Treating Delayed Ejaculation

Delayed Ejaculation (DE) is the least common sexual disorder in men, the most poorly understood and one of the most difficult to treat. This disorder may be lifelong or acquired, although the former is extremely rare. The prevalence of DE among American men is less than 1% (American Psychiatric Association APA, 2013). With DE, the man experiences marked delay, infrequency, or the complete inability to ejaculate. The symptom causes distress for the man and his partner. Physiological duration and ease of ejaculation are variable conditions among men; accordingly, psychological, cultural, relational, and contextual factors are superimposed on the man’s physical abilities. All factors must be considered when assessing and treating DE.

DE is underreported because it can co-occur with other sexual dysfunctions such as erectile dysfunction or low sexual desire. In fact, Apfelbaum (2000) concluded that DE is often a manifestation of low sexual desire. DE is also associated with aging as some older men experience degeneration of the nerves supplying the penis as they age, producing less sensitivity. DE may also be underreported due to embarrassment or belief in the mythological notion that a man is supposed to sustain erections for long periods of time before ejaculating. Finally, Jern et al. (2010) found no significant difference in the incidence of DE in heterosexual and same-gender men.

Several pharmacological agents (anticholinergic, antiadrenergic, antihypertensive, psychoactive, selective serotonin reuptake inhibitor drugs) are often associated with DE (Rowland et al., 2010). It is quite probable that as men age, they will need to take more medications for medical problems, many of which can affect ejaculation. (Richardson, Nalabanda, & Goldmeier, 2006). Because there has been little research about this particular disorder, the clinician will have to be astute and comprehensive in assessing the etiology. It is sometimes necessary to collaborate with health care providers to rule out medical issues.

Assessment

DE is a complex problem that can involve medical, psychological, or combined etiologies. See Foley and Gambescia (2020) for a comprehensive discussion of DE. Treatment must be driven by a thorough assessment of the etiology. Some of the common contributory factors associated with DE are the following: (1) relationship problems, such as partner sexual problems or partner health status, poor communication, or desire discrepancies; (2) individual vulnerabilities, such as history of sexual abuse or other psychiatric comorbidities, including anxiety, depression, or situational stressors; (3) cultural or religious factors that serve as inhibitors against sexual activity or negative attitudes toward sexuality; and (4) medical factors relevant to the prognosis. One way to conceptualize DE is to consider it as an outcome of a variety of biopsychosocial influences.

Individual Factors

From an individual psychological perspective, there are a number of potential etiologic factors for DE. Apfelbaum (2000) theorized that these men are out of touch with their sensory experiences. They feel they need to control or attend to their partner’s pleasure, delaying his own ejaculation, losing penile sensitivity, and becoming fatigued. He experiences performance anxiety over his partner’s performance (Rowland & Kolba, 2018) and later over his inability to ejaculate. Interestingly, some men have no difficulty ejaculating with self-stimulation but cannot ejaculate intravaginally.

Perelman (2018) identified three masturbatory factors associated with DE: (1) idiosyncratic masturbatory style that cannot be easily replicated by partner stimulation, (2) disparity between the man’s preferred erotic fantasy and the reality of his actual partner, and (3) frequent masturbation. In such cases, it is useful to recommend that the man masturbate less frequently and lower the amount of stimulation he provides for himself manually. Some men can only ejaculate in response to fetishistic behavior.

Also, Perelman (2018) postulated that men with DE have difficulty in modulating the degree of arousal versus the inhibition of arousal. In his “sexual tipping point model,” he suggests that the man should become aware of how he is constantly tuning up or down his level of arousal. This aspect of levels of arousal should be a focal point of treatment.

Relationship Issues

In some cases, the relationship may be the most important contributory factor. It has been proposed that insufficient pleasure from the sexual interaction, holding back as a way to gain power, ambivalence about commitment, insufficient stimulation from the partner, poor communication, and a lack of attraction to the partner as opposed to a fantasized partner could be contributors to DE (Apfelbaum, 2000).

Often, the couple will present for treatment of DE when conception is desired as a result of intercourse. The motivation for treatment in such cases is about achieving pregnancy rather than enjoyment of sexual activity. We have seen cases where there is considerable pressure on the man to ejaculate during coitus, unnatural or judgmental focus by the couple on his performance, and extreme sexual and relational dissatisfaction for both partners.

The response of the partner should also be kept in mind. Just as with ED, DE may become the single focus of a sexual interaction, thus increasing performance anxiety, which acts as a distractor from sexual sensations thereby reducing arousal. Sometimes the partners do not feel they are attractive enough or that they are incompetent lovers. As with any sexual dysfunction, partners often blame themselves for the man’s DE. Additionally, the partners may suffer from sexual anxiety, disappointment, and lack of confidence.