Doing sex therapy in NYC, you learn a lot about the sexual challenges men face. For 30+ years now as a Manhattan sex therapist, I’ve had a daily real-world education in what troubles NYC men in bed – and what to do about it.
Here’s my short list of the Top 10 Male Sex Problems in NYC – below. Any health care provider hoping to treat men’s sexual problems will need experience helping men with these ten concerns:
1. Erectile Dysfunction (ED)
Erectile Dysfunction is the most common reason men call me for sex therapy in NYC. Sometimes also the most urgent. Most men with acute ED are in serious distress and need to be seen quickly. There’s no precise female equivalent – except perhaps the discovery of an affair.
ED is surprisingly easy to misdiagnose, if you’re not careful. Men with physical ED due to medical causes tend to lack rigidity in all situations – even on awakening. Men with psychological ED, due purely to emotional causes, typically have intact rigidity on awakening and with self-stimulation.
In mixed ED, there’s a subtle degree of physical vulnerability that can range in expression depending on the situation. Mixed erectile dysfunction is often mistakenly diagnosed as purely psychological. This mistake can usually be avoided by taking a careful history.
As a sex therapist in NYC who’s also an MD, I pride myself on being able to offer men with psychological or mixed ED integrated medical and psychological treatment under one roof
See also: ED and condom use
2. Premature Ejaculation (PE)
PE is just as common as ED, but most men with PE suffer in silence. So do their partners.
Premature ejaculation is the source of untold misery in many marriages.
Myths about what causes premature ejaculation abound. Truth is, most men with serious PE simply have low orgasm thresholds. Just like men with delayed ejaculation tend to have high thresholds. In other words, whether you tend to climax quickly or not is largely a matter of having been born that way.
There’s a misconception that men with PE are “selfish.” Hey, he got his orgasm, right?
Wrong. Most men with PE say it’s like taking a few bites of a meal, then having the plate whisked away and being force-fed dessert. Not so satisfying.
Trying hard not to ejaculate is not so satisfying either – since that usually means keeping yourself relatively un-aroused. Hardly a recipe for great sex.
So what’s a man to do?
In my experience as a sex therapist, most men with lifelong serious PE who want to enjoy passionate lovemaking without worrying about ejaculating too soon need an assist from medication to raise their thresholds.
Prescribing for PE is a specialized art. Make sure you see an expert who knows how to do it safely and effectively, for minimum long-term risk. And who knows how to combine it with non-medical techniques as well.
3. Men Who Have Difficulty Ejaculating
There’s a bit of a double standard when it comes to having finicky orgasms. Most educated 21st-century couples know you should never hassle a woman about whether she’s had an orgasm. But when a male partner has trouble climaxing, women often get profoundly distressed. Especially if he has trouble ejaculating during intercourse – which is often the case in men I see in my sex therapy practice in NYC.
So-called Delayed Ejaculation (DE) used to be thought of as rare, but in my practice, it’s one of the most common conditions I see. Contrary to popular myth, it’s often highly treatable – often in just a few sessions.
Most DE is simply due to having a high orgasm threshold. To get there, you just need to be very strongly aroused. Just like most women with high orgasm thresholds.
Many men assume they’re strongly aroused just because they’re hard. Big mistake. Sex therapy for trouble ejaculating often starts with learning to recognize when you’re authentically turned on.
4. Men with Loss of Desire / Sexual Avoidance
When a man in a committed relationship stops initiating sex, it’s often confusing for his partner – since male desire is popularly assumed to be automatic. As a sex therapist in NYC, I frequently get distressed calls from women whose husbands have gone “missing in bed.”
Causes vary widely – from low testosterone to pornography to depression. But lots of times the problem is sexual avoidance, rather than true lack of desire. In particular, many men avoid sex because they’re worried they’re not going to be hard. The most common cause of men going missing in bed is performance anxiety because of ED.
Whatever the cause, couples tend to react in ways that just perpetuate the problem – something I discuss in detail in chapter 11 of my book, Love Worth Making. In fact, sexlessness itself can be self-perpetuating – so it’s best to intervene early.
I try to set aside at least an hour and a half for a new individual or couple, to give me time to review all the medical and psychological possibilities. I’ll often try to see each partner alone as well.
Some men who’ve lost desire can be helped quickly. Others need more extensive help. Make sure your sex therapist knows how to tell one from the other.
5. Men with Hypersexuality and Compulsive Sexuality
Men’s libido varies. Like most human attributes, there’s a bell-curve. There’s also a host of factors that can affect desire. Trauma, for example. Some men with traumatic backgrounds discover early that sex can soothe traumatic feelings.
I’m often asked my opinion on so-called “sex addiction.” As a sex therapist, I believe in not automatically viewing problem sex behavior through an addiction lens. Many high-libido men tend to use sexual arousal and orgasm as an all-purpose coping strategy for any kind of emotional distress.
Every mind has its assets, its vulnerabilities, and its own particular relationship with sexuality. Treatment of hypersexuality and compulsive sexuality can involve individual counseling, 12-step fellowships, internet-control apps, couples work, and even psychotropic medication.
After decades of experience as a sex therapist in NYC, I’ve learned it can take time, patience, and sometimes lots of trial and error to know what someone really needs.
6. Infidelity and Cyber-Infidelity
Infidelity has been around a long time – at least since language evolved 50,000 or so years ago and people started using terms like “marriage” and “forsaking all others till death do us part.”
Language also for the first time permitted people to ask direct questions – like, “Who was that hominid I saw you with last night?”
Your sexual mind doesn’t easily accept restrictions. As a sex therapist in NYC, I try to remind myself that sexually exclusive relationships have probably always been somewhat problematic.
Now of course there’s also “cyber-infidelity,” with varying opinions on whether porn use represents cheating. In the next few years, we’ll no doubt confront the same question about relationships with AI-generated virtual partners.
Most couples affected by infidelity still ultimately stay together. Sex therapy post infidelity can be a complicated process – since in addition to dealing with the emotional fallout from having been betrayed, there’s also the challenge of identifying sexual and emotional needs that may have gone unmet for years. Meeting these needs can go a long way to making fidelity feel worth the effort.
7. Bisexual Men
As a sex therapist, I see many men for whom same-sex attraction exists alongside opposite-sex attraction. Many couples come for sex therapy looking for help distinguishing myth from reality about male bisexuality.
Sophisticated research has been required to prove male bisexuality really exists, and that it’s not simply a way-station on the road to being gay. Nevertheless, male bisexuality is unfortunately still considered a third rail in most heterosexual relationships. Most bisexual men still keep it a secret from their partners, which often gives rise to shame and self-loathing.
Often, the biggest problem is the man’s having felt the need to keep his bisexuality a secret for so long. Consultation with a sex therapist who knows the research can often be quite helpful for couples looking for reassurance and guidance in this situation.
8. Other Variant Male Sexualities
By early adulthood, most men’s erotic interests are more or less fixed in a fairly narrow pattern.
In contrast to what’s known in the sex therapy field as female erotic plasticity or female sexual fluidity – where women’s sexual preferences can change over time – most adult men can tell you precisely what turns them on in a partner. It’s usually quite specific, and it tends not to change over time.
At the extreme, some men have unusually narrow sexual interests. They’re exclusively turned on by women’s feet; or by very specific kinds of female bodies, very specific erotic scenarios, or any of a host of other fixed erotic tastes. These variant interests can’t usually be changed.
Some, such as a preference for being sexually dominant, can be readily understood and accepted by partners – especially now that kink has gone mainstream. Others, such as an interest in being sexually submissive, tend to leave female partners confused and/or turned off.
In my sex therapy practice, men with a taste for dominance tend to have their pick of partners, while men with submissive tendencies often can’t get a date.
Sex therapy can be extremely useful for men with variant sexual interests and their partners – since understanding and accepting your sexual needs is fundamental for a sexually fulfilling relationship.
9. Neuro-Atypical Men
Psychology now recognizes that many men (and quite a few women as well) are “non-neurotypical” or “atypical,” in that their minds process information differently from most “neuro-typical” folks. The classic form is what used to be called Asperger’s Syndrome, now considered a variety of autism spectrum disorder (ASD).
Neuro-atypical men often have challenges in partner relationships due to trouble understanding partners’ emotions. Some with “sensory processing differences” have trouble tolerating sexual sensations. For instance, a partner’s mouth or vagina can be experienced as “too wet.”
Men with Attention-Deficit/Hyperactivity Disorder (ADHD) often struggle in relationships as well. Many find themselves the target of criticism in a way that echoes having been criticized as ADHD boys. Distractibility poses another problem, since good sex requires paying attention.
Sex therapy where one or both partners are neuro-atypical can require special creativity and “out of the box” thinking. If there’s a genuine commitment to understanding both people’s sexual needs, the prognosis for sexual happiness can be excellent.
See also: New York Magazine’s “The Cut” – Sex and ADHD
10. Men with Social Anxiety, Size Anxiety, and Other Kinds of Performance Anxiety
When a man first presents for sex therapy for ED, PE, DE, or some other sexual concern, I routinely screen for anxiety problems – since if you don’t address the underlying anxiety problem, treatment can get easily stalled.
The most common culprit is social anxiety, where anxiety is prompted by being the center of attention. For better or worse, during sex, you’re definitely the center of attention – so if you have social anxiety, sex can easily become a challenge.
Social anxiety is a prime cause of male sexual avoidance, and can be a key factor in men who are “40-year-old virgins.”
As a sex therapist in NYC, I feel strongly that experience treating anxiety problems should be part of every sex therapist’s toolbox. I’ve seen hundreds of men who required both sex therapy and anxiety treatment to gain the confidence they needed – and I’m pleased to be able to offer both.
See also: The Atlantic: On ‘Late’-in-Life Virginity Loss
As you can see from the list above, sex and relationship therapy for men covers a vast range of problems. Over 30+ years as a sex and relationship therapist in NYC, I’ve helped over 2,500 individuals and couples have better sex and more satisfying relationships – through cost-effective, solution-focused approaches that have taken me a lifetime to learn.
If you’re suffering from a sex or relationship challenge, contact me, and let’s talk about how you can get the help you need.
© Stephen Snyder MD 2024 New York City