Psychotherapeutic Treatment

Although a number of cognitive, dynamic, educational, and paradoxical procedures have been advocated for the treatment of premature ejaculation, the behavioral retraining procedure, originally developed by Semans (1956) and modified by Masters and Johnson (1970), is clearly the treatment of choice for this condition. If a decision is made to treat psychotherapeutically as opposed to psychopharmacologically, treatment modalities for practicing this technique vary widely - for example, daily versus weekly meetings with the therapist, group versus individual therapy, single therapists versus dual sex cotherapy teams (in which each partner has his or her own opposite-sex therapist), and regular contact with a therapist versus self-administered bibliotherapy with minimal therapist supervision. None of these variations seems to have much impact on the overall high effectiveness of the behavioral procedures, with typical treatment success rates running between 80% and 97% in a number of empirical studies (O’Donohue et al. 1993).

Overall treatment strategy In the stop-start, or “pause,” procedure developed by Semans (1956), the penis is manually stimulated until the man is fairly highly aroused. The couple then pauses until the man’s arousal subsides, at which time the stimulation is resumed. This sequence is repeated several times before stimulation is carried through to ejaculation, so the man ultimately experiences much more total time of stimulation than he ever has before and thus learns to have a higher threshold for ejaculation. The squeeze procedure, as developed by Masters and Johnson (1970), is much like the stop-start procedure, with the addition that when stimulation stops, the partner firmly squeezes the penis using the thumb and first two fingers at the place where the glans of the penis joins the shaft. This squeeze is applied to the ventral and dorsal aspects of the penis, on the frenulum and the coronal ridge. Although the squeeze seems to further reduce arousal for most men, some men find the squeeze also to be stimulating, producing heightened arousal and possibly speeding orgasm. In these men, the therapist may choose to abandon the squeeze component of therapy. After a few sessions of training, the necessity of pausing or squeezing diminishes, with the man able to experience several minutes of continuous penile stimulation without ejaculating. Next, the couple progresses to putting the penis in the vagina, but without any thrusting movements. If the man rapidly becomes highly aroused, the penis is withdrawn and the couple waits for arousal to subside, at which point the penis is reinserted. When good tolerance for inactive containment of the penis is achieved, the training procedure is repeated during active thrusting. Generally, 2-3 months of practice are sufficient for a man to be able to enjoy prolonged intercourse without any need for pauses or squeezes.

Patients with premature ejaculation that is not lifelong and that is secondary to erectile failure may respond well to the behavioral retraining program. However, as Cooper et al. (1993) indicated, the most effective treatment protocol is to first treat erectile problems and then treat the premature ejaculation. In practice, the treating clinician may have to make this judgment on a difficult discrimination of which is the more central problem.

Case management tactics Although the overall strategy for treatment sounds straightforward, in fact there are a host of tactical decisions to be made by the therapist that actually determine the success of the treatment with individual patients.

One management issue concerns the modality of stimulation to be used at the beginning of the treatment. If the patient has global premature ejaculation, with a short latency to ejaculation during masturbation, it is probably best that the patient begin the pause procedure in his own solitary masturbation. Masturbation, being less arousing to most patients than sex with their partner, usually responds rapidly to the pause procedure, with dramatic increases in orgasmic latency typically occurring within a few training sessions. An additional advantage of beginning with masturbation is that the patient is freed from anxiety about performing in the presence of his partner, in which context he may feel a need to demonstrate instant progress. Good generalization of this increase in orgasmic latency to sexual activity with a partner usually occurs, so that when the couple begins to do the training together, the partner is pleased to see that the technique obviously works. Indeed, sufficient generalization occurs that men without a current sexual partner can be treated, doing the training in their solitary masturbation, with the treatment effect carrying over fairly well when the patient does find a partner. If the patient’s premature ejaculation does not occur in masturbation, or if he does not masturbate, the training should begin with manual stimulation by the partner.

A second major tactical issue concerns the cooperation of the sexual partner. In many cases, partners of men who prematurely ejaculate are chronically sexually frustrated by the time the couple enters treatment. Women in particular may have often tried to get their male partners to seek treatment for many years, but the male role demands of being strong, independent, and sexually highly functional make it difficult for men to seek help (Zilbergeld 1992). During these years, the typical sexual scenario has been that when the couple has intercourse, the man climaxes quickly and goes to sleep, leaving his female partner feeling used and sexually frustrated. The female partner enters therapy gratefully, thinking that after years of servicing her husband or lover sexually, there is finally the prospect that she will have a fulfilling sex life. If this woman is asked by the therapist to service her husband or lover even more by stimulating his penis more frequently and for much longer periods of time than ever before, with no regard for her sexual satisfaction, should it be a surprise that she is resistant to performing the training procedures? (However, resistance is an unfair characterization of the woman’s distress at having her sexual needs apparently ignored by the therapist. This resistance actually represents a major tactical error on the part of the therapist.)

The therapist should always attend to the sexual needs of the premature ejaculation patient’s partner. If the couple is to engage in three sessions per week of the partner using the stimulation and pause procedure with the patient, the partner should then have three sessions per week in which the patient pleasures the partner. In these sessions, the female partner may have the patient bring her to orgasm through manual, oral, or electric vibrator stimulation of her genitals. These sessions may take place before she performs the pause training procedure with him, after the procedure, or on 3 different days of the week, at the woman’s option. The only activity that is not allowed is intercourse, as the man would, at this early point in therapy, merely ejaculate rapidly and again frustrate the woman. With this intervention, resistance to performing the training on the part of the partner is seldom seen.

A third issue concerns the frequency of the training sessions. Typically, the couple will start doing the training at a higher frequency than the male has been ejaculating prior to entering treatment. How much more frequently depends on the pretreatment frequency. If the man has only been having orgasm once every 2 weeks, a reasonable beginning frequency would be twice weekly. If the pretreatment frequency was three to four orgasms per week, training sessions might initially be prescribed on a daily basis. The reason for this increased frequency is to capitalize on the naturally occurring delay of ejaculation that results when the frequency of sex is increased. This physiological effect occurs for all men, not just men who prematurely ejaculate. By raising the frequency of orgasm, some increase in latency to ejaculation occurs independent of the actual training effect. Although this increase does not occur instantly - it may take a few days to a few weeks at the higher frequency of orgasm before the effect occurs - it is especially useful in dealing with very severe cases of global premature ejaculation. If the patient normally ejaculates with only a few seconds of stimulation, it is difficult to make the pause or squeeze procedure work - the patient simply ejaculates before any retraining of the ejaculation reflex can occur. In such cases, 1-2 weeks of massively increased frequency of orgasm will result in a delay of ejaculation long enough that the training procedure can become effective. However, a patient’s inability to comply with these treatment requests may sabotage outcome.

This artificial, therapist-prescribed increase in orgasm rate should occur only in the early stages of therapy. As therapy progresses, the couple should be instructed to make love only as often as they spontaneously wish to, and simply integrate the training procedure into these lovemaking sessions. If the artificially high rate of orgasm is maintained throughout treatment, what appears to be real retraining effects on ejaculatory latency may be only the physiological effect of increased frequency. Follow-up research has shown that when such a couple ends treatment and returns to their natural frequency of sexual activity, with the patient presumably cured of premature ejaculation, the patient will relapse to premature ejaculation (De Amicis et al. 1985). If most of the training is done at the couple’s naturally occurring frequency of sex, the gains seen at termination of treatment are maintained indefinitely.

Another management issue concerns the mental state of the man while the stimulate and pause training procedure is being used. Many men tend to overfocus on treatment, trying very hard to restrain their arousal or distract themselves to delay ejaculation. This is the wrong attitude. The man should be instructed to focus on the pleasure he is receiving, and to facilitate his arousal as much as possible. After all, the goal is not to learn to delay ejaculation while not enjoying sex, but to retrain the ejaculation reflex so that arousal can be prolonged while enjoying sex and focusing on pleasure. The therapist should reassure the patient that the training procedure will cure him - he need not try to reduce his arousal level. The therapist may explain that the pause and squeeze procedures always work if the patient allows the program to be customized to his individual needs. Failures occur only if patients drop out of treatment before having the opportunity to adjust the program parameters to their individual needs. This treatment is exactly like a program of weight lifting. If a person has weak muscles and lifts weights three times a week under the direction of a trainer who customizes the program to that person, his or her muscles will get stronger. Only if the person drops out of weight training will he or she fail to see improvement. Therefore, the patient need not engage in any mental maneuvers to facilitate his increase in ejaculatory latency. The pause and squeeze programs represent pure physical retraining of a reflex, and a man should relax and enjoy himself during this training, with the result that, after treatment, he has a long latency to ejaculation and does not need to try consciously to delay ejaculation or distract himself to lower his arousal level.

Specific treatment steps The goal of treatment, of course, is not to have the man be able to tolerate a long duration of sexual activity by pausing frequently while making love. Rather, the goal is to increase the amount of time the man can be aroused without needing to pause. Therefore, the number of pauses in stimulation that the man uses is reduced as the training takes effect, and he becomes able to receive sexual stimulation for longer periods of time before needing to pause. Typically, a patient begins pausing four times before reaching orgasm during the fifth interval of stimulation. Although the man might only be able to experience 30 seconds of stimulation initially before pausing, with a few training sessions, his stimulation intervals might increase to 1-2 minutes each. When the total duration of stimulation reaches 7-10 minutes, the patient is instructed to reduce the number of pauses to three before carrying through to ejaculation. Again, when the total duration of stimulation reaches 7-10 minutes with only three pauses, he is to reduce the number of pauses to two. This course would continue until the patient can enjoy 7-10 minutes of stimulation without pausing before ejaculating. At that point, we would move on to a more arousing type of stimulation, again having the man begin with four pauses and gradually tapering down the number of pauses as his latency to ejaculation increases.

The usual sequence of types of stimulation is to have the man begin with his own masturbation. As discussed previously, when he is able to enjoy masturbation for 7-10 minutes without pausing, he should move on to having the partner stimulate his penis manually. This stimulation usually begins with the partner’s hand being dry, as this feels less like the vagina and is less arousing to him. When he can enjoy the usual 7-10 minutes of stimulation without any pauses, stimulation with the partner’s hand lubricated to simulate the feel of the vagina is the next step. For couples that engage in fellatio, oral stimulation would be the next step.

The following step would be to have the female partner stimulate the patient to erection and then insert his penis in her vagina. This insertion is done with the male lying passively on his back, with the female kneeling astride him. No movement is allowed, just passive containment of the penis in the vagina. The results of this step are unpredictable. The man has not had his penis in the vagina for some time (intercourse is not allowed during the early stages of the training), so the patient may find passive containment of the penis to be so arousing that he needs to withdraw the penis almost immediately and thus discontinue stimulation. At the other extreme, since the man has been experiencing massive amounts of manual or oral stimulation of the penis, mere passive containment may be so unarousing that the man may lose his erection. I instruct the patient that should this occur, there is no cause to worry. He can simply move immediately to allowing movement rather than doing the pause training procedure with passive containment, during which his erections will return naturally.

When 10 minutes or so of passive containment without the need to withdraw is reached, the patient is allowed to experience coital movement. The first step is for the female partner to move while the patient remains passive. As the number of pauses needed to reach 10 minutes’ duration of intercourse in this way declines, penile thrusting by the man is allowed. Unrestrained mutual thrusting is the last step in the pause training procedure. At this point, the couple is free to engage in spontaneous intercourse, in any position. They may need to use the pause procedure for a while, until the man becomes able to enjoy unrestrained intercourse without needing to pause, but usually the number of pauses needed to be able to experience a long duration of intercourse declines fairly quickly.

In the preceding discussion, the training is described as involving only the pause, not the penile squeeze. If the couple progresses rapidly through the training program, the pause procedure may be all that is needed. However, if results are not good with the pause procedure, the squeeze procedure should be tried. In this procedure, the patient is instructed to have penile stimulation and, on stopping stimulation, firmly squeeze the penis for 15-30 seconds. The squeeze is then released, and a 30-second pause is taken before resuming stimulation. Although sex therapists tend to have strong opinions as to which of the two procedures - the pause-only or the squeeze-plus-pause - is more effective, most patients should try the squeeze at some point in their training program. Perhaps 50% of patients report that the pause-only and the squeeze-plus-pause procedures work equally well for them. However, other patients report that the squeeze-plus-pause is markedly superior to the pause-only. These patients find that if they only pause, they remain highly aroused for a long time and, on resuming stimulation, become aroused again very rapidly. However, if they squeeze, they lose their arousal immediately - some even experience a partial loss of erection - and, on resuming stimulation, become aroused more slowly than if they only had paused. For these patients, obviously, the squeeze-plus-pause procedure is the treatment of choice. Nonetheless, occasionally a patient finds that although the pause works well for him, squeezing actually is less effective. These patients find that the squeeze itself is additional stimulation; it makes them more aroused rather than less aroused as intended.

If the patient is not making therapeutic progress, the therapist can adjust the program outlined above in several ways. For example, a patient may report that he failed in his attempt to pause four times before carrying through to orgasm in the fifth interval of stimulation. Instead, ejaculation occurred during the third interval of stimulation. Questioning will usually reveal that the man was stimulated for too long a time in the first interval of stimulation before pausing. A pattern of decreasing length of time before needing to pause indicates that the patient is becoming too aroused in the first stimulation interval. Once a man closely approaches orgasm, the pause procedure is not effective in reducing arousal unless a very long pause is used - many minutes instead of 30 seconds. This kind of patient would be asked to remember how aroused he was when he first paused and then instructed to pause at a lower level of arousal. The most common mistake patients make with this training program is to become too aroused before pausing or pausing and squeezing. The patient should not be close to orgasm before pausing, just moderately highly aroused.

Another way to adjust the program if progress is not occurring is to lengthen the duration of the pause. A 1-minute pause rather than the usual 30-second pause may be used. Still another method is to have the patient do the training more often each week, until therapeutic gains begin to appear. Yet another option is to have the patient pause more frequently before ejaculation. Thus, the therapist can custom-tailor the training program to the individual patient by adjusting the level of arousal reached before pausing.

The duration of therapy is variable, but 2-3 months of training usually suffices for nearly all patients. For patients who were having sex only infrequently before beginning treatment, gains may be made much more rapidly. As previously noted, the therapist needs to be sure that genuine retraining of the ejaculation reflex has occurred, rather than just an artifactual increase in ejaculatory latency resulting from increased frequency. Of course, if the couple had been avoiding sex because of the frustration and conflict caused by premature ejaculation and will be engaging in more frequent intercourse once the problem is gone, this concern is eliminated.

Some variations on the pause and squeeze procedures have been reported. One variation involves reversing one of the physiological changes that occur during arousal. During high arousal, the scrotum contracts and elevates the testes. As well as having the patient cease stimulation or squeeze on the penis, the patient may also be instructed to stretch out the scrotum and reverse this testicular elevation. However, during high arousal, any additional stimulation of the scrotum and perineum may trigger an ejaculation, and thus may make the pause and squeeze procedures ineffectual. For this reason, this procedure is not recommended (LoPiccolo 1990).

A small variation in using the squeeze is to have the patient squeeze at the base of the penis instead of the juncture of the shaft and glans. This squeeze can be done during penile containment in the vagina and does not require withdrawal. Although not having to withdraw the penis may be an advantage, most patients do not find the squeeze at the base of the penis to be nearly as effective in lowering arousal as the standard squeeze.

Although clinicians have no real understanding of why the pause and squeeze procedures described by Semans (1956) and Masters and Johnson (1970) work, the procedures fit Guthrie’s (1952) theoretical paradigm for extinguishing stimulus-response connections by “crowding the threshold” - in this case, the connection between minimal stimulation and ejaculation. According to Guthrie, such extinction is produced by gradually exposing the subject to progressively more intense and more prolonged stimulation, but always keeping the intensity and duration of the stimulus just below the threshold for elicitation of the response.