Psychological and lifestyle factors have been discussed as potential contributors, including insufficient sleep, distraction due to worry, distraction from the environment, anxiety about pleasing their partner and anxiety about relationship problems. Religious guilt over sex can cause delayed ejaculation. "Spectatoring", the problem of perceiving sex as a performance rather than a mutual experience and process of pleasure "in the moment" can cause delayed ejaculation. Men who are solely aroused by sexual fetishes may be unable to ejaculate from regular intercourse. Idiosyncratic masturbation and lack of desire for stimuli are also proposed risk factors for DE. The word Idiosyncratic means something that pertains to an individual. In this case, it means a person who has a way of masturbating that is unique (or out of the ordinary). Most men stroke their penis with their hand in a way that vaguely imitates the stimulation from intercourse. An idiosyncratic style is defined as a technique not easily duplicated by a partner utilizing their hand, mouth, anus, or vagina. In these patients delayed ejaculation is adaptation to a certain masturbatory technique. Lawrence Sank (1998) wrote about the "Traumatic masturbatory syndrome", when the sensations a man feels when masturbating may bear little resemblance to the sensations he experiences during intercourse. Factors such as pressure, angle and grip during masturbation can make for an experience so different from sex with a partner that the ability to ejaculate is reduced or eliminated. One in three men with DE report Idiosyncratic masturbation. Also, high-frequency masturbation is associated with prolonged DE in penetrative sex with the partner accounting for another one third of the cases. Fantasy/partner disparity – that is to say, variant sexual fantasy during masturbation that was not incorporated into sex with their partner – accounted for one in five DEs. According to DSM-5-TR, "Delayed ejaculation is associated with highly frequent masturbation, use of masturbation techniques not easily duplicated by a partner, and marked disparities between sexual fantasies during masturbation and the reality of sex with a partner." Intravaginal ejaculation disorder is a peculiar Japanese case, but is very similar to "traumatic masturbatory syndrome," which is also mainly caused by intense masturbation. Diagnosis Diagnosis and management of DE warrant one of the most comprehensive medical evaluation in sexual health assessment that includes a full medical and sexual history performed along with a detailed physical examination. Understanding the quality of the sexual response cycle (desire, arousal, ejaculation, orgasm,