Excerpted from "The Male Biological Clock" by Harry Fisch
Chapter 3: The Viagra Generation

Sam came to see me about a problem even more common than erectile dysfunction. The number one male sexual problem is premature ejaculation—ejaculation that occurs sooner than desired, either before or shortly after penetration, causing distress to one or both partners. Roughly one-in-five men between the ages of 18 and 60 experience premature ejaculation.

Sam had been married for nearly seven years and only came to see me because his wife insisted he see a doctor—a very common pattern. In fact his wife came with him on the first visit, which I encourage because it’s helpful to hear both sides. When I asked Sam if he had a problem with his erections he said he didn’t think so. His wife rolled her eyes.

“Doctor, the thing is that Sam, well, he just doesn’t last very long if you know what I mean,” his wife said. “He’s in me for maybe 30 seconds…a minute tops, and he comes and that’s it. It’s all over before I’ve even begun and, I’ll tell you, I’m tired of it.”

Sam is actually on less of a hair trigger than some men with this problem. Some men are so sensitive they have an orgasm even before their penis has entered a woman’s vagina. Others climax within seconds of entry. It’s usually very frustrating for both partners. The man wants much more relaxed, lengthy love-making and the woman, whose orgasmic pattern is naturally longer and slower, never gets the chance to have an orgasm with the man inside her. Doctors need to question men about exactly what they are experiencing because some men don’t understand that loss of an erection after ejaculation is normal, thus they wrongly think their problem is erectile dysfunction when the actual problem is premature ejaculation.

Although it’s true that premature ejaculation tends to resolve with age--the male biological clock slows down the sexual response cycle—this usually happens long after a great deal of sexual dissatisfaction has occurred. Fortunately, premature ejaculation today is one of the easiest problems to treat, particularly if a man can talk easily about sex with his partner and he or she is willing to experiment to find more satisfying ways to have sex.

Although it’s common for men who want to slow down orgasm to try to distract themselves mentally by, for instance, doing math in their heads, this takes the man away from the moment and from a full connection with his partner. A better approach is to begin sexual stimulation until the man feels he is nearing the “point of no return.” He either withdraws or the stimulation is removed for about thirty seconds. The sequence is repeated as often as needed. In this way the man can gain control and confidence, which may reduce his tension and associated tendency to ejaculate prematurely.

A variation of this method is to gently squeeze the penis where the glans meets the penile shaft during the “break” periods just described. Some men report this reduces their urge to ejaculate.

In recent years doctors have seized on a normally undesirable side effect of some antidepressants to help men with premature ejaculation. The class of antidepressants called selective serotonin reuptake inhibitors (SSRIs) inhibit orgasm in many of the men who take them. Prozac was the first antidepressant in this class, but Zoloft, Paxil, and Luvox are also members. A member of the older class of tricyclic antidepressants, Anafranil, is also sometimes prescribed. Low doses of such drugs have proven very helpful for men suffering premature ejaculation. Effective doses range from about half the normal daily dose to doses typically used in depressed patients. Although the antideppressant effects of SSRIs typically take several weeks to kick in, their orgasm-delaying effects happen within about four hours, which means men can use them periodically if they want. Many men, however, prefer to simply take a pill a day so they don’t have to think about it and can more spontaneously respond to romantic situations.

Some men use one of a variety of anesthetic creams that mildly numb the penis and so delay orgasm. The creams must be used carefully, since using too much can cause erections to fail from lack of feeling. If used without a condom, the cream may also cause vaginal numbness in the partner. Condoms alone can reduce penile sensation sufficiently in some men with premature ejaculation to have satisfactory sex.

I gave Sam a prescription for a low dose of Zoloft. A week later he called and said things had definitely improved, but his wife thought he should try a higher dose. I raised the dose to that normally used by people who are depressed.

“It’s unbelieveable,” Sam said two weeks later. “For the first time in my life I’ve actually made love for 15 or 20 minutes. My wife and I even had simultaneous orgasms the other night…and that’s never happened before, believe me!”

Like most men, Sam felt some minor side effects in the first week of taking the medication—a slight stomach queasiness and a mild headache. Both have now disappeared.

“It’s kinda a double-whammy effect,” Sam jokes. “I’m happier because I can finally have good sex with my wife, and maybe I’m a little happier because of the antidepressant. Whatever…it’s great.”

The advent of safe, effective pills to enhance erections and, in effect, reverse this aspect of the male biological clock has been a tremendous boon to men and their partners. But as we saw with Harold’s story above, an erection is hardly the whole story of sex. When an erection-enhancing pill actually makes a relationship worse, the problem is often the man’s lack of appreciation that real intimacy is about more than mechanics, erections, penetration, and orgasm. Most women enjoy sex but not if the intimacy is gone. Many things contribute to romantic intimacy between people, of course, but some key factors are honesty, good communication styles, mutual respect, emotional security, healthy self-esteem and a good body image. All of these can take years to develop and if they’ve disappeared in a relationship (or if they never existed in the first place) no amount of soft music, candles, sexy underwear, or Viagra is going to do the trick.

I often joke with the partners of my male patients that if I could invent a listening pill—a pill that would make men pay attention to women and simply listen without interrupting—that I’d be a billionaire. Since that’s not going to happen, I simply want to pass on this advice to men:

  • Include your partner in your decision to explore erection-enhancing pills or techniques
  • Listen to your partner—let her talk
  • Don’t interrupt
  • Pay attention to your partner’s emotional, as well as physical desires
  • In lovemaking, relax and go slowly—at least at first

When a couple can talk openly about sex, when they approach a problem like erectile dysfunction as a team, when they avoid casting blame, and when they have an experimental or playful approach to trying new things, the chances are very, very good that they will both be far more satisfied with sex than they were before. One last thing: women, particularly post-menopausal women, can have sexual dysfunction just like men, and may also need assistance with desire or arousal. Such problems as painful sex, inability to achieve orgasm, thinning of vaginal tissues, lack of sexual desire, or inability to lubricate can seriously affect a couple’s sex life. Since this is a book about male sexual function, a complete discussion of the many treatment approaches to female sexual dysfunction is inappropriate. But women should know that many options exist, including the use of vibrators to enhance orgasm, different sexual positions to minimize pain, relaxation techniques, vaginal exercises, and more pharmacological approaches such as estrogen creams or testosterone replacement therapy.


  1. Laumann EO, Paik A, Rosen RC. Sexual dysfunction in the United States: prevalence and predictors. Journal of the American Medical Association. 1999;281(6):537-544
  2. Atmaca M, Kuloglu M, Tezcan E, Semercioz A. The efficacy of citalopram in the treatment of premature ejaculation: a placebo-controlled study. International Journal of Impotence Research. 2002 Dec;14(6):502-505.
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