World Journal of Urology

, Volume 23, Issue 2, pp 93–101

Cognitive and partner-related factors in rapid ejaculation: Differences between dysfunctional and functional men.

Authors

    • Clinical PsychologyDeptartment of Clinical Psychiatry and Psychotherapy
  • M. Schedlowski
    • Institute for Behavioral SciencesPsychology and Behavioral Immunobiology
  • T. H. C. Krüger
    • Clinical PsychologyDeptartment of Clinical Psychiatry and Psychotherapy
    • Institute for Behavioral SciencesPsychology and Behavioral Immunobiology
Topic Paper

DOI: 10.1007/s00345-004-0490-0

Cite this article as:
Hartmann, U., Schedlowski, M. & Krüger, T.H.C. World J Urol (2005) 23: 93. doi:10.1007/s00345-004-0490-0

Abstract

Despite the high prevalence of rapid ejaculation in community samples, there is still a paucity of data on cognitive and other relevant aspects of the subjective experience of premature ejaculation (PE) patients and their functional counterparts. Therefore, the main aim of this study was to expand our understanding of the complex nature of rapid ejaculation disorders by providing a detailed characterization of ejaculatory patterns, behavioral aspects, cognitive, and partner-related factors in a sample of unselected PE patients compared to a group of functional men. To explore the areas that might differentiate PE men from their sexually functional counterparts, a multidimensional self-administered questionnaire, the PEQuest, was created. This 36-item instrument addresses a number of domains relevant to ejaculatory function and dysfunction such as ejaculatory latencies and ejaculatory control, cognitions and feelings during sexual intercourse, factors interfering with ejaculatory control, techniques to delay ejaculation, and partnership factors. A total of 45 PE patients (mean age: 41.8 years) and 72 non-patients (mean age: 37.1 years) were included. The results show significant group differences in the majority of PEQuest domains. In the functional group, an average intravaginal latency time of 12.8 min (median: 10 min) was reported compared to 3.7 min (median: 2 min) in the patient group with 87% of PE patients ejaculating within 2 min and 100% within 5 min after penetration. In their subjective experience in sexual situations, PE patients were totally preoccupied with thoughts about controlling their orgasm, with the anxious anticipation of a possible failure, and thoughts about keeping their erection while the inner experience of functional men is focused on sexual arousal and sexual satisfaction. The factors that maximally impede the control of ejaculation are similar for both groups, but functional men normally succeed in adapting their sexual behavior to these factors whereas PE men fail in their efforts. Regarding partner-related factors, PE patients felt less secure and experienced with respect to female sexuality than their functional counterparts, and more often reported a discrepancy between their own limited experience and the more extensive sexual experience of their partner. In conclusion, a number of salient differences in ejaculatory behavior, cognitive-affective patterns, and partner-related factors between PE patients and functional men could be delineated in this study, indicating that chronic rapid ejaculation is a serious disorder with a profound impact on the man’s life and his partnership.

Keywords

Rapid/premature ejaculationEjaculatory dysfunctionEjaculatory controlEjaculatory latency

Introduction

Taken across all age groups, rapid or premature ejaculation (PE) is probably the most prevalent male sexual problem. In non-clinical samples, reports about problems with rapid ejaculation are mostly in the range of 20–40% of all men [9]. PE is also often a presenting problem in clinical samples, but the proportion of men seeking professional help is usually much lower than that for erectile disorders, being predominantly in the range of 10–20% [8]. This discrepancy may indicate that many men and couples can better accommodate this problem, but it may also show that this condition is still under-diagnosed and under-treated. Considering both the high prevalence and the frequent comorbidity with erectile dysfunctions (ED), it is obvious that PE has not attracted the same level of attention within the medical community as ED. In addition, there is a widespread lack of recognition of the personal distress PE causes patients and their partners. Consequently, patients are often reluctant to seek help and to discuss this issue with their physician because they are embarrassed and uncertain whether adequate treatment options are available to cure their problem.

Due to this situation, and compared to male ED, the state of knowledge concerning PE is in many respects unsatisfactory. From a psychological and sexological vantage point, this applies to: (1) diagnostic, definition and classification issues, (2) etiologic factors, (3) cognitive and affective aspects of PE patients’ subjective experience, (4) the impact of this sexual dysfunction on the man’s life, and (5) partner-related factors.

Criteria for establishing the diagnosis of PE have been grossly inconsistent. As there are still no reliable biological or psychological markers for this disorder, the clinician has to rely on certain behavioral criteria. While the criteria suggested in the past have had serious disadvantages (see Janini et al. in this issue), the intravaginal ejaculatory latency time (IELT) proposed by Waldinger et al. [10] has led to significant progress in terms of objectivity and reliability. However, although Waldinger et al. [10] have shown that 80% of men with lifelong PE ejaculate within 30 s after vaginal penetration, there is no consensus as to how an IELT that qualifies for the diagnosis of PE should be defined. Another important criterion for defining PE group membership is the patient’s subjective feeling of ejaculatory control. The man who regularly ejaculates without any control, even if his IELT might be longer than 2 or 3 min, is likely to see himself as having PE. For this reason, Rowland et al. [5] have pointed out that patient and partner satisfaction play a relatively greater role in a PE diagnosis than in other sexual dysfunction diagnoses. Overall, the diagnostic verification of PE remains critical, given that a self-identified status by the man may be discordant with the clinical assessment of the problem [5]. In our practical experience, however, there is usually a high agreement between our clinical evaluation and the patient’s self-diagnosis with rare exceptions in which a patient complains about an IELT of 10 min or even more.

It was thought for many years that PE is mainly caused by psychological factors, but neither psychoanalytic theories claiming that PE is due to unconscious hostile or anxious feelings towards women or hypotheses suggesting a higher degree of ‘neurotic symptoms’ or psychopathology in PE patients could be convincingly verified [2]. The most influential psychological model goes back to Kaplan [3] and proposes that the central etiologic factor in PE may be a lack of awareness of the level of sexual arousal and especially the pre-orgasmic sensations. This lack of sensory feedback, or ‘genital anesthesia’ as Kaplan called it, prevents the man from bringing his ejaculatory reflex under voluntary control. However, the hypothesis that PE men are less accurate and attuned to their level of arousal could not been supported by the available empirical data [5].

With regard to etiologic concepts, the pendulum has begun to swing in the other direction in the last few years, which is mainly due to the discovery that certain antidepressant drugs like clomipramin or various selective serotonin reuptake inhibitors (SSRIs) are able to significantly delay ejaculatory latency. The conclusion that serotonergic neurotransmission is involved in the regulation of orgasm and ejaculation has led to the widespread off-label use of these compounds as a new treatment option for PE and to a number of controlled clinical studies demonstrating that these agents are indeed efficacious in delaying ejaculation (see Waldinger in this issue). The development of some interesting new etiologic concepts like the ejaculation threshold hypothesis by Waldinger [11], postulating that a dysregulation of the serotonergic system, or, more specifically, of the activation of some serotonergic receptor subtypes, might be one component of the ‘organic substrate’ of PE have been investigated. Drugs acting on the serotonergic system are surely no pat solution for PE, however, as the improvement is usually lost when the medication is discontinued and many patients still do not reach ejaculatory control, even if their IELT is significantly longer. Thus, there are a number of interesting concepts but there is as yet no scientifically proven explanation for the etiology of PE, neither from the (neuro)biological nor from the psychological camp. Instead, as with most sexual disorders, there is probably no single cause for PE, which can probably result from a number of different causes and is possibly no homogeneous disorder.

As for the role of cognitive and affective factors in the regulation and dysregulation of ejaculatory function, the results of various psychophysiological studies indicate a significant role for central (cognitive) factors in the mediation of ejaculation latency [7; also see Rowland in this issue]. While the affective component of the sexual response of PE patients has recently been investigated by Rowland et al. [6], suggesting higher levels of specific negative affects in PE men than in sexually functional men, there is still a lack of data on cognitive and other relevant aspects of the subjective experience of PE patients compared to functional controls. In addition, there is a paucity of empirical research which might be apt to provide more insight into the complex nature of this dysfunction. Therefore, a more comprehensive examination of the problem is required to identify factors that characterize, predict, or account for PE. Rowland et al. [4] have pointed out that surprisingly few studies have compared detailed descriptions of both the objective and subjective aspects of ejaculation/orgasm across PE and sexually functional groups.

Therefore, it was the main goal of this study to provide an extensive description of this disorder with a special focus on cognitive factors and to explore the domains that might differentiate PE men from their sexually functional counterparts. Since data on ejaculatory/orgasmic patterns, on partnership factors, on variables interfering with ejaculatory control, and on individual control strategies in sexually functional men are rather scant, another purpose of this study was to collect comprehensive data pertaining to objective and subjective aspects of the regulation of orgasm and ejaculation in a sample of functional men compared to a patient group.

Materials and methods

Materials

To gather comprehensive information on ejaculatory patterns and other relevant domains, a multidimensional questionnaire was developed. In designing this instrument we adhered to the diagnostic criteria defined in ICD-10 and DSM-IV and added a number of items taken from an extensive literature review and our own clinical experience with this patient group. The first draft of the questionnaire was subjected to an independent expert rating and underwent a series of statistical item and reliability analyses after which a number of items were discarded. The version of the ‘PEQUEST used in this study was a 36-item self-administered questionnaire addressing a number of dimensions considered relevant to ejaculatory dysfunction such as partner-related factors, cognitions, performance anxiety, variables interfering with ejaculatory control, mechanisms used to delay ejaculation, etc. In addition, various items cover attributes of the man’s individual orgasmic pattern. An English version of the PEQuest is available upon request.

Subjects

For this study, functional subjects were recruited from the attendants of psychology courses in a German military school and dysfunctional subjects from the andrological outpatient unit of the Hanover Medical School. All patients underwent the diagnostic program of this unit including a semi-structured clinical interview according to DSM-IV criteria for PE. A total of 72 non-patients and 45 consecutive patients were included in this data analysis. The mean age was 41.8 years (SD=10.5) in the patient group and 37.1 years (SD=6.7) in the non-patient group. This significant (P<0.01) age difference was statistically controlled in a number of analyses and did not prove to be a significant factor. Consequently, age was discarded as a separate factor in the tests for group differences presented here.

Results

Ejaculatory response

In the patient group, the mean duration of the sexual dysfunction was 14.3 years (SD=10.5) and PE proved to be primary or lifelong in one half (48.9%) and secondary or acquired in the other half (51.1%). A total of 44.4% of our patients indicated that their ejaculatory dysfunction was confined to sexual intercourse, while 26.7% stated that the problem occurred during all forms of sexual activity with a partner, and 28.9% reported a global disorder which also occurred during masturbation. Looking at the severity of the dysfunction, 11.1% of our patient group reported that they experienced a rapid ejaculation on more than 25%, 13.3% on more than 50%, 24.4% on more than 75%, and 51.1% on 100% of occasions. Some 54.5% reported that they had experienced PE with each sex partner, 20.5% with the majority of partners, and 25% with a single partner.

In the functional group, an average intercourse duration (IELT) of 12.8 min (SD=8.6, median=10) was reported, compared to 3.7 min (SD=4.1, median=2) in the patient group (P<0.001). In Table 1 and Fig. 1, ejaculatory latencies are depicted in more detail for both groups.
Table 1

Ejaculatory latencies. Phase of sexual contact in which ejaculation usually (≥50% of cases) occurs

Phase

Patients

Non-patients

n

%

n

%

During foreplay

5

11

1

1

During intromission

9

20

1

1

Within 30 s after penetration

15

33

4

6

Within 1 min after penetration

2

5

2

3

Within 2 min after penetration

8

18

8

11

Within 5 min after penetration

6

13

30

42

More than 5 min after penetration

26

36

Fig. 1

Ejaculatory latencies

The cumulative percentages shown in Fig. 1 indicate that 87% of PE patients tended to ejaculate within 2 min and 100% within 5 min after vaginal penetration, which is in keeping with the results of Waldinger et al. [10]. Looking at the corresponding percentages of the non-patient group, it is evident that there is a profound difference with regard not only to the mean IELT, but also to ejaculatory patterns in general. On the other hand, almost a quarter (22%) of the functional men usually ejaculated within 2 min, suggesting that there is a significant overlap between patients seeking help for PE and a considerable minority of non-patients.

The second common criterion for establishing PE is the degree of subjective ejaculatory control. Overall, the results for this variable also show marked differences between both groups with almost 80% of patients reporting an ‘extremely poor (impossible)’, ‘very poor (almost impossible)’ or ‘poor (rarely possible)’ ejaculatory control, while the great majority (85.7%) of functional men indicated a ‘very good’, ‘good’ or ‘fair’ control. As the correlation between the two criteria IELT and ejaculatory control proved to be rather low in some earlier studies [1], suggesting that these features might embrace different aspects of the phenomenon PE, we were interested in the relationship between the two criteria in our sample.

As indicated in Table 2, there is a clear linear relationship between the different degrees of subjective control and the average IELT in the patient group, which is reflected by a highly significant (P<0.001) correlation coefficient (Spearman rank correlation) of rs=0.69. In the non-patient group, the correspondence between the two criteria is less impressive, yielding a correlation of only rs=0.23 (ns). When the categories of the variable ejaculatory control are reduced to three (poor, fair, good), however, the correlation coefficient increases to rs=0.331 which, albeit significant (P<0.01), is still considerably lower than in the patient group.
Table 2

Relationship between intravaginal latency time and feeling of ejaculatory control

Average duration of sexual intercourse (min)

Ejaculatory control

Patients

Non-patients

n

Mean

SD

n

Mean

SD

Extremely poor

13

1.4

1.7

Very poor

14

2.2

2.5

4

6.0

3.9

Poor

8

4.9

2.7

5

9.8

6.3

Fair

8

6.3

3.6

13

9.0

7.3

Good

2

15.0

7.1

41

14.5

8.6

Very good

9

15.3

9.9

Cognitions

Looking at the main cognitions during sexual intercourse, it is evident from Table 3 that our PE patients were totally preoccupied with thoughts about controlling their orgasm, while this was not a strong cognitive factor for the functional men. Other prevailing cognitions in PE patients referred to the anticipation of a possible failure and the embarrassing situation following a rapid ejaculation. To a lesser, but compared to the functional men again significantly higher degree, the PE men were concerned with distracting thoughts and thoughts about keeping their erection. Table 3 also shows that almost all men in both groups were concentrated on satisfying their partner, but in contrast to the functional men, only a small percentage (less than 17%) of our patients were focused on their own satisfaction.
Table 3

Cognitions during sexual intercourse. 1 For these items: 0=not at all, 4=very strong

Cognition

Patients

Non-patients

P

Mean1

SD

Mean

SD

Control of ejaculation

3.2

1.2

1.5

1.2

<0.001

Maintaining an erection

1.9

1.6

0.6

1.0

<0.001

Satisfaction of partner

3.5

1.0

3.1

1.0

0.05

Own sexual arousal

1.6

1.4

1.8

1.3

ns

Own sexual satisfaction

1.3

1.2

2.1

1.2

<0.001

Possible failure

2.5

1.5

0.6

1.1

<0.001

Certain fantasies

1.5

1.5

1.7

1.3

ns

Distracting (neutral) thoughts

2.0

1.3

1.3

1.3

<0.01

Situation after PE

2.5

1.6

0.7

1.1

<0.001

The fear of failure in sexual situations also proved to be significantly (P<0.001) higher in our patients, with 76% reporting ‘extremely high’, ‘very high’ or ‘high’ levels, while 86% of functional men indicated either a ‘moderate’ or ‘low’ level of fear.

Taken together, analysis of the predominant cognitions impressively shows that the subjective experience of PE patients and functional men during sexual intercourse was fundamentally different. While the functional men were preoccupied with positive thoughts relating to their own sexual arousal and satisfaction, the satisfaction of their partner, or sexual fantasies, the PE patients were concerned with controlling their ejaculation, anticipating yet another failure, distracting thoughts, or keeping their erection. Even more focused on satisfying their partner than the functional men, our patients seemed to have no capacity left for processing thoughts pertaining to positive or sexually related aspects of the situation.

Factors interfering with ejaculatory control

One domain of the ‘PEQuest’ addressed the factors that were felt to make ejaculatory control difficult for the two groups. Table 4 indicates that there were only minor differences between the functional and dysfunctional men men as to which factors are likely to reduce their control. Not surprisingly, the men of our sample unanimously reported that the level of sexual excitement and the coital activity of the partner were the factors most likely to render their ejaculatory control difficult. Interestingly, there were no group differences in the rating of factors like duration of sexual abstinence, the length of foreplay, and penile stimulation by the partner. The only significant group differences were found for the variables ‘missionary position’ and ‘softening of erection’, both reported as more difficult for controlling the ejaculation by the PE men.
Table 4

Factors interfering with ejaculatory control. 1 For these items: 0=no influence, 4=strong influence

Factors

Patients

Non-patients

P

Mean1

SD

Mean

SD

Time since last orgasm

1.4

1.7

1.4

1.6

ns

Penis stimulation by partner

2.2

1.6

2.4

1.3

ns

Length of foreplay

2.1

1.5

1.8

1.1

ns

Missionary position

2.1

1.5

1.3

1.1

<0.01

Position woman on top

2.1

1.4

2.0

1.3

ns

Position ‘a tergo’

2.5

1.3

2.2

1.4

ns

Partner’s strong coital movements

2.8

1.3

2.6

1.2

ns

Partner’s sexual excitement

2.3

1.3

2.4

1.2

ns

Partner’s passivity

1.2

1.3

0.9

1.3

ns

Softening of erection

1.8

1.6

0.6

1.1

<0.001

Certain fantasies

1.8

1.6

1.7

1.4

ns

Overall, while it seems that functional and dysfunctional men tend to agree on the factors that do and do not make ejaculatory control difficult, it is the more pronounced fear of losing the erection, together with the generally broader range of interfering factors, that prevents our patients from achieving a better control.

Ejaculation delaying techniques

Table 5 shows the techniques used to delay ejaculation in both groups. The results indicate that distraction is the favorite technique in the PE group, followed by the interruption of intercourse, gentle coital thrusting, and a short foreplay. In addition, about one fifth (21%) of our patients had used alcohol and 14% an anesthetic ointment, techniques that played no role for the functional group. Only two patients from our sample had tried prescription drugs. Gentle thrusting, interrupting or withdrawing for a moment, and distraction were the three techniques commonly used in the non-patient group.
Table 5

Techniques for delaying ejaculation; multiple responses possible

Technique

Patients

Non–patients

n

%

n

%

Distracting (neutral) thoughts

25

57

23

34

Short foreplay

9

21

5

7

Gentle thrusting

12

27

26

38

Interrupting/withdrawing for a few moments

17

39

24

35

Applying an anesthetic to penis

6

14

Alcohol

9

21

1

1

Prescription drug

2

5

Generally, 80% of our PE group versus 37% of the functional men always tried to minimize their level of sexual arousal in order to achieve better ejaculatory control. Another marked and statistically highly significant (P<0.001) difference between our PE patients and the functional group was related to the success of the delaying techniques used: 96% of the non-patient group, but only 43% of our patients reported that their techniques were usually successful. According to these results, almost 60% of our patients made the experience that all their efforts at delaying ejaculation were in vain.

Partner-related factors

As there is a lack of data pertaining to partner-related factors in PE, one section of the PEQuest addressed various aspects of this important domain. The results of these items indicate a number of interesting differences between the groups, which will be briefly summarized here but need to be analyzed in more detail in subsequent papers.

In general, PE patients felt less secure and experienced with respect to female sexuality than their functional counterparts. Thus, 74% of the non-patient group but only 39% (P<0.01) of the patient group rated themselves as ‘very’ or ‘rather’ experienced with female sexuality while there was no significant difference in the reported sexual experience of the partner. No significant differences were found for the rating of the partner’s sexual desire and ease of getting sexually aroused.

Three items of the PEQuest addressed the partner’s orgasmic functioning: in the first item, the men were asked to rate how easy it was for their partner to achieve an orgasm through various types of stimulation. No differences emerged for masturbation and sexual intercourse but, interestingly, the partner’s orgasmic capacity through manual or oral clitoral stimulation was rated as significantly lower by our PE patients than by the functional men. In addition, there was a marked group difference in the frequency of orgasm with 82% of functional versus 33% of PE men reporting that the female partner experienced an orgasm ‘almost always’ during the course of the sexual contact. In contrast, 44% of our patients, but only 4% of the non-patients stated that their partner ‘never’ or ‘rarely’ achieved an orgasm. The men were then asked how sure they were about the capacity and frequency of their partner’s orgasm. The results suggest a higher level of insecurity in our PE patients, of whom 27% rated themselves as insecure in this respect versus 4% in the non-patient group.

How do the patients of our sample rate their partner’s behavior and reaction with regard to their sexual dysfunction? For 23%, the reaction was ‘negative, not helpful’, for 19% ‘so-so’, and ‘positive’ for 58%. In addition, 28% of our patients were afraid of being left by their partner as a result of their ejaculatory dysfunction.

No significant difference was found in the opinion of patients and non-patients as to how long a man should be able to delay or control his ejaculation. The great majority of men in both groups would like to control their ejaculation until the partner has experienced her orgasm, but this percentage is even higher in the dysfunctional group (66% versus 44%).

Discussion

The main aim of this study was to expand our understanding of the complex nature of rapid ejaculation disorders by providing a detailed characterization of ejaculatory patterns, cognitive, and partner-related factors in a sample of unselected PE patients. Despite the high prevalence of ejaculatory disorders in community samples, there is still a lack of data on cognitive and other relevant aspects of the subjective experience of PE patients and their functional counterparts. As few studies have compared in depth analyses of both the objective and subjective aspects of ejaculation/orgasm across PE and sexually functional groups, another goal of this study was to collect comprehensive data pertaining to the regulation of ejaculation in a sample of functional men compared to PE patients. To explore the spheres that might differentiate PE men from their sexually functional counterparts, a multidimensional self-report questionnaire, the PEQuest, was created. This instrument addresses a number of domains relevant to ejaculatory function and dysfunction, such as ejaculatory latencies and ejaculatory control, cognitions and feelings during sexual intercourse, factors interfering with ejaculatory control, techniques to delay ejaculation and partnership factors. A total of 45 PE patients (mean age: 41.8 years) and 72 non-patients (mean age: 37.1 years) were be included in this data analysis.

The major findings may be summarized as follows:

Ejaculatory patterns and ejaculatory control

Compared to the non-patient group, our results show that the sexual problems of our patient group are clearly more severe and profound, pertaining to almost all areas covered by the PEQuest. It can thus be concluded, that, both from quantitative and qualitative angles, rapid ejaculation is a clear-cut and serious psychosomatic disorder defined by a significantly lower IELT and a sharply reduced or, in many cases, impossible ejaculatory control. There is some overlap with functional men reporting unsatisfactory control over their ejaculation and an average IELT of less than 2 min (22% of our functional men), but, at least in our sample, PE patients sought help not for a mild problem or for some sort of discontent regarding their sexual performance, but for a sexual disorder with a profound impact on the man’s life and on his partnership, which on the average had existed for more than 14 years before the patient arrived at our specialized unit.

The analysis of ejaculatory patterns yielded an average IELT of 12.8 min (median: 10 min) in the functional group as opposed to 3.7 min (median: 2 min) in the patient group. A total of 87% of PE patients usually ejaculated within 2 min and 100% within 5 min after vaginal penetration, which is in keeping with Waldinger’s [12] conclusion that PE is a matter of seconds and not of minutes. The marked distinction between both groups extends to the second common criterion for establishing PE, the degree of subjective ejaculatory control. Almost 80% of our patients reported an ‘extremely poor (impossible)’, ‘very poor (almost impossible)’ or ‘poor (rarely possible)’ control over their ejaculation, while the great majority (85.7%) of functional men indicated a ‘very good’, ‘good’ or ‘fair’ control.

In an earlier study [1] on functional men, the correlation between the two criteria IELT and ejaculatory control proved to be rather low, with a shared variance of only 10%, suggesting that these features might embrace different aspects of ejaculatory functioning. For the non-patient group, our findings are consistent with these results with a non-significant correlation between the two criteria of only rs=0.23. In the patient group, however, we found a clear linear relationship between the different degrees of subjective control and the average IELT, which is reflected by a highly significant correlation coefficient of rs=0.69. This interesting difference implies that there is indeed a discordance between the two criteria IELT and subjective ejaculatory control in functional men, which is probably indicative of a greater heterogeneity in terms of ejaculatory patterns in men without pronounced ejaculatory problems. Accordingly, there is a group of functional men exhibiting a rather poor ejaculatory control coupled with an unobtrusive IELT and vice versa. In men with serious rapid ejaculation, on the other hand, there is a strong congruence between IELT and ejaculatory control showing that PE patients are more homogeneous as a group and, obviously, have no degrees of freedom with respect to their ejaculatory functioning.

Overall, our findings suggest that in functional men concerns over the timing of their ejaculation, together with the corresponding self-definition as having a sexual problem, are significantly less dependent on the common criteria used to diagnose PE than in the dysfunctional group. Therefore, in dysfunctional men, valid and reliable behavioral criteria for diagnosing PE can be defined which might include an ejaculatory latency of less than 2 min in the majority of attempts at sexual intercourse over a period of 6 months together with a poor subjective control over the timing of ejaculation, with ejaculation occurring against the man’s will in at least 75% of cases.

Subjective experience and cognitions during sexual intercourse

It was one of the main purposes of this study to further our understanding of the ‘inner world’, and especially the thoughts and feelings of PE men in sexual situations. Therefore, one domain of PEQuest specifically focused on the subjective experience and on cognitions during sexual intercourse. In this area, we found the strongest group differences of all domains covered by our questionnaire.

Analysis of the predominant cognitions showed that the subjective experience of PE patients and functional men during sexual intercourse was fundamentally different. The functional men were preoccupied with positive thoughts relating to their own sexual arousal and satisfaction, the satisfaction of their partner, or sexual fantasies. PE patients, on the other hand, were totally preoccupied with thoughts about controlling their orgasm which was obviously of no great concern for the functional men. Other prevailing cognitions in PE patients involved performance anxiety together with the anxious anticipation of a possible failure and the embarrassing situation following a rapid ejaculation. To a lesser, but compared to the functional men again significantly higher degree, the PE men were concerned with distracting thoughts and thoughts about keeping their erection. Almost all men were concentrated on satisfying their partner, but, in contrast to the functional men, only a small percentage (less than 17%) of our patients were focused on their own satisfaction.

However impressive these differences may be, the state of research does not allow a clear cause-effect interpretation. Thus, it remains conjectural as to whether the cognitive and subjective differences that are in evidence here reflect the profound impact of the long-term sexual dysfunction on the man’s inner world or whether PE men start their sex life with a different set of thoughts and feelings or even a different cognitive-affective brain architecture which in turn renders them vulnerable to sexual dysfunctions. The findings of this study agree with and expand earlier work on the emotional response of PE men [6] indicating higher levels of specific negative affects like embarrassment/guilt and tension/worry compared to sexually functional men. In conclusion, it appears that both the affective and the cognitive response of PE patients in sexual situations involving partner interaction is dominated by cognitions and feelings which are in turn detrimental to a joyful and satisfying sexual experience. Based on these premises, interrupting this vicious circle has to be a central goal of every successful PE treatment strategy.

Factors interfering with ejaculatory control

What are the factors that are bound to make ejaculatory control difficult for functional and dysfunctional men? Interestingly, our findings indicate only minor differences between functional and dysfunctional men regarding the factors most likely to reduce control. Thus, both patients and non-patients unanimously reported that it is the level of sexual excitement and the coital activity of the partner that makes control over their ejaculation extremely difficult. Interestingly, there were no group differences in the rating of factors like time since last orgasm, length of foreplay, and penile stimulation by the partner. That manual or oral penile stimulation by the partner was not rated as a major factor interfering with ejaculatory control by our patients is in contrast to the findings of Rowland et al. [4] supporting the idea that the ‘hyper-arousability’ in PE men presumed by some theories seems to be restricted to stimulation involving penile stroking and touching, but not to other types of erotic stimulation. The findings of the present study may be indicative of the fact that, subjectively, PE men obviously do not view penile stimulation as particularly ‘dangerous’, while studies using psychophysiological methods yield discrepant results. However, this difference may also be due to the PE patients’ tendency to avoid all types of direct penile stimulation during foreplay in order to prolong the duration of sexual intercourse. As a result of this avoidance, penile stimulation may no longer be a significant interfering factor for them.

The only significant group differences were found for the variables ‘missionary position’ and ‘softening of erection’, both reported as more difficult for controlling the ejaculation by the PE men than by the non-patients. This is in keeping with the results of earlier studies suggesting that many PE patients find themselves in a war on two fronts, struggling with their ejaculatory control and, probably caused by the reduced sexual stimulation, desperately trying to keep up their erection.

Taken together, the results of the PEQuest indicate that in our non-patients ejaculatory functioning seems to be dependent on situational factors rendering their sexual functioning more vulnerable, but simultaneously more susceptible to positive influences. In addition, it seems that functional and dysfunctional men tend to agree about the factors that do and do not make ejaculatory control difficult, but it is the more pronounced fear of losing erection, together with the generally broader range of interfering factors that prevents our patients from achieving better control.

Ejaculatory delaying techniques

Given the dearth of empirical research on the behavior of functional and dysfunctional men during sexual intercourse [1], we were particularly interested in the techniques used to delay ejaculation and prolong intercourse. In an earlier study [1], the techniques most commonly reported by functional men were: slowing down thrusting, thinking distracting/non-sexual thoughts, alternating intercourse positions, making a few thrusts then stopping, using a different intercourse position, and using a condom. In addition, the delaying techniques reported to be most effective were: withdrawing for a few moments, ejaculating prior to intercourse, taking drugs. Overall, the results of the study by Grenier and Byers [1] could be confirmed by the present findings since distraction proved to be the favorite technique in the PE group, followed by the interruption of intercourse, gentle coital thrusting, and a short foreplay. In addition, about one fifth (21%) of our patients had used alcohol and 14% an anesthetic ointment. The latter techniques were uncommon in the functional group, where gentle thrusting, interrupting or withdrawing for a moment, and distraction were the three favorite techniques for prolonging intercourse. Interestingly, 80% of our PE group versus 37% of the functional men always tried to minimize their level of sexual arousal in order to achieve better ejaculatory control.

Another marked difference between our PE patients and the functional group related to the success of the delaying techniques used: 96% of the non-patient group, but only 43% of our patients reported that their techniques were usually successful. According to these results, almost 60% of our patients made the experience that all of their efforts at delaying their ejaculation were in vain. In addition, their strategies used (mostly distraction and minimizing arousal) to hold off ejaculation were not only insufficient and ineffective, but apt to induce secondary ED. Summarizing, it seems that for all men the factors that maximally interfere with the striving for ejaculatory control are similar, but functional men normally succeed in dealing with or adapting their sexual behavior to these factors while PE men fail in their efforts.

Partner-related factors

In a recent study on how PE impacts a man’s life [9], relationship issues proved to be the second most widely mentioned issue reported as being negatively affected by the sexual dysfunction involved. Concerns about inability to satisfy one’s partner together with feelings of insecurity and inferiority were widespread among PE patients and both were a burden on existing relationships and an obstacle for initiating new relationships. Overall, the findings of the present study confirm the importance of partner-related factors for ejaculatory functioning and yielded a number of interesting results with respect to the sexual experience of both partners, but also to dimensions of female sexuality itself. In the functional group, the male and female levels of sexual experience were largely congruent, whereas PE patients more often reported a discrepancy between their own limited experience and the more extensive sexual experience of their partner. Consequently, PE patients in this sample felt less secure and experienced with respect to female sexuality than their functional counterparts. Seventy-four percent of the non-patient group but only 39% of the patient group rated themselves as ‘very’ or ‘rather’ experienced with female sexuality.

PE patients and controls did not differ with regard to reported sexual experience and the rating of sexual desire and arousability of their partner. With respect to the partner’s orgasmic functioning, no differences between the functional and dysfunctional groups emerged for masturbation and sexual intercourse but, interestingly, the partner’s orgasmic capacity through manual or oral clitoral stimulation was rated as significantly lower by our PE patients than by the functional men. In addition, the frequency of orgasm was significantly lower in the PE group with 82% of functional versus 33% of PE men reporting that the female partner ‘almost always’ experienced an orgasm during the course of the sexual contact.

These results highlight the profound negative impact of PE on the sexual relationship and the sexual experience and satisfaction of both partners. The lower orgasmic capacity through clitoral simulation of the partners of PE patients puts an extra burden on these men who are expected to do what they can do the least: prolonging the sexual intercourse until the partner can experience her orgasm. Therefore, it is no surprise that almost a third of our patients were afraid of being left by their partner as a result of their ejaculatory dysfunction. The importance of partner-related factors clearly deserves further exploration. For this purpose, we have developed a partner questionnaire which will be employed in all subsequent studies.

No significant difference was found with respect to the opinion of patients and non-patients as to how long a man should be able to delay or control his ejaculation. The great majority of men in both groups would like to control their ejaculation until the partner has experienced her orgasm, but this percentage is even higher in the dysfunctional group (66% versus 44%). These high expectations are in sharp contrast to the reality of PE men and are likely to further contribute to the erosion of self-confidence.

Conclusion

Overall, this study has provided insights into the subjective experience and into various cognitive and behavioral factors of men suffering from rapid ejaculation compared to a group of sexually functional men. Due to the methodological shortcomings inherent in this study, such as a relatively small sample size, the limited age range of subjects, and the lack of some possibly relevant domains in the PEQuest, the extent to which these results can be generalized is unclear. However, a number of salient differences between PE patients and their functional counterparts could be delineated that deserve to be further explored in future studies.

The results of this study lend support to the idea that achieving and maintaining ejaculatory control is a lifelong task for all men and contradict the notion that functional men simply ‘have a good control’ without actively struggling for it. Although most men indicate having at least moderate control over the ejaculatory process, the relevant psychological mechanisms involved have yet to be explained. This important issue needs to be investigated in different directions. One interesting approach relates to the question of whether there is a group of men who are born with good ejaculatory control which only has to be refined in the course of gathering sexual experience. Or is what DSM-IV implies true, i.e. that all young men start with a limited ejaculatory control and some ‘learn’ how to control the timing of their ejaculation while others, for whatever reason, do not achieve this control. To answer this highly important question, long-term studies are required in which, ideally, the course of ejaculatory control should be observed in an unselected sample of young men over the course of their lifetime.

Copyright information

© Springer-Verlag 2005