Cognitive-Behavioral Interventions for Delayed Ejaculation (aka Retarded Ejaculation)
Various authors have put forward approaches to the treatment of delayed ejaculation that focus on cognitive behavioral approaches, including altering the levels of sexual inhibition of the man concerned and reframing various issues that might be associated with delayed ejaculation.
Foremost among these authors are McCarthy and Perelman, who highlighted two factors which seem to predispose a man towards the development of delayed ejaculation and the persistence of the condition once it has developed. These are harsh, idiosyncratic masturbatory patterns, and a discrepancy between a man’s internal world of erotic and sexual imagery and the reality of his sexual relationship with his partner.
In the latter case, with the cooperation of the couple, a therapist assisting a couple with delayed ejaculation can help the man to integrate those fantasies which support his masturbation into his sexual relationship, which has the effect of reducing his sexual guilt and making it more likely that he will reach the level of arousal necessary to achieve orgasm. Perelman suggested that there was a simple way in which an idiosyncratic masturbatory method could be changed: it was as simple as asking the man to change hands while masturbating.
Although this may sound bizarre, the switch actually makes the man focus on what stimulation he needs to achieve orgasm, and what kind of stimulation makes him become aroused in the first place. If he fails to reach orgasm simply by changing hands whilst masturbating, its absolutely no surprise that his partner cannot bring him to orgasm either, nor overcome his delayed ejaculation.
Using a more sophisticated treatment approach for men with delayed ejaculation, McCarthy used a combination of therapeutic techniques. Starting with cognitive behavioral work, the basic treatment strategy for delayed ejaculation was around identifying inhibitions and fears that a man may have about various aspects of sexuality, sexual attraction with his partner, and sexual fantasy.
Simply by constructing real-life sexual scenarios, and using some cognitive behavioral techniques, it becomes entirely possible for a man to overcome his anxiety about sex, whether this is conscious or subconscious. It’s certainly true that on occasion some sexual inhibitions have to be accepted, and ways to avoid them explored. But this is not a barrier tot he treatment of delayed ejaculation. This might include, for example, finding a way to increase a man’s level of arousal so that he was still sufficiently aroused to achieve orgasm.
As you can see, the object of this delayed ejaculation treatment is to use behavioral strategies to increase sexual stimulation, and to find triggers for a man’s orgasm that can help him achieve orgasm and overcome delayed ejaculation.
But in addition, it’s equally important to find a way of intervening in a man’s thought processes and to find a way of changing his attitudes towards sex. So, for example, one approach might be to encourage a man to approaches partner and ask for an increased level of intimacy and sexual stimulation. This can be notably lacking in men with delayed ejaculation.
The partner’s involvement is absolutely critical to the success of this strategy. If she (or he in the case of homosexual couples) is intimately involved in the treatment, the level of performance pressure that the man experiences is usually greatly reduced. And certainly when a couple work together with the objective of achieving sexual pleasure for the man (or for each other) the level of intimacy that they achieve, both verbally and physically, can be extremely effective in overcoming sexual inhibition and a sense of isolation that may otherwise affect the man with delayed ejaculation and his partner.
Usually men with delayed ejaculation have absolutely no problem getting an erection, but men in this situation often surmise that they are ready for intercourse simply because they do indeed have an erection. It transpires that in many cases the level of arousal that the man is experiencing is simply too low for him to achieve orgasm. That is a key factor behind many cases of delayed ejaculation.
In such cases, it may be necessary to do nothing more than to allow him “permission” to enjoy sex, and enjoy the process of becoming aroused, and enjoy the sensations that sex can produce; in addition he can be coached on how to request more stimulation from his partner, speak directly about his sexual needs to his partner, and basically enjoy the sensation of becoming more self-centered during the sexual interaction of the couple. This is a good step along the road to reducing the inhibitions that maintain retarded ejaculation.
As I’ve already suggested, the main techniques that can help in therapy for delayed ejaculation are (1) to use a number of different stimulation methods directed at achieving sexual arousal, and (2) to use orgasm triggers that can help the man tip over his point of ejaculatory inevitability. So for example, this might include the use of fantasy, role-play, nipple stimulation, scrotal stimulation, anal stimulation, and any other particular individual stimulation points that provide the man with additional arousal. One good way to identify the areas of the body that are particularly sensitive to sexual stimulation is for the man to experiment during masturbation.
Even so, it’s extremely important that moving from a position of delayed ejaculation with no climax in the vagina to full intravaginal ejaculation should be a gradual process. For a man with delayed ejaculation, treatment has to proceed slowly, so that he is highly aroused before he even attempts vaginal intercourse.
It’s obviously also important that a holistic approach to treatment is taken, an approach which takes into account every aspect of the man’s relationship and sexual functioning.
Adopting such a holistic approach might mean, for example, considering if there are any reasons why a man might have developed delayed ejaculation in the first place, and whether or not there are any advantages to him in not achieving orgasm during intercourse. Although this might seem like an impenetrable question, a good way to approach it is to ask the question “what is the risk involved for each partner in a relationship if the sexual dysfunction disappears?”
People almost always know the answers to such questions, even if they are not willing to admit it! But the information can usually be obtained when a person denies knowing by asking them either “if you did know, what would it be?” Or “have a guess, the first thing that comes to mind.”
To give you a flavor of the kind of things that I mean by this, an example might be that if a man was no longer inhibited by delayed ejaculation, he would want to catch up on lost sexual experience, or that he would cheat on his long-term relationship partner. If a couple is willing to answer such questions openly and honestly, the therapeutic process can be speeded up and energized in a way that promotes change.
Another option during therapeutic processes to test sexual realities. What this means in practice is that a variety of sexual scenarios can be outlined to a couple to gain understanding of what they are avoiding.
Couples usually will look for a simple solution to remove the sexual dysfunction from their relationship without wanting the rest of their relationship disturbed. Clearly this is almost impossible, since the sexual dysfunction – delayed ejaculation in this case – is most likely a product or a symptom of some deeper underlying issue. Therefore by exploring what we could call the erotic “dark area” both members of the couple help to overcome delayed ejaculation and at the same time explore their own sexual proclivities and discover aspects of each other that they have not previously explored.
For men with delayed ejaculation, an apparent over-concern for the sexual partner may well be one way of concealing the man’s own sexual fears. These may be based upon past traumatic experiences, or various emotional blockages, either of which can lead to reluctance to risk intimacy or allow full access to the self for the fear of repeated wounding. When the focus is changed from the interaction between the couple to the intra-psychic fears and conflicts of each individual, therapy of delayed ejaculation is likely to proceed much more quickly.
There will, of course, be some defensive reactions along the way, and probably the activation of some degree of unconscious guilt or shame. In situations like this the skill of the therapist is crucial, although it is a perfect opportunity to dig out the sexual fears of one individual that are being sheltered by the partner’s delayed ejaculation or other sexual problems. Complicity in constructing a defense like this is very common in delayed ejaculation.
Clement evolved the concept of the “ideal sexual scenario” in 2004, and it has been a very useful tool in exploring delayed ejaculation. Basically, it’s an approach that allows a couple to understand not only the sexual activity and fantasy and erotic potential they both already have and are living, but also the un-lived or unexpressed potential that is harder to elucidate.
Individually, each partner in a couple where the man has delayed ejaculation can be asked to write a script which describes his or her ideal sexual encounter. This should be written in great detail, and not focus on feelings but on behaviors and actions. When written, it’s put in an envelope, sealed, and later passed to the partner, who has the choice of opening it or not. Before that is done however, it’s also possible to ask each partner to write down what he or she imagines their partner might have included in their ideal sexual script.
Although that in itself is important, it’s also extremely significant to consider how each partner approaches this exercise, since it can reveal the sexual drama within the relationship and the concealed aspects of the relationship, particularly around fears that may be interfering with an open expression of sexuality.
Various responses to the envelopes exercise may take place: some couples can’t bear to open them, some show them to each other before the next session, and some actually compose a false plot based on a rosy scenario of tenderness, love and respect, whilst claiming that all their existing mutual needs are already met by the relationship. As you can imagine, an ideal sexual scenario exercise like this provides huge material for further therapy, and is especially useful for men and couples affected by delayed ejaculation.