Pe PDF

Coping with
Premature Ejaculation
How to Overcome PE,

Please Your Partner &Have Great Sex
MICHAEL E. METZ, PH.D.
BARRY W. MCCARTHY, PH.D.
New Harbinger Publications, Inc.

This is a highly readable book . . . clear and concise. Drs. Metz and
McCarthy provide the latest information and present a new, inno-
vative, comprehensive, biopsychosocial approach to the treatment of
premature ejaculation, the most common male sexual disorder. I
recommend it highly.
Pierre Assalian, MD, director, Human Sexuality Unit,
McGill University Health Center and president of the
17th World Congress of Sexology, Montreal, 2005
This is the most comprehensive guide to dealing with premature

ejaculation I have ever seen! It addresses subtypes, cognitive, emo-
tional, and behavioral components, medical issues, relapse, and the
ever-important influence of the couples relationship on the cause and
cure of this disorder. Drs. McCarthy and Metz have not only done a
great service to couples experiencing this problem, but to sex thera-
pists as well. I will definitely recommend the book to my clients and
will incorporate its exercises in my treatment protocol.
Jean D. Koehler, Ph.D., president, American Association
of Sex Educators, Counselors, and Therapists (AASECT)
Coping with Premature Ejaculation is chock-full of great suggestions

for improving ones sex life. Written by two experienced sex thera-
pists, the book offers sound advice and sensible suggestions for gain-
ing control over ejaculation and, more importantly, for becoming a
better lover!
Sandra R. Leiblum, Ph.D., director, Center for Sexual
& Relationship Health, UMDNJ-Robert Wood Johnson
Medical School.
Finally, an updated, comprehensive guide for a problem that affects

millions of men and their partners. These highly respected authors in
the field of sex therapy bring years of clinical experience and insight
to these pages in a format thats masterfully helpful. This is a great
book, and I plan to recommend it to all my patients who struggle with
premature ejaculation.
Dennis P. Sugrue, Ph.D., past president of the American
Association of Sex Educators, Counselors, and Therapists
(AASECT) and coauthor of Sex Matters for Women.
Coping with
Premature Ejaculation
How to Overcome PE,
& Please Your Partner

Have Great Sex
Michael E. Metz
Barry W. McCarthy
New Harbinger Publications

Mock
Final Version title page
Publishers Note
This publication is designed to provide accurate and authoritative information in regard to
the subject matter covered. It is sold with the understanding that the publisher is not
engaged in rendering psychological, financial, legal, or other professional services. If
expert assistance or counseling is needed, the services of a competent professional should
be sought.
Distributed in Canada by Raincoast Books.
Copyright 2003 by Michael E. Metz and Barry W. McCarthy
New Harbinger Publications, Inc.
5674 Shattuck Avenue
Oakland, CA 94609
Cover design by Amy Shoup
Edited by Jessica Beebe
Text design by Tracy Marie Carlson
All Rights Reserved
New Harbinger Publications Web site address: www.newharbinger.com

We want to express our gratitude and deep respect for the several
thousand men and couples we have clinically worked with over the
years. They invited us into their private lives, opening honestly to
their personal and sexual distress. While we can only thank them
anonymously, they have led us to develop a more comprehensive
understanding of premature ejaculation. We thank our patients who
have been the pathfinders for this new approach. This book pres-
ents the result of what we have learned from them and from the sci-
entific research and clinical efforts of our sex therapy colleagues. We
hope we have learned well enough and that this book will be helpful
to others with PE.
We also want to acknowledge the outstanding contributions of
the people we have happily worked with at New Harbinger Publica-
tions: Spencer Smith, acquisitions editor; Jessica Beebe, copy editor;
Amy Shoup, art director; Gretchen Gold, web manager, permissions,
and advertising; Troy DuFrene, marketing and sales; Michele
Waters, director of production; and Heather Mitchener, editorial
director. Thank you all.
Michael E. Metz
Barry W. McCarthy
Contents
1 Understanding Premature Ejaculation 1
2 Developing Realistic Expectations about Sex 15
3 Understanding the Causes and Effects of PE 29
4 Assessing Your PE 47
5 Planning Your Treatment and Preparing for Action 59
6 Medical, Pharmacologic, and Physiological 73

Treatments
7 Psychological and Relational Strategies and Skills 85
8 Psychosexual Skills: Enjoying Arousal and 105

Regulating Orgasm
9 Couple Sexuality: Building an Intimate, Interactive 135

Couple Sexual Style
10 Enjoying Sex and Preventing Relapse 147

vi Coping with Premature Ejaculation
Choosing an Individual, Couple, or 161

Sex Therapist
Resources 163
References 167
1
Understanding Premature
Ejaculation
What is premature ejaculation (PE)? You might expect that this is an

easy question to answer, but it depends on whom you ask. Masters
and Johnson (1970), the founders of modern sex therapy, stated that
a man has PE if he ejaculates before the woman reaches orgasm in 50
percent or more of their sexual encounters. PE is sometimes defined
as a problem accomplishing a normal length of time between
insertion and ejaculation. Studies have even defined PE by a specific
amount of intercourse time: less than one minute, two, three, four,
five, seven, or ten minutes, each amount based on a different reason.
Still others have proposed to define PE by the number of intra-
vaginal thrusts: eight thrusts, fifteen thrusts.
The best professional description of PE is that the man does not
have voluntary, conscious control, or the ability to choose in most encoun-
ters when to ejaculate. We think this is the most helpful definition
because conscious control reflects the interpersonal, cooperation, and
intimacy issues for couples better than some mechanical or numeri-
cal definition.
Contemporary popular culture dictates that to enjoy sex maxi-
mally, the man should be able to last at least an hour during inter-
course! Such myths about sexual performance are among the most
negative influences on male and couple sexual satisfaction.
Kevin and Monica had the most common sexual problem facing
young couples. Kevin suffered from PE. Both blamed Monicas non-
orgasmic response on Kevins PE. They believed that if Kevin could
last longer, Monica would easily be orgasmic during intercourse. Sex
2 Coping with Premature Ejaculation
would be perfect every time. It was Kevins duty as a man to make

sure Monica had an orgasm during intercourse each timean
extraordinary pressure on Kevin and his penis.
Kevin did some Internet research and read how easy it was to
cure PE. All he had to do was practice the squeeze technique (which
we do not recommend), in which the man or his partner squeezes the
underside of the tip of the penis to delay orgasm. He was very hope-
ful, but that broke down within two weeks. Kevin was stymied, and
Monica resented his being a technician rather than an involved lover.
Sex was no longer fun; it was a chore. Kevin was frustrated with
Monica and with himself. He thought that everyone else quickly
developed ejaculatory control. What was wrong with him? Or was it
her fault? Maybe they did not love each other and this was a
doomed relationship. Would PE destroy their marital bond?
Our Comprehensive Approach

If you are facing PE in your relationship, and especially if you are a
couple who has tried the common techniques for treating PE and
failed, we offer you our extensive experience, our clinical knowl-
edge, and a detailed approach to treating PE. Our approach inte-
grates the body, mind, and relationship aspects of PE to help you
appreciate the complexity of your problem, develop understanding
for yourself and your partner, build empathy for each others experi-
ence of PE, and create a detailed plan to organize your efforts to
change. This biopsychosocial approach will not only help you over-
come rapid ejaculation but deepen your intimacy and sexual joy.
Testing Your Knowledge of PE

How much do you really know about PE? Take this true-false quiz
before reading further.
True False Most men engage in intercourse for twenty to

thirty minutes.
True False A good lover prolongs intercourse until his

partner has an orgasm.
True False Women function like men: they have a single

orgasm during intercourse.
True False Men who ejaculate after two to seven minutes

of intercourse have poor ejaculatory control.
Understanding Premature Ejaculation 3
True False PE is caused by too much masturbation,

especially during adolescence.
True False Thrusting alone is enough for most women to

have an orgasm during intercourse.
True False PE is always caused by psychological

problems.
True False To deal with PE, the woman needs to be less

erotic and the man has to reduce arousal.
True False PE is natures way of increasing fertility.
True False PE is a symbol of a relational power struggle.
In fact, each of these items is false. Old and new myths about
PE abound. In this book we will confront myths, including that PE is
a simple, painless problem; intentional; purely psychological; the
womans fault; a sign of sexual inadequacy; caused by masturbating
too much or too fast; a sign of hostility; a symbol of male selfishness;
the same for everyone; a problem with only one cause and one treat-
ment; and a hopeless problem.
The Truth about PE

PE is the most common male sexual problem. The majority of male
adolescents and young adults begin their sexual lives as premature
ejaculators. Most men, as they gain experience, do develop ejacu-
latory control. However, approximately three in ten adult males
regularly experience PE.
The good news is that PE can be understood and changed. You
can increase your sexual satisfactionand your partnersby learn-
ing to control ejaculation. The challenge is to deal with the complex,
multicausal, multidimensional problem of PE and to enjoy sex with
enhanced ejaculatory control.
Kevin and Monica were approaching PE from a poor under-
standing of the problem and a self-defeating focus on sexual per-
formance. At its essence, sexuality is about sharing pleasure, not
passing a performance test. Healthy, integrated sexuality values
intimacy, pleasuring, and eroticism. Like most males, Kevin believed
that sex was about eroticism, frequency, and proving adequacy to
himself or to the woman. Kevin hadnt really thought about sex as a
way to share pleasure and to build intimacy. Yet, the reality is that
PE affected both Kevin and Monica.
Successful treatment combines taking individual responsibility

for sexuality and being an intimate sexual team. Understanding and
changing PE was primarily Kevins responsibility; Monica did not
cause Kevins PE, nor could she change it for Kevin. She could help
Kevin honestly and objectively assess the components of his PE and
be seriously involved in the change process.
PE is not a simple problem with one cause and one solution.
There are actually nine different types of PE. PE involves biological,
psychological, and relational factors, both in its causes and in its
effects. A successful change program must address all the relevant
factors. A successful program must also include a plan for dealing
with relapse. Our approach is effective because it helps you address
all of these issues.
It is helpful to realize that you are not alone. Guilt, stigma,
blame, and counterblame are unnecessary and will subvert your
motivation to resolve PE and enjoy couple sexuality.
Understanding Male Sexuality

It was once believed that the more masculine you were, the faster
you ejaculated. But there is more to sex and sexuality than your
penis, intercourse, and orgasm. Sexuality is about sharing and enjoy-
ing affection, pleasuring, intimate playfulness, eroticism, intercourse,
orgasm, tenderness, and passion for life.
The great advantage of male sexuality is that young males find
desire, arousal, and orgasm easy and predictable. Adolescents are
encouraged to value sexuality as an integral part of masculinity. Men
learn sexuality as automatic andfor better or worseautonomous.
In other words, the man needs nothing from the woman to achieve
desire, arousal, and orgasm.
This view of sexuality becomes problematic as the man and the
relationship age. Healthy sexuality is intimate and interactive, not
autonomous. Learning ejaculatory control is an interpersonal pro-
cess, not an individual one.
What Youll Need to Learn

What do you need to learn about PE and ejaculatory control? First,
this is a couple task. The woman plays an integral role in learning
ejaculatory control. Second, ejaculatory management exercises are
built on the solid foundation of nongenital and genital pleasuring.
Ejaculatory control is not about the man performing up to a
perfectionist standard or proving he can give the woman an orgasm

during intercourse, but about developing a mutually satisfying couple
style that includes pleasure-oriented intercourse. Learning ejaculatory
control should not mute or decrease pleasure. To the contrary, it will
expand physical pleasure as well as pleasure in the relationship.
There are several crucial skills in learning ejaculatory control.
Physiological Relaxation
The first skill is to learn how to relax your body during sexual
arousal. Physiological relaxation is the foundation for your bodys
healthy sexual functioning.
Identifying the Point of Ejaculatory Inevitability

The second skill is to learn to identify the point of ejaculatory
inevitability. After that point, orgasm is no longer voluntary. Even if
your mother-in-law walks in or something happens which is a sexual
turnoff, you will still ejaculate. Actually, the point of ejaculatory
inevitability is the beginning of the three- to ten-second orgasmic
response. Many men report the most sensations and feelings just a
second or two before they ejaculate. The ability to identify the point
of ejaculatory inevitability is crucial in the techniques well teach
you.
Ejaculatory Regulation
The third skill is learning to regulate your ejaculation. We will
teach you the two basic approaches: excitement toleration and excite-
ment saturation. In excitement toleration, you will learn to maintain
high levels of arousal without going on to ejaculation. With excite-
ment saturation, you will learn to focus on your own bodily sensa-
tions, patiently welcoming the pleasure, allowing your body to
become saturated or flooded with physical pleasure while slowing
ejaculation by maintaining physical relaxation. You will then have
reasonable control over when you ejaculate.
Cooperation for Intimacy

The fourth skill is to cooperate as a couple. Our approach to PE
works best when you and your partner work together. The point of
all these efforts is to enhance your closeness, comfort, pleasure, and

joy as a couple.
Increasing Pleasure
The fifth skill is to enhance your pleasure, not reduce it. Do-it-
yourself ejaculatory control techniques emphasize distracting your-
self and reducing arousalfor example, by wearing two condoms,
using a desensitizing cream on the head of the penis, thinking anti-
erotic thoughts about debt or cleaning bathrooms, or using distrac-
tion techniques such as going over baseball scores or multiplication
tables. These do reduce arousal but do not enhance ejaculatory con-
trol because they disconnect your awareness (the primary source of
control) from your sensations and body. In addition, they carry the
risk of causing a more severe sexual problem, erectile dysfunction.
Our approach to treating PE might seem counterintuitive
because the exercises involve increasing penile and erotic pleasure.
But youll find that increased awareness leads to increased control.
We emphasize taking in erotic sensations and feelings, not shutting
them out.
Most men can benefit from training in ejaculatory control.
Instead of viewing PE as a major problem that makes you inade-
quate or makes the woman feel that her sexual needs are ignored or
neglected, think of ejaculatory control as a skill the couplenot just
the mancan learn in order to enhance mutual sexual satisfaction.
Letting Go of Your Focus

on Performance
In movies, sex is always perfect. Both people are highly aroused
before touching even begins; sex is flawless, nonverbal, and intense;
they quickly have simultaneous orgasms and continue to make love
all day. Our discussion about PE is scientifically accurate,
sex-positive, helpful, and relevant to real couples, but it will not be
made into a movie or sell as a romantic story. We are not describing
a perfect fantasy model but what really goes on in a healthy sexual
relationship. By its very nature, couple sexuality is variable. If the
only purpose of sex were orgasm, men and women would mastur-
bate and not engage in a relationship or intercourse. Masturbation is
easier, more predictable, and more in your control than couple
sexuality. Yet the great majority of men and women prefer couple
sex to masturbation.
Giving up the performance-focused approach frees you to learn

ejaculatory control and enjoy couple sex. Having a reasonable
amount of control over when you ejaculate and enjoying the orgas-
mic experience is very different than making sure your partner is
orgasmic during intercourse before you are allowed to have an
orgasm. Since one in three women who are regularly orgasmic are
never orgasmic during intercourse (Foley, Kope, and Sugrue 2002),
this expectation is obviously flawed. Just as important, when you are
so obsessed with performance, you cannot enjoy sharing the pleasure
of intercourse. Rather than enjoying orgasm, you are judging your
performance.
Your focus on performance can become a major distraction for
your partner. While she may be distracted from pleasure by her own
unreasonable expectations, such perfectionist sexual goals interfere
with your positive feelings about sex and about each other, and
ignore the reality of variable sexual response. You are not a perfectly
functioning sexual machine. You are a sexual man with changing
and complex thoughts, behaviors, and feelings. You are not a rock or
an island. You are involved in an interpersonal sexual relationship.
Remember, the ultimate goal of learning ejaculatory control is
increased sexual and relationship satisfaction. In understanding the
role of sexuality in a relationship, desire and satisfaction are more
important than arousal and orgasm.
The Myth of One Cause, One

Treatment, and Easy Cure
The pop psychology belief about PE is that it has one cause (mastur-
bating too much and too fast and approaching couple sex the same
way), that there is one treatment (the squeeze technique), and that
change is quick and easy. Recently, a simplistic medical approach
has appeared which assumes that treating the man with antidepres-
sant medication alone will retard ejaculation. This requires no learn-
ing by the man and no participation by the woman.
Human sexual behavior, including PE, is multicausal and
multidimensional, with large individual and couple differences. The
best way to understand PE is as a physical, cognitive (mental),
behavioral, emotional, and relational phenomenon that can involve a
number of causes and interactive effects. It is crucial to address all
the factors which contribute to your type of PE so that you can
approach the problem successfully and avoid slipping into old
feelings, thoughts, and behaviors about PE.
It is risky to use a medication or a do-it-yourself technique like

a penile desensitizing cream and not involve your partner or even
tell her what you are doing. Even if this approach works and you
dont ejaculate as quickly, if you stop taking the medication or using
the cream, PE will likely return and might even be worse. What
does that do to your partner and relationship? She may blame you
and be angry, feeling you could delay ejaculation, but now you just
dont want to. She may view you as selfish and not caring about her
sexual feelings. If youre not approaching the problem as a team, a
relapse can leave you both demoralized and trapped in a blame-
counterblame pattern.
Relational Issues and PE

Relational problems can be a cause of PE, a result of PE, or both.
Even when PE is caused by a medical problem or a physical injury,
the frustration and sexual stress affects your relationship. Ideally, the
man would learn and share information about PE with his partner.
Unfortunately, that is the exception rather than the norm. Ideally, the
woman would be empathic and supportive and be an active ally in
trying to understand and resolve PE. Unfortunately, the woman may
be unsure and alternate between blaming herself and blaming her
partner. She might react in an extreme way, becoming overly sympa-
thetic and motherly, which is antierotic, or becoming angry and
demanding, which is intimidating and increases performance anxiety.
In learning ejaculatory control, most couples benefit from
working to increase communication, understanding, empathy, coop-
eration, and intimacy. This reinforces the concept that sex is more
than genitals, intercourse, and orgasm. Sexuality accounts for 15 to
20 percent of overall relationship satisfaction. Sexuality should not
be a deal maker or deal breaker for the relationship, as there are
other crucial facets to love and intimacy. Sexuality can enhance your
relationship and make it special. PE works against that process.
Improving ejaculatory control is worthwhile for you and your
relationship. The core of a relationship is a respectful, trusting, coop-
erative friendship enriched by emotional and sexual intimacy.
What if you do not have a partner, or have a tenuous relation-
ship in which you and your partner cant work together to learn
ejaculatory control? Our approach can still offer helpful information,
guidelines, and understanding. In addition, you can use the self-
exploration and masturbation exercises to learn and practice the
skills of physiological relaxation, identifying the point of ejaculatory
inevitability, and maintaining awareness at high levels of arousal.
When youre seeking a new relationship, its important to

choose a partner you are attracted to, comfortable with, and trust
would be an ally in learning ejaculatory control. Many men with PE
are so embarrassed that they avoid a sexual relationship, settling for
one-night stands and either ignoring the problem or apologizing for
their sexual performance. You need to approach the woman as a
sexual friend. Disclose the problem without apologizing. Tell her
that her sexual feelings and needs do matter to you, and request that
she be a cooperative, sharing partner in working together to improve
ejaculatory control and make this an enjoyable sexual relationship.
Your leadership is essential in the process of change.
Understanding Female Sexuality

The major sexual complaint of menthat the woman is not orgasmic
during intercourseis not a sexual dysfunction but a normal varia-
tion of female sexuality. Female sexual response is more variable and
complex than male sexual response. This does not mean better or
worse. The man usually has one orgasm which occurs during inter-
course. The woman might be singly orgasmic, nonorgasmic, or
multiorgasmic, and orgasm might occur during the pleasuring or
foreplay phase, during intercourse, or through afterplay.
Rather than expecting that the woman respond like himhave
one orgasm during intercourse without needing additional erotic
stimulationthe man needs to understand and accept that only one
in four women respond in that manner (Foley, Kope, and Sugrue
2001). Orgasmic response is a healthy, integral part of female sexual-
ity, but orgasmic response patterns are variable. Few women are
orgasmic 100 percent of the time. For women, sexual satisfaction
includes orgasm but is less rigidly tied to it. The majority of women
find it easier to be orgasmic with manual, oral, rubbing, or vibrator
stimulation than through intercourse. In fact, the most common
sexual response pattern is for the woman to be orgasmic with man-
ual or oral stimulation during the pleasuring phase, with the man
being orgasmic during intercourse.
To develop the intimate team approach that will help you over-
come PE effectively, you will need to understand, accept, and affirm
your partners patterns of arousal and orgasm. She has to develop
her sexual voice, not in reaction to what you think is right, but as a
way to express her feelings and preferences. Together, you create a
sexual relationship which is equitable and respectful of individual
preferences rather than based on a simplistic view of male-female
sexual differences.
Men grow up with the idea that they are supposed to be the
sexual experts and it is their job to be sure the woman is sexually
satisfied. We encourage you to consider a very different way to be in
an intimate relationship. Your partner is the expert on her sexuality.
Her desire, arousal, and orgasm are her responsibility, not yours.
The old definition of a good lover was a man who took responsibility
for the womans sexual satisfaction and was able to last long enough
so that he could give her an orgasm through intercourse alone. The
healthier, more realistic definition of a good lover is the man who
accepts the woman as an equal sexual person and intimate partner.
As a good lover, you are open to her sexual requests and guid-
ance. Each persons sexual enthusiasm and arousal feeds the others
desire, arousal, orgasm, and satisfaction. The man enjoys intercourse
for himself and the relationship. He is aware and involved in giving
and receiving pleasure during intercourse. Intercourse can involve a
range of positions and movements that add to the intimate, interac-
tive process. Being orgasmic is a natural extension of the arousal
process. Sex does not end with his ejaculation. There is an afterplay
phase in which he is open to her feelings and requests.
The man who is learning ejaculatory control with the goal of
ensuring that the woman has an orgasm during intercourse is setting
himself and the relationship up for failure and frustration. The
reason to improve ejaculatory control is to make the sexual experi-
ence more pleasurable and satisfying for both partners, not to prove
something to yourself or your partner. If she is orgasmic during
intercourse and that is her preference, enjoy it. However, it is poison
for you, the woman, and the relationship to put pressure on yourself
to last longer so you can give her an orgasm during intercourse. The
focus of ejaculatory control is to enhance the entire sexual experi-
ence: awareness, comfort, intimacy, pleasure, eroticism, intercourse,
orgasm, and afterplay.
PE and Other Sexual Problems

Although it might feel overwhelming to tackle more than one sexual
problem, PE often involves other sexual problems too, and youll be
more successful in dealing with PE if you consider these problems
along with PE.
Coexisting Sexual Problems in Men

For men, the most common coexisting sexual problems are
acquired inhibited sexual desire and acquired erectile dysfunction. Acquired
means that the man once experienced desire and erections, but now
they are problematic or nonexistent. Couple sex therapy is the treat-

ment of choice for both of these problems. Many men would rather
first try to resolve the problem using this books guidelines and exer-
cises. If that is not helpful within three to six months, then agree to
consult a sex therapist.
Acquired Inhibited Sexual Desire

The key to sexual desire is positive anticipation and feeling you
deserve good sex for you and your relationship. The usual reason for
male inhibited sexual desire is frustration and embarrassment over a
sexual dysfunction, especially erectile problems. Occasionally, inhib-
ited desire may be caused by medical illness or side effects of medi-
cations, disappointment with the partner or relationship, alcohol or
drug abuse, depression or anxiety, relationship stress or alienation,
lack of couple time or energy, and preoccupation with children,
extended family, or career. Youll need to identify the factors that
inhibit your sexual desire and actively confront and change them.
Many men feel so badly about PE that they fall into the cycle of
anticipatory anxiety, tense and unsatisfying sex, and sexual avoid-
ance. Sexual desire cannot be treated with benign neglect. Avoidance
just feeds the negative cycle. The hormone which most influences
sexual desire, testosterone, works on a feedback system. Sexual activ-
ity enhances testosterone, while stress and sexual avoidance decrease
testosterone.
In rebuilding male sexual desire, the key is to reinforce the
cycle of positive anticipation, pleasure-oriented sexual experiences,
and a regular rhythm of sexual encounters. You subvert your own
sexual desire when you view sexual intercourse as a pass-fail test or
tell yourself that anything less than a perfect sexual performance
means you are less of a man. Desire is about connecting with your
partner and sharing sexual pleasure.
Acquired Erectile Dysfunction

Erection problems are a major cause of male inhibited sexual
desire. The traditional view of male sexuality is that a real man is
able to have sex with any woman, any time, in any situation. This
unrealistic demand is self-defeating for the man and his penis. In
fact, by age forty, 90 percent of men have had at least one experience
in which they did not get or maintain an erection sufficient for inter-
course. So the most feared male sexual problem is in fact an almost
universal experience.
A common nonmedical cause of erectile dysfunction is trying to
cope with PE by decreasing arousal to slow ejaculation. Approxi-
mately one in three men with PE also report erectile problems
(Loudon 1988). The man feels caught between a rock and a hard
place: if there is a lot of stimulation he will quickly ejaculate, but lack
of stimulation results in erectile dysfunction. So the man rushes to
intercourse because he fears losing his erection before he ejaculates.
Most men would prefer to take a medication like Viagra
(sildenafil) or Cialis (tadalafil) to solve the erection problem, rather
than address it with the partner. In fact, Viagra or Cialis can be a valu-
able resource by increasing blood flow to the penis and reducing per-
formance anxiety. However, a pill cannot return the male to the easy,
automatic, autonomous erections of his youth. The key to regaining
erectile comfort and confidence is to relax, slow down and enjoy the
pleasuring process, take in erotic sensations, and not rush intercourse
or orgasm. It is crucial to be aware that the erection can wane but will
become easily erect again if you stay relaxed and actively participate
in the pleasuring and erotic process. You cannot be a spectator of
your penis; sex is an involved, interactive experience.
Coexisting Sexual Problems in Women

Common female sexual problems that coexist with PE are inhib-
ited sexual desire (acquired or lifelong), difficulty reaching orgasm (at all
or during partner sex), dyspareunia (painful intercourse), difficulty
becoming aroused, and vaginismus (constriction of the muscles of the
vaginal opening making penetration for intercourse difficult or
impossible). PE and female sexual dysfunction are often interrelated;
one problem may contribute to the other. As a couple, youll be most
successful at improving your sexual relationship if you each take
responsibility for communicating your needs and commit to working
together as an intimate team.
The Resources section at the end of this book lists a number of
excellent self-help sources for understanding and changing female
sexual problems and dysfunction. If you desire more help, we recom-
mend consultation with a credentialed sex therapist (see Choosing an
Individual, Couple, or Sex Therapist for guidelines). Seeing a sex ther-
apist is a sign of good judgment, not a sign that you are crazy or that
this is an overwhelming problem. A professional therapist assesses the
sexual problems and helps design a change program that addresses
the female problem, male problem, and couple problem. Ongoing
therapy helps the couple stay focused and motivated.
How You Can Best Use

This Book
This book presents a state-of-the-art approach to PE, integrating
new scientific research with the best, most comprehensive clinical
practice. Our goal is to help men and couples understand and
change the psychological, relational, medical, and situational factors
that cause PE.
To benefit from our program, youll need to take an active role
by engaging in the self-tests and exercises. We urge both partners to
be involved in the learning and change process, building awareness
and skills. As you work together to improve ejaculatory control, you
will enhance your sexual self-confidence and mutual enjoyment and
satisfaction.
Each chapter builds on information in the previous chapters.
The first three chapters include basic information and guidelines.
Chapters 4 and 5 actively involve you in becoming aware of your
personal type of PE and its impact on you and your relationship.
Chapters 6, 7, and 8 are the core of the change process. We will help
you carefully implement ejaculatory control strategies and tech-
niques targeted for your particular type of PE. Chapter 9 will help
you develop your unique couple sexual style. Chapter 10 presents a
range of strategies and techniques to help you maintain sexual gains
and prevent relapse. The more broad-based, flexible, and variable
your approach to sexincluding intercoursethe less vulnerable
you are to relapse.
Be Patient and Use All

Your Resources
PE is a complex problem with many causes and dimensions, but you
can understand it and change it. For some couples, learning ejacula-
tory control will be a fairly easy process involving just one or two
interventions, but most couples will need to use a number of tech-
niques. Be aware that the change process is usually gradual and
requires persistence, practice, and patience. It is important to remain
motivated and focused and to use all your resources to address the
factors involved in your PE.
These resources might include medical evaluation and treat-
ment, medication, exercise, relaxation, several or all of the cognitive
and behavioral techniques in this book, individual or couple therapy,
improved communication and conflict resolution skills, increased

emotional empathy, and time set aside for intimacy.
We congratulate you for having the courage and wisdom to
address the problem of PE. We want you to feel empowered and
motivated to resolve PE and enjoy the pleasures and satisfactions of
couple sexuality.
2
Developing Realistic
Expectations about Sex
As an adolescent, John absorbed the idea that a real man is always

ready for sex, no matter what the situation. John learned from sex
magazines and from talking to his buddies that a man was supposed
to be the sexual expert, and to have doubts or questions was to be a
wimp. Like in porn videos, John was to have an erection at will, and
his enormous penis would last as long as he wanted and satisfy the
woman every time.
John could not live up to the image of the perfect sexual
performer. John worried about penis size and about whether his
desire and experiences were below normal. He felt inadequate, defen-
sive, and guilty. He avoided serious conversations about sex. He felt
that if his friends knew about his PE, they would make fun of him.
Likewise, Johns girlfriend was filled with confusion and nega-
tive feelings. Did John care about her? She felt frustrated with the
sex, resentful that John would not talk with her, and angry that sex
did not get better. John and his partner were trapped in the miscom-
munication and myths perpetuated by the traditional male-female
double standard.
To approach PE successfully, youll need to take a critical look
at these traditional views. It is especially important to challenge male
performance myths, replacing these with positive, realistic expecta-
tions about the male body and couple sex. Part of the goal of PE
treatment is for the man and his partner to have reasonable expecta-
tions about sex and sexual function within the context of an intimate
relationship.
Understanding Your Body

To have control over when you ejaculate, you need to have an accu-
rate and realistic understanding of your sexual physiology (how
your sexual body works). In this chapter, we will explain in detail
the physiology of male and female sexual response, especially the
male ejaculation process. We will provide clear information about
sexual desire, arousal, and orgasm. We will take a closer look at
female desire and arousal and how this relates to PE. Then well
guide you through evaluating your sexual expectations, sharing
them with your partner, and working together to align your
expectations.
Anatomy and Physiology of Sexual Response

and Ejaculation
You may, at first thought, not be interested in the mechanics of
ejaculation. But youll find that accurate knowledge about your sex-
ual body gives you an appreciation of why strategies like whole-
body physical relaxation, conscious focus on pleasure, and pelvic
muscle relaxation can be helpful in developing ejaculatory control.
Accurate knowledge will also help you accept your body and its
workings without resentment and frustration.
The Human Sexual Response Cycle

In 1966, Masters and Johnson revolutionized the human
sexuality field by describing four stages of the sexual response cycle:
excitement, plateau, orgasm, and resolution. Not only did they describe
what happened during sexual arousal and orgasm, they measured
physiological changes in blood flow and neurological response. In
1974, psychiatrist Helen Kaplan broadened the Masters and Johnson
model to include an initial stage, sexual desire. Desire is associated
with psychological and relational factors rather than solely focused
on physiological factors.
The complete sexual response cycle consists of five phases:
desire, excitement (arousal), plateau, orgasm, and satisfaction
(resolution).
Desire. The desire phase involves sexual anticipation, fantasy,

yearning, and both physical and emotional openness to sexual
activity.
Excitement. During the excitement phase, in addition to a subjective

sense of sexual pleasure, you experience erection, and a few droplets
Developing Realistic Expectations about Sex 19
of secretions may appear from the tip of the penis. Women experi-
ence increased blood flow to the pelvis, vaginal lubrication, swelling
in the external genitalia, narrowing of the outer third of the vagina,
breast swelling, and lengthening and widening of the inner two-
thirds of the vagina.
Plateau. The plateau phase is when the bodys arousal levels off. If
the body is physiologically relaxed, it will maintain pleasurable
arousal without ejaculation or orgasm. This phase is limited or even
nonexistent for you as a man with PE. During the plateau phase, the
body settles in (becomes saturated with pleasure). Unless there is
continuing stimulation of your penis, it is normal for your erection to
go down or take a break. Not understanding that this is normal,
men unnecessarily panic, thinking that they have lost their erec-
tion and fearing it will never come back. This panic is a huge distrac-
tion, which disrupts the plateau phase, and indeed the erection,
which is then difficult to regain. But with calm relaxation and trust
in your body, all that is required is direct gentle touch to the penis
and your erection will easily come back from break.
The plateau phase is especially important for you to under-
stand because it is the platform for ejaculatory control. There are two
parts of this phase, excitement toleration and excitement saturation.
By becoming skilled at techniques based in the plateau phase, you
can enjoy pleasure and solidify ejaculatory control.
Orgasm. Sexual pleasure peaks during the orgasm phase and is

accompanied by rhythmic contraction of the pelvic muscles and the
release of sexual tension. In men, a sensation of ejaculatory inevita-
bility precedes the contractions that result in ejaculation. In women,
contractions occur in the outer third of the vaginal wall.
Satisfaction. During the satisfaction phase, the body gradually

returns to the nonaroused state. Both the man and woman experi-
ence a pleasant afterglow, feeling relaxed and sexually satisfied. The
length of the satisfaction or physical resolution phase is related to the
length of the arousal and plateau phases. With PE, because love-
making is brief, your erection will go down quickly after ejaculation.
As you learn more relaxed arousal and extended plateau love-
making, your penis will only go down halfway after ejaculation and
remain so for a while. For most men, this provides the option to
continue intercourse after a brief rest (perhaps thirty seconds) even
though the penis is not as hard as before. Intercourse during the
satisfaction phase can feel close and pleasing.
After ejaculation, men are temporarily unable to regain an erec-
tion and achieve orgasm, but women can respond alm ost
immediately to additional stimulation. For men, this period when

the body cannot sexually respond againthe refractory periodvar-
ies with age from almost unnoticed for a seventeen-year-old, to
thirty to sixty minutes for a man in midlife, to a day or two for a
sixty- to eighty-year-old man.
Ejaculation Physiology
To understand our approach to PE, youll need to know more
about how ejaculation works. The process of ejaculation involves
several events: erection, emission, ejaculation, and orgasm. These pro-
cesses are integrated by a complex set of interactions between the
neurological system, hormonal system, and vascular system that
combine to create a smooth chain of physiological events.
Erection refers to the events in the brain, nervous system, and vas-
cular system leading to penile rigidity.
Emission refers to the collection and transport of fluids from several

glands inside your groin that form the semen in preparation for ejac-
ulation. Sperm from your testicles travel through a small tube called
the vas deferens, which joins up in your prostate gland with the tube
exiting your bladder to form your urethra tube. Then your urethra (the
same tube that carries urine) runs through your chestnut-sized pros-
tate, then down and out through your penis.
With arousal, the neck or exit of the bladder closes (that is why
it is difficult to urinate when you are aroused and have an erection),
your testicles are drawn up against your body, and semen collects in
the verumontanum, a balloonlike chamber inside the prostate gland.
When you get so excited that you are about to ejaculate, the veru-
montanum fills with semen, enlarging to three times its normal size.
This pressure triggers the sensation of ejaculatory inevitability and
the reflex of ejaculation.
Technically, ejaculatory control is actually emission control
because once emission occurs you will ejaculate within seconds.
This is why we teach you how to work with your body to enjoy
more pleasure, and why we encourage you to just enjoy the
pleasure of ejaculation once you feel that it is inevitable. Consider a
space shuttle launch. The countdown proceeds to five, four, three,
two, one, ignition . . . , and several seconds later the mission con-
trol announcer declares, . . . and we have liftoff. Once ignition
occurs, there is no stopping the launch; it will take off. From your
sexual bodys perspective, ignition is emission, with the feeling of
ejaculatory inevitability, and liftoff is ejaculation, with the feeling of
orgasm.
Ejaculation is the process of pushing the seminal fluids out of the

balloon (verumontanum) inside the prostate through the urethra
and out of the penis. Ejaculation occurs when a critical level of
nerve input from the pressure of the verumontanum reaches the
spinal cord and causes the reflexive ejaculatory response. The pelvic
muscles are directly involved in ejaculation by rhythmically contract-
ing to force the semen out, so consciously relaxing them can assist
you in learning ejaculatory control. In chapter 8 youll learn how to
identify and relax these muscles as one of the PE management
techniques.
Orgasm refers to the subjective experience of pleasure associated

with ejaculation. Orgasm is a natural, healthy extension of the
pleasuring-arousal-intercourse process. Orgasm and ejaculation are
usually experienced as one and the same, although physiologically
they are two distinct processes. Orgasm is primarily an experience in
the brain. Though emission, ejaculation, and orgasm are integrated
events and seem simultaneous, technically, erection is not required
for ejaculation and ejaculation is not required for orgasm because
they are controlled by separate neurological mechanisms.
Ejaculation Neurology
How the nervous system (neurophysiology) brings about ejacula-
tion is only partially understood. Selective serotonin reuptake inhibitor
(SSRI) medications affect the level of serotonin in the neurologic
system, suppressing ejaculation. In chapter 6 we describe medica-
tions that can slow ejaculation.
With sexual activity, sensations are conveyed from your
genitals through the nerves deep in your abdomen and from there to
the spinal cord. These impulses stimulate reflexes in the spinal cord
or ascend the spinal cord to your brain.
While ejaculation is technically a biological reflex involving the
verumontanum in the prostate, your brain is very much involved in
the process. You interpret sensual information, which may either
augment (turn on) or inhibit (turn off) your arousal, and your
brain responds with signals sent down to your lower spinal cord.
From there, the impulse links up with neurologic impulses from
your verumontanum to signal your ejaculatory system, which results
in emission. At the same time, nerve signals are sent to stimulate
your pelvic floor muscles (the bulbocavernosus, ischiocavernosus, and
pubococcygeus muscles), resulting in those two to ten rhythmic
contractions characteristic of ejaculation.
This kind of basic knowledge about your body can help you
understand features of our comprehensive program. For example,
notice that your brain plays an interpreter role in your arousal and
influences ejaculation. You can help regulate your ejaculation by man-
aging your mental focus during arousal using cognitive ejaculation
control or pacing techniques that we will teach you (entrancement
arousal, the arousal continuum). Also appreciate that the pelvic mus-
cles are the muscles of ejaculation, and you can help regulate your
ejaculation by learning to relax these muscles during sexual excite-
ment. We will teach you these techniques in chapter 8.
Reconsidering Your Expectations of

Your Sexual Body
Now that youve read about the physiological process for ejacu-
lation, do you think your sexual expectations were grounded on
accurate knowledge of your body? What ideas did you have that
may have created unrealistic expectations of your bodys sexual
performance? Does understanding the ejaculatory process help you
accept your amazing body as well as its limitations? How open are
you to replacing your old ideas with new, realistic expectations?
The Integrated Model

of Sexuality
It is important to remember that sex is more than your penis, inter-
course, and ejaculation. Sexuality is an integral, positive part of you
as a man, and includes your attitudes, emotions, behavior, body
image, physical well-being, values, andmost importanthow you
feel about your relationship. At its essence, sexuality is an inter-
personal process. Although males and females have very different
sexual socialization as adolescents, men and women have many
more sexual similarities than differences as adults. Both you and
your partner can value sexuality as individuals and as a couple.
The integrated biopsychosocial model of sexual response
involves desire, arousal, orgasm, and satisfaction. Arousal and orgasm
have little enduring value unless you experience desire and satisfac-
tion, individually and as a couple. This broader concept of sexuality is
important to our program for understanding and changing PE. We
believe that sexuality is best understood and treated as a couple
issue. Even if you currently do not have a sexual partner, notice that
your mind will imagine a partner, react to a partner from your past,
or wish to meet that special woman in the near future. Even without
a partner now, you are in a sexual relationship in your mind.
Female Sexual Desire and PE

Part of being realistic about sexual expectations is accurately under-
standing female sexual desire and arousal. Physician Rosemary
Basson (2001) has outlined a new model for womens sexual arousal.
She notes that in the beginning phase of a new relationship, romantic
love and passionate sex lead to easy sexual response for women, but
in a long-term relationship (after one or more years), increased dis-
tractions and fatigue lead to a different kind of sexual response.
Basson depicts healthy female sexual response in an established
relationship as follows: Women begin in sexual neutrality, but sensing
an emotional need to be sexual, an opportunity to be sexual, her part-
ners desire, or an awareness of one or more potential benefits that are
important to her and the relationship (for example, emotional close-
ness, bonding, love, affection, healing, acceptance, or commitment),
she may choose to move from sexual neutrality to seeking sensual
contact and stimulation. With beginning sexual arousal, she may
become aware at that time of desire to continue the experience for
sexual reasons and experience more arousal which may or may not
include wanting orgasm. This arousal level brings her a sense of phys-
ical well-being with the added pleasure of spin-offs such as emotional
closeness, bonding, love, affection, and acceptance.
In this new model, women have a lower biological urge for the
release of sexual tension than men. Rather, womens motivation to
have sex stems from a number of potential gains that are not strictly
sexual but are additions to the physical pleasure. Womens sexual
arousal is greatly influenced by subjective mental excitement. Orgas-
mic release is not necessary for satisfaction; it does not occur at each
sexual encounter.
Womens sexual desire is often a responsive rather than a spon-
taneous event. It develops after initial sensual contact. While a mans
sexual desire may be energized by physical drive, typically a womans
sexual desire develops from her receptivity to gentle, relaxed sensual
touching. This touching leads down the path to sexual desire and
continues to emotional closeness, affection, sensuality, and eroticism.
Understanding Your Partners

Reaction to PE
This view of a womans sexual response offers an understand-
ing of why many women eventually become frustrated, hurt, or
angry at experiencing PE lovemaking. Not only is the sensual value
of sex frustrated, but more importantly the intimacy potential is
sabotaged. This is exacerbated when the man stops lovemaking

because of his frustration, apologizes, and goes away emotionally
or physically after ejaculating.
This understanding of your partners sexual response can help
you both become more accepting and respectful of each others sex-
ual experience. This gives you context and motivation for learning to
control ejaculation. You especially can learn to respond differently
when you ejaculate before you want. Too often, men mistakenly
think that PE is a sexual frustration for the woman rather than an
emotional intimacy frustration. It is less about your sexual perfor-
mance and more about shared closeness and emotional intimacy.
Developing Realistic Sexual

Expectations
To learn ejaculatory control, you need to pilot yourself with realistic
expectations. You cant expect more of your body than it is biologi-
cally built to do. Weve already looked at some of the myths about
male and female sexuality. Now lets take a look at your own expec-
tations about sex.
Exercise: Evaluating Your

Sexual Expectations
What do you expect about your sexual life? How does this compare
to what actually goes on with other couples? What are positive, real-
istic expectations? Consider what we know about couple sexuality
from clinical observations and scientific studies. At the beginning of
each section, ask yourself what your expectations are. If you are part
of a couple, ask your partner to do this exercise too. Write down
your responses.
Frequency
How often do you expect to have sex? What influences this: the
quality of your relationship, your bodys urge, the balance of work
and leisure time? Do you and your partner agree on frequency?
What does it mean if you are having less, or more, sex than you
expect?
The average sexual frequency for married couples is between
four times a week and once every two weeks. Contrary to popular
belief, married couples are more sexually active and satisfied than
couples who are dating or living together. For couples in their
twenties, average intercourse frequency is two to three times a week,

and for couples in their fifties, it is once a week (Michael et al. 1994).
Couples who are sexual less than twice a month may find it hard to
develop and maintain ejaculatory control. Youll have the most suc-
cess with ejaculatory control if you establish a regular rhythm of
being sexual.
Length
How long should sex last? What is the relationship between
time and quality? How long should intercourse last? One minute?
Five minutes? Thirty minutes? An hour? What does length of sex
mean for you?
The typical lovemaking encounter lasts from fifteen to forty-
five minutes, which includes two to seven minutes of intercourse
(Leiblum and Rosen 1989). A sexual encounter can vary from a
two-minute quickie to an intimate, sensual, erotic two-hour experi-
ence. Lovemaking includes verbal and nonverbal communication,
pleasuring, intercourse, and afterplay. Contrary to media myths and
male braggadocio, few intercourse experiences involve ten minutes
or longer of thrusting. These figures shock most men and women.
Arousal
In what situations do you find it easy to get an erection
(men)/become lubricated (women)? When is it more difficult? What
does it mean when you have difficulty getting an erection/becoming
lubricated? What does it mean when your erection/lubrication
wanes before or during intercourse?
Whether arousal failure happens once every ten times, once a
month, or once a year, it is normal to occasionally not have an erec-
tion or lubrication sufficient for intercourse (remember that its also
normal for your erection/lubrication to take a break during the
plateau phase). When this occurs, rather than panicking and feeling
you are back at square one, you can just continue with erotic,
nonintercourse sex to orgasm for one or both of you.
Ejaculatory Control
What is a realistic expectation about ejaculatory control? How
have you determined this? What does it mean if you ejaculate fast?
How much control are you supposed to have over ejaculation?
Whose responsibility is it to time ejaculation?
What about PE specifically? How do you know when you are
cured? What does it mean to have reasonable choice over when
to be orgasmic? What is a realistic expectation about orgasm for the
woman?
One key is to maintain the focus on sharing pleasure during

intercourse. In other words, if youre both satisfied with the pleasure
youre giving and receiving, ejaculatory control will matter less.
Another key is seeing intercourse as a mutual, interactive expe-
rience. Most men find it relatively easy to identify the point of ejacu-
latory inevitability and to learn slowing down and ejaculatory
control with manual and oral stimulation. Ejaculatory control during
intercourse is more challenging because it requires more cooperation
and interaction.
Satisfaction
What do you require to feel sexually and emotionally satisfied?
Must you ejaculate? Should every sexual encounter be equally satis-
fying? Why is a poor sexual experience distressing for you? Do you
think that mercy sex (only pleasing your partner) is okay? Com-
plete the sentence, I am wonderfully sexually satisfied when . . .
Even among well-functioning, satisfied married couples, half or
fewer of their experiences are equally satisfying to both partners. In
fact, if the couple has one or two experiences a month of movie-
quality sex, they can count themselves as very fortunate. Perhaps 20
to 25 percent of sexual experiences are very good for one partner
(usually the man) and good for the other. Another 20 to 25 percent of
sexual experiences are okay but not remarkable. The most important
thing to understand is that 5 to 15 percent of sexual experiences are
mediocre, dissatisfying, or dysfunctional (Frank, Anderson, and
Rubenstein 1978). Remember, this is true of well-functioning, satis-
fied couples.
Exercise: Negotiating
Reasonable Sexual Expectations
with Your Partner
Now that youve each examined your own expectations, youll want
to compare your expectations as a couple and try to come to a flex-
ible consensus that fits your relationship. This can be a difficult
process! Take your time. Do your best to remain open-minded and
communicate respectfully. It is normal and even healthy to have
differences. If you find that your expectations are very different or
youre having trouble communicating, you may want to seek help
from a therapist.
1. How often do you expect to have sex? Why is this frequency
important to you? Where does your sexual desire come
from? What is a comfortable frequency for you as a couple

that fits your lifestyle?
2. How long do you expect foreplay (pleasuring) to last? Inter-
course? Why is this length of time meaningful to you? Can
you agree on a range of time that is comfortable for you
both?
3. How comfortable are you accepting that it is normal for a
mans erection or a womans lubrication to come and go
during a relaxed sexual interaction?
4. What do you consider a good range of time for you to have
intercourse? How long do you like the slow, sensual inter-
course? How long the more intense intercourse? What is
your wish for varying the pace of intercourse?
5. In what percent of encounters should you choose when to
ejaculate?
6. In what percent of encounters should the woman have an
orgasm? How?
7. What determines your satisfaction with your sexual
interaction?
8. What percent of the time do you expect sex should be great,
what percent satisfactory, what percent all right, and what
percent poor quality? What do you think is reasonable?
9. How do you each want to handle times when sex goes
poorly?
Steve and Suzannes Story

Steve and Suzanne had been a couple for six years, married for
four years, and had an eighteen-month-old son. They agreed sex was
best in the early months of the relationship. The excitement of find-
ing each other, developing their relationship, experiencing romantic
love, and having new and exciting sex added a special charge to
their lives. Steve had lifelong PE, but the frequency of sex and the
enthusiasm of their romantic relationship made the ejaculatory prob-
lem seem unimportant. Suzanne felt attracted to Steve, attractive and
cared for by Steve, and very excited to be in this relationship. She
naively hoped that with time the quality of intercourse would
improve, but was not upset by the rapid ejaculation. Steve enjoyed
second intercourse opportunities where his control was somewhat

better. He found Suzannes passion and enthusiasm a real turn-on.
Steve was happy with Suzanne, their marriage, and their
family. Steve just ignored the PE problem. Some men find that with
increased sexual comfort and experience, ejaculatory control gradu-
ally improves without their needing to do anything specific.
However, for most men, PE becomes a chronic sexual problem,
which is what happened with Steve.
Suzanne eventually became frustrated and then sexually turned
off. At first she tried to raise the issue of intercourse quality
indirectly and tactfully, but Steve just ignored her or treated the
dissatisfaction as her problem.
Finally the issue exploded into a nasty argument after a sexual
encounter. Suzanne complained that Steve was so quick and selfish.
He accused Suzanne of being a whiner and frigid person. Having an
argument about sex when they were naked and emotionally vulnera-
ble felt awful, but they couldnt seem to stop themselves. Their
conversation quickly degenerated into hurt, defensiveness, and
anger. Steve felt unfairly attacked, and Suzanne felt Steve was mean
and had no desire to improve their sexual life.
Steve stewed about this for two days and then decided he would
show Suzanne. Without telling her, he made an appointment at a
male sex clinic which advertised on sports radio. Steve received medi-
cation which was to delay his orgasm. Without saying anything to
Suzanne, he became obsessed with the goal of getting Suzanne to
have an orgasm before he ejaculated. Sex became a crucial test of
Steves manhood: he had to hold out until she had an orgasm.
At first, Suzanne was pleased that Steve seemed more caring
and intercourse was lasting longer, but then she became turned off
by Steves obsessive focus on her orgasm. She began to dread and
resent sex. Suzannes desire and arousal was much reduced, which
further frustrated Steve, and he became even more defensive. Sex
was no longer an intimate, sharing experience; instead it was a strug-
gle over orgasm. The relationship was dispirited, sinking under the
weight of misunderstanding and performance pressure. Steve was
being his own worst enemy, and Suzanne was feeling increasingly
alienated and turned off.
It was Suzanne who made the call to a couple therapist with a
subspecialty in sex therapy. This was a very wise move. Steve and
Suzanne were ideal candidates for couple sex therapy because they
had a genuine marital bond of respect, trust, and intimacy and a
desire for a satisfying sexual relationship. The PE and sexual misun-
derstanding were draining intimacy and threatening to destabilize
their marriage.
The first priority in therapy was to reinforce the importance of

intimacy and pleasuring. Steve had misinterpreted Suzannes
comments as meaning that he was a terrible lover. With the help of
the therapist, Steve was able to understand that Suzanne valued him
as a loving, attractive husband and wanted to work with him to
enhance their sexual life so that the marriage was satisfying and
secure. Her request was that Steve be a more sensitive, slower lover.
Suzanne was not demanding that Steve be a perfect sexual performer
but a more involved, caring lover.
Suzanne had a variable arousal and orgasm pattern. She
enjoyed being orgasmic with manual and oral stimulation as well as
during intercourse. She did want Steve to develop better ejaculatory
control, but more importantly, she wanted Steve to be willing to
engage in additional erotic stimulation during intercourse. Steve
needed to affirm that he was learning ejaculatory control for himself
and the relationship, not to perform for Suzanne. With this new
understanding, they decided to work together on developing ejacula-
tory control.
At times, Steve and Suzanne found the ejaculatory control exer-
cises tedious, and change was slow, but as long as they continued to
communicate and cooperate, it was enjoyable. Suzanne felt that she
had an integral role in the exercises and that her emotional and
sexual feelings were important. Steve felt that Suzanne was an
intimate ally and that her desire and arousal enhanced the sexual
experience. As he came to understand and appreciate the nuances of
desire, arousal, orgasm, and satisfaction for himself and for Suzanne,
the sexual relationship and PE improved. As a bonus, Steve and
Suzanne expanded their repertoire of pleasuring and erotic tech-
niques. Both learned to be sexually assertive, express intimate feel-
ings, enjoy prolonged intercourse, see orgasm as a voluntary process,
and enjoy flexible, variable sexual experiences.
What You Can Expect from

Our Program for Change
In the same way that its important to have reasonable expectations
of yourself and your body, its important to know what you can
reasonably expect from our approach to PE. You wont become a
sexual machine that can last for hours and hours. You will learn
ejaculatory control and enjoy arousal during prolonged intercourse.
You will enhance your relationship by learning to enjoy and share
the entire sexual experience: intimacy, pleasuring, eroticism, arousal,
intercourse, and afterplay.
Learning ejaculatory control is like learning any skill. It is a

gradual process requiring feedback and practice. Youll need to
approach this as a team. After all, an interested, involved sexual
partner is the best aphrodisiac! You and your partner need to utilize
all of your resources to learn and maintain ejaculatory control.
The essence of ejaculatory control involves learning to carefully
attend to your bodys physical sensations, relaxing your body while
aroused, identifying the point of ejaculatory inevitability, maintain-
ing awareness of pleasurable sensations at high levels of arousal, and
having reasonable (not perfect) control over when you will let go
and orgasm. It involves cognitive, behavioral, and emotional skills; it
is not a mechanical process.
Many men find it easier to develop awareness, comfort, and
skills with self-stimulation. Practicing ejaculatory control during
partner sex, especially intercourse, is more complex and challenging,
but if you can do it by yourself, you can learn to do it during partner
sex.
Like Steve and Suzanne, you and your partner can expect to
develop greater intimacy and a more satisfying sex life. Its hard
work, but its worth it!
3
Understanding the Causes

and Effects of PE
Real-life problems are rarely simple, easy to solve, or magically

fixed, in spite of quick-fix promises. The major reason traditional
treatments of PE have failed to help so many is that PE is not a
simple problem with a simple cure. While the experience of PE is
pretty much the same for all menquick and uncontrolled ejacula-
tionthere are actually nine different types of PE, each with a
different cause. PE may be a physical problem, involving the
neurological system, medical illness, physical injuries, or side effects
of drugs. It may be psychological or interpersonal, stemming from
personality characteristics, unresolved issues from your family of
origin or personal history, anxieties and stressors, relationship
stresses, or sexual skills deficits.
Its not just the causes of PE that are complicatedthe effects
are complicated too. PE can have a devastating impact on your
self-esteem, your sex life, and your relationship. These effects, in
turn, can make PE worse. Its a vicious cycle.
In this chapter, well look at the nine different types of PE: four
physical, four psychological or relational, and one mixed type
involving another sexual dysfunction. Then well focus on the
psychological and relational causes and effects, because these are the
aspects that you have the most control over. The psychological and
relational causes are particularly complex and intertwining, so well
offer you a model to help you understand how these dimensions fit
together. In chapter 4 well help you determine which type or types
of PE you have. Then youll be prepared to develop a comprehensive

and effective approach to managing your PE.
Possible Causes of PE
Scientific research helps us to sort out myths from reality. When it
comes to PE, this difference is very important.
Neurologic System PE
Neurologic system PE is caused by a physiological predis-
position in the nervous system to ejaculate quickly. As youll remem-
ber from chapter 2, ejaculation is triggered by a reflex. Montreal
psychiatrist Pierre Assalian (1988) states that some men with PE
have a constitutionally hypersensitive sympathetic nervous system
(p. 215)in other words, a very quick reflex. This type of PE occurs
throughout a mans life, with every partner, and in all sexual situa-
tions, including masturbation.
Historically, this was the predominant explanation of PE. Rapid
ejaculation was believed to be normal and even to provide an evolu-
tionary advantage. Kinsey, Pomeroy, and Martin (1948) noted that 75
percent of men ejaculated in less than two minutes of intercourse.
Researchers including Bixler (1986) and Hong (1984) assumed that
human behavior is similar to animal behavior and noted that the
top dog or alpha animal ejaculates quickly. Hong observed that
the normal pattern for most primates is to ejaculate within three to
ten seconds of intercourse. Many professionals concluded from their
clinical impressions that PE must have physiological origins. For
example, urologist Schapiros classic report published in 1943 attrib-
utes PE to neurologic efficiency.
More recently, researchers have theorized that genetic inheri-
tance plays some role in the lifelong physiological predisposition to
ejaculate quickly. Waldinger (1998) found that 91 percent of men
with lifelong PE also had a first relative with lifelong PE. Rowland
(1999) found physiological differences between PE and non-PE
males. For example, men with PE have a faster bulbocavernosus reflex
(that is, a faster neurological response in the pelvic muscles).
Physical Illness PE
Physical illnesses may cause PE. Here the PE is acquired, not
lifelong, and occurs in all sexual situations. A number of acute
diseases are known to affect ejaculation speed. Some are common
Understanding the Causes and Effects of PE 33
illnesses, such as urinary tract infection, while others are very rare.
The illness that most frequently causes PE is prostatitis (prostate infec-
tion), although virtually any urologic illness may have this effect.
Physical Injury PE
Some cases of PE are caused by temporary or permanent physi-
cal damage to the body that directly or indirectly affects ejaculatory
mechanisms. Because of the injury, the neurological connection with
the genital area is compromised so that at least some sensation and
control of ejaculation is impaired or lost.
Drug Side-Effect PE
PE may occur as the result of use of or withdrawal from certain
chemical agents. This type of PE is acquired and occurs in all sexual
situations. Examples include withdrawal from certain tranquilizers
or opiates, or even use of over-the-counter cold medications like
Sudafed (pseudoephedrine).
Psychological System PE
Psychological system PE is caused by chronic psychological
disorders such as bipolar mood disorder (sometimes called manic
depression), obsessive-compulsive disorder, chronic depression, gen-
eralized anxiety disorder, schizophrenia, personality disorder (for
example, avoidant personality disorder, dependent personality
disorder, or borderline personality disorder), post-traumatic stress
disorder (the aftereffects of witnessing tragedy or being victimized),
or developmental disorders such as attention deficit/hyperactivity
disorder. It may also be caused by the ongoing psychological effects
of alcoholism or drug abuse, or by chronic, unresolved personal
issues.
While significant psychological problems may cause PE, the
vast majority of men with PE do not have major psychological prob-
lems. There is no common personality profile for men with psycho-
logical system PE. This type of PE typically occurs throughout a
mans life and in all sexual situations.
Psychological Distress PE
Psychological distress PE is caused by temporary psychological
difficulties such as an adjustment disorder (temporary depression or
anxiety), serious unusual stress, or acute depression. Psychological

distress may also result from PE, for example, when physical illness
PE causes psychological distress. While there is no typical psycho-
logical profile for men with PE, the scientific literature reports that
PE is more likely when the man has situational anxiety, reactive
depression, loss of confidence, mistrust, frustration, anger, restrictive
religious beliefs, negative feelings about his body and sexuality, or
unrealistic expectations of sexual performance, or when he experi-
ences internal conflicts such as between the roles of lover and father.
Psychosocial stresses (for example, occupational stress, the death of a
friend or parent, financial problems, or acculturation problems) may
precipitate PE. Sometimes it is difficult to determine which is the
chicken and which is the egg; it may be unclear whether the anxiety
is the cause or result of PE. Psychological distress PE is acquired.
Men tend to underestimate the effect that psychological stress
may have on their sexual functioning. The thinking goes something
like this: When there is such a profound problem as PE, the cause
must be profound as well. But in fact, it does not take much psycho-
logical distress to disrupt sexual functioning.
Relationship Distress PE
Complicated interpersonal dynamics may cause PE or result
from it. Relationship distress PE is rooted in interpersonal dynamics
such as failure to communicate, hurtful misunderstandings, fear of
romantic success, unresolved emotional conflicts, hypersensitivity to
your partner, profound discomfort with or fear of intimacy, or other
distresses such as mistrust in response to infidelity.
In short, general relationship deficiencies undermine the
mutual emotional acceptance that is important to healthy sexual
functioning. Even when PE is caused by something other than rela-
tionship distress, it can cause considerable damage to your relation-
ship. Relationship distress PE is commonly acquired and limited to
sex with the partner.
While there is no single interaction pattern among couples
facing PE, there are several common patterns.
! The man is hypersensitive to his partner, fears failing and

disappointing her, and is frequently self-blaming and apolo-
getic. The woman is either shy and compliant or direct and
aggressive.
! The man is self-absorbed and aloof from his partners

concerns. He may defend his dysfunction as a normal
physiological response, while she may feel emotionally

ignored and abandoned, and respond contentiously.
! The couple experiences unresolved relationship conflicts
accompanied by perceived rejection, blaming, and criticism.
They may struggle with the balance of autonomy and couple
cohesion, empathy deficits, or a conflict-resolution impasse.
One partner may feel abandoned by the other and take an
avoidant or hostile stance. The PE may be a reciprocal and
interactive problem that has more to do with relationship
distress than sex itself.
! A sexual problem like PE serves as a surrogate problem, pro-
viding a focus for the couples anxiety and dissatisfaction so
that the rest of the relationship can remain functional. Sex
might feel like the only relationship problem, but it is not.
! The mans PE coexists with a sexual dysfunction in the
woman. Some women experience inhibited arousal, while
others experience difficulty achieving orgasm in part because
of their partners PE. In other cases, her sex dysfunction inter-
acts with his PE. For example, because of her inhibited desire,
she may encourage him to get it over with. If she experi-
ences discomfort or pain during intercourse, he may hurry to
limit the discomfort. In still other cases of acquired PE, the
mans fast ejaculation may be a reaction to the womans psy-
chological distress (for example, anxiety or depression), or to
her negative attitude toward sex, general discomfort with a
sexual behavior (for example, oral sex), low sexual arousal, or
inhibited orgasm.
Psychosexual Skills Deficit PE

Psychosexual skills deficit PE typically results from the man not
having accurate and sufficient knowledge about his body, his
partners body, and sexual physiology (how sexual response works);
holding unreasonable expectations about sexual performance; and
lacking essential sensual skills to manage his body during sexual
arousal. Some men also lack dating or interpersonal skills. This type
of PE is lifelong but may not occur with masturbation.
Most men with psychologically caused PE usually have some
limitations in psychosexual skills, if only to compensate for individ-
ual stresses or relationship tensions that rob sexuality of its natural
bonding and emotional-healing capacity. In such cases the man has
difficulty focusing on his own sensations; becomes preoccupied with
anticipating failure; has difficulty relaxing his body while sexually

aroused; lacks awareness of techniques for managing PE or uses
ineffective techniques like distraction; focuses excessively on his
partners body and reactions; experiences restricted, uneasy, or
anxious sensuality; or entertains distorted thoughts (sex must be
spontaneous or emotions are not involved in sex).
PE with Another Sexual Dysfunction (Mixed PE)

PE that coexists with another sexual dysfunction such as low
sexual desire or erectile dysfunction occurs about one-third of the
time and can reflect a complicated combination of physical and
psychological causes. For example, a vascular cause for erectile
dysfunction may combine with psychological and relationship
distress that adds to PE. PE is sometimes caused by the mans efforts
to compensate for a fear of erectile dysfunction. Treating the erectile
dysfunction can, in turn, help resolve the PE. On the other hand,
some men try so hard to halt PE that they unintentionally cause
erectile dysfunction, which then leads to inhibited sexual desire.
The Multiple Dimensions of PE

In addition to understanding the multiple causes of PE, it is valuable
to appreciate that PE is also multidimensionalthat not only is there
rarely one cause of PE, there is an interaction between the biological,
medical, psychological, relational, and situational dimensions. For
example, a prostate infection (medical) may interact with your self-
esteem (psychological), affect communication with your partner
(relational), and even influence your feelings about work and home
life (psychological and situational). This intermingling and inter-
twining of the facets of our personalities and lives is normal. This is
partly why PE can feel so confusing, so difficult to sort out. Yes, PE
is complex.
To illustrate these dimensional interactions, consider Roberts
effort to understand his PE. We identify some of the interacting
dimensions in parentheses.
Roberts Story
Robert was thirty-four years old and had been married for eight
years. He thought that he had a pretty good life: a happy marriage to
Tonya, a five-year-old son, and a good career as a teacher. After
several years of what he considered okay sexual performance, he

began to ejaculate very quicklywithin one minute. He felt per-
plexed (psychological). He began to feel irritated with his penis as he
intended to last longer but his body seemed to betray him (biological
and psychological). He was confused, sensing the chaos of trying to
figure it out so he could do something about it (psychological). He
tried to be aware and sensitive to Tonya, even felt hypersensitive to
her actions, moods, and words, especially since she had recently said
she was less interested in sex (psychological and relational). Since
his PE developed after a long period of performing okay, he thought
that maybe there was something wrong with his body (biological,
medical). Should he see his doctor? But he hated going to his physi-
cian (psychological). He was almost phobic about blood draws (psy-
chological and biological).
He realized too that he was very down and anxious (psycho-
logical) about the whole sex thing. None of his efforts to slow down
ejaculation had helped. He was puzzled to notice that one time
recently when he drank too much, he was able to last a little longer
before ejaculating. Was alcohol an answer (biological)? He could not
let himself go that route (psychological). Another time he lasted a
little longer was when he had a sinus infection and had trouble
breathing (biological).
Robert realized he was beginning to withdraw from sex and
from Tonya (relational) but felt trapped, like he couldnt win
(psychological). Even at work he noticed he sometimes could not
concentrate well and felt distracted (relational, psychological). He
also noticed, at times, that he was impatient with his son (psycholog-
ical and relational). These things seemed to arise from his tension
over the PE (psychological). What is this chaos? What to do?
With the help of assessment and intervention strategies and
exercises, Robert and Tonya were able to understand and resolve his
PE. You can do it, too.
You Understand Your PE

All of these aspectsbiological/medical, psychological, relational,
situationalinteract in your effort to figure out your PE and change
it. Without some organizational model, the chaos feels overwhelm-
ing. We will help you sort it out, make sense of it, see what you are
up against, and figure out what you can do. If your case is simple,
we are very happy for you. If your case is multidimensional like
most, welcome aboard. We want to help you honestly see PE for the
complex problem it is, use this deeper understanding to overcome
the feeling of being overwhelmed and hopeless, and help you and
your partner cooperate to improve your sexual life and relationship.
The Psychological and

Relational Dimensions of PE
To help you understand the psychological and relationship aspects
of PE, we offer you a framework, the cognitive-behavioral-emotional
(CBE) model. This will help you make sense of the otherwise
confusing experience of PE and organize your couple approach to
overcoming PE.
The Cognitive-Behavioral-Emotional Model

The CBE model recognizes that each individual is composed of
cognitions, or thoughts; behaviors, or actions; and emotions, or feelings.
Well describe these components, then show you how they are
involved in your PE.
These dimensions of the CBE model interact almost automati-
callythoughts influencing feelings, feelings influencing behaviors,
and behaviors prompting thoughts and feelings. In the integrative
CBE model, each component is valued and promotes change. Your
insight will be strengthened by understanding the cognitions, behav-
iors, and emotions that constitute PE.
Cognitions or Thoughts
Cognitions involve ideas, beliefs, observations, interpretations,
and reasoning. Psychologists Norman Epstein and Donald Baucom
(2002) describe five distinct cognitions that affect our relationships:
assumptions, standards, perceptions, attributions (explanations), and
expectancies (expectations). These are unique to each person. Such
cognitions are beneficial or detrimental to you depending on their
effects on your feelings and actions.
Behaviors or Actions
We make decisions to act (or not act) based upon our thoughts
and feelings. Technically, action is always a choice or decision. The
freedom to choose your behavior may be mitigated by thoughts and
feelings, but responsible and mature living mandates accountability
for your behavior. While feelings are not viewed as ethical (that is,
not judged to be good or bad), behaviors are. Behaviors may be
constructive or destructive depending on their effect on each individ-
ual and the relationship.
Emotions or Feelings
Emotions are chemical-electrical energy events or experiences
in your body. You label this energy according to how you experience
these physical sensations: fear, sadness, loneliness, panic, satisfac-
tion, anger, worry, contentment, frustration, pleasure, irritability,
excitement, anxiety, wonderment, confusion, shame, guilt, comfort,
embarrassment, resentment, safety. Feelings are motivators that
prompt, penalize, or reward action. Feelings are not themselves good
or bad, right or wrong. Feelings influence the thoughts we have and
the actions we take. Emotions can be positive or negative depending
on how you subjectively experience them and how they influence
your behavior.
Sherry and Alexs Story

To illustrate this model, consider Alex and Sherrys experience
of PE. Be aware of their thoughts, actions, and feelings. To help you
identify these, we will label cognitions as (C), behaviors as (B), and
emotions as (E). You may find some features similar to your own
experience.
Alexs chronic PE led Sherry to perceive (C) him as selfish and
rejecting of her desires, and Sherry felt dismissed (E). Alex did not
intend (C) to be selfish. Rather, he was deeply perplexed (C) at his
performance failure (B) and feared disappointing Sherry (E). Yet
his actions (B) after ejaculating quickly appeared (C) selfish to
Sherry.
Here is an outline of what was happening. With fast ejaculation
(B), Alex appeared to Sherry (C) to be sexually satisfied by his orgasm
(B), but he typically stopped pleasuring (B) Sherry (he rolls over and
goes to sleep). Alex felt frustrated with himself (E), focused on his
failure (C), apologized (B) to Sherry for PE, and stopped lovemaking,
became quiet or withdrawn, or even left their bed (B).
For several years, Sherry had experienced Alexs PE and
observed him (C) failing to seek professional help (B). All of these
actions (B) seemed to Sherry to be insensitive (C) to her wants and
feelings, hurt her deeply (E), felt like an abandonment (E), and
seemed hard to interpret as anything other than an incredible selfish-
ness (C). Her hurt (E) sometimes manifested as complaints, criti-
cisms, and other expressions of anger (B), even rage at times. With
this, Alex thought he was betrayed (C), and he misunderstood (C)
Sherrys lack of support (B) when he failed (C) to control his ejacula-
tion (B), but was confused (C) about what to do (B). Everything that
he tried (B) (distracting himself, masturbating before lovemaking)
failed (C). He felt completely hopeless (E) and inadequate (C), and
avoided Sherry (B). She believed she was abandoned (C) and ignored
by Alex (B), and felt hurt and angry (E).
Alex and Sherrys story shows how these complex and
detrimental cognitions, behaviors, and emotions serve to cause,
maintain, or exacerbate PE, or may become the psychological effects
of PE caused by other factors. Some examples of negative cognitions
that can be involved in PE are I am a failure, I am sexually
inadequate, or He is just selfish. Negative behaviors include with-
drawal from your partner, silence, blaming, or failing to talk
constructively with each other about the problem. Detrimental
emotions include frustration, anger, shame, or confusion. Identifying
these negative dimensions is a step in the process of overcoming the
anguish of PE. You can stop these patterns and change them to more
reasonable cognitions, cooperative behaviors, and positive feelings.
Relationship Identity, Cooperation, and Intimacy

PE exists within a relationship, not in a vacuum. Understand-
ing relationship dimensions can help you make sense of your dis-
tress and alert you to areas to repair or strengthen as you address
PE. Lets look at the CBE model of relationship health.
Relationship Identity
Relationship identity refers to the cognitive life of your relation-
ship, comprising the expectations that each of you brings to the rela-
tionship, the relevance of your personal history, and what your
relationship means to each of you. For example, how do you balance
each others needs for individual autonomy and relationship
cohesion? In healthy relationships, each individual benefits from the
relationship, and the relationship benefits from the input of each
individual.
Relationship Cooperation
Relationship cooperation refers to your behavioral interactions:
how you communicate, work together in a balanced way, and
mutually solve problems effectively. Your thoughts and feelings are
hidden from each other unless you communicate them through a
behaviortypically by sharing through discussion or nonverbal
gestures. This is why communication is such an important part of
couple sexual growth.
Relationship Intimacy
Relationship intimacy refers to your relationships climate or
quality of emotional bond. Intimacy describes the emotional,
friendship, and sexual aspects of your relationshipfeelings of affec-

tion, commitment, and closeness.
These relationship themes fundamentally determine relation-
ship satisfaction.
PE and Sexual Relationship Identity,

Cooperation, and Intimacy
To help you more fully appreciate the interrelated dimensions of
your PE, well describe specific types of cognitions involved in
sexual relationship identity, behaviors that make up sexual relation-
ship cooperation, and emotions associated with sexual relationship
intimacy. The CBE model of relationship health can help you focus
on what to strive for, not simply what to stop or get over from the
past. Remember that the context for overcoming PE is not simply to
slow down your ejaculation, but to enhance your relationship
identity, cooperation, and emotional intimacy.
PE and the Role of Cognitions: Sexual

Relationship Identity
Your cognitions about PE comprise the sexual meaning of PE.
Discovering your and your partners meanings of sexuality and PE is
an important element in understanding your sexual dissatisfaction.
Does PE mean a limitation on pleasure? Shame? Failure? Alienation?
Does sex mean duty? Perfect performance? Is it dirty but exciting?
Disgusting? Or, does sex mean vulnerable sharing? Comfort? Gentle-
ness and tenderness? Acceptance? Playfulness? Intimacy?
The subjective meaning that PE has for you and your partner is
determined by these cognitions, and they influence your emotional
experiences during sex. You and your partner can understand each
other more fully by sharing your thoughts about PE and the
meaning of sex. You can also begin to change your experience of PE
by replacing negative thoughts with positive ones.
Detrimental and Beneficial Cognitions with PE

Following are some common detrimental thoughts that men
and women have when PE is a significant problem. We also offer
beneficial thoughts that can replace them to help you alter PEs
meaning and help motivate your changes. Be aware that beneficial
cognitions are grounded in accurate knowledge about sex.
Assumptions about sex are cognitions about the characteristics of

intimate relationships that you accept as true without question and
govern how you interact.
Detrimental Cognitions Beneficial Cognitions
! Good sex means long ! Good sex involves flexible
intercourse. ways to share pleasure
which invites personal and
relationship joys.
! Movie-type sex is normal. ! Movie sex portrays impulsive,
perfect-performance sex. We
are real lovers, not actors in a
Hollywood movie!
Standards or beliefs are cognitions about the characteristics that you
think your sexual partner or relationship should have, and the judg-
ments you make. Examples of detrimental versus beneficial standards
are:
! Sex should always be ! Sex is sometimes romantic,
romantic. sometimes routine, sometimes
joyful, sometimes monotonous,
sometimes deeply meaningful.
Sex is a healthy part of our
couple style.
! We should have sex four ! The frequency of sex should
times a week because Ive conform to the realities of our
heard that is normal for lives and be mutually satisfying.
our age.
Perceptions about sex are your cognitive selective focus. You
notice only a part of the information available. Which part depends
on your emotional state, level of fatigue, prior experiences in similar
situations, and preexisting cognitions and perceptions about sex.
! When he ejaculates, he ! His apology and withdrawal may
immediately apologizes and signal that he feels deeply
goes away physically and ashamed, sexually inadequate, a
emotionally, and I am failure. Ill ask him to physically
abandoned. stay involved after intercourse for
the closeness or to be satisfied by
other ways than intercourse.
! She punishes me with her ! Her anger manifests her hurt,

anger when I come fast. loneliness, or feelings of
emotional abandonment. I will
tell her that I want to under-
stand her feelings and to lead
the way with the program in
this book.
Attributions are the causal explanations you have about your PE.
The explanations reflect your understanding of and sense of control
over sexual experiences.
! He ejaculates so fast ! PE is more than selfishness.

because he is selfish. What must he be feeling?
Perhaps anxious? Ashamed?
Inadequate? Powerless? Betrayed
by his bodys fast ejaculation?
Afraid I will go to someone
else?
! She is so resistant or ! Sex is only one aspect of our

passive when having sex intimate relationship. I wonder if
because she no longer loves she is passive during lovemaking
me. I have ruined our because she anticipates the
marriage because of PE. touching will end when I ejacu-
late? When I ejaculate quickly,
I will ask her if I can hold her
and rest for a minute, and then
pleasure her with my hands.
Expectancies are the automatic predictions about what is likely to

occur: if this, then that. When thinking about PE, this often
includes expectations that you will fail.
! If we try to have sex, it ! I will ask her to be part of my

wont work because Ill effort to learn ejaculatory control
ejaculate fast; it will be a and heal the pain in our
disappointment, and shell relationship caused by PE.
be angry.
! If I ask for what I want ! I will ask him kindlyand not

sexually (like oral sex or during sexwhether he would
slower touch), he will get like me to offer suggestions
upset. about the kinds of touch I really
enjoy.
Changing the Way You Think about PE

You can change the way you think about PE based on realistic
expectations of yourself and your relationship. Research supports
that your way of thinking is the most important factor for change
and satisfaction. Your negative thoughts about PE function as a
self-fulfilling prophecy. Identifying the detrimental and limiting
cognitions that you and your partner may have adopted toward your
PE, and replacing them with realistic and constructive ones, is a very
useful change strategy.
Exercise: Changing Your

Thoughts about PE
Take a moment to consider your cognitions about your sex life: your
assumptions, beliefs, perceptions, explanations, and expectancies.
Each of these thoughts reflects the meaning sex has for you. How do
you want to reframe the meaning of sex for you and your partner?
What is its role in your intimate relationship? Choose one or two
thoughts that you think are the most detrimental. Write a positive
alternative for each. When those negative thoughts arise, consciously
shift to the positive thought. You can share your thoughts with each
other to help understand each other better.
PE and the Role of Behaviors: Sexual

Relationship Cooperation
Behaviors are the bridge between you and your partner. Your
thoughts and feelings can only be accurately known to each other
through your actions, verbal and nonverbal. To address PE, you and
your partner must focus on cooperative behavior that moves you
toward your goal.
When your PE is not constructively addressed, it manifests in
negative behavior. For example, the man avoids sex to avoid dis-
appointment, avoids talking about the problem, acts as though noth-
ing is wrong, pressures his partner to have orgasm other ways than
through intercourse, or makes love rigidly and mechanically as he

tries desperately to control his ejaculation. The woman may push her
lover away, say hurtful things, rush sex to get it over with to avoid
further hurt and frustration, or place limitations or conditions on sex.
Relationship conflict may cause PE when unresolved disagree-
ments or repeated negative interactions undermine emotional inti-
macy. PE may cause relationship conflict when it is chronic and
ignored. On the other hand, mutually resolved relationship conflict
enhances emotional and sexual intimacy. Ordinary conflict presents
opportunities for couples to deepen their emotional and sexual inti-
macy. Differences or disagreements about sexual interaction are
common and normal; the issue is how well you deal with them. PE is
an example of a relationship cooperation challenge. With a positive,
respectful, affirming process of conflict resolution, partners develop
a deeper understanding of how the other thinks and feels, a greater
sense of self-esteem, greater respect and admiration for each other,
more confidence that future conflict can be resolved, and increased
goodwill and comfort, which facilitates sexual desire.
Detrimental and Beneficial Behaviors with PE

There are detrimental behaviors that cause, maintain, or worsen
PE, as well as beneficial behaviors that may ameliorate or help PE.
Detrimental Actions Beneficial Actions

! Verbally criticizing your ! Calmly and openly expressing
partner or your partners your own feelings.
behavior.
! Withdrawing from your ! Staying, being present,
partner. disclosing your feelings, or
expressing your intention to
work together.
! Anticipating sexual ! Calmly talking with your
failure and then avoiding partner and openly acknowl-
initiating sex. edging the dilemma you feel.
! Acting aloof or cold. ! Showing warmth and interest
in cooperating, requesting
what you want in a positive
way.
! Apologizing when you ! Asking your partner how you
ejaculate fast. can be responsive to her
sexual feelings and desires,
and how you can please her.
! Expressing frustration at ! Reminding yourself that

yourself and your partner. expressing frustration doesnt
help, then refocusing and
recommitting to enhancing
sensual and sexual pleasure.
! Refusing to discuss the ! Talking calmly, sharing your
sexual problem. feelings, describing the
dilemma you face, and asking
for cooperation to enrich your
sexual relationship.
! Threatening an affair, ! Expressing your desire to join
separation, or divorce. This together to solve your
is truly poisonous behavior difficulty as a couple.
because threats create
anxiety and polarize you
as a couple.
Changing the Way You Act about PE

These examples of injurious behaviors (whether intended or
not) and more beneficial actions involving PE are changes you and
your partner can implement. Identifying your contribution and
seeing what constructive changes you need to make are essential to
your success.
Exercise: Changing Your

Behaviors about PE
From the list above, choose at least one and up to three behaviors to
focus on changing. If you slip into old detrimental behaviors, forgive
yourself, then recommit to choosing more positive behaviors.
PE and the Role of Feelings: Sexual

Relationship Intimacy
In the emotional life of your relationship, PE may bring about
hurtful feelings (humiliation, rejection, loneliness, or abandonment)
that undermine beneficial feelings (acceptance, closeness, and love).
The emotional suffering of many couples with PE is quiet, hidden,
and often deeply upsetting, which only adds to the confusion and
sense of hopelessness.
Detrimental Emotions with PE

Common feelings for the man with PE are bewilderment,
shame, disappointment, an intense sense of failure and inadequacy,
self-doubt, loneliness, humiliation, frustration, hurt, depression, embar-
rassment, heightened performance anxiety, hopelessness, interper-
sonal alienation, and dread of talking about sex.
The woman may at first feel supportive and sympathetic and
offer encouraging and affirming responses, but with chronic avoid-
ance by the man, she may feel lonely, emotionally abandoned,
resentful that he ignores the issue (by not talking about it and not
seeking help), sad, confused, frustrated, rejected, or alienated. She
may begin to dread sex as an ordeal to be endured.
Changing the Way You Feel about PE

Your goal as a couple is to transform these detrimental feelings
into more constructive and beneficial ones: self-confidence, warmth,
trust, comfort, closeness, calmness, understanding, love, empathy,
mutual acceptance, specialness, safety, pleasure, playfulness, collabo-
ration, and strength. Beginning to change your cognitions and
behaviors about PE will help transform your feelings about PE.
The meaning of PE to each partner has substantial emotional
significance. When the meaning of PE is hidden for you and your
partner, or when you are reluctant or unable to discuss the
distinctive meaning that PE has for you, it is very difficult to share
the experience of change and cooperate. Identifying and understand-
ing the meaning of PE provides an important foundation for you to
accept your dilemma and begin to replace detrimental cognitions,
actions, and feelings with beneficial thoughts, behaviors, and
emotions. Addressing PE as a couple will help you develop new
sexual and relationship meaning, a crucial resource in overcoming
PE. Dealing with PE is an opportunity to deepen relationship
intimacy by cooperating as an intimate team.
Exercise: Sharing Your

Feelings about PE
Share with each other what PE has felt like and how it has affected
you. When you learn to have good-enough sex, how do you want to
feel then about sex? About each other?
Accepting the Complexity of PE

All of the features we have highlightedphysiology, cognitions,
feelings, behaviors, and relationship identity, cooperation, and inti-
macyintertwine as components of PE. Be aware of the complexity,
but dont let it overwhelm you. Trust that you can address the
important factors, and trust that your efforts will be good enough.
By being so thorough, we offer you the opportunity to alleviate your
distress and improve your sexual experienceto enjoy sex more and
have great, intimate sex together!
4
Assessing Your PE
In this chapter, we will help you answer several important questions

about your PE. How do you know if PE is really a problem? What
are the criteria that differentiate PE from healthy sexual functioning?
If you decide you do have PE, what kind or type of PE do you have?
What are the causes? How severe is your PE? How do you decide
what to do to resolve it? Will you need professional help?
When you determine the causes and severity of your PE, you
take the most important step on the road to successfully resolving
the problem. You know what you are dealing with and can set a
course of actionindividually and as a coupleto remedy your PE.
We will guide you through this process. You will need to be
determined, patient, and decisive about using all your resources to
help you to succeed. You may need to develop a more comfortable,
cooperative relationship. You may need to find a wise and affirming
physician for a medical evaluation. You may need to consult with a
skilled and knowledgeable marital and sex therapist. Congratulate
yourself for having the courage to face a difficult problem!
Do You Have PE?

We define PE as the inadvertent and unsatisfying rapid speed of
male ejaculation. From a practical standpoint, you probably have PE
if you are unable to decide or choose approximately when you want
to ejaculate in more cases than not, and it is distressing to you and
your partner. Consider the following four questions:
1. Can you choose when to ejaculate most of the timein at

least four out of five sexual experiences?
2. Are you able to relax well enough to enjoy sensuous physi-
cal pleasure during lovemaking? Is sex more than orgasm?
3. Are you able to relax and feel close and connected during
lovemaking?
4. After you and your partner make love, are you both usually
pleased and satisfied with your sexual experience?
If you are not able to answer yes to these questions, you are
experiencing the common features of PE.
What Type of PE Do You Have?

To understand and remedy PE, it is crucial that you determine its
cause or causes and develop a specific treatment plan. You learned
about the nine causes of PE in chapter 3. We will help you examine
each one so that you can take comprehensive, constructive action.
Diagnosing Your Type of PE

We will guide you through a step-by-step process to help you
consider all of the causes that could be contributing to your PE. You
want to be inclusive because if you miss a cause, you will overlook a
potentially important factor in your change plan. Dont allow
yourself to fail by an oversight. Be conservative. Assume any cause
you suspect may be present until you know otherwisethat is, until
you can rule it out as a factor.
Overview of PE Types
The PE diagnostic process leads you first through those types
that are lifelong and then those that are acquired. Three types
(neurologic system, psychological system, and psychosexual skills
deficit) are considered when PE is lifelong, while six types (physical
illness, physical injury, drug side-effect, psychological distress, rela-
tionship distress, and mixed) are considered when PE is acquired.
The most common types of PE are neurologic system and psycho-
sexual skills deficit. The next most common are relationship distress,
psychological distress, and PE with another sexual dysfunction (usu-
ally erectile dysfunction). Occasionally we see physical illness PE
(usually caused by prostate infection). It is rare to see psychological
system PE, physical injury PE, or drug side-effect PE.
Assessing Your PE 51
Your Personal Diagnostic Team

It is best to review the diagnostic decision-tree sequence with
your partner so that you have a more comprehensive picture. Going
through this together will be very useful later as you work as a team
to resolve your PE.
It is wise to have a general physical examination with your
family physician if you suspect a biological cause. Take the lead and
ask your doctor to look for physical causes of your PE, especially
focusing on identifying signs of general illness, chronic physical
problems, localized genitourinary infection or inflammation, and
signs of either generalized neurologic disease or localized sensory
deficits that could cause or contribute to your PE.
Exercise: Diagnosing Your

Type of PE
As you follow these nine steps, note your answers on the PE
Diagnostic Summary Sheet at the end of this chapter. Do not conclude
that the first cause of PE is the only cause. Continue through each of
the nine steps in order to determine all of the possible causes or
manifestations.
Step 1: Do You Have Neurologic System PE?

Yes No Has PE occurred all your life?
Yes No Has PE occurred in all sexual situations (with
different partners, during masturbation)?
Yes No Do you think that your penis has a physiological
hypersensitivity; that is, does your penis feel
supersensitive?
Yes No Does your ejaculation seem to be an unconscious
reflex, an automatic reaction like an eye blink?
Yes No Are you confident that you do not have a serious,
chronic psychological problem?
If you answered yes to most of these, you may have neurologic
system PE.
Actually, it is not easy to conclusively diagnose neurologic sys-
tem PE. There are several simple neurological examinations your
physician or a neurologist may use, as well as some more involved
tests like bulbocavernosus reflex (BCR) testing. Until you see a
doctor, you usually will have to make an educated guess about the
likelihood that you have neurologic system PE.
Step 2: Do You Have Psychological System PE?

Yes No Has PE occurred in all sexual situations?
Yes No Have you been diagnosed withor do you think
you havea chronic, psychological character
pattern or unrelenting problem such as obsessive-
compulsive disorder, chronic depression,
generalized anxiety disorder, or a personality
disorder such as dependent personality?
Yes No Have you taken a formal psychological test that
suggests you have a chronic psychological problem?
If you answered yes to the first two questions and at least one
other, you may have psychological system PE.
While psychological system PE is rare, it is important to
consider this because if you do not address the underlying cause,
your efforts to remedy PE will be frustratingly unsuccessful. Careful
evaluation will help sort out to what extent the psychological prob-
lem must be treated in order to resolve your PE.
Step 3: Do You Have Psychosexual Skills Deficit PE?

Yes No Has PE occurred in almost all situations, especially
with a partner?
Yes No Do you focus your sexual attention almost
exclusively on your partnerher body, actions, and
sexual responses?
Yes No Are you so mentally distracted that you are unable
to physically relax during sex or unable to focus on
the pleasure of your own bodily sensations of
arousal? If you have learned arousal pacing
strategies such as stop-start pacing, do you find
them difficult to use?
Yes No Are you unaware of your bodys pelvic muscles
and how to use them for ejaculatory control?
Yes No Do you feel confused about your sexual response
and perplexed about how to regulate your sexual
arousal?
Yes No Do you feel shy about asking your partner for what
you want during sex?
Yes No Do you initiate and anxiously pursue sex with

highly arousing activities such as oral sex or
immediate intercourse rather than beginning slowly
with relaxed kissing and light massaging?
If you answered yes to most of these, you may have psycho-
sexual skills deficit PE.
Our program will be especially useful to you. Well teach you
skills in managing your body during sexual arousal, regulating your
level of arousal, and cooperating with your partner.
Step 4: Do You Have Physical Illness PE?

Yes No Has your PE been acquired (developed after a
period when you had adequate ejaculatory control
and choice)?
Yes No Does your PE occur in all situations?
Yes No Has it been more than a year since you have had
a general physical examination by your doctor
which included a complete blood count and
a prostate examination?
Yes No Do you have a family history of endocrine, blood,
or neurologic irregularities (for example, multiple
sclerosis)?
Yes No Did you or your partner contract a sexually
transmitted disease recently?
Yes No Have you had, or do you have, a physical illness
(such as prostatitis, neuritis, high blood pressure, or
epilepsy) known to cause PE?
other, you may have physical illness PE.
You will need thorough evaluation by a physician to determine
what condition might be causing or contributing to your PE. The
most common illnesses that cause PE are prostatitis (which can lin-
ger in a mild form for years without any obvious or clear symptoms
except for PE) and sexually transmitted diseases (for example,
chlamydia or gonorrhea).
Step 5: Do You Have Physical Injury PE?

Yes No Has your PE been acquired?
Yes No Has there been a physical injury, spinal injury,

pelvic surgery or trauma, or neurologic trauma that
coincided with or was followed some time later
by PE?
If you answered yes to all of these, you may have physical
injury PE.
If you suspect an injury may have caused your PE, consult with
your family physician, who will review your medical history and
recommend further testing.
Step 6: Do You Have Drug Side-Effect PE?

Yes No Have you recently stopped taking trifluoperazine
(Novoflurazine, Solazine, Stelazine, Suprazine, or
Terfluzine) or any opiate (for example, morphine)?
Yes No Are you taking a medication known to cause PE:
Norpramin (desipramine), or a cold medication
containing a form of ephedrine or pseudoephedrine
(Sudafed, Actifed, Comtrex, Dristan, Sinutab,
Robitussin, Triaminic, Broncholate, or Dimetane-DC)?
other, you may have drug side-effect PE.
If you have recently discontinued one of the tranquilizers men-
tioned above or any opiate, PE is a common reaction. Allowing time
for the body to readjust usually clears up the PE. If the PE lasts more
than six to eight weeks, you should consider what else may be caus-
ing or maintaining your PE. If you suspect that your PE is caused by
a medication youre currently taking, talk with your doctor about
your medication dosage or options.
Step 7: Do You Have Psychological Distress PE?

Yes No Are you experiencing significant psychological
distress such as depression, anxiety, grieving,
career stress, or parenting problems? Have you
recently gone through a major life transition such
as a career change, moving your residence, the
birth of your child, or sudden success?
Yes No Have you taken an objective psychological test that

verifies you are experiencing psychological stress?
other, you may have psychological distress PE.
The critical difference between psychological system PE and
psychological distress PE is its source and severity. Acquired psy-
chological distress PE is a reaction to life events and is usually easier
to treat.
Step 8: Do You Have Relationship Distress PE?

Yes No Does PE occur only with your partner?
Yes No Has your partner recently expressed dissatisfaction
with your general relationship?
Yes No Are you currently experiencing relationship distress
such as poor communication, a deficit in emotional
empathy, painful disagreements (fighting), or
unresolved conflicts?
Yes No Have you recently taken an objective relationship
test that suggests relationship distress?
Yes No Have you thought recently that marital or
relationship therapy might be helpful?
other, you may have relationship distress PE.
Relationship distress PE is usually distinguished by acquired
onset and situational occurrence in partner sex. In short, relationship
deficiencies undermine the mutual emotional acceptance that is
important to healthy sexual functioning.
Step 9: Do You Have PE with Another Sexual

Dysfunction (Mixed PE)?
Yes No In addition to PE, do you experience another
sexual problem such as erectile dysfunction,
inhibited sexual desire, or pain in your penis
during intercourse? Do you sometimes ejaculate
without an erection?
Yes No Does this additional sexual dysfunction occur
occasionally, frequently, or always?
If you answered yes to both of these, you may have PE with

another sexual dysfunction (mixed PE).
It is normal to have sexual difficulties on occasion, but when
this occurs regularly it represents a sexual dysfunction. Successful
treatment of the other sexual problem can help resolve the PE.
How Severe Is Your PE?

Determining the severity of your PE will help you gain perspective
on how challenging your PE is, how diligent you will need to be in
addressing it, and the extent to which you could benefit from profes-
sional consultation. Take a moment to complete the Premature Ejacu-
lation Severity Index (PESI). Make a copy and ask your partner to
also complete the PESI. Although she will not know answers to some
of the questions, her impressions of the severity of your PE can be
very helpful.
Exercise: Premature Ejaculation

Severity Index (PESI)
Circle the number that indicates what you typically experience for
the questions below.
1. How long has premature or rapid ejaculation been a problem for

you?
10 9 8 7 6 5 4 3 2 1 0
lifelong intermittent recent
(off and on) or new
problem
2. In what percent of all sex acts are you unable to choose when to
ejaculate?
10 9 8 7 6 5 4 3 2 1 0
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%
3. When do you usually ejaculate?

10 9 8 7 6 5 4 3 2 1 0
before at shortly After
penetration penetration after some
penetration intercourse
4. If you can have intercourse, how long is it before you typically

ejaculate?
10 9 8 7 6 5 4 3 2 1 0
not able 15 sec 30 sec 1 min 2 min 3 min 4 min 5 min 10 min 15 min more
to enter
5. Rate the intensity or vigor of physical stimulation at the time of

ejaculation.
10 9 8 7 6 5 4 3 2 1 0
very mild, very
little, intense,
or slow vigor-
ous,
or fast
6. How difficult is it for you to control or choose when you ejaculate?

10 9 8 7 6 5 4 3 2 1 0
extremely extremely
difficult easy to
to control control
7. How upset is your sexual partner by your premature ejaculation?

10 9 8 7 6 5 4 3 2 1 0
extremely very
troubled calm
8. How upset are you by your premature ejaculation?

10 9 8 7 6 5 4 3 2 1 0
extremely very
troubled calm
9. How much has your premature ejaculation affected your life in

general?
10 9 8 7 6 5 4 3 2 1 0
major no
impact significant
(for example, effect
ruined relationship)
10. How often when you have sex do you also have desire or erec-
tion problems?
10 9 8 7 6 5 4 3 2 1 0
100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0%
Scoring the PESI

To determine your severity index, add your responses to items
1 through 10.
Total score:
Now enter your total score in the appropriate category below to

indicate the severity of your PE.
020 Very mild severity
2040 Mild severity
4060 Moderate severity
6080 High severity
80100 Extreme severity
The lower your severity score, the more likely you are to be
able to successfully resolve your PE. The more severe your PE is, the
harder it will be to remedy and the more determined and disciplined
you and your partner will need to be. If your case is of moderate
severity, you have a good chance of addressing PE successfully
through the techniques in this book, but you will need to invest a
good amount of personal and relationship energy. If your PESI score
indicates high or extreme severity, it will be difficult to resolve PE on
your own, and it is very likely you would benefit from the coaching
and support of a trained marital and sex therapist.
Summarizing What You Know

about Your PE
At each step in the Diagnosing Your Type of PE exercise, you
recorded your impression about what types of PE you may have on
the PE Diagnostic Summary Sheet.
Now that you have completed the summary, review with your
partner your findings on the causes or effects of your PE. What have
you learned? What will you need to do to address PE together? What
does your PESI score tell you about how difficult it will be to resolve
your PE?
Exercise: PE Diagnostic
Summary Sheet
As you work through the diagnostic exercise in this chapter, mark
the types of PE you think you may have. Where applicable, list the
specific cause you suspect.
Neurologic system PE
Psychological system PE
(what condition? )
Psychosexual skills deficit PE
Physical illness PE
(what disease? )
Physical injury PE
(what injury? )
Drug side-effect PE
(what medication or drug? )
Psychological distress PE
(what distress? )
Relationship distress PE
(what distress? )
PE with another sexual dysfunction (mixed PE)
(what other dysfunction? )
Your summary sheet offers you a comprehensive view of what

areas youll need to address in your action plan to resolve PE. If you
think you may have a physiological or mixed type of PE, a medical
checkup may help you confirm this. If you think you may have a
psychological or mixed type of PE, a psychological consultation may
help you confirm this.
In the following chapters, we will explain the different treat-
ments and guide you to success. Treatments for physically based PE
(neurologic system, physical illness, physical injury, or drug side-
effect PE) are described in chapter 6. Treatments for psychologically
based PE (psychological system, psychological distress, or rela-
tionship distress PE) are described in chapter 7. Treatments for
psychosexual skills deficit PEand for repairing individual and rela-

tionship damage from PE caused by other factorsis described in
chapter 8. Mixed PE can be complicated and may require both physi-
cal and psychological treatments. If you are sure that your other
sexual dysfunction (e.g., ED) is compensation for or overreaction to
your PE, completing the exercises in the chapters that address the
possible causes of your PE can be beneficial. Otherwise, consultation
with your medical doctor and a professional marital and sex thera-
pist is sensible.
Now that youve identified all the elements contributing to
your PE, you can confidently engage in addressing these elements
and succeed!
5
Planning Your Treatment

and Preparing for Action
Michael and Rebecca realized they would need to stay disciplined

and focused if they were to master ejaculatory control. Michael had a
number of factors causing and influencing his PE, and Rebeccas
history of childhood sexual abuse and disappointing relationships
made her sexual desire fragile. Fortunately, both were motivated to
make sexuality a positive component of their marital bond.
Michael and Rebecca were successful in learning ejaculatory
control because they understood the importance of integrating the
cognitive, behavioral, emotional, and interpersonal dimensions of
sexuality. It was crucial for Michael and Rebecca to adopt positive
sexual attitudes. Michael was strongly influenced by traditional male
socialization, believing that if he failed at intercourse, he was a
failure as a man. Michael actually had high sexual desire but felt so
humiliated by PE that he avoided sex with Rebecca. Instead, Michael
compulsively masturbated, which caused him to feel guilty and
Rebecca to feel rejected. Gradually, Michael and Rebecca learned to
acknowledge the positive functions of sexuality. Especially impor-
tant for Rebecca was to accept that the essence of sexuality is giving
and receiving pleasure-oriented touching. This was totally different
than her childhood experiences with abusive sexuality.
Michael focused on learning the sensual self-entrancement and
arousal pacing techniques during partner sex (well teach these in
chapter 8). Together, they adopted an antiavoidance approach.
Michael realized that to learn ejaculatory control, he needed to act,
not agonize or apologize.
Michael and Rebecca developed a warm sexuality which was

mutual, pleasurable, and intimate. Michael viewed Rebecca as his
intimate sexual friend and ally in learning ejaculatory control. With
time, they achieved the fundamental aim of ejaculatory control:
increasing their individual sexual pleasure, increasing each others
pleasure, and enhancing their relationship by prolonging and enjoy-
ing sexual arousal. They focused not on perfect sexual performance
but on sharing sexual pleasure.
In this chapter, well help you follow a similar path to success.
You will work with your partner to develop a treatment plan for
your PE. You will learn how to prepare yourself and your relation-
shipcognitively, behaviorally, and emotionallyfor healing from
PE. To help you think differently about PE, well discuss the multiple
purposes of sex, the three basic types of sexual arousal, and their
relevance to learning ejaculatory control.
Developing Your Treatment Plan

Based on the causes and severity of your PE, which you determined
in chapter 4, you now can decide on strategies to change it. Chapters
6, 7, and 8 will help you through the steps to take in each of the
major areas: physiological, psychological, and relational. This section
will help you decide where to focus your efforts.
Strategies for Physically Caused PE

If you indicated the possibility of physically caused PE (neuro-
logic system PE, physical illness PE, physical injury PE, or drug
side-effect PE), focus on the strategies in chapter 6. If you think you
may have a physiological or mixed type of PE, a medical checkup
may help you confirm your type.
Strategies for Psychological and Relational PE

If you indicated the possibility of psychological system PE,
psychological distress PE, or relationship distress PE, carefully read
chapter 7. If you think you may have a psychological or mixed type
of PE, a psychological evaluation may help confirm your type and
develop a treatment strategy. There are some additional self-help
steps you may want to consider.
! Consult a well-respected book about the type of distress you
suspect.
Planning Your Treatment and Preparing for Action 63
! Seek feedback from your partner or someone else you trust.
! If you suspect psychological system PE, consider what you

know about your family history (for example, Grandpa was
always depressed).
! Search for psychology information and self-tests at trust-

worthy Internet sites (see the Resources section).
Strategies for Psychosexual Skills Deficit PE

If you indicated the possibility of psychosexual skills deficit PE,
focus on chapter 8.
Strategies for Coping with the Detrimental Effects of PE

Regardless of the cause of your PE, the strategies in chapters 7,
8, 9, and 10 can help you heal the detrimental effects of PE on your
well-being and the well-being of your relationship.
Preparing Yourself for

the Work Ahead
Unless you have a simple, biologically caused type of PE that can be
solved with direct medical treatment, you will need to learn new
skills. The skills have cognitive, behavioral, emotional, and relational
components. They are designed to help you affirm yourself, relax
your body, focus on your physical sensations, increase your
pleasure, and deepen your relationship closeness as well as control
ejaculation. Your efforts, step-by-step, will pay off with wonderful
feelings of satisfaction with yourself, your partner, and your love-
making. Yes, these skills are an effort; there is no easy fix. But it will
be worth it.
Here are the key points to remember:
! You have to pursue all of the dimensions of your PE.
! Remember that you are a complete person with thoughts,

feelings, and behaviors.
! Satisfying sex is a skill like any other physical or emotional

activity you have come to enjoy.
! As you approach learning the skills to manage PE, keep your

relationship perspective. Dont lose sight of the big
picture.
! Understand clearly your objectives: keep in mind what you
are trying to learn at each step.
! Patiently practice the specific skills for success and cooperate
with your partner.
! Closeness and satisfaction is the ultimate goal.
Is Sex a Skill ?
One of the common myths about sex is that it is supposed to be
natural or automatic, like eating and sleeping. Reproductive sex
does appear to be biologically natural. But the other functions of
sexheightened pleasure, personal self-esteem, and relationship
intimacyare achieved by learning psychosexual skills.
Think of any skill that brings satisfaction, especially a physical
activity: dancing, skiing, swimming, climbing, hang gliding, para-
chuting, even running. Marathon runners dont just go out and do it.
It takes discipline, concentration, psychological preparation, physical
conditioning, and learning pacing strategies. So if you want to become
a marathoner during sex, youll need some mental and physical
preparationsome training. Yes, biological sex is basically natu-
ralpenis goes into vaginabut to really enjoy emotionally intimate
sex takes attention, knowledge, and practice. Yes, it is annoying to
have to give such careful attention to something you wish would just
flow. But if you have PE, managing arousal takes training. That is
a fact.
A skill, whether cognitive, emotional, behavioral, or interper-
sonal, is the learned ability to perform the task well and with some
ease. Skills are developed through practice (repetition), persistence
(discipline), and patience. Can you remember learning new skills as
a child? Learning to ride a bike, for example, required a certain
degree of persistence and self-regulation of the fear of falling down.
You had to try time after time until it became natural. You proba-
bly tipped over, skinned a knee now and then, but didnt give up.
Managing PE means using practice, persistence, and patience to
learn cognitive, emotional, behavioral, and relational skills.
Cognitive Preparation
The most important sex organ in your body is between your ears:
your mind. During the skills training, you will want to be a kind but
strong gatekeeper, noticing what you are thinking and where your
attention is focused. Negative, pessimistic, self-defeating, or distract-
ing thoughts will not help. By focusing on the opportunity of each
step and exercise, you will do well. It is essential that you learn to
focus your attention and discipline your mind.
If you think that the training in this book will be too difficult,
reassure yourself that these skills are very manageable because you
do them in increments, not all at once. Accept that you might not feel
optimistic now; after all, you have tried so hard for so long without
real success. It is understandable that you fear that our comprehen-
sive approach might not work. Thats fine. The details may look
foreboding, but optimism is the caboose on the train. Wait for it. But
in the meantime, prepare yourself mentally to relax and engage in
the process.
Have a Positive Attitude toward Sex and a Deep

Commitment to Mutual Sexual Health
The first step is to consciously affirm the positive value of
healthy, physical, bodily sexuality. Sex is good. Pleasure is good.
You do not have to numb pleasure to learn ejaculatory control.
Take Personal Responsibility for Pursuing Sexual Growth

Take personal responsibility for your sexual responsiveness. Be
sexually responsible for yourselfbe accountable. There are individ-
ual skills that the man is responsible for learning, skills his partner is
responsible for learning, and skills the couple learns cooperatively.
Some of the more effective skills are neither commonsense nor
attainable without diligent effort. Being responsible means intention-
ally engaging in the change steps.
Prepare Yourself to Relax

The treatment steps will help you work through stresses that
undermine the physiological relaxation essential to healthy sexuality.
Realistic expectations based on accurate knowledge of sexual func-
tioning are reassuring; they are the cognitive precursors of physio-
logical relaxation.
Understanding the multiple purposes of sex can help you main-

tain realistic expectations and contribute to your and your partners
motivation to be flexible, patient, and cooperative.
The Four Purposes of Sex

Why do you have sex? If you are not sure why you are having
sex, you are more likely to have a problem. Automatic sex may
procreate, but it commonly falls short in the intimacy department.
Sexual science suggests that there are four purposes or
functions for sex.
Reproduction. Procreation is the natural or biological function of

sex.
Physical pleasure. Sensual enjoyment and physical pleasure is a

basic function of sex, especially in long-term, satisfying sexual
relationships.
Self-esteem. Individuals seek enhancement of their psychological self-

esteem through sex and pursue feelings of self-worth, confidence,
and pride in being a sexual person.
Relationship benefits. The interpersonal function of sex is to foster

love, intimacy, affection, joy, closeness, and couple satisfaction.
In healthy relationships, sex has multiple positive purposes. In
dysfunctional relationships, the purposes are distorted or negative:
manipulation, destructive control, or hurt. Yet even in healthy rela-
tionships, a single reason for sex can eclipse all the othersfor
instance, during infertility protocols when sex must occur at a partic-
ular time and under particular circumstancesand the pressures of
one-dimensional sex undermine other benefits like pleasure and inti-
macy and can cause PE, erectile dysfunction, or inhibited sexual
desire.
PE and the Purposes of Sex

PE interferes with the positive functions of sex, bringing dis-
tress to both the man and his partner. PE becomes intensely stressful
for the man as he becomes preoccupied with pleasing his partner,
trying to delay ejaculation in order to prevent the frustration and
hurt of a disrupted sexual experience. While he may be able to
impregnate, he finds very limited sensual or physical pleasure in sex,
suffers a loss of self-esteem, and feels tremendous shame and frus-
tration about being the source of hurt and damage in their intimate
relationship. His partner experiences frustration with each of the
purposes of sex as well: a diminution of physical pleasure, loss of
self-esteem, and confusing feelings of relational hurt and abandon-

ment. As long as the man is focused solely on performance and thus
experiences the outcome of sex to be negative, he will suffer perfor-
mance anxiety that exacerbates and reinforces PE. If you are to
resolve PE, you must think about sex in terms of pleasure,
self-esteem, and intimacy as well as good-enough ejaculatory
control.
The Styles of Sexual Arousal

Learning that your partner may have different reasons for
having sex and different ways of getting aroused helps couples
appreciate and accept their differences. It also helps you feel respect
and acceptance from the other as you mutually pursue satisfying sex.
This is an important aspect of how you think about sex.
In our experience, men with PE invariably and exclusively use
arousal strategies where the focus of erotic attention is on the part-
ner. To try to slow ejaculation, they use spectatoring (detached
self-observation) or other distraction techniques. This diverts your
focus from your own body and your own sensual experience, and
subsequently diminishes your ability to manage your sexual arousal.
In addition, men with PE initiate and pursue sex with highly arous-
ing activity (we call this sexual drag racing), rather than beginning
calmly and then gradually increasing stimulation. You may fail to
connect with your sensuality or even try to dissociate from physical
sensations during sexual activity. You may find it difficult to enjoy
the physical sensations in your whole body during arousal.
Lets take a look at the range of sexual arousal styles. We have
adapted Moshers (1980) suggestions and distinguished three basic
styles of arousal.
Sensual self-entrancement occurs through focusing on your own

physical sensations and sensual pleasure. Your attention is focused
primarily on your own body.
Partner interaction occurs through focusing on your partner: her

body, her responses, and the sexy or romantic interaction with
her. Your attention is outside your body.
Role enactment occurs through your private imagination or fantasy,

role-playing with your partner, or acting out feelings or fantasies.
Your attention is outside your body and more broadly focused than
in partner interaction arousal.
These styles are differentiated by where you focus your atten-

tion. Each style leads to a particular kind of behavior. For example,
the person who pursues arousal by partner interaction is active, eyes

open, focused on the interaction, looking at the partner, talkative
(engaging in romantic or sweet talk), and energetic. This is the
sexual style commonly portrayed on television and in moviespas-
sionate and impulsive. The person is turned on by focusing attention
outside himself, enjoying the partner, and getting carried away in
passion and eroticism.
On the other hand, the individual pursuing arousal primarily
by sensual self-entrancement immerses in his sensory experience and
closes his eyes, goes within, becomes quiet, and may look detached
and passive. Routine, sameness, and stylized touch help him to get
turned on.
The person aroused by role enactment enjoys sexual variety
and experimentation such as the partner dressing in sexy lingerie,
role-playing being tough or hard to get, acting out a scene from
a movie or fantasy, having sex in new places like at a hotel or
outdoors, or using toys like massage oil or a vibrator or dildo. By
trying new things, the person finds excitement and arousal through
sexual playfulness, freedom, and uniqueness. As with partner inter-
action arousal, the focus is on scenarios outside your body.
While individuals usually have a preference for one style, every
person has the capacity for arousal by each style and may use them
interchangeably. For example, you may begin lovemaking with play-
ful teasing (role enactment), change to enjoying touching your part-
ner and seeing her naked body (partner interaction), and then switch
to focusing on the sensations you feel in your own body while being
touched (entrancement). Your use of the three styles can vary over
time. Individuals and couples may go through developmental stages.
For example, early in a couples sexual life, partner interaction
arousal is common, giving way to sensual self-entrancement arousal
and a more sedate sexuality, then enlivened with role enactment or a
resurgence of partner interaction arousal. This process can explain
why couples who have mild cases of PE early in their relationship
grow out of it with relaxation and routine induced by familiarity.
Some couples pursue a different type of arousal from one sexual
meeting to the next: Tuesday, self-entrancement because I was
tired; Saturday, partner interaction arousal because I was really
turned on by my partner.
Understanding the Styles for Acceptance and Flexibility

Sexual partners who do not realize that there are different kinds
of arousal may misinterpret their partners behavior as hurtful and
take it personally. For example, the primarily self-entrancement-
focused woman having sex with a man aroused by partner interaction
finds his lovemaking efforts (the looking, talking, heavy breathing,

interacting, being expressive and passionate) distracting and wonders
why he is disturbing her focus and working against her arousal. This
man, on the other hand, might interpret his lovers self-entrancement
stylequiet and inward-focusedas disinterested, aloof, bored, or
even rejecting. The potential for misunderstanding and hurt is
evident.
You need to understand your partners sexual arousal style to
interpret each others behavior correctly. This illustrates the impor-
tance of sharing your sexual feelings, cooperating, and collaborating
in pleasure. This mutual understanding is crucial to your success in
the work ahead.
Be a Skeptic at First
What if you doubt that you can overcome PE? Its okay to have
a hesitant or doubtful attitude. This is not to encourage you to be
pessimistic, but rather to remind you that you cant force the change
you seek. You probably have already tried this, and it has failed you.
You dont have to believe in the skills to benefit from them. So its
fine to be a doubting Thomas or an honorary Missourian, adopting
the state motto: Show me. You do not have to make the skills work;
let the skills show you the way. All you have to do is relax and
focus. Just show up, so to speak, and do each step well enough.
Here are the key points to remember as you prepare yourself
mentally:
! Learn a positive attitude toward your body, sex, and love-
making, with a conscious commitment to mutual sexual
satisfaction.
! Take responsibility for your improvement.
! Operate from accurate knowledge and realistic expectations

of lovemaking.
! Realize that there are multiple purposes for sex. Dont be

trapped in a rigid performance focus.
! Be aware of the styles of arousal.
! Be a skeptic! Free yourself by adopting a show-me attitude

toward the steps.
! Remember that what and how you think directly influences

how you feel and what you do.
Emotional Preparation
You probably feel burdened by your PE, but you can begin to
let that feeling subside. You are a complete person, and by restruc-
turing the way you think about yourself as a sexual person and
learning to change how you function, you will come to feel better
about yourself and your partner. The way you think and what you
do influences how you feel.
Accept Your Honest Feelings about PE

Prepare yourself for the steps ahead by accepting that you may
have felt any of a long list of detrimental feelings: discouragement,
hurt, frustration, humiliation, anger, confusion, apprehension,
embarrassment, shame, guilt, depression, anxiety, worry, sadness,
bitterness. These feelings are reminding you that you are not satis-
fied with the way things are. It is time to change. Help prepare your-
self for change by accepting these negative feelings. Acceptance of
your honest emotional experience is an essential preparation for
growth. Having feelings does not mean you must act on them or feel
controlled by them. Our change program will help create a comfort
zone or safe harbor where the emotional hurts are manageable.
During the learning experiences in the steps ahead, be sure to
focus on your physical sensations. The sensual self-entrancement
arousal training, in particular, will help you accept and calm your
feelings. By focusing on your sensations, you will help yourself to
stop worrying about PE and feeling bad about sex. Calm, conscien-
tious focus on your own sensations will become your ally.
Distinguish Your Feelings from Your Behaviors

Make the distinction between being aware of your emotions
(feeling) and expressing your emotions (behavior). Recognize the
importance of owning your emotions, but realize there are risks and
harm in expressing unbridled negative feelings. Certainly do not
express destructive feelings as you work on the exercises together.
Internally soothe your negative feelings and remember that you can
choose to develop positive feelings through new behaviors.
Expressing negative feelings will only trap you in the past, and this
will be very discouraging for you both. If it seems impossible to
manage your feelings, this is an indication that you and your partner
could benefit from marital or sex therapy.
Here are the key points to remember as you prepare yourself
emotionally:
! Your feelings are important. Your sexual feelings are a big
part of the glue that holds your relationship together.
Feelings flow from how you are thinking and what you are
doing.
! Dont let old negative feelings run your life. Accept those
feelings, but dont let them interfere with new learning and
behaviors.
! Focus on your physical sensations to stop your mind from
worrying about PE.
! Do not express unbridled anger, frustration, or resentment
during your sexual work together. Acknowledge and inter-
nally calm these emotions and give yourself a chance to
grow.
Behavioral Preparation
Prepare yourself for the behavioral tasks by reminding yourself
of the need for self-discipline: regulation of your thoughts, feelings,
behaviors, and interactions. Yes, it is a bummer that you have to
work at this, but good things are built by effort. It is a good idea to
schedule your practice of the steps. Set aside the time and make each
step a priority. It will be hard at times, but it is necessary. Suck it up!
Be sure to consider the environment in which youll be doing
your skills learning. Many use the privacy of the bedroom, although
any secure, private, comfortable place is fine. Make sure it is free
from interruptions, since the goal is to create a safe place for
relaxation and undivided attention and focus.
Cultivate Self-Discipline
Doing the steps requires disciplined concentration on the plea-
sure in your body, a steady and dedicated commitment and determi-
nation to do the exercises day in, day out, over a number of weeks to
develop your skills.
Dedicate Yourself to Physical Relaxation

Learning detailed, physiologically focused relaxation tech-
niques is essential to ejaculatory control. It is counterintuitive, but
the body performs better when relaxed. Most men (and women) just
cannot believe that relaxation is essential for good sexual function-
ing. It is not common sense. You can take our word for it, or you can
think about this: Medications like Viagra help many men who have
erectile dysfunction, including men who also have PE. How does
Viagra work? Technically, this pill facilitates a chemical process
unique to enzymes in the penis that ultimately relaxes the muscles
surrounding the microscopic arteries, which in turn dilates the arter-

ies causing blood to engorge the penis, and voil: an erection! The
point is that even artificially induced relaxation brings about an
erection.
The mechanism for ejaculation is not a direct one, but rather a
psychological one. Men who ejaculate quickly because they worry
about maintaining a sufficient erection, when reassured by Viagra,
are thought to relax more, to not watch themselves so anxiously, and
because of the general relaxation, also last longer. Think about it,
men: Physiological relaxation helps sexual functioning.
Do the Steps in Order

The skills development exercises in chapters 7 and 8 should be
followed in order. Working ahead or skipping steps would be like
jumping into a swimming pool before you know how to swim! We
know you want to get to the good stuff. But patience is your friend.
Moving too quickly will undermine your ability to relax, which is
essential to progress. Take one step at a time, one exercise at a time,
one stage at a time. Remember the Chinese proverb, A journey of
one thousand miles begins with a single step.
Just Be Good Enough

It is essential that you understand what you are trying to do
and that you train yourself sufficiently to bring about changes in the
way you make love. The painful reality is that the way you have
been approaching sex has not worked. This means you must work
hard enough to bring about change, but you only need to learn and
do the skills well enough. Do not pressure yourself to be perfect. In
fact, it is important that you do not work too hard, because to
succeed, you must relax your mind and body. Striving for perfection
produces performance pressure and undermines your relaxation. So
we encourage you to practice the principle of just being good
enough.
Learn Sensual Self-Entrancement Arousal

Learning to trust sexual arousal by focusing on sensations in
your own body is essential to ejaculatory control. Men usually dont
believe this is possible, let alone normal. You will find erections
effortless and ejaculatory control easier when you learn to base your
arousal in sensual self-entrancement. During the skills work in
chapter 8, you will recognize that self-entrancement arousal is built
into the steps and encourages you to relax physically while sexually
aroused. You will truly find this arousal remarkable when you begin
to integrate it with the other steps to ejaculatory control and building

intimacy.
Here are some key points to remember about behavior:
! Realize you must discipline yourselfregulate your
thoughts, feelings, and actions. Yes, it is difficult.
! Learn to physically relax during arousal. It is an essential
skill.
! Do the steps in the proper sequence.
! Do not push to be perfect. Just be good enough!
! Learn sensual self-entrancement sexual arousal.
Interpersonal Preparation
You want to fix your penis and your ejaculation speed, yet
remember that the most important goal and predictor of success
and the greatest rewardis your relationship intimacy. If you are
working within a self-defeating environment, you will not succeed.
On the other hand, if you have addressed the relationship hurt and
divisiveness that have resulted from the PE and found relationship
forgiveness and healing, your intimate relationship will help you to
succeed at PE management. Your relationship is the system or
environment for your sexual growth. Be careful not to overlook the
essential importance of mutual support and acceptance. Keep your
perspective. Remember that your PE is but one aspect of your overall
relationship.
Sexual Cooperation Is Essential

While you can learn the skills for slowing ejaculation on your
own, it works best to do so with your lover so your intimate relation-
ship is working cooperatively. Cooperation provides a safe environ-
ment for learning the skills and gives both partners the opportunity
to heal from the old anguish. The process itself invites cooperation
and closeness.
Putting the other person first builds resentments when it is not
reciprocated. When both put the others feelings and happiness first,
the emotional benefits can be wonderful. We call this the give to
get pleasuring principle.
Prioritize Mutual Emotional Empathy

Emotional empathy (acceptance, affirmation, comfort, support,
understanding) is the glue of intimacy. It is fundamentally important
in healthy, satisfying relationships. Above all else, most individuals

look to their marriage for empathy and emotional comfort.
Forgive Yourself and Your Partner

Forgive yourself and your partner for the hurt and disappoint-
mentno matter how small or how monumentalthat youve expe-
rienced around sexuality. This requires a commitment. If you do not
forgive, your emotions will block your ability to focus on your
bodys sensations, to relax your body, and to learn the skills. What is
the shortcut to forgiveness? Be aware that the hurt was in the past.
The future can feel different. And with your partner? Say you are
sorry and ask for forgiveness and acceptance now.
Here are the key points to remember as you prepare your
relationship for the changes ahead:
! Relationship intimacy is your ultimate goal and your
ultimate reward.
! Relationship cooperation is essential.
! Verbally forgive yourself and your partner for the past
sexual hurt, pain, conflict, disappointment, and alienation.
Do not hold yourself and each other emotionally hostage for
the past.
! Talk with your partner about your sexual feelings. This will
help generate mutual understanding, empathy, and accep-
tance. This will also help you develop personal comfort with
sex and learn more about your partner.
! Keep your perspective. Satisfying sex is rooted in a healthy
relationship.
You may be feeling overwhelmed by the task ahead. Remember
that change is a process, and be willing to learn as you go. By
preparing yourself cognitively, emotionally, behaviorally, and
interpersonally, you give yourself the best possible chance to succeed
in managing PE. Be calm. Be patient. Be open. Dont worry about
being perfect. Just be good enough!
6
Medical, Pharmacologic,
and Physiological
Treatments
PE that originates from a biological cause needs treatment that

addresses the physiological problem. In this chapter we will discuss
the medical treatments and options for the four kinds of PE with
physical or biological causes. If these problems are a primary factor
in your PE, you need to carefully consider medical and physiological
interventions, or you will face disappointment and frustration in
your attempt to develop ejaculatory control. Remember, you want to
address all the factors involved in your type of PE and to use all
your resourcesincluding medical treatment, medication, and phys-
iological aidsto learn ejaculatory control.
Addressing the Medical Side of PE

In this chapter you will learn how to determine if you need a medi-
cal evaluation and how to work comfortably with your physician.
Then we will describe the treatments for the biological types of PE:
neurologic system PE, physical illness PE, physical injury PE, and
drug side-effect PE. There are a number of medications that have the
effect of slowing PE, as well as several other medical options for
managing PE. It is important to consider how to integrate these
medical interventions into your couple sexual relationship.
How to Determine Whether You Need

a Medical Evaluation
If you noted the possibility of a physical type of PE on your PE
Diagnostic Summary Sheet in chapter 4, it is important that you
discuss the problem with your physician. Your doctor can not only
determine whether your PE could have a physical cause but also
offer a medical or pharmacological treatment. For example, if you
confirm that you have lifelong neurologic system PE, your doctor
can help you consider in detail the use of medications. Or, if your PE
is acquired, your doctor can examine your prostate to see whether an
infection has caused PE. Your physician could also be your best
professional case manager, referring you to other trustworthy physi-
cians who specialize in sexual medicine, as well as psychologists,
marital therapists, or sex therapists.
How to Work Comfortably with Your Physician

Talking about your sexual concerns is likely something you are
not very comfortable doing. People talk about sex in general, but few
discuss their own sexuality, especially sexual difficulties. It is hard
for many to believe that nearly 50 percent of adults have sex
problems, sexual dysfunction, or sexual dissatisfaction (Laumann,
Paik, and Rosen 1999). Physicians and other health professionals in
general medical practice rarely recognize existing sexual problems or
dysfunctions in their patients.
Do not fault your doctor, because he or she lives in the same
society with the same discomforts. Most physicians assume that if
sexual concerns are important to you as the patient, you will initiate
discussion about it, while at the same time you may assume that
since your doctor has the professional training and the ability to help
with sexual problems, he or she will lead the inquiry and discussion.
Unfortunately, these attitudes serve to continue a silent avoidance of
sexual concerns, leaving you to worry privately without receiving
help.
We suggest that you take the lead, because your physician may
not. By raising the subject, you gain a sense of control over the
process. Your leadership can provide focus.
How to Talk with Your Doctor

Use your own impressions to determine whether your doctor is
likely to be comfortable talking about sexual concerns. Dont be
Medical, Pharmacologic, and Physiological Treatments 77
distressed if he or she seems uncomfortable at first, because most

physicians have received very little specific training in sexual medi-
cine. Most doctors very much want to be helpful and will be willing
to sort out the medical aspects with you.
Here are some suggestions for starting the discussion:
I want to talk to you about a sexual concern I have, but I am

embarrassed.
Im having a sex problem that Id like your help with.
I would like to ask you about a sex problem that Im having. Do you
think you can help me?
Can you refer me to a sexual medicine specialist?
My impression is that you dont specialize in sexual concerns, but

can you refer me to a doctor who does?
Depending on your suspicions about what is causing your PE,

you might ask your doctor a specific question:
For the past six months, Ive noticed that I ejaculate quickly, and I
wonder if I might have a physical illness that is causing this.
I wonder if I have a prostate infection. Should I have an exam, or

should we do some testing?
Im reading a book about premature ejaculation, and it suggests that

since its been a problem for over a year, I should talk to you to make
sure I dont have a prostate infection or some other illness that could
cause PE.
You can even take this book along to show your doctor the
section in chapter 4 where we list some of the illnesses that can cause
PE.
Your doctor does not have to be comfortable talking with
patients about sex to be a really good doctor; it just helps a lot. Your
doctor may be waiting for you to ask. Give him or her a chance to
help you.
Thank your doctor for being willing to talk with you about
your sexual concerns or offering you a referral. Then, as you leave
the office, congratulate yourself for taking the lead and being your
own sexual health advocate.
Whats Involved in a Medical Evaluation

Your general physician (whether an internist or family practi-
tioner), who knows you and your medical history best, is the likely
first choice to discuss your concerns about PE. You may be referred
to an urologist or sexual medicine specialist for further evaluation.
Medical evaluation for PE typically consists of three steps.
History
Your doctor will talk with you about your experience of PE.
This discussion may include general background, some basic
information about when and how fast you ejaculate, your personal
medical history, a brief sexual history, other symptoms or aspects of
your medical situation, your ideas of the cause, and how distressed
you are. Your doctor is trying to gain a more comprehensive
understanding of your situation as well as rule out some medical
possibilities that could cause your sexual problem.
Physical Examination
Your doctor will examine your body, focusing on your genital
area, and will check your prostate gland for signs of infection.
Testing
Some blood and urine tests may also be done to make sure
there is no systemic problem. If your doctor suspects a prostate
infection, he or she may want to take a sample of the fluid in the
prostate to determine the kind of infection.
Treatments for Neurologic System PE

By far the most common physiological type of PE is caused by an
overly efficient neurological system. In other words, your ejaculatory
reflex is hardwired to go off quickly.
If you think you have neurologic system PE, there are a number
of options for you to consider. Because neurologic system PE is hard-
wired in your body and that hardwiring cannot be overhauled, we
recommend that you try the psychosexual skills program in chapter
8 first to try to compensate for your overly efficient neurologic
system. If your case is particularly severe (you have a PESI score
above 80 or you often ejaculate before you can enter your partners
vagina), then the most promising medical treatment is medication
that acts on the nervous system to slow ejaculation.
There are international reports (Tullii, Guillaux, et al. 1994;
Schapiro 1943) that surgery (severing nerves in the penis to deaden
sensation or destroying tissue in the prostate) can slow rapid ejacula-

tion. The fact that some men resort to permanent injury to their
bodies to try to resolve PE demonstrates how profoundly distressing
PE can feel. We consider these treatments inappropriate and unethi-
cal because they are not only intrusive, radical, and unnecessary, but
also irreversible. In addition, we have found that particularly
detailed training in the psychosexual skills well teach in chapter 8,
combined with medication, is helpful for the great majority of men.
We also want to remind you to understand PE in the larger perspec-
tive of intimacy and relationship cooperation. If you have neurologic
system PE that is not severe, accepting the biological reality and
cooperatively adapting to it may be the most positive resolution.
Pharmacologic Interventions
A variety of antidepressants or antianxiety medications may
neurologically slow down ejaculation, allowing some men to last two
to ten times as long. The benefit may not be profoundfor the man
who ejaculates in ten to fifteen seconds, lasting ten times as long may
mean only two minutes of intercoursebut for the man with chronic
and severe PE, this may be quite satisfying. We recommend that you
consider medication if your PE is exceptionally severe, if it doesnt
respond to the psychosexual skills approach, or in conjunction with
sex therapy. Some medications are taken daily, while others are
taken several hours before sex.
Using medication is not a sign of weakness but a choice, and
many men find it an important resource in gaining ejaculatory
control. However, for some men, medication use implies the need to
depend on an external resource rather than their own ability and
does not support sexual self-esteem. Pharmacologic treatment alone
is often insufficient because of the lack of effect in some men, the
reluctance of some men to consistently use prescription medications,
or complicating psychological and relationship factors. There are
also concerns about the unknown effects of long-term use of medica-
tions for PE management.
Medication must be prescribed and monitored by a physician.
Weighing the costs and the benefits of using medications is part of
your decision making as a couple. For some men, obtaining the
desired effect of inhibiting ejaculation can be a matter of trial and
error of different medications and dosages. New medical treatments
for PE are being developed. Ask your doctor what is currently
available. We strongly advise against self-medication with alcohol,
recreational drugs, or some over-the-counter remedies, as they have
their own obvious risks.
Antidepressants
The selective serotonin reuptake inhibitor (SSRI) antidepressants
Prozac (fluoxetine), Zoloft (sertraline), Paxil (paroxetine), Luvox (flu-
voxamine), and Effexor (venlafaxine) are increasingly used to aid
men who suffer PE, capitalizing on a common side-effect of inhibit-
ing ejaculation. Studies and clinical experience confirm that these
medications delay ejaculation in 20 to 60 percent of cases. These
drugs increase the level of serotonin, and higher serotonin levels are
thought to inhibit ejaculation. These medications are taken daily.
An older class of antidepressants known as tricyclics, including
Anafranil (clomipramine) and Elavil (amitriptyline), also commonly
delay ejaculation. These medications increase levels of both serotonin
and norepinephrine. Anafranil has been frequently studied and is
noted to be very effective in inhibiting ejaculation when taken two to
four hours before the desired effect, especially for men who are
prone to be spectators in the bedroom and are highly anxious
about PE. The tricyclics, however, have more inconvenient side
effects than the SSRIs (for example, dry mouth).
Antianxiety Medications
Antianxiety medicines, if properly prescribed, may also be
useful. A number of medications that are effective in treating gener-
alized anxiety and panic attacks can help some men slow down
ejaculation. These medications include Librium (chlordiazepoxide),
Ativan (lorazepam), Valium (diazepam), and Xanax (alprazolam).
However, the inhibiting effect of these medications on ejaculation is
limited and not as dramatic as the effect of SSRIs, and they help less
than 10 percent of men with PE. These medications are taken one to
four hours before beginning sex.
Anesthetic Creams
Numbing creams have long been used to slow ejaculation by
deadening the sensations in the penis. If you use these creams, you
must then use a condom so that the cream does not numb your part-
ners vagina as well. There are, for convenience, condoms (Detane,
Mandelay, Performax) that you can buy over the counter with an
anesthetic (benzocaine) already packaged inside.
We understand some men feel desperate to slow ejaculation
and believe that they need to use anesthetics. We believe this is
unnecessary and an ill-advised quick fix that does not really solve
the issues of PE and cooperative lovemaking. To deaden the pleasure
in your penis is contrary to our approach, which is designed to
increase your pleasure, enhance intimacy with your partner, and
teach you to saturate your body with pleasure while you maintain
ejaculatory control.
Combination Treatments
Some physicians experiment with combination treatments that
include a number of medications designed to overwhelm the neuro-
logic system and reduce psychological anxiety. In severe cases of PE,
multiple treatments may be effective. For example, Viagra may be
used to ensure erection and overcome the fear of erectile dysfunc-
tion, while an anesthetic cream may be applied to numb the penis
and an antidepressant medication may be used to calm and inhibit
ejaculation.
Devices for Premature Ejaculation

In addition to pharmacologic treatments, devices are sometimes
used, although they have not been scientifically proven to be
effective.
Testicular Restraint Device

Some men have found that they can slow ejaculation by cuffing
the testicles in the hand and gently pulling or holding down. Although
not approved for use by the U.S. Food and Drug Administration,
Velcro-type devices that restrain testicular ascent are available through
mail order (often advertised in erotic magazines) and drugstores.
Penile Rubber Ring Device

British psychiatrists Wise and Watson (2002) have reported a
small pilot study that used a latex rubber ring on the base of the
penis daily for no more than thirty minutes, but not during sex.
Some of the men reported that they improved ejaculatory control
within a week of using the device. It may be that the device desensi-
tized or stressed the penile nerves or operated as a placebo (that is, it
worked simply because the men expected it to).
Biofeedback Training
Rome urologists La Pera and Nicastro (1996) devised an exten-
sive pelvic muscle training program similar to that used in treating
incontinence. This method includes three techniquespelvic muscle
exercises, electrostimulation, and biofeedbacktaught in twenty ses-
sions, three times per week. The training strengthens the pelvic mus-
cles and teaches men to recognize and control contraction of these
muscles. Approximately 60 percent of men with PE are helped by
this technique. La Pera and Nicastros work reinforces the impor-

tance of the pelvic muscles in ejaculatory control.
Treatments for Physical Illness PE

Your physician can treat medical disorders that directly cause PE.
Inflammatory disorders such as infection of the prostate or urethra
are treated with antibiotics that target the particular organism
causing the infection.
Evaluation for diabetes and over- or underactivity of the thy-
roid gland may be necessary if the history and physical examination
suggest a problem with these endocrine systems.
Treatments for Physical Injury PE

Medical treatments for the specific injuries that cause PE (such as
spinal cord injury, head injury, trauma to the sympathetic nervous
system, pelvic fractures and other torso traumas, or localized sensory
impairment) are currently very limited. When such injury results in
permanent physiological damage, treatment with medications that
slow ejaculation may offer help for some. Sex therapy can help you
learn to adapt to a permanent impairment. Chapters 8 and 9 offer
some guidance here.
Treatments for Drug Side-Effect PE

Because this type of PE is caused by either withdrawal from or use of
specific drugs, treatment is generally straightforward. When PE is
caused by drug withdrawal, normal sexual functioning will return
after the chemical leaves the body and the body rebalances. This may
require from two to six weeks, depending on the medication. When
PE results from a medication you are taking, you and your doctor
should discuss the possibility of stopping or switching to a different
medication if it is safe to do so. If normal function does not return,
you should suspect additional or other causes of your PE.
Treatments for PE with Another

Sexual Dysfunction (Mixed PE)
A medical examination can help identify physical causes for each
sexual dysfunctionerectile dysfunction or inhibited desirein
addition to the PE. Specialized tests such as duplex ultrasound,

cavernosometry or cavernosography, nocturnal penile tumescence
studies, or arteriography may be helpful in evaluating erectile dys-
function but do not provide much diagnostic insight in the evalua-
tion of PE itself. However, concerns about erectile dysfunction add to
PE, so these tests may be important if you are experiencing both PE
and erectile dysfunction.
If there are no identified physical causes, then review again the
possibilities of other causes, especially psychological or relationship
distress. Mixed PE commonly involves a deficit in psychosexual
skills, and skills learning may become your treatment of choice.
Cognitive behavioral sex therapy may also help remedy the detri-
mental effects of erectile dysfunctioninduced PE on you and your
relationship.
If you have PE with erectile dysfunction, oral medications and
other erectile dysfunction treatmentsvacuum constriction devices,
intracavernous or intraurethral pharmacotherapy, and penile pros-
thesescan be valuable resources. If your PE is a symptom of and
compensation for a fear of erectile dysfunction, treating the erectile
dysfunction can, in turn, resolve your PE.
Treatments for Erectile Dysfunction

Since erectile dysfunction is the most common factor in mixed
PE, lets take a look at the medical treatments currently available for
this problem.
Oral Medications
Medications such as Viagra and Cialis help initiate and main-
tain erection by relaxing the corpus cavernosum smooth muscle in
the penis. Such medications can be used for erectile dysfunction
whether its cause is physical, psychological, or medication related,
and they can relieve PE that results from overcompensation for fears
of erectile dysfunction. Among the most common unwanted effects
are headache, facial redness, indigestion, visual disturbances, and
nasal congestion. Each of these effects occurs in approximately 10 to
15 percent of men.
Medications Applied to the Penis

Erectile dysfunction is sometimes treated with medication
applied directly to the penis.
PGE1. The most commonly used is E1-prostaglandin (PGE1) or

alprostadil, which the man injects into the base of the penis a few
minutes before sexual activity. PGE1 may be used up to two to three

times a week. When erection is assured by injection therapy, men
with mixed PE may relax, thereby gaining control of ejaculation.
However, many men stop using injection therapy because they or
their partners find it awkward and clinical.
MUSE. Medicated Urethral System for Erection (MUSE) is a device

used to insert an alprostadil suppository into the urethral opening.
Reports of its effectiveness vary from 7 to 65 percent. The most com-
mon adverse effects are penile pain, urethral burning, dizziness, or
fainting. MUSE may be more user-friendly than injection therapy,
but it also has a very high dropout rate.
Vacuum Constriction Devices

Vacuum constriction devices draw blood into the penis, causing
an erection, and trap the blood there in order to maintain the erec-
tion for intercourse. These devices include a plastic tube that fits over
the penis in order to create an airtight cover. A vacuum is created
around the penis by motor or manual pumping. When erection
occurs by this means, a fitted rubber band is placed on the penis at
the base to retain the erection. An erection may be maintained by
this method for approximately thirty minutes. Again, there is a high
dropout rate due to lack of comfort on the part of either the man or
the woman.
Penile Prostheses
Nonsurgical prostheses include splints such as Rejoyn, a soft
rubber brace which holds the flaccid penis rigid. The brace exposes
the tip of the penis to allow for pleasure. Some women find the
device uncomfortable during intercourse. These are available with-
out prescription at many drugstores.
Rigid or flexible rods may be surgically implanted into the
penis to make it mechanically erect. There are inflatable models that
allow for artificial engorging and deflating of the penis by means of
a hydraulic system composed of tubes implanted in the penis and a
fluid reservoir or bulb implanted in one of the testicular sacks (the
testis is removed). The tubes are then inflated by squeezing the bulb
and deflated by a valve in the bulb. These surgeries do not allow for
an actual erection, but do permit the penis to be comfortably inserted
into the vagina. Because implants are irreversible and do not allow
any other treatments, an implant is the last option for treating
erectile dysfunction.
While these medical treatments are clearly helpful for many
men with PE combined with erectile dysfunction, they each have
significant limitations. These treatments succeed best when used

along with the PE skills program and when integrated into a flexible
style of couple sexuality that encompasses intimacy, pleasuring, and
eroticism.
Your Body and Person

Are Intertwined
When you suspect that medical problems are causing your PE, you
need to carefully evaluate medical and physical resources.
Approaching PE as a psychological or relationship problem without
addressing the medical cause will lead to confusion, frustration, dis-
appointment, and a sense of failure and hopelessness.
Your body and person are intrinsically intertwined. Appre-
ciating and respecting that your personality is fundamentally
grounded or housed in your body is important. With your body
healed, or the reality of its limitations understood, you are ready to
pursue the psychological and relationship skills to manage your PE
and enhance your intimacy.
7
Psychological and
Relational Strategies
and Skills
David developed PE during the second year of his marriage to

Kristin due to a mild prostate infection that was undetected and
untreated for four years. Although they eventually learned that
Davids PE was caused by a medical problem, David and Kristin
realized that the years of PE had cost them dearly. PE had played a
substantial role in undermining Davids self-esteem and confidence,
causing sexual stress that injured their overall relationship.
During the four years that they endured the PE, David and
Kristin became stressed and estranged by intense arguing and fight-
ingfirst about PE, and later about nonsexual issues. There were
days when they avoided each other not only sexually but personally.
The psychological distress he experienced with the recent death of
his father also weighed on David. The combination of grieving and
the relationship alienation caused by their arguing became a main-
taining cause of PE, even after antibiotics had cured the prostate
infection that initially caused the PE.
David and Kristins distress wasnt limited to the bedroomit
permeated their entire relationship. To recover, they learned how to
emotionally accept the hurt around their sexuality, how to heal the
mutual pain, and how to resolve relationship conflict. David and
Kristin learned crucial skills for relationship intimacy: understanding

and integrating relationship expectations, developing emotional
empathy, and implementing mutual conflict resolution.
This chapter is designed to help you approach the psychologi-
cal aspects of PE. This will be helpful to you if you have psycho-
logical system PE, psychological distress PE, relationship distress PE,
or other types of PE that have caused distress to you and your
relationship. You will learn an approach to address individual
psychological features that cause, maintain, or result from PE. Youll
also address distress in your relationship identity, relationship coop-
eration, or relationship intimacy that causes, maintains, or results
from PE. Well teach you skills to clarify your sexual relationship
identity, modify your interaction dynamics, and emotionally support
each other.
Well describe specific ways to become more aware of your
feelings and discuss the importance of investing emotionally in
your relationship to promote healing and enhance empathy. Well
teach you a specific communication skill, paraphrasing, to make
your emotional investment easier and safer, and well show you
ways to cooperate and resolve disagreements. These skills will help
you and your partner work as a team to learn ejaculatory control
and enjoy sex.
Approaches to Relieve
Individual Psychological
Distress
In this section, well look at ways to approach PE caused by long-
term or temporary individual psychological distress. With either
type, you should remain open to evaluation and treatment for chemi-
cal dependency if you have been medicating yourself with alcohol
or drugs. See the Resources section for more information.
Strategies to Resolve Psychological System PE

Psychological system PE is very difficult to address with self-
help approaches. However, you can gain insight with basic informa-
tion from a reliable book or a reputable Web site on the condition
you suspect. Consultation with a licensed clinical psychologist can
help you determine whether you have a chronic psychological prob-
lem that might cause your PE. Consultation usually includes one or
Psychological and Relational Strategies and Skills 89
more personal interviews, a historical review of your life, and some

psychological testing.
Treatment for PE caused by a psychological problem may
include individual or group psychotherapy, medication, and sex
therapy. Because your psychological system is complex and tends
to resist change, realize that it may take a considerable amount of
time and effort in therapy to address the feature you believe is
causing PE. When you feel ready, learn the psychosexual skills in
chapter 8.
Shanes Story: Obsessive-Compulsive Disorder

Shane had frequently wondered how different his life might be
without anxiety, hypersensitivity, perfectionism, and orderliness. He
had never thought that his PE was related to these traits, because he
had always ejaculated very fast. When life was particularly stressful,
Shane noticed that he would act more ritualistically, compulsively
checking whether the coffee pot was turned off or all doors were
locked, ruminating about what seemed to be small concerns, and
having trouble deciding to discard things. When it came to sex, he
constantly felt stressed and anxious, believing he should do sex
perfectly.
When Shane consulted with a psychologist, he described the
day-to-day features he suspected were obsessive-compulsive,
reviewed his personal history, and completed a psychological test.
The test results suggested that he did in fact have strong obsessive-
compulsive personality features as well as anxiety traits, which
supported the psychologists diagnosis: obsessive-compulsive
disorder (OCD).
Shanes treatment plan included learning about OCD by read-
ing two books, extended individual therapy to explore the nature of
his OCD and develop strategies to cope better, taking an SSRI medi-
cation (which not only alleviated his OCD but had the side-effect of
slowing ejaculation), brief couple therapy to enlist his wifes accep-
tance and support, and finally couple sex therapy to learn psych-
osexual skills for slowing ejaculation. While Shanes treatment
involved an extensive amount of time, he was able to make sig-
nificant progress in altering his personal quality of life, overcoming
PE, and enhancing relationship intimacy.
Strategies to Resolve Psychological Distress PE

If you indicated on your PE Diagnostic Summary Sheet in chap-
ter 4 that you have psychological distress PE, review what you noted
to be the stressors that cause your PE, as well as whether another
type of PE might be causing psychological distress that worsens the

sexual problem.
Most men prefer to address the specific psychological stressor
using self-help efforts since this type of problem is less severe and
chronic than psychological system PE. If self-help doesnt work for
you, use good judgment and seek appropriate professional therapy.
As a couple, you want to discuss how best to address the
sources of your psychological distress PE. For example, if you are
stressed about career issues thatfor the momentyou are not able
to resolve, you may decide together to accept this temporary distress
and compensate sexually by learning the skills in chapter 8. The
important thing is that you pay attention to the underlying psycho-
logical distress causing your PE and make sure that you work
together to prevent further problems.
Among your options, consider reading a reliable book or visit-
ing a reputable Web site on the type of stress you suspect. There are
a number of very good self-help books that can help you understand
your distress, and offer practical suggestions for adapting (see
Resources). If reading and reflecting on your circumstances is not
your style, or if your self-help approach is not effective, you will
benefit from talking with a psychologist. He or she can help you gain
perspective on your distress, offer objective psychological testing,
and help you consider further strategies for change. If marital issues
are causing your psychological distress (for example, an affair has
led to depression), this cause needs to be addressed. Medication may
be beneficial in addressing depression or anxiety rooted in current
stresses.
In some cases, resolution of the psychological problem will
restore normal sexual function, while in others the exercises in
chapter 8 or sex therapy may be needed to overcome secondary
problems, factors such as anticipatory anxiety, performance anxiety,
or loss of sexual confidence. These factors can maintain your PE even
when the psychological cause has been resolved.
When Your Partner Is Psychologically Distressed

PE may be your reaction to your partners psychological prob-
lem. In this case, your PE serves as a relationship symptom of her
psychological distress. Her psychological distress can cause PE when
you feel tension during lovemaking and your body reflexively
responds with urgency to get it over with. Depression, obsessive-
compulsive disorder, mood disorders, career distress, role conflicts,
sleep deprivation and fatigue, parenting stresses, family conflicts,
grieving the loss of a parent, loneliness, acute anxiety, and other
problemseven when mildcan subvert sexual enjoyment.
Treatment for her psychological distress is similar to what we

outlined above. Your empathy and emotional support for her is
important. Such distress is an opportunity to build deeper intimacy
by cooperatively addressing the difficulty.
Approaches to Alleviate
Relationship Distress
If you indicated on your PE Diagnostic Summary Sheet that you have
relationship distress PE, take a moment to recall the interpersonal
dynamics you believe might be causing or maintaining your PE. Even
if you have another type of PE, your relationship may have suffered.
Youll need to heal the hurt and restore relationship quality. This sec-
tion will offer you an approach to address the most common cogni-
tive, behavioral, and emotional features of relationship distress.
Your Partners Dissatisfaction

Similar to the way your partners psychological distress may be
transmitted to your body and affect your ejaculatory control, you can
emotionally sense your partners relationship dissatisfaction. Even
though you may feel satisfied with your relationship except for your
PE, your partner may feel lonely or disconnected from you and long
for more emotional intimacy. If your partner does feel dissatisfaction
with your interactions, this may be a factor in causing your PE as
well as a result of it. Ask her. You may want to avoid dealing with
her disappointment, but it is important to know because it is impor-
tant to address the problem.
Identifying Your Relationship Distresses

This exercise uses the identity-cooperation-intimacy model
described in chapter 3 to help you identify your relationship
distresses. Honestly answer the following questions, first individu-
ally, then as a couple.
Exercise: Identifying Your

Relationship Distresses
1. Identity Concerns
Are you struggling over expectations or disagreements regard-
ing gender roles, work and family commitments, day-to-day tasks,
the role of sex in your relationship, parenting, or balancing your

autonomy with cohesion as a couple? Do you feel an imbalance in
your desire to please your partner to the point that you neglect your
own wants?
2. Cooperation or Conflict Resolution Concerns
Do you feel your partner is demanding? Have you felt pressure
to ejaculate quickly in order to get it over with? How competitive
are you with each other? Are you ready to cooperate to do the skills
training? Have you offered forgiveness of each other (and yourself)
for the hurts? Can you be patient, warm, and kind with each other?
Are the outcomes to your disagreements emotionally satisfying for
each?
3. Emotional Intimacy Concerns
Have you been afraid of deeper intimacy or more solid close-
ness? Are there hidden hurts that linger due to unresolved relation-
ship conflicts? Have you corrected any empathy deficits? Are you
holding a grudge? Are you afraid you wont be able to change your
relationship feelings? How lonely do you feel in your relationship?
Recovering and Promoting Relationship Satisfaction

To alleviate relationship distress PE, you will need to work on
one or more of the following objectives:
! Identity: Clarify and integrate your relationship and sexual
beliefs, standards, perceptions, attributions, and expectan-
cies, and balance individual autonomy and couple bonding.
! Intimacy: Enhance your emotional empathy in order to heal
relationship injuries caused by conflict or by your PE.
! Cooperation: Modify interpersonal dynamics that may cause
or maintain your PE, such as communication deficits or a
conflict resolution impasse.
Clarifying Your Relationship Identity

Your beliefs, standards, and expectations of yourself and your
partner about how to be a couple make up your relationship iden-
tity, while your sexual relationship identity comprises your sexual
beliefs, standards, and expectations. Differences and misunderstand-
ings are to be expected; they are normal. Clarifying such
misunderstandings and integrating your new understandings into

your couple style is part of reducing relationship distress.
Consider your sexual relationship identity. What does sex mean
to you? A source of emotional vitality? Procreation? Pleasure? Duty?
Joy? What role should sex play in your relationship? Do you expect
to talk openly of your sexual wants, dislikes, joys, comfort, ideas?
Should your sex always be wild passion? Tender lovemaking? Do
you agree that there is more than one kind of sex? (Quickies?
Impulsive passion? Mechanical anxiety release? Romance?) Do you
and your partner expect to take turns being sexually selfish? Do you
expect sexual pleasure to decrease or increase over time? Are you
sexually playful? Respectful? Tender? Can sex bring consolation dur-
ing stressful periods? Although you have had problems, do you think
sex can improve? Do you share a standard of good-enough sex?
Balancing Autonomy and Couple Cohesion

At their core, relationship identity issues are usually problems
balancing individual autonomy and relationship cohesion. This can
play out in the sexual relationship and in the relationship as a
whole. The autonomy couple cohesion balance is the central feature
of your relationship identity. It directly influences your feelings as
a couple and forms the foundation for cooperation and intimacy
including sex.
Exercise: Seeking Balance in

Your General Relationship
Consider your thoughts and feelings about how well you are balanc-
ing your individuality and your relationship cohesion. Talk with
your partner directly about what you believe a relationship should
involve and how to do a satisfying relationship. What are your
expectations about how to communicate, deal with conflicts, express
affection? What do you each believe and feel about gender roles, the
role of sex, family-of-origin learnings, parental modeling of mar-
riage, prior relationship experiences, spiritual beliefs, career goals,
friendships, loyalties, religion, leisure, and social activities? What do
you bring to your relationship? What do you feel proud of? What
does your partner bring to the relationship that you appreciate?
Discuss (seeking information, not argument) your thoughts and
feelings about how well you each are doing with the amount of indi-
viduality in your relationship. Then discuss the level of union or
togetherness. Do you feel as independent as you want? Free or con-
strained? Do you have your own activities, interests? How stifled do
you feel? Do you have as much time for yourself as you think you
need? Where is your place to be alone, off duty?
What expectations do you have for your relationship, and how
well are these being met? How highly do you and your partner
prioritize your relationship? How lonely do you feel? How impor-
tant is your partner to you? You to your partner? Are you able to
have sufficient time together? To what degree do you approach daily
life with a couple or team mentality? Relationship identity is the
environment in which your sexual relationship lives.
Exercise: Seeking Balance in

Your Sexual Relationship
Discuss your thoughts about balance in your sexual relationship.
What does it mean to balance individuality and couple cohesion
during sex? Is individuality selfish? Does cohesion seem confining,
smothering, distracting? Does your sex always have to be raw and
physically passionate or deeply personal and romantic? Sexually,
what do you bring to your relationship? What are you proud of sex-
ually? What does your partner bring to your sexual relationship that
you appreciate? Share your thoughts. Your sexual relationship iden-
tity is founded upon who each of you is as a unique individual and
what you bring to your sex life.
When you strike a mutually satisfying and sustainable balance

between individuality and interpersonal cohesion, good-enough sex
results. Each of you contributes to the well-being of your relation-
ship, and your relationship contributes to your growth, develop-
ment, and well-being as individuals.
Enhancing Emotional Intimacy

Emotions about your relationship are the energy source for
your sexual feelings. When relationship distress infringes on this
positive energy, sexual problems can result. Feeling resentful,
rejected, or fearful of your partner undermines sexual energy. Sexual
problems like PE can drain your emotional energy as a couple. To
recover from distress associated with PE, you will want to take steps
to enhance your feelings of being an intimate team. You will want to
improve your ability to recognize and gently express your feelings,
deepen your appreciation of your partners feelings, and together
experience emotional empathy. Accepting and embracing each
others emotions will provide the foundation for working as a team

to learn the psychosexual skills in chapter 8.
Feelings Are Essential to Intimacy

We want to focus on your emotions in this chapter because feel-
ings are not only signs of the distress caused by your PE but also a
key to resolving your PE. Because your emotions are indispensable
for achieving sexual satisfaction, it is crucial that you be aware of
them and comfortable with them. Everyone who has a body has feel-
ings, but we differ in our level of awareness and comfort. Some are
very aware of their bodys sensations and feelings and have elabo-
rate words to express them. Others are aware of their feelings but
have few words to describe them clearly, or have learned to not
express them out of shame, fear, or sensitivity. Still others ignore
their feelings, believing emotions interfere with adult living.
What Are Feelings?

Feelings can be confusing, distracting, irritating, or frustrating
unless you understand what they are about. Because many people
especially menrely on reason more than emotion for direction in
life, feelings are often viewed as irritants, distractions, or even ene-
mies. Basically, feelings are biochemical energies in your body in
response to various situations, influenced by your past experiences
and current thoughts. Feelings are not enemies at all; they offer you
important information that your reason might overlook. Feelings
offer data about yourself and your experiences that are not available
to you from logic or thinking alone.
Feelings Can Be Complicated

Often we have mixed feelingswe feel two or more at the
same time. For example, you may worry that PE is impossible to
resolve, feel hurt and irritated at yourself or your partner, and feel
shame that you have failed to find a resolutionall simultaneously.
You may focus on only one dimension of the energy (feeling) in
your body, ignoring the other feelings. For example, focusing only
on frustration, you may miss feelings of hurt and worry.
One feeling can be converted to another. A person who is
taught to not feel anger may convert feelings of anger to shame. A
person who is taught that anger is okay but fear isnt may feel angry
when afraid or threatened.
Feelings Are Useful

People tend to think of feelings as positive or negative, good or
bad, depending on whether they agitate (like fear, anger, and guilt)
or encourage (like pleasure, contentment, and satisfaction). Our

approach to understanding feelings is to think of them as voices
trying to get your attention so youll consider factors other than logic
in your response to a situation. Feelings try to help you respond to
different situations. Every feeling is good in terms of its purpose to
serve you, protect you, and guide you. Your feelings offer honest
information, some of which you may not like. Listening for feelings
is an important skill.
Metaphors for Feelings

Consider two metaphors that a number of men and women
have told us helped them appreciate the value of emotions.
Psychological sonar. As you navigate through life, you are continu-

ously monitoring the environment for information about your situa-
tion. Imagine your logical reason to be your psychological radar,
supplying information about what is going on aboveground. Then
imagine that your emotional intelligence is your psychological
sonar, supplying information about what is going on below the
water. (If you are a sportsman, imagine the sonar fish finder in your
boat.) Different systems offer different information, and the compos-
ite information from both radar and sonar offers you a more
complete picture of your situation.
With PE, your radar or reason may have told you, I will
again fail to please her, while your sonar or emotions likely
alerted you with anxiety and tension in your body. Both alert you in
different ways to a challenging situation.
Lifelong, loyal friends. Another way to understand your feelings is

to consider them to be your buddies or lifelong, loyal friends. They
have been with you through your experiences, and they remember
them even when you forget. Each feeling, then, is a savvy veteran
of experience who will alert or protect you from situations that expe-
rience leads him to believe could distress you. Your friend vigilantly
looks after you. He will not lie to you, abandon you, or be silent
when concerned that you may forget or be misled by your logic. A
good buddy will take you aside, counsel you, even argue with you
when he thinks you could be making a mistake or overlooking
potential trouble. You may not like the counsel of these friends,
thinking they overprotect you or make things worse for you, but
they are just doing their job whether you like it or not.
Suppose you have experienced your partners disappointment
when you ejaculated quickly and concluded that you were inade-
quate. You experienced intercourse as failure. Your loyal friends
your feelings of shame and anxietywanted to protect you from
further failure, so they tried to get your attention and maybe even
advised you to avoid sex.
Exercise: Listening for

Your Feelings
Alone, provide yourself a quiet, relaxing atmosphere. Relax your
body until you are feeling calm, centered, and comfortably aware of
your body. Then imagine that you are a miniature explorer traveling
around inside your body to find where different feelings are most
strongly noticeable to you. Where in your body do you experience
joyful feelings? In your face, eyes, mouth? In your chest or legs?
Where in your body do you experience feelings of anxiety or fear? In
your stomach? In your chest? In your cold hands? Where in your
body do you experience anger? In your hot cheeks or ears? In your
throat or neck? In your stomach? Where in your body do you experi-
ence feelings of sadness? Where in your body do you experience
feelings of confusion, indecisiveness, ambivalence? Where in your
body do you experience feelings of sensuality with your partner?
Write down what you learned.
Are You Free to Feel?

While your feelings are valuable sources of personal informa-
tion, its not always a good idea to act on them. Whether and how to
act are ethical choices that you need to make. For example, a feeling
of anger offers personal information to you about your situation,
usually one in which you feel hurt, threatened, or blocked. Or,
experiencing PE, you may feel frustrated. These feelings get your
attention by agitating your body so you recognize the problem. What
you do with this information is the ethical issue.
The guiding principle is this: Accept your feelings, judge your
behaviors. When you make this distinction between your feelings
and behaviors, you are free to feel. You can feel frustration about PE
and choose not to express this feeling to your partner. Rather, you
can choose a more positive course of action by asking your partner
for a few moments to rest and recover, and then offering to pleasure
her as she wishes. You want to learn from your feelings but not let
them run your life; you dont have to act on them. You want to listen
to your feelings, consider their counsel, and decide how to respond
in a constructive fashion. Integrating your feelings and reason gives
you a more complete picture of your situation.
Value Your Partners Feelings

Accept your partners feelings as well as your own. Accepting a
feeling does not mean agreeing or condoning. It means listening,
valuing, caring, accepting, affirming, and nurturing her. You can
accept and affirm your partners feeling of anger without agreeing
with her interpretation (attribution) of the problem and without con-
doning the behaviors expressing anger. Dont try to fix or change
your partners feelings. Ironically, your acceptance is the major thing
that will help your partners feelings to change. Strive to acknowl-
edge, affirm, and accept feelings.
Different Ways of Expressing Feelings

There are many direct and indirect ways to express feelings.
The words to describe feelings are learned. Some words directly
describe emotions: I feel sad, I feel warm and close, I feel frus-
trated. Others express feelings indirectly. You might say, Isnt it a
nice day? to express I feel wonderful today or say, All you do is
spend money to mean I am worried about money. The more
directly you express your feelings, the more likely it is that your
partner will understand and interpret your meaning correctly.
You and your partner have your own emotional language, non-
verbal (a smile, a glance away) as well as verbal. How do you express
your feelings? How does your partner? How have you expressed
feelings about your PE? How has your partner? Verbally? Nonver-
bally? Negatively? Calmly? Dramatically? Developing healthier ways
to share feelings is important and will deepen your intimacy. Learning
to read your partners words and actions is part of the uniqueness
of intimacy. It takes months or years of sharing experiences, explain-
ing to each other your thoughts and feelings, for better and for worse.
Communicating emotions is an important skill in an intimate
relationship. For many men and women, it is difficult to feel close
without sharing verbally what and how you feel. Love involves shar-
ing warm, positive feelings and romance, but also involves sharing
feelings even when that may lead to conflict. Communicating nega-
tive feelings in a positive, constructive way can lead to emotional
closeness. You can still be loved and valued even if you are down,
anxious, or had a failure experience. Love tries to provide that safe
harbor amidst the storms of life.
Vulnerability within Emotional and Sexual Intimacy

Sharing your feelings with your partner is important to healing
and deepening your long-term sexual relationship. Emotional open-
ness and the nakedness of sex are the two most vulnerable and ten-
der aspects of committed love. During these experiences, we are
most exposed and fearful of rejection. You can appreciate your sensi-
tivity when you consider how it hurt when you shared feelings and
felt rejected or shamed. Or consider when you ejaculated quickly
and felt sexually vulnerable but your partner seemed frustrated, mis-
reading your distress as blame or abandonment. You probably
wanted to hide your emotional vulnerability and cover up your
physical nakedness. When you give and receive empathy while you
are vulnerable emotionally and sexually, you communicate powerful
acceptance and comfort, and generate trust and love.
Exercise: Expressing Feelings

and Emotions
If you have difficulty describing your feelings with words, use the
same words over and over, or tend to confuse feelings with
thoughts, you can fine-tune your skills with this couple exercise.
Below is a list of words that describe feelings or emotions. Add
any favorites of your own or others you can think of. Then do the
three building blocks that follow.
pleased excited comfortable
happy jubilant satisfied
glad elated contented
aroused surprised stimulated
confident eager peaceful
witty joyful calm
hopeful playful composed
fascinated silly thoughtful
angry frightened bored
provoked anxious weary
quarrelsome afraid apathetic
insulted cowardly complacent
irritated cautious tired
discontented uneasy worried
uncomfortable hesitant nervous
overwhelmed ashamed worthless
daring energetic embarrassed
intense distracted earnest
enraged hurt tender
confused passionate sad
Building block 1. Alone, take a moment to reflect and write down

some notes on your experience. What words do you use most fre-
quently to describe your feelings? What words do you hear your
partner use most often? Do you and your partner have different
favorite words to express a similar feeling? What are they? Which
feelings are most familiar to you? What are your labels or words for
these? What other feelings might be concealed behind these words?
After you have finished your notes, spend at least ten minutes each
sharing these with your partner.
Building block 2. For one full day, discuss with your partner your
impressions as you observe each other giving nonverbal signals such
as tone of voice, facial expressions, physical movements, and body
positions. Tell each other what you interpret the other to be feeling.
Share where you got your impression and check this out with each
other. For example, I see you chewing your nails and it makes me
think you are feeling nervous. Am I right? I hear you talking very
loudly and it makes me think you are feeling irritated. Are you? You
are quiet. Are you feeling sad? I feel your arm around me and it
makes me think you are feeling romantic. Do you want to make love?
Building block 3. What words do you use most frequently to
describe your sexual feelings? Like many men, you might use only
one word, good. This doesnt give your partner much to go on, so
think of additional descriptive words. What words do you hear your
partner use most often? Do you and your partner have favorite
words to express sexual feelings? What are they? Do you use words
during sex that turn you on? Turn you off? Which words? What are
your labels or names for each others body parts? Do you have play-
ful nicknames for these? What nonverbal signals do you use during
lovemaking? How do you interpret your partners tone of voice,
facial expressions, and physical movements during sex? How does
your partner interpret yours? Tell each other your impressions and
check these out with each other.
The Emotional Skill, Empathy

In intimate relationships, an important ideal is to feel emotion-
ally valued and accepted without conditions, to feel unconditional
positive regard from and for each other. Empathy, the skill of affirm-
ing feelings, is the glue of your relationship. It feels good to have
your successes and strengths accepted, but you feel especially loved
and respected when your vulnerabilities and weaknesses are
embraced. To empathize with your partner, imagine for a moment
that you are her. You imagine that you think and feel as she does,
that you experience her reality. When you are empathic with your
lover, you offer the greatest gifts: acceptance, nurturance, warmth,
respect, reassurance, validation, care, patience, and appreciation.
These are wonderful qualities to take into the bedroom!
Modifying Your Relationship Dynamics

Changing the relationship dynamics involved in your PE will
require effective communication and mutual conflict resolution.
Well begin by teaching paraphrasing, a communication skill which
helps develop the emotional skill of empathy.
Paraphrasing
Paraphrasing helps you clarify your relationship identity and
bring your intentions and your partners perceptions in line. This
cognitive congruence is the foundation for emotional empathy. With
careful use of paraphrasing, you and your partner will achieve
clarity of communication, emotional empathy, and readiness for
mutual conflict resolution. Heres how it works:
1. I message. Partner 1 reveals himself by expressing his
thoughts and feelings, trying to be clear, direct, and open as
he shares his personal message. The focus is on him only. He
says, I think . . . , I feel. . . . This is a personal disclosure
or sharing, an opening of his heart. Partner 2 may nod or say
uh-huh but not interrupt.
2. Paraphrase. Partner 2 listens with undivided attention, then
summarizes the I message in her own words, stating her
understanding of what Partner 1 has shared. The paraphrase
begins, What I think I hear you saying is. . . . Her focus is
solely upon him. Paraphrasing is empathetic listening
offering in her own words her understanding of his thoughts
and feelings.
3. Appraisal. Partner 1 then evaluates their effort for empa-
thetic understanding. He asks himself, As I listen to her
paraphrase, am I feeling completely understood? If he feels
a full empathetic understanding, then the appraisal is yes. If
not, the appraisal is no.
4. If the appraisal is no, Partner 1 begins the cycle again,
fine-tuning his I message.
There are two ways to use paraphrasing: two-way or leap-
frog paraphrasing, where partners switch roles when a yes
appraisal verifies empathy, and one-way or single-focus
paraphrasing, where the partners do not switch roles after a yes

appraisal, allowing the same partner to continue. One-way para-
phrasing offers the partner with several urgent messages the oppor-
tunity to continue working until satisfied.
The appraisal step empowers you by assuring that you will be
understood to your satisfaction, or discussion does not go further.
When it is your I message, you have the control to guarantee you
receive empathy. A yes appraisal means I certify that you under-
stand me now because I have heard and felt your empathy. When
the feeling being shared is complicated, it is reasonable to need ten,
twenty, or more I messages before the empathy is confirmed with
a yes. The first few I messages typically focus on describing the
content, and subsequent I messages focus on clarifying the quality
of your feelings about the content.
Paraphrasing will provide you the discipline and patience to
yield profound understanding. Your patience with the process
demonstrates that you value your partners feelings. Paraphrasing is
particularly valuable for talking about your sexual feelings. It
provides you a system to talk with understanding and appreciation.
Exercise: Paraphrasing
Take fifteen minutes to practice communicating using the two-way
paraphrasing format. At first, be very disciplined, saying nothing
outside the structure. Let the man begin with an I message. It will
help if you make an audiotape of your practice. Afterward, review
your audiotape together. If you have practiced with discipline, notice
that you can talk together calmly because the format gives you control
over the communication process. Notice that if you are loyal to the
paraphrasing discipline, you cannot have an argument! The structure
prevents it. You now have a format to achieve emotional empathy.
Using Your New Skills to Recover Emotionally from PE

Your new skills at empathizing and paraphrasing provide a
powerful foundation for overcoming the emotional hurt of PE. You
can now look at PE as an opportunity to grow together as a couple.
When you feel accepted and respected even if you fail sexually, you
develop a special bond with your partner. When you understand that
your partner felt hurt and abandoned because she assumed that you
valued sexual performance over personal intimacy, your bond is
deepened. Take the opportunity. Paraphrase your feelings.
There is no real love without hurt, pain, suffering, and disappoint-

ment. Normal day-to-day limitations to affection, occasional misunder-
standings and hurts, occasional mediocre sex, personal imperfections:
these are common relationship disappointments. Acceptanceor at
least toleranceof such vicissitudes of life is important for forgive-
ness. Regardless of its cause, your PE warrants compassion and
kindness from and for each other.
Forgiveness requires you to expand your understanding of
what PE means for each of you and to strengthen your relationship
cohesion with empathetic communication. By discovering each
others intentions and perceptions, you can change your perspective,
not looking backward but looking to the future. Learning to redefine
the sexual component of your intimate relationship while you learn
the practical lovemaking skills to overcome PE will solidify your
forgiveness and healing as lovers.
Renewal of intimacy requires honest acceptance that there has
been hurt in the past. These feelings do not need justification; they
are simply your loyal friends letting you know that aspects of sex
have been unsatisfying. It is essential to heal the emotional pain
because your relationship feelings are the energy source for your
sexual relationship.
Cooperation for Conflict Resolution

Most relationship disagreements or fights ultimately stem
from hurt feelings or a failure to share emotional empathy. Conflict
remains unresolved when partners reach an impasse in their efforts
to communicate effectively and empathetically to resolve differences.
If fighting has caused your PE, or if PE has caused fights, notice that
your lack of empathy for each others hurt and confusion was an
important issue, maybe even more important than sexual function.
Even relatively minor behavioral conflicts like tidiness and punctual-
ity can flare and become major emotional arguments when each
partner feels rejected. The skill of cooperation is required to resolve
conflicts in mutually satisfying ways.
Understanding Relationship Conflict and PE

The role of relationship conflict in PE is important because the
way you resolve differencesincluding sexual differenceseither
builds or diminishes intimacy.
To discover the role of relationship conflict in your experience
of PE, try the following exercise. Go on a fact-finding mission.
Exercise: Where, When, How,

and Why Do You Fight?
1. Where and when do you fight? When you have nonsexual con-
flicts, consider where you typically are and when the conflict
occurs. What are the patterns of your conflict? Do you tend to
fight on particular days? At particular times of the day? What
happens before the conflictwhat circumstances seem to set the
stage? For example, you might argue while driving home after
visiting your mother, or in the bedroom Saturday night after your
teenager misbehaves and after you have been drinking. Who else
is present or nearby when you have conflict? How long does the
disagreement typically last? What happens after the disagree-
ment? There may be individual issues that you bring to your rela-
tionship that create the environment for the conflict. What
unsettling events in the past might have influenced the way you
and your partner approach conflict resolution in the present?
When you understand that conflict may be linked to particular sit-
uations, you can anticipate and regulate conflict more effectively.
In your sexual relationship, consider these same questions.

What are the patterns of conflict in response to PE?
2. What do you do when you fight? Consider how you respond to

each other when disagreement occurs. Do you cooperate, con-
front, act playfully? Yield, evade, withdraw? If another person
was watching, what would that person see you doing? How do
you perceive that your partner feels and behaves when you
disagree?
When PE occurs, how does each of you respond? With shame?

Caring? Irritability? Tears? Withdrawal? Criticism? Are these
responses helpful? Constructive?
3. What does conflict mean? Why are you fighting, and what does
the disagreement mean to you? What thoughts typically go
through your mind about your partner and about the conflict?
What part of the conflict do you react most strongly to? What do
you think causes the conflict? What is upsetting to you about the
fact that you and your partner have a conflict in this particular
area? Do your conflicts reflect different beliefs about how your
relationship should be? What do you expect will result when the
two of you discuss important relationship topics? What would
you like to see happen? What would calm you or make you feel
satisfied?
Now, review these same questions as you focus specifically on

PE. Why is PE so painful? What are your thoughts and feelings?
What does PE represent or mean to each of you?
What you learn from these reflections will help you to better
understand your beliefs about conflict, your perceptions and attribu-
tions, and the meaning of your conflict. This knowledge can help
you work out mutual solutions to your disagreements and motivate
you to work as a team to resolve your PE.
Conflict Is an Opportunity for Intimacy

While many couples view disagreements as threats to their inti-
macy, in truth, addressing conflict or discord is the ordinary process
through which couples deepen their intimacy. When each partner
engages in a dispute with the goal of prevailing in what he or she
wants, the other partner feels unimportant, disregarded, and
rejected. However, with cooperation and mutual empathy, partners
learn to understand the meaning and deeper feelings behind the
conflict. Then both can participate in finding a mutually satisfying
resolution. The guiding principle is that each partner must feel emo-
tionally satisfied with the outcome.
Win-win solutions are not always achievable. When this is the
reality, couples are confronted with the need to accept their differ-
ences. Most couples are capable of achieving this when they feel a
sense of equity about who is doing the compromising. Integration of
differences is ideal; acceptance is satisfying; toleration is adequate.
Resolving Conflict Mutually

To mutually resolve conflictsincluding conflicts about PE
you need to cooperate to do the following:
! Be willing to vulnerably invest your thoughts and feelings in
your relationship.
! Apply self-discipline and leadership, and use structured

communicationparaphrasingto ensure that your inten-
tions and your partners perceptions are congruent.
! Use paraphrasing to generate emotional empathy.
! Formulate the issue or conflict as a couple problem. Address

PE as our problem. Ask yourselves, How do we resolve
this problem in such a way that we both feel good about it?
! Create a mosaic solution. The great majority of mutual solu-

tions are mosaic solutions, meaning that they are made up of
several specific behaviors which each partner contributes to
the resolution. Such solutions feel good for both partners.
Avoid either-or solutions, since they create a winner and
loser. The steps in chapter 8 will offer ways to develop your
mosaic sexual solution for PE.
! After you implement your resolution, evaluate it several
days or weeks later to discuss how well it is working. Con-
sider ways to strengthen it.
A system of mutual conflict resolution clarifies and integrates
relationship identity through effective communication, which pro-
motes satisfying conflict resolution (cooperation), which facilitates
empathy (intimacy), which in turn supports relationship identity,
and this positive cycle continues. This cognitive, emotional, and
behavioral integration forms the healthy relationship foundation for
you to overcome PE.
8
Psychosexual Skills:
Enjoying Arousal and
Regulating Orgasm
Mark and Lisa had been trying to remedy PE for more than six years.
They had read everything they could find about PE and had tried
every do-it-yourself technique, but nothing had really worked.
Marks family physician had agreed to prescribe a lidocaine anes-
thetic, which helped some, but Mark found it dissatisfying because
he lost much of the feeling in his penis and felt even further alien-
ated from his body. Lisa had tried to be passive during lovemaking,
saying little and avoiding touching Mark so as not to overexcite him.
She even expressed her dissatisfaction, trying to tone down his
excitement. Lisa appreciated Marks efforts, but still privately
resented the PE.
Over the years, Mark and Lisa had found the problem more
and more divisive, and they rarely talked of their feelings about
PEonly about what to do to fix it. Mark became more and more
preoccupied with his failure to perform, and over time he began to
avoid sex, anticipating that he would come fast and worrying that he
could not please Lisa. Lisa began to feel Mark was more concerned
about his penis and performance than about her. There were periods
when Mark would come fast, feel frustrated and irritated, apologize
to Lisa or berate himself for being messed up, and then leave the
bedroom. Lisa felt more and more abandoned by Mark as their sex-
ual interaction progressively worsened. It was hard for her to not
react angrily herself. It was all such a disappointment.
Lisa and Mark felt hopeless. Their efforts had brought no
significant changes. They were, in fact, doing worse and feeling more
and more alienated from each other. They felt inadequate, isolated,
and inferior to other couples who didnt have sex problems. They
had read that PE was the easiest male sex problem to correct, which
deepened their frustration and shame. Lisa felt angry that Mark
would not seek help from a professional sex therapist. Mark felt that
sex was too private, and he doubted that therapy could help.
Chronic PE was harming their overall marital relationship, limiting
their communication, and testing their emotional support of each
other. They were in marital as well as sexual trouble.
Mark and Lisa did eventually go to sex therapy, but only after
Lisa became so frustrated that she threatened to divorce Mark if he
didnt get his problem fixed. Lisa was hurt that it took such a
severe threat to get Mark to act. It was hard for her to recognize his
avoidance as a measure of how deep his shame was.
With the help of their sex therapist, Dr. Hernandez, Mark and
Lisa began to comprehensively address the problem. Because their
case was severe (they had a PESI score of 75), they needed to
complete a very detailed series of steps to remedy both the PE and
the damage to their relationship. Dr. Hernandez used a diagnostic
process like the one outlined in chapter 4 to help Mark determine
that his PE was caused by neurologic system predisposition and
psychosexual skills deficit, and that the harm PE had already caused
to the intimate relationship was also serving to maintain PE. Mark
decided he did not want to take medication, so Dr. Hernandez
helped them outline a strategy to compensate for the neurologic
quickness and the skills deficit by cooperatively improving their
psychosexual skills. The early sessions of therapy worked to heal the
marital harm that had occurred.
In this chapter, well teach you the psychosexual skills to
address PE. Youll learn to relax and regulate your arousal. You and
your partner will learn to cooperate in ways that will provide sexual
and relationship support, safety, and comfort. Well provide detailed
instructions every step of the way. Well show you how Mark and
Lisa gradually overcame PE, and how you can overcome it too. You
will be amazed that PE can be effectively managed. You will not
only last longer but enjoy significantly more pleasure, emotional con-
nection, and intimacy.
Psychosexual Skills: Enjoying Arousal and Regulating Orgasm 109
How to Approach Learning

the Psychosexual Skills
Well begin by giving you an overview of the skills so you under-
stand clearly what you are trying to achieve with each skill, how
each skill relates to the others, and how to put the skills together.
Understanding the Four Phases of Skills Learning

There are eleven steps to learning the psychosexual skills, and
these steps can be divided into four phases. As you work through
the steps, be sure you understand the goal for each phase so that the
exercises make sense.
Phase One: Comfort and Relaxation

The first series of exercises promotes comfort with your sexual-
ity as an individual and couple, and teaches you individual cognitive
and behavioral skills for relaxing your body. The essential skill is to
focus on physical sensations in order to relax your body. This will
help you pace your arousal.
Phase Two: Pleasure Toleration

In phase two, youll work together as an intimate team to stay
relaxed with increasingly more erotic stimulation. By focusing on
relaxation, you will learn that you can welcome morenot less
pleasure without ejaculating. The essential skill is to tolerate increas-
ingly intense pleasure without stepping off into ejaculatory
inevitability.
Phase Three: Pleasure Saturation

In phase three, youll learn how to have extended intercourse.
The exercises will teach you how to begin intercourse, and then how
to extend the closeness. Youll learn to enjoy intercourse, saturating
yourselves with pleasure. The essential skill is integrating the cog-
nitive and behavioral skills to manage PE during intercourse.
Phase Four: Long-Term Satisfaction

In the final phase, you will meld the psychosexual skills with
the psychological and relationship aspects into your couple sexual
style. The essential skill is integrating the multidimensional features
to overcome PE as an intimate team, and to ensure long-term satis-
faction with a sensible relapse prevention plan.
This chapter will guide you through the first three phases.
Chapters 9 and 10 will guide you through phase four.
How to Tailor Your Steps to Your Level of Severity

Work with your partner to decide what steps fit your situation
best. If you are recovering from PE caused by a medical, psychologi-
cal, or relationship problem (and these have been treated), or your
PE severity is mild, discuss together whether you want to do all the
steps or only those that you think will help you recover. For exam-
ple, if your PE was caused by a prostate infection, you likely do not
need to learn every skill; instead, the pelvic muscle (PM) control
training (step three), relaxed couple pleasuring (step six), and the
intimate intercourse technique (step ten) may be enough to help you
recover. If you have moderate PE (PESI 5070), completing most of
the eleven steps will probably resolve your PE if you choose your
course judiciously. For example, in phase two, pleasure toleration,
you may elect to bypass step eight, the individual stop-start pacing
exercise, and concentrate instead on learning step nine, the couple
stop-start pacing exercise. If your PESI severity score was severe
(greater than 70), you will need to complete every exercise. The most
reliable approach is to complete all of the steps; however, if you elect
to not learn some steps and your program does not bring about the
results you want, you can retrace your steps and complete them all,
or you can consult a sex therapist for help. The more severe your PE,
the more likely working with a marital and sex therapist will be
helpful.
What If You Experience Distress during an Exercise?

Because youre trying to extend your skills and comfort level,
some of these exercises may bring mild discomfort or anxiety. This is
to be expected. However, should any of these exercises cause signifi-
cant distress or discouragement (which is the opposite of what we
want for you), be wise: protect yourselves from unintended hurt by
seeking professional coaching and support.
The Psychosexual Skills: The

Nitty-Gritties for Success
As they worked through the psychosexual skills, Mark and Lisa learned
a reasonable way of thinking about PE and a realistic approach to
changing it. They learned the importance of physiological relaxation,
the importance of accepting personal responsibility, and the skill of

cooperating by giving and receiving pleasure.
Mark and Lisa were challenged by the amount of discipline
required, but they gradually gained confidence and began to see
success. Lisa especially enjoyed sensual experiences which not only
slowed the touching process but felt like a more genuine, meaningful
connection with Mark. Working together helped them to feel closer
as a couple.
During the process, if either became confused, they reminded
each other of the larger goal: relationship closeness, with cooperation
as the best way to accomplish this. Mark found it helpful to remember
that physical relaxation was the essential strategy, and discovered that
he could achieve this by focusing on the sensations in his body.
Dr. Hernandez encouraged Mark and Lisa to acknowledge the
difficult aspects of learning the psychosexual skills. At first, the exer-
cises seemed a huge intrusion into lovemakingtoo mechanical and
impersonal. Mark and Lisa accepted this, reminding themselves that
they would eventually develop a more personalized couple sexual
style.
Dr. Hernandez also coached Mark and Lisa to handle
unintended ejaculation during any of the steps by staying focused on
the effort. He suggested that Mark simply acknowledge the mistake
by saying oops or a work in progress, then pause thirty to sixty
seconds before continuing. Mark was not to get sidetracked by
sulking or apologizing. Mark discovered that when he did ejaculate
unintentionally, it was because he lost focus on his physical sensa-
tions, was not sufficiently relaxed, or had miscalculated how well he
was doing the particular step.
Finally, Dr. Hernandez told Mark and Lisa that if either
thought things werent going well during an exercise, they should
simply ignore this, focus on the physical sensations involved, and
wait until after they completed the exercise to discuss their percep-
tions. Dr. Hernandez suggested that Mark and Lisa thank each other
after each session, no matter how poorly it might have seemed to go.
The guideline: Deeply appreciate your partners support and effort,
and say so.
Phase One: Comfort and Relaxation

The exercises in phase one help increase your sexual self-esteem,
teach you several fundamental arousal management skills, and
enhance your sexual comfort as a couple by inviting you to share
your sexual feelings. Learning body relaxation will provide the
foundation for later steps, and will help counter the performance
anxiety that accompanies PE. You will learn to become sensuously
and sexually aroused while maintaining physiological relaxation.
Step One: Affirming Your Sexuality and

Increasing Couple Sexual Comfort
Goal: Develop acceptance of your body and of sex, and develop open-
ness with your partner
Mark and Lisa found that affirming their sexuality and enjoy-
ing sexual comfort helped them heal emotionally and broke the
barriers of cautiousness and apprehension that had developed
between them because of PE. Through this step, each worked to feel
positive about his or her body and about sex, and they were able to
discuss their motivations and feelings about their sexual experiences.
Positive Body Image

Scientific research consistently finds that sexual satisfaction is
strongly related to how proud, self-respectful, and comfortable you
are with your body, nudity, and touch. This is why a healthy, posi-
tive attitude toward sexuality is so important. If you dont have
positive feelings about your body, other good things are stifled,
especially your ability to physiologically relax and focus on
sensuality.
Body self-acceptance may be difficult in our glamour-conscious
culture, but it is an important component in self-esteem and is essen-
tial to intimate lovemaking. Worrying about your bodys attractive-
ness is a major distraction. Remember that distraction contributes to
sexual dysfunction. Your negative thoughts about your body (Im
fat, My stomach is too puffy, I dont like the way my penis
looks) are distractions.
We all have expectations about our sexual selves that are unre-
alistic and self-defeating. It is important to honestly examine your
feelings about your body. There are some things you can change for
the better and other things you must simply accept and live with.
Individual Exercise:
Body Image Awareness
Set aside private, quiet, comfortable time for yourself. It is best to use
a full-length mirror for this exercise. First, bring yourself to a state of
calm and centeredness. Focus on your body. Begin by undressing in
front of the mirror, and be aware of the way your body looks in vari-
ous stages of dress and undress. When you are completely nude,
stand in front of the mirror and examine your body in minute detail.
Really look. Make eye contact. Be with yourself in the mirror. Survey
your entire body.
Talk to yourself as you progress. Say out loud how you
honestly feel about various aspects of your body. Include each little
scar, mole, wrinkle, and pimple. You can exaggerate your feelings.
Be loud about those parts that disgust you and exclaim proudly your
feelings about the parts you like. Move around, and watch your
body as you change postures. Notice your muscles tense up, and
notice your soft parts. Flex your muscles, pose, turn, dance, move
seductively. Be aware of those parts of yourself that you usually
avoid looking at: bulging stomach, small chest, skinny legs. Try to
see these parts of yourself with some acceptance and a positive
attitude. Integrate them into your view of your entire body.
Below are questions you might consider while you are doing
this exercise.
! What do you like best about your body? What are you most
proud of? How do you show this to your partner?
! How do you feel when your partner touches or looks at the

parts of your body that you feel good about, proud of, and
pleased with?
! What do you like least about your body? What are you
ashamed of? How do you hide these parts of yourself? Do
you avoid looking at them? Do you focus a lot of attention
and self-criticism on them?
! How do you feel when your partner looks at or touches the

parts of your body you dont like or feel ashamed of?
! How can you affirm your body and your physical self-image
each day? Each time you make love?
Take a moment to consider what you can do to help yourself

feel more confidence in your body. You might get a haircut, buy a
piece of clothing that makes you feel sexy, or commit to getting in
shape. Let it be something that helps you feel like your new, sexier
self.
Couple Sexual Comfort

Sexual comfort feels good and creates an atmosphere in which
you can learn the skills successfully. Partners who accept each
others shyness and even embarrassment with nudity, and who learn
more about each others personal thoughts and feelings toward their
bodies and sexuality, feel more comfortable together. It was essential
for Mark and Lisa to know that they could express their sexual feel-
ings and be met with acceptance, respect, and caring.
You and your partner can develop increased sexual comfort by
talking gently and openly about your positive sexual thoughts, feel-
ings, wishes, and desires, as well as your sexual discomforts and
inhibitions. Your sexual feelings are deeply personal and significant,
so they deserve respect and tender care.
Couple Exercise: Talking

with Your Partner about
Sexual Feelings
With mutual acceptance, take time to share your thoughts about the
following.
Talk first about what you learned about sexuality as a child and
adolescent. What did you learn about masturbation, marriage, pet-
ting, intercourse, oral sex, orgasm, how a man or woman was sup-
posed to act during sex? Who taught you this? Talk about what it
meant to you at the time as well as now.
What are your attitudes or beliefs about sexuality? What is
okay and what is not okay during lovemaking? What do you believe
is okay but dont feel is okay? What do you believe about inter-
course? Oral sex? Anal intercourse? Experimentation? Sharing sexual
fantasies? What do you believe about masturbation? Masturbating
privately? With your partners awareness? Without your partner
knowing? Stimulating yourself while your partner watches? Mutual
manual stimulation (simultaneously or taking turns)?
Talk about what you sexually like and appreciate about your
partner.
Talk about how you feel about what you do together sexually.
What do you really like about sex with each other?
Discuss with your partner sexual concerns you have, remem-
bering to speak empathetically, warmly, and respectfully.
Share what you are feeling as you discuss your sexual
thoughts, feelings, and beliefs. How does it feel to talk about sex?
Mark and Lisa found the body awareness exercise and talking
about sex particularly helpful. Mark realized that his shyness about
his body contributed to his anxiety during sex and made it difficult
to relax. He also became more aware of his pleasure in touching Lisa,
which allowed him to feel close to her. Lisa learned she felt
conflicted about her bodyshe liked her face, eyes, and breasts, but
felt her legs were ugly. She also shared that as a young girl she had
been taught that sex was bad and still felt that intercourse was dirty.
She even wondered if her discomfort somehow encouraged Mark to
ejaculate quickly to get it over with. Such open discussions facilitated
their comfort. Paradoxically, Mark worried that because this open-
ness made him feel more sexually attracted to Lisa, it would make
the PE worse. Dr. Hernandez reassured Mark that feeling attraction
and comfort was healthy, and that he would learn how to enjoy this
feeling in subsequent steps.
Step Two: Training Your Mind and Body for Relaxation

Goal: Learn relaxation, the foundation for ejaculatory control and
pleasure
Satisfying sexual functioning depends on physical relaxation.
You cant duck or bypass this skill if youre going to control ejacula-
tion! Well teach you to relax in your body, as opposed to the more
common out-of-body relaxation strategies which focus on calm
images (natural beauty) or soothing sounds (ocean waves). In-body
relaxation helps eliminate performance anxiety and helps you focus
on the physical sensations of pleasure. This body-focused relaxation
is the foundation for sensual self-entrancement arousal. This is
where your mental focus needs to be.
How to Handle Distractions

As you do the activities in this step, notice that when you try to
focus on physical sensations, your mind may wander or jump to
other places (work, kids, shopping, sports) 50 percent or more of the
time. Thats okay at first. Remember, this is a skill! If you didnt need
to develop it, it would be automatic.
When you notice you are distracted, dont fight with the
distraction or try to bulldoze it out of your mind. That just makes it
worse. Take a moment to simply accept the distraction. Say hello to
it; acknowledge it. This is important because every distraction has an
emotional piece to it, a tiny energy of pressure or urgency. There is
an emotional nudge to attend to it. If you ignore or fail to acknowl-
edge the distraction, it will get stronger and will become a bigger
distraction, pestering you for attention (remember that the function
of a feeling is to get your attention). Talk to it for a moment so it

knows youre paying attention, then gently set it aside until later.
You might imagine you see the distraction on your computer screen
and then calmly press the sleep key to clear the screen. Or imagine
you place the distraction in a file folder labeled do later. Then
calmly bring your attention back to the bodily sensation you are
focusing on. At first, you will be spending a lot of time calming dis-
tractions, but gradually youll find it easier to focus on the physical
sensations. When youre focused on sensations more than 80 percent
of the time, thats good enough!
Physical Relaxation
Make yourself very comfortable in a chair, sofa, or bed, loosening
any tight clothing. Close your eyes and relax. Breathe deeply and
slowly: gradually inhale as you slowly count to five, then exhale to
the count of five. Concentrate on feeling the air move slowly in and
out of your body.
Concentrate on your toes. Relax them. Feel all the tension leave
your toes. Breathe calmly, deeply. Relax your feet. Let all the tension
in your feet disappear. Now let the tension in your calves disappear.
Breathe slowly, deeply. Imagine a soothing feeling rising through
your legs, through your knees to your thighs. Let your legs feel com-
pletely relaxed and free of tension. Breathe calmly, deeply, and feel
the air glide through you.
Now focus on your pelvis. Let the muscles relax and let go of
tension. Let this soothing feeling move through your buttocks; feel
your buttocks relax. Feel yourself breathing deeply as the tension in
the lower half of your body disappears. Then let the tension in your
back begin to disappear. Let this soothing feeling wrap around your
chest, shoulders, neck, down your arms and hands. Let this soothing
feeling move through your face. Feel your facial muscles relax as you
breathe calmly. Feel the tension disappear from your forehead, eye-
brows, jaws. Just rest and allow your body and mind to feel relaxed
and comfortable.
Although this is essentially an individual exercise, you and

your partner can do it side-by-side. Lisa and Mark found it helpful
to make an audiotape (about five minutes long) of these directions.
By listening to the tape, they could concentrate more easily. They did
the relaxation exercise seven times. This was good enough, and they
were ready to move to step three.
Step Three: Learning Pelvic Muscle Control

Goal: Identify and learn to consciously control your pelvic muscle
This is the dont be a tight ass if you want to control ejacula-
tion skill. It is common for your body to tighten in response to the
pressures, tensions, and burdens of life. This includes unconsciously
tightening your pelvic muscle (PM). By learning to relax it, you give
yourself a premier technique to slow down ejaculation.
Pelvic Muscle Training

The easiest way to locate the PM is to imagine you are squeez-
ing off urination or twitching your penis. Youll feel a mild sensa-
tion in one or more of the following areas: your penis, groin, the
perineal area (between your testicles and anus), the gluteus maximus
(butt) muscles, or the anus. Because the PM is muscle tissue, it can be
conditioned or trained to perform more efficiently. What follows is a
typical experience for many men, but your body may vary, so experi-
ment to find what works for you.
The PM is used in two ways. First, because total body relax-
ation is the foundation for good ejaculatory control, attention to
relaxing the PM during sexual activity is an efficient way to relax
your whole body. If your PM relaxes, your whole body will follow.
Second, when you keep your PM relaxed, the muscles involved in
ejaculation are relaxed, reserved, or held back. Otherwise, youd be
priming the pump of ejaculation by reflexively tightening the PM
during sexual excitement.
PM Basic Training
This exercise will improve your conscious awareness of the sensa-
tions of your PM and strengthen the muscle. Contract or tighten
your PM and hold for three seconds, then relax it for three seconds
while you continue to consciously focus on the sensations. Do this
ten timestightening three seconds, relaxing three secondsfor a
total of one minute.
Do this set (contracting and relaxing the PM ten times) at three
different times every day. At first it may be difficult to tighten and
hold the muscle for three full seconds, but do what you can (one or
two seconds) and build up your strength over time. When this is
easy, move on to the next exercise.
The PM Continuum
This exercise will increase your awareness of the sensation of your
PM and increase your mental control of your PM. Visualize that your
PM can be tightened in varying degrees of intensity, not simply tight
or relaxed. Imagine a continuum from 1 to 10, at first with three
marks: 1 (relaxed), 5 (medium), and 10 (tight). Practice moving from
one point to another, holding the PM at that level for three seconds,
then relax. For example, tighten the PM to 10 and hold for three sec-
onds, then return to 1 for three seconds, then tighten to 5 and hold
for three seconds, and then relax to 1. Practice this until it becomes
easy. Once you learn this, extend the continuum from three stopping
points to five stopping points (101517131). This will
be good enough.
Step Four: Cognitive Pacing with the

Sexual Arousal Continuum
Goal: Broaden the range of your sexual arousal
The PM training is a behavioral pacing skill. Next well show
you how to develop a sexual arousal continuum as a foundation for
your cognitive pacing skills. This continuum will be crucial when
you learn progressive intercourse in step eleven.
Each of us has our own sexual arousal patterns or desired
sequences that blend reality and imagination and facilitate sexual
arousal. By understanding the level of arousal evoked by specific
images, behaviors, and feelings, you can consciously modify eroti-
cism in order to slow down, hold steady, or intensify arousal. In
order to do so, you must develop awareness of how calming or
stimulating a specific image, feeling, or behavior is for you.
Individual Exercise: Developing

Your Own Arousal Continuum
Make a detailed, specific list of images, feelings, behaviors, tech-
niques, and scenarios that you find arousing. Using a scale of 1 to
100, with 100 equaling ejaculation or orgasm, assign an arousal level
to each. In his list, Mark rated closed-lip kissing 20, fondling Lisas
breasts with clothes on 35, Lisa gently stroking his penis 60, fondling
her naked breasts while Lisa gently stroked his penis 75.
Developing his detailed continuum taught Mark awareness of

the arousal value of various sensual and sexual activities. It took him
a number of weeks to fully delineate this continuum (he eventually
distinguished more than forty specific focal points). This cognitive
awareness created a powerful pacing technique that he later used to
regulate his arousal during intercourse with Lisa.
Mark found that the things that occurred to him first were all
highly arousing behaviors and images: focus on Lisas breasts and
genitals, oral sex, and intercourseall items above 50. It was chal-
lenging for him to develop the 1 to 50 range of arousal items. Lisa
also developed her continuum, and Mark learned that she found the
opposite was true for her arousal pattern. She focused first on
nongenital scenarios and found it more challenging to list the more
arousing items. As they each completed an arousal continuum, Mark
and Lisa talked openly of what they most enjoyed, which enhanced
their sexual anticipation.
Step Five: Maintaining Relaxation during Arousal

Goal: Learn to combine relaxation and sensual self-entrancement
arousal
This exercise will show you how easy it is to get an erection, let
it subside, and regain it when you stay relaxed and focus on self-
entrancement arousal. It is particularly helpful for men who also
worry about erection problems. Youll want to practice this exercise
several times. The first times you do this exercise, your goal is to
relax and touch yourself without getting an erection. Then patiently
allow an erection with the minimum of touch. Then youll practice
getting, losing, and regaining a relaxed erection.
Individual Exercise: Relaxed

Self-Entrancement Arousal
In a private place, remove all your clothes and gently massage your
body all over for fifteen minutes. Do not pursue arousal. Use this
time to focus on your bodys sensations to help you relax.
As you touch your entire body, be aware of the feeling of your
skin and your hands on your skin. Try different kinds of touch:
softer and harder, tickling or scratching, pinching lightly, fingering.
Notice which feels better and where. Be aware of your bodys con-
tours: the soft, fatty parts; the bony parts; the firm, muscled parts. Be
aware of the different textures of your skincoarse, soft, smooth,
hairyand how each feels different to your hand. Try to notice your
emotional reactions as well. Then, for another fifteen minutes,
progressively do each of the following parts.
1. Soothing Genital Touch
After soothing your whole body for fifteen minutes, begin
exploring your testicles and penis with very soft and slow touch. Do
not use the intense stroking that you would with masturbation.
Instead, concentrate on the quiet, calm sensations. Relax your PM
and keep it relaxed. For at least five minutes, use featherlike touch-
ing or fingering to explore your sensations without getting an erec-
tion. Relax and concentrate on calm sensations. Do this exercise
twice.
2. Finding Your Calm Erection
This time, when you have calmly touched your genitals for
more than five minutes, decide to very slowly obtain an erection by
continuing your total body relaxation, keeping your PM relaxed, and
fingering your penis. Calmly let an erection happen. Patiently touch
and gently pleasure your penis. The more relaxed and focused you
are on the sensation, the easier it will become erect. You are practic-
ing getting an erection with self-entrancement arousalmaximum
body relaxation, minimal touch, and absence of sexual fantasy.
Be patient. Typically, it will take a number of minutes before an
erection begins. Do not press it or you will undermine your physical
relaxation foundation. After several minutes of consistently calm
touch, increase the stimulation just a little, then be patient. You are
trying to find the minimum of touch you require to get an erection.
This may take some practice and patience, and may not occur the
first time you do this exercise. If it does occur, be sure you are not
rushing it, because you would probably conclude that you need
more stimulation than is really necessary.
If an erection does not occur, keep your PM relaxed and gradu-
ally increase the touch to your penis. Try gently using both hands.
Focus on the pleasure; be patient. If after three exercises you have
not begun to find your calm erection, then you may begin to add
mildly arousing partner interaction fantasy. Using your arousal con-
tinuum, imagine very low-arousal items (10, 12, 15, or 20). You are
searching for the mildest physical and cognitive arousals that you
need for an easy erection. If you come to focus on items above 25 on
your arousal continuum and have not begun an easy erection, it
likely means that you are not as physically relaxed as you believe.
Back up and focus again on sensual relaxation.
When your calm erection begins, enjoy it for several minutes.
Stay focused and be sure your PM is relaxed. Then choose to let your
erection subside by stopping the touch to your penis. Do this exer-
cise a minimum of two times.
3. Choosing to Wax and Wane
This time, choose to let your erection subside about 50 percent
by stopping or changing the touch to your penis. Concentrate on the
sensations. As you feel it subside, stay focused on the sensations. Then
simply change the touch to gradually bring back a relaxed erection.
Notice that when youre physically relaxed, it is easier to get an erec-
tion, although it may take a little more time. Notice that you can lose
your erection and regain it easily when you are calm and patient.
Phase Two: Pleasure Toleration

Now that youve expanded your comfort with your body and your
partner and learned relaxation and self-entrancement arousal, youre
ready to expand your pleasure as a couple by learning arousal toler-
ation together. Youll learn to better identify and respect your point
of ejaculatory inevitability while tolerating progressively heightened
stimulation.
Step Six: Relaxed Couple Pleasuring

Goal: Enjoy relaxed, nonerotic, sensual touch
Mark and Lisa found that the soothing, relaxing touch in this
exercise helped them to explore the sensations in their bodies,
increase pleasure, and overcome the barriers impeding the relaxed
flow of healthy sexual response. This exercise will help you learn
that when youre relaxed, touch can be very pleasant without being
sexually arousing.
Couple Exercise:
Relaxed Pleasuring
Set aside one hour, and choose a private, softly lit, and comfortable
place. Undress and prepare yourself to be relaxed and focused. For
fifteen minutes, pleasure the entire back of your partners nude

body; then for fifteen minutes, pleasure the front of her body with
the exception of her breasts and genitals. Then have her reciprocate,
spending fifteen minutes on your back, then fifteen minutes on your
front, again avoiding the area around your nipples and your geni-
tals. This touch is not intended as massage (designed to loosen up
tight muscles) but a relaxed, comforting, sensual touch, a surface
gliding, a pleasuring.
Keep your attention on your body, focusing upon the sensa-
tions you feel as you are being touched or are touching. Feel free to
guide your partner by giving verbal directions (Your rubbing
makes me feel warm and secure, I really like what you are doing
now, Your kisses on my shoulder are so soothing) or taking his or
her hand, showing how you want to be touched. If your partner
caresses you in a manner that does not please you, take responsibil-
ity to speak up. Instead of complaining, you might say, It feels
better when you press more gently, or I would enjoy a softer
touch. Otherwise, let the time be fairly quiet so that you can con-
centrate on the sensations and pleasurable feelings. If your body
responds with an erection, you probably are overdoing the touch or
coming too close to erotic zones, so make subtle adjustments. If you
are relaxing with the pleasure, you will not feel sexually aroused or
erect. If you do arouse, simply focus more carefully on the pleasur-
able sensations, and your excitement will subside.
Feel free to experiment with sensations. Touch, hold, kiss, lick,
suck, or otherwise caress your partners body in a way that is pleas-
ant and interesting. You may want to explore the joy of touch by
using massage oil or talcum powder, or caressing with feathers, silk,
fleece, or flannel. Remember those little places: eyelids, toes, scalp,
behind the knees, bridge of the nose.
While you are receiving, selfishly soak up every sensation.
Enjoy your here-and-now experience, focusing on sensory pleasures.
By taking turns, you have the opportunity to concentrate on your
own feelings whether giving or receiving. Although pleasing your
partner is an important part of a sensual encounter, pleasing yourself
is equally important.
Finally, do not use the exercise as an introduction to sex. Not
having sex for at least three hours afterward will help protect the
relaxing nature of this exercise. If your mind and body anticipate
that you will have sex at the end of the exercise, this will become a
distraction from your focus on the pleasure. Remember, this is a
sensual relaxation exercise.
When you and your partner are both able to comfortably relax,
focus on the sensual pleasure, limit mental distractions to less that 20
percent of the time, and not experience erotic response (such as
erection), you are ready to move on to the next step.
Mark and Lisa did four sessions of this relaxed pleasuring
exercise. At first, Mark would get an erection by simply pleasuring
Lisas legs, thighs, or stomach. Dr. Hernandez suggested that Mark
focus more carefully on what he was feeling in his fingers as he
touched Lisa, narrow his concentration and avoid fantasizing when
looking at Lisas breasts or genitals, and allow his body to relax.
Over time, Mark was able to relax and focus more comfortably with-
out having erections. This was an indication that he had achieved the
level of comfort and relaxation needed at this step.
Step Seven: Partner Genital Exploration

Goal: Learn more about your own sensations and your partners;
enjoy calm, relaxed touch and physical relaxation in an otherwise erotic
situation
In this exercise, you and your partner will take turns leading
each other in an exploration of your genitals. The purpose is to
provide a sensual exploration of the bodys erotic parts, to practice
sexual leadership with your own body, and to become more comfort-
able looking at and touching each others genitals in a relaxing,
nonarousing way. This exercise is a show-and-tell about your body
and erogenous zones.
Couple Exercise: Partner

Genital Exploration
This entire exercise should take approximately one hour. Begin with
thirty minutes (fifteen minutes for each of you) of relaxed pleasuring
of the nongenital parts of the body. (This is a shortened version of
the relaxed couple pleasuring exercise.)
Have your partner comfortably position herself in a reclining
position, her back propped up with pillows. Position yourself com-
fortably alongside her, facing her. For the next fifteen minutes, have
her lead you in an exploration of the erogenous parts of her body.
Discuss the sensations: what she prefers, what is uncomfort-
able. Be sure to discuss how you can enrich her pleasure. Ask ques-
tions of each other to learn or confirm what you experience. Use a
scale of 1 to 10 to talk about how erotically sensitive a particular area
is when relaxed.
Gently explore the sensations of her breasts, nipples, stomach

and abdomen, hips and upper thighs, inner thighs, outer lips of the
vagina and perineum (the area between her vagina and anus), and
inside the vagina. Some women have uncomfortable feelings about
examinations, associating this with impersonal gynecological exams,
so let her take the lead. Be sure she feels comfortable and in control.
Give her your hand and ask her to direct your touch. She might have
you form a Y-shape with your index and middle fingers and show
you how to gently pleasure the outer lips of her vagina. Talk,
describe, and discuss.
When you are ready to explore sensations inside her vagina,
have her guide you in inserting one of your fingers (usually the
middle finger) and direct you in slowly pleasuring the inside of her
vagina. Imagine the vagina as the face of a clock, with the top being
12:00. Have her guide your pleasuring, explaining her sensations.
Many women notice they feel very little beyond three-quarters to
one inch inside. Proceed around the face of the clock to 3:00, 6:00,
and 9:00, stopping at each point, exploring and discussing the sensa-
tions. Work cooperatively to learn, confirm, relax, and enjoy.
Now it is your turn. Take the lead in the exploration of your
body. Begin with your chest and nipples. Take your partners hand
and direct her, explaining your sensations and using the 1-to-10 scale
to note the level of sensitivity you feel. Be sure you feel comfortable
and in control, especially when she is exploring your testicles and
penis. You might have her cup one or both testicles and describe for
her your sensations, or ask her to explore different parts with her
index finger, showing her how to pleasure you. Many women have
heard that mens testicles are very delicate. Be sure to teach her
about your testicles so she is not over- or undersensitive to you.
Then explore the sensations in your penis. Have her gently place
your penis back onto your stomach. Ask her to take her index finger
and, beginning at the base of your penis, very slowly explore sensa-
tions up the penile shaft. Show her the more sensitive part on your
penis. Be sure to give her feedback about what you are feeling each
step of the way. Have her ask you questions about your sensations.
Do this exercise a minimum of three times before moving to the

next step. The repetition will increase your comfort. Conscious relax-
ation and focus on the sensations will allow you to feel calm, pleased,
and comfortable while doing what would otherwise be erotic.
Lisa and Mark engaged in the partner genital exploration exer-
cise four times. Both were surprised that there was little erotic feel-
ing in the genitals while in a relaxed state. By the fourth session,
Mark and Lisa rated the sensations in nipples, lips of the vagina,
clitoris, shaft of the penis, and even the head of the penis in the
range of 1 to 3. This was quite a change from what they expected
and from what occurred the first time they tried the exercise. During
the first two sessions, Mark began to get an erection as Lisa guided
his finger ever so slowly to different points on her breast and nipple.
He had to take several deep breaths to calm himself, pause for a
moment to let his erection go away, and then focus carefully on the
feeling in his fingers and her explanation of the sensation. He found
it difficult at first to not get an erotic movie going in his imagination,
and this, he observed later, was what caused his erection. In short, he
had to refrain from partner interaction arousal.
Mark and Lisa became more comfortable each time they
completed this exercise, and they were surprised at how relaxed they
felt in a potentially erotic situation. In fact, Mark worried that he
would lose his natural excitement with Lisas body and would have
trouble getting an erection with her. Dr. Hernandez reassured Mark
that now that he knew how to relax and maintain focus on his sensa-
tions, his erections would come and go easily.
Step Eight: Individual Pacing Training

Goal: During self-pleasuring, learn to become highly aroused without
ejaculating by first pausing, then slowing your physical and mental
stimulation
The stop-start technique, originally described by Semans (1956),
is one of the skills that is most often associated with success at learn-
ing ejaculatory control. Remember the plateau phase of the sexual
response cycle, which we explained in chapter 2? Stop-start pacing
teaches you how to remain in the plateau phase for as long as you
choose without going on to orgasm. This technique blends behav-
ioral pacing (varying levels of physical stimulation) with cognitive
pacing (choosing a more or less arousing focus for your thoughts).
You learn to control your cognitive arousal by shifting between self-
entrancement arousal and partner interaction arousal (in the form of
fantasy).
Stop-Start Pacing
There are four stages of the stop-start training. Practice each stage at
least three times before moving on to the next stage. This is a
thirty-minute exercise, including fifteen minutes of general
relaxation followed by fifteen minutes of pleasuring your penis. The

approach varies according to the stage you are working on. First you
pause, then you simply slow the stimulation. Then you will add
fantasy (partner interaction arousal) to the mix.
The first half of the exercise is the same for all stages. Take a
few moments to get comfortable on your bed, and then spend fifteen
minutes gently and slowly touching and soothing your body all over
with the exception of your genitals. Use this time to focus on your
bodys sensations and calm yourself. From time to time during this
self-pleasuring, turn your attention to your PM. Tighten and relax it
several times to heighten your awareness of its level of relaxation.
Consciously direct your PM to relax.
1. Stimulation Pausing
In this stage, you practice using only self-entrancement arousal
and preventing ejaculatory inevitability by stopping stimulation.
After the fifteen minutes of relaxing touch and PM relaxation,
calmly shift your attention to your genitals. With a dry hand (no
lotion or other lubrication), masturbate for fifteen minutes without
ejaculation. Focus on your penis, attending to the pleasure, the sen-
sation. The first time you do this exercise, touch very calmly, very
slowly: a sensual fingering of your penis and testicles, groin, thighs.
At subsequent sessions, gradually increase your touching, stroking
and allowing yourself to become more excited. Do not rush. Do not
push it. Do not get carried away. Keep your attention only on the
sensations in your penis (no fantasy or distractions).
Eventually you will become more excited and feel that you are
approaching the point of ejaculatory inevitability. When you sense
this coming, stop the stimulation, hold your penis gently, and do
nothing but focus on the sensation in your penis. The urge to ejacu-
late will subside in fifteen seconds to three minutes. You may also
experience a partial loss of erection; this is common and nothing to
be concerned about. When the desire to ejaculate has passed, slowly
resume your masturbation. You will probably have to stop a number
of times to avoid ejaculation when you first do this exercise. Keep
your PM relaxed. Over time, you will learn how to recognize
approaching ejaculatory inevitability, how to anticipate the need to
stop, when to stop, and how long to wait. The number of times you
need to stop will gradually decrease.
Here are some problems you may have:
! You ejaculate with surprise. When this happens, usually you
are not focusing carefully on the sensations in your penis,
your PM is not as relaxed as you thought, or you are trying
too hard. Simply relax, play it safe (dont go too close to the
brink), and focus on the physical pleasure.
! You find you need to stop again as soon as you resume masturbat-
ing. This means that you are not allowing sufficient time for
the ejaculatory urge to diminish. Double the time you pause.
! You get discouraged and dont think you are making any progress
because you continue to ejaculate before you choose or the number
of required pauses does not diminish. This may mean that you
are too tense while doing the exercise. Calm your body while
you pleasure yourself. Be sure to monitor your PM. Be
patient.
When you feel confident of your ability to relax your body and
feel in control, and when you need only two or three stops during
the fifteen minutes, you can move on.
2. Stimulation Pacing
In this stage, you continue to use only self-entrancement

arousal, and this time you prevent ejaculatory inevitability by pacing
(slowing, not stopping) stimulation.
After the fifteen minutes of relaxing touch and PM relaxation,
masturbate for fifteen minutes without ejaculating and without stop-
ping or pausing. When you reach high levels of excitement, make
changes in your stimulation to decrease the arousal. You can slow
down the pace, change the pressure you are applying, vary the site
of maximum stimulation (for example, by stimulating only the shaft
of your penis rather than the tip), or change the type of stroking (for
example, using longer strokes or circular motions). Focus only on
your body; no fantasy! Remember to relax your PM and keep it
relaxed.
Find what works best for you to pace your arousal. Explore and
master this. With pacing rather than stopping, more subtle types of
adjustment need to be made a bit sooner. Do not hesitate to slow
early. If you make the change too late, you can always stop to pre-
vent ejaculation.
When you feel that you are doing well enough with this stage,
and youre not having to stop or pause, move on to stage 3.
3. Fantasy and Stimulation Pausing
This stage begins to incorporate partner interaction arousal.

You back off from the point of ejaculatory inevitability by stopping
stimulation.
During the fifteen minutes of self-pleasuring, begin to fantasize

about having sex with your partner. The idea is to move the focus of
your concentration back and forth from your own body (self-
entrancement arousal) to a fantasy of your partner (partner interac-
tion). Spend five to fifteen seconds on your sensations, then five to
fifteen seconds on the fantasy, then five seconds relaxing your PM.
Start the fantasy with the first touch or kiss, and go through the
stages that might occur in this imagined sexual event. You can use
the sexual arousal continuum you outlined earlier.
Take your time with the imagery! You dont have to get
through an entire sexual event in one session. Go slowly, calmly. Use
the stop-start technique, and when you stop, imagine pausing during
your fantasy sexual interaction with your lover. Imagine she is strok-
ing you, orally pleasuring you, or having intercourse, and picture
placing your hand on her hand to pause, wait, then resume. You are
mentally rehearsing the stop-start technique in preparation for inter-
course. Remember to keep your PM relaxed.
As you get better at this, try including in your fantasy compo-
nent the erotic images you find most stimulating: imagine your penis
entering her vagina, and imagine vigorous thrusting during
intercourse.
Dont get discouraged if your progress is slow. This is the more
challenging stage. Youre learning to balance your focus on your
own physical sensations, your PM, and your fantasyall while mon-
itoring how excited you are becoming. If you feel frustrated, simply
stop or pause sooner.
When you are comfortable and in control while fantasizing
erotic scenes, you are ready to move to stage 4.
4. Fantasy and Stimulation Pacing
This stage is identical to stage 3 except that now you pace (slow)
rather than pause. As you make adjustments in your masturbation,
imagine yourself making them in partner sex. Take it as slowly as you
need to. When this stage is going well, use a lubricant on your penis to
simulate the sensations of intercourse.
When you are comfortable with your individual ejaculatory

control, blending self-entrancement, partner interaction fantasy, and
PM relaxation, you are ready to learn couple stop-start pacing.
Step Nine: Couple Pacing Training

Goal: Learn to become highly aroused without ejaculating when your
partner is stimulating you
This is the teasing-can-be-fun step! This exercise teaches you to
integrate self-entrancement arousal, partner interaction arousal, and
PM relaxation while your partner is pleasuring you. This is where
you need your partners assistance and patience.
Couple Exercise:
Stop-Start Pacing
Couple stop-start pacing consists of four stages, just like individual
stop-start pacing. Each practice session takes one hour. Repeat each
step until you are relaxed doing it before moving on to the next.
Each session begins with thirty minutes of relaxed couple
pleasuring, which you learned in step six. Then, for fifteen minutes,
your partner directs you in pleasuring her body in whatever fashion
she wishes, allowing her to become highly aroused but without
going on to orgasm. The final fifteen minutes is different for each of
the four stages. As you work through these stages, be sure to com-
municate with your partner and keep your PM relaxed. All of the
suggestions for individual stop-start pacing apply here as well.
1. Pausing
During your fifteen minutes of arousal practice, guide your
partner to touch your penis and testicles, groin, and thighs calmly
and gently. Keep your attention only on the sensations in your penis
(that is, focus on self-entrancement arousal). When you feel that you
are approaching the point of ejaculatory inevitability, signal her to
stop stroking, pause, and gently hold your penis. Focus on the sensa-
tion as she holds you. When the desire to ejaculate has passed,
slowly resume stimulation.
2. Pacing
Instead of stopping or pausing to prevent ejaculation, work
with your partner to slow the stroking without stopping. Then
have her increase stimulation again when you are relaxed and not
at risk of ejaculating. Be sure to focus only on your sensations, not
on your partner. Remember that you can always stop to prevent
ejaculation.
3. Pausing with Partner Focus
Gradually shift the focus of your concentration from your own

sensations to enjoyment of your partner (looking at her or watching
her touch you) to relaxing your PM. When you first shift your focus
to your partner, be careful not to overstimulate yourselfremember
your arousal continuum. When you realize you are getting close to
ejaculatory inevitability, pause. As you progress, you may want to
use a lubricant on your penis to heighten the pleasure and more
closely simulate feelings of intercourse. You are training yourself to
enjoy more pleasure without ejaculating.
4. Pacing with Partner Focus
This final stage builds on stage 3 by slowing instead of pausing.
You are well on your way to learning to integrate relaxation,

cooperation, self-entrancement arousal, and partner interaction
arousal. You gain significant power by learning to control the pacing
of your arousal.
Mark and Lisa found that during the fifteen minutes Mark was
pleasuring Lisa, he had to focus carefully on the touch he was giv-
ing, on the physical sensation in his hand, and close his mind to
Lisas sounds and movementin short, he had to not watch the
erotic movie he was facilitating. At first, when Lisa was pleasuring
Mark, he needed to pause often, but by the third session he could
arouse close to ejaculation, keep his PM relaxed, and enjoy the plea-
sure of high arousal without ejaculating.
The key features of Marks work during this step were relaxing
the PM, focusing principally on sensual self-entrancement arousal
and then carefully beginning to allow some partner interaction focus,
and pacing the touch he received from Lisa. Monitoring these three
features was quite complicated at firsthe felt like he was juggling
too many thingsbut with repetition and his just-be-good-enough
attitude, it became easier and more comfortable.
Mark became concerned when he ejaculated during the second
exercise (pacing without partner focus). He was feeling relaxed,
enjoying the feel of Lisa stroking his penis, concentrating on the
pleasurable sensations, monitoring his PM to keep it relaxed, and
anticipating the point of inevitabilityand yet he still ejaculated.
When he later evaluated what happened, it became clear that while
he was doing all the right things, he still was allowing an erotic
movie to play out in his mind. Mark realized that even though he
was carefully orchestrating his focus, he was also having brief
images of partner interaction. He looked at Lisa stroking him,

glimpsed her breasts, her eyes, even had images of intercourse flash
through his mind. When he realized this, it made sense that he had
lost control and subsequently ejaculated. He was amazed to experi-
ence this power of his mind. By adjusting his mental focus, he could
regulate his arousal. It was a dramatic demonstration to Mark of the
difference between self-entrancement and partner interaction
arousal. This was one of his most important experiences in learning
to pace his sexual arousal.
Phase Three: Pleasure Saturation

In this phase, youll learn to experience prolonged intercourse and
enjoy more intense sexual stimulation without ejaculating quickly.
Youll learn to stay relaxed while welcoming the sensual pleasure of
intercourse. Pleasure saturationsoaking yourselves with plea-
sure is one of your rewards for learning ejaculatory control. Well
coach you as you integrate or orchestrate the skills to overcome PE
during intercourse. At first this might be awkward, but with practice
it will become second nature.
Step Ten: Intimate Intercourse

Goal: Learn to calmly adapt to intercourse
Mark and Lisa gained confidence from their success with
stop-start pacing, but both felt anxious about this next step. Inter-
course was where Mark had the most trouble controlling his arousal
and ejaculation. Their anxiety was understandable. Many men with
PE feel that intercourse is the ultimate test of their success in ejacula-
tory control.
This exercise will help you take the next step successfully by
showing you how to keep your PM relaxed during insertion and by
teaching you to stay relaxed while acclimating (adjusting) to the
sensation of your partners vagina.
Couple Exercise: Initiating and

Acclimating to Intercourse
Relax by doing thirty minutes of couple relaxed pleasuring. Then lie
on your back as your partner straddles you and helps you gain an
erection. Using only self-entrancement arousal (that is, focusing on
your own sensations), allow yourself to become aroused and erect.

When you are ready to begin intercourse, be sure your PM is relaxed
at the 2 or 3 level. This is particularly important at the moment of
starting intercourse because when she is inserting your penis, it is
natural for the PM to tighten or salute as a reflex. If you allow this
to happen, you are unwittingly tightening the very muscles involved
in ejaculation, thereby priming the pump. Relaxing the PM muscle,
especially during insertion, will offer some reserve.
While focusing on your penis, keep the PM relaxed while your
partner slowly inserts you. Once inside, simply rest, enjoying the
warmth and closeness. Focus on the pleasure in your penis. Wait,
calmly expecting to reach the physical pleasure saturation point
where your penis acclimates to the warmth and sensuousness of her
vagina. For most men, this sensation develops after approximately
ten to fifteen minutes of resting inside the vagina, but we have seen a
range of seven to twenty-seven minutes. Move only minimally to
maintain your erection. Your objective is to remain entirely passive,
alternating your attention between maintaining PM relaxation and
focusing on the pleasure in your penis. It is important to focus on
self-entrancement arousal throughout this step.
After acclimation occurs, you can begin to tolerate and enjoy
more intense pleasure while you maintain ejaculatory control. Enjoy
at least fifteen minutes of relaxed intercourse, then feel free to choose
to ejaculate. Rest for a moment to catch your breath, then stay with
your partner and pleasure her in whatever ways she prefers. She is
also now free to experience orgasm if she wishes.
When Mark and Lisa first tried this, it took Mark eighteen min-
utes of relaxed intercourse to begin to experience acclimation. The
sensation of acclimating is commonly vague at first, so we recom-
mend that you wait three minutes beyond when you think it is
happening, just to play it safe. The good news is that once you expe-
rience acclimation, it usually does not take as long in future sessions,
but at first ten, fifteen, or twenty minutes or longer is not unusual. In
successive sessions, Marks acclimating time lessened to about eight
minutes.
When the acclimation was established, he and Lisa began to
slowly move during intercourse. Mark maintained his focus on the
sensations of relaxed pleasure. At first he feared this would make
him ejaculate, and he was surprised to find it actually helped him
not to. Mark could accept the pleasure without moving to the point
of ejaculatory inevitability. They could pause or pace movement to
avoid ejaculation. Both were amazed that they were able to have
twenty minutes or more of careful intercourse after acclimating (for a

total of more than thirty minutes of intercourse), even though it was
reserved and subdued. Lisa said she loved the relaxed feeling of
closeness while calmly enjoying intercourse.
As Marks comfort increased, he was able to keep his PM at a 2
or 3 ranking as he focused on the pleasure in his penis. So Dr.
Hernandez suggested that Mark cautiously begin adding moments
of partner involvement arousal, focusing on Lisas body and move-
ments and even looking into Lisas eyes. After some shyness, they
both remarked how much they liked this. They were surprised that
this also felt calming and close.
Step Eleven: Progressive Intercourse

Goal: Integrate the skills and become open to spontaneity
Buoyed by their progress with the acclimating step, Mark and
Lisa decided they were ready to put together everything theyd
learned by trying progressive intercourse. They took thirty minutes at
the start of a session to enjoy pleasant, soothing touch. They talked
little, focusing on the pleasing sensations. At first they simply
enjoyed relaxed intercourse, waiting for the acclimating. When this
occurred, they began to enjoy slow, reserved intercourse movement
for ten minutes or so. At first only Lisa would do the moving (to
help Mark focus on relaxed pleasure), but gradually Mark and Lisa
would take turns moving, then move together cooperatively and
slowly.
Mark had some trouble keeping himself focused, but gradually
got into a pattern of alternately focusing on the pleasure in his penis
for fifteen seconds and monitoring his PM for five to ten seconds to
keep it relaxed.
When he became comfortable with this pattern, they switched
from Lisa on top to Mark on top. This required more careful man-
agement of PM relaxation because being on top uses the muscles dif-
ferently and makes it harder to relax them. Mark also had to be more
careful to stay focused on sensations in his own body. When this,
too, became easier, he began to add small doses of a third focus:
Lisa! Mark allowed himself five-second increments of partner inter-
action arousal (looking at Lisas body) before returning his attention
to the sensation in his penis, the PM, and his penis again.
Orchestrating this was taxing at first, but it worked because
their intercourse movement was slow. Mark was doing okay pacing
and didnt need to pause now. Slowly Mark became more comfort-
able and confident integrating PM relaxation, exquisite focus on the
pleasure in his penis, and calm and gradual inclusion of partner

interaction arousal.
During the fourth practice session of progressive intercourse,
Mark inadvertently ejaculated. His first emotional reaction was to
feel deeply despondent, but he was wonderfully helped by Lisas
gentle reminder that he was making such good progress. He also
realized his reaction was the same old negative onefeeling like a
failure. He caught himself and emotionally regrouped. He realized
that Lisa was correct: it was just a goof, not a relapse. He was making
good progress.
From this setback, Mark learned that he needed to guarantee
that acclimation had occurred by waiting an extra minute, and
needed to not get sloppy about maintaining his focus on self-
entrancement arousal, monitoring his PM, and being careful about
the partner interaction arousal. This is where the arousal continuum
he had designed earlier was helpful. When he evaluated what hap-
pened when he ejaculated without choosing to, he realized that he
was not only focusing less on his body and the PM, but also focusing
more on Lisas body and movements. Mark recognized that he had
made a mental mistake: he had shifted too quickly from a moder-
ately arousing item on his continuum (a 55 item, watching her
breasts as she moved up and down on me) to a highly arousing
item (a 90 item, imagining Lisa getting close to orgasm). This
confirmed for Mark the power of cognitive pacing.
Mark was able to accept more and more stimulation as he
balanced focus on the pleasure in his penis (self-entrancement), PM
relaxation, Lisas body and activity (partner interaction), and at times
imaginary items on his arousal continuum that were less exciting
than the actual activity he and Lisa were sharing. Here he was coor-
dinating four cognitive and behavioral pacing techniques, grounded
in physiological relaxation, within a cooperative relationship and
with the pause technique as a backup.
As Mark became more proficientand more confidenthe and
Lisa began to focus more on her feeling freer to do what she desired.
They had more sessions where Mark asked her to have intercourse
her waya kind of teasing with intercourse similar to the stop-start
teasing with manual stimulation. This allowed Lisa to loosen the
restraints she had felt for so long, and allowed Mark to practice his
cognitive pacing techniques. As Mark and Lisa cooperated more,
they increased their comfort, pleasure, and confidence. They were
focusing more on pleasure and closeness and less on ejaculation.
It was not all easy, however. There were good days and not-
so-good days. It took longer than they had wished. There were
moments of worry, sessions that bombed. They had to remind each
other what they were trying to do with each step so that they did not
revert to old ways of thinking, feeling, and acting. It took self-
discipline and cooperation. But they cooperated. They concentrated.
Their alliance and patience were indispensable. They were good
enough. They were feeling closer, warmer, more secure together.
They were succeeding.
Couple Exercise: Progressive

Intercourse
You are ready to experience more variety, excitement, and pleasure
during intercourse. Follow Mark and Lisas example. Remember to
establish intercourse acclimation and to balance your focus for ade-
quate management of arousal, but also allow yourself to enjoy
expanding your freedom with intercourse.
As you add partner interaction arousal, keep in mind your
arousal continuum. Dont drag race. That is, dont start at 50! Begin
slowly, gradually, gently. Stay focused on each specific activity or
image for at least fifteen seconds before changing. Shift attention in
small steps. Do not change from one focus to another that is more
than five points above.
If you have a setback, simply learn from it and regroup.
Remember, you are still learning to integrate the different dimen-
sions of arousal management. With practice, you will find coordinat-
ing your arousal becomes second nature, requiring less conscious
attention. This reopens your sexual relationship to more personal
feelings and deeper intimacy. Enjoy!
What If These Skills Dont

Work for You?
While this program is helpful for most men and couples, do not be
discouraged if some of the skills do not work as well for you. It is
not well understood why the same skills that help many men dont
work for othersor may even have the opposite effect. For example,
some men find that PM relaxation does not help. Rather, these men
find that tightening, holding, and exhausting the PM is more effec-
tive. So dont be afraid to experiment with how various techniques
work for your body. If you get stuck, it would be wise to consult
with an experienced marital and sex therapist to help you develop
your own way to integrate the skills for increasing ejaculatory con-
trol and sexual intimacy.
9
Couple Sexuality: Building

an Intimate, Interactive
Couple Sexual Style
Now that youve built solid skills to improve your sexual relation-
ship, youll want to consider how this fits into the big picture of
your relationship. Your relationship has undoubtedly changed as
youve learned the skills in this book. Youve developed new levels
of intimacy, communication, and closeness. This is a good time to
ask yourself what you want your relationship to be like, and how
sexuality will fit in.
You owe it to yourself and your partner to develop a comfort-
able, pleasurable, and functional couple sexual style. This will help
you maintain the progress youve made in dealing with PE and will
strengthen your long-term sexual and relationship satisfaction. Healthy
sexuality is a team effort, not an individual performance. Emotional
and sexual intimacy is the glue of your couple bond. Your intimate
relationship is the energy source for a vital, satisfying sexuality.
The traditional belief was that the more emotional intimacy, the
better the marriage. In fact, that is a myth. A crucial factor in devel-
oping a cooperative marital style is maintaining balance between
autonomy and intimacy; that is, balance between individuality and
couple focus.
In this chapter, well take a look at the common marital styles
and the role sexuality plays in each. We will examine both strengths
and potential problems of each marital and sexual style. We will also
examine dating and serious relationships and the role of sexuality in

these. Finally, well guide you through actively and consciously
choosing a couple style that works for you.
Marital and Sexual Styles

There are four marital styles. In their order of frequency, they are
complementary, conflict minimizing, best friend, and emotionally expres-
sive. Of course, these are not pure categories, but one style commonly
predominates for a given couple. Each style describes a different
approach to intimacy, autonomy, communication, power dynamics,
and the role of sex within the relationship, as well as a different
approach to initiating sex, interacting during sex, and ending sexual
encounters.
The Complementary Couple Style

The complementary couple style is the most common. The
partners respect each others contributions, each partner has his or
her domain of competence and power, and each values moderate
intimacy balanced by a clear sense of autonomy. These couples are
able to resolve conflicts and maintain dialogue about difficult issues.
Each partner feels valued, respected, and cared for. The emotional
tone of the relationship is affirming.
Complementary couples have a good sexual relationship, see-
ing sexuality as a positive, integral component in the marriage but
certainly not the most important factor.
The trap for this marital style is to fall into a pattern of routine,
mechanical sex. Sex becomes a low priority, occurring late at night
after all the important things in life (like putting the children to sleep,
paying bills, walking the dog, and watching the The Tonight Show) are
done. Sex might be functional (for instance, the man maintains good
ejaculatory control), but it lacks excitement and emotional intimacy.
The couple thinks about their premarital sexual experiencesand
possibly their experience working together to learn ejaculatory
controland they miss that sense of connection and specialness.
Marital sexuality cannot rest on its past success; setting aside
couple time and valuing intimate sexuality are crucial. To maintain
healthy sexuality, complementary couples can decide to make sexual
initiation a shared domain, or one spouse can claim it as his or her
domain. Ideally, each spouse would be comfortable initiating and
each would feel free to say no and perhaps offer an alternative way
to connect.
Couple Sexuality: Building an Intimate, Interactive Couple Sexual Style 141
Traditionally, it is the male who makes sexuality his domain.

This is fine as long as he is committed to maintaining a satisfying
sexuality. The danger is that he might overemphasize intercourse as
a performance at the expense of intimacy, affection, and pleasuring.
Improved ejaculatory control alone will not be enough to ensure the
womans anticipation, pleasure, and satisfaction. The other danger,
especially with the aging of the people and the marriage, is that the
mans focus on performance and intercourse subverts satisfaction. A
broad-based, variable, flexible approach to couple sexuality is more
likely to promote desire and satisfaction, and helps inoculate the
couple against sexual dysfunction. Maintaining a vital sexual rela-
tionship is a couple task, with the womans sexual feelings and
voice playing an integral role.
The Conflict-Minimizing Couple Style

The conflict-minimizing couple style is the most stable. These
marriages are usually organized along traditional gender roles, with
the man as the prime income generator and the woman the home-
maker, although other patterns are common in recent years. They are
characterized by avoidance of strong emotional expression (espe-
cially anger), limited intimacy, and emphasis on children, family,
and religious values. The emotional and practical rules of the mar-
riage are clearly understood and consistently implemented. Conflict-
minimizing couples value security over intimacy and family over the
couple relationship. People value this marital style because of the
predictability and security.
The role of sex is de-emphasized. Often, the limited emotional
expression in these relationships results in inhibited erotic expres-
sion. Sexual problems are typically minimized. The couple avoids
confronting sexual issues.
Initiating sex and establishing sexual frequency is viewed as
the mans role. The sexual scenario emphasizes intercourse, with a
focus on one-way foreplay rather than mutual pleasuring. The expec-
tation is that she will function like him: have a single orgasm during
intercourse. Sex is his domain, affection and feelings are her domain.
There are several possible sexual traps with this marital style.
The biggest is that sex becomes marginal and mechanical, and even-
tually very infrequent. The couple falls into the cycle of a low-sex or
no-sex marriage. Another trap is that the focus on intercourse makes
the man vulnerable to erectile dysfunction and inhibited sexual
desire as he ages. When couples stop having sex, whether at forty,
sixty, or eighty, it is almost always the mans unilateral, unspoken
decision. He is too frustrated and embarrassed by sexual problems
and decides sex is not worth the effort. The partners have not been
intimate friends, which makes it hard to develop intimate, interactive
sexuality.
Conflict-minimizing couples miss the opportunity to use con-
flicts to deepen intimacy, and underplay the positive role of sexual-
ity in sharing pleasure and energizing their marital bond. We urge
couples who choose this marital style to be sure that sexuality,
including enjoying ejaculatory control and intercourse, plays a
healthy 15 to 20 percent role in marital vitality and satisfaction.
The Best Friend Couple Style

The best friend couple style is characterized by the highest
degree of intimacy, acceptance, and sharing; equitable distribution of
roles and responsibilities; and a strong commitment to a close, vital
marriage. Although this is the cultural ideal, this marital style runs the
risk of leading to disappointment and alienation when emotional and
sexual expectations are not met or there are irresolvable conflicts.
When both individuals choose this marital style and devote the
time and psychological energy to make it successful, this can be a
very impressive marriage. However, it is not the right marital style
for the majority of couples. Best friend couples have a high divorce
rate, based on disappointment and resentment toward the spouse
and the marriage. The marriage cannot live up to the love means
never having to say youre sorry promise.
Sex is a positive, integral, vital resource. Sexuality energizes the
marital bond and makes it special. The couple enjoys touching both
inside and outside the bedroom. Intimacy, pleasuring, and eroticism
are valued by both people and integrated into their lovemaking.
They develop a sexual style that is flexible and responsive to the feel-
ings and preferences of both partners.
What are the traps of this marital style? The biggest emotional
trap is relationship enmeshment, meaning that the couple sacrifices
autonomy and individuality for the sake of the couple bond. When
things do not work well, they may regress to hurt, blaming, and
resentment. Disappointment and disillusion rob the marriage of
vitality. The couple lacks conflict resolution skills and is bitter over
thwarted hopes and expectations.
The biggest sexual trap is inhibited sexual desire. Ideally, inti-
macy and couple time serve as bridges to sexual desire, but too
much intimacy can stifle erotic feelings. In truth, either too little or
too much intimacy can subvert desire. If the couple is so emotionally
close that they cannot make sexual requests, if they de-eroticize each
other, or if they are so worried about hurting each other that they do
not share negative sexual feelings, they are in trouble. They need to
have a mutually comfortable level of intimacy that promotes connec-
tion and sexual desire.
Best friend couples are not assertive in dealing with sexual
dysfunction or dissatisfaction. They expect that each should know
what the other is thinking and what the other wants without having
to ask or explain. The cultural myth is that love is all we need. But
when there is a sexual dysfunction, love is not enough. Warm feel-
ings and caring communication are very helpful, but are not enough
to overcome PE and maintain a satisfying sexual relationship. The
combination of taking personal responsibility and working as an
intimate team can be a challenge for best friend couples. They often
become stuck in a cycle of avoidance, not wanting to push the other,
waiting for the other to initiate. Avoidance compounds the sexual
problem.
The Emotionally Expressive Couple Style

The emotionally expressive couple style is the most volatile and
unstable, but the most engaging, fun, and erotic. Intimacy in this
style is like an accordion: sometimes very close, other times very dis-
tant. Emotionally expressive couples have the highest intensity of
feelings, both loving and angry. These couples value intimacy and
vitality without being afraid of conflict or anger. When this marital
style works well, the couple has a vibrant and exciting relationship.
They value sexuality that is spontaneous, adventuresome, playful,
and energizing.
Unfortunately, this is the most unstable marital style, the most
likely to result in divorce. The conflicts become too frequent and
intense. Emotionally expressive couples can deal with disappoint-
ment, anger, and conflict, but if they cross the line into personal
put-downs, contempt, and disrespect, this breaks the marital bond.
There are a number of potential sexual problems. A particularly
unhealthy pattern is to use sex to make up after an abusive fight. It is
poisonous for physical or emotional fights to serve as foreplay for
sex. Another problem is that a gradual, step-by-step approach to
dealing with PE or another sexual dysfunctionor a relapseis not
compatible with this couple style. They want a more spontaneous,
freewheeling approach. If the sexual problem is not quickly resolved,
they fall into the trap of feeling demoralized, bitter, and blaming.
Problematic sex increases the risk of an affair or breakup.
To combat these traps, the emotionally expressive couple needs
to remain aware of respecting personal and sexual boundaries. If
there is a sexual problem or dysfunction, they must address it with-

out putting down the spouse or destabilizing the relationship.
Choosing a Marital and

Sexual Style
It is important for you and your partner to adopt a couple style,
especially in how you deal with intimacy and conflicts. It is crucial
that you adopt a sexual style that is compatible with, and hopefully
enhances, your marital style. One style is not better than another, but
mutual endorsement of your chosen couple and sexual style is part
of being a marital team. It is not the mans (or the womans) decision
to make alone, but a cooperative choice based on respect and empa-
thy for each spouses preferences, needs, and values.
As you choose your style, the two most important issues to
address are the amount of intimacy and the importance of sexuality.
Intimacy includes sexuality, but is much more than sexuality. Espe-
cially important in emotional intimacy is the degree and quality of
personal self-disclosure and empathy. Sexual intimacy includes
affectionate, playful, sensual, and erotic touch in addition to inter-
course. An example of a problematic intimacy and sexuality pattern
is when one spouse (typically the woman) desires high levels of
emotional intimacy, while the other spouse wants sex to be the main
source of connection. This couple is likely to have a pursuer and a
distancer. When couples fall into the pursuer-distancer trap, both
emotional intimacy and sexuality suffer. Sex ought not to become a
power struggle, but a mutual, voluntary, and pleasure-oriented
experience within an emotionally satisfying relationship.
Traditional sexual socialization dictates that males value sexual
frequency and eroticism while females value intimacy and affection.
This generates heated arguments on talk shows and in bars, but
sheds little light on the reality and complexity of couple sexuality. To
honestly assess your desires about your sexual relationship, you and
your partner need to look beyond rigid sex roles. This may be partic-
ularly difficult for conflict-minimizing couples.
In choosing the marital and sexual style thats right for you,
discuss together the strengths and vulnerabilities of each style. For
example, the sexual style least impacted by PE and other sexual
problems is the conflict-minimizing style. Sexual expectations are
lower and sexual problems de-emphasized. Marital rules are very
important for conflict-minimizing couples. Yet these couples face
crises when an affair violates the core rule of fidelity or an infertility
problem threatens the core value of family. So a conflict-minimizing
couple may be able to take PE in stride, but may be less resilient in

other ways.
Nick and Donnas Story

Before Nick and Donna started working on ejaculatory control
together, Nick had given no thought to a couple or sexual style; his
focus was on intercourse frequency as a way to compensate for PE.
Donna had hoped for a best friend marriage with abundant commu-
nication and touching. If anything, Nick tended toward the conflict-
minimizing style, and he especially did not want to talk about sexual
problems. Nicks emphasis on intercourse, Donnas frustration with
the chronic PE, her disappointment with his reluctance to talk about
sexual issues, and her resentment at always being the one to reach
out for affection upset her deeply. She questioned Nicks commit-
ment and the viability of the marriage.
The ejaculatory control program was successful for Nick and
Donna. Much to Nicks surprise, slowing down the sexual process,
focusing on pleasure, taking medication (Nick had neurologic system
PE), and especially learning to do a good-enough job of using the
psychosexual skills dramatically improved their sexual enjoyment
and satisfaction. Donna enjoyed her role as an active, involved
spouse during the ejaculatory control exercises. Nick appreciated
Donna as an intimate ally in facing up to and changing PE.
Nick was now willing to address general relationship issues as
well as a PE relapse prevention program. Donna appreciated this,
but was still bothered by Nicks reluctance to discuss emotional
issues. Finally, Nick disclosed that he feared that Donnas demands
for emotional intimacy were really a hidden agenda to limit his
personal autonomy. He was afraid she did not so much want to be
close to him as to overwhelm him emotionally and be critical of him.
Donna had grown up with the cultural myth that the more intimacy,
the better. Nick reassured her that he loved her and valued the
marriage but did not want to lose his autonomy or feel smothered.
Contrary to gender myths, men have similar needs for intimacy
and security as women. The difference is not in needs, but in fears.
The man fears being controlled or being seen as deficient or failing
his partner. As they discussed their feelings, preferences, and fears, it
became clear to Nick and Donna that a complementary couple style
would fit them best. This allowed a balance of autonomy and togeth-
erness, with moderate amounts of emotional intimacy, and fit well
with the personal responsibilityintimate team approach to sexuality.
Both Nick and Donna were highly motivated to maintain their
sexual gains around ejaculatory control and sexual enjoyment and
not allow a relapse. It was important to Nick that Donna realize that
he was more emotionally open to her than to any other person in his
life, and that he highly valued her and the marriage and enjoyed
marital sexuality. At the same time, he needed to have a personal
and emotional life apart from her. He especially wanted the freedom
to hang out with his buddies from the soccer team, and the time and
space to keep active in local politics. This was not a rejection of
Donna, but something which was healthy for him. Nick was an
antsy, high-energy guy who found sitting and talking about feelings
uncomfortable. He and Donna developed a pattern of doing house
chores in tandem and talking about emotional, sexual, and life-
planning issues as they worked side by side.
Men in Dating or
Living-Together Relationships
Many men with PE are single, divorced, or in cohabitating relation-
ships. How do the couple and sexual styles relate to them? Consider
that there are three levels of relationship connection: sexual friend-
ships, lover relationships, and serious relationships. At all levels of a
relationship, there are two important guidelines. The first is to treat
the woman with respect and have an understanding that you will try
to not do anything emotionally or sexually that is harmful to her or
to yourself. The second is to be realistic about the relationship and
not to overpromise or be manipulative.
A sexual friendship relationship is just what it sounds like: you
are friends who have an active sexual relationship. As with any other
friendship, you want to treat the person well, expect to be treated
well in turn, and freely share activities and emotions. However, you
do not promise a lifelong relationship or change life plans, career, or
where you live for the woman, nor do you ask her to make those
changes for you. Both people are direct and clear about their expecta-
tions. Whether the relationship lasts six months or three years, the
reality is it will end. Hopefully, you wish each other well and remain
friends, but there are no guarantees.
The lover relationship involves more closeness, more sharing
(you may or may not live together), and more of an emotional
investment. Lovers meet each others families, make long-term vaca-
tion and holiday plans, and integrate each other into their lives.
However, you do not change your life or career plans for a lover.
You do not promise a lifetime commitment or plan to have children
in a lover relationship.
The serious relationship has the potential to result in marriage.

This is the type of relationship in which you consider changing your
life in tandem with your partner and discuss all the hard and sensi-
tive issues involved in sharing your lives emotionally, practically,
financially, and sexually.
Issues of respect, trust, and emotional and sexual intimacy are
just as relevant for nonmarried couples as for married ones. How-
ever, sexualityincluding PEshould not make or break the future
of the relationship. For example, the fact that the woman helped you
with ejaculatory control does not mean that you owe heror that
she owes youa lifelong commitment. Conversely, struggling with a
sexual dysfunction is problematic but need not be a reason to termi-
nate a relationship. As in a marriage, sexuality should play an
important but not primary role.
Developing Your Couple Sexual Style

Your task is to establish your unique sexual style by exploring and
sharing your sexual desires, feelings, and preferences. This exercise
is divided into phases, the first to do individually. Then youll share
your thoughts and reach understandings and agreements about your
unique couple style. Youll discover what is uniquely and mutually
pleasurable and satisfying for you.
Exercise: Developing Your

Couple Sexual Style
1. Think about and then write out (this makes it more concrete) the
answers to the following questions. Do not be politically correct
or try to second-guess your partner. Be free and explicit.
! How much intimacy do you want in your life and
relationship?
! What are the most important emotions you want to share in
your relationship?
! What is your preferred way to deal with differences and
conflicts?
! What is your preferred couple style: complementary, conflict
minimizing, best friend, or emotionally expressive?
! How important is sex in your life? How important is your
relationship?
! In terms of affectionate touch, do you prefer kissing, holding

hands, or hugging?
! How much do you enjoy cuddling? How important is it to
you?
! How do you distinguish affectionate touch from seductive or
sensual touch?
! How much do you enjoy sensual touch? Do you prefer
taking turns or mutually giving and receiving?
! What is the meaning and value of playful touching? How
comfortable are you with affectionate nicknames for your
genitals?
! How much do you enjoy erotic scenarios and techniques? Do
you prefer single stimulation or multiple stimulation, taking
turns or mutual stimulation, using external stimuli or not?
Do you enjoy erotic sex as a route to orgasm or only as a
pleasuring experience?
! What is your preferred intercourse position? Man on top,
woman on top, rear entry, side to side? What type of thrust-
ing do you prefer? In and out? Circular? Deep inside? Shal-
low? Do you want to engage in multiple stimulation during
intercourse?
! How much do you value afterplay as a part of your love-
making style?
2. Read your partners responses and then carefully discuss together
each question, clarifying both the practical and emotional dimen-
sions. Remember that you are not clones of each other. You want
to maintain your individuality and not feel embarrassed or apolo-
getic about your emotional and sexual desires. Your preferences
and sensitivities are part of who you are as a sexual person and
must be integrated into your couple style for you to be truly
satisfied.
3. Divide your answers into three categories:
Areas you agree on. These will enhance your enjoyment and satis-
faction with each other and your relationship. For example, you both
agree that you want a complementary couple style. You want sex to
play a 15 to 20 percent energizing role; there are no major sexual
secrets or conflicts; you both enjoy affectionate and playful touch
more than sensual touch; on occasion you find erotic sex to orgasm
highly satisfying; you agree on two favorite intercourse positions;
and you both value quiet, bonding afterplay.
Areas you can reach agreement on. Identify differences you can
accept and perhaps even enjoy. Perhaps one spouse prefers a
conflict-minimizing couple style while the other wants the closeness
of the complementary style; one partner values sharing daily feelings
and experiences while the other is more emotionally reserved; the
spouse who puts more value on sex agrees to be the prime initiator;
one person prefers kissing and the other holding hands; one would
rather do sexual touching standing up and the other likes lying in bed;
he likes verbalizing sexual fantasies while she likes to close her eyes
and fantasize; she likes to switch intercourse positions while he pre-
fers to be on top. These are not matters of right or wrong. You can
integrate your preferences or take turns. Enjoy your partners sexual
style. Remember, an involved, aroused partner is the best aphrodisiac.
Differences to accept or adapt to. Finally, when there are genuine

major differences between you, work to accept or adapt to them. For
example, one wants a conflict-minimizing relationship while the other
wants an emotionally expressive style; one puts a very high priority
on sex while the other is indifferent; one wants a daily sensual
massage and the other hates massage; she wants to use a vibrator dur-
ing intercourse to help her be orgasmic and he is turned off by the
vibrator; he wants to try a variety of intercourse positions but she
strongly prefers rear entry; he likes being sexual early in the morning
while she only wants to be sexual late at night; he wants to experi-
ment with swinging relationships and she values monogamy. It is not
easy, or even possible, to integrate many of these differences, but there
are two major coping strategies. One is to acknowledge your differ-
ences but not let them turn into a power struggle. Instead, accept them
and try to work around them. It helps to remember that difference
does not equal rejection. The second strategy is to agree to enter
couple therapy to understand the meaning of the differences, and,
with the help of the professional, find a common ground for intimacy
and sexuality.
The goal of this exercise is to develop a comfortable, pleasur-

able, functional, and mutually satisfying couple sexual style. This
exercise encourages you to take personal responsibility for your
sexuality and to grow as a unique, intimate team.
You can be proud of yourselves for working together to
address PE and improve ejaculatory control. In sharing emotional
and sexual feelings and preferences, youll increase understanding,
empathy, and acceptance. This will provide the foundation for a
couple sexual style that ensures both satisfaction and security.
10
Enjoying Sex and

Preventing Relapse
It took time, energy, and cooperation for you to learn ejaculatory

control. You cannot rest on your laurels; you need to devote time
and energy to maintain a vital sexuality and prevent relapse. To now
expect that PE will never reoccur is unrealistic and sets you up for
feelings of failure and sets the couple up to return to the
blame-counterblame cycle. Positive, realistic expectations include
accepting that arousal and orgasm are inherently variable. Whether
once every ten times, once a month, or once a year, rapid ejaculation
will reoccur. This is a normal part of good-enough sex. The reality is
that rapid ejaculation is an occasional part of most couples sexual
experience, even invited: a quickie. Especially important is to not
panic and feel you are back to square one each time you experience
rapid ejaculation. The key is to accept the occasional episode of rapid
ejaculation as normal, treat it as a lapse, and commit to not allowing
it to become a pattern (relapse).
In this chapter, well help you develop a personal, specific
relapse prevention plan. It is crucial that you decide how youll
respond when PE occurs rather than hope it will magically never
happen again. Well take a look at the cognitive, behavioral, and
emotional foundations of relapse prevention. Well briefly review the
key concepts from the ejaculatory control program. Then we will
present ten specific strategies and techniques to promote healthy
sexuality and prevent relapse. You can choose two to four strategies
that are relevant to you and incorporate them in your couple sexual
style.
The Foundation of Relapse

Prevention
Youve already formed the basis for relapse prevention by develop-
ing a comprehensive understanding of PE, identifying all the factors
contributing to your PE, using all your resources, learning a range of
steps and skills, following the personal responsibilityintimate team
model of change, and building a couple sexual style that integrates
intimacy, pleasuring, and eroticism and emphasizes realistic expecta-
tions of ejaculatory control and couple sex.
You can think of relapse prevention in terms of its cognitive,
behavioral, and emotional foundations.
The Cognitive Foundation of Relapse Prevention

The most important cognitive approach to preventing relapse is
to accept that on occasion you will ejaculate rapidly. Treat these
experiences as a normal variation, not a cue for anticipatory or
performance anxiety. This allows you (and your partner) to think of
the experience as a lapse but not be afraid of a relapse. Cognitively,
you can approach the next encounter with positive anticipation,
relaxing more, using more self-entrancement arousal, enjoying a
pleasurable buildup of stimulation, perhaps purposely using slow-
down or stop-start pacing, and inviting your partner to control the
type and speed of intercourse thrusting.
A key to relapse prevention is shifting your focus from perfor-
mance-oriented intercourse to involvement in the whole lovemaking
process, affection through afterplay. Intercourse is the natural exten-
sion of intimacy, pleasuring, and eroticism. It is a continuation of the
pleasuring process, not a pass-fail test apart from this. Decide to let
the length of intercourse vary with your desires. The skills you have
learned will aid you in maintaining reasonable control over when
you choose to ejaculate. Keep the perspective that you are sharing
with your partner, not performing for her.
Think of your partner as your intimate friend whose pleasure
and arousal feed yours rather than as a demanding critic for whom
you must perform. Welcome her arousal, especially during inter-
course, rather than feeling intimidated that she has to hold back so
you do not ejaculate. Enjoy both her arousal and your own. Enjoy
Enjoying Sex and Preventing Relapse 153
your orgasm as well as her orgasm; orgasm need not occur in perfect
sequence for it to be satisfying.
Our concept of good-enough ejaculatory control and a good-
enough sexual relationship is crucial for relapse prevention. Decide
that your goal is to be good enough, not perfect.
The Behavioral Foundation of Relapse Prevention

The most important behavioral foundation for relapse preven-
tion is to generalize your comfort and confidence with stop-start and
arousal pacing techniques. You learned these skills in a systematic
manner in the ejaculatory control exercises; now the challenge is to
use them in unstructured, spontaneous sex to maintain good-enough
ejaculatory control. Youll need to integrate these techniques into
your couple sexual style. If there has been a break in your regular
rhythm of sexual intercourse (if one of you has been traveling or has
been ill), you may find it helpful to briefly return to using the
techniques in a more structured way.
You want to aim for sexual encounters that involve a relaxed
sexual pace (not drag racing); giving and receiving pleasure-oriented
touching; being comfortable with the plateau phase and maintaining
arousal; transitioning to intercourse as a continuation of the pleasur-
ing process; monitoring your PM, using intercourse acclimation if
needed; varying intercourse movements (such as using circular or
longer strokes) at moderate levels of speed; moving to orgasm as a
natural extension of the erotic flow; enjoying the orgasmic
experience physically, emotionally, and relationally; and being an
active participant in the afterplay phase.
Ejaculatory control requires a regular rhythm of sexual experi-
ences with both people being involved and valuing their sexual
relationship. The risk is regressing to infrequent, low-quality sex,
which promotes a return to PE.
The Emotional Foundation of Relapse Prevention

Interpersonally, an important relapse prevention approach is to
value and reinforce your couple sexual style and to view each other
as intimate friends. Your feelings for each other are the glue that
bonds you. Personal responsibility for sexuality, emotional sharing,
and being an intimate team are ongoing parts of your life and
relationship. Especially important is setting aside quality couple time
when you share feelings and are empathic about your life and rela-
tionship, including your sexuality. You want to enjoy a broad-based,
flexible couple style that integrates emotional intimacy, pleasuring,

and eroticism.
Key Concepts in Ejaculatory Control

As you develop your couple sexual style and work to maintain ejac-
ulatory control, youll want to keep in mind the key concepts youve
learned. Consider which concepts were the most difficult for you to
master. These are the ones that will need your continued attention in
order to prevent relapse.
! Premature ejaculation is the most frequent male sexual prob-
lem. The majority of adolescents and young adults begin as
rapid ejaculators. Thirty percent of adult males complain of
quick ejaculation.
! Realistic expectations and goals are crucial. Base them on the

physical realities of your body, accurate knowledge, and the
principle of just being good enough.
! Do-it-yourself techniques to reduce arousal do not help in

gaining ejaculatory control. By interfering with arousal, these
techniques can cause erectile dysfunction.
! The strategy for ejaculatory control is counterintuitive.

Rather than decreasing pleasure, you want to increase
comfort, awareness, and pleasure.
! The important individual skills for ejaculatory control are

physical relaxation during lovemaking, balancing sensual
self-entrancement and partner interaction arousal focus, PM
relaxation, and cognitive and behavioral arousal pacing.
! Ejaculatory control requires you to identify the point of

ejaculatory inevitability and maintain awareness at high
levels of arousal.
! Ejaculatory control during partner sex, especially inter-

course, is complex and challenging.
! Only one in four women have the same response pattern as

men (a single orgasm during intercourse). The goal of ejacu-
latory control is not to guarantee that your partner has an
orgasm during intercourse. The goal is to increase pleasure
and eroticism for both of you.
! Three of the most effective behavioral tools are PM relax-

ation, the stop-start technique, and the intercourse acclima-
tion technique.
! Learning ejaculatory control is a gradual process requiring
practice and feedback. If your PE is severe, you should not
skip any of the steps in chapter 8.
! Relax your PM as much as possible as you initiate inter-
course to give your body some margin for ejaculatory
control.
! When you begin learning ejaculatory control during inter-
course, begin with the woman-on-top position and be sure to
allow enough time for acclimation.
! Other intercourse positions are more challenging. Utilize
longer, slower thrusting or circular thrusting. Alternate
which partner controls the thrusting. Ejaculatory control is
most difficult in the man-on-top position with short, rapid
thrusting.
! Sensations of orgasm begin at the point of ejaculatory inevi-
tability. Once you reach the point of inevitability, theres no
turning back. Whether you arrive there prematurely or
voluntarily, enjoy the feelings and sensations and do not be
upset or angry. Beating up on yourself does not facilitate
ejaculatory control.
! Your partners emotional and sexual feelings are very impor-
tant. Her role is an intimate, involved partner. You can
pleasure her to arousal and orgasm with manual, oral,
rubbing, or vibrator stimulation. Most women prefer this
before ejaculation, but some prefer after. Sex does not end
when you ejaculate.
! Remember that you can use medication as an additional
resource, especially if you have neurologic system PE (your
quick ejaculatory response is hardwired). You can practice
ejaculatory control exercises while taking medication and
then gradually eliminate medication (be sure to talk with
your doctor).
! Sexuality is about giving and receiving pleasure, not
performing perfectly. Enjoy and share the entire sexual expe-
rience: intimacy, pleasure, eroticism, arousal, intercourse,
and afterplay.
Jonathan and Angelas Story

For most of the eight years they had been together (the last six
as a married couple), Jonathan had a severe, chronic PE pattern. The
sexual problem did not affect Angelas feelings of love for Jonathan
or her commitment to the marriage, but it did have a negative impact
on their sexual relationship. Angela began to have trouble with
sexual desire, arousal, and orgasm.
Jonathan and Angela had a complementary couple style that fit
them well in most ways, but sexuality did not play the 15 to 20 per-
cent energizing role. For Angela, sexuality was a disappointment but
not a major factor in her life. Their four-year-old son and two-year-
old daughter kept them busy; that was Angelas rationale for why
they were sexual only two to three times a month. If she asked,
Jonathan would manually stimulate her before moving to inter-
course, and usually Angela would be orgasmic. However, over time
and because of the children, Angela began to settle for quick inter-
course and became reluctant to ask for the time and stimulation to
meet her sexual needs.
Jonathan did not like to think about the PE problem. He
alternated between blaming himself and blaming Angela. Jonathan
especially blamed Angela for the infrequency of sex. He wistfully
recalled the first eight months of their relationship, when they had
sex each time they were together and neither Jonathan nor Angela
worried about PE.
It was not until they were engaged that Angela tactfully told
Jonathan that she would enjoy sex more if it was slower and more
loving. Jonathan wanted to please Angela, but was not clear about
what she meant. He did spend more time on kissing and caressing,
but as soon as Angelas underwear was off, Jonathan focused on
manually stimulating her to orgasm, which he found very arousing.
As soon as she was orgasmic he would enter her, and after a few
rapid, exciting strokes he would ejaculate. Jonathan felt good about
their sexual life; his only complaint was frequency. He assumed she
was pleased because she was easily orgasmic with manual stimula-
tion and did not say anything to the contrary.
During and after their first pregnancy (which was wanted and
planned), there was a significant decrease in sexual frequency. The
second pregnancy was unplanned, but their daughter was very much
wanted. Two young children and sleep deprivation wiped out
Angelas sexual receptivity and responsivity, but not Jonathans. They
fell into a push-pull power struggle over frequency of intercourse.
After a particularly rushed intercourse, Jonathan asked whether
she would like to make love again and offered to stimulate her to
orgasm first. Angela felt put upon, and told him so. Jonathan
responded in what he thought was a joking manner about mothers
not being very sexy. Angela found this objectionable and told him to
stop being so self-centered, that he should be glad she was willing to
put up with his PE. Jonathan and Angela had fallen into the trap of
arguing about sex while naked and vulnerable, right after a sexual
encounteralways a bad idea.
Angela wanted to enhance intimacy and pleasuring in the
marriage, while Jonathan wanted to increase the frequency of sexual
intercourse. These are not incompatible goals, but Angela and
Jonathan needed to communicate and work together to improve
their sexual relationship.
A crucial step was to determine what type of PE Jonathan had.
Together, they completed the PE diagnostic process in chapter 4.
Angela encouraged Jonathan to seek help, realizing that his PE was
lifelong, occurred in all situations, and was neurologically based.
Angela accompanied Jonathan to his appointment with the internist,
who agreed that he was suffering from the neurological system type
of PE. It was Angela who encouraged a full treatment plan: taking
medication, learning psychosexual skills, and increasing empathy
and intimacy. Jonathan had been so caught up in embarrassment
about having PE that he found it hard to have frank talks about PE
and what it meant to Angela and to the relationship.
The internist asked if they wanted a referral to a psychologist
or a sex therapist, but they decided to work together to try methods
such as those in this book first. Angela said she was open to couple
sex therapy if there was not significant improvement after six
months. Jonathan was motivated to address PE as a couple, partly
because he was anxious about sex therapy. (Typically, men are very
willing to attend sex therapy if there is a female dysfunction, but
much more hesitant if there is a male dysfunction.)
With Jonathan more aware and motivated, Angela playing an
active role in improving psychosexual skills, the use of Zoloft, and
increased empathy and cooperation, they saw gradual but quite sig-
nificant improvement in ejaculatory control and much improvement
in sexual frequency and satisfaction. What made the most difference
for Jonathan was using pelvic muscle exercises, learning to enjoy slow,
sensual stimulation, and utilizing circular thrusting during inter-
course. What made the most difference for Angela was increasing
nongenital and genital pleasuring, using multiple stimulation during
intercourse, and developing enjoyable afterplay scenarios.
The issue that now concerned Jonathan and Angela was how to
maintain and generalize their sexual gains and ensure that they did
not relapse. Jonathans biggest question was whether he needed to
continue taking medication or could wean himself from it. Angela

wanted assurance that even when they no longer had to schedule
time to do sexual exercises, they would still make time for each other
and nurture their intimate bond. Jonathan made an appointment
with his internist, who helped him develop a schedule to slowly
reduce medication. Angela told Jonathan that she valued sensual,
playful touch as well as erotic touch and intercourse.
The relapse prevention strategy that mattered most to Angela
was setting aside couple time every six to eight weeks when there
was a specific ban on intercourse. This allowed them to experiment
with both sensual and erotic scenarios to maintain a sense of sexual
adventure and realize that not all sexual touch had to result in inter-
course. The relapse prevention strategy that mattered most to Jona-
than was purposefully enjoying the sensations at the plateau phase
rather than quickly moving to intercourse, as well as using a variety
of intercourse positions and types and rhythms of thrusting. The
hardest thing for Jonathan was accepting that it was okay to enjoy
the feelings of orgasm when he ejaculated before he would have
chosen to. Jonathan accepted that a pleasure orientation was health-
ier than a performance orientation. When Jonathan did experience a
rapid ejaculation lapse, he did not go away but instead held and
pleasured Angela. To ensure that he did not become self-conscious
about the early ejaculation, they would try to have another sexual
encounter in the next one to three days. Jonathan enjoyed spending
more time in the pleasuring, intercourse, and afterplay phases.
Even though they had two careers, two growing children, and a
busy life, Jonathan and Angela set aside time to be an intimate sex-
ual couple. Sexual intercourse and ejaculatory control were a critical
part of their couple sexual style. In addition, they valued and
enjoyed a broad-based, flexible relationship that included emotional
intimacy, affectionate and sensual touch, playful touching both in
and out of the bedroom, enjoying a variety of pleasuring and erotic
scenarios, and basking in afterplay. Jonathan and Angelas new
couple style valued both marital intimacy and erotic sexuality.
Relapse Prevention Strategies

The best overall relapse prevention strategy is for both you and
your partner to commit to devoting the time and energy it takes to
maintain a high-quality intimate relationship. This includes main-
taining a regular rhythm of affectionate, sensual, playful, and erotic
sexual connectionwhether three times a week or once every ten
daysrather than regressing to the intercourse-or-nothing
approach to touching. But healthy sexuality is much more than fre-

quency. A vital sexuality involves attending to physical health and
healthy habits (including not smoking, good eating habits, regular
exercise, a healthy sleep pattern, and moderate drinking or no
drinking). You want to have a good relationship with a primary
care physician to ensure that an illness or medication side effect
does not interfere with your sexual functioning. You need to be
committed to enhancing your personal well-being and the
well-being of your partner.
There are ten specific relapse prevention strategies for you to
consider.
Strategy One: Hold Couple Meetings

Having regular times (for example, every month) to discuss
your intimate relationship is crucial to maintaining a vital relation-
ship. One advantage of working as an intimate team in learning
ejaculatory control or being in couple therapy is that you regularly
engage in serious communication about your relationship. You want
to continue to devote the time and energy to nurture and enhance
your intimate relationship. Its important to show your partner your
desire to maintain your intimate bond.
Strategy Two: Have a Formal Follow-Up Meeting

Planning a six-month follow-up (by yourselves or with a thera-
pist) will help you remain committed and accountable to good-
quality, enjoyable sex and prevent relapse by ensuring that you do
not slip back into unhealthy sexual attitudes, behaviors, or feelings.
The biggest trap is to treat PE and intimacy with benign neglect. If
you dont pay attention, sex will regress to marginal quality and
become infrequent.
Strategy Three: Have Pleasuring Sessions

Setting aside time for a pleasuring session (with a prohibition
on orgasm) reinforces communication, sensuality, and playfulness.
This allows you to enjoy sensuality and experiment with new things:
an alternative pleasuring position, body lotion, a new setting or
milieu. This helps keep you focused on pleasure and flexibility.
Maintaining pleasuring and sensuality combats relapse not just for
PE but for other sexual problems as well.
Strategy Four: Calmly Accept Your

Lapses as Simple Tests
In any change process, when you begin to achieve reasonable
success, you will be tested. This is normal. When your new skills are
challenged and you do a good-enough job of handling the test, you
will be able to relax, settle in, and feel calmly confident. You will
realize that your progress is for real, not a fluke. Your success will
become believable. You have learned the skills of sexual cooperation
and intimacy.
As a couple, you will likely be tested a minimum of two times.
The usual test is a lapse, an experience of PE as severe as it ever was.
You will have automatic thoughts of self-doubt: The treatment
approach didnt work! Were back where we started from. Fail-
ure! Were going to return to the hurt, anger, and frustration.
These are normal thoughts, and you actually need to go back to the
old experience several times in order to reaffirm for yourselves that
these fears are not accurate.
When you are tested, what is important is that you pass the
challenge together. You do this by handling the rapid ejaculation
with the understanding and physical, emotional, and relationship
skills you have learned throughout this book. In other words, while
you may ejaculate fast, do not allow yourselves to relapse to han-
dling it in the old dysfunctional way. Rather, accept the quickness,
adapt your lovemaking, continue to pleasure and touch, and stay
connected. Let it only be an oops! event. Afterward, calmly discuss
whether you think the quick ejaculation was simply a random event
or whether there are some adjustments you will want to make
together for the next times you make love. These might include tak-
ing more time to relax your bodies, making love more slowly,
attending more to relaxing your PM before you initiate intercourse,
allowing more time for vaginal acclimation, or using circular inter-
course motions. You can smile and shrug off the experience and
make a date in the next one to three days when you have the time
and energy for a sensuous, slower lovemaking experience.
The better you pass this test, the more assured your success
will be. If you dont handle the testing well, it will take more practice
at passing more tests to confirm your success. That is why it helps if
you consciously anticipate the tests together so that you are not
taken off guard.
Strategy Five: Remember to Focus on

Reasonable Expectations
We hope that by now youve let go of your ideas about movie-
quality sex and erections that last for hours. If sexuality is to remain
positive and nurture your intimate bond, you need to keep your
expectations reasonable and accept flexibility and variability. Adopt
a broad-based approach to touching and eroticism. Remember there
are multiple purposes for sex. Allow sexuality to meet a variety of
individual and couple needs. Sometimes sex is a tension reducer,
sometimes a way to share closeness; other times a short, passionate
encounter, a way to heal an argument, a bridge to reduce emotional
distance. It is a reality that sex is often better for one partner than the
other.
Strategy Six: Schedule Intimate Couple Time

The importance of setting aside quality couple time, especially
intimacy dates or weekends without the kids, cannot be emphasized
enough. Nurture your relationship intimacy. For couples with
children, it is especially important to set aside couple time, whether a
night out each week or a weekend away without the children at least
once a year. Couples often report better sex on vacation, validating
the importance of getting away even for an hour or two. Couple time
can include going for a walk, having a sexual date, going to dinner,
or having an intimate talk.
Strategy Seven: Let Your Couple Sexual

Style Develop over Time
There is not one right way to be sexual. Each couple develops
their unique style of initiation, pleasuring, erotic scenarios and tech-
niques, intercourse, and afterplay. The more flexible your couple
sexual style and the more you accept the multiple functions of touch-
ing and sexuality, the greater your resistance to relapse. Develop a
comfortable, functional, satisfying sexual style that meets both of
your needs and energizes your relationship.
Strategy Eight: Remember That Good-Enough Sex

Ranges from Disappointing to Great
Be prepared to cope with disappointing or negative sexual
experiences. The single most important technique in relapse preven-
tion is the ability to accept and not overreact to experiences that are
mediocre, unsatisfying, or dysfunctional. Any couple can get along if
everything goes well. The challenge is to accept disappointing or
dysfunctional experiences without panicking or blaming. Rapid ejac-
ulation, inhibited sexual desire, losing an erection, female non-
orgasmic response, a miscommunication about a sexual date: these
happen to all couples. Intimate couples accept occasional mediocre
or disappointing experiences and take pride in having a resilient
sexual style.
Strategy Nine: Saturate Each Other with

Multidimensional Touch
Intimacy includes sexuality, but is much more than sexual
intercourse. You need a variety of intimate and erotic ways to
connect, reconnect, and maintain connection. These include affection-
ate touch, holding, nongenital pleasuring, playful touch, erotic
stimulation, and intercourse. This gives you lots of tools to build
bridges to sexual desire. The more ways you have to maintain
intimate and sexual connection, the better you can avoid relapse.
Strategy Ten: Keep Expanding Your Sexual Repertoire

The importance of maintaining an erotic relationship and hav-
ing a variety of sexual alternatives and scenarios cannot be overem-
phasized. A flexible sexual repertoire is a major antidote to relapse.
Sexuality that meets a range of needs, feelings, and situations will
serve you well in maintaining ejaculatory control and supporting
your sexual and emotional gains. Couples who express intimacy
through massage, holding hands, bathing together, enjoying playful
touch, engaging in semiclothed cuddling, and enjoying nude sensual
touch have a flexible repertoire. Couples who are open to quickies,
prolonged and varied erotic scenarios, various intercourse positions,
multiple stimulation during intercourse, and planned as well as
spontaneous sexual encounters have a robust sexual relationship.
Choosing an Individual,
Couple, or Sex Therapist
This is a self-help book, but it is not a do-it-yourself therapy book.

Men and couples are often reluctant to consult a therapist, feeling
that to do so is a sign of craziness, a confession of inadequacy, or an
admission that your life and relationship are in dire straits. In reality,
seeking professional help is a sign of psychological wisdom and
strength. Entering individual, couple, or sex therapy means you real-
ize there is a problem and you have made a commitment to resolve
the issues and promote individual and couple growth.
The mental health field can be confusing. Couple and sex
therapy are clinical subspecialties. They are offered by several
groups of professionals including psychologists, social workers, mar-
riage therapists, psychiatrists, and pastoral counselors. The profes-
sional background of the practitioner is less important than his or
her competence in dealing with your PE and other specific problems.
Many people have health insurance that provides coverage for
mental health, and thus can afford the services of a private practi-
tioner. Those who do not have either the financial resources or insur-
ance could consider a city or county mental health clinic, a university
or medical school outpatient mental health clinic, or a family services
center. Some clinics have a sliding fee scale (the fee is based on your
ability to pay).
When choosing a therapist, be assertive in asking about creden-
tials and areas of expertise. Ask the clinician what will be the focus
of the therapy, how long therapy can be expected to last, and
whether the emphasis is specifically on sexual problems or more
generally on individual, communication, or relationship issues. Be

especially diligent in asking about credentials such as university
degrees and licensing. Be wary of people who call themselves per-
sonal counselors, marriage counselors, or sex counselors. There are
poorly qualified peopleand some outright quacksin any field.
One of the best ways to obtain a referral is to call a local profes-
sional organization such as a psychological association, marriage and
family therapy association, mental health association, or mental
health clinic. You can ask for a referral from a family physician,
clergy or rabbi, or trusted friend. If you live near a university or
medical school, call to find out what mental and sexual health
services may be available.
For a sex therapy referral, contact the American Association of
Sex Educators, Counselors, and Therapists through the Internet at
www.aasect.org or write or call for a list of certified sex therapists in
your area: P.O. Box 5488, Richmond, VA 23220; (804) 644-3288.
Another resource is the Society for Sex Therapy and Research
(SSTAR) at www.sstarnet.org.
For a marital therapist, check the Web sites for the American
Association of Marriage and Family Therapy at www.therapistloca-
tor.net or the Association for the Advancement of Behavioral Ther-
apy (AABT) at www.aabt.com.
Feel free to talk with two or three therapists before deciding on
one with whom to work. Be aware of your level of comfort with the
therapist, degree of rapport, whether the therapist has special skill
working with couples, and whether the therapists assessment of the
problem and approach to treatment makes sense to you.
Once you begin, give therapy a chance to be helpful. There are
few miracle cures. Change requires commitment and is a gradual
and often difficult process. Although some people benefit from
short-term therapy (fewer than ten sessions), most find the therapeu-
tic process requires four months to a year or longer. The role of the
therapist is that of a consultant rather than a decision maker. Ther-
apy requires effort, both in the session and at home. Therapy helps
to change attitudes, feelings, and behavior. Although it takes courage
to seek professional help, therapy can be a tremendous help in evalu-
ating and changing individual, relational, and sexual problems.
Resources
Suggested Reading on Male Sexuality

Joannides, Paul. 1999. The Guide to Getting It On. West Hollywood,
Calif.: The Goofy Foot Press.
McCarthy, Barry, and Emily McCarthy. 1998. Male Sexual Awareness.
New York: Carroll and Graf.
Milsten, Richard, and Julian Slowinski. 1999. The Sexual Male: Prob-
lems and Solutions. New York: W. W. Norton & Company.
Zilbergeld, Bernie. 1999. The New Male Sexuality. New York: Bantam
Books.
Suggested Reading on Female Sexuality

Ellison, Carol. 2001. Womens Sexualities. Oakland, Calif.: New Har-
binger Publications.
Foley, Sallie, Sally Kope, and Dennis Sugrue. 2002. Sex Matters for
Women: A Complete Guide to Taking Care of Your Sexual Self. New
York: Guilford Publications.
Goodwin, Aurelie, and Marc Agronin. 1997. A Womans Guide to
Overcoming Sexual Fear and Pain. Oakland, Calif.: New Harbinger
Publications.
Heiman, Julian, and Joseph LoPiccolo. 1988. Becoming Orgasmic:
Womens Guide to Sexual Fulfillment. New York: Prentice-Hall.
Leiblum, Sandra, and Judith Sachs. 2002. Getting the Sex You Want: A
Womans Guide to Becoming Proud, Passionate, and Pleased in Bed.
New York: Crown Publishers (Random House).
Suggested Reading on Couple Sexuality

Holstein, Lana. 2002. How to Have Magnificent Sex: The Seven Dimen-
sions of a Vital Sexual Connection. New York: Harmony Books
(Random House).
McCarthy, Barry, and Emily McCarthy. 1998. Couple Sexual Aware-
ness. New York: Carroll and Graf.
. 2002. Sexual Awareness. New York: Carroll and Graf.
Schnarch, David. 2002. Passionate marriage: Sex, love, and intimacy in
emotionally committed relationships. New York: Norton.
Other Notable Sexuality Readings

Butler, Robert, and Myrna Lewis. 2002. The New Love and Sex after
Sixty. New York: Ballantine.
Maltz, Wendy. 2001. The Sexual Healing Journey. New York:
Harper-Collins.
McCarthy, Barry, and Emily McCarthy. 2003. Rekindling Desire. New
York: Brunner/Routledge.
Michael, Robert, John Gagnon, Edward Laumann, and Gina Kolata.
1994. Sex in America: A Definitive Survey. New York: Little, Brown
and Company.
Suggested Reading on Relationship Satisfaction

Chapman, Gary. 1995. The Five Love Languages: How to Express Heart-
felt Commitment to Your Mate. Chicago: Northfield Publishing.
Doherty, William. 2001. Take Back Your Marriage. New York: Guilford
Press.
Gottman, John. 1999. The Seven Principles for Making Marriage Work.
New York: Crown Publishing.
Markman, Howard, Scott Stanley, and Susan L. Blumberg. 2001.
Fighting for Your Marriage: Positive Steps for Preventing Divorce and
Preserving a Lasting Love. San Francisco: Jossey-Bass Publishers.
Resources 169
Videotapes: Ejaculatory Control Techniques

Desjardins, Jean-Yves, and Nicole Audette. 1997. The Lovers Guide to
Ejaculatory Control. 55 min.
Pacific Media Entertainment, P.O. Box 4326, Chatsworth, CA 91311.
Fax (818) 341-3562.
www.pacificmediaent.com.
Polonsky, Derek, and Marian Dunn. 1991. You Can Last Longer. Vol. 8,
Better Sex Videos Series. 38 min.
Distributor: Sinclair Intimacy Institute, P.O. Box 8865, Chapel Hill,
NC 27515.
(800) 955-0888. Fax (800) 794-3318.
www.bettersex.com.
Videotapes: Sexual Enrichment

The Couples Intimacy Guide to Great Sex over 40, vols. 1 and 2. 1995. 60 min.
Sinclair Institute, P.O. Box 8865, Chapel Hill, NC 27515.
(800) 955-0888. Fax (800) 794-3318.
www.bettersex.com.
Holstein, Lana. 2001. Magnificent Lovemaking. 79 min.
Canyon Ranch Bookstore, Tucson, AZ. 85750
(520) 749-9000, extension 4380.
Perry, Michael, and Goedele Liekens. 1991. Sex: A Lifelong Pleasure
series.
Sinclair Intimacy Institute, P.O. Box 8865, Chapel Hill, NC 27515.
(800) 955-0888. Fax (800) 794-3318.
www.bettersex.com.
Sommers, Frank. The Great Sex Video Series. Distributor: Pathway
Productions, Inc., 360 Bloor Street West, Suite 407A, Toronto
M5S 1X1, Canada.
(416) 922-4506. Fax (416) 922-7512.
E-mail: how2video@ aol.com.
Stubbs, Kenneth Ray. 1994. Erotic Massage. 58 min.
Secret Garden, P.O. Box 67, Larkspur, CA 94977.
Professional Associations
American Association of Sex Educators, Counselors, and Therapists
(AASECT): P.O. Box 54388, Richmond, VA 23220-0488.
www.aasect.org.
(804) 644-3288
Association for the Advancement of Behavioral Therapy (AABT): 305

Seventh Avenue, New York, NY 10001-6008.
(212) 647-1890.
www.aabt.org.
Sex Information and Education Council of the United States
(SIECUS): 130 West 42nd Street, Suite 350, New York, NY 10036.
(212) 819-7990. Fax (212) 819-9776.
www.seicus.org.
Society for Scientific Study of Sexuality (SSSS): David Fleming, Exec-
utive Director. P.O. Box 416, Allentown, PA 18105-0416.
(610) 530-2483.
www.sexscience.org.
Society for Sex Therapy and Research (SSTAR): www.sstarnet.org.
Sex Toys, Books, and Videos

Good Vibrations Mail Order: 938 Howard Sreet, Suite 101, San Fran-
cisco, CA 94110.
(800) 289-8423. Fax (415) 974-8990.
www.goodvibes.com.
References
Assalian, P. 1988. Clomipramine in the treatment of premature ejacu-

lation. Journal of Sex Research 4:213215.
Basson, R. 2001. Using a different model for female sexual response
to address womens problematic low sexual desire. Journal of Sex
and Marital Therapy 27:395403.
Bixler, R. H. 1986. Of apes and men (including females!). Journal of
Sex Research 20:10912.
Epstein, N., and D. Baucom. 2002. Enhanced Cognitive Behavioral Ther-
apy for Couples: A Contextual Approach. Washington, D.C.: Ameri-
can Psychological Association.
Foley, S., S. Kope, and D. Sugrue. 2002. Sex Matters for Women: A
Complete Guide to Taking Care of Your Sexual Self. New York:
Guilford Publications.
Frank, E., C. Anderson, and D. Rubenstein. 1978. Frequency of sexual
dysfunction in normal couples. New England Journal of Medi-
cine 229(3): 11115.
Hong, K. 1984. Survival of the fastest: On the origin of premature
ejaculation. Journal of Sex Research 20:10912.
Kaplan, H. S. 1974. The New Sex Therapy. New York: Brunner/Mazel.
Kinsey, A. C., B. W. Pomeroy, and C. E. Martin. 1948. Sexual Behavior
in the Human Male. Philadelphia: W. B. Saunders.
La Pera, G., and A. Nicastro. 1996. A new treatment for premature
ejaculation: The rehabilitation of the pelvic floor. Journal of Sex
and Marital Therapy 22:2226.
Laumann, E., A. Paik, and R. Rosen. 1999. Sexual dysfunction in the

United States: Prevalence and predictors. Journal of the American
Medical Association 261:53744.
Leiblum, S., and R. Rosen, eds. 1989. Principles and Practice of Sex
Therapy: Update for the 1990s. New York: Guilford Publications.
Loudon, J. B. 1988. Potential confusion between erectile dysfunction
and premature ejaculation: An evaluation of men presenting
with erectile difficulty at a sex therapy clinic. Journal of Sex and
Marital Therapy 13(4):397401.
Masters, W. H., and V. E. Johnson. 1966. Human Sexual Response.
Boston: Little, Brown and Company.
. 1970. Human Sexual Inadequacy. Boston: Little, Brown and
Company.
Michael, R., J. Gagnon, E. Laumann, and G. Kolata. 1994. Sex in
America: A Definitive Survey. New York: Little, Brown and Com-
pany.
Mosher, D. L. 1980. Three psychological dimensions of depth of
involvement in human sexual response. Journal of Sex Research
16(1):142.
Rowland, D. L. 1999. Issues in the laboratory study of human sexual
response: A synthesis for the nontechnical sexologist. Journal of
Sex Research 36:113.
Schapiro, B. 1943. Premature ejaculation: A review of 1130 cases.
Journal of Urology 50:37479.
Semans, J. H. 1956. Premature ejaculation: A new approach. South
Medical Journal 49:35358.
Tullii, R. E., C. H. Guillaux, R. Vaccari, and R. Ferreira. 1994. Prema-
ture ejaculation selective neurotomy: A new therapeutic tech-
nique. Basis, indication, and results. International Journal of
Impotence Research 6 Suppl. 1P:109-104-103.
Waldinger, M. 1998. Familial occurrence of primary premature ejacu-
lation. Psychiatric Genetics 8:3740.
Wise, M., and J. Watson. 2002. A new treatment for premature ejacu-
lation: Case series for a desensitizing band. Sexual and Relation-
ship Therapy 15(4):34550.
We Want Your Candid
Feedback:
We are very interested in your response to our book and welcome
your feedback!
For example:
! Why did you buy our book?
! What has been helpful to you?
! What about our approach do you like?
! What do you wish we had addressed more fully?
Please send an email or letter with your comments, requests, or

ideas to:
CopingWithPE@aol.com
Or:
Michael E. Metz, Ph.D.
Meta Associates
Baker Court, Suite 440,
821 Raymond Avenue
St. Paul, Minnesota 55114
MMetzMpls@aol.com
Barry W. McCarthy, Ph.D.

Washington Psychological Center
4201 Connecticut Avenue, N.W.
Suite 602
Washington, DC 20008
McCarthy160@comcast.net
We Welcome Your Requests:

We also welcome requests to present workshops, training sessions,
and lectures about PE, sexual health, marital and sexual wellness,
and couple conflict.
Thank you very much. Michael Metz and Barry McCarthy

Michael Metz, Ph.D., works in the Twin Cities of MinneapolisSt.
Paul, Minnesota and is the countrys leading sexologist in the area of
PE. He is a major spokesperson for a comprehensive, integrated bio-
psychosocial approach to addressing and resolving sexual problems.
After twelve years on the faculty of the University of Minnesota
Medical School, he currently works in private practice with Meta
Associates as a psychologist, marital therapist, and sex therapist
treating individuals and couples, and is affiliated with the University
of Minnesotas Department of Family Social Science. He has pub-
lished more than forty-five professional articles and conducted
numerous workshops and talks on marital and sex therapy. He is the
author of the Styles of Conflict Inventory (SCI), a clinical assessment
instrument to evaluate the conflict patterns in relationships.
Barry McCarthy, Ph.D., is a clinical psychologist, with a subspecialty

in marriage and sex therapy, practicing at the Washington Psycho-
logical Center in Washington, DC. He is professor of psychology at
American University where he teaches an undergraduate human
sexual behavior course. Barry, with his wife Emily, has written seven
well-respected books, the most recent being Getting It Right the First
Time, Sexual Awareness, and Rekindling Desire. In addition, Barry has
published over fifty-five professional articles, fourteen book chap-
ters, and presented over one hundred and ten workshops nationally
and internationally.

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Coping with

How to Overcome PE,

MICHAEL E. METZ, PH.D.

BARRY W. MCCARTHY, PH.D.

New Harbinger Publications, Inc.

This is the most comprehensive guide to dealing with premature

Coping with Premature Ejaculation is chock-full of great suggestions

Finally, an updated, comprehensive guide for a problem that affects

How to Overcome PE,

& Please Your Partner

New Harbinger Publications

All Rights Reserved

New Harbinger Publications Web site address: www.newharbinger.com

1 Understanding Premature Ejaculation 1

2 Developing Realistic Expectations about Sex 15

3 Understanding the Causes and Effects of PE 29

5 Planning Your Treatment and Preparing for Action 59

6 Medical, Pharmacologic, and Physiological 73

7 Psychological and Relational Strategies and Skills 85

8 Psychosexual Skills: Enjoying Arousal and 105

9 Couple Sexuality: Building an Intimate, Interactive 135

10 Enjoying Sex and Preventing Relapse 147

Choosing an Individual, Couple, or 161

What is premature ejaculation (PE)? You might expect that this is an

would be perfect every time. It was Kevins duty as a man to make

Our Comprehensive Approach

Testing Your Knowledge of PE

True False Most men engage in intercourse for twenty to

True False A good lover prolongs intercourse until his

True False Women function like men: they have a single

True False Men who ejaculate after two to seven minutes

True False PE is caused by too much masturbation,

True False Thrusting alone is enough for most women to

True False PE is always caused by psychological

True False To deal with PE, the woman needs to be less

True False PE is natures way of increasing fertility.

True False PE is a symbol of a relational power struggle.

The Truth about PE

Successful treatment combines taking individual responsibility

Understanding Male Sexuality

What Youll Need to Learn

perfectionist standard or proving he can give the woman an orgasm

Identifying the Point of Ejaculatory Inevitability

Cooperation for Intimacy

all these efforts is to enhance your closeness, comfort, pleasure, and

Letting Go of Your Focus

Giving up the performance-focused approach frees you to learn

The Myth of One Cause, One

It is risky to use a medication or a do-it-yourself technique like

Relational Issues and PE

When youre seeking a new relationship, its important to

Understanding Female Sexuality

PE and Other Sexual Problems

Coexisting Sexual Problems in Men

they are problematic or nonexistent. Couple sex therapy is the treat-

Acquired Inhibited Sexual Desire

Acquired Erectile Dysfunction

Coexisting Sexual Problems in Women

How You Can Best Use