Review Article

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

Michael A. Perelman


The Sexual Tipping Point® (STP) model is an integrated approach to the etiology, diagnosis and treatment of men with delayed ejaculation (DE), including all subtypes manifesting ejaculatory delay or absence [registered trademark owned by the MAP Educational Fund, a 501(c)(3) public charity]. A single pathogenetic pathway does not exist for sexual disorders generally and that is also true for DE specifically. Men with DE have various bio-psychosocial-behavioral & cultural predisposing, precipitating, maintaining, and contextual factors which trigger, reinforce, or worsen the probability of DE occurring. Regardless of the degree of organic etiology present, DE is exacerbated by insufficient stimulation: an inadequate combination of “friction and fantasy”. High frequency negative thoughts may neutralize erotic cognitions (fantasy) and subsequently delay, ameliorate, or inhibit ejaculation, while partner stimulation (friction) may prove unsatisfying. Assessment requires a thorough sexual history including inquiry into masturbatory methods. Many men with DE engage in an idiosyncratic masturbatory style, defined as a masturbation technique not easily duplicated by the partner’s hand, mouth, or vagina. The clinician’s most valuable diagnostic tool is a focused sex history (sex status). Differentiate DE from other sexual problems and review the conditions under which the man can ejaculate. Perceived partner attractiveness, the use of fantasy during sex, anxiety-surrounding coitus and masturbatory patterns require meticulous exploration. Identify important DE causes by juxtaposing an awareness of his cognitions and the sexual stimulation experienced during masturbation, versus a partnered experience. Assist the man in identifying behaviors that enhance immersion in excitation and minimize inhibiting thoughts, in order to reach ejaculation in his preferred manner. Discontinuing, reducing or altering masturbation is often required, which evokes patient resistance. Coaching tips are offered on how to ensure adherence to this suspension, manage resistance and facilitate success. Depending on motivation level, masturbation interruption may be compromised and negotiated. Encourage a man who continues to masturbate to alter style (“switch hands”) and to approximate the stimulation likely to be experienced with his partner. Success will require most men to be taught to learn bodily movements and fantasies that approximate the thoughts and sensations experienced in masturbation. Fertility issues, as well as patient/partner anger are important causational factors, which often require individual and/or conjoint consultation. Drug treatment would benefit men particularly with severe DE, regardless of concomitant psychosocial-behavioral and cultural complications. When and if a safe effective medication for DE becomes available, this author’s transdisciplinary perspective supports appropriate medication use when integrated with counseling. This approach emphasizes the utility of a biopsychosocial-cultural perspective combined with special attention to the patient’s narrative. Treatment is patient-centered, holistic and integrates a variety of therapies as needed.

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