Psychological treatment approaches for premature ejaculation

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Psychological approaches to the treatment of rapid ejaculation

Stanley E. Althof PhD has written extensively about PE, and these notes are based on his article in JMHG Vol. 3 No. 2, pp. 180- 186, June 2006.

In this article he reviewed the psychological theories and various treatment approaches to premature ejaculation. It also describes the potential negative psychological effect of this condition on the man and his partner.

As part of the article he provided some suggestions as to how a man might approach the issue of treatment for PA, and how his partner might take part in this. He also discussed the effects and usefulness of a treatment approach that combined drugs and psychotherapy: in doing so, he discussed the limits of psychotherapy, and assessed how successful psychological interventions for rapid ejaculation can be. His conclusions may have relevance for improving the quality of psychotherapy for men experiencing rapid ejaculation; in any event, there's no question that psychological interventions are a crucial aspect of the treatment of rapid ejaculation.

Althof observed that it's comparatively easy to increase the intravaginal ejaculatory latency time (IELT) by offering men SSRIs, even though they are not licensed for use as a treatment for premature ejaculation. What is more difficult is restoring the confidence of a man and establishing a satisfactory relationship between him and his partner when his sense of sexual prowess and confidence has been diminished by his consistent inability to control the timing of his ejaculation. Indeed, Althof claimed in the article that the administration of SSRIs is now the routine treatment of choice.

But he also observes that, just as with the use of Viagra, the administration of drugs alone has proved to be a false dawn in the treatment of conditions, like this, that have a major psychological component. The point is, of course, that drugs in isolation cannot always overcome the psychological factors which may cause, or contribute to the cause of, the sexual dysfunction. It's also quite obvious, especially to those couples where premature ejaculation has been a persistent difficulty, that administering drugs to the man may not have any influence on the psychological effects that the man's PE has on his partner.

If, therefore, psychological factors play a part in either causing or worsening man's rapid ejaculation, it follows that psychotherapy of some kind is essential as an intervention in the treatment of both the man and his partner when a couple has experienced rapid ejaculation and it has affected their relationship. The question arises, which treatments are more effective in dealing with the condition?

Perhaps the first step in establishing this information is to decide whether or not it's clear where the cause of a man's PE actually lies. There are those experts who suggest that the condition is entirely psychological in origin; there are those who suggest that it is entirely organic in origin; and there are those who suggest that is the result of a combination of many factors.

The difficulty is that none of the theories that purport to explain the origin of premature ejaculation are backed up by evidence-based studies. As far back as 1927, psychoanalysts were suggesting that PE was the product of unconscious hostility towards women, combined with a conscious or unconscious pleasure in losing control (originally of urination as a child, later of the release of semen as an adult).

Later psychoanalytic explanations centered on the narcissism and selfishness of the man who ejaculates prematurely, apparently unconcerned for his partner's pleasure.

In the 1940s the idea evolved that quick ejaculation was some kind of psychosomatic disorder: in other words, that premature ejaculation was a symptom of some unresolved stress which manifested through the reproductive system rather than in some other way, such as an acidic stomach.

More recent psychological thinking suggests that anxiety is the major factor that lies behind a short IELT, in other words, a rapid ejaculation.

Anxiety has many causes, and the word itself is used imprecisely to describe different emotional states: in the context of rapid ejaculation this could include such things as a phobia about the vagina; conflict caused by anger at some aspect of a man's relationship and guilt about expressing this anger or hostility; and performance anxiety where a man is anticipating his failure during the sexual act. The latter condition is the one that we tacitly think of as performance anxiety -- a form of anxiety that anticipates failure, which then causes failure of the erectile or ejaculatory mechanism, thereby prompting further anxiety and a negative reinforcement cycle of anxiety and further failure.

Of course, Masters and Johnson saw rapid ejaculation in the context of incorrectly learned early experiences: they interviewed men with rapid ejaculation and discovered that many of them had had early sexual experiences characterized by the need for haste and secretiveness and imbued with nervousness.

Intuitively, it's not hard to see how having sex in the back of the car, say, with the fear of discovery, or engaging in paid sex with a sex worker, could produce anxiety and a rapid ejaculation. However, the problem is that these early conditioning experiences may not be unique to men with rapid ejaculation - such things also happen to many of the men who subsequently go on to develop good control of their ejaculation.

It's also been mooted that the lack of awareness, a lack of feedback from one's own body regarding the level of arousal one has reached during sex, is a factor in arriving unexpectedly at the point of no return. This suggestion is backed up somewhat by the fact that many men with PE do report that they move from low levels of arousal to the point of ejaculation without conscious awareness, in other words, their ejaculation takes them by surprise.

How does performance anxiety affect PE?

Of all of these possible causes, the one that seems most likely to have a major impact on the development of rapid ejaculation is anxiety. It is observed in almost all men with PE, and we know it is a major factor in other sexual dysfunctions like erectile issues. Certainly the negative feedback of failure and increased anxiety is a powerful and potent combination in worsening sexual performance, and possibly even causing a man to avoid sexual encounters.

We also need to consider how this kind of performance anxiety and its consequences affect a man and his relationship, and the quality of the sexual relationship between him and his partner. Men in this position report a low level of sexual self-confidence, and a reluctance or inhibition about establishing new relationships. Those who are already in relationship worry about being able to satisfy their partner, and may have concerns about the partner's faithfulness (or lack thereof) as a result of their sexual dysfunction. This is often raised in counseling.

It's also a common observation that men with PE may become preoccupied with thoughts of control, anxious anticipation of their ejaculation, worry and embarrassment, and the challenge of maintaining an erection in the face of their anxiety. This is in direct contrast to men who report satisfaction with sex and with their control of ejaculation - they show a focus on sexual arousal and satisfaction.

It follows that in the face of these negative consequences of PE, a couple's level of intimacy is likely to be lower than it is within a relationship where the man sees himself as functioning well in the sexual arena. One of the major causes of the disruption of relationship between a man with PE and his partner is in fact this loss of intimacy.

In addition partners may be distressed by the man's low-level sexual performance, the lack of sexual satisfaction that they receive during sexual encounters, and the man's perceived lack of consideration and his failure to listen to the partner's feelings about the situation. Of course, some men do give their partners an orgasm by manual or oral stimulation: for many couples that is a satisfactory solution, but for others it results in further performance anxiety and pressure on the man because he now feels that he has to sexually satisfy his partner in this way. It's observable that men with high levels of performance anxiety have a fragile self-esteem, and often believe that their partners do not understand how bad they feel about the problem. It is this which helps to makes PE a major issue for the couple, not just for the man.

Treatment options in the psychological area

As a rule of thumb, psychotherapy, or counseling, is clearly indicated where the cause of the PE is obviously psychological in origin, or where major emotional factors are maintaining the dysfunction. It is particularly indicated in couples where the man's PE serves as a distraction from sexual dysfunction in the woman, such as lack of orgasm, or where the relationship is clearly in jeopardy because of other factors.

It's also important to establish the partner's role in the man's PE: for example, if she is putting pressure on him to in "last 20 minutes because it takes me that long to have an orgasm" then at the very least she requires factual information about the nature of sexual relationships and the low possibility of a man being able to make a woman orgasm during sex alone.

Psychodynamic psychotherapy is essential for single men not in relationships who are seeking treatment for PE, since this allows the therapist to address their reluctance to enter into new relationships at the same time. In addition, of course, psychotherapy for a man with premature ejaculation can only proceed to a certain extent without a partner who can assist in the practical training exercises that are necessary to establish greater control.

When a man is already in a relationship, psychotherapy is recommended when the issues that appear to support his PE are in the main psychic rather than interpersonal: in other words if a man was anxious about the act of sex or felt hostile towards women, solo therapy might be more appropriate at least initially than couples' therapy.

If the relationship is in jeopardy or looks as though it has no future, then individual therapy may also be the appropriate treatment, but once again treatment options are limited when it comes to the practical aspect of training.

Couples therapy is the treatment of choice in those cases where a couple is functional and a man and his partner are both emotionally healthy and dedicated to pursuing treatment. With the full co-operation of the partner, hopefully the effect of PE on both the man and his partner can be explored, and a treatment strategy developed which involves them both.

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References

[1] Althof S. Psychological treatment strategies for rapid ejaculation: Rationale, practical aspects and outcome. World J Urol 2005; 23:89-92.

[2] Waldinger MD, Zwinderman AH, Schweitzer DH, Olivier B. Relevance of methodological design for the interpretation of efficacy of drug treatment of premature ejaculation: A systematic review and metaanalysis. Int J Impot Res 2004-13.

[3] Waldinger MD, The neurobiological approach to premature ejaculation. J Urof 2002 68(6):2359-67.

[4] Althof S:  When an erection alone is not enough: biopsychosocial obstacles to lovemaking. Int J Impot Res 2002;4(Supp l): 599-104.

[5] Abraharn K. Selected Papers, (5, 10) Institute of Psychoanalysis. London. Hogarth Press; 1927.

[6] MeMahon CG, Abdo C, Incrocci L, Perelman M, Rowland D, Stuckey 8, et al. Disorders of Orgasm and Ejaculation in Men. In: Lue IT, Basson R, Rosen, Giutiano F, Khoury 5, Montorsi F, editors. Sexual Medicine Sexual Dysfunctions in Men and Women Edition, 21. 20U; p. 411-68.

[7] Schapiro B. Premature ejaculation, a review of 1130 cases. J Urol 1943;50: 374-9.

[8] Masters W, Johnson V. Human Sexual Inadequacy. Boston: little Brown; 1970.

[9] Perelman M, MeMahon C, Barada J. Evaluation and Treatment of the Ejaculatory Disorders. In: lue T, editor. Atlas of Male Sexual Dysfunction. Philadelphia, Pennsylvania. Current Medicine, Inc.; 2004p. 127-57.

[10] Kaplan H. PE: How to overcome premature ejaculation. New York: Bruner/Mazel; 1989.

[11] Symonds T, Roblin D, Hart K, Althof S. How does premature ejaculation impact a man's life? J Sex Marital Ther 2003;3(29):361-70.

[12] Hartmann U, Schediowski M, Kruger THC. Cognitive and partner-related factors in rapid ejaculation. World J Urology 2005; 23:93-101

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