Sentimentalists and other
Metaphors of Premature Ejaculation
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
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
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
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 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
adjustment for the feelings varies with all manner of odd circumstances."
e.g. drugs, weather, fatigue, illness, sounds, rhythms, reunions, processions.
sentimentality are noticeable along life's span: children and over experienced
adults are less so; adolescents and young adults are more.
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
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.
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.
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
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.
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
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