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.
Triggers
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
following:
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
Types
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.
Tests
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
relatives)
Treatment
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
him)
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
formulations)
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/
