This article was downloaded by: [Ecole Hautes Etudes Commer-Montreal]

On: 13 January 2015, At: 15:35

Publisher: Routledge
Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered
office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK

Sexual and Marital Therapy

Publication details, including instructions for authors and
subscription information:
http://www.tandfonline.com/loi/csmt19

An alternative, combined approach

to the treatment of premature
ejaculation in Asian men
a
Mamta Gupta
a
South Bedfordshire Community Health Care Trust , Luton,
United Kingdom
Published online: 14 Dec 2007.

To cite this article: Mamta Gupta (1999) An alternative, combined approach to the treatment
of premature ejaculation in Asian men, Sexual and Marital Therapy, 14:1, 71-76, DOI:
10.1080/02674659908405390

To link to this article: http://dx.doi.org/10.1080/02674659908405390

PLEASE SCROLL DOWN FOR ARTICLE

Taylor & Francis makes every effort to ensure the accuracy of all the information (the
“Content”) contained in the publications on our platform. However, Taylor & Francis,
our agents, and our licensors make no representations or warranties whatsoever as to
the accuracy, completeness, or suitability for any purpose of the Content. Any opinions
and views expressed in this publication are the opinions and views of the authors,
and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content
should not be relied upon and should be independently verified with primary sources
of information. Taylor and Francis shall not be liable for any losses, actions, claims,
proceedings, demands, costs, expenses, damages, and other liabilities whatsoever
or howsoever caused arising directly or indirectly in connection with, in relation to or
arising out of the use of the Content.

This article may be used for research, teaching, and private study purposes. Any
substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing,
systematic supply, or distribution in any form to anyone is expressly forbidden. Terms
& Conditions of access and use can be found at http://www.tandfonline.com/page/
terms-and-conditions
 Sexual and Marital Therapy, Vol. 14, No. 1, 1999 71

SHORT PAPER
An alternative, combined approach
to the treatment of premature
ejaculation in Asian men
Downloaded by [Ecole Hautes Etudes Commer-Montreal] at 15:35 13 January 2015

MAMTA GUPTA
South Bedfordshire Community Health Care Trust, Luton, United Kingdom

Premature ejaculation (PE) is a common problem (Kinsey et al., 1948), especially

amongst Asian males, where it is well recognized as Dhat syndrome (Gupta, 1994;
Bhatias & Malik, 1991; Bhugra & Cordle, 1986, 1988). It was the third commonest
problem seen in men attending our Sexual Dysfunction clinics in Central Luton,
which has an Asian population of up to 20%. A significant number of the men
referred to us with the problem of erectile failure were in fact premature ejaculators.
They lost their erection as a result of rapid ejaculation rather than because of their
inability to get an erection in the first place. Some men reported ejaculation in the
absence of any tactile stimulation or with minimal tactile stimulation, with visual
erotic stimulus only, even before attaining a full erection. It is accepted that not all
premature ejaculators fail to recognize the moment of ejaculatory inevitability or the
point of no return. They have a short arousal phase and an almost non-existent
plateau phase of their arousal cycle. In my experience, such men do not show a good
response to the behavioural sex therapy approach alone.
I have seen a few young men suffering from PE who are physically fit and train
quite extensively, one or two of them even calling themselves ‘adrenaline junkies’.
(We know that the sympathetic or alpha-adrenergic nervous system plays a large role
in emmission and ejaculation in men.) They all had very good relationships and
sexual techniques.
A vast majority of men seen at our clinics had suffered from PE for many years
before seeking help. Following referral, they remained a few further months on the
waiting list before they were finally seen. By this time they were desperate for a
‘quick fix’ and found the behavioural approach too slow. In addition, these men
frequently had religious or cultural objections to using the standard Stop-Start and
Squeeze techniques, as both require masturbation which is unacceptable and a
taboo in Asian cultures (Gupta, 1994). Similar to men with erectile failure, men
with PE find it difficult to approach women and make relationships because of their
fear of failure. Their partners, who are also unsatisfied, frequently feel rejected and
are very angry. They lose interest in sex because they rarely reach orgasm during sex.
Received for publication 3rd July 1998; accepted 30th September 1998.

0267-4653/99/01007 1-06 0 British Association for Sexual and Marital Therapy

 7 2 Marnta Gupta

Even non-sexual contact between them disappears over time, for fear of where it
may lead.
Asian men with PE have of a host of associated psychosomatic symptoms like
depression, sleeplessness, generalized weakness, thin and watery semen and various
urinary complaints. Semen is considered to be a precious substance in Indian
cultures. Some of the Indian names for semen are dhatu (metal or base substance)
and niani (jewel). Atharua-ved, one of the ancient Indian religious books, mentions
that a hundred drops of blood are required to make one drop of semen. Its loss is
inevitably seen as a loss of strength, the possible psychological reason behind these
symptoms. Collectively, these symptoms are known as Dhat syndrome (Gupta,
Downloaded by [Ecole Hautes Etudes Commer-Montreal] at 15:35 13 January 2015

1994). According to Indian belief, weak semen will not produce a male child, which
is of great importance in Indian culture. This adds to “the sense of failure as a man”.
Loss of erection following an early ejaculation is seen as an additional sign of
weakness. Homeopathic, Ayurvedic and quack medicines claiming to cure the
problem of rnardana-karnzori or male weakness caused by loss of semen abound in
Asia. Huge hoardings advertising treatments and miracle cures offered by dubious
practitioners can be seen all along the major railway tracks and road sides in India.
These practitioners prey on men’s desire to attain potency and/or delay ejaculation,
to sometimes unrealistic lengths. When these men come to a doctor or a therapist,
they are looking for a cure. They are not receptive to long-term home assignments.
They have a high drop-out rate from the behavioural treatment programmes.
Stop-Start and Squeeze techniques show a slow response, if any. The men may
agree to the assignments set by the therapist to be polite, but very seldom carry them
out in the manner they were prescribed. Their female partners do not always
participate in the treatment programme. If they come for counselling, they are there
because they have been told to come by their husbands. They rarely join in the
discussion sitting quietly throughout the session. They may not say ‘no’ during the
session but will often not participate in learning the Stop-Start and Squeeze
techniques. Masturbation is seen to be a bad thing even for a man. How can one
expect women to do such things? Loss of semen through masturbation is seen as a
waste of the precious substance leading to weakness of their husbands.
Understandably, the women are reluctant to participate; “nice Indian women don’t
do these sorts of things anyway!”. Replacing the word ‘masturbation’ with
‘pleasuring’ may occasionally help but cultural beliefs of centuries cannot be
changed overnight (Gupta, 1994).
Sex therapy of course has a major role in improving the couple’s relationship,
their understanding of the anatomy and physiology (the how and why) of sex, the
mechanism of premature ejaculation and the techniques that may work in
overcoming it. Communication, which may be non-existent by the time they come
for help, can be restored through counselling. Bans and limits with set programmes
help to reduce performance anxiety, while excessive sympathetic stimulation has a
negativehastening effect on ejaculatory control, thanks to alpha-adrenergic
stimulation. However, these type of programmes take time which is not always
acceptable to these couples and often not available on the National Health Service.
Some couples may have perfectly good relationships, with good sexual
 A combined approach to premature ejaculation 73

communication and lovemaking techniques. They may not see the point of long
periods of bansnimits. In this group of men who would not otherwise ‘go the
distance’, a combination approach to therapy seems to show a definite advantage.
Serotonin Re-uptake Inhibitors (SSRIs) and antidepressants which selectively
inhibit the uptake of serotonin, have been used with some success in the treatment
of premature ejaculation (Riley, 1995; Waldinger et al., 1997; Althof, 1995; Balon,
1996), although there is no definite evidence that there is any abnormality of 5-HT
activity in these men.
We know that the penile constriction ring, when used with or without the
vacuum pump in the treatment of erectile failure, sometimes makes ejaculation
Downloaded by [Ecole Hautes Etudes Commer-Montreal] at 15:35 13 January 2015

difficult. So why not use it for men who want to make ejaculation ‘difficult’? With
this in mind I have used this side-effect of the constriction ring positively, in the
treatment of premature ejaculation, in men who did not want to learn any of the
standard techniques to achieve ejaculatory control for reasons discussed earlier.
Ejaculatory control learnt through the behavioural model alone has a questionable
long-term outcome anyway (Metz & Pryor, 1997).
Also, as the available time for consultations becomes more and more restricted
under National Health restraints, the idea of using all three treatment options
simultaneously makes sense. If these men could be given the ‘quick fix’ treatment
they were seeking with the drug therapy temporarily, it may decrease their sense of
failure or hopelessness and make them more receptive to exploring other options. It
would cut down the hard-pressed consultation time and drop-out rates. As they
gained confidence from medically induced immediate control of ejaculation and
could see that relief was in sight and possible, it might get them motivated to learn
other techniques like Stop-Start and Squeeze. They could then be given the penile
constriction ring to be placed at the base of the penis, as an additional help in
controlling their ejaculation. The medication and the constriction ring would enable
them to have satisfactory sexual intercourse relatively early on, while they were
learning ejaculatory control. Being able to have intercourse may actually reduce their
anxiety IcveIs, another plus in delaying ejaculation. Those who did not want to
participate in learning Stop-Start and Squeeze techniques at all, because of their
strong objections to masturbation-related assignments, could use the ring alone,
following the drug treatment.
We have tried this combined approach at our clinic. Unfortunately the number
of men who were able to use this approach was too small to draw any definite
conclusions as our clinic was withdrawn because of lack of funding. More work and
validation is necessary. The approach we used was as follows:
The initial approach to treatment was essentially the same as before. A full
assessment on the first visit was followed by education, discussion of possible causes
of PE and discussion of a plan of action. The combined treatment option was
discussed with the couples at length. It was explained that the selected drugs and the
sex therapy techniques were already in use for the treatment of PE and the
constriction rings were in use for maintaining an erection where it sometimes caused
ejaculatory problems. Nothing new was on trial. All we were trying was to combine
all the approaches.
 74 Mamta Gupta

Each couple was given sensate focus-type assignments, with the usual limits and
bans. Work on improving communication continued as normal. The couple was
always given back-up written handouts. This, in my experience reduces the chances
of failure to understand the tasks, omissions and excuses for not carrying out thc
agreed programmes. The drug paroxetine was prescribed early on and continued for
a maximum of 12-14 weeks. The constriction ring was introduced before the
withdrawal of paroxetine.
We were able to offer this treatment plan to eight men before our clinic was
closed, comprising five Asian Muslims, two Caucasians and one Afro-Caribbean.
We followed the plan described below.
Downloaded by [Ecole Hautes Etudes Commer-Montreal] at 15:35 13 January 2015

Premature ejaculation (alternative plan using medication ring) +

Assessment, education on how and why of ejaculation and ‘the point of tzo return’
Assignments: Ban sexual intercourse. Start sex-therapyhensate focus I & 11 Improve
communication.
+
Man to self-stimulate, Stop-Start Squeeze X 3 times ejaculates on 4th attempt
Dry hands and focus on sensations. Prescribe peroxetine 10 mg daily X 2 wks.
v
Check progresdfailure. Troubleshoot. Next step:
Woman stimulates, man guiding. Man focuses on feelings. StopStart + Squeeze X 3
t i m e s 2 ejaculate on 4th attempt. Paroxetine 10-20 mg, as required X 2 wks.
v
Check progresdfailure. Troubleshoot. Next step:
Woman astride. No penetration. Stop-Start + Squeeze X 3 times 3 use the ring after
3rd Stop. Ejaculate on 4th attempt, man guiding. Focus on feelings.
Continue 10-20 mg paroxetine X 2 wks.
v
Check progresdfailure. Troubleshoot. Next step:
Woman on top. Penetration only. No Thrusting. Stop-Start + Squeeze X 3 times, ring
on after 3rd stop. Ejaculates outside vagina. Focus on feeling.
Continue paroxetine to 10 mg X 2 wks.
v
Check progresdfailure. Troubleshoot. Next step:
Woman on top. Ring on. Man holds her buttocks, penetrates and moves her up &
down, slowly.
Stop-Start X 3. Man ejaculates in vagina, on 4th attempt.
Continue paroxetine 10 mg X 2 wks.
v
Ring on. Side to side position. Penetration and increasing movements.
Slow and start X 3. Man ejaculates on 4th attempt. Paroxetine 10 mg X 2 wks.
v
Ring on. Man on top. Slow and start X 3. Man ejaculates on 4th attempt.
Stop paroxetine. Continue with the ring and StopStart
 A combined approach to premature ejaculation 75

The men were informed that they may have to stretch the ring to facilitate
ejaculation. The Ring could be used for as long as required or until the man
was confident. They were told that they must remember to take it off before falling
asleep!
Patient information sheets about the drugs were prepared in collaboration with
our community pharmacist. Other drugs can be used if side-effects are experienced
e.g. Anafranil 10 + 25 + 50 +25 50 mg or Sertraline 50 4 100 4 50 mg.
Three men did not attend after the first appointment, after their GPs were asked
to prescribe paroxetine (our clinic did not have funding for prescribing medication).
They did not reply to a hrther letter or enquiry, therefore we do not know if they
Downloaded by [Ecole Hautes Etudes Commer-Montreal] at 15:35 13 January 2015

ever took paroxetine, whether sex therapy techniques were tried and worked for them
or for how long they used these. Of the remaining four, three Asian Muslim and one
Afro-Caribbean, all reported a sense of relief when paroxetine showed an immediate
positive effect on their long-missing ejaculatory control. Stop-Start and Squeeze
techniques although learnt, were not very popular except for one single and rather
naive young Asian man who had no understanding of sexual function, was very keen
to learn and reported a fair improvement through educational and behavioural
therapy programmes alone. He learnt Stop-Start and Squeeze techniques with
enthusiasm. His initial, religious reluctance to try masturbatory exercises was
overcome through education and the knowledge that it may be permissible within his
culture to use these for treatment purposes only (Gupta, 1994). A positive response
to the exercises helped his motivation. He left for Pakistan at this point and was lost
to follow-up. All men knew from the beginning that the medicine was only temporary
because of its possible negative effects on desire and erection and that it would be
withdrawn in 12-14 weeks. The only long-term option on offer was to learn
ejaculatory control and the use of a constriction ring.
All three men showed improvement with medication, as expected. On the two
visits following the discontinuation of paroxetine, all reported that the ring was
working well in controlling the ejaculation during penetrative sexual intercourse.
They were less anxious about their performance, which probably helped. At three to
five months the men and their partners were reported to be happy with the outcome.
They were managing satisfactory sexual intercourse with the ring, while continuing
to practice the Stop-Start techniques off and on, and only halfheartedly. None of
them had remained on paroxetine. Longer-term follow-ups were not possible
because of the discontinuation of the clinic at this stage.

Discussion
For men who have a long-standing PE because of a short plateau phase of arousal
and failure to recognize the point of ejaculation inevitability, sex therapy techniques
gains are low and short-lived. A combined approach using sex therapy, pharmacology
and the penile constriction ring gives the couple an option to have
sexual intercourse when the only block to sexual intercourse is premature ejaculation.
A quick response to medication decreases the frustration felt by the sufferers and
their partners and may enhance their compliance with the behavioural treatment
 76 Mamta Gupta

plans. In men with strong cultural objections to sex therapy programmes involving
masturbatory assignments, medication like paroxetine and the use of a constriction
ring together give them alternative options. For those who do not want to either take
the drugs or learn the assignments involving masturbation, a constriction ring may
be all that is required, although it must be noted that the reluctance to try out sex
therapy programmes may be the result of unresolved and relevant psychological
issues. For couples who have a good relationship, where the only block to sexual
intercourse is PE, long-term behavioural programmes are not always necessary and
may not be seen as an effective use of limited National Health time and resources.
As mentioned earlier, our Sexual Dysfunction Service was discontinued at this
Downloaded by [Ecole Hautes Etudes Commer-Montreal] at 15:35 13 January 2015

point because of lack of funding and we were unable to continue, It is impossible to

draw any definite conclusions from such a small number of men and our study will
require further validation. However, until the mechanism of ejaculatory control is
understood better, use of this approach may offer an alternative treatment to some
men.

Acknowlegements
Thanks to Owen Mumford for providing the constriction rings for the trial. Thanks
to my colleague, Dr S. Smith, for her support and participation in this work and to
Mrs Pat Williams, the Community Pharmacist, for her help in designing the drug
information sheets for men.

References
ALII’HOF,S.E. (1995) Pharmacological treatment of rapid ejaculation: preliminary strategies, concerns
and questions, Sexual and Marital Therapy, 10, pp. 247-251.
BALON,R.J.(1996) Antidepressants in the treatment of premature ejaculation, Sexual and ManlaI
Therapy, 22, pp. 85-96.
BHAI~A, M.S. & MAUK S.C. (1991) Dhat Syndrome, a useful diagnostic entity in Indian culture, Bnlkh
Journal of Psychiaty, 159, pp. 691-695.
Bnmw, D. & CORDLE, C. (1986) A case control study of sexual dysfunction in Asian and non-Asian
men, Sexual and M a r i d Therapy, 3, pp. 71-76.
BHUGKA, D. & CORDLE, C. (1988) Sexual dysfunction in Asian couples, British MedicalJournal, 292, pp.
111-1 12.
GUITA,M. (1984) Sexuality in the Indian Subcontinent, Sexual and Marital Therapy, 9, pp. 57-69.
KINSEY A.C., POMEROY B.W. & MARTIN C.E. (1948) Sexual Behavior in the Human Male (Philadelphia,
PA, W. B. Saunders).
METZ,M.E. & PRYOR, J. I. (1997) Prcmature ejaculation: a psychophysiological review, Journal of Sex
and Marital Therapy, 23, pp. 3-23.
RILEYA.J. (1995) Premature ejaculation: approaches to management, Uwk~gy,1, pp. 91-94.
WALDiNGan M.D., HENGEVELD, M.W. & ZWINDERMAN, A.H. (1 997) Ejaculation-retarding properties of
paroxetine in patients with premature ejaculation: a double blind, randomised, dose response study,
British Journal of Urology, 79, pp. 592-595.

Contributor
GUPTA,MBBS, MFCH, BASMT Accred, Senior Clinical Medical Officer.
MAMTA