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Gluttons, Sentimentalists and other Metaphors of Premature Ejaculation

 

Uri Wernik

 

                      

 

Premature Ejaculation (PE) is one of the two most frequent complaints presented by males in sex therapy, and yet it is rarely discussed in the current sexological literature or professional meetings.  It has become almost common knowledge that PE is a well understood phenomenon and an easy problem to treat and thus, it is no longer considered a challenge to therapists or theorists.  The present article aims to open this topic for discussion and to show that the last word on PE has yet not been said.

A case could be made that basically not much has been added to the understanding of PE since Kinsey (1948).  Very little was developed in its treatment since Masters and Johnson (1970) who used Semans' (1956) approach.  A noteworthy exception is Zilbergeld's (1975) contribution, which enabled helping males without an available partner.

The impression one gets from the different therapy manuals (e.g. Kaplan, 1974) is that in addition to relationship and dynamic aspects, which most therapists nowadays deal with, standard "sensate focus" plus "squeeze" or "start stop" will do the trick.  The results are almost guaranteed to be successful with practically all clients.  Quite often a 90% success rate is mentioned in this context.               

 

 PE Between Practice and Theory

 

The above picture is much too optimistic.  At best, as will be shown later, it is somewhat justified in regard to one subgroup of PE only.  The "standard understanding" and "quick fix" approach to PE is based on overlooking clients who drop out of therapy (Zilbergeld and Evans 1980), refusal to treat males without partners, and acceptance of verbal reports of change from clients.  Often these clients undergo a frustrating therapy regime and at the same time are given to understand that their problem is trivial and something serious must be wrong with them if they do not improve.

Therapists, on their part, usually hesitate to report failures for the fear of being considered inferior clinicians.  Thus, the "90%" myth is perpetuated.  In informal conversations with colleagues, after my own confession that treating PE is not such a simple success story, most of them were relieved to admit both failures and partial improvements.               

Dissatisfaction with the prevalent ways of treating PE necessitates a re-evaluation of the relevant accepted theoretical notions.  This will be done to see if PE can be better diagnosed and if other therapy measures can be derived. 

Five etiological hypotheses are mentioned by most discussants: 1. PE is a result of an unconscious aggression towards one's sex partner.  2. PE is a learned response,  "imprinted" in the first sexual encounter. 3. PE is related to lack of awareness about one’s position in the continuum between beginning of arousal and orgasm.  4. PE is a direct result of infrequent orgasms.  5. PE is caused and/or exacerbated by (performance) anxiety.

The last hypothesis, although reasonable, is too general i.e. applicable to all sexual dysfunctions.  Yet, together with the fourth one, only these two have direct practical implications, which can be addressed in therapy.  Usually though, the issue is not frequency per se, but the vicious cycle of sexual frustration and declining interest.

The other three hypotheses stand on shaky ground: The first hypothesis might as well be the opposite of the truth: many sensitive and loving men were "blamed" in vain, adding guilt to their anxiety.  The second one is a post hoc explanation, which could never be tested in a controlled study. It is quite plausible that most people have less than optimal conditions, and are quite anxious when they have intercourse for the first time. The third notion is inapplicable to many males who are very aware of an imminent ejaculation even before intromission.   

Each of these theories treats all clients as if they have the same kind and degree of PE.  It is not clear at all how these factors interact and what their relation is to specific interventions in therapy.  Thus, for practical clinical purposes, these theories are insufficient, and the therapist must generate knowledge and guidance by other means. 

 

The Use of Metaphor in Psychotherapy

 

Metaphor is a basic tool in all understanding and discovery, scientific or clinical. It can be defined as "a series of words in which a comparison is being made between two or more entities that are literally dissimilar" or as "borrowing between contexts of meaning" (Angus & Rennie, 1988).  Metaphors are extensively discussed in linguistics (Bakhtin, 1985) philosophy (Johnson, 1981) and psychoanalysis (Arlow, 1979).  Recently their role in psychotherapy is gaining more recognition (Barker, 1985; Brooks, 1985). 

The problem of overweight for example, when considered through the metaphor of addiction i.e. alcoholism, leads to the development of OA (Overeaters Anonymous) the equivalent of AA.  Similarly, sexual preoccupation in light of the same metaphor ends with S.A. (Sexaholics Anonymous).  In these examples, a theoretical conceptualization as well as a therapeutical technique is suggested.  Whether they are socially desirable, valid or effective, are still open questions.   

Confronted with a clinical problem, resistant to the customary measures, with no satisfactory guiding theory, the sex therapist has no option but to ask herself "What is this situation or phenomenon like?” In other words, look for a good metaphor. If lucky, and the metaphor proves productive in generating interventions which seem to work, new hypotheses can be formulated.  Such metaphoric knowledge can be improved and enriched, but until tested in a controlled study it can be only used heuristically.

 

PE is not really a Problem, or is it 

 

The more appropriate metaphors a therapist commands, the better the ability to observe, understand and treat the varieties and gradations of PE.  Examining them with a given client would make a good intake and blueprint for therapy planning.  As this is a study that describes sex therapy under conditions of uncertainty and complexity, it might be instructive to describe how this fact is reflected in the initial approach to a client.  The general framework and therapy socialization will be presented here almost verbatim:

I have two things to tell you - one, PE is not really a problem; two, PE is not a simple problem.  PE is not really a problem, because - a. it does not have any physiological basis. b.  Most males ejaculate after 30 to 90 seconds of effective stimulation. (Kinsey 1948) c. "PE" is desirable from an evolutionary point of view (Hong 1984).  You are simply a potent fully responding copulator. d. It is not a question of malfunctioning, but rather of culturally determined preference. 

It was culturally decided to ask males to slow down rather than ask females to hurry up.  PE for the male is the equivalent of hairy legs for the female - both try different manipulations to appear not as they are, but as they are supposed to be.  One could try to oppose these expectations, but not everyone, nor any partner are open enough to see things in a liberated way. Of course it is only natural when we have fun, to want to make the experience last longer.

Before you change anything, you must first accept it.   Intellectual acceptance is not enough, and it is important that you and your partner acknowledge it as a valid and positive sexual expression.  In no other way except by rapid ejaculation, can a male show his partner his enthusiasm, attraction and excitement.  For this reason, it is necessary to ejaculate vigorously every few times, and every time you have a new partner or renew contact after a break.  Do not hide your response and do it loud and clear- using words such as: "I am so excited that I must come now".

Now, that you have accepted the phenomenon, we can start its modification if you so desire.  First of all, you must remember that it is not an easy job.  There are many aspects to PE and many measures to choose from.  It is quite similar to improving skills in any sport - you have to learn all components of the game and practice them all separately and together before any gains can be noticed.

Before we can tailor your specific "training program" we have to review and better understand your own background and approach to sexuality.  So, let me ask you a few questions... 

 

Gluttony and Sentimentality

 

As was mentioned before, different metaphors seem to fit different PE clients and each person can be characterized by more than one metaphor.  Nevertheless, in the following section, the metaphor and not the individual becomes a point of reference, and commonalties of males in a given PE subgroup will be suggested.  Although it might be tempting to think in terms of factors or defined classes of PE, from a formal point of view, it would be only justifiable to say that for some men with certain characteristics, a particular metaphor seems more appropriate.  Two metaphors seem to be more salient, each of them implying basically different therapeutic approaches. They will be reviewed and there implications for therapy delineated.  Then the other metaphors will be similarly considered. 

 

Food and Gluttony

 

Food, war, conversation and work are among the basic metaphors of sex (Wernik, 1987).  King Solomon’s Song of Songs is full of fruits, tastes, and smells. "Dish" is slang for an attractive female, tasting, licking and sucking, are often mentioned in relation to sexual activity.  One major subgroup of PE consists of males, which can be characterized as gluttons and gobblers i.e. they approach intercourse as a means to release tension, or to breaking the unpleasant sensation of hunger. A related metaphor would be the secretion of bodily wastes: some people feel that "it is bad to hold it in". These men typically, ejaculate shortly after intromission and come quickly in masturbation too. They come more slowly when they are not in control, as in manual or oral sex.  PE disappears or becomes milder when they have sex for the second time i.e. after they satisfied their hunger.

 With this group, the question actually asked in therapy is: "how can gluttons be turned into gourmands?"  The answer is, that anything that will make them give up control, pay attention to their own sensations, their partner's needs, or to a different approach to sex - can adequately delay their response.  Of course, it would not make any sense to attempt changes while such a person is "hungry" i.e. has low frequency sexual outlet.  When deprived for a long period, even a "gourmand" sensualist might forget his inclination. This conceptualization supplies a rationale for the acclaimed effectiveness of the "standard therapy package" (Masters and Johnson, 1970) as well as for its less successful results with males who cannot be described as gluttons.

A completely different picture can be seen in another major subgroup. Here men ejaculate before, during, or immediately after intromission. In masturbation, they report lasting as long as they choose.  In manual sex, they have much less control and with oral sex, the situation is usually closer to intercourse.  When having sex for a second time, PE still happens.  Whereas in the first group the response is stable across situations e.g. identity and behavior of partner, or the nature of stimulation - in the second group, it is situation specific. With these males, the results of the "standard therapy package" are quite poor.

 

Sentimentality and its Cure

 

 In order to further my understanding and to formulate some ideas for intervention with this group, I started looking for another human analogy.  Uncontrolled crying in an emotionally charged situation seemed to be appropriate, as the sudden appearance of tears is equivalent to the release of drops of semen. This leads to the concept of sentimentality and to the discovery that it has not been dealt with at all in modern psychology. Fortunately, it is discussed by I.A. Richards in his book Practical Criticism, (1929).

Following are some notions of sentimentality taken from this classic book:

a) "A person may be said to be sentimental when his emotions are too easily stirred, too light on the trigger...too susceptible, the flood gates of their emotions too easily raised."

b) "The trigger adjustment for the feelings varies with all manner of odd circumstances." e.g. drugs, weather, fatigue, illness, sounds, rhythms, reunions, processions.

c) Differences in sentimentality are noticeable along life's span: children and over experienced adults are less so; adolescents and young adults are more.

d) It is not a momentary thing but rather "a persisting, organized system of dispositions.  Sentiments, in this sense, are formed in us through our past experience in connection with the central object."

e) "Most, if not all, sentimental fixations and distortions of feelings are the result of inhibitions... undue curtailment in one direction seems to imply excess in an opposite direction (Pp. 242-5).”

The importance of the humanities for psycho-sex-therapy is not an empty claim.  Richards' descriptions read as if they were written about a subgroup of PE, rather than poems, thus supplying the metaphor with content validity.  Once it was realized that with this group, the question to be asked is -"how can an over emotional person change into a stoic?"- Different interventions were suggested and implemented.  Until further research is carried out, the titles of these techniques should be regarded as metaphoric:  

Inoculation: A careful assessment reveals that "sentimentalists" are sensitized to specific aspects of the sexual encounter. These could be related to the relationship (a female partner conceived as enacting the role of a saint, whore, mother or sister) or to sensations (seeing or feeling particular bodily organs e.g. vagina, breasts; deep kissing or oral contact; reaction to partner's arousal or orgasm; impact of depth, warmth, wetness, friction, smell).  In those encounters where their special "trigger" is missing - clients typically report that PE does not take place.  Variations of desensitization, and flooding via relaxation, hypnosis, or in vivo masturbation can be prescribed accordingly.

Amendment: Some PE clients reported that they had much better control under special physical conditions.  Two of which were found to be more general and replicable.  The first, after intense aerobic effort such as jogging, bicycling, dancing etc.- when feeling not tired, but rather exhausted and alert.  The second, when the penis is felt to be cool rather than hot: after a cold shower, after penis and testicles are sponged with alcohol or rubbed with an ice cube.  The client is asked to try these and if satisfied, to use them in order to stop the existing anxiety vicious cycle or as desired.

Deprogramming:  In order to effect change, the set pattern of sensitivities and inhibitions underlying PE must be disrupted and counteracted.  Clients are instructed to imagine, rehearse and when appropriate to enact a variety of different scripts contradictory to their habitual ones. Some possibilities are: being worried about inhibited ejaculation, expressing or fantasizing anger and aggression, imagining being unable to inhibit a need to urinate while inside the vagina, trying to express excitement and nervousness with crying or sweating. 

 

Other Metaphors of PE

 

In addition to the above-mentioned characterization of sentimentalists and gluttons, in order to understand and treat PE in a comprehensive manner, other variables must be considered as well.  These are arousal, control, lovemaking skills and the couple's relationship system.  The metaphors of drama, Nocturnal Enuresis, playing in harmony and the penis' talk - will help to clarify these factors and the implied interventions.

 

Drama: Tension, Climax and Anticlimax

 

PE is an event enfolding in a time dimension.  As such it invites the metaphor of a drama or a story.   Drama is characterized by tension, which makes the audience or readers want to know what comes next.  This tension is maintained until the moment of its resolution - its climax.  In light of this metaphor, PE might take place under two conditions.  First, when prior to intercourse there is a prolonged state of anticipatory arousal accompanied by uncertainty, inhibition, guilt and/or anxiety.  This process can continue for hours or days.  The longer, the more tense and complicated the internal struggle, the higher the chance and stronger the drive to an early climax.  This script is typical for "first times" and "illicit affairs".  In short, for stories where the drama reaches its highest point with the realization that the elusive event is for sure going to take place.  Thus the meeting of penis and vagina becomes a mere technicality: an anticlimax rather than a climax, as in more "mundane" stories.

Second, PE could be construed as a story lacking in tension, where the reader is not curious about the end, and finds it difficult to finish the first few pages.  This is a problem of low or slow arousal, which necessitates vigorous penile stimulation.  Thus the male approaches intromission and reaches his maximal erection concurrently and close to his ejaculation.

 The therapeutic implications are quite clear.  In the first case, reconciliation ("knowing that you want me, moves me so much that I am about to come.") and or differentiation ("I want to celebrate this moment of closeness and have sex later") are in order. In the second situation, prescribing a more effective sexual stimulation (e.g. visual, imaginary and auditory) would be more appropriate.

 

Nocturnal Enuresis

 

Some clinicians suspect that PE is related to a history of Nocturnal Enuresis.  As there is no empirical support for this impression, it might be more appropriate to treat it as a metaphor only.  This metaphor highlights the problem of "controlling something that is not under one's control” i.e. learn how not to urinate while sleeping.  Issues of control and lack of control are central with males who avoided masturbation due to either early beginning of nocturnal emissions or intercourse, inhibitions or late sexual awakening. These men missed an opportunity to practice mastering their ejaculation.  When a more general control issue is identified, the therapeutic question becomes: "How to teach control when a person believes that he is not in control?"  Two approaches, as in the treatment of Enuresis, are possible.  A paradoxical approach would be asking a person to urinate in bed or ejaculate as fast as he can (Haley, 1973).  The second approach consists of interventions which increase a sense of mastery by gradual skill training: Prescribed masturbation, Kegel exercises (1952) and self stimulation to a time criterion as suggested by Zilbergeld (1975), are all appropriate.

 

Duet Playing

 

Actually most males suffer from PE, as it takes them less time than females to reach orgasm. Thus, couples are usually confronted with the problem of coordinating their rhythms to their mutual satisfaction.  This brings to mind the metaphor of playing or singing a duet.  When information or performance are lacking, instruction is in order.  Clients can be taught to understand the nature of their partners' orgasm, and to improve their "technique". 

Appropriate advice on slow intromission, rotating movements, pauses, breathing and muscle contraction can be found in most self-help and therapy manuals such as Zeiss & Zeiss (1978). I would like to suggest two additional measures: In oriental "pillow books” intercourse is described by position as well as by tempo.  Based on this idea, clients are instructed to pace their thrusts according to different formulas such as -"5 shallow 1 deep", or if they so incline, with accordance to music.  I also found that teaching arousal monitoring ("notes reading") could be best done by "internalization" of the arousal scale.  The client is asked to visualize such a scale on his forehead and specific questions about its' shape, color, direction and graphics are asked in order to help this process.

 

Penis’ Talk

 

PE is occasionally a response to a situation where the partner is (either or/and) uncooperative, angry, pressuring, rejecting, sensitive to pain, aversive to semen, unattractive or not attracted and unloving.   In such a situation, the therapist's task is to help the couple hear the unconscious message delivered by the penis.  The humanization of the penis is a powerful therapeutic metaphor in sex therapy.  The penis is a good friend that feels is in better contact with the unconscious than the whole person, and talks - although in simple sentences such as degrees of erection or ejaculation.  Thus the couple can understand that PE is actually an elegant solution to an approach - avoidance conflict: "do it - but get it over with quickly".  This enables them to look for other solutions to the basic problems, which includes couple therapy and separation if necessary.

 

 

 

Bibliography

 

Angus, L.E., Rennie, D.L. (1988). Therapist participation in metaphor generation: collaborative and noncollaborative styles.  Psychotherapy, 52, 552-560.

Arlow, J. (1979). Metaphor and the psychoanalytic situation. Psychoanalytic Quarterly, 84, 363-385.

Baker, P. (1985).  Using Metaphor in Psychotherapy. New York: Brunner/Mazel.

Bakhtin, M. (1984) Problems of Dostoevsky’s  Poetics  (C.   Emerson, trans.) Cambridge, Mass.: Harvard University Press.

Brooks, R. (1985). The beginning sessions of child therapy: Of message and Metaphor.  Psychotherapy, 22 , 761-69.

Haley, J. (1973).  Uncommon Therapy: The Psychiatric Techniques of Milton H. Erickson. New York: Norton.

Hong, L.K. (1984). Survival of the fastest. On the origin of premature ejaculation.  Journal of Sex Research, 20, 109-122.

Johnson, M. (1981).  Philosophical Perspectives on Metaphor. Minneapolis: University of Minnesota Press.

Kaplan, H.S. (1974). The New Sex Therapy. New York: Brunner/Mazel.         

Kegel, A.H. (1952). Sexual functions of the pubococcygeus muscle. Western Journal of  Surgery, 60, 521-24.

Kinsey,A.C., Pomeroy, W.B., Martin,C.E. (1948). Sexual  Behavior in the Human Male. Philadelphia and London: Saunders.

Masters,W.H., Johnson,V.E. (1970). Human Sexual Inadequacy.Boston: Little, Brown.

Richards,I.A. (1929).  Practical Criticism. New York: Harcourt, Brace and Company. 

Semans,J.H. (1956). Premature ejaculation: a new approach. Southern Journal of Medicine, 49,353-357.

Wernik, U. (1987).  Open Minded Sex. (in Hebrew). Jerusalem: Keter Publishing Co.

Zeiss, R.A., Zeiss,A. (1978).  Prolong Your Pleasure. New York: Pocket Books.

Zilbergeld, B. (1975). Group treatment of sexual dysfunction in  men without partners.  Journal of Sex Therapy, 1, 204-14.

Zilbergeld, B., Evans, M. (1980). The inadequacies of Masters and Johnson.  Psychology Today, 41, 28-43.

 

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