Retarded Ejaculation (Sexual Healing Guides Book 4)

Later, she began seeing a female psychologist who knew a surrogate who was looking for help. Rita began training with the surrogate and taking on some of her clients for a percentage of the fee.

Sometimes it was fun. But the money was good—so good that she was able to open her own practice. In a typical first session, she talks with the client in the living room a bit before retiring to the bedroom. I use long pieces of silk and my fingertips. The last part of the session is determined by what the problem is. What happens in future sessions depends on the client. There is no sex just for the sake of having sex. Many of her clients come to her because they have fetishes they feel uncomfortable revealing to their partners—they can only come when being tickled, say, or while sucking on a toe.

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Loosened latency criteria could result in false positive diagnoses, but requiring a licensed HCC evaluation of the control and distress criteria reduced that risk.



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There is substantial evidence that satisfactory sexual intercourse and the distress related to both PE and DE are probably mediated more by perceived control over ejaculation than by latency time 30 - Similar to the ISSM recommendations, the definition would be further qualified as lifelong primary or acquired secondary , global or situational.

Analogous to DSM 5 definitions would then be specified as mild, moderate, or severe. It must be emphasized that the preceding conceptualization of how both PE and DE could be redefined does not mean that everyone outside the 4—10 minutes IELT range would be diagnosed with a sexual disorder. For instance, a man who usually ejaculates in 3 minutes, who is not distressed would not be labeled PE, nor would a man who ejaculates in 15 minutes who is not distressed be labeled DE.

As biological causes of DE are reviewed elsewhere in this journal, this article focuses on psychosocial-behavioral and cultural causes. However, medical examination, laboratory testing and sexual history to rule out anatomical, hormonal, neurological abnormalities which may result in DE, should be obtained for every patient whenever possible. Certainly, there is significant pre-clinical research indicating the importance of biological predisposition in EjD. Genetically predetermined ejaculatory thresholds do have a prodigious impact on ejaculatory ease and latency time, and distribute similarly to other human characteristics 5 , Yet, scatter clouds rather than trigger points are better metaphors for ejaculatory threshold.

The timing of a particular ejaculation is the result of a variety of psychosocial-cultural and behavioral factors influencing that biologically predetermined range Such a multilayered conceptualization is different from current animal models that postulate an exclusive neurobiological threshold model Yet, the very nature of genetic predisposition and its manifestations are variable.

A man whose IELT is greater than 35 minutes may be suffering from DE that is primarily biological in its etiology, secondary to genetic predisposition, disease or pharmaceutical side effects. Such a man should be diagnosed with a life-long primary DE even if his bio-psychosocial-cultural factors are not yet fully comprehended.

Nosology and etiology are related but separate constructs. Presumably he suffers from a susceptibility that interacted with a variety of psychosocial, environmental, cultural and medical risk factors resulting in dysfunction 5 , 7. Although a biopsychosocial model is the ideal lens to view etiology, there is benefit from reviewing the earlier psychological and behavioral theories which variously emphasized ineffective sexual communication, cultural and religious prohibitions, mood disorders, fatigue, trauma, and feeling overly pressured to have sex.

Introduction

Other commonly invoked psychosocial factors were: Additional presumed causes of DE included: Depression can lead to DE as it is the most important clinical condition affecting sexual desire; this relationship is bidirectional Although medications for depression may affect desire through shared underlying mechanisms, studies have demonstrated that depression itself may have a more significant adverse effect on desire and orgasmic capacity than anti-depressant medication side effects 40 - Subsequent work supported his observations that these men often present due to partner pressure 10 , Perelman documented DE cases caused by men confusing ED medication induced vasocongestion, with genuine sexual arousal Regardless of the degree of organic etiology, DE is exacerbated by insufficient stimulation: Fantasy refers to all erotic thoughts and feelings that are associated with a given sexual experience.

Perelman identified three masturbation related factors associated with DE: These men were engaging in patterns of self-stimulation notable for one or more of the following idiosyncrasies: In fact, some men report penile irritation and erythema secondary to their masturbatory pattern 13 , Almost universally, these men fail to communicate their preferences to either the partners or doctors , because of embarrassment. Disparity between the reality of sex with their partner and their preferred sexual fantasy whether or not unconventional used during masturbation is another cause of DE That disparity takes many forms, such as partner attractiveness, body type, sexual orientation, and the specific sex activity performed 10 , Clinical experience affirms that bifurcating etiology into a rigid duality such as psychogenic and biologic is too categorical.

Genetic predispositions affect the typical speed and ease of ejaculation for any particular organism; however, many of these components are then influenced by experience and present context Biogenic and psychogenic etiologies are neither independent nor mutually exclusive.

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The STP and other biopsychosocial-cultural models all explain this variation both between and within given individuals, and provide a better theoretical basis for understanding DE 5 , The evaluation of DE focuses on uncovering causes of the disorder. A urologist will often conduct a genitourinary examination and medical history that may identify physical anomalies, as well as contributory neurologic and endocrinologic especially androgen levels factors Evaluate for illnesses that result in neuropathies, e.

While objective diagnostic procedures have scientific and research appeal, in clinical settings the diagnosis of DE is often subjective and imprecise. There are no syndrome-specific tests or inventories to support a more objective diagnosis, and the most valuable diagnostic tool is a focused sex history sex status 3 , Just as pathophysiology should not be assumed without medical investigation, a psychogenic etiology should not be assumed and a sex status is critical A sex status typically begins by differentiating DE from other sexual problems and reviewing the conditions under which the man can ejaculate.

Perceived partner attractiveness, the use of fantasy during sex, anxiety-surrounding coitus and masturbatory patterns all require meticulous exploration.

Identify important causes of DE by juxtaposing an awareness of his cognitions and the sexual stimulation he experiences during masturbation versus a partnered experience. Below are questions, clinicians can incorporate into the interview to enhance understanding: Additional questions will identify other etiological factors that improve or worsen performance, particularly those related to psychosexual arousal.

Investigate previous treatment approaches, including the use of herbal therapies, home remedies, etc. Sexual and relationship inventories in general and even ones specific to ejaculation, like the MSHQ 55 may improve research methodology, but regrettably provide limited clinical utility. A safe effective medication for DE does not yet exist.

Psychosexual therapy for delayed ejaculation based on the Sexual Tipping Point model

Patient and partner when present education should be integrated into the history taking process to the extent it does not interfere with rapport building or obtaining the necessary information. Be sensitive to patient preference regarding partner participation, as patient and partner cooperation is more critical to successful treatment than partner attendance at all office visits Before the evaluation concludes, offer the patient a formulation that highlights the immediate cause of his problem and how it can be alleviated.

Explain how the mental and physical erotic stimulation he is receiving is insufficient for him to ejaculate in the manner he desires manual, oral, coital, etc. Usually the patient will ask about prognosis. Provide a hopeful answer based on clinical evidence, such as: Help the man identify behaviors that enhance his ability to be immersed in excitation and minimize inhibiting thoughts, in order to reach ejaculation in his preferred manner. Discussion of a potential biologic predisposition is useful in reducing patient and partner anxiety and mutual recriminations, while improving therapeutic alliance 8.

Current treatments usually emphasizes integrating behavioral masturbatory retraining, within a nuanced sex therapy 2 , 37 , 45 , 53 , 58 , Masturbation can serve as rehearsal for partnered sex. By informing the patient how 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 DE therapy is evoking higher levels of psychosexual arousal within mutually satisfying experiences. Men with primary DE need to identify their sexual arousal preferences through self-exploration and stimulation. Masturbation training is similar to models described for women; yet the use of vibrators, often recommended by urologists, are rarely needed Fantasizing and use of erotica including internet pornography can help block thoughts that might otherwise interfere with arousal.

Validate not encourage an auto-sexual orientation when encountering it in a man, and assist in removing stigma suggesting withholding toward his partner. Finally, encourage the man and his partner to share their preferences, so that both their needs are met.

Healing Hands

For both primary and secondary DE as soon as therapeutically possible obtain an agreement from the patient to temporarily refrain from ejaculating alone. If he initially insists on continuing to masturbate alone, it is essential he do so in a manner different from his normal routine. Transitioning from manual to oral, to coital stimulation is typical, as each provides progressively less friction than the other. Twenty-five years ago, lack of adequate stimulation was the salient variable for an early primary DE case of this author.

The cause was sexual ignorance, inexperience, and a complete lack of adequate penile stimulation. They lay quietly together during coitus, waiting for his ejaculation to occur. But regrettably, such sex education is almost never sufficient in and of itself. Primary and secondary DE treatments share similarities. Reducing or discontinuing masturbation typically for 14—60 days , often evokes patient resistance. The clinician must provide support to ensure adherence to this suspension. Depending on motivation level, masturbation interruption must sometimes be compromised and negotiated.

When appropriate, the clinician might incorporate this conversation into treatment: Success will require most men to be taught to: Encouraging compliance necessitates understanding that this is a temporary requirement needed to expand sexual repertoire. Below are tips to manage resistance and facilitate success.

Coach an answer if the patient appears to draw a blank stare when asked how he might think and move his body differently. First ask more questions: Sex therapists may find that simultaneous exploration of both intra and interpersonal conflicts, depending on progress is required. Give men permission to move in a manner to maximize their pleasure. Their partner will take care of themselves, or he can learn how to help later. Reframe the concept of selfishness: Sexual fantasies may need realignment so that thoughts experienced during masturbation better match those occurring during coitus.

Significant disparity tends to characterize more severe relationship problems and treatment recalcitrance