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Premature Ejaculation

Lorraine Benuto, Ph.D., edited by C. E. Zupanick, Psy.D.

As mentioned, many couples come into therapy because of "premature ejaculation." However, upon receiving correct information, they learn they had nothing to be concerned about. They just had some false expectations. Still, Premature Ejaculation is one of the most common complaints of men or couples presenting with ejaculatory disorders. It may have a significant impact on an individual/couple's quality of life and sexual satisfaction.

Premature ejaculation can affect men across all ages making this a fairly common male sexual disorder. In fact, research shows that premature ejaculation may affect 20-30% of men between the ages of 18 and 70 years of age.

In the past, experts did not agree about the precise definition of premature ejaculation. Some researchers and clinicians defined premature ejaculation in terms of time (i.e., ejaculation in less than 1 minute) while others defined premature ejaculation in terms of partner satisfaction. And others defined the disorder in terms of the dissatisfaction of the individual (Schuster, 2006). Thus, a person who ejaculates within 30 seconds of penetration, who is satisfied with this time, and whose partner is satisfied with this, may or may not be classified as having a disorder, depending upon which diagnostic criteria are to be used. However, in the DSM-5, premature ejaculation has been defined as ejaculation happening within 1 minute of vaginal penetration and before the male wishes it to happen.

To be diagnosed with Premature (Early) Ejaculation, there must be:

  • A persistent or ongoing pattern of ejaculation happening during partnered sexual activity within approximately 1 minute following vaginal penetration and before the individual wishes it. The diagnosis may be applied to men engaged in nonvaginal sexual activities, but specific duration criteria have not yet been created.

The symptom must have been present for at least 6 months and must be experienced in 75-100% of sexual activity.

It must cause significant stress in the male's life.

It must also cannot be the result of a mental disorder, severe relationship distress (such as partner violence), a medical condition, or because of a substance or medication.

The clinician should specify whether the condition is:

  • Lifelong - the problems have been present since the person became sexually active
  • Acquired - the problems began after a period of relatively normal sexual function

It should also be noted whether it is:

  • Generalized - not limited to certain types of stimulation, situations or partners
  • Situational - only happens with certain types of stimulation, situations or partners

Finally, the condition can be:

  • mild - ejaculation happens within approximately 30 seconds to 1 minute of vaginal penetration
  • moderate - ejaculation happens within approximately 15-30 seconds of vaginal penetration
  • severe - ejaculation happening prior to sexual activity, at the start of sexual activity, or within approximately 15 seconds of vaginal penetration

The neurobiology (brain/body reasons) for ejaculation has received a lot of attention with the hope of finding a medication treatment. From a neurological perspective, the ejaculatory process is controlled by both the central and the peripheral nervous system (Schuster, 2006). However, since the exact cause of premature ejaculation is disputed, treatment options are broad. They include behavioral and psychological interventions, as well as attempts to modify the amount stimulation felt, or to delay the ejaculatory reflex through medication (Ellsworth & Kirshenbaum, 2008). The ejaculatory reflex is simply defined as any other reflex is. For example, during a physical exam a doctor tests reflexes by tapping the patient's bent knee with a small, rubber hammer. This causes the knee to reflexively jerk upward. The ejaculatory reflex is very similar: if the man receives adequate stimulation, his natural response is to ejaculate.

Premature Ejaculation Treatment Options (as proposed by Schuster, 2006)

a) Sex Therapy: Initially, premature ejaculation was believed to be a learned behavior. The good thing about learned behaviors is that they can also be unlearned. But how did this learning happen? For the typical male, first sexual experiences often happen in alone through masturbation where the emphasis is on reaching orgasm quickly. Often during early sexual experiences there is an emphasis on being "quick" as circumstances may cause a fear of being "caught." Thus, it becomes easy to understand how one might learn to ejaculate too quickly.

According to the basic principles of behaviorism, what can be learned can also be unlearned. Behaviorism refers to a basic set of principles that describe how behaviors are learned and maintained (e.g., teaching a dog to sit). Behavioral principles also apply to how maladaptive, previously learned behaviors can be unlearned, or replaced with more adaptive ones. The principles of behaviorism are often used in the treatment of many sexual disorders. One such treatment was developed in 1956 by Dr. James Semans; named the start-stop method for treating premature ejaculation. This technique includes self-masturbation. The penis is stimulated until arousal is heightened, but stopped right before the start of the ejaculatory reflex. Masturbation is then stopped until the sensation subsides and then the activity is repeated. This exercise is completed several times until the man is able to experience vaginal penetration without immediately feeling the inevitability of ejaculation.

Presently, the most common type of sex therapy prescribed for individuals who are experiencing premature ejaculation is the "squeeze technique" developed by Masters and Johnson during their revolutionary experiments in the 1970s. The individual is instructed to masturbate and then to squeeze the erect penis (at the head) before the ejaculatory reflex is stimulated. Using this technique, the individual will learn voluntary control over ejaculation by learning to delay ejaculation while remaining sexually aroused.

While both above techniques can be successful, it is important to include the partner in the treatment plan. This is because while many men are able to master the "squeeze technique" on their own, once they are in the presence of their partner, they find themselves overwhelmingly aroused and/or anxious, and unable to apply the technique with their partner. Because of this, the man is often encouraged to engage in this practice first alone, then later in the presence of his partner, and finally, having the partner act as the "squeezer" so-to-speak.

b) Decreasing Penile Sensitivity: The penis, particularly the glans, is incredibly sensitive. Historically, creams or gels containing local anesthetics were applied to the penis to reduce sensitivity, with the goal of delaying ejaculation. While this mode of treatment may be convenient and inexpensive, some men complain that the glans becomes so numb that they lose too much sensitivity. As a result, they experience erectile difficulties. Additionally, it may be necessary to use a condom when using topical treatments as women often report losing sensation when the penis (complete with anesthetic) enters the vagina.

c) Medication Therapy: Currently no medications have been approved by the Food and Drug Administration for the treatment of premature ejaculation. However, research has indicated that antidepressants may function as a treatment for premature ejaculation. It is important to note that as with all medications antidepressants have many side effects. Some of these include nausea, drowsiness, perspiration, and even erectile dysfunction itself. Medications must be carefully considered with a qualified health care provider.



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