1 of 53

Michael A. Perelman, Ph.D.

Founder & Chairman

MAP Education & Research Foundation

New York, N.Y. 10075 USA

The STP Model Helps Optimize The Diagnosis & Treatment Of SD

Today’s lecture will include xx power point slides, many of which will be presented only briefly.
Biomedical Vs Bio and a STP one pager will be handed out.
A pdf of today’s presentation will be available upon request to Michael@mapedfund.org

Additional material is available for free at

MAP Education & Research Foundation’s

Website: mapedfund.org

PGY IV Presentation, 2023.03.30

2 of 53

The STP Model Helps Optimize �The Diagnosis & Treatment Of SD

Describe the Sexual Tipping Point^®model’s integrated approach to illustrating the etiology, diagnosis and treatment of SD.
Obtaining a “sex status,” and its use within a STP framework.
Clinical vignettes illustrating the STP approach to SD, and/or time for questions regarding your own cases.

AGENDA

3 of 53

The STP is an easy way to depict both the mental and physical elements of sexual function and dysfunction, facilitating an integrated treatment approach.

Perelman MA. J Sex Med. 2006; 3:1004-1012;

Perelman MA. J Sex Med, 2009;6(3):629-32.

The STP Model Helps Optimize The

Diagnosis & Treatment Of SD

Why?

4 of 53

��

Adapted from Rosen, CIEF

Because sexual response is best understood as an endpoint, representing the cumulative interaction of every cognitive, behavioral, social and cultural factor, not merely the biomedical or “physical” determinants!

5 of 53

The Sexual Tipping Point, Illustrates All �The Intra And Interindividual Variability, �Characterizing Sexual Disorders’ Etiology, Diagnosis And Treatment

Inhibition

Excitation

Insipient Metabolic Syndrome

6 of 53

THE SMALL CIRCLES IN THE MENTAL & PHYSICAL “CONTAINERS”

ON THE SEXUAL BALANCE BEAM, SYMBOLIZE ALL THE MULTITUDE OF FACTORS THAT DETERMINE SEXUAL RESPONSE. THEY FUNCTION AS DIMMER SWITCH.

AS ILLUSTRATED BELOW, THE NET SUM OF ALL THESE FACTORS DETERMINES THE STP, SHOWN ON THE SEXUAL BALANCE SCALE AT ANY MOMENT IN TIME.

Inhibition

Excitation

EACH DIMMER IS LIKE A MICRO VARIABLE SWITCH THAT SYMBOLIZES A FACTOR’S VARYING POLARITY (+,-,=) & MAGNITUDE

Perelman MA. The Sexual Tipping Point is a Variable Switch Model. Curr Sex HealthRpts 2018;10:1.

7 of 53

Perelman MA. The Sexual Tipping Point is a Variable Switch Model. Curr Sex HealthRpts 2018;10:1.

THE STP ALSO ILLUSTRATES HOW EACH INDIVIDUAL FACTOR (DIMMER) CAN DEVIATE FROM A “NORMAL” RANGE, AND THUS, HELP TO IDENTIFY WHETHER THAT FACTOR IS PREDISPOSING, PRECIPITAITING AND/OR CURRENTLY MAINTAINING A SEXUAL DISORDER.

THE SEXUAL TIPPING POINT MODEL

Inhibition

Excitation

8 of 53

THE STP ILLUSTRATES HOW MANY OF THESE FACTORS

CAN BE BI-DIRECTIONAL & EVEN SIMULTANEOUS IN THEIR IMPACT

9 of 53

Numerous Physical Factors In the Brain Can Excite Or Inhibit

Complements of Jim Pfaus

Neuronal inhibition can be the complement to neuronal excitement (Komisaruk et al, 2023).

The proposed mechanism of action for Flibanserin (Addyi) is attributed to displaying agonist activity on 5-HTA1 and antagonist on 5-HTA2, resulting in lowering of serotonin in the brain as well as an effect on increasing norepinephrine and dopamine neurotransmitters.

10 of 53

MENTAL: Thoughts Or Fantasy Can Also Be Bidirectional

1. I feel attracted to the person.

2. I want to experience physical pleasure.

3. It feels good.

4. I want to show my affection for my partner.

5. I want to express my love

6. I feel sexually aroused and want the release.

7. I feel horny.

8. It’s fun.

9. I am in love.

10. I love being swept up by the moment.

11. I wanted to please my partner.

12. I want the closeness/intimacy.

13. I want the pure pleasure.

14. I want an orgasm/orgasm

15. This is exciting,

16. I wanted to feel connected to the person.

17. The person's physical appearance turns me on.

18. Love this setting.

19. This person really desires me.

20. This person makes me feel sexy.

Turn On Thoughts

Turn Off:

Negative Thoughts

Meston, CM and DM Buss. "Why Humans Have Sex,”

Archives of Sexual Behavior (2007) 36:477.

Complements of Eli Lilly

11 of 53

MENTAL: Relationship Factors Are Also Bidirectional

Often, the most common damage to the relationship is how a man’s age-related changes in diminished desire (and shift in erection threshold) can lead to a sexual disorder, often resulting in with-drawl of any affection.
So often a man will avoid expressing affection for fear it will be mistaken for sex initiation.
The absence of affection can result in partner’s feeling rejected, questioning their attractiveness and negative thoughts regarding their own self-esteem and self worth.
That can result in bitterness, and significantly increased tension, loss of intimacy and love.

A VERY VICIOUS CYCLE

The Treatment Goal, Would Be To Reverse That And Create A Virtuous Circle

12 of 53

MENTAL: RELATIONSHIP TENSIONS

CAN DEFINITELY RESULT IN SD

We Used To Teach That The 5 Most Common Issues Couples Argued About Were:

Sex , Money, Kids, In-laws & family relations,

Domestic chores and Religion

Three years ago we added. Covid!

Covid (and it’s sequela) and Politics (Especially in the USA).

Tension from any of these may result in precipitating/maintaining a sex disorder.

It is not just marital tension, as divorce itself

can of course do the same!

13 of 53

An Ever More Common Chief Complaint:

“I found my husband watching porn and now I feel betrayed.”

Accessed 2022.30.22: https://www.theguardian.com/lifeandstyle/2022/jan/30/ask-philippa-perry-i-found-my-husband-watching-porn-and-now-i-feel-betrayed

While just “testing” himself and/or continuing a masturbation practice may reassure him that all is working fine.
But the discovery of masturbation aided by porn, can be very dire!

14 of 53

Here An STP Cartoon Depicts the Etiology of A Man Who Suffers �From ED, Secondary to Being Humiliated by his Ex-wife!

Mental Factors = Psychosocial & Cultural

15 of 53

Accessed: 2022.01.31

www.psychologytoday.com/us/blog/sexual-tipping-point/201906/call-it-what-it-is-biomedical-psychosocial-and-cultural

MEDICAL VS PSYCHOSOCIAL BIOPSYCHOSOCIAL

VS BIOMEDICAL PSYCHOSOCIAL & CULTURAL MODEL

16 of 53

Eventually These Factors Will Be Shown As Vectors When This STP Cartoon

Can Be Illustrated In Three Dimensions.

17 of 53

What’s The Take-Away From This Talk’s First Section?

Second:

An individual’s sexual function at any given moment in time, is determined by the net sum of those factors.

Third:

Identify the key interfering

factors as initial treatment targets.***

Fourth:

Inspire hope by explaining

the STP formulation and

the initial treatment targets

to the patient.

First:

Recognize that SD is always determined by Biomedical Psychosocial & Cultural Factors

INHIBITION

A

M

P

M

EXCITATION

A

18 of 53

The sex status is not

a questionnaire or a test.

It is a flexible, focused

history taking method

to uncover the key psychosexual- behavioral & cultural factors.

Kaplan HS, The Sexual Desire Disorders 1995;

Perelman MA. Int J Impot 2003; Res (15 Suppl 5):S67-74;

Perelman MA, FSD. In: Goldstein et al, 2005.

THE ANSWER IS A SEX STATUS.

PART TWO: SOME KEY TREATMENT CONCEPTS & TIPS: IDENTIFY KEY STP FACTORS AS THE PATH TO SUCCESS

How to Identify Key STP factors?

19 of 53

A good Sexual Status creates a“video picture”in your mind about the friction, frequency, fantasy and feelings the patient is experiencing, by identifying the factors that precipitate and maintain the distressing sexual disorder.

Althof, Rosen, Perelman, Rubio. SOP for Sex History, JSM, 2013

Perelman MA. Int J Impot Res. 2005;15(suppl 50:S67-S74.

Perelman, In Balon & Segraves, 2005

Perelman, In Goldstein, FSD, 2005

Key Concepts & Questions To Optimize

Diagnosis & Treatment Of Sexual Dysfunction

HOW DO YOU DO THAT?

20 of 53

How do we do that?��Ask focused questions; step back and then probe again, depending on the patient’s comfort with the inquiry.

STP & Sex Status: Key Concepts to Optimize

Diagnosis & Treatment Of Sexual Dysfunction

Perelman M. Int J Impot 2003; Res (15 Suppl 5):S67-74;

Perelman MA. J Sex Med. 2006; 3:1004-1012.

21 of 53

Perelman MA. Int J Impot Res. 2005;15(suppl 50:S67-S74.

Perelman, In Balon & Segraves, 2005; Perelman, In Goldstein, FSD, 2005

Depending on your time (the patient’s responses and comfort level, and your own), probe for needed details

and sexual experiences that illuminate the key factors.

Ask specific questions, listen, clarify:

“ Tell me what you mean by DE.” ( the CC)
“ Tell me what you mean by PE.” ( the CC)
“ Tell me what you mean by ED.” ( the CC)
“ Tell me what you mean by no desire.” ( the CC)
“ Tell me about the pain, location, intensity, etc “ (the CC)

“ What do you think is causing this problem?”

This may vary with your new patients vs. established patients

who have been in your practice for years.

SEX STATUS: Taking a focused sex history is critical!

22 of 53

Perelman MA. Int J Impot Res. 2005;15(suppl 50:S67-S74.

Perelman, In Balon & Segraves, 2005

Perelman, In Goldstein, FSD, 2005

Sexual Status Exam

For me, one of the best single probes you can ask is:

“ Tell me about your last sexual experience”

That gives me a “video picture” in my mind,

that helps me identify immediate and remote causes.

23 of 53

Sex Status Exam

You want to answer these questions:

Does the patient have a sexual disorder, & what is the diagnosis?
What are key underlying biomedical, psychosocial, cultural factors?

What are the “immediate” maintaining factors

(current cognitions, emotions, behaviors, organic, medical, etc)?

b. Any potential “deeper” mental and/or physical causes emerging?

(predisposing, precipitating)?

3. Do any underlying factors require pre-treatment, or can they be

bypassed, modified, or treated concurrently?

(eg. depression, marital conflict, drugs, ETOH, etc.

What Are The Critical Evaluation Issues?

Kaplan, 1983; Perelman, 2000, 2005

24 of 53

STP Approach To Treating SD

Predisposing, (constitutional, prior life experience)
Precipitating, exacerbating and/or
Maintaining, a sexual dysfunction, disorder or concern.

Answers determine treatment targets and help you decide on initial interventions which can be timed, based on whether a factor is more of an “immediate or remote” cause… or as many of us conceptualize:

Althof et al, JSM, 2005; Althof et al, JSM, 2009;

Basson R. JSMT. 2000;

Hawton K. Br J Hosp Med 1985

EXPLAINING THE STP AND TREATMENT TARGETS,

NOT ONLY PROVIDES HOPE,

BUT BEGINS THE RECOVERY PROCESS

BY REFRAMING PATIENT COGNITIONS!

25 of 53

Question…where do you begin?

HSK conceptualized the issue as starting with the more immediate psychological causes ones that are currently maintaining the problem?

How do you determine that?

26 of 53

One of my easiest cases took place 35 years ago. He was a 60 y.o. man who suffered from ED and was referred by his urologist for a presurgical consultation for psych clearance prior to an intended penile prosthesis surgery. John was in excellent health and had maintained a rigorous exercise schedule as a marathon runner most of his adult life. Because of an achilles injury he no longer ran marathons, but still woke up early every morning to run 5 miles.

In our first session after complementing him on his regimen and good health, I asked what he thought the impact on his sex life might be if he cut the running back to 2 miles, three times a week and slept in later on the other 4 days. He laughed and said he would give it some thought. We scheduled a follow-up session to complete the evaluation .

Sometimes Brief Education

Is All That Is Needed To Assist The Patient/Partner

Accessed 2022.01.30: https://www.psychologytoday.com/us/blog/sexual-tipping-point/201808/the-link-between-lack-sleep-and-sex-problems

He cancelled 6 days later leaving me a message that he was running less frequently and for shorter distances. But he had already had two successful intercourse experiences with his wife, and they were both thrilled. Fortunately, the surgeon who himself became increasingly more sophisticated about sexual response continued referring to me.

27 of 53

Perelman MA. Int J Impot Res. 2005;15(suppl 50:S67-S74.

Perelman, In Balon & Segraves, 2005

Perelman, In Goldstein, FSD, 2005

Therapeutic Probe & The Sexual Status Exam

Treatment begins with the first contact with the therapist as all is an opportunity for teachable moments.
Sex therapists will offer a suggestion or “homework assignment”

such as: , SF, self exploration, S/S, etc.

Pharmaceuticals can also act as a therapeutic probe
Detailed examination of those experiences (or failure to act on them) at follow-up sessions will reveal the initial causes of potential treatment failure, whether current and superficial (“no time”) or relationship and/or deeper issues which may require intervention.
Pivot and adjust the timing of your interventions according to the pushback received.
Continuously reassess and to vary your delivery to the unique way and manner your patients can absorb it (eg.use their language).

28 of 53

Importance of Follow-Up

Get Another Sex Status at Follow-Up

Explore the most recent sexual experience
If Rx, was a sexual pharmaceutical used properly?

Barada, 2001 Hatzichristou, 2001 Perelman 2000,2002

29 of 53

Weaning & Relapse Prevention�

USING THIS APPROACH, PATIENTS MAY BE WEANED FROM THE DRUG OR THEIR MEDICATION CAN BE REDUCED, FURTHER IMPROVING the RISK / REWARD RATIO.

WHEN GREATER ILLNESS OR STRESS CHANGES “THE SEXUAL TIPPING POINT^” MORE MEDICATION AND/OR COACHING MAYBE ADDED TO THE EQUATION.

Perelman, IJIR,2004;

Perelman M. Handbook of Sexual Dysfunction 2005

Perelman, In Goldstein, FSD, 2005

30 of 53

WHEN TO REFER

The More Relationship Strife, the Less Likely

Medication & Education Alone Will Succeed

Identifying Psychological Factors Does Not Necessarily Mean You Must Directly Address All of Them
Referral

Patient request
Practice to your level of comfort

Perelman, IJIR, 2004

Perelman M. Handbook of Sexual Dysfunction 2005

Perelman M. Urol Clin North Am. 2005;32:431-445.

31 of 53

Future SD Treatments

Sexual Balance: STP Illustrating an Integrated Treatment

of HSDD Secondary to VVS & ED

There Will Be New Drugs

32 of 53

PART TWO: SOME KEY TREATMENT �CONCEPTS, TIPS & EXAMPLES

The STP model is applicable to men, women, gay, straight and otherwise.
But as a cisgender man at the end of my career, I primarily limit my public commentary to issues of concern to men.
There are many who comment on women, but I typically only do so when publishing by invitation in the company of female lead authors from ISSWSH.

That said, in practice I treat men, women & couples.

33 of 53

With The Introduction Of Sexual Pharmaceuticals My Interest Shifted To Combination Treatments

GOAL: Identify key non-medical treatment variables that could improve safety and efficacy, knowing that guaranteed “a place at the table” given Pharma’s medical hegemony at that time.

34 of 53

Most Important Diagnostic Issue To Clarify, Is Whether

He Can Differentiate PS From Emission (EI) & Ejection

Men with PE typically lack skill in identifying PS and/or adequately managing their body’s response to PS (progressively escalating sensations of sexual arousal during coitus), regardless of other predisposing etiological factors; whether genetic serotonin thresholds, nerve transmission rates, or psychosocial- cultural variables.

Perelman M. J Sex Med 2006;3:1004-1012

PE FINAL PATHWAY:

THE MOST IMPORTANT KEY TO PE CASES

35 of 53

Treating PE Is More Than Just Improving IELT.

ISSM Definitions Also Emphasize Control & Distress!

AUA PE Guidelines, 2004;

Perelman, M. Handbook of Sexual Dysfunction, 2005

Perelman MA. J Sex Med. 2006;3:1004-1012.

Medical Tx. of PE is limited, by PE’s multi-dimensional etiology.

Is Assessing His Capacity To Discern The Difference Between PS & Emission Necessary ?

Patients usually relapse when withdrawn from medical treatment, which will often generate a referral to you!

Medical approaches (pills, topical creams, sprays), emphasized symptomatic improvement, w/out considering long- term learning, relationship issues, or relapse with discontinuation.

Yes! And especially for physicians who treat with meds!

36 of 53

The man with PE, frequently does not recognize his rapid approach to his ejaculatory tipping point.
He often does not realize, when he says:

“Uh -oh; I’m going to come now!”

He is already coming!
He is confusing his PS, with the emission stage of his ejaculation.
For him, it is too late to stop or slow down.

MOST OF THESE MEN DO NOT HAVE A CHOICE!

HE SUFFERS FROM AN INABILTY TO DELAY

AND HAS NO CHOICE!

An orgasm is like a sneeze, he needs to get a clue before it happens!

37 of 53

https://www.psychologytoday.com/us/blog/sexual-tipping-point/201810/what-does-sneeze-and-premature-ejaculation-have-in-common

38 of 53

Some cannot discern Premonitory Sensations (PS)

Too fast for awareness: > muscle tension, > heart rate, testicular elev. etc.
Some recognize, but ignore PS and hope they don’t “cum” yet.

Some confuse PS and the Emission Phase:

He’s thinking “Uh-Oh, I’m going to cum!” It’s really,

“Shoot I’m coming.” He’s confusing strong PS, with the emission stage of his ejaculation.

For him, it is too late to stop or slow down. No choice point!

Subsequently: Ejection and Orgasm take place

2-4 seconds later, no matter what he does.
Trying to “hold back” only, results in an unsatisfactory partially RE.

Three Common Errors Made By Men With PE

Perelman, 2005 SMSNA PE Debate

39 of 53

Can He Identify His �Premonitory Sensations (PS)?

In that case a medication is needed to reset this threshold, or “ejaculatory tipping point” so that he has the time to more easily recognize, and respond to PS ?

Perelman M. J Sex Med 2006;3:1004-1012

PE’S FINAL PATHWAY:

40 of 53

WHAT TO DO: AN ELEGANT SOLUTION: �AN INTEGRATED TREATMENT FOR THE METABOLIC SYNDROME PATIENT.

INTEGRATED TREATMENT: THE IDEAL SOLUTION TO BALANCE RISK/BENEFIT

Counseling

?

PDE-5

NEW DRUG

?

41 of 53

WHY DE Is A Disorder Which You Can Treat With Greater Facility Than Most Urologists

42 of 53

DE IS AN EJACULATORY DISORDER WHICH SHOULD CAPTURE YOUR INTEREST!

DE IS REPORTED AT LOW RATES, RARELY EXCEEDING 3%.

Masters and Johnson initially reported only 17 cases.
Apfelbaum reported 34 cases
Kaplan reported fewer than 50 cases.

SOME UROLOGISTS & SEX THERAPISTS (MAP 400+CASES) ARE NOW REPORTING GREATER INCIDENCE OF DE (Aging, PDE5s )

Simons J, Carey MP (2001) Prevalence of sexual dysfunctions: results from a decade of research. Arch Sex Res 30(2):177–219 , Masters WH, Johnson VE (1970) Human sexual inadequacy. Little, Brown & Co: Boston., Apfelbaum B (2000) Retarded ejaculation; a much-misunderstood syndrome. In: Lieblum SR, Rosen RC, eds, Principles and practice of sex therapy, 2nd ed, Guilford Press: New York, pp 205-241. Kaplan H (1995) The evaluation of sexual disorders: psychologic and medical aspects. Brunner/Mazel: New York. Perelman M, McMahon C, Barada J (2004) Evaluation and Treatment of Ejaculatory Disorders. Atlas of Male Sexual Dysfunction, Current Medicine LLC, Philadelphia, pp 127–157. Perelman MA (2003). Regarding ejaculation: delayed and otherwise. J Androl 24:496. Perelman MA, Rowland DL. “Retarded Ejaculation.” World Journal of Urology, 2006 Dec;24(6):645-52.

TREATING DE IS A BIG OPPORTUNITY

FOR SEX THERAPISTS!

43 of 53

DE: TREATMENT

WHY?

There are no FDA approved drug treatments for DE!
Numerous drugs, herbs and medication dosing strategies have been described for in the treatment of antidepressant related DE

(there is some Level 3 evidence for PDE-5s.) (Nurenberg, Segraves, Clayton, Ashton)

There are continued reports of experimentation by physicians seeking a pharmaceutical to reduce IELT, but no evidence to support these anecdotal claims. Eg. Cyproheptadine ( Rabinowitz), Buproprion, Duloxetine (Helstrom et al, Ropinirole; Shabsigh,; Eliot, McMahon, Waldinger, Personal communication & ISSM List Serve)
Unfortunately, despite reports of highly effective approaches (up to 80% success reported) there is only low-level evidence recommending sex therapy for DE.

Perelman & Rowland, WJU, 2006; Perelman, WAS, 2007

44 of 53

Psychosexual Therapy Should be Considered First Line Therapy for the Management of Delayed Ejaculation

Perelman: “I want to thank the SMSNA program committee for inviting me to speak on this frequently misunderstood topic.”

“And thanks, to the AUA, for their summer program’s emphasis on:

“Clinicians should consider referring men diagnosed with lifelong or acquired delayed orgasm to a mental health professional with expertise in sexual health.”

Recognizing the role of mental health professionals

in managing disorders of ejaculation.”

“And most important to this debate:

Thanks to Dr. Shindel, for Chairing the AUA Committee,

“Guidelines On Ejaculation Disorders,” which recommended:

DEBATE

45 of 53

Psychosexual Therapy Should be Considered First Line Therapy for the Management of Delayed Ejaculation

Perelman: “I want to thank the SMSNA program committee for inviting me to speak on this frequently misunderstood topic.”

“And thanks, to the AUA, for their summer program’s emphasis on:

“Clinicians should consider referring men diagnosed with lifelong or acquired delayed orgasm to a mental health professional with expertise in sexual health.”

Recognizing the role of mental health professionals

in managing disorders of ejaculation.”

“And most important to this debate:

Thanks to Dr. Shindel, for Chairing the AUA Committee,

“Guidelines On Ejaculation Disorders,” which recommended:

DEBATE

46 of 53

Psychosexual Therapy Should be Considered First Line Therapy for the Management of Delayed Ejaculation

“Sex Coaching (by any of you ) should be the first line therapy for SD.
Perelman: “You do NOT need to be a skilled sex therapist, to assist many men with DE.”

“You only need to ask key questions and provide crucial suggestions to make a difference in their lives!”

Perelman, M, “What a Sex Therapist Wants You To Know About Treating Men With Sexual Disorders,”

In Essentials of Mens’ Health, Ed. O’ Leary, M and Bhasin, S. McGraw-Hill Global, 2020.

Perelman, M, Invited Commentary: Sex Coaching for Non-Sexologist Physicians: How to Use

the Sexual Tipping Point Model. The Journal of Sexual Medicine , Vol.15, Issue 12. Dec. 2018.

Perelman, M. “Psychosexual therapy for delayed ejaculation based on the Sexual Tipping Point® Model,” Translational Andrology and Urology-Focused Issue on Ejaculatory Dysfunction-Edited by Dr. Chris G McMahon, Home / Vol 5, No 4 (August 2016).

But the title of this debate should have been:

47 of 53

Why Is That?

Overwhelmingly, the SD cases seen are situational:

“Only occurring with certain types of stimulation, situations, or partners.”

The vast majority of SD patients are complaining about SD during coitus and can usually

ejaculate with self-stimulation.

The following information would allow a urologist to help many men with SD, without the need for drugs and and may negate the need for a referral to a sex therapist!

Yes, but how many urologists are willing to spend the time?

The.embedded poster is from this AUA presentation

48 of 53

WHAT TO DO FIRST?

A good sex history will likely expose the psychosocial & cultural reasons for SD: insufficient penile or psychological stimulation, high frequency and/or idiosyncratic masturbation, preference for masturbation over partnered sex, and psychological conflict regarding ejaculation. These issues often overlap.

Ask specific questions like:

What is the frequency of your masturbation, How do you masturbate,
In what way does the stimulation you provide differ from your partner’s stimulation style, in terms of speed, pressure, etc.
Have you communicated your preference to your partner(s), and if so, what was the response?”
Assess his subjective experience during solo and partnered sexual activity, including the degree to which he is focused on arousing thoughts and pleasurable sensations versus anti-erotic intrusive thoughts (e.g., “It’s taking too long!”).
Follow-up to clarify other, relevant etiological factors: Perceived partner attractiveness, the use of fantasy during sex, coital anxiety, etc
Juxtapose his cognitions, pleasure, type of friction experienced during masturbation (including fantasy, watching/reading pornography) with a partnered experience.

Perelman, M, Invited Commentary: Sex Coaching for Non-Sexologist Physicians: How to Use the Sexual Tipping Point Model. The Journal of Sexual Medicine, Vol.15, Issue 12. Dec. 2018.

49 of 53

High Frequency & Idiosyncratic Masturbation

Now in the AUA Guidelines chaired by Dr. Shindel:

“some men report ….high-frequency masturbation, and/or an idiosyncratic masturbation style (i.e., referring to speed, pressure, and intensity that do not mimic sensations during intercourse), or a discrepancy between the reality of sex with a partner and sexual fantasy.”
Ejaculation frequency is often a primary cause of DE especially as men age.
With age, some men used to high masturbation frequency can no longer sustain it, with out losing the ability to ejaculate with their partner.
Ejaculatory thresholds differ across men and across situations as described by Sexual Tipping Point Model.
This is all illustrated and fully explained on the mapedfund.org website

for those seeking greater understanding.

https://www.auanet.org/guidelines/guidelines/disorders-of-ejaculation, accessed 2021.10.15

http://www.mapedfund.org, accessed 2021.10.15

My 2005 AUA poster first documented “Idiosyncratic Masturbation” and high frequency masturbation as hidden causes of DE.

DEBATE

50 of 53

��

If You Or Your Patient Are Uncomfortable With This Strategy

Recognize The Following Yourself And Tell Him:

“Accumulating evidence indicates men suffering from DE, masturbate in a manner that is different from how their partner’s hand, mouth, vagina or anus feels.”
“Understanding of how you stimulate yourself and if it differs from your partnered experience will help me assist you.”

The Psychology Today Blog called:

“Why Delayed Ejaculation Is More Common Than Folks Realize.” summarizes masturbation’s putative role in the etiology of DE.

https://www.psychologytoday.com/us/blog/sexual-tipping-point/201812/why-delayed-ejaculation-is-more-common-folks-realize

51 of 53

DE Will Often Require Alteration of Masturbatory Habits: Whether Type of Friction, Frequency and/or Fantasy

The solution is usually decreasing ejaculatory frequency while

finding ways to increase the quality of friction and erotic thought per the Sexual Tipping Point Model.

Typically, he must temporarily suspend masturbatory activity and

limit ejaculatory release to his/their desired goal activity:

-- Usually penetrative sex.

Temporarily refraining from ejaculating alone, will cause

the desire for a “release” to increase, and the stimulation needed to ejaculate during partnered sex to more easily occur.

Tip: Switch Hands, 72 Hour delay

While this may not suffice to solve the problem entirely,

success during partnered sex, has increased probability.

Perelman, M. “Understanding, Diagnosing and Treating Delayed Ejaculation Using the Sexual Tipping Point Model,” In P. Nobre et al (eds), Encyclopedia of Sexuality and Gender, Springer International Publishing AG, 2021.

52 of 53

��

If You Or Your Patient Are Uncomfortable With This Strategy

Recognize The Following Yourself And Tell Him:

“Accumulating evidence indicates men suffering from DE, masturbate in a manner that is different from how their partner’s hand, mouth, vagina or anus feels.”
“Understanding of how you stimulate yourself and if it differs from your partnered experience will help me assist you.”

The Psychology Today Blog called:

“Why Delayed Ejaculation Is More Common Than Folks Realize.” summarizes masturbation’s putative role in the etiology of DE.

https://www.psychologytoday.com/us/blog/sexual-tipping-point/201812/why-delayed-ejaculation-is-more-common-folks-realize

53 of 53

Thank You �For Listening!

The STP Model Helps Optimize The

Diagnosis & Treatment Of SD

Other STP videos and related publications and presentations

are available free at: mapedfund.org

For questions contact michael@mapedfund.org