Stephen Snyder's Blog

10 Things To Consider If Your Man Can’t Ejaculate During Sex

"I think there's something wrong with him – or with me. We'll have sex for thirty minutes and he still can't come. I can't help thinking he's just not that attracted to me anymore."

If you're a woman reading this article, chances are you've had some version of this thought. You're watching the man you love struggle to reach orgasm during sex, and despite his reassurances, you can't shake the feeling that somehow it's all your fault.

I’m here to help. 

I’m an MD sex therapist based in New York City who specializes in male ejaculation problems.  

I’ve treated hundreds of men for this issue. And here’s the most important thing I can tell you right away:

This isn't about you. It's not about how attractive you are, how good you are in bed, or how much he desires you.

What is it about?  That’s what I’m going to explain in this article. I’ll also show you ten things to consider right now that might help.

Here’s a guide to what you’ll find:

Items 1-5 below are mostly psychological.   Items 6-9 get into the nitty-gritty: practical tips for what to do in bed.In Item 10, I’ll show you how to find professional help, if needed. 

Feel free to skip ahead, if you like. But I think the whole discussion makes more sense if you read it all in order.

Ready?  Let’s get started . . .

1. Use what you already know about female orgasm.

You know we’re living in a golden age for female orgasm, right? 

No one these days thinks there’s anything wrong with a woman if she has trouble having an orgasm through intercourse alone.  Everyone today knows a woman is entitled to climax any way she wants. 

It’s also, of course, a golden age for vibrators and other sex toys – delivered to your door next-day, courtesy of Amazon Prime.  

But the most magnificent thing about female orgasm in the 21st Century is the first thing I mentioned above:    

No one these days thinks there’s anything wrong with a woman if she has trouble having orgasms through intercourse alone.

For most of the 20th Century, women weren’t so lucky.  

Freud’s patient Marie Bonaparte was so desperate to orgasm through intercourse that she underwent psychoanalysis for it. When this didn’t work, she had three separate operations to relocate her clitoris closer to her vagina. You can read the whole sordid tale here.

Millions of women who needed clitoral stimulation to climax were told they were defective, and fortunes were spent on psychological treatment to correct this assumed defect.

Happily, we’re mostly past all that. Women today are done with thinking there’s something wrong with them for not being able to orgasm from intercourse alone. 

Unfortunately, we men aren’t so lucky. In fact, we’re about a century late to the party. 

Most people today are still in the dark ages of thinking all men should climax in the same way – and if they don’t, there’s something wrong with them. 

So if your male partner struggles to climax during sex, ask yourself the following: 

Do you really want to repeat the whole sorry history of misinformation about the female orgasm in bed with your man right now?

If not, then please continue reading below.

2. Understand that the way we think about male orgasm is totally unfair.

Here’s a question:

Why do we call it “delayed ejaculation”?  Why not call delayed ejaculation what it really is – a problem with orgasm? 

The answer is pretty obvious, right?  Men are supposed to ejaculate. That’s how the species gets perpetuated. That’s their job. 

The problem with this line of reasoning, as every sex therapist knows, is you never want to use the words “sex” and “job” in the same sentence.

But there’s something deep in the human psyche that does exactly that, when it comes to men.  

In the modern world, we’ve now evolved to where we know female sexuality is about pleasure, not performance. But “men and pleasure” is a bigger intellectual jump.

There’s something deep in our souls that values men chiefly for being “pleasure providers” – not pleasure consumers.

Right or wrong, we value men for what they’re able to produce, be it semen or a paycheck.  

Plus, there’s the not insignificant fact that men are famous for being able to come easily.  A man who struggles to climax during intercourse is different from what’s expected. 

When it comes to sex, “different” nearly always tends to shade into “wrong.” That’s definitely going to push your anxiety buttons. “What’s wrong with this man?” you wonder.  “Is he gay? Kinky? All psychologically messed up?”

My advice: Give him the same consideration you’d give a female friend who struggles to climax with a partner and tells you she feels broken.

“Nonsense,” you’d say. “You’re fine, just as you are. It’s not a performance.” 

We men don’t get told that very often.   

3. Be skeptical when you read on the internet about Delayed Ejaculation.

If you Google “causes of delayed ejaculation,” what you’ll find may make your heart race – and not in a good way. 

Scary medical stuff – like stroke, spinal cord injury, multiple sclerosis, and birth defects. 

Scary psychological stuff – like “sex addiction” and “pornography addiction.”

In a rational world, there’d be a boxed warning at the top of all these sites, warning you that by and large the people who put them together are writers – not doctors – who’ve never actually treated anyone for a problem ejaculating.  

They’ve composed the article the same way you’d write a term paper in high school:  You’d look things up.

But there’s very little published medical or psychological research on DE. The writers simply did their best, based on what they could find.   

As a result, much of what you’ll read online is just medical folklore. Not evidence-based, but enough to scare the daylights out of the average reader.

What you generally won’t learn on the internet is that most men who struggle to ejaculate with a partner don’t have any medical or psychological disorder at all. 

Most are simply at the other end of the bell curve from premature ejaculation.  It just happens to take a lot of stimulation for them to climax.  

But medical websites tend to work within the medical model. If there’s a problem, there must be an accompanying medical disorder. Or barring that, a psychological disorder. 

Very rarely will you see any mention of natural human variation as an underlying cause of DE. 

Most of the many hundreds of men I’ve treated for DE do not suffer from any medical or psychological disorder at all.  They simply tend to have more than average difficulty reaching orgasm. Full stop.

So skip the internet search, if you can.

Instead, use the most authoritative source in the world:  Ask him yourself.

Let me show you how . . . 

4. Have a heart-to-heart talk with him.

Let’s say you’re dating a man for several weeks, and you’re having sex and everything but you’re pretty sure he hasn’t climaxed yet.  

You don’t want to ask, for fear of making him uncomfortable. But still, you’re pretty darn curious!

Here’s my preferred approach:

One day, after a particularly good sexual encounter together (always the best time to ask about something like this), turn to him and say, “Hey, I want to ask you something:  What’s your favorite way to come?” 

It’s simple. It’s positive. And it’s a completely open-ended invitation to tell you anything he wants on the subject – especially if accompanied by the same friendly, understanding look you’d give a female friend who struggled to climax with a partner. 

If, in fact, he does struggle to climax during partner sex, with any luck he’ll trust you enough to share this with you.

“Is it frustrating?” you ask, continuing to give him that same understanding look – and trying not to sound anxious. “Anything I can do to help?”  

Suddenly, you get an idea:  “If you ever want to try finishing by yourself here in bed with me, I’m totally okay with that.” 

Maybe he’ll take you up on the offer, and you’ll get to see how he does it.  Lots of guys with DE have to masturbate with a very firm grip.  Or by stroking very fast.  Or in a particular way that’s not easy for a partner to replicate. 

You’ll read online that over-energetic masturbation can cause DE, but I think many times it’s the reverse.  There’s a bell curve for male orgasm thresholds, just like there is for women.  For a lot of guys, an intense technique is the only way he can reach his very high orgasm threshold.  

Now that you have some information, let’s consider what to do with it . . . 

5. Have a heart-to-heart talk with yourself.

As a sex therapist who specializes in this condition, I’ve helped many hundreds of men learn to ejaculate during intercourse.  There are lots of potential techniques.  

On the other hand, it’s never a good idea to make a relationship conditional on your partner changing something about themselves.  

Let’s say your man is able to learn to climax during intercourse. Can I guarantee he’ll be able to do it every time – under any conditions? Of course not. 

So I’d advise you to ask yourself the following two questions:

1. Is it really important to me as a woman for him to climax inside me every time? Would I be okay if he only ejaculates inside me some of the time? Or would that just not feel good for me?

2. If we decide to have kids together, how important is it to me to always receive his semen through intercourse?  Would I be okay if some of the time we improvised other ways of getting his semen inside me?  (See HERE and HERE for examples – and see Item 9 below).  Or would that feel too disappointing? 

It’s okay to be honest. There are no right answers here. 

In sex therapy, we talk about “vitamin A” – acceptance. It’s an essential ingredient in any couple’s relationship.  But there’s no law that says you have to be all-accepting. 

If you’re going to be worrying about his DE to the point of unhappiness, then maybe he’s just not the right partner for you.  As a sex therapist, I would never want you to stay with someone who doesn’t meet your sexual needs.

On the other hand, some disappointment in relationships is universal.  Accepting disappointments is a mark of maturity – provided they’re disappointments you can authentically live with without being miserable.  

These are intensely personal matters. No one’s going to fault you if you decide his DE tendency is a deal-breaker for you.  

On the other hand, maybe you would like more information about how the two of you might make this work.  

If so, read on . . . . 

6. Practical Tip: Why men with Delayed Ejaculation should avoid prolonged intercourse. 

If all you knew about sex was from porn, you’d think intercourse should always last at least 30 minutes and involve at least three changes of position. 

But in the real world, most people tell me the most rewarding part of intercourse is the first ten minutes.  After that, truth be told, the magic tends to diminish a bit – unless it’s your first week together or you’re taking psychedelics.  

As a sex therapist, I hear way too many accounts of couples having penetrative sex for 30 minutes or longer in the hopes that he’ll maybe finally have an orgasm.  

Not exactly a recipe for passion, right?  

I usually advise men with DE to limit intercourse to just ten minutes. That might sound counterintuitive at first.  But a man’s passion tends to peak at the moment of penetration – like a tennis ball coming in fast over the net.  

Most men with DE tell me that after the first ten minutes or so, penetrative sex becomes a futile quest to recapture the original excitement while contending with the nagging worry that it’s not going to work.

By 30 minutes after penetration, the ball has lost its bounce and is rolling towards the backstop.  No way to effectively hit it over the net.

Here’s a better way...

7. Practical Tip: Don’t let him penetrate until he’s very excited.

Medically speaking, orgasm is simply a reflex.  Like all reflexes, there’s a threshold of stimulation you need to achieve it.  Men with DE tend to have high thresholds, so it takes a lot of arousal to activate their orgasm reflex. 

Let’s imagine arousal on a scale from 0-100.  Most men assume that once they get hard, they’re fully aroused and it’s time to penetrate.  But let’s say it only takes an arousal level of 20 or so for a young, healthy man to get hard. If you penetrate at a 20, but your orgasm threshold is a 70, you’ve got a big climb ahead. 

Like all men everywhere, men with DE tend to hurry penetration before they’re sufficiently aroused. But as discussed above, a man’s arousal tends to decline significantly after the initial thrill of penis meets vagina has passed. After 10 minutes of intercourse, he’s like a tennis ball that’s lost its bounce.  Not very likely he’ll be able to climax. 

Often, the best workaround for a man with DE whose orgasm threshold is 70 is to delay penetration until foreplay has already excited him to a 50 or so. (How to tell?  For starters, at a 50 most men have trouble composing a full sentence). 

If you wait till he’s at a 50 before letting him penetrate, he’ll have a good headstart for getting to 70 before his ball loses its bounce. 

Note: For the above workaround to succeed, during foreplay he should be getting most of his arousal from psychological stimulation:  The sight, scent, and feel of your body. The drama of the moment. (If he’s at all kinky, that’s a plus). 

Don’t go overboard with penis stimulation during foreplay. Best to tease his penis a bit, keeping it away from the appetizers so it’s maximally hungry for the main course. 

Then after penetration, by mutual agreement he should have permission to ravish you to his heart’s content.

That’s where we’re going next . . .

8. Practical Tip: Tell him it’s okay to be a bit selfish in bed. 

Let’s say the two of you have followed my advice so far.  You’ve delayed penetration until  he was so aroused he couldn’t put together a proper English sentence. 

At this point, you may want to reassure him that now is not the time to act like a gentleman.  Now is the time for him to be a bit of a beast.

If he’s like most men I see with DE, he may be a bit shy about really “letting go” during intercourse. It’s essential for a man with DE to learn to do this. Tell him you don’t mind being treated a bit more ruthlessly in bed, provided he’s properly relished you first.  Many men with DE need to know it’s okay to be a bit rougher in bed.

Tell him it’s okay if he focuses entirely on his own arousal. Tell him you don’t mind if he pushes it to the max. Tell him you’d like that. 

Best to tell him you don’t care if he comes or not. You just want him to enjoy you passionately and get as excited as he wants. 

After all, the best way to get an orgasm is not to chase the orgasm. It’s to push arousal as high as it can go, until you hit your orgasm threshold.  

9. Practical Tip: Have a back-up plan. 

Say you’ve followed all my advice so far, and you’ve had ten minutes of gloriously passionate penetrative sex, but there’s no male orgasm in sight. What to do next? 

First, there’s no law that once you’ve started intercourse you have to keep doing it till he comes. Don’t just keep doing the same thing over and over again, hoping for a different result.  

Maybe have him pull out and do something else for a while. Then go back to penetrative sex, once it’s fresh again. 

Thought experiment:  Imagine if during intercourse your clitoris was buried deep inside you, like the tip of his penis is now.  It might feel great, but it would also limit your options somewhat for how to stimulate it.

Even in the best lovemaking, a man with DE can eventually hit a point where he’s run out of options for ejaculating inside you.

That’s why you need a backup plan.

The classic backup plan is for him to pull out and give himself an orgasm with his own hand, in bed – holding you with one hand, and holding his penis with the other.

Unfortunately, most men with DE have to sneak off to the bathroom by themselves to give themselves an orgasm after you fall asleep. But the bathroom can be a rather cold and lonely place.  Much better to have him do it in bed with you, where it’s all cozy and loving.  

In sex therapy, we call this “going to Haagen Dazs”:   Imagine you’re at a fine restaurant. The meal was wonderful, but they’re all out of dessert. Happily, there’s a Haagen Dazs right next door. 

It’s a fine way to end the meal, and they have loads of flavors to choose from.  All he needs is your acceptance that it’s okay.  

Unless, of course, his self-stimulating in bed next to you doesn’t feel okay for you. Hey, it’s a private matter. I’ve met lots of women who know intellectually it’s fine, but for whatever reason it bothers them or turns them off.  

If that’s the case, maybe consider having him self-stimulate almost to orgasm, then penetrate just before he comes, so he’ll still ejaculate inside you. Some sex positions are obviously better for this than others. 

Or perhaps it might be time to have another heart-to-heart talk with yourself, as in Item 5 above. 

That, or you could get some guidance from a professional . . .

10. How to get professional help for Delayed Ejaculation

To find competent professional help for DE, you have to know what you’re looking for.

Many couples affected by DE will first consult a primary care physician or a urologist – often prompted by an internet article listing all the possible physical causes of DE.  

But such physical causes turn out to be rather uncommon. The usual outcome is a referral to a sex therapist. 

But most sex therapists don’t have much experience treating men with DE. 

Lacking specific knowledge, a sex therapist may shift into “relational” mode and propose weekly psychotherapy, hoping that a deeper understanding of the couples’ issues will somehow help the man’s DE.  That’s mostly wishful thinking.

Most couples affected by DE don’t need psychotherapy – or even “sex therapy.”   

Remember, in most cases DE isn’t caused by psychological problems. The root cause of most men’s DE is simply a natural tendency to need more stimulation to climax. 

Most commonly, what a man with DE needs is to understand his specific requirements for reaching orgasm and why his current sexual practices aren’t working.  Plus a specific action plan for what to do differently.

In many cases, all of this can be accomplished in a single consultation session. 

My advice:  Interview a few sex therapists by phone. Ask how many men they’ve personally treated for DE.  Ask about their success rates.   

Most importantly, ask how long treatment typically takes.  

Look for a sex therapist who says, “The main thing is to get all the specific details. That usually doesn’t take too long.”

The post 10 Things To Consider If Your Man Can’t Ejaculate During Sex appeared first on Stephen Snyder MD.

Delayed Ejaculation vs Premature Ejaculation: Similarities & Differences in Approach

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.  

Similarity #1: Meet Your “Orgasm Threshold”

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.

Similarity #2: Born This Way

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.

Similarity #3: Your Orgasmic Range

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.

Difference #1: Boosting Arousal is Easier than Squelching It

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.

Difference #2: Raising Your Orgasm Threshold is Easier than Lowering It 

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.

Difference #3: DE, PE, and Your Partner’s Orgasmic Needs

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.  

Some Final Similarities Between DE and PE

One final thing DE and PE have in common . . . 

When it comes to evaluation and treatment, the same general recommendations apply:

1. Get help early on . . .

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. 

2. . . . from someone who knows these conditions well.

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. 

3. Ignore most of what you read online.

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.  

4. Remember, all sensible approaches are based on acceptance.

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.

The post Delayed Ejaculation vs Premature Ejaculation: Similarities & Differences in Approach appeared first on Stephen Snyder MD.

NYC Women’s Top 10 Sex Therapy Concerns

As a sex and relationship therapist in Manhattan, almost every working day for the last three decades, I’ve done something few men ever get to do:  I’ve listened to women tell me about their lives.

We men don’t usually cross gender lines in private conversation. But I highly recommend it. As I’ve written elsewhere, Freud’s famous unanswered question, “What does a woman want?”, isn’t so hard to answer if you just simply ask.  

Men and women still don’t understand each other very well. As an NYC sex therapist working mostly with heterosexual couples, I’ve seen first-hand the mischief that can cause. 

So in the hope of promoting better understanding, here’s my short list of the 10 women’s sex concerns I hear the most. 

1. Situational Loss of Desire

When I was a young sex therapist, a national study claimed to have discovered an epidemic of loss of sexual desire in adult American women, with roughly 40% reporting no desire at all.

This turned out to be both true and untrue. The figure 40% was more or less valid. But the implication – that there was something wrong with these women – was for the most part incorrect. 

In fact, a woman’s level of sexual desire is often simply a response to her life situation. I see many women in NYC lose desire simply because the partnered sex they’ve been having just isn’t very desirable.

The secrets to good sex are largely emotional. But many couples aren’t yet aware of this.

(If you’re one of them, you may want to look at Chapter 1 of my book, Love Worth Making – free pdf available here).

Sometimes a woman’s loss of sexual desire points to some other factor – such as physical exhaustion, body image concerns, painful sex, depression, sexual side effects of medications, or chronic marital unhappiness. Or, most commonly, lots of these factors in combination.

As a solution-focused NYC sex therapist working with over 2,500 individuals and couples, I’ve spent decades researching ways for women to reclaim desire. Desire problems can be simple or complex. It’s a good idea to make sure your therapist knows how to distinguish one from the other.      

2. Non-Situational Loss of Desire 

A good sex therapist should be able to help you address most of the psychological causes of low desire. But sex is both psychological and biological.

Many women have perfectly good sex for years, in perfectly good marriages, then hit a point where desire just seems to disappear – presumably for reasons that are at least in part biological. 

In my NYC sex therapy practice, this commonly happens after the birth of a child.  Often no specific cause can be found. 

Truth is, we understand very little yet about the biological underpinnings of desire. As a sex therapist, though, I’ve learned to pay close attention when a woman tells me, “Something’s been lost.”

For years, people have wondered whether the subtle biological changes that often accompany women’s life events might respond to biological treatments.

In 2015, the FDA approved the first such treatment – flibanserin, more commonly known as Addyi. 

Does Addyi work? Yes, in about half the women who try it.  It’s not a magic bullet. But as an NYC sex therapist who’s also an MD, I’ve seen Addyi and other biological treatments for loss of desire sometimes be a useful adjunct to sex therapy. 

Every woman is different. Often you don’t know in advance what’s going to work for whom.  

3. Mismatched Sexual Desire

In a perfect world, you’d each fill out a questionnaire before the first date. With questions like, “How important is sex to you? How many orgasms a week do you need to feel happy and fulfilled?” But many couples fall in love knowing nothing about each other in this regard. 

There’s a bell curve when it comes to desire, as with most human attributes. People on the high end of desire tend to use sex as an all-purpose tool to help regulate their emotions. For most folks on the low end, that makes no sense at all. 

Happily, there are good work-arounds. In my practice, I encourage couples to get specific about what they really need, in the moment.  Physical touch?  Reassurance?  An orgasm?  To feel desired? There are lots of ways to get these things, short of full-on sex.  

Achieving happiness as a mixed-desire couple is a bit of an art. I’ve spent decades helping couples honor each others’ sexual natures and avoid common mistakes that can get in the way.   

4. Not Feeling Desired

Most women assume men automatically want sex  – so when a man loses desire, it tends to be highly confusing.

Every day I get calls from women whose male partners have “gone missing in bed.”  Most often, it turns out he hasn’t lost desire at all. Often he’s simply become sexually avoidant. 

Male sexual avoidance is a growing problem these days. Maybe it’s related to men’s and women’s changing gender roles and expectations. 

Whatever the reason, once a man starts avoiding his female partner in bed, it often prompts vicious cycles of hurt and recrimination that can be hard to stop.  Best to have him seen quickly, before too much damage has been done.    

By the way, if you’re hoping to convince your man to get help, keep in mind that most men don’t like the word “therapy.” Better to call it a “consultation.”

If he still refuses to go, tell him you’re going for a consultation anyway. Tell him the longer he waits to come in, the more expensive it will be in the long run. That often gets the ball rolling.

5. Inability to Orgasm with a Partner, or Under Any Circumstances

Penis-vagina intercourse was never an efficient way for women to climax. Many heterosexual women have historically struggled to reach orgasm during partner sex. 

But great strides have been made lately in bringing the latest climax-enabling technologies to an eager public. I like to remind people that sex should be easy.  And with vibrators just getting better every year, there’s no reason getting an orgasm should ever again feel like work.

By the way, the best way to use a vibrator during partner sex is to control it with your own hand – just like when you’re by yourself.

Don’t worry about your partner feeling left out. Most men find female orgasms intensely erotic, no matter how they’re obtained.

Your chances of reaching orgasm will also most likely depend on how sexually aroused you are.  So before you start trying to climax, best to make sure you’re authentically turned on. 

If you’re someone who’s never had an orgasm under any circumstances – even by yourself – relax, you’re in good company.  In fact, there’s never been a better time to learn. Best to consult with a sex therapist who can introduce you to the most effective resources and techniques.     

See also:

The GOOP Interview:  Sex Therapist on Vibrators, Intimacy, and PleasureThe GOOP Podcast:  Why Sex Therapists Don’t Care About OrgasmsPsychologyToday: Two Roads to OrgasmPsychologyToday: Saying Yes to Female Orgasm6. Painful Sex

No, it’s not in your head. 

Most women have, at some point, experienced pain with intercourse. Many experience it on a consistent basis. Some tell their partners. Many don’t.

A number of common medical conditions can cause sexual pain – from endometriosis, to pelvic floor muscle dysfunction, to vulvar vestibular inflammation and Mast Cell Activation Syndrome (MCAS).  Proper diagnosis usually requires the input of a sexual pain specialist. Your general gynecologist may not have adequate training or experience. 

Women in New York City are lucky to have access to specialized sexual pain treatment that’s not available in many parts of the country.

I keep an active rolodex of specialists in the NYC area, collaborate with them as needed, and work with couples to keep their erotic connection alive during times when intercourse is simply not practical.

Fortunately, with state-of-the-art treatment, most women with sexual pain can now be helped.

7. Effects of Sexual and/or Psychological Trauma

I hear many NYC women describe feeling emotionally or physically numb during sex.  This often points to a past experience of sexual or emotional trauma. Trauma often has wide-ranging effects on a woman’s erotic life.

For one, trauma tends to distort how you think about sex. For example, thinking that sex is something you do for other people, not for you. 

Trauma also tends to affect how you think about yourself as a sexual person. For example, assuming you must have done something shameful or bad to make the trauma happen. 

Trauma also tends to produce automatic negative reactions, often when you least expect them.  During peak arousal, you can suddenly feel frozen, panicked, overwhelmed, or unreal. 

Automatic reactions can sometimes start at the most inopportune times – such as when you fall in love with someone wonderful, and life is looking good.  Very paradoxical. No one knows why. 

The traditional explanation is that you feel safe enough to confront painful memories. I’m not sure. As a sex therapist who sees a lot of people with trauma, I think sometimes it’s your unconscious paradoxically trying to make sure you don’t get too happy.

Talk therapy has its place in the treatment of trauma, but often it’s best to bring the body into the conversation as well.  Most often through dance, art, movement, or specialized treatment approaches such as Somatic Experiencing.

8. Infidelity

I frequently see couples whose sexual and emotional troubles have been quietly simmering for years until an episode of infidelity suddenly brings things to a boil. 

In the long run, most couples affected by infidelity do end up staying together, so it’s well worth the time and energy to do it right. 

Traditional accounts of infidelity often feature cheating husbands and betrayed wives. That made sense when women were economically dependent and punishments for female infidelity more severe. But recently, as women have more fully entered the workforce, there’s been more discussion of what happens when it’s the wife who’s unfaithful.      

As an NYC sex therapist, I’ve spent decades helping couples heal from infidelity. First, by being honest about what happened. Then, by being clear about what you each need in order to stay together.  

Infidelity ranks high on anyone’s list of the most severe stresses a relationship can sustain. Relationship guru Esther Perel famously likens it to finding out you have cancer. But with honesty, perseverance, and faith, many couples eventually move beyond infidelity to a better marriage than they had before.

9. Dealing with a Partner’s Neuro-Atypicality

Sooner or later, many women in heterosexual relationships come to the realization that their male partner’s mind works in unexpected ways. Maybe he has an astonishing ability to remember facts, but can’t remember a conversation you had an hour ago. Or he lacks the ability to put feelings into words, or has no idea people he’s talking to might be bored, or can focus so intently on something that he doesn’t hear you call his name. 

We mental health folks refer to such individuals as “non-neurotypical,” “neuro-atypical,” or just “atypical.”  Some turn out to have a mild form of Autism Spectrum Disorder (ASD).  Some have Attention-Deficit/Hyperactivity Disorder (ADHD) – often combined with ASD and/or OCD.  Others have forms of atypicality that science has yet to classify. 

Many women are neuro-atypical as well. But women ordinarily have more ability to “mask” atypicality, due to gender-related advantages in empathy and language ability. 

Neuro-atypical men, on the other hand, tend to be in “double jeopardy” from being both male and atypical.  As an NYC sex therapist, I see many, many atypical men brought in by their exasperated wives – and very few atypical women brought in by their exasperated husbands.

Neuro-atypicality in a male partner can have far-reaching consequences for a relationship – both in and out of the bedroom.  Often the first step is to realize his quirks are more neurological than psychological.  Once this is recognized, sex and relationship therapy with such couples can often be quite productive and rewarding. 

10. Trouble Finding a Good Partner

Why do women freeze their eggs?  No, it’s not to prioritize career over childbearing. Most women who freeze their eggs do so because they haven’t yet been able to find a good partner.  

For the first time in history, the majority of adult American women are unmarried. And no, it’s not from being “too picky.” Most single women I see have tried over and over again to find a workable compromise with men who were far from perfect.

The stark reality is it’s not easy to find someone whom you desire, who desires you back, and who’s truly ready for a life partnership.

Most women I see tend to work hard on themselves. Often too hard. Most men tend not to work hard enough. The results speak for themselves. Sure, things were simpler when we had less choice and stronger communities.  But I believe finding a good man has always been a bit of a challenge.

As a male therapist, I’ve seen enough young men in my practice to know the species very well.  And I’m often sought as a guide by single women trying to find a good man who’s also real, reliable, and ready.   

—

I hope the above survey gives you a sense of the wide range of sex and relationship issues confronted by women and their partners today. 

Being a sex and relationship therapist requires a diverse set of skills that can take a lifetime to master.  I’ve spent decades developing cost-effective, solution-focused approaches to the most important sex and relationship concerns faced by women and their partners. 

If you’re suffering from a sex or relationship issue in your life, contact me, and let’s discuss the best approach for your needs.

© Stephen Snyder MD   2024
New York City     

The post NYC Women’s Top 10 Sex Therapy Concerns appeared first on Stephen Snyder, MD.

NYC Women's Top 10 Sex Therapy Concerns

As a sex and relationship therapist in Manhattan, almost every working day for the last three decades, I’ve done something few men ever get to do:  I’ve listened to women tell me about their lives.

We men don’t usually cross gender lines in private conversation. But I highly recommend it. As I’ve written elsewhere, Freud’s famous unanswered question, “What does a woman want?”, isn’t so hard to answer if you just simply ask.  

Men and women still don’t understand each other very well. As an NYC sex therapist working mostly with heterosexual couples, I’ve seen first-hand the mischief that can cause. 

So in the hope of promoting better understanding, here’s my short list of the 10 women’s sex concerns I hear the most. 

1. Situational Loss of Desire

When I was a young sex therapist, a national study claimed to have discovered an epidemic of loss of sexual desire in adult American women, with roughly 40% reporting no desire at all.

This turned out to be both true and untrue. The figure 40% was more or less valid. But the implication – that there was something wrong with these women – was for the most part incorrect. 

In fact, a woman’s level of sexual desire is often simply a response to her life situation. I see many women in NYC lose desire simply because the partnered sex they’ve been having just isn’t very desirable.

The secrets to good sex are largely emotional. But many couples aren’t yet aware of this.

(If you’re one of them, you may want to look at Chapter 1 of my book, Love Worth Making – free pdf available here).

Sometimes a woman’s loss of sexual desire points to some other factor – such as physical exhaustion, body image concerns, painful sex, depression, sexual side effects of medications, or chronic marital unhappiness. Or, most commonly, lots of these factors in combination.

As a solution-focused NYC sex therapist working with over 2,500 individuals and couples, I’ve spent decades researching ways for women to reclaim desire. Desire problems can be simple or complex. It’s a good idea to make sure your therapist knows how to distinguish one from the other.      

2. Non-Situational Loss of Desire 

A good sex therapist should be able to help you address most of the psychological causes of low desire. But sex is both psychological and biological.

Many women have perfectly good sex for years, in perfectly good marriages, then hit a point where desire just seems to disappear – presumably for reasons that are at least in part biological. 

In my NYC sex therapy practice, this commonly happens after the birth of a child.  Often no specific cause can be found. 

Truth is, we understand very little yet about the biological underpinnings of desire. As a sex therapist, though, I’ve learned to pay close attention when a woman tells me, “Something’s been lost.”

For years, people have wondered whether the subtle biological changes that often accompany women’s life events might respond to biological treatments.

In 2015, the FDA approved the first such treatment – flibanserin, more commonly known as Addyi. 

Does Addyi work? Yes, in about half the women who try it.  It’s not a magic bullet. But as an NYC sex therapist who’s also an MD, I’ve seen Addyi and other biological treatments for loss of desire sometimes be a useful adjunct to sex therapy. 

Every woman is different. Often you don’t know in advance what’s going to work for whom.  

3. Mismatched Sexual Desire

In a perfect world, you’d each fill out a questionnaire before the first date. With questions like, “How important is sex to you? How many orgasms a week do you need to feel happy and fulfilled?” But many couples fall in love knowing nothing about each other in this regard. 

There’s a bell curve when it comes to desire, as with most human attributes. People on the high end of desire tend to use sex as an all-purpose tool to help regulate their emotions. For most folks on the low end, that makes no sense at all. 

Happily, there are good work-arounds. In my practice, I encourage couples to get specific about what they really need, in the moment.  Physical touch?  Reassurance?  An orgasm?  To feel desired? There are lots of ways to get these things, short of full-on sex.  

Achieving happiness as a mixed-desire couple is a bit of an art. I’ve spent decades helping couples honor each others’ sexual natures and avoid common mistakes that can get in the way.   

4. Not Feeling Desired

Most women assume men automatically want sex  – so when a man loses desire, it tends to be highly confusing.

Every day I get calls from women whose male partners have “gone missing in bed.”  Most often, it turns out he hasn’t lost desire at all. Often he’s simply become sexually avoidant. 

Male sexual avoidance is a growing problem these days. Maybe it’s related to men’s and women’s changing gender roles and expectations. 

Whatever the reason, once a man starts avoiding his female partner in bed, it often prompts vicious cycles of hurt and recrimination that can be hard to stop.  Best to have him seen quickly, before too much damage has been done.    

By the way, if you’re hoping to convince your man to get help, keep in mind that most men don’t like the word “therapy.” Better to call it a “consultation.”

If he still refuses to go, tell him you’re going for a consultation anyway. Tell him the longer he waits to come in, the more expensive it will be in the long run. That often gets the ball rolling.

5. Inability to Orgasm with a Partner, or Under Any Circumstances

Penis-vagina intercourse was never an efficient way for women to climax. Many heterosexual women have historically struggled to reach orgasm during partner sex. 

But great strides have been made lately in bringing the latest climax-enabling technologies to an eager public. I like to remind people that sex should be easy.  And with vibrators just getting better every year, there’s no reason getting an orgasm should ever again feel like work.

By the way, the best way to use a vibrator during partner sex is to control it with your own hand – just like when you’re by yourself.

Don’t worry about your partner feeling left out. Most men find female orgasms intensely erotic, no matter how they’re obtained.

Your chances of reaching orgasm will also most likely depend on how sexually aroused you are.  So before you start trying to climax, best to make sure you’re authentically turned on. 

If you’re someone who’s never had an orgasm under any circumstances – even by yourself – relax, you’re in good company.  In fact, there’s never been a better time to learn. Best to consult with a sex therapist who can introduce you to the most effective resources and techniques.     

See also:

The GOOP Interview:  Sex Therapist on Vibrators, Intimacy, and PleasureThe GOOP Podcast:  Why Sex Therapists Don’t Care About OrgasmsPsychologyToday: Two Roads to OrgasmPsychologyToday: Saying Yes to Female Orgasm6. Painful Sex

No, it’s not in your head. 

Most women have, at some point, experienced pain with intercourse. Many experience it on a consistent basis. Some tell their partners. Many don’t.

A number of common medical conditions can cause sexual pain – from endometriosis, to pelvic floor muscle dysfunction, to vulvar vestibular inflammation and Mast Cell Activation Syndrome (MCAS).  Proper diagnosis usually requires the input of a sexual pain specialist. Your general gynecologist may not have adequate training or experience. 

Women in New York City are lucky to have access to specialized sexual pain treatment that’s not available in many parts of the country.

I keep an active rolodex of specialists in the NYC area, collaborate with them as needed, and work with couples to keep their erotic connection alive during times when intercourse is simply not practical.

Fortunately, with state-of-the-art treatment, most women with sexual pain can now be helped.

7. Effects of Sexual and/or Psychological Trauma

I hear many NYC women describe feeling emotionally or physically numb during sex.  This often points to a past experience of sexual or emotional trauma. Trauma often has wide-ranging effects on a woman’s erotic life.

For one, trauma tends to distort how you think about sex. For example, thinking that sex is something you do for other people, not for you. 

Trauma also tends to affect how you think about yourself as a sexual person. For example, assuming you must have done something shameful or bad to make the trauma happen. 

Trauma also tends to produce automatic negative reactions, often when you least expect them.  During peak arousal, you can suddenly feel frozen, panicked, overwhelmed, or unreal. 

Automatic reactions can sometimes start at the most inopportune times – such as when you fall in love with someone wonderful, and life is looking good.  Very paradoxical. No one knows why. 

The traditional explanation is that you feel safe enough to confront painful memories. I’m not sure. As a sex therapist who sees a lot of people with trauma, I think sometimes it’s your unconscious paradoxically trying to make sure you don’t get too happy.

Talk therapy has its place in the treatment of trauma, but often it’s best to bring the body into the conversation as well.  Most often through dance, art, movement, or specialized treatment approaches such as Somatic Experiencing.

8. Infidelity

I frequently see couples whose sexual and emotional troubles have been quietly simmering for years until an episode of infidelity suddenly brings things to a boil. 

In the long run, most couples affected by infidelity do end up staying together, so it’s well worth the time and energy to do it right. 

Traditional accounts of infidelity often feature cheating husbands and betrayed wives. That made sense when women were economically dependent and punishments for female infidelity more severe. But recently, as women have more fully entered the workforce, there’s been more discussion of what happens when it’s the wife who’s unfaithful.      

As an NYC sex therapist, I’ve spent decades helping couples heal from infidelity. First, by being honest about what happened. Then, by being clear about what you each need in order to stay together.  

Infidelity ranks high on anyone’s list of the most severe stresses a relationship can sustain. Relationship guru Esther Perel famously likens it to finding out you have cancer. But with honesty, perseverance, and faith, many couples eventually move beyond infidelity to a better marriage than they had before.

9. Dealing with a Partner’s Neuro-Atypicality

Sooner or later, many women in heterosexual relationships come to the realization that their male partner’s mind works in unexpected ways. Maybe he has an astonishing ability to remember facts, but can’t remember a conversation you had an hour ago. Or he lacks the ability to put feelings into words, or has no idea people he’s talking to might be bored, or can focus so intently on something that he doesn’t hear you call his name. 

We mental health folks refer to such individuals as “non-neurotypical,” “neuro-atypical,” or just “atypical.”  Some turn out to have a mild form of Autism Spectrum Disorder (ASD).  Some have Attention-Deficit/Hyperactivity Disorder (ADHD) – often combined with ASD and/or OCD.  Others have forms of atypicality that science has yet to classify. 

Many women are neuro-atypical as well. But women ordinarily have more ability to “mask” atypicality, due to gender-related advantages in empathy and language ability. 

Neuro-atypical men, on the other hand, tend to be in “double jeopardy” from being both male and atypical.  As an NYC sex therapist, I see many, many atypical men brought in by their exasperated wives – and very few atypical women brought in by their exasperated husbands.

Neuro-atypicality in a male partner can have far-reaching consequences for a relationship – both in and out of the bedroom.  Often the first step is to realize his quirks are more neurological than psychological.  Once this is recognized, sex and relationship therapy with such couples can often be quite productive and rewarding. 

10. Trouble Finding a Good Partner

Why do women freeze their eggs?  No, it’s not to prioritize career over childbearing. Most women who freeze their eggs do so because they haven’t yet been able to find a good partner.  

For the first time in history, the majority of adult American women are unmarried. And no, it’s not from being “too picky.” Most single women I see have tried over and over again to find a workable compromise with men who were far from perfect.

The stark reality is it’s not easy to find someone whom you desire, who desires you back, and who’s truly ready for a life partnership.

Most women I see tend to work hard on themselves. Often too hard. Most men tend not to work hard enough. The results speak for themselves. Sure, things were simpler when we had less choice and stronger communities.  But I believe finding a good man has always been a bit of a challenge.

As a male therapist, I’ve seen enough young men in my practice to know the species very well.  And I’m often sought as a guide by single women trying to find a good man who’s also real, reliable, and ready.   

—

I hope the above survey gives you a sense of the wide range of sex and relationship issues confronted by women and their partners today. 

Being a sex and relationship therapist requires a diverse set of skills that can take a lifetime to master.  I’ve spent decades developing cost-effective, solution-focused approaches to the most important sex and relationship concerns faced by women and their partners. 

If you’re suffering from a sex or relationship issue in your life, contact me, and let’s discuss the best approach for your needs.

© Stephen Snyder MD   2024
New York City

The post NYC Women's Top 10 Sex Therapy Concerns appeared first on Stephen Snyder MD.

10 Biggest Male Sex Problems NYC Sex Therapist Sees in Manhattan

Doing sex therapy in NYC, you learn a lot about the sexual challenges men face. For 30+ years now as a Manhattan sex therapist, I’ve had a daily real-world education in what troubles NYC men in bed – and what to do about it. 

Here’s my short list of the Top 10 Male Sex Problems in NYC – below.  Any health care provider hoping to treat men’s sexual problems will need experience helping men with these ten concerns:

1. Erectile Dysfunction (ED)

Erectile Dysfunction is the most common reason men call me for sex therapy in NYC. Sometimes also the most urgent. Most men with acute ED are in serious distress and need to be seen quickly. There’s no precise female equivalent – except perhaps the discovery of an affair. 

ED is surprisingly easy to misdiagnose, if you’re not careful. Men with physical ED due to medical causes tend to lack rigidity in all situations – even on awakening.  Men with psychological ED, due purely to emotional causes, typically have intact rigidity on awakening and with self-stimulation.

In mixed ED, there’s a subtle degree of physical vulnerability that can range in expression depending on the situation. Mixed erectile dysfunction is often mistakenly diagnosed as purely psychological. This mistake can usually be avoided by taking a careful history. 

As a sex therapist in NYC who’s also an MD, I pride myself on being able to offer men with psychological or mixed ED integrated medical and psychological treatment under one roof

See also: ED and condom use 

2. Premature Ejaculation (PE)

PE is just as common as ED, but most men with PE suffer in silence. So do their partners.

Premature ejaculation is the source of untold misery in many marriages.

Myths about what causes premature ejaculation abound. Truth is, most men with serious PE simply have low orgasm thresholds.  Just like men with delayed ejaculation tend to have high thresholds.  In other words, whether you tend to climax quickly or not is largely a matter of having been born that way.

There’s a misconception that men with PE are “selfish.”  Hey, he got his orgasm, right?

Wrong. Most men with PE say it’s like taking a few bites of a meal, then having the plate whisked away and being force-fed dessert. Not so satisfying.

Trying hard not to ejaculate is not so satisfying either – since that usually means keeping yourself relatively un-aroused. Hardly a recipe for great sex.

So what’s a man to do? 

In my experience as a sex therapist, most men with lifelong serious PE who want to enjoy passionate lovemaking without worrying about ejaculating too soon need an assist from medication to raise their thresholds.

Prescribing for PE is a specialized art. Make sure you see an expert who knows how to do it safely and effectively, for minimum long-term risk. And who knows how to combine it with non-medical techniques as well.  

3. Men Who Have Difficulty Ejaculating

There’s a bit of a double standard when it comes to having finicky orgasms. Most educated 21st-century couples know you should never hassle a woman about whether she’s had an orgasm.  But when a male partner has trouble climaxing, women often get profoundly distressed.  Especially if he has trouble ejaculating during intercourse – which is often the case in men I see in my sex therapy practice in NYC. 

So-called Delayed Ejaculation (DE) used to be thought of as rare, but in my practice, it’s one of the most common conditions I see. Contrary to popular myth, it’s often highly treatable – often in just a few sessions.

Most DE is simply due to having a high orgasm threshold.  To get there, you just need to be very strongly aroused.  Just like most women with high orgasm thresholds.

Many men assume they’re strongly aroused just because they’re hard.  Big mistake.  Sex therapy for trouble ejaculating often starts with learning to recognize when you’re authentically turned on. 

4. Men with Loss of Desire / Sexual Avoidance

When a man in a committed relationship stops initiating sex, it’s often confusing for his partner – since male desire is popularly assumed to be automatic.  As a sex therapist in NYC, I frequently get distressed calls from women whose husbands have gone “missing in bed.” 

Causes vary widely – from low testosterone to pornography to depression. But lots of times the problem is sexual avoidance, rather than true lack of desire.  In particular, many men avoid sex because they’re worried they’re not going to be hard.  The most common cause of men going missing in bed is performance anxiety because of ED. 

Whatever the cause, couples tend to react in ways that just perpetuate the problem – something I discuss in detail in chapter 11 of my book, Love Worth Making. In fact, sexlessness itself can be self-perpetuating – so it’s best to intervene early. 

I try to set aside at least an hour and a half for a new individual or couple, to give me time to review all the medical and psychological possibilities. I’ll often try to see each partner alone as well.

Some men who’ve lost desire can be helped quickly. Others need more extensive help. Make sure your sex therapist knows how to tell one from the other. 

5. Men with Hypersexuality and Compulsive Sexuality  

Men’s libido varies. Like most human attributes, there’s a bell-curve. There’s also a host of factors that can affect desire.  Trauma, for example. Some men with traumatic backgrounds discover early that sex can soothe traumatic feelings.

I’m often asked my opinion on so-called “sex addiction.” As a sex therapist, I believe in not automatically viewing problem sex behavior through an addiction lens.  Many high-libido men tend to use sexual arousal and orgasm as an all-purpose coping strategy for any kind of emotional distress.

Every mind has its assets, its vulnerabilities, and its own particular relationship with sexuality.  Treatment of hypersexuality and compulsive sexuality can involve individual counseling, 12-step fellowships, internet-control apps, couples work, and even psychotropic medication. 

After decades of experience as a sex therapist in NYC,  I’ve learned it can take time, patience, and sometimes lots of trial and error to know what someone really needs.

6. Infidelity and Cyber-Infidelity     

Infidelity has been around a long time – at least since language evolved 50,000 or so years ago and people started using terms like “marriage” and “forsaking all others till death do us part.”

Language also for the first time permitted people to ask direct questions – like, “Who was that hominid I saw you with last night?” 

Your sexual mind doesn’t easily accept restrictions. As a sex therapist in NYC, I try to remind myself that sexually exclusive relationships have probably always been somewhat problematic.

Now of course there’s also “cyber-infidelity,” with varying opinions on whether porn use represents cheating.  In the next few years, we’ll no doubt confront the same question about relationships with AI-generated virtual partners. 

Most couples affected by infidelity still ultimately stay together.  Sex therapy post infidelity can be a complicated process – since in addition to dealing with the emotional fallout from having been betrayed, there’s also the challenge of identifying sexual and emotional needs that may have gone unmet for years.  Meeting these needs can go a long way to making fidelity feel worth the effort.     

7. Bisexual Men  

As a sex therapist, I see many men for whom same-sex attraction exists alongside opposite-sex attraction.  Many couples come for sex therapy looking for help distinguishing myth from reality about male bisexuality. 

Sophisticated research has been required to prove male bisexuality really exists, and that it’s not simply a way-station on the road to being gay. Nevertheless, male bisexuality is unfortunately still considered a third rail in most heterosexual relationships. Most bisexual men still keep it a secret from their partners, which often gives rise to shame and self-loathing.

Often, the biggest problem is the man’s having felt the need to keep his bisexuality a secret for so long.  Consultation with a sex therapist who knows the research can often be quite helpful for couples looking for reassurance and guidance in this situation. 

8. Other Variant Male Sexualities  

By early adulthood, most men’s erotic interests are more or less fixed in a fairly narrow pattern.  

In contrast to what’s known in the sex therapy field as female erotic plasticity or female sexual fluidity – where women’s sexual preferences can change over time – most adult men can tell you precisely what turns them on in a partner. It’s usually quite specific, and it tends not to change over time. 

At the extreme, some men have unusually narrow sexual interests. They’re exclusively turned on by women’s feet; or by very specific kinds of female bodies, very specific erotic scenarios, or any of a host of other fixed erotic tastes.  These variant interests can’t usually be changed.

Some, such as a preference for being sexually dominant, can be readily understood and accepted by partners – especially now that kink has gone mainstream. Others, such as an interest in being sexually submissive, tend to leave female partners confused and/or turned off.

In my sex therapy practice, men with a taste for dominance tend to have their pick of partners, while men with submissive tendencies often can’t get a date.

Sex therapy can be extremely useful for men with variant sexual interests and their partners – since understanding and accepting your sexual needs is fundamental for a sexually fulfilling relationship.

9. Neuro-Atypical Men

Psychology now recognizes that many men (and quite a few women as well) are “non-neurotypical” or “atypical,” in that their minds process information differently from most “neuro-typical” folks. The classic form is what used to be called Asperger’s Syndrome, now considered a variety of autism spectrum disorder (ASD).  

Neuro-atypical men often have challenges in partner relationships due to trouble understanding partners’ emotions. Some with “sensory processing differences” have trouble tolerating sexual sensations. For instance, a partner’s mouth or vagina can be experienced as “too wet.”  

Men with Attention-Deficit/Hyperactivity Disorder (ADHD) often struggle in relationships as well. Many find themselves the target of criticism in a way that echoes having been criticized as ADHD boys. Distractibility poses another problem, since good sex requires paying attention. 

Sex therapy where one or both partners are neuro-atypical can require special creativity and  “out of the box” thinking. If there’s a genuine commitment to understanding both people’s sexual needs, the prognosis for sexual happiness can be excellent.

See also: New York Magazine’s “The Cut” – Sex and ADHD    

10. Men with Social Anxiety, Size Anxiety, and Other Kinds of Performance Anxiety 

When a man first presents for sex therapy for ED, PE, DE, or some other sexual concern, I routinely screen for anxiety problems – since if you don’t address the underlying anxiety problem, treatment can get easily stalled.

The most common culprit is social anxiety, where anxiety is prompted by being the center of attention. For better or worse, during sex, you’re definitely the center of attention – so if you have social anxiety, sex can easily become a challenge. 

Social anxiety is a prime cause of male sexual avoidance, and can be a key factor in men who are “40-year-old virgins.”

As a sex therapist in NYC, I feel strongly that experience treating anxiety problems should be part of every sex therapist’s toolbox. I’ve seen hundreds of men who required both sex therapy and anxiety treatment to gain the confidence they needed – and I’m pleased to be able to offer both.

See also: The Atlantic:  On ‘Late’-in-Life Virginity Loss

As you can see from the list above, sex and relationship therapy for men covers a vast range of problems. Over 30+ years as a sex and relationship therapist in NYC, I’ve helped over 2,500 individuals and couples have better sex and more satisfying relationships – through cost-effective, solution-focused approaches that have taken me a lifetime to learn. 

If you’re suffering from a sex or relationship challenge, contact me, and let’s talk about how you can get the help you need. 

© Stephen Snyder MD 2024 New York City

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10 Biggest Male Sex Problems NYC Sex Therapist Sees in Manhattan

Doing sex therapy in NYC, you learn a lot about the sexual challenges men face. For 30+ years now as a Manhattan sex therapist, I’ve had a daily real-world education in what troubles NYC men in bed – and what to do about it. 

Here’s my short list of the Top 10 Male Sex Problems in NYC – below.  Any health care provider hoping to treat men’s sexual problems will need experience helping men with these ten concerns:

1. Erectile Dysfunction (ED)

Erectile Dysfunction is the most common reason men call me for sex therapy in NYC. Sometimes also the most urgent. Most men with acute ED are in serious distress and need to be seen quickly. There’s no precise female equivalent – except perhaps the discovery of an affair. 

ED is surprisingly easy to misdiagnose, if you’re not careful. Men with physical ED due to medical causes tend to lack rigidity in all situations – even on awakening.  Men with psychological ED, due purely to emotional causes, typically have intact rigidity on awakening and with self-stimulation.

In mixed ED, there’s a subtle degree of physical vulnerability that can range in expression depending on the situation. Mixed erectile dysfunction is often mistakenly diagnosed as purely psychological. This mistake can usually be avoided by taking a careful history. 

As a sex therapist in NYC who’s also an MD, I pride myself on being able to offer men with psychological or mixed ED integrated medical and psychological treatment under one roof

See also: ED and condom use 

2. Premature Ejaculation (PE)

PE is just as common as ED, but most men with PE suffer in silence. So do their partners.

Premature ejaculation is the source of untold misery in many marriages.

Myths about what causes premature ejaculation abound. Truth is, most men with serious PE simply have low orgasm thresholds.  Just like men with delayed ejaculation tend to have high thresholds.  In other words, whether you tend to climax quickly or not is largely a matter of having been born that way.

There’s a misconception that men with PE are “selfish.”  Hey, he got his orgasm, right?

Wrong. Most men with PE say it’s like taking a few bites of a meal, then having the plate whisked away and being force-fed dessert. Not so satisfying.

Trying hard not to ejaculate is not so satisfying either – since that usually means keeping yourself relatively un-aroused. Hardly a recipe for great sex.

So what’s a man to do? 

In my experience as a sex therapist, most men with lifelong serious PE who want to enjoy passionate lovemaking without worrying about ejaculating too soon need an assist from medication to raise their thresholds.

Prescribing for PE is a specialized art. Make sure you see an expert who knows how to do it safely and effectively, for minimum long-term risk. And who knows how to combine it with non-medical techniques as well.  

3. Men Who Have Difficulty Ejaculating

There’s a bit of a double standard when it comes to having finicky orgasms. Most educated 21st-century couples know you should never hassle a woman about whether she’s had an orgasm.  But when a male partner has trouble climaxing, women often get profoundly distressed.  Especially if he has trouble ejaculating during intercourse – which is often the case in men I see in my sex therapy practice in NYC. 

So-called Delayed Ejaculation (DE) used to be thought of as rare, but in my practice, it’s one of the most common conditions I see. Contrary to popular myth, it’s often highly treatable – often in just a few sessions.

Most DE is simply due to having a high orgasm threshold.  To get there, you just need to be very strongly aroused.  Just like most women with high orgasm thresholds.

Many men assume they’re strongly aroused just because they’re hard.  Big mistake.  Sex therapy for trouble ejaculating often starts with learning to recognize when you’re authentically turned on. 

4. Men with Loss of Desire / Sexual Avoidance

When a man in a committed relationship stops initiating sex, it’s often confusing for his partner – since male desire is popularly assumed to be automatic.  As a sex therapist in NYC, I frequently get distressed calls from women whose husbands have gone “missing in bed.” 

Causes vary widely – from low testosterone to pornography to depression. But lots of times the problem is sexual avoidance, rather than true lack of desire.  In particular, many men avoid sex because they’re worried they’re not going to be hard.  The most common cause of men going missing in bed is performance anxiety because of ED. 

Whatever the cause, couples tend to react in ways that just perpetuate the problem – something I discuss in detail in chapter 11 of my book, Love Worth Making. In fact, sexlessness itself can be self-perpetuating – so it’s best to intervene early. 

I try to set aside at least an hour and a half for a new individual or couple, to give me time to review all the medical and psychological possibilities. I’ll often try to see each partner alone as well.

Some men who’ve lost desire can be helped quickly. Others need more extensive help. Make sure your sex therapist knows how to tell one from the other. 

5. Men with Hypersexuality and Compulsive Sexuality  

Men’s libido varies. Like most human attributes, there’s a bell-curve. There’s also a host of factors that can affect desire.  Trauma, for example. Some men with traumatic backgrounds discover early that sex can soothe traumatic feelings.

I’m often asked my opinion on so-called “sex addiction.” As a sex therapist, I believe in not automatically viewing problem sex behavior through an addiction lens.  Many high-libido men tend to use sexual arousal and orgasm as an all-purpose coping strategy for any kind of emotional distress.

Every mind has its assets, its vulnerabilities, and its own particular relationship with sexuality.  Treatment of hypersexuality and compulsive sexuality can involve individual counseling, 12-step fellowships, internet-control apps, couples work, and even psychotropic medication. 

After decades of experience as a sex therapist in NYC,  I’ve learned it can take time, patience, and sometimes lots of trial and error to know what someone really needs.

6. Infidelity and Cyber-Infidelity     

Infidelity has been around a long time – at least since language evolved 50,000 or so years ago and people started using terms like “marriage” and “forsaking all others till death do us part.”

Language also for the first time permitted people to ask direct questions – like, “Who was that hominid I saw you with last night?” 

Your sexual mind doesn’t easily accept restrictions. As a sex therapist in NYC, I try to remind myself that sexually exclusive relationships have probably always been somewhat problematic.

Now of course there’s also “cyber-infidelity,” with varying opinions on whether porn use represents cheating.  In the next few years, we’ll no doubt confront the same question about relationships with AI-generated virtual partners. 

Most couples affected by infidelity still ultimately stay together.  Sex therapy post infidelity can be a complicated process – since in addition to dealing with the emotional fallout from having been betrayed, there’s also the challenge of identifying sexual and emotional needs that may have gone unmet for years.  Meeting these needs can go a long way to making fidelity feel worth the effort.     

7. Bisexual Men  

As a sex therapist, I see many men for whom same-sex attraction exists alongside opposite-sex attraction.  Many couples come for sex therapy looking for help distinguishing myth from reality about male bisexuality. 

Sophisticated research has been required to prove male bisexuality really exists, and that it’s not simply a way-station on the road to being gay. Nevertheless, male bisexuality is unfortunately still considered a third rail in most heterosexual relationships. Most bisexual men still keep it a secret from their partners, which often gives rise to shame and self-loathing.

Often, the biggest problem is the man’s having felt the need to keep his bisexuality a secret for so long.  Consultation with a sex therapist who knows the research can often be quite helpful for couples looking for reassurance and guidance in this situation. 

8. Other Variant Male Sexualities  

By early adulthood, most men’s erotic interests are more or less fixed in a fairly narrow pattern.  

In contrast to what’s known in the sex therapy field as female erotic plasticity or female sexual fluidity – where women’s sexual preferences can change over time – most adult men can tell you precisely what turns them on in a partner. It’s usually quite specific, and it tends not to change over time. 

At the extreme, some men have unusually narrow sexual interests. They’re exclusively turned on by women’s feet; or by very specific kinds of female bodies, very specific erotic scenarios, or any of a host of other fixed erotic tastes.  These variant interests can’t usually be changed.

Some, such as a preference for being sexually dominant, can be readily understood and accepted by partners – especially now that kink has gone mainstream. Others, such as an interest in being sexually submissive, tend to leave female partners confused and/or turned off.

In my sex therapy practice, men with a taste for dominance tend to have their pick of partners, while men with submissive tendencies often can’t get a date.

Sex therapy can be extremely useful for men with variant sexual interests and their partners – since understanding and accepting your sexual needs is fundamental for a sexually fulfilling relationship.

9. Neuro-Atypical Men

Psychology now recognizes that many men (and quite a few women as well) are “non-neurotypical” or “atypical,” in that their minds process information differently from most “neuro-typical” folks. The classic form is what used to be called Asperger’s Syndrome, now considered a variety of autism spectrum disorder (ASD).  

Neuro-atypical men often have challenges in partner relationships due to trouble understanding partners’ emotions. Some with “sensory processing differences” have trouble tolerating sexual sensations. For instance, a partner’s mouth or vagina can be experienced as “too wet.”  

Men with Attention-Deficit/Hyperactivity Disorder (ADHD) often struggle in relationships as well. Many find themselves the target of criticism in a way that echoes having been criticized as ADHD boys. Distractibility poses another problem, since good sex requires paying attention. 

Sex therapy where one or both partners are neuro-atypical can require special creativity and  “out of the box” thinking. If there’s a genuine commitment to understanding both people’s sexual needs, the prognosis for sexual happiness can be excellent.

See also: New York Magazine’s “The Cut” – Sex and ADHD    

10. Men with Social Anxiety, Size Anxiety, and Other Kinds of Performance Anxiety 

When a man first presents for sex therapy for ED, PE, DE, or some other sexual concern, I routinely screen for anxiety problems – since if you don’t address the underlying anxiety problem, treatment can get easily stalled.

The most common culprit is social anxiety, where anxiety is prompted by being the center of attention. For better or worse, during sex, you’re definitely the center of attention – so if you have social anxiety, sex can easily become a challenge. 

Social anxiety is a prime cause of male sexual avoidance, and can be a key factor in men who are “40-year-old virgins.”

As a sex therapist in NYC, I feel strongly that experience treating anxiety problems should be part of every sex therapist’s toolbox. I’ve seen hundreds of men who required both sex therapy and anxiety treatment to gain the confidence they needed – and I’m pleased to be able to offer both.

See also: The Atlantic:  On ‘Late’-in-Life Virginity Loss

As you can see from the list above, sex and relationship therapy for men covers a vast range of problems. Over 30+ years as a sex and relationship therapist in NYC, I’ve helped over 2,500 individuals and couples have better sex and more satisfying relationships – through cost-effective, solution-focused approaches that have taken me a lifetime to learn. 

If you’re suffering from a sex or relationship challenge, contact me, and let’s talk about how you can get the help you need. 

© Stephen Snyder MD 2024 New York City

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Is TeleHealth Sex & Relationship Therapy Effective? 7 Ways it Might Be Better

I recently attended a Zoom meeting with 20+ other New York City sex and relationship therapists on the subject of how online counseling, or “TeleHealth,” has transformed their practices. Some of what I heard surprised me.

Many said they missed seeing their clients in person, and that TeleHealth therapy was harder and took more energy. Those were things I’d expected to hear.

Surprisingly, though, many colleagues reported that they actually liked doing TeleHealth therapy. Some said they expected to hate it, but found it unexpectedly interesting and full of creative possibilities.

I’ve been doing TeleHealth somewhat longer than the average sex and relationship therapist. So I felt I understood both the negative feelings and the positive ones.

TeleHealth therapy is different from traditional in-office therapy.

It’s also typically harder to do, at least for the therapist.

But hey, that’s true of lots of innovations in health care. After all, it’s harder to do endoscopic surgery than the traditional kind. But way easier for the patient, and in the long run that’s what counts.

I believe there are at least seven specific advantages to TeleHealth therapy for sex and relationship problems.

Let’s start with the most obvious:

1. TeleHealth Sex and Relationship Therapy Can be More Private

 

Most obviously, there’s no physical waiting room. There’s no possibility of anyone else seeing you, or gawking at you, or sitting there wondering what your specific problems might be. Big improvement, privacy-wise.

On the other hand, if you’re quarantining at home with others, you might not have as much privacy in the actual session. As my colleague Dr. Daniel Watter notes, “Patients are aware of family members walking around, concerned that they might be overheard, sometimes even not wanting family members to know they’re in therapy.”

During the recent Covid-19 pandemic, both Dr Watter and I spent a fair amount of time with clients phoning in from their cars—which was the only place they could find under the circumstances.

If you don’t have access to a car or an office, air-pods can do a lot to reduce the sounds of therapy. And for ultra-private details, there’s always text-messaging, which is now included on some HIPAA-compliant TeleHealth platforms.

 

2. TeleHealth Sex and Relationship Therapy Can Eliminate Geographic Boundaries to Good Care

 

Most places simply don’t have enough fully-trained sex therapists, so seeing a good sex therapist can easily mean having to travel long distances—or its New York City equivalent, expensive parking or multiple subway line transfers. TeleHealth sex and relationship counseling eliminates all these problems with a click of the mouse.

As my colleague Dr. Bat-Sheva Marcus at Maze Women’s Sexual Health notes, “On-line therapy offers patients unprecedented access to a wide variety of therapists. You can find specialists in a very focused field and choose a therapist who’s a perfect fit rather than just someone convenient.”

There are downsides to everything, though. And one downside to the spread of TeleHealth is that there are now well-financed “therapy companies” investing large sums to advertise online. Like any business, these companies need to squeeze the most value from every dollar they spend. So they may rely on relatively inexperienced or less successful therapists to do the direct service.

Buyer beware.

 

3. TeleHealth Sex and Relationship Therapy Takes Place in a More Natural Setting

Think of it as the 21st Century equivalent of the doctor’s house call.

TeleHealth counseling means finally getting to see your clients in their natural environment. True, there’s lots of clinical information lost. As a practitioner, you lose access to many non-verbal cues when you only see clients as “talking heads” on a screen. But what you lose in access to body language, you occasionally make up for in greater awareness of the setting.

As a sex and relationship therapist, I find it valuable to see how my clients’ homes are arranged—particularly their bedrooms—and to witness the distractions they have to contend with. Like children and pets.

Children and pets are second only to TV and electronics as obstacles to lovemaking.

 

4. TeleHealth Sex and Relationship Therapy Can Give Clients More Power

 

In sports this is known as “the home field advantage.”

With TeleHealth, the client has the home field advantage. You’re granting me entrance to your space, rather than the other way around.

The shift in power can be dramatic. When I’ve asked clients in traditional office-based therapy to describe what it felt like when they first arrived at my office, they often tell me that even before we met, when they were just sitting in my waiting room, they felt anxious and worried that I might judge or criticize them.

TeleHealth doesn’t eliminate this kind of anxiety, but it mutes it. The client is more in control. This can be a very positive change, since worrying you’re going to be judged or criticized is as big an impediment to good communication in therapy as it is in real life.

 

5. TeleHealth Sex and Relationship Therapy Can Help Empower People in Relationships

 

One practical advantage of TeleHealth for couples is that the two of you don’t have to be in the same room together. One of you can be in their office in Midtown Manhattan, the other can be on a business trip out-of-town, and I can connect you together from my office on the Upper West Side via 3-way video.

The first time I tried doing this, I was worried there wouldn’t be enough feeling of “togetherness” for it to work. But the session was unexpectedly productive. I struggled to understand why.

In the years that followed, I’ve noted this phenomenon over and over: A couple gets more productive work done in couples therapy when they’re physically separated than when they’re together in the same room.

The answer, as I’ve written elsewhere, is that most couples suffer not from being too separate, but from being too merged together. When couples occupy the same space, they adjust to each other in tiny ways, each sacrificing a bit of their self-hood, and the relationship is diminished as a result.

Three-way TeleHealth sessions can sometimes help a couple “differentiate” more fully. Relieved of the need to adjust to each other, they can speak with greater authority as individuals. This can feel like opening a window to let in fresh air.

 

6. TeleHealth Sex and Relationship Therapy Can Be More Collaborative

TeleHealth, by reducing the power disparity between therapist and patient, can make therapy much more of a collaborative effort. This enhances motivation, reduces dependency, and empowers clients as partners in learning and exploration.

I often encourage clients to audio-record sessions, since many clients have trouble remembering details of what we talked about. But recordings take time to listen to afterwards. If the matter is particularly complicated—as often occurs in sex and relationship therapy—I’ll often spend a few minutes at the end of the session typing out detailed notes, so we can all remember everything.

With TeleHealth, we can take this to the next level: I can create a document on Google Drive, share it with the individual or couple on my screen, and we can make notes  together during the session. They can actually see me typing, rather than having to wait to get my notes later.

A few decades ago, so-called Cognitive Therapists would assign clients to fill out worksheets, noting their negative thoughts and critiquing them. On Google Drive, a therapist and client can now do this work on split-screen in real time, working collaboratively online while talking face to face.

 

7. TeleHealth Sex and Relationship Therapy Can Be More Creative

Take away the physical constraints of the office, the waiting room, and the need to physically transport yourself to a particular location, and therapy can get much more creative.

With TeleHealth sessions, it’s not necessary to decide in advance whether you’re going to see a couple individually or separately. If I’m conducting a couple’s session and it feels like I need to confer separately with each individual for a few minutes, that’s easily done.

There’s more room in TeleHealth for medical creativity as well. As an MD sex therapist, I often do sexual medicine evaluations for men and women whose sex problems involve a combination of biological and psychological factors. With TeleHealth, I can put everything about a patient on my desktop at once, with their medication list in one window, my cumulative office notes in another, and our live video discussion in a third window.

It’s much easier to be “present” when you’re seeing everything at once, and not wasting time rummaging around in your files for important data.

 

The Future of TeleHealth Sex and Relationship Therapy in the 21st Century

 

That being said, there’s something about the seclusion of the traditional office therapy setting, and the reassurance of having a trusted listener physically present in the room, that may be impossible to reproduce online. Only time will tell, though, how much this difference is real—and how much it’s simply the comfort of what’s familiar.

To quote Dr Marcus again, “TeleHealth therapy may not be exactly as helpful or productive as an in-person consult, but with a sensitive and savvy clinician it can be pretty darn close.”

The way we communicate with our healthcare providers has changed dramatically since the advent of broadband and the smartphone. It’s now less authoritarian. More democratic.

Sex and relationship therapy too is becoming more democratic, more collaborative, and less limited by conventional modes of practice. I have decades of experience in my field. But my patients have access to the entire internet, and they frequently find interesting things online that I didn’t know about.

TeleHealth is simply another way for people to take greater responsibility for their health care. These days, the so-called “internet of things” allows patients to take much more charge of the data they share. Blood pressure readings, electrocardiographic rhythms, photos of skin lesions and sore throats, and sleep recordings can now all be up-loaded to your primary care doctor.

As a sex and relationship therapist, I have high hopes for this powerful new technology. And I can’t wait to see what our field will do with it in the years ahead.

 

© Stephen Snyder MD   2020    New York City

 

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What Causes Premature Ejaculation?

Part 2 of a new three-part series for men with premature ejaculation and their partners, on contemporary issues in the understanding and treatment of PE.

See also:

Toward a New Definition of Premature Ejaculation

Eight Ways for Men with Premature Ejaculation to Last Longer in Bed

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As a sex therapist, the first thing you notice on googling “causes of premature ejaculation” is  that much of what’s written online is highly questionable.

In fact, a great deal of it is pure nonsense.

Even highly respectable medical sites seem to lose their minds when it comes to the causes of premature ejaculation. Some tend to repeat long-debunked ideas, such as that PE “can often be traced back to early trauma,” or that it’s “caused by strict sexual upbringing.”

My absolute favorite was the site that attributed premature ejaculation to “overexcitement or too much stimulation.” (As if there were some other more preferred kind of sex, that wasn’t so darn stimulating!)

But here’s the kicker:

Not one of the leading medical information sites on page one of Google mentions the totally obvious thing that’s responsible for most cases of premature ejaculation that we sex therapists see every day.

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Two kinds of causes of premature ejaculation

What you’d never know from reading Google, is that there are roughly two big categories of men who present for treatment of premature ejaculation.

The less common kind are men who used to have reasonable ejaculatory control, but then something happened to make them lose their control, and now they find themselves ejaculating too quickly.

The cause is often medical. Most commonly, this “acquired premature ejaculation,” as it’s called, is accompanied by erectile dysfunction (ED).

Treating the man’s ED often helps resolve his premature ejaculation as well.

Other causes of acquired premature ejaculation have been reported, such as inflammation of the prostate, hyperthyroidism, or withdrawal from certain recreational or prescription drugs. But these seem to be rarer.

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The most common cause of premature ejaculation

Now let’s talk about the other category of men who suffer from PE, so-called “lifelong premature ejaculation.”  This other category is much more common, at least in my office.

Men with lifelong premature ejaculation report that they’ve always ejaculated extremely easily—starting with their earliest experience of partner sex.

The striking thing about most men with lifelong premature ejaculation is that they seem otherwise to be perfectly fine.

Most of them have no medical or psychiatric illness. And contrary to what you might expect from reading Google, a great many of them seem to have had perfectly normal, sex-positive upbringings.

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If you ask these men what caused their premature ejaculation, most of them will tell you they just seem to have been born that way. Research seems to support this idea. There’s even some evidence that PE can run in families.

For some reason, though, you rarely see “born that way” on a list of causes of premature ejaculation on the leading medical sites on Google.

Why not? Simple. These sites are oriented towards the detection and treatment of disease. And there’s very little evidence that lifelong premature ejaculation is a disease.

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If lifelong premature ejaculation is not a disease, then what causes it?  

Simply put, most cases of lifelong premature ejaculation seem to be the due to natural human variation in how easy or hard it is to climax.

As we’ve discussed elsewhere, an orgasm is simply a reflex. And all reflexes work the same way. Sensory inputs, once they reach a certain threshold of intensity, cause neurons to fire to make some set of muscles somewhere contract. 

That’s true whether we’re talking about your knee-jerk reflex, your sneeze reflex, your orgasm reflex, or any of the other thousands of reflexes in your body.

In the case of the orgasm reflex, the relevant sensory inputs are both physical and psychological. But the principle is the same. Once these inputs reach a particular level—what we call your “orgasm threshold”—the reflex simply “happens.”

Think of your orgasm threshold as a number, from 1-100. There’s lots of variation in people’s orgasm thresholds. As just about everyone knows, if they’ve had more than one sex partner in their life.

Let’s say the average woman has an orgasm threshold of 60. But some women’s orgasm threshold will be only 40—in which case they’ll tend to climax easily and often. And some women, just from simple statistics, will have an orgasm threshold of 80—in which case if she wants to reliably climax during partner sex, she’ll probably need a good vibrator.

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Premature ejaculation is just a variant of normal.

Now let’s talk about men.

Let’s say the average man has an orgasm threshold of around 40. But there are some guys—not many, but some—who clock in around 80. You see guys like this in porn, thrusting away forever, never worrying they’re going to ejaculate too soon, and finally finishing themselves off by hand.

When men like this come to see me for treatment, it’s usually to help them figure out how to ejaculate inside a vagina.

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At the other end of the bell curve, some men have natural orgasm thresholds as low as 30. The minute a man like this gets hard, he’ll be vulnerable to ejaculating too quickly. 

In a nutshell, that’s the most common cause of “lifelong premature ejaculation. Nothing more than natural statistical variation.

Like women who can’t climax without a vibrator, these men just happen to be on the way far-end of their gender-specific bell curve.

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Myths about what causes premature ejaculation

 

Now that you know what causes most cases of premature ejaculation, we can go ahead and dispel some popular myths.

Here are the three most common:

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Myth #1:  Men with premature ejaculation are selfish.

It’s easy to see how this myth got started, since by definition a man with premature ejaculation does reach climax quickly and consistently.

But if you ask most men with PE, they’ll tell you their premature orgasms aren’t very satisfying at all.

Why? Simple: Male or female, straight or gay, the quality of your orgasm is mostly dependent on the quality and duration of the arousal leading up to it.

As I write in Chapter 6 of my book, Love Worth Making, we sex therapists tend to think of sex as like a good meal: appetizers, main course, dessert.

A man with PE sits down to eat, has a few bites of salad and a piece of a roll, then all of a sudden they whisk everything away, bring him dessert, and hand him the check.

Poor guy, he’s still hungry.

Most men with very low orgasm thresholds have never had a really good orgasm in their life.

Sad but true.

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Myth #2:  Men with premature ejaculation are lazy.

According to this myth, premature ejaculation is very easy to treat by simple psychological means. All that’s needed is some simple training in “stop/start.” If a man hasn’t overcome his premature ejaculation by this method, then he must be too lazy.

In fact, premature ejaculation is not at all easy to treat by psychological means. Most men with PE desperately want to last longer in bed. Many  go to extraordinary lengths to suppress their arousal.

As we discussed in the previous article in this series, none of these techniques — from stop/start, to numbing creams, to thinking about zombies — ever lead to really good sex.

As a sex therapist, I have a hard time understanding how so many otherwise reputable authors can claim that stop/start cures premature ejaculation.

I wonder if it’s because most of them have never tried to hold back an orgasm.

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Myth #3:  Men with premature ejaculation are immature.

According to this myth, the orgasm reflex is like the urination reflex. And men with prematurity are like children who never learned to hold their urine. They’re simply immature.

In fact, this analogy makes no sense.

We’re designed to overcome the urination reflex. Children don’t have to struggle to hold back their urine. Urinary control happens naturally, once their developing nervous systems are capable of it.

We’re not designed to overcome the orgasm reflex. In fact, the orgasm reflex is actually more like the sneeze reflex.

No one expects you to learn not to sneeze. Chances are, you couldn’t if you tried.

And if there’s lots of pepper in the air, no one thinks you’re immature if you’re the first person to sneeze out loud.

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Can understanding the root cause of premature ejaculation help guide treatment?

Yes, absolutely. If low orgasm thresholds are the root cause of most premature ejaculation, we’d naturally want to look for ways for men with low thresholds to raise them higher.

Since Prozac become popular in the late 1980’s, it’s been known that virtually all members of the so-called “serotonin reuptake inhibitor” (SRI) class of medications have the potential to raise orgasm thresholds. This is a predictable, dose-related side effect.

No SRI is currently approved for treatment of premature ejaculation in the United States. As a result, SRI treatment for PE in the US is still “off-label,” meaning it requires informed consent.

We sexual medicine practitioners have been prescribing these medications off-label here for decades, sometimes with life-changing results.

They’re not a panacea. But combined with the right psychological techniques, medication for PE can make a real difference in a couple’s erotic life.

What’s more, psychological techniques often work much better once a man’s orgasm threshold gets high enough for him to experience greater sexual arousal without ejaculating.

In Part Three of this series, we’ll discuss how this works, in greater detail.

Stay tuned.

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Parts of this article have been adapted from Love Worth Making: How to Have Ridiculously Great Sex in a Long-Lasting Relationship by Stephen Snyder, M.D. Copyright © 2018 by the author and reprinted with permission of St. Martin’s Press, LLC.

Medical Disclaimer
All content here is for informational purposes only. Please consult a licensed mental health professional for all individual questions and issues.

 

The post What Causes Premature Ejaculation? appeared first on Stephen Snyder, MD.

Eight Ways for Men with Premature Ejaculation to Last Longer in Bed

Part 3 of a new three-part series, for men with premature ejaculation and their partners, on contemporary issues in the understanding and treatment of PE.

See also:

Toward a New Definition of Premature Ejaculation

What Causes Premature Ejaculation?

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How can men with PE learn to last longer in bed?

As we discussed in Part Two of this series, when a man can’t last very long in bed, most often that’s just due to how he’s wired.

Most men with “lifelong premature ejaculation” seem to have what we call “low orgasm thresholds,” where it doesn’t take much stimulation to activate their orgasm reflex.

There’s a bell-curve for orgasm thresholds. Most men who can’t last more than a minute during intercourse just happen to be have been born on the extreme low end of the bell-curve.

In a way, men with premature ejaculation are similar to that other classic bell-curve outlier, the woman with an extremely high orgasm threshold, who can’t climax unless she has complete quiet and half an hour with her vibrator.

Both represent extremes of common gender-based tendencies. In both cases, it’s ultimately all about the thresholds.

 

Eight ways for men with premature ejaculation to last longer in bed

In Part One of this series on premature ejaculation, we looked at some new ideas for defining premature ejaculation.

In Part Two, we looked at what causes it.

Now in Part Three, we’re going to discuss options for managing this condition.

In what follows below, I’m going to start with the most common practical work-arounds that men with premature ejaculation tend to try on their own (#’s 1-5, below). Then we’ll discuss the major techniques recommended by sexuality professionals (#’s 6-8, below).

Ready? Okay, let’s take a look at all the options available today for men with PE who want to last longer in bed:

#1:  How to last longer in bed by making sure your partner comes first

 

This method was made famous by my colleague Ian Kerner in his book She Comes First, which is basically a guide to cunnilingus. Here’s how it goes:

Let’s say you tend to climax immediately on penetration, but your partner needs a half hour of serious clitoral stimulation to make an orgasm happen.

Kerner solves the problem by re-branding cunnilingus as not foreplay but “coreplay.”

In other words, it’s the main event.

Here’s the technique: She comes first, after the requisite half hour of vigorous cunnilingus. Then you climb on top, enter her, ejaculate immediately, and Voilà . . . near-simultaneous orgasms.

Nice, huh? Well, that’s assuming you both just love cunnilingus. Not everyone does.

Instead, some men just finger their partner to stimulate her to orgasm. Unlike the tongue, though, fingers and hands tend to get tired.

Often a good vibrator is called for. Some couples find this works well.

But the only reason he lasts longer is by keeping his penis out of the action until the very end. If she really loves intercourse, she might miss getting more of it, even if she gets an orgasm every time.

Let’s look at the pros and cons of this method, overall:

Pros:

Acceptance of his tendency to be premature.Great for her, if she’s honestly not that crazy about intercourse. Some women just aren’t. (Hint: best to ask)]

Cons:

Not so great, if what she really craves is a “blended orgasm” with you inside her. (Again, best to ask)The classic cunnilingus version of this technique lacks face-to-face contact, except at the end, and it only works if you both love cunnilingus.The “fingering” version of this technique can tend to cause hand fatigue.#2:  How to last longer in bed by making sure there’s a second round

 

Couples who use this technique will specifically plan on him ejaculating right away.

They’ll do penetration fairly early in foreplay, as a quick appetizer. Then after he climaxes, they’ll settle down in bed together, talk, snuggle and enjoy each other’s company until he gets hard again—at which time they’ll go for Round Two.

Most men with premature ejaculation will last longer in Round Two. Mostly because by that point they’re less intensely excited.

As a sex therapist, I’m skeptical of anything that relies on you being less excited. I mean, why have sex at all, unless it’s to enjoy being as excited as possible?

You may remember we discussed this issue at length in Part One of this series, where we referred to this kind of thing as “Arousal Reduction” or AR. Arousal Reduction is at the heart of most traditional work-arounds for premature ejaculation.

Unfortunately, Arousal Reduction by definition means less exciting sex. Many men with PE who need a Round Two say they regret never really being able to enjoy hot sex fueled by full-throated desire.

Some men will do Round One all by themselves, then do Round Two later with their partner. But that’s like showing up at the restaurant, having already eaten. Hardly an ideal solution.

Let’s look at the pros and cons of trying to last longer in bed by waiting for Round Two:

 

Pros: 

No performance demand on him in Round One.Full acceptance of his inability to delay ejaculation.

Cons:

Not all men with premature ejaculation actually last longer in Round Two.Not suitable for quickie sex, since requires two rounds.Works best for younger men. Few others have the time and energy for it.Relies too much on “Arousal Reduction (AR)” as explained above.

 

#3:  How to last longer in bed by reducing physical sensation

 

There are lots of variations on this theme, but the basic idea is the same.

Sexual excitement, roughly speaking, consists of physical plus psychological stimulation—“friction plus fantasy,” if you will.

Reduce the physical sensation, and you’ve removed half the problem. Now it’s much easier to stay below what’s called your orgasm threshold.

The classic way to last longer by reducing sensation is to use a condom. Other popular methods involve numbing the penis with local anesthetic: sprays, wipes, creams, etc.

These all work by the principle of Arousal Recuction (AR), as we discussed above. Who else but a man with premature ejaculation would ever try to have less exciting sex?

One interesting variation on this theme, which I’d still classify as AR, is what’s called “coital alignment technique.”  Here’s how it’s done:

Place your penis as deep inside her vagina as you can. Only the outermost part of her vagina has muscles capable of gripping your penis tightly. If you keep your penis deep inside her, the sensitive head of your penis stays far away from the tighter outermost part of her vagina.

If you press your pelvis firmly up against hers, she can now grind against your body to stimulate her own clitoris. Lots of good clitoral stimulation for her, but your penis remains near-motionless inside her, minimizing physical stimulation for you.

Condoms, creams, sprays, wipes, and coital alignment all have in common that they seek to minimize physical sensation. Let’s look at the pros and cons of trying to last longer in bed by such means:

Pros:

Condoms also help prevent STI’s.

Cons:

Creams, sprays, and wipes aren’t most couples’ romantic ideal.All these techniques rely on Arousal Reduction (AR).

 

#4:  How to last longer in bed by reducing psychological excitement

 

Sexual arousal keeps you in the moment. If you take yourself out of the moment, your arousal will probably drop. You might last longer, but it’s not going to be very memorable sex.

There are lots of way take yourself out of the moment, by distracting yourself and  thinking about something else entirely. Some guys try to last longer by thinking of irrelevant stuff. (How many state capitals can you name?)

More commonly, a man might make himself think of something negative or unpleasant, to turn himself off. His least favorite elementary school teacher, for example.

Other techniques include avoiding sex positions that you find especially exciting. Or avoiding partners who you find especially exciting.

Understandable, as accommodations to a low arousal threshold. But clearly dismal, as strategies for lovemaking.

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Oh, and one more thing:

Partners tend to hate these techniques most of all. I mean, how would you want to have sex with someone while they’re thinking about their least favorite teacher?

After all, it’s not just about how long intercourse lasts. It’s also about whether you’re emotionally present with your partner, or just doing multiplication tables in your head.

Here’s my run-down of the pros and cons of trying to last longer in bed by reducing your level of psychological excitement:

 

Pros:

Unlike numbing creams and sprays, you can do this on a moment’s notice, any time you like.

Cons:

Doesn’t usually work very well.Do you really want your mind to automatically start associating sexual intercourse with memories of your least favorite teacher?You’re mentally “off someplace else.” which might irritate your partner.Even if it doesn’t, it’s not likely to be much of a bonding experience for the two of you.

 

#5:  How to last longer in bed by ingesting alcohol or other substances

 

Men with premature ejaculation have historically used a wide range of psycho-active substances to last longer in bed.

Some addicts report that heroin is remarkably effective for premature ejaculation. (Heroin withdrawal can produce the opposite effect).  The milder opioid tramadol (which also has serotonin-enhancing effects in the central nervous system) has been shown effective for PE in research studies.

Occasionally men also report good results with certain strains of cannabis.

But by far the most widely used recreational drug for premature ejaculation is alcohol.

Pros: 

Easily available and socially acceptable (alcohol).Useful for relaxation—especially if you’re anxious.

Cons:

Risk of sedation, including falling asleep before or during lovemaking.Risk of not remembering much the next morning.Risk of addiction.Not the greatest idea, if you have an early start time in the office the next day.Need to avoid driving home afterwards.Can be tricky sometimes to get the dose just right—especially if you’re with a new partner and you’re not sure exactly when sex is going to happen.

 

#6:  Learning to last longer in bed with sex therapy

 

Sex therapy, as originally developed by Masters and Johnson in the 1960’s, had two techniques for treating premature ejaculation: “sensate focus” and “start-stop.”

“Sensate focus” was what we’d now call a “mindfulness” practice. Intercourse was forbidden at first. Instead, you’d spend time touching your partner or being touched by them, just paying quiet attention to your sensations in the moment.

Many couples liked the easy sensuality of sensate focus. And the absence of any pressure to have intercourse often felt like a relief. But sensate focus by itself didn’t necessarily help men with premature ejaculation last longer in bed.

The second technique, “start-stop,” was specifically intended to help a man with PE last longer. Building on the mindful self-observation habits he’d learned through sensate focus, he would carefully note his level of arousal, and stop when he felt the earliest sign of an impending orgasm—then resume stimulation once the feeling passed.

A man with PE would practice this first by himself, until he was confident enough to attempt it during partner sex.

Many sex therapists still recommend sensate focus and start-stop for men with premature ejaculation who want to last longer in bed. But I routinely see men who’ve tried these techniques and been discouraged by the results.

Here’s my run-down of the pros and cons of traditional sex therapy for PE:

 

Pros:

Improved communicationLearning to more carefully observe your own arousalSlower pace of lovemakingLess focus on intercourse

Cons:

Highly controlled, which many couples experience as “too clinical”Often doesn’t translate well into spontaneous, passionate sexCost can be prohibitive, since treatment often requires ongoing sessionsOften ineffective for PE, especially if severeStop/start automatically involves Arousal Reduction (AR), as discussed above,  since stimulation has to stop as soon as arousal starts to climb to orgasm.

 

#7:  How to last longer in bed by taking medication to raise your orgasm threshold

 

When Prozac, the first FDA-approved “selective serotonin reuptake inhibitor” (or SRI for short), came on the market in the late 1980’s, many women taking this drug for the first time noticed they couldn’t orgasm.

The reason soon became clear: SRI’s tend to raise orgasm thresholds. And once this was recognized, it didn’t take long for researchers to wonder whether SRI’s might help men with PE last longer in bed.

During the first decade and a half after Prozac came on the market, I counted over 30 published medical papers documenting the effectiveness of SRI’s for PE.

Not just Prozac, but also sertaline/Zoloft, paroxetine/Paxil, and citalopram/Celexa. I’ve seen it work with the NSRI’s (venlafaxine/Effexor, duloxetine/Cymbalta) as well.

None of these medications has even been FDA-approved for premature ejaculation, so in the US their use for PE is still what’s called “off-label,” meaning it requires informed consent.

I’ve treated hundreds of men with SRI’s for premature ejaculation. Many have been among my most grateful patients.

Like any medication, off-label treatment of PE with SRI’s (and other medications that are occasionally useful) involves weighing potential risks vs benefits. That’s why it’s necessary to get a thorough evaluation first—ideally by an MD who specializes in sexual medicine—and only to take medication for PE under a doctor’s supervision.

In most of the original studies of SRI’s for PE, medication was given every day. These days, to minimize the risk of side effects, I often recommend a man use them just as-needed, when he plans to have sex.

There can be some loss of spontaneity, but I think for most men the risk/benefit balance favors as-needed use over daily use.

Let’s look at the pros and cons of using SRI’s off-label for PE:

Pros:

Medication-based treatment is unique in its ability to raise a man’s orgasm threshold.Enhanced orgasm thresholds mean less need to practice Arousal Reduction (AR).Medication often works when traditional treatments have failed.Medication-based treatment can be more cost-effective, since fewer office visits are required.

Cons:  

Careful patient selection, patient education, and supervision of treatment are essential.Medication only raises a man’s orgasm threshold for a certain number of hours after he takes it, so timing is required, which reduces spontaneity. Unless the medication is taken every day, which raises the risk of side effects.Medications are not a permanent cure. Once you stop medication, your orgasm threshold returns to its natural state.

 

#8:  How to last longer in bed by combining medication with sex therapy

 

There’s a lot more to good sex than perfectly timed orgasms.

If on medication you no longer have to worry about ejaculating every time your partner moves her pelvis, that’s a great improvement. But it won’t necessarily get you great sex.

One of the great contributions of traditional sex therapy was to help couples get beyond performance-based notions of sex, and to cultivate a mindful awareness of their own experience.

When you do that, sex often improves. Communication often improves as well.

Treatment that combines medication and sex therapy for PE can be the best of both worlds. Medication can a man’s “ticket of admission” to a world of much greater erotic discovery.

And sex therapy techniques tend to work much better when a man with PE on medication no longer has to stay so focused on not getting too excited.

 

Pros:

Medication, by reducing a man’s need to do Arousal Reduction (AR), can allow him to make better use of sex therapy.Sex therapy techniques for PE often work better after medication is added.

Cons:

Requires a health care provider who is skilled in both medication and sex therapy.Otherwise, two separate care providers are needed: one to supervise medication, and the other to conduct sex therapy.

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Sexology and sexual medicine have come a long way towards being able to help men with premature ejaculation. But we still have a long way to go in educating more men with PE about treatment options for this condition.

I congratulate you for reading this far, and I hope you’ve gained some useful knowledge.

Please feel free to write me with any questions.

Stephen Snyder MD
New York City  2020

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Parts of this article have been adapted from Love Worth Making: How to Have Ridiculously Great Sex in a Long-Lasting Relationship by Stephen Snyder, M.D. Copyright © 2018 by the author and reprinted with permission of St. Martin’s Press, LLC.

Medical Disclaimer
All content here is for informational purposes only. Please consult a licensed mental health professional for all individual questions and issues.

 

 

The post Eight Ways for Men with Premature Ejaculation to Last Longer in Bed appeared first on Stephen Snyder, MD.

Toward a Better Definition of Premature Ejaculation

Part 1 of a new three-part series for men with premature ejaculation and their partners, on contemporary issues in the understanding and treatment of PE.

See also:

What Causes Premature Ejaculation?

Eight Ways Men with Premature Ejaculation Can Last Longer in Bed

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How fast is too fast?

The answer’s always been a bit foggy.

Over the last few decades, researchers have experimented with definitions like “lack of control over ejaculation, “ejaculation with minimal stimulation,” or “ejaculation before you want it to happen.”

Which do seem to capture the essence of the thing. But unfortunately they’re too subjective for research purposes.

Lately the field has moved towards defining premature ejaculation in more objective terms by simply noting how long a man lasts after penetration.  Researchers call this your “intravaginal ejaculation latency time,” of IELT for short.

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What is IELT?

It’s less technical than it sounds. To measure your IELT, your partner simply clicks a stopwatch at the moment of penetration, then clicks it again when you ejaculate.

In the current DSM-5 definition of premature ejaculation, your IELT has to be consistently a minute or less to qualify you as potentially having PE. (The DSM-5 notes that duration criteria haven’t been established yet for men whose sexual activities don’t involve vaginas).

This helps eliminate what my colleague Paul Joannides calls “El Prematuro Loco”:  guys with normal IELTs who freak out because they can’t last as long as the guys in porn.

But as a sex therapist who treats men with premature ejaculation, I’m troubled by this duration-based definition, since it fails to capture relevant details, like what exactly were you doing during penetration, and how much was it actually turning you on?    

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What the current definition of premature ejaculation ignores

Consider the following: Let’s say you and your partner are doing what’s called “motionless intercourse,” a common technique for managing PE, where you lie completely still together for the first two minutes after penetration. No thrusting at all.

Let’s say with motionless intercourse you can increase your IELT from 30 seconds to 2 minutes. According to the latest criteria, you now technically no longer have premature ejaculation.

For motionless intercourse to work, though, sex has to be very controlled. No moaning, or anything else that might get you too excited.

You see the problem, right? It’s not just a matter of how long sex lasts. We also need information about whether you (and your partner) felt free to be fully turned on.

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What else the current definition of PE ignores

Almost all men with premature ejaculation, in the hopes of lasting longer, consistently do things to keep themselves from getting too aroused—from motionless intercourse, to “start-stop,” where you return to motionless intercourse every time you feel an orgasm might be around the corner, to numbing creams and sprays, to thinking about your least favorite elementary school teacher, to masturbating beforehand so you’re not so highly excited.

These are all ways to keep yourself less aroused. Think about that, for a moment. Who else but a man with premature ejaculation would ever think of doing such a thing?

To have good sex, you have to be in the moment. But if you’re trying not to get too excited so you won’t have an orgasm too quickly, that takes you out of the moment.

In fact, the whole point is to take you out of the moment. Again, who else in the universe but a man with premature ejaculation would ever dream of doing that?

Oh, and one more thing . . .

Let’s not forget the man’s partner. I often hear from partners of men with PE that their biggest frustration is when he removes himself from the erotic moment, in a desperate attempt not to get too excited.

It’s not just about how long intercourse lasts. It’s also about whether there’s any joy in lovemaking.

To quote one exasperated wife, “I don’t really mind him coming so quickly inside me. Intercourse has never been especially my thing. What really upsets me is that all he focuses on is not getting too excited. It’s like I’m not even there.”

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A better definition of premature ejaculation

I propose we define premature ejaculation, not just by how long a man takes to come, but by the kind of efforts he has to make not to come.

Let’s say we define premature ejaculation not just by the fact that a man comes very quickly, but also by the fact that he has to do some form of “Arousal Reduction”—“AR,” if you will—in order not to come quickly.

We might express this logically as follows:

PE = rapid ejaculation + AR

Where AR might include everything from thinking about flesh-eating zombies during intercourse, to avoiding sex positions that really turn you on, to avoiding partners who really turn you on, to avoiding intercourse entirely.

When you consider things from an AR perspective, many of the traditional work-arounds for premature ejaculation—like motionless intercourse, stop-start, numbing creams and sprays, or masturbating first before going on a date—suddenly just look like extensions of the problem.

From an AR viewpoint, these all just look like forms of Arousal Reduction.

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Implications of this new definition of premature ejaculation for treatment

What we’d really like, as a treatment for premature ejaculation, would be something that not only enables a man and his partner to enjoy sex longer, but also relieves him of the need to do AR. So he and his partner can enjoy getting more aroused, not less.

Do any current treatments for premature ejaculation meet this higher standard?

In fact, some do. But they’re not widely known.

For decades now, we sexual medicine specialists have been treating men with persistent, severe premature ejaculation by combining psychological techniques with medication. For many men, this kind of combination treatment provides not only longer-lasting sex, but also freedom from having to do AR.

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So why don’t more people know these treatments exist?

For one, none of these medications are yet approved in the US for the treatment of premature ejaculation. They’re approved for other uses, but their use in men with premature ejaculation is what’s called “off-label,” which requires informed consent.

Their effectiveness for premature ejaculation has been shown in multiple published studies. But until one of these medications gets approved in the US for premature ejaculation, you’ll never see a TV ad in this country saying, “Ask your doctor about PE.”

To really understand how combination treatment for PE actually works, though, we’ll need to discuss what actually causes premature ejaculation in the first place. 

That’s where we’re going in Part Two of this series.  I hope you’ll join me.

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Parts of this article have been adapted from Love Worth Making: How to Have Ridiculously Great Sex in a Long-Lasting Relationship by Stephen Snyder, M.D. Copyright © 2018 by the author and reprinted by permission of St Martin’s Press.

Medical Disclaimer
All content here is for informational purposes only. Please consult a licensed mental health professional for all individual questions and issues.

The post Toward a Better Definition of Premature Ejaculation appeared first on Stephen Snyder, MD.