A Comprehensive Guide to Premature Ejaculation

Premature ejaculation (PE), also known as early ejaculation, is the most commonly

cited male sexual issue, reported to affect 20-30% of the male population. However,

with most cases turning out to be occasional or situational, the current thinking puts the

prevalence of treatment- worthy PE closer to 8-15%.

For those who have it or whose partners are dealing with it, early ejaculation can be

confounding and stress-inducing. On average, most couples engage in intercourse for

five to six minutes, and while no set time is innately adequate or inadequate, with PE it

could be a mere fifteen seconds or one minute, at which point both parties usually agree

something isn’t working. Left untreated this can lead to guilt, shame, insecurity, and

relationship conflict—all reason enough to seek help. Yet most men don’t due to

embarrassment, confusion, or lack of awareness about available treatment options.

Sometimes the issue goes away on its own, but it just as often doesn’t. It can come on

later in life or be lifelong. For those in the latter group PE occurs during puberty or their

first sexual experience, then continues to occur throughout their life. While most men

will experience it at least once in their life, treatment- worthy PE is a pattern of

unintentional ejaculation, occurring sooner than intended, usually within the first two

minutes of sexual activity or intercourse. Whether ten seconds or two minutes, the

determining factors are that it's (1) an ongoing loss of control and (2) significant enough

to cause distress.

Most doctors do little more than prescribe antidepressants and recommend sex therapy

before ushering the afflicted out the door. Progress for the patient becomes piecemeal,

through trial and error or bits of information gleaned from online forums or Google

Scholar. Surrogate Partners offer experiential therapy and have an excellent track

record, as do some intimacy coaches and somatic body-workers, yet these niche

modalities aren’t available in every US city, nor is PE a one-size fits all issue. PE’s

causes are complex and most often stem from a combination of factors.


The causes of premature ejaculation are varied. More research is needed (on men of

every sexual orientation) but factors can be psychological, behavioral, cognitive,

developmental, hormonal, genetic, neurobiological, and environmental. They include the


 hypersensitivity of the glans

 performance anxiety

 pelvic floor muscle (PFM) tension / hyper-toned PFM

 a naturally faster neurological response in the PFM

 neurotransmitter disorder (serotonin dysregulation, low dopamine or oxytocin)

 genetic variations

 hyperthyroidism / thyroid disease

 low prolactin

 prostatitis

 disease, injury, drugs (prescription or street), and other lifestyle factors

 lack of sensory awareness (being too much in one’s head/thoughts)

 catastrophizing (negative association leading to a failure spiral)

 interpersonal dynamics, ongoing relationship conflicts

 ingrained childhood masturbation habits (always done in a rush)

 fear of pregnancy, vulnerability, failure

 disassociation, feeling detached or inauthentic


PE can be generalized (occurring with different partners in a variety of environments) or

situation specific, such as only with one certain person or a certain type of person

(known as situational or variable). For most men it is occasional and happens rarely

over the course of their life. For the rest, it tends to be either acquired or lifelong.

 acquired (APE): begins after extended period of normal sexual functioning then

becomes ongoing (aka secondary PE)

 lifelong (LPE): exists to some degree from the onset of sexual activity and is

ongoing (aka primary PE)

Acquired PE can have physiological or psychological causes. It should be checked out

by a medical doctor as a first line of defense. Psychological issues, such as relational

stress, trauma, or anxiety can spark acquired PE at any age (though is more prevalent

in younger men). Acquired PE can manifest as situational or generalized PE. It is

treatable with a variety of modalities and techniques, many with excellent success rates.

Lifelong PE has not been well understood in the past, yet new research suggests a

strong genetic component, specifically issues related to serotonin receptors. Pelvic floor

tension is also a common contributor.


As you can see, premature ejaculation is complicated—though again, quite treatable. In

order for treatment to be effective, determining the correct approach for each individual

is paramount. The average family doctor may not be up on the latest research, tests,

and treatments, and some doctors are incapable of frank, open discussion about sexual

function. Finding a qualified physician willing to do comprehensive testing is your best

bet. Some tests and other factors to consider are:

 urinary issues, prostatitis

 thyroid hormone levels (TSH, T3, T4)

 cortisol level (stress hormone)

 testosterone level (free & total)

 other hormone levels (SHBG, DHEA, DHT, E2)

 organic acids test (for serotonin markers)

 pelvic floor exam by a physical therapist specializing in PFM

 nervous system issues

 family genetics (men with lifelong PE may inquire about the same among male



There are many ways to address premature ejaculation. In the past, the most common

was a reduction in the man's level of pleasurable sexual sensation. But why should this

be the go-to approach? It not only requires tremendous restraint on his part but results

are inconsistent. Counterintuitive as it seems, increasing one’s capacity for pleasure is

the more effective approach. It can (and should) be done gradually, through a series of

exercises during which the client learns to accept, embrace, and enjoy a higher degree

of overall bodily pleasure. Acquired PE tends to respond well to this method, especially

when its causes are primarily psychological.

Men with lifelong PE can also benefit from embodiment practices, although APE and

LPE generally requires type-specific, highly individualized protocols. The goal is to

overcome PE by addressing the myriad of emotional and physical causes, not to

temporarily override it (which is the only thing that other — sensation

decreasing—methods do).

Other past treatment methods that have fallen out of favor (for good reason) are:

 the stop/start method

 the squeeze technique

 mental distractions (baseball, grandma, etc.) 

Other minimally effective “stop-gap” measures that don’t address the core issue and

can actually worsen it long-term are:

 condoms, one or more (to minimize sensation)

 numbing sprays (again, to minimize sensation, and therefore pleasure)

 antidepressants (which have side effects and can be a challenge to discontinue)

 SSRIs (which potentially impair fertility and erectile function)

 limiting sex positions, such as to woman on top (again, minimizes sensation for


 pre-sex / pre-date masturbation (yet another sacrifice of sensation for him) 

More effective approaches, resulting in sustained improvement and in some cases

complete eradication of PE issues are:

 masturbation practice (mindful masturbation, peaking exercises, etc.)

 successive approximation (shaping behavior gradually, incrementally)

 pelvic floor therapy 1

 Kegels and (especially) Reverse Kegels (pelvic floor exercises)

 yoga2 and other stretching techniques

 TheraWand prostate massager3, when hypertonic (non-relaxing) pelvic floor

muscles are indicated

 breathing techniques (to stimulate the parasympathetic nervous system)

 mindfulness meditations, embodiment exercises

 acupuncture4

 Chinese herbs

 endocrine therapies such as bio-identical hormone therapy, thyroid regulation5

 OTC supplementation (probiotics, 5-HTP6, zinc7, various neurotransmitter


 sex therapy / couples therapy

 intimacy coaching, Surrogate Partner Therapy, and other experiential modalities

1 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4003840/

2 https://www.sciencedirect.com/science/article/abs/pii/S1743609515316945

3 https://link.springer.com/article/10.1007/s10484-015-9325-6

4 https://www.sciencedirect.com/science/article/abs/pii/S0302283811000303

5 https://pubmed.ncbi.nlm.nih.gov/20345874/

6 https://pubmed.ncbi.nlm.nih.gov/9676898/

7 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2800928/