Treatment of Delayed Ejaculation |
How exactly do you treat delayed ejaculation?Another factor of major importance that has to be looked at during any assessment of a man with delayed ejaculation is how the man masturbates. It's not only about the method that he uses to physically stimulate himself, but also about the erotic imagery and the inner processes in his mind which play a part in producing his arousal. One question in particular that seems to be very important is whether or not a man has sexual fantasies about which he feels conflicted or perhaps even tries to suppress as he masturbates. One of the reasons this is important is that these deep rooted intrapsychic variables can be evaluated to reveal whether or not feelings of anger or hostility are present towards his sexual partner, or indeed towards women in general, and whether or not they should be interpreted as a sign of some fundamental sexual conflict. Looking at a man's fantasy life as he masturbates, as well as the physical means that he uses to stimulate himself, and of course, the speed with which he reaches ejaculation, can all produce hypotheses relating to the psychodynamic model which assumes subconscious issues may be preventing him from reaching the point of orgasm and ejaculation. It's also important to ensure that a man understands the difference between delayed ejaculation and erectile dysfunction, because some men lose their erection during sex and are then unable to ejaculate -- they may regard this as an inability to ejaculate or delayed ejaculation. It is the analysis of complex unconscious issues such as these that allows a psychodynamic treatment methodology to be developed for delayed ejaculation. Although there have been no scientifically adequate, large-scale studies conducted on delayed ejaculation, a variety of therapeutic techniques have evolved, some based on experience with men who have the condition, and others based on theoretical considerations. In the original sex therapy methodology, treatment approaches were derived from the basic assumptions underlying the psychodynamic model which has been previously outlined on this website. There are now two opposing points of view for understanding and treating delayed ejaculation: they are called the inhibition model and the desire-deficit model. The inhibition approach was the model developed by the founders of classic sexual therapy such as Masters and Johnson and Helen Singer Kaplan. They distinguished two different starting points for the origin of therapy. The first is somewhat behaviorally orientated; it assumes a man is not receiving enough stimulation of an adequate kind to take him to the point of ejaculatory inevitability. If this is so, then it follows that stimulation may be increased proportionately so that he is enabled to reach his own organic orgasmic threshold. It's a model that assumes inadequate stimulation as the cause of DE rather than some kind of inhibition, because it supposes that by stimulating the man more vigorously the neural mechanisms responsible for ejaculation can be activated. (Note that a psychodynamic approach would take a very different view: assuming that the man is inhibited in some way, and that his failure to ejaculate can be traced back to some kind of internal emotional or psychic conflict, such as an unconscious aggression towards his partner, or a desire to withhold from the satisfaction of sexual intercourse. Kaplan tried to combine both concepts, as she proposed that while the immediate cause of delayed ejaculation might be inadequate stimulation or fear of failure, these might sometimes -- although not necessarily always -- originate in more profound subconscious conflict.) This seems rather like a case of adapting the theory to suit the circumstances: however, it is true that treatment can be aimed at either increasing sexual arousal through prolonged, and much harder stimulation, or at interpreting the unconscious defense mechanisms that cause the man to experience delayed ejaculation during sex. The objection that we have to this model is that treatment that consists of a higher level of more vigorous stimulation to the man's penis appears to be contradictory to the very nature of sex as a loving, sensual, and bodily orientated expression of the deepest emotions that a man or woman can express towards another one. But although we would like to hold to the view that psychodynamic treatment is the method of choice, it remains a fact that some men, stimulated by vigorous masturbation by their partner, on a progressive scale that eventually leads to ejaculation outside the vagina, and then to a rapid transfer of the penis into the woman's vagina just before he ejaculates, so he finally ejaculates inside her, does seem to lead to some kind of "breaking of the barriers" for some men, with the result that, having achieved this objective, they are able to ejaculate inside their partner with much less difficulty on subsequent occasions. Even so, we find it difficult to recommend this method because it is intuitively difficult to accept that failure of ejaculation can simply be solved by vigorous stimulation of the penis. However, one set of circumstances in which we are prepared to believe that this might be an effective treatment is where a man has conditioned himself during adolescence to respond to extremely hard and vigorous masturbation. We know that traumatic masturbatory syndrome can indeed inhibit ejaculation in males; and we also know that it is the product of masturbation methods such as "humping the bed", where vigorous, even harsh, stimulation is applied to the penis before the adolescent boy reaches orgasm. The difficulty we have here is that we do not know whether these boys are stimulating their penises in this way because they already have some kind of stimulation threshold disadvantage or because they are psychodynamically inhibited about the whole expression of their sexuality, so that normal masturbation -- which involves engagement with the penis, self-stimulation by the hand, and a fantasy life to accompany all this -- is threatening and potentially dangerous to them. The desire-deficit model is a model developed by Apfelbaum in Retarded ejaculation: A much misunderstood syndrome, in Sandra Leiblum and RC Rosen (Eds): Principles and practice of sex therapy, Third edition. New York: Guilford Press, 2000. Apfelbaum sees the inhibition of ejaculation as an excitement and desire disorder which is disguised as a performance disorder. What this means in practical terms is that any kind of intense stimulation directed to the goal of ejaculation and/or orgasm is seen by the man concerned as a very demanding and almost punitive strategy, which serves to heighten his anxiety rather than decrease it. Apfelbaum has strongly opposed, as we do, the "almost aggressive attack" on the penis -- i.e. vigorous stimulation -- to try and overcome delayed ejaculation, and has suggested that the enforcement of orgasm during intercourse inside the woman's vagina at any price is simply bypassing the arousal and desire deficit which needs to be uncovered and clarified before a man can become aware of, and take responsibility for, his subconscious refusal to ejaculate during intercourse. Apfelbaum has coined the term "counter bypassing" for this therapeutic model, in which treatment is aimed at a man understanding and acknowledging his lack of desire and arousal during intercourse. Our own observations confirm that most men with delayed ejaculation do have a sense that they are withholding from their partner in some way, and that they should be more giving. It follows from this that it is absolutely essential to change the attitude of a man with DE, to allow him to reinterpret common myths and distorted beliefs around what may be going on during his failure to ejaculate, and to bring him back to normalcy during sexual intercourse. There's been considerable debate about whether or not these two models are actually as incompatible as they may first seem. The work of Apfelbaum has indeed shown that the sustained erections of a man with delayed ejaculation cannot be regarded as any indication of his level of arousal; in fact they signify his lack of desire and excitement, particularly when he has partner specific DE. Apfelbaum specifically warned against forcing a man to become orgasmic during intercourse at all costs, and leveled a number of other criticisms against the inhibition model. However, subsequent workers have pointed out that Apfelbaum's model is based on the analysis of only one group of men who have delayed ejaculation; therefore his conclusions may not be transferable to other men with the same condition. A significant percentage of men with delayed ejaculation do actually show features of obsessive-compulsive disorder, anxiety disorder and paraphilia. In such cases it would indeed appear that delayed ejaculation is an expression of a level of inhibited arousal and desire towards a sexual partner or even sexual intercourse itself. But as always, such a desire deficit is only one part of a much more deeper psychic or interpersonal pathology that needs to be adequately uncovered and treated. Another objection which has been raised to Apfelbaum's work is that he suggested one of the key diagnostic signs of delayed ejaculation is that a man would only find his own erotic touch arousing; that he actually prefers some kind of autosexual experience -- which means masturbation by himself -- to any other form of homosexual or heterosexual involvement. As we've already mentioned, many men with delayed ejaculation do have an idiosyncratic way of masturbating, but these men do not on the whole report that they get greater enjoyment for masturbation than from sex with a partner. All that we can say is that they can -- and do -- reach orgasm more easily through masturbation than through sex; indeed, it is often the only way in which they can achieve ejaculation. It's possible to interpret this fact as an expression of an alternative to sexual intercourse, a form of compensation, rather than a true orientation. And indeed, it is often the case that men with delayed ejaculation express an intense desire for intercourse and orgasm with a sexual partner, and that this desire puts even more pressure on them rather than less. Apfelbaum's approach is about encouraging a man with DE to express his feelings, so that he can become aware of his lack of arousal and thence overcome the expectations that he believes sex is putting upon him. This can be achieved by the therapist skillfully providing him with new interpretations to explain away the convictions he holds around the meaning and significance of sex and ejaculation. In other words, it's a form of reframing the belief system of the patient, a process which allows the therapist to open the door to a new understanding of sex. Depending on how deeply rooted the man's psychodynamic conflict may be, treatment may last anywhere between one or two sessions and an extended period of therapy. In treating men who have delayed ejaculation, one must be aware of the variations between different categories of the condition. Both concepts described above do indeed seem to reflect the truth around delayed ejaculation for different subgroups of men. One approach looks at issues of aggression, hostility, and the unconscious forces which hold a man apart from the unification of sexual experience with his partner; the other approach addresses defensiveness, feelings of guilt, excessive giving to the partner, and the man's desire to be in control. All of these impulses can be reconciled, although they have to be integrated for complete healing and restoration of normal sexual function. In the treatment model for delayed ejaculation on this website, we have attempted to reconcile these two approaches and provided both the psychodynamic explanations that may be necessary for some men and behavioral conditioning processes that will result in successful ejaculation during intercourse for others.
[ Treatment for delayed
ejaculation that actually works ] |