Ejaculation Problems: Too Slow or Too Fast?
By Martin V. Cohen, Ph.D. and
Stanley Ducharme, Ph.D.
For 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 article
will explore some of the psychological factors and treatment options related to
these two distinct male dysfunctions.
In 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.
Problems 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
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.
Ejaculation 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, this 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
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.
In 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
Although 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
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. Antidepressant
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 increased control.
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, its 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.
© 2005 Martin V. Cohen, Ph.D. and Stanley