Fpsyg 12 693121

CONCEPTUAL ANALYSIS
published: 09 August 2021

doi: 10.3389/fpsyg.2021.693121
Is Ejaculation Frequency in Men

Related to General and Mental
Health? Looking Back and Looking
Forward
Anna Mascherek* , Mirjam Christina Reidick, Jürgen Gallinat and Simone Kühn
Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
Despite its relevance for human sexuality, literature on potential effects of ejaculation
frequency and masturbation on general and mental health outcomes is sparse. Reasons
for this knowledge gap include a general lack of interest, but also methodological
challenges and still existing superstition. This paper reconciles literature from various
fields to extract relevant information on how ejaculation frequency effects general and
mental health outcomes. Culture-bound syndromes have been reported in countries
still strictly tabooing or condemning masturbation. Masturbatory guilt describes a
Edited by:
phenomenon in individuals experiencing a discrepancy between moral standards and
Joana Carvalho, own behavior with respect to masturbation. Abstinence is one aspect under study in
University of Porto, Portugal the area of fertility treatment. Specific time frames and their respective implications on
Reviewed by: quality of sperm remain inconclusive. Limited temporal resolution capacities hamper
Alan Shindel,
University of California, the precise study of brain structures directly activated during ejaculation. The relation
San Francisco, United States between ejaculation frequency and hormonal influences remains poorly understood.
Emmanuele A. Jannini,
University of Rome Tor Vergata, Italy
Future research that specifically addresses ejaculation frequency and potential mental
*Correspondence:
and general health outcomes is needed. In contrast to extracting knowledge as a
Anna Mascherek byproduct from other studies with a different focus, this enables sound study designs
a.mascherek@uke.de and could provide evidence-based results which could then be further discussed
Specialty section:
and interpreted.
This article was submitted to
Keywords: ejaculation frequency, general and mental health, moral incongruence, quality of sperm, brain
Health Psychology, structure and function, modifiable lifestyle behavior, abstinence
a section of the journal
Frontiers in Psychology
Received: 09 April 2021 INTRODUCTION
Accepted: 19 July 2021
Published: 09 August 2021
A growing body of research and campaigns promote masturbation as safe self-sex behavior and no
Citation: ill effects of masturbation have been reported up until today. Still, online communities promoting
Mascherek A, Reidick MC, abstinence from masturbation are on the rise with a steadily growing number of followers. The
Gallinat J and Kühn S (2021) Is
subreddit “NoFap” and its accompanying website (NoFapp LLC, 2020) has currently more than
Ejaculation Frequency in Men Related
to General and Mental Health?
738,000 followers. It represents an online community where members challenge themselves to
Looking Back and Looking Forward. abstain from pornography and masturbation to strengthen mental and physical health, (re)gain
Front. Psychol. 12:693121. self-confidence, increase productivity by raising energy levels, and improve social (and romantic)
doi: 10.3389/fpsyg.2021.693121 interactions (Fernandez et al., 2021). Some of the more radical points of view within the community
Frontiers in Psychology | www.frontiersin.org 1 August 2021 | Volume 12 | Article 693121

Mascherek et al. Ejaculation Frequency and General Health
even promote abstinence from orgasm in general, not only from PREVALENCE OF MASTURBATION
masturbation, as a healing experience. The most interesting
aspect of such internet-based, social-media movements is Masturbation to orgasm has been scientifically and medically
the widespread notion that masturbation as such is subject recognized as a common practice among humans across the
to negative appraisal (Hartmann, 2020). The motivation to lifespan (Smith et al., 1996; Meston, 1997; Waite et al., 2009;
abstain is rooted in the belief that masturbation is unhealthy Robbins et al., 2011). Research on the frequency of masturbation
(Zimmer and Imhoff, 2020). And while hypersexuality and shows that men and women report masturbating regularly,
excessive pornography consumption have been acknowledged as however, with differences in frequency. In an American sample,
problematic behavior (Kafka and Hennen, 2003; Kafka, 2010; 38% of women and 61% of men reported masturbatory behavior
Grubbs et al., 2019a,b), this is not scientifically established over the past year (Das, 2007). These numbers are confirmed in
for the effect of masturbation and ejaculation on general or a British sample with 33% of women and 66% of men reporting
mental health at all. masturbation within the preceding 4 weeks (Mercer et al., 2013).
In the present paper, we discuss literature from different fields Similar numbers are reported for Australia (Richters et al.,
that have addressed the potential relation between ejaculation 2014), implying that the prevalence is high and rather universal.
frequency1 and general and mental health outcomes. We will Estimates are also probably conservative due to a potential lack
touch on different domains such as abstinence, quality of sperm, of disclosure. Interestingly, epidemiological studies do not only
and lifestyle variables. The overarching aim of the present study report differences in frequency as a function of gender and age
is to elucidate potential knowledge gaps. We discuss reasons to (Mercer et al., 2013), but also of educational-level, frequency
conduct research to fill those gaps rather than presenting an in- of sexual intercourse, or religious affiliation (Gerressu et al.,
depth description of the detailed study situation in every field. 2008). It is established that masturbation is a common behavior
Many studies cited in the present paper do not primarily focus on in both, men and women (Carvalheira and Leal, 2013), with
the potential relation between ejaculation frequency and general women being even more sparsely covered in the literature. We
and mental health. Our topic of interest is often marginally decided to focus on behavior in men only, as it was beyond
referenced when addressing the actual research question of the the scope of the paper to cover both. However, masturbatory
respective study. However, in reconciling those side-aspects from behavior in women is an interesting and widely understudied
different studies and even from different disciplines, a picture topic, in particular since it seems to be even more tabooed than
emerges revealing open questions for future studies. To get a masturbatory behavior in men.
solid overview of the literature, two of the authors independently Before turning to existing literature, we provide a brief
conducted a comprehensive literature search. The search ended historical summary on social attitudes toward masturbatory
when no new records could be found and also no additional practices and historic changes. We do so, because on the one
information could be extracted from the references, leaving the hand, social perception of masturbation faces a centuries-long
study team with a sound overview over the relevant literature. history of ostracism, and on the other hand, beliefs and attitudes
We believe that our endeavor is a valid concern as ejaculation potentially mediate the effects of masturbation on health.
frequency represents a central aspect of the sexual response
cycle. It is, however, not strictly limited to solely reproductive
purposes, e.g., when thinking of masturbation, but can be HISTORICAL PERSPECTIVE ON
considered a modifiable lifestyle variable. Taking this perspective, MASTURBATION
surprisingly little is known about ejaculation frequency and
potential implications for general and mental health. For a The modern perspective of health professionals implies that
comprehensive summary of the points discussed below, see masturbation is a positive aspect of healthy sexual development
Table 1. within the range of normal human behavior (Driemeyer, 2013).
Masturbation is also an important part of sex therapy (LoPiccolo
and Lobitz, 1972; Zamboni and Crawford, 2003), however, not
1 without controversy (Christensen, 1995). Yet, while the scientific
An ambiguity of definitions exists for different terms used throughout the
manuscript. Several related terms are used in the literature with each being used community recognizes masturbation as normal and beneficial
with a different emphasis while also often being applied interchangeably. Central behavior, the social discourse is still characterized by taboo (Das,
terms are “ejaculation” (Moser, 2011) and “orgasm” (Wakefield, 2012), as well as 2007; Das et al., 2009; Carvalheira and Leal, 2013). This illustrates
total sexual outlet (TSO) which refers to orgasms per week, independent of sexual
activity. “Masturbation” usually refers to sexual activities performed on oneself,
a discrepancy between social reality and social appraisal. The
typically focusing on stimulation of the genitals to orgasm (Meston and Frohlich, glorification of abstinence that is pursued by some social media
2000), with different perceptions in lay people (Atwood and Gagnon, 1987). movements, can be interpreted as a modern version of the
“Abstinence” describes the practice of refraining from some or all aspects of sexual historic perspective taken on masturbation.
activity. Spiritual texts often describe orgasm and ejaculation as two different
entities and suggest men to learn to reach orgasms without ejaculation to not As early as from the time of Hippocrates, but most
loose energy. The terms “sperm” and “semen” are also often used interchangeably prominently from the beginning of the 18th century,
although representing different biological entities. Semen describes the fluid of the masturbation was regarded as deviant and harmful behavior
ejaculate that carries the sperm out of the male body, sperm refers to the actual
that eventually led to insanity as well as bodily decay (Whorton,
gamete. In the present paper we will not solve or further address the problem of
definitions. We will mainly stick to “frequency of ejaculation,” however, will use 2001). Even nocturnal emission as the involuntary physical
different terms, if used in respective studies or contexts. reaction was deemed sinful. Loss of semen was generally believed

TABLE 1 | Summary of positions presented and empirical questions to be addressed.
Position General understanding from Empirical research questions

the literature
Masturbation and ejaculation
. . .and the historical perspective Ejaculation and masturbation have Which factors exert systematic
a long history of superstition. and significant impact on societal
Perspectives on masturbation attitudes toward masturbation and
have changed from representing a ejaculation frequency.
harmful and deviant behavior to Is there an effect of societal
being perceived as normal and attitudes on attitudes toward
even healthy. However, this general masturbation and ejaculation on
notion varies depending on group individual level?
membership. Large differences Can those effects be categorized
exist between countries, becoming or explained?
evident in so-called “culture-bound
syndromes.” Differences in attitude
also run along group membership
holding different value systems,
educational levels, or professions.
. . .and quality of sperm Sperm quality is described along Does ejaculation frequency
six parameters (WHO significantly impact quality of
spermiogram). Abstinence as sperm?
influential factor has repeatedly If ejaculation frequency impacts
been described, however, without quality of sperm, which are the
clear time specifications. parameters mostly affected?
Is the effect of ejaculation
frequency different for ejaculation
due to masturbation or sexual
intercourse?
. . .and hormonal influences Human male sexuality is influenced Are there potential associations
by a complex interplay of between different biomarkers and
biomarkers, predominantly by frequency?
testosterone. The focus of How do ejaculation/masturbation
literature lies on the causal frequency and testosterone levels
direction. Little is known on the affect each other in the long run?
effects of ejaculation and Does ejaculation/masturbation
masturbation frequency on abstinence significantly affect
testosterone levels. testosterone levels?
. . . and brain function and Limited temporal resolution of Which brain structures are
structure imaging techniques and other activated during ejaculation?
context factors hamper the precise What effects does frequent
study of processes directly ejaculation have on typically
involved in ejaculation and orgasm. involved structures and their
function?
Does a thorough understanding of
the ejaculation process aid in the
understanding and treatment of
sexual dysfunctions?
. . .and modifiable lifestyle variables Mental and general health and Is there a relation between
well-being are subject to different masturbation and ejaculation
behaviors subsumed under the frequency and mental and general
term “modifiable lifestyle factors.” health/well-being?
Masturbation and ejaculation Is the potential relation between
frequency have not been listed, masturbation and ejaculation
however, represent modifiable, frequency and mental and general
individual, and presumably health/well-being mediated
influential factors regarding through personal beliefs?
well-being. Some studies argue Is a potential discrepancy between
that not the behavior itself but personal beliefs and individual
rather accompanying attitudes and behavior more important than the
potential discrepancies between actual belief itself?
attitudes and behavior might exert
the influence on well-being.

to weaken the male’s body and constitution. While this view profound moral component in common that is paramount
has a long-standing history in religious writings, it also came for the development of psychological strain and distress. The
to the notion in medical writings in the late 1700s. It was syndromes can be described as type of anxiety disorder. Up
strongly promoted in the 19th and early 20th century (Bullough, until today, there is no proof of existence of a biological
2003) from both, medical as well as religious and pedagogical relation between masturbation or nocturnal emissions and any
perspectives (Stolberg, 2000). The notion that masturbation was of the described symptoms above (Sumathipala et al., 2004).
sinful and dangerous to body and mind prevailed throughout Nonetheless, awareness of the phenomena is important as
the 19th century. Historical change started around the turn of they cause real and severe psychological distress in individuals
the century. The predominant view was more and more labeled (Ventriglio et al., 2016).
as superstitious. It was promoted as unlikely that masturbation Scientific literature today is not always completely free from
caused mental illnesses (Patton, 1986; Whorton, 2001). Alfred reservations toward masturbation (Brody and Costa, 2009;
Kinsey published his seminal work on sexual practices in Jiao et al., 2019). However, addressing ideology is difficult.
America in the mid-1940s (Kinsey et al., 1948). From thereon, It sometimes lies under scientific veneer, referencing scientific
at least the scientific perspective changed rapidly. Masturbation studies (Speed and Cragun, 2018). In other work, ideology is
today is acknowledged as natural, normal, and even beneficial more striking and easier detected (Brody et al., 2012; Hoseini,
sexual behavior (Levin, 2007). It is promoted as one safe-sex 2017). There is a corrective lobby for ideological articles (Speed
behavior, preventing sexually transmitted diseases and unwanted and Cragun, 2018). Especially with a topic inherently prone to
pregnancies especially in adolescence (e.g., Robinson et al., 2002). bias, it is essential to raise awareness for both the interpretation
Societal change and official positions are mirrored in documents of existing literature and the conduction of future studies.
provided by the World Health Organization (WHO) on sexual Literature is often biased by a “WEIRD”-perspective. Henrich
education in Europe (WHO Regional Office for Europe and et al. (2010) established WEIRD as an acronym by describing
BZgA, 2010). Masturbation practices are described as normal a tendency in psychological science to base results on samples
developmental aspects of healthy sexuality and fundamental that mainly represent Western, Educated, Industrialized, Rich,
aspect of sexual education. and Democratic societies. In their seminal work, Henrich et al.
An indirect effect of masturbation on mental health has been (2010) pointed to the fact that more than 80% of the studies
implied by literature on so-called culture-bound syndromes. In published are based on samples representing only around 12%
this context, it can be generally subsumed under the heading of the world’s population. He demanded to at least incorporate a
of semen-loss anxiety. The term culture-bound syndrome is critical reflection on sampling in the limitation section of a paper
not without controversy itself, as it is suspected of reproducing if relying on WEIRD individuals. While Henrich’s work addressed
imperialistic or eurocentristic worldviews. However, it should be psychological science as a whole, his point especially applies
understood as a description of a bundle of symptoms that can to the understanding of masturbatory practices and attitudes
only be found in specific culturally or socially defined groups. toward masturbation.
Culture-bound syndromes are not unique to sexual behavior,
bulimia nervosa, for example, has been described as a culture-
bound phenomenon mainly present in the western hemisphere MASTURBATION AND QUALITY OF
(Sumathipala et al., 2004). The dhat-syndrome is mainly present SPERM
on the Indian subcontinent and describes a general semen-
loss anxiety. The symptoms are predominantly found in young, The relation between ejaculation and quality of sperm is a
unmarried Indian men. Symptoms are fatigue, weakness, anxiety, central question in the discussion of potential effects of frequent
and feelings of guilt (Udina et al., 2013). The symptoms resemble ejaculation and health. Ejaculation is an essential part of male
those of affective or anxiety disorders, however, the causal reproduction. In the context of reproduction and assisted fertility
attribution of the symptoms by dhat-patients is semen loss due treatment ejaculation is important as a necessary body function.
to nocturnal emissions or masturbation. But also, the quality of the resulting semen plays a vital part in the
A related, yet geographically distinct, syndrome is described reproductive success of human individuals. Standard procedures
by shen-k’uei (Sumathipala et al., 2004) in China. Again, loss for the preparation of a spermiogram are defined in the WHO’s
of semen due to nocturnal emission, frequent intercourse, laboratory manual on the analysis of human sperm (World
or masturbation is causally linked to anxiety, weakness, and Health Organization (WHO), 2010). A spermiogram evaluates
insomnia by patients. Etiological explanations for the syndrome the quality of sperm along the following dimensions: semen
are rooted in classical Chinese medicine. Similar syndromes volume, sperm concentration, total sperm count per ejaculate,
were described in western cultures in the 19th century. sperm motility, sperm morphology, and sperm vitality. Sperm
Mainly based on religious grounds, masturbation was prohibited concentration, motility, and morphology represent the three
and ostracized. It was believed that masturbation and also classical parameters analyzed in nearly all laboratories (Wang
nocturnal emission causes disorders such as weakness, headaches, and Swerdloff, 2014). Although those parameters with respective
anxiety, and general physical weakness (Stolberg, 2000). Those reference limits have been acknowledged as guiding principles,
beliefs clearly resemble those of dhat- and shen-k’uei- patients. it is also well established that the references are not set in stone.
The strong cultural and societal impact on the development Studies showed that depending on measurement technology, but
of psychological strain is striking. All syndromes have a also depending on geographic location and even racial and ethnic

affiliation, the references of the parameters vary (Jørgensen et al., context of collecting semen samples should always be taken
2001; Swan Shanna et al., 2003; Wang and Swerdloff, 2014). into account as potentially influential (Handelsman et al., 2013).
One question that has received considerable attention is Other studies report semen samples collected from penile-
whether or not abstinence affects the quality of sperm. This vaginal intercourse as being higher in quality than semen
question has mainly been studied in the field of reproductive from masturbation (Zavos and Goodpasture, 1989; Sofikitis and
medicine and infertility. However, it is interesting in its own right Miyagawa, 1993). These studies altogether underline the potential
to understand the possible relation between ejaculation frequency impact of variables other than the actual specimen. While this
and health. A recent review (Hanson et al., 2018) summarized might not be decisive in the context of reproductive medicine
the question of whether or not abstinence has an impact on the and fertilization, it is relevant for basic research to understand
quality of sperm. Reviewing 28 publications published since the underlying mechanisms.
year 2000, the authors conclude that the impact of abstinence Although research shows inconclusive results concerning
on sperm quality is complex and inconclusive. As of today, it the medical benefit of abstinence, social movements pursue
remains unclear which parameter ultimately is most important this idea. The focus often lies on perceived mental and
for successful fertilization. There is some evidence that abstinence social benefits including better health, increased masculinity,
of less than 3 days is associated with higher pregnancy rates and mental clarity (NoFap LLC, 2016). Scientific evidence is
in artificial insemination (Sánchez-Martín et al., 2013; Ayad lacking; however, initiators of the movement repeatedly refer to
et al., 2018). Although sperm count and semen volume seem scientific literature, making it difficult to distinguish empirical
to improve with longer abstinence, this is not certain for evidence from ideology.
motility, vitality, and morphology. Be this either due to study
design and assessment method or real findings remains unclear.
Some studies conclude that abstinence could be recommended,
however, with a plateau being reached after a few days (De Jonge
HORMONAL INFLUENCES AND
et al., 2004; Levitas et al., 2005; Hanson et al., 2018). The WHO’s RELATED BIOMARKERS IN THE
general recommendation of 2–7 abstinence days to improve CONTEXT OF EJACULATION AND
semen parameters is challenged as evidence is inconclusive. MASTURBATION
A worldwide trend in a general reduction in the quality of
human male sperm parameters is observed (Virtanen et al., The male testis has two central functions: spermatogenesis and
2017), though, again, not without inconsistencies. Explanatory synthesis as well as secretion of hormones (Amann, 1989).
approaches name the effect of biological as well as environmental Sexuality is strongly influenced by hormones (Krüger et al., 2003)
or lifestyle variables on sperm quality, such as pollution, age, in particular, by sex hormones including androgens, estrogens,
nutrition, and stress (MacDonald et al., 2009; Li et al., 2011; and progesterone (for a review see Meston and Frohlich,
Virtanen et al., 2017; Arab et al., 2018; Durairajanayagam, 2018; 2000). Human male sexuality is predominantly influenced by
Ilacqua et al., 2018). In those studies, so-called modifiable lifestyle the androgen testosterone. The testosterone synthesis process
factors are examined. Modifiable lifestyle factors refer to behavior starts with the secretion of gonadotropin-releasing hormone in
that is ultimately controlled by the individual. Modifiable lifestyle the hypothalamus, which in turn acts on the secretion of the
factors may be protective as well as harmful. Results of studies gonadotropins luteinizing hormone (LH) and follicle-stimulating
are inconclusive with respect to precisely describing the impact hormone in the anterior pituitary. LH subsequently acts on
of specific lifestyle-variables. Yet, the overarching tone is that Leydig cells in the testicles and this leads to testosterone release
lifestyle variables are influential. This is true for more objectifiable (Hock, 2016). Next to being involved in spermatogenesis (Nassar
variables such as nutrition habits, smoking, or alcohol intake, but and Leslie, 2021), testosterone is predominantly associated with
also for less obvious aspects such as stress (Ilacqua et al., 2018), the initiation of sexual arousal and desire (Vignozzi et al., 2008);
or depression and anxiety (Wdowiak et al., 2017). According to with higher levels of testosterone often being linked to increased
our reading, masturbation and ejaculation have generally been sexual activity and interest (e.g., Carani et al., 2005). Sexual
neglected as unique lifestyle factors with a potential impact on activity itself appears to have a short-term effect on testosterone
both sperm quality and general health and well-being. Especially as far as testosterone levels appear to increase after watching
as masturbation comprises a part of the sexual response itself, erotic stimuli or penile-vaginal intercourse, as a review shows
it could be linked way closer to sperm quality than other rather (Van Anders and Watson, 2006). Additionally, a naturalistic
distant aspects of general lifestyle (e.g., physical activity). study in a sex club supported that testosterone levels increase
Some studies on quality of sperm suggest that the assessment temporarily when observing and especially when engaging in
method should be included as covariate. Methodological aspects sexual behavior (Escasa et al., 2011). Masturbation in particular
have proven influential over and above differences in the sperm seems to have the same temporary trend, yet results are limited
itself (Brackett and Lynne, 2000). One study reported that (Van Anders and Watson, 2006; Escasa et al., 2011). Studies
semen samples collected from masturbation at home or the on patients with erectile dysfunction give further support for
clinic differed significantly with respect to sperm motility, total an influence of sexual activity on testosterone levels (Jannini
count, and concentration (Elzanaty and Malm, 2008). From et al., 1999, 2009; Carosa et al., 2002, 2004). Low or a loss of
a randomized controlled trial on whether erotic magazines sexual activity due to erectile dysfunction is accompanied by
facilitated semen collection, the authors conclude that the low testosterone levels; while a resumption of sexual activity

appears to restore testosterone levels, irrespective of the cause or been used to assess orgasmic intensity in healthy individuals
treatment of the erectile dysfunction. To note, sexual activity was (Mollaioli et al., 2021).
ascribed as full sexual intercourse and, therefore, no conclusion As mentioned, the male testis has two major functions.
specifically concerning masturbation can be drawn yet (Jannini Next to the secretion of hormones, particularly testosterone,
et al., 1999, 2009; Carosa et al., 2002, 2004). testicles produce sperm (Amann, 1989). Testosterone is just
Social media sites that promote masturbatory abstinence one factor that contributes to spermatogenesis and testicular
regularly claim that there is scientific evidence that abstinence development. Neurotrophins, growth factors in the nervous
is beneficial for men’s testosterone levels. Those assertions are system, came to our attention, as they are possibly also involved
accompanied by claims that promote stronger mental health in testis development and spermatogenesis (for a review of the
(Hartmann, 2020). These sites support their statement by role of neurotrophins in male reproduction see Li and Zhou,
referencing a study (Jiang et al., 2003), in which a peak in 2013). It is interesting that neurotrophins, which are typically
serum testosterone levels after 7 days of abstinence was reported involved in diverse parts of neuronal growth and functions such
in male participants. Notably, the results were reported on the as differentiation, survival, synaptic plasticity, or apoptosis (Li
basis of a small sample size. To the best of our knowledge, and Zhou, 2013; Bathina and Das, 2015), appear to be also
these results were not replicated so far. In this line of research, involved in non-neuronal tissues (Müller et al., 2006; Li and
another study investigated the effect of 3-weeks abstinence on Zhou, 2013). Both, the nerve growth factor (NGF) and the
different endocrine responses including testosterone. Here, the brain-derived neurotrophic factor (BDNF), belong to the group
authors reported that abstinence led to an increase in basal of neurotrophins and have been found in ejaculated sperm.
testosterone level, yet did not alter the typical cardiovascular and Especially BDNF was proposed as a marker for semen quality
endocrine responses to orgasm. Therefore they concluded that (Zheng et al., 2011). In line with this is the finding that treatment
abstinence has an insufficient impact on endocrine responses of sperm with BDNF increases the motility of sperm, as BDNF
(Exton et al., 2001). To note, this study also had a small is assumed to have protective effects against oxidative stress.
sample size. Far-reaching statements about beneficial effects of Therefore, BDNF has been suggested to improve sperm in order
abstinence on male’s testosterone levels need to be taken with to ultimately help fertilization (Najafi et al., 2017). To note, this
caution. Indeed, the role of testosterone in sexual activity appears area of research is rather limited and we do not want to suggest
to be more nuanced. any association or draw any conclusion of what this means with
In this line of inquiry, a focus lies on identifying the causal regard to ejaculation and masturbation frequency in specific. Yet,
direction, meaning whether testosterone levels cause certain we want to acknowledge the complex interplay of biomarkers
sexual behavior (i.e., hormonal causation pattern; Kraemer in male sexuality. Along with this and also the next paragraph
et al., 1976; Knussmann et al., 1986; Carani et al., 2005; we want to mention the recent review (Matos et al., 2021) that
Archer, 2006; Finkelstein et al., 2013) or whether a certain pointed to a striking similarity between the brain and testis.
behavior or environment causes testosterone levels to change [i.e., Thus, further research is encouraged to generate profound
reverse relationship, “social modulation” model (Van Anders knowledge and aid the understanding of potential relations, for
and Watson, 2006; Van Anders et al., 2015; Das and Sawin, instance that NGF possibly mediates the effects of testosterone in
2016)]. The causal pattern of testosterone is often studied in spermatogenesis (Li and Zhou, 2013).
connection with sexual activity, relationship commitment, and
parenting effort. Das and Sawin (2016), for example, attempted
to unravel the causal pattern of the effects of testosterone on EJACULATION, MASTURBATION, AND
frequency of partnered sex and masturbation as well as on BRAIN FUNCTION AND STRUCTURE
relationship quality. They conducted a longitudinal study with
a representative United States sample of older, both male and Ejaculation and orgasm are very brief, time-limited actions of
female, adults (aged 57–85). For the male participants, a higher human male sexual behavior. A large body of research deals
masturbation frequency predicted higher levels of testosterone with the brain’s functional and structural setup and functional
which gives support for the social modulation model. On the connectivity within the human sexual response (Poeppl et al.,
other hand, higher levels of testosterone negatively affected 2014; Ruesink and Georgiadis, 2017). Comprehensive reviews on
relationship quality later in life, which points to a hormonal the broader picture of human male sexual response with respect
causation (Das and Sawin, 2016). Moreover, the connection to brain imaging can be found elsewhere. Generally, broader
between ejaculation frequency and testosterone levels might play aspects of the sexual cycle (wanting, liking, ad inhibition) are
a role in understanding and explaining ejaculatory dysfunctions under study [see (Georgiadis et al., 2012) for an extensive review].
(Rastrelli et al., 2018). A low level of testosterone is associated Only few studies exist that directly analyze brain activation
with reduced volume in ejaculation and delayed ejaculation. High during orgasm, because imaging techniques are hampered by
levels of testosterone are associated with premature ejaculation their temporal resolution capacities.
(Corona et al., 2008). Premature ejaculation, in turn, may Two studies from the same group vividly illustrate the
influence orgasmic pleasure. In specific, lower scores on the methodological difficulties. Georgiadis et al. (2007) analyzed
“Orgasmometer,” a subjective measure for the intensity of an brain activation during ejaculation in a positron emission
orgasm, are observed for individuals with premature ejaculation tomographic study. They report decreased activity in prefrontal
(Limoncin et al., 2016). The orgasmometer as a tool has also cortex areas, supporting the notion that the prefrontal cortex

exerts inhibitory control over sexual functions. The authors also behavior and its accompanying physical reactions. Massive
report increased activity, most prominent in the left dentate guilt is experienced by some individuals, which then, in
nucleus within the cerebellum and the ventrolateral part of the turn, influences psychological and relational well-being. One
transition zone of midbrain and thalamus. The results described study (Castellini et al., 2016) reported that this so-called
above came from a re-analysis of data previously published ego-dystonic masturbation was significantly related to higher
by the same group (Holstege et al., 2003). The re-analysis led scores of anxiety and depression scales, sexual dysfunctions,
to more precise results due to an improved signal-to-noise and relational as well as intrapsychic problems in a sample
ratio. The authors concluded that the refinement led to more of over 4,000 human male outpatients of an andrology and
precise images of human male brain activity during ejaculation. sexual medicine clinic in Italy. The results indicate that
Results from the first analyses were classified as artefactual. The masturbation seems to be a common behavior even in individuals
authors critically discuss that, simply due to a refined analysis- with negative attitudes toward it. In their study, intra- and
technique, activation in the striatum, the midbrain, the thalamus, interindividual psychological strain was caused by the moral
the cerebellar hemispheres, and parts of the neocortex could attitudes that were in conflict with the individual behavior.
no longer be attributed to the human male ejaculatory process. One study (Chakrabarti et al., 2002) portrays a man in a
Although those regions are all involved in the sexual response, single-case study, who developed a depression of clinical extent
they were not directly linked to the ejaculatory process. on the ground of masturbatory guilt. He was successfully
Sexuality, in general, is a well-established subject in research, treated by providing education and information about human
but this is less the case for the specific aspect of human male male sexuality and masturbation. Although this case study
ejaculation. This also applies to research on neural correlates can only function for illustrative purposes, it underlines to
in patients with lifelong premature ejaculation. Some studies which extent beliefs might mediate the relation between
reported decreased brain activity in the left inferior frontal masturbation and health.
gyrus and left insula (Zhang et al., 2017; Yang et al., 2018). But A theoretical framework that incorporates moral beliefs,
those results refer to general differences in activation between norms, and personal attitudes has been proposed (Grubbs
a clinical and a healthy sample. Research on brain activity et al., 2019a,b). It provides a to-be-tested idea of how
specifically during ejaculation would enable the understanding of masturbatory behavior generally impacts mental health.
potential impact of frequent ejaculation on brain structure and The authors (Grubbs et al., 2019b) promote the idea that not
function. Knowledge here could enable the deeper understanding the behavior itself or its frequency is the driving force in the
of mechanisms underlying sexual dysfunctions. reported psychological strain but its moral evaluation. Hence,
self-reported psychological difficulties might be understood
as an expression of moral incongruence: a discrepancy
between beliefs and behavior. The theoretical framework
THE RELATION BETWEEN was tested in exploratory studies in the area of pornography
MASTURBATION AND EJACULATION consumption, reporting that the strongest predictors of
AND WELL-BEING AS WELL AS self-reported pornography addiction are religiousness and
LIFESTYLE moral incongruence (Grubbs et al., 2019a). We believe that
the framework could be suitably applied to masturbation
Contrasting its prevalence, surprisingly little is known about the accompanied by negative feelings.
impact of ejaculation and masturbation on mental health and Another study (Zimmer and Imhoff, 2020) examined the
well-being (but see Brody, 2006, 2010; Levin, 2007). Human motivation for abstinence in a large, online-based survey.
sexual behavior is influenced by psychosocial and cultural aspects The authors found that the motivation to abstain from
and is not solely determined by biological factors. Literature masturbation most strongly correlated with attitudes toward
on hypersexuality and problematic pornography consumption masturbation. Expected negative impact of masturbation,
repeatedly found self-reported feelings of guilt, shame, or religiosity, conservatism, and lower trust in science were related
perceived wrongdoing in study participants. A phenomenon to the motivation to abstain. This study validates the idea
called “masturbatory guilt” has been described in individuals. that the relation between masturbation and negative effects
Individuals who masturbate but on the other hand despise could be mediated by personal attitudes and beliefs. Self-
masturbation as morally reprehensible (Grubbs et al., 2019b) reported excessive masturbation or even addictive behavior have
experience feelings of guilt. Superstition and ostracism have been documented as cause for distress. Studies also found
been banned from the general scientific discourse. However, penile insensitivity, sometimes less satisfying partnered sex,
it may persist in day-to-day behavior and thoughts of and often an association with pornography consumption (Park
laypersons. Although societal attitudes have fundamentally et al., 2016; Dwulit and Rzymski, 2019). Studies addressing
changed, masturbation still remains a supplanted and tabooed compulsive sexual behavior describe compulsive masturbation
topic for many. Negative effects of masturbation are caused as one dimension of the self-reported behavior causing
by feelings of guilt, moral attitudes, and religious beliefs distress (Raymond et al., 2003; Kaplan and Krueger, 2010).
and not by the behavior itself, for which no ill effects Those studies show that masturbation contributes to stress
have been found (Coleman, 2003). Pivotal for negative health in individuals reporting hypersexual behavior. Individuals that
effects of masturbation is a subjective evaluation of the report compulsive masturbation often describe the frequency

as problematic. Hence, the distress might truly be a dose- phenomenon. Studies reporting a seemingly direct relation
dependent effect. between masturbatory frequency and (mental) health wrongly
That behavior patterns can cause distress when excessively derive causal conclusions from correlational data (Jiao et al.,
practiced, in particular when a lack of control is perceived will be 2019), which is highly contestable. Case-control experiments
acknowledged in the ICD-11 in its category of compulsive sexual and longitudinal data are needed to establish a substantial
behavior disorder (Kraus et al., 2018; Fuss et al., 2019). Kafka causal relation. As an area of research strongly influenced by
(2010) reviewed the epidemiological literature on frequency cultural and social norms, the notion of studies representing
of sexual behavior to define and propose diagnostic criteria WEIRD populations (Henrich et al., 2010) becomes an
for hypersexuality for the DSM-5, but the diagnosis was not essential aspect.
included. Kafka (1997) proposed a total sexual outlet (TSO, Scientifically, masturbation is often addressed as a secondary
orgasms per week, and independent of sexual activity) of 7 aspect within areas of reproductive medicine, epidemiological
or more orgasms/week for a minimum duration of 6 months studies on general sexual activity, or sexual disorders [see e.g.,
(Atwood and Gagnon, 1987; Långström and Hanson, 2006) as Wellings et al. (1990, 2006)]. However, up to date, research
quantifiable criterium for hypersexuality. However, this criterium specifically addressing masturbation as the phenomenon of
is still under debate (Moser, 2011; Wakefield, 2012). Besides interest in itself remains an underrepresented aspect. Also, the
the described difficulties, masturbation exhibits a plethora of concept of masturbation lacks a precise definition (Motofei
positive effects on both mental and physical health (Mercer and Rowland, 2005; Alwaal et al., 2015; Kirschbaum and
et al., 2005; Robbins et al., 2011; Mercer et al., 2013). It Peterson, 2018). In an attempt to describe concepts held by
is commonly incorporated into sex therapy (LoPiccolo and the population about what behavior classifies as masturbation,
Lobitz, 1972) and supports the development of comfort with Kirschbaum and Peterson (2018) it was found that participants
one’s own body (Regnerus et al., 2017). Attempts to foster held different notions of masturbation including a range of
the development of a healthy sexuality explicitly incorporate behaviors and situations (Atwood and Gagnon, 1987). Yet,
masturbation as normal behavior. It is described as a powerful “having an orgasm” and “being alone” were significant common
way to increase both immediate well-being and general sexual denominators. The authors conclude that the vagueness of
health and comfort. Masturbation is also promoted as a safe- the definition, with only the aspects “orgasm” and “alone”
sex behavior (Robinson et al., 2002; Coleman, 2003) to prevent as common denominators, mirrors a social discourse that
the transmission of diseases. Some empirical studies found that is lacking an open discussion. Hence, behaviorally specific
masturbation reduces the risk of prostate cancer (Leitzmann language is recommended for research on masturbation, as
et al., 2004; Aboul-Enein et al., 2016; Rider et al., 2016), the term per se leaves room for interpretation. Explicitly
although not completely conclusive [e.g., see Dimitropoulou et al. defining, whether behavior solely in conjunction with orgasm
(2009)]. For the causal understanding of the potential relation or a broader scope of behaviors are addressed, should be a
between masturbation and prostate cancer risk, experimental, minimal requirement.
and longitudinal studies are needed. An interesting fundamental research direction would be
In what follows, we now discuss the most important the comprehensive examination of if and how masturbation
pending issues associated with masturbation and ejaculation affects quality of sperm parameters. Reproductive medicine has
frequency from the perspective of psychology and neuroscience, intensively examined aspects of sperm quality. While this is
including accompanying methodological challenges. We perfectly appropriate for understanding fertility difficulties, it
emphasize that our ideas are broad topics of potential does not fit for a derivation of knowledge concerning healthy
importance and not specific outlines of studies that are populations. It is also not suited for the study of the effects on
ready for implementation. general or mental health. The selectivity of the sample makes
it difficult if not impossible to isolate idiosyncrasies due to
infertility from general aspects. Hence, results from reproductive
DISCUSSION medicine are revealing, however, impose a limitation on the
transferability to the general population. It is difficult to design
Pushing the idea that attitudes and beliefs mediate a potential experimentally controlled studies in healthy individuals. Ethical
relation between masturbation and negative feelings, creates restrictions make the intentional manipulation of sperm quality
a need for understanding the causal relation between both challenging or even unlawful. From our point of view, more
constructs. It is inherent to correlational studies that no well-designed studies examining masturbation as a vital and
causal relationship can be established. As masturbation has a active part of healthy sexual activity and development across
long-standing history of superstition and ostracism up until the lifespan are needed. Studies that systematically assess
today (Brody et al., 2012; Hoseini, 2017), causal studies are masturbatory behavior longitudinally and its potential changes
essential. Without the possibility for causal interpretation, or differential (age) impacts are lacking. No study has come
results remain open to the respective theoretical background to our attention that, for example, longitudinally addresses
individuals hold. Although this argument is vital for any masturbatory behavior and potential effects in older age or
researcher in any field, it seems of special importance in in adults’ reproductive age along developmental trajectories.
an area where (a) not enough evidence-based knowledge Some studies have addressed sexual activity within the context
exists at present and (b) social tabooing is still part of the of successful aging and potential relations with other central

variables such as cognitive functioning (Wright et al., 2017, 2019; scientific results, sometimes the scientific background itself is
Allen, 2018), but masturbation is treated as a secondary variable. biased (Tashakori et al., 2017; Jiao et al., 2019). For the sake
Studies including masturbation as a potential predictor for health of providing a solid background against which teaching about
outcomes (comparable to studies including partnered sex), would masturbation and health effects is warranted, more unbiased,
be an interesting field of research across all ages. Research well-conducted studies are needed. Without evidence-based
on both, ejaculation frequency as well as masturbation and its studies, the discussion remains opinion-based without a true
relation to brain structure and function are needed. Studying right or wrong. Although this is true for any topic, we believe
brain functional as well as structural mechanisms involved that it is especially important in an area ballasted with centuries
and affected by masturbation and ejaculation in a healthy, of superstition and ostracism.
non-clinical sample of individuals could provide important
insight into the underlying mechanisms. Results could exhibit
potential effects of frequent ejaculation on brain structure. Also CONCLUSION
they would enable the localization of brain structures that
could be predictive of frequent masturbation and ejaculation. The aim of the present paper was the attempt of reconciling
Potential mediating constructs such as moral incongruence existing literature on “effects of ejaculation on general and mental
and its relation to brain structure and function could be health.” To succeed at this ambitious task, we aimed at providing
studied in more detail. an overview and raising important questions that need to be
Those studies must suitably address the technical difficulties answered. We also aimed at providing a background for which
in the assessment of ejaculation with imaging techniques new projects could be designed, and, ultimately, proposing a
(Georgiadis et al., 2007). Besides technical difficulties, sample direction for future research on this topic. We have learned
size could impose a special challenge for studies in this field. from the literature that masturbation is a common behavior
Successful recruitment must overcome both the challenge of that falls within the normal range of healthy sexual activity. It
the delicate matter itself and the demands on individuals is promoted as safe-sex behavior and applied in sex therapy
participating in an imaging study. Limitations in study designs (LoPiccolo and Lobitz, 1972; WHO Regional Office for Europe
are not unique to our area of interest, but a problem and BZgA, 2010). While this has been generally acknowledged
often seen in experimental research. However, it presumably in the scientific community, it is still subject to social tabooing
is of special importance in a field that is still subject and often marked with shame causing distress (Castellini et al.,
to impression management, social desirability, and shame 2016). In behavioral and social sciences, research on implications
at the same time. of lifestyle variables for general and mental health is common.
We encourage future research to address the probably This is true for risk but also for everyday behavior such as physical
mediating effect of attitudes (personal as well as societal), activity, nutrition, and social interactions (e.g., Owen and Corfe,
religious beliefs, and cultural norms on the relation between 2017; Warburton and Bredin, 2017; Alegría et al., 2018). It follows
masturbation and mental health. Coleman (2003) already made that systematically addressing the question of whether and how
this assessment almost 20 years ago; however, it still applies masturbation and ejaculation as a lifestyle variable are related to
today. While no direct negative effects of masturbation on health and well-being represents a timely area of research.
health emerged up to date, the indirect impact on mental health
has been discussed. The relation between masturbation and
distress in individuals experiencing a discrepancy between beliefs AUTHOR CONTRIBUTIONS
and attitudes and own behavior (i.e., moral incongruency, see
Grubbs et al., 2019a,b), is in urgent need of a variety of well- AM, MR, and SK drafted the manuscript. AM, MR, SK, and JG
designed and well-conducted studies. Existing studies reporting conducted the research and contributed to and have approved
distress in combination with masturbatory behavior are either the final manuscript. All authors contributed to the article and
confounded by pornography consumption (Grubbs et al., 2019b) approved the submitted version.
or examine individuals claiming to suffer from compulsive sexual
behavior in general (Kaplan and Krueger, 2010). While this is an
interesting and relevant aspect, we consider it equally important FUNDING
to understand the relation between frequency of masturbation,
attitudes, and health in its own right. Understanding this relation SK has been funded by a Heisenberg grant from the German
could offer the opportunity to rebut stigmatization and prevailing Science Foundation (DFG KU 3322/1-1), the European
against superstition. Union (ERC-2016-StG-Self-Control-677804), and the Jacobs
Research addressing the question of mental health and Foundation (JRF 2016–2018).
masturbation is, indeed, still sometimes biased by a traditional
and historical perspective on masturbation, making a scientific
evaluation of results difficult (Brody and Costa, 2009; Brody et al., ACKNOWLEDGMENTS
2012; Hoseini, 2017; Jiao et al., 2019). While Zimmer and Imhoff
(2020) critically discuss the fact that masturbatory guilt and We thank Johannes Fuss and Lawrence Murphy for their very
distress is often particularly present in individuals not trusting helpful comments.

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CONCEPTUAL ANALYSIS

published: 09 August 2021

Is Ejaculation Frequency in Men

Frontiers in Psychology | www.frontiersin.org 1 August 2021 | Volume 12 | Article 693121

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TABLE 1 | Summary of positions presented and empirical questions to be addressed.

Position General understanding from Empirical research questions

Masturbation and ejaculation

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REFERENCES Coleman, E. (2003). Masturbation as a means of achieving sexual health. J. Psychol.

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