How Does Premature Ejaculation Impact a Man s Life?

Journal of Sex & Marital Therapy ISSN: 0092-623X (Print) 1521-0715 (Online) Journal homepage: http://www.tandfonline.com/loi/usmt20 How Does Premature Ejaculation Impact a Man s Life? T. SYMONDS, D. ROBLIN, K. HART & S. ALTHOF To cite this article: T. SYMONDS, D. ROBLIN, K. HART & S. ALTHOF (2003) How Does Premature Ejaculation Impact a Man s Life?, Journal of Sex & Marital Therapy, 29:5, 361-370, DOI: 10.1080/00926230390224738 To link to this article: https://doi.org/10.1080/00926230390224738 Published online: 19 Jan 2011. Submit your article to this journal Article views: 1613 View related articles Citing articles: 126 View citing articles Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalinformation?journalcode=usmt20 Download by: [37.44.202.15] Date: 29 December 2017, At: 00:37

Journal of Sex & Marital Therapy, 29:361 370, 2003 Copyright 2003 Brunner-Routledge ISSN: 0092-632X print / 1521-0715 online DOI: 10.1080/00926230390224738 How Does Premature Ejaculation Impact a Man s Life? T. SYMONDS, D. ROBLIN, AND K. HART Pfizer Global Research & Development, Sandwich, Kent, United Kingdom S. ALTHOF Center for Marital and Sexual Health, Beachwood, Ohio, USA No systematic study has examined the psychological impact of premature ejaculation (PE) on the man and his partner. This study explores this vital issue by reporting on interviews of 28 men with self-diagnosed PE. From a qualitative perspective, these interviews assess whether these men had concerns about their PE and, if so, what they were. These men focused on two major themes: impact on self-confidence and future/current relationships. This suggests that PE has a similar qualitative impact on the individual as erectile dysfunction. Further investigation will need to determine how prevalent these concerns are in the PE population and also to delineate the impact on the men s partners. Premature ejaculation (PE), also referred to as rapid ejaculation, is a prevalent condition with between 22 and 38% of the adult male population suffering from this disorder (Laumann, Paik, & Rosen, 1999; Spector & Carey, 1990). Some specialists believe that PE is the most common male sexual disorder, affecting perhaps as many as 75% of men at some point in their lives (McMahon, 1998). Patients with sexual dysfunction are reluctant to raise the subject of ejaculatory dysfunction with their physician because they are embarrassed and uncertain if efficacious treatments exist to remedy their problem. Clinicians fail to ask about sexual matters because they are more concerned with health conditions with associated mortality and morbidity risks, are under intense time pressure, and may be uncomfortable asking patients about their sexual lives. Perhaps these phenomena account for Australian and Canadian doctors reporting that they found a rate of sexual dysfunction of only 0.2 5.4% in their patients (Fisher, 1986; Littman & Arnot, Address correspondence to Tara Symonds, Outcomes Research, Pfizer Global Research & Development, Sandwich Laboratories, Pfizer Ltd., Sandwich, Kent, CT13 9NJ, United Kingdom. E-mail: tara_symonds@sandwich. pfizer.com 361

362 T. Symonds et al. 1987). Moreover, in the case of PE, this is coupled with the lack of recognition of PE as causing patients and partners significant distress and the limited choice and lack of awareness of the available therapeutic options. It could also be that some men do not care about their ejaculatory dysfunction or, perhaps, they are either selfish lovers or are unconcerned with how long they last. Finally, they may deny, minimize, or not recognize PE as a significant problem, and it is only when their partner complains that men then seek treatment. Both the Diagnostic and Statistical Manual of Mental Disorders (DSM- IV; American Psychiatric Association, 1994) and the International Statistical Classification of Diseases and Related Health Problems (ICD-10; World Health Organization, 1992 1994) provide definitions of PE: DSM-IV criteria: PE is persistent or recurrent ejaculation with minimal sexual stimulation before, upon, or shortly after penetration and before the person wishes it and is associated with marked distress or interpersonal difficulty (APA, 1994). ICD-10 definition: There is 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. The problem is not the result of prolonged abstinence from sexual activity (WHO, 1992 1994). The DSM-IV criteria are nonspecific, relying heavily on the clinician s judgment as to what constitutes before, upon, or shortly after penetration. Similarly, it calls for judgment regarding lack of control of ejaculation and interpersonal difficulties. The ICD-10 definition provides more of a focus on latency and, indeed, defines a latency time postintromission of within 15 s of the beginning of intercourse. DSM-IV also calls for three additional specifiers when diagnosing rapid ejaculation: lifelong versus acquired, generalized versus situational, and that due to psychological factors versus that due to combined factors. Clinicians use the distinction between primary (lifelong) and secondary (acquired) to determine the focus of treatment. If a man has never achieved control, clinicians presume that this is a developmental problem because an issue has never been sufficiently resolved. Secondary problems suggest that something relatively recent has happened, and clinicians tend to focus on the recent past. Terms such as psychogenic and organic, although suitable as descriptors for erectile dysfunction (ED), remain hypothetical for PE (Rowland & Slob, 1997). Limited attempts to provide a consensus and more objective criteria for the diagnosis of PE have not succeeded. Despite this, most men presenting with PE readily recognize their problem, and there is no lack of self-diagno-

Impact of Premature Ejaculation 363 sis. There is no clear definition of the intravaginal ejaculatory latency time (IELT) that qualifies for the diagnosis of PE. Waldinger, Hengeveld, Zwinderman, and Olivier (1998) argue that the standard be set at an IELT of less than 1 min. Others would recommend that PE be defined to occur prior to or within 1 to 2 min following vaginal intromission. Men with latencies above 3 min are thought to overlap with sexually functioning individuals who do not view themselves as having a problem. Men with PE also report little or no control over ejaculation, whereas sexually functional men do perceive a relatively high degree of control. Unfortunately, there is no wellcontrolled study of ejaculatory latency in normal men over the life span. We do not know if IELT stays the same, increases, or decreases with age. TREATMENT The cause of PE has been considered to be more psychological than physiological. Because of this assumption, sex therapy was considered the treatment of choice with behavioral and/or cognitive approaches proving to be the most successful. These approaches include the stop-start technique developed in 1956 by Semans and later adopted by Masters & Johnson (1970), as well as other psychotherapeutic approaches that have become the gold standard for treatment of PE (Seftel & Althof, 1997). Many of these techniques require some degree of partner cooperation and have been associated with short-term success rates of 43 65%, depending on the population studied, motivation, and therapist (St. Lawrence & Madakasira, 1992). However, most patients do not maintain benefits, and relapse is common (Bancroft & Coles, 1976; DeAmicus, Goldberg, Lopicollo, Friedman, & Davies, 1985). No pharmacological agents are licensed for use in PE. However, certain antidepressants (monoamine oxidase inhibitors, tricyclic antidepressants, selective serotonin reuptake inhibitors [SSRIs]) and other drug classes (topical anaesthesia, neuroleptics, α-blockers, β-blockers, anxiolytics, smooth muscle relaxants), as well as oral PDE5 inhibitor agents (e.g., sildenafil), have been used off-label and in clinical studies (Chen, Greenstein, Mabjeesh, & Matzkin, 2001; Roblin, 2000). Double-blind, placebo-controlled studies with clomipramine and the major SSRIs, using strict dosages in carefully selected populations, have repeatedly demonstrated that these agents are efficacious in delaying ejaculation. However, when subjects discontinue the medication, improvements are lost, and ejaculation latencies tend to return to baseline. THE PSYCHOLOGICAL IMPACT OF PE The effect of this condition on men is poorly understood; however, it can cause significant distress. Indeed, the DSM-IV (APA, 1994) definition necessi-

364 T. Symonds et al. tates distress for PE to be considered a problem. Within the DSM-IV definition, reference is also made to interpersonal difficulty, perhaps referring to the embarrassing nature of the dysfunction resulting in men moving away from beginning or establishing new relationships, or even when PE may have a negative impact on men and their partners in a stable relationship (Rust, Golombok, & Collier, 1988). It has also been shown that dissatisfaction with sex life is highest in men with PE, compared with those who have erectile difficulties (Moore & Goldstein, 1980). Anecdotal reports suggest that PE impacts a man s quality of life (QoL); however, there is little specific detail of what particular aspects of his QoL are affected. PE has been associated with increased anxiety, as assessed in a large-scale population survey (Dunn, Croft, & Hackett, 1999). To date, there has been little direct interviewing of patients about what the issues are for men who ejaculate prematurely. We therefore conducted 28 interviews with PE sufferers to specifically probe how this condition has affected their life and to inquire about what treatment options, if any, men were aware of and had tried. Barriers to treatment seeking were also examined. METHOD As part of a program to understand the condition of PE, we conducted a series of 28 qualitative individual in-person interviews with self-reported PE sufferers in three states, New Jersey, California, and Illinois, during August 1999. We recruited PE sufferers via newspaper advertisements and then screened them via telephone prior to individual interviews. Study participants were required to have experienced PE (by their own definition) for at least 2 years. They were also required to be between the ages of 25 and 70 and to be free from alcohol or drug dependency (all self-reported). We designed the sample to include each of the following, although no specific quotas were set: A range of ages; A range of self-reported severity (mild/moderate/severe PE) and a range of treatments pursued; A range of relationship status at time of interview (with/without a steady sexual partner); Individuals with and without a diagnosis of PE from a sex therapist or primary care physician. We did not stipulate a requirement for a specific time to ejaculation for study participation; we only required that the man feel that he ejaculated prematurely. Through the course of the interview, each participant mentioned latency times. As might be expected, there was a wide range of times mentioned, from prior to intromission to 10 min. However, the majority of men

Impact of Premature Ejaculation 365 sampled (79%) reported ejaculating between prior or on penetration to 2 minutes post penetration. Table 1 summarizes the sample characteristics. Interviews were carried out by two male researchers, lasted 30 45 min, and were tape-recorded and subsequently transcribed to enable analysis. The interviews followed a semistructured discussion format, with open-ended questions designed to explore the sufferer s experience and views on PE. The section of the interview that is reported here questioned respondents on the impact, if any, that PE has had on their self-image ( what impact, if any, has the condition had on the way you see yourself? ), their sex life ( what impact, if any, has the condition had on your sex life? ), general relationship with partner ( in what way, if any, has the condition had an impact on your relationship with a partner? ), and their everyday life ( what impact, if any, has your condition had on your everyday life? ). Interviewees were also asked about their experience of treatment options. We analyzed the transcripts of the interviews to ascertain recurring themes and concepts. Since these themes were similar regardless of severity of the condition, time to ejaculation (inclusive of the two men with latency times between 5 and 10 min), and previous diagnosis or not, we present the results as one group. RESULTS Impact on a Man s Lfe The overriding concern for men with PE was the erosion of their sexual selfconfidence. To a lesser extent, they also were concerned with the impact of TABLE 1. Sample Characteristics of the 28 Men Sampled Age 26 35: 28% 35 50: 36% 51 70: 36% Mean age (n = 26): 45.54 (SD = 11.99) Severity (Self-reported) Severe: 28% Moderate: 68% Mild: 4% Lifelong or acquired condition Lifelong: 46% Acquired: 54% Sought treatment from a physician /other healthcare professional Yes: 39% No: 61% Current relationship status Steady : 82% Not with steady : 18%

366 T. Symonds et al. the sexual dysfunction on their relationship, anxiety around performing adequately, embarrassment about having the condition, and feelings of depression. SELF-ESTEEM Three quarters (68%) of interviewees mentioned that confidence generally or in a sexual encounter was affected by their PE. PE has connotations that longer equals better, which may be the main influencing factor for impact on confidence. The following are examples of how men spoke about the effect on their confidence: It s deflated my confidence, a lot ; Well yeah. It does affect the way you see yourself because... you kind of get down on yourself sometimes ; I think you lose a little self-esteem having a problem ; Makes me feel inferior to what I suspect is the average. There were a number of occasions when reduced confidence was specifically attributed to loss of confidence as a sexual partner: Lower self-esteem. I m not going out with many girls anymore. I m just afraid ; I would say not sure of myself in a relationship. You feel like you re not capable, like you re half the man you should be. It drives you to the point where you stress yourself out ; Yeah. Because I feel like I m not, the best way to put it, living up to my manhood. RELATIONSHIP Relationship issues were the second most widely mentioned issue reported by the sample (50%). Specifically, men focused on their reluctance to establish new relationships (other than for reasons of lack of self-confidence, as explained earlier), and for men in existing relationships, on their distress regarding not satisfying their partner. It is perhaps this area of initiating relationships that is of most concern for the PE sufferer, because he is reluctant to enter into a sexual encounter for fear of disappointing his partner or for fear of ridicule because he cannot perform adequately: A lot of times I would avoid getting too involved with anybody because of the simple fact that I just really thought it was like a lost deal. So I didn t want to get too serious because there was too much pain involved in it ; Yeah. Sometimes you try not to have relationships, kind of because you want to avoid that because it s like a depressing thing ; When you re looking for a partner you tend to think about it more. At least I tend to think about it more. Or in the initial stages when you are dating, you re thinking about it to that point. There is also the issue of how PE affects the man s life once he is in a relationship. One interviewee was particularly concerned about his inability to satisfy his wife. Another interviewee, because of feelings of inferiority and insecurity, would argue more with his wife: It does bother me that sometimes I can t make my spouse achieve an orgasm ; We get into a lot of

Impact of Premature Ejaculation 367 arguments... If she s going out sometimes I think that she s cheating. Things like that. The overriding problem for the PE interviewee was initiating a new relationship. Those already with a partner had found understanding partners and/or had found ways around the problem. Starting and maintaining a relationship may arguably be a larger issue for PE patients than for ED sufferers because a large proportion of PE sufferers are in the younger age range and therefore probably more likely to still be dating. ANXIETY Anxiety often is mentioned as either being a reason for PE or a consequence of PE, but, more often, it is a combination of the two. It is perhaps surprising then that only 36% of interviewees specifically mentioned feeling anxiety related to their PE (either causing it or because of it): Anxious, all the time anxious (about having sex) ; A little bit (anxious). I used to all the time. I used to all the time (be anxious) ; all that contributes towards kind of an inner turmoil that causes anxiety. EMBARRASSMENT AND DEPRESSION Less widely mentioned effects of PE were embarrassment about the condition and depression. However, this may be an underreporting, because the interviewer never directly asked if PE had resulted in any feelings of embarrassment or depression. It could be that PE is similar to the ED research, where there is a strong correlation (not cause and effect) between ED and depression. We now know that men with ED suffer from depression significantly more often than men without ED (Seidman, Roose, Menza, Shabsigh, & Rosen, 2001; Shabsigh et al. 1998): It s just I m dead. It s very embarrassing and I just don t feel good after that, It was me I was kind of ashamed of it, embarrassed. I didn t feel like I was satisfying my partner or satisfying myself. The image ; I wouldn t say it causes anxiety. It s a little depressing knowing you re not fulfilling your wife, that s the thing about it ; Well the more you think about things you have no control over the more depressing it is, and depression is not a good thing to be carrying around with you all the time. TREATMENT AWARENESS Eighty-nine percent of interviewees have tried some form of treatment for their PE, regardless of whether or not they have consulted a health care professional. As Table 2 highlights, the most commonly cited approaches tried were more behavioral/psychological approaches. A number of men (21%) had also tried a variety of herbal remedies and/or creams and lotions. It is interesting to note that, of those men who had sought treatment from a physician, 38% had tried some form of pharmaceutical drug even though no drugs are licensed for use in this condition.

368 T. Symonds et al. The primary reason cited by men for not consulting a physician about their PE was the embarrassment of talking about this topic (67%). But nearly half the men (47%) also believe that there is no treatment and therefore have never considered consulting a physician. CONCLUSION Two major themes emerged from the qualitative interviews of men suffering from PE. They were the men s sense of PE causing lower self-esteem and their concern with the impact of the dysfunction on forming a relationship. Other issues were mentioned but to a lesser extent. The open nature of the interview may have led to an underreporting of some issues. Further probing of impact on emotional health may have produced more discussion of these issues. But, in general, the results from these interviews are in keeping with the assumed impact implicit within the DSM-IV definition of PE and also in the report by Rust, Golombok, and Collier (1988). In those clinical trials where off-label use of antidepressants have been used, the primary endpoint for efficacy is IELT. The DSM-IV definition combines the idea of latency and control as important aspects of the condition, and it has been recommended that these two be dual criteria of assessment (Grenier & Byers, 1995). But from these interviews, there is also a clear case to consider assessing additional concepts around QoL (avoidance of relationships, impact on current relationship, psychological well-being, depression, self-esteem, sexual self-confidence, sense of masculinity, and impact on the partner). Future studies, which aim to assess the impact of therapy, should therefore focus on not only objective measures such as latency and, to a certain extent, control but also the impact on the man s relationship and self-esteem. It is interesting to note that there was no direct correlation between the severity and the time to ejaculation reported by the respondents. For example, three (50%) of those who report ejaculation times of prior to or on penetration classified themselves as moderate, and three (50%) classified themselves as severe. Furthermore, men who self-diagnosed themselves as severe or moderate also reported similar concerns about their PE. It would not be possible to state from looking at a particular transcript whether the TABLE 2. Treatment Options Tried by All Men Regardless of Whether or Not They Had Previously Consulted a Health Care Professional for Treatment Treatment option % of all men Stop-start-squeeze technique 54% Distraction/focus technique 36% Creams/lotions/thicker condoms 21% Masturbation prior to intercourse 21% Herbal treatment 21%

Impact of Premature Ejaculation 369 man considered himself a severe or moderate PE sufferer. Similarly, severity did not predict the men who did and did not seek treatment. Some clinicians believe that PE is not as distressing as ED, which is the reason why many men choose not to seek treatment. However, the results of this study would argue that it is more a function of the embarrassing nature of the condition and the belief that there are no efficacious treatments. Although, it could be that some men only seek treatment because of partner need rather than their own concern; this was not explored in the interviewees and would be something to be considered in a future similar study. The opportunity sampling method that we used allowed men who felt comfortable talking about their condition to volunteer for the interviews; therefore, these participants are more likely to be comfortable speaking openly and candidly about their experience of having PE. However, our sample may not be representative of the population of PE sufferers and therefore might be biased. For example, we do not know if the present participants are more or less distressed about their PE and, therefore, the issues they report may be an over or under report of the PE population as a whole. Future studies might consider using more specific sampling techniques to ensure representativeness. Twenty-eight men may be a low figure for such a qualitative study; however, our aim was to begin to understand the concerns and issues of men with PE rather than relying on anecdotal reports. A future study might probe further the issues around self-esteem and relationships. These interviews may specifically look at anxiety, depression, and embarrassment to ensure these are, or are not, truly concerns. Additionally, interviews with partners would elucidate the salient issues from their individual perspective. Overall, this study has provided a first insight into how men with PE feel and talk about their condition. The main issues were self-esteem and relationship. These issues should be investigated further in any future studies looking at impact of PE on men s lives. It may also be worthwhile to interview partners to determine what the impact is to them also. REFERENCES American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, D.C.: Author. Bancroft, J., & Coles, L. (1976). Three years experience in a sexual problems clinic. British Medical Journal, 1 (Suppl. 4), 1575. Chen, J., Greenstein, A., Mabjeesh, N. J., & Matzkin, H. (2001). Role of sildenafil in the treatment of premature ejaculation. International Journal of Impotence Research, 13, S48. DeAmicus, L. A., Goldberg, D. C., Lopicollo, J., Friedman, J., & Davies, L. (1985). Clinical follow up of couples treated for sexual dysfunction. Archives of Sexual Behavior, 14, 467.

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