Premature ejaculation: what the research says and what actually works

“Sorry.”

A single word, said into the dark, almost in a whisper. And after it a long silence in which neither of them knows what to say. He is ashamed; she doesn’t know whether to comfort him or act as if nothing happened. The next day nobody mentions it. The next time, he tenses up before anything has even begun, and the thing he fears happens again.

Premature ejaculation is one of the most common sexual worries for men and at the same time one of the least talked about. The internet is full of quick tips and miracle fixes, but in reality things are both simpler and more complicated. In this post I want to summarise what the professional literature says, what actually helps, and why this is not only a man’s problem but something that happens within a couple.

Let me say at the start what this post is not. I am not a sexologist or a sex therapist but a therapist in training under supervision in marriage and family therapy. In couples therapy intimacy can be one of the themes we talk about, but for a sexual dysfunction itself the right path is a doctor or a specialist in sexual medicine.

When is it actually a problem?

One of the first things people don’t know is that “too soon” is not a matter of feeling; in the professional literature it has a fairly precise definition. In 2014 the International Society for Sexual Medicine (ISSM) proposed a definition that many specialists use today. Summarised with care, it has three components:

• time: in the form present from a man’s first sexual experiences, ejaculation always or nearly always happens within about one minute of the start of intercourse; in the form that appears later in life, there is a noticeable and bothersome shortening, often to about three minutes or less;
• control: the man is unable to delay ejaculation always or nearly always when he tries;
• consequences: because of this he experiences distress, frustration or shame, or starts to avoid intimacy.

The definition was designed around heterosexual intercourse, which is one of its limits. But its essential point applies more widely: only all three components together amount to a dysfunction. A man who sometimes comes sooner than he would like does not necessarily have a dysfunction. And neither does a man who always comes quickly if neither he nor his partner is distressed by it.

How long is “normal”?

Many men compare themselves with an image they get from films, conversations with friends or pornography. That image has little to do with reality.

The Dutch researcher Marcel Waldinger and his colleagues carried out a study in which several hundred couples in five countries used a stopwatch to measure how much time passed from the start of intercourse to ejaculation. The median was about five and a half minutes, and the range between couples was enormous, from less than a minute to more than half an hour. This means two things. First, that many perfectly ordinary encounters are shorter than many people imagine. And second, that there is no single right number a man should be aiming for.

In surveys where people judge for themselves whether they come “too soon”, considerably more men describe themselves as affected than meet the strict professional definition. That doesn’t mean the others are imagining the problem. It means that for many the main difficulty is expectation and worry, not the minutes themselves.

See a doctor first

As with all sexual difficulties, the same applies here: start with your GP, who can refer you to a urologist if needed. This is especially important if the problem appeared later in life when it wasn’t there before. In that case the doctor will also check for other possible causes, such as erection, thyroid or prostate problems. For some men, premature ejaculation develops as a response to the fear of losing an erection: they hurry “while it still works”. I wrote more about this in Erection problems and the mind: when the body is not the main culprit.

A doctor can also prescribe medication or topical products that help some men. Whether they are right for you is the doctor’s call, not the internet’s, and not that of a friend who “ordered something”. It is better to avoid products bought online without a prescription.

The shame nobody sees

What often comes to light in therapy is not so much the problem itself as the shame around it. A man to whom this happens often feels he is “less of a man”, that he has let his partner down, that she will laugh at him or leave him. That shame silences him: he doesn’t talk about it with a doctor, with friends, and most often not with his partner.

Shame differs from guilt in that it doesn’t say “I did something wrong” but “I am wrong”. That is why it is so hard to do anything with it; I wrote about this in Guilt and shame are not the same — and the difference matters. When a difficulty is experienced as proof of who you are, you don’t tackle it as a difficulty; you hide from it.

And shame has another consequence: it raises tension. Premature ejaculation and anxiety are closely linked. The more a man worries before intimacy, the more his body is on alert and the faster it responds. The post Sexual anxiety: the fear of failing and how to break the loop looks at this loop more broadly. The first step out of it is often not a technique but giving the shame some words. In the knowledge base I have written more about this emotion under shame.

A couple, not just a man

Premature ejaculation is usually treated as a man’s problem. But it happens between two people, and both carry their part.

A man often shuts himself away in his attempt at control. During intimacy he thinks about anything else to slow down, or he avoids tenderness and foreplay because he fears everything will be “too fast”. His partner, though, often doesn’t experience this as control but as absence: “It’s as if he isn’t there.” “As if he doesn’t care about me.” She hears the apology, but not what is going on inside him.

That is why, in therapy and in the professional literature, an observation keeps coming up that often surprises men: what bothers partners is frequently not so much the length of intercourse as the fact that the man withdraws, doesn’t talk about it, and seems worried and absent during intimacy. That is good news, because it means a great deal can change even before anything in the body changes.

The conversation that breaks this loop is often surprisingly short. It might sound like this (a composite, not a real person):

“You always apologise to me. I don’t know what to say to that.”
“What am I supposed to say? That I messed up again?”
“I don’t know if you messed up. But I know that afterwards you’re gone. You turn away.”
“Because I’m ashamed.”
“That wasn’t what bothered me. What bothered me was being left on my own afterwards.”

In this short exchange something important happens: the problem moves out of his head and into their shared space. It is no longer a secret he carries, but something they can talk about. I wrote about how to move from blame to what each of you really wants in From blame to needs: how a couple learns a new language.

What the professional literature says about treatment

The ISSM guidelines describe two main paths: treatment with medication, guided by a doctor, and psychological and behavioural approaches. A combination of both is often best: medication can ease the problem quickly, while the psychological part helps with the anxiety, shame and relationship strain that build up around it.

Among the behavioural approaches, two techniques are the best known. I will describe them only briefly and without detail, as they are best practised with a sex therapy specialist.

The stop–start technique goes back to a 1956 paper by the American urologist James Semans. Its aim is for a man to learn to recognise how close he is to ejaculation and to let arousal settle at the right moment before continuing. It is not about endurance, but about awareness.

The squeeze technique, described by Masters and Johnson, is based on a similar principle, except that arousal is reduced for a moment by gentle pressure, which the couple uses following a specialist’s guidance.

What the two have in common is that the man does not try to think of something else; quite the opposite. They teach him to be more present in his body, not less. And both work best when the couple practises them together, not when the man does them alone in secret. The guidelines also note that the effect of behavioural techniques can fade over time if the couple stops practising and talking. There is no magic fix that works once and for all.

What actually works, and what doesn’t

When men look for a solution on their own, they often reach for strategies that make the problem worse.

Thinking about something else seems logical, but it cuts a man off from his body, so he finds it harder to notice when he is approaching ejaculation. At the same time it cuts him off from his partner, who often feels it as absence.

Alcohol and various “calming” substances may change something in the short term, but they quickly become a new problem, and closeness that is only possible under the influence is not real relaxation.

Avoiding intimacy reduces the number of “failures”, but at the same time increases fear and distance. Every next attempt carries even more weight. The post Anxiety and avoidance: why avoiding helps you today and hurts you tomorrow explains why.

So what does help? A combination of a medical check-up, lowering tension, paying more attention to the body, and open conversation within the couple. Practising mindfulness helps with attention, and self-compassion helps with shame: the ability to treat yourself the way you would treat a friend in a similar struggle. It also helps when sex widens beyond a single measure. When closeness no longer means only intercourse that has to last a certain time, the pressure drops, and often the problem with it. If a disagreement about how often you each even want closeness has built up between you as well, read When sexual desire is mismatched: sex in a long relationship.

Exercise: a conversation outside the bedroom

This exercise is for a couple and it is not sexual. Do it at a calm moment, not after a difficult evening. It takes about half an hour.

1. Choose a time and place that have nothing to do with sex. A walk, the kitchen table, a drive. Agree that this is a conversation, not problem-solving.
2. Each of you says one sentence about what you fear. He might say: “I’m afraid of disappointing you.” His partner might say: “I’m afraid you don’t want me.” The other only listens and doesn’t argue.
3. Each of you says one sentence about what you miss. Not about what is wrong, but about what you would like more of: touch, laughter, time, words.
4. Together, find one form of closeness without a goal to try this week: a hug before sleep, a bath together, a massage. Agree that it won’t lead “further” unless you both want it to.
5. After a week, come back to the conversation. What was different? What was hard? You don’t have to solve anything; it’s enough that the subject stays open.

If the conversation keeps ending in an argument or tears, that is not a sign that you did something wrong. It is often a sign that more has built up around the subject than the two of you can untangle alone, and that is when it makes sense to look for help.

Where this approach is not enough

I want to be honest about the limits.

Psychology does not replace a doctor. In the form present from a man’s first sexual experiences, biology also plays an important role, and conversation alone will not change it. Medication prescribed by a doctor is then often an important part of the help.

Not every difficulty in a couple is about sex. If there is a lot of resentment, criticism or distance in a relationship, premature ejaculation can end up as the scapegoat: something tangible to blame, while what hurts more stays unsaid.

Your partner is not your therapist. Exercises as a couple are useful, but nobody should take on the role of coach in the bedroom. If that happens, it is better to seek out a specialist.

Humiliation is not “encouragement”. If mockery, comparisons with others or threats come up around this subject, it is no longer a question of technique but of a relationship that needs help. If you ever experience violence in your relationship, in Slovenia you can call the SOS helpline for women and children victims of violence on 080 11 55, and in an emergency 112 or the police on 113.

What to remember

• Specialists speak of premature ejaculation only when a short time, an inability to delay and distress come together.
• There is no “normal” duration: the range between couples is very wide, and many encounters are shorter than we imagine.
• See a doctor first, especially if the problem appeared later in life; medication should be prescribed by a doctor.
• The stop–start and squeeze techniques teach more presence, not less, and work best as a couple and with a specialist.
• What often bothers a partner more than time is withdrawal and silence, so a conversation outside the bedroom changes more than you might expect.