Premature Ejaculation—All About Time?
Just about every week, a man or a couple come in and ask about treatment for "Premature Ejaculation" (PE). People used to say "I come too fast" or "He comes too fast." After a few minutes on the internet, people have learned they have a condition, with a name, diagnostic criteria, and prognosis. That's not necessarily a good thing.
People can also discover that the DSM-5 (the insurance industry's bible of mental & sexual problems) classifies the severity of the problem thus:
* Mild, in which ejaculation occurs 30-60 seconds after vaginal penetration
* Moderate, when ejaculation occurs 15-30 seconds after vaginal penetration
* Severe, in which ejaculation occurs prior to, upon, or less than 15 seconds after vaginal penetration.
There is so much wrong with that powerful little paragraph.
"Vaginal penetration" is not an expression I use. I prefer "insertion" to "penetration." In fact, I prefer "vaginal envelopment" or "containment." These all sound nicer and easier than "penetration." You can make up your own phrase to describe the experience.
Then there's the idea that these increments of 15 seconds are meaningful to people. No one likes to come involuntarily upon entering a vagina. But virtually no one would be grateful—or feel their problem were solved—if they had 14 extra seconds of intercourse. That's about two, maybe three thrusts. Two or three anxiety-filled, guilt-ridden, about-to-be-disappointed thrusts. So the DSM's alleged differences between "mild", "moderate", and "severe" are pointless.
And by the way, try telling a guy who comes in 31 seconds (or his partner) that his problem is "mild."
The DSM-5 is about two decades behind the times on this. There isn't a sex therapist in a thousand who would agree with the time delineations. Most sex therapists say "rapid ejaculation" instead of "premature" anyway; to see what I call it, keep reading.
The DSM also says that as many as 30% of men "report concern" about PE, yet they say that according to their dandy new criteria, "only 1-3% of men would be diagnosed with the disorder." I'm certain that's not accurate; in any case, it's a bizarre contrast. The DSM also says that PE "may increase with age" which is absolutely, positively wrong. Ask a hundred middle-aged men about their ejaculations, and the big complaint won't be how quickly they come, but how slowly—when they come at all.
In a brief fit of thoughtfulness, the DSM notes the existence of culture-related issues, which is a big understatement. If a couple is upset that he comes after "only" 12 minutes, does he have PE? In the old Soviet Union, women would get insulted if a guy didn't come after a minute or two—"Don't you find me exciting?" I would translate the DSM's "culture" as "expectations, beliefs, and self-image" as a way of overriding the silly time dimensions.
I know that physicians in general don't have much time to discuss sex (or anything else) with patients. Hence many prescribe Viagra without knowing whether the guy has an actual problem, whether he's drinking, having an affair, hates his wife, or hates his penis. Similarly, if a guy says "I have PE," an MD or psychologist would ideally ask NOT "how fast is too fast" (although that's better than nothing), but rather "and what's the problem with that?"
Because PE isn't a problem. People turn it into a problem by withdrawing in disappointment, or blaming their partner, or having affairs, or refusing to try other ways of being sexual or intimate. And then they (or their partner) blame the PE.
My experience in treating PE is that half the time I don't treat it at all. I treat power struggles, shame, unrealistic expectations, fear of conception, discomfort talking about sex, and myths about "real sex." The rest of the time I treat anxiety and/or depression, which are the typical physiological triggers of the unwanted ejaculation—as opposed to too much pleasure, which is what a lot of people assume it is.
A combination of these various interventions usually reverses the PE. More importantly, people often start enjoying sex again. That's the goal of sex, you know—to enjoy sex, not to last a long time.
Some practitioners prescribe anti-depressants like Zoloft to slow down ejaculation. It often works, but doing that without a thorough psycho-social evaluation is like giving someone Vicodin for physical pain without finding out about any structural problems (e.g., spinal stenosis) or lifestyle issues (e.g., jogging when injured). It may provide short-term relief, but it could be laying the foundation for bigger problems later.
So if I don't say PE and I don't even like the gentler "Rapid Ejaculation," what do I call it? I encourage patients to say "I come faster than I want to" (if they do). That helps us focus on the real problem—not the "I come faster…" but the "…than I want to." It creates the expectation that we're going to talk about expectations, communication, arousal, the relationship, and the meaning of sex.
Yeah, I know "I come faster than I want to" is a lot of words, and it doesn't have a quick acronym like PE. That's OK—there's plenty of time.
Indiana Can't Make Abortion a Thought Crime
This spring Indiana criminalized abortion if the reason is the genetic abnormality of the fetus (for example, Down Syndrome). Last week a federal judge declared the law unconstitutional.
Even if you believe legal abortion should be limited to a certain time period—say, likely fetal viability—this overturned law attempted a staggering intrusion into the private decision-making of Americans contemplating a legal behavior. It empowered the state to judge residents' thinking, values, and lifestyle. It allowed the state to withhold a legal right if it doesn't like someone's reason for exercising that right.
Any "conservative" would protest if such a law involved driving a car, getting surgery, or buying a gun: "You can have breast implants to help you keep your husband, but not to help your lingerie modelling career;" "You can get a blood transfusion if you want to get healthy and return to your job as a go-go dancer, but not if you're just going to be a homemaker," etc.
This law said the state could decide if your reason for exercising your right to an abortion is good enough—and it named one reason as simply not good enough.
A real "conservative" can only support such government intrusion by being completely dishonest or by admitting that he/she value something more than logic and the rule of law. Note that two-thirds of Indiana's overwhelmingly Republican state legislature are supported by the National Right to Life Committee, and draw your own conclusions about civic treachery.
A handful of states ban otherwise-legal abortion if it's based on the gender, race, or ethnicity of the fetus. Such laws show the anti-choice movement's cynical opportunism. They say they want to ban all abortions at all times. To market this position and make it more palatable, they cut intellectual corners—tolerating abortion in the case of pregnancy following rape (why? Isn't it still an "innocent unborn child?"), or trying to limit abortion for reasons of which they don't approve (trying to shape the gender balance of a family, or prevent the lifelong responsibility of a Down Syndrome birth).
But why bother to pass a law about Down Syndrome fetuses? There are less than 10,000 such pregnancies in America each year; in addition to the roughly 800 that die without intervention, less than half are aborted. Indiana, with 2% of the country's population, would expect less than 200 such abortions per year.
One anti-choice website laments the loss of Down Syndrome children—"Aborting Babies With Down Syndrome Has Wiped Out 30% of the Down Syndrome Community," it cries.
Putting aside the fact that these abortions aren't done on "babies" (a willful medical, legal, and moral distortion that isn't even worth discussing) it's fascinating to note the concept that a bigger Down Syndrome Community is better than a smaller one. Um, no: while it's great that there's a source of support between families who choose this jaw-dropping, lifelong responsibility, creating more such challenged families is not a positive thing.
One might as well say that since Alcoholics Anonymous helps people and families deal with problem drinkers, creating more and more alcoholics who can be helped this way is a good thing.
The overturned Indiana law also required that all aborted fetuses be buried or cremated, rather than be routinely incinerated along with other medical tissue. This is another attempt to regulate how people deal with the consequences of their private decisions.
If someone electing a legal abortion conceptualizes her choice as "losing a child" whom she wants to commemorate, she can do a wide range of things, including giving the "child" a name or observing the "child's" death anniversary. On the other hand, if a woman sees her abortion as ending an unwanted pregnancy, the state has no right to force her to deal with the fetus as if it were a person.
As a marriage & family therapist, I have dealt with many cases in which people felt they had to expand their families and their life narratives to include the "lost child" forever—invariably compromising the quality of life of themselves and their other children. If real people in the real world don't want to elevate a fetus into the status of personhood, the state should not force them to do so with unwanted burials—and the inevitable emotional meanings and attachments that follow. Shame on Indiana for attempting to manipulate its own citizens doing something perfectly legal.
Most states now make the experience of a simple abortion as miserable as possible for residents who have the nerve to pursue a safe, legal medical procedure. States continue to throw tantrums and just invent reasons that people can't have abortions, or that health care providers can't provide them.
These phony "conservatives" want to shrink "Big Government" just small enough to fit under people's bedroom doors. Have they no shame?
National Men's Health Week
National Men's Health Week is June 13-19, 2016. Guys, here are 6 tips for better sexual health. Ladies, feel free to listen in.
* Don't have sex drunk
While drinking, your judgment is compromised, your sensitivity to others is reduced, and your penis slows WAY down. As Shakespeare tells MacDuff in Macbeth, "drinking stimulates desire but hinders performance." Every year, dozens of men come to see me for supposed erection problems that are simply penises functioning normally when their owners are hammered.
And let's be honest—sex while drunk doesn't even feel good. It's usually the idea of sex that people desire when drunk; the actual experience is typically sloppy, uncomfortable, and unsatisfying.
You know about "beer goggles," right? The scientific term is "We do crazy stuff after drinking." Be smarter than that. Remember, people are held accountable for what they do while drinking, even if they don't care at the time.
* Don't take contraceptive risks
Short of vehicular manslaughter, nothing will change your life like an unintended pregnancy. For a healthy future, don't risk it—either use birth control, or enjoy sexual activities other than intercourse. Withdrawal? That's the method used by many people who become parents when they hadn't planned to. Besides, trying desperately to enjoy sex while not ejaculating can really get on your nerves, and even exacerbate sexual difficulties.
For a healthy present, find a reliable birth control method. And remember that vasectomy is inexpensive, simple, virtually 100% effective, and it has absolutely no effect on sexual function. Except to make sex a lot more relaxed.
* If you watch porn, don't neglect your partner or her feelings
If your partner doesn't like you watching porn, discuss this with her (I rarely hear gay couples argue about porn), find out exactly what her objections are—and address them, rather than blowing them off. Most couples arguing about porn are actually arguing about something else—sometimes sexual, sometimes not. Even if the two of you agree to disagree, it's vital that your partner feels understand rather than dismissed.
If your partner wants more sex with you than you do with her, you might want to discuss that, too—although most couples would rather walk across the Sahara barefoot than discuss that incredibly sensitive topic. But that's often what the porn argument is really about.
* Don't proceed to intercourse if you're not ready
The reasons that men proceed to intercourse when they're not ready include: fear of losing their erection; boredom with the erotic activities that precede intercourse; fear that the woman will change her mind; assumptions about what a woman wants.
Of course, sex doesn't always have to include intercourse. More to the point, if you're not enjoying what you're doing before it, discuss that with your partner. Engaging in "foreplay" as an unpleasant but mandatory cost to getting laid is a terrible waste. It can also create resentment and make your penis unenthusiastic.
If you start fooling around and you realize you're just too tired, too worried, too angry, or you've had too much to drink, look at your partner in a friendly way and say so. She may be disappointed, but at least she won't be having lousy sex and wondering why.
* Have realistic expectations of your body
Our bodies are not like ATMs, ready to deliver 24/7, rain or shine. It's unrealistic to think we can get erect when we're worried, can slide a penis into anything without lubrication, can ignore lower back pain while thrusting, or climax when we're not excited.
Our bodies can be the site of wonderful sexual feelings. If we expect miracles, or if we forget that emotions affect our sexual functioning, we're inviting disappointment. Don't blame your body for working perfectly when you don't give it the right conditions to do what you want it to.
* Remember, real sex doesn't feel like porn looks
While partner sex can be wonderful, most of the time it isn't an incredibly intense experience like porn portrays. Nor do most people feel as confident, as uninhibited, as spontaneous, as self-accepting, or as physically powerful as the characters portrayed in porn.
People who try to recreate in real life the emotional experiences that fictional characters portray (whether in porn, James Bond films, or car commercials) will always feel disappointed. Don't try to create fantasy sex. Relax and create real sex.
* * *
Why haven't I mentioned STDs?
All the information anyone needs about the symptoms, diagnosis, and treatment of STDs is available on a jillion websites. Millions of people pay lip service to "awareness" and "protection," although far fewer people actually consider STDs when making sexual decisions. Whether safer-sex behaviors include outercourse, condoms, or honest conversation, one more professional's encouragement probably won't make much difference.
So here's what I'd say: If you have an STD, tell your partner. Preferably yesterday. Definitely today. This isn't an issue of sexuality. It's a matter of personal integrity and trust. And at the end of the day, that's way more important than one less sexual encounter.
