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Sam is laid back, with an easy smile. The 33-year-old recently moved from California to Oregon with his wonderful girlfriend. Everything is going pretty well for Sam, aside from one problem that has emerged over the past year: He can't seem to orgasm during sex.

"Sometimes, when I have sex, whether there is oral or not, I don't orgasm and I become flaccid or too tired to go on," Sam told me over email. While he can successfully sustain an erection and engage in penetrative sex, he can't always finish—a situation that has been torturing him.

Which is why Sam, whose name I've changed to protect his privacy, reached out to me, knowing the issues I cover—wondering if other men suffer from this same issue. Turns out many do. While most sexual dysfunction literature focuses on premature ejaculation or erectile dysfunction, a notable percentage of men face conditions known as "delayed ejaculation" and "anejaculation."

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The disorders are defined by the "persistent or recurrent delay in, or absence of, orgasm after a normal sexual excitement phase" that "causes marked distress or interpersonal difficulty," according to the Diagnostic and Statistical Manual of Mental Disorders. In more concrete terms, this usually means having penetrative sex for more than 25 or 30 minutes and still not being able to orgasm. (Fun fact: On average, men orgasm within 5 to 11 minutes of penetrative sex).

"Delayed ejaculation and anejaculation are probably the least common, least studied, and least understood of the male sexual dysfunctions," writes Chris McMahon, a physician at the Australian Centre for Sexual Health in Sydney, in a review paper for the peer-reviewed journal Medicine Today. The conditions are estimated to affect somewhere between 7 and 11% of men, though hard numbers are difficult to come by, since the problem is under diagnosed. For example, when I asked Sam if he had seen a doctor about his issue, he told me he hadn't—and that it never occurred to him it could be "a medical issue."

In fact, most men who suffer from the problem aren't aware it's a medical issue, according to experts—they only discover that it is when they finally decide to consult a doctor. And when men do seek treatment, the disorder can be difficult to diagnose and treat, since it can be caused by an a host of different medical, neurological, and psychological factors, said Mike Butcher, a urologist at Southern Illinois University who has written several papers on delayed ejaculation's causes and treatments.

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For example, people with diabetes may experience delayed ejaculation because diabetes causes neuropathic disease, Butcher told me. The nerves responsible for an erection are different from the nerves responsible for ejaculation—thus, a man may see normal blood flow to the penis, but he might not experience enough stimulation to orgasm.

Other medical issues that cause delayed ejaculation can include a range of diseases, surgery, birth defects, delayed nerve sensation, and medications, said Butcher, "all of which need to be addressed on an individual level." According to McMahon in Australia, about 25% of cases are lifelong, meaning the men have never been able to successfully orgasm during sex, while 75% are acquired, meaning the men could orgasm at some point but cannot now.

Experts estimate that nearly three-quarters of cases are rooted in psychological issues. "Psychological inhibition of ejaculation typically occurs in young men and is the most common calls of delayed ejaculation seen in clinical practice," McMahon told me. Basically, these men are physically able to ejaculate—as proven through masturbation—but can't in the context of sex.

(I would be remiss not to note here that a full third of women say they have trouble reaching orgasm during sex, according to Planned Parenthood statistics, and can likely relate to this situation. But we'll save that story for another day.)

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For men, this psychological block can occur for a number of reasons, but the specific cause may be hard to pinpoint. For example, Sam can't trace his issue to any medical issue—he isn't sure why it's suddenly happening to him. "Some of my friends have told me that subconsciously I don't like / love my girlfriend if I'm not orgasming, but that can't be further from the truth," he told me. Seeing a doctor could begin to help him understand what's going on.

Experts, commenting in a general sense (not on Sam's specific case), told me that delayed ejaculation and anejaculation can often be the result of sexual anxiety, extreme stress, or even fear of sexual consequences. "Some men are afraid they’re causing their partner pain during sex, especially if the female partner has a history of sexual dysfunction. Or they’re afraid to be a parent, or they may have issues around religion, [believing sex is wrong]," said Butcher.

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For some men, their inability to orgasm during penetrative sex is a result of their individual masturbation techniques.

"Orgasm as a sexual experience is a little bit of a learned behavior," said Butcher, "all of us are gonna figure out how to have a orgasm…and that conditioning is important."

Some men, he said, develop masturbation habits that make it difficult for them to orgasm through regular sex with another person. For example, if a man usually masturbates with various objects, he may condition himself to orgasm only when his penis is inside something specific (i.e., not a body part). In that case, Butcher said, he can get an erection but can't get to the same threshold neurologically with a real-life partner as when masturbating.

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Men with this issue have to relearn how to orgasm—outside of whatever masturbation techniques they're using. Or as Butcher put it, "Masturbation retraining is important, as well as understanding how to have sensation and appreciate the body without the same techniques."

Regardless of the cause, for most men, the problem won't just go away on its own. And because of this persistence, it can be extremely stressful for men and their partners. As Sam told me, his girlfriend has been very understanding about the issue, and they continue to have sex, but sometimes "she is a bit worried that I am not attracted to her, which is in no way the case."

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In some cases, Butcher said, delayed ejaculation can lead to depression and anxiety—and create anxiety in romantic relationships, which comes with its own set of consequences. "That anxiety can carry over into other areas of life. It can affect their confidence, their work, what they want to do and how they think of themselves," Butcher told me.

Unfortunately, the treatment options for delayed ejaculation are limited, and certain types of antidepressants only make the problem worse. As McMahon explained, "Drug treatment of delayed or inhibited ejaculation has met with limited success," and no drugs have been approved specifically to treat the problem. While some doctors may prescribe drugs to address one aspect of delayed ejaculation—which usually means targeting dopamine, serotonin and oxytocin levels—these medications are not designed specifically for the condition, and McMahon said the results have been "relatively poor."

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One major problem both McMahon and Butcher brought up is a lack of awareness around the disorder, and the fact that many men don't seek treatment for sexual dysfunction.

"Younger men tend to delay requests for treatment until they wish to start a family," McMahon told me. "I commonly see men referred from IVF clinics for treatment. Men, in general, have a reluctance to seek treatment for any form of sexual dysfunction."

When men do finally make it to the doctor, they may be misdiagnosed, since delayed ejaculation isn't on every medical professional's radar. The experts want to change that.

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"I want everyone to know about it, so we can find some treatments and have the awareness that it does exist," Butcher said. "It’s true, it's real, and it's out there."

Taryn Hillin is Fusion's love and sex writer, with a large focus on the science of relationships. She also loves dogs, Bourbon barrel-aged beers and popcorn — not necessarily in that order.