TL;DR: Performance anxiety is a key part of PE and a good starting point for treatment. Once anxiety is lowered, it’s much easier to build essential sexual skills and confidence.
Premature ejaculation is a biopsychosocial problem
A biopsychosocial problem… that sounds complex, doesn’t it? But let me assure you that it isn’t.
The term biopsychosocial simply means that in order to treat a so-called medical condition, it’s essential to understand the biological, psychological and social factors.
Otherwise, treatment might be a longer process than it needs to be or prove completely ineffective. Medication, for example, is often prescribed without consideration of the bigger picture. Pills might numb the symptoms, but the problem remains.
This applies to all kinds of illnesses, pains and so-called dysfunctions. And it certainly applies to premature ejaculation.
- Biological factors: some men last longer than others (and some men struggle to reach ejaculation). Our autonomic nervous system, serotonin and prolactin levels, blood circulation, penile sensitivity and medical history all play a role in determining our natural finishing time.
- Psychological factors: let’s say that in our first sexual experiences, we come sooner than expected. Worries can soon escalate to anxiety around sex. Trying to relax doesn’t make any difference, and a feeling of hopelessness sets in. Fears of ‘I can’t do this’ become self-fulfilling prophecies.
- Social factors: when we perceive negative feedback from our partners (real or not), we feel the pressure even more. Deeper fears of ‘I can’t have a sexual relationship’ set in. Due to embarrassment or stigma, there might be limited opportunities to discuss the problem and seek help. We feel alone, ashamed and extremely frustrated.
Performance anxiety keeps us stuck
So some guys need to work on sexual skills more than others. This is completely natural, just like any other activity such as running or lifting weights. Why should sex be any different?
But anxiety hijacks our progress; it makes this work difficult to face up to and even harder to put into practice. This can leave us vulnerable to promises of quick-fix solutions, and the further frustration when they don’t work.
Other cognitive elements of premature ejaculation
If you have struggled with PE, I’m sure you know what performance anxiety feels like. See if you recognise some of these additional thoughts or feelings:
- I get over-excited. Sex is great, of course, but some guys over-hype it in their minds. This might be due to the rush of anticipation when they were younger, or feelings of missing out on something amazing. They grow up and have partners and real sexual experience, but the over-excitement persists.
- I expect a porn film. Porn can be great entertainment but not necessarily a great sexual education. Part of us knows that real sex isn’t like that, but part of us still wants it to be. This can ramp up our expectation of ourselves to bizarre levels.
- I give orgasms to my partner. Another unhelpful takeaway from porn, the ‘it’s all on me’ mindset heaps on additional pressure. It also blocks us from sharing and communicating with our partner. We assume that we naturally must know what feels good for her.
- A test of my masculinity. Guys sometime worry that PE is a symptom of deeper issues with their masculinity. When we feel alone and that every other guy is happily banging away with abandon, such fears and doubts can go all kinds of places.
- Head in the sand. This might be avoidance of addressing the problem, which leads to constant swings between optimism (this time will be OK!) and despair (again?!!). Or avoidance of sex altogether, which gets awkward fast in a monogamous relationship.
These are all common psychological elements of premature ejaculation, and forms of performance anxiety.
So we should tackle our performance anxiety first?
Yes. Every man who experiences PE has some mix of the biopsychosocial factors going on. The ratios will be different for every individual; it will be more of a physical thing for some guys, or more stress-related or more linked to the dynamic of his relationship.
All these factors overlap and feed into each other. Whatever the mix, guys don’t need deep psychosexual analysis or an epic journey of self-discovery. They need to learn how to relax and build skills.
Lowering anxiety is the best place to begin. Here are two reasons why:
1) At the neurological level, the transition from erection to ejaculation requires increased activation of the sympathetic nervous system. Our nervous system goes from an ‘open resting’ state to an ‘activated’ state.
We know that both anxiety and excitement engage the sympathetic nervous system more rapidly, and make this process a quick switch rather than a gradual, sensual transition.
When we regularly experience this quick switch, we call it premature ejaculation. But if we can lower our emotional arousal – the mix of excitement and performance anxiety – we can naturally slow the process down.
2) There are things we can do to help ourselves last longer. I’m sure you’ve heard the standard advice: slower breathing, different positions, mental focus, etc. Well some of these things are genuinely useful, but it’s hard to utilise them when we are in activated panic mode.
Emotional arousal – excitement and anxiety – hijacks our resourcefulness. It’s our survival instinct at work. If we’re running away from a tiger, there’s no time to stop and mull things over. If we’re having anxious sex surrounded by predators and rival males, finishing up takes priority over prolonged pleasure.
But with lower emotional arousal, our resourcefulness comes back online. We can recall the things that have helped before and we’re open to experimentation. When we start to figure out what works for us, we’re gaining the skills.
So one way or another, relaxing into sex is key.
Don’t antidepressant pills shortcut this?
We’re talking about SSRI medication, which is increasingly used to treat premature ejaculation. This might be as a daily dose, or dapoxetine (marketed as Priligy) which can be taken a few hours before sex.
Antidepressant medication does flatten out emotional arousal, so yes – it’s kind of a shortcut. These pills flood the brain with increased serotonin, and extending the time to ejaculation is a known side-effect. Researchers are currently trying to figure out exactly why.
The extension in time isn’t immense; most men typically gain a few minutes. But this can have a positive effect. Guys get to experience what longer intercourse feels like, their partners might feel more satisfied and confidence can build.
SSRI medication may have a useful place in a PE treatment plan, but reliance on pills can introduce additional stressors. This medication is expensive, there are side-effects and the timing of on-demand pills can be tricky.
It’s also worth noting that some men experience faster premature ejaculation after stopping their SSRI. Whether this is due to some kind of serotonin adjustment or a nocebo effect, it’s something that guys should be mindful of when going down this route.
When it comes down to pills vs skills, I’m firmly on the side of skills for overcoming premature ejaculation. This is the foundation of real and lasting confidence.
So what starts to work once we’re less anxious?
When we’re in a calmer and more resourceful state, here are some of the behavioural techniques that can help us enjoy intercourse for longer:
Opening up to sensation
The ability to soak up and enjoy all the sensations of pleasure. This will be a new experience for some guys, so used to shutting down and numbing themselves for fear of being tipped over the edge.
When intercourse begins, there will be initial waves of intense pleasure. If you can ride those initial waves and get beyond them, you’ll know that you can acclimatise and settle into sex. It’s that ‘hey, I’m doing this’ state of awareness.
As the saying goes, we can’t stop the waves but we can learn to surf. Lower emotional arousal is essential for keeping balance and staying up.
Variation of movement and tempo
We know that subtle changes of penetration angle, depth and speed help us to feel in control and keep up the momentum of shared pleasure. But anxiety pushes this awareness out of our minds.
Slower, deeper breathing
This is the classic way to lower anxiety and it works. But chances are you’ve already tried it during sex. You may even be rolling your eyes as you read this.
When you’re stressed and activated and desperate not to come, a bit of deeper breathing is unlikely to make any difference. It’s not a brake pedal. But when utilised in a more relaxed state, breathing can help you to prolong that state.
Deep body relaxation
Those tantric gurus were onto something with their ‘cool draws’ and ‘channelling of sexual energy’. I teach a simple variation of this called the elevator, a rapid way to let go of lower-body tension. Muscular tension is another sure-fire way to engage the sympathetic nervous system and reach ejaculation sooner.
But it’s hard to be a tantric guru when you’re in panic mode. Breathing and relaxing feels compromised and desperate, and we end up discarding these approaches when they didn’t get a chance to work.
With lowered excitement and anxiety, we can get out of our heads and into the moment. We’re able to connect with our partners, synchronise our movement, communicate, laugh and enjoy true pleasure exchange. This is the essence of satisfying sex, after all.
When we’re not consumed by performance anxiety, we can find the balance of awareness and relaxation that enables these techniques to work.
How do we get less anxious around sex?
So to the million-dollar-golden-unicorn question. How do we learn to be less anxious about sex?
1) Firstly, understand that most of us don’t relax enough, or deeply enough. This applies in general, in our day-to-day experience. We’re always on, activated, distracted, agitated. So learning how to experience relaxation outside of sex is essential, and there are plenty of ways to go about this.
2) A lot of PE advice is about stamina, strength and taking control. This naturally appeals to us; guys are inclined to solve problems by powering through.
But a proven psychological truism is this: imagination is stronger than will. If we can rehearse and experience laid-back sexual confidence in our mind first, this disrupts the old associations of fear.
I use an approach called guided imagery to achieve this, engaging the imaginations of my clients in various creative ways. This method is also effective in sports and professional coaching.
We’re not just talking about positive thinking here; building realistic expectation makes a difference. It changes the way we act, move, talk, engage with our partners. It shifts our self-talk and emotional response from anxiety to capability.
3) As well as gaining skills, it’s important to stay grounded in realistic expectation of ourselves. Sex is unpredictable; it will be underwhelming at times, just as it will be awesome and affirming. Sex and relationships and life would be pretty boring otherwise, don’t you think?
If you’d like to up your relaxation game, I’ll be sharing some guided imagery exercises specifically for guys who struggle with PE. In the meantime, remember to find more relaxation in your day-to-day, and watch out for those tricky cognitive limitations.
Even if nature handed you a slightly faster ejaculation response, nature also gave you the brains, agility and motivation to enjoy exceptional sexual experiences.