Why Some Men Find Orgasms Elusive

New York Times

07-03-2025

Most men, as many as 70 percent, say they reach orgasm quicker than they'd like. But there is an inverse problem that can set in with age: lasting too long.
For some men, reaching climax can take 30 minutes or more. Sex that lasts this long can be uncomfortable, painful and distressing for men and their partners.
Delayed orgasm, as the condition is known, is more commonly associated with women — and for good reason, given the persistent orgasm gap in heterosexual relationships. But up to 10 percent of men over the age of 40 struggle with it, too. In extreme cases, some men can never reach climax, a disorder called anorgasmia.
Orgasm disorders are not well studied or understood, and the little research that does exist tends to focus on premature ejaculation, defined as unintentionally reaching orgasm within two minutes according to the American Urological Association.
But sexual health experts increasingly recognize delayed orgasm as a 'huge problem,' said Dr. Rachel Rubin, a urologist and sex medicine specialist in Maryland. While there are no interventions approved by the Food and Drug Administration, there are some treatment options, including off-label medications, sex therapy and stimulating devices, as well as lifestyle and behavior changes.
How orgasms work
Orgasms are basically a massive reflex, kind of like a 'giant sneeze,' Dr. Rubin said. Just one requiring a 'perfect genital-brain connection.'
The process starts with visual, mental or physical sexual stimulation, triggering the brain to release dopamine, which increases excitement. After sufficient stimulation, the brain releases a surge of pleasure-inducing chemicals, like oxytocin, creating the sensation we think of as an orgasm.
For most men, ejaculation occurs at the same time, 'but they are separate processes,' said Dr. Alan Shindel, a urologist based in San Francisco. While orgasm mostly happens in the brain, ejaculation is a series of involuntary muscle contractions.
Complications affecting the genitals, pelvic floor muscles, spinal cord and brain can make orgasms premature, delayed, muted or even painful, Dr. Rubin said. Given the complexity involved, she said, 'it's actually amazing that more things don't go wrong.'
Causes of delayed orgasm in men
Many physical, neurological or psychological conditions can contribute to delayed orgasm. Here are some of the most widespread causes.
The most common triggers of delayed orgasm are medications and other drugs, including alcohol, said Dr. Landon Trost, a urologist based in Utah. The guidelines from the urological association list 45 different drugs associated with delayed orgasm.
The class of antidepressants called selective serotonin reuptake inhibitors is among the most frequent culprits. These drugs increase serotonin, a chemical that inhibits the neural pathways involved in orgasm, thus raising the threshold required to climax. (For this reason, S.S.R.I.'s are a common off-label treatment for men who ejaculate too quickly.)
Opiates, alcohol, antipsychotics and blood pressure medications, like beta blockers, can also make orgasm difficult by dampening the nervous system's response to sexual stimulation.
Many neurological conditions — including multiple sclerosis, Parkinson's disease, strokes and brain injuries — impair the neural pathways between the brain and genitals, which can result in dulled pleasure, delayed orgasm or painful ejaculation.
Diabetes is another big neurological contributor that often leads to nerve damage. 'It's not just toes and fingers' that are affected, Dr. Shindel said. 'The penis is an extremity, too.'
Spinal injuries are another common cause of delayed orgasm, added Dr. Irwin Goldstein, a urologist based in San Diego. These can include something as simple as a slipped disk.
Another common trigger is the pain or discomfort men may be causing to their partners, which often results in delayed or lack of orgasm for both. Roughly 75 percent women experience pain during intercourse at some point in their lives, some of which is caused by vaginal dryness and irritation, symptoms that can greatly increase at the onset of menopause. The condition is easily treatable with options like local vaginal estrogen, Dr. Rubin said, but often goes undiagnosed and undertreated.
It is 'extremely important' for clinicians treating men for delayed orgasm to 'ask about their partners,' Dr. Rubin said. Differences in libido, preferred types of sex acts and performance expectations can also make it difficult for an orgasm to occur.
Mood disorders — like depression, anxiety and stress — are other common contributors to delayed orgasm. In one self-reported survey, 41 percent of men with moderate to severe delayed orgasm said anxiety and stress during sex was a main reason they were unable to reach climax. Depression in particular can blunt the brain's ability to process pleasure, making orgasm difficult or muted.
Treatments for delayed orgasm
Before treatment, men and their doctors should discuss when the problem started, Dr. Trost said. A sudden onset of delayed orgasm may have a clear trigger (new medications, relationship-related stress or sleep disturbances, for example) and can often be easily reversed. Cases brought on more gradually by age-related conditions and chronic illness may be trickier to treat.
Cases of permanent inability to reach orgasm — caused by the lack of certain dopamine receptors or traumatic brain or spinal injuries — are the most difficult to treat. There are no F.D.A.-approved treatments for delayed orgasm, but clinicians do have a few tools at their disposal.
Several dopamine-promoting drugs — like bupropion, buspirone and cabergoline — have helped counter delayed orgasm for men in some small, randomized control trials.
Sex therapy and counseling are always a good idea for any man with a sexual dysfunction, Dr. Shindel said. Therapy should ideally involve partners, he added, since sexual disorders 'are never just one person's problem.'
Sometimes 'a little more stimulation' can help men reach orgasm more easily, Dr. Rubin said. Sex toys, like vibration devices for the genitals, perineum, prostate or anus, can be helpful to heighten stimulation enough to reach orgasm, she said.
These options don't work for everybody though, said Dr. Shindel, who hopes for new treatments soon. Just as Viagra transformed erectile dysfunction, he said, the same could someday happen for delayed orgasm.
'We're still looking for an orgasm pill,' he said.