Cognitive Behavioral Treatment Of Delayed Ejaculation
Establishing The Facts
Two factors that seem to maintain delayed ejaculation are high-frequency idiosyncratic masturbatory behavior and the discrepancy between a man's inner world of fantasy and the actual forms of his sexual expression with his partner.
To overcome this, a couple need to integrate his masturbation fantasies into their sexual relationship, which will not only reduce feelings of guilt but also make it easier to overcome retarded ejaculation.
And something as simple as encouraging the man to masturbate with his other hand - which may well fail to produce an orgasm - can be helpful in letting him understand how his retarded ejaculation and idiosyncratic masturbation have perhaps become an ingrained pattern of behavior.
From a cognitive - behavioral therapy viewpoint, the basic strategy is to identify inhibitions and anxieties so that the therapist and client can come up with new sexual scenarios and develop appropriate techniques to overcome them.
The aim is always to increase erotic stimulation and identify the man's orgasm triggers, but, as we have observed already, interventions which seek to change cognitions and produce changes in attitude are equally important. Here are some crucial aspects of this program:
Intimacy between the two partners is likely to reduce performance pressure on the man significantly; mutual pleasuring and giving will increase verbal and physical intimacy, and this will help to overcome inhibition and sexual isolation.
An "automatic" erection does not necessarily mean a man is ready to have sex. His subjective arousal may be too low.
A major treatment strategy is to give a man permission to enjoy sexual pleasure and to encourage him to see his ejaculation as a natural culmination of his sexual arousal.
As treatment for delayed ejaculation proceeds, a man learns to be more direct in his requests for stimulation and more straightforward in allowing himself to enjoy erotic feelings. By being more "selfish," he will experience more subjective sexual arousal and is more likely to enjoy an orgasm during sex.
A great help in the treatment of delayed ejaculation can be multiple forms of stimulation and knowing what will trigger his orgasm. Multiple stimulation might include fantasy, testicle stimulation or playing with his partner's breast or anal area during sexual intercourse.
Orgasm triggers are very variable from person to person, but you can find out many of them by using fantasy during masturbation. Intravaginal ejaculation must be approached gradually, with a couple only starting intercourse when they are both highly aroused.
Treatment Protocols Outlined
Two factors tend to promote and maintain retarded ejaculation: vigorous and idiosyncratic masturbation patterns and a big gap between a man's inner world of erotic imagery and the actual reality of his sexual life with his partner.
Bringing his masturbatory fantasies into the open will help to relieve guilt and aids honest communication between the couple: if they can incorporate these fantasies into their sex life, this is likely to be helpful in increasing the man's arousal and aiding ejaculation.
There are other simple techniques which can help a man in this situation - even something as simple as switching hands during masturbation, for example, will increase his awareness of the way in which he masturbates and how difficult he may be making it for himself to attain orgasm and ejaculation. If his other hand can't bring him to climax, no wonder his partner couldn't do it either!
There are many therapies which help overcome delayed ejaculation. One starting point is to examine the inhibitions and fears which may lie behind the problem and to develop sexual situations and techniques to overcome them.
Another good strategy is for the man to ask his partner for increased intimacy and eroticism. Cognitive-behavioral strategies involve a three-part combination: (1) forming a connected and close intimate sexual team, (2) enjoying comfort with sexual pleasuring, and (3) increasing the level of erotic stimulation.
1 If a man and his partner form an intimate team, the degree of performance pressure which the man feels will be a lot lower. Helping each other to enjoy pleasure is important in generating the increased level of intimacy that can overcome inhibition and a sense of separateness. This is a crucial first step in overcoming DE.
2. An erection does not mean a man is ready for intercourse. A man may need to be more aroused. A man needs to understand that he can enjoy sexual pleasure and gradually increasing arousal, and ejaculation is the expected end point of arousal.
The more direct the man can be about requesting stimulation, and the more he can enjoy erotic feelings, the more confident he will be of his ability to be sexual and the more likely he is to enjoy high levels of arousal that ill take him to orgasm. The need to be selfish, to seek out his on pleasure, is a key factor in recovering his orgasmic capacity and overcoming DE.
3. There are many ways of getting greater stimulation and greater arousal: enjoying sexual fantasies during partner sex, enjoying stimulation of the testes, perineum, anus and nipples are just some of these. Each man can discover his individual orgasm triggers.
Finally, a man who is hoping to find some effective treatment for overcoming retarded ejaculation should not initiate sexual intercourse until he's very aroused. Fantasies can be an effective way of heightening arousal.
It's important for each partner to ask themselves what's at risk if the man changes the way he responds during sex. There will certainly be some consequences if the symptoms of retarded ejaculation disappear, though what they might be will be different from couple to couple.
For example, the woman might wonder if the man will search out new sexual experiences with other women; the woman might wonder if he will find her as desirable as he does now; and so on.
These points, and others like them, can be very enlightening for a couple to discuss as they work through these issues.
When treating DE, a couple need to look at their erotic life together. One of the biggest questions is what happens to the foundations of the relationship when they start to work on their sexual issues.
If they have a boring sexual life, and an inhibited attitude to sexual experimentation, bringing some of heir hidden and dark sexual shadows into the light may make their sex lives more vibrant, flowing and exciting.
Men with DE often show exaggerated concern for their partner as a way of hiding the things they fear. Changing the focus of attention from the couple's conflicts with each other onto each partner's own conflicts and fears can be very illuminating!
It's exciting to discover new erotic worlds, but it can also be scary and lead to defensiveness, fear and guilt. A man overcoming delayed ejaculation should be aware of which of his own sexual fears have been sheltered by his sexual problems.
A very effective way of getting to the bottom of a person's unmet or unexpressed wishes or desires is to have them imagine being completely self-centered in sex, with no need to think of the partner. What then would be an ideal sexual scenario?
Lifelong or chronic delayed ejaculation is more common than most men realize. It's also different for each man who has it: a different combination of factors has caused it, a different approach to treatment will cure it.
There are two basic models of treatment for male anorgasmia. These are called the "inhibition model" and the "desire deficit model." Don't worry about these terms, they are just scientific language for some simple ideas.....
The so-called inhibition model and the approach to treatment which comes from it was promoted by the famous sex therapists Masters and Johnson, and Helen Singer Kaplan.
This approach to curing ejaculatory dysfunction assumes that a man is not receiving enough sexual stimulation - in either quality or quantity - to reach his orgasmic threshold, his point of no return, also known as the point of ejaculatory inevitability, so he is not able to ejaculate.
Obviously, the implication here is that if the level of sexual stimulation can be increased above his ejaculatory threshold, then he will be able to ejaculate - though the problem is that his ejaculatory threshold may be so high as to make this impossible.
Is this a case of inadequate stimulation or a high stimulation threshold?
These are actually quite different things when you consider them: for example, the high stimulation threshold concept behind delayed ejaculation might mean that a man's delayed ejaculation comes from inhibition of his orgasmic capacity because he is consciously or unconsciously expressing deep rooted hostility and anger towards women.
Inadequate stimulation might also result from a man having an insensitive penis, or penile nerves, perhaps because he learned to masturbate as an adolescent with an idiosyncratic technique such as thrusting his penis against the mattress without using his hand.
Obviously the conclusion behind this line of reasoning is that treatment methods for DE might either have the aim of increasing sexual arousal through intense stimulation or they might aim to interpret and resolve conscious and unconscious impulses and neurotic defense mechanisms; or they might, of course, aim at both these objectives.
If a man has a lot of anxiety around sex and especially around his sexual performance as a lover, then any treatment approach which aims to increase stimulation thresholds - for example by rough and powerful manual stimulation of the penis - as a treatment for DE may actually have the side-effect of increasing a man's anxiety even further (after all, the problem is the result of performance anxiety in the first place).
This any kind of aggressive approach to curing the desire disorder, or overcoming a high ejaculatory threshold, is likely to be counter-productive. It certainly sounds counter-intuitive to suggest a scheme like this for a man whose symptoms are probably rooted in anxiety anyway.
The desire deficit model
In sex therapist Bernard Apfelbaum's view, DE speaks of arousal and desire deficits which need to be understood, therapeutically approached, and clarified so that a man can take responsibility for dealing with the unconscious conflicts which have caused his delayed ejaculation in the first place.
Apfelbaum described this as "counter bypassing", and suggested that treatment for delayed ejaculation should explore with a man his lack of desire for sexual intercourse and his lack of arousal which leads to his inability to ejaculate during sex.
It is a fact that most men with such sexual dysfunctions are firmly convinced they are withholding something from their partner and that they should be more giving; this implies that changing a man's attitude and separating his distorted beliefs around sex in general and DE in particular are a main component of this treatment approach.
When a man has delayed ejaculation, he may often have a long-lasting erection, which he can maintain for hours - but this is not a sign of his arousal.
Indeed, many men in this situation have very low desire: they do not actually want to have sex, they do not desire their partner, but they feel at the same time compelled to have intercourse to please their partner.
This ejaculation problem is very often partner-specific, and the fact that a different partner, as in our case history, results in a lessening of the symptoms is indicative that we need to expand the range of therapies beyond aggressive stimulation of the penis to overcome the desire deficit.
Having said that, there are problems with Apfelbaum's approach. Other therapists have observed that many men with ejaculation problems show features of affective disorders, obsessive-compulsive disorders, paraphilia, anxiety disorders, and even various personality disorders.
In such cases, DE itself is very likely to be a sign of inhibited arousal and desire in a partner-specific context, but backed up by a profound intrapsychic or interpersonal psychopathology that needs effective treatment.
Apfelbaum also suggested that in cases of slow or non-existent ejaculation, only the man's own touch is erotically arousing, which makes him autosexual (i.e. masturbatory) rather than heterosexual or homosexual.
However, it's possible to see idiosyncratic masturbation as the simple expression of the fact that a man can only reach orgasm through masturbation rather than a sign that he only finds his own touch arousing - though of course the latter statement might also be true.
In other words, DE is not necessarily a sign of auto sexuality, or autoeroticism, and this will be especially true when a man is clear that he wishes he could ejaculate during sex, and when he is clear that this wish comes from his own desires rather than his desire to please his partner or from an externally imposed standard which dictates that ejaculation during orgasm is the goal of sexual intercourse.
However, there is no clear division between different approaches in the treatment, and any treatment which is effective in opening up the subconscious drives and inhibitions which affect a man's sexual relationship with his partner is a worthwhile endeavor.
Open expression of feelings, awareness of lack of arousal, and the ability to indulge one's own desires rather than focus on the needs of one's partner, are all clearly highly desirable objectives, whether within or without the framework of delayed ejaculation treatment.
In therapy, this process is facilitated by offering or stimulating different interpretations of beliefs held by the man and his partner around sex and intercourse in particular.
This is of course a kind of reframing approach which allows men and their partners to "see things in a different light", a kind of decontamination of the beliefs which the man holds.
There may be some powerful insights which have an impact on the cognitive level almost immediately - others, more deeply rooted in the unconscious, may take longer to change. Surrogate therapy with specially trained partners has also been helpful too.
What all this tells us is that the overall approach to treatment need not be limited to one modality. All treatment approaches reflect some reality for one man or another with delayed ejaculation.
Apfelbaum and Kaplan look at different sides of the same coin: on the one side, the unconscious aggression and hostility that makes a man experience low arousal with his partner; on the other, feelings of guilt, shame, a tendency to excessive giving during sex, and so on. Both of these approaches can be useful with different patients.
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Updated August 12, 2016