For a mutually gratifying sexual experience, it is important for both partners to ensure their own and each other's physical, psychological, and relational well being

Performance anxiety can often lead to sex problems between couples

It is commonly said that sex is between the two ears and not between the two legs, and therefore sexual issues often emanate from the mind. Of course, there could be some issues requiring medical intervention or intervention from an experienced sex therapist, or psychotherapist and/or a relationship counsellor too. But for now, let us examine some common sexual issues couples have and how to solve them.

Unrealistic Expectations

There are a number of myths and misconceptions that both men and women have that interfere with sexual intimacy. Men unnecessarily worry about the size of their organ, have 'pornographic' sexual performance expectations from themselves and their partners, and expect their partner to have a certain fantasy body. Women expect men to do all the work to 'ensure' their orgasm thus putting performance pressure on men, and expect 'optimal' erection and performance at all times and for them to have an erection 'at will'. Having a sex education session with a qualified sexuality counsellor can help keep expectations from oneself and one's partner, realistic.

Fear of Unplanned Pregnancy

Women cannot relax in sex if they fear pregnancy. This is especially true if no contraception has been used or if there is a fear of failure of contraceptives. Therefore men and women must both take responsibility of contraception during sex. Many men often claim to use the withdrawal technique which is 'not at all' an effective contraceptive measure, but in addition, it also often leaves the woman dissatisfied in sex as she might not be able to climax with the sudden withdrawal. Mutually accepted contraceptive measures must be used by both, after consultation with a gynaecologist.

Insufficient Foreplay

Often a hurried penetration without foreplay leads to discomfort or pain during intercourse. A woman needs to be aroused and sufficiently lubricated to enjoy sex.

Men should learn to arouse their woman through foreplay that she enjoys, and women should freely communicate what they enjoy as foreplay to their partners. Free and frank communication about what one likes, and prolonged foreplay makes sex a mutually satisfying and pleasurable experience.

Penetration Phobia

It is rooted in a deep psychological fear related to the genitals, due to either physical and/or psychological trauma during the earlier years of life, or as a 'learned fear' by hearing myths about painful penetration during the vulnerable and impressionable growing years. A woman might experience Vaginismus, which is an 'involuntary spasm' of the muscle controlling the entrance to the vagina during attempts of penetration. This could cause pain and discomfort. This involuntarily tightening of the muscles of her vagina, makes penetration painful and impossible.

Due to this unconscious and unwarranted apprehension, a woman may reject all advances and attempts of penetration made by her partner. She requires the help of an experienced psychotherapist and sexual counsellor who will help through healing her early trauma and teaching her relaxation and a gradual desensitisation technique.

Tight Hymen

The hymen is a thin membrane that covers the vagina. It may or may not be present at birth. In some women the hymen is extra thick and tight. This makes it either impossible to tear during intercourse, or then it may cause severe pain and bleeding if penetration is attempted forcibly in spite of pain. If the hymen is found to be unusually thick and tight on examination by a gynaecologist, then a small surgery - Hymenectomy - may be necessary before attempting intercourse.

Painful Intercourse

Painful intercourse or Dyspareunia could be due to various causes. The pelvic muscles may be extra tight, one may not be adequately aroused and lubricated in the vagina, the hymen may still be partially intact, or then there might be an injury or an infection involving the vulva and/or vagina. It is not uncommon to experience some discomfort or pain during the first intercourse.

If intercourse is attempted after adequate, mutually arousing and satisfying foreplay, then this discomfort/pain can be minimized or even eliminated.

If the pain continues, then the cause of pain must be found before attempting intercourse. If a couple continues to attempt intercourse in spite of pain, things may only get worse. What is a physical problem could then become a psychological one. Pain is like an alarm, which alerts us into investigating the cause of the problem. A gynaecologist must be consulted to find out any medical cause and treat it, and then a sex therapist must guide the couple for mutually comfortable intercourse.

Arousal Issues

Female arousal is as necessary as male erection for a couple to enjoy intercourse. Whenever a woman is unable to get aroused, penetration feels forced and could be painful and unpleasant.

FSAD ( Female Sexual Arousal Disorder ) could be the result of physical causes like hormonal, neuro-vascular, biochemical and other organic issues.

Psychological issues that contribute to FSAD are physical or psychological abuse, low self-esteem, distorted body image and other life stressors. Unrealistic expectations from the male partner and unresolved emotional and relational issues between the couple also can cause FSAD. In addition, certain medications can also interfere with arousal. This should be addressed by the relevant medical expert such as gynaecologist or endocrinologist etc., as well as by an experienced psychotherapist and sexuality counsellor depending on the cause.

Lack of Emotional Intimacy

There maybe a lack of emotional involvement from either side because of distancing due to mounting conflicts. At such times, women often do not get aroused and men though aroused initially, might not be able to sustain the erection as the conflict areas may clutter the mind-space and take away from moment. This should be addressed by conflict-resolution between each other, with or without the help of a counsellor.

Also during the early attempts at intercourse especially in arranged marriages, girls may find it difficult to respond as they still getting to know the partner and 'feel intimate' before 'getting intimate'. Therefore it is better to wait till the intimate feeling arises, and not rush things so as to not create forced and unpleasant first experiences.

Performance Anxiety

Anxiety about impotence and fear of failure in attaining or maintaining an erection, ranks first in order of prevalence, in all the sexual fears that men have. Ironically, the fear itself is the greatest cause of impotence and thus avoidance of partner sex.

If a man is more focused on how well he is performing with a partner, rather than on enjoying the sensations in the sexual act, it may be difficult to attain or maintain an erection. This can become a vicious cycle, where the anxiety about the erection becomes so intense, that he is unable to have an erection, which leads to even more anxiety.

The way to remedy this problem is to learn to relax. The more you relax and enjoy the experience of sexual touching, whether you have an erection or not, the more likely you are to get an erection. A couple needs to know that there is no possible way that a man can have an erection 'at will'; just as we cannot have the flow of saliva, tears or digestive juices 'at will'. These things happen on their own in response to situations & circumstances.

When a man is involved in foreplay, without 'spectating' or 'monitoring' his organ, the erection naturally happens. Behind the fear of failure to get an erection, is a fundamental anxiety - the fear of being rejected. The wife's understanding & cooperation plays a very important role in getting over such psychogenic impotence. An experienced relationship and sexuality counsellor can help in this matter.

Premature Ejaculation

This is the most common sexual complaint of men. There is no organic cause that is medically treated. It is psycho-behavioural in origin. Ejaculating early is a 'learned reflex response' that can be effectively re-conditioned by teaching couples behavioural techniques like the 'squeeze technique' or the 'stop-start technique'. A trained sexuality counsellor needs to be consulted for the same.

Erectile Dysfunction

If a man is unable to get an erection or maintain it, penetrative intercourse is impossible. There could be organic (biological) or psychogenic or situational causes for the same. If the causes are organic, then medical or surgical intervention maybe advised. This of course requires a entailed psycho-sexual history taking , physical examination and various investigations to determine the cause before intervention is planned.

Organic causes include diabetes, disorders of pituitary, thyroid or adrenal glands, diminished Testosterone levels, neurological conditions, injuries to the spinal cord or brain, kidney disease, atherosclerosis or other vascular problems, injury to genitals, surgical procedures, chronic alcoholism and/or other drug use, and reactions to certain medications especially hypertension medications, antipsychotics and antidepressant drugs.

If however the cause is psychogenic i.e. stemming from the psyche, then sexual counselling and psychotherapy is the way forward. Relationship issues, past traumatic events, stress and mood disorders are addressed with the help of a psychotherapist.

To conclude, a couple's ability to have mutually comfortable, satisfying and pleasurable intercourse depends on many factors such as comfort level with each other, life circumstances, the level of relaxation you feel, the health status, the level of your sexual arousal, the quality and duration of foreplay you have engaged in, amount of lubrication at your vagina at the time of penetration, status of your hymen, technique and position used during penetration, etc.

Therefore, it is important that both ensure their own and each other's physical, psychological, and relational well being, to engage in mutually gratifying sexual intimacy.