Why Delayed Ejaculation Is More Common Than Folks Realize

A renowned urologist stopped me on the street yesterday for a brief curbside consultation: “Mike, why am I seeing so many new referrals for delayed ejaculation and how can I help them?”

This blog will provide the answer(s) by defining and describing delayed ejaculation (DE) as well as explaining its possible causes. My next blog post provides suggestions on how to cope with DE and offers an alternative treatment approach that doctors will hopefully embrace.

What’s in a name and the definition of DE?

Delayed ejaculation is the least understood of the male sexual dysfunctions. Men with DE find it difficult or impossible to ejaculate and/or experience orgasm. Historically, DE has been called by a variety of different names including retarded ejaculation, inadequate ejaculation, diminished ejaculation, and male-orgasmic disorder. Today, doctors refer to DE as “delayed ejaculation” in the hope of reducing the stigma associated with the condition. DE is typically defined as a marked delay in ejaculation and/or infrequency or absence of ejaculation.

What is the difference between delayed ejaculation and anorgasmia?

Some men do experience both conditions, but confusion arises over ejaculation and orgasm as they usually occur simultaneously. However, they are in reality separate but related phenomena. Orgasm (intense pleasure and/or release at the sexual climax) is typically concurrent with ejaculation (expulsion of semen from the penis) but is a central (brain) sensory event with significant variation between men. Orgasm is a mental/emotional process and while occurring in the brain there can be significant variation between a man’s different sexual experiences.

Ejaculation is the process during which semen is deposited in the urethra (urine tube) and then ejected by forceful contractions of the pelvic muscles. Orgasm may occur without erection or ejaculation and vice versa. Hence, pleasurable orgasms may still occur in men who no longer have a prostate (the organ that produces most of what is in semen). Although, some men do experience a difference in the quality of their orgasm subsequent to prostate-related procedures.

How long is too long?

Controversy exists regarding the temporal metric (time) used when defining both premature ejaculation and DE. “Worldwide” normative studies indicate that heterosexual males in stable relationships have an approximate 5-6 minutes median (average) intravaginal ejaculatory latency time (IELT), or time spent in penile-vaginal containment or thrusting.

Influenced by those studies, professional groups like the International Society of Sexual Medicine’s ejaculation disorder definitions invoked a concept of percentage from the average (or standard deviation) that is often used in medicine. However, male ejaculatory latency data displays a large disparity in those global studies, meaning too narrow a focus and emphasis on time is now viewed as a disservice to clinicians and patients alike. Most sex therapists and a growing number of urologists support the view that DE’s impact on an individual man, in terms of control and distress rather than time, should be considered the more important criteria when diagnosing both PE and DE. The definition also requires that DE must be present for greater than six months and also be causing significant distress. Additionally, DE must be experienced on all or almost all occasions of sexual activity where the man does not desire the delay and/or experiences the delay as out of his own control.

Ejaculatory difficulty may occur in all situations (generalized) or be limited to certain experiences (situational). It may be lifelong (primary) or acquired (secondary). If a man is distressed by these symptoms only occasionally, that is not a sexual dysfunction. However, reassurance that this condition is becoming progressively more commonplace, is likely to offer little solace. If you and/or your partner suffer from such a situation and want to do something about it, keep reading and check out the next blog on coping with DE.

What characterizes men with DE?

Men with DE may fail to ejaculate during any sexual act whether masturbation, or partnered manual, oral, coital, or anal stimulation, etc. However, they usually have no difficulty attaining or maintaining erections, and most of these men are able to ejaculate with solo masturbation. In fact, the most common pattern reported to doctors is of a man who is typically unable to ejaculate in the presence of a partner (especially during intercourse) but is able to orgasm and ejaculate during solo masturbation.

Men with DE frequently seek treatment with a partner-related complaint. Men with DE typically report greater sexual dissatisfaction, lower sense of arousal, anxiety about their sexual performance, and suffer more general health issues than sexually functional men. Like other male sexual dysfunctions, men with DE often describe feeling “less of a man.”

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What impact does DE have on men and their partners?

Men with DE typically report less partnered sex and more relationship distress. Some partners initially enjoy extended intercourse. At first, his “sexual stamina” may be embraced by both the man and his partner as a longer lovemaking time can lead to increased intimacy and pleasure.

However, as the problem lingers, partners may eventually experience pain and sometimes even injury. At first, some women blame themselves and often question their desirability. But eventually, many partners become angry at the perceived rejection and the questioning shifts from, “does he really find me attractive” to “what’s wrong with him.”

As unhappiness increases, questions regarding the possibility of infidelity (e.g. affair) or questions regarding his sexual orientation can lead to such severe tension that complete avoidance of partnered sexual activity occurs with a resulting breakdown of communication and intimacy. In fact, to avoid anticipated negative reactions from their partner, some men even fake orgasms. To be sure, DE is particularly upsetting when couples are trying to become pregnant.

How common is DE?

DE prevalence rates in the professional literature were reported to be low for decades and rarely exceeded 3 percent. However, many men seeking medical attention for this condition may be misdiagnosed by their physician as suffering from ED. In such cases, men might not be able to attain climax during sex and lose their erections due to fatigue or anxiety about not being able to ejaculate.

Regardless of the statistical survey rates, it is clear that millions of men do suffer from this condition. Furthermore, DE does become more common as men age. Subsequently, it does seem likely that DE rates will continue to rise even into the near future as our population ages in so many countries worldwide.

What physical factors (biomedical & pharmaceutical) cause DE?

Per the Sexual Tipping Point model (STP) of sexual response, like other sexual disorders, DE is usually caused by a combination of physical and mental factors. Aging is highly correlated with sexual disorders. Aging, of course, increases the likelihood of age-related diseases, and their associated treatment/medications/surgeries all have sexual side effects.

In fact, one often overlooked cause of the increased prevalence of men suffering from DE is the ever-increasing use of pharmacotherapy to treat both medical and sexual problems. For instance, nocturnal (nighttime) increased urinary urges and increased urinary frequency are common and often disruptive occurrences for aging men. Those conditions are often treated by 5-alpha reductase inhibitors (5aRIs) that are used to “shrink” aging prostates as in, “he has a ‘growing’ problem not a ‘going’ problem” (as explained by television commercials). Those same drugs (e.g. finasteride) are also used with young men in the last decade to treat alopecia (baldness). They have side effects that can negatively impact ejaculation regardless of a man’s age.

Serotonin reuptake inhibitors (SRIs) used to treat depression cause a decline in ejaculatory capacity and an increase in ejaculatory latency: “it takes longer to cum.” Additionally, many men are using “sex drugs” for erectile dysfunction (ED) in part because an aging population also means an increase in ED’s prevalence.

While ED drugs (Viagra, Levitra, Cialis, etc.) help many men gain and keep an erection, that does not mean those men are really adequately sexually aroused! Their penis is harder, but some of them are not really “turned on,” they are just pharmaceutically helped to have better blood flow that results in an erection. To have an orgasm, they need to be sexually excited in their mind, not just having functional equipment.

What other physical factors may play a role in DE? There is increasing evidence that some men have natural variation in their ejaculation latency (how long they last during sex) and this may lead to DE-like problems for some couples.

Many believe DE is a neurobiological variation of a “normal” ejaculatory statistical distribution curve. It is known from studies in animals as well as humans from around the world that there is a great variation between couples in how long sexual intercourse lasts. Some of these differences may be cultural, but there is increasing evidence that predisposing genetic factors have an effect on the speed and ease of ejaculation by modulating brain chemicals and a variety of biological mechanisms that control ejaculation. Additionally, changes in penile sensitivity with age or neurological disease may also play a role in DE. Again, as men age, some who never had a sensitivity problem before will begin to notice a decreased ability to fully experience the stimulation provided during sex. They will then find themselves, at first periodically and then consistently, having difficulty ejaculating under circumstances in which they were previously functional.

What “Mental” (psychosocial-behavioral and cultural) factors cause DE?

Per the STP model, there are of course “Mental” or psychosocial-behavioral and cultural factors that explain DE? Theories of psychosocial causes of DE tended to highlight four categories: psychic conflict, insufficient stimulation (compared to masturbation) and relational issues. Early psychodynamic explanations saw DE as an outgrowth of psychic conflicts suggesting malingering, unconscious, and unexpressed anger, whereas other theorists suggested that men with DE were “unwilling” to receive pleasure. Other early mental health explanations saw DE as an outgrowth of anxiety, lack of confidence, and poor body image, etc. Anxiety can draw the man’s attention away from sexual cues that enhance arousal and can interfere with genital stimulation sensation resulting in insufficient excitement for climax; this is true even if an erection was maintained. Some early theorists emphasized fear: of semen loss; of female genitals; of hurting the partner through ejaculation; and of ‘defiling’ the partner. Depression can lead to DE as it is the most important condition affecting sexual desire; this relationship is bidirectional or goes in both directions. Masters and Johnson (1971) suggested that DE in some men might be associated with the orthodoxy of religious belief. Such beliefs may limit the sexual experience necessary for learning to ejaculate or may result in an inhibition of normal function.

Masturbation related factors have been shown to be a frequent cause of DE. In reviewing my patient charts in the early 1990s, I identified three masturbatory factors associated with DE: masturbatory frequency, idiosyncratic masturbatory style, and an unsettling disparity between masturbatory fantasy and reality. High frequency (varies from man to man) masturbation is often associated with DE. However, the primary factor causing DE is usually an “idiosyncratic masturbatory style,” a term I coined and defined as a technique not easily duplicated by the partner during sex. What the man rehearsed by himself is so different from what he is experiencing from his partner that he is unable to function and ejaculate. These men engage in patterns of self-stimulation notable for one or more of the following idiosyncrasies: speed, pressure, duration, body posture/position, and specificity of focus on a particular “spot” in order to produce orgasm/ejaculation. In fact, some of these men even report having to visit dermatologists to treat the penile irritation caused by their masturbatory patterns. Yet, such practices are rarely discussed at all (let alone in the detail necessary for a change) with either their partner or any of their healthcare professionals for reasons of embarrassment and/or shame. Finally, sometimes there is a disparity between the reality of sex with their partners and the sexual fantasies (whether or not unconventional) these men prefer using during masturbation are another cause of DE. That disparity takes many forms, such as partner attractiveness, body type, sexual orientation, and the specific sex activity performed.

There are many partner issues that affect males’ ejaculatory interest and capacity, but two require special attention, especially pregnancy concerns and resentment. The pressure of a woman’s “biological clock” is often an initial reason that couples seek treatment. Clinicians from various theoretical persuasions have correctly noted pregnancy concerns among men with DE and also observe how referrals may be tied to a female partner’s wish to conceive. Distress is often greatest when conception “fails,” yet fear of pregnancy leads some men to avoid dating or to avoid sex altogether.

Anger generally is an important factor that can be both a direct cause and a maintainer of sexual dysfunction. Anger acts as a powerful anti-aphrodisiac and must be ameliorated through individual and/or couples' consultation. While some men avoid sexual contact entirely when angry, others attempt to perform, only to find themselves insufficiently aroused and unable to function. A partner who is upset and fears being found unattractive can easily become very angry. That can lead to the kind of mutual recriminations which evoke negative consequences for both partners. Misguided accusations and questions regarding the man’s sexual orientation can be especially provocative and problematic. Such tensions often lead to avoidance of partnered sex entirely as feelings of disconnection increase.

Which are more important, the mental or physical factors — i.e., mind or body?

Clinical experience demonstrates that separating causes, diagnosis, and treatment into categories such as psychogenic and biologic is too limiting. The most useful approach to understanding human responses is that of integrating—rather than isolating—the biological and psychological, social, behavioral and cultural factors. A doctor’s goal should be identifying both the mental and physical elements that contribute to each man’s varied response. Delayed ejaculation is best understood as an endpoint response that represents the interaction of biological, medical, psychological, social, and cultural factors.

My next blog post will discuss how to best diagnose the condition and what healthcare professionals have done in the past to help these men, as well as a recommendation for a different approach that effectively helps men seeking an easier path to ejaculation.