What causes premature ejaculation?

In Part 1 of our Complete Guide to PE, we considered the reasons why men feel under pressure to live up to sexual expectations. Now we’ll explore exactly what causes premature ejaculation.

A doctor once said to me that “whatever causes PE, it feels like it runs deep”. Any man who has experienced the problem will be able to relate to this. We’re able train our bodies to do so many things, but making sex last longer feels like fighting against something ‘deep’ in our nature.

Are we struggling against our genetic template, handed down through our fathers and grandfathers? Could PE indicate a medical condition or psychological issue? Or are we simply doing something wrong when we have sex, over and over again? Let’s delve into the research and latest medical opinion to find out.

Medical causes

Most experts agree that the vast majority of men with premature ejaculation are in good physical health and do not have any anatomical defects. That said, there are some medical factors that are worth consideration.

Specific medical conditions

Conditions with a higher prevalence in men who struggle with PE have been found to include high blood pressure (specifically penile blood pressure), prostatitis (infection or inflammation of the prostate gland – note that this is not prostate cancer) and multiple sclerosis.

If you have family history of any of these conditions, it would be sensible to consult your doctor. But understand that premature ejaculation not regarded as a direct symptom of these conditions and they are relatively rare.

Penis sensitivity

This is commonly attributed to premature ejaculation because for many men, it feels like the cause. So much of the sensation and heat of intercourse is felt right there. But remember that your penis has approximately 4000 nerve endings that transmit pleasure signals to the brain. If there’s an overload of stimulation, it’s more likely to be happening in your head. Your penis is simply doing its duty on the front line.

It’s true that some men have higher penis sensitivity than others. Some men are indeed extremely sensitive down there. In a 2007 study, male volunteers had receptors placed on different areas of their penises and their duration of intercourse measured. Variances in sensitivity were recorded, but with absolutely no correlation to the timings ¹

What does this tell us about numbing sprays and condoms? Well, they possibly do help the small minority of men who are hypersensitive. For the rest of us, any benefits may be due to the placebo effect. Applying the product makes us feel more confident and assured, especially if we’ve paid £30 for 15ml with express shipping.

In case you were wondering, it has also been proven that circumcised men experience the same intercourse duration times as uncut men. It makes no difference to their ability to delay ejaculation.

PC muscle strength

There’s a heap of advice out there about strengthening the perineum muscle by doing lots of kegels. Some men naturally have more strength and control in this area, and a regular workout probably has some health benefits (bladder control in later life, for example). Kegel exercises may also help us to become more aware of muscle tension and enhance our ability to relax our pelvic floor.

But can we effectively delay ejaculation by strengthening our PC muscle? Sexology export Francois de Carufel calls this out as a myth. Ejaculation is a reflex action, involving the prostate and various ducts and glands. We have zero control over this process. The ejaculation reflex cannot be stopped or controlled by clenching anything ².

Genetic factors

In terms of evolution and survival, the ability to ejaculate rapidly was an advantage. Long, luxurious sex sessions would leave our ancestors much more exposed to predators or too exhausted to run away. Our physiology evolved to get the job done.

But how significant are genetic factors, and can we override them? Could PE have been handed down through generations? Your dad and granddad could no doubt shed some light on this, but I understand you not particularly wanting to go there. The science on this is sprawling, so let’s get down to the essentials.

Firstly, it has long been suspected that our genes play a role. Research suggests that first degree male relatives of men with lifelong premature ejaculation have an increased likelihood of experiencing it themselves ³.

However, this is not clear evidence of causation. These relatives are likely to live together for some time, inevitably sharing the same attitudes and learnings about sex. In a 2013 study of twins, experts concluded that while genetic factors have some relevance, environmental factors make the biggest contribution to cases of premature ejaculation. We should never underestimate the influence of our parents’ attitudes and messaging on all of our sexual programming.

The genetic factors that might relate to PE are neurological. In a 2017 Chinese study, 32 men with lifelong premature ejaculation and no history of medication underwent MRI brain scans. Their scans were compared to a control group of men with no complaint of PE. The PE group had thicker cortex in widespread regions, including the frontal, parietal and occipital lobe, and limbic system. This is an interesting discovery, and further MRI research is likely to follow.

This difference in brain structure could affect the neurotransmission of serotonin, dopamine and oxytocin. Research into the effect of these processes on sexual performance is ongoing ⁴.

What’s so special about intercourse?

When we evaluate the research into genetic factors, and into premature ejaculation in general, we need to remember: it is always focused on the duration of penis-in-vagina intercourse. Studies invariably talk about the measurement of ‘intravaginal ejaculation latency time’ or IELT. An inability to make intercourse last is the main complaint, after all. But it’s interesting to note that men generally last for considerably longer during foreplay and masturbation. Research shows that the average duration of masturbation (4.4 minutes) is the same for all men ⁵.

As Francois de Carufel points out, the process of arousal and sexual excitement begins well before intercourse. A peak in sexual excitement is the cause of ejaculation. Are we supposed to believe that genetic, neurological factors wait until intercourse commences before kicking in? That our genetic evolution ignored foreplay? This is very unlikely. Carufel concludes that genetic factors must influence the entire duration of arousal and sexual excitement. If their influence was significant, men who can only make intercourse last for seconds would only be able to masturbate for seconds too. This may be the case for some men, but it is rare.

So the reasons why intercourse can tip us over the edge so quickly are behavioural rather than genetic. When we thrust away, we give ourselves continuous and intense stimulation. We are engaging muscles and breathing hard. All the significance of being inside a female partner floods into our mind, along with our self-imposed pressures and expectations. These are not genetic factors at play. It is the way we deploy our bodies and our imaginations.

I emphasise this point because for men who struggle to make sex last, it is positive news. Our options would be severely limited if the condition was fixed in our genetic makeup. But this is simply not the case. The ISSM guidelines conclude that men with numerous genetic variants may be predisposed to development of premature ejaculation, but only to a small degree and for a limited number of men.

When men obtain the skills and perspective to manage sexual excitement, they can significantly improve their performance. This applies to men with lifelong PE, regardless of genetic factors or their neurological structure.

Psychological causes

When we consider the psychological causes of any condition, we’re essentially talking about our imaginations and self-preservation instincts getting in the way. And this can certainly be a factor in premature ejaculation.

Anxiety

Of all the psychological causes, this is the big one. It includes performance anxiety (“I have to last longer this time”) and separation anxiety (“she will look for someone else if I can’t satisfy her”). It usually manifests as a feedback loop, where anxious thoughts make it difficult for us to monitor and manage our sexual excitement. This leads us to come much sooner than we wanted, and we feel even more anxious about the next time. A few rounds of this loop and we can begin to feel hopeless, with severe consequences for our mental health ⁶.

Remember that anxiety activates the sympathetic nervous system, which plays a major role in triggering the ejaculation reflex. More general forms of anxiety may also contribute to this. A 2001 study found that a high proportion of men with social anxiety also struggled to manage their sexual excitement. Just as the saying goes, anxiety is excitement without the breathing.

Fear of intimacy

Some therapists attribute premature ejaculation to a deep fear and avoidance of intimacy. A man might genuinely love and desire his partner, but he harbours a subconscious need to rush through sex and get it over as quickly as possible.

He might have developed these fears in childhood, reacting to an over-affectionate mother or a parent who was awkward with affection. There is little research on this hypothesis, but it certainly sounds feasible for some men.

Relationship dynamic

Conflicts of interest in the bedroom, and in the broader relationship, can make sex an anxious experience. Power struggles, resentment, jealousy and relationship insecurity can wreak havoc on the management of sexual excitement. At the more toxic end of the spectrum, premature ejaculation and sexual dissatisfaction might even be used by the female partner to humiliate and control.

Sexological and behavioural causes

As a therapist, this is the area of causation that I find most relevant to clients. Behavioural causes often have some element of psychological anxiety or sexual misunderstanding, but they can be understood and treated in practical ways. In some fortunate cases, it can even be as simple as “learn how to move your pelvis in this way instead of that”.

Not having sex often enough

As a general rule, infrequent ejaculation means more rapid ejaculation. If you only have sex occasionally (due to circumstance, tiredness, children or choice), then regular masturbation will help reset the clock. Studies show that men who have sex more frequently find it easier to maintain control and feel less anxious about coming too soon ⁷. When sex doesn’t feel like a rare, special occasion there is less build-up of performance anxiety.

An exception to this rule is when we have a hot, new partner. We’re getting laid every day, maybe multiple times a day, but we struggle to make it last. Of course, this is the novelty of attraction sending our sexual excitement levels through the roof. This scenario adds pressure to impress and excite her too. Once the novelty has worn off a bit, we can usually get into our stride.

For men who struggle with PE, infrequent sex can also be due to avoidance. Our partners may desire sex, but we make excuses or fall asleep in order to avoid the stress and struggle. When we eventually do have sex, we’re psychologically anxious and physiologically pent up. Ironically, a part of us just wants to get it over and done with. In the next section, we’ll look at strategies to break out of such a behaviour loop.

Focus on release

In discussion with men about their PE, I’ve noticed a tendency for sex to be referred to as “tension release” or “letting off steam”. They certainly have a point; sex is a great way to relieve stress. However, this can also reveal a limited perception of sex and another behavioural cause of the problem.

Research has found that some men envisage tension release as the only purpose of sex. They perceive penis-in-vagina as the grand finale, and don’t pay much attention to the erotic and sensory dimensions of arousal and erection.

Men might be subconsciously bringing their attitude towards masturbation (quick relief) into sex with their partners. With increases in our lifestyle stresses and tensions, and the convenience of porn-assisted quick relief, it’s easy to see how this could become their default sexual response.

Stuck in a habitual loop

We all go through phases of regular and irregular sex, for a whole multitude of reasons. But what if we’ve never been able to make sex last, regardless of frequency? Well, lifelong premature ejaculation may well be caused by lifelong behavioural habits too.

To put it another way: some of us never learned how to manage our sexual excitement. After a number of let-downs, we effectively gave up trying. Psychologists call this learned helplessness. Or we might continually repeat habits that don’t work very well, such as counting backwards or doing kegels during intercourse. We tell ourselves to try harder next time, overlooking that fact that it never works.

If this sounds like your experience, I’m not criticising. It’s very easy to fall into a lifelong premature ejaculation habit. When sex becomes a long-term cycle of stress and failure, how do we get the opportunity to learn and experience what a prolonged sexual encounter can feel like? Under what conditions can we give ourselves the breaks?

The ability to control our excitement levels can seem frustratingly elusive. It might require changes to the way we perceive the mechanics of sex, or learning how to access a state of relaxation that we’ve never sampled before.

Sexual excitement and over-stimulation

Remember that for all men, regardless of our genetic profiles, sensitivity or age, sexual excitement has to rise and peak for ejaculation to happen. Rising sexual excitement is caused by stimulation. When there is over-stimulation, excitement peaks too quickly and we experience premature ejaculation.

Our partners provide a plethora of stimulation: their appearance, expressions, movements, touch, vocal sounds and breathing. All of this reaches inside of us, stoking our desires. As we move and grind our bodies, we get immense stimulation from body heat, friction and muscular tension.

So what are the behavioural causes of over-stimulation? Francois de Carufel explains these typical scenarios:

• The man who performs rapid, vigorous stimulation to give his partner an orgasm before he does. This turns sex into a race, and the frantic stimulation rockets him over the finish line. This is very common in men who struggle to maintain a hard-on, producing another race against time situation.
• The man who gets lost in the moment and rushes to the pleasure of orgasm, even if he tells himself (and his partner) he would like to last longer. It’s not necessarily a pleasant ‘lost in the moment’ in the cases of anxiety or fear of intimacy.
• Men that transform their partner into a hyper-stimulus. This might be due to sexual fantasy or the relationship dynamic as discussed above.

Specific movements can over-stimulate sexual excitement. For many men, these are subconscious, habitual actions that they may never have noticed or questioned:

• Thrusting with the trunk as a single movement.
• Moving the pelvis too speedily. In reality, this porn-sex move over-stimulates the man while the partner feels very little.
• Trying to maintain the same rhythmic tempo for as long as possible.
• Clenching: buttocks, PC muscle, arms, hands. Some men do this intentionally, thinking it will keep them hard or will prevent ejaculation. Some positions can generate unhelpful muscle tensions too.
• Breathing rapidly.
• Holding breath.

To summarise, there’s plenty to work with here. Our ability to make sex last is not hard-wired in our genetics. Sometimes we need help to identify what’s causing our own particular issue. But whatever the cause, we can all learn how to manage our sexual excitement and last longer in bed. Good news, everyone.

Coming up in Part 3: we’ll review all the various treatments for premature ejaculation and their effectiveness.

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