Treatment Methods For Delayed Ejaculation:
How To Ejaculate During Sex

Treating delayed ejaculation (2) 

An innovative and distinctly original model of the causation of delayed ejaculation with important implications for the treatment of this disorder was developed by Apfelbaum (2000). Apfelbaum maintained that delayed ejaculation is essentially a subtle and specific desire and excitement problem, masked by a dysfunction. For Apfelbaum the most frequent form of coital orgasmic inhibition was a "partner anorgasmia," due to the fact that most delayed ejaculation patients experience difficulty in reaching a sexual climax only in the presence of a partner. Responsible for this partner anorgasmia is a phenomenon that Apfelbaum called the "autosexual orientation" of the man who can only allow and relish his own masturbatory self-stimulation. The partner-related arousal and desire difficulty will be "masked" through the robust, automatic (or even "premature"), and prolonged erections of the patient. These erections, however, are not an expression of true sexual desire and sexual excitement, but are rather "desynchronized" and will primarily be used by the man to fulfill his partner's expectations. Apfelbaum offered no plausible explanation for this high grade of genital reactivity but disagreed with assumptions that men with delayed ejaculation harbor strong (conscious or unconscious) feelings of hostility or rejection against women. Instead, he saw these men as persons who are not able to be selfish enough, who cannot take care of their own needs and wishes, and who are unable to stand up for their own satisfaction. They live under the yoke of conscientiousness, of self-control, and of fulfilling their duties as well as under continuous pressure to satisfy and please the partner. Dominated by this omnipresent feeling of not being able to give enough, the man, through his sexual symptom, conveys the impression to his partner that she cannot do anything good for him, either. Her resigned withdrawal thus closes the circle of "autosexuality."

Apfelbaum's arousal-deficit model of delayed ejaculation could be confirmed by a recent psychophysiological study, as Rowland, Keeney, and Slob (2004) found that, regarding self-reported sexual arousal, men with delayed ejaculation indicated significantly lower levels than each of the other three groups: functional counterparts, men with ED, and men with PE. This factor, more than actual erectile response, appeared to characterize men with this dysfunction. The cause for this lower arousal was not explained in the study. Factors involved may include physiological ones such as low penile sensitivity and/or hyporesponsivity or elevated threshold of the ejaculatory reflex, as well as the psychological ones described above. Again, cause and effect relationships between psychological or relationship factors and self-reported sexual arousal remained elusive. We return to Apfelbaum's approach in the treatment section.

Diagnostic and Differential Diagnostic Aspects

The evaluation of psychological factors in patients with delayed ejaculation does not substantially differ from the usual diagnostic procedures established for sexual dysfunctions. The symptomatology must be clarified by means of a detailed sexual history, preferably with inclusion of the partner, which forms the basis of a proper diagnostic classification including the usual formal criteria like lifelong versus acquired, and situational versus global.

The main goal of the diagnostic assessment is to determine the conditions under which orgasms are possible or impossible for the individual patient. As usual, the level of immediate, here-and-now causative factors should be explored first, through a detailed analysis of the patient's thoughts and feelings during sexual encounters. Important aspects include:

• What are his "start conditions"? Does he experience enormous pressure to succeed right from the beginning or does this pressure emerge later during intercourse?

• What is his degree of spectatoring?

What is the relationship between subjective sexual arousal and penile erection?

Does he want and receive sexual stimulation from his partner?

Are there sexual fantasies and can they be used without feelings of guilt?

Can the patient monitor his own feelings and emotions during the sexual contact with his partner or is he totally focused on satisfying lier?

Does he have the feeling that his partner becomes frustrated, bored, or annoyed during prolonged intercourse or that she is doing it just for his sake- (mercy sex)?

• Are there apprehensions in connection with the experience of orgasm/ejaculation or with the loss of control of which the patient is aware?

Can the partner achieve a coital orgasm, and if so, how quickly?

* Does the patient continue intercourse after his partner's orgasm?

Another focal point to be addressed during the evaluation process relates to how the patient masturbates. Again, the inner processes, the masturbatory technique, and especially the erotic imagery involved should be explored. Are there sexual fantasies (possibly paraphilic) about which the patient feels conflicted and which he tries to suppress?

Examination at the level of immediate causes is followed by an evaluation of more deep-rooted intrapsychic or dyadic variables. Given the low degree of specificity of these factors, the clinician should consider the above-mentioned categories and scrutinize them in a comprehensive manner. It should be determined if feelings of anger or hostility toward the partner can be identified or if they should be interpreted as a sign of more fundamental conflicts. In most cases, hypotheses can be derived from sexual history, which may then be assessed more closely by targeted questioning. However, these psychodynamically complex issues, predominantly unconscious to the patient, often are revealed only in the course of a longer therapeutic process. Therefore, the investigator should not try to enforce rapid clarification.

In terms of differential diagnosis, delayed ejaculation causes no particular problems. Attention should be paid to differentiating delayed ejaculation from ED, since some men lose their erection and don't ejaculate and may regard this as ejaculatory inability. As with all sexual dysfunctions, it should be determined if delayed ejaculation is secondary to a psychiatric illness (depression, anxiety disorder, obsessive-compulsive disorder) or is caused by drugs or medication (see below).

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