Are Specific Sexual Activities During Partnered Sex and Masturbation Related to Sexual Problems in Men?

Abstract

Objectives

To evaluate whether the presence of sexual problems in men (i.e., erectile dysfunction, premature ejaculation, or delayed ejaculation) is associated with differential sexual behavior during masturbation and partnered sex.

Methods

Cisgender participants (n = 2,807) completed an internet-based, cross-sectional questionnaire about sexual interest, behavior, and functioning.

Results

Men with premature ejaculation were less likely to engage in foreplay-type behaviors, whereas men with erectile dysfunction or delayed ejaculation were more likely to include self-stimulation and/or other stimulation strategies during partnered sex.

Conclusions

Different behavioral patterns among dysfunctional men represent potential strategies for modulating sexual arousal levels.

Introduction

A substantial portion of men—estimated at 30 to 50%–experience difficulty of one type or another during sexual activity with their partner (Anderson et al., 2022; Irfan et al., 2020; McCabe et al., 2016; Rosen, 2000; Rowland, Oosterhouse, et al., 2021). These difficulties may include, but are not limited to, ejaculating too quickly after the onset of penile stimulation (i.e., premature ejaculation [PE]), having difficulty getting or keeping an erection (i.e., erectile dysfunction [ED]), and—despite having adequate erectile response—difficulty reaching ejaculation (i.e., delayed ejaculation [DE]). The extent to which such dysfunctional responses can be modified depends on both the etiological factors responsible for the problem and the available remediation actions. Furthermore, approaches to treatment—no matter the etiology—that combine both biomedical and psychosexual strategies may offer better long-term treatment outcomes (Cormio et al., 2015; Khan et al., 2017; 2019; Li et al., 2006; Perelman, 2006; Shao & Li, 2008; Tang et al., 2004; Yuan et al., 2008), as each approach brings unique assets to the therapeutic process. For example, inclusion of biomedical/pharmaceutical strategies may improve the man’s confidence in the adequacy of his sexual response, whereas psychosexual strategies may address issues surrounding improved motivation, partner communication, shared intimacy, feelings of self-efficacy, and overall sexual satisfaction.

Perhaps sometimes overlooked in the above treatment scheme is the role that variation in sexual stimulation/behaviors might play in enhancing sexual response/arousal (e.g., for problems with ED or DE) or in attenuating it (e.g., for problems with PE). Indeed, the relevance of sexual stimulation and arousal to achieving optimal sexual response in men with sexual problems has not only been fundamental to understanding sexual dysfunctions for decades, but has also been demonstrated through several lines of research. First, men who experience sexual problems during partnered sex often do not display similar levels of dysfunctionality during masturbation—a pattern that has been found for both ED and ejaculatory disorders such as PE and DE (Perelman, 2020; Rowland, Hamilton, et al., 2021; Rowland, Teague, et al., 2022). Thus, when men have complete control over the physical (e.g., frequency and intensity of penile stimulation) and psychosexual (e.g., stimuli with high subjective arousal value) stimuli that produce arousal as occurs during masturbation, their level of dysfunctional symptomology is greatly attenuated. The nature of such stimulation and its consequential effects on arousal might either enhance the arousal (when the problem stems from inadequate erection or orgasm deficiency) or attenuate it (when the problem is associated with hyperarousal as occurs in men with PE). Second, a growing body of evidence suggests that both PE and DE may be viewed as disorders of physiological and/or psychosexual arousal, either too much for situations involving PE (Lucas Bustos et al., 2023; Rowland, 2010; Rowland & Crawford, 2011; Ventus & Jern, 2021; Zorba et al., 2012), or too little for situations involving DE (Perelman, 2020; Rowland et al., 2004, 2005; Rowland, Hamilton, et al., 2021). And finally, one recent analysis has demonstrated that PE symptomology varies with the type of sexual activity/stimulation during partnered sex, whether vaginal penetrative, anal penetrative, or non-penetrative (e.g., mutual masturbation) (McNabney et al., 2022).

Taken together, the above literature highlights the important adjunctive role for sexual stimulation as a means of optimizing arousal levels in order to overcome sexual difficulty. This idea, long rooted in the early treatment protocols of Masters and Johnson (Masters & Johnson, 1970) and Semans (Semans, 1956), intimates that men with sexual dysfunctions may not only show different likelihoods of engaging in various types of sexual activities compared with sexually functional men (Dodge et al., 2016; Herbenick et al., 2010), but might also show differences in the most-to-least preferred activities. Indeed, in the age of new pharmaceuticals designed to treat sexual problems, it appears that some of the critical strategies embedded in psychosexual therapies that pre-dated the drug era may have been overshadowed—if not lost entirely—in the rush to embrace these new low effort/readily accessible biomedical approaches. In light of this development, the critical role for sexual stimulation in countering dysfunctional response may warrant rejuvenation to counterbalance today’s pharmaceutically-oriented approach toward resolving problems of sexual performance (e.g., De Carufel & Trudel, 2006; Rowland, 2007) by providing a more natural approach to controlling arousal levels that builds on relational communication during partnered sex.

Rationale and goals

Multiple sources suggest that the type and/or intensity of sexual stimulation—typically mediated through specific sexual activities during partnered sex—play an important role in optimizing levels of sexual arousal and performance. Yet, direct support for this assumption has, to our knowledge, never been reported. At the same time, men showing a sexual dysfunction tend to differ from sexually functional men in a variety of other ways, for example, along psychological, behavioral, and relational dimensions related to masturbation and partnered sex, overall relationship satisfaction, self-reported levels of interest in sex, the presence of medical issues, and levels of self-reported anxiety (McCabe et al., 2016; Rosen, 2000; Rowland et al., 2005; Rowland, Hamilton, et al., 2021). As such, assessment of differences in specific sexual activities between men with and without sexual dysfunctions would benefit by inclusion of covariates that control for—and specify the role of—these other dimensions.

This present study examines the extent to which men and their partners attempt to cope with the man’s sexual problem by adjusting their sexual activities to either increase (for ED or DE) or reduce (for PE) sexual stimulation and arousal during partnered sex. To this end, we:

1. assessed the prevalence of specific sexual activities during partnered sex and masturbation in men with and without sexual dysfunctions (Aim 1);

2. determined whether the prevalence of specific sexual activities differed between men with and without sexual problems (Aim 2);

3. related patterns of sexual activities during partnered sex and masturbation to four factors known to covary with sexual problems, including self-reported importance of sex, frequency of partnered sex, frequency of masturbation, and relationship satisfaction (Aim 3);

4. explored the possibility that some stimulation-arousal strategies used by dysfunctional men might actually interfere with their arousal during partnered sex (Aim 4).

Materials and methods

Participants

Participants were recruited by voluntary self-selection from July 2019 through February 2020 to complete an online survey pertaining to sexual health and behavior. The sample was recruited through two approaches. The first group was recruited from the United States and other English-speaking countries (n = 699) and included men who responded to the research homepage, postings on several reddit.com forums, or any of the unpaid social media (e.g., Facebook) and public announcements/advertisements (e.g., online, social media, listservs, special interest groups, etc.). The second group was recruited from Hungary and included men who responded to comparable forum posts (using online magazine websites: Origo She, Index Dívány, Style.hu, HV), unpaid online/public advertisements (online, social media, special interest groups, public media), or the Hungarian research homepage (n = 3,243). An additional anonymously-coded group (not included in the data analysis) consisted of men attending a major university in Hungary (n = 134) who took a paper-and-pencil version of the questionnaire for the sole purpose of establishing test-retest reliability on questionnaire items after 4–6-weeks (Table 1).

Table 1.

List of major study variables (timeframe for sexuality measures based on past 12–24 months).

Variable name/type	Response options (abbreviated)	Test-retest r
Participant Age	In years	NA
Education (attainment)	1 = Less than high school 6 = Graduate or Post-baccalaureate	NA
Sexual orientation	0 = Asexual or non-sexual 1 = Primarily heterosexual 2 = Somewhat heterosexual 3 = Bisexual 4 = Somewhat homosexual 5 = Primarily homosexual	NA
Interest in sex	1 = Very low 5 = Very high	0.67
Importance of sex	1= Not at all important 5= Very important	0.75
Overall relationship satisfaction	1= Not at all satisfied/low quality 5= Very satisfied/high quality	0.89
Frequency of partnered sex	1 = Almost never 9 = More than once/day	0.81
Frequency of masturbation	1 = Almost never 10 = More than several times/day	0.78
Composite IIEF-5 (partnered sex)	Range from 4 - 20 Lower scores = greater erectile difficulty	0.89
PEDT Score (partnered sex) (Measure of ejaculatory control)	≤ 8 = No PE 9–12 = Probable PE 13–15 = Definite PE	0.85
Difficulty reaching orgasm (Measure of DE, partnered sex)	1 = Not at all 5 = Almost always	0.77
Bother/Distress related to dysfunction	1 = Almost never 5 = Almost always	0.78
Sexual activities, partnered sex (Yes/no checklist)	-Vaginal intercourse -Anal intercourse-enterer -Anal intercourse-receiver -Non-penile stimulation (e.g., nipples, testicles) -Oral stimulation-receiver -Oral stimulation-giver -Use of stimulatory aids (vibrators, rings, genital jewelry, etc.) -Penile stimulation, self -Penile stimulation, by/with partner -Erotic enhancements (pornography of any type, mirrors, etc.) -Sexual fantasy, partner -Sexual fantasy, not the partner -Other	NA
Sexual activities, masturbation	-Penile stimulation, hand/other method -Anal stimulation -Non-penile stimulation (e.g., nipples) -Use of stimulatory aids -Erotic enhancements (porn, mirrors) -Sexual fantasy, partner -Sexual fantasy, not the partner -Other	NA

Note. NA = Not Available.

The completion rate for the survey was 81% of those who initially opened it. Among those completing the survey, men who were under 18 years old; had never had partnered sex or had never reached orgasm during partnered sex (n = 1,703); did not have a current or recent partner (the latter defined as within the past 12 to 24 months); did not identify as cisgender (i.e., transgender/non-binary) or provided no information for the gender identity item; identified as “asexual” (n = 59); or showed inconsistent responses as determined by embedded “attention checks,” were excluded. The final sample consisted of 2,807 men 18+ years of age (mean = 37.66, SD = 12.89; range = 18–85).

Survey questionnaire

During the survey development, seven in-person focus sessions were conducted. Two included men in the USA (n = 10, mean age = 32.4, range = 22–58), and five included men from Hungary (n = 79, mean age = 22.7, range = 19–26). Participants reviewed questionnaire items for clarity and face-validity, suggested wording changes and additional/alternate response options for survey items (e.g., additional activity categories), and assessed the time required for survey completion (Catania et al., 2015). For Hungarian respondents, the questionnaire was translated to Hungarian and back-translated to English by professional translators. For existing standardized assessment scales embedded in the questionnaire (see below), previously validated question formats were used, with minor modifications as necessary (e.g., replacing “intercourse” with “partnered sex”).

The first part of the online survey queried about demographic characteristics, including age, level of educational attainment, anxiety/depression for over 6 months (continuously or intermittently) during the past 1–2 years (as a proxy for psychological health), and any chronic medical conditions related to sexual functioning. The second part examined participants’ sexual histories during the past 1–2 years, including sexual orientation, partner status, importance of and interest in sex, overall relationship satisfaction, and sexual relationship satisfaction. This section also evaluated the frequencies of partnered sex, masturbation, and pornography use during masturbation. The third section addressed major sexual dysfunctions in men and included relevant items from the International Index of Erectile Function (IIEF-5) (Rosen et al., 1999), and the Premature Ejaculation Diagnostic Tool (PEDT) (Symonds et al., 2007), as well as questions aimed at assessing DE (Rowland, Attinger, et al., 2023; Rowland & Cote-Leger, 2020; Rowland, McNabney, et al., 2023).

Measures

Major organizing variable and definitions of dysfunctional groups

The major organizing variable was whether or not men reported symptoms of a sexual dysfunction, with four defined groups: (1) “having no sexual dysfunction” (CONTROL); (2) premature ejaculation only (PE); (3) delayed ejaculation only (DE); (4) combined ED and ED + DE (ED/ED + DE).

No dysfunction

The CONTROL group was defined as those men having no PE, no or only very mild ED, and no or very mild DE. These men also indicated a moderate-to-high level of interest in sex (≥ “3” or higher on a five-point scale).

PE

PE was assessed using three of the five items from the PEDT focusing on ejaculatory control, the construct most central to PE (Patrick et al., 2007). Two items related to “bother/distress” were not included as they represent consequences of PE, a distinct construct (see Cronbach and Meehl (1955), Rowland, Althof, et al. (2022), Rowland, McNabney, et al. (2022), Rowland and Cooper (2022), and Strauss and Smith (2009) to justify this approach). Response options ranged from one to five, with higher scores indicating a higher probability of PE. Using a scoring rubric that relied on a proportional cutoff identical to the original instrument, consistent with the overall diagnostic categories for the PEDT, scores of 13–15 represented “definite PE” and were used to define the PE group. Internal reliability for the three items was 0.89.

DE

Because no Patient Reported Outcomes (PROs) have been validated for assessing DE, we selected an experimenter-derived item to assess DE symptomology which asked respondents about their “difficulty reaching orgasm during partnered sex,” an item known to differentiate between men with and without DE (Rowland, Attinger, et al., 2023; Rowland & Cote-Leger, 2020; Rowland, McNabney, et al., 2023). Responses were scaled 1–5, with higher scores representing greater difficulty. For this item, 1–2 represented “no/mild DE,” 3 represented “moderate DE,” and 4–5 represented “moderately-severe to severe DE,” with the 4–5 (severe) category (i.e., 75% of the time or more) used to define DE men for comparisons with other groups. The 75% frequency aligns with the DSM-5 criterion for DE (American Psychiatric Association, 2013).

ED

ED was assessed with four IIEF-5 items related specifically to erection (one item on satisfaction during intercourse was not included) (see Cronbach and Meehl (1955), Rowland, Althof, et al. (2022), Rowland, McNabney, et al. (2022), Rowland and Cooper (2022), and Strauss and Smith (2009) to justify this approach). Response options ranged from 1 to 5, with lower scores indicating a higher likelihood of erectile problems. Using a scoring rubric that relied on a proportional cutoff identical to the original instrument, men scoring from four to nine (moderately-severe to severe ED) were used to define the ED group. Internal reliability for the four items was 0.89. Due to the relatively low number of men with only ED who met the inclusion criteria, we combined the ED group with men who reported comorbid ED and DE, so designated as the ED/ED + DE group.

Primary outcome variables

Prevalence of specific sexual activities during partnered sex and (separately) masturbation

The likelihood of engaging in specific sexual activities was the outcome variable (see Table 1). Designated activities were derived from the existing literature as cited in the Introduction, which were then reviewed and revised by three doctoral level experts (two sexologists, one non-sexological clinical psychologist). Activities and response options were also reviewed by the focus groups, which modified and/or endorsed the list of existing sexual activity categories.

Explanatory covariates

Four variables known to be related to sexual function/dysfunction (McCabe et al., 2016; Rosen, 2000; Rowland et al., 2005; Rowland, Hamilton, et al., 2021) were included as explanatory covariates in the regression analyses. These four variables were chosen not only for their intrinsic connection with sexually dysfunctional status, but also because they serve as proxies for other variables that differ across functional and dysfunctional groups. Thus, anxiety levels, medical conditions, medication use, pornography use, age, and sexual satisfaction often cluster with the four variables included below (McCabe et al., 2016; Rosen, 2000; Rowland et al., 2005; Rowland, Castleman, et al., 2023; Rowland, Hamilton, et al., 2021; Rowland, Morrow, et al., 2022). To avoid collinearity of covariates, variance inflation factors for the four included variables were determined to be less than 3.0.

Importance of/Interest in Sex represented the composite of two items, the first querying about the person’s general interest in sexual activity (1 = not at all; 5 = very much), and the second about the importance of sexual activity (1 = not at all; 5 = very much). These two items were combined due to their strong correlation (r = .72). For convenience, this variable was denoted as “importance of sex.”

Frequencies of Partnered Sex and (separately) Masturbation were assessed by two separate items. The frequency of partnered sex was assessed on a nine-point scale (1 = Almost never, 9 = More than once a day), frequency of masturbation on a 10-point scale (1 = Never, 10 = > 4 times/day).

Relationship Satisfaction was represented by a single item ranging on a five-point scale from 1 (not at all satisfied/low quality) to 5 (very satisfied/high quality).

Procedure

Ethics approval was obtained from the IRBs at the authors’ institutions in the USA and Hungary. The survey incorporated best practices in that no incentives or rewards were offered; completion time was under 20 minutes; anonymity was guaranteed; safeguards prevented multiple submissions; and attention checks ensured internal reliability (Kays et al., 2013; Kirana et al., 2023). In addition, test-retest reliability and internal reliability indices were determined for measures as appropriate, thereby enhancing confidence in the validity/reliability of participants’ responses. Informed consent was obtained by participants’ checking boxes attesting (1) to their current age of ≥ 18 years, and (2) to their informed consent, before accessing the questionnaire. Respondents could end participation at any time by closing the webpage.

Data analysis

Frequencies of responses were established for sexual activities (yes/no options) during partnered sex and masturbation, comparing the control (no dysfunction) group with each one of the three dysfunctions groups separately using binomial logistic regression. In a preliminary set of analyses, origin-of-data (Hungary vs. USA+) differed on several demographic variables, so this variable and participant age were statistically controlled in the regression models. This preliminary analysis indicated that age played a significant role in 47 of 63 comparisons, although the adjusted ORs were typically very low, 1.0 ± 0.03 for partnered sex, and 1.0 ± 0.015 for masturbation. Origin of data played a significant role in 20 of 63 comparisons, with the largest ORs related to the Hungarian group being less likely to engage in penetrative anal intercourse, give oral stimulation during partnered sex, or use stimulatory aids during masturbation. Given these effects, both variables were retained in the second series of regression analyses.

In a second series of binomial logistic regression analyses, we assessed the role of the additional four explanatory covariates (specified previously) in accounting for variance in sexual activities. For group comparisons on these variables, p was set at .01 to control for family-wise α. Given the exploratory/preliminary nature of this study, we did not to further adjust α downward, as our goals were to detect even fairly subtle patterns that might represent viable candidates for future investigations and to identify possible avenues for exploration within clinical/therapeutic settings.

Results

Description of the sample

Table 2 presents bivariate comparisons between men in the dysfunctional groups (PE, DE, and ED/ED + DE) and healthy controls on demographic and sexual history variables. On average, men with ED/ED + DE were older (45.1 vs. 37.7 years) and significantly more likely to report medical issues than men in the control group (41% vs. 17%, z = −5.82, p < .001). Compared to the control group, significantly fewer men with PE reported a bisexual or gay sexual orientation (10% vs. 17%, z = 3.40, p < .001). Together with the DE group, ED/ED + DE men also were more likely to report a history of anxiety/depression compared to control (31% and 32% vs. 16%, respectively). All dysfunctional groups reported greater bother/distress than the control group. Frequency of partnered sex was significantly lower in the PE and ED/ED + DE groups, and relationship satisfaction was lowest in the PE group.

Table 2.

Comparison of control and dysfunctional groups on select demographic and sexual measures.

Variable	Control mean (SD) (n = 1,994)	Only PE mean (SD) (n = 378)	Only DE mean (SD) (n = 281)	ED/ED + DE mean (SD) (n = 156)	t/z-statistic (PE)*	t/z-statistic (DE)*	t/z-statistic (ED)*
Age	37.7 (12.73)a	37.7 (12.06)a	38.7 (14.13)a	45.1 (15.79)b	0.009	−1.228	−5.364
Education	2.89 (1.57)a	2.48 (1.52)b	2.79 (1.51)a	2.88 (1.62)a	3.203	0.916	−0.009
Medical issues (%)	0.17a	0.20a	0.21a	0.41b	−0.859	−1.594	−5.824
Ongoing anxiety (%)	0.16a	0.21a	0.31b	0.32b	−1.684	−5.930	−3.486
Gay/bisexual identity (%)	0.17a	0.10b	0.18a	0.16a	3.396	−0.415	0.281
Relationship satisfaction	3.21 (1.82)a	2.71 (1.91)b	2.96 (1.80)a	2.73 (1.81)a	3.351	2.017	2.363
Frequency, partnered sex	6.34 (1.60)a	5.87 (1.57)b	6.08 (1.81)a	5.09 (1.75)b	3.592	2.343	7.186
Frequency, masturbation	5.54 (2.19)a	5.30 (2.36)a	5.90 (2.19)a	5.63 (2.24)a	1.324	−2.468	−0.215
Bother/distress	2.76 (1.73)a	3.62 (1.84)b	3.80 (1.70)b	4.33 (1.49)b	−6.114	−9.010	−8.030
Importance of sex	8.38 (1.45)a	8.21 (1.51)a	8.30 (1.63)a	7.98 (1.70)a	1.444	0.818	2.566

Notes. *Value based on equal variances for t-tests. Proportions compared with z-tests. Columns sharing the same subscript as the Control group (“a”) are not significantly different from Control, with p ≥ .01. Columns with subscript “b” are significantly different from Control at p < .01.

Prevalence of sexual activities (Aim 1)

Partnered sex

Descending order of activities

Tables 3 and 4 presents activities during partnered sex and masturbation in order of descending frequency based on the control (sexually functional) group. Men in this group engaged most frequently in vaginal intercourse, giving and receiving oral stimulation, non-penile stimulation by the partner, and partner stimulation of the penis. Penile self-stimulation occurred less frequently, along with anal sex (giver and receiver), use of erotic enhancements, use of stimulatory aids, and partner-based or non-partner-based sexual fantasy.

Table 3.

Frequencies of activities during partnered sex.

Type of activity		Control (n = 1,994)	Only PE (n = 378)	Only DE (n = 281)	ED/ED + DE (n = 156)
Vaginal intercourse	% Yes	84.4	85.7	76.5 ** ↓↓	74.4
Oral stimulation-giver	% Yes	83.8	71.7 *** ↓↓	80.8	77.6
Oral stimulation-receiver	% Yes	82.5	67.7 *** ↓↓	79.7	62.8 ** ↓↓↓
General body stimulation	% Yes	72.2	56.9 *** ↓↓	65.8	57.7 ** ↓↓
Penile stimulation, partner	% Yes	69.3	57.4 ** ↓↓	67.3	62.8
Penile stimulation, self	% Yes	40.0	27.8 ** ↓↓	46.3 * ↑	46.8 ** ↑↑
Anal intercourse-enterer	% Yes	29.6	17.7 * ↓↓	28.1	20.5
Fantasy-partner	% Yes	23.7	16.1	28.8	23.1
Stimulatory aids	% Yes	23.0	19.0	22.4	18.6
Erotic enhancements	% Yes	15.8	11.1	15.3	13.5
Fantasy-not partner	% Yes	12.8	9.3	19.9 ** ↑↑	20.5* ↑
Anal intercourse-receiver	% Yes	12.0	7.4 * ↓↓	12.5	9.6
Other	% Yes	1.7	1.1	1.8	0.6

Notes. Comparisons were between the control group and each dysfunctional group. * p < .05, ** p < .01, *** p ≤ .001. ORs > 1.0 suggest higher odds of the outcome in the dysfunctional group compared to controls, and ORs < 1.0 suggest lower odds of the outcome compared to controls. Standardized odds ratios suggested low-moderate effect sizes (Rosenthal 1996), with arrows indicating both direction and effect: ↓↑ = small effect (OR < 1.4 or > 0.70); ↑↑↓↓ = moderate effect (OR > 1.4 or < 0.70); ↑↑↑↓↓↓ = strong effect (OR > 2.0 or < 0.50).

Table 4.

Frequencies of activities during masturbation.

Type of activity		Control (n = 1,994)	Only PE (n = 378)	Only DE (n = 281)	ED/ED + DE (n = 156)
Penile stimulation	% Yes	85.2	78.3 ** ↓↓	81.1 * ↓↓	85.3
Erotic enhancements	% Yes	71.0	63.8 ** ↓↓	68.3	65.4
Fantasy-not partner	% Yes	45.4	42.3	42.0	41.0
Fantasy-partner	% Yes	43.0	34.9	37.0	34.0
General body stimulation	% Yes	20.2	18.5	18.9	25.0
Anal stimulation	% Yes	10.9	7.7	9.6	9.6
Stimulatory aids	% Yes	9.2	7.1	7.5	10.9
Other	% Yes	0.6	0.8	1.1	0.0

Notes. Comparisons were between the control group and each dysfunctional group. * p < .05, ** p < .01, *** p ≤ .001. ORs > 1.0 suggest higher odds of the outcome in the dysfunctional group compared to controls, and ORs < 1.0 suggest lower odds of the outcome compared to controls. Standardized odds ratios suggested low-moderate effect sizes (Rosenthal, 1996), with arrows indicating both direction and effect: ↓↑ = small effect (OR < 1.4 or >0.70); ↑↑↓↓ = moderate effect (OR > 1.4 or < 0.70); ↑↑↑↓↓↓ = strong effect (OR > 2.0 or < 0.50).

Men with various sexual dysfunctions showed identical or similar hierarchical orderings. Specifically, men with PE showed a descending order identical with the control group; men with only DE or ED/ED + DE showed minor variations in the hierarchy, endorsing oral sex (as the giver) more frequently than vaginal sex. Other minor transpositions of order occurred within these latter two dysfunctional groups, mostly for low-frequency activities.

Masturbation

Descending order of activities

Based on the control group, the most frequently endorsed activities during masturbation were penile stimulation and the use of erotic enhancements (Tables 3 and 4). Both partner and non-partner sexual fantasies hovered in the midrange (40–45%). Non-penile stimulation, anal stimulation, and the use of stimulatory aids were endorsed by 20% or fewer participants. Men with sexual dysfunctions showed identical descending orders as the control group.

Activity differences between control and dysfunctional groups (Aim 2)

After establishing the general pattern of responses (% yes) for each of the groups, frequencies of endorsement for each of the partnered sex and masturbation activities were analyzed in a series of binomial logistic regressions, comparing each of the dysfunctional groups (PE, DE, and ED/ED + DE) to healthy controls (Tables 3 and 4). In these regression models, preliminary analyses included the control covariates of age and origin-of-data (USA vs. Hungary), followed by a second set of analyses in which all four explanatory covariates—known to vary with dysfunctional status—were included as well (Aim 3, Table 5). Thus, differences in the prevalence levels of sexual activities between groups could not be attributed merely to variation in either the control or explanatory variables (Tables 3 and 4). To reduce clutter and density of information and to increase readability of the table, for these analyses odds ratios and confidence intervals are not presented. However, significance levels are indicated by asterisks, and direction and magnitude of effect are indicated by the direction and number of arrows, as interpreted in the table notes.

Table 5.

Relationships between sexual dysfunction covariates and specific sexual activities during partnered sex and masturbation, adjusting for nationality/origin of data and participant age.

Partnered sex activity	Importance of sex	Frequency of partnered sex	Frequency of masturbation	Relationship satisfaction
Vaginal intercourse		↑ **	↓ ***	↑ **
Anal intercourse-enterer	↑ **	↑ ***	↑ ***
Anal intercourse-receiver			↑ ***
Non-penile stimulation	↑ ***	↑ ***
Oral stimulation-receiver		↑ ***	↑ ***
Oral stimulation-giver		↑ ***	↑ ***
Stimulatory aids	↑ ***	↑ ***	↑ **	↑ ***
Penile stimulation, self	↑ ***	↑ **	↑ ***
Penile stimulation, partner	↑ ***	↑ ***	↑ ***
Erotic enhancements	↑ ***	↑ ***	↑ ***
Fantasy-partner	↑ ***	↑ ***	↑ ***	↑ **
Fantasy-not the partner	↑ ***		↑ ***

Masturbation activity	Importance of sex	Frequency of partnered sex	Frequency of masturbation	Relationship satisfaction
Penile stimulation		↓ **	↑ ***
Anal stimulation	↑ ***		↑ ***
Non-penile stimulation	↑ **	↓ **	↑ ***
Stimulatory aids	↑ ***		↑ ***
Erotic enhancements	↑ ***	↓ **	↑ ***
Fantasy-partner	↑ ***	↑ ***	↑ ***	↑ ***
Fantasy-not the partner	↑ **	↓ ***	↑ ***	↓ ***

Note. Appropriate effect size comparisons are within each column rather than across columns. ** p < 0.01, *** p ≤ .001. Standardized odds ratios suggest low-moderate effect sizes (Rowland, McNabney, et al., 2022), with arrows indicating both direction and effect: ↓↑ = small effect (OR < 1.4 or > 0.70); ↑↑↓↓ = moderate effect (OR > 1.4 or < 0.70).

Activity differences during partnered sex

Compared to the control group, men with PE reported the most substantial activity differences during partnered sex, with significantly lower endorsement of foreplay-type activities (e.g., giving and receiving oral stimulation, manual stimulation of the penis/mutual masturbation, and stimulation of non-penile erogenous zones). Men with PE were also less likely to engage in penetrative or receptive anal sex than controls.

Men with DE were less likely to engage in penile-vaginal intercourse, and men with ED/ED + DE had significantly lower odds of receiving oral stimulation or engaging in stimulation of erogenous zones (e.g., nipples, testicles). Interestingly, men with either DE or ED/ED + DE both reported higher odds of self-stimulation and non-partner sexual fantasy during partnered sex.

Activity differences during masturbation

Masturbation activities were relatively consistent across all dysfunctional groups, with only three significant differences from controls. Men with either PE or DE both reported significantly lower odds of direct penile stimulation during masturbation. Moreover, men with PE were less likely to use erotic enhancements—such as video pornography or magazines—during masturbation.

Associations between explanatory covariates and specific sexual activities (Aim 3)

Table 5 illustrates the effects of four empirically relevant covariates—relationship satisfaction, importance of sex, frequency of partnered sex, and frequency of masturbation—on endorsement of the previously described activities during partnered sex and masturbation using a series of binomial logistic regression models. For these analyses, we retained nationality/origin of data and participant age as control covariates and adjusted the type I error rate for multiple comparisons (α = 0.01). To simplify the results presented in Table 5 and to emphasize patterns of results for each of the explanatory covariates, individual odds ratios and confidence intervals are not presented. For this table, significance levels are indicated by asterisks, and direction and magnitude of effect are indicated by the direction and number of arrows, as interpreted in the table notes.

Relationship satisfaction

During partnered sex, higher relationship satisfaction predicted higher activity in vaginal intercourse, use of stimulatory aids, and partner sexual fantasy. For masturbation, higher relationship satisfaction was associated with higher odds of partner sexual fantasy and lower non-partner sexual fantasies. Effect sizes were small.

Importance of sex

During partnered sex, greater importance of sex predicted higher engagement in every type of activity except vaginal intercourse, receptive anal sex, and giving or receiving oral sex. During masturbation, greater importance of sex predicted higher odds of engaging in every activity except penile stimulation. Effect sizes were small.

Frequency of partnered sex

During partnered sex, higher rates of partnered sex predicted greater engagement in all activities except receptive anal intercourse, and non-partner sexual fantasy. During masturbation, higher frequency of partnered sex predicted lower penile stimulation, non-penile (i.e., other erogenous zone) stimulation, use of erotic enhancements, and non-partner sexual fantasy, but higher odds of engaging in partner sexual fantasy. Effect sizes were small.

Frequency of masturbation

During partnered sex, higher frequency of masturbation predicted lower likelihood of vaginal intercourse and greater likelihood of engaging in all other types of sexual activity except for non-penile stimulation. During masturbation, higher frequency of masturbation predicted higher odds of engaging in every type of sexual activity. Effect sizes were small.

Discussion

Our findings revealed three distinct patterns: (1) a high level of consistency across control and dysfunctional groups in the hierarchy of sexual activities during partnered sex and masturbation; (2) specific differences in activities between control and dysfunctional groupings; and (3) significant, but weak, associations between the prevalence of specific sexual activities and the four explanatory covariates explored in this study.

Hierarchy of activities

During partnered sex, the hierarchy of activities for vaginal intercourse, oral sex (receiver and giver), and anal sex (enterer) were similar to those reported elsewhere (Dodge et al., 2016; Herbenick et al., 2010). Hierarchies for men with various sexual dysfunctions were similar to controls, suggesting that dysfunctional status did not result in large differences in the types of activities used by couples during partnered sex. Several minor adjustments did occur, for example, men with ED/ED + DE and pure DE were more likely to give oral stimulation to their partner than engage in vaginal intercourse, patterns suggesting that men having diminished capacity for intercourse might compensate with oral sex as a way of pleasing their partner.

Control vs. dysfunctional group differences

A second aim of this analysis was to determine whether men might adjust their specific sexual activities to accommodate the need for greater or lesser stimulation during partnered sex. In fact, such dysfunction-related adjustments did appear in all three dysfunctional groups.

Specifically, men with PE were more likely to avoid a number of foreplay activities (e.g., manual stimulation by the partner or self, oral stimulation, etc.) typically aimed at increasing early levels of arousal. As such, these men appear to use strategies that counteract their problem of too much arousal, too quickly (Lucas Bustos et al., 2023; Rowland, 2010; Rowland & Crawford, 2011; Ventus & Jern, 2021; Zorba et al., 2012). During masturbation, these men were also less likely to use erotic enhancements such as pornography.

In similar dysfunction-related adjustments, men with either DE or ED (with comorbid DE)—who might benefit from increased levels of stimulation—were more likely to include manual self-stimulation and to use non-partner sexual fantasies, presumably as ways to enhance arousal. And for men with ED/ED + DE, the aforementioned activities may have displaced less effective strategies such as partner stimulation of non-penile regions.

Explanatory covariates and specific sexual activities

Relationship conditions, the importance of sex, and the frequency of partnered and solo sex are known to differ between men with and without a sexual dysfunction (Dodge et al., 2016; Herbenick et al., 2010; Hevesi et al., 2023; Rowland, Castleman, et al., 2023; Rowland, Morrow, et al., 2022; Rowland, Padilla, et al., 2023) and, as such, they represent possible confounding factors when examining control/dysfunctional group differences in stimulation activities. Thus, understanding their association with engagement in specific sexual activities is important.

Generally, the greater the importance of sex and the greater the frequency of partnered sex or masturbation, then the higher the engagement in most partnered sexual activities. Consistent with prior research (Hevesi et al., 2023; Rowland, Castleman, et al., 2023; Rowland, Morrow, et al., 2022; Rowland, Padilla, et al., 2023), these measures were likely tapping into the same construct, namely a general interest and desire for sexual activity and pleasure. Exceptions to the above patterns were fairly predictable. For example, men who masturbated more frequently were less likely to have vaginal intercourse, a general proxy for partnered sex. Prior analyses have associated higher frequency of masturbation with dysfunctional status and other problems tied to partnered sex (e.g., limited access to the partner (Rowland, Padilla, et al., 2023)). Other exceptions, for example, ones regarding the use of sexual fantasy during partnered sex, have possible relevance to understanding dysfunctions such as ED and DE, and are discussed in detail in the next section. Interestingly, relationship satisfaction had the fewest associations with specific partnered sexual activities, being characterized primarily by a greater frequency of partnered sex, a finding consistent with other studies (Rowland, Castleman, et al., 2023; Rowland, Morrow, et al., 2022).

During masturbation, greater frequency of partnered sex predicted lower odds of engaging in most sexual activities. In contrast, greater interest in sex and higher frequency of masturbation were associated with higher odds of engaging in most sexual activities. These patterns reiterate well-known associations between masturbation activity, the importance of sex, relationship satisfaction, and partnered sex activity—the former pair and latter pair being positively correlated, but the pairs themselves being negatively correlated with one another (Gerressu et al., 2008; Hevesi et al., 2023; McNulty et al., 2016; Perry, 2020; Rowland, Castleman, et al., 2023; Rowland, Morrow, et al., 2022; Rowland, Padilla, et al., 2023; Schoenfeld et al., 2017). Notable exceptions occurred regarding the use of sexual fantasy during masturbation (see below).

The convergence of specific sexual activities, dysfunctional status, and explanatory covariates

Finally, our data enable a preliminary exploration of an idea reported in clinical circles, namely, that men with ED or DE use sexual-stimulation activities that might actually interfere with arousal during partnered sex (Aim 4) (Perelman & Rowland, 2006; Rowland, Hamilton, et al., 2021). Specifically, drawing from previous reports as well as the current data, we demonstrate how the convergence of three factors—dysfunctional status, explanatory covariates, and prevalent sexual activities in ED or DE men—offer some support for this clinical observation.

Compared with functional counterparts, men with ED or DE typically (1) masturbate more frequently; (2) have less partnered sex; and (3), report overall lower relationship satisfaction (Hevesi et al., 2023; McNulty et al., 2016; Rowland, Morrow, et al., 2022; Rowland, Castleman, et al., 2023). Furthermore, even though men with DE or ED may engage in some activities intended to increase their arousal (e.g., self-stimulation), they might also unwittingly engage in activities that negatively impact their performance during partnered sex. For example, men with DE (and to some extent men with ED) were more likely to engage in non-partner sexual fantasy during partnered sex. Yet clinical observations suggest that the use of sexual fantasies that focus on persons other than the immediate partner could well interfere with sexual arousal during partnered sex (e.g., Perelman, 2020; Perelman & Rowland, 2006). However, as demonstrated in this study, men with lower relationship satisfaction were also more likely to engage in non-partner sexual fantasy, as were men who have less frequent partnered sex (also, independent of DE status and relationship satisfaction). As shown in this study, each of these factors—dysfunctional status, lower relationship satisfaction, and lower frequency of partnered sex—contributed independently to the increased likelihood of using non-partner sexual fantasy during partnered sex. Although the effect size for any one of the conditions noted above was relatively small, the convergence of these independent factors might present a formidable challenge for some men—with or without ED or DE—who need strong stimulation and arousal for successful partnered sex.

Furthermore, if the conditions above were combined with a high level of sexual interest—and its behavioral correlate, a high frequency of masturbation—the situation might be exacerbated. A prior study reported a significant though weak association between a high frequency of masturbation and men’s self-reported difficulty reaching orgasm during partnered sex (Rowland, Morrow, et al., 2022). While the concurrence of these factors may be infrequent, it might give credence to clinical reports suggesting relationships between masturbation frequency, non-partner sexual fantasy, and relationship issues on the one hand, and inadequate arousal for men with DE and/or ED during partnered sex on the other (Perelman & Rowland, 2006). Notable is the fact that it is not so much the specific sexual activities during masturbation that might contribute to the problem, but rather the frequency of masturbation coupled with the use of non-partner sexual fantasy during partnered sex. Furthermore, the above problem might be worsened by discordance between the sexual stimulation activities of masturbation and those of partnered sex (Perelman, 2020; Perelman & Rowland, 2006), an issue currently under investigation. Consistent with this notion, in women, the more the stimulation during masturbation emulates stimulation during partnered sex, the lower the woman’s self-reported orgasmic difficulty (Rowland et al., 2020).

Limitations

Although we followed best practices for online survey distribution and collection of data, recruitment strategies that rely heavily on social media are subject to biases in education, class, social media access, and other factors, all of which may limit generalization to the overall population, particularly in non-Western settings (Henrich et al., 2010). Second, respondents were not clinically assessed for sexual dysfunctions; rather, we relied on validated instrument scores to assign dysfunctional status. Third, our measures did not include the frequency of engaging in specific sexual activities. Thus, it was possible to determine only how likely—but not how frequently—men in various groups engaged in a particular behavior, information that could provide further insight into this issue. Fourth, as a cross-sectional study, inferences of causality between dysfunctional symptomology and preferences for specific sexual activities during partnered sex and masturbation must be drawn cautiously. Fifth, we limited our explanatory covariates to six non-collinear variables known to vary across functional and dysfunctional groupings and thus that could also serve as a proxy for other variables that cluster around them. However, future analyses might identify additional (non-correlated) explanatory variables. And finally, in this multinational survey, our focus was not on delineating possible differences between countries, but rather showing that specific patterns of activity emerged within a diverse sample, even when country origin-of-data was controlled. Nevertheless, further exploration of national differences could be useful in identifying activity patterns specific to world regions.

Conclusions and implications for therapy

In this multinational survey, the relative hierarchy of frequencies of specific sexual activities during partnered sex and masturbation is similar across sexually functional and dysfunctional men. However, factors known to differentiate men with and without sexual problems (interest in sex, relationship satisfaction, and the frequencies of masturbation and partnered sex) are also associated with the prevalence of specific sexual activities. Dysfunctional and functional men exhibit several differences in the prevalence of activities, some aimed at attenuating arousal for men with PE and others for increasing arousal for men with ED and DE. In some instances, however, the use of arousing stimulatory activities that do not align well with the demands of partnered sex may interfere with achieving maximal arousal levels.

The current findings have implications for the therapeutic process for men with sexual dysfunctions. Once-common strategies regarding the role of stimulation as a means to enhance or attenuate arousal (Masters & Johnson, 1970; Semans, 1956) that had been lost to the “pharmaceutical age” of sexual remediation are worth reconsideration for several reasons. Men are often capable of regulating their arousal levels through the use (or avoidance) of specific types of stimulation, including those used during masturbation—and in doing so their dysfunctional symptomology is often attenuated. Furthermore, transferring these techniques to situations involving partnered sex could foster communication within the sexual dyad regarding aspects of arousal, pleasure, intimacy, and overall sexual satisfaction. In addition, identification of highly arousing stimuli—including fantasies, erotic materials, stimulatory aids, etc.—that can be incorporated into lovemaking could benefit the couple’s efforts to optimize arousal levels for both partners, a significant issue when the partner may also struggle with a problem such as orgasmic difficulty. At the same time, highly arousing stimuli used during masturbation that do not transfer well to partnered sex might be identified and replaced with other mutually acceptable—but equally arousing—types of stimulation. In the end, the couple’s joint efforts to enhance or moderate the man’s arousal levels have the potential not only to foster sexual communication but also to increase overall pleasure and satisfaction for each partner.

Funding Statement

The author(s) reported there is no funding associated with the work featured in this article.

Author contributions

Conceptualization: DR, KH; Study Design and Methodology: DR, KH; Study Implementation and Data Collection: DR, KH; Data Cleaning and Management: DR, SM, DA, KJH; Data Analyses: SM, DA, KJH; Visualization: SM, DA, KJH; Writing Draft: DR, SM, DA, KJH; Finalized Draft: DR, SM; Final Review: DR, SM, DA, KJH, KH.

Disclosure statement

The authors have no conflicts of interest to declare.

Other statements

IRB review and approval was obtained from Valparaiso University USA and Eötvös Loránd University, Hungary.