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Psychoanalysis and premature ejaculationOriginal article on the science of psychoanalysis and PE can be found here In 2006, Marcel Waldinger reopened the debate about the efficacy of psychoanalysis as a treatment method for premature ejaculation. Between 1920 and 1960 psychoanalysis was the treatment of choice for this condition, although no scientific research had ever been carried out on how effective it was at treating the problem. Waldinger argues that the recent classification of three different types of premature ejaculation has created a new opportunity for a resurgence of psychoanalytic investigation into the origin of this problem. These three types are: (1) lifelong premature ejaculation, where the condition has existed for as long as a man has been sexually active and where he does indeed have a short IELT*; (2) acquired premature ejaculation, which is premature ejaculation that develops later in life after previously "normal" sexual experiences; and (3) normal variable premature ejaculation, which may be simply reflect the normal variability of the male sexual experience. *IELT is "Intravaginal ejaculatory latency time", the time between penetration and ejaculation. In passing, Waldinger makes the observation that there is a parallel between the treatment of premature ejaculation with topical anesthetic ointments in the 1940s and 50s when psychoanalysis was the treatment of choice, and the current use of SSRI or tricyclic antidepressants, when behavior therapy has become more widespread as a treatment. In the 1940s, the use of the anesthetic ointments was off-label, just as the use of the antidepressants is off-label nowadays. Also, neither psychoanalysis nor behavioral therapy have been subjected to scientific studies about how effective they are in in treating premature ejaculation. However premature ejaculation is not currently seen as a condition that needs to be treated by psychoanalysis. Treatment usually consists of daily dosage of selective serotonin reuptake inhibitors, or "on demand" treatment with tricyclic antidepressants such as clomipramine, or the use of topical anesthetics. This approach may be premature. It is obvious that the pharmacological approach to treating rapid ejaculation stems from the perception of it as being a neurobiological condition. Nonetheless, drug treatment is inadequate in that it does not explain how premature ejaculation is perceived either by the man concerned or by his partner, nor does it contribute to a better understanding of the unconscious mental processes which may be involved in both the etiology of the condition and in its maintenance. Waldinger therefore takes an approach which discusses the usefulness of revisiting a psychoanalytic approach to treating premature ejaculation. At the time that psychoanalysis was first developed, very little was known about PE. For example, it was 1943 before Bernard Schapiro distinguished between the two types of PE which were eventually named "Lifelong PE" and "Acquired PE". Obviously when the first psychoanalyst to study PE, a man by the name of Karl Abraham, was working in the field, in the 1920s, there was no knowledge of the neurobiological pathways involved in the ejaculation reflex, nor the neuropharmacological options that would become available to deal with rapid ejaculation. Let us take a moment to revisit the "official" definitions of premature ejaculation as set out in the DSM IV. Although they are not based on evidence linked research, the DSM IV diagnostic criteria for premature ejaculation are as follows: (1) persistent and recurrent ejaculation with minimal sexual stimulation before, on, or shortly after penetration before the person wishes it; (2) marked distress or interpersonal difficulty; and (3) not exclusively due to direct effects. Waldinger and Schweitzer analyzed two studies in 2004/2005 and discovered that the DSM IV definition actually produces a high percentage of PE diagnoses which turn out to be false positives. This is this is because the DSM IV definition is rather overweighted towards the men who complain about having PE, whilst ignoring the actual duration of their IELT. In practical terms what this means is that the definition set out formally in DSM IV does not take account of the fact that there is a great variability between men in how long it takes them to ejaculate, not to mention the fact that there is also similar variation in how long both partners wish sex to last. This ambiguity, and the need to clarify exactly what we mean when we talk about premature ejaculation, has led to attempts to form a quantitative definition of the condition. There is evidence that the current average IELT is about six and half minutes in 18 to 30 year old men. If PE is defined as an IELT percentile below 2.5 that would mean a man who ejaculates in less than a minute and a half has premature ejaculation....but the problem is that many men and their partners with an IELT of less than 1.5 minutes are very happy with their sexual performance and do not regard it as a problem. On this basis they would not be defined as having premature ejaculation. Contrast this with the man who has an IELT of two minutes before he ejaculates, but believes he has poor control, is very distressed about this situation, and has some interpersonal difficulties with his partner because of it: all of this means that even though he does not fall into the conventional range of the current definition of the condition, he would still be diagnosed with PE. Waldinger & colleagues define PE using evidence-based data to subdivide premature ejaculation into two groups, which we know as lifelong and acquired. They've recently proposed a third type which they call "natural variable PE". This term is applied to men who experience an inconsistent type of early ejaculation; this type of PE is not some of manifestation of a true pathology but simply a normal variation in the human male's ejaculatory control. Waldinger further proposes that normal variable PE will account for the extremely high number of men who consider themselves to be early ejaculators (that is to say between 20 and 40% of the population.) He contrasts this with the percentage of men who have lifelong and acquired PE, which he claims has never been investigated in detail, but he assumes it to be rather low at between 1% and 5% of the male population. This approach to defining premature ejaculation is rather radical because it puts the emphasis back onto the fact that men are generally dissatisfied with their sexual performance, when in reality they may be experiencing nothing more than the natural variability of male sexual response. If this is so, and it certainly seems likely, then it follows that the majority of men who report themselves as having PE should not be pathologised or treated with antidepressants; they should probably receive a non-invasive psychological therapy such as sexual psychotherapy or counseling. There are almost no reports of psychoanalytic investigation of premature ejaculation, so modern therapists have a blank canvas on which to work. One of the flaws of the very few accounts of psychoanalysis which do exist is that they tend to extrapolate from individual cases of premature ejaculation to generalized explanations such as "castration anxiety" and "hatred of women". These are not useful in actually understanding either the etiology of quick ejaculation or how psychoanalysis might assist in its the understanding and treatment. Lifelong acquired and normal variable premature ejaculationComplaints of PE are expressed by four groups of men. The categorization depends on the duration of IELT, how it varies throughout life, and the personal experience of the man concerned. Men who are defined as having lifelong PE or acquired PE usually have an IELT of less than one and a half minutes. However a minority of men with lifelong PE can last as long as three minutes. And in cases of lifelong PE, early ejaculation takes place at every experience of sexual intercourse. By contrast, men with normal variable premature ejaculation experience considerable variability and inconsistency in the length of time for which they are able to maintain self-control before ejaculating. Premature like ejaculatory dysfunctionThis term has been proposed to explain the considerable number of men who described themselves as having PE even though they have a normal or even a long IELT duration. In a study conducted over several centers in the United States by experienced clinicians, men were defined as having PE (or not) according to DSM IV criteria: this revealed that out of 190 men with PE, 48% were able to last at least two minutes after penetration before ejaculating, while 13% of men who complained that they had PE ejaculated between 5 and 25 minutes after penetration. The study revealed a low positive predictive value for the definition of PE according to DSM IV. An important point here is that many men who have normal and even long IELT durations still report that they experience early ejaculation. It may be premature to draw too many conclusions from this work, but here's the rub: while, according to the DSM IV definition these men do have PE, the question arises as to whether it's a well founded clinical judgment to define men as having PE if they can actually enjoy between 5 and 25 minutes of intercourse before ejaculating. One of the problems in assessing such information is that nobody has any data about how accurate self-assessments of time between penetration and ejaculation actually are, particularly when they are self-reported. Even allowing for some margin of error, however, it is clear that there men fall, broadly speaking, into two categories: those with long IELT durations, and those with short IELT durations. The problem is in understanding why these men have different outcomes during intercourse. Men with long and short IELT durations may have some differences in either their psychological make-up or their neurobiological physiology. Men who are described as having lifelong premature ejaculation are usually mentally healthy but are unable to control their ejaculation for more than 1 to 1.5 minutes. This contrasts sharply with men who complain of premature ejaculation but have a normal or even a long IELT: they are usually able to delay their ejaculation to some degree but they may have psychological issues that affect their judgment of how adequate their sexual performance is in reality; alternatively, they may have relationship issues around sexual intercourse, perhaps focusing on their partner's different expectations of intercourse. It seems more relevant to treat men in the latter group with some kind of counseling, or by providing sexual psychological information or engaging in psychotherapy of some kind. It is these men for whom the term "premature-like ejaculatory dysfunction" has been proposed. It is a condition that is characterized by misperceptions about the man's "staying power" - and often involves the belief that what is in fact a normal or even a long duration of intercourse is too short. Clearly this involves a subjective misjudgment of the man's own performance against some standard of what he regards as normal ejaculatory performance. It's quite clear that a condition like this is most likely to be caused by psychological, cultural or other issues within the relationship. Premature-like ejaculatory dysfunction diagnostic criteria
1 Subjective perception of rapid ejaculation
during most occurrences of sexual intercourse Waldinger claims that there is more and more evidence accumulating to suggest that lifelong PE - where the time between penetration and ejaculation is shorter than 1 to 1.5 minutes - is a neurobiological dysfunction, from which psychological issues and relationship issues may arise. He observes that drug treatment with SSRIs and clomipramine have become fairly standard procedures for this condition. It is not clear how men with lifelong PE and men with premature-like ejaculatory dysfunction differ in emotional or physiological functioning. But Waldinger observes that there are many men with lifelong PE who have adopted coping strategies that enable them and their partners to manage very well with a short IELT, although he does acknowledge that there are men who have serious interpersonal or emotional problems because of their ejaculatory dysfunction. Men with long and short IELT duration may have some differences in either their psychological make-up or their neurobiological physiology. Men who are described as having lifelong premature ejaculation are usually emotionally stable but are unable to control their ejaculation for more than 1 or 1.5 minutes. This contrasts sharply with men who complain of premature ejaculation but have a normal or long IELT: they are usually able to delay their ejaculation to some degree but they may have psychological issues that affect their judgment of how adequate their sexual performance is in reality; alternatively, they may have relationship issues around sexual intercourse, perhaps focusing on the partners' different expectations around intercourse. Psychoanalytic research Two of the fundamental questions which underpin research into the emotional and psychological origins of any kind of rapid ejaculation are these: (1) what is the psychological make up which causes men to develop this experience? and (2) what are the psychological characteristics of men who believe that they are suffering from PE while they actually have an objectively long IELT that falls within the normal range? Waldinger also proposes the question: do Oedipal and pre-Oedipal fixations or arrested development produce a difference in the way men understand and behave in response to their ability to control when they reach sexual climax? Clearly, if men have resolved Oedipal problems they are likely to display different sexual behavior to men who have unresolved Oedipal problems. He also raises the interesting question of how separation-individuation issues may affect a man's ability to cope with his ejaculatory responses, and asks which defense mechanisms are promoted by PE, and how PE might influence object relationships? He observes that a thorough psychoanalytic investigation is necessary for each individual patient before any psychodynamic diagnosis can be made. These are, however, very interesting questions. Psychoanalysis was the main "talking" therapy for many decades during which time scientists did not believe that subjective mental states could be investigated by serious brain research. It was only with the advent of brain imaging technology and the new sciences of molecular neurobiology that a relationship was established between psychodynamic concepts and subjective emotional experience. We now know and appreciate that neurochemical and neuroanatomical changes in brain structure do indeed have a relationship to psychosocial influences and to the meaning that a man or woman attributes to those influences. We know that both psychotherapeutic interventions and the natural processes of learning in everyday life can result in permanent alterations in brain structure and function. In other words, events of learning and memory can potentially be seen as biological processes. It's perhaps for this reason, particularly in the last 30 years, that various neuroscientists and psychoanalysts have started to enter into speculation about how neurobiology may explain Freudian concepts. Bridging the gap between the subjective approach of psychoanalysis and the objective science of the biological approach of neuroscience will bring more understanding to the interpretation of mental functioning. Unfortunately there was little formal research to report at the time of the writing of the paper that is currently under review. Waldinger simply suggested that the aim of any psychoanalytic treatment or investigation would be better expressed as the hope that a man could evolve a better coping strategy rather than as an aspiration to a complete cure. He also raised the possibility that psychoanalytic treatment in conjunction with a daily drug regime might lead to the evolution of better coping strategies when compared to either treatment offered in isolation. This approach has subsequently been investigated in later research projects and in general found to be true. In summary, Waldinger observes that the integration of neurobiological and psychoanalytic research into premature ejaculation will contribute to the neuropsychoanalysis of the various PE syndromes. (The Neuropsychoanalysis Society was set up in 2000; its aims are to bridge the gaps between psychoanalysis and neuroscience.) |
Other helpful sources of information on the subject of rapid ejaculation Premature ejaculation is said to occur when a man reaches orgasm during sexual intercourse before he or his partner wishes to achieve climax. Round one third of men experience the frustration of premature or rapid ejaculation. Happily it can be successfully treated. Therapist Paula Hall explains how. Premature ejaculation (PE) means reaching orgasm too quickly, and it's probably the most common sexual problem. In a survey of thousands of British men, around one in ten often or sometimes had this trouble. People ask what is the most common question received by this column. By a long way, it is: "How do I solve my rapid ejaculation problem?" So we look at ways to cure an issue that plagues many men. As you may expect, PE is much more common in younger men - there's a marked tendency for IELT to improve with age. Men generally get better ejaculation control as they grow older. |
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