Psychological aspects of men's sexual health in the context of infertility

Ciklus seksualnog odgovora obuhvaća tjelesne i psihičke reakcije koje nastaju prilikom seksualnih aktivnosti bez obzira o kojoj vrsti seksualnih aktivnosti je riječ. Najčešće se ciklus objašnjava kao linearna izmjena četiri faze: stage of sexual desire, potom excitement, phase orgasm i na kraju resolution phase. The desire phase denotes the psychological function of motivation and interest in sexual activity, thinking and fantasizing about sex. In the arousal phase (which can follow without the desire phase, with physical stimulation of the genitals or other erogenous zones), the most visible change in the entire cycle occurs: the erection of the penis. In addition to erection, during this phase the testicles (testicles) rise, as well as other changes in the body.The orgasm phase includes ejaculation and orgasm. Ejaculation means the ejection of semen, and orgasm is a psychological experience of great pleasure. Most often, these two events take place simultaneously, but it is also possible for them to be separated or for one to be missing. Finally, in the dissolution phase, the body returns to its pre-arousal state. In men, a refractory period occurs after orgasm, or a period in which he cannot ejaculate again.

At each of these stages, difficulties may arise. If they last long enough and cause personal suffering or interpersonal tension, we are talking about sexual disorders. Sexual disorders related to the sexual response cycle are reduced sexual desire, erectile dysfunction, premature ejaculation, delayed ejaculation, etc.

Men's sexual health is closely related to infertility in two ways.Infertility can be caused by sexual disorders, but it itself also contributes to the appearance of sexual disorders. In some men, the problem of infertility is caused by a sexual problem or as it is called coital infertility caused by erectile dysfunction or ejaculation disorder (either premature or delayed). In those whose infertility is not caused by a sexual problem, various sexual problems can occur as a result of coping with infertility and infertility treatment, from reduced sexual desire, erectile dysfunction to problems with ejaculation and orgasm.

So far, research has been much more focused on researching sexual dysfunctions in women struggling with infertility than in men.Nevertheless, those carried out show that in the general population about 25% deal with sexual disorders, while on the samples of men with infertility information is obtained about a significantly higher percentage. 48-56% of them also have a sexual disorder and are predominantly significantly less satisfied with their sexual life.

Infertility leaves its mark on different aspects of a couple's life. Ono izaziva osjećaje srama, krivnje, tuge, tjeskobe te ako traje dugo predstavlja jedno od najstresnijih razdoblja života. Seksualni odnosi prestaju biti spontani i izgube svoju erotsku vrijednost upravo zato jer je isključivo i usko povezan sa začećem za kojim se toliko žudi pa je užitak teško ostvariv. Upravo zato jer manjka ili se teže ostvaruje seksualno uzbuđenje, nije rijetkost da se muškarci koji su sami neplodni ili su u partnerstvu u kojem je neplodnost prisutna, razvija seksualna disfunkcija. Nadalje, sam tretman neplodnosti također diktira učestalost i vrijeme seksualnih odnosa, a tako reguliran i kontroliran intimni odnos od strane stručnjaka za neplodnost nerijetko se simbolički doživljava kao da su liječnici također prisutni za vrijeme seksa. Problemi se javljaju zbog emocionalnog stanja koje prati spoznaja o neplodnosti  te forsiranih i diktiranih seksualnih odnosa tijekom tretmana neplodnosti.

In infertile men, hypoactive sexual desire and lack of sexual satisfaction are the most common types of sexual dysfunction. Research shows percentages between 8.9% and 68.7%. Erectile dysfunction has a prevalence of one in six infertile men, and ejaculation disorder has a prevalence of one in ten infertile men.

Disorder of reduced (hypoactive) sexual desire

Nedostatak seksualne želje ili motivacije za seksom jedan je od rjeđih poremećaja koji se javljaju kod muškaraca. Procjena je da barem 10 % muškaraca ima ovaj poremećaj, a na hrvatskom uzorku dobiveno je da otprilike 4% of men experienced a lack of sexual desire and motivation.Reduced sexual desire in men is defined as a state of reduced or absent motivation for sexual activities, disappearance or significant reduction in the appearance of sexual thoughts and fantasies; lack of initiation of sexual activity and rejection of the partner's attempts to initiate sexual activity; disappearance or reduction of excitement and pleasure during sexual activities lasting at least 6 months. Although men with reduced sexual desire (which they have always had) do not experience high levels of personal suffering, they do experience high levels of stress due to partner problems caused by lack of interest. In men with this problem, it is not possible to produce a visual or verbal sexual stimulus.

Razlozi smanjene seksualne želje mogu biti mnogobrojni od biological, osobnih psychological do partnership. Of the biological ones, these are most often health problems, from hormonal disorders to depression, and often the result of treatment, especially of some mental illnesses and disorders of addiction to psychoactive substances. However, psychological and social factors also play a significant role. Of the psychological ones, high levels of stress and anxiety should certainly be highlighted, but also interpersonal ones such as bad partner relationships, poor communication, lack of closeness and intimacy or too closeness in a long-term relationship, the appearance of sexual boredom and saturation.

Isto tako ponekad je potrebno istražiti postoje li neke druge specifične seksualne preferencije poput specifičnog obrasca postizanja uzbuđenja, preferiranja masturbacije nad koitusom, prisutnosti parafilije, seksualnog poremećaja partnera ili partnerice, neprorađene seksualne traume kao i konflikt oko seksualne orijentacije.  Moguće je da osoba ima neki drugi seksualni poremećaj (erektilni ili prijevremenu ejakulaciju) zbog čega posljedično izbjegava seks zbog srama i nelagode te tjeskobe iščekivanja neuspješnog seksualnog odnosa.

Erectile disorder

The problem with sexual arousal in men is the problem of achieving or maintaining an erection or the firmness of the penis necessary for sex. According to the criteria, a man cannot achieve or maintain an erection in at least 75% of sexual activities, or the rigidity (firmness) of the erection is insufficient for sexual activity. Many men are afraid of such a situation, and how strong the fear of performance is, the fact that almost every fifth young man fears that he will have problems with erection during the first sexual intercourse tells us.

Treba naglasiti kako većina muškaraca povremeno ima problem s erekcijom i to je sasvim normalno. Nerealno je očekivanje da se od trenutka postizanja erekcije, čvrstoća penisa neće mijenjati. Isto tako withlabljenje erekcije dio je normalnog procesa starenja pa će erekcija, koju muškarac ima s 20 godina, sa starenjem biti sve slabija. Ako muškarac tijekom seksa osjeti da mu penis postaje mekši i prestraši se „da će mu pasti“, „da neće moći potrajati u seksu“, „da neće biti dovoljno muško“, „da će ga partner-ica ostaviti“ ili „da je to siguran znak da je impotentan“ – dolazi do dodatnog smanjenja seksualnog uzbuđenja i njegovo će se negativno proročanstvo ostvariti odnosno izgubit će erekciju. Jednom kada u potpunosti izgube erekciju, muškarci najčešće čine ključnu pogrešku, a to je da prestaju sa seksualnom aktivnosti tj. pobjegnu od nelagode. Kada bi nastavili s različitim drugim oblicima seksualnog ponašanja (maženje, ljubljenje, stimuliranje partnera-ice rukom, oralno zadovoljavanje), u pravilu bi se ponovno uzbudili tj. doživjeli erekciju. Od svih seksualnih poremećaja ovo je onaj for which men most often seek help jer, kako se čini, ono it represents significant frustration and suffering for men.

Uzroci erektilnih smetnji su različiti, neki su fizički, a neki psihološki. Važno je moći napraviti razliku je li nečija erekcija uzrokovana nekim tjelesnim problemom ili psihološkim čimbenicima. Ako osoba ima jutarnje erekcije, ako ima erekciju tijekom masturbiranja, ako doživljava spontane erekcije tijekom dana ili ako erekciju ima s drugim partnerom ili partnericom, možemo biti sigurni da na problem djeluju psihološki faktori.  Ako su odgovori na ova pitanja negativni tada je potrebno napraviti specijalistički pregled liječnika – najbolje urologa.

Najčešći fizički uzroci erektilne smetnje su začepljenje krvnih žila što dovodi i do smanjene prohodnosti arterije u penisu. Sjedilački stil života, masnoće u krvi, metabolički sindrom, pušenje cigareta, pretilost i kronična izloženost stresu najčešći su čimbenici razvoja ovih smetnji.

There are many psychological factors, from personal emotional problems (such as anxiety and depression, fear of performance during sex, fear of intimacy), partner problems (e.g. bad relationship, partner's sexual disturbances or physical illnesses and conditions) and negative attitudes about masculinity ("You are a real man if you can always and never fail"). Although less common, the possibility that erectile dysfunction may be a reflection of some other sexual interests and desires, due to which current sexual relations are not sufficiently exciting, should not be ignored.

Premature ejaculation

Premature ejaculation is not easy to define.Although it is difficult to determine how fast is really and problematically too fast, the latest interpretations say that it is a sexual disorder in which a man reaches orgasm and ejaculates (i.e. ejects sperm from the penis) within 1 minute or before he wants it from the beginning of vaginal penetration. Unfortunately, in some men (albeit very rarely) ejaculation occurs even before the penetration of the penis into the vagina has been achieved, which also causes frustration for the partner. This kind of situation is an obstacle to conception.

It is known that men with this problem do not pay enough attention to the level of their own arousal in the pre-orgasm phase, and non-pharmacological treatments are precisely aimed at training and good recognition of arousal levels, which change rapidly, in order to develop a sense of control.Among men who have premature ejaculation, there are a large number of them who have elevated levels of anxietye osobito socijalne anksioznosti. Za istražiti je te osjećaje – sram i krivnju – koji zasigurno ne pomažu kod ovog problema.

Delayed ejaculation

Delayed ejaculation is a significantly less common sexual problem for men (between 1% and 3%), compared to premature ejaculation and erectile dysfunction. Delayed ejaculation is a sexual problem in which a man, despite adequate stimulation, cannot achieve ejaculation and orgasm or achieves them with great difficulty. For diagnostic purposes, it is necessary to distinguish whether it is retrograde ejaculation (when a man experiences an orgasm, but does not ejaculate normally, but instead into the bladder and ultimately wets the ejaculate), anejaculation (a disorder when a man achieves an orgasm, but does not ejaculate, i.e. does not eject sperm) or the inability to achieve an orgasm and ejaculate. It should also be determined whether there are circumstances in which a man can ejaculate (eg during masturbation or with a specific fantasy) or whether he cannot ejaculate under any circumstances.

Biologically uzroci se uglavnom odnose na određene zdravstvene probleme koji mogu potaknuti ovaj problem poput hipogonadizma, nesanice, poremećaja rada štitnjače, poremećaja pituitarne žlijezde, posljedica operacije prostate, zlouporabe droga i konzumiranja alkohola (osobito dugotrajnog), smanjene osjetljivosti glansa penisa, ozljede kralježničke moždine, multiple skleroze, dugotrajnog i težeg oblika dijabetesa te uzimanja određenih lijekova (npr. antidepresiva). Od psiholoških čimbenika delayed ejaculation is usually the complete absence of ejaculation in sexual intercourse, while ejaculation can be achieved without major difficulties in masturbation, and these are partner problems in the form of broken relationships or lack of attraction towards the partner.

Furthermore, this problem is associated to a significant extent with anxiety, which can arise from an extremely high need to satisfy the partner, a lack of confidence that he will be a good enough sexual partner, a bad image of his own body and genitals, feelings of sexual unattractiveness, negative comparisons with other men that his partner had until then, etc. Such thoughts would be more reflected in some men's loss of desire for sex or a decrease in excitement, i.e. a loss of erection. In this group of men, the erection is preserved, but the discomfort caused by such considerations during sex reduces the subjective feeling of excitement, so it is logical that the climax is experienced with difficulty or not at all. Therefore, it is logical that men with delayed ejaculation achieve orgasm and ejaculation more easily by masturbating than during partner sex, because then the aforementioned concerns do not disturb them.Sometimes the problem also occurs due to a specific pattern of stimulation during masturbation (eg a strong and rough squeeze of the penis) that is difficult to achieve in other ways in partner sex.

Važno je i naglasiti kako različita istraživanja i klinička opažanja pokazuju da se kod muškaraca s odgođenom ejakulacijom nailazi na značajno više, snažno izraženih, religioznih stavova. Vodeći se uvjerenjem kako seksualna aktivnost, koja ne vodi reprodukciji, predstavlja ‘rasipanje sjemena’, muškarci s ovim problemom izbjegavaju masturbiranje te rjeđe ejakuliraju u seksualnim odnosima. Ako i masturbiraju, onda je masturbacija vrlo često praćena snažnim osjećajem krivnje. Takav obrazac potpomaže nastanku i održavanju smetnji.

Author: Ph.D. Tanja Jurin, Univ. spec. wedge. psycho.

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