Part 3 of a new three-part series, for men with premature ejaculation and their partners, on contemporary issues in the understanding and treatment of PE.
Toward a New Definition of Premature Ejaculation
What Causes Premature Ejaculation?
As we discussed in Part Two of this series, when a man can’t last very long in bed, most often that’s just due to how he’s wired.
Most men with “lifelong premature ejaculation” seem to have what we call “low orgasm thresholds,” where it doesn’t take much stimulation to activate their orgasm reflex.
There’s a bell-curve for orgasm thresholds. Most men who can’t last more than a minute during intercourse just happen to be have been born on the extreme low end of the bell-curve.
In a way, men with premature ejaculation are similar to that other classic bell-curve outlier, the woman with an extremely high orgasm threshold, who can’t climax unless she has complete quiet and half an hour with her vibrator.
Both represent extremes of common gender-based tendencies. In both cases, it’s ultimately all about the thresholds.
In Part One of this series on premature ejaculation, we looked at some new ideas for defining premature ejaculation.
In Part Two, we looked at what causes it.
Now in Part Three, we’re going to discuss options for managing this condition.
In what follows below, I’m going to start with the most common practical work-arounds that men with premature ejaculation tend to try on their own (#’s 1-5, below). Then we’ll discuss the major techniques recommended by sexuality professionals (#’s 6-8, below).
Ready? Okay, let’s take a look at all the options available today for men with PE who want to last longer in bed:
This method was made famous by my colleague Ian Kerner in his book She Comes First, which is basically a guide to cunnilingus. Here’s how it goes:
Let’s say you tend to climax immediately on penetration, but your partner needs a half hour of serious clitoral stimulation to make an orgasm happen.
Kerner solves the problem by re-branding cunnilingus as not foreplay but “coreplay.”
In other words, it’s the main event.
Here’s the technique: She comes first, after the requisite half hour of vigorous cunnilingus. Then you climb on top, enter her, ejaculate immediately, and Voilà . . . near-simultaneous orgasms.
Nice, huh? Well, that’s assuming you both just love cunnilingus. Not everyone does.
Instead, some men just finger their partner to stimulate her to orgasm. Unlike the tongue, though, fingers and hands tend to get tired.
Often a good vibrator is called for. Some couples find this works well.
But the only reason he lasts longer is by keeping his penis out of the action until the very end. If she really loves intercourse, she might miss getting more of it, even if she gets an orgasm every time.
Let’s look at the pros and cons of this method, overall:
Couples who use this technique will specifically plan on him ejaculating right away.
They’ll do penetration fairly early in foreplay, as a quick appetizer. Then after he climaxes, they’ll settle down in bed together, talk, snuggle and enjoy each other’s company until he gets hard again—at which time they’ll go for Round Two.
Most men with premature ejaculation will last longer in Round Two. Mostly because by that point they’re less intensely excited.
As a sex therapist, I’m skeptical of anything that relies on you being less excited. I mean, why have sex at all, unless it’s to enjoy being as excited as possible?
You may remember we discussed this issue at length in Part One of this series, where we referred to this kind of thing as “Arousal Reduction” or AR. Arousal Reduction is at the heart of most traditional work-arounds for premature ejaculation.
Unfortunately, Arousal Reduction by definition means less exciting sex. Many men with PE who need a Round Two say they regret never really being able to enjoy hot sex fueled by full-throated desire.
Some men will do Round One all by themselves, then do Round Two later with their partner. But that’s like showing up at the restaurant, having already eaten. Hardly an ideal solution.
Let’s look at the pros and cons of trying to last longer in bed by waiting for Round Two:
There are lots of variations on this theme, but the basic idea is the same.
Sexual excitement, roughly speaking, consists of physical plus psychological stimulation—“friction plus fantasy,” if you will.
Reduce the physical sensation, and you’ve removed half the problem. Now it’s much easier to stay below what’s called your orgasm threshold.
The classic way to last longer by reducing sensation is to use a condom. Other popular methods involve numbing the penis with local anesthetic: sprays, wipes, creams, etc.
These all work by the principle of Arousal Recuction (AR), as we discussed above. Who else but a man with premature ejaculation would ever try to have less exciting sex?
One interesting variation on this theme, which I’d still classify as AR, is what’s called “coital alignment technique.” Here’s how it’s done:
Place your penis as deep inside her vagina as you can. Only the outermost part of her vagina has muscles capable of gripping your penis tightly. If you keep your penis deep inside her, the sensitive head of your penis stays far away from the tighter outermost part of her vagina.
If you press your pelvis firmly up against hers, she can now grind against your body to stimulate her own clitoris. Lots of good clitoral stimulation for her, but your penis remains near-motionless inside her, minimizing physical stimulation for you.
Condoms, creams, sprays, wipes, and coital alignment all have in common that they seek to minimize physical sensation. Let’s look at the pros and cons of trying to last longer in bed by such means:
Sexual arousal keeps you in the moment. If you take yourself out of the moment, your arousal will probably drop. You might last longer, but it’s not going to be very memorable sex.
There are lots of way take yourself out of the moment, by distracting yourself and thinking about something else entirely. Some guys try to last longer by thinking of irrelevant stuff. (How many state capitals can you name?)
More commonly, a man might make himself think of something negative or unpleasant, to turn himself off. His least favorite elementary school teacher, for example.
Other techniques include avoiding sex positions that you find especially exciting. Or avoiding partners who you find especially exciting.
Understandable, as accommodations to a low arousal threshold. But clearly dismal, as strategies for lovemaking.
Oh, and one more thing:
Partners tend to hate these techniques most of all. I mean, how would you want to have sex with someone while they’re thinking about their least favorite teacher?
After all, it’s not just about how long intercourse lasts. It’s also about whether you’re emotionally present with your partner, or just doing multiplication tables in your head.
Here’s my run-down of the pros and cons of trying to last longer in bed by reducing your level of psychological excitement:
Men with premature ejaculation have historically used a wide range of psycho-active substances to last longer in bed.
Some addicts report that heroin is remarkably effective for premature ejaculation. (Heroin withdrawal can produce the opposite effect). The milder opioid tramadol (which also has serotonin-enhancing effects in the central nervous system) has been shown effective for PE in research studies.
Occasionally men also report good results with certain strains of cannabis.
But by far the most widely used recreational drug for premature ejaculation is alcohol.
Sex therapy, as originally developed by Masters and Johnson in the 1960’s, had two techniques for treating premature ejaculation: “sensate focus” and “start-stop.”
“Sensate focus” was what we’d now call a “mindfulness” practice. Intercourse was forbidden at first. Instead, you’d spend time touching your partner or being touched by them, just paying quiet attention to your sensations in the moment.
Many couples liked the easy sensuality of sensate focus. And the absence of any pressure to have intercourse often felt like a relief. But sensate focus by itself didn’t necessarily help men with premature ejaculation last longer in bed.
The second technique, “start-stop,” was specifically intended to help a man with PE last longer. Building on the mindful self-observation habits he’d learned through sensate focus, he would carefully note his level of arousal, and stop when he felt the earliest sign of an impending orgasm—then resume stimulation once the feeling passed.
A man with PE would practice this first by himself, until he was confident enough to attempt it during partner sex.
Many sex therapists still recommend sensate focus and start-stop for men with premature ejaculation who want to last longer in bed. But I routinely see men who’ve tried these techniques and been discouraged by the results.
Here’s my run-down of the pros and cons of traditional sex therapy for PE:
When Prozac, the first FDA-approved “selective serotonin reuptake inhibitor” (or SRI for short), came on the market in the late 1980’s, many women taking this drug for the first time noticed they couldn’t orgasm.
The reason soon became clear: SRI’s tend to raise orgasm thresholds. And once this was recognized, it didn’t take long for researchers to wonder whether SRI’s might help men with PE last longer in bed.
During the first decade and a half after Prozac came on the market, I counted over 30 published medical papers documenting the effectiveness of SRI’s for PE.
Not just Prozac, but also sertaline/Zoloft, paroxetine/Paxil, and citalopram/Celexa. I’ve seen it work with the NSRI’s (venlafaxine/Effexor, duloxetine/Cymbalta) as well.
None of these medications has even been FDA-approved for premature ejaculation, so in the US their use for PE is still what’s called “off-label,” meaning it requires informed consent.
I’ve treated hundreds of men with SRI’s for premature ejaculation. Many have been among my most grateful patients.
Like any medication, off-label treatment of PE with SRI’s (and other medications that are occasionally useful) involves weighing potential risks vs benefits. That’s why it’s necessary to get a thorough evaluation first—ideally by an MD who specializes in sexual medicine—and only to take medication for PE under a doctor’s supervision.
In most of the original studies of SRI’s for PE, medication was given every day. These days, to minimize the risk of side effects, I often recommend a man use them just as-needed, when he plans to have sex.
There can be some loss of spontaneity, but I think for most men the risk/benefit balance favors as-needed use over daily use.
Let’s look at the pros and cons of using SRI’s off-label for PE:
There’s a lot more to good sex than perfectly timed orgasms.
If on medication you no longer have to worry about ejaculating every time your partner moves her pelvis, that’s a great improvement. But it won’t necessarily get you great sex.
One of the great contributions of traditional sex therapy was to help couples get beyond performance-based notions of sex, and to cultivate a mindful awareness of their own experience.
When you do that, sex often improves. Communication often improves as well.
Treatment that combines medication and sex therapy for PE can be the best of both worlds. Medication can a man’s “ticket of admission” to a world of much greater erotic discovery.
And sex therapy techniques tend to work much better when a man with PE on medication no longer has to stay so focused on not getting too excited.
Sexology and sexual medicine have come a long way towards being able to help men with premature ejaculation. But we still have a long way to go in educating more men with PE about treatment options for this condition.
I congratulate you for reading this far, and I hope you’ve gained some useful knowledge.
Please feel free to write me with any questions.
Stephen Snyder MD
New York City 2020
Parts of this article have been adapted from Love Worth Making: How to Have Ridiculously Great Sex in a Long-Lasting Relationship by Stephen Snyder, M.D. Copyright © 2018 by the author and reprinted with permission of St. Martin’s Press, LLC.
All content here is for informational purposes only. Please consult a licensed mental health professional for all individual questions and issues.