as a test: the alarm fires, and the alarm is incompatible with arousal.

It isn't a question of willingness or attraction. Many people experiencing it desire their partner without any doubt: that's exactly what makes it incomprehensible from the inside.

Erectile difficulties and low desire

These are two different problems and worth separating, even when they arrive together.

With erectile difficulty the body doesn't respond as expected, and trying to control the response makes it less likely. With low desire there's no failed attempt: the start is missing, and that tends to produce guilt rather than fear.

Low desire rarely has a single cause. Prolonged stress matters, sleep matters, the stage of the relationship matters, current medication matters, and so does whatever else is going on. Treating it as a purely sexual problem often means looking in the wrong place.

First of all: medical assessment. Erectile difficulty can have vascular, hormonal, metabolic or medication-related causes. So can low desire. A medical examination isn't a formality here — it's the first step.

Premature and delayed ejaculation

Here too, control sits at the centre of the difficulty, in two opposite directions.

With premature ejaculation you try to hold back, and the effort of holding back increases arousal. With delayed ejaculation you try to arrive, and the effort of arriving moves attention onto the outcome rather than the sensation.

They're different experiences, but what maintains them is the same: attention that supervises instead of participating.

Pain during sex

When intimacy is associated with pain, the body learns to anticipate it. Muscular tension arrives before the thought, and often before contact.

A particularly difficult cycle forms: fear of pain produces tension, tension produces pain, pain confirms the fear.

Here too, medical assessment comes first, and in this case it isn't negotiable: pain during sex has possible physical causes that a specialist needs to rule out before any psychological work.

Therapy in English for sexual difficulties in Milan and Monza

I'm an Italian psychologist and psychotherapist, registered with the Order of Psychologists of Lombardy. I see people in two practices in Milan, in Monza and in Cernusco sul Naviglio, and online, in English and in Italian.

These are subjects many people find hard to raise at all — and harder still in a second language, with a clinician they've just met. That's part of why I work in English: not as an accommodation, but because the language you can describe something in determines whether you describe it.

The first session is about understanding what we're dealing with: how long, in what circumstances, whether it happens always or only sometimes, what's already been tried. It's a clinical conversation, not an interrogation, and it doesn't require telling more than you want to tell.

From there the work concerns three things: understanding the specific mechanism maintaining the difficulty, reducing the role of checking and control, and — where there's a partner — working on how the difficulty gets communicated, because the silence around these subjects is almost always part of them.

Many of these difficulties have a recognisable anxiety component, and that's the ground I've worked on for years.

When it makes sense to ask for help

— Has a medical assessment already been done?

— Am I avoiding intimacy so as not to be in that situation?

— Do I check, during, whether I'm working properly?

— Have I talked to my partner about it, or am I going around it?

The difficulty doesn't have to be constant for it to be worth discussing.