PE Treatment - Psychological - Counseling & Therapy

In 2006, Marcel Waldinger reopened the debate about the efficacy of psychotherapy as a treatment method for premature ejaculation. Between 1920 and 1960 psychological treatment 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 psychological treatment 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 (or at least was until Dapoxetine was licensed for use in this context in Europe). Also, neither psychotherapy, psychological treatment nor behavioral therapy have been subjected to scientific studies about how effective they are in in treating premature ejaculation.

Some experts do not regard premature ejaculation as a condition that needs to be treated by psychotherapy. For them, treatment usually consists of daily dosage of selective serotonin reuptake inhibitors or the use of topical anesthetics. This dismissal of psychological approaches 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 psychological treatment approach for premature ejaculation.

At the time that psychological treatment 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 Premature Ejaculation" and "Acquired Premature Ejaculation". 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.

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 psychological treatment 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 psychological treatment might assist in its the understanding and treatment.

Psychoanalytic research

Original article on the science of psychological treatment and PE can be found here

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. psychological treatment 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 psychological treatment 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 neuropsychological treatment of the various PE syndromes. (The Neuropsychological Treatment Society was set up in 2000; its aims are to bridge the gaps between psychological treatment and neuroscience.)


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