Sex Matters®: Louanne Cole Weston, PhD Meet Louanne | More Q&A From Louanne Cole Weston "I'm having trouble with premature ejaculation. What can I do?"

The opinions expressed herein are the author's alone and have not been influenced by WebMD.

I'm often asked what the cause of rapid ejaculation is. Is it mental or physical? And what can be done to help a man last longer?

Rapid ejaculation was once thought to be strictly a mental problem related to anxiety and habitual behaviors (for example, masturbating very rapidly). For 25 years, sex therapists have treated it that way. That is, get rid of the anxiety about sexual issues and probably the rapid ejaculation will go away. A new way of thinking is emerging in our field that divides this sexual difficulty into two groups: lifelong rapid ejaculation and situational rapid ejaculation. So now our task is trying to sort out the possible underlying cause for different men.

Here's the difference between the two. A man who ejaculates rapidly (against his personal wishes at the time) may find that this has been the case for him in every sexual experience with every partner he has ever had. Or a man may find that sometimes he lasts longer than others. This variation may relate to the particular partner he's with, the situation in which the sex is occurring, or the type of stimulation he's receiving.

In treating my clients, my assessment of a man presenting with this problem goes like this. If a man has always had rapid ejaculation, then it may be that he is neurologically wired to do so. I can't know for sure, but there is a chance that it's true. So for a little while, I ask him to approach it from the angle of changing his behaviors and re-patterning. He then tries various techniques to see what kind of change he can create.

If there's little to no change, the next step is to add the use of small doses of the antidepressants Prozac, Paxil, or Zoloft. He will stay on this low dose for about a year while he tries to incorporate the habit of lasting longer as his learned and, eventually, usual experience. After a year, a client then experiments with reducing or gradually discontinuing the antidepressant to see what effect it has.

At that point we can begin to assess whether this man was having lifelong ejaculation due to his brain wiring or just due to his anxiety. The clients who can taper off the medication without resuming rapid ejaculation, we can somewhat safely describe as situational. They simply needed the aid of the chemical coupled with the behavioral changes in order to learn to respond differently.

Those who ejaculate rapidly once off the medication might be driven by wiring or by anxiety, but we can't know for sure. What we do know is that their enjoyment of their sexuality is enhanced by being on a low dose of antidepressant. I usually recommend that those men consider a longer trial of the antidepressant, with another assessment of how they function while off the medication at a later date. For some men, the best scenario is to stay on the medication as long as they desire its enhancing effect.

What about the men whose rapid ejaculation is brought on by their anxiety? Sex therapists often find that a man doesn't last very long when his nervous system is engaged in an anxious manner. We deal with how a man can avoid that type of engagement and replace it with one that brings him pleasure in place of anxiety. That usually involves helping him understand what thoughts are running in his mind when he is being sexual and how he thinks about sex in general.

Very often men who experience rapid ejaculation view sex as a performance test. No chart exists anywhere that tells how long a man should last when being sexually stimulated during intercourse or in other manners. Yet, some men who ejaculate rapidly act as though there is an agreed upon standard for how people ought to behave sexually. (Sometimes these "standards" are based upon their viewing commercially produced sexually explicit videos which rely heavily upon many hours of taping and the wonders of editing.)

Sometimes rapid ejaculation can be brought on by a "self-fulfilling prophecy" which involves the following cycle: A man has nervous feelings about a previous sexual experience that he disliked. He thinks about it during the sex he is currently having, instead of thinking about his sexual sensations. The nervous feelings lead to rapid ejaculation. He then has another experience which he believes is negative. At the next sexual encounter, he recalls the most recent negative experience and so reinforces the cycle. This may lead men to dread the experience and lose touch with the pleasure of sexual interactions. They tend to believe that if they were "real men," they could white-knuckle their way to a long-lasting erection any time they thought they should or the circumstances required it. They also think that no one else (or very few) ever experience similar situations. These are mistaken ideas that lead away from enjoyable sex. Life is filled with so many arenas in which evaluation of one's performance makes sense. Taking that attitude into sex doesn't make sense and doesn't work.

Some men with erection dysfunction develop rapid ejaculation because they become very concerned that they will lose their erection unless they "act fast" -- a faulty theory. I describe it as a faulty theory because the body's nervous system is capable of softening an erection more quickly than a man can rush to insert it. In other words, hurrying just doesn't work and can reinforce the problem.

So what does work? Several changes in attitudes can do a lot to help a man last longer.

• Greater control over timing comes from being very aware of one's body, not less aware. This awareness permits men to adjust the speed, depth, and angle of intercourse (or any stimulation) to modulate their own arousal. Over the years, men have tried to delay orgasm by thinking about taking out the trash or trying to remember baseball scores. This approach puts a man at greater distance from his sexual experience and therefore lessens his ability to last longer.
• Anxiety reduction is crucial to a man's having his orgasm when he wants to. Many things can contribute to sexual anxiety, but lack of positive experiences is at the top of the list. Keep in mind that "performing" is not the point of having sex with someone, creating shared sexual pleasure is.
• To keep many options open for creating pleasure, de-emphasize intercourse as the primary way of sharing. Intercourse is only one way to be sexual and not necessarily the most pleasurable way for a partner.
• On his own, a man can self-stimulate to learn greater voluntary control over the timing of his ejaculations. He should re-create the circumstances in which he ejaculates most rapidly, including his body position, the amount and direction of the pressure on his penis and the amount of lubrication. It's also important that he move his body to re-create the sexual behavior during which he wants to last longer -- not just his hand. Once he's gotten very aroused, he should slow down (or stop entirely, if necessary) and not have an orgasm. This process of approaching and holding off should be repeated one or two times during each practice session before reaching orgasm. That will create much greater awareness of exactly how aroused a man is and let him know that greater awareness creates more voluntary control.

Once the habit of rapid ejaculation is developed, it can be a challenge for some men to change on their own. Fortunately, this is one of the most common and successful areas of therapy and one in which the process of change can be very pleasurable. A skilled therapist can guide a man to a solution whether or not he has a helpful partner. However, when a cooperative partner is available, the potential for positive change is quite high and the relationship itself plays a very important part in fostering the changes that both people want.

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