Premature ejaculation (PE)
This is a most common male sexual problem. And unfortunately one fundamental problems in this field is that there is no universally accepted definition. Even so, most men intuitvely have some sense of the speediness or delayed quality of their ejaculation. of us would probably recognize a case of premature ejaculation, especially if you were the man to whom it was happening!
Most experts would agree that between a quarter and four tenths of all men experience ejaculation before they wish it to happen. Of course, perception is a big factor in this condition, and most doctors or therapists will use the premature ejaculation definition in The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM IV), which is: “Premature ejaculation is persistent or recurrent ejaculation with minimal sexual stimulation before, on, or shortly after penetration and before the man in question wishes it.”
In addition, when you define PE this way, you see a need to specify also that early ejaculation must cause marked distress or interpersonal difficulty. Another definition of premature ejaculation is that PE is “persistent or repeated ejaculation with little stimulation before or just after penetration and certainly before the man wishes it, and over which the man in question has almost no voluntary control.”
There’s also a implied condition that the speed of ejaculation must cause the man or his partner some emotional distress. Well, that is highly subjective, and not all couples are bothered hugely by quick ejaculation, even if the man in question would like to be able to last longer in bed.
The key things, of course, in identifying a case of premature ejaculation are as follows: (1) there is a short interval between penetration (intromission) and ejaculation, (2) that there is a lack of voluntary control over ejaculation and that (3) there is some emotional upset for one or both partners.
Video on premature ejaculation
There is an alternative definition, in the International Classification of Diseases, Tenth Edition, that specifies a time limit for the length of lovemaking – fifteen seconds. Well, that seems nothing less than ridiculous, for many men who ejaculate within two (or five) minutes would probably consider themselves premature ejaculators, so fifteen seconds is ludicrous, and in any case, any defined cut-off time is purely arbitrary.
Having said that, most experts agree that men who ejaculate within one minute of insertion or penetration have premature ejaculation. Waldinger and colleagues have done much to define time limits between insertion and ejaculation that may be considered to fall within the definition, and this is of course useful in identifying those men who may be good candidates for coaching in how to prevent premature ejaculation, as well as identifying suitable treatments. Their median is 5.4 minutes. Such definitions have been welcomed by researchers as a way to assess the effectiveness of treatments.
Obviously it’s crucial for men who have a tendency to come quickly to identify themselves as having no voluntary control over ejaculation. One point that many researchers miss is that men who cannot control their ejaculation may well not understand that it is in fact possible to exert voluntary control over such an apparently involuntary bodily function. They may well be upset about the lack of control that they have in bed over their ejaculation, but they often do not appreciate that it is in fact possible to control their ejaculation through voluntary effort.
Historically, defining premature ejaculation was thought of as a purely psychological problem and behavioral therapy was thought of as the best treatment. The so-called “stop-start technique” was the first and classic treatment for premature ejaculation – it requires a man’s partner to stimulate his penis until he is almost at the point of no return, then to stop the stimulation until he knows he is no longer near ejaculation (in other words, until his arousal has dropped below the point at which there is a danger of him ejaculating).
The pattern of stimulation and stopping stimulation is repeated until there is a degree of control over ejaculation. A similar technique was put forward by Masters and Johnson in 1970, though they asked the man’s partner to squeeze his frenulum after she stopped stimulating him – presumably because such pressure can cause a loss of erection, so it will obviously take longer for him to get fully aroused again.
The reality, of course, is that many cases of premature and delayed ejaculation are caused by a lack of sexual confidence, by psychosexual anxiety, and by interpersonal issues such as anger or lack of interest in the partner’s well-being, pleasure or satisfaction (what you might call a kind of sexual selfishness).
Although teaching these techniques to delay ejaculation has been a main plank of psychosexual therapy, it may well be much more important in a psychodynamic sense for therapy to be directed at helping a man regain his sexual confidence, reduce his sexual performance anxiety, and more than anything else to resolve any interpersonal difficulties with his sexual partner. Treatment success is rather variable, and the reason for that appears to be that ejaculation is a spinal reflex which is strongly controlled by higher cortical centers – in other words, establishing voluntary control over orgasm and ejaculation is difficult.
Well, that is a matter of opinion. I think that when the motivation to overcome premature ejaculation is there, establishing voluntary control is not actually that difficult. Sure, it takes time and practice, but the key thing is motivation. This control can be developed. It is influenced by past experiences and present context, but there are a very few men with what one might consider to be the classically defined case of premature ejaculation; that is to say, an ejaculation latency which is so short and difficult to control that they may fall into a category where premature ejaculation can be defined with reference to a man’s genetic bias towards early ejaculation. (As an aside, if you’re interested, see here for information on endorphins and ejaculation.)
So, the very nature of this condition means that there is no clear definition of PE. Indeed, some authors have speculated that in fact far from being a dysfunction, it is actually the normal state of the male reproductive system! Authors have tended to come up with their own definitions based on their interest in the field, influenced by their research bias and individual judgments.
So, for example, the two most common definitions are completely different: the first, due mainly to Waldinger, suggests that a man has PE if he ejaculates within a minute of vaginal penetration; while the second, which originated with Masters and Johnson, states that a man has PE if he ejaculates before his partner has obtained sexual satisfaction. This implies, of course, that a woman will indeed reach orgasm during intercourse, which is a challenging assumption. Many surveys have demonstrated that, at the most, 15% of women regularly reach orgasm during intercourse.
Implicit in the Masters and Johnson definition of PE, then, is the presumption that were a man able to continue making love for longer, his partner would be able to reach orgasm during intercourse. This is highly questionable since most women achieve orgasm by stimulation of the clitoris, which tends not to happen during regular intercourse. In practical terms, therefore, this definition has to be seen as unworkable, and much better is the definition proposed by the American Urological Association. They suggest PE is defined as “ejaculation that occurs sooner than desired either before or shortly after penetration, causing distress to one or both partners”. More here.
Needless to say, it has been suggested that rapid ejaculation is an evolutionary advantage: the faster you impregnate a woman, the safer you are, and the more likely are your genes to pass on to the next generation. This may be so, but it doesn’t alter the fact that today premature ejaculation is a social, if not an evolutionary, handicap.
So what is the answer? One answer is to adopt a multi-disciplinary approach which combines all available treatment methods for PE. We shall look at the various premature ejaculation treatment options on this website.
Premature ejaculation, based upon the Asian Journal of Andrology, 2008 Jan; 10: 102-109