Problems: Too Slow or Too Fast?
Stanley Ducharme, Ph.D.
men, erectile dysfunction and ejaculatory problems are the
most common sexual difficulties. With the introduction of
Viagra however, problems of erectile dysfunction are much
less frequent and more easily treated. In contrast, ejaculatory
problems continue to be commonplace among men and often
create feelings of shame and embarrassment for those men
who struggle with this difficulty.
When does an ejaculation problem become a disorder? This
is a subjective question and is based on the level of distress
that is experienced by the man or his partner. The time
from initiating sexual activity to ejaculation varies from
one individual to another. This time period is called the
ejaculatory latency. What may be a problem for one man may
be acceptable to another. Typically, ejaculatory disorders
fall into two categories. These are: delayed ejaculation
and early ejaculation. This column will explore some of
the psychological factors and treatment options related
to these two distinct male dysfunctions.
the vast majority of cases, the most effective therapeutic
approach for ejaculatory dysfunction is a combination of
biologic and psychologic therapy. In this way, both the
emotional and physical aspects of the problem can be addressed.
From an emotional standpoint, it is important to understand
the history and background of the individual. Issues such
as depression, anxiety, past sexual experiences, psychological
trauma and relationship history are important considerations
that need to be discussed early in the evaluation.
Regardless of the psychological issues, a good medical or
urologic work-up is always encouraged before embarking on
a behavioral treatment program. In this manner, any medical
considerations that contribute to the problem can to be
understood from the onset. From a medical perspective, ejaculatory
dysfunction is often considered to be a nerve related issue.
In such cases, penile sensitivity may be evaluated using
various instruments that produce vibration. In addition,
a medical history is obtained paying particular attention
to any previous neurologic injury or trauma to the penis.
Other sexual dysfunctions such as low desire and erectile
dysfunction may also accompany the ejaculatory problem and
need to be addressed.
The psychological definition of delayed ejaculation refers
to the inability to have an ejaculation during sexual intercourse.
Interestingly enough, ejaculatory issues are rarely defined
as a dysfunction if they occur only during masturbation.
As a result, an important diagnostic question for sex therapists
is the context in which the problem occurs. Does this difficulty
occur with self-stimulation, with all partners or with specific
partners? This question will ultimately be important as
a treatment program is designed and implemented.
of delayed ejaculation tend to be somewhat rare and not
well understood by psychologists and sex therapists. In
addition, they are not well understood by most medical doctors
and urologists. It is not unusual for doctors to minimize
the dysfunction and to dismiss it. For many men, finding
the right professional, who has experience and realizes
the seriousness of the problem may be one of the most difficult
aspects in the treatment process.
In many cases, the man himself may tend to delay treatment
or to minimize the distress of the situation. At other times,
there is the hope that ejaculatory problems will disappear
without proper treatment. Unfortunately however, problems
such as delayed ejaculation seldom disappear without professional
intervention. For many men, feelings of shame prevent them
from seeking medical and professional help.
In spite of the lack of information regarding delayed ejaculation,
the most successful approach, for sex therapists, is to
engage both members of the couple into addressing the problem.
Thus, ejaculatory dysfunction is always perceived as a couple’s
issue. Resolving the problem is most successful when both
partners can work together as a team toward a successful
solution. If the man is in a relationship, he needs the
support and understanding of his partner. This helps to
insure a successful treatment. Otherwise, the partner’s
frustration and distress may contribute to the continuation
of the problem. Overcoming an ejaculation problem when under
stress and pressure from a partner is extremely difficult
for any man.
Ejaculatory problems can have a devastating affect on self-esteem.
Men with ejaculation problems undoubtedly have feelings
of inadequacy, feelings of failure and a negative view of
themselves. They feel that they have little to offer in
a relationship and to tend to avoid emotional and physical
intimacy. Over time, partners become frustrated and communication
becomes strained. Thus, resentments, anger and feelings
of rejection often accompany an ejaculation problem. In
couples where ejaculation is an issue, the partner often
internalizes this dysfunction as their mistake; the partner
feels responsible ultimately intensifying the man's stress
and performance anxiety.
problems may also contribute to a low libido and lack of
interest in sexual activity. Without ejaculation, sex can
become a source of frustration and devoid of satisfaction.
As a result, sexual activity can be perceived as more work
than pleasure. In some cases, the woman may not be interested
in sexual intimacy because of her frustration and anger
at the situation. Ultimately in such cases, couples agree
to avoid sexual contact rather than face the emotional pain
of another sexual failure.
For some men, there may be additional psychological issues
that underlie an ejaculatory dysfunction. For example, there
may be issues of performance anxiety related to infertility,
fears of rejection or the desire to please a partner. Early
psychological trauma can also be a significant factor. If
sexual abuse of the man has occurred, these can have a direct
correlation to the sexual dysfunction itself. Sex can serve
as a trigger to bring back painful emotional feelings and
memories from the past. Ignoring these important emotional
issues can lead to difficulties resolving the problem or
to a future re-occurrence of the sexual dysfunction.
Traditional behavioral sex therapy for delayed ejaculation
is as follows: the man begins by masturbating, then starts
intercourse when he is almost ready to ejaculate; the procedure
continues with the man beginning intercourse earlier and
earlier. The partner may assist the man to masturbate and
maintains a supportive and encouraging attitude. Sensitivity
may be improved with the use of androgens such as testosterone
or by using a vibrator.
In July 2003, the World Health Organization recommended
that the term “pre-mature ejaculation” be replaced
by the more neutral phrase “ early ejaculation”.
In contrast to delayed ejaculation, early ejaculation difficulties
are much more common and frequently seen in sexual medicine
clinics. The literature suggests that early ejaculation
is the most common of any male sexual difficulties. It is
certainly one of the most stressful.
By definition, early ejaculation is an ejaculation that
occurs before it is desired. Typically, the ejaculation
has become inevitable either during foreplay or in the first
moments following penetration. In spite of his best efforts,
the man experiences a sense of helplessness in controlling
his ejaculation. A significant amount of distress from the
man or his partner almost always accompanies an early ejaculation.
The partner feels equally unsatisfied and frustrated.
Psychologists and sex therapists tend to view ejaculatory
control as a skill that is mastered via masturbation during
adolescence and early adulthood. As a result, most men ejaculate
quickly in their early sexual years when they are young
and inexperienced. With masturbation, the adolescent or
young man learns various techniques that allow him to maintain
a high level of arousal without ejaculating. As the young
man becomes sexually active with a partner, these skills
can then be transferred to his new sexual encounters. As
the man becomes more sexually experienced, latency of ejaculation
increases although not always to the satisfaction of the
man and his partner.
addition to early sexual experiences, family attitudes toward
sexuality as well as cultural and religious beliefs all
play a role in sexual development and ejaculatory control.
For example, when a boy is young he may feel rushed or ashamed
about masturbation; he may feel guilty because of religious
or cultural values; he may feel conflicted regarding self-pleasuring.
Such circumstances may provide the groundwork for future
problems with sexual desire, erections or ejaculation. In
other cases, these early messages may lead to areas of conflict
regarding trust and intimate relationships.
less common, some men develop early ejaculatory problems
later in life. After years of satisfying sexual experiences,
these men suddenly find themselves struggling to maintain
ejaculatory control. Sometimes, these problems develop with
a new partner, after a divorce, during periods of stress
or when dealing with infertility issues. At other times,
there may be no clear precipitating events to the onset
of a early ejaculation pattern. Essentially, treatment for
these cases is similar to younger men but psychological
issues are probably even more critical to address.
As mentioned, the most effective approach is a combination
of psychological assistance and medical intervention. In
this way, the man can quickly achieve positive sexual experiences
and gain a sense of confidence. Urologists and other medical
doctors typically treat early ejaculation with a combination
of medications and creams. Anti-depressant medications such
as Paxil and Zoloft are often prescribed and are taken by
the patient 2 hours prior to sexual activity. If this is
not effective, the patient is further instructed to take
the medication on a daily basis rather than before sexual
activity. The dosages are usually adjusted as the patient
Viagra is also prescribed for many men with early ejaculation.
Viagra helps to maintain the erection after ejaculation
and reduces the refractory time before a second erection
can be obtained. These medications may be combined with
various creams aimed at reducing sensitivity. After successful
intercourse and renewed confidence, men begin to learn the
signs of pending ejaculation and ultimately learn to gain
Sex therapy for early ejaculation includes learning a behavioral
program designed to improve self-control. In a therapeutic
program, the first step is usually education. It is important
that the couple have an understanding of the problem, it’s
origins, the prognosis and the need to work together toward
a satisfying solution. The partner must also understand
that the man is not being selfish and that ejaculatory control
is unsatisfying for him as well. The most common behavioral
approach taught by sex therapists is either the squeeze
technique or an approach described as “start and stop”.
These techniques, originally developed by Masters and Johnson,
require patience, practice and a commitment to solving the
problem. Specific instructions are adapted to the individual
and unique characteristics of each patient. With the instructions
from the therapist, the patient begins a series of daily
masturbatory exercises designed to help him understand his
ejaculation pattern and gain control.
In summary, under the right circumstances and with ongoing
motivation, ejaculation disorders can be overcome. The most
important lesson to be learned by men and their partners
is that there is hope and there are therapies that can help
resolve the distress of ejaculatory difficulties. Often
the first step, deciding to seek treatment and finding the
proper professional is the most difficult.