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By Sex therapist and relationship counselor
TODAY contributor
updated 10/2/2008 3:44:45 PM ET 2008-10-02T19:44:45

In the last year I’ve not only seen a significant increase in the number of men who are grappling with some form of DE (delayed ejaculation) — guys who can only reach orgasm via masturbation, guys who can't reach it at all — I've also been hearing increasingly from the partners of men with DE: women who are confused, at a loss, and fearful that their own desirability, or possible lack of sexual skill, may be part of the problem.

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To get to the heart of the matter, I sat down with Dr. Michael A. Perelman, sex therapist extraordinaire and co-director of the Human Sexuality Program at Cornell Hospital in New York City. A pioneer in building a bridge between medicine and psychology in the treatment of sexual issues, Michael is one of the world's foremost experts on MODS (Male Orgasmic Disorders) and DEDs (Diminished Ejaculatory Disorders) and reassures us, with empathy and insight, that one’s sex life should never be declared DNR (Do Not Resuscitate).

Ian Kerner: In an article you co-wrote for the World Journal of Urology in 2006, you say that DE has historically had a relatively low prevalence (less than 3 percent of the population.) But that's changing, isn't it?

Dr. Michael A. Perelman: Yes, the prevalence of delayed ejaculation is rising for a few reasons: First of all, more and more medications that are being used regularly in this country, particularly anti-depressants, have the side effect of increasing the amount of time it takes before someone is able to reach orgasm, or even negating the potential for orgasm completely by altering transmitters in the brain.

Additionally, as we’ve been getting better at developing sexual medicines, particularly those used to treat erectile dysfunction, there’s a conundrum: These drugs often reduce the amount of stimulation required for a man to achieve an erection, but then some of these men erroneously think they’re sufficiently turned-on when in fact they’re not. They may have a physiological marker of sexual excitation (an erection), but they’re not really turned on in the sense of being emotionally and psychologically excited. Men with DE often have little or no difficulty attaining or keeping their erections. Yet despite their good erections, many of them report low levels of subjective sexual arousal. 

Kerner: That’s a fascinating point and one that’s sure to cause confusion amongst the partners of those with DE: Just because a guy has an erection doesn't mean he's turned on.

Perelman: Younger women, especially, are used to guys getting erections merely from the thought of sex let alone physical touch. Their experience is, ‘if he wants to have sex with me then he has an erection -- he has a tool available -- and if he doesn’t have that tool something must be wrong.’ The same is true of his orgasm, and if a woman’s partner is experiencing DE she’s likely to first question her own attractiveness, and then get angry and start to resent her partner.

Kerner: When, in fact, it might just be a natural change in a man’s sexual response?

Perelman: Absolutely. Another big non-pharmacological factor in the increasing prevalence of DE is the baby boomers (the largest bulge in our population) reaching an age where sexually-related disorders become more prevalent. We know that as men get older the amount of time it takes to reach orgasm increases. That’s just a natural part of the aging process — like not being able to run as fast or needing to wear glasses. But many men can’t accept these natural changes. They want to have sexual experiences (and responses) that are similar to the ones of their youth and they become distressed when they can’t. The more a guy gets upset about a sexual issue, the more likely it is to further impede the ejaculatory process or even wipe it out all together.

Kerner: And speaking of negative thinking, to what extent can DE be caused by guilt and shame, or fears such as getting a woman pregnant?

Perelman: Psychosocial and cultural factors often play a significant role in cases of DE. For example, in most orthodox religions where sex is extremely structured (no masturbation, no sex outside of marriage), there are going to be individuals who just don't have enough experience to learn how to reach orgasm. Or their shame and guilt will inhibit them from truly immersing themselves mentally and emotionally in the experience of sex. Some of these men will even develop odd masturbation styles that require more friction than usual to overcome their negative feelings and achieve orgasm. They end up training themselves to reach orgasm through a masturbation pattern that’s very different from what it feels like to be stimulated by an actual person.

Kerner: What about the guy who’s under pressure to have procreative sex but feels ambivalent about becoming a father?

Perelman: Some of these men will insist on using a condom and then just tolerate the anger of their partner; so they're able to reach orgasm but it causes significant relationship problems. But then there are other men who don’t have the courage to address the situation with their partner, and this lack of constructive communication will almost certainly lead to DE.

Kerner: Many men are also socialized to always be in control, to never express their feelings — could this “holding back” of emotions lead to DE?

Perelman: Control issues frequently play a role. There are men who, in general, have trouble letting go and experiencing pleasure in life. Or, they have sex by the numbers to check it off their to-do list and do what they feel is necessary “to be a man,” but in the end they’re not really immersed in the sensuality of the sexual experience. Some men have never really had the ability to use their mind to enhance arousal, but they’ve always been able to rely on physical stimulation to get them where they’re going. They might not even be aware that they’re mentally disconnected or know that their enjoyment of sex could be different. As these men age and start to deal with erectile problems, they may turn to a drug such as Viagra or Cialis, but ultimately that’s not enough because the critical piece that was missing, the piece they have to work on, is the ability to mentally immerse themselves in the experience of sex and forge a sexually intimate connection with their partner.  

So what should you do if you, or your partner, are struggling with DE? Consider the following:

Focus more on foreplay: Particularly the mental aspects. Don't assume a man is turned on just because he has an erection. Perelman writes, “…men may lack sufficient levels of physical and/or psychosexual arousal during coitus to achieve orgasm.” This may be especially true if a man is using an erectile stimulant such as Viagra, in which case his erection could be an indication that blood is flowing into his penis, but that his mind may not be going with that flow. Says Perelman, “To obtain and maintain an erection requires both friction and fantasy, and as men age they need both more friction and more fantasy. You can’t just have one without the other.”

Get a clean bill of health. Your sexual health is a barometer of your overall health and DE can be a sign that something else is not working. Writes Perelman, “It is essential to distinguish those factors that are physiological from those that are pathophysiological. Physiological refers to factors that are biologically inherent to the system, through genetic and normal maturation processes. Pathophysiological refers to those factors that occur through disruption of the normal physiological processes, through disease, trauma, surgery, medication.”  If you’re taking prescription drugs, pay particular attention to potential side effects. This is especially true of anti-depressants that raise serotonin levels. You don’t have to choose between your sanity and sex life, but you do need to address the issue with an experienced prescribing doctor. Also as men age it’s common for their prostates to swell and to interfere with urination. Commonly prescribed alpha-blockers may also cause delayed ejaculation.

Take a masturbation break. As men age it’s not only perfectly natural to experience longer refractory periods (the time between erections), but also an increased latency period (the time it takes to reach ejaculation). In the past, you may have been able to masturbate regularly and have sex regularly, but if you're masturbating more than you're having sex, and you're experiencing delayed ejaculation, it's time to stop "laying hands."

Turn off the porn. It creates unrealistic "sexpectations." Writes Perelman, "Disparity between the reality of sex with the partner and the sexual fantasy (whether or not unconventional) used during masturbation is another potential cause of DE.” Additionally, the influence of porn is increasingly a major factor in male sexual anxiety, “…the evaluative/performance aspect of sex with a partner often creates sexual performance anxiety for the man, a factor that may contribute to DE. Such anxiety typically stems from the man’s lack of confidence to perform adequately, to appear and feel attractive (body image), to satisfy his partner sexually, to experience an overall sense of self-efficacy, and to measure up against the competition.”

Communicate. If you're experiencing some form of pressure or anxiety, or feeling angry, or less attracted to your partner, or just plain bored with your sex life, those issues may be contributing to the problem. People change. Relationships change. Why should sex stay the same? Not talking about the issue — with a partner or doctor or therapist — might be the worst thing you could do. Writes Perelman, “…men with DE indicate high levels of relationship distress, sexual dissatisfaction, anxiety about their sexual performance, and general health issues — significantly higher than sexually functional men.”

Plato wrote, “If a person isn’t aware of a lack, he cannot desire the thing which he isn’t aware of lacking.” For the man who is suffering from DE, being aware of the lack or change in the ejaculatory process is the first step to reclaiming a true sense of desire.

Ian Kerner is a sex therapist, relationship counselor and New York Times best-selling author of numerous books, including "She Comes First" and the soon-to-be-published "Love in the Time of Colic: the New Parents' Guide to Getting it On Again." He was born and raised in New York City, where he lives with his wife and two sons. He can be reached at www.IanKerner.com

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