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Coping with Premature Ejaculation
(05/05/2004) by Michael Metz, PhD & Barry McCarthy, PhD
This excerpt from the book is printed with permission from New Harbinger Publications.
What is premature ejaculation (PE)? You might expect that this is an easy question to answer, but it depends on whom you ask. Masters and Johnson (1970), the founders of modern sex therapy, stated that a man has PE if he ejaculates before the woman reaches orgasm in 50 percent or more of their sexual encounters. PE is sometimes defined as a problem accomplishing a “normal” length of time between insertion and ejaculation. Studies have even defined PE by a specific amount of intercourse time: less than one minute, two, three, four, five, seven, or 10 minutes, each amount based on a different reason. Still others have proposed to define PE by the number of intravaginal thrusts: eight thrusts, 15 thrusts.
The best professional description of PE is that the man does not have voluntary, conscious control, or the ability to choose in most encounters when to ejaculate. We think this is the most helpful definition because conscious control reflects the interpersonal, cooperation, and intimacy issues for couples better than some mechanical or numerical definition.
Contemporary popular culture dictates that to enjoy sex maximally, the man should be able to last at least an hour during intercourse! Such myths about sexual performance are among the most negative influences on male and couple sexual satisfaction.
Kevin and Monica had the most common sexual problem facing young couples. Kevin suffered from PE. Both blamed Monica’s nonorgasmic response on Kevin’s PE. They believed that if Kevin could last longer, Monica would easily be orgasmic during intercourse. Sex would be perfect every time. It was Kevin’s duty as a man to make sure Monica had an orgasm during intercourse each time—an extraordinary pressure on Kevin and his penis.
Kevin did some Internet research and read how easy it was to cure PE. All he had to do was practice the squeeze technique (which we do not recommend), in which the man or his partner squeezes the underside of the tip of the penis to delay orgasm. He was very hopeful, but that broke down within two weeks. Kevin was stymied, and Monica resented his being a technician rather than an involved lover. Sex was no longer fun; it was a chore. Kevin was frustrated with Monica and with himself. He thought that everyone else quickly developed ejaculatory control. What was wrong with him? Or was it her fault? Maybe they did not love each other and this was a doomed relationship. Would PE destroy their marital bond?
Our Comprehensive Approach
If you are facing PE in your relationship, and especially if you are a couple who has tried the common techniques for treating PE and failed, we offer you our extensive experience, our clinical knowledge, and a detailed approach to treating PE. Our approach integrates the body, mind, and relationship aspects of PE to help you appreciate the complexity of your problem, develop understanding for yourself and your partner, build empathy for each other’s experience of PE, and create a detailed plan to organize your efforts to change. This biopsychosocial approach will not only help you overcome rapid ejaculation but deepen your intimacy and sexual joy.
Testing Your Knowledge of PE
How much do you really know about PE? Take this true-false quiz before reading further.
True False Most men engage in intercourse for 20 to 30 minutes.
True False A good lover prolongs intercourse until his partner has an orgasm.
True False Women function like men: they have a single orgasm during intercourse.
True False Men who ejaculate after two to seven minutes of intercourse have poor ejaculatory control.
True False PE is caused by too much masturbation, especially during adolescence.
True False Thrusting alone is enough for most women to have an orgasm during intercourse.
True False PE is always caused by psychological problems.
True False To deal with PE, the woman needs to be less erotic and the man has to reduce arousal.
True False PE is nature’s way of increasing fertility.
True False PE is a symbol of a relational power struggle.
In fact, each of these items is false.
Old and new myths about PE abound. In this book we will confront myths, including that PE is a simple, painless problem; intentional; purely psychological; the woman’s fault; a sign of sexual inadequacy; caused by masturbating too much or too fast; a sign of hostility; a symbol of male selfishness; the same for everyone; a problem with only one cause and one treatment; and a hopeless problem.
The Truth about PE
PE is the most common male sexual problem. The majority of male adolescents and young adults begin their sexual lives as premature ejaculators. Most men, as they gain experience, do develop ejaculatory control. However, approximately three in ten adult males regularly experience PE.
The good news is that PE can be understood and changed. You can increase your sexual satisfaction—and your partner’s—by learning to control ejaculation. The challenge is to deal with the complex, multicausal, multidimensional problem of PE and to enjoy sex with enhanced ejaculatory control.
Kevin and Monica were approaching PE from a poor understanding of the problem and a self-defeating focus on sexual performance. At its essence, sexuality is about sharing pleasure, not passing a performance test. Healthy, integrated sexuality values intimacy, pleasuring, and eroticism. Like most males, Kevin believed that sex was about eroticism, frequency, and proving adequacy to himself or to the woman. Kevin hadn’t really thought about sex as a way to share pleasure and to build intimacy. Yet, the reality is that PE affected both Kevin and Monica.
Successful treatment combines taking individual responsibility for sexuality and being an intimate sexual team. Understanding and changing PE was primarily Kevin’s responsibility; Monica did not cause Kevin’s PE, nor could she change it for Kevin. She could help Kevin honestly and objectively assess the components of his PE and be seriously involved in the change process.
PE is not a simple problem with one cause and one solution. There are actually nine different types of PE. PE involves biological, psychological, and relational factors, both in its causes and in its effects. A successful change program must address all the relevant factors. A successful program must also include a plan for dealing with relapse. Our approach is effective because it helps you address all of these issues.
It is helpful to realize that you are not alone. Guilt, stigma, blame, and counterblame are unnecessary and will subvert your motivation to resolve PE and enjoy couple sexuality.
Understanding Male Sexuality
It was once believed that the more masculine you were, the faster you ejaculated. But there is more to sex and sexuality than your penis, intercourse, and orgasm. Sexuality is about sharing and enjoying affection, pleasuring, intimate playfulness, eroticism, intercourse, orgasm, tenderness, and passion for life.
The great advantage of male sexuality is that young males find desire, arousal, and orgasm easy and predictable. Adolescents are encouraged to value sexuality as an integral part of masculinity. Men learn sexuality as automatic and—for better or worse—autonomous. In other words, the man needs nothing from the woman to achieve desire, arousal, and orgasm.
This view of sexuality becomes problematic as the man and the relationship age. Healthy sexuality is intimate and interactive, not autonomous. Learning ejaculatory control is an interpersonal process, not an individual one.
What You’ll Need to Learn
What do you need to learn about PE and ejaculatory control? First, this is a couple task. The woman plays an integral role in learning ejaculatory control. Second, ejaculatory management exercises are built on the solid foundation of nongenital and genital pleasuring. Ejaculatory control is not about the man performing up to a perfectionist standard or proving he can give the woman an orgasm during intercourse, but about developing a mutually satisfying couple style that includes pleasure-oriented intercourse. Learning ejaculatory control should not mute or decrease pleasure. To the contrary, it will expand physical pleasure as well as pleasure in the relationship.
There are several crucial skills in learning ejaculatory control.
Physiological Relaxation
The first skill is to learn how to relax your body during sexual arousal. Physiological relaxation is the foundation for your body’s healthy sexual functioning.
Identifying the Point of Ejaculatory Inevitability
The second skill is to learn to identify the point of ejaculatory inevitability. After that point, orgasm is no longer voluntary. Even if your mother-in-law walks in or something happens which is a sexual turnoff, you will still ejaculate. Actually, the point of ejaculatory inevitability is the beginning of the three- to ten-second orgasmic response. Many men report the most sensations and feelings just a second or two before they ejaculate. The ability to identify the point of ejaculatory inevitability is crucial in the techniques we’ll teach you.
Ejaculatory Regulation
The third skill is learning to regulate your ejaculation. We will teach you the two basic approaches: excitement toleration and excitement saturation. In excitement toleration, you will learn to maintain high levels of arousal without going on to ejaculation. With excitement saturation, you will learn to focus on your own bodily sensations, patiently welcoming the pleasure, allowing your body to become saturated or flooded with physical pleasure while slowing ejaculation by maintaining physical relaxation. You will then have reasonable control over when you ejaculate.
Cooperation for Intimacy
The fourth skill is to cooperate as a couple. Our approach to PE works best when you and your partner work together. The point of all these efforts is to enhance your closeness, comfort, pleasure, and joy as a couple.
Increasing Pleasure
The fifth skill is to enhance your pleasure, not reduce it. Do-it- yourself ejaculatory control techniques emphasize distracting yourself and reducing arousal—for example, by wearing two condoms, using a desensitizing cream on the head of the penis, thinking anti-erotic thoughts about debt or cleaning bathrooms, or using distraction techniques such as going over baseball scores or multiplication tables. These do reduce arousal but do not enhance ejaculatory control because they disconnect your awareness (the primary source of control) from your sensations and body. In addition, they carry the risk of causing a more severe sexual problem, erectile dysfunction.
Our approach to treating PE might seem counterintuitive because the exercises involve increasing penile and erotic pleasure. But you’ll find that increased awareness leads to increased control. We emphasize taking in erotic sensations and feelings, not shutting them out.
Most men can benefit from training in ejaculatory control. Instead of viewing PE as a major problem that makes you inadequate or makes the woman feel that her sexual needs are ignored or neglected, think of ejaculatory control as a skill the couple—not just the man—can learn in order to enhance mutual sexual satisfaction.
Letting Go of Your Focus on Performance
In movies, sex is always perfect. Both people are highly aroused before touching even begins; sex is flawless, nonverbal, and intense; they quickly have simultaneous orgasms and continue to make love all day. Our discussion about PE is scientifically accurate, sex-positive, helpful, and relevant to real couples, but it will not be made into a movie or sell as a romantic story. We are not describing a perfect fantasy model but what really goes on in a healthy sexual relationship. By its very nature, couple sexuality is variable. If the only purpose of sex were orgasm, men and women would masturbate and not engage in a relationship or intercourse. Masturbation is easier, more predictable, and more in your control than couple sexuality. Yet the great majority of men and women prefer couple sex to masturbation.
Giving up the performance-focused approach frees you to learn ejaculatory control and enjoy couple sex. Having a reasonable amount of control over when you ejaculate and enjoying the orgasmic experience is very different than making sure your partner is orgasmic during intercourse before you are allowed to have an orgasm. Since one in three women who are regularly orgasmic are never orgasmic during intercourse (Foley, Kope, and Sugrue 2002), this expectation is obviously flawed. Just as important, when you are so obsessed with performance, you cannot enjoy sharing the pleasure of intercourse.
Rather than enjoying orgasm, you are judging your performance.
Your focus on performance can become a major distraction for your partner. While she may be distracted from pleasure by her own unreasonable expectations, such perfectionist sexual goals interfere with your positive feelings about sex and about each other, and ignore the reality of variable sexual response. You are not a perfectly functioning sexual machine. You are a sexual man with changing and complex thoughts, behaviors, and feelings. You are not a rock or an island. You are involved in an interpersonal sexual relationship. Remember, the ultimate goal of learning ejaculatory control is increased sexual and relationship satisfaction. In understanding the role of sexuality in a relationship, desire and satisfaction are more important than arousal and orgasm.
The Myth of One Cause, One Treatment, and Easy Cure
The pop psychology belief about PE is that it has one cause (masturbating too much and too fast and approaching couple sex the same way), that there is one treatment (the squeeze technique), and that change is quick and easy. Recently, a simplistic medical approach has appeared which assumes that treating the man with antidepressant medication alone will retard ejaculation. This requires no learning by the man and no participation by the woman.
Human sexual behavior, including PE, is multicausal and multidimensional, with large individual and couple differences. The best way to understand PE is as a physical, cognitive (mental), behavioral, emotional, and relational phenomenon that can involve a number of causes and interactive effects. It is crucial to address all the factors which contribute to your type of PE so that you can approach the problem successfully and avoid slipping into old feelings, thoughts, and behaviors about PE.
It is risky to use a medication or a do-it-yourself technique like a penile desensitizing cream and not involve your partner or even tell her what you are doing. Even if this approach works and you don’t ejaculate as quickly, if you stop taking the medication or using the cream, PE will likely return and might even be worse. What does that do to your partner and relationship? She may blame you and be angry, feeling you could delay ejaculation, but now you just don’t want to. She may view you as selfish and not caring about her sexual feelings. If you’re not approaching the problem as a team, a relapse can leave you both demoralized and trapped in a blame- counter-blame pattern.
Relational Issues and PE
Relational problems can be a cause of PE, a result of PE, or both. Even when PE is caused by a medical problem or a physical injury, the frustration and sexual stress affects your relationship. Ideally, the man would learn and share information about PE with his partner. Unfortunately, that is the exception rather than the norm. Ideally, the woman would be empathic and supportive and be an active ally in trying to understand and resolve PE. Unfortunately, the woman may be unsure and alternate between blaming herself and blaming her partner. She might react in an extreme way, becoming overly sympathetic and “motherly,” which is anti-erotic, or becoming angry and demanding, which is intimidating and increases performance anxiety.
In learning ejaculatory control, most couples benefit from working to increase communication, understanding, empathy, cooperation, and intimacy. This reinforces the concept that sex is more than genitals, intercourse, and orgasm. Sexuality accounts for 15 to 20 percent of overall relationship satisfaction. Sexuality should not be a deal maker or deal breaker for the relationship, as there are other crucial facets to love and intimacy. Sexuality can enhance your relationship and make it special. PE works against that process.
Improving ejaculatory control is worthwhile for you and your relationship. The core of a relationship is a respectful, trusting, cooperative friendship enriched by emotional and sexual intimacy. What if you do not have a partner, or have a tenuous relationship in which you and your partner can’t work together to learn ejaculatory control? Our approach can still offer helpful information, guidelines, and understanding. In addition, you can use the self-exploration and masturbation exercises to learn and practice the skills of physiological relaxation, identifying the point of ejaculatory inevitability, and maintaining awareness at high levels of arousal.
When you’re seeking a new relationship, it’s important to choose a partner you are attracted to, comfortable with, and trust would be an ally in learning ejaculatory control. Many men with PE are so embarrassed that they avoid a sexual relationship, settling for one-night stands and either ignoring the problem or apologizing for their sexual performance. You need to approach the woman as a “sexual friend.” Disclose the problem without apologizing. Tell her that her sexual feelings and needs do matter to you, and request that she be a cooperative, sharing partner in working together to improve ejaculatory control and make this an enjoyable sexual relationship. Your leadership is essential in the process of change.
Understanding Female Sexuality
The major sexual complaint of men—that the woman is not orgasmic during intercourse—is not a sexual dysfunction but a normal variation of female sexuality. Female sexual response is more variable and complex than male sexual response. This does not mean better or worse. The man usually has one orgasm which occurs during intercourse. The woman might be singly orgasmic, nonorgasmic, or multiorgasmic, and orgasm might occur during the pleasuring or foreplay phase, during intercourse, or through after play.
Rather than expecting that the woman respond like him—have one orgasm during intercourse without needing additional erotic stimulation—the man needs to understand and accept that only one in four women respond in that manner (Foley, Kope, and Sugrue 2001). Orgasmic response is a healthy, integral part of female sexuality, but orgasmic response patterns are variable. Few women are orgasmic 100 percent of the time. For women, sexual satisfaction includes orgasm but is less rigidly tied to it. The majority of women find it easier to be orgasmic with manual, oral, rubbing, or vibrator stimulation than through intercourse. In fact, the most common sexual response pattern is for the woman to be orgasmic with manual or oral stimulation during the pleasuring phase, with the man being orgasmic during intercourse.
To develop the intimate team approach that will help you overcome PE effectively, you will need to understand, accept, and affirm your partner’s patterns of arousal and orgasm. She has to develop her “sexual voice,” not in reaction to what you think is right, but as a way to express her feelings and preferences. Together, you create a sexual relationship which is equitable and respectful of individual preferences rather than based on a simplistic view of male-female sexual differences.
Men grow up with the idea that they are supposed to be the sexual experts and it is their job to be sure the woman is sexually satisfied. We encourage you to consider a very different way to be in an intimate relationship. Your partner is the expert on her sexuality. Her desire, arousal, and orgasm are her responsibility, not yours. The old definition of a good lover was a man who took responsibility for the woman’s sexual satisfaction and was able to last long enough so that he could give her an orgasm through intercourse alone. The healthier, more realistic definition of a good lover is the man who accepts the woman as an equal sexual person and intimate partner.
As a good lover, you are open to her sexual requests and guidance. Each person’s sexual enthusiasm and arousal feeds the other’s desire, arousal, orgasm, and satisfaction. The man enjoys intercourse for himself and the relationship. He is aware and involved in giving and receiving pleasure during intercourse. Intercourse can involve a range of positions and movements that add to the intimate, interactive process. Being orgasmic is a natural extension of the arousal process. Sex does not end with his ejaculation. There is an after play phase in which he is open to her feelings and requests.
The man who is learning ejaculatory control with the goal of ensuring that the woman has an orgasm during intercourse is setting himself and the relationship up for failure and frustration. The reason to improve ejaculatory control is to make the sexual experience more pleasurable and satisfying for both partners, not to prove something to yourself or your partner. If she is orgasmic during intercourse and that is her preference, enjoy it. However, it is poison for you, the woman, and the relationship to put pressure on yourself to last longer so you can give her an orgasm during intercourse. The focus of ejaculatory control is to enhance the entire sexual experience: awareness, comfort, intimacy, pleasure, eroticism, intercourse, orgasm, and after play.
PE and Other Sexual Problems
Although it might feel overwhelming to tackle more than one sexual problem, PE often involves other sexual problems too, and you’ll be more successful in dealing with PE if you consider these problems along with PE.
Coexisting Sexual Problems in Men
For men, the most common coexisting sexual problems are acquired inhibited sexual desire and acquired erectile dysfunction. Acquired means that the man once experienced desire and erections, but now they are problematic or nonexistent. Couple sex therapy is the treatment of choice for both of these problems. Many men would rather first try to resolve the problem using this book’s guidelines and exercises. If that is not helpful within three to six months, then agree to consult a sex therapist.
Acquired Inhibited Sexual Desire
The key to sexual desire is positive anticipation and feeling you deserve good sex for you and your relationship. The usual reason for male inhibited sexual desire is frustration and embarrassment over a sexual dysfunction, especially erectile problems. Occasionally, inhibited desire may be caused by medical illness or side effects of medications, disappointment with the partner or relationship, alcohol or drug abuse, depression or anxiety, relationship stress or alienation, lack of couple time or energy, and preoccupation with children, extended family, or career. You’ll need to identify the factors that inhibit your sexual desire and actively confront and change them.
Many men feel so badly about PE that they fall into the cycle of anticipatory anxiety, tense and unsatisfying sex, and sexual avoidance. Sexual desire cannot be treated with benign neglect.
Avoidance just feeds the negative cycle. The hormone which most influences sexual desire, testosterone, works on a feedback system. Sexual activity enhances testosterone, while stress and sexual avoidance decrease testosterone.
In rebuilding male sexual desire, the key is to reinforce the cycle of positive anticipation, pleasure-oriented sexual experiences, and a regular rhythm of sexual encounters. You subvert your own sexual desire when you view sexual intercourse as a pass-fail test or tell yourself that anything less than a perfect sexual performance means you are less of a man. Desire is about connecting with your partner and sharing sexual pleasure.
Acquired Erectile Dysfunction
Erection problems are a major cause of male inhibited sexual desire. The traditional view of male sexuality is that a real man is able to have sex with any woman, any time, in any situation. This unrealistic demand is self-defeating for the man and his penis. In fact, by age forty, 90 percent of men have had at least one experience in which they did not get or maintain an erection sufficient for intercourse. So the most feared male sexual problem is in fact an almost universal experience.
A common non-medical cause of erectile dysfunction is trying to cope with PE by decreasing arousal to slow ejaculation. Approximately one in three men with PE also report erectile problems (Loudon 1988). The man feels caught between a rock and a hard place: if there is a lot of stimulation he will quickly ejaculate, but lack of stimulation results in erectile dysfunction. So the man rushes to intercourse because he fears losing his erection before he ejaculates.
Most men would prefer to take a medication like Viagra (sildenafil) or Cialis (tadalafil) to solve the erection problem, rather than address it with the partner. In fact, Viagra or Cialis can be a valuable resource by increasing blood flow to the penis and reducing performance anxiety. However, a pill cannot return the male to the easy, automatic, autonomous erections of his youth. The key to regaining erectile comfort and confidence is to relax, slow down and enjoy the pleasuring process, take in erotic sensations, and not rush intercourse or orgasm. It is crucial to be aware that the erection can wane but will become easily erect again if you stay relaxed and actively participate in the pleasuring and erotic process. You cannot be a “spectator” of your penis; sex is an involved, interactive experience.
Coexisting Sexual Problems in Women
Common female sexual problems that coexist with PE are inhibited sexual desire (acquired or lifelong), difficulty reaching orgasm (at all or during partner sex), dyspareunia (painful intercourse), difficulty becoming aroused, and vaginismus (constriction of the muscles of the vaginal opening making penetration for intercourse difficult or impossible). PE and female sexual dysfunction are often interrelated; one problem may contribute to the other. As a couple, you’ll be most successful at improving your sexual relationship if you each take responsibility for communicating your needs and commit to working together as an intimate team.
The Resources section at the end of this book lists a number of excellent self-help sources for understanding and changing female sexual problems and dysfunction. If you desire more help, we recommend consultation with a credentialed sex therapist (see Choosing an Individual, Couple, or Sex Therapist for guidelines). Seeing a sex therapist is a sign of good judgment, not a sign that you are crazy or that this is an overwhelming problem. A professional therapist assesses the sexual problems and helps design a change program that addresses the female problem, male problem, and couple problem. Ongoing therapy helps the couple stay focused and motivated.
(02/2004)
About the Authors
Michael Metz, PH.D., is the country's leading sexologist in the area of Premature Ejaculation (PE). Dr. Metz, who works in the Twin Cities of Minneapolis-St. Paul, Minnesota, is a major spokesperson for a comprehensive, integrated biopsychosocial approach to addressing and resolving sexual problems. After 12 years on the faculty of the University of Minnesota Medical School, he currently works in private practice with Meta Associates as a psychologist, marital therapist and sex therapist treating individuals and couples. He is affiliated with the University of Minnesota's Department of Family Social Science. Dr. Metz has published more than 45 professional articles and conducted numerous workshops and talks on marital and sex therapy. He is the author of the Styles of Conflict Inventory (SCI), a clinical assessment instrument to evaluate the conflict patterns in relationships.
Barry McCarthy, PH.D., is a clinical psychologist with a subspecialty in marriage and sex therapy practicing at the Washington Psychological Center in Washington DC. He is professor of psychology at American University where he teaches an undergraduate human sexual behavior course. Barry, with his wife Emily, has written seven well-respected books, the most recent being Sexual Awareness: Couple Sexuality for the Twenty-First Century, and Rekindling Desire: A Step By Step Program to Help Low-Sex and No-Sex Marriages. In addition, he has published more than 55 professional articles, 14 book chapters, and presented more than 110 workshops nationally and internationally
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