When I first started out as a sex therapist over thirty years ago, delayed ejaculation and premature ejaculation were thought to have nothing in common. One man comes too fast, the other too slow. Different causes, different treatments, different everything.
Turns out that’s only partly true. While they’re indeed opposites in many ways, there are some important similarities.
Unless you understand the similarities, there’s no way to treat these conditions effectively.
Biologically speaking, orgasm is simply a reflex. The orgasm reflex is a lot like the sneeze reflex. Get enough pepper in your nose, and eventually you’ll hit the threshold where you can’t resist sneezing.
Orgasms, of course, tend to be a lot more fun. And unlike sneezing, the inputs are psychological as well as sensory. But otherwise, the concept is the same.
Including the fact that orgasms, like sneezes, don’t happen unless stimulation reaches a certain threshold.
There’s no medical test to measure your “orgasm threshold.” It’s purely a theoretical concept. But it’s an essential concept if you want to understand and treat DE and PE.
Orgasm thresholds seem to lie on a bell curve. Most men fall somewhere in the middle, but some men are outliers on one end or another.
Men with lifelong premature ejaculation typically have very low orgasm thresholds. If there were an instrument that could measure your sexual arousal from 0 to 100, a man with PE might need only a 30 or so to climax.
Men with lifelong delayed ejaculation tend to have very high orgasm thresholds. Let’s say 70 or 80. In other words, it takes a serious amount of arousal to reach orgasm.
As I discuss in Chapter 9 of my book Love Worth Making, this is just normal human variation. There's nothing inherently wrong with having a low threshold or a high one. That’s just how you’re wired.
Try Googling “Delayed Ejaculation,” and you’ll find articles from general medical websites listing all sorts of medical causes for DE – some of them pretty scary. One prominent article starts by mentioning stroke, spinal cord injury, and multiple sclerosis, right off the bat!
This needlessly frightens innocent men. In reality, if you made a pie chart of all men with DE, those due to neurological injury would be a tiny slice.
These medical articles do tend to mention that antidepressants can cause DE – which is a larger group, but still not an especially big slice of the pie.
What all these articles online fail to mention is that the majority of men who present for treatment of delayed ejaculation haven’t acquired DE through any medical or pharmacologic mishap at all.
As an MD sex therapist who specializes in this area, I’ve treated many hundreds of men for delayed ejaculation. And the biggest slice of the clinical pie consists of men who’ve always needed a lot of stimulation to climax – either by themselves or with a partner.
In sex therapy, we say these men have primary delayed ejaculation. They’re like women who can only come with a vibrator. That’s just where they are on the bell curve of orgasm thresholds. As far as I can tell, it mostly seems to be innate.
You’ll often hear that extreme masturbation techniques cause delayed ejaculation. I think it’s often the opposite: Men adopt extreme techniques to compensate for their naturally high orgasm thresholds.
Research on delayed ejaculation is still in its infancy. But research on premature ejaculation suggests that rapid ejaculation may be to some extent hereditary. I think it’s likely that DE may have a familial component, too.
I’ve noticed that lifelong DE and lifelong PE sometimes run in families. I’ve treated fathers and sons for the same ejaculatory tendency. If I stay in practice long enough, I imagine I’ll see the grandsons too.
Google “Delayed Ejaculation” online, and you’ll also find lists of “psychological causes of DE.” These lists tend to be broad and wide-ranging. Typical entries include “depression,” “poor body image,” or “feeling guilty about sexual intercourse.”
All terribly misleading. In fact, some men will respond to the situations above by being unable to ejaculate. But other men will respond to the exact same kind of situation by being premature.
Situational factors can be important, but they don’t determine whether you’ll ejaculate quickly or slowly. As I’ve argued above, a lifelong tendency to be quick or slow is probably mostly innate.
Most men report there’s a range of how quick or slow they tend to be. For both delayed ejaculation and premature ejaculation, psychological factors can certainly influence where you end up within that range.
But it’s extremely rare to see psychological factors turn a man with longstanding DE into a premature ejaculator – or vice versa.
Your sexual mind has both accelerators and brakes. The accelerators are simple to understand. Whatever your orgasm threshold, the more strongly turned on you are, the quicker you’ll tend to ejaculate.
The brakes tend to be trickier. On the one hand, turn-offs tend to lower your level of arousal, making it less likely you’ll hit your orgasm threshold. But there are also situations where negative emotions like fear or anxiety can make a man with PE ejaculate quicker.
Performance anxiety, for example. Or ambivalence about a partner, feelings of mistrust, or secretly wanting to end the relationship.
A man with DE might react to the identical situations by having even more trouble ejaculating. In both cases, your biology sets the range of expectable outcomes, and psychology determines where you’ll happen to fall within that range with a particular partner at a given time.
Once you see the underlying similarities between DE and PE, you’re in a better position to understand the differences.
Treatment of delayed ejaculation is conceptually simple: You just need to figure out how to reach your high orgasm threshold during partner sex, without exhausting yourself or your partner.
Fortunately, techniques that help a man do this all have the potential to promote really good sex. Maximizing psychological arousal during foreplay, for instance. Delaying penetration until you’re highly aroused. Being a bit less cautious in bed. Plus a few other things I’d be happy to teach you about in the office.
All these things maximize arousal. Which is what people naturally do when they’re having really good sex. The goals for treatment of DE are the same as for good lovemaking.
Treatment for premature ejaculation is more problematic. All the traditional treatment approaches involve what I’ve referred to elsewhere as “arousal reduction”: limiting your arousal, in order to stay below your orgasm threshold. That’s by definition not going to be very good sex.
Most men with PE already intuitively practice arousal reduction. They masturbate before sex; do math puzzles in their head; avoid sex positions that really turn them on; or avoid sex partners who really turn them on. Obviously not a recipe for great sex.
What’s more, all the traditional behavioral approaches for premature ejaculation – such as motionless intercourse, “start/stop,” the “squeeze technique” – also serve to keep arousal low.
Partners of men with PE tend to hate these techniques. They rightly note that limiting a man’s arousal takes all the spontaneous joy out of lovemaking.
Happily, men with premature ejaculation now have an ace up their sleeve.
Since shortly after Prozac came on the market in 1987, it’s been recognized that all the so-called SSRI’s (selective serotonin reuptake inhibitors) have the potential to raise a man’s orgasm threshold.
No SSRI has been specifically approved by the FDA for premature ejaculation. So prescribing an SSRI for PE is considered “off-label.”
But off-label prescribing is perfectly legitimate, provided the patient has been informed that the treatment is off-label. Plus, there have now been over 30 published studies documenting the usefulness of SSRI’s in men with premature ejaculation.
Most men with DE have no such options. As I mentioned earlier, research on delayed ejaculation is in its infancy. We know very little about how to lower men’s orgasm thresholds.
Or women’s orgasm thresholds either, for that matter.
As an MD sex therapist who specializes in male ejaculatory concerns, I’ve occasionally had men report being helped by medication. Some men with DE and ADHD, for instance, find that being able to focus better on a stimulant helps them climax during intercourse. But we’re still a long way from having medications to reliably facilitate orgasm.
At this point in time, the lesson from pharmacology is that it’s easier to raise a man’s orgasm threshold than to lower it.
You’ll never see a porn star ejaculate quickly. Having a high orgasm threshold is practically a requirement for the job.
But you’ll see lots of men with DE in porn. Many male porn stars seem to need to finish themselves off by hand at the end. Many are presumably unable to ejaculate otherwise.
In the real world, things are different. Sure, the ability to last a long time during intercourse is impressive. But in heterosexual relationships, women tend to vary in whether they want prolonged intercourse on a regular basis.
For some women, intercourse is what excites them the most. They’d rather orgasm during intercourse, with or without clitoral assistance, than any other way. A woman like this needs a man who can thrust for as long as she needs.
Other women prefer direct clitoral stimulation. They’d rather be with a man who loves cunnilingus and really knows how to give them an orgasm that way. After she comes, they’re totally fine if he climaxes within a minute or two of penetration.
As with most things sexual, it’s best to ask. Unfortunately, many heterosexual men just assume a woman wants what you see in porn. This leads to a lot of stressed men, and a lot of very bored women.
Still, some sexual pairings are more natural than others. A man who ejaculates quickly just isn’t an ideal match for a woman who yearns for 15 minutes of intercourse. And a man who struggles to ejaculate during intercourse isn’t ideal for a woman who just wants to come from cunnilingus, finish him off with a minute or two of intercourse, then go to sleep.
But people don’t always choose their ideal sexual match. As a sex therapist, I’m often in the position of suggesting workarounds.
Successful treatment of DE tends to be a win-win for everybody, since it gives him the flexibility to come fast or slow, depending on the needs of the moment. (Just remember that ejaculation tends to be more difficult after very prolonged intercourse. If he’s lasted a long time, don’t be surprised if he needs to finish himself off by hand).
As mentioned above, best results for PE often tend to involve medication. But a lot depends on the quality of your relationship. As I write in Chapter 9 of Love Worth Making, sometimes a man may just have a very critical partner, and his prematurity makes him an easy target for her criticism. In that situation, taking a drug to make her happy usually doesn’t work.
One final thing DE and PE have in common . . .
When it comes to evaluation and treatment, the same general recommendations apply:
These conditions can cause tremendous suffering – most of it avoidable with proper management.
Sexual insecurity due to DE or PE can have a major impact on who you date, who and when you marry, and whether you find long-term satisfaction and fulfillment as a couple.
Contrary to popular myth, neither DE nor PE typically gets better over time. So it’s almost always best to get help early.
Don’t rely on your regular therapist for help with DE or PE. Even most sex therapists lack the tools to comprehensively evaluate and treat men with these two conditions.
Make sure you get help from someone who knows these conditions well, and who’s treated enough men to know the range of issues, options, and outcomes.
Ask them in advance how many men they’ve treated with your condition.
Contrary to what you might think after looking online, most men with lifelong DE don’t have sex addiction or childhood trauma. But many do feel broken because of their DE.
Most men with DE are genuinely attracted to their partners, and would love to climax during intercourse if they knew how.
Most men with PE would love to last longer if they could. Contrary to what you might read online, there’s no evidence for PE being caused by depression, sexual abuse, poor body image, or masturbating too quickly as a teenager.
If anyone who tells you PE is easy to treat with behavioral techniques, chances are they’ve never struggled to hold back an orgasm.
Acceptance reduces anxiety. Less anxiety means better arousal. Better arousal means better sex, regardless of your threshold.
Your orgasm threshold is not a moral failing. It's not a sign of psychological damage. It's just a fact about your body, like your height or your eye color.
Avoid taking it personally. His ejaculation timing isn't a reflection of how attractive you are or how much he desires you. Talk openly about what to do when his threshold doesn't cooperate. Having a backup plan reduces performance pressure.
Delayed ejaculation and premature ejaculation often respond well to treatment, once you understand what you're really dealing with.
It's not about becoming "normal"—it's about becoming yourself, sexually speaking.