Clinical Case: Treatment of Premature Ejaculation
(PE) and Erectile Dysfunction (ED)
Premature Ejaculation (PE) and Erectile Dysfunction (ED)
are the two most common male sexual dysfunctions. Both cause
men considerable emotional and relational distress.
The definition of PE is difficult, but centers on orgasm
occurring before the man wishes it to. Most men begin their
sexual lives as premature ejaculators.
As they gain comfort and experience, most men develop ejaculatory
control. For reasons that are
unclear, three in ten adult males fail
to develop ejaculatory control and experience premature ejaculation
as a lifelong problem. Not being able
to control to their satisfaction when they have an orgasm, these
men suffer quietly, feeling an unremitting sense of shame
and humiliation
that is reinforced by their partners' frustration and anger.
Erectile Dysfunction (ED) refers to men having difficulty
obtaining or maintaining firm erections. By the age of 40,
about 90% of men
have experienced difficulty obtaining or maintaining an erection
adequate for intercourse at least once. By the age of 50,
over 50% of
men report mild to moderate ED. If an erection problem does
not remit within six months, the man (and couple) becomes
trapped in a cycle
of anticipatory anxiety, performance failure, and sexual
avoidance.
Approach to Treating Premature Ejaculation and Erectile
Dysfunction
My approach to treating PE and ED is primarily cognitive-behavioral.
I draw the cognitive component of my approach from Voice
Therapy. I
recommend medication as an adjuct to sex therapy where this
seems appropriate. For the sake of clarity, the process of
change is
described as four discreet steps. The steps are illustrated
using the clinical case of a man experiencing primary premature
ejaculation
and secondary erectile dysfunction.
Clinical Case
: Male Experiencing Primary Premature Ejaculation
(PE) and Secondary Erectile Dysfunction (ED)
Hugh, a computer programmer and single male in his mid 30s,
called requesting help for premature ejaculation. He had
read some
literature about PE, and experimented with the stop-start
technique, but without success. He had recently started to
date a new woman
whom he had feelings for, and was eager to solve his sexual
problem before this relationship became sexual.
STEP 1: Assessing the sexual problem
In Step 1, a respectful, therapeutic relationship is established
in which the client feels comfortable discussing sexuality.
An
assessment of the individual's current sexual functioning,
sexual history, and relationship history is conducted in
order to define
clearly the sexual problem. Treatment options are discussed
and a therapeutic agreement is reached to work toward the
resolution of the
problem.
When Hugh arrived at the first session late, it was clear
that he was uncomfortable. When I asked what it was like
to be in my office,
he stated, "This is the last place I thought I'd be." He
went on to say that he had prided his ability to handle problems
on his own,
and that he felt weak having to talk to me. I conveyed I
understood how difficult it was for him to be talking to
me, and asked what I
could do to make the experience as comfortable as possible
for him. Hugh said he didn't know, but would let me know
if he thought of
something. I then asked if it was okay to tell me what brought
him to see me in more detail than in our telephone contac
Hugh indicated that he had experienced premature ejaculation
in all his relationships with women, and he was apprehensive
about this occurring again with the woman
he had met recently. Typically, Hugh ejaculated within one
minute after intromission. If
Hugh hadn't had sex in several weeks or was with a new partner, he would
ejaculate within seconds after intromission. When Hugh ejaculated
prematurely, he experienced his orgasms as weak and ungratifying.
An exploration of other aspects of Hugh's current sexual
functioning revealed that he self-stimulated about three
times a week. Typically, he masturbated
in a goal-directed manner and reached climax in about five
minutes. Hugh admitted to having typical
sexual fantasies and occasionally using
internet pornography to increase his arousal while maturbating.
When asked, Hugh
also admitted to variable erectile dysfunction.
Although he had firm erections upon waking and when self-stimulating,
typically he had difficulty maintaining his erection with a new partner, often losing
it shortly after commencing intercourse. Once Hugh got to
know the partner, he
maintained his erection better but invariably ejaculated
prematurely. Hugh denied any pain associated with sex. He
reported being in good health, on no medications, and active physically.
An exploration of his sexual history revealed that Hugh
had had no unwanted sexual experiences in childhood. He had
learned to masturbate around age 14 in
a goal-oriented manner focused on reaching climax quickly.
Hugh's first experience of intercourse
at age 21 had been a one-night stand in
which he had ejaculated prematurely. His first experience
of ED had occurred several years later
when he met a woman he really liked, his first love.
An assessment of his relationship history indicated that
Hugh had not felt confident enough to date as a teen. His
first real relationship had been at age
23, when he met his first love through a friend. Hugh had
felt devestated when this woman
ended the relationship after nine months, largely he believes because
of his sexual problems. After this, Hugh had ended relationships
mostly
himself after several months rather than face the painful
rejection he anticipated. The exception had been when he
had met a woman he really liked in his
early 30s, but had again felt rejected painfully after one
year. He had thought he wouldn't try
again until he had
met Glenda several weeks before calling me. He felt really
drawn to Glenda, a single parent, and had decided it was
time to deal with
his sexual problem by calling me.
When I asked Hugh how he had attempted to deal with his
PE, he reported he had tried to distract himself by thinking
about work or sports. I explained that
this strategy reduced sexual arousal, thereby increasing
the risk of ED, without increasing ejaculatory control. Hugh's other strategy had been to have a second
intercourse as quickly as possible. He had found the second
orgasm less
satisfying, and received feedback from partners that they
had felt more like an object during the second intercourse.
Based on my assessment, I informed Hugh that PE was the
primary sexual problem and ED the secondary problem. The
PE had occurred first, and the ED had
developed later as a consequence of the PE. He had developed
ED in part as the result of his "do
it yourself" strategy to avoid ejaculating quickly by distracting himself.
Although there is neither an agreed-on physical cause of
PE, nor a generalizable psychological issue or underlying
conflict that causes PE, I suggested that
anxiety was a factor in maintaining his PE. As the result
of anxiety, he was less aware of his
level of sexual arousal, resulting in
a lack of ejaculatory control. I indicated that for men under
40, most ED is psychogenic (related to
psychological factors) rather than biogenic
(related to physical or medical factors). I suggested that
his ED was psychogenic because
he had had firm erections upon waking
and when self-stimulating. His ED was maintained by anticipatory
and performance anxiety. Hugh
seemed relieved to hear that both PE and ED were treatable, and that it was
best to treat both concurrently.
I explained that both PE and ED could be treated by medication
or sex therapy, or a combination of these approaches. In
treating PE medically, Hugh could take
an antidepressant in either a daily small dose or a moderate
dose four hours before sex.
The downside of treating PE medically
is that when the antidepressant is stopped, PE returns (a
rebound effect), sometimes more severely.
One option would be to practice ejaculatory
control exercises (sex therapy) while taking medication,
and then gradually phasing out the
medication. Another option would be first
to try sex therapy, which focuses on learning and mastery,
with medication as a fall-back.
The latter option appealed to Hugh, who was reluctant to use medication.
In treating the ED medically, I explained that Hugh could
take Viagra, or one of the newer oral erectogenic agents,
Cialis or Levitra. These PDE-5 inhibitors
block a chemical (PDE-5) that causes the degradation of another
chemical, cyclic GMP, that creates
erections, thereby maintaining the erection.
Oral erectogenic agents also serve as a positive psychological
stimulus to reduce
performance anxiety. One option would
be to take an oral erectogenic agent while using sex therapy
to develop erectile confidence. Another
option would be to try sex therapy first, with medication as a fall-back. Once
again, Hugh opted for the latter option.
I suggested to Hugh that there was no quick fix to developing
ejaculatory control and erectile confidence with sex therapy.
If he was willing to commit to a process
of change requiring five to ten sessions, and to do practice
exercises consistently between
sessions, he could develop ejaculatory control and erectile confidence.
STEP 2: Developing ejaculatory control and erectile confidence
concurrently
In Step 2, the client is introduced to self-stimulation
exercises to develop ejaculatory control. Concurrently, the
client is encouraged to enlist the support of a partner as a sexual friend to
increase erectile confidence.
In introducing self-stimulation exercises as a means to
develop ejaculatory control, I explained that ejaculation,
like bladder control, is a voluntary reflex.
Just as Hugh had learned to bring bladder function under
voluntary control as a child, so also
he could learn how to bring the ejaculatory reflex under voluntary control as
an adult.
I introduced Hugh to the notion of an 11-point arousal scale,
where zero represents no sexual arousal, and ten represents
ejaculation. Men who ejaculate prematurely
during intercourse move rapidly from low levels of arousal
to ejaculation. In learning control,
the challenge is to stay at a constant, high level of arousal,
between 7.5 and 8 on the 11-point arousal scale.
I introduced self-stimulation exercises as a strategy for
learning ejaculatory control. In phase 1, I instructed Hugh
to masturbate with a dry hand in his usual
way until he felt an orgasm approaching. He was to pay particular
attention to the sensations in his
penis and groin in order to heighten his
awareness of what it felt like to approach orgasm. When he
felt the orgasm approaching,
he was to stop masturbating and take a
few deep breaths, waiting anywhere from 10 seconds to a minute
until his arousal had dropped
significantly. He was to repeat the process,
and on the fourth repitition allow himself to reach orgasm.
I instructed him to do this exercise
three times a week for two weeks.
In phase 2, I instructed Hugh to try to keep the arousal
at a constant, high level, between 7.5 and 8 on the arousal
scale. As he approached "6" or "7",
he was to slow the rhythm of masturbating in order to maintain
a constant,
high level of arousal. By way of analogy, I suggested he think about driving a stick shift
car and keeping it stationary on a hill. With his left foot
on the clutch, and
his right foot on the accelerator, he was to keep the car
from either moving forward or rolling back by balancing the
two. It was okay if he didn't gauge his
arousal accurately and suddenly ejaculated. The challenge
was to go a little slower the next time, paying attention to keeping the level of arousal high and constant.
He was to do this three times a week for up to 15 minutes.
I stressed the
importance of practice in learning control, drawing a comparison
with how athletes use repititon to master a particular skill.
In phase 3, the only difference was the addition of a lubricant
(e.g., KY Jelly, Astroglide). I explained that the lubricant
simulates more the sensation of the penis
being in a lubricated vagina, which is more stimulating than "dry" masturbation.
Hugh agreed to repeat the exercise, and to pay attention to how this felt different.
At the same time that Herb was developing ejaculatory control
by practicing the self-stimulation exercises, at my suggestion
he was "
going slow" by getting to know and trust his new female
friend, Glenda. When I suggested that he consider telling
Glenda about his sexual issues in order
to ask for her understanding and support as a sexual friend,
he wasn't sure this was a good idea.
He was afraid she would dump him. When
I suggested that it would be better to face possible rejection
early on rather than down the
road, he agreed to talk with her. He was surprised that she responded positively,
indicating she wanted to help him with his sexual issues.
I indicated that the foundation for regaining erectile comfort
and confidence is nongenital and genital pleasuring. I recommended
that he and Glenda engage in a special
type of touch called "nondemand" pleasuring.
I explained that nondemand pleasuring is touching that is valued
for itself, with no pressure or demand for intercourse. In
phase 1, they were free to engage in any type of sensuous
and playful touch short of orgasm and
intercourse. As examples, I suggested that they sensuously
massage each other, or touch while cuddling
in bed, or playfully "fool around" on the couch or in the
car. The goal of this touch was to experience pleasure and
to feel close rather than
to turn each other on.
While engaging in nondemand pleasuring, I suggested that
a crucial strategy toward regaining erectile confidence was
for Hugh to become comfortable with the waxing and waning of his erections.
Men are used to going to intercourse and orgasm on the first
erection, so when
an erection fades, they panic and give up. Hugh confirmed
that this was true for him. He would "spectator" by
observing his penis, and the moment his
erection waned, he would feel devestated and give up. I informed
him that the process of waxing and waning
of erections can occur 2 to 5 times in
a 45 minute pleasuring session. I assured him that by resuming
pleasurable touch and stimulation,
he would regain his erection. As Hugh
and Glenda engaged in nondemand pleasuring with a temporary
ban on orgasm and intercourse,
Hugh developed confidence in the abilty to regain his erections.
In phase 2, I instructed Hugh and Glenda to engage in any
type of erotic stimulation culminating in orgasm, but excluding
intercourse. The goal was to arouse and
turn each other on. Fortunately, both were comfortable giving
and receiving manual and oral
sex. I suggested that they heighten their
arousal while giving and receiving manual and oral sex by
using multiple stimulation (e.g.,
fantasy, kissing, touching breasts and testicles).
While engaging in erotic touch, I informed Hugh that a second
strategy for overcoming the performance anxiety that maintained
his ED was to know that he could pleasure
Glenda fully with his ten fingers and tongue, without a firm
penis. Having repeated
experiences of pleasuring Glenda in this
way would eliminate all performance anxiety because he would
know that giving Glenda pleasure
did not depend on a firm penis.
Hugh was skeptical initially, but reported that although
Glenda liked intercourse, she had expressed real satisfaction
with how he was pleasuring her. Knowing
that he didn't have to have a firm penis to pleasure Glenda
really did reduce his performance
anxiety. What surprised him the most was that he was having terrific orgasms.
A third strategy for developing erectile confidence was
to separate out the negative thought process that mediated
his anxiety. Following the Voice Therapy
approach to cognition (for more information, see the link "Approach
to Counselling"),
I explained that it was common for men with ED to "listen" to a negative
thought process preceeding sex that mediated anticipatory
anxiety, during sex that
mediated performance anxiety, and following sex that mediated
guilt and self-blame. I suggested that listening to a negative
thought process has a strong negative influence on erectile functioning
because "the penis is attached to the heart".
Hugh identified readily his negative thought process. Before
sex, he would tell himself, "I'm not going to keep it
up, and even if I do, I will come too
soon. What's the point of trying. I should just avoid sex." During
sex, he would tell himself, "I'm
not going to keep it up. See, it's softening. I'm losing it." After losing
his erection, he would say to himself, "I've disappointed
her again. I'm a lousy
lover. She won't want to stay with me."
I suggested that Hugh say these thoughts in the 2nd person, "You",
as if someone else was addressing him. Hugh stated: You're
not going to keep it up, and even if you
do, you will come too soon. What's the point of trying. You
should avoid sex.... You're
not going to keep it up. See it's softening.
You're losing it.... You've disappointed her again. You're
a lousy lover. She won't want to stay with
you." Hugh was surprised about how
differently he experienced these thoughts when he said them
in the 2nd person. He realized
that listening to these thoughts caused him to anticipate sex negatively,
contributed to losing his erection, and left him demoralized
afterward.
When I suggested that he counter these thoughts from his
healthy point of view in the 1st person, "I", he
asserted: "Whether or not I get and
maintain a firm erection doesn't matter. I can always regain
my erection. Even if I don't, I don't need a firm
erection to have wonderful sex with Glenda." Holding
on to this healthy thought process increased his confidence
and comfort with
respect to erectile functioning.
As Hugh and Glenda engaged in erotic touch leading to orgasm
but exluding intercourse, Hugh became increasingly aware
of the negative thought process. He found
that the mere awareness of the negative inner voice enabled
him to "separate it out",
and to refocus on giving and receiving
pleasure in the moment. The more he stayed absorbed in the
moment, the more pleasure and arousal he
felt, and the more his erection took care of itself.
Hugh was experiencing ejaculatory control during the self-stimulation
exercises. He was also experiencing erectile confidence.
The next step was to extend ejaculatory control and erectile confidence
to intercourse.
STEP 3: Extending ejaculatory control and erectile confidence
to intercourse.
In Step 3, the goal is to experience ejaculatory control
and erectile confidence with intercourse. A step-by-step
process is used to make the transition to full intercourse.
When I asked Hugh how he felt about moving to intercourse,
he stated he felt anxious but ready to take this step. I
indicated it was understandable that he
felt anxious, and that it would not be unusual if he lost
control and came quickly, or lost his
erection. He found it reassuring when
I provided him with the following step-by-step process for
resuming intercourse. As was typical
of their love-
making, they were to arouse each other with sensuous and
erotic touch. Once they were aroused, because the hardest
situation for ejaculatory control is with
the man on top using short, rapid thrusting, I suggested
that he begin by lying on his back
with Glenda in the on-top postion. The
first step was for Glenda to insert his penis gradually,
in stages, into her vagina until it
was inserted fully. He was to pay attention
to what that felt like without moving or thrusting. Once
he felt in control and confident, the
next step was for Glenda to begin moving
slowly. Hugh's task was to pay attention to his level of
arousal, trying to keep this between 7.5
and 8 by telling Glenda how much or how
little to move. After getting close to coming three to four
times, in the third step Hugh
was to begin thrusting, allowing himself
to climax. If at any point in this process he lost control
and ejaculated, he was to treat
this as a learning experience. If at any
point his erection began to wane, he was to be aware of any
negative thought process,
and to counter with his healthy point
of view that he would be able to regain his erection. If
either of these events occurred, he was
encouraged to assume a "trust" position
with Glenda, in which they held each other and felt close
before talking about the experience
and/or resuming love-
making.
At the next session, Hugh reported that on their first attempt
at intercourse he had ejaculated sooner than he wanted to,
but that he had taken this in stride and
not over reacted. He had also continued to pleasure Glenda
to orgasm after he ejaculated
rather than stopping, which helped them
both to feel more positive about the experience. He was pleased
that in subsequent sessions
he had maintained control. He found it
harder to maintain control while thrusting, but this too
had improved with practice.
He also reported that his penis had softened
on one occasion during intercourse, but after assuming a "trust" position
and resuming touch, he had regained his
erection. I congratulated Hugh on his accomplishment, attributing
his progress to his hard efforts. I also requested
that he convey my commendation to Glenda for how supportive she
had been as a sexual friend.
Step 4: Maintaining treatment gains
In Step 4, the client is introduced to strategies to maintain
treatment gains. Relapse prevention is important, particularly
in the treatment of PE, because outcome research shows that after
treatment men tend to return to pretreatment levels of control.
I informed Hugh that research showed that if he wanted to
maintain ejaculatory control over time, it was important
to use strategies of relapse prevention.
First, practice and frequency were the most effective strategies
he could use to maintain control.
I suggested he practice by continuing
to have one session of self-stimulation each week in which
he focused on maintaining a constant,
high level of arousal. I recommended that
he and Glenda establish a regular pattern of sexual activity
in order to maintain a healthy
sexual frequency. Second, if he ejaculated
quickly or lost his erection, it was important to accept
these experiences as lapses to
be learned from rather than as relapses
to be feared. It was normal to sometimes not have a firm
erection, and to lose ejaculatory
control. Third, I recommended that he schedule a "booster" session
with me in six months, as an opportunity to monitor and fine
tune his progress.
Conclusion
PE and ED are common male sexual dysfunctions that cause
considerable emotional and relational distress. Cognitive-behavioral
sex therapy provides a change process
for developing ejaculatory control and erectile confidence,
and extending these changes
to sexual intercourse.
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