Of all the male sexual dysfunctions, delayed ejaculation (DE) is the least understood, least common and least studied. This paper aims to review and integrate the diverse psychological theories and proposed psychological interventions for DE. Clinicians will then be able to more clearly discern the relevant psychological/interpersonal issues of the patient/couple and implement systematically based effective interventions. After reviewing the literature, it is clear that no one theory accounts for all the varied presentations of DE, and no theory by itself has strong empirical support. However, awareness of the diverse points of view helps clinicians conduct better assessments and broaden their understanding of the patient's ejaculatory dysfunction. Similarly, no one psychological intervention works for all patients, nor will unsystematic random selection of interventions. This paper stresses on the need to clearly identify the source of the dysfunction and select treatments based upon the precipitating and maintaining factors. Much work remains to be done with regard to our understanding and treatment of DE. Specifically, we need to craft an evidence-based definition, assess the true prevalence of the dysfunction, demonstrate the efficacy of psychological interventions and design validated outcome measures.
Of all the male sexual dysfunctions, delayed ejaculation (DE) is the least understood, least common and least studied.1 DE is one of the three conditions that fall under the classification of diminished ejaculatory disorders; the other two being retrograde ejaculation and anejaculation or anorgasmia.2 Although not an ejaculatory disorder per se, men also complain of diminished force, volume and sensations with ejaculation.
The essential biological causes of delayed, retrograde and anejaculation include anatomic, neurogenic, infective, endocrine and medication factors.1 Psychological and interpersonal factors are also responsible for precipitating and maintaining DE and anejaculation. However, there is little unanimity concerning the psychological/interpersonal causes of DE, and similarly little agreement as to the most efficacious psychological interventions for the troubling dysfunction.
The aim of this paper is to review and integrate the diverse psychological theories and proposed interventions for DE in such a manner that clinicians can more clearly discern the relevant psychological/interpersonal issues of the patient/couple and develop systematically based effective interventions. This paper will offer case examples to highlight each major psychological perspective and related intervention.
For the purpose of this paper, a man can be diagnosed with DE when he finds it both difficult or impossible to ejaculate and experience the sensations of orgasm despite the presence of adequate sexual stimulation, erection and conscious desire to achieve orgasm.3, 4 It is an involuntary response that causes significant distress to the man and his partner. Some men struggle to ejaculate to the point of complete physical exhaustion of both sexual partners. This phenomenon may occur with one or all the following sexual behaviors: masturbation, partner manual or oral stimulation and coitus. Thus, despite having good erections, these men report low levels of subjective sexual arousal compared with sexually functional men.5
Using a biopsychosocial approach, the clinician attempts to identify the relevant biological, psychological, interpersonal, contextual and societal issues that serve as predisposing, precipitating or maintaining factors in the development of the symptom.6 The diagnosis of psychogenic is typically based on the variability of the DE. Specifically, the man may easily ejaculate with masturbation but not with any partner-related sexual behaviors. DE due to medical factors tends to be constant; they occur in every situation, with every partner and under almost all circumstances.
Over the years, an overabundance of diagnoses has been crafted to describe DE or anejaculation. These terms appear in Table 1. Having so many diagnostic labels describing the same or similar conditions belies how little we know about it.
The American Psychiatric Association's Diagnostic and Statistical Manual, 4th Edition, Text Revision (DSM-IV-TR) includes the diagnosis ‘Male Orgasmic Disorder (MOD)’ to describe problems of delayed ejaculation or anejaculation.7 The criteria set for MOD are as follows:
Persistent or recurrent delay in, or absence of, orgasm following a normal sexual excitement phase during sexual activity that the clinician, taking into account the person's age, judges to be adequate in focus, intensity and duration.
The disturbance causes marked distress or interpersonal difficulty.
The orgasmic dysfunction is not better accounted for by another axis I disorder and is not due exclusively to the direct physiological effects of a substance or a general medical condition.
In addition, DSM-IV-TR instructs the clinician to specify whether the condition is lifelong (since the onset of his sexual life) or acquired (appears after a period of normal function) and whether it is generalized (with himself and all sexual partners) or situational (specific to one partner or one type of sexual behavior) for example, intercourse but not masturbation.
Unfortunately, the DSM-IV-TR criterion set for MOD is not evidence based, lacks specific operational criteria (for example, what length of time constitutes male orgasmic disorder?), is excessively vague and relies on the subjective judgment of the diagnostician. Thus, given the vagueness and subjectivity of the DSM diagnosis, one clinician might diagnose a man with MOD if his intravaginal ejaculatory latency time (IELT) is 12 min, whereas another would not diagnose the dysfunction until his IELT threshold reaches 30 min. DE need not be based on coital ejaculatory latency alone; the same subjectivity might occur with delays in manual and/or oral stimulation.
Proposals for DSM V include changing the name of the dysfunction from MOD to DE. It is also recommended that the severity and duration of the symptom be included into the definition of the disorder (for example, 75% of sexual occasions over a period of 6 months). Finally, in place of the etiological subtypes, it is recommended that a designation of ‘associated features’ be included.8, 9
Concerns regarding diagnostic clarity are not focused on just DE. The same problem (no operational definition, excessive vagueness and clinician subjectivity) was apparent with the DSM-IV-TR definition of premature ejaculation (PE). Ultimately, a group of sexual medicine experts under the sponsorship of the International Society for Sexual Medicine crafted an evidence-based definition for PE.10 This definition relied heavily on a multinational population-based study where couples used a stopwatch to time coital IELT.11 By examining the mean, median and standard deviations, the PE definition committee recommended that the IELT cutoff for PE be approximately 1 min, which corresponds to two standard deviations (the 0.5 and 2.5 percentiles) below the mean.
Similarly, an objective IELT cutoff for DE could be defined as the time equal to or greater than two standard deviations above the mean, obtained using the same multinational population-based data set that was employed to construct the PE diagnosis which corresponds to approximately 25 min. In addition to a 25-min IELT, men also have to evidence distress or bother with their DE.1 No professional organization or regulatory authority has to date accepted this proposal for DE.
Psychological and interpersonal impact of delayed ejaculation
The psychological and interpersonal impact of DE is often not fully appreciated by some clinicians. They erroneously perceive DE to be a positive attribute that allows the man to ‘bestow multiple coital orgasms to his partner.’ They fail to understand that DE is involuntary and causes distress for the man and his partner.
It is not uncommon for men with DE to ‘fake orgasm.’ They perceive it as a demand from their partner to reach orgasm. DE men believe that there is something wrong with them and may become preoccupied with their symptom. High levels of relationship distress, sexual dissatisfaction, anxiety regarding their sexual performance and general health issues are significantly higher in DE men than sexually functional men.12
Partners of men with DE may initially enjoy the extended periods of intercourse. However, as they become aware that the man has not experienced orgasm, they begin to question why he is not ejaculating. Partners often blame themselves feeling that they are not attractive or ‘sexy’ enough for the patient. They feel unneeded and rejected. In addition, extended coitus can also cause pain for the partner.
The most vexing concern for the couple is that anejaculation results in failure to conceive. This is often the time when the couple presents for treatment.
Figure 1 illustrates the four major psychological theories assumed to cause DE. No one theory accounts for all the varied presentations of DE, and no theory by itself has strong empirical support. However, awareness of these diverse points of view allows clinicians to conduct better assessments and broaden their understanding of the patient's ejaculatory dysfunction. Integrating aspects from different etiological theories will capture the majority of psychologically based DE, although this remains to be empirically tested.
The first theory, championed by Bancroft and Masters and Johnson, perceives DE as being due to insufficient penile or mental stimulation often associated with aging or diminished penile sensation.13, 14 It is not uncommon for men with DE to report having an insensate penis, or diminished ability to experience penile sensations. Psychophysiological studies conducted by Rowland report that the DE men experience less sexual arousal than normal men.5 Psychological issues are strongly suggested when men report having intact penile sensation while masturbating, yet have diminished sensation when being stimulated by their partner.
A 79-year-old married man requested consultation because of a 5-year history of being unable to achieve orgasm/ejaculation with his wife. By himself, with intense stimulation, he is able to ejaculate, although it takes him much longer than it previously did. The patient reported a significant decrease in penile sensation. He was distressed by the DE but not depressed or anxious. His wife was not concerned about his absent ejaculation and she enjoyed their sexual encounters even if he did not experience orgasm/ejaculation with her. The patient characterized his marriage as long-standing and good. The couple had intercourse once every 10 days, and the patient reported having good erectile reliability and sexual desire.
The second theory promulgated by Perelman focuses on the man's masturbatory patterns and fantasy life.12, 15 Retrospectively reviewing the charts of 80 patients, aged 19–77 years, Perelman identified three factors associated with DE: (i) a relatively high frequency of masturbation; (ii) an idiosyncratic style of masturbation; and (iii) disparity between the reality of sex with his partner and the use of sexual fantasy during masturbation. Thirty-five percent of men in his cohort reported masturbating at least every other day, or more. Idiosyncratic masturbatory style refers to the speed, pressure, duration and intensity necessary to produce an orgasm. These methods tend to be very dissimilar to what men might experience with a partner, and therefore are difficult to reproduce in partner-related sexual activity.
Disparity between fantasy and the patient's real-life experience is not specific to men with DE; however, the majority of non-DE men with discordant fantasy versus real-life experience are able to ejaculate during partner sexual behavior. The disparity between the man's fantasy life and his real world may include fantasies concerning partner attractiveness and body type, sexual orientation and the specific sex activity performed.5
A 31-year-old healthy married man and his wife presented because of their difficulty in trying to conceive a child. The man was totally unable to ejaculate with intercourse and could rarely ejaculate with partner hand or mouth stimulation. However, he masturbated to orgasm, in private, twice daily, by lying on his stomach and rubbing his penis against the sheets of their bed. He never used his hands to stimulate himself. In addition, he almost exclusively fantasized about sado-masochistic scenes of tying up and whipping women. On occasion, he had asked his wife to participate in light sado-masochistic play; she had steadfastly refused to experiment. The wife was upset not just about their difficulty in conceiving and his unconventional fantasy life, but because she believed that she was unattractive and could not sexually please her husband in a conventional manner.
The third psychological theory put forth by Apfelbaum considers DE to be a subtle and disguised sexual desire disorder masquerading as an ejaculatory problem.16 Apfelbaum bases his theory on anecdotal data from his practice. He believes that these men are autosexual, meaning that they prefer sex with themselves to partner sex. They enjoy their own touch and find their partners' stimulation inhibiting. Some men in his sample report diminished sensation with partner stimulation; their stimulation remains intact when they are self-pleasuring. These men feel guilty about rebuffing their partners wish for sexual activity or depriving them of their (the man's) orgasmic experience. Another dynamic reported by Apfelbaum is these men's inordinate need to please their partners.
Apfelbaum also describes these men as experiencing ‘automatic erections’, which are erections in the absence of mental arousal. We are accustomed to thinking that any loss of erotic arousal would be reflected by a loss of erection. Not only does the delayed ejaculator not lose his erection but the erections tend to be prolonged in the absence of sexual arousal.
A 38-year-old engaged man reported being unable to ejaculate with his partner. He had no problems ejaculating by himself. The patient had significant performance anxiety, which had led to an avoidance of partner sexual behavior. He spoke of loving his partner and wanting to please her. His inability to have an orgasm in her presence was causing distress in the relationship. The patient had become increasingly aware of his lack of sexual arousal toward his fiancée and was desperate to fix the problem.
The last theory considers DE as an outgrowth of psychic conflict. These ideas are based on case reports from psychodynamically oriented psychotherapists. The following conflicts have been described in the literature: (i) Loss of self from loss of semen; (ii) fear of harm from female genitals; (iii) fear that ejaculation may hurt the partner; (iv) fear of impregnating the female; (v) fear of defiling the partner with semen; (vi) hostility toward partner (vii); unwillingness to give oneself; and (viii) guilt from strict religious upbringing.17, 18, 19, 20, 21, 22, 23, 24
Two case examples
Divorced for 1 year, this 61-year-old man had started a long-distance relationship with an ex-girlfriend. He was married for 35 years and, although extremely unhappy, took many years to end the marriage. The patient has mild ED, for which he takes a PDE5i, and hypogonadism (T=220 ng dl−1), for which he uses a gel. The patient was readily able to ejaculate by himself. Initially he had no sexual problems with this new partner. However, over time he was finding her self-centered, histrionic and demanding. He was puzzled that he had developed a problem with DE.
A 25-year-old married man had been unable to coitally ejaculate. The couple had been trying to conceive and he was under pressure from his wife to resolve the problem. Family history revealed that his mother died giving birth to his brother and the patient had harbored the fear that his wife would also die should she become pregnant.
Performance anxiety and loss of sexual confidence are likely outcomes of DE, resulting in men avoiding partner sexual activity. Performance anxiety and loss of sexual confidence are likely to maintain the symptom of DE; they are not likely to have precipitated it.
Organized by the patient's and clinician's conceptualization of what is causing the distressing symptom of DE, Figure 2 illustrates four groupings of psychological interventions. It is difficult to accurately report on treatment outcomes because the published studies use small samples, using uncontrolled and non-randomized methodologies, without validated outcome measures or follow-up, and no agreed-upon measure of success.6
Treatment interventions should be selected based on the patient's presenting issues. No one intervention will work for all patients, nor will unsystematic random selection of interventions. There are advantages to see the man alone, as well as seeing the man with his partner. Obviously, when there is significant partner distress it may be best to see the couple; conversely, when the main issue is more psychodynamically oriented and concerns unresolved childhood issues, it may be best to see the man alone. Performance anxiety and loss of sexual confidence also require attention, usually after the precipitating factors have been addressed. One additional point for clinicians to consider is the need to schedule booster or maintenance sessions after therapy is terminated to maintain gains and prevent relapses.25
Treatments for insufficient stimulation
By explaining the need for increased penile and mental stimulation, the therapist recommends that the patient incorporate the use of a vibrator during lovemaking. It is important to ask whether the patient is willing to consider using a vibrator and whether there are any partner, cultural, social or religious issues that might interfere with using a vibrator. If there are any issues, they need to be worked through before using the vibrator. The majority of men readily accept the recommendation once the clinician explains the therapeutic rationale. For naive patients, the therapist may need to offer suggestions for specific vibrators and where the patient might purchase the device.
With regard to the need for enhanced mental stimulation, in the form of fantasy, written erotica or commercial pornography, the clinician begins with a discussion about how this may be helpful and necessary. Education needs to precede using the materials so that everyone ‘is on the same page’ and willing to cooperate with the therapy. Therapists need to be respectful of patient's and partner's sensitivities with regard to such materials and may need to work through resistances should they be present. Gentle humor is often helpful in discussing these concerns, such as the patient telling me, ‘so you are saying the wife and I should spend the weekend watching pornography!’
Finally, the clinician might suggest that the patient and/or partner use vigorous thrusting for the purpose of heightening penile and mental stimulation. This approach would be absolutely the wrong approach to patients who fit Apfelbaum's categorization of the DE man who has a disguised and subtle desire disorder masquerading as an ejaculatory dysfunction. Such men will not benefit from increasing levels of mental or physical stimulation. However, it will prove helpful to men with diminished sensation.
Returning to the case of the 79-year-old married man with the 5-year history of DE. I recommended that they incorporate a vibrator into their lovemaking, not just for him but for his partner as well, if she was interested. We discussed placement of the vibrator near the frenulum and coital positions (rear entry), which would make it easier to use the device. One month later, the patient returned reporting that he was able to ejaculate on three out of four experiences. His wife had also used the vibrator and found it fun and exciting.
Treatments for idiosyncratic or high-frequency masturbation and disparities in fantasy and reality
Masturbatory retraining and realigning sexual fantasies with the patient's reality are often helpful for treating men with these issues.12, 15 Masturbatory retraining consists of men adopting more traditional methods of masturbation where they use their hands to stimulate themselves. An alternative to manual masturbation is using a sex toy known as ‘the sleeve.’ The reason for offering these suggestions is that the patient's current method of masturbation is not likely to produce sensations encountered in partner sexual play. By switching to an alternative method of masturbation, or slowly introducing it into the patient masturbatory repertoire, the patient becomes acquainted with new sensations that mimic sexual play. As always, before commencing any intervention, the therapist needs to educate the patient as to why the intervention is being considered, and explore whether any issues/resistances might interfere with effectively incorporating these suggestions.
Realigning sexual fantasies can be much more difficult than any of the other interventions. This is because of the persistence of an individual's fantasy life; some patients exclusively fantasize to unconventional themes, whereas others have a broad repertoire that may include conventional, as well as unconventional, themes. The problem with exclusively unconventional fantasy is that it is likely to be very different from the reality of the patient's current sexual practices, resulting in diminished arousal with partner sexual activity.
Beginning with the therapist's explanation of why the patient's fantasy life likely interferes with partner sexual behavior, he/she suggests that the patient tone down unconventional themes, blend in more conventional themes or try to totally eliminate unconventional themes. This is difficult for patients to achieve, but depending on their motivation, it is possible.
Returning to the case of the couple who presented for difficulties in conceiving, I initially saw the man because I wanted to make specific suggestions concerning his masturbatory style. The patient was resistant to changing his masturbation technique because he was uncomfortable using his hands to pleasure himself and was uncertain that he could ejaculate in this manner. I suggested that he needed to think about the ‘greater good’, that is, conceiving a child and reducing his wife's distress. I urged him to use his hands to stroke his penis, because it would be similar to the type of stimulation he might experience with partner sex/intercourse. It took several weeks of discussion, but he was ultimately able to ejaculate in this manner.
I then saw the couple and asked his wife if she was willing to use her hands to stimulate his penis, and she agreed. She began stimulation and he found it necessary to ‘take over’ from her to ejaculate. After several weeks, the couple graduated to intercourse with the wife using her hand around his penis to further enhance penile stimulation. He was able to ejaculate intravaginally one-third of the time. From the couples perspective this was a great success. We did not do any work to address the man's sado-masochistic fantasies.
Treatment of disguised and subtle desire disorder masquerading as an ejaculatory dysfunction
Afelbaum characterizes the man with DE as ‘the workhorse of sexual relationships.’ Such a man is overly concerned with pleasing his partner and, paradoxically, although not being aroused, desperately seeks to ejaculate, not for his pleasure but to please the partner. Apfelbaum encourages the man to openly express his lack of arousal and feelings of hostility or lack of connectedness to his partner. His aim in therapy is to help the man recognize his fundamental lack of arousal and overcome the powerful performance demands that these individuals typically experience.16
By making the man's feelings and thoughts conscious and verbalized, it allows him to feel validated and removes the angry accusations of his being withholding and hostile to his partner. He is also taught to share his sexual preferences so that both partners' needs can be embraced in their sexual interactions. Performance anxiety is treated by sensate focus.
Returning to the 38-year-old engaged man, he was able to ejaculate with masturbation but not with his partner. He loved his fiancée, but she was becoming increasingly upset with his inability to ejaculate in her presence.
I saw the couple together to help facilitate their communication, discuss his avoidance of sexual contact, give voice to his awareness of lack of arousal, lessen her demands that he ejaculate and help focus on pleasurable sex (not necessarily orgasmic sex) for both partners. I helped her understand that his autosexual orientation was not a reflection of her attractiveness and that no person could force him to ejaculate. He was able to own his enjoyment of masturbation over partner sex and with that teach her about his sexual needs. By giving voice to his anxieties, he was less avoidant of partner sex, more willing to allow her to pleasure him in the manner he liked and felt less compulsive about pleasing her. She was able to feel better about herself and their relationship and understood that she did not have to take responsibility for his orgasm.
Treatment of DELayed Ejaculation due to psychic conflict
The aim of psychodynamic treatment is to give meaning and understanding to a symptom, thus allowing patients to make the necessary changes in their lives. The DE is perceived as a symptom that arose because of some conflict in the patient's life (for example, fear of impregnating his partner, hostility and so on). Over time, the therapist interprets the meaning of the DE symptom based on the patient's life history and current circumstances.17, 18, 19, 20, 21, 22, 23, 24
Insight is probably not enough; typically, patients then need to make changes in their life and relationship to overcome the symptom. There are multiple possible meanings for the DE symptom. Some are unconscious and some are clearly evident to the patient. This kind of therapeutic work can be conducted either individually or in couple's treatment.
Returning to the case of the 61-year-old divorced man who was involved in a long-distance dating relationship, he was becoming more aware of his negative feelings regarding this woman. I told him that his penis was smarter than he was, and that the DE symptom was present because of his growing unhappiness with the quality of the relationship. He realized he had great difficulty leaving bad relationships—such as his marriage—or his current relationship. I did not tell him what to do, but agreed with what he knew needed to be done. He ended the relationship and felt relieved. He called several months later to tell me he had begun dating a local woman and had no problem with DE.
Much work remains to be done with regard to our understanding and treatment of DE. Specifically, we need to craft an evidence-based definition, assess the true prevalence of the dysfunction, demonstrate the efficacy of psychological interventions and design validated outcome measures. In addition, it is important that we separate dysfunctions of orgasm from dysfunction of ejaculation and be more specific in our use of language.
In terms of psychological theories and interventions, there is a strong need for more controlled research examining all the precipitating and maintaining factors. Controlled and randomized outcome studies, using validated measures with sufficient follow-up periods, are necessary to determine the most efficacious methods of treatment. Existing studies are inadequate to make educated recommendations regarding treatment.
Another area of psychological research would include combining medical and psychological interventions. Recent studies have demonstrated that patients with erectile dysfunction and PE do better with combination treatment than pharmacotherapy alone. To date, there have been no studies on combining the off-label medications recommended for DE with any psychotherapeutic intervention.
From a psychological perspective it seems clear that there is no one theory that explains the symptom of DE in all men. Awareness of these diverse points of view allows clinicians to broaden their understanding of their patient's ejaculatory dysfunction. It is likely that integrating aspects of the different etiological psychological theories will account for the majority of psychologically based DE and offers a means of selecting the most appropriate treatment.