Coping with

Premature Ejaculation
How to Overcome PE,
Please Your Partner $$gHave Cireat Sex

New Harbinger Publications, Inc.

“This is a highly readable book . . . clear and concise. Drs.
Metz and McCarthy provide the latest information and
present a new, inno- vative, comprehensive, biopsychosocial
approach to the treatment of premature ejaculation, the most
common male sexual disorder. I recommend it highly.”
—Pierre Assalian, MD, director, Human Sexuality
Unit, McGill University Health Center and
president of the 17th World Congress of
Sexology, Montreal, 2005

“This is the most comprehensive guide to dealing with

premature ejaculation I have ever seen! It addresses
subtypes, cognitive, emo- tional, and behavioral components,
medical issues, relapse, and the ever-important influence of
the couples’ relationship on the cause and cure of this
disorder. Drs. McCarthy and Metz have not only done a great
service to couples experiencing this problem, but to sex thera-
pists as well. I will definitely recommend the book to my
clients and will incorporate its exercises in my treatment
protocol.”
—Jean D. Koehler, Ph.D., president, American
Association of Sex Educators, Counselors, and
Therapists (AASECT)

“Coping with Premature Ejaculation is chock-full of great

suggestions for improving one’s sex life. Written by two
experienced sex thera- pists, the book offers sound advice and
sensible suggestions for gain- ing control over ejaculation
and, more importantly, for becoming a better lover!”
—Sandra R. Leiblum, Ph.D., director, Center for
Sexual & Relationship Health, UMDNJ-Robert
Wood Johnson Medical School.

“Finally, an updated, comprehensive guide for a problem that

affects millions of men and their partners. These highly
respected authors in the field of sex therapy bring years of
clinical experience and insight to these pages in a format
that’s masterfully helpful. This is a great book, and I plan to
recommend it to all my patients who struggle with premature
ejaculation.”
—Dennis P. Sugrue, Ph.D., past president of the
American Association of Sex Educators, Counselors,
and Therapists (AASECT) and coauthor of Sex
Matters for Women.
Coping with
Premature Ejaculation

&
How to Overcome PE,
Please Your Partner
Have Great Sex

MICHAEL E. METZ
BARRY W. MCCARTHY

NEW HARBINGER PUBLICATIONS

Final Version Mock
title
page
 Publisher’s Note
This publication is designed to provide accurate and authoritative
information in regard to the subject matter covered. It is sold with the
understanding that the publisher is not engaged in rendering
psychological, financial, legal, or other professional services. If expert
assistance or counseling is needed, the services of a competent
professional should be sought.
Distributed in Canada by Raincoast Books.
Copyright © 2003 by Michael E. Metz and Barry W. McCarthy
New Harbinger Publications,
Inc. 5674 Shattuck Avenue
Oakland, CA 94609
Cover design by Amy
Shoup Edited by Jessica
Beebe
Text design by Tracy Marie Carlson

All Rights Reserved

New Harbinger Publications’ Web site address: www.newharbinger.com

We want to express our gratitude and deep respect for the
several thousand men and couples we have clinically worked
with over the years. They invited us into their private lives,
opening honestly to their personal and sexual distress.
While we can only thank them anonymously, they have led us
to develop a more comprehensive understanding of
premature ejaculation. We thank our patients who have been
the “pathfinders” for this new approach. This book pres- ents
the result of what we have learned from them and from the
sci- entific research and clinical efforts of our sex therapy
colleagues. We hope we have learned well enough and that
this book will be helpful to others with PE.
We also want to acknowledge the outstanding
contributions of the people we have happily worked with at
New Harbinger Publica- tions: Spencer Smith, acquisitions
editor; Jessica Beebe, copy editor; Amy Shoup, art director;
Gretchen Gold, web manager, permissions, and advertising;
Troy DuFrene, marketing and sales; Michele Waters,
director of production; and Heather Mitchener, editorial
director. Thank you all.
—Michael E. Metz
—Barry W. McCarthy
 Contents

1 Understanding Premature Ejaculation 1

2 Developing Realistic Expectations about Sex 15

3 Understanding the Causes and Effects of PE 29

4 Assessing Your PE 47

5 Planning Your Treatment and Preparing for Action 59

6 Medical, Pharmacologic, and Physiological 73

Treatments

7 Psychological and Relational Strategies and Skills 85

8 Psychosexual Skills: Enjoying Arousal and

Regulating Orgasm 105

9 Couple Sexuality: Building an Intimate, Interactive

Couple Sexual Style 135

10 Enjoying Sex and Preventing Relapse 147

vi Coping with Premature Ejaculation

Choosing an Individual, Couple, or 161

Sex Therapist

Resources 163

References 167
 1

Understanding Premature
Ejaculation

What is premature ejaculation (PE)? You might expect that

this is an easy question to answer, but it depends on whom
you ask. Masters and Johnson (1970), the founders of
modern sex therapy, stated that a man has PE if he
ejaculates before the woman reaches orgasm in 50 percent
or more of their sexual encounters. PE is sometimes defined
as a problem accomplishing a “normal” length of time
between insertion and ejaculation. Studies have even defined
PE by a specific amount of intercourse time: less than one
minute, two, three, four, five, seven, or ten minutes, each
amount based on a different reason. Still others have
proposed to define PE by the number of intra- vaginal
thrusts: eight thrusts, fifteen thrusts.
The best professional description of PE is that the man
does not have voluntary, conscious control, or the ability to
choose in most encoun- ters when to ejaculate. We think this
is the most helpful definition because conscious control
reflects the interpersonal, cooperation, and intimacy issues
for couples better than some mechanical or numeri- cal
definition.
Contemporary popular culture dictates that to enjoy sex
maxi- mally, the man should be able to last at least an hour
during inter- course! Such myths about sexual performance
are among the most negative influences on male and
couple sexual satisfaction.
Kevin and Monica had the most common sexual problem
facing young couples. Kevin suffered from PE. Both blamed
Monica’s non- orgasmic response on Kevin’s PE. They
believed that if Kevin could last longer, Monica would easily
be orgasmic during intercourse. Sex
2 Coping with Premature

would be perfect every time. It was Kevin’s duty as a man to

make sure Monica had an orgasm during intercourse each
time—an extraordinary pressure on Kevin and his penis.
Kevin did some Internet research and read how easy it
was to cure PE. All he had to do was practice the squeeze
technique (which we do not recommend), in which the man
or his partner squeezes the underside of the tip of the penis
to delay orgasm. He was very hope- ful, but that broke down
within two weeks. Kevin was stymied, and Monica resented
his being a technician rather than an involved lover. Sex was
no longer fun; it was a chore. Kevin was frustrated with
Monica and with himself. He thought that everyone else
quickly developed ejaculatory control. What was wrong with
him? Or was it her fault? Maybe they did not love each
other and this was a doomed relationship. Would PE
destroy their marital bond?

Our Comprehensive Approach

If you are facing PE in your relationship, and especially if
you are a couple who has tried the common techniques for
treating PE and failed, we offer you our extensive
experience, our clinical knowl- edge, and a detailed
approach to treating PE. Our approach inte- grates the body,
mind, and relationship aspects of PE to help you appreciate
the complexity of your problem, develop understanding for
yourself and your partner, build empathy for each other’s
experi- ence of PE, and create a detailed plan to organize
your efforts to change. This biopsychosocial approach will
not only help you over- come rapid ejaculation but deepen
your intimacy and sexual joy.

Testing Your Knowledge of PE

How much do you really know about PE? Take this true-false
quiz before reading further.
True Fals Most men engage in intercourse for
e twenty to
thirty minutes.
True Fals A good lover prolongs intercourse until
e his partner has an orgasm.

True Fals Women function like men: they have a

e single orgasm during intercourse.

True Fals Men who ejaculate after two to seven

e minutes of intercourse have poor
ejaculatory control.
 Understanding Premature 3

True False PE is caused by too much masturbation,

especially during adolescence.
True Fals Thrusting alone is enough for most
e women to have an orgasm during
intercourse.
True Fals PE is always caused by psychological
e problems.

True Fals To deal with PE, the woman needs to

e be less erotic and the man has to
reduce arousal.
True Fals PE is nature’s way of increasing
e fertility.
True Fals PE is a symbol of a relational power
e struggle.
In fact, each of these items is false. Old and new
myths about PE abound. In this book we will confront myths,
including that PE is a simple, painless problem; intentional;
purely psychological; the woman’s fault; a sign of sexual
inadequacy; caused by masturbating too much or too fast; a
sign of hostility; a symbol of male selfishness; the same for
everyone; a problem with only one cause and one treat-
ment; and a hopeless problem.

The Truth about PE

PE is the most common male sexual problem. The majority of
male adolescents and young adults begin their sexual lives
as premature ejaculators. Most men, as they gain
experience, do develop ejacu- latory control. However,
approximately three in ten adult males regularly experience
PE.
The good news is that PE can be understood and
changed. You can increase your sexual satisfaction—and
your partner’s—by learn- ing to control ejaculation. The
challenge is to deal with the complex, multicausal,
multidimensional problem of PE and to enjoy sex with
enhanced ejaculatory control.
Kevin and Monica were approaching PE from a poor
under- standing of the problem and a self-defeating focus on
sexual per- formance. At its essence, sexuality is about
sharing pleasure, not passing a performance test. Healthy,
integrated sexuality values intimacy, pleasuring, and
eroticism. Like most males, Kevin believed that sex was
about eroticism, frequency, and proving adequacy to himself
or to the woman. Kevin hadn’t really thought about sex as a
way to share pleasure and to build intimacy. Yet, the
reality is that PE affected both Kevin and Monica.
4 Coping with Premature

Successful treatment combines taking individual

responsibility for sexuality and being an intimate sexual
team. Understanding and changing PE was primarily Kevin’s
responsibility; Monica did not cause Kevin’s PE, nor could
she change it for Kevin. She could help Kevin honestly and
objectively assess the components of his PE and be
seriously involved in the change process.
PE is not a simple problem with one cause and one
solution. There are actually nine different types of PE. PE
involves biological, psychological, and relational factors,
both in its causes and in its effects. A successful change
program must address all the relevant factors. A successful
program must also include a plan for dealing with relapse.
Our approach is effective because it helps you address all of
these issues.
It is helpful to realize that you are not alone. Guilt,
stigma, blame, and counterblame are unnecessary and will
subvert your motivation to resolve PE and enjoy couple
sexuality.

Understanding Male Sexuality

It was once believed that the more masculine you were,
the faster you ejaculated. But there is more to sex and
sexuality than your penis, intercourse, and orgasm.
Sexuality is about sharing and enjoy- ing affection,
pleasuring, intimate playfulness, eroticism, intercourse,
orgasm, tenderness, and passion for life.
The great advantage of male sexuality is that young
males find desire, arousal, and orgasm easy and predictable.
Adolescents are encouraged to value sexuality as an integral
part of masculinity. Men learn sexuality as automatic and—
for better or worse—autonomous. In other words, the man
needs nothing from the woman to achieve desire, arousal,
and orgasm.
This view of sexuality becomes problematic as the man
and the relationship age. Healthy sexuality is intimate and
interactive, not autonomous. Learning ejaculatory control is
an interpersonal pro- cess, not an individual one.

What You’ll Need to Learn

What do you need to learn about PE and ejaculatory control?
First, this is a couple task. The woman plays an integral role
in learning ejaculatory control. Second, ejaculatory
management exercises are built on the solid foundation of
nongenital and genital pleasuring. Ejaculatory control is
not about the man performing up to a
 Understanding Premature 5

perfectionist standard or proving he can give the woman an

orgasm during intercourse, but about developing a mutually
satisfying couple style that includes pleasure-oriented
intercourse. Learning ejaculatory control should not mute or
decrease pleasure. To the contrary, it will expand physical
pleasure as well as pleasure in the relationship.
There are several crucial skills in learning ejaculatory
control.

Physiological Relaxation
The first skill is to learn how to relax your body during
sexual arousal. Physiological relaxation is the foundation for
your body’s healthy sexual functioning.

Identifying the Point of Ejaculatory Inevitability

The second skill is to learn to identify the point of
ejaculatory inevitability. After that point, orgasm is no longer
voluntary. Even if your mother-in-law walks in or something
happens which is a sexual turnoff, you will still ejaculate.
Actually, the point of ejaculatory inevitability is the
beginning of the three- to ten-second orgasmic response.
Many men report the most sensations and feelings just a
second or two before they ejaculate. The ability to identify
the point of ejaculatory inevitability is crucial in the
techniques we’ll teach you.

Ejaculatory Regulation
The third skill is learning to regulate your ejaculation.
We will teach you the two basic approaches: excitement
toleration and excite- ment saturation. In excitement
toleration, you will learn to maintain high levels of arousal
without going on to ejaculation. With excite- ment
saturation, you will learn to focus on your own bodily sensa-
tions, patiently welcoming the pleasure, allowing your body
to become saturated or flooded with physical pleasure while
slowing ejaculation by maintaining physical relaxation. You
will then have reasonable control over when you ejaculate.

Cooperation for Intimacy

The fourth skill is to cooperate as a couple. Our
approach to PE works best when you and your partner
work together. The point of
6 Coping with Premature

all these efforts is to enhance your closeness, comfort,

pleasure, and joy as a couple.

Increasing Pleasure
The fifth skill is to enhance your pleasure, not reduce it.
Do-it- yourself ejaculatory control techniques emphasize
distracting your- self and reducing arousal—for example, by
wearing two condoms, using a desensitizing cream on the
head of the penis, thinking anti- erotic thoughts about debt
or cleaning bathrooms, or using distrac- tion techniques
such as going over baseball scores or multiplication tables.
These do reduce arousal but do not enhance ejaculatory con-
trol because they disconnect your awareness (the primary
source of control) from your sensations and body. In
addition, they carry the risk of causing a more severe sexual
problem, erectile dysfunction.
Our approach to treating PE might seem
counterintuitive because the exercises involve increasing
penile and erotic pleasure. But you’ll find that increased
awareness leads to increased control. We emphasize taking
in erotic sensations and feelings, not shutting them out.
Most men can benefit from training in ejaculatory
control. Instead of viewing PE as a major problem that
makes you inade- quate or makes the woman feel that her
sexual needs are ignored or neglected, think of ejaculatory
control as a skill the couple—not just the man—can learn in
order to enhance mutual sexual satisfaction.

Letting Go of Your Focus

on Performance
In movies, sex is always perfect. Both people are highly
aroused before touching even begins; sex is flawless,
nonverbal, and intense; they quickly have simultaneous
orgasms and continue to make love all day. Our
discussion about PE is scientifically accurate, sex-
positive, helpful, and relevant to real couples, but it will not
be made into a movie or sell as a romantic story. We are
not describing a perfect fantasy model but what really goes
on in a healthy sexual relationship. By its very nature, couple
sexuality is variable. If the only purpose of sex were
orgasm, men and women would mastur- bate and not engage
in a relationship or intercourse. Masturbation is easier, more
predictable, and more in your control than couple sexuality.
Yet the great majority of men and women prefer couple
sex to masturbation.
 Understanding Premature 7

Giving up the performance-focused approach frees you

to learn ejaculatory control and enjoy couple sex. Having a
reasonable amount of control over when you ejaculate and
enjoying the orgas- mic experience is very different than
making sure your partner is orgasmic during intercourse
before you are allowed to have an orgasm. Since one in three
women who are regularly orgasmic are never orgasmic
during intercourse (Foley, Kope, and Sugrue 2002), this
expectation is obviously flawed. Just as important, when you
are so obsessed with performance, you cannot enjoy sharing
the pleasure of intercourse. Rather than enjoying orgasm,
you are judging your performance.
Your focus on performance can become a major
distraction for your partner. While she may be distracted
from pleasure by her own unreasonable expectations, such
perfectionist sexual goals interfere with your positive
feelings about sex and about each other, and ignore the
reality of variable sexual response. You are not a perfectly
functioning sexual machine. You are a sexual man with
changing and complex thoughts, behaviors, and feelings. You
are not a rock or an island. You are involved in an
interpersonal sexual relationship. Remember, the ultimate
goal of learning ejaculatory control is increased sexual and
relationship satisfaction. In understanding the role of
sexuality in a relationship, desire and satisfaction are more
important than arousal and orgasm.

The Myth of One Cause, One

Treatment, and Easy Cure
The pop psychology belief about PE is that it has one cause
(mastur- bating too much and too fast and approaching
couple sex the same way), that there is one treatment (the
squeeze technique), and that change is quick and easy.
Recently, a simplistic medical approach has appeared
which assumes that treating the man with antidepres- sant
medication alone will retard ejaculation. This requires no
learn- ing by the man and no participation by the woman.
Human sexual behavior, including PE, is multicausal
and multidimensional, with large individual and couple
differences. The best way to understand PE is as a physical,
cognitive (mental), behavioral, emotional, and relational
phenomenon that can involve a number of causes and
interactive effects. It is crucial to address all the factors
which contribute to your type of PE so that you can approach
the problem successfully and avoid slipping into old feelings,
thoughts, and behaviors about PE.
8 Coping with Premature

It is risky to use a medication or a do-it-yourself

technique like a penile desensitizing cream and not
involve your partner or even tell her what you are doing.
Even if this approach works and you don’t ejaculate as
quickly, if you stop taking the medication or using the
cream, PE will likely return and might even be worse.
What does that do to your partner and relationship? She may
blame you and be angry, feeling you could delay ejaculation,
but now you just don’t want to. She may view you as selfish
and not caring about her sexual feelings. If you’re not
approaching the problem as a team, a relapse can leave you
both demoralized and trapped in a blame- counterblame
pattern.

Relational Issues and PE

Relational problems can be a cause of PE, a result of PE,
or both. Even when PE is caused by a medical problem or a
physical injury, the frustration and sexual stress affects your
relationship. Ideally, the man would learn and share
information about PE with his partner. Unfortunately, that is
the exception rather than the norm. Ideally, the woman
would be empathic and supportive and be an active ally in
trying to understand and resolve PE. Unfortunately, the
woman may be unsure and alternate between blaming
herself and blaming her partner. She might react in an
extreme way, becoming overly sympa- thetic and “motherly,”
which is antierotic, or becoming angry and demanding,
which is intimidating and increases performance anxiety.
In learning ejaculatory control, most couples benefit
from working to increase communication, understanding,
empathy, coop- eration, and intimacy. This reinforces the
concept that sex is more than genitals, intercourse, and
orgasm. Sexuality accounts for 15 to 20 percent of overall
relationship satisfaction. Sexuality should not be a deal
maker or deal breaker for the relationship, as there are
other crucial facets to love and intimacy. Sexuality can
enhance your relationship and make it special. PE works
against that process.
Improving ejaculatory control is worthwhile for you and
your relationship. The core of a relationship is a respectful,
trusting, coop- erative friendship enriched by emotional
and sexual intimacy.
What if you do not have a partner, or have a tenuous
relation- ship in which you and your partner can’t work
together to learn ejaculatory control? Our approach can still
offer helpful information, guidelines, and understanding. In
addition, you can use the self- exploration and masturbation
exercises to learn and practice the skills of physiological
relaxation, identifying the point of ejaculatory inevitability,
and maintaining awareness at high levels of arousal.
 Understanding Premature 9

When you’re seeking a new relationship, it’s important

to choose a partner you are attracted to, comfortable with,
and trust would be an ally in learning ejaculatory control.
Many men with PE are so embarrassed that they avoid a
sexual relationship, settling for one-night stands and either
ignoring the problem or apologizing for their sexual
performance. You need to approach the woman as a “sexual
friend.” Disclose the problem without apologizing. Tell her
that her sexual feelings and needs do matter to you, and
request that she be a cooperative, sharing partner in
working together to improve ejaculatory control and make
this an enjoyable sexual relationship. Your leadership is
essential in the process of change.

Understanding Female Sexuality

The major sexual complaint of men—that the woman is not
orgasmic during intercourse—is not a sexual dysfunction but
a normal varia- tion of female sexuality. Female sexual
response is more variable and complex than male sexual
response. This does not mean better or worse. The man
usually has one orgasm which occurs during inter- course.
The woman might be singly orgasmic, nonorgasmic, or
multiorgasmic, and orgasm might occur during the
pleasuring or foreplay phase, during intercourse, or
through afterplay.
Rather than expecting that the woman respond like him
—have one orgasm during intercourse without needing
additional erotic stimulation—the man needs to understand
and accept that only one in four women respond in that
manner (Foley, Kope, and Sugrue 2001). Orgasmic response
is a healthy, integral part of female sexual- ity, but orgasmic
response patterns are variable. Few women are orgasmic
100 percent of the time. For women, sexual satisfaction
includes orgasm but is less rigidly tied to it. The majority of
women find it easier to be orgasmic with manual, oral,
rubbing, or vibrator stimulation than through intercourse. In
fact, the most common sexual response pattern is for the
woman to be orgasmic with man- ual or oral stimulation
during the pleasuring phase, with the man being orgasmic
during intercourse.
To develop the intimate team approach that will help
you over- come PE effectively, you will need to understand,
accept, and affirm your partner’s patterns of arousal and
orgasm. She has to develop her “sexual voice,” not in
reaction to what you think is right, but as a way to express
her feelings and preferences. Together, you create a sexual
relationship which is equitable and respectful of individual
preferences rather than based on a simplistic view of male-
female sexual differences.
1 Coping with Premature

Men grow up with the idea that they are supposed to be

the sexual experts and it is their job to be sure the woman is
sexually satisfied. We encourage you to consider a very
different way to be in an intimate relationship. Your partner
is the expert on her sexuality. Her desire, arousal, and
orgasm are her responsibility, not yours. The old definition
of a good lover was a man who took responsibility for the
woman’s sexual satisfaction and was able to last long enough
so that he could give her an orgasm through intercourse
alone. The healthier, more realistic definition of a good lover
is the man who accepts the woman as an equal sexual
person and intimate partner.
As a good lover, you are open to her sexual requests
and guid- ance. Each person’s sexual enthusiasm and
arousal feeds the other’s desire, arousal, orgasm, and
satisfaction. The man enjoys intercourse for himself and the
relationship. He is aware and involved in giving and
receiving pleasure during intercourse. Intercourse can
involve a range of positions and movements that add to the
intimate, interac- tive process. Being orgasmic is a natural
extension of the arousal process. Sex does not end with his
ejaculation. There is an afterplay phase in which he is
open to her feelings and requests.
The man who is learning ejaculatory control with the
goal of ensuring that the woman has an orgasm during
intercourse is setting himself and the relationship up for
failure and frustration. The reason to improve ejaculatory
control is to make the sexual experi- ence more pleasurable
and satisfying for both partners, not to prove something to
yourself or your partner. If she is orgasmic during
intercourse and that is her preference, enjoy it. However, it
is poison for you, the woman, and the relationship to put
pressure on yourself to last longer so you can give her an
orgasm during intercourse. The focus of ejaculatory control
is to enhance the entire sexual experi- ence: awareness,
comfort, intimacy, pleasure, eroticism, intercourse, orgasm,
and afterplay.

PE and Other Sexual Problems

Although it might feel overwhelming to tackle more than one
sexual problem, PE often involves other sexual problems too,
and you’ll be more successful in dealing with PE if you
consider these problems along with PE.

Coexisting Sexual Problems in Men

For men, the most common coexisting sexual problems
are acquired inhibited sexual desire and acquired erectile
dysfunction. Acquired means that the man once
experienced desire and erections, but now
 Understanding Premature 1

they are problematic or nonexistent. Couple sex therapy is

the treat- ment of choice for both of these problems. Many
men would rather first try to resolve the problem using this
book’s guidelines and exer- cises. If that is not helpful within
three to six months, then agree to consult a sex therapist.

Acquired Inhibited Sexual Desire

The key to sexual desire is positive anticipation and
feeling you deserve good sex for you and your relationship.
The usual reason for male inhibited sexual desire is
frustration and embarrassment over a sexual dysfunction,
especially erectile problems. Occasionally, inhib- ited desire
may be caused by medical illness or side effects of medi-
cations, disappointment with the partner or relationship,
alcohol or drug abuse, depression or anxiety, relationship
stress or alienation, lack of couple time or energy, and
preoccupation with children, extended family, or career.
You’ll need to identify the factors that inhibit your sexual
desire and actively confront and change them.
Many men feel so badly about PE that they fall into the
cycle of anticipatory anxiety, tense and unsatisfying sex, and
sexual avoid- ance. Sexual desire cannot be treated with
benign neglect. Avoidance just feeds the negative cycle. The
hormone which most influences sexual desire, testosterone,
works on a feedback system. Sexual activ- ity enhances
testosterone, while stress and sexual avoidance decrease
testosterone.
In rebuilding male sexual desire, the key is to
reinforce the cycle of positive anticipation, pleasure-
oriented sexual experiences, and a regular rhythm of sexual
encounters. You subvert your own sexual desire when you
view sexual intercourse as a pass-fail test or tell yourself
that anything less than a perfect sexual performance means
you are less of a man. Desire is about connecting with your
partner and sharing sexual pleasure.

Acquired Erectile Dysfunction

Erection problems are a major cause of male inhibited
sexual desire. The traditional view of male sexuality is
that a real man is able to have sex with any woman, any
time, in any situation. This unrealistic demand is self-
defeating for the man and his penis. In fact, by age forty,
90 percent of men have had at least one experience in which
they did not get or maintain an erection sufficient for inter-
course. So the most feared male sexual problem is in fact an
almost universal experience.
A common nonmedical cause of erectile dysfunction is
trying to cope with PE by decreasing arousal to slow
ejaculation. Approxi- mately one in three men with PE
also report erectile problems
1 Coping with Premature

(Loudon 1988). The man feels caught between a rock and a

hard place: if there is a lot of stimulation he will quickly
ejaculate, but lack of stimulation results in erectile
dysfunction. So the man rushes to intercourse because he
fears losing his erection before he ejaculates.
Most men would prefer to take a medication like Viagra
(sildenafil) or Cialis (tadalafil) to solve the erection problem,
rather than address it with the partner. In fact, Viagra or
Cialis can be a valu- able resource by increasing blood flow
to the penis and reducing per- formance anxiety. However, a
pill cannot return the male to the easy, automatic,
autonomous erections of his youth. The key to regaining
erectile comfort and confidence is to relax, slow down and
enjoy the pleasuring process, take in erotic sensations, and
not rush intercourse or orgasm. It is crucial to be aware that
the erection can wane but will become easily erect again if
you stay relaxed and actively participate in the pleasuring
and erotic process. You cannot be a “spectator” of your
penis; sex is an involved, interactive experience.

Coexisting Sexual Problems in Women

Common female sexual problems that coexist with PE
are inhib- ited sexual desire (acquired or lifelong), difficulty
reaching orgasm (at all or during partner sex), dyspareunia
(painful intercourse), difficulty becoming aroused, and
vaginismus (constriction of the muscles of the vaginal
opening making penetration for intercourse difficult or
impossible). PE and female sexual dysfunction are often
interrelated; one problem may contribute to the other. As a
couple, you’ll be most successful at improving your sexual
relationship if you each take responsibility for
communicating your needs and commit to working together
as an intimate team.
The Resources section at the end of this book lists a
number of excellent self-help sources for understanding and
changing female sexual problems and dysfunction. If you
desire more help, we recom- mend consultation with a
credentialed sex therapist (see Choosing an Individual,
Couple, or Sex Therapist for guidelines). Seeing a sex ther-
apist is a sign of good judgment, not a sign that you are
crazy or that this is an overwhelming problem. A
professional therapist assesses the sexual problems and
helps design a change program that addresses the female
problem, male problem, and couple problem. Ongoing
therapy helps the couple stay focused and motivated.
 Understanding Premature 1

How You Can Best Use

This Book
This book presents a state-of-the-art approach to PE,
integrating new scientific research with the best, most
comprehensive clinical practice. Our goal is to help men
and couples understand and change the psychological,
relational, medical, and situational factors that cause PE.
To benefit from our program, you’ll need to take an
active role by engaging in the self-tests and exercises. We
urge both partners to be involved in the learning and
change process, building awareness and skills. As you work
together to improve ejaculatory control, you will enhance
your sexual self-confidence and mutual enjoyment and
satisfaction.
Each chapter builds on information in the previous
chapters. The first three chapters include basic information
and guidelines. Chapters 4 and 5 actively involve you in
becoming aware of your personal type of PE and its impact
on you and your relationship. Chapters 6, 7, and 8 are the
core of the change process. We will help you carefully
implement ejaculatory control strategies and tech- niques
targeted for your particular type of PE. Chapter 9 will help
you develop your unique couple sexual style. Chapter 10
presents a range of strategies and techniques to help you
maintain sexual gains and prevent relapse. The more broad-
based, flexible, and variable your approach to sex—including
intercourse—the less vulnerable you are to relapse.

Be Patient and Use All

Your Resources
PE is a complex problem with many causes and dimensions,
but you can understand it and change it. For some couples,
learning ejacula- tory control will be a fairly easy process
involving just one or two interventions, but most couples will
need to use a number of tech- niques. Be aware that the
change process is usually gradual and requires persistence,
practice, and patience. It is important to remain motivated
and focused and to use all your resources to address the
factors involved in your PE.
These resources might include medical evaluation and
treat- ment, medication, exercise, relaxation, several or all of
the cognitive and behavioral techniques in this book,
individual or couple therapy,
1 Coping with Premature

improved communication and conflict resolution skills,

increased emotional empathy, and time set aside for
intimacy.
We congratulate you for having the courage and
wisdom to address the problem of PE. We want you to feel
empowered and motivated to resolve PE and enjoy the
pleasures and satisfactions of couple sexuality.
 2

Developing Realistic
Expectations about Sex

As an adolescent, John absorbed the idea that a real man is

always ready for sex, no matter what the situation. John
learned from sex magazines and from talking to his buddies
that a man was supposed to be the sexual expert, and to
have doubts or questions was to be a wimp. Like in porn
videos, John was to have an erection at will, and his
enormous penis would last as long as he wanted and satisfy
the woman every time.
John could not live up to the image of the perfect sexual
performer. John worried about penis size and about whether
his desire and experiences were below normal. He felt
inadequate, defen- sive, and guilty. He avoided serious
conversations about sex. He felt that if his friends knew
about his PE, they would make fun of him.
Likewise, John’s girlfriend was filled with confusion and
nega- tive feelings. Did John care about her? She felt
frustrated with the sex, resentful that John would not talk
with her, and angry that sex did not get better. John and his
partner were trapped in the miscom- munication and myths
perpetuated by the traditional male-female double standard.
To approach PE successfully, you’ll need to take a
critical look at these traditional views. It is especially
important to challenge male performance myths, replacing
these with positive, realistic expecta- tions about the male
body and couple sex. Part of the goal of PE treatment is for
the man and his partner to have reasonable expecta- tions
about sex and sexual function within the context of an
intimate relationship.
1 Coping with Premature

Understanding Your Body

To have control over when you ejaculate, you need to have
an accu- rate and realistic understanding of your sexual
physiology (how your sexual body works). In this chapter,
we will explain in detail the physiology of male and female
sexual response, especially the male ejaculation process. We
will provide clear information about sexual desire, arousal,
and orgasm. We will take a closer look at female desire and
arousal and how this relates to PE. Then we’ll guide you
through evaluating your sexual expectations, sharing them
with your partner, and working together to align your
expectations.

Anatomy and Physiology of Sexual Response

and Ejaculation
You may, at first thought, not be interested in the
mechanics of ejaculation. But you’ll find that accurate
knowledge about your sex- ual body gives you an
appreciation of why strategies like whole- body physical
relaxation, conscious focus on pleasure, and pelvic muscle
relaxation can be helpful in developing ejaculatory control.
Accurate knowledge will also help you accept your body and
its workings without resentment and frustration.

The Human Sexual Response Cycle

In 1966, Masters and Johnson revolutionized the human
sexuality field by describing four stages of the sexual
response cycle: excitement, plateau, orgasm, and resolution.
Not only did they describe what happened during sexual
arousal and orgasm, they measured physiological changes in
blood flow and neurological response. In 1974, psychiatrist
Helen Kaplan broadened the Masters and Johnson model to
include an initial stage, sexual desire. Desire is associated
with psychological and relational factors rather than solely
focused on physiological factors.
The complete sexual response cycle consists of five
phases: desire, excitement (arousal), plateau, orgasm, and
satisfaction (resolution).
Desire. The desire phase involves sexual anticipation,
fantasy, yearning, and both physical and emotional openness
to sexual activity.
Excitement. During the excitement phase, in addition to a
subjective sense of sexual pleasure, you experience
erection, and a few droplets
 Developing Realistic Expectations about 1

of secretions may appear from the tip of the penis. Women

experi- ence increased blood flow to the pelvis, vaginal
lubrication, swelling in the external genitalia, narrowing of
the outer third of the vagina, breast swelling, and
lengthening and widening of the inner two- thirds of the
vagina.
Plateau. The plateau phase is when the body’s arousal
levels off. If the body is physiologically relaxed, it will
maintain pleasurable arousal without ejaculation or orgasm.
This phase is limited or even nonexistent for you as a man
with PE. During the plateau phase, the body “settles in”
(becomes saturated with pleasure). Unless there is
continuing stimulation of your penis, it is normal for your
erection to go down or “take a break.” Not understanding
that this is normal, men unnecessarily panic, thinking that
they have “lost” their erec- tion and fearing it will never
come back. This panic is a huge distrac- tion, which disrupts
the plateau phase, and indeed the erection, which is then
difficult to regain. But with calm relaxation and trust in
your body, all that is required is direct gentle touch to the
penis and your erection will easily come back from
“break.”
The plateau phase is especially important for you to
under- stand because it is the platform for ejaculatory
control. There are two parts of this phase, excitement
toleration and excitement saturation. By becoming skilled
at techniques based in the plateau phase, you can enjoy
pleasure and solidify ejaculatory control.
Orgasm. Sexual pleasure peaks during the orgasm phase
and is accompanied by rhythmic contraction of the pelvic
muscles and the release of sexual tension. In men, a
sensation of ejaculatory inevita- bility precedes the
contractions that result in ejaculation. In women,
contractions occur in the outer third of the vaginal wall.
Satisfaction. During the satisfaction phase, the body
gradually returns to the nonaroused state. Both the man
and woman experi- ence a pleasant afterglow, feeling
relaxed and sexually satisfied. The length of the satisfaction
or physical resolution phase is related to the length of the
arousal and plateau phases. With PE, because love- making
is brief, your erection will go down quickly after ejaculation.
As you learn more relaxed arousal and extended plateau
love- making, your penis will only go down halfway after
ejaculation and remain so for a while. For most men, this
provides the option to continue intercourse after a brief rest
(perhaps thirty seconds) even though the penis is not as hard
as before. Intercourse during the satisfaction phase can
feel close and pleasing.
After ejaculation, men are temporarily unable to regain
an erec- tion and achieve orgasm, but women can
respond alm ost
2 Coping with Premature

immediately to additional stimulation. For men, this

period when the body cannot sexually respond again—the
refractory period—var- ies with age from almost unnoticed
for a seventeen-year-old, to thirty to sixty minutes for a
man in midlife, to a day or two for a sixty- to eighty-year-
old man.

Ejaculation Physiology
To understand our approach to PE, you’ll need to know
more about how ejaculation works. The process of
ejaculation involves several events: erection, emission,
ejaculation, and orgasm. These pro- cesses are integrated by
a complex set of interactions between the neurological
system, hormonal system, and vascular system that combine
to create a smooth chain of physiological events.

Erection refers to the events in the brain, nervous system,

and vas- cular system leading to penile rigidity.

Emission refers to the collection and transport of fluids

from several glands inside your groin that form the semen in
preparation for ejac- ulation. Sperm from your testicles
travel through a small tube called the vas deferens, which
joins up in your prostate gland with the tube exiting your
bladder to form your urethra tube. Then your urethra (the
same tube that carries urine) runs through your chestnut-
sized pros- tate, then down and out through your penis.
With arousal, the neck or exit of the bladder closes (that
is why it is difficult to urinate when you are aroused and
have an erection), your testicles are drawn up against your
body, and semen collects in the verumontanum, a balloonlike
chamber inside the prostate gland. When you get so excited
that you are about to ejaculate, the veru- montanum fills
with semen, enlarging to three times its normal size. This
pressure triggers the sensation of ejaculatory inevitability
and the reflex of ejaculation.
Technically, ejaculatory control is actually emission
control because once emission occurs you will ejaculate
within seconds. This is why we teach you how to work
with your body to enjoy more pleasure, and why we
encourage you to just enjoy the pleasure of ejaculation
once you feel that it is inevitable. Consider a space shuttle
launch. The countdown proceeds to “five, four, three, two,
one, ignition . . . ,” and several seconds later the mission
con- trol announcer declares, “. . . and we have liftoff.” Once
ignition occurs, there is no stopping the launch; it will take
off. From your sexual body’s perspective, ignition is
emission, with the feeling of ejaculatory inevitability, and
liftoff is ejaculation, with the feeling of orgasm.
 Developing Realistic Expectations about 2

Ejaculation is the process of pushing the seminal fluids out

of the “balloon” (verumontanum) inside the prostate through
the urethra and out of the penis. Ejaculation occurs when
a critical level of nerve input from the pressure of the
verumontanum reaches the spinal cord and causes the
reflexive ejaculatory response. The pelvic muscles are
directly involved in ejaculation by rhythmically contract- ing
to force the semen out, so consciously relaxing them can
assist you in learning ejaculatory control. In chapter 8 you’ll
learn how to identify and relax these muscles as one of the
PE management techniques.

Orgasm refers to the subjective experience of pleasure

associated with ejaculation. Orgasm is a natural, healthy
extension of the pleasuring-arousal-intercourse process.
Orgasm and ejaculation are usually experienced as one and
the same, although physiologically they are two distinct
processes. Orgasm is primarily an experience in the brain.
Though emission, ejaculation, and orgasm are integrated
events and seem simultaneous, technically, erection is not
required for ejaculation and ejaculation is not required for
orgasm because they are controlled by separate
neurological mechanisms.

Ejaculation Neurology
How the nervous system (neurophysiology) brings about
ejacula- tion is only partially understood. Selective serotonin
reuptake inhibitor (SSRI) medications affect the level of
serotonin in the neurologic system, suppressing ejaculation.
In chapter 6 we describe medica- tions that can slow
ejaculation.
With sexual activity, sensations are conveyed from
your genitals through the nerves deep in your abdomen and
from there to the spinal cord. These impulses stimulate
reflexes in the spinal cord or ascend the spinal cord to
your brain.
While ejaculation is technically a biological reflex
involving the verumontanum in the prostate, your brain is
very much involved in the process. You interpret sensual
information, which may either augment (“turn on”) or inhibit
(“turn off”) your arousal, and your brain responds with
signals sent down to your lower spinal cord. From there, the
impulse links up with neurologic impulses from your
verumontanum to signal your ejaculatory system, which
results in emission. At the same time, nerve signals are
sent to stimulate your pelvic floor muscles (the
bulbocavernosus, ischiocavernosus, and pubococcygeus
muscles), resulting in those two to ten rhythmic contractions
characteristic of ejaculation.
This kind of basic knowledge about your body can help
you understand features of our comprehensive program.
For example,
2 Coping with Premature

notice that your brain plays an “interpreter” role in your

arousal and influences ejaculation. You can help regulate
your ejaculation by man- aging your mental focus during
arousal using cognitive ejaculation control or “pacing”
techniques that we will teach you (entrancement arousal, the
arousal continuum). Also appreciate that the pelvic mus-
cles are the muscles of ejaculation, and you can help
regulate your ejaculation by learning to relax these muscles
during sexual excite- ment. We will teach you these
techniques in chapter 8.

Reconsidering Your Expectations of

Your Sexual Body
Now that you’ve read about the physiological process
for ejacu- lation, do you think your sexual expectations were
grounded on accurate knowledge of your body? What
ideas did you have that may have created unrealistic
expectations of your body’s sexual performance? Does
understanding the ejaculatory process help you accept your
amazing body as well as its limitations? How open are you to
replacing your old ideas with new, realistic expectations?

The Integrated Model

of Sexuality
It is important to remember that sex is more than your penis,
inter- course, and ejaculation. Sexuality is an integral,
positive part of you as a man, and includes your attitudes,
emotions, behavior, body image, physical well-being, values,
and—most important—how you feel about your relationship.
At its essence, sexuality is an inter- personal process.
Although males and females have very different sexual
socialization as adolescents, men and women have many
more sexual similarities than differences as adults. Both
you and your partner can value sexuality as individuals
and as a couple.
The integrated biopsychosocial model of sexual
response involves desire, arousal, orgasm, and satisfaction.
Arousal and orgasm have little enduring value unless you
experience desire and satisfac- tion, individually and as a
couple. This broader concept of sexuality is important to our
program for understanding and changing PE. We believe
that sexuality is best understood and treated as a couple
issue. Even if you currently do not have a sexual partner,
notice that your mind will imagine a partner, react to a
partner from your past, or wish to meet that special woman
in the near future. Even without a partner now, you are in
a sexual relationship in your mind.
 Developing Realistic Expectations about 2

Female Sexual Desire and PE

Part of being realistic about sexual expectations is
accurately under- standing female sexual desire and arousal.
Physician Rosemary Basson (2001) has outlined a new
model for women’s sexual arousal. She notes that in the
beginning phase of a new relationship, romantic love and
passionate sex lead to easy sexual response for women, but
in a long-term relationship (after one or more years),
increased dis- tractions and fatigue lead to a different
kind of sexual response.
Basson depicts healthy female sexual response in an
established relationship as follows: Women begin in sexual
neutrality, but sensing an emotional need to be sexual, an
opportunity to be sexual, her part- ner’s desire, or an
awareness of one or more potential benefits that are
important to her and the relationship (for example,
emotional close- ness, bonding, love, affection, healing,
acceptance, or commitment), she may choose to move from
sexual neutrality to seeking sensual contact and stimulation.
With beginning sexual arousal, she may become aware at
that time of desire to continue the experience for sexual
reasons and experience more arousal which may or may not
include wanting orgasm. This arousal level brings her a
sense of phys- ical well-being with the added pleasure of
spin-offs such as emotional closeness, bonding, love,
affection, and acceptance.
In this new model, women have a lower biological urge
for the release of sexual tension than men. Rather, women’s
motivation to have sex stems from a number of potential
gains that are not strictly sexual but are additions to the
physical pleasure. Women’s sexual arousal is greatly
influenced by subjective mental excitement. Orgas- mic
release is not necessary for satisfaction; it does not occur at
each sexual encounter.
Women’s sexual desire is often a responsive rather than
a spon- taneous event. It develops after initial sensual
contact. While a man’s sexual desire may be energized by
physical drive, typically a woman’s sexual desire develops
from her receptivity to gentle, relaxed sensual touching. This
touching leads down the path to sexual desire and continues
to emotional closeness, affection, sensuality, and eroticism.

Understanding Your Partner’s

Reaction to PE
This view of a woman’s sexual response offers an
understand- ing of why many women eventually become
frustrated, hurt, or angry at experiencing PE lovemaking.
Not only is the sensual value of sex frustrated, but more
importantly the intimacy potential is
2 Coping with Premature

sabotaged. This is exacerbated when the man stops

lovemaking because of his frustration, apologizes, and “goes
away” emotionally or physically after ejaculating.
This understanding of your partner’s sexual response
can help you both become more accepting and respectful of
each other’s sex- ual experience. This gives you context and
motivation for learning to control ejaculation. You especially
can learn to respond differently when you ejaculate before
you want. Too often, men mistakenly think that PE is a
sexual frustration for the woman rather than an emotional
intimacy frustration. It is less about your sexual perfor-
mance and more about shared closeness and emotional
intimacy.

Developing Realistic Sexual

Expectations
To learn ejaculatory control, you need to pilot yourself with
realistic expectations. You can’t expect more of your body
than it is biologi- cally built to do. We’ve already looked at
some of the myths about male and female sexuality. Now
let’s take a look at your own expec- tations about sex.

E XERCISE : E VALUATING Y OUR

S EXUAL E XPECTATIONS
What do you expect about your sexual life? How does this
compare to what actually goes on with other couples? What
are positive, real- istic expectations? Consider what we know
about couple sexuality from clinical observations and
scientific studies. At the beginning of each section, ask
yourself what your expectations are. If you are part of a
couple, ask your partner to do this exercise too. Write
down your responses.

Frequency
How often do you expect to have sex? What influences
this: the quality of your relationship, your body’s urge, the
balance of work and leisure time? Do you and your
partner agree on frequency? What does it mean if you are
having less, or more, sex than you expect?
The average sexual frequency for married couples is
between four times a week and once every two weeks.
Contrary to popular belief, married couples are more
sexually active and satisfied than couples who are dating
or living together. For couples in their
 Developing Realistic Expectations about 2

twenties, average intercourse frequency is two to three

times a week, and for couples in their fifties, it is once a
week (Michael et al. 1994). Couples who are sexual less than
twice a month may find it hard to develop and maintain
ejaculatory control. You’ll have the most suc- cess with
ejaculatory control if you establish a regular rhythm of
being sexual.

Length
How long should sex last? What is the relationship
between time and quality? How long should intercourse
last? One minute? Five minutes? Thirty minutes? An hour?
What does length of sex mean for you?
The typical lovemaking encounter lasts from fifteen to
forty- five minutes, which includes two to seven minutes of
intercourse (Leiblum and Rosen 1989). A sexual encounter
can vary from a two-minute quickie to an intimate, sensual,
erotic two-hour experi- ence. Lovemaking includes verbal
and nonverbal communication, pleasuring, intercourse, and
afterplay. Contrary to media myths and male braggadocio,
few intercourse experiences involve ten minutes or longer
of thrusting. These figures shock most men and women.

Arousal
In what situations do you find it easy to get an erection
(men)/become lubricated (women)? When is it more difficult?
What does it mean when you have difficulty getting an
erection/becoming lubricated? What does it mean when
your erection/lubrication wanes before or during
intercourse?
Whether arousal failure happens once every ten times,
once a month, or once a year, it is normal to occasionally not
have an erec- tion or lubrication sufficient for intercourse
(remember that it’s also normal for your erection/lubrication
to “take a break” during the plateau phase). When this
occurs, rather than panicking and feeling you are back at
square one, you can just continue with erotic,
nonintercourse sex to orgasm for one or both of you.

Ejaculatory Control
What is a realistic expectation about ejaculatory
control? How have you determined this? What does it mean
if you ejaculate fast? How much control are you supposed
to have over ejaculation? Whose responsibility is it to
“time” ejaculation?
What about PE specifically? How do you know when you
are “cured”? What does it mean to have “reasonable” choice
over when to be orgasmic? What is a realistic expectation
about orgasm for the woman?
2 Coping with Premature

One key is to maintain the focus on sharing pleasure

during intercourse. In other words, if you’re both satisfied
with the pleasure you’re giving and receiving, ejaculatory
control will matter less.
Another key is seeing intercourse as a mutual,
interactive expe- rience. Most men find it relatively easy to
identify the point of ejacu- latory inevitability and to learn
slowing down and ejaculatory control with manual and oral
stimulation. Ejaculatory control during intercourse is more
challenging because it requires more cooperation and
interaction.

Satisfaction
What do you require to feel sexually and emotionally
satisfied? Must you ejaculate? Should every sexual
encounter be equally satis- fying? Why is a poor sexual
experience distressing for you? Do you think that “mercy
sex” (only pleasing your partner) is okay? Com- plete the
sentence, “I am wonderfully sexually satisfied when . . .”
Even among well-functioning, satisfied married couples,
half or fewer of their experiences are equally satisfying to
both partners. In fact, if the couple has one or two
experiences a month of movie- quality sex, they can count
themselves as very fortunate. Perhaps 20 to 25 percent of
sexual experiences are very good for one partner (usually
the man) and good for the other. Another 20 to 25 percent of
sexual experiences are okay but not remarkable. The most
important thing to understand is that 5 to 15 percent of
sexual experiences are mediocre, dissatisfying, or
dysfunctional (Frank, Anderson, and Rubenstein 1978).
Remember, this is true of well-functioning, satis-
fied couples.

E XERCISE : N EGOTIATING
R EASONABLE S EXUAL E XPECTATIONS
WITH Y OUR P ARTNER
Now that you’ve each examined your own expectations,
you’ll want to compare your expectations as a couple and try
to come to a flex- ible consensus that fits your relationship.
This can be a difficult process! Take your time. Do your best
to remain open-minded and communicate respectfully. It is
normal and even healthy to have differences. If you find that
your expectations are very different or you’re having trouble
communicating, you may want to seek help from a
therapist.
1. How often do you expect to have sex? Why is this
frequency important to you? Where does your
sexual desire come
 Developing Realistic Expectations about 2

from? What is a comfortable frequency for you as a

couple that fits your lifestyle?
2. How long do you expect foreplay (pleasuring) to last?
Inter- course? Why is this length of time meaningful
to you? Can you agree on a range of time that is
comfortable for you both?
3. How comfortable are you accepting that it is normal
for a man’s erection or a woman’s lubrication to
come and go during a relaxed sexual interaction?
4. What do you consider a good range of time for you to
have intercourse? How long do you like the slow,
sensual inter- course? How long the more intense
intercourse? What is your wish for varying the
pace of intercourse?
5. In what percent of encounters should you choose
when to ejaculate?
6. In what percent of encounters should the woman
have an orgasm? How?
7. What determines your satisfaction with your sexual
interaction?
8. What percent of the time do you expect sex should be
great, what percent satisfactory, what percent all
right, and what percent poor quality? What do you
think is reasonable?
9. How do you each want to handle times when sex goes
poorly?

Steve and Suzanne’s Story

Steve and Suzanne had been a couple for six years,
married for four years, and had an eighteen-month-old son.
They agreed sex was best in the early months of the
relationship. The excitement of find- ing each other,
developing their relationship, experiencing romantic love,
and having new and exciting sex added a special charge
to their lives. Steve had lifelong PE, but the frequency of sex
and the enthusiasm of their romantic relationship made the
ejaculatory prob- lem seem unimportant. Suzanne felt
attracted to Steve, attractive and cared for by Steve, and
very excited to be in this relationship. She naively hoped that
with time the quality of intercourse would improve, but was
not upset by the rapid ejaculation. Steve enjoyed
2 Coping with Premature

second intercourse opportunities where his control was

somewhat better. He found Suzanne’s passion and
enthusiasm a real turn-on.
Steve was happy with Suzanne, their marriage, and
their family. Steve just ignored the PE problem. Some men
find that with increased sexual comfort and experience,
ejaculatory control gradu- ally improves without their
needing to do anything specific. However, for most men,
PE becomes a chronic sexual problem, which is what
happened with Steve.
Suzanne eventually became frustrated and then sexually
turned off. At first she tried to raise the issue of
intercourse quality indirectly and tactfully, but Steve just
ignored her or treated the dissatisfaction as her problem.
Finally the issue exploded into a nasty argument after a
sexual encounter. Suzanne complained that Steve was so
quick and selfish. He accused Suzanne of being a whiner and
frigid person. Having an argument about sex when they
were naked and emotionally vulnera- ble felt awful, but they
couldn’t seem to stop themselves. Their conversation quickly
degenerated into hurt, defensiveness, and anger. Steve felt
unfairly attacked, and Suzanne felt Steve was mean and had
no desire to improve their sexual life.
Steve stewed about this for two days and then decided
he would “show” Suzanne. Without telling her, he made an
appointment at a male sex clinic which advertised on sports
radio. Steve received medi- cation which was to delay his
orgasm. Without saying anything to Suzanne, he became
obsessed with the goal of getting Suzanne to have an
orgasm before he ejaculated. Sex became a crucial test of
Steve’s manhood: he had to hold out until she had an
orgasm.
At first, Suzanne was pleased that Steve seemed more
caring and intercourse was lasting longer, but then she
became turned off by Steve’s obsessive focus on her
orgasm. She began to dread and resent sex. Suzanne’s
desire and arousal was much reduced, which further
frustrated Steve, and he became even more defensive.
Sex was no longer an intimate, sharing experience; instead it
was a strug- gle over orgasm. The relationship was
dispirited, sinking under the weight of misunderstanding and
performance pressure. Steve was being his own worst
enemy, and Suzanne was feeling increasingly alienated and
turned off.
It was Suzanne who made the call to a couple therapist
with a subspecialty in sex therapy. This was a very wise
move. Steve and Suzanne were ideal candidates for couple
sex therapy because they had a genuine marital bond of
respect, trust, and intimacy and a desire for a satisfying
sexual relationship. The PE and sexual misun- derstanding
were draining intimacy and threatening to destabilize their
marriage.
 Developing Realistic Expectations about 2

The first priority in therapy was to reinforce the

importance of intimacy and pleasuring. Steve had
misinterpreted Suzanne’s comments as meaning that he was
a terrible lover. With the help of the therapist, Steve was
able to understand that Suzanne valued him as a loving,
attractive husband and wanted to work with him to enhance
their sexual life so that the marriage was satisfying and
secure. Her request was that Steve be a more sensitive,
slower lover. Suzanne was not demanding that Steve be a
perfect sexual performer but a more involved, caring lover.
Suzanne had a variable arousal and orgasm pattern.
She enjoyed being orgasmic with manual and oral
stimulation as well as during intercourse. She did want
Steve to develop better ejaculatory control, but more
importantly, she wanted Steve to be willing to engage in
additional erotic stimulation during intercourse. Steve
needed to affirm that he was learning ejaculatory control for
himself and the relationship, not to perform for Suzanne.
With this new understanding, they decided to work together
on developing ejacula- tory control.
At times, Steve and Suzanne found the ejaculatory
control exer- cises tedious, and change was slow, but as long
as they continued to communicate and cooperate, it was
enjoyable. Suzanne felt that she had an integral role in the
exercises and that her emotional and sexual feelings were
important. Steve felt that Suzanne was an intimate ally and
that her desire and arousal enhanced the sexual experience.
As he came to understand and appreciate the nuances of
desire, arousal, orgasm, and satisfaction for himself and for
Suzanne, the sexual relationship and PE improved. As a
bonus, Steve and Suzanne expanded their repertoire of
pleasuring and erotic tech- niques. Both learned to be
sexually assertive, express intimate feel- ings, enjoy
prolonged intercourse, see orgasm as a voluntary process,
and enjoy flexible, variable sexual experiences.

What You Can Expect from

Our Program for Change
In the same way that it’s important to have reasonable
expectations of yourself and your body, it’s important to
know what you can reasonably expect from our approach to
PE. You won’t become a sexual machine that can last for
hours and hours. You will learn ejaculatory control and enjoy
arousal during prolonged intercourse. You will enhance
your relationship by learning to enjoy and share the entire
sexual experience: intimacy, pleasuring, eroticism, arousal,
intercourse, and afterplay.
3 Coping with Premature

Learning ejaculatory control is like learning any skill. It

is a gradual process requiring feedback and practice. You’ll
need to approach this as a team. After all, an interested,
involved sexual partner is the best aphrodisiac! You and your
partner need to utilize all of your resources to learn and
maintain ejaculatory control.
The essence of ejaculatory control involves learning to
carefully attend to your body’s physical sensations, relaxing
your body while aroused, identifying the point of ejaculatory
inevitability, maintain- ing awareness of pleasurable
sensations at high levels of arousal, and having reasonable
(not perfect) control over when you will let go and
orgasm. It involves cognitive, behavioral, and emotional
skills; it is not a mechanical process.
Many men find it easier to develop awareness, comfort,
and skills with self-stimulation. Practicing ejaculatory
control during partner sex, especially intercourse, is more
complex and challenging, but if you can do it by yourself, you
can learn to do it during partner sex.
Like Steve and Suzanne, you and your partner can
expect to develop greater intimacy and a more satisfying sex
life. It’s hard work, but it’s worth it!
 3

Understanding the
Causes and Effects of
PE

Real-life problems are rarely simple, easy to solve, or

magically fixed, in spite of quick-fix promises. The major
reason traditional treatments of PE have failed to help so
many is that PE is not a simple problem with a simple
cure. While the experience of PE is pretty much the same for
all men—quick and uncontrolled ejacula- tion—there are
actually nine different types of PE, each with a different
cause. PE may be a physical problem, involving the
neurological system, medical illness, physical injuries, or
side effects of drugs. It may be psychological or
interpersonal, stemming from personality characteristics,
unresolved issues from your family of origin or personal
history, anxieties and stressors, relationship stresses, or
sexual skills deficits.
It’s not just the causes of PE that are complicated—the
effects are complicated too. PE can have a devastating
impact on your self-esteem, your sex life, and your
relationship. These effects, in turn, can make PE worse.
It’s a vicious cycle.
In this chapter, we’ll look at the nine different types of
PE: four physical, four psychological or relational, and one
mixed type involving another sexual dysfunction. Then we’ll
focus on the psychological and relational causes and effects,
because these are the aspects that you have the most control
over. The psychological and relational causes are
particularly complex and intertwining, so we’ll offer you a
model to help you understand how these dimensions fit
together. In chapter 4 we’ll help you determine which type
3 Coping with Premature

or types
3 Coping with Premature

of PE you have. Then you’ll be prepared to develop a

comprehensive and effective approach to managing your
PE.

Possible Causes of PE
Scientific research helps us to sort out myths from reality.
When it comes to PE, this difference is very important.

Neurologic System PE
Neurologic system PE is caused by a physiological
predis- position in the nervous system to ejaculate quickly.
As you’ll remem- ber from chapter 2, ejaculation is triggered
by a reflex. Montreal psychiatrist Pierre Assalian (1988)
states that some men with PE have a “constitutionally
hypersensitive sympathetic nervous system” (p. 215)—in
other words, a very quick reflex. This type of PE occurs
throughout a man’s life, with every partner, and in all sexual
situa- tions, including masturbation.
Historically, this was the predominant explanation of
PE. Rapid ejaculation was believed to be normal and even to
provide an evolu- tionary advantage. Kinsey, Pomeroy, and
Martin (1948) noted that 75 percent of men ejaculated in
less than two minutes of intercourse. Researchers including
Bixler (1986) and Hong (1984) assumed that human
behavior is similar to animal behavior and noted that the
“top dog” or “alpha” animal ejaculates quickly. Hong
observed that the normal pattern for most primates is to
ejaculate within three to ten seconds of intercourse. Many
professionals concluded from their clinical impressions that
PE must have physiological origins. For example, urologist
Schapiro’s classic report published in 1943 attrib- utes PE
to neurologic efficiency.
More recently, researchers have theorized that genetic
inheri- tance plays some role in the lifelong physiological
predisposition to ejaculate quickly. Waldinger (1998) found
that 91 percent of men with lifelong PE also had a first
relative with lifelong PE. Rowland (1999) found
physiological differences between PE and non-PE males.
For example, men with PE have a faster bulbocavernosus
reflex (that is, a faster neurological response in the pelvic
muscles).

Physical Illness PE
Physical illnesses may cause PE. Here the PE is
acquired, not lifelong, and occurs in all sexual situations. A
number of acute diseases are known to affect ejaculation
speed. Some are common
 Understanding the Causes and Effects of 3

illnesses, such as urinary tract infection, while others are

very rare. The illness that most frequently causes PE is
prostatitis (prostate infec- tion), although virtually any
urologic illness may have this effect.

Physical Injury PE
Some cases of PE are caused by temporary or
permanent physi- cal damage to the body that directly or
indirectly affects ejaculatory mechanisms. Because of the
injury, the neurological connection with the genital area is
compromised so that at least some sensation and control of
ejaculation is impaired or lost.

Drug Side-Effect PE
PE may occur as the result of use of or withdrawal from
certain chemical agents. This type of PE is acquired and
occurs in all sexual situations. Examples include
withdrawal from certain tranquilizers or opiates, or even
use of over-the-counter cold medications like Sudafed
(pseudoephedrine).

Psychological System PE
Psychological system PE is caused by chronic
psychological disorders such as bipolar mood disorder
(sometimes called manic depression), obsessive-compulsive
disorder, chronic depression, gen- eralized anxiety disorder,
schizophrenia, personality disorder (for example, avoidant
personality disorder, dependent personality disorder, or
borderline personality disorder), post-traumatic stress
disorder (the aftereffects of witnessing tragedy or being
victimized), or developmental disorders such as attention
deficit/hyperactivity disorder. It may also be caused by the
ongoing psychological effects of alcoholism or drug abuse,
or by chronic, unresolved personal issues.
While significant psychological problems may cause
PE, the vast majority of men with PE do not have major
psychological prob- lems. There is no common personality
profile for men with psycho- logical system PE. This type of
PE typically occurs throughout a man’s life and in all
sexual situations.

Psychological Distress PE
Psychological distress PE is caused by temporary
psychological difficulties such as an adjustment disorder
(temporary depression or
3 Coping with Premature

anxiety), serious unusual stress, or acute depression.

Psychological distress may also result from PE, for example,
when physical illness PE causes psychological distress.
While there is no typical psycho- logical profile for men
with PE, the scientific literature reports that PE is more
likely when the man has situational anxiety, reactive
depression, loss of confidence, mistrust, frustration, anger,
restrictive religious beliefs, negative feelings about his
body and sexuality, or unrealistic expectations of sexual
performance, or when he experi- ences internal conflicts
such as between the roles of lover and father. Psychosocial
stresses (for example, occupational stress, the death of a
friend or parent, financial problems, or acculturation
problems) may precipitate PE. Sometimes it is difficult to
determine which is the chicken and which is the egg; it
may be unclear whether the anxiety is the cause or result
of PE. Psychological distress PE is acquired.
Men tend to underestimate the effect that psychological
stress may have on their sexual functioning. The thinking
goes something like this: “When there is such a profound
problem as PE, the cause must be profound as well.” But in
fact, it does not take much psycho- logical distress to
disrupt sexual functioning.

Relationship Distress PE
Complicated interpersonal dynamics may cause PE or
result from it. Relationship distress PE is rooted in
interpersonal dynamics such as failure to communicate,
hurtful misunderstandings, fear of romantic success,
unresolved emotional conflicts, hypersensitivity to your
partner, profound discomfort with or fear of intimacy, or
other distresses such as mistrust in response to infidelity.
In short, general relationship deficiencies undermine
the mutual emotional acceptance that is important to healthy
sexual functioning. Even when PE is caused by something
other than rela- tionship distress, it can cause considerable
damage to your relation- ship. Relationship distress PE is
commonly acquired and limited to sex with the partner.
While there is no single interaction pattern among
couples facing PE, there are several common patterns.
●
The man is hypersensitive to his partner, fears failing
and disappointing her, and is frequently self-blaming
and apolo- getic. The woman is either shy and
compliant or direct and aggressive.
●
The man is self-absorbed and aloof from his partner’s
concerns. He may defend his dysfunction as a
normal
 Understanding the Causes and Effects of 3

physiological response, while she may feel

emotionally ignored and abandoned, and respond
contentiously.
●
The couple experiences unresolved relationship
conflicts accompanied by perceived rejection,
blaming, and criticism. They may struggle with the
balance of autonomy and couple cohesion, empathy
deficits, or a conflict-resolution impasse. One partner
may feel abandoned by the other and take an
avoidant or hostile stance. The PE may be a
reciprocal and interactive problem that has more to
do with relationship distress than sex itself.
●
A sexual problem like PE serves as a surrogate
problem, pro- viding a focus for the couple’s anxiety
and dissatisfaction so that the rest of the relationship
can remain functional. Sex might feel like the only
relationship problem, but it is not.
●
The man’s PE coexists with a sexual dysfunction in
the woman. Some women experience inhibited
arousal, while others experience difficulty achieving
orgasm in part because of their partner’s PE. In other
cases, her sex dysfunction inter- acts with his PE. For
example, because of her inhibited desire, she may
encourage him to “get it over with.” If she experi-
ences discomfort or pain during intercourse, he may
hurry to limit the discomfort. In still other cases of
acquired PE, the man’s fast ejaculation may be a
reaction to the woman’s psy- chological distress (for
example, anxiety or depression), or to her negative
attitude toward sex, general discomfort with a sexual
behavior (for example, oral sex), low sexual arousal,
or inhibited orgasm.

Psychosexual Skills Deficit PE

Psychosexual skills deficit PE typically results from the
man not having accurate and sufficient knowledge about his
body, his partner’s body, and sexual physiology (how sexual
response works); holding unreasonable expectations about
sexual performance; and lacking essential sensual skills to
manage his body during sexual arousal. Some men also lack
dating or interpersonal skills. This type of PE is lifelong
but may not occur with masturbation.
Most men with psychologically caused PE usually have
some limitations in psychosexual skills, if only to compensate
for individ- ual stresses or relationship tensions that rob
sexuality of its natural bonding and emotional-healing
capacity. In such cases the man has difficulty focusing on
his own sensations; becomes preoccupied with
3 Coping with Premature

anticipating failure; has difficulty relaxing his body while

sexually aroused; lacks awareness of techniques for
managing PE or uses ineffective techniques like distraction;
focuses excessively on his partner’s body and reactions;
experiences restricted, uneasy, or anxious sensuality; or
entertains distorted thoughts (“sex must be spontaneous” or
“emotions are not involved in sex”).

PE with Another Sexual Dysfunction (Mixed PE)

PE that coexists with another sexual dysfunction such
as low sexual desire or erectile dysfunction occurs about
one-third of the time and can reflect a complicated
combination of physical and psychological causes. For
example, a vascular cause for erectile dysfunction may
combine with psychological and relationship distress that
adds to PE. PE is sometimes caused by the man’s efforts to
compensate for a fear of erectile dysfunction. Treating the
erectile dysfunction can, in turn, help resolve the PE. On the
other hand, some men try so hard to halt PE that they
unintentionally cause erectile dysfunction, which then
leads to inhibited sexual desire.

The Multiple Dimensions of PE

In addition to understanding the multiple causes of PE, it is
valuable to appreciate that PE is also multidimensional—that
not only is there rarely one cause of PE, there is an
interaction between the biological, medical, psychological,
relational, and situational dimensions. For example, a
prostate infection (medical) may interact with your self-
esteem (psychological), affect communication with your
partner (relational), and even influence your feelings about
work and home life (psychological and situational). This
intermingling and inter- twining of the facets of our
personalities and lives is normal. This is partly why PE can
feel so confusing, so difficult to sort out. Yes, PE is
complex.
To illustrate these dimensional interactions, consider
Robert’s effort to understand his PE. We identify some of the
interacting dimensions in parentheses.

Robert’s Story
Robert was thirty-four years old and had been married
for eight years. He thought that he had a pretty good life: a
happy marriage to Tonya, a five-year-old son, and a good
career as a teacher. After
 Understanding the Causes and Effects of 3

several years of what he considered “okay” sexual

performance, he began to ejaculate very quickly—within one
minute. He felt per- plexed (psychological). He began to feel
irritated with his penis as he intended to last longer but his
body seemed to betray him (biological and psychological).
He was confused, sensing the chaos of trying to figure it out
so he could do something about it (psychological). He tried
to be aware and sensitive to Tonya, even felt hypersensitive
to her actions, moods, and words, especially since she had
recently said she was “less interested in sex” (psychological
and relational). Since his PE developed after a long period of
performing okay, he thought that maybe there was
something wrong with his body (biological, medical). Should
he see his doctor? But he hated going to his physi- cian
(psychological). He was almost phobic about blood draws
(psy- chological and biological).
He realized too that he was very down and anxious
(psycho- logical) about the whole sex thing. None of his
efforts to slow down ejaculation had helped. He was puzzled
to notice that one time recently when he drank too much, he
was able to last a little longer before ejaculating. Was
alcohol an answer (biological)? He could not let himself go
that route (psychological). Another time he lasted a little
longer was when he had a sinus infection and had trouble
breathing (biological).
Robert realized he was beginning to withdraw from sex
and from Tonya (relational) but felt trapped, like he couldn’t
win (psychological). Even at work he noticed he sometimes
could not concentrate well and felt distracted (relational,
psychological). He also noticed, at times, that he was
impatient with his son (psycholog- ical and relational). These
things seemed to arise from his tension over the PE
(psychological). What is this chaos? What to do?
With the help of assessment and intervention strategies
and exercises, Robert and Tonya were able to understand
and resolve his PE. You can do it, too.

You Understand Your PE

All of these aspects—biological/medical, psychological,
relational, situational—interact in your effort to figure out
your PE and change it. Without some organizational model,
the chaos feels overwhelm- ing. We will help you sort it out,
make sense of it, see what you are up against, and figure
out what you can do. If your case is simple, we are very
happy for you. If your case is multidimensional like most,
welcome aboard. We want to help you honestly see PE for
the complex problem it is, use this deeper understanding
to overcome
3 Coping with Premature

the feeling of being overwhelmed and hopeless, and help you

and your partner cooperate to improve your sexual life and
relationship.

The Psychological and

Relational Dimensions of PE
To help you understand the psychological and relationship
aspects of PE, we offer you a framework, the cognitive-
behavioral-emotional (CBE) model. This will help you make
sense of the otherwise confusing experience of PE and
organize your couple approach to overcoming PE.

The Cognitive-Behavioral-Emotional Model

The CBE model recognizes that each individual is
composed of cognitions, or thoughts; behaviors, or actions;
and emotions, or feelings. We’ll describe these components,
then show you how they are involved in your PE.
These dimensions of the CBE model interact almost
automati- cally—thoughts influencing feelings, feelings
influencing behaviors, and behaviors prompting thoughts
and feelings. In the integrative CBE model, each component
is valued and promotes change. Your insight will be
strengthened by understanding the cognitions, behav- iors,
and emotions that constitute PE.

Cognitions or Thoughts
Cognitions involve ideas, beliefs, observations,
interpretations, and reasoning. Psychologists Norman
Epstein and Donald Baucom (2002) describe five distinct
cognitions that affect our relationships: assumptions,
standards, perceptions, attributions (explanations), and
expectancies (expectations). These are unique to each
person. Such cognitions are beneficial or detrimental to you
depending on their effects on your feelings and actions.

Behaviors or Actions
We make decisions to act (or not act) based upon our
thoughts and feelings. Technically, action is always a choice
or decision. The freedom to choose your behavior may be
mitigated by thoughts and feelings, but responsible and
mature living mandates accountability for your behavior.
While feelings are not viewed as ethical (that is, not judged
to be good or bad), behaviors are. Behaviors may be
constructive or destructive depending on their effect on each
individ- ual and the relationship.
 Understanding the Causes and Effects of 3

Emotions or Feelings
Emotions are chemical-electrical “energy” events or
experiences in your body. You label this energy according to
how you experience these physical sensations: fear, sadness,
loneliness, panic, satisfac- tion, anger, worry, contentment,
frustration, pleasure, irritability, excitement, anxiety,
wonderment, confusion, shame, guilt, comfort,
embarrassment, resentment, safety. Feelings are
“motivators” that prompt, penalize, or reward action.
Feelings are not themselves good or bad, right or wrong.
Feelings influence the thoughts we have and the actions we
take. Emotions can be positive or negative depending on
how you subjectively experience them and how they
influence your behavior.

Sherry and Alex’s Story

To illustrate this model, consider Alex and Sherry’s
experience of PE. Be aware of their thoughts, actions, and
feelings. To help you identify these, we will label cognitions
as (C), behaviors as (B), and emotions as (E). You may find
some features similar to your own experience.
Alex’s chronic PE led Sherry to perceive (C) him as
selfish and rejecting of her desires, and Sherry felt dismissed
(E). Alex did not intend (C) to be selfish. Rather, he was
deeply perplexed (C) at his performance “failure” (B) and
feared disappointing Sherry (E). Yet his actions (B) after
ejaculating quickly appeared (C) selfish to Sherry.
Here is an outline of what was happening. With fast
ejaculation (B), Alex appeared to Sherry (C) to be sexually
satisfied by his orgasm (B), but he typically stopped
pleasuring (B) Sherry (“he rolls over and goes to sleep”).
Alex felt frustrated with himself (E), focused on his failure
(C), apologized (B) to Sherry for PE, and stopped
lovemaking, became quiet or withdrawn, or even left their
bed (B).
For several years, Sherry had experienced Alex’s PE
and observed him (C) failing to seek professional help (B).
All of these actions (B) seemed to Sherry to be insensitive
(C) to her wants and feelings, hurt her deeply (E), felt like an
abandonment (E), and seemed hard to interpret as anything
other than an incredible selfish- ness (C). Her hurt (E)
sometimes manifested as complaints, criti- cisms, and other
expressions of anger (B), even rage at times. With this, Alex
thought he was betrayed (C), and he misunderstood (C)
Sherry’s lack of support (B) when he failed (C) to control his
ejacula- tion (B), but was confused (C) about what to do (B).
Everything that he tried (B) (distracting himself,
masturbating before lovemaking) failed (C). He felt
completely hopeless (E) and inadequate (C), and
4 Coping with Premature

avoided Sherry (B). She believed she was abandoned (C) and
ignored by Alex (B), and felt hurt and angry (E).
Alex and Sherry’s story shows how these complex and
detrimental cognitions, behaviors, and emotions serve to
cause, maintain, or exacerbate PE, or may become the
psychological effects of PE caused by other factors. Some
examples of negative cognitions that can be involved in PE
are “I am a failure,” “I am sexually inadequate,” or “He is
just selfish.” Negative behaviors include with- drawal from
your partner, silence, blaming, or failing to talk
constructively with each other about the problem.
Detrimental emotions include frustration, anger, shame, or
confusion. Identifying these negative dimensions is a step in
the process of overcoming the anguish of PE. You can stop
these patterns and change them to more reasonable
cognitions, cooperative behaviors, and positive feelings.

Relationship Identity, Cooperation, and Intimacy

PE exists within a relationship, not in a vacuum.
Understand- ing relationship dimensions can help you make
sense of your dis- tress and alert you to areas to repair or
strengthen as you address PE. Let’s look at the CBE
model of relationship health.

Relationship Identity
Relationship identity refers to the cognitive life of your
relation- ship, comprising the expectations that each of you
brings to the rela- tionship, the relevance of your personal
history, and what your relationship means to each of you.
For example, how do you balance each other’s needs for
individual autonomy and relationship cohesion? In healthy
relationships, each individual benefits from the relationship,
and the relationship benefits from the input of each
individual.

Relationship Cooperation
Relationship cooperation refers to your behavioral
interactions: how you communicate, work together in a
balanced way, and mutually solve problems effectively. Your
thoughts and feelings are hidden from each other unless you
communicate them through a behavior—typically by sharing
through discussion or nonverbal gestures. This is why
communication is such an important part of couple sexual
growth.

Relationship Intimacy
Relationship intimacy refers to your relationship’s
“climate” or quality of emotional bond. Intimacy
describes the emotional,
 Understanding the Causes and Effects of 4

friendship, and sexual aspects of your relationship—feelings

of affec- tion, commitment, and closeness.
These relationship themes fundamentally determine
relation- ship satisfaction.

PE and Sexual Relationship Identity,

Cooperation, and Intimacy
To help you more fully appreciate the interrelated
dimensions of your PE, we’ll describe specific types of
cognitions involved in sexual relationship identity,
behaviors that make up sexual relation- ship cooperation,
and emotions associated with sexual relationship intimacy.
The CBE model of relationship health can help you focus
on what to strive for, not simply what to stop or “get over”
from the past. Remember that the context for overcoming PE
is not simply to slow down your ejaculation, but to enhance
your relationship identity, cooperation, and emotional
intimacy.

PE and the Role of Cognitions: Sexual

Relationship Identity
Your cognitions about PE comprise the sexual
“meaning” of PE. Discovering your and your partner’s
meanings of sexuality and PE is an important element in
understanding your sexual dissatisfaction. Does PE mean a
limitation on pleasure? Shame? Failure? Alienation? Does
sex mean duty? Perfect performance? Is it “dirty but
exciting”? Disgusting? Or, does sex mean vulnerable
sharing? Comfort? Gentle- ness and tenderness?
Acceptance? Playfulness? Intimacy?
The subjective meaning that PE has for you and your
partner is determined by these cognitions, and they
influence your emotional experiences during sex. You and
your partner can understand each other more fully by
sharing your thoughts about PE and the meaning of sex.
You can also begin to change your experience of PE by
replacing negative thoughts with positive ones.

Detrimental and Beneficial Cognitions with PE

Following are some common detrimental thoughts that
men and women have when PE is a significant problem. We
also offer beneficial thoughts that can replace them to help
you alter PE’s meaning and help motivate your changes. Be
aware that beneficial cognitions are grounded in accurate
knowledge about sex.
 4 Coping with Premature

Assumptions about sex are cognitions about the

characteristics of intimate relationships that you accept as
true without question and govern how you interact.
Detrimental Cognitions Beneficial Cognitions
●
Good sex means ●
Good sex involves
long intercourse. flexible ways to share
pleasure which invites
personal and
relationship joys.
●
Movie-type sex is normal. ● Movie sex portrays impulsive,
perfect-performance sex.
We are real lovers, not
actors in a Hollywood
movie!
Standards or beliefs are cognitions about the
characteristics that you think your sexual partner or
relationship should have, and the judg- ments you make.
Examples of detrimental versus beneficial standards are:
Detrimental Cognitions Beneficial Cognitions
●
Sex should always ●
Sex is sometimes
be romantic. romantic, sometimes
routine, sometimes joyful,
sometimes monotonous,
sometimes deeply
meaningful. Sex is a
●
We should have sex healthy part of our couple
four times a week style.
because I’ve heard ●
that is normal for our The frequency of sex should
conform to the realities of
age.
our lives and be mutually
satisfying.
Perceptions about sex are your cognitive “selective
focus.” You notice only a part of the information available.
Which part depends on your emotional state, level of
fatigue, prior experiences in similar situations, and
preexisting cognitions and perceptions about sex.
Detrimental Cognitions Beneficial Cognitions
●
When he ejaculates, he ●
His apology and withdrawal
immediately apologizes may signal that he feels
and goes away deeply ashamed, sexually
physically and inadequate, a failure. I’ll ask
emotionally, and I am him to physically stay
abandoned. involved after intercourse for
the closeness or to be
satisfied by other ways than
intercourse.
 Understanding the Causes and Effects of 4

●
She punishes me with ●
her anger when I Her anger manifests her
come fast. hurt, loneliness, or feelings
of emotional abandonment.
I will tell her that I want
to under- stand her
feelings and to lead the
way with the program in
this book.

Attributions are the causal explanations you have about

your PE. The explanations reflect your understanding of and
sense of control over sexual experiences.

Detrimental Cognitions Beneficial Cognitions

●
He ejaculates so ●
PE is more than selfishness.
fast because he is What must he be feeling?
selfish. Perhaps anxious? Ashamed?
Inadequate? Powerless?
Betrayed by his body’s fast
ejaculation? Afraid I will go
to someone else?
●
Sex is only one aspect of
●
She is so resistant or our intimate relationship. I
passive when having wonder if she is passive
sex because she no during lovemaking because
longer loves me. I have she anticipates the touching
ruined our marriage will end when I ejacu- late?
because of PE. When I ejaculate quickly,
I will ask her if I can hold
her and rest for a minute, and
then pleasure her with my
hands.

Expectancies are the automatic predictions about what is

likely to occur: “if this, then that.” When thinking about
PE, this often includes expectations that you will fail.

Detrimental Cognitions Beneficial Cognitions

●
If we try to have sex, ●
I will ask her to be part of
it won’t work because my effort to learn ejaculatory
I’ll ejaculate fast; it control and heal the pain in
will be a our relationship caused by
disappointment, and PE.
she’ll be angry.
 4 Coping with Premature

●
If I ask for what I ●
want sexually (like I will ask him kindly—and
oral sex or slower not during sex—whether he
touch), he will get would like me to offer
upset. suggestions about the kinds
of touch I really enjoy.

Changing the Way You Think about PE

You can change the way you think about PE based on
realistic expectations of yourself and your relationship.
Research supports that your way of thinking is the most
important factor for change and satisfaction. Your
negative thoughts about PE function as a self-fulfilling
prophecy. Identifying the detrimental and limiting cognitions
that you and your partner may have adopted toward your
PE, and replacing them with realistic and constructive ones,
is a very useful change strategy.

E XERCISE : C HANGING Y OUR

T HOUGHTS ABOUT PE
Take a moment to consider your cognitions about your sex
life: your assumptions, beliefs, perceptions, explanations,
and expectancies. Each of these thoughts reflects the
meaning sex has for you. How do you want to reframe the
meaning of sex for you and your partner? What is its role in
your intimate relationship? Choose one or two thoughts that
you think are the most detrimental. Write a positive
alternative for each. When those negative thoughts arise,
consciously shift to the positive thought. You can share your
thoughts with each other to help understand each other
better.

PE and the Role of Behaviors: Sexual

Relationship Cooperation
Behaviors are the “bridge” between you and your
partner. Your thoughts and feelings can only be accurately
known to each other through your actions, verbal and
nonverbal. To address PE, you and your partner must focus
on cooperative behavior that moves you toward your goal.
When your PE is not constructively addressed, it
manifests in negative behavior. For example, the man avoids
sex to avoid dis- appointment, avoids talking about the
problem, acts as though noth- ing is wrong, pressures his
partner to have orgasm other ways than
 Understanding the Causes and Effects of 4

through intercourse, or makes love rigidly and

mechanically as he tries desperately to control his
ejaculation. The woman may push her lover away, say
hurtful things, rush sex to get it over with to avoid further
hurt and frustration, or place limitations or conditions on
sex. Relationship conflict may cause PE when unresolved
disagree- ments or repeated negative interactions
undermine emotional inti- macy. PE may cause
relationship conflict when it is chronic and ignored. On
the other hand, mutually resolved relationship conflict
enhances emotional and sexual intimacy. Ordinary conflict
presents opportunities for couples to deepen their emotional
and sexual inti- macy. Differences or disagreements about
sexual interaction are common and normal; the issue is how
well you deal with them. PE is an example of a relationship
cooperation challenge. With a positive, respectful, affirming
process of conflict resolution, partners develop a deeper
understanding of how the other thinks and feels, a greater
sense of self-esteem, greater respect and admiration for
each other, more confidence that future conflict can be
resolved, and increased
goodwill and comfort, which facilitates sexual desire.

Detrimental and Beneficial Behaviors with PE

There are detrimental behaviors that cause, maintain, or
worsen PE, as well as beneficial behaviors that may
ameliorate or help PE.
Detrimental Actions Beneficial Actions
●
Verbally criticizing ●
your partner or your Calmly and openly
partner’s behavior. expressing your own
●
feelings.
Withdrawing from
your partner. ●
Staying, being present,
disclosing your feelings,
●
or expressing your
Anticipating sexual intention to work
“failure” and then together.
avoiding initiating sex. ●
Calmly talking with your
partner and openly
acknowl- edging the
dilemma you feel.
●
Acting aloof or cold. ● Showing warmth and interest
in cooperating,
requesting what you want
in a positive way.
●
Apologizing when ●
Asking your partner how
you ejaculate fast. you can be responsive to
her sexual feelings and
desires, and how you can
please her.
 4 Coping with Premature

●
Expressing frustration ●
at yourself and your Reminding yourself that
partner. expressing frustration
doesn’t help, then
refocusing and
recommitting to
● enhancing sensual and
Refusing to discuss sexual pleasure.
the sexual problem. ●
Talking calmly, sharing
your feelings, describing
the dilemma you face, and
● asking for cooperation to
Threatening an affair, enrich your sexual
separation, or divorce. relationship.
This is truly poisonous ●
behavior because Expressing your desire to
threats create anxiety join together to solve your
and polarize you as a difficulty as a couple.
couple.

Changing the Way You Act about PE

These examples of injurious behaviors (whether
intended or not) and more beneficial actions involving PE
are changes you and your partner can implement.
Identifying your contribution and seeing what constructive
changes you need to make are essential to your success.

E XERCISE : C HANGING Y OUR

B EHAVIORS ABOUT PE
From the list above, choose at least one and up to three
behaviors to focus on changing. If you slip into old
detrimental behaviors, forgive yourself, then recommit to
choosing more positive behaviors.

PE and the Role of Feelings: Sexual

Relationship Intimacy
In the emotional life of your relationship, PE may bring
about hurtful feelings (humiliation, rejection, loneliness, or
abandonment) that undermine beneficial feelings
(acceptance, closeness, and love). The emotional suffering of
many couples with PE is quiet, hidden, and often deeply
upsetting, which only adds to the confusion and sense of
hopelessness.
 Understanding the Causes and Effects of 4

Detrimental Emotions with PE

Common feelings for the man with PE are
bewilderment, shame, disappointment, an intense sense of
failure and inadequacy, self-doubt, loneliness, humiliation,
frustration, hurt, depression, embar- rassment, heightened
performance anxiety, hopelessness, interper- sonal
alienation, and dread of talking about sex.
The woman may at first feel supportive and sympathetic
and offer encouraging and affirming responses, but with
chronic avoid- ance by the man, she may feel lonely,
emotionally abandoned, resentful that he ignores the issue
(by not talking about it and not seeking help), sad, confused,
frustrated, rejected, or alienated. She may begin to dread
sex as an ordeal to be endured.

Changing the Way You Feel about PE

Your goal as a couple is to transform these detrimental
feelings into more constructive and beneficial ones: self-
confidence, warmth, trust, comfort, closeness, calmness,
understanding, love, empathy, mutual acceptance,
specialness, safety, pleasure, playfulness, collabo- ration,
and strength. Beginning to change your cognitions and
behaviors about PE will help transform your feelings
about PE.
The meaning of PE to each partner has substantial
emotional significance. When the meaning of PE is hidden
for you and your partner, or when you are reluctant or
unable to discuss the distinctive meaning that PE has for
you, it is very difficult to share the experience of change
and cooperate. Identifying and understand- ing the meaning
of PE provides an important foundation for you to accept
your dilemma and begin to replace detrimental cognitions,
actions, and feelings with beneficial thoughts, behaviors, and
emotions. Addressing PE as a couple will help you develop
new sexual and relationship meaning, a crucial resource in
overcoming PE. Dealing with PE is an opportunity to deepen
relationship intimacy by cooperating as an intimate team.

E XERCISE : S HARING Y OUR

F EELINGS ABOUT PE
Share with each other what PE has felt like and how it has
affected you. When you learn to have good-enough sex, how
do you want to feel then about sex? About each other?
4 Coping with Premature

Accepting the Complexity of PE

All of the features we have highlighted—physiology,
cognitions, feelings, behaviors, and relationship identity,
cooperation, and inti- macy—intertwine as components of
PE. Be aware of the complexity, but don’t let it overwhelm
you. Trust that you can address the important factors, and
trust that your efforts will be good enough. By being so
thorough, we offer you the opportunity to alleviate your
distress and improve your sexual experience—to enjoy sex
more and have great, intimate sex together!
 4

Assessing Your PE

In this chapter, we will help you answer several important

questions about your PE. How do you know if PE is really
a problem? What are the criteria that differentiate PE from
healthy sexual functioning? If you decide you do have PE,
what kind or type of PE do you have? What are the causes?
How severe is your PE? How do you decide what to do to
resolve it? Will you need professional help?
When you determine the causes and severity of your PE,
you take the most important step on the road to
successfully resolving the problem. You know what you are
dealing with and can set a course of action—individually and
as a couple—to remedy your PE.
We will guide you through this process. You will need to
be determined, patient, and decisive about using all your
resources to help you to succeed. You may need to develop a
more comfortable, cooperative relationship. You may need to
find a wise and affirming physician for a medical evaluation.
You may need to consult with a skilled and knowledgeable
marital and sex therapist. Congratulate yourself for having
the courage to face a difficult problem!

Do You Have PE?

We define PE as the inadvertent and unsatisfying rapid
speed of male ejaculation. From a practical standpoint, you
probably have PE if you are unable to decide or choose
approximately when you want to ejaculate in more cases
than not, and it is distressing to you and your partner.
Consider the following four questions:
5 Coping with Premature

1. Can you choose when to ejaculate most of the

time—in at least four out of five sexual
experiences?
2. Are you able to relax well enough to enjoy sensuous
physi- cal pleasure during lovemaking? Is sex more
than orgasm?
3. Are you able to relax and feel close and connected
during lovemaking?
4. After you and your partner make love, are you both
usually pleased and satisfied with your sexual
experience?
If you are not able to answer yes to these questions, you
are experiencing the common features of PE.

What Type of PE Do You Have?

To understand and remedy PE, it is crucial that you
determine its cause or causes and develop a specific
treatment plan. You learned about the nine causes of PE in
chapter 3. We will help you examine each one so that you
can take comprehensive, constructive action.

Diagnosing Your Type of PE

We will guide you through a step-by-step process to
help you consider all of the causes that could be contributing
to your PE. You want to be inclusive because if you miss a
cause, you will overlook a potentially important factor in
your change plan. Don’t allow yourself to fail by an
oversight. Be conservative. Assume any cause you suspect
may be present until you know otherwise—that is, until you
can rule it out as a factor.

Overview of PE Types
The PE diagnostic process leads you first through those
types that are lifelong and then those that are acquired.
Three types (neurologic system, psychological system, and
psychosexual skills deficit) are considered when PE is
lifelong, while six types (physical illness, physical injury,
drug side-effect, psychological distress, rela- tionship
distress, and mixed) are considered when PE is acquired.
The most common types of PE are neurologic system and
psycho- sexual skills deficit. The next most common are
relationship distress, psychological distress, and PE with
another sexual dysfunction (usu- ally erectile dysfunction).
Occasionally we see physical illness PE (usually caused by
prostate infection). It is rare to see psychological system PE,
physical injury PE, or drug side-effect PE.
 Assessing Your 5

Your Personal Diagnostic Team

It is best to review the diagnostic decision-tree
sequence with your partner so that you have a more
comprehensive picture. Going through this together will be
very useful later as you work as a team to resolve your PE.
It is wise to have a general physical examination with
your family physician if you suspect a biological cause. Take
the lead and ask your doctor to look for physical causes of
your PE, especially focusing on identifying signs of general
illness, chronic physical problems, localized genitourinary
infection or inflammation, and signs of either generalized
neurologic disease or localized sensory deficits that could
cause or contribute to your PE.

E XERCISE : D IAGNOSING Y OUR

T YPE OF PE
As you follow these nine steps, note your answers on the PE
Diagnostic Summary Sheet at the end of this chapter. Do not
conclude that the first cause of PE is the only cause.
Continue through each of the nine steps in order to
determine all of the possible causes or manifestations.

Step 1: Do You Have Neurologic System PE?

Ye No Has PE occurred all your life?
s
Ye No Has PE occurred in all sexual situations
s (with different partners, during
masturbation)?
Ye No Do you think that your penis has a
s physiological hypersensitivity; that is, does
your penis feel supersensitive?

Ye No Does your ejaculation seem to be an

s unconscious reflex, an automatic reaction
like an eye blink?
Ye No Are you confident that you do not have a
s serious, chronic psychological problem?
If you answered yes to most of these, you may have
neurologic system PE.
Actually, it is not easy to conclusively diagnose
neurologic sys- tem PE. There are several simple
neurological examinations your physician or a neurologist
may use, as well as some more involved tests like
bulbocavernosus reflex (BCR) testing. Until you see a
doctor, you usually will have to make an educated guess
about the likelihood that you have neurologic system PE.
5 Coping with Premature

Step 2: Do You Have Psychological System PE?

Yes No Has PE occurred all your life?
Yes No Has PE occurred in all sexual situations?
Yes No Have you been diagnosed with—or do you
think you have—a chronic, psychological
character pattern or unrelenting problem
such as obsessive- compulsive disorder,
chronic depression, generalized anxiety
disorder, or a personality disorder such as
dependent personality?
Yes No Have you taken a formal psychological test
that suggests you have a chronic
psychological problem?
If you answered yes to the first two questions and at
least one other, you may have psychological system PE.
While psychological system PE is rare, it is important to
consider this because if you do not address the underlying
cause, your efforts to remedy PE will be frustratingly
unsuccessful. Careful evaluation will help sort out to what
extent the psychological prob- lem must be treated in
order to resolve your PE.

Step 3: Do You Have Psychosexual Skills Deficit PE?

Yes No Has PE occurred all your life?
Yes No Has PE occurred in almost all situations,
especially with a partner?
Yes No Do you focus your sexual attention almost
exclusively on your partner—her body,
actions, and sexual responses?
Yes No Are you so mentally distracted that you are
unable to physically relax during sex or
unable to focus on the pleasure of your own
bodily sensations of arousal? If you have
learned arousal pacing strategies such as
stop-start pacing, do you find them difficult
to use?
Yes No Are you unaware of your body’s pelvic
muscles and how to use them for
ejaculatory control?
Yes No Do you feel confused about your sexual
response and perplexed about how to
regulate your sexual arousal?
Yes No Do you feel shy about asking your partner
for what you want during sex?
 Assessing Your 5

Yes No Do you initiate and anxiously pursue sex

with highly arousing activities such as oral
sex or immediate intercourse rather than
beginning slowly with relaxed kissing and
light massaging?
If you answered yes to most of these, you may have
psycho- sexual skills deficit PE.
Our program will be especially useful to you. We’ll
teach you skills in managing your body during sexual
arousal, regulating your level of arousal, and cooperating
with your partner.

Step 4: Do You Have Physical Illness PE?

Ye No Has your PE been acquired (developed after
s a period when you had adequate ejaculatory
control and choice)?

Ye No Does your PE occur in all situations?

s
Ye No Has it been more than a year since you
s have had a general physical examination by
your doctor which included a complete
blood count and
a prostate examination?
Ye No Do you have a family history of endocrine,
s blood, or neurologic irregularities (for
example, multiple sclerosis)?

Ye No Did you or your partner contract a sexually

s transmitted disease recently?

Ye No Have you had, or do you have, a physical

s illness (such as prostatitis, neuritis, high
blood pressure, or epilepsy) known to cause
PE?
If you answered yes to the first two questions and at
least one other, you may have physical illness PE.
You will need thorough evaluation by a physician to
determine what condition might be causing or contributing
to your PE. The most common illnesses that cause PE are
prostatitis (which can lin- ger in a mild form for years
without any obvious or clear symptoms except for PE) and
sexually transmitted diseases (for example, chlamydia or
gonorrhea).

Step 5: Do You Have Physical Injury PE?

Yes No Has your PE been acquired?
Yes No Does your PE occur in all situations?
5 Coping with Premature

Yes No Has there been a physical injury, spinal

injury, pelvic surgery or trauma, or
neurologic trauma that coincided with or was
followed some time later
by PE?
If you answered yes to all of these, you may have
physical injury PE.
If you suspect an injury may have caused your PE,
consult with your family physician, who will review your
medical history and recommend further testing.

Step 6: Do You Have Drug Side-Effect PE?

Yes No Has your PE been acquired?
Yes No Does your PE occur in all situations?
Yes No Have you recently stopped taking
trifluoperazine (Novoflurazine, Solazine,
Stelazine, Suprazine, or Terfluzine) or any
opiate (for example, morphine)?
Yes No Are you taking a medication known to cause
PE: Norpramin (desipramine), or a cold
medication containing a form of ephedrine or
pseudoephedrine (Sudafed, Actifed, Comtrex,
Dristan, Sinutab,
Robitussin, Triaminic, Broncholate, or Dimetane-DC)?
If you answered yes to the first two questions and at
least one other, you may have drug side-effect PE.
If you have recently discontinued one of the
tranquilizers men- tioned above or any opiate, PE is a
common reaction. Allowing time for the body to readjust
usually clears up the PE. If the PE lasts more than six to
eight weeks, you should consider what else may be caus- ing
or maintaining your PE. If you suspect that your PE is
caused by a medication you’re currently taking, talk with
your doctor about your medication dosage or options.

Step 7: Do You Have Psychological Distress PE?

Yes No Has your PE been acquired?
Yes No Does your PE occur in all situations?
Yes No Are you experiencing significant
psychological distress such as depression,
anxiety, grieving, career stress, or parenting
problems? Have you recently gone through
a major life transition such as a career
change, moving your residence, the
birth of your child, or sudden success?
 Assessing Your 5

Yes No Have you taken an objective psychological

test that verifies you are experiencing
psychological stress?
If you answered yes to the first two questions and at
least one other, you may have psychological distress PE.
The critical difference between psychological system PE
and psychological distress PE is its source and severity.
Acquired psy- chological distress PE is a reaction to life
events and is usually easier to treat.

Step 8: Do You Have Relationship Distress PE?

Ye No Has your PE been acquired?
s
Ye No Does PE occur only with your partner?
s
Ye No Has your partner recently expressed
s dissatisfaction with your general relationship?

Ye No Are you currently experiencing relationship

s distress such as poor communication, a
deficit in emotional empathy, painful
disagreements (fighting), or unresolved
conflicts?
Ye No Have you recently taken an objective
s relationship test that suggests relationship
distress?
Ye No Have you thought recently that marital or
s relationship therapy might be helpful?
If you answered yes to the first two questions and at
least one other, you may have relationship distress PE.
Relationship distress PE is usually distinguished by
acquired onset and situational occurrence in partner sex. In
short, relationship deficiencies undermine the mutual
emotional acceptance that is important to healthy sexual
functioning.

Step 9: Do You Have PE with Another Sexual

Dysfunction (Mixed PE)?
Yes No In addition to PE, do you experience
another
sexual problem such as erectile
dysfunction, inhibited sexual desire, or
pain in your penis during intercourse? Do
you sometimes ejaculate without an
erection?
Yes No Does this additional sexual dysfunction
occur occasionally, frequently, or always?
 5 Coping with Premature

If you answered yes to both of these, you may have PE

with another sexual dysfunction (mixed PE).
It is normal to have sexual difficulties on occasion, but
when this occurs regularly it represents a sexual
dysfunction. Successful treatment of the other sexual
problem can help resolve the PE.

How Severe Is Your PE?

Determining the severity of your PE will help you gain
perspective on how challenging your PE is, how diligent you
will need to be in addressing it, and the extent to which you
could benefit from profes- sional consultation. Take a
moment to complete the Premature Ejacu- lation Severity
Index (PESI). Make a copy and ask your partner to also
complete the PESI. Although she will not know answers to
some of the questions, her impressions of the severity of
your PE can be very helpful.

E XERCISE : P REMATURE E JACULATION

S EVERITY I NDEX (PESI)
Circle the number that indicates what you typically
experience for the questions below.

1. How long has premature or rapid ejaculation been a

problem for you?
10 9 8 7 6 5 4 3 2 1 0
lifelong intermittent recent
(off and on) or new
problem

2. In what percent of all sex acts are you unable to choose

when to ejaculate?
10 9 8 7 6 5 4 3 2 1 0
100 90 80% 70% 60% 50% 40 30 20 10% 0%
% % % % %

3. When do you usually ejaculate?

1 9 8 7 6 5 4 3 2 1 0
0
before at shortly After
penetratio penetratio after some
n n penetratio intercour
n se
 Assessing Your 5

4. If you can have intercourse, how long is it before you

typically ejaculate?
10 9 8 7 6 5 4 3 2 1 0
not able 15 sec 30 sec 1 min 2 min 3 min 4 min 5 min 10 min 15 min
more to enter

5. Rate the intensity or vigor of physical stimulation at the

time of ejaculation.
10 9 8 7 6 5 4 3 2 1 0
very mild, very
little, intense,
or slow vigor-
ous,
or fast

6.How difficult is it for you to control or choose when you

ejaculate? 10 9 8 7 6 5 4 3 2
1 0
extremely extremely
difficult easy to
to control control

7.How upset is your sexual partner by your premature

ejaculation? 10 9 8 7 6 5 4 3 2
1 0
extremely very
troubled calm

8. How upset are you by your premature ejaculation?

10 9 8 7 6 5 4 3 2 1 0
extremely very
troubled calm

9. How much has your premature ejaculation affected

your life in general?
10 9 8 7 6 5 4 3 2 1 0
major no
impact significant
(for example, effect
ruined relationship)

10.How often when you have sex do you also have desire
or erec- tion problems?
10 9 8 7 6 5 4 3 2 1 0
100% 90% 80% 70 60 50% 40 30 20 10% 0%
% % % % %
5 Coping with Premature

Scoring the PESI

To determine your severity index, add your responses
to items 1 through 10.
Total score:
Now enter your total score in the appropriate category
below to indicate the severity of your PE.

0–20 Very mild severity

20–40 Mild severity

40–60 Moderate severity

60–80 High severity

80–100 Extreme severity

The lower your severity score, the more likely you

are to be able to successfully resolve your PE. The more
severe your PE is, the harder it will be to remedy and the
more determined and disciplined you and your partner will
need to be. If your case is of moderate severity, you have a
good chance of addressing PE successfully through the
techniques in this book, but you will need to invest a good
amount of personal and relationship energy. If your PESI
score indicates high or extreme severity, it will be difficult to
resolve PE on your own, and it is very likely you would
benefit from the coaching and support of a trained marital
and sex therapist.

Summarizing What You Know

about Your PE
At each step in the Diagnosing Your Type of PE exercise, you
recorded your impression about what types of PE you may
have on the PE Diagnostic Summary Sheet.
Now that you have completed the summary, review with
your partner your findings on the causes or effects of your
PE. What have you learned? What will you need to do to
address PE together? What does your PESI score tell you
about how difficult it will be to resolve your PE?
 Assessing Your 5

E XERCISE : PE D IAGNOSTIC
S UMMARY S HEET
As you work through the diagnostic exercise in this
chapter, mark the types of PE you think you may have.
Where applicable, list the specific cause you suspect.
Neurologic system PE
Psychological system PE
(what condition? )
Psychosexual skills deficit PE
Physical illness PE
(what disease? )
Physical injury PE
(what injury? )
Drug side-effect PE
(what medication or drug? )
Psychological distress PE
(what distress? )
Relationship distress PE
(what distress? )
PE with another sexual dysfunction (mixed PE)
(what other dysfunction? )

Your summary sheet offers you a comprehensive view of

what areas you’ll need to address in your action plan to
resolve PE. If you think you may have a physiological or
mixed type of PE, a medical checkup may help you confirm
this. If you think you may have a psychological or mixed type
of PE, a psychological consultation may help you confirm
this.
In the following chapters, we will explain the different
treat- ments and guide you to success. Treatments for
physically based PE (neurologic system, physical illness,
physical injury, or drug side- effect PE) are described in
chapter 6. Treatments for psychologically based PE
(psychological system, psychological distress, or rela-
tionship distress PE) are described in chapter 7.
Treatments for
6 Coping with Premature

psychosexual skills deficit PE—and for repairing individual

and rela- tionship damage from PE caused by other factors—
is described in chapter 8. Mixed PE can be complicated and
may require both physi- cal and psychological treatments. If
you are sure that your other sexual dysfunction (e.g., ED) is
compensation for or overreaction to your PE, completing the
exercises in the chapters that address the possible causes of
your PE can be beneficial. Otherwise, consultation with your
medical doctor and a professional marital and sex thera- pist
is sensible.
Now that you’ve identified all the elements
contributing to your PE, you can confidently engage in
addressing these elements— and succeed!
 5

Planning Your Treatment

and Preparing for Action

Michael and Rebecca realized they would need to stay

disciplined and focused if they were to master ejaculatory
control. Michael had a number of factors causing and
influencing his PE, and Rebecca’s history of childhood sexual
abuse and disappointing relationships made her sexual
desire fragile. Fortunately, both were motivated to make
sexuality a positive component of their marital bond.
Michael and Rebecca were successful in learning
ejaculatory control because they understood the importance
of integrating the cognitive, behavioral, emotional, and
interpersonal dimensions of sexuality. It was crucial for
Michael and Rebecca to adopt positive sexual attitudes.
Michael was strongly influenced by traditional male
socialization, believing that if he “failed” at intercourse, he
was a failure as a man. Michael actually had high sexual
desire but felt so humiliated by PE that he avoided sex with
Rebecca. Instead, Michael compulsively masturbated, which
caused him to feel guilty and Rebecca to feel rejected.
Gradually, Michael and Rebecca learned to acknowledge the
positive functions of sexuality. Especially impor- tant for
Rebecca was to accept that the essence of sexuality is giving
and receiving pleasure-oriented touching. This was totally
different than her childhood experiences with abusive
sexuality.
Michael focused on learning the sensual self-
entrancement and arousal pacing techniques during partner
sex (we’ll teach these in chapter 8). Together, they adopted
an antiavoidance approach. Michael realized that to learn
ejaculatory control, he needed to act, not agonize or
apologize.
6 Coping with Premature

Michael and Rebecca developed a warm sexuality which

was mutual, pleasurable, and intimate. Michael viewed
Rebecca as his intimate sexual friend and ally in learning
ejaculatory control. With time, they achieved the
fundamental aim of ejaculatory control: increasing their
individual sexual pleasure, increasing each other’s pleasure,
and enhancing their relationship by prolonging and enjoy-
ing sexual arousal. They focused not on perfect sexual
performance but on sharing sexual pleasure.
In this chapter, we’ll help you follow a similar path to
success. You will work with your partner to develop a
treatment plan for your PE. You will learn how to prepare
yourself and your relation- ship—cognitively, behaviorally,
and emotionally—for healing from PE. To help you think
differently about PE, we’ll discuss the multiple purposes of
sex, the three basic types of sexual arousal, and their
relevance to learning ejaculatory control.

Developing Your Treatment Plan

Based on the causes and severity of your PE, which you
determined in chapter 4, you now can decide on strategies
to change it. Chapters 6, 7, and 8 will help you through
the steps to take in each of the major areas: physiological,
psychological, and relational. This section will help you
decide where to focus your efforts.

Strategies for Physically Caused PE

If you indicated the possibility of physically caused PE
(neuro- logic system PE, physical illness PE, physical
injury PE, or drug side-effect PE), focus on the strategies in
chapter 6. If you think you may have a physiological or
mixed type of PE, a medical checkup may help you confirm
your type.

Strategies for Psychological and Relational PE

If you indicated the possibility of psychological system
PE, psychological distress PE, or relationship distress PE,
carefully read chapter 7. If you think you may have a
psychological or mixed type of PE, a psychological
evaluation may help confirm your type and develop a
treatment strategy. There are some additional self-help
steps you may want to consider.
●
Consult a well-respected book about the type of
distress you suspect.
 Planning Your Treatment and Preparing for 6

●
Seek feedback from your partner or someone else you
trust.
●
If you suspect psychological system PE, consider
what you know about your family history (for
example, “Grandpa was always depressed”).
●
Search for psychology information and self-tests at
trust- worthy Internet sites (see the Resources
section).

Strategies for Psychosexual Skills Deficit PE

If you indicated the possibility of psychosexual skills
deficit PE, focus on chapter 8.

Strategies for Coping with the Detrimental Effects of PE

Regardless of the cause of your PE, the strategies in
chapters 7, 8, 9, and 10 can help you heal the detrimental
effects of PE on your well-being and the well-being of your
relationship.

Preparing Yourself for

the Work Ahead
Unless you have a simple, biologically caused type of PE that
can be solved with direct medical treatment, you will need to
learn new skills. The skills have cognitive, behavioral,
emotional, and relational components. They are designed to
help you affirm yourself, relax your body, focus on your
physical sensations, increase your pleasure, and deepen
your relationship closeness as well as control ejaculation.
Your efforts, step-by-step, will pay off with wonderful
feelings of satisfaction with yourself, your partner, and your
love- making. Yes, these skills are an effort; there is no easy
fix. But it will be worth it.
Here are the key points to remember:
●
You have to pursue all of the dimensions of your PE.
●
Remember that you are a complete person with
thoughts, feelings, and behaviors.
●
Satisfying sex is a skill like any other physical or
emotional activity you have come to enjoy.
6 Coping with Premature

●
As you approach learning the skills to manage PE,
keep your “relationship” perspective. Don’t lose
sight of the big picture.
●
Understand clearly your objectives: keep in mind
what you are trying to learn at each step.
●
Patiently practice the specific skills for success and
cooperate with your partner.
●
Closeness and satisfaction is the ultimate goal.

Is Sex a Skill?
One of the common myths about sex is that it is
supposed to be “natural” or automatic, like eating and
sleeping. Reproductive sex does appear to be biologically
natural. But the other functions of sex—heightened
pleasure, personal self-esteem, and relationship intimacy—
are achieved by learning psychosexual skills.
Think of any skill that brings satisfaction, especially a
physical activity: dancing, skiing, swimming, climbing, hang
gliding, para- chuting, even running. Marathon runners don’t
just go out and do it. It takes discipline, concentration,
psychological preparation, physical conditioning, and
learning pacing strategies. So if you want to become a
“marathoner” during sex, you’ll need some mental and
physical preparation—some “training.” Yes, biological sex is
basically natu- ral—penis goes into vagina—but to really
enjoy emotionally intimate sex takes attention, knowledge,
and practice. Yes, it is annoying to have to give such careful
attention to something you wish would just “flow.” But if you
have PE, managing arousal takes training. That is a fact.
A skill, whether cognitive, emotional, behavioral, or
interper- sonal, is the learned ability to perform the task well
and with some ease. Skills are developed through practice
(repetition), persistence (discipline), and patience. Can you
remember learning new skills as a child? Learning to ride a
bike, for example, required a certain degree of persistence
and self-regulation of the fear of falling down. You had to try
time after time until it became “natural.” You proba- bly
tipped over, skinned a knee now and then, but didn’t give
up. Managing PE means using practice, persistence, and
patience to learn cognitive, emotional, behavioral, and
relational skills.
 Planning Your Treatment and Preparing for 6

Cognitive Preparation
The most important sex organ in your body is between your
ears: your mind. During the skills training, you will want to
be a kind but strong “gatekeeper,” noticing what you are
thinking and where your attention is focused. Negative,
pessimistic, self-defeating, or distract- ing thoughts will not
help. By focusing on the opportunity of each step and
exercise, you will do well. It is essential that you learn to
focus your attention and discipline your mind.
If you think that the training in this book will be too
difficult, reassure yourself that these skills are very
manageable because you do them in increments, not all at
once. Accept that you might not feel optimistic now; after all,
you have tried so hard for so long without real success. It is
understandable that you fear that our comprehen- sive
approach might not work. That’s fine. The details may look
foreboding, but optimism is the caboose on the train. Wait
for it. But in the meantime, prepare yourself mentally to
relax and engage in the process.

Have a Positive Attitude toward Sex and a Deep

Commitment to Mutual Sexual Health
The first step is to consciously affirm the positive value
of healthy, physical, bodily sexuality. Sex is good.
Pleasure is good. You do not have to numb pleasure to
learn ejaculatory control.

Take Personal Responsibility for Pursuing Sexual Growth

Take personal responsibility for your sexual
responsiveness. Be sexually responsible for yourself—be
accountable. There are individ- ual skills that the man is
responsible for learning, skills his partner is responsible for
learning, and skills the couple learns cooperatively. Some of
the more effective skills are neither commonsense nor
attainable without diligent effort. Being responsible means
intention- ally engaging in the change steps.

Prepare Yourself to Relax

The treatment steps will help you work through stresses
that undermine the physiological relaxation essential to
healthy sexuality. Realistic expectations based on accurate
knowledge of sexual func- tioning are reassuring; they are
the cognitive precursors of physio- logical relaxation.
6 Coping with Premature

Understanding the multiple purposes of sex can help

you main- tain realistic expectations and contribute to your
and your partner’s motivation to be flexible, patient, and
cooperative.

The Four Purposes of Sex

Why do you have sex? If you are not sure why you are
having sex, you are more likely to have a problem.
Automatic sex may procreate, but it commonly falls short
in the intimacy department.
Sexual science suggests that there are four purposes
or functions for sex.
Reproduction. Procreation is the “natural” or biological
function of sex.
Physical pleasure. Sensual enjoyment and physical
pleasure is a basic function of sex, especially in long-term,
satisfying sexual relationships.
Self-esteem. Individuals seek enhancement of their
psychological self- esteem through sex and pursue feelings
of self-worth, confidence, and pride in being a sexual
person.
Relationship benefits. The interpersonal function of sex is
to foster love, intimacy, affection, joy, closeness, and
couple satisfaction.
In healthy relationships, sex has multiple positive
purposes. In dysfunctional relationships, the purposes are
distorted or negative: manipulation, destructive control, or
hurt. Yet even in healthy rela- tionships, a single reason for
sex can eclipse all the others—for instance, during infertility
protocols when sex must occur at a partic- ular time and
under particular circumstances—and the pressures of one-
dimensional sex undermine other benefits like pleasure and
inti- macy and can cause PE, erectile dysfunction, or
inhibited sexual desire.

PE and the Purposes of Sex

PE interferes with the positive functions of sex, bringing
dis- tress to both the man and his partner. PE becomes
intensely stressful for the man as he becomes preoccupied
with pleasing his partner, trying to delay ejaculation in
order to prevent the frustration and hurt of a disrupted
sexual experience. While he may be able to impregnate, he
finds very limited sensual or physical pleasure in sex, suffers
a loss of self-esteem, and feels tremendous shame and frus-
tration about being the source of hurt and damage in their
intimate relationship. His partner experiences frustration
with each of the purposes of sex as well: a diminution of
physical pleasure, loss of
 Planning Your Treatment and Preparing for 6

self-esteem, and confusing feelings of relational hurt and

abandon- ment. As long as the man is focused solely on
performance and thus experiences the outcome of sex to be
negative, he will suffer perfor- mance anxiety that
exacerbates and reinforces PE. If you are to resolve PE,
you must think about sex in terms of pleasure, self-
esteem, and intimacy as well as good-enough ejaculatory
control.

The Styles of Sexual Arousal

Learning that your partner may have different reasons
for having sex and different ways of getting aroused helps
couples appreciate and accept their differences. It also helps
you feel respect and acceptance from the other as you
mutually pursue satisfying sex. This is an important aspect
of how you think about sex.
In our experience, men with PE invariably and
exclusively use arousal strategies where the focus of erotic
attention is on the part- ner. To try to slow ejaculation,
they use “spectatoring” (detached self-observation) or other
distraction techniques. This diverts your focus from your
own body and your own sensual experience, and
subsequently diminishes your ability to manage your sexual
arousal. In addition, men with PE initiate and pursue sex
with highly arous- ing activity (we call this sexual drag
racing), rather than beginning calmly and then gradually
increasing stimulation. You may fail to connect with your
sensuality or even try to dissociate from physical sensations
during sexual activity. You may find it difficult to enjoy the
physical sensations in your whole body during arousal.
Let’s take a look at the range of sexual arousal styles.
We have adapted Mosher’s (1980) suggestions and
distinguished three basic styles of arousal.
Sensual self-entrancement occurs through focusing on
your own physical sensations and sensual pleasure. Your
attention is focused primarily on your own body.
Partner interaction occurs through focusing on your
partner: her body, her responses, and the “sexy” or
“romantic” interaction with her. Your attention is outside
your body.
Role enactment occurs through your private imagination
or fantasy, role-playing with your partner, or acting out
feelings or fantasies. Your attention is outside your body and
more broadly focused than in partner interaction arousal.
These styles are differentiated by where you focus your
atten- tion. Each style leads to a particular kind of
behavior. For example,
6 Coping with Premature

the person who pursues arousal by partner interaction is

active, eyes open, focused on the interaction, looking at the
partner, talkative (engaging in romantic or “sweet” talk),
and energetic. This is the sexual style commonly portrayed
on television and in movies—pas- sionate and impulsive. The
person is turned on by focusing attention outside himself,
enjoying the partner, and getting carried away in passion
and eroticism.
On the other hand, the individual pursuing arousal
primarily by sensual self-entrancement immerses in his
sensory experience and closes his eyes, goes within,
becomes quiet, and may look detached and passive. Routine,
sameness, and stylized touch help him to get turned on.
The person aroused by role enactment enjoys sexual
variety and experimentation such as the partner dressing in
sexy lingerie, role-playing being “tough” or “hard to get,”
acting out a scene from a movie or fantasy, having sex in
new places like at a hotel or outdoors, or using “toys” like
massage oil or a vibrator or dildo. By trying new things, the
person finds excitement and arousal through sexual
playfulness, freedom, and uniqueness. As with partner inter-
action arousal, the focus is on scenarios outside your
body.
While individuals usually have a preference for one
style, every person has the capacity for arousal by each style
and may use them interchangeably. For example, you may
begin lovemaking with play- ful teasing (role enactment),
change to enjoying touching your part- ner and seeing her
naked body (partner interaction), and then switch to
focusing on the sensations you feel in your own body while
being touched (entrancement). Your use of the three styles
can vary over time. Individuals and couples may go through
developmental stages. For example, early in a couple’s
sexual life, partner interaction arousal is common, giving
way to sensual self-entrancement arousal and a more sedate
sexuality, then enlivened with role enactment or a
resurgence of partner interaction arousal. This process can
explain why couples who have mild cases of PE early in their
relationship “grow out of it” with relaxation and routine
induced by familiarity. Some couples pursue a different type
of arousal from one sexual meeting to the next: Tuesday,
self-entrancement “because I was tired”; Saturday, partner
interaction arousal “because I was really turned on by my
partner.”

Understanding the Styles for Acceptance and Flexibility

Sexual partners who do not realize that there are
different kinds of arousal may misinterpret their partner’s
behavior as hurtful and take it personally. For example, the
primarily self-entrancement- focused woman having sex with
a man aroused by partner interaction
 Planning Your Treatment and Preparing for 6

finds his lovemaking efforts (the looking, talking, heavy

breathing, interacting, being expressive and passionate)
distracting and wonders why he is disturbing her focus and
working against her arousal. This man, on the other hand,
might interpret his lover’s self-entrancement style—quiet
and inward-focused—as disinterested, aloof, bored, or even
rejecting. The potential for misunderstanding and hurt is
evident.
You need to understand your partner’s sexual arousal
style to interpret each other’s behavior correctly. This
illustrates the impor- tance of sharing your sexual feelings,
cooperating, and collaborating in pleasure. This mutual
understanding is crucial to your success in the work ahead.

Be a Skeptic at First
What if you doubt that you can overcome PE? It’s okay
to have a hesitant or doubtful attitude. This is not to
encourage you to be pessimistic, but rather to remind you
that you can’t force the change you seek. You probably have
already tried this, and it has failed you. You don’t have to
believe in the skills to benefit from them. So it’s fine to be a
doubting Thomas or an honorary Missourian, adopting the
state motto: Show me. You do not have to make the skills
work; let the skills show you the way. All you have to do
is relax and focus. Just show up, so to speak, and do
each step well enough.
Here are the key points to remember as you prepare
yourself mentally:
●
Learn a positive attitude toward your body, sex, and
love- making, with a conscious commitment to mutual
sexual satisfaction.
●
Take responsibility for your improvement.
●
Operate from accurate knowledge and realistic
expectations of lovemaking.
●
Realize that there are multiple purposes for sex.
Don’t be trapped in a rigid performance focus.
●
Be aware of the styles of arousal.
●
Be a skeptic! Free yourself by adopting a show-me
attitude toward the steps.
●
Remember that what and how you think directly
influences how you feel and what you do.
7 Coping with Premature

Emotional Preparation
You probably feel burdened by your PE, but you can
begin to let that feeling subside. You are a complete person,
and by restruc- turing the way you think about yourself as a
sexual person and learning to change how you function, you
will come to feel better about yourself and your partner.
The way you think and what you do influences how you
feel.

Accept Your Honest Feelings about PE

Prepare yourself for the steps ahead by accepting that
you may have felt any of a long list of detrimental feelings:
discouragement, hurt, frustration, humiliation, anger,
confusion, apprehension, embarrassment, shame, guilt,
depression, anxiety, worry, sadness, bitterness. These
feelings are reminding you that you are not satis- fied with
the way things are. It is time to change. Help prepare your-
self for change by accepting these negative feelings.
Acceptance of your honest emotional experience is an
essential preparation for growth. Having feelings does not
mean you must act on them or feel controlled by them. Our
change program will help create a comfort zone or safe
harbor where the emotional hurts are manageable.
During the learning experiences in the steps ahead, be
sure to focus on your physical sensations. The sensual self-
entrancement arousal training, in particular, will help you
accept and calm your feelings. By focusing on your
sensations, you will help yourself to stop worrying about PE
and feeling bad about sex. Calm, conscien- tious focus on
your own sensations will become your ally.

Distinguish Your Feelings from Your Behaviors

Make the distinction between being aware of your
emotions (feeling) and expressing your emotions (behavior).
Recognize the importance of owning your emotions, but
realize there are risks and harm in expressing unbridled
negative feelings. Certainly do not express destructive
feelings as you work on the exercises together. Internally
soothe your negative feelings and remember that you can
choose to develop positive feelings through new behaviors.
Expressing negative feelings will only trap you in the past,
and this will be very discouraging for you both. If it seems
impossible to manage your feelings, this is an indication that
you and your partner could benefit from marital or sex
therapy.
Here are the key points to remember as you prepare
yourself emotionally:
●
Your feelings are important. Your sexual feelings
are a big part of the glue that holds your
relationship together.
 Planning Your Treatment and Preparing for 7

Feelings flow from how you are thinking and what

you are doing.
●
Don’t let old negative feelings run your life. Accept
those feelings, but don’t let them interfere with new
learning and behaviors.
●
Focus on your physical sensations to stop your mind
from worrying about PE.
●
Do not express unbridled anger, frustration, or
resentment during your sexual work together.
Acknowledge and inter- nally calm these emotions
and give yourself a chance to grow.

Behavioral Preparation
Prepare yourself for the behavioral tasks by reminding
yourself of the need for self-discipline: regulation of your
thoughts, feelings, behaviors, and interactions. Yes, it is a
bummer that you have to work at this, but good things are
built by effort. It is a good idea to schedule your practice of
the steps. Set aside the time and make each step a priority.
It will be hard at times, but it is necessary. Suck it up!
Be sure to consider the environment in which you’ll be
doing your skills learning. Many use the privacy of the
bedroom, although any secure, private, comfortable place
is fine. Make sure it is free from interruptions, since the
goal is to create a safe place for relaxation and undivided
attention and focus.

Cultivate Self-Discipline
Doing the steps requires disciplined concentration on
the plea- sure in your body, a steady and dedicated
commitment and determi- nation to do the exercises day in,
day out, over a number of weeks to develop your skills.

Dedicate Yourself to Physical Relaxation

Learning detailed, physiologically focused relaxation
tech- niques is essential to ejaculatory control. It is
counterintuitive, but the body performs better when relaxed.
Most men (and women) just cannot believe that relaxation is
essential for good sexual function- ing. It is not common
sense. You can take our word for it, or you can think about
this: Medications like Viagra help many men who have
erectile dysfunction, including men who also have PE. How
does Viagra work? Technically, this pill facilitates a chemical
process unique to enzymes in the penis that ultimately
relaxes the muscles
7 Coping with Premature

surrounding the microscopic arteries, which in turn dilates

the arter- ies causing blood to engorge the penis, and voilà:
an erection! The point is that even artificially induced
relaxation brings about an erection.
The mechanism for ejaculation is not a direct one, but
rather a psychological one. Men who ejaculate quickly
because they worry about maintaining a sufficient erection,
when reassured by Viagra, are thought to relax more, to not
watch themselves so anxiously, and because of the general
relaxation, also last longer. Think about it, men:
Physiological relaxation helps sexual functioning.

Do the Steps in Order

The skills development exercises in chapters 7 and 8
should be followed in order. Working ahead or skipping
steps would be like jumping into a swimming pool before you
know how to swim! We know you want to get to the good
stuff. But patience is your friend. Moving too quickly will
undermine your ability to relax, which is essential to
progress. Take one step at a time, one exercise at a time,
one stage at a time. Remember the Chinese proverb, A
journey of one thousand miles begins with a single step.

Just Be Good Enough

It is essential that you understand what you are
trying to do and that you train yourself sufficiently to bring
about changes in the way you make love. The painful
reality is that the way you have been approaching sex has
not worked. This means you must work hard enough to bring
about change, but you only need to learn and do the skills
well enough. Do not pressure yourself to be perfect. In fact,
it is important that you do not work too hard, because to
succeed, you must relax your mind and body. Striving for
perfection produces performance pressure and undermines
your relaxation. So we encourage you to practice the
principle of just being good enough.

Learn Sensual Self-Entrancement Arousal

Learning to trust sexual arousal by focusing on
sensations in your own body is essential to ejaculatory
control. Men usually don’t believe this is possible, let alone
normal. You will find erections effortless and ejaculatory
control easier when you learn to base your arousal in
sensual self-entrancement. During the skills work in chapter
8, you will recognize that self-entrancement arousal is built
into the steps and encourages you to relax physically while
sexually aroused. You will truly find this arousal remarkable
when you begin
 Planning Your Treatment and Preparing for 7

to integrate it with the other steps to ejaculatory control and

building intimacy.
Here are some key points to remember about behavior:
●
Realize you must discipline yourself—regulate
your thoughts, feelings, and actions. Yes, it
is difficult.
●
Learn to physically relax during arousal. It is an
essential skill.
●
Do the steps in the proper sequence.
●
Do not push to be perfect. Just be good enough!
●
Learn sensual self-entrancement sexual arousal.

Interpersonal Preparation
You want to “fix” your penis and your ejaculation speed,
yet remember that the most important goal and predictor of
success— and the greatest reward—is your relationship
intimacy. If you are working within a self-defeating
environment, you will not succeed. On the other hand, if you
have addressed the relationship hurt and divisiveness that
have resulted from the PE and found relationship
forgiveness and healing, your intimate relationship will help
you to succeed at PE management. Your relationship is the
“system” or environment for your sexual growth. Be careful
not to overlook the essential importance of mutual support
and acceptance. Keep your perspective. Remember that your
PE is but one aspect of your overall relationship.

Sexual Cooperation Is Essential

While you can learn the skills for slowing ejaculation on
your own, it works best to do so with your lover so your
intimate relation- ship is working cooperatively. Cooperation
provides a safe environ- ment for learning the skills and
gives both partners the opportunity to heal from the old
anguish. The process itself invites cooperation and
closeness.
Putting the other person first builds resentments when
it is not reciprocated. When both put the other’s feelings and
happiness first, the emotional benefits can be wonderful.
We call this the “give to get” pleasuring principle.

Prioritize Mutual Emotional Empathy

Emotional empathy (acceptance, affirmation, comfort,
support, understanding) is the glue of intimacy. It is
fundamentally important
7 Coping with Premature

in healthy, satisfying relationships. Above all else, most

individuals look to their marriage for empathy and
emotional comfort.

Forgive Yourself and Your Partner

Forgive yourself and your partner for the hurt and
disappoint- ment—no matter how small or how monumental
—that you’ve expe- rienced around sexuality. This requires a
commitment. If you do not forgive, your emotions will block
your ability to focus on your body’s sensations, to relax
your body, and to learn the skills. What is the shortcut to
forgiveness? Be aware that the hurt was in the past. The
future can feel different. And with your partner? Say you are
sorry and ask for forgiveness and acceptance now.
Here are the key points to remember as you prepare
your relationship for the changes ahead:
●
Relationship intimacy is your ultimate goal and your
ultimate reward.
●
Relationship cooperation is essential.
●
Verbally forgive yourself and your partner for the
past sexual hurt, pain, conflict, disappointment, and
alienation. Do not hold yourself and each other
emotionally hostage for the past.
●
Talk with your partner about your sexual feelings.
This will help generate mutual understanding,
empathy, and accep- tance. This will also help you
develop personal comfort with sex and learn more
about your partner.
●
Keep your perspective. Satisfying sex is rooted in a
healthy relationship.
You may be feeling overwhelmed by the task ahead.
Remember that change is a process, and be willing to learn
as you go. By preparing yourself cognitively, emotionally,
behaviorally, and interpersonally, you give yourself the best
possible chance to succeed in managing PE. Be calm. Be
patient. Be open. Don’t worry about being perfect. Just be
good enough!
 6

Medical, Pharmacologic,
and Physiological
Treatments

PE that originates from a biological cause needs treatment

that addresses the physiological problem. In this chapter we
will discuss the medical treatments and options for the four
kinds of PE with physical or biological causes. If these
problems are a primary factor in your PE, you need to
carefully consider medical and physiological interventions,
or you will face disappointment and frustration in your
attempt to develop ejaculatory control. Remember, you want
to address all the factors involved in your type of PE and
to use all your resources—including medical treatment,
medication, and phys- iological aids—to learn ejaculatory
control.

Addressing the Medical Side of PE

In this chapter you will learn how to determine if you need a
medi- cal evaluation and how to work comfortably with your
physician. Then we will describe the treatments for the
biological types of PE: neurologic system PE, physical illness
PE, physical injury PE, and drug side-effect PE. There are a
number of medications that have the effect of slowing PE, as
well as several other medical options for managing PE. It is
important to consider how to integrate these medical
interventions into your couple sexual relationship.
7 Coping with Premature

How to Determine Whether You Need

a Medical Evaluation
If you noted the possibility of a physical type of PE on
your PE Diagnostic Summary Sheet in chapter 4, it is
important that you discuss the problem with your physician.
Your doctor can not only determine whether your PE could
have a physical cause but also offer a medical or
pharmacological treatment. For example, if you confirm that
you have lifelong neurologic system PE, your doctor can
help you consider in detail the use of medications. Or, if your
PE is acquired, your doctor can examine your prostate to
see whether an infection has caused PE. Your physician
could also be your best professional case manager, referring
you to other trustworthy physi- cians who specialize in
sexual medicine, as well as psychologists, marital therapists,
or sex therapists.

How to Work Comfortably with Your Physician

Talking about your sexual concerns is likely something
you are not very comfortable doing. People talk about sex in
general, but few discuss their own sexuality, especially
sexual difficulties. It is hard for many to believe that nearly
50 percent of adults have sex problems, sexual dysfunction,
or sexual dissatisfaction (Laumann, Paik, and Rosen 1999).
Physicians and other health professionals in general medical
practice rarely recognize existing sexual problems or
dysfunctions in their patients.
Do not fault your doctor, because he or she lives in the
same society with the same discomforts. Most physicians
assume that if sexual concerns are important to you as the
patient, you will initiate discussion about it, while at the
same time you may assume that since your doctor has the
professional training and the ability to help with sexual
problems, he or she will lead the inquiry and discussion.
Unfortunately, these attitudes serve to continue a silent
avoidance of sexual concerns, leaving you to worry privately
without receiving help.
We suggest that you take the lead, because your
physician may not. By raising the subject, you gain a sense
of control over the process. Your leadership can provide
focus.

How to Talk with Your Doctor

Use your own impressions to determine whether your
doctor is likely to be comfortable talking about sexual
concerns. Don’t be
 Medical, Pharmacologic, and Physiological 7

distressed if he or she seems uncomfortable at first, because

most physicians have received very little specific training in
sexual medi- cine. Most doctors very much want to be
helpful and will be willing to sort out the medical aspects
with you.
Here are some suggestions for starting the discussion:
I want to talk to you about a sexual concern I have, but I
am embarrassed.

I’m having a sex problem that I’d like your help with.

I would like to ask you about a sex problem that I’m

having. Do you think you can help me?

Can you refer me to a sexual medicine specialist?

My impression is that you don’t specialize in sexual

concerns, but can you refer me to a doctor who
does?
Depending on your suspicions about what is causing
your PE, you might ask your doctor a specific question:
For the past six months, I’ve noticed that I ejaculate
quickly, and I wonder if I might have a physical
illness that is causing this.

I wonder if I have a prostate infection. Should I have an

exam, or should we do some testing?

I’m reading a book about premature ejaculation, and it

suggests that since it’s been a problem for over a year, I
should talk to you to make sure I don’t have a prostate
infection or some other illness that could cause PE.
You can even take this book along to show your doctor
the section in chapter 4 where we list some of the illnesses
that can cause PE.
Your doctor does not have to be comfortable talking
with patients about sex to be a really good doctor; it just
helps a lot. Your doctor may be waiting for you to ask. Give
him or her a chance to help you.
Thank your doctor for being willing to talk with you
about your sexual concerns or offering you a referral.
Then, as you leave the office, congratulate yourself for
taking the lead and being your own sexual health advocate.
7 Coping with Premature

What’s Involved in a Medical Evaluation

Your general physician (whether an internist or family
practi- tioner), who knows you and your medical history best,
is the likely first choice to discuss your concerns about PE.
You may be referred to an urologist or sexual medicine
specialist for further evaluation. Medical evaluation for PE
typically consists of three steps.

History
Your doctor will talk with you about your experience of
PE. This discussion may include general background, some
basic information about when and how fast you ejaculate,
your personal medical history, a brief sexual history, other
symptoms or aspects of your medical situation, your ideas of
the cause, and how distressed you are. Your doctor is trying
to gain a more comprehensive understanding of your
situation as well as rule out some medical possibilities that
could cause your sexual problem.

Physical Examination
Your doctor will examine your body, focusing on your
genital area, and will check your prostate gland for signs
of infection.

Testing
Some blood and urine tests may also be done to
make sure there is no systemic problem. If your doctor
suspects a prostate infection, he or she may want to take a
sample of the fluid in the prostate to determine the kind of
infection.

Treatments for Neurologic System PE

By far the most common physiological type of PE is caused
by an overly efficient neurological system. In other words,
your ejaculatory reflex is hardwired to go off quickly.
If you think you have neurologic system PE, there are a
number of options for you to consider. Because neurologic
system PE is hard- wired in your body and that hardwiring
cannot be overhauled, we recommend that you try the
psychosexual skills program in chapter
8 first to try to compensate for your overly efficient
neurologic system. If your case is particularly severe (you
have a PESI score above 80 or you often ejaculate before
you can enter your partner’s vagina), then the most
promising medical treatment is medication that acts on the
nervous system to slow ejaculation.
There are international reports (Tullii, Guillaux, et al.
1994; Schapiro 1943) that surgery (severing nerves in the
penis to deaden
 Medical, Pharmacologic, and Physiological 7

sensation or destroying tissue in the prostate) can slow rapid

ejacula- tion. The fact that some men resort to permanent
injury to their bodies to try to resolve PE demonstrates how
profoundly distressing PE can feel. We consider these
treatments inappropriate and unethi- cal because they are
not only intrusive, radical, and unnecessary, but also
irreversible. In addition, we have found that particularly
detailed training in the psychosexual skills we’ll teach in
chapter 8, combined with medication, is helpful for the great
majority of men. We also want to remind you to understand
PE in the larger perspec- tive of intimacy and relationship
cooperation. If you have neurologic system PE that is not
severe, accepting the biological reality and cooperatively
adapting to it may be the most positive resolution.

Pharmacologic Interventions
A variety of antidepressants or antianxiety medications
may neurologically slow down ejaculation, allowing some
men to last two to ten times as long. The benefit may not be
profound—for the man who ejaculates in ten to fifteen
seconds, lasting ten times as long may mean only two
minutes of intercourse—but for the man with chronic and
severe PE, this may be quite satisfying. We recommend that
you consider medication if your PE is exceptionally severe, if
it doesn’t respond to the psychosexual skills approach, or in
conjunction with sex therapy. Some medications are taken
daily, while others are taken several hours before sex.
Using medication is not a sign of weakness but a choice,
and many men find it an important resource in gaining
ejaculatory control. However, for some men, medication use
implies the need to depend on an external resource rather
than their own ability and does not support sexual self-
esteem. Pharmacologic treatment alone is often insufficient
because of the lack of effect in some men, the reluctance of
some men to consistently use prescription medications, or
complicating psychological and relationship factors. There
are also concerns about the unknown effects of long-term
use of medica- tions for PE management.
Medication must be prescribed and monitored by a
physician. Weighing the costs and the benefits of using
medications is part of your decision making as a couple. For
some men, obtaining the desired effect of inhibiting
ejaculation can be a matter of trial and error of different
medications and dosages. New medical treatments for PE
are being developed. Ask your doctor what is currently
available. We strongly advise against self-medication with
alcohol, recreational drugs, or some over-the-counter
remedies, as they have their own obvious risks.
8 Coping with Premature

Antidepressants
The selective serotonin reuptake inhibitor (SSRI)
antidepressants Prozac (fluoxetine), Zoloft (sertraline), Paxil
(paroxetine), Luvox (flu- voxamine), and Effexor (venlafaxine)
are increasingly used to aid men who suffer PE, capitalizing
on a common side-effect of inhibit- ing ejaculation. Studies
and clinical experience confirm that these medications delay
ejaculation in 20 to 60 percent of cases. These drugs
increase the level of serotonin, and higher serotonin levels
are thought to inhibit ejaculation. These medications are
taken daily.
An older class of antidepressants known as tricyclics,
including Anafranil (clomipramine) and Elavil (amitriptyline),
also commonly delay ejaculation. These medications increase
levels of both serotonin and norepinephrine. Anafranil has
been frequently studied and is noted to be very effective in
inhibiting ejaculation when taken two to four hours before
the desired effect, especially for men who are prone to be
“spectators” in the bedroom and are highly anxious about
PE. The tricyclics, however, have more inconvenient side
effects than the SSRIs (for example, dry mouth).

Antianxiety Medications
Antianxiety medicines, if properly prescribed, may also
be useful. A number of medications that are effective in
treating gener- alized anxiety and panic attacks can help
some men slow down ejaculation. These medications include
Librium (chlordiazepoxide), Ativan (lorazepam), Valium
(diazepam), and Xanax (alprazolam). However, the inhibiting
effect of these medications on ejaculation is limited and not
as dramatic as the effect of SSRIs, and they help less than 10
percent of men with PE. These medications are taken one to
four hours before beginning sex.

Anesthetic Creams
Numbing creams have long been used to slow
ejaculation by deadening the sensations in the penis. If you
use these creams, you must then use a condom so that the
cream does not numb your part- ner’s vagina as well. There
are, for convenience, condoms (Detane, Mandelay,
Performax) that you can buy over the counter with an
anesthetic (benzocaine) already packaged inside.
We understand some men feel desperate to slow
ejaculation and believe that they need to use anesthetics. We
believe this is unnecessary and an ill-advised quick fix that
does not really solve the issues of PE and cooperative
lovemaking. To deaden the pleasure in your penis is contrary
to our approach, which is designed to increase your
pleasure, enhance intimacy with your partner, and
 Medical, Pharmacologic, and Physiological 8

teach you to saturate your body with pleasure while you

maintain ejaculatory control.

Combination Treatments
Some physicians experiment with combination
treatments that include a number of medications designed to
overwhelm the neuro- logic system and reduce psychological
anxiety. In severe cases of PE, multiple treatments may be
effective. For example, Viagra may be used to ensure
erection and overcome the fear of erectile dysfunc- tion,
while an anesthetic cream may be applied to numb the penis
and an antidepressant medication may be used to calm and
inhibit ejaculation.

Devices for Premature Ejaculation

In addition to pharmacologic treatments, devices are
sometimes used, although they have not been scientifically
proven to be effective.

Testicular Restraint Device

Some men have found that they can slow ejaculation by
cuffing the testicles in the hand and gently pulling or holding
down. Although not approved for use by the U.S. Food and
Drug Administration, Velcro-type devices that restrain
testicular ascent are available through mail order (often
advertised in erotic magazines) and drugstores.

Penile Rubber Ring Device

British psychiatrists Wise and Watson (2002) have
reported a small pilot study that used a latex rubber ring
on the base of the penis daily for no more than thirty
minutes, but not during sex. Some of the men reported that
they improved ejaculatory control within a week of using the
device. It may be that the device desensi- tized or stressed
the penile nerves or operated as a placebo (that is, it worked
simply because the men expected it to).

Biofeedback Training
Rome urologists La Pera and Nicastro (1996) devised an
exten- sive pelvic muscle training program similar to that
used in treating incontinence. This method includes three
techniques—pelvic muscle exercises, electrostimulation, and
biofeedback—taught in twenty ses- sions, three times per
week. The training strengthens the pelvic mus- cles and
teaches men to recognize and control contraction of these
muscles. Approximately 60 percent of men with PE are
helped by
8 Coping with Premature

this technique. La Pera and Nicastro’s work reinforces the

impor- tance of the pelvic muscles in ejaculatory control.

Treatments for Physical Illness PE

Your physician can treat medical disorders that directly
cause PE. Inflammatory disorders such as infection of the
prostate or urethra are treated with antibiotics that target
the particular organism causing the infection.
Evaluation for diabetes and over- or underactivity of the
thy- roid gland may be necessary if the history and physical
examination suggest a problem with these endocrine
systems.

Treatments for Physical Injury PE

Medical treatments for the specific injuries that cause PE
(such as spinal cord injury, head injury, trauma to the
sympathetic nervous system, pelvic fractures and other torso
traumas, or localized sensory impairment) are currently very
limited. When such injury results in permanent physiological
damage, treatment with medications that slow ejaculation
may offer help for some. Sex therapy can help you learn to
adapt to a permanent impairment. Chapters 8 and 9 offer
some guidance here.

Treatments for Drug Side-Effect PE

Because this type of PE is caused by either withdrawal from
or use of specific drugs, treatment is generally
straightforward. When PE is caused by drug withdrawal,
normal sexual functioning will return after the chemical
leaves the body and the body rebalances. This may require
from two to six weeks, depending on the medication. When
PE results from a medication you are taking, you and your
doctor should discuss the possibility of stopping or switching
to a different medication if it is safe to do so. If normal
function does not return, you should suspect additional or
other causes of your PE.

Treatments for PE with Another

Sexual Dysfunction (Mixed PE)
A medical examination can help identify physical causes for
each sexual dysfunction—erectile dysfunction or
inhibited desire—in
 Medical, Pharmacologic, and Physiological 8

addition to the PE. Specialized tests such as duplex

ultrasound, cavernosometry or cavernosography, nocturnal
penile tumescence studies, or arteriography may be helpful
in evaluating erectile dys- function but do not provide much
diagnostic insight in the evalua- tion of PE itself. However,
concerns about erectile dysfunction add to PE, so these tests
may be important if you are experiencing both PE and
erectile dysfunction.
If there are no identified physical causes, then review
again the possibilities of other causes, especially
psychological or relationship distress. Mixed PE commonly
involves a deficit in psychosexual skills, and skills learning
may become your treatment of choice. Cognitive behavioral
sex therapy may also help remedy the detri- mental effects of
erectile dysfunction–induced PE on you and your
relationship.
If you have PE with erectile dysfunction, oral
medications and other erectile dysfunction treatments—
vacuum constriction devices, intracavernous or intraurethral
pharmacotherapy, and penile pros- theses—can be valuable
resources. If your PE is a symptom of and compensation for
a fear of erectile dysfunction, treating the erectile
dysfunction can, in turn, resolve your PE.

Treatments for Erectile Dysfunction

Since erectile dysfunction is the most common factor in
mixed PE, let’s take a look at the medical treatments
currently available for this problem.

Oral Medications
Medications such as Viagra and Cialis help initiate and
main- tain erection by relaxing the corpus cavernosum
smooth muscle in the penis. Such medications can be used
for erectile dysfunction whether its cause is physical,
psychological, or medication related, and they can relieve
PE that results from overcompensation for fears of erectile
dysfunction. Among the most common unwanted effects are
headache, facial redness, indigestion, visual disturbances,
and nasal congestion. Each of these effects occurs in
approximately 10 to 15 percent of men.

Medications Applied to the Penis

Erectile dysfunction is sometimes treated with
medication applied directly to the penis.
PGE1. The most commonly used is E1-prostaglandin (PGE1)
or alprostadil, which the man injects into the base of the
penis a few
8 Coping with Premature

minutes before sexual activity. PGE1 may be used up to two

to three times a week. When erection is assured by injection
therapy, men with mixed PE may relax, thereby gaining
control of ejaculation. However, many men stop using
injection therapy because they or their partners find it
awkward and clinical.

MUSE. Medicated Urethral System for Erection (MUSE) is a

device used to insert an alprostadil suppository into the
urethral opening. Reports of its effectiveness vary from 7 to
65 percent. The most com- mon adverse effects are penile
pain, urethral burning, dizziness, or fainting. MUSE may be
more user-friendly than injection therapy, but it also has
a very high dropout rate.

Vacuum Constriction Devices

Vacuum constriction devices draw blood into the penis,
causing an erection, and trap the blood there in order to
maintain the erec- tion for intercourse. These devices
include a plastic tube that fits over the penis in order to
create an airtight cover. A vacuum is created around the
penis by motor or manual pumping. When erection occurs
by this means, a fitted rubber band is placed on the penis at
the base to retain the erection. An erection may be
maintained by this method for approximately thirty minutes.
Again, there is a high dropout rate due to lack of comfort on
the part of either the man or the woman.

Penile Prostheses
Nonsurgical prostheses include splints such as Rejoyn,
a soft rubber brace which holds the flaccid penis rigid. The
brace exposes the tip of the penis to allow for pleasure.
Some women find the device uncomfortable during
intercourse. These are available with- out prescription at
many drugstores.
Rigid or flexible rods may be surgically implanted
into the penis to make it mechanically erect. There are
inflatable models that allow for artificial engorging and
deflating of the penis by means of a hydraulic system
composed of tubes implanted in the penis and a fluid
reservoir or bulb implanted in one of the testicular sacks
(the testis is removed). The tubes are then inflated by
squeezing the bulb and deflated by a valve in the bulb. These
surgeries do not allow for an actual erection, but do permit
the penis to be comfortably inserted into the vagina. Because
implants are irreversible and do not allow any other
treatments, an implant is the last option for treating
erectile dysfunction.
While these medical treatments are clearly helpful for
many men with PE combined with erectile dysfunction,
they each have
 Medical, Pharmacologic, and Physiological 8

significant limitations. These treatments succeed best when

used along with the PE skills program and when integrated
into a flexible style of couple sexuality that encompasses
intimacy, pleasuring, and eroticism.

Your Body and Person

Are Intertwined
When you suspect that medical problems are causing your
PE, you need to carefully evaluate medical and physical
resources. Approaching PE as a psychological or relationship
problem without addressing the medical cause will lead to
confusion, frustration, dis- appointment, and a sense of
failure and hopelessness.
Your body and person are intrinsically intertwined.
Appre- ciating and respecting that your personality is
fundamentally grounded or housed in your body is
important. With your body healed, or the reality of its
limitations understood, you are ready to pursue the
psychological and relationship skills to manage your PE and
enhance your intimacy.
 7

Psychological and
Relational Strategies
and Skills

David developed PE during the second year of his

marriage to Kristin due to a mild prostate infection that was
undetected and untreated for four years. Although they
eventually learned that David’s PE was caused by a medical
problem, David and Kristin realized that the years of PE had
cost them dearly. PE had played a substantial role in
undermining David’s self-esteem and confidence, causing
sexual stress that injured their overall relationship.
During the four years that they endured the PE, David
and Kristin became stressed and estranged by intense
arguing and fight- ing—first about PE, and later about
nonsexual issues. There were days when they avoided each
other not only sexually but personally. The psychological
distress he experienced with the recent death of his father
also weighed on David. The combination of grieving and the
relationship alienation caused by their arguing became a
main- taining cause of PE, even after antibiotics had cured
the prostate infection that initially caused the PE.
David and Kristin’s distress wasn’t limited to the
bedroom—it permeated their entire relationship. To recover,
they learned how to emotionally accept the hurt around their
sexuality, how to heal the mutual pain, and how to resolve
relationship conflict. David and
8 Coping with Premature

Kristin learned crucial skills for relationship intimacy:

understanding and integrating relationship expectations,
developing emotional empathy, and implementing mutual
conflict resolution.
This chapter is designed to help you approach the
psychologi- cal aspects of PE. This will be helpful to you if
you have psycho- logical system PE, psychological distress
PE, relationship distress PE, or other types of PE that have
caused distress to you and your relationship. You will learn
an approach to address individual psychological features
that cause, maintain, or result from PE. You’ll also address
distress in your relationship identity, relationship coop-
eration, or relationship intimacy that causes, maintains, or
results from PE. We’ll teach you skills to clarify your sexual
relationship identity, modify your interaction dynamics, and
emotionally support each other.
We’ll describe specific ways to become more aware of
your feelings and discuss the importance of investing
emotionally in your relationship to promote healing and
enhance empathy. We’ll teach you a specific
communication skill, paraphrasing, to make your
emotional investment easier and safer, and we’ll show
you ways to cooperate and resolve disagreements. These
skills will help you and your partner work as a team to
learn ejaculatory control and enjoy sex.

Approaches to Relieve
Individual Psychological
Distress
In this section, we’ll look at ways to approach PE caused by
long- term or temporary individual psychological distress.
With either type, you should remain open to evaluation and
treatment for chemi- cal dependency if you have been
“medicating” yourself with alcohol or drugs. See the
Resources section for more information.

Strategies to Resolve Psychological System PE

Psychological system PE is very difficult to address with
self- help approaches. However, you can gain insight with
basic informa- tion from a reliable book or a reputable
Web site on the condition you suspect. Consultation with a
licensed clinical psychologist can help you determine
whether you have a chronic psychological prob- lem that
might cause your PE. Consultation usually includes one or
 Psychological and Relational Strategies and 89

more personal interviews, a historical review of your life,

and some psychological testing.
Treatment for PE caused by a psychological problem
may include individual or group psychotherapy, medication,
and sex therapy. Because your psychological system is
complex and tends to resist change, realize that it may take
a considerable amount of time and effort in therapy to
address the feature you believe is causing PE. When you
feel ready, learn the psychosexual skills in chapter 8.

Shane’s Story: Obsessive-Compulsive Disorder

Shane had frequently wondered how different his life
might be without anxiety, hypersensitivity, perfectionism,
and orderliness. He had never thought that his PE was
related to these traits, because he had always ejaculated
very fast. When life was particularly stressful, Shane noticed
that he would act more ritualistically, compulsively checking
whether the coffee pot was turned off or all doors were
locked, ruminating about what seemed to be small concerns,
and having trouble deciding to discard things. When it came
to sex, he constantly felt stressed and anxious, believing he
should “do sex perfectly.”
When Shane consulted with a psychologist, he
described the day-to-day features he suspected were
obsessive-compulsive, reviewed his personal history, and
completed a psychological test. The test results suggested
that he did in fact have strong obsessive- compulsive
personality features as well as anxiety traits, which
supported the psychologist’s diagnosis: obsessive-
compulsive disorder (OCD).
Shane’s treatment plan included learning about OCD by
read- ing two books, extended individual therapy to explore
the nature of his OCD and develop strategies to cope better,
taking an SSRI medi- cation (which not only alleviated his
OCD but had the side-effect of slowing ejaculation), brief
couple therapy to enlist his wife’s accep- tance and support,
and finally couple sex therapy to learn psych- osexual skills
for slowing ejaculation. While Shane’s treatment involved an
extensive amount of time, he was able to make sig- nificant
progress in altering his personal quality of life, overcoming
PE, and enhancing relationship intimacy.

Strategies to Resolve Psychological Distress PE

If you indicated on your PE Diagnostic Summary Sheet
in chap- ter 4 that you have psychological distress PE,
review what you noted to be the stressors that cause your
PE, as well as whether another
9 Coping with Premature

type of PE might be causing psychological distress that

worsens the sexual problem.
Most men prefer to address the specific psychological
stressor using self-help efforts since this type of problem is
less severe and chronic than psychological system PE. If self-
help doesn’t work for you, use good judgment and seek
appropriate professional therapy.
As a couple, you want to discuss how best to address
the sources of your psychological distress PE. For example,
if you are stressed about career issues that—for the moment
—you are not able to resolve, you may decide together to
accept this temporary distress and compensate sexually by
learning the skills in chapter 8. The important thing is that
you pay attention to the underlying psycho- logical distress
causing your PE and make sure that you work together to
prevent further problems.
Among your options, consider reading a reliable book or
visit- ing a reputable Web site on the type of stress you
suspect. There are a number of very good self-help books
that can help you understand your distress, and offer
practical suggestions for adapting (see Resources). If
reading and reflecting on your circumstances is not your
style, or if your self-help approach is not effective, you will
benefit from talking with a psychologist. He or she can help
you gain perspective on your distress, offer objective
psychological testing, and help you consider further
strategies for change. If marital issues are causing your
psychological distress (for example, an affair has led to
depression), this cause needs to be addressed. Medication
may be beneficial in addressing depression or anxiety rooted
in current stresses.
In some cases, resolution of the psychological problem
will restore normal sexual function, while in others the
exercises in chapter 8 or sex therapy may be needed to
overcome secondary problems, factors such as anticipatory
anxiety, performance anxiety, or loss of sexual confidence.
These factors can maintain your PE even when the
psychological cause has been resolved.

When Your Partner Is Psychologically Distressed

PE may be your reaction to your partner’s psychological
prob- lem. In this case, your PE serves as a relationship
symptom of her psychological distress. Her psychological
distress can cause PE when you feel tension during
lovemaking and your body reflexively responds with urgency
to “get it over with.” Depression, obsessive- compulsive
disorder, mood disorders, career distress, role conflicts,
sleep deprivation and fatigue, parenting stresses, family
conflicts, grieving the loss of a parent, loneliness, acute
anxiety, and other problems—even when mild—can subvert
sexual enjoyment.
 Psychological and Relational Strategies and 91

Treatment for her psychological distress is similar to

what we outlined above. Your empathy and emotional
support for her is important. Such distress is an opportunity
to build deeper intimacy by cooperatively addressing the
difficulty.

Approaches to Alleviate
Relationship Distress
If you indicated on your PE Diagnostic Summary Sheet that
you have relationship distress PE, take a moment to recall
the interpersonal dynamics you believe might be causing or
maintaining your PE. Even if you have another type of PE,
your relationship may have suffered. You’ll need to heal the
hurt and restore relationship quality. This sec- tion will offer
you an approach to address the most common cogni- tive,
behavioral, and emotional features of relationship distress.

Your Partner’s Dissatisfaction

Similar to the way your partner’s psychological distress
may be transmitted to your body and affect your ejaculatory
control, you can emotionally sense your partner’s
relationship dissatisfaction. Even though you may feel
satisfied with your relationship except for your PE, your
partner may feel lonely or disconnected from you and long
for more emotional intimacy. If your partner does feel
dissatisfaction with your interactions, this may be a factor
in causing your PE as well as a result of it. Ask her. You
may want to avoid dealing with her disappointment, but it is
important to know because it is impor- tant to address the
problem.

Identifying Your Relationship Distresses

This exercise uses the identity-cooperation-intimacy
model described in chapter 3 to help you identify your
relationship distresses. Honestly answer the following
questions, first individu- ally, then as a couple.

E XERCISE : I DENTIFYING Y OUR

R ELATIONSHIP D ISTRESSES
1. Identity Concerns
Are you struggling over expectations or disagreements
regard- ing gender roles, work and family commitments,
day-to-day tasks,
9 Coping with Premature

the role of sex in your relationship, parenting, or balancing

your autonomy with cohesion as a couple? Do you feel an
imbalance in your desire to please your partner to the point
that you neglect your own wants?
2. Cooperation or Conflict Resolution Concerns
Do you feel your partner is demanding? Have you felt
pressure to ejaculate quickly in order to “get it over with”?
How competitive are you with each other? Are you ready to
cooperate to do the skills training? Have you offered
forgiveness of each other (and yourself) for the hurts? Can
you be patient, warm, and kind with each other? Are the
outcomes to your disagreements emotionally satisfying for
each?
3. Emotional Intimacy Concerns
Have you been afraid of deeper intimacy or more solid
close- ness? Are there hidden hurts that linger due to
unresolved relation- ship conflicts? Have you corrected any
empathy deficits? Are you holding a grudge? Are you afraid
you won’t be able to change your relationship feelings? How
lonely do you feel in your relationship?

Recovering and Promoting Relationship Satisfaction

To alleviate relationship distress PE, you will need to
work on one or more of the following objectives:
●
Identity: Clarify and integrate your relationship and
sexual beliefs, standards, perceptions, attributions,
and expectan- cies, and balance individual autonomy
and couple bonding.
●
Intimacy: Enhance your emotional empathy in order
to heal relationship injuries caused by conflict or by
your PE.
●
Cooperation: Modify interpersonal dynamics that may
cause or maintain your PE, such as communication
deficits or a conflict resolution impasse.

Clarifying Your Relationship Identity

Your beliefs, standards, and expectations of yourself
and your partner about how to be a couple make up your
relationship iden- tity, while your sexual relationship
identity comprises your sexual beliefs, standards, and
expectations. Differences and misunderstand- ings are to
be expected; they are normal. Clarifying such
 Psychological and Relational Strategies and 93

misunderstandings and integrating your new understandings

into your couple style is part of reducing relationship
distress.
Consider your sexual relationship identity. What does
sex mean to you? A source of emotional vitality?
Procreation? Pleasure? Duty? Joy? What role should sex
play in your relationship? Do you expect to talk openly of
your sexual wants, dislikes, joys, comfort, ideas? Should your
sex always be wild passion? Tender lovemaking? Do you
agree that there is more than one kind of sex? (Quickies?
Impulsive passion? Mechanical anxiety release? Romance?)
Do you and your partner expect to take turns being “sexually
selfish”? Do you expect sexual pleasure to decrease or
increase over time? Are you sexually playful? Respectful?
Tender? Can sex bring consolation dur- ing stressful
periods? Although you have had problems, do you think sex
can improve? Do you share a standard of good-enough
sex?

Balancing Autonomy and Couple Cohesion

At their core, relationship identity issues are usually
problems balancing individual autonomy and relationship
cohesion. This can play out in the sexual relationship and
in the relationship as a whole. The autonomy couple
cohesion balance is the central feature of your relationship
identity. It directly influences your feelings as a couple
and forms the foundation for cooperation and intimacy—
including sex.

E XERCISE : S EEKING B ALANCE IN

Y OUR G ENERAL R ELATIONSHIP
Consider your thoughts and feelings about how well you are
balanc- ing your individuality and your relationship
cohesion. Talk with your partner directly about what you
believe a relationship should involve and how to “do” a
satisfying relationship. What are your expectations about
how to communicate, deal with conflicts, express affection?
What do you each believe and feel about gender roles, the
role of sex, family-of-origin learnings, parental modeling of
mar- riage, prior relationship experiences, spiritual beliefs,
career goals, friendships, loyalties, religion, leisure, and
social activities? What do you bring to your relationship?
What do you feel proud of? What does your partner bring
to the relationship that you appreciate?
Discuss (seeking information, not argument) your
thoughts and feelings about how well you each are doing
with the amount of indi- viduality in your relationship. Then
discuss the level of union or togetherness. Do you feel as
independent as you want? Free or con- strained? Do you
have your own activities, interests? How stifled do
9 Coping with Premature

you feel? Do you have as much time for yourself as you think
you need? Where is your place to be alone, “off duty”?
What expectations do you have for your relationship,
and how well are these being met? How highly do you and
your partner prioritize your relationship? How lonely do you
feel? How impor- tant is your partner to you? You to your
partner? Are you able to have sufficient time together? To
what degree do you approach daily life with a couple or team
mentality? Relationship identity is the environment in which
your sexual relationship lives.

E XERCISE : S EEKING B ALANCE IN

Y OUR S EXUAL R ELATIONSHIP
Discuss your thoughts about balance in your sexual
relationship. What does it mean to balance individuality and
couple cohesion during sex? Is individuality selfish? Does
cohesion seem confining, smothering, distracting? Does your
sex always have to be raw and physically passionate or
deeply personal and romantic? Sexually, what do you bring
to your relationship? What are you proud of sex- ually? What
does your partner bring to your sexual relationship that you
appreciate? Share your thoughts. Your sexual relationship
iden- tity is founded upon who each of you is as a unique
individual and what you bring to your sex life.

When you strike a mutually satisfying and sustainable

balance between individuality and interpersonal cohesion,
good-enough sex results. Each of you contributes to the well-
being of your relation- ship, and your relationship
contributes to your growth, develop- ment, and well-being
as individuals.

Enhancing Emotional Intimacy

Emotions about your relationship are the “energy
source” for your sexual feelings. When relationship distress
infringes on this positive energy, sexual problems can result.
Feeling resentful, rejected, or fearful of your partner
undermines sexual energy. Sexual problems like PE can
drain your emotional energy as a couple. To recover from
distress associated with PE, you will want to take steps to
enhance your feelings of being an intimate team. You will
want to improve your ability to recognize and gently express
your feelings, deepen your appreciation of your partner’s
feelings, and together experience emotional empathy.
Accepting and embracing each
 Psychological and Relational Strategies and 95

other’s emotions will provide the foundation for working as

a team to learn the psychosexual skills in chapter 8.

Feelings Are Essential to Intimacy

We want to focus on your emotions in this chapter
because feel- ings are not only signs of the distress caused
by your PE but also a key to resolving your PE. Because
your emotions are indispensable for achieving sexual
satisfaction, it is crucial that you be aware of them and
comfortable with them. Everyone who has a body has feel-
ings, but we differ in our level of awareness and comfort.
Some are very aware of their body’s sensations and feelings
and have elabo- rate words to express them. Others are
aware of their feelings but have few words to describe them
clearly, or have learned to not express them out of shame,
fear, or sensitivity. Still others ignore their feelings,
believing emotions interfere with adult living.

What Are Feelings?

Feelings can be confusing, distracting, irritating, or
frustrating unless you understand what they are about.
Because many people— especially men—rely on reason more
than emotion for direction in life, feelings are often viewed
as irritants, distractions, or even ene- mies. Basically,
feelings are biochemical energies in your body in response
to various situations, influenced by your past experiences
and current thoughts. Feelings are not enemies at all; they
offer you important information that your reason might
overlook. Feelings offer data about yourself and your
experiences that are not available to you from logic or
thinking alone.

Feelings Can Be Complicated

Often we have “mixed feelings”—we feel two or more at
the same time. For example, you may worry that PE is
impossible to resolve, feel hurt and irritated at yourself or
your partner, and feel shame that you have failed to find a
resolution—all simultaneously.
You may focus on only one dimension of the energy
(feeling) in your body, ignoring the other feelings. For
example, focusing only on frustration, you may miss
feelings of hurt and worry.
One feeling can be converted to another. A person
who is taught to not feel anger may convert feelings of
anger to shame. A person who is taught that anger is okay
but fear isn’t may feel angry when afraid or threatened.

Feelings Are Useful

People tend to think of feelings as positive or negative,
good or bad, depending on whether they agitate (like fear,
anger, and guilt)
9 Coping with Premature

or encourage (like pleasure, contentment, and satisfaction).

Our approach to understanding feelings is to think of them
as voices trying to get your attention so you’ll consider
factors other than logic in your response to a situation.
Feelings try to help you respond to different situations.
Every feeling is good in terms of its purpose to serve you,
protect you, and guide you. Your feelings offer honest
information, some of which you may not like. Listening for
feelings is an important skill.

Metaphors for Feelings

Consider two metaphors that a number of men and
women have told us helped them appreciate the value of
emotions.
Psychological sonar. As you navigate through life, you are
continu- ously monitoring the environment for information
about your situa- tion. Imagine your logical reason to be your
“psychological radar,” supplying information about what is
going on “aboveground.” Then imagine that your emotional
intelligence is your “psychological sonar,” supplying
information about what is going on “below the water.” (If
you are a sportsman, imagine the sonar fish finder in your
boat.) Different systems offer different information, and the
compos- ite information from both radar and sonar offers
you a more complete picture of your situation.
With PE, your “radar” or reason may have told you, “I
will again fail to please her,” while your “sonar” or emotions
likely alerted you with anxiety and tension in your body.
Both alert you in different ways to a challenging situation.
Lifelong, loyal friends. Another way to understand your
feelings is to consider them to be your “buddies” or lifelong,
loyal friends. They have been with you through your
experiences, and they remember them even when you
forget. Each feeling, then, is a savvy veteran of experience
who will alert or protect you from situations that expe-
rience leads him to believe could distress you. Your friend
vigilantly looks after you. He will not lie to you, abandon
you, or be silent when concerned that you may forget or be
misled by your logic. A good buddy will take you aside,
counsel you, even argue with you when he thinks you could
be making a mistake or overlooking potential trouble. You
may not like the counsel of these friends, thinking they
overprotect you or make things worse for you, but they
are just doing their job whether you like it or not.
Suppose you have experienced your partner’s
disappointment when you ejaculated quickly and concluded
that you were inade- quate. You experienced intercourse as
failure. Your loyal friends— your feelings of shame and
anxiety—wanted to protect you from
 Psychological and Relational Strategies and 97

further failure, so they tried to get your attention and maybe

even advised you to avoid sex.

E XERCISE : L ISTENING FOR

Y OUR F EELINGS
Alone, provide yourself a quiet, relaxing atmosphere. Relax
your body until you are feeling calm, centered, and
comfortably aware of your body. Then imagine that you are a
miniature explorer traveling around inside your body to find
where different feelings are most strongly noticeable to you.
Where in your body do you experience joyful feelings? In
your face, eyes, mouth? In your chest or legs? Where in your
body do you experience feelings of anxiety or fear? In your
stomach? In your chest? In your cold hands? Where in your
body do you experience anger? In your hot cheeks or ears?
In your throat or neck? In your stomach? Where in your body
do you experi- ence feelings of sadness? Where in your body
do you experience feelings of confusion, indecisiveness,
ambivalence? Where in your body do you experience
feelings of sensuality with your partner?
Write down what you learned.

Are You Free to Feel?

While your feelings are valuable sources of personal
informa- tion, it’s not always a good idea to act on them.
Whether and how to act are ethical choices that you need to
make. For example, a feeling of anger offers personal
information to you about your situation, usually one in which
you feel hurt, threatened, or blocked. Or, experiencing PE,
you may feel frustrated. These feelings get your attention by
agitating your body so you recognize the problem. What you
do with this information is the ethical issue.
The guiding principle is this: Accept your feelings, judge
your behaviors. When you make this distinction between
your feelings and behaviors, you are free to feel. You can
feel frustration about PE and choose not to express this
feeling to your partner. Rather, you can choose a more
positive course of action by asking your partner for a few
moments to rest and recover, and then offering to pleasure
her as she wishes. You want to learn from your feelings but
not let them run your life; you don’t have to act on them. You
want to listen to your feelings, consider their counsel, and
decide how to respond in a constructive fashion. Integrating
your feelings and reason gives you a more complete picture
of your situation.
9 Coping with Premature

Value Your Partner’s Feelings

Accept your partner’s feelings as well as your own.
Accepting a feeling does not mean agreeing or condoning. It
means listening, valuing, caring, accepting, affirming, and
nurturing her. You can accept and affirm your partner’s
feeling of anger without agreeing with her interpretation
(attribution) of the problem and without con- doning the
behaviors expressing anger. Don’t try to “fix” or change your
partner’s feelings. Ironically, your acceptance is the major
thing that will help your partner’s feelings to change. Strive
to acknowl- edge, affirm, and accept feelings.

Different Ways of Expressing Feelings

There are many direct and indirect ways to express
feelings. The words to describe feelings are learned. Some
words directly describe emotions: “I feel sad,” “I feel warm
and close,” “I feel frus- trated.” Others express feelings
indirectly. You might say, “Isn’t it a nice day?” to express “I
feel wonderful today” or say, “All you do is spend money” to
mean “I am worried about money.” The more directly you
express your feelings, the more likely it is that your partner
will understand and interpret your meaning correctly.
You and your partner have your own emotional
language, non- verbal (a smile, a glance away) as well as
verbal. How do you express your feelings? How does your
partner? How have you expressed feelings about your PE?
How has your partner? Verbally? Nonver- bally? Negatively?
Calmly? Dramatically? Developing healthier ways to share
feelings is important and will deepen your intimacy.
Learning to “read” your partner’s words and actions is part
of the uniqueness of intimacy. It takes months or years of
sharing experiences, explain- ing to each other your
thoughts and feelings, for better and for worse.
Communicating emotions is an important skill in an
intimate relationship. For many men and women, it is
difficult to feel close without sharing verbally what and how
you feel. Love involves shar- ing warm, positive feelings and
romance, but also involves sharing feelings even when that
may lead to conflict. Communicating nega- tive feelings in a
positive, constructive way can lead to emotional closeness.
You can still be loved and valued even if you are down,
anxious, or had a failure experience. Love tries to provide
that safe harbor amidst the storms of life.

Vulnerability within Emotional and Sexual Intimacy

Sharing your feelings with your partner is important to
healing and deepening your long-term sexual relationship.
Emotional open- ness and the nakedness of sex are the two
most vulnerable and ten- der aspects of committed love.
During these experiences, we are
 Psychological and Relational Strategies and 99

most exposed and fearful of rejection. You can appreciate

your sensi- tivity when you consider how it hurt when you
shared feelings and felt rejected or shamed. Or consider
when you ejaculated quickly and felt sexually vulnerable
but your partner seemed frustrated, mis- reading your
distress as blame or abandonment. You probably wanted to
hide your emotional vulnerability and cover up your physical
nakedness. When you give and receive empathy while you
are vulnerable emotionally and sexually, you communicate
powerful acceptance and comfort, and generate trust and
love.

E XERCISE : E XPRESSING F EELINGS

AND E MOTIONS
If you have difficulty describing your feelings with words,
use the same words over and over, or tend to confuse
feelings with thoughts, you can fine-tune your skills with
this couple exercise.
Below is a list of words that describe feelings or
emotions. Add any favorites of your own or others you can
think of. Then do the three “building blocks” that follow.
pleased excited comfortabl
e
happy jubilant satisfied
glad elated contented
aroused surprised stimulated
confident eager peaceful
witty joyful calm
hopeful playful composed
fascinated silly thoughtful
angry frightened bored
provoked anxious weary
quarrelsome afraid apathetic
insulted cowardly complacent
irritated cautious tired
discontented uneasy worried
uncomfortable hesitant nervous
overwhelmed ashamed worthless
daring energetic embarrasse
d
intense distracted earnest
enraged hurt tender
confused passionate sad
1 Coping with Premature

Building block 1. Alone, take a moment to reflect and write

down some notes on your experience. What words do you
use most fre- quently to describe your feelings? What words
do you hear your partner use most often? Do you and your
partner have different favorite words to express a similar
feeling? What are they? Which feelings are most familiar to
you? What are your labels or words for these? What other
feelings might be concealed behind these words? After you
have finished your notes, spend at least ten minutes each
sharing these with your partner.
Building block 2. For one full day, discuss with your
partner your impressions as you observe each other giving
nonverbal signals such as tone of voice, facial expressions,
physical movements, and body positions. Tell each other
what you interpret the other to be feeling. Share where you
got your impression and check this out with each other. For
example, “I see you chewing your nails and it makes me
think you are feeling nervous. Am I right?” “I hear you
talking very loudly and it makes me think you are feeling
irritated. Are you?” “You are quiet. Are you feeling sad?” “I
feel your arm around me and it makes me think you are
feeling romantic. Do you want to make love?”
Building block 3. What words do you use most frequently
to describe your sexual feelings? Like many men, you might
use only one word, good. This doesn’t give your partner
much to go on, so think of additional descriptive words.
What words do you hear your partner use most often? Do
you and your partner have favorite words to express sexual
feelings? What are they? Do you use words during sex that
turn you on? Turn you off? Which words? What are your
labels or names for each other’s body parts? Do you have
play- ful nicknames for these? What nonverbal signals do you
use during lovemaking? How do you interpret your
partner’s tone of voice, facial expressions, and physical
movements during sex? How does your partner interpret
yours? Tell each other your impressions and check these
out with each other.

The Emotional Skill, Empathy

In intimate relationships, an important ideal is to feel
emotion- ally valued and accepted without conditions, to feel
unconditional positive regard from and for each other.
Empathy, the skill of affirm- ing feelings, is the glue of your
relationship. It feels good to have your successes and
strengths accepted, but you feel especially loved and
respected when your vulnerabilities and weaknesses are
embraced. To empathize with your partner, imagine for a
moment that you are her. You imagine that you think and
feel as she does,
 Psychological and Relational Strategies and 10

that you experience her reality. When you are empathic with
your lover, you offer the greatest gifts: acceptance,
nurturance, warmth, respect, reassurance, validation, care,
patience, and appreciation. These are wonderful qualities
to take into the bedroom!

Modifying Your Relationship Dynamics

Changing the relationship dynamics involved in your PE
will require effective communication and mutual conflict
resolution. We’ll begin by teaching paraphrasing, a
communication skill which helps develop the emotional
skill of empathy.

Paraphrasing
Paraphrasing helps you clarify your relationship identity
and bring your intentions and your partner’s perceptions in
line. This cognitive congruence is the foundation for
emotional empathy. With careful use of paraphrasing, you
and your partner will achieve clarity of communication,
emotional empathy, and readiness for mutual conflict
resolution. Here’s how it works:
1. “I” message. Partner 1 reveals himself by expressing
his thoughts and feelings, trying to be clear, direct,
and open as he shares his personal message. The
focus is on him only. He says, “I think . . . ,” “I feel
” This is a personal disclosure
or sharing, an opening of his heart. Partner 2 may
nod or say “uh-huh” but not interrupt.
2. Paraphrase. Partner 2 listens with undivided
attention, then summarizes the “I” message in her
own words, stating her understanding of what
Partner 1 has shared. The paraphrase begins, “What
I think I hear you saying is ” Her focus is
solely upon him. Paraphrasing is empathetic listening
— offering in her own words her understanding of his
thoughts and feelings.
3. Appraisal. Partner 1 then evaluates their effort for
empa- thetic understanding. He asks himself, “As I
listen to her paraphrase, am I feeling completely
understood?” If he feels a full empathetic
understanding, then the appraisal is yes. If not, the
appraisal is no.
4. If the appraisal is no, Partner 1 begins the cycle
again, fine-tuning his “I” message.
There are two ways to use paraphrasing: two-way or
“leap- frog” paraphrasing, where partners switch roles
when a yes appraisal verifies empathy, and one-way
or single-focus
1 Coping with Premature

paraphrasing, where the partners do not switch roles after a

yes appraisal, allowing the same partner to continue. One-
way para- phrasing offers the partner with several urgent
messages the oppor- tunity to continue working until
satisfied.
The appraisal step empowers you by assuring that you
will be understood to your satisfaction, or discussion does
not go further. When it is your “I” message, you have the
control to guarantee you receive empathy. A yes appraisal
means “I certify that you under- stand me now because I
have heard and felt your empathy.” When the feeling being
shared is complicated, it is reasonable to need ten, twenty,
or more “I” messages before the empathy is confirmed
with a yes. The first few “I” messages typically focus on
describing the content, and subsequent “I” messages focus
on clarifying the quality of your feelings about the content.
Paraphrasing will provide you the discipline and
patience to yield profound understanding. Your patience
with the process demonstrates that you value your partner’s
feelings. Paraphrasing is particularly valuable for talking
about your sexual feelings. It provides you a system to talk
with understanding and appreciation.

E XERCISE : P ARAPHRASING
Take fifteen minutes to practice communicating using the
two-way paraphrasing format. At first, be very disciplined,
saying nothing outside the structure. Let the man begin with
an “I” message. It will help if you make an audiotape of your
practice. Afterward, review your audiotape together. If you
have practiced with discipline, notice that you can talk
together calmly because the format gives you control over
the communication process. Notice that if you are loyal to
the paraphrasing discipline, you cannot have an argument!
The structure prevents it. You now have a format to
achieve emotional empathy.

Using Your New Skills to Recover Emotionally from PE

Your new skills at empathizing and paraphrasing provide
a powerful foundation for overcoming the emotional hurt
of PE. You
can now look at PE as an opportunity to grow together as a
couple. When you feel accepted and respected even if you
“fail” sexually, you develop a special bond with your partner.
When you understand that your partner felt hurt and
abandoned because she assumed that you valued sexual
performance over personal intimacy, your bond is deepened.
Take the opportunity. Paraphrase your feelings.
 Psychological and Relational Strategies and 10

There is no real love without hurt, pain, suffering, and

disappoint- ment. Normal day-to-day limitations to affection,
occasional misunder- standings and hurts, occasional
mediocre sex, personal imperfections: these are common
relationship disappointments. Acceptance—or at least
tolerance—of such vicissitudes of life is important for
forgive- ness. Regardless of its cause, your PE warrants
compassion and kindness from and for each other.
Forgiveness requires you to expand your
understanding of what PE means for each of you and to
strengthen your relationship cohesion with empathetic
communication. By discovering each other’s intentions and
perceptions, you can change your perspective, not looking
backward but looking to the future. Learning to redefine the
sexual component of your intimate relationship while you
learn the practical lovemaking skills to overcome PE will
solidify your forgiveness and healing as lovers.
Renewal of intimacy requires honest acceptance that
there has been hurt in the past. These feelings do not
need justification; they are simply your loyal friends letting
you know that aspects of sex have been unsatisfying. It is
essential to heal the emotional pain because your
relationship feelings are the energy source for your sexual
relationship.

Cooperation for Conflict Resolution

Most relationship disagreements or “fights” ultimately
stem from hurt feelings or a failure to share emotional
empathy. Conflict remains unresolved when partners reach
an impasse in their efforts to communicate effectively and
empathetically to resolve differences. If fighting has caused
your PE, or if PE has caused fights, notice that your lack of
empathy for each other’s hurt and confusion was an
important issue, maybe even more important than sexual
function. Even relatively minor behavioral conflicts like
tidiness and punctual- ity can flare and become major
emotional arguments when each partner feels rejected. The
skill of cooperation is required to resolve conflicts in
mutually satisfying ways.

Understanding Relationship Conflict and PE

The role of relationship conflict in PE is important
because the way you resolve differences—including sexual
differences—either builds or diminishes intimacy.
To discover the role of relationship conflict in your
experience of PE, try the following exercise. Go on a fact-
finding mission.
1 Coping with Premature

E XERCISE : W HERE , W HEN , H OW ,

AND W HY D O YOU F IGHT ?
1. Where and when do you fight? When you have nonsexual
con- flicts, consider where you typically are and when the
conflict occurs. What are the patterns of your conflict?
Do you tend to fight on particular days? At particular
times of the day? What happens before the conflict—what
circumstances seem to set the stage? For example, you
might argue while driving home after visiting your
mother, or in the bedroom Saturday night after your
teenager misbehaves and after you have been drinking.
Who else is present or nearby when you have conflict?
How long does the disagreement typically last? What
happens after the disagree- ment? There may be
individual issues that you bring to your rela- tionship that
create the environment for the conflict. What unsettling
events in the past might have influenced the way you and
your partner approach conflict resolution in the present?
When you understand that conflict may be linked to
particular sit- uations, you can anticipate and regulate
conflict more effectively.
In your sexual relationship, consider these same
questions.
What are the patterns of conflict in response to PE?
2. What do you do when you fight? Consider how you
respond to each other when disagreement occurs. Do you
cooperate, con- front, act playfully? Yield, evade,
withdraw? If another person was watching, what would
that person see you doing? How do you perceive that your
partner feels and behaves when you disagree?
When PE occurs, how does each of you respond? With
shame? Caring? Irritability? Tears? Withdrawal? Criticism?
Are these responses helpful? Constructive?
3. What does conflict mean? Why are you fighting, and what
does the disagreement mean to you? What thoughts
typically go through your mind about your partner and
about the conflict? What part of the conflict do you react
most strongly to? What do you think causes the conflict?
What is upsetting to you about the fact that you and your
partner have a conflict in this particular area? Do your
conflicts reflect different beliefs about how your
relationship should be? What do you expect will result
when the two of you discuss important relationship
topics? What would you like to see happen? What would
calm you or make you feel satisfied?
 Psychological and Relational Strategies and 10

Now, review these same questions as you focus

specifically on PE. Why is PE so painful? What are your
thoughts and feelings? What does PE represent or mean
to each of you?

What you learn from these reflections will help you to

better understand your beliefs about conflict, your
perceptions and attribu- tions, and the meaning of your
conflict. This knowledge can help you work out mutual
solutions to your disagreements and motivate you to work
as a team to resolve your PE.

Conflict Is an Opportunity for Intimacy

While many couples view disagreements as threats to
their inti- macy, in truth, addressing conflict or discord is the
ordinary process through which couples deepen their
intimacy. When each partner engages in a dispute with the
goal of prevailing in what he or she wants, the other
partner feels unimportant, disregarded, and rejected.
However, with cooperation and mutual empathy, partners
learn to understand the meaning and deeper feelings behind
the conflict. Then both can participate in finding a mutually
satisfying resolution. The guiding principle is that each
partner must feel emo- tionally satisfied with the outcome.
Win-win solutions are not always achievable. When this
is the reality, couples are confronted with the need to accept
their differ- ences. Most couples are capable of achieving
this when they feel a sense of equity about who is doing the
compromising. Integration of differences is ideal;
acceptance is satisfying; toleration is adequate.

Resolving Conflict Mutually

To mutually resolve conflicts—including conflicts about
PE— you need to cooperate to do the following:
●
Be willing to vulnerably invest your thoughts and
feelings in your relationship.
●
Apply self-discipline and leadership, and use
structured communication—paraphrasing—to ensure
that your inten- tions and your partner’s perceptions
are congruent.
●
Use paraphrasing to generate emotional empathy.
●
Formulate the issue or conflict as a couple problem.
Address PE as “our” problem. Ask yourselves, “How
do we resolve this problem in such a way that we
both feel good about it?”
1 Coping with Premature

●
Create a mosaic solution. The great majority of
mutual solu- tions are mosaic solutions, meaning that
they are made up of several specific behaviors which
each partner contributes to the resolution. Such
solutions feel good for both partners. Avoid either-or
solutions, since they create a winner and loser. The
steps in chapter 8 will offer ways to develop your
mosaic sexual solution for PE.
●
After you implement your resolution, evaluate it
several days or weeks later to discuss how well it is
working. Con- sider ways to strengthen it.
A system of mutual conflict resolution clarifies and
integrates relationship identity through effective
communication, which pro- motes satisfying conflict
resolution (cooperation), which facilitates empathy
(intimacy), which in turn supports relationship identity,
and this positive cycle continues. This cognitive, emotional,
and behavioral integration forms the healthy relationship
foundation for you to overcome PE.
 8

Psychosexual Skills:
Enjoying Arousal and
Regulating Orgasm

Mark and Lisa had been trying to remedy PE for more than
six years. They had read everything they could find about PE
and had tried every do-it-yourself technique, but nothing had
really worked. Mark’s family physician had agreed to
prescribe a lidocaine anes- thetic, which helped some, but
Mark found it dissatisfying because he lost much of the
feeling in his penis and felt even further alien- ated from his
body. Lisa had tried to be passive during lovemaking, saying
little and avoiding touching Mark so as not to overexcite
him. She even expressed her dissatisfaction, trying to tone
down his excitement. Lisa appreciated Mark’s efforts, but
still privately resented the PE.
Over the years, Mark and Lisa had found the
problem more and more divisive, and they rarely talked
of their feelings about PE—only about what to do to fix it.
Mark became more and more preoccupied with his “failure”
to perform, and over time he began to avoid sex, anticipating
that he would come fast and worrying that he could not
please Lisa. Lisa began to feel Mark was more concerned
about his penis and performance than about her. There
were periods
1 Coping with Premature

when Mark would come fast, feel frustrated and irritated,

apologize to Lisa or berate himself for being “messed up,”
and then leave the bedroom. Lisa felt more and more
abandoned by Mark as their sex- ual interaction
progressively worsened. It was hard for her to not react
angrily herself. It was all such a disappointment.
Lisa and Mark felt hopeless. Their efforts had brought
no significant changes. They were, in fact, doing worse and
feeling more and more alienated from each other. They felt
inadequate, isolated, and inferior to other couples who
didn’t have sex problems. They had read that PE was the
easiest male sex problem to correct, which deepened their
frustration and shame. Lisa felt angry that Mark would not
seek help from a professional sex therapist. Mark felt that
sex was too private, and he doubted that therapy could
help. Chronic PE was harming their overall marital
relationship, limiting their communication, and testing their
emotional support of each other. They were in marital as
well as sexual trouble.
Mark and Lisa did eventually go to sex therapy, but only
after Lisa became so frustrated that she threatened to
divorce Mark if he didn’t “get his problem fixed.” Lisa was
hurt that it took such a severe threat to get Mark to act. It
was hard for her to recognize his avoidance as a measure
of how deep his shame was.
With the help of their sex therapist, Dr. Hernandez,
Mark and Lisa began to comprehensively address the
problem. Because their case was severe (they had a PESI
score of 75), they needed to complete a very detailed
series of steps to remedy both the PE and the damage to
their relationship. Dr. Hernandez used a diagnostic process
like the one outlined in chapter 4 to help Mark
determine that his PE was caused by neurologic system
predisposition and psychosexual skills deficit, and that the
harm PE had already caused to the intimate relationship
was also serving to maintain PE. Mark decided he did not
want to take medication, so Dr. Hernandez helped them
outline a strategy to compensate for the neurologic
quickness and the skills deficit by cooperatively improving
their psychosexual skills. The early sessions of therapy
worked to heal the marital harm that had occurred.
In this chapter, we’ll teach you the psychosexual skills
to address PE. You’ll learn to relax and regulate your
arousal. You and your partner will learn to cooperate in ways
that will provide sexual and relationship support, safety, and
comfort. We’ll provide detailed instructions every step of the
way. We’ll show you how Mark and Lisa gradually overcame
PE, and how you can overcome it too. You will be amazed
that PE can be effectively managed. You will not only last
longer but enjoy significantly more pleasure, emotional con-
nection, and intimacy.
 Psychosexual Skills: Enjoying Arousal and Regulating 10

How to Approach Learning

the Psychosexual Skills
We’ll begin by giving you an overview of the skills so you
under- stand clearly what you are trying to achieve with
each skill, how each skill relates to the others, and how
to put the skills together.

Understanding the Four Phases of Skills Learning

There are eleven steps to learning the psychosexual
skills, and these steps can be divided into four phases. As
you work through the steps, be sure you understand the
goal for each phase so that the exercises make sense.

Phase One: Comfort and Relaxation

The first series of exercises promotes comfort with your
sexual- ity as an individual and couple, and teaches you
individual cognitive and behavioral skills for relaxing your
body. The essential skill is to focus on physical sensations in
order to relax your body. This will help you pace your
arousal.

Phase Two: Pleasure Toleration

In phase two, you’ll work together as an intimate team
to stay relaxed with increasingly more erotic stimulation. By
focusing on relaxation, you will learn that you can welcome
more—not less— pleasure without ejaculating. The essential
skill is to tolerate increas- ingly intense pleasure without
stepping off into ejaculatory inevitability.

Phase Three: Pleasure Saturation

In phase three, you’ll learn how to have extended
intercourse. The exercises will teach you how to begin
intercourse, and then how to extend the closeness. You’ll
learn to enjoy intercourse, saturating yourselves with
pleasure. The essential skill is integrating the cog- nitive
and behavioral skills to manage PE during intercourse.

Phase Four: Long-Term Satisfaction

In the final phase, you will meld the psychosexual skills
with the psychological and relationship aspects into your
couple sexual style. The essential skill is integrating the
multidimensional features to overcome PE as an intimate
team, and to ensure long-term satis- faction with a sensible
relapse prevention plan.
1 Coping with Premature

This chapter will guide you through the first three

phases.
Chapters 9 and 10 will guide you through phase four.

How to Tailor Your Steps to Your Level of Severity

Work with your partner to decide what steps fit your
situation best. If you are recovering from PE caused by a
medical, psychologi- cal, or relationship problem (and
these have been treated), or your PE severity is mild,
discuss together whether you want to do all the steps or only
those that you think will help you recover. For exam- ple, if
your PE was caused by a prostate infection, you likely do not
need to learn every skill; instead, the pelvic muscle (PM)
control training (step three), relaxed couple pleasuring (step
six), and the intimate intercourse technique (step ten) may
be enough to help you recover. If you have moderate PE
(PESI 50–70), completing most of the eleven steps will
probably resolve your PE if you choose your course
judiciously. For example, in phase two, pleasure toleration,
you may elect to bypass step eight, the individual stop-start
pacing exercise, and concentrate instead on learning step
nine, the couple stop-start pacing exercise. If your PESI
severity score was severe (greater than 70), you will need to
complete every exercise. The most reliable approach is to
complete all of the steps; however, if you elect to not learn
some steps and your program does not bring about the
results you want, you can retrace your steps and complete
them all, or you can consult a sex therapist for help. The
more severe your PE, the more likely working with a marital
and sex therapist will be helpful.

What If You Experience Distress during an Exercise?

Because you’re trying to extend your skills and comfort
level, some of these exercises may bring mild discomfort or
anxiety. This is to be expected. However, should any of these
exercises cause signifi- cant distress or discouragement
(which is the opposite of what we want for you), be wise:
protect yourselves from unintended hurt by seeking
professional coaching and support.

The Psychosexual Skills: The

Nitty-Gritties for Success
As they worked through the psychosexual skills, Mark and
Lisa learned a reasonable way of thinking about PE and a
realistic approach to changing it. They learned the
importance of physiological relaxation,
 Psychosexual Skills: Enjoying Arousal and Regulating 11

the importance of accepting personal responsibility, and the

skill of cooperating by giving and receiving pleasure.
Mark and Lisa were challenged by the amount of
discipline required, but they gradually gained confidence
and began to see success. Lisa especially enjoyed sensual
experiences which not only slowed the touching process but
felt like a more genuine, meaningful connection with Mark.
Working together helped them to feel closer as a couple.
During the process, if either became confused, they
reminded each other of the larger goal: relationship
closeness, with cooperation as the best way to accomplish
this. Mark found it helpful to remember that physical
relaxation was the essential strategy, and discovered that he
could achieve this by focusing on the sensations in his
body.
Dr. Hernandez encouraged Mark and Lisa to
acknowledge the difficult aspects of learning the
psychosexual skills. At first, the exer- cises seemed a huge
intrusion into lovemaking—too mechanical and impersonal.
Mark and Lisa accepted this, reminding themselves that they
would eventually develop a more personalized couple sexual
style.
Dr. Hernandez also coached Mark and Lisa to handle
unintended ejaculation during any of the steps by staying
focused on the effort. He suggested that Mark simply
acknowledge the mistake by saying “oops” or “a work in
progress,” then pause thirty to sixty seconds before
continuing. Mark was not to get sidetracked by sulking or
apologizing. Mark discovered that when he did ejaculate
unintentionally, it was because he lost focus on his physical
sensa- tions, was not sufficiently relaxed, or had
miscalculated how well he was doing the particular step.
Finally, Dr. Hernandez told Mark and Lisa that if
either thought things weren’t going well during an exercise,
they should simply ignore this, focus on the physical
sensations involved, and wait until after they completed the
exercise to discuss their percep- tions. Dr. Hernandez
suggested that Mark and Lisa thank each other after each
session, no matter how poorly it might have seemed to go.
The guideline: Deeply appreciate your partner’s support and
effort, and say so.

Phase One: Comfort and Relaxation

The exercises in phase one help increase your sexual self-
esteem, teach you several fundamental arousal
management skills, and enhance your sexual comfort as a
couple by inviting you to share your sexual feelings.
Learning body relaxation will provide the
1 Coping with Premature

foundation for later steps, and will help counter the

performance anxiety that accompanies PE. You will learn to
become sensuously and sexually aroused while
maintaining physiological relaxation.

Step One: Affirming Your Sexuality and

Increasing Couple Sexual Comfort
Goal: Develop acceptance of your body and of sex, and
develop open- ness with your partner
Mark and Lisa found that affirming their sexuality and
enjoy- ing sexual comfort helped them heal emotionally and
broke the barriers of cautiousness and apprehension that
had developed between them because of PE. Through this
step, each worked to feel positive about his or her body and
about sex, and they were able to discuss their motivations
and feelings about their sexual experiences.

Positive Body Image

Scientific research consistently finds that sexual
satisfaction is strongly related to how proud, self-respectful,
and comfortable you are with your body, nudity, and touch.
This is why a healthy, posi- tive attitude toward sexuality is
so important. If you don’t have positive feelings about your
body, other good things are stifled, especially your ability to
physiologically relax and focus on sensuality.
Body self-acceptance may be difficult in our glamour-
conscious culture, but it is an important component in self-
esteem and is essen- tial to intimate lovemaking. Worrying
about your body’s attractive- ness is a major distraction.
Remember that distraction contributes to sexual
dysfunction. Your negative thoughts about your body (“I’m
fat,” “My stomach is too puffy,” “I don’t like the way my
penis looks”) are distractions.
We all have expectations about our sexual selves that
are unre- alistic and self-defeating. It is important to
honestly examine your feelings about your body. There are
some things you can change for the better and other things
you must simply accept and live with.

I NDIVIDUAL E XERCISE :
BODY I MAGE A WARENESS
Set aside private, quiet, comfortable time for yourself. It is
best to use a full-length mirror for this exercise. First, bring
yourself to a state of calm and centeredness. Focus on your
body. Begin by undressing in
 Psychosexual Skills: Enjoying Arousal and Regulating 11

front of the mirror, and be aware of the way your body looks
in vari- ous stages of dress and undress. When you are
completely nude, stand in front of the mirror and examine
your body in minute detail. Really look. Make eye contact. Be
with yourself in the mirror. Survey your entire body.
Talk to yourself as you progress. Say out loud how
you honestly feel about various aspects of your body. Include
each little scar, mole, wrinkle, and pimple. You can
exaggerate your feelings. Be loud about those parts that
disgust you and exclaim proudly your feelings about the
parts you like. Move around, and watch your body as you
change postures. Notice your muscles tense up, and notice
your soft parts. Flex your muscles, pose, turn, dance, move
seductively. Be aware of those parts of yourself that you
usually avoid looking at: bulging stomach, small chest,
skinny legs. Try to see these parts of yourself with some
acceptance and a positive attitude. Integrate them into
your view of your entire body.
Below are questions you might consider while you are
doing this exercise.
●
What do you like best about your body? What are you
most proud of? How do you show this to your
partner?
●
How do you feel when your partner touches or looks
at the parts of your body that you feel good about,
proud of, and pleased with?
●
What do you like least about your body? What are you
ashamed of? How do you hide these parts of yourself?
Do you avoid looking at them? Do you focus a lot of
attention and self-criticism on them?
●
How do you feel when your partner looks at or
touches the parts of your body you don’t like or
feel ashamed of?
●
How can you affirm your body and your physical self-
image each day? Each time you make love?

Take a moment to consider what you can do to help

yourself feel more confidence in your body. You might get a
haircut, buy a piece of clothing that makes you feel sexy, or
commit to getting in shape. Let it be something that helps
you feel like your new, sexier self.
1 Coping with Premature

Couple Sexual Comfort

Sexual comfort feels good and creates an atmosphere in
which you can learn the skills successfully. Partners who
accept each other’s shyness and even embarrassment with
nudity, and who learn more about each other’s personal
thoughts and feelings toward their bodies and sexuality, feel
more comfortable together. It was essential for Mark and
Lisa to know that they could express their sexual feel- ings
and be met with acceptance, respect, and caring.
You and your partner can develop increased sexual
comfort by talking gently and openly about your positive
sexual thoughts, feel- ings, wishes, and desires, as well as
your sexual discomforts and inhibitions. Your sexual feelings
are deeply personal and significant, so they deserve respect
and tender care.

C OUPLE E XERCISE : T ALKING

WITH Y OUR P ARTNER ABOUT
S EXUAL F EELINGS
With mutual acceptance, take time to share your thoughts
about the following.
Talk first about what you learned about sexuality as a
child and adolescent. What did you learn about
masturbation, marriage, pet- ting, intercourse, oral sex,
orgasm, how a man or woman was sup- posed to act during
sex? Who taught you this? Talk about what it meant to you
at the time as well as now.
What are your attitudes or beliefs about sexuality?
What is okay and what is not okay during lovemaking?
What do you believe is okay but don’t feel is okay? What do
you believe about inter- course? Oral sex? Anal intercourse?
Experimentation? Sharing sexual fantasies? What do you
believe about masturbation? Masturbating privately? With
your partner’s awareness? Without your partner knowing?
Stimulating yourself while your partner watches? Mutual
manual stimulation (simultaneously or taking turns)?
Talk about what you sexually like and appreciate about
your partner.
Talk about how you feel about what you do together sexually.
What do you really like about sex with each other?
Discuss with your partner sexual concerns you have,
remem- bering to speak empathetically, warmly, and
respectfully.
Share what you are feeling as you discuss your
sexual thoughts, feelings, and beliefs. How does it feel to
talk about sex?
 Psychosexual Skills: Enjoying Arousal and Regulating 11

Mark and Lisa found the body awareness exercise and

talking about sex particularly helpful. Mark realized that his
shyness about his body contributed to his anxiety during
sex and made it difficult to relax. He also became more
aware of his pleasure in touching Lisa, which allowed him
to feel close to her. Lisa learned she felt conflicted about
her body—she liked her face, eyes, and breasts, but felt her
legs were ugly. She also shared that as a young girl she had
been taught that sex was bad and still felt that intercourse
was dirty. She even wondered if her discomfort somehow
encouraged Mark to ejaculate quickly to get it over with.
Such open discussions facilitated their comfort.
Paradoxically, Mark worried that because this open- ness
made him feel more sexually attracted to Lisa, it would
make the PE worse. Dr. Hernandez reassured Mark that
feeling attraction and comfort was healthy, and that he
would learn how to enjoy this feeling in subsequent steps.

Step Two: Training Your Mind and Body for Relaxation

Goal: Learn relaxation, the foundation for ejaculatory
control and pleasure
Satisfying sexual functioning depends on physical
relaxation. You can’t duck or bypass this skill if you’re going
to control ejacula- tion! We’ll teach you to relax in your body,
as opposed to the more common out-of-body relaxation
strategies which focus on calm images (natural beauty) or
soothing sounds (ocean waves). In-body relaxation helps
eliminate performance anxiety and helps you focus on the
physical sensations of pleasure. This body-focused relaxation
is the foundation for sensual self-entrancement arousal.
This is where your mental focus needs to be.

How to Handle Distractions

As you do the activities in this step, notice that when
you try to focus on physical sensations, your mind may
wander or jump to other places (work, kids, shopping,
sports) 50 percent or more of the time. That’s okay at first.
Remember, this is a skill! If you didn’t need to develop it, it
would be automatic.
When you notice you are distracted, don’t fight with the
distraction or try to bulldoze it out of your mind. That just
makes it worse. Take a moment to simply accept the
distraction. Say hello to it; acknowledge it. This is important
because every distraction has an emotional piece to it, a
tiny energy of pressure or urgency. There is an emotional
nudge to attend to it. If you ignore or fail to acknowl- edge
the distraction, it will get stronger and will become a bigger
distraction, pestering you for attention (remember that the
function
1 Coping with Premature

of a feeling is to get your attention). Talk to it for a moment

so it knows you’re paying attention, then gently set it
aside until later. You might imagine you see the distraction
on your computer screen and then calmly press the “sleep”
key to clear the screen. Or imagine you place the distraction
in a file folder labeled “do later.” Then calmly bring your
attention back to the bodily sensation you are focusing on. At
first, you will be spending a lot of time calming dis- tractions,
but gradually you’ll find it easier to focus on the physical
sensations. When you’re focused on sensations more than 80
percent of the time, that’s good enough!

I NDIVIDUAL E XERCISE :
P HYSICAL R ELAXATION
Make yourself very comfortable in a chair, sofa, or bed,
loosening any tight clothing. Close your eyes and relax.
Breathe deeply and slowly: gradually inhale as you slowly
count to five, then exhale to the count of five. Concentrate
on feeling the air move slowly in and out of your body.
Concentrate on your toes. Relax them. Feel all the
tension leave your toes. Breathe calmly, deeply. Relax your
feet. Let all the tension in your feet disappear. Now let the
tension in your calves disappear. Breathe slowly, deeply.
Imagine a soothing feeling rising through your legs, through
your knees to your thighs. Let your legs feel com- pletely
relaxed and free of tension. Breathe calmly, deeply, and feel
the air glide through you.
Now focus on your pelvis. Let the muscles relax and let
go of tension. Let this soothing feeling move through your
buttocks; feel your buttocks relax. Feel yourself breathing
deeply as the tension in the lower half of your body
disappears. Then let the tension in your back begin to
disappear. Let this soothing feeling wrap around your chest,
shoulders, neck, down your arms and hands. Let this
soothing feeling move through your face. Feel your facial
muscles relax as you breathe calmly. Feel the tension
disappear from your forehead, eye- brows, jaws. Just rest
and allow your body and mind to feel relaxed and
comfortable.

Although this is essentially an individual exercise,

you and your partner can do it side-by-side. Lisa and Mark
found it helpful to make an audiotape (about five minutes
long) of these directions. By listening to the tape, they could
concentrate more easily. They did
 Psychosexual Skills: Enjoying Arousal and Regulating 11

the relaxation exercise seven times. This was good enough,

and they were ready to move to step three.

Step Three: Learning Pelvic Muscle Control

Goal: Identify and learn to consciously control your pelvic
muscle
This is the “don’t be a tight ass if you want to control
ejacula- tion” skill. It is common for your body to tighten in
response to the pressures, tensions, and burdens of life. This
includes unconsciously tightening your pelvic muscle (PM).
By learning to relax it, you give yourself a premier
technique to slow down ejaculation.

Pelvic Muscle Training

The easiest way to locate the PM is to imagine you are
squeez- ing off urination or “twitching” your penis. You’ll feel
a mild sensa- tion in one or more of the following areas: your
penis, groin, the perineal area (between your testicles and
anus), the gluteus maximus (butt) muscles, or the anus.
Because the PM is muscle tissue, it can be conditioned or
trained to perform more efficiently. What follows is a typical
experience for many men, but your body may vary, so experi-
ment to find what works for you.
The PM is used in two ways. First, because total body
relax- ation is the foundation for good ejaculatory control,
attention to relaxing the PM during sexual activity is an
efficient way to relax your whole body. If your PM relaxes,
your whole body will follow. Second, when you keep your PM
relaxed, the muscles involved in ejaculation are relaxed,
reserved, or held back. Otherwise, you’d be “priming the
pump” of ejaculation by reflexively tightening the PM during
sexual excitement.

I NDIVIDUAL E XERCISE :
PM B ASIC T RAINING
This exercise will improve your conscious awareness of the
sensa- tions of your PM and strengthen the muscle.
Contract or tighten your PM and hold for three seconds,
then relax it for three seconds while you continue to
consciously focus on the sensations. Do this ten times—
tightening three seconds, relaxing three seconds—for a total
of one minute.
Do this set (contracting and relaxing the PM ten times)
at three different times every day. At first it may be difficult
to tighten and hold the muscle for three full seconds, but
do what you can (one or
1 Coping with Premature

two seconds) and build up your strength over time. When

this is easy, move on to the next exercise.

I NDIVIDUAL E XERCISE :
T HE PM C ONTINUUM
This exercise will increase your awareness of the sensation
of your PM and increase your mental control of your PM.
Visualize that your PM can be tightened in varying degrees
of intensity, not simply tight or relaxed. Imagine a
continuum from 1 to 10, at first with three marks: 1
(relaxed), 5 (medium), and 10 (tight). Practice moving from
one point to another, holding the PM at that level for three
seconds, then relax. For example, tighten the PM to 10 and
hold for three sec- onds, then return to 1 for three seconds,
then tighten to 5 and hold for three seconds, and then relax
to 1. Practice this until it becomes easy. Once you learn this,
extend the continuum from three stopping points to five
stopping points (10—1—5—1—7—1—3—1). This will be
good enough.

Step Four: Cognitive Pacing with the

Sexual Arousal Continuum
Goal: Broaden the range of your sexual arousal
The PM training is a behavioral pacing skill. Next we’ll
show you how to develop a sexual arousal continuum as a
foundation for your cognitive pacing skills. This continuum
will be crucial when you learn progressive intercourse in
step eleven.
Each of us has our own sexual arousal patterns or
desired sequences that blend reality and imagination and
facilitate sexual arousal. By understanding the level of
arousal evoked by specific images, behaviors, and feelings,
you can consciously modify eroti- cism in order to slow
down, hold steady, or intensify arousal. In order to do so,
you must develop awareness of how calming or stimulating
a specific image, feeling, or behavior is for you.

I NDIVIDUAL E XERCISE : D EVELOPING

Y OUR O WN A ROUSAL C ONTINUUM
Make a detailed, specific list of images, feelings, behaviors,
tech- niques, and scenarios that you find arousing. Using
a scale of 1 to 100, with 100 equaling ejaculation or
orgasm, assign an arousal level
 Psychosexual Skills: Enjoying Arousal and Regulating 11

to each. In his list, Mark rated closed-lip kissing 20, fondling

Lisa’s breasts with clothes on 35, Lisa gently stroking his
penis 60, fondling her naked breasts while Lisa gently
stroked his penis 75.
Developing his detailed continuum taught Mark
awareness of the arousal value of various sensual and sexual
activities. It took him a number of weeks to fully delineate
this continuum (he eventually distinguished more than forty
specific focal points). This cognitive awareness created a
powerful pacing technique that he later used to regulate his
arousal during intercourse with Lisa.
Mark found that the things that occurred to him first
were all highly arousing behaviors and images: focus on
Lisa’s breasts and genitals, oral sex, and intercourse—all
items above 50. It was chal- lenging for him to develop the 1
to 50 range of arousal items. Lisa also developed her
continuum, and Mark learned that she found the opposite
was true for her arousal pattern. She focused first on
nongenital scenarios and found it more challenging to list
the more arousing items. As they each completed an arousal
continuum, Mark and Lisa talked openly of what they most
enjoyed, which enhanced their sexual anticipation.

Step Five: Maintaining Relaxation during Arousal

Goal: Learn to combine relaxation and sensual self-
entrancement arousal
This exercise will show you how easy it is to get an
erection, let it subside, and regain it when you stay relaxed
and focus on self- entrancement arousal. It is particularly
helpful for men who also worry about erection problems.
You’ll want to practice this exercise several times. The first
times you do this exercise, your goal is to relax and touch
yourself without getting an erection. Then patiently allow an
erection with the minimum of touch. Then you’ll practice
getting, losing, and regaining a relaxed erection.

I NDIVIDUAL E XERCISE : R ELAXED

S ELF -E NTRANCEMENT A ROUSAL
In a private place, remove all your clothes and gently
massage your body all over for fifteen minutes. Do not
pursue arousal. Use this time to focus on your body’s
sensations to help you relax.
As you touch your entire body, be aware of the feeling
of your skin and your hands on your skin. Try different
kinds of touch: softer and harder, tickling or scratching,
pinching lightly, fingering.
1 Coping with Premature

Notice which feels better and where. Be aware of your

body’s con- tours: the soft, fatty parts; the bony parts; the
firm, muscled parts. Be aware of the different textures of
your skin—coarse, soft, smooth, hairy—and how each feels
different to your hand. Try to notice your emotional
reactions as well. Then, for another fifteen minutes,
progressively do each of the following parts.
1. Soothing Genital Touch
After soothing your whole body for fifteen minutes,
begin exploring your testicles and penis with very soft and
slow touch. Do not use the intense stroking that you would
with masturbation. Instead, concentrate on the quiet, calm
sensations. Relax your PM and keep it relaxed. For at least
five minutes, use featherlike touch- ing or fingering to
explore your sensations without getting an erec- tion. Relax
and concentrate on calm sensations. Do this exercise
twice.
2. Finding Your Calm Erection
This time, when you have calmly touched your genitals
for more than five minutes, decide to very slowly obtain an
erection by continuing your total body relaxation, keeping
your PM relaxed, and fingering your penis. Calmly let an
erection happen. Patiently touch and gently pleasure your
penis. The more relaxed and focused you are on the
sensation, the easier it will become erect. You are practic-
ing getting an erection with self-entrancement arousal—
maximum body relaxation, minimal touch, and absence of
sexual fantasy.
Be patient. Typically, it will take a number of minutes
before an erection begins. Do not press it or you will
undermine your physical relaxation foundation. After several
minutes of consistently calm touch, increase the stimulation
just a little, then be patient. You are trying to find the
minimum of touch you require to get an erection. This may
take some practice and patience, and may not occur the
first time you do this exercise. If it does occur, be sure you
are not rushing it, because you would probably conclude
that you need more stimulation than is really necessary.
If an erection does not occur, keep your PM relaxed and
gradu- ally increase the touch to your penis. Try gently using
both hands. Focus on the pleasure; be patient. If after
three exercises you have not begun to find your calm
erection, then you may begin to add mildly arousing partner
interaction fantasy. Using your arousal con- tinuum, imagine
very low-arousal items (10, 12, 15, or 20). You are searching
for the mildest physical and cognitive arousals that you need
for an easy erection. If you come to focus on items above 25
on your arousal continuum and have not begun an easy
erection, it
 Psychosexual Skills: Enjoying Arousal and Regulating 12

likely means that you are not as physically relaxed as you

believe. Back up and focus again on sensual relaxation.
When your calm erection begins, enjoy it for several
minutes. Stay focused and be sure your PM is relaxed. Then
choose to let your erection subside by stopping the touch to
your penis. Do this exer- cise a minimum of two times.
3. Choosing to Wax and Wane
This time, choose to let your erection subside about 50
percent by stopping or changing the touch to your penis.
Concentrate on the sensations. As you feel it subside, stay
focused on the sensations. Then simply change the touch to
gradually bring back a relaxed erection. Notice that when
you’re physically relaxed, it is easier to get an erec- tion,
although it may take a little more time. Notice that you can
lose your erection and regain it easily when you are calm
and patient.

Phase Two: Pleasure Toleration

Now that you’ve expanded your comfort with your body and
your partner and learned relaxation and self-entrancement
arousal, you’re ready to expand your pleasure as a couple by
learning arousal toler- ation together. You’ll learn to better
identify and respect your point of ejaculatory inevitability
while tolerating progressively heightened stimulation.

Step Six: Relaxed Couple Pleasuring

Goal: Enjoy relaxed, nonerotic, sensual touch
Mark and Lisa found that the soothing, relaxing touch in
this exercise helped them to explore the sensations in their
bodies, increase pleasure, and overcome the barriers
impeding the relaxed flow of healthy sexual response. This
exercise will help you learn that when you’re relaxed,
touch can be very pleasant without being sexually arousing.

C OUPLE E XERCISE :
R ELAXED P LEASURING
Set aside one hour, and choose a private, softly lit, and
comfortable place. Undress and prepare yourself to be
relaxed and focused. For
1 Coping with Premature

fifteen minutes, pleasure the entire back of your partner’s

nude body; then for fifteen minutes, pleasure the front of
her body with the exception of her breasts and genitals.
Then have her reciprocate, spending fifteen minutes on your
back, then fifteen minutes on your front, again avoiding the
area around your nipples and your geni- tals. This touch is
not intended as massage (designed to loosen up tight
muscles) but a relaxed, comforting, sensual touch, a surface
gliding, a pleasuring.
Keep your attention on your body, focusing upon the
sensa- tions you feel as you are being touched or are
touching. Feel free to guide your partner by giving verbal
directions (“Your rubbing makes me feel warm and secure,”
“I really like what you are doing now,” “Your kisses on my
shoulder are so soothing”) or taking his or her hand,
showing how you want to be touched. If your partner
caresses you in a manner that does not please you, take
responsibil- ity to speak up. Instead of complaining, you
might say, “It feels better when you press more gently,” or
“I would enjoy a softer touch.” Otherwise, let the time be
fairly quiet so that you can con- centrate on the sensations
and pleasurable feelings. If your body responds with an
erection, you probably are overdoing the touch or coming
too close to erotic zones, so make subtle adjustments. If you
are relaxing with the pleasure, you will not feel sexually
aroused or erect. If you do arouse, simply focus more
carefully on the pleasur- able sensations, and your
excitement will subside.
Feel free to experiment with sensations. Touch, hold,
kiss, lick, suck, or otherwise caress your partner’s body in a
way that is pleas- ant and interesting. You may want to
explore the joy of touch by using massage oil or talcum
powder, or caressing with feathers, silk, fleece, or flannel.
Remember those little places: eyelids, toes, scalp, behind
the knees, bridge of the nose.
While you are receiving, selfishly soak up every
sensation. Enjoy your here-and-now experience, focusing on
sensory pleasures. By taking turns, you have the opportunity
to concentrate on your own feelings whether giving or
receiving. Although pleasing your partner is an important
part of a sensual encounter, pleasing yourself is equally
important.
Finally, do not use the exercise as an introduction to
sex. Not having sex for at least three hours afterward will
help protect the relaxing nature of this exercise. If your
mind and body anticipate that you will have sex at the end
of the exercise, this will become a distraction from your
focus on the pleasure. Remember, this is a sensual
relaxation exercise.
 Psychosexual Skills: Enjoying Arousal and Regulating 12

When you and your partner are both able to comfortably

relax, focus on the sensual pleasure, limit mental
distractions to less that 20 percent of the time, and not
experience erotic response (such as erection), you are
ready to move on to the next step.
Mark and Lisa did four sessions of this relaxed
pleasuring exercise. At first, Mark would get an erection by
simply pleasuring Lisa’s legs, thighs, or stomach. Dr.
Hernandez suggested that Mark focus more carefully on
what he was feeling in his fingers as he touched Lisa, narrow
his concentration and avoid fantasizing when looking at
Lisa’s breasts or genitals, and allow his body to relax.
Over time, Mark was able to relax and focus more
comfortably with- out having erections. This was an
indication that he had achieved the level of comfort and
relaxation needed at this step.

Step Seven: Partner Genital Exploration

Goal: Learn more about your own sensations and
your partner’s; enjoy calm, relaxed touch and physical
relaxation in an otherwise erotic situation
In this exercise, you and your partner will take turns
leading each other in an exploration of your genitals. The
purpose is to provide a sensual exploration of the body’s
erotic parts, to practice sexual leadership with your own
body, and to become more comfort- able looking at and
touching each other’s genitals in a relaxing, nonarousing
way. This exercise is a show-and-tell about your body and
erogenous zones.

C OUPLE E XERCISE : P ARTNER

G ENITAL E XPLORATION
This entire exercise should take approximately one hour.
Begin with thirty minutes (fifteen minutes for each of you) of
relaxed pleasuring of the nongenital parts of the body.
(This is a shortened version of the relaxed couple
pleasuring exercise.)
Have your partner comfortably position herself in a
reclining position, her back propped up with pillows.
Position yourself com- fortably alongside her, facing her. For
the next fifteen minutes, have her lead you in an exploration
of the erogenous parts of her body.
Discuss the sensations: what she prefers, what is
uncomfort- able. Be sure to discuss how you can enrich her
pleasure. Ask ques- tions of each other to learn or confirm
what you experience. Use a scale of 1 to 10 to talk about
how erotically sensitive a particular area is when relaxed.
1 Coping with Premature

Gently explore the sensations of her breasts, nipples,

stomach and abdomen, hips and upper thighs, inner thighs,
outer lips of the vagina and perineum (the area between her
vagina and anus), and inside the vagina. Some women have
uncomfortable feelings about examinations, associating this
with impersonal gynecological exams, so let her take the
lead. Be sure she feels comfortable and in control. Give her
your hand and ask her to direct your touch. She might have
you form a Y-shape with your index and middle fingers and
show you how to gently pleasure the outer lips of her
vagina. Talk, describe, and discuss.
When you are ready to explore sensations inside her
vagina, have her guide you in inserting one of your fingers
(usually the middle finger) and direct you in slowly
pleasuring the inside of her vagina. Imagine the vagina as
the face of a clock, with the top being 12:00. Have her guide
your pleasuring, explaining her sensations. Many women
notice they feel very little beyond three-quarters to one
inch inside. Proceed around the face of the clock to 3:00,
6:00, and 9:00, stopping at each point, exploring and
discussing the sensa- tions. Work cooperatively to learn,
confirm, relax, and enjoy.
Now it is your turn. Take the lead in the exploration of
your body. Begin with your chest and nipples. Take your
partner’s hand and direct her, explaining your sensations
and using the 1-to-10 scale to note the level of sensitivity you
feel. Be sure you feel comfortable and in control, especially
when she is exploring your testicles and penis. You might
have her cup one or both testicles and describe for her your
sensations, or ask her to explore different parts with her
index finger, showing her how to pleasure you. Many women
have heard that men’s testicles are very delicate. Be sure
to teach her about your testicles so she is not over- or
undersensitive to you. Then explore the sensations in your
penis. Have her gently place your penis back onto your
stomach. Ask her to take her index finger and, beginning at
the base of your penis, very slowly explore sensa- tions up
the penile shaft. Show her the more sensitive part on your
penis. Be sure to give her feedback about what you are
feeling each step of the way. Have her ask you questions
about your sensations.

Do this exercise a minimum of three times before

moving to the next step. The repetition will increase your
comfort. Conscious relax- ation and focus on the sensations
will allow you to feel calm, pleased, and comfortable while
doing what would otherwise be erotic.
Lisa and Mark engaged in the partner genital
exploration exer- cise four times. Both were surprised that
there was little erotic feel- ing in the genitals while in a
relaxed state. By the fourth session,
 Psychosexual Skills: Enjoying Arousal and Regulating 12

Mark and Lisa rated the sensations in nipples, lips of the

vagina, clitoris, shaft of the penis, and even the head of
the penis in the range of 1 to 3. This was quite a change
from what they expected and from what occurred the first
time they tried the exercise. During the first two sessions,
Mark began to get an erection as Lisa guided his finger ever
so slowly to different points on her breast and nipple. He had
to take several deep breaths to calm himself, pause for a
moment to let his erection go away, and then focus carefully
on the feeling in his fingers and her explanation of the
sensation. He found it difficult at first to not get an erotic
movie going in his imagination, and this, he observed later,
was what caused his erection. In short, he had to refrain
from partner interaction arousal.
Mark and Lisa became more comfortable each time they
completed this exercise, and they were surprised at how
relaxed they felt in a potentially erotic situation. In fact,
Mark worried that he would lose his natural excitement with
Lisa’s body and would have trouble getting an erection with
her. Dr. Hernandez reassured Mark that now that he knew
how to relax and maintain focus on his sensa- tions, his
erections would come and go easily.

Step Eight: Individual Pacing Training

Goal: During self-pleasuring, learn to become highly
aroused without ejaculating by first pausing, then slowing
your physical and mental stimulation
The stop-start technique, originally described by
Semans (1956), is one of the skills that is most often
associated with success at learn- ing ejaculatory control.
Remember the plateau phase of the sexual response cycle,
which we explained in chapter 2? Stop-start pacing teaches
you how to remain in the plateau phase for as long as you
choose without going on to orgasm. This technique blends
behav- ioral pacing (varying levels of physical stimulation)
with cognitive pacing (choosing a more or less arousing
focus for your thoughts). You learn to control your cognitive
arousal by shifting between self- entrancement arousal and
partner interaction arousal (in the form of fantasy).

I NDIVIDUAL E XERCISE :
S TOP -S TART P ACING
There are four stages of the stop-start training. Practice
each stage at least three times before moving on to the
next stage. This is a thirty-minute exercise, including
fifteen minutes of general
1 Coping with Premature

relaxation followed by fifteen minutes of pleasuring your

penis. The approach varies according to the stage you are
working on. First you pause, then you simply slow the
stimulation. Then you will add fantasy (partner interaction
arousal) to the mix.
The first half of the exercise is the same for all
stages. Take a few moments to get comfortable on your bed,
and then spend fifteen minutes gently and slowly touching
and soothing your body all over with the exception of your
genitals. Use this time to focus on your body’s sensations
and calm yourself. From time to time during this self-
pleasuring, turn your attention to your PM. Tighten and
relax it several times to heighten your awareness of its level
of relaxation. Consciously direct your PM to relax.
1. Stimulation Pausing
In this stage, you practice using only self-entrancement
arousal and preventing ejaculatory inevitability by
stopping stimulation.
After the fifteen minutes of relaxing touch and PM
relaxation, calmly shift your attention to your genitals. With
a dry hand (no lotion or other lubrication), masturbate for
fifteen minutes without ejaculation. Focus on your penis,
attending to the pleasure, the sen- sation. The first time you
do this exercise, touch very calmly, very slowly: a sensual
fingering of your penis and testicles, groin, thighs. At
subsequent sessions, gradually increase your touching,
stroking and allowing yourself to become more excited. Do
not rush. Do not push it. Do not get carried away. Keep your
attention only on the sensations in your penis (no fantasy
or distractions).
Eventually you will become more excited and feel that
you are approaching the point of ejaculatory inevitability.
When you sense this coming, stop the stimulation, hold your
penis gently, and do nothing but focus on the sensation in
your penis. The urge to ejacu- late will subside in fifteen
seconds to three minutes. You may also experience a partial
loss of erection; this is common and nothing to be
concerned about. When the desire to ejaculate has passed,
slowly resume your masturbation. You will probably have to
stop a number of times to avoid ejaculation when you first do
this exercise. Keep your PM relaxed. Over time, you will
learn how to recognize approaching ejaculatory inevitability,
how to anticipate the need to stop, when to stop, and how
long to wait. The number of times you need to stop will
gradually decrease.
Here are some problems you may have:
●
You ejaculate with surprise. When this happens,
usually you are not focusing carefully on the
sensations in your penis, your PM is not as relaxed
as you thought, or you are trying
 Psychosexual Skills: Enjoying Arousal and Regulating 12

too hard. Simply relax, play it safe (don’t go too close

to the brink), and focus on the physical pleasure.
●
You find you need to stop again as soon as you
resume masturbat- ing. This means that you are not
allowing sufficient time for the ejaculatory urge to
diminish. Double the time you pause.
●
You get discouraged and don’t think you are making
any progress because you continue to ejaculate
before you choose or the number of required pauses
does not diminish. This may mean that you are too
tense while doing the exercise. Calm your body while
you pleasure yourself. Be sure to monitor your PM.
Be patient.
When you feel confident of your ability to relax your
body and feel in control, and when you need only two or
three stops during the fifteen minutes, you can move on.
2. Stimulation Pacing
In this stage, you continue to use only self-
entrancement arousal, and this time you prevent ejaculatory
inevitability by pacing (slowing, not stopping) stimulation.
After the fifteen minutes of relaxing touch and PM
relaxation, masturbate for fifteen minutes without
ejaculating and without stop- ping or pausing. When you
reach high levels of excitement, make changes in your
stimulation to decrease the arousal. You can slow down the
pace, change the pressure you are applying, vary the site
of maximum stimulation (for example, by stimulating only
the shaft of your penis rather than the tip), or change the
type of stroking (for example, using longer strokes or
circular motions). Focus only on your body; no fantasy!
Remember to relax your PM and keep it relaxed.
Find what works best for you to pace your arousal.
Explore and master this. With pacing rather than stopping,
more subtle types of adjustment need to be made a bit
sooner. Do not hesitate to slow early. If you make the
change too late, you can always stop to pre- vent
ejaculation.
When you feel that you are doing well enough with this
stage, and you’re not having to stop or pause, move on
to stage 3.
3. Fantasy and Stimulation Pausing
This stage begins to incorporate partner interaction
arousal. You back off from the point of ejaculatory
inevitability by stopping stimulation.
1 Coping with Premature

During the fifteen minutes of self-pleasuring, begin to

fantasize about having sex with your partner. The idea is to
move the focus of your concentration back and forth from
your own body (self- entrancement arousal) to a fantasy of
your partner (partner interac- tion). Spend five to fifteen
seconds on your sensations, then five to fifteen seconds on
the fantasy, then five seconds relaxing your PM. Start the
fantasy with the first touch or kiss, and go through the
stages that might occur in this imagined sexual event. You
can use the sexual arousal continuum you outlined earlier.
Take your time with the imagery! You don’t have to
get through an entire sexual event in one session. Go slowly,
calmly. Use the stop-start technique, and when you stop,
imagine pausing during your fantasy sexual interaction with
your lover. Imagine she is strok- ing you, orally pleasuring
you, or having intercourse, and picture placing your hand on
her hand to pause, wait, then resume. You are mentally
rehearsing the stop-start technique in preparation for inter-
course. Remember to keep your PM relaxed.
As you get better at this, try including in your fantasy
compo- nent the erotic images you find most stimulating:
imagine your penis entering her vagina, and imagine
vigorous thrusting during intercourse.
Don’t get discouraged if your progress is slow. This is
the more challenging stage. You’re learning to balance
your focus on your own physical sensations, your PM, and
your fantasy—all while mon- itoring how excited you are
becoming. If you feel frustrated, simply stop or pause
sooner.
When you are comfortable and in control while
fantasizing erotic scenes, you are ready to move to stage
4.
4. Fantasy and Stimulation Pacing
This stage is identical to stage 3 except that now you
pace (slow) rather than pause. As you make adjustments in
your masturbation, imagine yourself making them in partner
sex. Take it as slowly as you need to. When this stage is
going well, use a lubricant on your penis to simulate the
sensations of intercourse.

When you are comfortable with your individual

ejaculatory control, blending self-entrancement, partner
interaction fantasy, and PM relaxation, you are ready to
learn couple stop-start pacing.
 Psychosexual Skills: Enjoying Arousal and Regulating 12

Step Nine: Couple Pacing Training

Goal: Learn to become highly aroused without
ejaculating when your partner is stimulating you
This is the teasing-can-be-fun step! This exercise
teaches you to integrate self-entrancement arousal, partner
interaction arousal, and PM relaxation while your partner is
pleasuring you. This is where you need your partner’s
assistance and patience.

C OUPLE E XERCISE :
S TOP -S TART P ACING
Couple stop-start pacing consists of four stages, just like
individual stop-start pacing. Each practice session takes one
hour. Repeat each step until you are relaxed doing it
before moving on to the next.
Each session begins with thirty minutes of relaxed
couple pleasuring, which you learned in step six. Then, for
fifteen minutes, your partner directs you in pleasuring her
body in whatever fashion she wishes, allowing her to
become highly aroused but without going on to orgasm.
The final fifteen minutes is different for each of the four
stages. As you work through these stages, be sure to com-
municate with your partner and keep your PM relaxed. All of
the suggestions for individual stop-start pacing apply here
as well.
1. Pausing
During your fifteen minutes of arousal practice, guide
your partner to touch your penis and testicles, groin, and
thighs calmly and gently. Keep your attention only on the
sensations in your penis (that is, focus on self-entrancement
arousal). When you feel that you are approaching the point
of ejaculatory inevitability, signal her to stop stroking,
pause, and gently hold your penis. Focus on the sensa- tion
as she holds you. When the desire to ejaculate has
passed, slowly resume stimulation.
2. Pacing
Instead of stopping or pausing to prevent ejaculation,
work with your partner to slow the stroking without
stopping. Then have her increase stimulation again when
you are relaxed and not at risk of ejaculating. Be sure to
focus only on your sensations, not on your partner.
Remember that you can always stop to prevent ejaculation.
3. Pausing with Partner Focus
1 Coping with Premature

Gradually shift the focus of your concentration from

your own sensations to enjoyment of your partner (looking at
her or watching her touch you) to relaxing your PM. When
you first shift your focus to your partner, be careful not to
overstimulate yourself—remember your arousal continuum.
When you realize you are getting close to ejaculatory
inevitability, pause. As you progress, you may want to use a
lubricant on your penis to heighten the pleasure and more
closely simulate feelings of intercourse. You are training
yourself to enjoy more pleasure without ejaculating.

4. Pacing with Partner Focus

This final stage builds on stage 3 by slowing instead of

pausing.

You are well on your way to learning to integrate

relaxation, cooperation, self-entrancement arousal, and
partner interaction arousal. You gain significant power by
learning to control the pacing of your arousal.
Mark and Lisa found that during the fifteen minutes
Mark was pleasuring Lisa, he had to focus carefully on the
touch he was giv- ing, on the physical sensation in his
hand, and close his mind to Lisa’s sounds and movement
—in short, he had to not watch the erotic movie he was
facilitating. At first, when Lisa was pleasuring Mark, he
needed to pause often, but by the third session he could
arouse close to ejaculation, keep his PM relaxed, and enjoy
the plea- sure of high arousal without ejaculating.
The key features of Mark’s work during this step were
relaxing the PM, focusing principally on sensual self-
entrancement arousal and then carefully beginning to allow
some partner interaction focus, and pacing the touch he
received from Lisa. Monitoring these three features was
quite complicated at first—he felt like he was juggling too
many things—but with repetition and his just-be-good-
enough attitude, it became easier and more comfortable.
Mark became concerned when he ejaculated during the
second exercise (pacing without partner focus). He was
feeling relaxed, enjoying the feel of Lisa stroking his penis,
concentrating on the pleasurable sensations, monitoring his
PM to keep it relaxed, and anticipating the point of
inevitability—and yet he still ejaculated. When he later
evaluated what happened, it became clear that while he
was doing all the right things, he still was allowing an
erotic movie to play out in his mind. Mark realized that
even though he was carefully orchestrating his focus,
he was also having brief
 Psychosexual Skills: Enjoying Arousal and Regulating 13

images of partner interaction. He looked at Lisa stroking

him, glimpsed her breasts, her eyes, even had images of
intercourse flash through his mind. When he realized this, it
made sense that he had lost control and subsequently
ejaculated. He was amazed to experi- ence this power of his
mind. By adjusting his mental focus, he could regulate his
arousal. It was a dramatic demonstration to Mark of the
difference between self-entrancement and partner
interaction arousal. This was one of his most important
experiences in learning to pace his sexual arousal.

Phase Three: Pleasure Saturation

In this phase, you’ll learn to experience prolonged
intercourse and enjoy more intense sexual stimulation
without ejaculating quickly. You’ll learn to stay relaxed while
welcoming the sensual pleasure of intercourse. Pleasure
saturation—soaking yourselves with plea- sure— is one of
your rewards for learning ejaculatory control. We’ll coach
you as you integrate or orchestrate the skills to overcome PE
during intercourse. At first this might be awkward, but with
practice it will become second nature.

Step Ten: Intimate Intercourse

Goal: Learn to calmly adapt to intercourse
Mark and Lisa gained confidence from their success
with stop-start pacing, but both felt anxious about this next
step. Inter- course was where Mark had the most trouble
controlling his arousal and ejaculation. Their anxiety was
understandable. Many men with PE feel that intercourse is
the ultimate test of their success in ejacula- tory control.
This exercise will help you take the next step
successfully by showing you how to keep your PM relaxed
during insertion and by teaching you to stay relaxed while
acclimating (adjusting) to the sensation of your partner’s
vagina.

C OUPLE E XERCISE : I NITIATING AND

A CCLIMATING TO I NTERCOURSE
Relax by doing thirty minutes of couple relaxed pleasuring.
Then lie on your back as your partner straddles you and
helps you gain an erection. Using only self-entrancement
arousal (that is, focusing on
1 Coping with Premature

your own sensations), allow yourself to become aroused and

erect. When you are ready to begin intercourse, be sure your
PM is relaxed at the 2 or 3 level. This is particularly
important at the moment of starting intercourse because
when she is inserting your penis, it is natural for the PM to
tighten or “salute” as a reflex. If you allow this to happen,
you are unwittingly tightening the very muscles involved in
ejaculation, thereby “priming the pump.” Relaxing the PM
muscle, especially during insertion, will offer some
reserve.
While focusing on your penis, keep the PM relaxed
while your partner slowly inserts you. Once inside, simply
rest, enjoying the warmth and closeness. Focus on the
pleasure in your penis. Wait, calmly expecting to reach the
physical pleasure “saturation point” where your penis
acclimates to the warmth and sensuousness of her vagina.
For most men, this sensation develops after approximately
ten to fifteen minutes of resting inside the vagina, but we
have seen a range of seven to twenty-seven minutes. Move
only minimally to maintain your erection. Your objective is to
remain entirely passive, alternating your attention between
maintaining PM relaxation and focusing on the pleasure in
your penis. It is important to focus on self-entrancement
arousal throughout this step.
After acclimation occurs, you can begin to tolerate and
enjoy more intense pleasure while you maintain ejaculatory
control. Enjoy at least fifteen minutes of relaxed intercourse,
then feel free to choose to ejaculate. Rest for a moment to
catch your breath, then stay with your partner and pleasure
her in whatever ways she prefers. She is also now free to
experience orgasm if she wishes.

When Mark and Lisa first tried this, it took Mark

eighteen min- utes of relaxed intercourse to begin to
experience acclimation. The sensation of acclimating is
commonly vague at first, so we recom- mend that you wait
three minutes beyond when you think it is happening, just to
play it safe. The good news is that once you expe- rience
acclimation, it usually does not take as long in future
sessions, but at first ten, fifteen, or twenty minutes or longer
is not unusual. In successive sessions, Mark’s acclimating
time lessened to about eight minutes.
When the acclimation was established, he and Lisa
began to slowly move during intercourse. Mark maintained
his focus on the sensations of relaxed pleasure. At first he
feared this would make him ejaculate, and he was
surprised to find it actually helped him not to. Mark could
accept the pleasure without moving to the point of
ejaculatory inevitability. They could pause or pace movement
to avoid ejaculation. Both were amazed that they were
able to have
 Psychosexual Skills: Enjoying Arousal and Regulating 13

twenty minutes or more of careful intercourse after

acclimating (for a total of more than thirty minutes of
intercourse), even though it was reserved and subdued. Lisa
said she loved the relaxed feeling of closeness while calmly
enjoying intercourse.
As Mark’s comfort increased, he was able to keep his
PM at a 2 or 3 ranking as he focused on the pleasure in his
penis. So Dr. Hernandez suggested that Mark cautiously
begin adding moments of partner involvement arousal,
focusing on Lisa’s body and move- ments and even looking
into Lisa’s eyes. After some shyness, they both remarked
how much they liked this. They were surprised that this also
felt calming and close.

Step Eleven: Progressive Intercourse

Goal: Integrate the skills and become open to spontaneity
Buoyed by their progress with the acclimating step,
Mark and Lisa decided they were ready to put together
everything they’d learned by trying progressive intercourse.
They took thirty minutes at the start of a session to enjoy
pleasant, soothing touch. They talked little, focusing on the
pleasing sensations. At first they simply enjoyed relaxed
intercourse, waiting for the acclimating. When this occurred,
they began to enjoy slow, reserved intercourse movement for
ten minutes or so. At first only Lisa would do the moving
(to help Mark focus on relaxed pleasure), but gradually Mark
and Lisa would take turns moving, then move together
cooperatively and slowly.
Mark had some trouble keeping himself focused, but
gradually got into a pattern of alternately focusing on the
pleasure in his penis for fifteen seconds and monitoring his
PM for five to ten seconds to keep it relaxed.
When he became comfortable with this pattern, they
switched from Lisa on top to Mark on top. This required
more careful man- agement of PM relaxation because being
on top uses the muscles dif- ferently and makes it harder to
relax them. Mark also had to be more careful to stay
focused on sensations in his own body. When this, too,
became easier, he began to add small doses of a third
focus: Lisa! Mark allowed himself five-second increments of
partner inter- action arousal (looking at Lisa’s body) before
returning his attention to the sensation in his penis, the
PM, and his penis again.
Orchestrating this was taxing at first, but it worked
because their intercourse movement was slow. Mark was
doing okay pacing and didn’t need to pause now. Slowly
Mark became more comfort- able and confident integrating
PM relaxation, exquisite focus on the
1 Coping with Premature

pleasure in his penis, and calm and gradual inclusion of

partner interaction arousal.
During the fourth practice session of progressive
intercourse, Mark inadvertently ejaculated. His first
emotional reaction was to feel deeply despondent, but he
was wonderfully helped by Lisa’s gentle reminder that he
was making such good progress. He also realized his
reaction was the same old negative one—feeling like a
failure. He caught himself and emotionally regrouped. He
realized that Lisa was correct: it was just a goof, not a
relapse. He was making good progress.
From this setback, Mark learned that he needed to
guarantee that acclimation had occurred by waiting an extra
minute, and needed to not get sloppy about maintaining his
focus on self- entrancement arousal, monitoring his PM, and
being careful about the partner interaction arousal. This is
where the arousal continuum he had designed earlier was
helpful. When he evaluated what hap- pened when he
ejaculated without choosing to, he realized that he was not
only focusing less on his body and the PM, but also focusing
more on Lisa’s body and movements. Mark recognized that
he had made a mental mistake: he had shifted too quickly
from a moder- ately arousing item on his continuum (a 55
item, “watching her breasts as she moved up and down
on me”) to a highly arousing item (a 90 item, “imagining
Lisa getting close to orgasm”). This confirmed for Mark the
power of cognitive pacing.
Mark was able to accept more and more stimulation as
he balanced focus on the pleasure in his penis (self-
entrancement), PM relaxation, Lisa’s body and activity
(partner interaction), and at times imaginary items on his
arousal continuum that were less exciting than the actual
activity he and Lisa were sharing. Here he was coor-
dinating four cognitive and behavioral pacing techniques,
grounded in physiological relaxation, within a cooperative
relationship and with the pause technique as a backup.
As Mark became more proficient—and more confident—
he and Lisa began to focus more on her feeling freer to do
what she desired. They had more sessions where Mark asked
her to have intercourse her way—a kind of teasing with
intercourse similar to the stop-start teasing with manual
stimulation. This allowed Lisa to loosen the restraints she
had felt for so long, and allowed Mark to practice his
cognitive pacing techniques. As Mark and Lisa cooperated
more, they increased their comfort, pleasure, and
confidence. They were focusing more on pleasure and
closeness and less on ejaculation.
It was not all easy, however. There were good days
and not- so-good days. It took longer than they had wished.
There were moments of worry, sessions that bombed. They
had to remind each
 Psychosexual Skills: Enjoying Arousal and Regulating 13

other what they were trying to do with each step so that they
did not revert to old ways of thinking, feeling, and acting. It
took self- discipline and cooperation. But they cooperated.
They concentrated. Their alliance and patience were
indispensable. They were good enough. They were feeling
closer, warmer, more secure together. They were
succeeding.

C OUPLE E XERCISE : P ROGRESSIVE

I NTERCOURSE
You are ready to experience more variety, excitement, and
pleasure during intercourse. Follow Mark and Lisa’s
example. Remember to establish intercourse acclimation and
to balance your focus for ade- quate management of arousal,
but also allow yourself to enjoy expanding your freedom
with intercourse.
As you add partner interaction arousal, keep in mind
your arousal continuum. Don’t drag race. That is, don’t start
at 50! Begin slowly, gradually, gently. Stay focused on each
specific activity or image for at least fifteen seconds before
changing. Shift attention in small steps. Do not change from
one focus to another that is more than five points above.
If you have a setback, simply learn from it and regroup.
Remember, you are still learning to integrate the different
dimen- sions of arousal management. With practice, you will
find coordinat- ing your arousal becomes second nature,
requiring less conscious attention. This reopens your sexual
relationship to more personal feelings and deeper intimacy.
Enjoy!

What If These Skills Don’t

Work for You?
While this program is helpful for most men and couples, do
not be discouraged if some of the skills do not work as
well for you. It is not well understood why the same skills
that help many men don’t work for others—or may even have
the opposite effect. For example, some men find that PM
relaxation does not help. Rather, these men find that
tightening, holding, and exhausting the PM is more effec-
tive. So don’t be afraid to experiment with how various
techniques work for your body. If you get stuck, it would
be wise to consult with an experienced marital and sex
therapist to help you develop
1 Coping with Premature

your own way to integrate the skills for increasing

ejaculatory con- trol and sexual intimacy.
 9

Couple Sexuality: Building

an Intimate, Interactive
Couple Sexual Style

Now that you’ve built solid skills to improve your sexual

relation- ship, you’ll want to consider how this fits into the
“big picture” of your relationship. Your relationship has
undoubtedly changed as you’ve learned the skills in this
book. You’ve developed new levels of intimacy,
communication, and closeness. This is a good time to ask
yourself what you want your relationship to be like, and how
sexuality will fit in.
You owe it to yourself and your partner to develop a
comfort- able, pleasurable, and functional couple sexual
style. This will help you maintain the progress you’ve made
in dealing with PE and will strengthen your long-term sexual
and relationship satisfaction. Healthy sexuality is a team
effort, not an individual performance. Emotional and sexual
intimacy is the glue of your couple bond. Your intimate
relationship is the energy source for a vital, satisfying
sexuality.
The traditional belief was that the more emotional
intimacy, the better the marriage. In fact, that is a myth. A
crucial factor in devel- oping a cooperative marital style is
maintaining balance between autonomy and intimacy; that
is, balance between individuality and couple focus.
In this chapter, we’ll take a look at the common marital
styles and the role sexuality plays in each. We will examine
both strengths and potential problems of each marital and
sexual style. We will also
1 Coping with Premature

examine dating and serious relationships and the role of

sexuality in these. Finally, we’ll guide you through actively
and consciously choosing a couple style that works for
you.

Marital and Sexual Styles

There are four marital styles. In their order of frequency,
they are complementary, conflict minimizing, best friend,
and emotionally expres- sive. Of course, these are not pure
categories, but one style commonly predominates for a given
couple. Each style describes a different approach to
intimacy, autonomy, communication, power dynamics, and
the role of sex within the relationship, as well as a different
approach to initiating sex, interacting during sex, and ending
sexual encounters.

The Complementary Couple Style

The complementary couple style is the most common.
The partners respect each other’s contributions, each
partner has his or her domain of competence and power,
and each values moderate intimacy balanced by a clear
sense of autonomy. These couples are able to resolve
conflicts and maintain dialogue about difficult issues. Each
partner feels valued, respected, and cared for. The emotional
tone of the relationship is affirming.
Complementary couples have a good sexual
relationship, see- ing sexuality as a positive, integral
component in the marriage but certainly not the most
important factor.
The trap for this marital style is to fall into a pattern of
routine, mechanical sex. Sex becomes a low priority,
occurring late at night after all the important things in life
(like putting the children to sleep, paying bills, walking the
dog, and watching the The Tonight Show) are done. Sex
might be functional (for instance, the man maintains good
ejaculatory control), but it lacks excitement and emotional
intimacy. The couple thinks about their premarital sexual
experiences—and possibly their experience working together
to learn ejaculatory control—and they miss that sense of
connection and specialness.
Marital sexuality cannot rest on its past success; setting
aside couple time and valuing intimate sexuality are crucial.
To maintain healthy sexuality, complementary couples can
decide to make sexual initiation a shared domain, or one
spouse can claim it as his or her domain. Ideally, each
spouse would be comfortable initiating and each would feel
free to say no and perhaps offer an alternative way to
connect.
 Couple Sexuality: Building an Intimate, Interactive Couple Sexual 14

Traditionally, it is the male who makes sexuality his

domain. This is fine as long as he is committed to
maintaining a satisfying sexuality. The danger is that he
might overemphasize intercourse as a performance at the
expense of intimacy, affection, and pleasuring. Improved
ejaculatory control alone will not be enough to ensure the
woman’s anticipation, pleasure, and satisfaction. The other
danger, especially with the aging of the people and the
marriage, is that the man’s focus on performance and
intercourse subverts satisfaction. A broad-based, variable,
flexible approach to couple sexuality is more likely to
promote desire and satisfaction, and helps inoculate the
couple against sexual dysfunction. Maintaining a vital sexual
rela- tionship is a couple task, with the woman’s sexual
feelings and “voice” playing an integral role.

The Conflict-Minimizing Couple Style

The conflict-minimizing couple style is the most stable.
These marriages are usually organized along traditional
gender roles, with the man as the prime income generator
and the woman the home- maker, although other patterns
are common in recent years. They are characterized by
avoidance of strong emotional expression (espe- cially
anger), limited intimacy, and emphasis on children,
family, and religious values. The emotional and practical
rules of the mar- riage are clearly understood and
consistently implemented. Conflict- minimizing couples value
security over intimacy and family over the couple
relationship. People value this marital style because of the
predictability and security.
The role of sex is de-emphasized. Often, the limited
emotional expression in these relationships results in
inhibited erotic expres- sion. Sexual problems are typically
minimized. The couple avoids confronting sexual issues.
Initiating sex and establishing sexual frequency is
viewed as the man’s role. The sexual scenario emphasizes
intercourse, with a focus on one-way foreplay rather than
mutual pleasuring. The expec- tation is that she will function
like him: have a single orgasm during intercourse. Sex is his
domain, affection and feelings are her domain. There are
several possible sexual traps with this marital style.
The biggest is that sex becomes marginal and mechanical,
and even- tually very infrequent. The couple falls into the
cycle of a low-sex or no-sex marriage. Another trap is that
the focus on intercourse makes the man vulnerable to
erectile dysfunction and inhibited sexual desire as he ages.
When couples stop having sex, whether at forty, sixty, or
eighty, it is almost always the man’s unilateral, unspoken
decision. He is too frustrated and embarrassed by sexual
problems
1 Coping with Premature

and decides sex is not worth the effort. The partners have
not been intimate friends, which makes it hard to develop
intimate, interactive sexuality.
Conflict-minimizing couples miss the opportunity to use
con- flicts to deepen intimacy, and underplay the positive
role of sexual- ity in sharing pleasure and energizing their
marital bond. We urge couples who choose this marital style
to be sure that sexuality, including enjoying ejaculatory
control and intercourse, plays a healthy 15 to 20 percent
role in marital vitality and satisfaction.

The Best Friend Couple Style

The best friend couple style is characterized by the
highest degree of intimacy, acceptance, and sharing;
equitable distribution of roles and responsibilities; and a
strong commitment to a close, vital marriage. Although this
is the cultural ideal, this marital style runs the risk of
leading to disappointment and alienation when emotional
and sexual expectations are not met or there are
irresolvable conflicts.
When both individuals choose this marital style and
devote the time and psychological energy to make it
successful, this can be a very impressive marriage.
However, it is not the right marital style for the majority of
couples. Best friend couples have a high divorce rate, based
on disappointment and resentment toward the spouse and
the marriage. The marriage cannot live up to the “love
means never having to say you’re sorry” promise.
Sex is a positive, integral, vital resource. Sexuality
energizes the marital bond and makes it special. The couple
enjoys touching both inside and outside the bedroom.
Intimacy, pleasuring, and eroticism are valued by both
people and integrated into their lovemaking. They develop
a sexual style that is flexible and responsive to the feel- ings
and preferences of both partners.
What are the traps of this marital style? The biggest
emotional trap is relationship enmeshment, meaning that the
couple sacrifices autonomy and individuality for the sake of
the couple bond. When things do not work well, they may
regress to hurt, blaming, and resentment. Disappointment
and disillusion rob the marriage of vitality. The couple lacks
conflict resolution skills and is bitter over thwarted hopes
and expectations.
The biggest sexual trap is inhibited sexual desire.
Ideally, inti- macy and couple time serve as bridges to
sexual desire, but too much intimacy can stifle erotic
feelings. In truth, either too little or too much intimacy can
subvert desire. If the couple is so emotionally close that they
cannot make sexual requests, if they de-eroticize each other,
or if they are so worried about hurting each other that they
do
 Couple Sexuality: Building an Intimate, Interactive Couple Sexual 14

not share negative sexual feelings, they are in trouble. They

need to have a mutually comfortable level of intimacy that
promotes connec- tion and sexual desire.
Best friend couples are not assertive in dealing with
sexual dysfunction or dissatisfaction. They expect that each
should know what the other is thinking and what the other
wants without having to ask or explain. The cultural myth is
that love is all we need. But when there is a sexual
dysfunction, love is not enough. Warm feel- ings and caring
communication are very helpful, but are not enough to
overcome PE and maintain a satisfying sexual relationship.
The combination of taking personal responsibility and
working as an intimate team can be a challenge for best
friend couples. They often become stuck in a cycle of
avoidance, not wanting to push the other, waiting for the
other to initiate. Avoidance compounds the sexual problem.

The Emotionally Expressive Couple Style

The emotionally expressive couple style is the most
volatile and unstable, but the most engaging, fun, and
erotic. Intimacy in this style is like an accordion: sometimes
very close, other times very dis- tant. Emotionally expressive
couples have the highest intensity of feelings, both loving
and angry. These couples value intimacy and vitality without
being afraid of conflict or anger. When this marital style
works well, the couple has a vibrant and exciting
relationship. They value sexuality that is spontaneous,
adventuresome, playful, and energizing.
Unfortunately, this is the most unstable marital style,
the most likely to result in divorce. The conflicts become too
frequent and intense. Emotionally expressive couples can
deal with disappoint- ment, anger, and conflict, but if they
cross the line into personal put-downs, contempt, and
disrespect, this breaks the marital bond.
There are a number of potential sexual problems. A
particularly unhealthy pattern is to use sex to make up after
an abusive fight. It is poisonous for physical or emotional
fights to serve as foreplay for sex. Another problem is that
a gradual, step-by-step approach to dealing with PE or
another sexual dysfunction—or a relapse—is not compatible
with this couple style. They want a more spontaneous,
freewheeling approach. If the sexual problem is not quickly
resolved, they fall into the trap of feeling demoralized, bitter,
and blaming. Problematic sex increases the risk of an
affair or breakup.
To combat these traps, the emotionally expressive
couple needs to remain aware of respecting personal and
sexual boundaries. If
1 Coping with Premature

there is a sexual problem or dysfunction, they must address

it with- out putting down the spouse or destabilizing the
relationship.

Choosing a Marital and

Sexual Style
It is important for you and your partner to adopt a couple
style, especially in how you deal with intimacy and conflicts.
It is crucial that you adopt a sexual style that is compatible
with, and hopefully enhances, your marital style. One style is
not better than another, but mutual endorsement of your
chosen couple and sexual style is part of being a marital
team. It is not the man’s (or the woman’s) decision to make
alone, but a cooperative choice based on respect and empa-
thy for each spouse’s preferences, needs, and values.
As you choose your style, the two most important issues
to address are the amount of intimacy and the importance of
sexuality. Intimacy includes sexuality, but is much more than
sexuality. Espe- cially important in emotional intimacy is the
degree and quality of personal self-disclosure and empathy.
Sexual intimacy includes affectionate, playful, sensual, and
erotic touch in addition to inter- course. An example of a
problematic intimacy and sexuality pattern is when one
spouse (typically the woman) desires high levels of emotional
intimacy, while the other spouse wants sex to be the main
source of connection. This couple is likely to have a
“pursuer” and a “distancer.” When couples fall into the
pursuer-distancer trap, both emotional intimacy and
sexuality suffer. Sex ought not to become a power struggle,
but a mutual, voluntary, and pleasure-oriented experience
within an emotionally satisfying relationship.
Traditional sexual socialization dictates that males value
sexual frequency and eroticism while females value intimacy
and affection. This generates heated arguments on talk
shows and in bars, but sheds little light on the reality and
complexity of couple sexuality. To honestly assess your
desires about your sexual relationship, you and your partner
need to look beyond rigid sex roles. This may be partic-
ularly difficult for conflict-minimizing couples.
In choosing the marital and sexual style that’s right for
you, discuss together the strengths and vulnerabilities of
each style. For example, the sexual style least impacted by
PE and other sexual problems is the conflict-minimizing
style. Sexual expectations are lower and sexual problems de-
emphasized. Marital rules are very important for conflict-
minimizing couples. Yet these couples face crises when an
affair violates the core rule of fidelity or an infertility
problem threatens the core value of family. So a conflict-
minimizing
 Couple Sexuality: Building an Intimate, Interactive Couple Sexual 14

couple may be able to take PE in stride, but may be less

resilient in other ways.

Nick and Donna’s Story

Before Nick and Donna started working on ejaculatory
control together, Nick had given no thought to a couple or
sexual style; his focus was on intercourse frequency as a way
to compensate for PE. Donna had hoped for a best friend
marriage with abundant commu- nication and touching. If
anything, Nick tended toward the conflict- minimizing style,
and he especially did not want to talk about sexual problems.
Nick’s emphasis on intercourse, Donna’s frustration with the
chronic PE, her disappointment with his reluctance to talk
about sexual issues, and her resentment at always being
the one to reach out for affection upset her deeply. She
questioned Nick’s commit- ment and the viability of the
marriage.
The ejaculatory control program was successful for Nick
and Donna. Much to Nick’s surprise, slowing down the
sexual process, focusing on pleasure, taking medication
(Nick had neurologic system PE), and especially learning to
do a good-enough job of using the psychosexual skills
dramatically improved their sexual enjoyment and
satisfaction. Donna enjoyed her role as an active, involved
spouse during the ejaculatory control exercises. Nick
appreciated Donna as an intimate ally in facing up to and
changing PE.
Nick was now willing to address general relationship
issues as well as a PE relapse prevention program. Donna
appreciated this, but was still bothered by Nick’s reluctance
to discuss emotional issues. Finally, Nick disclosed that he
feared that Donna’s demands for emotional intimacy were
really a hidden agenda to limit his personal autonomy. He
was afraid she did not so much want to be close to him as to
overwhelm him emotionally and be critical of him. Donna
had grown up with the cultural myth that the more intimacy,
the better. Nick reassured her that he loved her and valued
the marriage but did not want to lose his autonomy or feel
smothered.
Contrary to gender myths, men have similar needs for
intimacy and security as women. The difference is not in
needs, but in fears. The man fears being controlled or
being seen as deficient or failing his partner. As they
discussed their feelings, preferences, and fears, it became
clear to Nick and Donna that a complementary couple style
would fit them best. This allowed a balance of autonomy and
togeth- erness, with moderate amounts of emotional
intimacy, and fit well with the personal responsibility–
intimate team approach to sexuality. Both Nick and Donna
were highly motivated to maintain their sexual gains
around ejaculatory control and sexual enjoyment and
1 Coping with Premature

not allow a relapse. It was important to Nick that Donna

realize that he was more emotionally open to her than to any
other person in his life, and that he highly valued her and
the marriage and enjoyed marital sexuality. At the same
time, he needed to have a personal and emotional life
apart from her. He especially wanted the freedom to hang
out with his buddies from the soccer team, and the time and
space to keep active in local politics. This was not a rejection
of Donna, but something which was healthy for him.
Nick was an antsy, high-energy guy who found sitting and
talking about feelings uncomfortable. He and Donna
developed a pattern of doing house chores in tandem and
talking about emotional, sexual, and life- planning issues as
they worked side by side.

Men in Dating or
Living-Together Relationships
Many men with PE are single, divorced, or in cohabitating
relation- ships. How do the couple and sexual styles relate to
them? Consider that there are three levels of relationship
connection: sexual friend- ships, lover relationships, and
serious relationships. At all levels of a relationship, there are
two important guidelines. The first is to treat the woman
with respect and have an understanding that you will try to
not do anything emotionally or sexually that is harmful to
her or to yourself. The second is to be realistic about the
relationship and not to overpromise or be manipulative.
A sexual friendship relationship is just what it sounds
like: you are friends who have an active sexual relationship.
As with any other friendship, you want to treat the person
well, expect to be treated well in turn, and freely share
activities and emotions. However, you do not promise a
lifelong relationship or change life plans, career, or where
you live for the woman, nor do you ask her to make those
changes for you. Both people are direct and clear about their
expecta- tions. Whether the relationship lasts six months or
three years, the reality is it will end. Hopefully, you wish
each other well and remain friends, but there are no
guarantees.
The lover relationship involves more closeness, more
sharing (you may or may not live together), and more of an
emotional investment. Lovers meet each other’s families,
make long-term vaca- tion and holiday plans, and integrate
each other into their lives. However, you do not change
your life or career plans for a lover. You do not promise a
lifetime commitment or plan to have children in a lover
relationship.
 Couple Sexuality: Building an Intimate, Interactive Couple Sexual 14

The serious relationship has the potential to result in

marriage. This is the type of relationship in which you
consider changing your life in tandem with your partner and
discuss all the hard and sensi- tive issues involved in sharing
your lives emotionally, practically, financially, and sexually.
Issues of respect, trust, and emotional and sexual
intimacy are just as relevant for nonmarried couples as for
married ones. How- ever, sexuality—including PE—should
not make or break the future of the relationship. For
example, the fact that the woman helped you with
ejaculatory control does not mean that you owe her—or
that she owes you—a lifelong commitment. Conversely,
struggling with a sexual dysfunction is problematic but need
not be a reason to termi- nate a relationship. As in a
marriage, sexuality should play an important but not
primary role.

Developing Your Couple Sexual Style

Your task is to establish your unique sexual style by
exploring and sharing your sexual desires, feelings, and
preferences. This exercise is divided into phases, the first to
do individually. Then you’ll share your thoughts and reach
understandings and agreements about your unique couple
style. You’ll discover what is uniquely and mutually
pleasurable and satisfying for you.

E XERCISE : D EVELOPING Y OUR

C OUPLE S EXUAL S TYLE
1. Think about and then write out (this makes it more
concrete) the answers to the following questions. Do not
be “politically correct” or try to second-guess your
partner. Be free and explicit.
●
How much intimacy do you want in your life
and relationship?
●
What are the most important emotions you want to
share in your relationship?
●
What is your preferred way to deal with
differences and conflicts?
●
What is your preferred couple style: complementary,
conflict minimizing, best friend, or emotionally
expressive?
●
How important is sex in your life? How important
is your relationship?
1 Coping with Premature

●
In terms of affectionate touch, do you prefer kissing,
holding hands, or hugging?
●
How much do you enjoy cuddling? How important is it
to you?
●
How do you distinguish affectionate touch from
seductive or sensual touch?
●
How much do you enjoy sensual touch? Do you
prefer taking turns or mutually giving and
receiving?
●
What is the meaning and value of playful touching?
How comfortable are you with affectionate nicknames
for your genitals?
●
How much do you enjoy erotic scenarios and
techniques? Do you prefer single stimulation or
multiple stimulation, taking turns or mutual
stimulation, using external stimuli or not? Do you
enjoy erotic sex as a route to orgasm or only as a
pleasuring experience?
●
What is your preferred intercourse position? Man on
top, woman on top, rear entry, side to side? What
type of thrust- ing do you prefer? In and out?
Circular? Deep inside? Shal- low? Do you want to
engage in multiple stimulation during intercourse?
●
How much do you value afterplay as a part of your
love- making style?
2. Read your partner’s responses and then carefully discuss
together each question, clarifying both the practical and
emotional dimen- sions. Remember that you are not clones
of each other. You want to maintain your individuality
and not feel embarrassed or apolo- getic about your
emotional and sexual desires. Your preferences and
sensitivities are part of who you are as a sexual person
and must be integrated into your couple style for you to
be truly satisfied.
3. Divide your answers into three categories:
Areas you agree on. These will enhance your enjoyment
and satis- faction with each other and your relationship. For
example, you both agree that you want a complementary
couple style. You want sex to play a 15 to 20 percent
energizing role; there are no major sexual secrets or
conflicts; you both enjoy affectionate and playful touch more
than sensual touch; on occasion you find erotic sex to
orgasm highly satisfying; you agree on two favorite
intercourse positions; and you both value quiet, bonding
afterplay.
 Couple Sexuality: Building an Intimate, Interactive Couple Sexual 14

Areas you can reach agreement on. Identify differences

you can accept and perhaps even enjoy. Perhaps one
spouse prefers a conflict-minimizing couple style while the
other wants the closeness of the complementary style; one
partner values sharing daily feelings and experiences while
the other is more emotionally reserved; the spouse who puts
more value on sex agrees to be the prime initiator; one
person prefers kissing and the other holding hands; one
would rather do sexual touching standing up and the other
likes lying in bed; he likes verbalizing sexual fantasies while
she likes to close her eyes and fantasize; she likes to switch
intercourse positions while he pre- fers to be on top. These
are not matters of right or wrong. You can integrate your
preferences or take turns. Enjoy your partner’s sexual style.
Remember, an involved, aroused partner is the best
aphrodisiac.
Differences to accept or adapt to. Finally, when there are
genuine major differences between you, work to accept or
adapt to them. For example, one wants a conflict-minimizing
relationship while the other wants an emotionally expressive
style; one puts a very high priority on sex while the other is
indifferent; one wants a daily sensual massage and the other
hates massage; she wants to use a vibrator dur- ing
intercourse to help her be orgasmic and he is turned off by
the vibrator; he wants to try a variety of intercourse
positions but she strongly prefers rear entry; he likes being
sexual early in the morning while she only wants to be
sexual late at night; he wants to experi- ment with swinging
relationships and she values monogamy. It is not easy, or
even possible, to integrate many of these differences, but
there are two major coping strategies. One is to
acknowledge your differ- ences but not let them turn into a
power struggle. Instead, accept them and try to work around
them. It helps to remember that difference does not equal
rejection. The second strategy is to agree to enter couple
therapy to understand the meaning of the differences, and,
with the help of the professional, find a common ground for
intimacy and sexuality.

The goal of this exercise is to develop a comfortable,

pleasur- able, functional, and mutually satisfying couple
sexual style. This exercise encourages you to take personal
responsibility for your sexuality and to grow as a unique,
intimate team.
You can be proud of yourselves for working together
to address PE and improve ejaculatory control. In sharing
emotional and sexual feelings and preferences, you’ll
increase understanding, empathy, and acceptance. This will
provide the foundation for a couple sexual style that
ensures both satisfaction and security.
 10

Enjoying Sex and

Preventing Relapse

It took time, energy, and cooperation for you to learn

ejaculatory control. You cannot rest on your laurels; you
need to devote time and energy to maintain a vital sexuality
and prevent relapse. To now expect that PE will never
reoccur is unrealistic and sets you up for feelings of failure
and sets the couple up to return to the blame-
counterblame cycle. Positive, realistic expectations include
accepting that arousal and orgasm are inherently variable.
Whether once every ten times, once a month, or once a year,
rapid ejaculation will reoccur. This is a normal part of good-
enough sex. The reality is that rapid ejaculation is an
occasional part of most couples’ sexual experience, even
invited: a “quickie.” Especially important is to not panic and
feel you are back to square one each time you experience
rapid ejaculation. The key is to accept the occasional episode
of rapid ejaculation as normal, treat it as a lapse, and
commit to not allowing it to become a pattern (relapse).
In this chapter, we’ll help you develop a personal,
specific relapse prevention plan. It is crucial that you decide
how you’ll respond when PE occurs rather than hope it will
magically never happen again. We’ll take a look at the
cognitive, behavioral, and emotional foundations of relapse
prevention. We’ll briefly review the key concepts from the
ejaculatory control program. Then we will present ten
specific strategies and techniques to promote healthy
sexuality and prevent relapse. You can choose two to four
strategies
1 Coping with Premature

that are relevant to you and incorporate them in your couple

sexual style.

The Foundation of Relapse

Prevention
You’ve already formed the basis for relapse prevention by
develop- ing a comprehensive understanding of PE,
identifying all the factors contributing to your PE, using all
your resources, learning a range of steps and skills,
following the personal responsibility–intimate team model of
change, and building a couple sexual style that integrates
intimacy, pleasuring, and eroticism and emphasizes realistic
expecta- tions of ejaculatory control and couple sex.
You can think of relapse prevention in terms of its
cognitive, behavioral, and emotional foundations.

The Cognitive Foundation of Relapse Prevention

The most important cognitive approach to preventing
relapse is to accept that on occasion you will ejaculate
rapidly. Treat these experiences as a normal variation, not a
cue for anticipatory or performance anxiety. This allows you
(and your partner) to think of the experience as a lapse but
not be afraid of a relapse. Cognitively, you can approach the
next encounter with positive anticipation, relaxing more,
using more self-entrancement arousal, enjoying a
pleasurable buildup of stimulation, perhaps purposely using
slow- down or stop-start pacing, and inviting your partner to
control the type and speed of intercourse thrusting.
A key to relapse prevention is shifting your focus from
perfor- mance-oriented intercourse to involvement in the
whole lovemaking process, affection through afterplay.
Intercourse is the natural exten- sion of intimacy, pleasuring,
and eroticism. It is a continuation of the pleasuring process,
not a pass-fail test apart from this. Decide to let the length
of intercourse vary with your desires. The skills you have
learned will aid you in maintaining reasonable control
over when you choose to ejaculate. Keep the perspective
that you are sharing with your partner, not performing for
her.
Think of your partner as your intimate friend whose
pleasure and arousal feed yours rather than as a demanding
critic for whom you must perform. Welcome her arousal,
especially during inter- course, rather than feeling
intimidated that she has to hold back so you do not
ejaculate. Enjoy both her arousal and your own. Enjoy
 Enjoying Sex and Preventing 15

your orgasm as well as her orgasm; orgasm need not occur

in perfect sequence for it to be satisfying.
Our concept of good-enough ejaculatory control and a
good- enough sexual relationship is crucial for relapse
prevention. Decide that your goal is to be good enough,
not perfect.

The Behavioral Foundation of Relapse Prevention

The most important behavioral foundation for relapse
preven- tion is to generalize your comfort and confidence
with stop-start and arousal pacing techniques. You learned
these skills in a systematic manner in the ejaculatory control
exercises; now the challenge is to use them in unstructured,
spontaneous sex to maintain good-enough ejaculatory
control. You’ll need to integrate these techniques into your
couple sexual style. If there has been a break in your regular
rhythm of sexual intercourse (if one of you has been
traveling or has been ill), you may find it helpful to briefly
return to using the techniques in a more structured way.
You want to aim for sexual encounters that involve a
relaxed sexual pace (not drag racing); giving and receiving
pleasure-oriented touching; being comfortable with the
plateau phase and maintaining arousal; transitioning to
intercourse as a continuation of the pleasur- ing process;
monitoring your PM, using intercourse acclimation if
needed; varying intercourse movements (such as using
circular or longer strokes) at moderate levels of speed;
moving to orgasm as a natural extension of the erotic flow;
enjoying the orgasmic experience physically, emotionally,
and relationally; and being an active participant in the
afterplay phase.
Ejaculatory control requires a regular rhythm of sexual
experi- ences with both people being involved and valuing
their sexual relationship. The risk is regressing to
infrequent, low-quality sex, which promotes a return to PE.

The Emotional Foundation of Relapse Prevention

Interpersonally, an important relapse prevention
approach is to value and reinforce your couple sexual style
and to view each other as intimate friends. Your feelings for
each other are the glue that bonds you. Personal
responsibility for sexuality, emotional sharing, and being an
intimate team are ongoing parts of your life and relationship.
Especially important is setting aside quality couple time
when you share feelings and are empathic about your life
and rela- tionship, including your sexuality. You want to
enjoy a broad-based,
1 Coping with Premature

flexible couple style that integrates emotional intimacy,

pleasuring, and eroticism.

Key Concepts in Ejaculatory Control

As you develop your couple sexual style and work to
maintain ejac- ulatory control, you’ll want to keep in mind
the key concepts you’ve learned. Consider which concepts
were the most difficult for you to master. These are the ones
that will need your continued attention in order to prevent
relapse.
●
Premature ejaculation is the most frequent male
sexual prob- lem. The majority of adolescents and
young adults begin as rapid ejaculators. Thirty
percent of adult males complain of quick ejaculation.
●
Realistic expectations and goals are crucial. Base
them on the physical realities of your body, accurate
knowledge, and the principle of just being good
enough.
●
Do-it-yourself techniques to reduce arousal do not
help in gaining ejaculatory control. By interfering
with arousal, these techniques can cause erectile
dysfunction.
●
The strategy for ejaculatory control is
counterintuitive. Rather than decreasing pleasure,
you want to increase comfort, awareness, and
pleasure.
●
The important individual skills for ejaculatory control
are physical relaxation during lovemaking, balancing
sensual self-entrancement and partner interaction
arousal focus, PM relaxation, and cognitive and
behavioral arousal pacing.
●
Ejaculatory control requires you to identify the point
of ejaculatory inevitability and maintain awareness at
high levels of arousal.
●
Ejaculatory control during partner sex, especially
inter- course, is complex and challenging.
●
Only one in four women have the same response
pattern as men (a single orgasm during intercourse).
The goal of ejacu- latory control is not to guarantee
that your partner has an orgasm during intercourse.
The goal is to increase pleasure and eroticism for
both of you.
 Enjoying Sex and Preventing 15

●
Three of the most effective behavioral tools are PM
relax- ation, the stop-start technique, and the
intercourse acclima- tion technique.
●
Learning ejaculatory control is a gradual process
requiring practice and feedback. If your PE is severe,
you should not skip any of the steps in chapter 8.
●
Relax your PM as much as possible as you initiate
inter- course to give your body some margin for
ejaculatory control.
●
When you begin learning ejaculatory control during
inter- course, begin with the woman-on-top position
and be sure to allow enough time for acclimation.
●
Other intercourse positions are more challenging.
Utilize longer, slower thrusting or circular thrusting.
Alternate which partner controls the thrusting.
Ejaculatory control is most difficult in the man-on-top
position with short, rapid thrusting.
●
Sensations of orgasm begin at the point of ejaculatory
inevi- tability. Once you reach the point of
inevitability, there’s no turning back. Whether you
arrive there prematurely or voluntarily, enjoy the
feelings and sensations and do not be upset or angry.
Beating up on yourself does not facilitate ejaculatory
control.
●
Your partner’s emotional and sexual feelings are very
impor- tant. Her role is an intimate, involved partner.
You can pleasure her to arousal and orgasm with
manual, oral, rubbing, or vibrator stimulation. Most
women prefer this before ejaculation, but some prefer
after. Sex does not end when you ejaculate.
●
Remember that you can use medication as an
additional resource, especially if you have neurologic
system PE (your quick ejaculatory response is
hardwired). You can practice ejaculatory control
exercises while taking medication and then gradually
eliminate medication (be sure to talk with your
doctor).
●
Sexuality is about giving and receiving pleasure, not
performing perfectly. Enjoy and share the entire
sexual expe- rience: intimacy, pleasure, eroticism,
arousal, intercourse, and afterplay.
1 Coping with Premature

Jonathan and Angela’s Story

For most of the eight years they had been together (the
last six as a married couple), Jonathan had a severe,
chronic PE pattern. The sexual problem did not affect
Angela’s feelings of love for Jonathan or her commitment to
the marriage, but it did have a negative impact on their
sexual relationship. Angela began to have trouble with
sexual desire, arousal, and orgasm.
Jonathan and Angela had a complementary couple style
that fit them well in most ways, but sexuality did not play the
15 to 20 per- cent energizing role. For Angela, sexuality was
a disappointment but not a major factor in her life. Their
four-year-old son and two-year- old daughter kept them
busy; that was Angela’s rationale for why they were sexual
only two to three times a month. If she asked, Jonathan
would manually stimulate her before moving to inter- course,
and usually Angela would be orgasmic. However, over time
and because of the children, Angela began to settle for quick
inter- course and became reluctant to ask for the time and
stimulation to meet her sexual needs.
Jonathan did not like to think about the PE problem. He
alternated between blaming himself and blaming Angela.
Jonathan especially blamed Angela for the infrequency of
sex. He wistfully recalled the first eight months of their
relationship, when they had sex each time they were
together and neither Jonathan nor Angela worried about PE.
It was not until they were engaged that Angela tactfully
told Jonathan that she would enjoy sex more if it was slower
and more loving. Jonathan wanted to please Angela, but was
not clear about what she meant. He did spend more time on
kissing and caressing, but as soon as Angela’s underwear
was off, Jonathan focused on manually stimulating her to
orgasm, which he found very arousing. As soon as she was
orgasmic he would enter her, and after a few rapid, exciting
strokes he would ejaculate. Jonathan felt good about their
sexual life; his only complaint was frequency. He assumed
she was pleased because she was easily orgasmic with
manual stimula- tion and did not say anything to the
contrary.
During and after their first pregnancy (which was
wanted and planned), there was a significant decrease in
sexual frequency. The second pregnancy was unplanned, but
their daughter was very much wanted. Two young children
and sleep deprivation wiped out Angela’s sexual receptivity
and responsivity, but not Jonathan’s. They fell into a push-
pull power struggle over frequency of intercourse.
After a particularly rushed intercourse, Jonathan asked
whether she would like to make love again and offered to
stimulate her to
 Enjoying Sex and Preventing 15

orgasm first. Angela felt put upon, and told him so. Jonathan
responded in what he thought was a joking manner about
mothers not being very sexy. Angela found this
objectionable and told him to stop being so self-centered,
that he should be glad she was willing to put up with his PE.
Jonathan and Angela had fallen into the trap of arguing
about sex while naked and vulnerable, right after a sexual
encounter—always a bad idea.
Angela wanted to enhance intimacy and pleasuring in
the marriage, while Jonathan wanted to increase the
frequency of sexual intercourse. These are not incompatible
goals, but Angela and Jonathan needed to communicate
and work together to improve their sexual relationship.
A crucial step was to determine what type of PE
Jonathan had. Together, they completed the PE diagnostic
process in chapter 4. Angela encouraged Jonathan to seek
help, realizing that his PE was lifelong, occurred in all
situations, and was neurologically based. Angela
accompanied Jonathan to his appointment with the internist,
who agreed that he was suffering from the neurological
system type of PE. It was Angela who encouraged a full
treatment plan: taking medication, learning psychosexual
skills, and increasing empathy and intimacy. Jonathan had
been so caught up in embarrassment about having PE that
he found it hard to have frank talks about PE and what it
meant to Angela and to the relationship.
The internist asked if they wanted a referral to a
psychologist or a sex therapist, but they decided to work
together to try methods such as those in this book first.
Angela said she was open to couple sex therapy if there was
not significant improvement after six months. Jonathan was
motivated to address PE as a couple, partly because he was
anxious about sex therapy. (Typically, men are very willing
to attend sex therapy if there is a female dysfunction, but
much more hesitant if there is a male dysfunction.)
With Jonathan more aware and motivated, Angela
playing an active role in improving psychosexual skills, the
use of Zoloft, and increased empathy and cooperation, they
saw gradual but quite sig- nificant improvement in
ejaculatory control and much improvement in sexual
frequency and satisfaction. What made the most difference
for Jonathan was using pelvic muscle exercises, learning to
enjoy slow, sensual stimulation, and utilizing circular
thrusting during inter- course. What made the most
difference for Angela was increasing nongenital and genital
pleasuring, using multiple stimulation during intercourse,
and developing enjoyable afterplay scenarios.
The issue that now concerned Jonathan and Angela was
how to maintain and generalize their sexual gains and
ensure that they did not relapse. Jonathan’s biggest
question was whether he needed to
1 Coping with Premature

continue taking medication or could wean himself from it.

Angela wanted assurance that even when they no longer had
to schedule time to do sexual exercises, they would still
make time for each other and nurture their intimate bond.
Jonathan made an appointment with his internist, who
helped him develop a schedule to slowly reduce medication.
Angela told Jonathan that she valued sensual, playful touch
as well as erotic touch and intercourse.
The relapse prevention strategy that mattered most to
Angela was setting aside couple time every six to eight
weeks when there was a specific ban on intercourse. This
allowed them to experiment with both sensual and erotic
scenarios to maintain a sense of sexual adventure and
realize that not all sexual touch had to result in inter- course.
The relapse prevention strategy that mattered most to Jona-
than was purposefully enjoying the sensations at the plateau
phase rather than quickly moving to intercourse, as well as
using a variety of intercourse positions and types and
rhythms of thrusting. The hardest thing for Jonathan was
accepting that it was okay to enjoy the feelings of orgasm
when he ejaculated before he would have chosen to.
Jonathan accepted that a pleasure orientation was health-
ier than a performance orientation. When Jonathan did
experience a rapid ejaculation lapse, he did not go away but
instead held and pleasured Angela. To ensure that he did not
become self-conscious about the early ejaculation, they
would try to have another sexual encounter in the next one
to three days. Jonathan enjoyed spending more time in the
pleasuring, intercourse, and afterplay phases.
Even though they had two careers, two growing
children, and a busy life, Jonathan and Angela set aside time
to be an intimate sex- ual couple. Sexual intercourse and
ejaculatory control were a critical part of their couple
sexual style. In addition, they valued and enjoyed a broad-
based, flexible relationship that included emotional intimacy,
affectionate and sensual touch, playful touching both in
and out of the bedroom, enjoying a variety of pleasuring and
erotic scenarios, and basking in afterplay. Jonathan and
Angela’s new couple style valued both marital intimacy
and erotic sexuality.

Relapse Prevention Strategies

The best overall relapse prevention strategy is for both
you and your partner to commit to devoting the time and
energy it takes to maintain a high-quality intimate
relationship. This includes main- taining a regular rhythm of
affectionate, sensual, playful, and erotic sexual connection—
whether three times a week or once every ten days—rather
than regressing to the intercourse-or-nothing
 Enjoying Sex and Preventing 15

approach to touching. But healthy sexuality is much more

than fre- quency. A vital sexuality involves attending to
physical health and healthy habits (including not smoking,
good eating habits, regular exercise, a healthy sleep pattern,
and moderate drinking or no drinking). You want to have a
good relationship with a primary care physician to ensure
that an illness or medication side effect does not interfere
with your sexual functioning. You need to be committed to
enhancing your personal well-being and the well-being
of your partner.
There are ten specific relapse prevention strategies for
you to consider.

Strategy One: Hold Couple Meetings

Having regular times (for example, every month) to
discuss your intimate relationship is crucial to maintaining
a vital relation- ship. One advantage of working as an
intimate team in learning ejaculatory control or being in
couple therapy is that you regularly engage in serious
communication about your relationship. You want to
continue to devote the time and energy to nurture and
enhance your intimate relationship. It’s important to show
your partner your desire to maintain your intimate bond.

Strategy Two: Have a Formal Follow-Up Meeting

Planning a six-month follow-up (by yourselves or with a
thera- pist) will help you remain committed and accountable
to good- quality, enjoyable sex and prevent relapse by
ensuring that you do not slip back into unhealthy sexual
attitudes, behaviors, or feelings. The biggest trap is to treat
PE and intimacy with benign neglect. If you don’t pay
attention, sex will regress to marginal quality and become
infrequent.

Strategy Three: Have Pleasuring Sessions

Setting aside time for a pleasuring session (with a
prohibition on orgasm) reinforces communication,
sensuality, and playfulness. This allows you to enjoy
sensuality and experiment with new things: an alternative
pleasuring position, body lotion, a new setting or milieu.
This helps keep you focused on pleasure and flexibility.
Maintaining pleasuring and sensuality combats relapse not
just for PE but for other sexual problems as well.
1 Coping with Premature

Strategy Four: Calmly Accept Your

Lapses as Simple Tests
In any change process, when you begin to achieve
reasonable success, you will be tested. This is normal. When
your new skills are challenged and you do a good-enough job
of handling the test, you will be able to relax, settle in, and
feel calmly confident. You will realize that your progress is
for real, not a fluke. Your success will become believable.
You have learned the skills of sexual cooperation and
intimacy.
As a couple, you will likely be tested a minimum of two
times. The usual test is a lapse, an experience of PE as
severe as it ever was. You will have automatic thoughts of
self-doubt: “The treatment approach didn’t work!” “We’re
back where we started from.” “Fail- ure!” “We’re going to
return to the hurt, anger, and frustration.” These are normal
thoughts, and you actually need to go back to the old
experience several times in order to reaffirm for yourselves
that these fears are not accurate.
When you are tested, what is important is that you pass
the challenge together. You do this by handling the rapid
ejaculation with the understanding and physical, emotional,
and relationship skills you have learned throughout this
book. In other words, while you may ejaculate fast, do not
allow yourselves to relapse to han- dling it in the old
dysfunctional way. Rather, accept the quickness, adapt your
lovemaking, continue to pleasure and touch, and stay
connected. Let it only be an “oops!” event. Afterward, calmly
discuss whether you think the quick ejaculation was simply a
random event or whether there are some adjustments you
will want to make together for the next times you make love.
These might include tak- ing more time to relax your bodies,
making love more slowly, attending more to relaxing your
PM before you initiate intercourse, allowing more time for
vaginal acclimation, or using circular inter- course motions.
You can smile and shrug off the experience and make a
date in the next one to three days when you have the time
and energy for a sensuous, slower lovemaking experience.
The better you pass this test, the more assured your
success will be. If you don’t handle the testing well, it will
take more practice at passing more tests to confirm your
success. That is why it helps if you consciously anticipate
the tests together so that you are not taken off guard.
 Enjoying Sex and Preventing 16

Strategy Five: Remember to Focus on

Reasonable Expectations
We hope that by now you’ve let go of your ideas about
movie- quality sex and erections that last for hours. If
sexuality is to remain positive and nurture your intimate
bond, you need to keep your expectations reasonable and
accept flexibility and variability. Adopt a broad-based
approach to touching and eroticism. Remember there are
multiple purposes for sex. Allow sexuality to meet a variety
of individual and couple needs. Sometimes sex is a tension
reducer, sometimes a way to share closeness; other times a
short, passionate encounter, a way to heal an argument, a
bridge to reduce emotional distance. It is a reality that sex is
often better for one partner than the other.

Strategy Six: Schedule Intimate Couple Time

The importance of setting aside quality couple time,
especially intimacy dates or weekends without the kids,
cannot be emphasized enough. Nurture your relationship
intimacy. For couples with children, it is especially important
to set aside couple time, whether a night out each week or a
weekend away without the children at least once a year.
Couples often report better sex on vacation, validating the
importance of getting away even for an hour or two. Couple
time can include going for a walk, having a sexual date,
going to dinner, or having an intimate talk.

Strategy Seven: Let Your Couple Sexual

Style Develop over Time
There is not one right way to be sexual. Each couple
develops their unique style of initiation, pleasuring, erotic
scenarios and tech- niques, intercourse, and afterplay. The
more flexible your couple sexual style and the more you
accept the multiple functions of touch- ing and sexuality, the
greater your resistance to relapse. Develop a comfortable,
functional, satisfying sexual style that meets both of your
needs and energizes your relationship.
1 Coping with Premature

Strategy Eight: Remember That Good-Enough Sex

Ranges from Disappointing to Great
Be prepared to cope with disappointing or negative
sexual experiences. The single most important technique in
relapse preven- tion is the ability to accept and not overreact
to experiences that are mediocre, unsatisfying, or
dysfunctional. Any couple can get along if everything goes
well. The challenge is to accept disappointing or
dysfunctional experiences without panicking or blaming.
Rapid ejac- ulation, inhibited sexual desire, losing an
erection, female non- orgasmic response, a
miscommunication about a sexual date: these happen to all
couples. Intimate couples accept occasional mediocre or
disappointing experiences and take pride in having a
resilient sexual style.

Strategy Nine: Saturate Each Other with

Multidimensional Touch
Intimacy includes sexuality, but is much more than
sexual intercourse. You need a variety of intimate and erotic
ways to connect, reconnect, and maintain connection. These
include affection- ate touch, holding, nongenital pleasuring,
playful touch, erotic stimulation, and intercourse. This gives
you lots of tools to build bridges to sexual desire. The more
ways you have to maintain intimate and sexual connection,
the better you can avoid relapse.

Strategy Ten: Keep Expanding Your Sexual Repertoire

The importance of maintaining an erotic relationship
and hav- ing a variety of sexual alternatives and scenarios
cannot be overem- phasized. A flexible sexual repertoire is a
major antidote to relapse. Sexuality that meets a range of
needs, feelings, and situations will serve you well in
maintaining ejaculatory control and supporting your sexual
and emotional gains. Couples who express intimacy through
massage, holding hands, bathing together, enjoying playful
touch, engaging in semiclothed cuddling, and enjoying nude
sensual touch have a flexible repertoire. Couples who are
open to “quickies,” prolonged and varied erotic scenarios,
various intercourse positions, multiple stimulation during
intercourse, and planned as well as spontaneous sexual
encounters have a robust sexual relationship.
Enjoying Sex and Preventing 16
 Choosing an Individual,
Couple, or Sex Therapist

This is a self-help book, but it is not a do-it-yourself therapy

book. Men and couples are often reluctant to consult a
therapist, feeling that to do so is a sign of craziness, a
confession of inadequacy, or an admission that your life and
relationship are in dire straits. In reality, seeking
professional help is a sign of psychological wisdom and
strength. Entering individual, couple, or sex therapy means
you real- ize there is a problem and you have made a
commitment to resolve the issues and promote individual
and couple growth.
The mental health field can be confusing. Couple
and sex therapy are clinical subspecialties. They are
offered by several groups of professionals including
psychologists, social workers, mar- riage therapists,
psychiatrists, and pastoral counselors. The profes- sional
background of the practitioner is less important than his
or her competence in dealing with your PE and other specific
problems. Many people have health insurance that
provides coverage for mental health, and thus can afford
the services of a private practi- tioner. Those who do not
have either the financial resources or insur- ance could
consider a city or county mental health clinic, a university or
medical school outpatient mental health clinic, or a family
services center. Some clinics have a sliding fee scale (the
fee is based on your
ability to pay).
When choosing a therapist, be assertive in asking about
creden- tials and areas of expertise. Ask the clinician what
will be the focus of the therapy, how long therapy can be
expected to last, and whether the emphasis is specifically
on sexual problems or more
1 Coping with Premature

generally on individual, communication, or relationship

issues. Be especially diligent in asking about credentials
such as university degrees and licensing. Be wary of people
who call themselves per- sonal counselors, marriage
counselors, or sex counselors. There are poorly qualified
people—and some outright quacks—in any field.
One of the best ways to obtain a referral is to call a local
profes- sional organization such as a psychological
association, marriage and family therapy association, mental
health association, or mental health clinic. You can ask for a
referral from a family physician, clergy or rabbi, or trusted
friend. If you live near a university or medical school, call to
find out what mental and sexual health services may be
available.
For a sex therapy referral, contact the American
Association of Sex Educators, Counselors, and Therapists
through the Internet at www.aasect.org or write or call for a
list of certified sex therapists in your area: P.O. Box 5488,
Richmond, VA 23220; (804) 644-3288. Another resource is
the Society for Sex Therapy and Research (SSTAR) at
www.sstarnet.org.
For a marital therapist, check the Web sites for the
American Association of Marriage and Family Therapy at
www.therapistloca- tor.net or the Association for the
Advancement of Behavioral Ther- apy (AABT) at
www.aabt.com.
Feel free to talk with two or three therapists before
deciding on one with whom to work. Be aware of your level
of comfort with the therapist, degree of rapport, whether the
therapist has special skill working with couples, and whether
the therapist’s assessment of the problem and approach to
treatment makes sense to you.
Once you begin, give therapy a chance to be helpful.
There are few miracle cures. Change requires commitment
and is a gradual and often difficult process. Although
some people benefit from short-term therapy (fewer than
ten sessions), most find the therapeu- tic process requires
four months to a year or longer. The role of the therapist is
that of a consultant rather than a decision maker. Ther- apy
requires effort, both in the session and at home. Therapy
helps to change attitudes, feelings, and behavior. Although it
takes courage to seek professional help, therapy can be a
tremendous help in evalu- ating and changing individual,
relational, and sexual problems.
 Resources

Suggested Reading on Male Sexuality

Joannides, Paul. 1999. The Guide to Getting It On. West
Hollywood, Calif.: The Goofy Foot Press.
McCarthy, Barry, and Emily McCarthy. 1998. Male Sexual
Awareness.
New York: Carroll and Graf.
Milsten, Richard, and Julian Slowinski. 1999. The Sexual
Male: Prob- lems and Solutions. New York: W. W.
Norton & Company.
Zilbergeld, Bernie. 1999. The New Male Sexuality. New York:
Bantam Books.

Suggested Reading on Female Sexuality

Ellison, Carol. 2001. Women’s Sexualities. Oakland, Calif.:
New Har- binger Publications.
Foley, Sallie, Sally Kope, and Dennis Sugrue. 2002. Sex
Matters for Women: A Complete Guide to Taking Care of
Your Sexual Self. New York: Guilford Publications.
Goodwin, Aurelie, and Marc Agronin. 1997. A Woman’s
Guide to Overcoming Sexual Fear and Pain. Oakland,
Calif.: New Harbinger Publications.
Heiman, Julian, and Joseph LoPiccolo. 1988. Becoming
Orgasmic: Women’s Guide to Sexual Fulfillment. New
York: Prentice-Hall.
1 Coping with Premature

Leiblum, Sandra, and Judith Sachs. 2002. Getting the Sex

You Want: A Woman’s Guide to Becoming Proud,
Passionate, and Pleased in Bed. New York: Crown
Publishers (Random House).

Suggested Reading on Couple Sexuality

Holstein, Lana. 2002. How to Have Magnificent Sex: The
Seven Dimen- sions of a Vital Sexual Connection. New
York: Harmony Books (Random House).
McCarthy, Barry, and Emily McCarthy. 1998. Couple Sexual
Aware- ness. New York: Carroll and Graf.
———. 2002. Sexual Awareness. New York: Carroll and Graf.
Schnarch, David. 2002. Passionate marriage: Sex, love, and
intimacy in emotionally committed relationships. New York:
Norton.

Other Notable Sexuality Readings

Butler, Robert, and Myrna Lewis. 2002. The New Love and
Sex after Sixty. New York: Ballantine.
Maltz, Wendy. 2001. The Sexual Healing Journey.
New York: Harper-Collins.
McCarthy, Barry, and Emily McCarthy. 2003. Rekindling
Desire. New York: Brunner/Routledge.
Michael, Robert, John Gagnon, Edward Laumann, and Gina
Kolata. 1994. Sex in America: A Definitive Survey. New
York: Little, Brown and Company.

Suggested Reading on Relationship Satisfaction

Chapman, Gary. 1995. The Five Love Languages: How to
Express Heart- felt Commitment to Your Mate.
Chicago: Northfield Publishing.
Doherty, William. 2001. Take Back Your Marriage. New York:
Guilford Press.
Gottman, John. 1999. The Seven Principles for Making Marriage
Work.
New York: Crown Publishing.
Markman, Howard, Scott Stanley, and Susan L. Blumberg.
2001. Fighting for Your Marriage: Positive Steps for
Preventing Divorce and Preserving a Lasting Love. San
Francisco: Jossey-Bass Publishers.
 Resources 169

Videotapes: Ejaculatory Control Techniques

Desjardins, Jean-Yves, and Nicole Audette. 1997. The Lover’s
Guide to Ejaculatory Control. 55 min.
Pacific Media Entertainment, P.O. Box 4326, Chatsworth,
CA 91311. Fax (818) 341-3562.
www.pacificmediaent.com.
Polonsky, Derek, and Marian Dunn. 1991. You Can Last
Longer. Vol. 8, Better Sex Videos Series. 38 min.
Distributor: Sinclair Intimacy Institute, P.O. Box 8865,
Chapel Hill, NC 27515.
(800) 955-0888. Fax (800) 794-3318.
www.bettersex.com.

Videotapes: Sexual Enrichment

The Couples Intimacy Guide to Great Sex over 40, vols. 1 and 2.
1995. 60 min.
Sinclair Institute, P.O. Box 8865, Chapel Hill, NC
27515. (800) 955-0888. Fax (800) 794-3318.
www.bettersex.com.
Holstein, Lana. 2001. Magnificent Lovemaking. 79 min.
Canyon Ranch Bookstore, Tucson, AZ.
85750 (520) 749-9000, extension 4380.
Perry, Michael, and Goedele Liekens. 1991. Sex: A Lifelong
Pleasure
series.
Sinclair Intimacy Institute, P.O. Box 8865, Chapel Hill,
NC 27515. (800) 955-0888. Fax (800) 794-3318.
www.bettersex.com.
Sommers, Frank. The Great Sex Video Series. Distributor:
Pathway Productions, Inc., 360 Bloor Street West,
Suite 407A, Toronto M5S 1X1, Canada.
(416) 922-4506. Fax (416) 922-7512.
E-mail: how2video@ aol.com.
Stubbs, Kenneth Ray. 1994. Erotic Massage. 58 min.
Secret Garden, P.O. Box 67, Larkspur, CA 94977.

Professional Associations
American Association of Sex Educators, Counselors, and
Therapists (AASECT): P.O. Box 54388, Richmond, VA
23220-0488.
www.aasect.org.
(804) 644-3288
1 Coping with Premature

Association for the Advancement of Behavioral Therapy

(AABT): 305 Seventh Avenue, New York, NY 10001-6008.
(212) 647-1890.
www.aabt.org.
Sex Information and Education Council of the United
States (SIECUS): 130 West 42nd Street, Suite 350, New
York, NY 10036. (212) 819-7990. Fax (212) 819-9776.
www.seicus.org.
Society for Scientific Study of Sexuality (SSSS): David
Fleming, Exec- utive Director. P.O. Box 416,
Allentown, PA 18105-0416.
(610) 530-2483.
www.sexscience.org.
Society for Sex Therapy and Research (SSTAR):
www.sstarnet.org.

Sex “Toys,” Books, and Videos

Good Vibrations Mail Order: 938 Howard Sreet, Suite 101,
San Fran- cisco, CA 94110.
(800) 289-8423. Fax (415) 974-8990.
www.goodvibes.com.
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Foley, S., S. Kope, and D. Sugrue. 2002. Sex Matters for
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We Want Your Candid
Feedback:
We are very interested in your response to our book and
welcome your feedback!
For example:
●
Why did you buy our book?
●
What has been helpful to you?
●
What about our approach do you like?
●
What do you wish we had addressed more fully?
Please send an email or letter with your comments,
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m Or:
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Meta Associates
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We also welcome requests to present workshops, training
sessions, and lectures about PE, sexual health, marital
and sexual wellness, and couple conflict.

Thank you very much. Michael Metz and Barry McCarthy

Michael Metz, Ph.D., works in the Twin Cities of
Minneapolis–St. Paul, Minnesota and is the country’s leading
sexologist in the area of PE. He is a major spokesperson for
a comprehensive, integrated bio- psychosocial approach to
addressing and resolving sexual problems. After twelve
years on the faculty of the University of Minnesota Medical
School, he currently works in private practice with Meta
Associates as a psychologist, marital therapist, and sex
therapist treating individuals and couples, and is affiliated
with the University of Minnesota’s Department of Family
Social Science. He has pub- lished more than forty-five
professional articles and conducted numerous workshops
and talks on marital and sex therapy. He is the author of the
Styles of Conflict Inventory (SCI), a clinical assessment
instrument to evaluate the conflict patterns in
relationships.

Barry McCarthy, Ph.D., is a clinical psychologist, with a

subspecialty in marriage and sex therapy, practicing at the
Washington Psycho- logical Center in Washington, DC. He is
professor of psychology at American University where he
teaches an undergraduate human sexual behavior course.
Barry, with his wife Emily, has written seven well-respected
books, the most recent being Getting It Right the First Time,
Sexual Awareness, and Rekindling Desire. In addition, Barry
has published over fifty-five professional articles, fourteen
book chap- ters, and presented over one hundred and ten
workshops nationally and internationally.