Journal of Sex & Marital Therapy
ISSN: 0092-623X (Print) 1521-0715 (Online) Journal homepage: http://www.tandfonline.com/loi/usmt20
Premature ejaculation: Some thoughts about its pathogenesis Stephen B. Levine M.D. To cite this article: Stephen B. Levine M.D. (1975) Premature ejaculation: Some thoughts about its pathogenesis, Journal of Sex & Marital Therapy, 1:4, 326-334, DOI: 10.1080/00926237508403707 To link to this article: http://dx.doi.org/10.1080/00926237508403707
Published online: 14 Jan 2008.
Submit your article to this journal
Article views: 12
View related articles
Citing articles: 12 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=usmt20 Download by: [Deakin University Library]
Date: 06 November 2015, At: 03:38
Journal of Sex & Marital Therapy Vol. 1, No. 4, Summer 1975
Premature Ejaculation: Some Thoughts about Its Pathogenesis
Downloaded by [Deakin University Library] at 03:38 06 November 2015
Stephen B . Levine, M.D.
ABSTRACT: Premature ejaculation has always been assumed to be a male sexual dysfunction whose pathogenesis involved either male physiologic or psychologic considerations. A small series of unselected cases is presented that suggests that premature ejaculation may also result from hidden female arousal difficulties. The clinical material illustrates that the newer penile stimulation therapies for premature ejaculation are not required for every couple with this complaint.
The pathogenesis of premature ejaculation remains unclarified. Psychodynamic work with the symptom has at various times drawn attention t o both remote and current forces in the man's life. Speculation based on early psychoanalytic therapy' laid sole emphasis on the unconscious residuals of the mother-son relationship. Unconscious rage against women and fear of castration or injury in a dangerous vagina were the forces thought to explain not only premature ejaculation but impotence as well.2? Steke14 disagreed with the notion that childhood fixations were always important explanations for the symptom. He reported that he saw many cases where the basic pathogenesis involved either the lack of love for the partner or intense moral conflict about the relationship. Although it seems obvious that both current and remote forces might operate t o produce premature ejaculation, this has not been emphasized in the literature. Because no systematic data were ever published, it is impossible to know how frequently premature ejaculation resolved as a result of psychodynamic therapy. Until Semans5 introduced a highly efficacious prototypic penile stimulation technique, premature ejaculation was felt by nonpsychiatrists t o be an untreatable condition. Semans did not speculate about pathogenesis of the problem; however, Masters and Johnson,6 who refined the Semans squeeze technique, hypothesized that premature ejaculation was a physiologic not a Dr. Levine is Assistant Professor of Psychiatry, Case Western Reserve University, 2040 Abington Road, Cleveland, Ohio 44106. The author would like to thank Lillian Levine, David Agle, and Marvin Wasman for their helpful suggestions during the development of this paper.
326
Downloaded by [Deakin University Library] at 03:38 06 November 2015
Stephen 3.Leuine
32 7
psychologic disorder. Their hitherto unheard of success rate of 97.8% with 186 couples lent great weight t o whatever they said about the condition. They felt that early sexual experiences with women whose sexual pleasure was not valued (often prostitutes) set up a lasting learned or conditioned low physiologic threshold for ejaculation. K a ~ l a n , ~ , who introduced more flexibility into the couple treatment of premature ejaculation, emphasized that for some reason (perhaps unconscious conflict) the premature ejaculator was not aware of his sensations premonitory to orgasm. Successful therapy was carried out based on helping the man increase his awareness. All of the writers on this subject have assumed that premature ejaculation is a male sexual problem. Explanations of its pathogenesis, however incomplete, are always given in terms of his fixations, his moral conflicts, his physiologic threshold, or his defensive needs. This view of the pathogenesis stresses persists in spite of the fact that each of the major therapists 4 9 s 7 6 , 7 the need for partner cooperation for the treatment. Kaplan in particular tells the couple that the prognosis for reversing the dysfunction is excellent and that the responsibility for therapeutic success is theirs. The main hypothesis of this paper is that some cases of premature ejaculation are masked female sexual dysfunctions that find expression in brevity of vaginal containment. The cause of the brevity in these cases has t o d o with the female’s intrapsychic needs. Evidence for this hypothesis has come from my clinical experience as a psychiatrist working with the new sexual t h e r a p i e ~ . ~ CASE REPORTS Case 1 A 22-year-old alcohol-abusing mother, who alternated periods of fasting with gluttony and self-induced vomiting, came for treatment of depression. She had vociferous complaints about her husband’s premature ejaculation. After 6 months of twice a week therapy marked by her lability and impulsivity, it emerged that she was frightened of sexual arousal and interfered with his attempts to achieve ejaculatory control by thrusting rapidly, rushing foreplay, insisting on positions that were extremely stimulating for him, and refusing a second intercourse. These behaviors enabled her to get intercourse over with as quickly as possible. She recognized that they decreased her exposure to arousal and helped her not to feel so alone in her sense of incompetence. She viewed him as an otherwise highly successful person, incompetent only in intercourse. She was his first sexual partner.
This case draws attention to the wife’s intrapsychic needs and her capacity for sexual excitement as a critical factor in the symptom called premature ejaculation. Case 2 A 45-year-old cosmetology student was referred from the inpatient service where she had
Downloaded by [Deakin University Library] at 03:38 06 November 2015
328
Journal of Sex &Marital Therapy
just completed her sixth admission. She felt that her recurrent depressions and suicide attempts were in large part due to her sexual frustration. She had not been orgasmic for 18 years except for masturbation and then only occasionally. She began the evaluation by viciously berating her 43-year-old janitor husband for his three-thrust maximum premature ejaculation, general sexual ignorance, and heavy drinking. He responded inarticulately, but was able to similarly humiliate her by calling her a “pillaholic,” a reference to her many years of drug abuse. They both agreed that seeking therapy was a good thing and if successful would improve their argumentative relationship. His first marriage had ended because of premature ejaculation. Using the Semans squeeze technique, this chronically conflicted couple achieved excellent ejaculatory control in three sessions. Her long-suffering, hostile, belittling attitude changed dramatically with the first night’s success, as did his pouting. He stopped drinking. But when his ejaculatory control was such that her emphatically stated desire for orgasm the “normal” way became a possibility, she began avoiding sexual encounters and berating him. He was quickly restored to his former helpless bewilderment. When confronted with her resistance, she tearfully announced that she could not continue therapy and threatened suicide. Alone, she confessed she had a lover with whom she has been quite responsive (orgasmic) for many years. She said her only desire in lovemaking with her husband was to get it over with as fast as possible. The temporary remission of premature ejaculation was followed by total abstinence from sexual contact.
Although the premature ejaculation was reversed dramatically in this case, the woman could not tolerate the resultant shift in their marital equilibrium. It was n o t clear exactly why because as a historian she was untrustworthy. Was it her inherent fear of sexual arousal as in Case l? Did his ejaculatory control fracture her rationalization for maintaining her affair and threaten her with the possibility of giving her “lover” up? Did it destroy her ability to displace her angry frustrations or sense of deprivation stemming from other sources to her husband? The basic question here remained unanswered. Case 3 A couple in their mid-20s, with a 2-year-old son, were referred by the husband’s psychotherapist a t the termination of an 18-month treatment. Premature ejaculation and marital conflict continued to plague their 4-year marriage. Therapy was delayed while she decided whether to leave her husband or have conjoint treatment. Prior to marriage she had been sexually responsive in both of two relationships. The latter she had ended because, while the sex was superb, the relationship was unbearable. Her shy, gentle, kind, nonassertive husband was a welcome relief from the psychological brutality of her boyfriend. But presently she longed for the boyfriend’s capacity to bring her to orgasm with 10 to 20 minutes of hard thrusting. She was adamant that her husband, no matter how successful the therapy, could never provide for her sexual needs. In recent years she felt increasingly hopeless about sex and, when she could not avoid it, wanted it over with as soon as possible. As evidence for her hopelessness she explained that in an agreed-upon mutual affair with another couple she had two orgasms, while she heard that her husband’s performance was pathetic. He had had frequent experience with prostitutes for 2 years and had come from an overly close maternal relationship. His wife’s sexual requirements seemed an impossible goal to him too, but he grew progressively more confident as the early phases of treatment with the Semans squeeze technique progressed well. He had gone from at most 10 seconds of thrusting to over a minute when her fatigue, headaches, prolonged menses, unexplained depression, and finally argumentativeness put a stop to carrying out therapeutic tasks. When these were clarified as resistances, she continued to externalize all blame until she finally acknowledged she was again trying to decide whether to remain in
Stephen B. Levine
329
Downloaded by [Deakin University Library] at 03:38 06 November 2015
the marriage. She decided to remain, but declined further therapy. He was sullen, hurt, and quietly enraged, but helpless without her cooperation.
This man’s anxiety about sex as reflected in his “sexual incompetence” and premature ejaculation was met with rejection which only increased his anxiety and seemingly kept him from achieving control. Again with this case, the exact reasons for the wife’s failure t o cooperate could not be clarified. Toleration of sexual excitement per se was not her problem, however. That the fate of a man whose sexual life is initially crippled by anxiety could be different was illustrated by Case 4. Case 4 A 3 1-year-old accountant sought consultation in desperation for his impotence. He was contemplating just leaving his 34-year-old bride of 2 months so that she might find someone better. In previous sexual experiences with prostitutes and one-night stands, he claimed never to have had any difficulty. In striking contrast to his severe anxiety about performing, his wife was comfortable and confident about her own sexual capacities. She said she loved him very much. She pointed out that his impotence was mostly premature ejaculation and was preventing consummation. During a brief prohibition of intercourse she was able to help him relax. She was patient, optimistic, and made no demands. After 1 week she was having orgasms with penis in vagina prior to his ejaculation.
The wife in Case 3 could not create a similar relaxed, loving, understanding atmosphere. I n spite of her stated desires for longer intercourse, she still seemed to want him t o get it over with quickly. These cases demonstrated that the female could prevent or enable a reversal of premature ejaculation in a susceptible man. It seemed a reasonable hypothesis that the female might also have a pathogenic role in the failure of a man t o achieve ejaculatory control. Case 5 A suicidal, unassertive, shy, 25-year-old woman who seemed quite uncomfortable with her femininity was being treated with psychotherapy. As her depression improved, she attempted to talk about her sexual problem. Her husband’s approaches to make love usually produced only anxiety and tears. She constantly thought of her father and his questionable suicide. She longed to be held close by her husband and preferred it to intercourse which never aroused her to any significant degree. She occasionally permitted herself self-stimulation but could not achieve orgasm. She described her husband as gentle, kind, and patient and most of the time felt she loved him very much. Therapy became unproductive because she felt she could not talk about their sexual life. She suggested that her husband be seen with her. He was a soft-spoken, appreciative young man who blamed their sexual problems on his premature ejaculation; he could never last more than 10 to 15 seconds. He was quite busy in graduate school and did not seem to grasp the profoundness of her depressive isolation and preoccupation with her father’s death. We talked of his pattern of self-blame, and he acknowledged he was in a group experience trying to help himself with learning to express anger directly when appropriate. Therapy for his premature ejaculation consisted of informing him that his diagnosis was probably wrong and that the primary problem seemed to be his wife’s inability to be sexual and communicate to him her desires.
330
Journal of Sex -3Marital Therapy
Downloaded by [Deakin University Library] at 03:38 06 November 2015
Although angry at first, she recognized its accuracy and soon went on to have her first orgasm. He was delighted about her increased responsiveness and found he could repeatedly last 2 to 3 minutes during intercourse. Before returning to psychotherapy his annoying pattern of doing just what he pleased to her regardless of her sexual wishes was clarified. By the time the conjoint therapy ended, this behavior ceased.
The woman’s failure to be responsive during 2 years of marriage was in part due to a depression precipitated by her father’s death during her engagement, and in part t o her fears of being sexual. The husband’s misdiagnosis was a product of his self-punitive, nonassertive character. She was not regularly orgasmic during conjoint therapy but was capable of high levels of arousal. This change permitted his vaginal containment time t o improve without specific therapy. Several months later she became so angry at him for the return of his annoying failure t o respect her sexual wishes that she withdrew emotionally from lovemaking. Ten-second prematurity quickly redeveloped. The wife’s emotional withdrawal was the factor common t o both periods of premature ejaculation though the motivation for the withdrawal varied considerably. The premature ejaculation in the next case had a happier ending but also involved an erroneous self-diagnosis by an unassertive man in a deteriorated relationship. Case 6 A couple in their early 50s were referred for treatment of premature ejaculation. Throughout their 27 years of marriage vaginal containment time was never more than 30 seconds, usually much less. Their “miserable” sex life was compounded by her life-long global sexual inhibition. She blamed this only partially on his prematurity, for the awareness that they had intercourse only when she no longer could avoid it left her with a strong sense of personal sexual failure. Her husband reported being premature prior to marriage with three prostitutes. The seriousness of the premature ejaculation was de-emphasized, and the suggestion was made that it might improve without specific treatment. The responsiveness of both improved immediately. During nondemand exercises both were shocked by his new, seemingly endless capacity to stimulate and be stimulated without the former inevitable quick ejaculation. She became regularly orgasmic for the first time in her life. When they moved on to intercourse, his vaginal containment time was 2 minutes. Both partners were amazed that they each were so capable sexually. She discarded the self-image of frigid. He no longer considered himself an incompetent lover. In 2 months of continuing, wife-initiated sexual relationships he was able to thrust for up to 5 minutes.
The next case is an even more striking example of erroneous self-diagnosis, a misdiagnosis that hid basic nonsexual concerns. Case 7 A soft-spoken, gentle, 28-year-old man, recently separated from his sexually unresponsive wife of 7 years, began a relationship with a single, sexually responsive woman. He was relieved to discover he could participate in sexual relations rather than feel like he was
Downloaded by [Deakin University Library] at 03:38 06 November 2015
Stephen B. Leuine
33 I
imposing in some animalistic way. He and his new companion went on a 3-month vacation totally free of all responsibilities. They often made love twice a day, had intercourse in three positions for a total of 30 t o 45 minutes. She was multiply orgasmic. He was stunned by the contrast to his quick ejaculations during marriage. Eight months later, about to be married in 3 months, they came complaining of premature ejaculation. Although both were concerned, he was much more so. After vacation they had returned to their jobs and the problems of the finalization of the divorce, separation from his child, mixed religious marriage, and the wedding. His vaginal containment time began waning, and their sex life became increasingly mundane. He could only provide her with one or two orgasms. Rarely, she had none. He could have intercourse for only 5 or 6 minutes and ejaculated before he was ready to switch positions. Not only did he see himself as a premature ejaculator, but saw his performance as getting worse. His fiancde was much more sensible about sexuality and urged him t o seek help because she could not quell his ever-increasing anxiety. He was told he was not a premature ejaculator. Therapy focused on trying to understand the source of his excessive performance anxiety. He strongly denied being greatly conflicted about the upcoming marriage, but he was aware of a vague anxiety that he would be abandoned by his fiancee. She was quite supportive and helped him in many ways including being more selfish with his sexuality. His anxiety diminished considerably, and the quality of their sexual relations improved.
In contrast, the last case represents an example of a premature ejaculation that is primarily a male sexual dysfunction. Case
8
A 6 1-year-old, recently retired businessman presented for help for premature ejaculation. He secretly considered himself a sexual cripple. Now that time was no longer an excuse, he wanted to see if he could be helped. He had lasted less than 10 seconds all his life with each of several partners and often had anteportal ejaculation. About his wife he rationalized, “She is semifrigid anyway.” She was a 60-year-old, very disappointed womani having longed for his affection throughout their 4 0 years together. By her 30s she had given up hope for sexual arousal because of his constricted sex life. She was sad about this loss, for she thought herself capable of passion. She had been occasionally orgasmic by hand stimulation, b u t was embarrassed to ask for it. She had not masturbated in recent years. He characteristically was undemonstrative and could not stand t o be fondled or touched by anyone. He realized he was different than his friends in that he never found any enjoyment in looking at pictures of seminude females. He refused t o see R-rated movies. He was in many ways successful, but his life was extremely routinized. He was in control of everything, worked long and hard, and avoided surprises and excitement. In therapy he was the one who developed striking resistances. He fought doing the sexual tasks more than weekly, forgot instructions, planned interferring trips out of town, and was often “too tired” from social and athletic activities. Significant progress with his symptom did not begin until termination was threatened. Now the premature ejaculation is somewhat better; he can last about 2 minutes when he follows instructions, but he cannot often d o that. His explanation for the obvious therapeutic difficulty is the inflexibility of age and the persistence of old habits. But he provided two memories that seem t o suggest another explanation for his anxiety and inability t o experience sexual abandon. He slept with his father during much of his childhood. On at least two occasions, he remembered being awakened by his parents having intercourse beside him. He tried hard not to see them and return to sleep. Several years later when the patient was into puberty, his “good-for-nothing” father pointed to the patient and angrily told his mother, “Why don’t you have sex with him, he’s old enough now!”
332
Journal of Sex &Marital Therapy
Downloaded by [Deakin University Library] at 03:38 06 November 2015
DISCUSSION The mechanism whereby premature ejaculation, a male dysfunction, masks an underlying female dysfunction, may involve two things: (a) the failure of the female t o provide her partner with a patient, nondestructive incentive t o develop control; and (b) the use of displacement to defend against recognition of her sexual anxieties. It is the woman’s lack of mental involvement in lovemaking that provides the unspoken message “Hurry up! ” This ongoing message may be more important as an explanation for the persistence of the prematurity in some cases than early “learning” with prostitutes. The uninvolvement of the unresponsive wife is similar t o the prostitute. The uninvolvement may occur initially because of her intolerance of sexual arousal or simply because she is angry at her husband for other reasons. But the phenomenon of the uninvolved wife may contain both elements, and clinical distinctions become difficult. The hypothesis that the female may be the crucial determinant when some men fail to develop ejaculatory control is not really a new idea. In 1927, Steke14 wrote, “one sees ejaculatio praecox most often in men who complain of frigid wives. The women attribute their frigidity to the relative impotence of their husbands, whereas the frigidity is really the cause of the ejaculatio praecox.. . . The unconscious of one partner often perceives a resistance in the other partner and reacts to it with impotence and ejaculatio praecox.” Stekel recognized that this was one of many determinants; the others originated in the male and induced a great deal of female suffering. Several of my cases of premature ejaculation were treated only by an encouraging disagreement with the man’s self-diagnosis. Vaginal containment times for the husbands in Cases 5 and 6 at least quadrupled just with the increased responsiveness of their wives. The stop-short technique of Kaplan,’ or the Semans’ squeeze technique, was not used. For neither of the wives was 2 minutes of thrusting sufficient t o reach orgasm, however. Considering Semans’ claim that his method enabled the male to delay ejaculation indefinitely and that both Masters and Johnson and Kaplan speak of ejaculation when the man chooses, perhaps these two men have not been “cured” by sex therapy standards. They at least now resemble the vast majority of men Kinsey’ described and can now begin the natural process of learning further ejaculatory control-that is, as long as their wives continue to be responsive. The newer penile stimulation techniques are not always necessary to reverse premature ejaculation. Cases 4, 5 , and 6 suggest that some couples suffering from apparent premature ejaculation either do not really have the condition or have such a mild form that it is readily reversible without specific therapy. Careful diagnostic evaluation of every couple presenting this complaint is requisite t o separate cases with the severe variety of premature ejaculation from those that represent masked female sexual dysfunction. The therapist’s concept of pathogenesis can prove vital. If
Downloaded by [Deakin University Library] at 03:38 06 November 2015
Stephen B. Levine
333
premature ejaculation is always assumed t o be a male dysfunction, one might erroneously engage the man in psychotherapy or briefly treat the couple with the Semans squeeze technique and miss the opportunity to assist the female partner in developing her capacity for sexual arousal. Like other types of sexual dysfunction, premature ejaculation has a range of severity in the population, and the border between it and normality is vague. Unfortunately, little is known about the natural history of ejaculatory control and the prevalence of severe forms of prematurity. When these epidemiologic aspects are clarified, it will be easier to both define premature ejaculation and assess the relative frequencies of its various major determinants. The hypothesis that a cause of some cases of premature ejaculation lies primarily in the female partner, even if correct, says nothing about how frequent a cause it is. My clinical experience, as that of other workers, is not taken from a representative sample of the population. Basic work in the epidemiology of premature ejaculation is needed. Given the reputation of the new techniques for reversing premature ejaculation, some explanation is in order for the failure to achieve a lasting reversal of the symptom in half of this series. Lack of therapist skill is always a factor to be considered. Probably more important here, though, is the fact that none of the couples who came for help were rejected. Unselected cases tend t o lower success. Masters and Johnson6 point out that their series is a highly selected one because of the requirements of time and money and high motivation for cure. Kaplan's group accepts all motivated couples except those in which either partner exhibits active severe psychopathology or in which the sexual symptom appears t o be functioning t o prevent psychop a t h ~ l o g y .This ~ paper attests to some of the reasons for these criteria. For two of the cases, the near-successful resolution of the premature ejaculation threatened the equilibrium of the female partner. In a third case, the symptom seemed to be a needed defense against a fuller sexual participation which apparently threatened the man with the repressed conflicts from his youth. The presence of a new effective mode of therapy has eclipsed work on a more comprehensive conceptual framework for premature ejaculation, much like penicillin curtailed the development of knowledge about the biology of pneumococcus. Attention has turned to the dissemination of information to primary physicians on how t o treat the c0ndition.'~7 Medical school teaching places heavy emphasis on the treatability of premature ejaculation. Many schools now show a film demonstrating the successful use of the Semans squeeze technique. Premature ejaculation is a popular topic in throwaway medical journals. This small series of cases suggests that premature ejaculation may indicate a primary male dysfunction, a primary but masked female dysfunction, a deteriorated relationship, a misdiagnosis, or some combination of these. The symptom may have less to d o with time and more to d o with the quality and
334
Journal of Sex &Marital Therapy
meaning of a couple's interactions. This may be why premature ejaculation has not been adequately defined. These complexities contrast with the current emphasis on disseminating a simple solution, a penile squeeze technique, for often complicated intrapsychic and interpersonal problems.
Downloaded by [Deakin University Library] at 03:38 06 November 2015
REFERENCES 1. Abraham K: Ejaculatory praecox. In Selected Papers of Karl Abraham. London, Hogarth Press, 1949. 2. Cooper A J: Factors in male sexual inadequacy: A review. J New Ment Dis 149:337-359, 1969. 3. Noy P, Wolstein S , et al: Clinical observations on the psychogenesis of impotence. Brit J Med Psycho1 39:43-53, 1966. 4. Stekel W: Impotence in the Male: Yolume Two. New York, Liveright, 1927. 5. Semans J H: Premature ejaculation: A new approach. J CJrol49:533-537, 1956. 6. Masters W,Johnson V: Human Sexual Inadequacy. Boston, Little, Brown, 1970. 7. Kaplan H: The New Sex Therapy. New York, Brunner-Mazel, 1974. 8. Kaplan H, et al: Group treatment of premature ejaculation. Arch Sex Behau 3:443-452, 1974. 9. Kinsey A, Pomeroy W B, Martin C E: Sexual Behavior in the Human Male. Philadelphia, W B Saunders, 1948. 10. Adelson E R: Brief guide to office counseling: Premature ejaculation. Med Aspects Hum Sex 8:83-84, 1974. 11. AMA Committec on Human Sexuality ( R Long, Chmn): Human Sexuality. Chicago, AMA, 1972.
ISSN: 0092-623X (Print) 1521-0715 (Online) Journal homepage: http://www.tandfonline.com/loi/usmt20
Premature ejaculation: Some thoughts about its pathogenesis Stephen B. Levine M.D. To cite this article: Stephen B. Levine M.D. (1975) Premature ejaculation: Some thoughts about its pathogenesis, Journal of Sex & Marital Therapy, 1:4, 326-334, DOI: 10.1080/00926237508403707 To link to this article: http://dx.doi.org/10.1080/00926237508403707
Published online: 14 Jan 2008.
Submit your article to this journal
Article views: 12
View related articles
Citing articles: 12 View citing articles
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=usmt20 Download by: [Deakin University Library]
Date: 06 November 2015, At: 03:38
Journal of Sex & Marital Therapy Vol. 1, No. 4, Summer 1975
Premature Ejaculation: Some Thoughts about Its Pathogenesis
Downloaded by [Deakin University Library] at 03:38 06 November 2015
Stephen B . Levine, M.D.
ABSTRACT: Premature ejaculation has always been assumed to be a male sexual dysfunction whose pathogenesis involved either male physiologic or psychologic considerations. A small series of unselected cases is presented that suggests that premature ejaculation may also result from hidden female arousal difficulties. The clinical material illustrates that the newer penile stimulation therapies for premature ejaculation are not required for every couple with this complaint.
The pathogenesis of premature ejaculation remains unclarified. Psychodynamic work with the symptom has at various times drawn attention t o both remote and current forces in the man's life. Speculation based on early psychoanalytic therapy' laid sole emphasis on the unconscious residuals of the mother-son relationship. Unconscious rage against women and fear of castration or injury in a dangerous vagina were the forces thought to explain not only premature ejaculation but impotence as well.2? Steke14 disagreed with the notion that childhood fixations were always important explanations for the symptom. He reported that he saw many cases where the basic pathogenesis involved either the lack of love for the partner or intense moral conflict about the relationship. Although it seems obvious that both current and remote forces might operate t o produce premature ejaculation, this has not been emphasized in the literature. Because no systematic data were ever published, it is impossible to know how frequently premature ejaculation resolved as a result of psychodynamic therapy. Until Semans5 introduced a highly efficacious prototypic penile stimulation technique, premature ejaculation was felt by nonpsychiatrists t o be an untreatable condition. Semans did not speculate about pathogenesis of the problem; however, Masters and Johnson,6 who refined the Semans squeeze technique, hypothesized that premature ejaculation was a physiologic not a Dr. Levine is Assistant Professor of Psychiatry, Case Western Reserve University, 2040 Abington Road, Cleveland, Ohio 44106. The author would like to thank Lillian Levine, David Agle, and Marvin Wasman for their helpful suggestions during the development of this paper.
326
Downloaded by [Deakin University Library] at 03:38 06 November 2015
Stephen 3.Leuine
32 7
psychologic disorder. Their hitherto unheard of success rate of 97.8% with 186 couples lent great weight t o whatever they said about the condition. They felt that early sexual experiences with women whose sexual pleasure was not valued (often prostitutes) set up a lasting learned or conditioned low physiologic threshold for ejaculation. K a ~ l a n , ~ , who introduced more flexibility into the couple treatment of premature ejaculation, emphasized that for some reason (perhaps unconscious conflict) the premature ejaculator was not aware of his sensations premonitory to orgasm. Successful therapy was carried out based on helping the man increase his awareness. All of the writers on this subject have assumed that premature ejaculation is a male sexual problem. Explanations of its pathogenesis, however incomplete, are always given in terms of his fixations, his moral conflicts, his physiologic threshold, or his defensive needs. This view of the pathogenesis stresses persists in spite of the fact that each of the major therapists 4 9 s 7 6 , 7 the need for partner cooperation for the treatment. Kaplan in particular tells the couple that the prognosis for reversing the dysfunction is excellent and that the responsibility for therapeutic success is theirs. The main hypothesis of this paper is that some cases of premature ejaculation are masked female sexual dysfunctions that find expression in brevity of vaginal containment. The cause of the brevity in these cases has t o d o with the female’s intrapsychic needs. Evidence for this hypothesis has come from my clinical experience as a psychiatrist working with the new sexual t h e r a p i e ~ . ~ CASE REPORTS Case 1 A 22-year-old alcohol-abusing mother, who alternated periods of fasting with gluttony and self-induced vomiting, came for treatment of depression. She had vociferous complaints about her husband’s premature ejaculation. After 6 months of twice a week therapy marked by her lability and impulsivity, it emerged that she was frightened of sexual arousal and interfered with his attempts to achieve ejaculatory control by thrusting rapidly, rushing foreplay, insisting on positions that were extremely stimulating for him, and refusing a second intercourse. These behaviors enabled her to get intercourse over with as quickly as possible. She recognized that they decreased her exposure to arousal and helped her not to feel so alone in her sense of incompetence. She viewed him as an otherwise highly successful person, incompetent only in intercourse. She was his first sexual partner.
This case draws attention to the wife’s intrapsychic needs and her capacity for sexual excitement as a critical factor in the symptom called premature ejaculation. Case 2 A 45-year-old cosmetology student was referred from the inpatient service where she had
Downloaded by [Deakin University Library] at 03:38 06 November 2015
328
Journal of Sex &Marital Therapy
just completed her sixth admission. She felt that her recurrent depressions and suicide attempts were in large part due to her sexual frustration. She had not been orgasmic for 18 years except for masturbation and then only occasionally. She began the evaluation by viciously berating her 43-year-old janitor husband for his three-thrust maximum premature ejaculation, general sexual ignorance, and heavy drinking. He responded inarticulately, but was able to similarly humiliate her by calling her a “pillaholic,” a reference to her many years of drug abuse. They both agreed that seeking therapy was a good thing and if successful would improve their argumentative relationship. His first marriage had ended because of premature ejaculation. Using the Semans squeeze technique, this chronically conflicted couple achieved excellent ejaculatory control in three sessions. Her long-suffering, hostile, belittling attitude changed dramatically with the first night’s success, as did his pouting. He stopped drinking. But when his ejaculatory control was such that her emphatically stated desire for orgasm the “normal” way became a possibility, she began avoiding sexual encounters and berating him. He was quickly restored to his former helpless bewilderment. When confronted with her resistance, she tearfully announced that she could not continue therapy and threatened suicide. Alone, she confessed she had a lover with whom she has been quite responsive (orgasmic) for many years. She said her only desire in lovemaking with her husband was to get it over with as fast as possible. The temporary remission of premature ejaculation was followed by total abstinence from sexual contact.
Although the premature ejaculation was reversed dramatically in this case, the woman could not tolerate the resultant shift in their marital equilibrium. It was n o t clear exactly why because as a historian she was untrustworthy. Was it her inherent fear of sexual arousal as in Case l? Did his ejaculatory control fracture her rationalization for maintaining her affair and threaten her with the possibility of giving her “lover” up? Did it destroy her ability to displace her angry frustrations or sense of deprivation stemming from other sources to her husband? The basic question here remained unanswered. Case 3 A couple in their mid-20s, with a 2-year-old son, were referred by the husband’s psychotherapist a t the termination of an 18-month treatment. Premature ejaculation and marital conflict continued to plague their 4-year marriage. Therapy was delayed while she decided whether to leave her husband or have conjoint treatment. Prior to marriage she had been sexually responsive in both of two relationships. The latter she had ended because, while the sex was superb, the relationship was unbearable. Her shy, gentle, kind, nonassertive husband was a welcome relief from the psychological brutality of her boyfriend. But presently she longed for the boyfriend’s capacity to bring her to orgasm with 10 to 20 minutes of hard thrusting. She was adamant that her husband, no matter how successful the therapy, could never provide for her sexual needs. In recent years she felt increasingly hopeless about sex and, when she could not avoid it, wanted it over with as soon as possible. As evidence for her hopelessness she explained that in an agreed-upon mutual affair with another couple she had two orgasms, while she heard that her husband’s performance was pathetic. He had had frequent experience with prostitutes for 2 years and had come from an overly close maternal relationship. His wife’s sexual requirements seemed an impossible goal to him too, but he grew progressively more confident as the early phases of treatment with the Semans squeeze technique progressed well. He had gone from at most 10 seconds of thrusting to over a minute when her fatigue, headaches, prolonged menses, unexplained depression, and finally argumentativeness put a stop to carrying out therapeutic tasks. When these were clarified as resistances, she continued to externalize all blame until she finally acknowledged she was again trying to decide whether to remain in
Stephen B. Levine
329
Downloaded by [Deakin University Library] at 03:38 06 November 2015
the marriage. She decided to remain, but declined further therapy. He was sullen, hurt, and quietly enraged, but helpless without her cooperation.
This man’s anxiety about sex as reflected in his “sexual incompetence” and premature ejaculation was met with rejection which only increased his anxiety and seemingly kept him from achieving control. Again with this case, the exact reasons for the wife’s failure t o cooperate could not be clarified. Toleration of sexual excitement per se was not her problem, however. That the fate of a man whose sexual life is initially crippled by anxiety could be different was illustrated by Case 4. Case 4 A 3 1-year-old accountant sought consultation in desperation for his impotence. He was contemplating just leaving his 34-year-old bride of 2 months so that she might find someone better. In previous sexual experiences with prostitutes and one-night stands, he claimed never to have had any difficulty. In striking contrast to his severe anxiety about performing, his wife was comfortable and confident about her own sexual capacities. She said she loved him very much. She pointed out that his impotence was mostly premature ejaculation and was preventing consummation. During a brief prohibition of intercourse she was able to help him relax. She was patient, optimistic, and made no demands. After 1 week she was having orgasms with penis in vagina prior to his ejaculation.
The wife in Case 3 could not create a similar relaxed, loving, understanding atmosphere. I n spite of her stated desires for longer intercourse, she still seemed to want him t o get it over with quickly. These cases demonstrated that the female could prevent or enable a reversal of premature ejaculation in a susceptible man. It seemed a reasonable hypothesis that the female might also have a pathogenic role in the failure of a man t o achieve ejaculatory control. Case 5 A suicidal, unassertive, shy, 25-year-old woman who seemed quite uncomfortable with her femininity was being treated with psychotherapy. As her depression improved, she attempted to talk about her sexual problem. Her husband’s approaches to make love usually produced only anxiety and tears. She constantly thought of her father and his questionable suicide. She longed to be held close by her husband and preferred it to intercourse which never aroused her to any significant degree. She occasionally permitted herself self-stimulation but could not achieve orgasm. She described her husband as gentle, kind, and patient and most of the time felt she loved him very much. Therapy became unproductive because she felt she could not talk about their sexual life. She suggested that her husband be seen with her. He was a soft-spoken, appreciative young man who blamed their sexual problems on his premature ejaculation; he could never last more than 10 to 15 seconds. He was quite busy in graduate school and did not seem to grasp the profoundness of her depressive isolation and preoccupation with her father’s death. We talked of his pattern of self-blame, and he acknowledged he was in a group experience trying to help himself with learning to express anger directly when appropriate. Therapy for his premature ejaculation consisted of informing him that his diagnosis was probably wrong and that the primary problem seemed to be his wife’s inability to be sexual and communicate to him her desires.
330
Journal of Sex -3Marital Therapy
Downloaded by [Deakin University Library] at 03:38 06 November 2015
Although angry at first, she recognized its accuracy and soon went on to have her first orgasm. He was delighted about her increased responsiveness and found he could repeatedly last 2 to 3 minutes during intercourse. Before returning to psychotherapy his annoying pattern of doing just what he pleased to her regardless of her sexual wishes was clarified. By the time the conjoint therapy ended, this behavior ceased.
The woman’s failure to be responsive during 2 years of marriage was in part due to a depression precipitated by her father’s death during her engagement, and in part t o her fears of being sexual. The husband’s misdiagnosis was a product of his self-punitive, nonassertive character. She was not regularly orgasmic during conjoint therapy but was capable of high levels of arousal. This change permitted his vaginal containment time t o improve without specific therapy. Several months later she became so angry at him for the return of his annoying failure t o respect her sexual wishes that she withdrew emotionally from lovemaking. Ten-second prematurity quickly redeveloped. The wife’s emotional withdrawal was the factor common t o both periods of premature ejaculation though the motivation for the withdrawal varied considerably. The premature ejaculation in the next case had a happier ending but also involved an erroneous self-diagnosis by an unassertive man in a deteriorated relationship. Case 6 A couple in their early 50s were referred for treatment of premature ejaculation. Throughout their 27 years of marriage vaginal containment time was never more than 30 seconds, usually much less. Their “miserable” sex life was compounded by her life-long global sexual inhibition. She blamed this only partially on his prematurity, for the awareness that they had intercourse only when she no longer could avoid it left her with a strong sense of personal sexual failure. Her husband reported being premature prior to marriage with three prostitutes. The seriousness of the premature ejaculation was de-emphasized, and the suggestion was made that it might improve without specific treatment. The responsiveness of both improved immediately. During nondemand exercises both were shocked by his new, seemingly endless capacity to stimulate and be stimulated without the former inevitable quick ejaculation. She became regularly orgasmic for the first time in her life. When they moved on to intercourse, his vaginal containment time was 2 minutes. Both partners were amazed that they each were so capable sexually. She discarded the self-image of frigid. He no longer considered himself an incompetent lover. In 2 months of continuing, wife-initiated sexual relationships he was able to thrust for up to 5 minutes.
The next case is an even more striking example of erroneous self-diagnosis, a misdiagnosis that hid basic nonsexual concerns. Case 7 A soft-spoken, gentle, 28-year-old man, recently separated from his sexually unresponsive wife of 7 years, began a relationship with a single, sexually responsive woman. He was relieved to discover he could participate in sexual relations rather than feel like he was
Downloaded by [Deakin University Library] at 03:38 06 November 2015
Stephen B. Leuine
33 I
imposing in some animalistic way. He and his new companion went on a 3-month vacation totally free of all responsibilities. They often made love twice a day, had intercourse in three positions for a total of 30 t o 45 minutes. She was multiply orgasmic. He was stunned by the contrast to his quick ejaculations during marriage. Eight months later, about to be married in 3 months, they came complaining of premature ejaculation. Although both were concerned, he was much more so. After vacation they had returned to their jobs and the problems of the finalization of the divorce, separation from his child, mixed religious marriage, and the wedding. His vaginal containment time began waning, and their sex life became increasingly mundane. He could only provide her with one or two orgasms. Rarely, she had none. He could have intercourse for only 5 or 6 minutes and ejaculated before he was ready to switch positions. Not only did he see himself as a premature ejaculator, but saw his performance as getting worse. His fiancde was much more sensible about sexuality and urged him t o seek help because she could not quell his ever-increasing anxiety. He was told he was not a premature ejaculator. Therapy focused on trying to understand the source of his excessive performance anxiety. He strongly denied being greatly conflicted about the upcoming marriage, but he was aware of a vague anxiety that he would be abandoned by his fiancee. She was quite supportive and helped him in many ways including being more selfish with his sexuality. His anxiety diminished considerably, and the quality of their sexual relations improved.
In contrast, the last case represents an example of a premature ejaculation that is primarily a male sexual dysfunction. Case
8
A 6 1-year-old, recently retired businessman presented for help for premature ejaculation. He secretly considered himself a sexual cripple. Now that time was no longer an excuse, he wanted to see if he could be helped. He had lasted less than 10 seconds all his life with each of several partners and often had anteportal ejaculation. About his wife he rationalized, “She is semifrigid anyway.” She was a 60-year-old, very disappointed womani having longed for his affection throughout their 4 0 years together. By her 30s she had given up hope for sexual arousal because of his constricted sex life. She was sad about this loss, for she thought herself capable of passion. She had been occasionally orgasmic by hand stimulation, b u t was embarrassed to ask for it. She had not masturbated in recent years. He characteristically was undemonstrative and could not stand t o be fondled or touched by anyone. He realized he was different than his friends in that he never found any enjoyment in looking at pictures of seminude females. He refused t o see R-rated movies. He was in many ways successful, but his life was extremely routinized. He was in control of everything, worked long and hard, and avoided surprises and excitement. In therapy he was the one who developed striking resistances. He fought doing the sexual tasks more than weekly, forgot instructions, planned interferring trips out of town, and was often “too tired” from social and athletic activities. Significant progress with his symptom did not begin until termination was threatened. Now the premature ejaculation is somewhat better; he can last about 2 minutes when he follows instructions, but he cannot often d o that. His explanation for the obvious therapeutic difficulty is the inflexibility of age and the persistence of old habits. But he provided two memories that seem t o suggest another explanation for his anxiety and inability t o experience sexual abandon. He slept with his father during much of his childhood. On at least two occasions, he remembered being awakened by his parents having intercourse beside him. He tried hard not to see them and return to sleep. Several years later when the patient was into puberty, his “good-for-nothing” father pointed to the patient and angrily told his mother, “Why don’t you have sex with him, he’s old enough now!”
332
Journal of Sex &Marital Therapy
Downloaded by [Deakin University Library] at 03:38 06 November 2015
DISCUSSION The mechanism whereby premature ejaculation, a male dysfunction, masks an underlying female dysfunction, may involve two things: (a) the failure of the female t o provide her partner with a patient, nondestructive incentive t o develop control; and (b) the use of displacement to defend against recognition of her sexual anxieties. It is the woman’s lack of mental involvement in lovemaking that provides the unspoken message “Hurry up! ” This ongoing message may be more important as an explanation for the persistence of the prematurity in some cases than early “learning” with prostitutes. The uninvolvement of the unresponsive wife is similar t o the prostitute. The uninvolvement may occur initially because of her intolerance of sexual arousal or simply because she is angry at her husband for other reasons. But the phenomenon of the uninvolved wife may contain both elements, and clinical distinctions become difficult. The hypothesis that the female may be the crucial determinant when some men fail to develop ejaculatory control is not really a new idea. In 1927, Steke14 wrote, “one sees ejaculatio praecox most often in men who complain of frigid wives. The women attribute their frigidity to the relative impotence of their husbands, whereas the frigidity is really the cause of the ejaculatio praecox.. . . The unconscious of one partner often perceives a resistance in the other partner and reacts to it with impotence and ejaculatio praecox.” Stekel recognized that this was one of many determinants; the others originated in the male and induced a great deal of female suffering. Several of my cases of premature ejaculation were treated only by an encouraging disagreement with the man’s self-diagnosis. Vaginal containment times for the husbands in Cases 5 and 6 at least quadrupled just with the increased responsiveness of their wives. The stop-short technique of Kaplan,’ or the Semans’ squeeze technique, was not used. For neither of the wives was 2 minutes of thrusting sufficient t o reach orgasm, however. Considering Semans’ claim that his method enabled the male to delay ejaculation indefinitely and that both Masters and Johnson and Kaplan speak of ejaculation when the man chooses, perhaps these two men have not been “cured” by sex therapy standards. They at least now resemble the vast majority of men Kinsey’ described and can now begin the natural process of learning further ejaculatory control-that is, as long as their wives continue to be responsive. The newer penile stimulation techniques are not always necessary to reverse premature ejaculation. Cases 4, 5 , and 6 suggest that some couples suffering from apparent premature ejaculation either do not really have the condition or have such a mild form that it is readily reversible without specific therapy. Careful diagnostic evaluation of every couple presenting this complaint is requisite t o separate cases with the severe variety of premature ejaculation from those that represent masked female sexual dysfunction. The therapist’s concept of pathogenesis can prove vital. If
Downloaded by [Deakin University Library] at 03:38 06 November 2015
Stephen B. Levine
333
premature ejaculation is always assumed t o be a male dysfunction, one might erroneously engage the man in psychotherapy or briefly treat the couple with the Semans squeeze technique and miss the opportunity to assist the female partner in developing her capacity for sexual arousal. Like other types of sexual dysfunction, premature ejaculation has a range of severity in the population, and the border between it and normality is vague. Unfortunately, little is known about the natural history of ejaculatory control and the prevalence of severe forms of prematurity. When these epidemiologic aspects are clarified, it will be easier to both define premature ejaculation and assess the relative frequencies of its various major determinants. The hypothesis that a cause of some cases of premature ejaculation lies primarily in the female partner, even if correct, says nothing about how frequent a cause it is. My clinical experience, as that of other workers, is not taken from a representative sample of the population. Basic work in the epidemiology of premature ejaculation is needed. Given the reputation of the new techniques for reversing premature ejaculation, some explanation is in order for the failure to achieve a lasting reversal of the symptom in half of this series. Lack of therapist skill is always a factor to be considered. Probably more important here, though, is the fact that none of the couples who came for help were rejected. Unselected cases tend t o lower success. Masters and Johnson6 point out that their series is a highly selected one because of the requirements of time and money and high motivation for cure. Kaplan's group accepts all motivated couples except those in which either partner exhibits active severe psychopathology or in which the sexual symptom appears t o be functioning t o prevent psychop a t h ~ l o g y .This ~ paper attests to some of the reasons for these criteria. For two of the cases, the near-successful resolution of the premature ejaculation threatened the equilibrium of the female partner. In a third case, the symptom seemed to be a needed defense against a fuller sexual participation which apparently threatened the man with the repressed conflicts from his youth. The presence of a new effective mode of therapy has eclipsed work on a more comprehensive conceptual framework for premature ejaculation, much like penicillin curtailed the development of knowledge about the biology of pneumococcus. Attention has turned to the dissemination of information to primary physicians on how t o treat the c0ndition.'~7 Medical school teaching places heavy emphasis on the treatability of premature ejaculation. Many schools now show a film demonstrating the successful use of the Semans squeeze technique. Premature ejaculation is a popular topic in throwaway medical journals. This small series of cases suggests that premature ejaculation may indicate a primary male dysfunction, a primary but masked female dysfunction, a deteriorated relationship, a misdiagnosis, or some combination of these. The symptom may have less to d o with time and more to d o with the quality and
334
Journal of Sex &Marital Therapy
meaning of a couple's interactions. This may be why premature ejaculation has not been adequately defined. These complexities contrast with the current emphasis on disseminating a simple solution, a penile squeeze technique, for often complicated intrapsychic and interpersonal problems.
Downloaded by [Deakin University Library] at 03:38 06 November 2015
REFERENCES 1. Abraham K: Ejaculatory praecox. In Selected Papers of Karl Abraham. London, Hogarth Press, 1949. 2. Cooper A J: Factors in male sexual inadequacy: A review. J New Ment Dis 149:337-359, 1969. 3. Noy P, Wolstein S , et al: Clinical observations on the psychogenesis of impotence. Brit J Med Psycho1 39:43-53, 1966. 4. Stekel W: Impotence in the Male: Yolume Two. New York, Liveright, 1927. 5. Semans J H: Premature ejaculation: A new approach. J CJrol49:533-537, 1956. 6. Masters W,Johnson V: Human Sexual Inadequacy. Boston, Little, Brown, 1970. 7. Kaplan H: The New Sex Therapy. New York, Brunner-Mazel, 1974. 8. Kaplan H, et al: Group treatment of premature ejaculation. Arch Sex Behau 3:443-452, 1974. 9. Kinsey A, Pomeroy W B, Martin C E: Sexual Behavior in the Human Male. Philadelphia, W B Saunders, 1948. 10. Adelson E R: Brief guide to office counseling: Premature ejaculation. Med Aspects Hum Sex 8:83-84, 1974. 11. AMA Committec on Human Sexuality ( R Long, Chmn): Human Sexuality. Chicago, AMA, 1972.
