It’s basically the same story with ejaculation control. Many men (maybe even most) learn some rudimentary degree of ejaculation control and awareness when they’re teenagers. Many men don’t. You can still learn it when you’re an adult. You may ultimately be less confident than someone who learned it early, but even then there are things you can learn to do to cope with the anxiety generated by a lack of confidence. I feel uncomfortable giving someone a stigmatizing label (“You’re a premature ejaculator”) when the problem is simply that they didn’t learn something growing up that many other people did learn.
The pervasiveness of premature ejaculation is illustrated by the following. Remember that in Kinsey’s day, the 1940s, men reported an average time spent in sexual intercourse of two to three minutes. In surveys taken in the 1990s, men reported average times of six to seven minutes, meaning that the average time spent during sexual intercourse doubled or tripled in about fifty years. However, if you ask most men how long they would like to last during intercourse, the desired average is about twenty minutes.
In the course of my research for this book, I used the Internet to look up articles published in the last few years on all of the sexual dysfunctions. There are at least ten times more articles on premature ejaculation than there are on any of the other sexual dysfunctions. This clearly shows the extent of this problem, as well as the fact that many men are still very concerned about it. The good news is that the program for premature ejaculation described in this book (Chapter 23) has been shown to be very successful. Premature ejaculation has the second-highest treatment success rate of any of the sexual dysfunctions (lifelong vaginismus has the highest). I believe that the goal of lasting twenty minutes or more during sexual intercourse is attainable for most men. That has certainly been my experience in treating this problem.
Causes of Premature Ejaculation
The major cause of premature ejaculation is anxiety. It is almost never caused by a physical problem. The only medical conditions I know of that can cause premature ejaculation are alcohol withdrawal and opiate withdrawal. A man with premature ejaculation may not feel as if he is anxious—on the other hand, he may panic at the thought of any sexual encounter. Either way, his body has learned a response in which tensed muscles, irregular breathing patterns, and distracting thoughts are triggering his ejaculation. By learning to recognize both his level of anxiety and his level of arousal, he can learn to last as long as he would like.
If you have been experiencing a problem with rapid ejaculation, you may feel as if everything on your body is connected to your genitals. A kiss or touch anywhere on your body triggers a genital response and the accompanying panic. You may try to ignore your genitals and think of something else. You may find yourself masturbating to ejaculation several times a day in order to “wear down” your arousal level before you attempt sexual intercourse. (This usually doesn’t work; all it does is get you used to ejaculating more frequently, which actually makes the problem worse.) You may worry constantly that you are not satisfying your partner and that she is going to leave you, and you may try to make up for your premature ejaculation in other ways in the relationship. When you are close to ejaculation, you may think “Oh no!” rather than feel pleasant anticipation.
Very severe premature ejaculation involves ejaculating with any kind of stimulation prior to penetration. Other cases are less severe. If you simply ejaculate sooner than you want to when you are inside your partner’s vagina, your problem may be only that you are not having sexual intercourse often enough. Consider your body and how often you spontaneously have an erection and feel like ejaculating. If you have those feelings daily, but have intercourse only once a week, you may find that with more frequent intercourse you will not ejaculate as quickly. You might try having intercourse as many times as you would like to for a few days to find out what the optimum frequency of sexual intercourse is for you. (Of course this implies that you must have a willing partner.)
Robert
One of my former clients, Robert, age thirty-eight, was married for a number of years to a woman who constantly belittled him, but for whom he cared a great deal. After every sexual encounter she told him he had failed to satisfy her. He began to ejaculate sooner and sooner during intercourse, and eventually he began to ejaculate before penetration. His wife had a number of extramarital affairs and told him all of the details, including how well her lovers had satisfied her and how long they had lasted. Eventually she refused to have intercourse with Robert at all.
Robert tried to make up for his perceived inadequacies in other ways, such as buying his wife gifts. I say “perceived” inadequacies, because when Robert entered therapy after starting divorce proceedings, he found that after going through the program described in this book with a cooperative partner, he had no problems at all lasting as long as he wanted. Robert’s story illustrates how a partner can contribute to sexual problems. His was a case of acquired situational premature ejaculation. Chances are that Robert never would have developed premature ejaculation if his partner had not exploited his self-doubt. In any event, he went on to a satisfying second marriage.
Albert
Here’s a case of lifelong generalized premature ejaculation. Albert, fortyfour, had one of the most severe cases of premature ejaculation I had ever seen. He ejaculated at a mere touch anywhere on his body, and had done so since he first attempted to have sexual intercourse more than twenty years before. Through the program of exercises I describe in this book, Albert learned to maintain intercourse for up to half an hour. Altogether he spent almost a year in therapy, but for a case of such severity and duration his progress was truly remarkable.
chapter 10
Male Orgasm Disorder
Male orgasm disorder is currently defined in the DSM-IV as the “persistent or recurrent delay in, or absence of, orgasm following a normal sexual excitement phase during sexual activity that the clinician, taking into account the person’s age, judges to be adequate in focus, intensity, and duration.” Older terms for this problem include retarded ejaculation, ejaculatory incompetence, inhibited male orgasm, and inhibited ejaculation.
Right away we see that there is a problem of changing definitions of male orgasm disorder. The DSM-IV basically defines it as having a problem reaching orgasm. Previous descriptions defined it as having a problem with ejaculation. Which is it? We know from Chapter 2 that orgasm and ejaculation are not exactly the same thing, although they occur together most of the time. Orgasm is a full-body response that includes rapid heart rate, increased blood pressure, rapid breathing, muscle contractions all over the body, and psychological sensations ranging from relief or release to intense pleasure. Ejaculation is a localized genital response in which the PC muscle spasms and semen is released from the penis.
This confusion about diagnosis makes it really important to figure out exactly what is going on with a man who suspects he has this disorder. In many cases a man with male orgasm disorder cannot have either an ejaculation or an orgasm. In some cases, a man can have an orgasm but not an ejaculation. Getting proper treatment depends on knowing exactly what the nature of the problem is.
Although male orgasm disorder is much more rare than premature ejaculation or erection problems, I have treated enough cases of it to have an opinion about what constitutes it. I see it as a problem with ejaculation rather than orgasm. I think it should still be called inhibited ejaculation.
Patterns of Male Orgasm Disorder
In lifelong male orgasm disorder, a man has never been able to ejaculate at all with any type of stimulation. I’ve never heard of a case like this. During adolescence, more likely than not a boy will have an ejaculation (a nocturnal emission, or wet dream) as a result of the erections that occur during REM sleep. In acquired male orgasm disorder, a man has been able to ejaculate in the past, but has difficulty doing so now. In generalized male orgasm disorder, a man cannot ejaculate under any circumstances—not during sleep, with masturbation, during genital fond
ling, oral sex, or intercourse. Again, this is extremely rare. In situational male orgasm disorder, a man can ejaculate with some forms of stimulation but not with others, or with some partners but not with others. In the most common form of situational problems with ejaculation, a man can ejaculate with masturbation but not with any partner activities, or he can ejaculate with all sexual activities except intercourse. Men who have this problem can sometimes reach orgasm without ejaculation. This usually becomes an issue if the man’s partner is trying to become pregnant, and many men put off solving the problem until a pregnancy is desired.
Followers of some Eastern religious traditions believe that ejaculating is physically bad for a man because it depletes his chi or vital essence, so they try to avoid ejaculating during sexual activity. Instead, they train themselves to experience intense sexual pleasure (including orgasm) without ejaculation, and they don’t consider the absence of ejaculation a problem.
Supposedly, male orgasm disorder is more prevalent among homosexual men than among heterosexual men, although I haven’t read any theories about why this might be the case, and I have no personal experience working with this population.
What’s Normal?
Some men who subscribe to Eastern religious traditions believe that it’s normal to ejaculate very infrequently, or that it’s normal to regularly have orgasms without ejaculating. These men constitute a minority. I would have to say from everything I’ve read that it’s normal for a heterosexual man to be able to ejaculate during sexual intercourse with a woman within about twenty minutes. This seems to be the most common pattern of ejaculatory behavior.
Physical Causes of Ejaculation Difficulties
Alcohol consumption can cause a man to have difficulty ejaculating. So can the use of illegal stimulants like amphetamines and cocaine. In fact, men often take these substances on purpose to delay ejaculation. Some antidepressants (particularly those that are in the classes called monoamine oxidase inhibitors, or MAOIs) can cause a man to have difficulty ejaculating. The antianxiety agents known as the selective serotonin reuptake inhibitors (or SSRIs) can also cause a man to have difficulty ejaculating. These include commonly prescribed drugs, such as Prozac, Paxil, and Zoloft, as well as other, newer drugs in the same class. In fact, the SSRIs are notorious for causing difficulty with ejaculation. Physicians should never prescribe them for a man who already has tendencies toward delayed ejaculation, but this is done all the time.
Prostate problems such as benign enlargement of the gland can cause difficulty with ejaculation or painful ejaculation. Often, men who’ve had their prostate glands removed due to cancer can have orgasms but can no longer ejaculate. Nervous-system disorders such as multiple sclerosis can also slow down the ejaculatory reflex.
Psychological and Behavioral Causes of Male Orgasm Disorder
Based on my observation, the biggest behavioral cause of male orgasm disorder is a man’s masturbation habits. A man who becomes accustomed to masturbating frequently and for a long period of time using a very hard, fast stroke runs the risk of experiencing delayed or absent orgasm during sexual intercourse. He has accustomed himself to a high degree of stimulation that his partner’s vagina cannot duplicate.
Another behavioral factor is the regular use of the withdrawal method of birth control (which isn’t a reliable method, by the way). This practice involves the man’s pulling out of his partner’s vagina when he senses that he is about to ejaculate, and then masturbating until he ejaculates outside of the vagina. This habit can cause a man to develop the inability to ejaculate during intercourse. I treated a man named Robert for male orgasm disorder. Ever since he’d begun having sexual intercourse, in high school, he had used the withdrawal method. By the time I saw him in his mid-forties, he could not ejaculate with intercourse at all and was starting to develop erection problems on top of his ejaculation problems. Through the use of the exercises outlined in this book, he learned to ejaculate with intercourse.
A sexual trauma can cause an inability to ejaculate. Another sex therapist once told me of a case involving a man in his early twenties who was making love with his girlfriend at her parents’ house when the parents were out of town. The two were going at it on the couch when the parents came home unexpectedly and threw the door open just as he reached his climax. He jumped off the couch naked and ejaculated right in front of the parents. He was so mortified by the experience that he suffered a temporary inability to climax at all. Fortunately, sex therapy exercises helped him relax and regain his ability to ejaculate.
Another cause of difficulty with ejaculation, especially during intercourse, is developing a mentality of working at ejaculating rather than enjoying the sensations of intercourse. The man starts anticipating his ejaculation and orgasm before he is really close. In other words, he doesn’t wait until arousal level 9 to start thinking about ejaculating. He’s gotten into the habit of thinking about it at around level 6. As part of this pattern, he starts to thrust harder and faster and either consciously or unconsciously tightens his PC muscle, which in turn delays the ejaculation he seeks even more.
Other writers often cite the so-called delivery-boy mentality as a cause of problems with ejaculation. This term refers to a man who is more concerned with his partner’s pleasure than his own pleasure, especially during intercourse. He sees it as his job to deliver orgasms to his partner as part of a compulsive need to please her. Holding off ejaculating on purpose as part of this mindset can create problems with ejaculation.
Other writers cite “automatic erections” as a contributor to orgasm problems. Some men experience very hard erections very quickly, even when they aren’t psychologically aroused. They have intercourse but they can’t ejaculate because they’re not even close to orgasm on the arousal scale. In my experience, this hasn’t been a very common contributor to problems with ejaculation.
In the psychoanalytic view, which is no longer very popular, premature ejaculation is thought to be caused by a fear of women, and inhibited ejaculation is thought to be caused by anger at women. In this view, a man has an unconscious motivation to punish his female partner by withholding ejaculation. From a conscious standpoint, this doesn’t make a lot of sense, because if he withholds ejaculation, he’s punishing himself, not his partner. However, as I describe in more detail below, a man’s anger at his partner or at women in general can often be deeply unconscious.
Sometimes a man becomes afraid to ejaculate because a partner in the past has berated him for ejaculating too quickly. One of the most common causes of inhibited ejaculation is a fear of premature ejaculation, even when a man doesn’t have this problem. This can cause a man to overrely on strategies to delay his ejaculation, which in turn can cause him to be unable to ejaculate at all.
Men often try to learn about women’s sexual desires by watching pornographic movies. Doing so can lead to inhibited ejaculation because pornographic movies generally show scenes of intercourse that go on for abnormally long times (if you think of the average time frame of intercourse as being about six to eight minutes, as the most recent surveys show). Men who watch a lot of pornography can become convinced that women prefer intercourse to continue for twenty minutes or more, when in fact this is not necessarily the case. (When was the last time you saw a pornographic movie that showed a man ejaculating within a minute of penetration? It doesn’t happen, although from a statistical standpoint this is much more true to life than an intercourse scene that lasts twenty minutes or more.)
A problem with inhibited ejaculation is defined not so much by the lack of ability to ejaculate as it is by the man’s feelings about ejaculation. As I mentioned earlier, psychologically based inhibited ejaculation usually involves the feeling of “working at” ejaculating rather than enjoying the sensations of intercourse. Frequently, the cause of frustration for the man is the fact that he is working at it, rather than the inability to ejaculate itself. He may sense that his level of physical arousal has remained high during intercourse, but that his
emotional arousal has remained at or backed off to a low level.
Treatment Outlook
Male orgasm disorder is one of the more difficult sexual dysfunctions to treat in therapy. That’s because many men with this problem just live with it and don’t seek treatment, so we hardly ever see the “easy” cases that could be resolved in a few sessions. The men who have such a severe problem with ejaculation that they seek treatment often have waited twenty or more years to do so, and by then the problem is pretty well entrenched. In my view, a lifelong inability to ejaculate during sexual intercourse is very difficult to treat, especially if a man is in his forties or fifties. On the other hand, acquired problems with ejaculation are highly treatable. The ability to ejaculate with masturbation but not with sexual intercourse is also highly treatable, as is the inability to ejaculate because of unusual masturbation habits. My general rule of thumb is that if a man was able to ejaculate successfully with sexual intercourse at any time in the past, he can most likely learn to do so again.
Sexual Healing Page 11
