|The definition of premature ejaculation is imprecise
and the subject of disagreement among sex therapists and researchers. Masters
and Johnson suggested that ejaculation occurs prematurely if the woman does not
reach orgasm during intercourse at least 50 percent of the time. This definition
is problematic, as some women reach orgasm very rapidly during intercourse,
while for others, orgasm never occurs during intercourse, regardless of
duration. Kaplan proposed that a lack of voluntary control over the occurrence
of orgasm defined premature ejaculation. However, it is not clear that the
ejaculation reflex is truly subject to voluntary control. Rather, the
ejaculation reflex, similar to the sneezing reflex, is at best only partially
under voluntary control.
The Diagnostic and Statistical Manual of the
American Psychiatric Association defines premature ejaculation as "ejaculation
with minimal sexual stimulation or before, upon, or shortly after penetration
and before the person wishes it." This definition acknowledges that there must
be a subjective element to the diagnosis of premature ejaculation. As well as
considering the duration of intercourse, the nature of the couple's sexual
interaction must be evaluated. A couple who engages in 45 minutes of
unrestrained manual and oral-genital foreplay, followed by one minute of
pleasurable intercourse, would not be considered to be troubled by premature
ejaculation. However, ejaculation after ten minutes of intercourse might be
premature if this duration can only be achieved by avoiding all foreplay;
spraying the penis with a skin anesthetic; wearing three condoms; thinking
unpleasant, distracting thoughts; and biting one's tongue so the pain interferes
with sexual arousal.
The rates of premature ejaculation found in population
studies have varied between 10 percent and 25 percent of men surveyed, probably
due to differences in the definition of the problem. In terms of actual duration
of intercourse, the 1948 Kinsey Report found that "for perhaps three-quarters of
all males, orgasm is reached within two minutes" of intercourse, but Hunt's 1974
study found that the average duration of intercourse had increased dramatically,
to 10 to 14 minutes, in the intervening 26 years. This dramatic change in the
societal norm for duration of intercourse has increased the distress of men who
suffer from premature ejaculation.
Premature ejaculation, according to Bancroft, is
typically a younger man's problem, with the majority of cases involving men
under the age of 30. Premature ejaculation is typical for young men in their
first sexual experiences and might be considered normal at this time. However,
as these men have no history of successful sexual relationships as a basis for
their sexual self-esteem, self-blame and self-labeling as dysfunctional often
occur. With continued sexual experience, most men spontaneously get over their
initial premature ejaculation. Along with the effects of experience, as a normal
physiological change in aging the time required for a man to reach orgasm
increases, but this is a slow change occurring over many years. A young man
whose premature ejaculation is not resolved with greater sexual experience would
have to wait 20 or 30 years for normal aging processes to solve his problem.
Premature ejaculation does not seem to be caused by any
physiological factors or medical conditions. While Kaplan suggested that some
local diseases or medications could cause premature ejaculation, Bancroft did
not find this to be the case.
Research has also failed to connect premature
ejaculation with the complex individual psychodynamic and couple-relationship
problems associated with other sexual dysfunctions, such as hypoactive sexual
desire. Rather, premature ejaculation seems to be typical of young, sexually
inexperienced males who simply have not learned to slow down and modulate their
arousal and to prolong the pleasurable process of making love. Men who have sex
only infrequently are also prone to ejaculate prematurely. Indeed, Kinsey,
Pomeroy, and Martin proposed that the primary cause of premature ejaculation was
a low frequency of sexual activity. Research has indicated that sensory
thresholds in the penis are lowered by infrequent sexual activity and that
premature ejaculation patients have a low rate of sexual activity. However, it
may well be that premature ejaculation makes sex an unpleasant failure
experience, which is therefore avoided, rather than that low frequency of sexual
activity causes premature ejaculation.
Anxiety and ejaculation both involve activation of the
sympathetic nervous system, so anxiety about trying to delay ejaculation can
make the problem worse. Masters and Johnson proposed that men learn to be rapid
ejaculators during adolescent masturbation, when they often hurry to ejaculate
because of fear of being discovered by parents. However, such experiences seem
to have been equally common in men who are not premature ejaculators. There has
even been some speculation by evolutionary biologists that rapid ejaculation may
have been selected for during primate evolution, through a "survival of the
fastest" process. A male who could ejaculate rapidly would be more likely to
reproduce successfully, as there would be less chance of the female escaping,
another male interrupting, or a predator attacking before coitus was completed.
Kaplan proposed that premature ejaculators cannot
accurately perceive their own arousal level and therefore cannot engage in
self-control. However, one laboratory study comparing premature ejaculators and
age-matched normal control subjects actually found that the premature
ejaculators were more accurate when their self-ratings were compared to
objective measures of physiological arousal. It may be that premature
ejaculators, who because of their problem keep their attention focused on how
close they are to ejaculation during sexual activity, have trained themselves to
be unusually accurate self-observers of arousal. None of the theories of the
cause of premature ejaculation is well supported by research, except that
premature ejaculation is typical of younger, less experienced men and men who
have sex infrequently.
The treatment of premature ejaculation, using the
"pause" and "squeeze" procedures developed by Semans and by Masters and Johnson,
has been found to be highly effective. Research has demonstrated that such
procedures work well in group as well as in individual treatment, and in
self-help programs; they can be practiced in individual masturbation with
relatively good transfer of therapeutic gains when sex with a partner is
resumed. Success rates of 90 percent to 98 percent are reported.
In the stop-start or pause procedure, the penis is
manually stimulated until the man is fairly highly aroused. The couple then
pauses until his arousal subsides, at which time the stimulation is resumed.
This sequence is repeated several times before stimulation is carried through to
ejaculation, so the man ultimately experiences much more total time of
stimulation than he ever has before and thus learns to have a higher threshold
The squeeze procedure is much like the stop-start procedure,
with the addition that when stimulation stops, the woman firmly squeezes the
penis between her thumb and forefinger, at the place where the glans of the
penis joins the shaft. This squeeze seems to further reduce arousal. After a few
weeks of this training, the necessity of pausing diminishes, with the man able
to experience several minutes of continuous penile stimulation without
ejaculating. Next, the couple progresses to putting the penis in the vagina but
without any thrusting movements. If the man rapidly becomes highly aroused, the
penis is withdrawn and the couple waits for arousal to subside, at which point
the penis is reinserted. When good tolerance for inactive containment of the
penis is achieved, the training procedure is repeated during active thrusting.
Generally, two to three months of practice is sufficient for a man to be able to
enjoy prolonged intercourse without any need for pauses or squeezes.
We have no real understanding of why the pause and
squeeze procedures described by Semans in 1956 and Masters and Johnson in 1970
work. The pause procedure fits Guthrie's theoretical paradigm for
counter conditioning by "crowding the threshold." Additionally, the stimulation
and pause procedure is typically repeated by the patient several times per week,
thus raising the frequency of sex and raising the sensory threshold of the
penis. Either or both of these mechanisms may underlie the effectiveness of
Some variations on the pause and squeeze procedures
have been reported, typically as clinical case reports. One variation described
by LoPiccolo involves reversing one of the physiological changes that occurs
during high arousal. During high arousal, the scrotum contracts and elevates the
testes close to the body.
As well as having the patient cease stimulation or
squeeze on the penis, the patient may also be instructed to stretch out the
scrotum and reverse this testicular elevation. However, during high arousal, any
additional stimulation of the scrotum and perineum may trigger an ejaculation
and thus may make the pause and squeeze procedure ineffectual. Empirical data on
the effectiveness of this technique are lacking.
Segraves reported that drugs and medications that block
sympathetic arousal often have the effect of delaying ejaculation. Such agents
include anti-anxiety, antidepressant, and major tranquilizing medications;
sedatives; some medications used to treat high blood pressure; and some
antihistamines. However, because of serious side effects, the use of medication
in treating premature ejaculation is not recommended, especially when the
effectiveness of the behavioral retraining procedure is considered. Many of the
recreational or "street" drugs such as alcohol, marijuana, cocaine, "downers"
(barbiturates), and heroin also delay ejaculation, and although some men do use
such agents to deal with their premature ejaculation, this is even more unwise
than the use of prescription medications.
It is somewhat puzzling that although there is little
agreement about the definition or cause of premature ejaculation, and no real
understanding of how the treatment procedure works, treatment is virtually 100
percent effective. If one has to have a sexual dysfunction, this is the one to
Bancroft, J. Human Sexuality and Its
Problems. New York: Churchill Livingston, 1989.
Frank, E., C. Anderson, and D. Rubinstein.
Frequency of Sexual Dysfunction in "Normal" Couples. New England Journal of
Medicine, Vol. 299 (1978), pp. 111-15.
J. R., B.A. Gladue, C. W. Roberts, and J. LoPiccolo. Historical and Current
Factors Discriminating Sexually Functional from Sexually Dysfunctional Married
Couples. Journal of Marital and Family Therapy, Vol. 12 (1986), pp.
Hong, L. K. Survival of the Fastest.
Journal of Sex Research, Vol. 20 (1984), pp. 109-22.
Hunt, M. Sexual Behavior in the 1970s.
Chicago: Playboy Press, 1974.
Kaplan, H. S. The New Sex Therapy. New
York: Brunner/Mazel, 1974.
K. Ejaculation and Emission: Normal Physiology, Dysfunction, and Therapy. In R.
J. Krane, M. B. Siroky, and I. Goldstein, eds., Male Sexual Dysfunction.
Boston: Little, Brown, 1983.
P. R., and R. Auerbach. Treatments of Premature Ejaculation and Psychogenic
Impotence: A Critical Review of the Literature. Archives of Sexual Behavior,
Vol. 8 (1979), pp. 81-100.
Kinsey, A. C., W. B. Pomeroy, and C. E.
Martin. Sexual Behavior in the Human Male. Philadelphia: Saunders, 1948.
J. Treatment of Sexual Dysfunction. In A. S. Bellak, M. Hersen, and A. E. Kazdin,
eds., International Handbook of Behavior Modification and Therapy. 2nd
ed. New York: Plenum Press, 1990.
Masters, W. H., and V. E. Johnson. Human
Sexual Inadequacy. Boston: Little, Brown, 1970.
Sanders, D. The Woman Book on Sex and Love,
London: Joseph, 1985.
Sanders, D. The Woman Report on Men.
London: Sphere, 1987.
R. T. Drugs and Desire. In R. C. Rosen and S.R. Leiblum, eds., Sexual Desire
Disorders. New York: Guilford, 1988.
J. H. Premature Ejaculation: A New Approach. Southern Medical Journal.
Vol. 49 (1956), pp. 353-57.
W.F., J. H. Geer, and W. T. O'Donohue. Premature Ejaculation: Investigation of
Factors in Ejaculatory Latency. Journal of Abnormal Psychology, Vol. 93
(1984), pp. 242-45.