Effectiveness of Cognitive Behavioral Therapy on Premature Ejaculation in an Iranian Sample

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1 Effectiveness of Cognitive Behavioral Therapy on Premature Ejaculation in an Iranian Sample Mohammad Soltanizadeh 1, Hamid Taher Neshatdoust 1, Mehrdad Kalantari 1, Mehrdad Salehi 2, Mohammad Hossein Izadpanahi 3 1 Department of Psychology, Faculty of Educational Sciences and Psychology, University of Isfahan, Isfahan, Iran. 2 Department of Psychiatry, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran. 3 Department of Urology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran. Corresponding Author: Mohammad Soltanizadeh, Faculty of Psychology and Education, University of Isfahan, Isfahan, Iran. Postal Code: , Abstract Heretofore, there have been few investigations regarding to effectiveness of cognitive behavioral therapy on premature ejaculation in Islamic eastern cultures such as Iran. These investigations have many methodological problems. In this research, the effectiveness of cognitive behavioral therapy on premature ejaculation was studied using a controlled design with 3-months follow-up in Iranian sample. The sample involved 20 men with premature ejaculation that randomly assigned in two experimental and control groups. All participants responded to Index of Premature Ejaculation (IPE), Beck Anxiety Inventory (BAI), Beck Depression Inventory (BDI), The World Health Organization Quality of Life (WHOQOL)- BREF, Enriching and Nurturing Relationship Issues, Communication and Happiness Questionnaire (ENRICH) and socio-demographic questionnaire. Also, they measured intravaginal ejaculatory latency time (IELT) using stopwatch. The results of ANCOVA indicated that cognitive behavioral therapy could improve premature ejaculation and increase IELT and men's sexual satisfaction significantly. But it didn't show any effect on anxiety, total marital satisfaction and quality of life. The effect of therapy was kept until 3-months follow-up. Cognitive behavioral therapy is an effective method to decrease premature ejaculation and improve men's sexual satisfaction who suffered this disorder. Keywords: Premature Ejaculation; Cognitive Behavioral Therapy; Sexual Satisfaction; IELT 1. Introduction According to the results of numerous epidemiological studies (Montague et al., 2004; Rosen, 2000), premature ejaculation (PE) is likely the most prevalent sexual dysfunction. Overall, the prevalence rate of PE falls somewhere between 25 and 40% in the global population of men across all age groups (Lumann, Paik & Rosen, 1999; Lumann et al., 2005). Results of the National Health and Social Life Survey (NHSLS), a large study of sexual behavior in a demographically representative sample of adults in the United States, indicate a prevalence rate of 29%. (Lumman et al., 1994). Similar findings are reported in the Global Study of Sexual Attitudes and Behaviors (GSSAB), a large and survey-based study where the prevalence of common sexual dysfunctions was studied in 29 countries stratified into seven geographic regions. The majority of the prevalence rates reported in these seven regions were very similar to the one reported by the NHSLS, with four of the seven regions reporting prevalence rates from 27.4 to 30.5% (Lumman et al., 2005). Despite the predominance of PE, the creation of a standardized definition and diagnostic criteria has been elusive. In 1970, Masters and Johnson defined the condition as the inability of a man to delay ejaculation long enough for his partner to reach orgasm on 50% of intercourse COPY RIGHT 2012 Institute of Interdisciplinary Business Research 491

2 attempts. The obvious criticism of this definition is its dependence on the partner s ability or likelihood to orgasm. A precise definition of PE has yet to be formulated, although many published reports use either the American Psychiatric Association (1994) Diagnostic and Statistical Manual of Mental Disorders or the International Classification of Diseases (ICD-10) definition. The ICD-10 (World Health Organization, 1993) defines PE as: an inability to delay ejaculation sufficiently to enjoy lovemaking, manifest as either of the following: (1) occurrence of ejaculation before or very soon after the beginning of intercourse (if a time limit is required: before or within 15 seconds of the beginning of intercourse); (2) ejaculation occurs in the absence of sufficient erection to make intercourse possible and the problem is not the result of prolonged abstinence from sexual activity. The main criteria for premature ejaculation in DSM-IV-TR (American Psychiatric Association, 2000) include: a persistent or recurrent ejaculation with minimal sexual stimulation before, on or shortly after penetration and before the person wishes it. The clinician must take into account factors that affect the duration of the excitement phase, such as age, novelty of the sexual partner or situation and recent frequency of sexual activity. Currently, the most accepted definitions of PE come from the DSM-IV-R and ICD-10, which both refer to PE as a condition of short ejaculatory latency that causes personal distress and is beyond the patient's ability to control. Both definitions are echoed by the American Urological Association (AUA), which states "PE is ejaculation that occurs sooner than desired, either before or shortly after penetration, causing distress to either one or both partners" (Montague et al., 2004). Some definitions include a measure of time to define the PE. The time between vaginal penetration and ejaculation is referred to as the intravaginal ejaculatory latency time (IELT). The recommended IELT for diagnosing PE has varied in the literature from 1 to 2 min or less (Rowland, Cooper & Schneider, 2001; McMahon et al. 2004). Importantly, there no widely accepted standard for normal ejaculatory latency exists. However, a recently published study by Patrick et al. (2005) on a large community-based population of men and their partners might give the best estimate of normal ejaculatory latency to date. The investigators found that the median intravaginal ejaculatory latency time (IELT), recorded using a partnerheld stopwatch, was 7.3 min for men without PE, whereas men with PE had a median IELT of 1.8 min. In this research we use two subjective (Index of Premature Ejaculation, Symonds et al., 2007) and objective (IELT) measures for operational definition of PE. PE affects the individual, his partner, the relationship, and overall quality of life (QOL). The association between sexual satisfaction, life satisfaction, and overall well-being has been recognized for more than 30 years (Bell, 1972; Masters & Johnson, 1970). PE has been shown to have a significant negative psychological impact on men with the dysfunction, which typically results in increased anxiety and loss of sexual confidence, and leads to distress and reduced satisfaction with the sexual experience (Barnes & Eardley, 2007). McCabe (1997) showed that men with PE had lower levels of satisfaction in all life areas assessed compared to sexually functional men. McCullough & Bull (2004) reported the results of 1158 men responding to a sexual health survey. The authors found that men with PE were significantly more likely to report low satisfaction with their sexual relationship, low satisfaction with sexual intercourse and difficulty relaxing during intercourse. The female partners of men with PE also reported that satisfaction COPY RIGHT 2012 Institute of Interdisciplinary Business Research 492

3 with the sexual relationship decreased with increasing severity of the man s condition (Byers & Grenier, 2003). To date, the cause of PE has not been conclusively determined. Not surprisingly, there are those who advocate for an entirely biological explanation and those who insist that it is a wholly psychological condition. Even if we were able to state unequivocally that a man s premature ejaculation is due to biological factors exclusively, he would probably manifest a psychological response that might further worsen the condition. Additionally, his partner may be psychologically affected by the dysfunction, regardless of the underlying cause. Given that psychological factors can either worsen the condition or in some cases may be responsible for precipitating and maintaining the dysfunction, psychotherapy remains a vital intervention to help men and their partners who suffer from rapid ejaculation (Althof, 2006). Clinical observation and theoretical models emphasize the importance of core cognitive structures (schemas or core beliefs) on sexual dysfunctional processes (Carey, Wincze, & Meisler, 1993; McCarthy, 1986; Rosen, Leiblum, & Spector, 1994; Sbrocco & Barlow, 1996). Barlow during the last two decades has developed an invaluable work on the study of cognitive factors underlying sexual dysfunctional behaviors. Barlow s (1986) cognitive-affective model postulated that the interaction between autonomic arousal (sympathetic activation) and cognitive interference plays a central role in determining sexually functional and dysfunctional responses. Sbrocco and Barlow (1996) and Wiegel, Scepkowski, and Barlow (2007) further developed the original model, indicating that schematic vulnerability is one of the main components implicated in sexual dysfunction. Sbrocco and Barlow (1996) suggested that individuals with sexual dysfunction have a set of sexual beliefs usually unrealistic and inaccurate and assume a rigid and inflexible character. Whenever these demanding and unrealistic referential standards are not met, catastrophic personal implications may arise, facilitating the development of negative self-views (negative self-schemas) and predisposing individuals to develop sexual difficulties. Besides Barlow s theoretical model, increasing attention is being paid to the application of cognitive approaches to sex therapy. In this regard, some therapeutic approaches with particular emphasis on cognitive strategies and interventions have been developed (Carey et al., 1993; McCarthy, 1986; Rosen et al., 1994). Also, Nobre and Pinto-Gouveia (2009) concluded that specific faulty cognitive constructions underlying sexual dysfunctions and encourage the development of models and treatment approaches based on cognitive theory. Psychological treatments depend on principles of learning and cognitive processing as the mechanisms of change and rely on a general literature that has been well articulated and continues to expand (e.g., Barlow, 1986). It is clear that learning new patterns, changing one s conceptualizations, and practicing different thoughts and behaviors can lead one out of many disorders and certain illnesses (Dobson & Craig, 1998). Laboratory investigations of behaviorally based sex therapy support its value. There is more research supporting the efficacy of behavioral therapy for sexual problems than any other form of treatment, with the possible exception of medical intervention (Rosen & Leiblum, 1987; Schover & Leiblum, 1994). More than one-half of clients show improvement after behavioral treatment, and clients generally are thought to maintain their gain (Barlow, 1986; Hawton, Catalan & Fagg, 1991; Schover & LoPiccolo, 1982). Typically, these studies have used carefully trained and selected therapists operating in research clinics and offered therapy to clients without comorbid problems. Behavioral sex therapy rests on the theory that, once organic causes have been ruled out, sexual difficulties are the result of a combination of factors that are amenable to change through COPY RIGHT 2012 Institute of Interdisciplinary Business Research 493

4 relatively brief intervention. Anxiety has been emphasized as a central factor in the development and maintenance of dysfunctional behavior (Beck & Bozman, 1995; Bozman & Beck, 1991, Barlow, 1986). Other factors implicated are misattribution of physiological arousal (Cohen, Rosen & Goldstein, 1985; Rook & Harnmen, 1977), cognitive distraction (Southern, 1985), restrictive learning history and deficits in sexual technique and skill (Hurlbert, 1993). Because of the belief by some researchers that PE is due to a learned behavior because of performance anxiety, sex therapy became the mainstay of treatment for many years and today is still one option for treating PE. Cognitive behavior therapy attempts to alleviate sexual difficulties through a combination of techniques, including education (i.e., information regarding sexual anatomy and stages of arousal), cognitive restructuring (i.e., identification of thoughts and core beliefs that may be influencing sexual functioning), communication skills, training, and sensate focus exercises (McCabe, 2001; Rosen, Leiblum, & Spector, 1994; Leiblum & Rosen, 1988). Sensate focus consists of a graded series of mutual body-touching exercises. The sensate focus exercises serve to reduce performance anxiety, create pleasurable sexual experiences, and help people become aware of sexual responses and preferences. Other common form of sex therapy is the squeeze technique during which the patient and/or his partner squeeze the erect penile shaft before the ejaculatory reflex is stimulated. Using this technique, the patient will learn to voluntarily delay ejaculation while maintaining sexual excitation (Masters & Johnson, 1970). MacCabe (2001) evaluates a cognitive behavior therapy program for people with sexual dysfunction. He found that the treatment led to lower levels of sexual dysfunction, more positive attitudes toward sex, perceptions that sex was more enjoyable, fewer affected aspects of sexual dysfunction in their relationship, and a lower likelihood of perceiving themselves as a sexual failure. As sexual values and the meaning of sexuality depend on culture, the efficacy of psychotherapy models may not necessarily be similar in different cultures. Therefore there is a need for culture-specific applications of psychotherapies. Based on previous research, CBT was effective in treating PE. Therefore, the aim of the present study was to investigate the efficacy of CBT on PE and satisfaction of a group of Iranians with PE and is this method effective in other countries, or therapeutic effects based on culture, family structure and the other conditions. It is necessary to study more carefully in the countries with different cultures and family structures. 2. Method 2.1. Participants The participants were comprised of 20 males who were currently in heterosexual relationships. Some participants were referred by medical practitioners, others selected by an advertisement placed in a local newspaper calling for subjects to take part in a study of premature ejaculation in return for free treatment. Participants met the following selection criteria: (1) 18 years age or older and married, (2) their marriage last for at least 1 year, (3) having no history of or current psychiatric disorder, (4) no substance abuse (alcohol or drugs), (5) free of disease, medication use, or surgical procedures that might impact sexual function, (6) having at least one sexual relationship in a week, (7) having no other sexual dysfunction including erectile disorder. (8) no concurrent use of other treatment for PE. Participants must have reported a minimum 6-month history of disorder. All participants agreed to take part in the weekly meetings and to an 8-week waiting period. The mean age of the participants was 36.6 (SD=6.01). The socio-demographic characteristics of the participants in the two groups are presented in Table 1 and 2. T-tests and chi-square tests COPY RIGHT 2012 Institute of Interdisciplinary Business Research 494

5 yielded no statistically significant differences between the two groups regarding education, wife's education, occupation, wife's occupation, socioeconomic status, child number, age, wife's age and duration of marriage. Table 1. Frequency of demographic variables in CBT and control groups Groups Demographic variables CBT Control Education Wife's Education Socioeconomic Status Child Number Occupation Wife's Occupation Elementary School 1 2 High School Diploma 3 3 Post Diploma 2 2 Bachelor 4 3 Elementary School 0 1 High School Diploma 5 7 Post Diploma 1 1 Bachelor 4 0 M.A. 0 1 Weak 3 2 Average 4 4 Rich 3 3 Very Rich Employed 3 4 Unemployed 7 6 Employed 3 3 Unemployed 7 7 χ Table 2. Mean and standard deviation of age, wife's age and duration of marriage variables Groups N M SD t Age CBT Control Wife's Age CBT Duration of Marriage Control CBT Control Procedure This study was designed as a randomized waiting list controlled clinical trial that have a 3- month follows-up. Patients diagnosed with PE, using the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV-TR) (American Psychiatric Association, 2000) criteria. Participants answered the questionnaire after completing a clinical assessment for sexual dysfunction conducted by a psychiatrist and a clinical psychologist. Kappa (κ) coefficient (Cohen, 1960) was used to determine the inter-rater reliability of the clinical interviews. Coefficient of the agreement between interviewers was Besides, all participants were visited by an urologist, in order to refuse their probable physical problems led to premature ejaculation. All patients diagnosed with PE were asked to participate in the study. An explanation of the purpose of the study was given by one of the researchers involved in the project and a consent form was signed. The participants were randomly allocated to either cognitive behavior therapy COPY RIGHT 2012 Institute of Interdisciplinary Business Research 495

6 (10 males) or control groups (10 males). Subjects in the two groups were measured pretreatment, post-treatment, and at 3-month follow-up. In order to measure IELT, subjects of both groups were asked to measure 3 times the interval between penetration and ejaculation by themselves using a stopwatch before beginning the treatment or waiting period, after treatment and 3 months after treatment or end of waiting period. Treatment occurred over 8 weeks, one evening per week, for approximately two hours a session. Cognitive behavioral therapy of PE involves these components. Cognitive components were briefly including presenting correct information about sexual function and premature ejaculation, being familiar with CBT logic and mentioning how the thoughts and beliefs effect on sexual function especially premature ejaculation, recognizing irrational thoughts and being familiar with sexual myth, training the replacement of rational thoughts with irrational thoughts. Behavioral components included training Kegel exercises to control PC muscles contraction, sensate focus exercises including focus on nonsexual and sexual zones, using squeeze technique during stimulation of the penis by partner to learn delay ejaculation and using this technique during intercourse. Because of ethical issues, waiting group received cognitive behavioral therapy after 3-months follow-up Instruments Index of Premature Ejaculation (IPE; Symonds et al., 2007) IPE is a diagnostic tool based on Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) which consists of 5 items and captures the essence of DSM-IV-TR: control, frequency, minimal stimulation, distress, and interpersonal difficulty. Factor analysis of the 5 items retained the one-factor solution. The reliability of the 5-item version was good (Cronbach's alpha = 0.71; test-retest reliability = 0.73). Difference in mean score between the time-defined population and self-reported no-pe group was highly statistically significantly different (Symonds et al., 2007). As well as using this scale for subjective evaluation of premature ejaculation; IELT is also used to measure the time of delay ejaculation objectively Beck Depression Inventory-II (BDI; Beck, Steer & Brown, 1996) The BDI-II is a self-report inventory for adolescents and adults that assesses the presence and severity of depressive symptoms experienced during the past two weeks. The BDI-II includes 21 items each one consists of four statements reflecting varying degrees of symptom severity. Respondents are instructed to circle the number (ranging from 0 to 3) that corresponds with the statement that best applies to them. A rating of 0 indicates an absence of a symptom, while a rating of 3 is indicative of a severe symptom. Ratings from the 21 items are summed to calculate a total score, which can range from 0 to 63. In Dabson and Mohammadkhani investigation (2007) on 354 Iranian subjects with major depression, validity coefficient of BDI-II was The Cronbach's alpha reliability coefficient was In general, the results confirmed validity and reliability of this inventory. COPY RIGHT 2012 Institute of Interdisciplinary Business Research 496

7 Beck Anxiety Inventory (BAI; Beck, & Steer, 1990). The BAI is a 21-item self-report questionnaire asks about common symptoms of anxiety, such as feeling nervous, scared, and fear of dying, and was designed to distinguish anxiety symptoms from depressive symptoms. Each item is rated on a 4-point Likert scale for symptom severity in the past week, ranging from 0 (not at all) to 3 (severely). The range of total scores is from 0 to 63, with higher numbers suggesting greater degrees of anxiety. The instrument has excellent internal consistency (α =.92) and high test retest reliability (r =.75; Beck & Steer, 1990) The World Health Organization Quality of Life (WHOQOL)-BREF WHOQOL-BREF is a 26-item instrument consisting of four domains: physical capacity (PC, 7 items), psychological well-being (PW, 6 items), social relationships (SR, 3 items), and environmental health (EN, 8 items). The PC domain includes items on mobility, daily activities, functional capacity and energy, pain, and sleep. The PW domain measures self-image, negative thoughts, positive attitudes, self-esteem, mentality, learning ability, memory and concentration, religion, and the mental status. The SR domain contains questions on personal relationships, social support, and sex life. The EN domain covers issues related to financial resources, safety, health and social services, living physical environment, opportunities to acquire new skills and knowledge, recreation, general environment, and transportation (WHO, 1996). The WHOQOL- BREF has well to excellent psychometric properties of reliability and performs well in preliminary tests of validity (Skevington et al., 2004). A study by Nejat et al. (2006) demonstrated good-to-excellent reliability and acceptable validity of this questionnaire in various groups of subjects in Iran Enriching and Nurturing Relationship Issues, Communication and Happiness Questionnaire (ENRICH; Olson, Fournier & Druckman, 1983). ENRICH was designed as a multidimensional inventory, which assesses theoretically valuable and clinically useful dimensions of marital relationships. This questionnaire has 115 items and is scored using the Likert scale ranging from 1 to 5. This questionnaire is made of 12 subscales. The first scale has 5 items and the rest have 10 items. The subscales are included: idealistic distortion, marital satisfaction, personality issues, communication, conflict resolution, financial management, leisure activities, sexual relationship, children and parenting, family and friends, equalitarian roles and religious orientation. This questionnaire was measured according to Iranian norms and its validity and reliability was approved by Asrar and Haghshenas (2005). In Mahdavian's research (1997), the reliability was 0.94 using the retesting method Socio-demographic questionnaire: This questionnaire includes questions such as age, education, length of marriage, income and socio-economic level. 3. Results In order to study the effectiveness of CBT on PE we performed an analysis of covariance (ANCOVA) using SPSS (Statistical Package for Social Sciences). Before performing the analysis, normality and equality of variance hypothesis were tested with Kolmogorov-Smirnov and Levene test, respectively. These hypotheses were approved. COPY RIGHT 2012 Institute of Interdisciplinary Business Research 497

8 Table 3 shows the mean and standard deviation scores for pre-test, post-test and follow-up of the two groups used in the study. Table 3. Summary of the descriptive data (means and standard deviations) of two groups Pre-Test Post-Test Follow-up Variables Groups M SD M SD M SD Depression Anxiety Sexual Satisfaction Marital Satisfaction Quality of Life PE IELT CBT Control CBT Control CBT Control CBT Control CBT Control CBT Control CBT Control In table 4 the results of ANCOVA to compare the dependent variables between CBT and control groups in post-test step are illustrated. In order to conduct ANCOVA, depression, anxiety and demographic variables of subjects and pre-test scores were controlled. Table 4. A summary of ANCOVA results to compare the dependent variables between CBT and control groups in post-test Dependent Eta Observed SS df MS F P Variables Squared Power Anxiety Sexual Satisfaction Marital Satisfaction Quality of Life PE IELT Results of table 4 indicate that cognitive behavioral therapy could increase men's sexual satisfaction [F=50.921, P= 0.001]. It also improved premature ejaculation [F=13.095, P<0.05] and increased IELT [F= , P<0.0001].However it didn't have any effect on anxiety, total marital satisfaction and quality of life. Table 5 illustrates the results of ANCOVA by eliminating effects of pretest, anxiety, depression and demographic variables after 3-months follow-up. COPY RIGHT 2012 Institute of Interdisciplinary Business Research 498

9 As it is shown, there is a significant difference between sexual satisfaction [F=50.974, P=0.001], subjective index of premature ejaculation [F=12.891, P<0.05] and IELT [F= , P<0.0001] of control and CBT groups; and effects of therapy after passing a 3 months are still stable. There was no change in amount of anxiety, total marital satisfaction and quality of life. Table 5. A summary of ANCOVA results to compare dependent variables in follow-up Dependent Eta Observed SS df MS F P Variables Squared Power Anxiety Sexual Satisfaction Marital Satisfaction Quality of Life PE IELT Discussion In the present study, control and the treated groups did not differ on at least the demographic variables investigated here. Both groups were the same in educational level, wife's education, socioeconomic status, child number, occupation status and wife's occupation status, age and age of their wives and duration of their marriage. Results of the current study indicated that CBT had improved men's PE. This therapy could effect on the subjective perception of males about controlling and delaying their ejaculation. As well as an effect on subjective perception of males, CBT could effect on objective measure of premature ejaculation and increase IELT. Follow up of subjects after 3 months indicated that effects of the treatment on premature ejaculation still exist. Subjects' scores in self-report measure of premature ejaculation and IELT in a 3-month follow-up in comparison with the pretest had a significant difference. The reasons that cause CBT to effect on premature ejaculation are as follows. Baker and de Silva (1988) showed that men with a sexual dysfunction especially premature ejaculation and erectile disorder have some irrational and distorted beliefs. Such irrational beliefs have a negative relationship with expected and desirable sexual behaviors. Besides, Barlow (1988) believes that cognitive interference acts as a continuity factor in sexual dysfunction. McCabe (2001) also recognized that CBT decreases sexual dysfunctions in men and women and improves premature ejaculation. So it seems that cognitive interference increases arousal, consequently negative feelings in males and therefore intensifies premature ejaculation. For example, sexual stimuli aren't perceived as they really are; therefore there may be no sexual arousal or an inhibition will happen. In other words, attention to the thoughts creating anxiety is incompatible with a complete attention to the sensual stimuli which are important for sexual arousal. Since sexual situations for males with PE can cause anxiety, they avoid these situations to deal with their anxiety. Avoidance can lead to decrease the opportunities for training ejaculatory control and therefore PE is worsening. Cognitive behavioral therapy gives them the opportunities to face such situations and increases their ability in controlling and delaying ejaculation. The results indicated that CBT can improve PE without any effect on males' anxiety. Regarding to the PE, anxiety is not the only major or accelerator factor of PE, although levels of negative emotions in the men with PE is high (Rawland, Tai & Slob, 2003); and this factor can COPY RIGHT 2012 Institute of Interdisciplinary Business Research 499

10 intensify it. Men with PE are prepared to have a rapid and high arousal in their sympathetic system during sexual arousal. Anxiety is associated with increased sympathetic system activity and therefore can affect PE. Strasberg et al. (1990) also recognized that anxiety has not a stable role in PE and differs depending on the physical vulnerability. So lack of decrease in people's anxiety due to therapy can be result of primary difference of people in this factor. On the other hand, cognitive behavioral therapy of PE led to increase of participants' sexual satisfaction, but didn't have any effect on total marital satisfaction. As McCabe (2001) mentioned cognitive behavioral therapy not only improves sexual dysfunction but also increases a positive view toward the sexual relation and its pleasure. Also, improvement in PE increases the spouse's satisfaction with sexual relationship and decreases her negative feedbacks to this problem. With improvement in men's PE, men have more confidence toward themselves to satisfy their spouse. Their concerns regarding to this fact that their spouse may not be orgasm will decrease. These factors lead to increase in the males' sexual satisfaction. Total marital satisfaction involves several aspects and as therapy was only concentrated on sexual dysfunction, so it is likely to see no change in total marital satisfaction. We should note the certain limitations of this study. Small sample size limits the generalizability of the results. One more limitations of this investigation was lack of dividing the males according to the type of premature ejaculation (primary and secondary); it is recommended to accomplish the future investigations about psychotherapies as per a factorial plan and with considering type of the premature ejaculation. The present study also underscores that even effective techniques of psychotherapy should be modified according to cultural expectations, values, and gender roles. Acknowledgements I gratefully acknowledge all the peoples participated in this study and without whom it would not be possible. COPY RIGHT 2012 Institute of Interdisciplinary Business Research 500

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