Input: Write a detailed section about the treatment of premature ejaculation, including the role of psychotherapy, pharmacotherapy, and combined therapy. Discuss the various psychological theories for the development of premature ejaculation, including psychoanalytic and behavioral-learning perspectives. Also, discuss the impact of premature ejaculation on the man and his partner, and the evaluation process for this condition. In your discussion, include case vignettes to illustrate the challenges and successes of treatment. Finally, provide information on the outcome studies for psychotherapy and pharmacotherapy in the treatment of premature ejaculation.

Response:
Additionally, a genetic study of 1,196 Finnish male twins between the ages of 33 and 43

years (Jern et al., 2007) suggested that genetics accounts for 28% of the variance, with no shared environmental variance (0%) and 72% nonshared environmental variance. One 116

possible interpretation of these findings is that genetic influences may create a diathesis or predisposition in some men to ejaculate prematurely.

Endocrine control of the ejaculatory reflex is still not completely clarified (Corona et al., 2011). There is evidence to indicate a link between depression, serotonin, and thyroid hormones. Carani reported that 50% of men with hyperthyroidism had PE and, when successfully treated, the prevalence of PE fell to 15% (Carani, Isidori, & Granata, 2005).

Regarding the heightened penile sensitivity and/or nerve conduction hypothesis, the findings of several studies have been contradictory. Some support this notion; others show no relationship between PE and either heightened penile sensitivity or rapidity of the bulbocavernosus reflex (Fanciullacci, Colpi, Beretta, & Zanollo, 1988; Gospodinoff, 1989; Mirone et al., 2001).

**Psychological Theories**

There are multiple psychological explanations as to why men develop PE.

Unfortunately, none of the theories evolve from evidence-based research; rather, they are the products of thoughtful synthesis by clinicians from several schools of thought.

Although untested, the theories are thought provoking and have been helpful to clinicians over the years.

In 1927, Karl Abraham, a German psychoanalyst, speculated that PE is due to a combination of the man's unconscious hostile feelings toward women and his passive pleasure, as a child, in losing control of his urination (passive urethral eroticism), which in adulthood transforms itself into his passive pleasure in giving up control of ejaculation. Thus ejaculation into the woman's vagina was equated with "soiling" or

"debasing" her. The man takes his sexual pleasure, unconsciously soils her, and in so doing deprives her of sexual pleasure. Simultaneously he gives himself over to the passive pleasure of letting go of his ejaculation without any attempt to control his sexual excitement or delay ejaculation (Abraham, 1927).

A second psychoanalytic explanation focuses on the man's unresolved excessive narcissism during infancy, which results in his placing exaggerated importance on his penis. This hypothesis might explain the selfishness observed in some rapid ejaculators who seem unconcerned with pleasuring their partners.

In 1943, Bernard Schapiro introduced the notion that PE was a psychosomatic disorder. In his view, premature ejaculation is a bodily symptom that expresses the man's psychological conflict, akin to psychosomatic explanations for headache, backache, and stomach pain. In his view, because men with PE had "weakened"

genitourinary systems, they became rapid ejaculators rather than expressing their psychological conflict through another organ system (e.g., headache; Schapiro, 1943).

Psychodynamic theorists consider anxiety to be the primary etiological agent in precipitating the symptom of rapid ejaculation. However, anxiety is not a singular concept; it is employed to characterize at least three different mental phenomena.

Anxiety may refer to (1) a phobic response, such as being fearful (i.e., afraid of the dark, 117

wet, unseen vagina); (2) an affect, the end result of conflict resolution in which two contradictory urges are at play (i.e., the man is angry at his partner but feels guilty about directly expressing his hostility); or (3) anticipatory anxiety, commonly referred to as performance anxiety, in which preoccupation with sexual failures and poor performance leads to deteriorating sexual function and avoidance of future sexual interactions.

Conceptualizing PE in more of a behavioral-learning perspective, Masters and Johnson (1970) emphasized the concept of "early learned experience." By reviewing the case histories of men with PE, Masters and Johnson noted that many men described first sexual experiences characterized by haste and nervousness, for example, making love in the backseat of an automobile or an encounter with a prostitute. Masters and Johnson speculated that based on their initial experiences the men became conditioned to ejaculate rapidly.

Kaplan (1989) considered "lack of sexual sensory awareness" to be the immediate, here-and-now cause of rapid ejaculation. She believed that men fail to develop sufficient feedback regarding their level of sexual arousal. Such men experience themselves as going from low levels of arousal to ejaculation without any awareness.

**The Role of Performance Anxiety**

Performance anxiety per se does not generally cause the initial episode of rapid ejaculation; however, it is pernicious in maintaining the dysfunction. By the time patients present for psychological intervention, the initial precipitating event often is obscured because of the intensity of the man's performance anxiety. A further complication of performance anxiety is that it distracts the man from focusing on his level of arousal, rendering him helpless to exert voluntary control over sexual arousal and ejaculation. In fact, men believe that focusing on their level of arousal will only cause them to ejaculate even more rapidly.

**IMPACT ON THE MAN AND THE COUPLE**

Premature ejaculation affects both individual and relationship quality of life (QOL).

Qualitative research showed that the majority of men with PE (68%) report a decrease in sexual self-confidence. Moreover, half of the single men describe either avoidance of relationships or reluctance to establish new relationships. Men in relationships report distress at not satisfying their partners, with some worrying that their partners would be unfaithful to them because of their PE.

Embarrassment regarding discussing PE was the primary reason for not consulting a physician, cited by 67% of respondents. Interestingly, almost half thought no treatment existed (47%).

Hartmann, Schedlowski, and Kruger (2005) characterize men with PE as preoccupied with thoughts about controlling their orgasm, with anxious anticipation of a possible 118

failure, with thoughts about embarrassment and about keeping their erections. In contrast, they found that functional men focused on sexual arousal and sexual satisfaction.

Intimacy is also affected in men with PE. Men with PE scored lower on all aspects of intimacy (emotional, social, sexual, recreational, and intellectual) and had lower QOL

(lower levels of satisfaction in all areas) than sexually functional men (McCabe, 1997).

PE also has a negative effect on the partner's QOL. A recent study showed a relationship between PE and lower partner sexual satisfaction in heterosexual couples (Byers & Grenier, 2003). Partners are not just distressed because of the quality of the man's sexual performance; they are also upset because the condition and the man's associated distress often lead to a rapid and unwanted interruption of intimacy. Women are also angry with their partners with PE because they do not feel that their concerns have been genuinely "heard" by the men nor that they are unwilling to "fix" the problem. Men likewise believe that their partners do not understand the degree of frustration and humiliation that they routinely experience. This disconnection between the men and their partners is the basis for considerable relationship tension. Thus, for men in stable relationships, PE should be recognized as a couple's issue. All these studies suggest that the psychosocial impact of PE on the patient and partner has profound psychosocial consequences.

**EVALUATION**

Although clinicians conceptually separate evaluation and treatment processes, patients do not. For them the "cure" begins with the first encounter. The patient is, of course, correct; the attentive therapist is aware that the psychotherapeutic relationship and all its transference ramifications are initiated with the first handshake and entry into the consulting room.

**Attend to the Therapeutic Relationship before Attending to the Data**

The establishment of a respectful, comfortable, and healing relationship with the patient(s) is the primary goal of the evaluation session. Too often the secondary goal of gathering data displaces the more human process of relating to one another. The man and his partner are likely to be anxious and uncomfortable; they are about to share aspects of their intimate life with a stranger.

Talking about sexual matters does not come naturally to most people. The therapist must first set them at ease before progressing into the more difficult material. When couples seem ready to work, one can ask, "What brings you in?" Others may need more soothing, so asking, "How is it for you to come in today and talk with me?" may be helpful. For the very anxious patient, it may be advisable to start by asking, "Did you have any trouble finding the office?"

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**Look for Early Resistance**

Infrequently, even when the presenting problem is sexual, there are first meetings at which sexual issues are not discussed. This is significant and challenges the therapist to assess whether the resistance belongs to the patient or to the therapist. I still recall my reluctance to ask an elderly European gentleman about his sexual life because he very much reminded me of my father. Unknowingly, I was avoiding taking a sexual history.

At 15 minutes into the hour this man asked, "So, when are you going to ask me about sex?" He was right. I laughed to myself, recognizing the countertransference, and was able to proceed.

Patients' reluctance to share sexual material may arise from a number of factors. The old analytic maxim "resistance before conflict" is good advice. Inquiry should shift from descriptions of the couple's sexual life to understanding what prevents the man or woman from discussing this subject.

In most ordinary clinical interviews, sociocultural and religious prohibitions against talking about sexual life are encountered. These include: "In our family, such matters were never discussed" and "I grew up thinking it was wrong to talk about sex with anyone." Sometimes the gender of the interviewer is the focus of the resistance. "I can't talk about this with a male/female doctor." Acknowledging the patient's discomfort and giving permission and reassurance often overcomes resistance stemming from these sources. If the therapist's gender continues to be an unyielding source of resistance, referral should be made to a colleague of the opposite gender.

Patients' expectations regarding treatment also contribute to resistance. Couples do not know what to expect. Some are afraid that the therapist will physically examine them or watch them engage in sexual behavior. Others may have concerns about the therapist being sexual with them or asking them to engage in sexual behaviors that they consider unconventional.

**The Secret: The Pitfalls from Collusion**

A stronger, more persistent source of resistance initially stems from patients' reluctance to reveal aspects of their lives that are embarrassing, shameful, or hurtful to themselves or their partners. These secrets kept from the therapist may have their origins in fragments of traumatic childhood sexual experiences, awareness of unconventional fantasies, extramarital relationships, or conflictual young adult life events that have not been shared with others, such as the suicide of a brother, periods of sexual promiscuity, a visit to a prostitute, having been raped, or a homosexual encounter.

Some patients rationalize that these events, feelings, or fantasies are unrelated to the current problem and therefore do not need to be shared. Conversely, others are keenly aware of the impact of the secrets on their psychological and sexual lives but lack sufficient trust, courage, or motivation to address these problematic life dilemmas.

Honesty between patient and therapist is the cornerstone of treatment. Conscious avoidance and withholding of information compromises the therapeutic process. My 120

current policy is not to begin couple treatment if one partner asks me not to talk about a relatively current and important issue, for example, a 2-year affair that ended 2 months before. I have less difficulty agreeing to maintain a secret such as "Twenty years ago, on an out-of-town business trip, I had a one-night affair." My rationale is that I do not see a brief, remote affair as necessarily relevant and that disclosure of the event to the partner may prove to be more destructive than helpful.

**Assessment: What to Ask**

Each therapist needs to develop his or her style and method of assessing PE. What follows is my method. Figure 5.1 offers an assessment and treatment algorithm that readers might find helpful.

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**FIGURE 5.1** **.** Algorithm for the management of PE. Reprinted with permission from D. Rowland.

If the man with PE is in a relationship, I generally ask to see the couple together and the man and woman alone separately. Partners are not always initially willing to be part of the process. In that situation, I see the man alone. I begin by asking a patient when the PE began and whether there was ever a time when he had control over ejaculation. I chart the course of the problem and ask specifically about average IELT, degree of voluntary control, distress, and sexual satisfaction. I want to know why he or they have chosen to seek treatment at this point in time and what prevented them from seeking 122

consultation previously.

I move on to take a sexual history to identify whether there are any coexisting sexual dysfunctions and to learn whether the patient has PE with all partners or only specific partners. Then I ask the patient to recount in detail a recent sexual encounter. This helps to clarify the degree of performance anxiety, the narrowness or broadness of his sexual repertoire, his cognitions and affect, what happens after he ejaculates, and the responses of the partner to his dysfunction. I attempt to ascertain whether he attends to or has an awareness of his level of sexual arousal. I inquire as to the strategies he has employed to delay ejaculation and whether or not they were successful. I also ask if he was previously in psychotherapy and what that experience was like for him. From a medical standpoint, I ask about health issues inquiring about prostatitis and hyperthyroidism, specifically in acquired PE.

The next portion of the assessment focuses on his interpersonal relationship and the impact of PE on the couple's sexual and nonsexual intimacy and overall relationship.

Questions about the partner are broached, such as the following: Does she suffer from any sexual dysfunctions? Does she engage in strategies to help delay his rapid ejaculation, or does she seem to encourage his ejaculating rapidly? Is she willing to participate in treatment? These questions allow the therapist to form preliminary judgments regarding the partner's willingness to help with treatment versus her potential to sabotage it.

Lastly, I try to ascertain the patient's interpersonal style, psychological comorbidities, and limitations or strengths regarding treatment. All this data should help me to develop preliminary hypotheses as to the predisposing, precipitating, maintaining, and contextual factors and what resistances might interfere with treatment (McCabe et al., 2009).

**THE FIRST DECISION: INDIVIDUAL OR COUPLE TREATMENT,**

**PHARMACOTHERAPY, OR COMBINED PSYCHOLOGICAL–**

**PHARMACOLOGICAL THERAPY**

The evaluation concludes with the therapist offering the patients his or her understanding of the issues and treatment recommendations. There are several distinct possibilities: individual therapy for one or both partners, conjoint or couple treatment, pharmacotherapy alone, or combined pharmacological and psychological treatment.

It seems odd that combined pharmacological and psychological treatment of sexual problems has not established itself as a mainstream intervention for either mental health clinicians or sexual health physicians who treat sexual problems (e.g., urologists or family practice physicians). Generally, mental health clinicians offer psychological interventions, and medical practitioners offer pharmacological treatment. Studies on combined medical and psychological therapy all demonstrate that combined treatment is superior to medical treatment alone (Li, Zhy, Xu, Sun, & Wang, 2006; Steggall, Fowler, & Pryce, 2008; Tang, Ma, Zhao, Liu, & Chen, 2004; Yuan, Dai, Yang, Guo, & 123

Liang, 2008). What follows is a discussion of psychotherapy alone, pharmacological treatment alone, and combined therapy.

**When to Offer What**

Psychotherapy alone is best reserved for men and couples for whom the precipitating and maintaining factors are clearly psychological and the psychosocial obstacles are too great to surmount with pharmacotherapy alone. Examples of these psychosocial obstacles include: (1) patient variables, such as the degree of performance anxiety or presence of depression; (2) partner issues, such as how she copes with the sexual dysfunction or whether his rapid ejaculation obscures her sexual dysfunction; (3) interpersonal nonsexual variables, such as a chronically unsatisfying relationship; (4) contextual variables, including lack of privacy; and (5) each partner's expectations from treatment (e.g., "he should last 20 minutes because it takes me that long to have an orgasm").

Individual psychotherapy is the default choice for single men not in relationships. In addition to treating the sexual dysfunction, therapy must address these men's often-seen reluctance to enter into new relationships for fear of humiliating themselves and disappointing the woman. Psychotherapy can only go so far without the presence of a partner. For these men, treatment is sometimes divided into two phases: treatment when there is no partner and later resumption of treatment when they establish a new relationship.

For men in relationships, individual psychotherapy is recommended when the psychological variables supporting the dysfunction are thought to be more intrapsychic than interpersonal, for example, fear of penetrating a dark, wet, warm vagina or excessive fear of or hostility to women. These are generally products of unresolved childhood issues that continue to interfere in the man's adult sexual life. Individual psychotherapy may also be the treatment of choice when the relationship is deemed too chaotic or unworkable or when the partner refuses to participate. Individual treatment in these situations is of course limited given the limitations of the interpersonal environment.

Conjoint psychotherapy is recommended for men with either lifelong or acquired forms of PE in which both partners are relatively psychologically healthy and motivated to pursue treatment. Ideally, the precipitating and maintaining factors can be elucidated, the impact of the dysfunction on both partners can be clarified, and interventions directed at him, her, and both of them can be initiated.

Pharmacotherapy alone is recommended when the man has severe lifelong premature ejaculation, is sexually experienced, is in a satisfying relationship, and has reasonable expectations regarding treatment outcome. These men must understand that pharmacotherapy alone will not "cure" the problem; the rapid ejaculation will return as soon as they stop taking the medication. They must therefore be willing to continue on the medication for the foreseeable future.

Combined therapy offers the best of both worlds (Althof, 2003, 2005, 2006; Perelman, 124

2003, 2006). Pharmacotherapy will rapidly delay ejaculation and allow the man to regain some sexual confidence. Psychotherapy will help the man or couple maximize gains from pharmacotherapy. It seeks to help men and couples overcome the psychosocial obstacles that interfere with making effective use of the pharmacological intervention.

The man can be taught to attend to sensations rather than fear his arousal. He can learn to pace his arousal and expand his sexual repertoire without fear that it will lead to rapid ejaculation. In time, he can be slowly weaned from pharmacotherapy and implement what he has learned in psychotherapy. Not all men will be able to give up the pharmacological intervention; some, however, will be pleased that "on their own" they have triumphed over adversity.

**PSYCHOTHERAPY ALONE**

Present-day psychotherapy for rapid ejaculation is an integration of psychodynamic, systems, behavioral, and cognitive approaches within a short-term psychotherapy model (Althof, 2005; Kaplan, 1989; Levine, 1992; Masters & Johnson, 1970; McCarthy, 1990; Metz & McCarthy, 2003; Semans, 1956; Zilbergeld, 1992). The guiding principles of treatment are to learn to control ejaculation while understanding the meaning of the symptom and the context in which it occurs. Psychotherapy and behavioral interventions improve ejaculatory control by helping men and couples to: (1) learn techniques to control and/or delay ejaculation, (2) gain confidence in their sexual performance, (3) lessen performance anxiety, (4) modify rigid sexual repertoires, (5) surmount barriers to intimacy, (6) resolve interpersonal issues that precipitate and maintain the dysfunction, (7) come to terms with feelings or thoughts that interfere with sexual function, and (8) increase communication. Psychodynamically oriented therapists view the dysfunction as a metaphor through which the couple is trying to simultaneously conceal and express conflicting aspects of themselves or the relationship.

In symbolic terms, the dysfunction contains a compromised solution to one of life's dilemmas.

Alternatively, behavior therapists understand the dysfunction as a conditioned response or a maladaptive response to interpersonal or environmental occurrences.

They provide exercises known as stop–start or the squeeze technique as homework to help the man comfortably attend to his sensations and learn to pace his arousal. I find a modified stop–start method (detailed later in the chapter) much more effective than the squeeze technique because it does not require withdrawal from the vagina, and squeezing too hard can be painful for the man.

Men fear focusing on their sexual excitement, believing it will cause them to ejaculate even more quickly. They attempt to diminish or limit their sexual excitement by resorting to wearing multiple condoms, applying desensitization ointment to the penis, repeatedly masturbating prior to intercourse, not allowing partners to stimulate them, or distracting themselves by performing complex mathematical computations while making love. These tactics, however creative, curtail the pleasures of lovemaking and are 125

generally unsuccessful. These men typically describe themselves as having two points on their subjective excitement scale—no excitement and the point of ejaculatory inevitability. They fail to focus on their arousal and are unable to perceive or linger in midrange sexual excitement. In treatment, men are instructed to focus on their sexual arousal. By utilizing graduated behavioral exercises, they are taught to identify and become familiar with intermediate levels of sexual excitement. Successively, beginning with masturbation and moving progressively through foreplay and intercourse, they master the ability to linger in this range, thereby delaying ejaculation. A more detailed description of the stop–start technique is given in David and Trish's upcoming vignette.

In addition to teaching the men sexual skills and resolving the interpersonal and intrapsychic issues related to rapid ejaculation, it is also helpful to address the cognitive distortions that help maintain the dysfunction. Rosen, Leiblum, and Spector (1994), in discussing erectile dysfunction, list eight forms of cognitive distortion that may interfere with sexual function. These forms of distortion are just as applicable to rapid ejaculation and include: (1) all-or-nothing thinking ("I am a complete failure because I come quickly"); (2) overgeneralization ("If I had trouble controlling my ejaculation last night, I won't be able to this morning"); (3) disqualifying the positive ("My partner says our lovemaking is satisfying because she doesn't want to hurt my feelings"); (4) mind reading ("I don't need to ask, I know how she felt about last night"); (5) fortune-telling ("I am sure things will go badly tonight"); (6) emotional reasoning ("Because a man feels something is true, it must be"); (7) categorical imperatives ("should," "ought to," and

"must" dominate the man's cognitive processes); and (8) catastrophizing ("If I fail tonight my girlfriend will dump me").

Psychoeducational interventions also aim to rework the behavioral repertoire of the man or couple, referred to as their sexual script (Gagnon, Rosen, & Leiblum, 1982). Self-help books, such as that by Metz and McCarthy (2003), may prove helpful to men either by themselves or as a supplement to treatment. Men with rapid ejaculation limit foreplay because they fear becoming too excited. By modifying rigid and narrow scripts, therapists may help couples establish a more satisfying sexual life.

**Resistance**

No therapy ever progresses without some resistance on the part of the patient or couple.

It is to be expected. Resistance seeks to keep the status quo. It is not easy for patients to give up comfortable, yet maladaptive, behaviors. But with confrontation, interpretation, and gentle humor patients can be encouraged to relinquish resistance and "try on" new behavioral and interpersonal routines.

**Case Illustrations of Psychotherapy**

What follow are two vignettes that characterize different aspects of psychological treatment. The first portrays a middle-aged couple who both were motivated and 126

committed to overcoming his rapid ejaculation. The second vignette describes a complicated drama in which rapid ejaculation was the least of this couple's problems.

**Case 1: David**

David, a 45-year-old married antique dealer with lifelong rapid ejaculation, came for consultation at the urging of his wife, Trish. She had become increasingly frustrated with the lack of intimacy in their marriage and was totally "disgusted" with the quality of their sexual life. She was tired of hearing him apologize after ejaculating and simply wanted him to do something, anything, to fix it.

In conjoint treatment, David sheepishly admitted that he was afraid of vaginas. He joked about being "a real Freudian case." He wasn't exactly sure why he developed this fear, but he never felt comfortable with the warmth and wetness of Trish's vagina. He was glad that he could finally talk about this hidden fear, and over time it dissipated.

Trish was surprised; this was a part of David she didn't know. It precipitated intense anger at David, which expressed itself in demeaning and excessively critical comments.

This resistance gave way to my interpretation that her anger served as an obstacle to David's sharing his subjective life with her. I also spoke about zones of privacy and that none of us can ever know the other completely.

Conjoint treatment had four initial foci: (1) talking with David regarding his fear of vaginas, (2) instructing him on how to focus in on his arousal and control it, (3) addressing the relational and intimacy issues, and (4) decreasing her level of anger.

I suggested that they temporarily suspend attempts at intercourse. They were both agreeable to this. Trish talked about feeling simultaneously angry at all the years David did nothing and happy that he was finally addressing the problem.

In terms of behavioral exercises, we began with an updated version of stop–start in which I asked David to imagine sexual arousal on a scale from 0 to 10, where 9 is a point of ejaculatory inevitability. I explained to him that I wanted to teach him to linger in the midrange of excitement, somewhere between 5 and 7. I asked him to go home and masturbate, imagining his arousal on the 0–10 scale. When he reached 6 he was to stop and allow his arousal to dissipate to a 3 or 4. Then he was to start masturbating again and stop at 6. I told him to do this four times before allowing himself to ejaculate. He was to practice these exercises at least four times per week.

After several weeks of talking about his fears, abstaining from intercourse, and practicing masturbating to midlevel arousal, we moved on to having Trish masturbate him to midranges of arousal. She was told to manually or orally stimulate him until he asked her to stop. David's task was to concentrate on his level of arousal and ask Trish to stop when he reached a 6. Then, as he had previously, he was to allow his excitement to diminish and allow it to build up to 6 several times before achieving orgasm. Trish was a supportive and committed partner and understood the purpose of the exercise. She was told that she could ask David to pleasure her in any noncoital fashion. She did so on several occasions.

Following David's mastering his excitement with manual or oral stimulation, I 127

suggested that the couple have 2 minutes of intercourse without thrusting. This was a test to see whether David's fear of the wet and warm vagina would interfere with his ability to concentrate on arousal. I urged David not to apologize should he ejaculate, but rather to hold Trish and continue being emotionally intimate with her. Trish greatly appreciated this suggestion. David did surprisingly well; he ejaculated only once out of six attempts and remembered not to apologize. The couple moved on to have intercourse with thrusting, and again David was instructed to stop the exciting movements when he reached a level of 6 on the 0–10 arousal scale. He was to follow the same pattern of stopping, allowing his arousal to diminish and then resuming thrusting until he reached 6. They were to do this several times before he could ejaculate.

All along we had also been discussing how they could deepen their level of intimacy.

David's fears and Trish's anger were identified as roadblocks to intimacy. With a little help from me, as they worked together on the sexual problem, each was able to be more intimate with the other. Within 4 months, David had achieved moderate to good control, and both felt that their relationship had significantly improved. I continued to see them every 4 months for 2 years to ensure that they sustained their gains.

**Case 2: Ken**

Ken, a self-centered, 26-year-old, married stockbroker sought treatment for lifelong rapid ejaculation. He took no responsibility for his dysfunction, projecting the blame to his wife, Mia, for being too attractive. He harshly reproached her, saying, "You get me too excited." In addition to his conspicuous narcissism, he also was severely compulsive, having to change his underwear and shower several times daily. He dismissed my suggestion to consider taking SSRI medication that could simultaneously diminish his compulsivity and delay ejaculatory latency. He insisted that he did not need any psychotropic medication.

The marital climate was dominated by his jealousy of Mia's professional success. Mia was depressed and overwhelmed; her mother had recently passed away, and she had two young boys under age 3.

None of my interventions were successful. Ken refused medication, and Mia had little energy available to devote to conjoint therapy. The couple never made time to complete behavioral assignments; they wanted a quick, simple fix to all their problems.

After 6 weeks we mutually agreed to terminate.

Interestingly, Mia came to my office 8 years later complaining of anorgasmia. Now divorced and thriving professionally, she was a single mother of two young preteen boys. She described the painful process of her marriage disintegrating as she helplessly watched Ken spiral downward professionally, propelled by his cocaine abuse and sexual addiction to prostitutes. Whether true or not, Ken told her that he never ejaculated rapidly with prostitutes, only with her.

Mia continued in treatment for approximately a year and a half. She had begun a new relationship and was afraid of allowing herself to be vulnerable to another man. Her sexual symptom served to create distance and protect her from feeling too close to her 128

boyfriend.

**Psychotherapy Outcome Studies**

Evidence-based medicine has become the gold standard for judging the efficacy of psychological or medical interventions. Studies at the highest level require moderate to large sample sizes with designs being randomized, placebo-controlled, double-blinded, and with 6-month to 1-year follow-up data. Sex therapy treatment outcome studies can be characterized as uncontrolled, unblinded trials; few meet the requirements for high-level evidence-based studies. The literature consists of reports on small to moderately sized cohorts of participants who received different forms of psychological interventions with limited or no follow-up. In most studies, active treatment was not compared with placebo, control, or wait-list groups. With few exceptions, the quality of the PE

treatment outcome studies is inadequate.

Masters and Johnson (1970) reported on 186 men who were seen in their quasi-residential model utilizing multiple treatment modalities, including the squeeze technique, sensate focus, and individual and conjoint therapy, as well as sexual skills and communication training. They reported "failure rates" of 2.2% and 2.7% immediately posttherapy and at 5-year follow-up, respectively. Never before or since has any clinical center been able to replicate either the initial or posttreatment efficacy rates reported by Masters and Johnson. For example, only 64% of men in Hawton and colleagues'

(Hawton & Catalan, 1986; Hawton, Catalan, & Fagg, 1992) studies and 80% of Kaplan's (1983) cohort were characterized as successful in overcoming rapid ejaculation immediately posttherapy.

In a recent study, De Carufel and Trudel (2006) demonstrated an eightfold increase in IELT among men treated with behavioral techniques compared with a wait-list control condition. The participants maintained their gains at the 3-month follow-up and reported increased sexual satisfaction in addition to the gains in IELT. This is one of the few high-quality PE treatment outcome studies.

The majority of studies with long-term follow-up noted a tendency for men to suffer relapses. In writing about the problem of relapse in treating all forms of sexual dysfunction, Hawton et al. (1992) reported that recurrence of or continuing difficulty with the presenting sexual problem was commonly being reported by 75% of couples; this caused little to no concern for 34%. Patients indicated that they discussed the difficulty with the partner, practiced the techniques learned during therapy, accepted that difficulties were likely to recur, and read books about sexuality. In spite of the decrease in IELT over time, patient sexual satisfaction remained very high!

The concept of relapse prevention has begun to be incorporated into sex therapy.

McCarthy (1993), in discussing relapse prevention, suggests that therapists schedule periodic "booster" or "maintenance" sessions following termination. Patients remark that knowing that they will be seen again in 6 months keeps them on target, because they know they will have to "report" on their progress. The follow-up sessions can also be used to work out any "glitches" that have interfered with their progress.

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**PHARMACOTHERAPY**

There are presently two methods of pharmacological treatment of rapid ejaculation: (1) both daily and "as-needed" dosing schedules of SSRIs or clomipramine (a tricyclic antidepressant), and (2) topical administration of prilocaine/lidocaine.

Dapoxetine has received approval for the treatment of PE in over 30 countries, but not in the United States. It is a rapid-acting and short-half-life SSRI with a pharmacokinetic profile suggesting a role as an on-demand treatment for PE (Buvat, Tesfaye, Rothman, Rivas, & Giuliano, 2009; Hellstrom et al., 2005; McMahon et al., 2009; Pryor et al., 2006). No drug–drug interactions associated with dapoxetine, including phosphodiesterase inhibitor drugs, have been reported. In clinical trials, dapoxetine 30 mg or 60 mg taken 1–2 hours before intercourse is more effective than placebo from the first dose, resulting in a 2.5–3.0-fold increases in IELT, increased ejaculatory control, decreased distress, and increased satisfaction. Dapoxetine was comparably effective in men with both lifelong and acquired PE. Treatment-related side effects were uncommon and dose-dependent and included nausea, diarrhea, headache, and dizziness. There was no indication of an increased risk of suicidal ideation or suicide attempts and little indication of withdrawal symptoms with abrupt dapoxetine cessation (Levine, 2006).

Off-label treatment with the SSRIs paroxetine (Paxil), sertraline (Zoloft), and fluoxetine (Prozac) and the tricyclic antidepressant clomipramine (Anafranil) has been successfully employed to treat rapid ejaculation. It is believed that all have similar mechanisms of action. The dose range for each drug is paroxetine: 20–40 mg; clomipramine, 12.5–50 mg; sertraline, 50–200 mg; and fluoxetine, 20–40 mg.

Ejaculation delay is observed within the first week and tends to improve over several weeks. Side effects from these medications are dose-related and include fatigue, yawning, nausea, gastrointestinal upset, and excessive sweating. There is some controversy over whether these medications cause impulsive behaviors and increased suicidal ideation. Given the seriousness of these side effects, patients on pharmacotherapy for rapid ejaculation should be closely monitored. Although infrequent, some men report diminished libido and erectile dysfunction after starting on these medications. Side effects are seen in the first week but generally diminish over the course of 2–3 weeks. Finally, these drugs should not be abruptly discontinued. Doing so may lead to an unpleasant "withdrawal syndrome" (Althof et al., 2010).

Greater success has been achieved with daily dosing than with "as-needed" schedules.

However, men prefer "as-needed" schedules for several reasons, including cost and convenience, and because sexual activity for most men is not a daily event.

The use of topical local anesthetics such as lidocaine and/or prilocaine as a cream, gel, or spray is well established and is moderately effective in delaying ejaculation.

PSD502 is a lidocaine–prilocaine spray currently in clinical trials. Trial results indicated that the treated group reported a 6.3-fold increase in IELT and associated improvements in self-administered questionnaire measures of control and sexual satisfaction (Dinsmore et al., 2007). Because of the unique formulation of the compound, there were 130

minimal reports of hypoethesias and transfer to the partner. Other topical anesthetics are associated with significant penile hypoanesthesia and possible transvaginal absorption, resulting in vaginal numbness and resultant female anorgasmia unless a condom is used.

There are reports that PDE5 inhibitors can also be of benefit to men with rapid ejaculation (Aversa et al., 2011). There is controversy over whether or not they truly benefit men with rapid ejaculation.

**COMBINED PSYCHOLOGICAL–PHARMACOLOGICAL THERAPY**

The psychological aspects of a combined psychological–pharmacological treatment are different from those of psychotherapy alone. Such interventions are more directive, advice oriented, educational, and technique focused. They target the psychosocial obstacles created after the onset of the dysfunction, such as avoidance of foreplay, restrictive sexual patterns that are resented by partners, and unwillingness to discuss the problem, which itself creates a barrier. The goals of combined therapy include (1) identifying and working through the resistance to medical intervention that leads to premature discontinuation, (2) reducing or eliminating performance anxiety, (3) helping the patient to gain sexual confidence, (4) understanding the context in which men and couples make love, and (5) helping patients to modify maladaptive sexual scripts.

Combined treatment may be especially helpful when the treatment effects of pharmacotherapy are modest. By lessening the psychosocial obstacles that interfere with treatment and offering patients methods to delay ejaculation, the impact of pharmacotherapy can be enhanced.

**Case Illustration of Combined Therapy**

Rick, a 27-year-old male, had been married to Laura for 3 years. He described a lifelong history of PE. They had significant marital discord focusing on his lack of vocational success and his involvement with a quasi-cult-like group. Laura had become increasingly angry at his lack of success and time devoted to this group, as well as having an unsatisfying sexual life.

Rick was asking for medication to help his PE. Because of the significant marital discord, we recommended combination pharmacological and psychological therapy. He received 20 mg of paroxetine, which was slowly increased to 40 mg, and both partners were seen in weekly conjoint psychotherapy. Our rationale was to demonstrate to both partners rapid success in delaying ejaculation while we focused on their interpersonal issues.

Rick looked to the cult-like group for support and affirmation because he was feeling badly about himself, his vocational failures, and the marriage. Laura was angry at the 131

increasing distance between them and his downward spiraling.

Rick and Laura used the conjoint sessions to discuss their disappointments and also practiced the graduated stop–start technique. After 3 months Rick's IELT had quadrupled, sex was more frequent, and he terminated his involvement in the group.

Laura's anger had dissipated, and she was satisfied with the progress in their sexual life.

After 4 months we began to slowly decrease the dose of paroxetine but reminded Rick about attending to his level of excitement. At 6 months he was taking 10 mg of paroxetine and was able to maintain his increase in IELT. Rick felt more confident in general and was looking to change careers. Laura was supportive of his career change and feeling better about their marriage.

**CONCLUSIONS**

In spite of our most diligent efforts, it is not possible to help all individuals who present for treatment of rapid ejaculation. For some, none of the interventions—psychotherapy alone, pharmacotherapy alone, or combined treatment—overcome early trauma, the aftermath of years of destructive interactions, or limited psychological resources in the man or the couple.

There are instances in which patients achieve profound psychological gains, yet their control over ejaculation does not improve. Similarly, the man may demonstrate significantly improved IELT, yet the relationship issues remain.


Input: Could not generate response.

Response:
Psychotherapy and pharmacotherapy have their limitations. We cannot help everyone; not all patients want their problem resolved. Some patients may do better with another therapist or a physician, but there are some who will not benefit from any treatment. At these times, the therapist should discuss the limitations of his or her method of intervention and discuss any and all other reasonable options for ejaculatory delay. Although these cases are discouraging, in general the majority of men and couples achieve modest gains sexually, psychologically, and relationally in treatment.

**REFERENCES**

Abraham, K. (1927). Selected papers. London: Hogarth Press.

Althof, S. (2003). Therapeutic weaving: The integration of treatment techniques. In S. Levine, C. Risen, & S. Althof (Eds.), Handbook of clinical sexuality for mental health professionals (pp. 359–376). New York: Brunner Routledge.

Althof, S. (2005). Psychological treatment strategies for rapid ejaculation: Rational, practical aspects and outcome.

World Journal of Urology, 23(2), 89–92.

Althof, S. (2006). Sex therapy in the age of pharmacotherapy. Annual Review of Sex Research, 116–132.

Althof, S., Abdo, C., Dean, J., Hackett, G., McCabe, M., McMahon, C., et al. (2010). International Society for Sexual Medicine Guidelines for the Diagnosis and Treatment of PE. Journal of Sexual Medicine, 7, 2847–2969.

American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed,, text rev.).

Washington, DC: Author.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: Author.

132

Aversa, A., Francomano, D., Bruzziches, R., Natali, M., Spera, G., & Lenzi, A. (2011). Is there a role for phosphodiesterase type-5 inhibitors in the treatment of premature ejaculation? International Journal of Impotence Research, 23, 17–23.

Buvat, J., Tesfaye, F., Rothman, M., Rivas, D. A., & Giuliano, F. (2009). Dapoxetine for the treatment of premature ejaculation: Results from a randomized, double-blind, placebo-controlled phase 3 trial in 22 countries.

European Urology, 55(4), 957–967.

Byers, S., & Grenier, G. (2003). Premature or rapid ejaculation: Heterosexual couples' perception of men's ejaculatory behavior. Archives of Sexual Behavior, 32(3), 261–270.

Carani, C., Isidori, A. M., & Granata, A. (2005). Multicenter study on the prevalence of sexual symptoms in male hypo- and hyperthyroid patients. Journal of Clinical Endocrinology and Metabolism, 90, 6472–6479.

Cooper, A., Cernoskey, Z., & Colussi, K. (1993). Some clinical and psychometric characteristics of primary and secondary premature ejaculators. Journal of Sex and Marital Therapy, 8, 276–288.

Corona, G., Jannini, E. A., Lotti, F., Boddi, V., De Vita, G., Forti, G., et al. (2011). Premature and delayed ejaculation: two ends of a single continuum influenced by hormonal milieu. International Journal of Andrology, 34(1), 41–48.

De Carufel, F., & Trudel, G. (2006). Effects of a new functional sexological treatment for premature ejaculation.

Journal of Sex and Marital Therapy, 32, 97–114.

Dinsmore, W. W., Hackett, G., Goldmeier, D., Waldinger, M., Dean, J., Wright, P., et al. (2007). Topical eutectic mixture for premature ejaculation (TEMPE): A novel aerosol-delivery form of lidocaine-prilocaine for treating premature ejaculation. British Journal of Urology International, 99(2), 369–375.

Dresser, M. J., Desai, D., Gidwani, S., Seftel, A., & Modi, N. B. (2006). Dapoxetine, a novel treatment for premature ejaction, does not have pharmacokinetic interactions with phosphodiesterase-5 inhibitors. International Journal of Impotence Research, 18, 104–110.

Fanciullacci, F., Colpi, G., Beretta, G., & Zanollo, A. (1988). Cortical evoked potentials in subjects with true premature ejaculation. Andologia, 20, 326–330.

Gagnon, J., Rosen, R., & Leiblum, S. (1982). Cognitive and social aspects of sexual dysfunction: Sexual scripts in sex therapy. Journal of Sex and Marital Therapy, 8, 44–56.

Gospodinoff, J. (1989). Premature ejaculation: Clinical subgroups and etiology. Journal of Sex and Marital Therapy, 15, 130–134.

Grenier, G., & Byers, S. (1997). Rapid ejaculation: A review of conceptual, etiological, and treatment issues. Archives of Sexual Behavior, 24, 447–472.

Hartmann, U., Schedlowski, M., & Kruger, T. H. (2005). Cognitive and partner-related factors in rapid ejaculation: Differences between dysfunctional and functional men. World Journal of Urology, 23(2), 93–101.

Hawton, K., & Catalan, J. (1986). Prognostic factors in sex therapy. Behavior Research and Therapy, 24, 377–385.

Hawton, K., Catalan, J., & Fagg, J. (1992). Sex therapy for erectile dysfunction: Characteristics of couples, treatment outcome, and prognostic factors. Archives of Sexual Behavior, 21, 162–175.

Hellstrom, W. J., Althof, S., Gittelman, M., Streidle, C., Ho, K. F., Kell, S., et al. (2005). Dapoxetine for the treatment of men with premature ejaculation (PE): Dose-finding analysis. Journal of Urology, 173(4), 238.

Jannini, E. A., & Lenzi, A. (2005). Ejaculatory disorders: Epidemiology and current approaches to definition, classification and subtyping. World Journal of Urology, 23(2), 68–75.

Jern, P., Santtila, P., Alanko, K., Harlaar, N., Johansson, A., von der Pahlen, B., et al. (2007). Premature and delayed ejaculation: Genetic and environmental effects in a population-based sample of Finnish twins. Journal of Sexual Medicine, 4, 1739–1749.

Kaplan, H. S. (1983). The evaluation of sexual disorders: Medical and psychological aspects. New York: Brunner/Mazel.

Kaplan, H. S. (1989). How to overcome premature ejaculation. New York: Brunner/Mazel.

Laumann, E., Nicolosi, A., Glasser, D., Paik, A., Gingell, C., Moreira, E., et al. (2005). Sexual problems among women and men aged 40–80 years: Prevalence and correlates identified in the Global Study of Sexual Attitudes and Behaviors. International Journal of Impotence Research, 17, 39–57.

Laumann, E., Paik, A., & Rosen, R. (1999). Sexual dysfunction in the United States: Prevalence and predictors.

Journal of the American Medical Association, 281, 537–544.

Levine, L. (2006, November). Evaluation of withdrawal effects with dapoxetine in the treatment of premature ejaculation (PE). Poster presented at the meeting of the SMSNA.

Levine, S. B. (1992). Sexual life: A clinician's guide. New York: Plenum.

Li, P., Zhy, G., Xu, P., Sun, J., & Wang, P. (2006). Interventional effect of behavioral psychotherapy on patients with premature ejaculation [Chinese]. Zhonghua Nan Ke Xue, 12, 717–719.

Masters, W., & Johnson, V. (1970). Human sexual inadequacy. Boston: Little, Brown.

McCabe, M. (1997). Intimacy and quality of life among sexually dysfunctional men and women. Journal of Sex and 133

Marital Therapy, 23, 276–290.

McCabe, M., Althof, S. E., Assalian, P., Chevret-Measson, M., Leiblum, S. R., Simonelli, C., et al. (2009).

Psychological and interpersonal dimensions of sexual function and dysfunction. Journal of Sexual Medicine, 7(1, Pt. 2), 327–336.

McCarthy, B. (1990). Cognitive-behavioral strategies and techniques in the treatment of early ejaculation. In S.

Leiblum & R. Rosen (Eds.), Principles and practice of sex therapy: Update for the 1990s (pp. 141–167). New York: Guilford Press.

McCarthy, B. (1993). Relapse prevention strategies and techniques in sex therapy. Journal of Sex and Marital Therapy, 19, 142–147.

McMahon, C., Kim, S., Park, N., Chang, C., Rivas, D., Tesfaye, F., et al. (2009). Treatment of premature ejaculation in the Asia–Pacific region: Results From a phase III double-blind, parallel-group study of dapoxetine. Journal of Sexual Medicine, 7, 256–268.

McMahon, C. G., Althof, S. E., Waldinger, M. D., Porst, H., Dean, J., Sharlip, I. D., et al. (2008). An evidence-based definition of lifelong premature ejaculation: Report of the International Society for Sexual Medicine (ISSM) ad hoc committee for the definition of premature ejaculation. Journal of Sexual Medicine, 5(7), 1590–1606.

Metz, M., & McCarthy, B. (2003). Coping with premature ejaculation: How to overcome PE, please your partner, and have great sex. Oakland, CA: New Harbinger.

Mirone, V., Longo, N., Fusco, F., Mangiapia, F., Granata, A., & Perretti, A. (2001). Can the BC reflex evaluation be useful for the diagnosis of primary premature ejaculation? International Journal of Impotence Research, 13, S47.

Pagani, E., Rodrigues, O., Torselli, M., & Genari, D. (1996). Characterization of 305 men with complaints of premature ejaculation. International Journal of Impotence Research, 8, 172.

Perelman, M. (2003). Sex coaching for physicians: Combination treatment for patient and partner. International Journal of Impotence Research, 15, S67–S74.

Perelman, M. (2006). A new combination treatment for premature ejaculation. A sex therapist's perspective.

Journal of Sexual Medicine, 3, 1004–1012.

Pryor, J. L., Althof, S. E., Steidle, C., Rosen, R. C., Hellstrom, W. J., Shabsigh, R., et al. (2006). Efficacy and tolerability of dapoxetine in treatment of premature ejaculation: An integrated analysis of two double-blind, randomised controlled trials. Lancet, 368(9539), 929–937.

Rosen, R., Leiblum, S., & Spector, I. (1994). Psychologically based treatment for male erectile disorder: A cognitive-interpersonal model. Journal of Sex and Marital Therapy, 20, 67–85.

Porst, H., Montorsi, F., Rosen, R., Gaynor, L., Grupe, S., & Alexander, J. (2007). The premature ejaculation prevalence and attitudes (PEPA) survey: A multinational survey. European Urology, 51, 816–823.

Schapiro, B. (1943). Premature ejaculation: A review of 1130 cases. Journal of Urology, 50, 374–379.

Semans, J. (1956). Premature ejaculation. Southern Medical Journal, 49, 352–358.

Sigmond, S. T., Roblin, D., Hart, K., & Althof, S. (2003). How does premature ejaculation affect a man's life. Journal of Sex and Marital Therapy, 29, 361–370.

Steggall, M., Fowler, C., & Pryce, A. (2008). Combination therapy for PE: Results of a small-scale study. Sex and Relationship Therapy, 23, 365–376.

Tang, W., Ma, L., Zhao, L., Liu, Y., & Chen, Z. (2004). Clinical efficacy of Viagra with behavior therapy against premature ejaculation [Chinese]. Zhonghua Nan Ke Xue, 10, 366–367.

Waldinger, M. (2008). Premature ejaculation: Different pathophysiologies and etiologies determine its treatment.

Journal of Sex and Marital Therapy, 34, 1–13.

Waldinger, M., Berendsen, H. H., Blok, B. F., Olivier, B., & Holstege, G. (1998). Premature ejaculation and serotonergic antidepressants-induced delayed ejaculation: The involvement of the serotonergic system.

Behavioral Brain Research, 92, 111–118.

Waldinger, M., Hengeveld, M. W., & Zwinderman, A. (1998). An empirical operationalization study of DSM-IV

diagnostic criteria for premature ejaculation. International Journal of Psychiatry in Clinical Practice, 2, 287.

Waldinger, M., Rietschel, M., Nothen, N., Hengeveld, M. W., & Olivier, B. (1998). Familial occurrence of primary premature ejaculation. Psychiatric Genetics, 8, 37–40.

Waldinger, M. D., Zwinderman, A. H., Schweitzer, D. H., & Olivier, B. (2004). Relevance of methodological design for the interpretation of efficacy of drug treatment of premature ejaculation: A systematic review and metaanalysis. International Journal of Impotence Research, 16(4), 369–381.

World Health Organization. (1994). International classification of diseases and related health problems (10th ed.).

Geneva, Switzerland: Author.

Yuan, P., Dai, J., Yang, Y., Guo, J., & Liang, R. (2008). A comparative study on treatment for premature ejaculation: Citalopram used in combination with behavioral therapy versus either citalopram or behavioral therapy alone

[Chinese]. Chinnese Journal of Andrology, 22, 35–38.

Zilbergeld, B. (1992). The new male sexuality. New York: Bantam Books.

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**CHAPTER 6**

Delayed Ejaculation

Michael A. Perelman

**"D** elayed ejaculation (DE) is probably the least common, and least understood of the male sexual dysfunctions," this chapter begins. In fact, delayed ejaculation is often misdiagnosed or at least misunderstood by clinicians, many of whom do not fully grasp the interpersonal and psychological distress caused by this relatively rare condition. According to Perelman, a key factor for understanding many men with DE is that the reality of partnered sex pales in comparison with the intensity of technique and fantasy occurring during masturbation. This conceptualization highlights the importance of taking a thorough sexual history, including specific questions about the method of masturbation. Improving communication and increasing sexual satisfaction during partnered sex are keys to treatment success. DE may be similar to hypoactive sexual desire in men, in that the sexual problem is a manifestation of a preference for some other type sexual activity rather than partnered sex. In the case of DE, this preference is associated with a style of masturbation and accompanying fantasy with which partnered sex does not compete.

**Michael A. Perelman PhD,** is Clinical Professor of Psychiatry, Reproductive Medicine, and Urology at the Weill Medical College of Cornell University in New York City. He is the Co-Director of the Human Sexuality Program, Payne Whitney Clinic of the New York Presbyterian Hospital. Dr. Perelman has served on several professional society boards of directors and is currently the Past President of the Society for Sex Therapy and Research (SSTAR).

He has been elected a Fellow of both the Sexual Medicine Society of North America (SMSNA) and the International Society for the Study of Women's Sexual Health (ISSWSH). The American Association of Sex Educators, Counselors, and Therapists (AASECT) certify him as a sex therapy diplomate, supervisor, sex educator, sex counselor, and continuing education provider and recently honored him with the 2012 Award for Professional Standard of Excellence.

Delayed ejaculation (DE) is probably the least common and least understood of the male sexual dysfunctions (MSDs). A man diagnosed with DE finds it difficult or impossible to ejaculate and experience orgasm. This diagnosis requires distress about the symptom(s), adequate sexual stimulation, and a conscious desire to achieve orgasm. Failure to ejaculate may occur during masturbation or partner manual, coital, or anal stimulation.

Men with DE usually have no difficulty attaining or maintaining erections.

Confusion about nosology has been the case historically for the full spectrum of male orgasm and ejaculatory disorders, from premature ejaculation (PE) through various diminished ejaculatory disorders (DEDs; Perelman, McMahon, & Barada, 2004).

Nomenclature misunderstanding is in part related to the fact that ejaculation and orgasm usually occur simultaneously, despite being separate physiological phenomena.

Orgasm is usually coincident with ejaculation but is a central sensory event that has significant subjective variation. In the fifth edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-5; American 135

Psychiatric Association, 2013), the condition is labeled "delayed ejaculation" instead of the imprecise "male orgasmic disorder" or the pejorative "retarded ejaculation." The definition requires one of two symptoms: either a marked delay in or a marked infrequency or absence of ejaculation on 75–100% of occasions for at least 6 months.

The DSM-IV (American Psychiatric Association, 2000) subtype (due to psychological or combined factors) has been eliminated; however, delayed ejaculation is still characterized in DSM-5 as lifelong or acquired and generalized or situational.

Although this chapter focuses on DE, there are other DEDs or alterations of ejaculation and/or orgasm that include anejaculation, painful ejaculation, and retrograde ejaculation. DED also encompasses reductions in volume, force, sensation of ejaculation, and the rarer postorgasmic illness syndrome (POIS; Perelman et al., 2004).

These distinctions are important for sex therapists because the specificity of the patient's complaint affects both the treatment provided and the medical understanding needed to coordinate with the patient's physician(s). A man's psychological reaction to real anatomical changes, even when minor, may affect his experience of orgasm. For instance, transurethral procedures causing retrograde ejaculation should not be casually dismissed, whether or not this probable side effect was discussed in advance of surgery

—especially if it was not. Finally, even slight changes in semen volume might alter orgasm in a manner that is very "real" for some men. A man taking an antidepressant who is suffering from DE requires a different treatment approach than does a patient whose orgasm and ejaculation are "weaker" when taking a 5-alpha reductase inhibitor (5

αRI) for alopecia.

Men with DE typically report less coital activity, higher levels of relationship distress, sexual dissatisfaction, lower subjective arousal, anxiety about their sexual performance, and were general health issues than sexually functional men (Abdel-Hamid & Saleh, 2011; Rowland, van Diest, Incrocci, & Slob, 2005). The psychological and interpersonal impact of DE is often not appreciated by clinicians, who sometimes misperceive and fail to diagnose this condition. Some partners enjoy the extended intercourse; however, they eventually may experience pain, injury, and/or distressing questions (e.g., "Does he really find me attractive?"). Although initially blaming themselves, partners might become angry at the often misguidedly perceived rejection. Some men will fake orgasm to avoid an anticipated negative reaction. Distress is often greatest when conception

"fails," yet fear of pregnancy leads some men to avoid dating or to avoid sex altogether (Corona et al., 2006; Perelman, 2004).

DE prevalence rates in the literature are low, rarely exceeding 3% (Laumann, Paik, & Rosen, 1999; Rowland, Keeney, & Slob, 2004). The intravaginal ejaculatory latency time (IELT) distribution curves recently used to characterize and define PE can assist in understanding DE prevalence (McMahon et al., 2008). Male IELT exhibits a skewed distribution in PE, with men ejaculating more rapidly than women tend to reach orgasm (Patrick et al., 2005; Waldinger, McIntosh, & Schweitzer, 2009). Segraves (2010) pointed out the difficulty in both diagnosis and the ensuing confusion about prevalence rates when depending only on IELT duration data. The concept of "control" does not correlate perfectly with IELT and is, of course, mitigated by volition (Jern, Gunst, Sandqvist, Sandnabba, & Santtila, 2011). Some men with an IELT of 20 minutes may 136

deliberately delay their ejaculation, whereas others might be distressed over not ejaculating after 10 minutes, especially if their partners are "already done."

DE has been seen as a clinical rarity since the beginning of sex therapy. Yet DE rates will likely rise secondary to demographics and our male population's age-related ejaculatory decline (Perelman, 2003a). DE rates will also rise due to increased use of 5

αRI (Rowland, 2006) and the widespread use of selective serotonin reuptake inhibitors (SSRIs; Georgiadis, Reinders, Van der Graaf, Paans, & Kortekaas, 2007). Despite rates remaining low relative to other MSDs, many men do suffer from DE.

**ETIOLOGY**

Neither pathophysiology nor psychogenic etiology should be assumed without both medical investigation and a focused psychosexual history. Of course, biogenic and psychogenic etiologies are neither independent nor mutually exclusive. Genetically predetermined ejaculatory thresholds have a prodigious impact on ejaculatory ease and latency time and are distributed in a manner similar to a number of other human characteristics (Perelman, 2009; Waldinger, 2011). However, human experience is better explained when one postulates that such thresholds predetermine a range of response, a

"scattercloud" rather than a "trigger point." The timing of a particular ejaculation would be the result of a variety of psychosocial, cultural, and behavioral (PSCB) factors that influence the biologically predetermined range (Perelman & Rowland, 2006). This integrated biological and PSCB model would account for the variation in latencies between men and the intraindividual range of each man. This multilayered conceptualization is different from current animal models that postulate an exclusive neurobiological threshold model, as well as different from the early "psychological"

theories described next (Olivier et al., 2011). A bio-psychosocial-cultural model explains the variation, both between and within given individuals, and provides a better theoretical model (Perelman & Rowland, 2006).

**PSYCHOLOGICAL AND BEHAVIORAL MODELS**

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 are "unwilling" to receive pleasure. Some dynamic theorists ascribe fear: of semen loss; of female genitals; of hurting the partner through ejaculation; and of "defiling" the partner. Clinicians from various theoretical persuasions note pregnancy concerns among men with DE and also observe how referrals may be tied to a female partner's wish to conceive (Althof, 2012; Perelman & Rowland, 2006). Masters and Johnson (1970) first suggested an association between DE and religion; for a few men, orthodox beliefs limit the experience needed to learn how to ejaculate and thus 137

normal function is inhibited.

Other factors associated with partnered sex that contribute to DE include anxiety, lack of confidence, and poor body image (Perelman & Rowland, 2006). Anxiety draws the man's attention away from erotic cues that enhance arousal and can interfere with genital stimulation sensation, resulting in insufficient excitement for climax, even if erection is maintained. Apfelbaum (2000) considers DE to be a desire disorder specific to partnered sex, believing that these men prefer sex with themselves rather than partnered sex. Apfelbaum suggests that a couple may interpret the man's erectile response as erroneous evidence that he is sufficiently aroused to attain orgasm (Apfelbaum, 2000). Perelman later posited that inadequate arousal was probably responsible for increased anecdotal reports of DE when men used oral medications for erectile dysfunction (ED) (Perelman, 2003a). Those men did not experience sufficient erotic excitement before and during coitus to reach orgasm, believing their erections indicated sexual arousal when they primarily indicated vasocongestive success.

Perelman identifies three factors highly associated with DE: higher frequency of masturbation (more than three times per week); idiosyncratic masturbatory style, and a disparity between the reality of sex with a partner compared with preferred sexual fantasies during masturbation (Perelman, 2002, 2005). While preparing this chapter, I reviewed 175 records from my practice of men ages 18–90 diagnosed with DE over the last 20 years. Almost 90% of these men could orgasm relatively easily with masturbation, and coital anorgasmia was almost exclusively the primary diagnosis. Although DE is correlated with high-frequency masturbation, the most frequent behavioral factor causing DE is an "idiosyncratic masturbatory style," which I define as a technique not easily duplicated by the partner's hand, mouth, or vagina. Specifically, many men with DE engage in self-stimulation that is striking in terms of the speed, pressure, intensity, duration, and the "spot" focused upon to produce an orgasm (Perelman, 2005). In fact, some of these men will report penile irritation and erythema secondary to their masturbatory pattern (Abdel-Hamid & Saleh, 2011; Perelman, 2001). Almost universally, these men fail to communicate their stimulation preferences to their partners (or to previous doctors) because of shame or embarrassment. The disparity between the reality of sex with their partners and the sexual fantasies (whether or not unconventional) they prefer to use during masturbation is another cause of DE

(Perelman, 2001). That disparity takes many forms, such as partner attractiveness, body type, sexual orientation, and the specific sex activity performed (Perelman, 2002; Rowland et al., 2004).

**BIOLOGICAL MODELS**

In some instances, a somatic condition accounts for DE, as any procedure or disease that disrupts sympathetic or somatic innervation to the genital region has the potential to interfere with ejaculation and orgasm. Thus spinal cord injury, multiple sclerosis, pelvic-region surgery, severe diabetes, alcoholic neuropathies, hormonal abnormalities, 138

and medications that inhibit α-adrenergic innervation of the ejaculatory system are associated with DE (Master & Turek, 2001; Vale, 1999; Witt & Grantmyre, 1993).

Comprehensive lists of agents causing ejaculatory delay are available and include many antihypertensive antiadrenergic agents and antidepressants, as well as antipsychotic drugs (Segraves, 2010; Perelman et al., 2004).

Low penile sensitivity, often associated with aging (Paick, Jeong, & Park, 1998; Rowland, 1998) may exacerbate difficulty reaching orgasm, but it is not usually a primary cause. Variability in the sensitivity of the ejaculatory reflex may be a factor.

Recently, Waldinger and Schweitzer (2005) advocated for an etiology based on appreciating orgasmic disorders as neurobiological variants of a "normal" ejaculatory distribution curve. This view is derived from animal studies (primarily male rat latencies; Pattij et al., 2005), as well as studies demonstrating similar (albeit skewed) distribution curves for a random population of men from different countries (Waldinger et al., 2009). IELT reflects genetic biological variability, and diagnosable orgasmic disorders are primarily deviations from "normal" behavior. However, ejaculatory latency is an endpoint consequence that is also determined by a range of PSCB factors, not just a genetically determined biological set point.

Dichotomizing etiology, diagnosis, and treatment into classifications such as psychogenic and biological are too categorical. Genetic predispositions affect the typical speed and ease of ejaculation for any particular organism; however, many of these components are influenced by past experiences and present context (Perelman, 2006b).

The most useful approach to understanding human responses is to integrate—rather than isolate—the biological and PSCB components. The goal is identifying peripheral and/or central orgasmic elements that contribute to each man's varied response.

Our understanding of the biology of male orgasmic processes is increasing markedly but remains limited; for instance, even the male refractory period is poorly characterized (Paduch, Bolyakov, Beardsworth, & Watts, 2010). "Normal" male orgasm is refractory subsequent to the previous ejaculation, yet refractory latency increases for men secondary to surgical, medical, or pharmaceutical complications. Given new data showing that cognitive processes can affect neurotransmitters, distinctions between psychology and biology are clearly less binary than many previously presumed (Etkin, Pittenger, Polan, & Kandel, 2005). Delayed ejaculation is best understood as an endpoint response that represents the interaction of biological, psychological, social, and cultural factors.

**EVALUATION AND DIAGNOSIS**

The evaluation of DE focuses on uncovering potential physical and learned causes of the disorder. The Sexual Tipping Point® (STP) model offers a clinically useful heuristic for conceptualizing the role both biogenic and PSCB factors play in determining the etiology of MSDs generally, and DE in particular (Perelman, 2009). The STP is the 139

characteristic threshold for an expression of a sexual response for any individual, which may vary dynamically within and between sexual experiences. The specific threshold for the sexual response is determined by these multiple factors for any given moment or circumstance, with one factor or another dominating as others recede in importance.

Every man, whether he experiences a "normal" ejaculatory latency or delayed ejaculation, has a multidimensional, predetermined "ejaculatory tipping point" (EjTP; Perelman, 2006a). Appropriate assessment appreciates the interdependent influence of these factors on the endpoint dysfunction for each man (see Figures 6.1 and 6.2).

**FIGURE 6.1**.  The multifactorial etiology of sexual function and dysfunction: Sex is always both mental and physical; the mental factors can turn you on as well as turn you off, and the same is true of physical factors.

Copyright 2013 MAP Educational Fund and adapted for use with permission.

140

**FIGURE 6.2**. Key to the Sexual Tipping Point model. Copyright 2013 MAP Educational Fund and adapted for use with permission.

It is frequently useful for a urologist to conduct a genitourinary examination and medical history that may identify physical anomalies, as well as contributory neurological and endocrinological (especially androgen levels) factors (Corona et al., 2012). Attention should be given to identifying reversible urethral, prostatic, epididymal, and testicular infections. Finally, with secondary DE in particular, adverse pharmaceutical side effects—most commonly from serotonin-based prescriptions—

should be ruled out.

A focused psychosexual evaluation is critical and typically begins by differentiating this MSD from other sexual problems and reviewing the conditions under which the man is able to ejaculate. The problem's developmental course should be noted, including variables that improve or worsen performance (particularly those related to psychosexual arousal). What distinguishes sex therapists from all other health care providers is our comfort using highly detailed and specific sexual language. Perceived partner attractiveness, the use of fantasy during sex, anxiety surrounding coitus, and masturbatory patterns all require exploration. For instance, the patient should be asked: (1) "What is the frequency of your masturbation?"; (2) "How do you masturbate?"; (3)

"In what way does the stimulation you provide yourself differ from your partner's stimulation style, in terms of speed, pressure, etc.?"; (4) "Have you communicated your preference to your partner(s), and if so, what was their response?" Additional questions can be asked to give greater specificity to the putative role of masturbation in the disorder and to clarify other relevant etiological factors. If orgasmic attainment was possible previously, life events and circumstances temporally related to orgasmic cessation should be reviewed. Events in question may include pharmaceuticals, illness, 141

or a variety of psychological stressors. A therapist should investigate previous treatment approaches, including the use of herbal therapies, home remedies, and so forth.

Information regarding the partner's perception of the problem and her satisfaction with the relationship may help. Sexual and relationship inventories in general, and even ones specific to ejaculation, such as the Male Sexual Health Questionnaire (MSHQ), improve research methodology but provide only limited diagnostic enhancement (Rosen et al., 2004; Wei, Dunn, Litwin, Sandler, & Sanda, 2000).

**TREATMENT**

Discussion of a potential biological predisposition is helpful in reducing patient and partner anxiety and mutual recriminations while improving therapeutic alliance (Perelman, 2004, 2005). Masters and Johnson (1970) first advocated specific exercises when treating DE. Current approaches usually emphasize integrating a behavioral masturbatory retraining within a nuanced sex therapy (Apfelbaum, 2000; Masters & Johnson, 1970; Perelman, 2003b, 2006a; Sank, 1998). Masturbation can serve as rehearsal for partnered sex. By informing the patient how his masturbation conditioned his response, stigma is minimized and partner cooperation can be evoked. Of course, masturbation retraining is only a means to an end; the goal of therapy for DE is evoking higher levels of psychosexual arousal within a mutually satisfying experience.

It is useful to help men with primary DE identify their sexual arousal preferences through self-exploration and stimulation. Masturbation training is similar to models described for women, but the use of vibrators, often recommended by urologists, is rarely needed (Perelman, 2006a). Masturbation exercises progressing from neutral to pleasurable sensations (without orgasm) remove the "demand" aspects of performance (Apfelbaum, 2000). Fantasizing can help block thoughts that might otherwise interfere with arousal. Some men with DE manifest an overeagerness to "please" that must be addressed. In general, a clinician should validate (not encourage) an autosexual orientation when encountering it in a man, as this helps remove the stigma that DE is a form of withholding from a partner. General anxiety-reduction techniques may also be helpful in treating some men with DE. Finally, couple therapy, when appropriate, involves encouraging the man and his partner to share their sexual preferences so that both their needs are met.

Lack of adequate stimulation was the salient variable for the first couple I treated for DE over 30 years ago. A very young and sexually naïve Orthodox Jewish couple presented with a symptom of primary DE, which interfered with their religiously mandated desire for a large family. The cause was a complete lack of stimulation, as the couple would lie quietly together during coitus, waiting for his ejaculation to occur.

Once informed of the need for friction and the benefit of movement, a pregnancy soon ensued, and they now have eight children (Perelman, 1994). Although education is a necessary part of therapy, it is almost never sufficient in and of itself.

Therapy for secondary DE shares similarities with treatment for primary DE.

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However, the patients with secondary DE should be counseled to suspend masturbatory activity temporarily and limit orgasmic release to their desired goal activity, that is, coital orgasm. Reducing or discontinuing both masturbation (typically 14–60 days) and (usually) noncoital orgasm evokes patient resistance. The clinician needs to provide support to ensure adherence to this suspension. Depending on motivation level, masturbation interruption must sometimes be compromised and negotiated. A man continuing to masturbate might be encouraged to alter style ("switch hands") and to approximate the stimulation likely to be experienced through manual, oral, or vaginal stimulation by his partner (Perelman & Rowland, 2006). In addition to suspending noncoital orgasmic release, the patient should use fantasy and bodily movements during coitus that approximate the thoughts and sensations experienced in masturbation.

Single men should use condoms during masturbation to rehearse "safe sex." Sexual fantasies may be realigned so that thoughts experienced during masturbation better match those occurring during coitus. Efforts to increase the arousing capacity of the partner by reducing the disparity between the man's fantasy and the actuality of sex with his partner may be useful. Significant disparity tends to characterize more severe and recalcitrant DE and relationship problems, with consequently poorer prognosis (Perelman, 2001).

**TREATMENT OUTCOME**

To date there is no evidence for a pharmaceutical demonstrating anything beyond anecdotal success in decreasing ejaculatory latency, and there is no approved drug treatment for DE. Researchers have explored "antidotes" such as yohimbine, cyproheptadine, and bupropion, among others; however, this research was typically confined to animal experiments (Carro-Juareza & Rodriguez-Manzo, 2003) or focused on antidepressant-induced DE (Clayton et al., 2004; McCormick, Olin, & Brotman, 1990). There is some limited support for the use of bupropion, but a recent study concludes that the drug seems to be of only limited benefit (Abdel-Hamid & Saleh, 2011). Clearly further trials are needed.

Unlike urologists, some sex therapists report good success rates when treating DE

(Masters & Johnson, 1970; Perelman & Rowland, 2006); yet these results should be viewed as exploratory, albeit encouraging. Althof (2012) notes the difficulty in evaluating sex therapy treatment outcomes, because the published studies use small samples, uncontrolled, nonrandomized methodologies, and lack validated outcome measures. Disparity between the results of different professionals may well reflect clinically different treatment populations. Only well-designed multicenter clinical trials will establish an answer. In the meantime, the two cases that follow demonstrate how a sex therapist can effectively support mutual sexual harmony and satisfaction with couples suffering from DE.

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**CASE DISCUSSIONS**

**Case 1**

George (53) had become less attracted to Janice (52) but wanted the coitus with orgasm that once characterized their sex life. He did not wish to "hurt" Janice by discussing his diminished attraction. He suffered from "metabolic syndrome" and was hypogonadal.

Coital activity had gradually disappeared. He had masturbated to "help fall asleep" at least two to three times per week since adolescence. He now needed greater pressure, speed, and focused attention on "sensitive parts" to orgasm with masturbation. His physician, presuming he had ED, took a brief sex history and obtained a testosterone level. The doctor gave sildenafil samples (with limited instruction) and told George not to worry. Returning for follow-up, George said, "The pills I took 15 minutes before sex did not work; soon after penetration, I lost my erection." When he lost his erection, the couple argued. The physician attributed George's remaining problems to his low testosterone level and prescribed a topical androgen gel. George telephoned the physician 4 weeks later and indicated that "the gel had not helped," and the physician reportedly told him it was "in his head" and suggested a sex therapist, referring him to me. George wanted treatment and had "no patience for lengthy 'shrinking' or touchy-feely stuff." Problems with the patient's sexual script and the earlier treatment were apparent. Coital intercourse with his spouse was no longer arousing. George reported,

"It felt like work." Detailed inquiry revealed that his wife's vagina felt "slack." Was the sildenafil ineffective, or was his hypogonadal status the key factor, despite the gel normalizing his T levels? These and other issues were not likely to become clear, even with the most exact testing. Problems with his physician's treatment plan were summarized in a manner to generate hope. George was enlisted in developing a new plan. He agreed to stop masturbating until he was able to have coitus with orgasm on three successive occasions with his wife. This goal was arbitrary but generated by the patient himself and therefore useful, as discontinuing masturbation is difficult to motivate. He continued using both the sildenafil and the testosterone his physician prescribed. Proper instructions for using the PDE5 were given, and George was educated about men's need for greater stimulation with aging. He asked for more direct penile touching from his wife and complimented her improved technique. George preferred a coital position different from the female-superior posture they previously used. Conveniently, Janice agreed, as the earlier position was uncomfortable after her recent knee surgery. Male-superior coitus allowed him to control the angle and pace of thrusting. George was instructed to close his eyes and fantasize about whatever "worked best." Initially guilty for thinking of someone other than Janice, he was reassured that he could open his eyes at the moment of orgasm, and that could become his new fantasy.

He was instructed to move inside her in a manner that duplicated (as closely as possible) the sensations he preferred during masturbation. He was reassured that once his capacity was restored, if Janice had any concerns, the couple could be seen together, and he could learn additional techniques. Earlier he declined couple counseling, as 144