Premature Ejaculation—All About Time?

Just about every week, a man or a couple come in and ask about treatment for “Premature Ejaculation” (PE). People used to say “I come too fast” or “He comes too fast.” After a few minutes on the internet, people have learned they have a condition, with a name, diagnostic criteria, and prognosis. That’s not necessarily a good thing.

People can also discover that the DSM-5 (the insurance industry’s bible of mental & sexual problems) classifies the severity of the problem thus:

* Mild, in which ejaculation occurs 30-60 seconds after vaginal penetration
* Moderate, when ejaculation occurs 15-30 seconds after vaginal penetration
* Severe, in which ejaculation occurs prior to, upon, or less than 15 seconds after vaginal penetration.

There is so much wrong with that powerful little paragraph.

“Vaginal penetration” is not an expression I use. I prefer “insertion” to “penetration.” In fact, I prefer “vaginal envelopment” or “containment.” These all sound nicer and easier than “penetration.” You can make up your own phrase to describe the experience.

Then there’s the idea that these increments of 15 seconds are meaningful to people. No one likes to come involuntarily upon entering a vagina. But virtually no one would be grateful—or feel their problem were solved—if they had 14 extra seconds of intercourse. That’s about two, maybe three thrusts. Two or three anxiety-filled, guilt-ridden, about-to-be-disappointed thrusts. So the DSM’s alleged differences between “mild”, “moderate”, and “severe” are pointless.

And by the way, try telling a guy who comes in 31 seconds (or his partner) that his problem is “mild.”

The DSM-5 is about two decades behind the times on this. There isn’t a sex therapist in a thousand who would agree with the time delineations. Most sex therapists say “rapid ejaculation” instead of “premature” anyway; to see what I call it, keep reading.

The DSM also says that as many as 30% of men “report concern” about PE, yet they say that according to their dandy new criteria, “only 1-3% of men would be diagnosed with the disorder.” I’m certain that’s not accurate; in any case, it’s a bizarre contrast. The DSM also says that PE “may increase with age” which is absolutely, positively wrong. Ask a hundred middle-aged men about their ejaculations, and the big complaint won’t be how quickly they come, but how slowly—when they come at all.

In a brief fit of thoughtfulness, the DSM notes the existence of culture-related issues, which is a big understatement. If a couple is upset that he comes after “only” 12 minutes, does he have PE? In the old Soviet Union, women would get insulted if a guy didn’t come after a minute or two—“Don’t you find me exciting?” I would translate the DSM’s “culture” as “expectations, beliefs, and self-image” as a way of overriding the silly time dimensions.

I know that physicians in general don’t have much time to discuss sex (or anything else) with patients. Hence many prescribe Viagra without knowing whether the guy has an actual problem, whether he’s drinking, having an affair, hates his wife, or hates his penis. Similarly, if a guy says “I have PE,” an MD or psychologist would ideally ask NOT “how fast is too fast” (although that’s better than nothing), but rather “and what’s the problem with that?”

Because PE isn’t a problem. People turn it into a problem by withdrawing in disappointment, or blaming their partner, or having affairs, or refusing to try other ways of being sexual or intimate. And then they (or their partner) blame the PE.

My experience in treating PE is that half the time I don’t treat it at all. I treat power struggles, shame, unrealistic expectations, fear of conception, discomfort talking about sex, and myths about “real sex.” The rest of the time I treat anxiety and/or depression, which are the typical physiological triggers of the unwanted ejaculation—as opposed to too much pleasure, which is what a lot of people assume it is.

A combination of these various interventions usually reverses the PE. More importantly, people often start enjoying sex again. That’s the goal of sex, you know—to enjoy sex, not to last a long time.

Some practitioners prescribe anti-depressants like Zoloft to slow down ejaculation. It often works, but doing that without a thorough psycho-social evaluation is like giving someone Vicodin for physical pain without finding out about any structural problems (e.g., spinal stenosis) or lifestyle issues (e.g., jogging when injured). It may provide short-term relief, but it could be laying the foundation for bigger problems later.

So if I don’t say PE and I don’t even like the gentler “Rapid Ejaculation,” what do I call it? I encourage patients to say “I come faster than I want to” (if they do). That helps us focus on the real problem—not the “I come faster…” but the “…than I want to.” It creates the expectation that we’re going to talk about expectations, communication, arousal, the relationship, and the meaning of sex.

Yeah, I know “I come faster than I want to” is a lot of words, and it doesn’t have a quick acronym like PE. That’s OK—there’s plenty of time.

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