Imagine the frustration and confusion of struggling to reach orgasm during sex, despite having a rock-hard erection. For men with delayed ejaculation (DE), this is a reality that can strain relationships and erode self-esteem. But what causes DE, and how can it be treated?

Understanding delayed ejaculation

Delayed ejaculation, also known as retarded ejaculation, affects less than 3% of men.1 Although orgasm is used interchangeably with ejaculation, it is a different physiological state and is a sense of pleasure that manifests itself with various body changes. It is often misunderstood and can be challenging to treat. Contrary to popular belief, DE is not just about “lasting longer.” It’s a complex condition involving psychological, relationship, and physiological factors.

A 2014 review by Shin and Spitz examined the pathophysiology, epidemiology, evaluation, and treatment of delayed ejaculation (DE).2 The authors emphasize the importance of a focused history and physical examination, including a detailed sexual history, examination of the genitalia, and inquiry into the status of the partner.

Laboratory tests may be used to detect abnormalities in blood count, glucose level, hormone levels, or kidney function. Treatment approaches depend on the underlying cause of DE. If a correctable etiology is discovered, treatment focuses on reversing the condition.

However, in some cases, DE may be a lifelong problem or result from irreversible factors such as age-related sensation loss or diabetes-related neuropathy. In these instances, treatment may involve a combination of behavioral modification, sexual therapy, and potentially pharmaceutical drugs. Partner participation in therapy may also be necessary. The authors conclude that future research will continue to shed light on the complex biological and psychosocial factors contributing to DE, leading to more effective treatments.

Research suggests that men with DE often share certain characteristics:3

  • High achievers who demand a lot from themselves
  • Tendency to mistake erection for arousal
  • Unusual masturbation patterns incompatible with partner sex
  • History of childhood trauma or difficulty with emotional intimacy

The role of arousal in delayed ejaculation

One key insight is that DE is better understood as an arousal phase disorder rather than an orgasm disorder.4 Many men with DE have little sexual arousal despite having an erection. They may experience a “premature erection” without the high levels of desire typically needed for erection.

This low arousal makes reaching orgasm difficult, as sex therapist Dr. Stephen Snyder explains: “No arousal, no high arousal. No high arousal, no orgasm.”5 Learning to recognize and communicate genuine sexual arousal is crucial for men with DE and their partners.

Masturbation patterns and delayed ejaculation

Sex therapists emphasize the importance of taking a detailed masturbation history when assessing DE.6 Men with DE often engage in self-stimulation that is very different from partnered sex in terms of speed, pressure, duration, location, and intensity needed to orgasm.

Frequent porn use combined with idiosyncratic masturbation habits can further condition the orgasmic threshold in ways incompatible with partnered sex. 7 Masturbation retraining, used as a “dress rehearsal” for sex with a partner, is now a common therapeutic approach.

Medical treatments for delayed ejaculation

While psychological and relationship factors play a significant role in DE, medical causes should also be ruled out. These may include:8

  • Anatomical abnormalities
  • Neuropathy
  • Hormonal imbalances
  • Medications (especially ED drugs)
  • antidepressant-induced DE (especially SSRIs)
  • hypogonadism
  • hyperprolactinemia9

Experimental treatments like the dopamine agonist amantadine have shown moderate success.10

A newer approach involves off-label use of low-dose Adderall (amphetamine/dextroamphetamine). A 2024 study found Adderall effective for DE in 31% of patients, with doses ranging from 5-20mg taken 1-4 hours before sex. 11

However, larger studies are needed and Adderall carries risks of misuse, so it should only be used under medical supervision. The average age of patients was 59 years, and 65% had abnormal biothesiometry results, suggesting potential neurological factors. Non-drug approaches, especially sex therapy to address relationship dynamics and arousal problems, remain central to DE treatment.

Putting the pieces together

Overcoming delayed ejaculation requires patience, open communication, and a multi-pronged approach tailored to each individual and couple. Key strategies include:

  • Identifying and communicating sexual arousal patterns
  • Masturbation retraining to retool the orgasmic threshold
  • Uncovering relational dynamics and emotional blocks
  • Ruling out medical causes and cautiously considering medication
  • Working with a sex therapist to develop an individualized plan

By better understanding the complex mix of factors behind DE, and having empathy for the men struggling with this frustrating condition, we can offer new paths to more satisfying sexual connections.


  1. Alwaal A, Breyer BN, Lue TF. Normal male sexual function: emphasis on orgasm and ejaculation. Fertil Steril. 2015 Nov;104(5):1051-60. doi: 10.1016/j.fertnstert.2015.08.033. PMID: 26385403.
  2. Shin, Daniel & Spitz, Aaron. (2014). The Evaluation and Treatment of Delayed Ejaculation. Sexual Medicine Reviews. 2. 10.1002/smrj.25
  3. Shaw J. Play therapy with the sexual workhorse: successful treatment with twelve cases of inhibited ejaculation. J Sex Marital Ther. 1990 Fall;16(3):159-64. doi: 10.1080/00926239008405262. PMID: 2246793.
  4. Sadowski DJ, Butcher MJ, Köhler TS. A review of pathophysiology and management options for delayed ejaculation. Sex Med Rev. 2022 Jan;10(1):60-75. doi: 10.1016/j.sxmr.2021.01.005. PMID: 33612383.
  5. Jenkins LC, Mulhall JP. Delayed orgasm and anorgasmia. Fertil Steril. 2015 Nov;104(5):1082-8. doi: 10.1016/j.fertnstert.2015.09.029. PMID: 26439762.
  6. Snyder, S. (2022). Love Worth Making: How to Have Ridiculously Great Sex in a Long-Lasting Relationship. St. Martin’s Griffin.
  7. Perelman MA. Delayed Ejaculation. J Sex Med. 2016 Jun;13(6):831-7. doi: 10.1016/j.jsxm.2016.01.007. PMID: 27045255.
  8. Blair L. Masturbation and Pornography Use Among Coupled Heterosexual Men With Decreased Sexual Desire: How Many Roles of Masturbation? J Sex Marital Ther. 2022;48(4):310-332. doi: 10.1080/0092623X.2021.2018176. PMID: 35020761.
  9. Althof SE. Psychological interventions for delayed ejaculation/orgasm. Int J Impot Res. 2012 Aug;24(4):131-6. doi: 10.1038/ijir.2012.2. PMID: 22415331.
  10. Piche, Kristen & Mann, Uday & Patel, Premal. (2020). Treatment of Delayed Ejaculation. Current Sexual Health Reports. 12. 1-10. 10.1007/s11930-020-00287-z.
  11. Paduch DA, Polzer PK, Ni X, Basaria S. Testosterone Replacement in Androgen-Deficient Men With Ejaculatory Dysfunction: A Randomized Controlled Trial. J Clin Endocrinol Metab. 2015 Aug;100(8):2956-62. doi: 10.1210/jc.2014-4434. PMID: 26158203; PMCID: PMC4524400.
  12. Johnson A, Dymanus K, Quesada-Olarte J, Levine L. Is Adderall Effective in the Treatment of Delayed Ejaculation? A Continued Retrospective Analysis. J Sex Med. 2024;21(3):S258-S259. doi: 10.1093/jsxmed/qdae001.245.