Definition

The definition of premature ejaculation is somewhat subjective and has therefore been the focus of disagreement among sex therapists and researchers. In DSM-IV, premature ejaculation is defined as persistent or recurrent ejaculation with minimal sexual stimulation before, on, or shortly after penetration and before the person wishes it. The DSM-IV criteria for premature ejaculation are presented in

Table 66-1. Within the definition is the acknowledgment that there is a subjective element to the diagnosis of premature ejaculation. Factors such as the person’s age, the frequency of sexual activity, and the novelty of the sexual partner are to be considered. Although these factors are important, the clinician must also consider the quality of the couple’s sexual interaction and not merely how long intercourse lasts. Most men who ejaculate within 1 minute of vaginal entry would be considered as prematurely ejaculating. In some cases, however, such a diagnosis would be entirely unjustified. Consider, for example, a couple who engages in 45 minutes of unrestrained mutual manual and oral genital stimulation, followed by simultaneous orgasms during less than 1 minute of vigorous, pleasurable intercourse. If this pattern is satisfying to the couple (and it certainly would be for most people), it would be nonsensical to consider the man to be suffering from premature ejaculation.

However, even a man who routinely engages in 10 minutes of penile-vaginal intercourse might in some cases be accurately described as suffering from severe premature ejaculation if he is able to delay ejaculation only by using a strategy that essentially degrades the quality of, and removes the pleasure from, the couple’s sexual interactions. For example, a man might avoid all foreplay (either direct stimulation of his genitals or the arousal he experiences from touching his partner’s breasts and genitals), as this leads to his ejaculating rapidly during intercourse. Similarly, some men have sex only in the dark, as the sight of their partner is too arousing for them. Other men spray the penis with a skin anesthetic to deaden sensation. Patients may wear more than one condom during intercourse, may lie absolutely still while their partner moves, or may intermittently stop moving while requiring their partner to also stop moving until ejaculatory inevitability passes. Other men distract themselves by thinking unpleasant thoughts or by self-inflicting pain by biting their tongue or cramping their leg muscles. In all such cases, a diagnosis of premature ejaculation would be called for despite a long duration of intercourse.

In applying the DSM-IV diagnostic definition, therefore, the clinician should consider not only how long intercourse lasts but also the couple’s level of satisfaction with their sexual interaction. A couple should have the freedom to engage in spontaneous sexual activity without the need to constrain their behavior in an attempt to prolong intercourse.

However, the definition of premature ejaculation cannot be totally dependent on the couple’s subjective satisfaction. There are cases in which both husband and wife were troubled by what they agreed was the husband’s severe premature ejaculation, despite the fact that they engaged in 20-30 minutes of unrestrained foreplay, followed by 10-15 minutes of vigorous intercourse. Typically, such cases involve one or both of the partners wanting the woman to have orgasm during intercourse rather than during manual or oral stimulation of her clitoris. The couple has the mistaken belief that simply increasing the duration of intercourse will accomplish this goal. These cases should not be treated with techniques for increasing the duration of intercourse. Rather, the couple should be reassured about the normality of the woman’s sexual response pattern, or perhaps be instructed in techniques for reaching orgasm in coitus (Heiman and LoPiccolo 1988).

Diagnostic Issues

Once a clinician has determined that a patient meets the diagnostic criteria for a diagnosis of premature ejaculation by virtue of the duration and quality of the couple’s sexual interaction, the diagnosis should be refined and made more specific. Such specification focuses on issues that impact the course of treatment. One important issue is the specification of whether the premature ejaculation is global or situational (Schover et al. 1982). Does the man ejaculate rapidly in his own solitary masturbation as well as with his partner? Does ejaculation occur rapidly during manual or oral stimulation of his penis by his partner, or is it specific to vaginal intercourse? As is discussed in the section on treatment, below, these diagnostic issues determine the initial course of therapy.

Another important diagnostic distinction is whether the pattern of premature ejaculation is lifelong or not (Schover et al. 1982). Lifelong premature ejaculation (i.e., since the patient first became sexually active) is most typically seen in younger men who are often less sexually experienced. Premature ejaculation that is not lifelong is more often seen in older men and is frequently associated with erectile failure (Cooper et al. 1993; Gospodinoff 1989). Lifelong premature ejaculation can be treated in a simple and direct manner. Premature ejaculation that is not lifelong and that is associated with intermittent or partial erectile failure has a poorer prognosis; in these cases, concomitant treatment of the erectile failure is indicated.

Another diagnostic issue to be considered is an accurate assessment of the frequency of sexual activity and orgasm. Some cases of premature ejaculation are simply a result of very infrequent sexual activity, whereas other men have premature ejaculation despite frequent intercourse and orgasm. Pretreatment frequency of sexual activity determines the frequency of the sexual exercises prescribed during treatment, and should therefore be assessed carefully.

Prevalence

It is difficult to arrive at an accurate figure for the population base rate of premature ejaculation. Epidemiological studies of the general population have found rates of premature ejaculation varying from 9% to 38% (Bancroft 1989; O’Donohue et al. 1993; Spector and Carey 1990). The National Health and Social Life Survey (NHSLS), a comprehensive and rigorously evaluated investigation of sexual behavior, reported the prevalence of premature ejaculation in the United States to be 30.7% (Laumann et al. 1999). Differences in the definition of premature ejaculation and sample selection probably account for the wide range of results. Among patients seen at sex therapy clinics, premature ejaculation has been found to be the presenting complaint in between 15% and 45% of cases (Bancroft 1989; Dekker 1993; O’Donohue et al. 1993; Spector and Carey 1990).

The data gathered by Kinsey et al. (1948) on 5,300 American men indicated that “for perhaps three-quarters of all males, orgasm is reached within 2 minutes after the initiation of sexual relations, and for a not inconsiderable number of males the climax may be reached within less than a minute or even within 10 or 20 seconds after coital entrance” (p. 580). Hunt (1974) studied 2,000 American males and found, in contrast to Kinsey et al., that the mean duration of intercourse was 10-14 minutes. Hunt considered whether methodological or definitional differences could account for this striking change, and concluded that they could not. Instead, Hunt observed that American culture has come “to hold extended duration of intercourse in high regard…a dramatic and historic change has taken place in the practice of marital coitus in America” (p. 206). This change has increased the distress of men who suffer from rapid ejaculation, of course, as well as increasing the number of men who define themselves as men who prematurely ejaculate.

Etiology

Lifelong premature ejaculation is most often seen in younger men, with the majority of patients being in their 30s or younger (Bancroft 1989). Premature ejaculation is typical for young men in their first sexual experiences. With increased sexual experience, most men spontaneously get over their initial premature ejaculation. In addition, as men age, the time required to reach orgasm naturally increases, but this is a slow change occurring over many years. A young man with premature ejaculation would need 20 or 30 years for normal aging processes to solve his problem.

As previously noted, premature ejaculation that is not lifelong is often associated with partial erectile failure in older men. Ironically, these men may consciously or unconsciously “race” to early orgasm to prevent loss of erection from leading to a premature end of intercourse. The mechanism that underlies this association is not clear, as just as many older men with erectile failure suffer from concurrent inability to ejaculate. Physiological studies have not found any abnormalities in these patients that would account for the premature ejaculation (Cooper et al. 1993). Gospodinoff (1989) reported some evidence that men with lifelong premature ejaculation have shorter bulbocavernosus reflex latency compared with men with premature ejaculation that is not lifelong. However, replication of these study results is needed; furthermore, it is unclear whether this difference is related to lifelong premature ejaculation or merely reflects the greater age of the subjects whose premature ejaculation is not lifelong.

The highly tentative possible exception of a shortened bulbocavernosus reflex notwithstanding, premature ejaculation does not seem to be caused by any physiological factors or medical conditions. Although Kaplan (1974) suggested that some local diseases or medications could cause premature ejaculation, this has not been found to be the case (Bancroft 1989; Segraves and Segraves 1993).

Research has also failed to connect premature ejaculation with the complex individual psychodynamic and couple relationship problems associated with other sexual dysfunctions (e.g., hypoactive sexual desire). Rather, premature ejaculation seems to be typical of men who simply have not learned to modulate their arousal and prolong the process of making love. As previously noted, men who have sex infrequently are also prone to ejaculating prematurely. Indeed, Kinsey et al. (1948) proposed that the primary cause of premature ejaculation was a low frequency of sexual activity. Some researchers (e.g., Kedia 1983) have indicated that sensory thresholds in the penis are lowered by infrequent sexual activity. However, although most investigators have found that premature ejaculation patients have a low rate of sexual activity (e.g., Spiess et al. 1984), one group of investigators (Strassberg et al. 1987) did not find this pattern in premature ejaculation patients. There has been more consistent evidence from laboratory and self-report studies that men who prematurely ejaculate may simply have a lower threshold for ejaculation, with ejaculation occurring at moderate levels of sexual arousal (Spiess et al. 1984; Strassberg et al. 1990).

Anxiety and ejaculation both involve activation of the sympathetic nervous system, so anxiety about trying to delay ejaculation has traditionally been suggested to be a strong causative factor to premature ejaculation (Bancroft 1989). However, results from studies have suggested that the relationship between anxiety and premature ejaculation is subtle and indirect, and that anxiety is not central to the etiology of the disorder (Beck and Barlow 1984; Spiess et al. 1984; Strassberg et al. 1987; St. Lawrence and Madakasira 1992).

Masters and Johnson (1970) proposed that men learn to be rapid ejaculators during adolescent masturbation, when they often hurry to ejaculate because of a fear of being discovered by parents. However, such experiences seem to have been equally common in men who do not prematurely ejaculate (Heiman et al. 1986).

There has been some speculation by evolutionary biologists that rapid ejaculation may have been selected for during primate evolution, through a “survival of the fastest” process (Hong 1984). A male who could ejaculate rapidly would be more likely to reproduce successfully, as there would be less chance of the female escaping, another male interrupting, or a predator attacking before coitus was completed.

Kaplan (1974) proposed that men who prematurely ejaculate cannot accurately perceive their own arousal level and therefore cannot engage in self-control. However, Spiess et al. (1984) and Strassberg et al. (1987), in their laboratory studies comparing men who prematurely ejaculate and age-matched normal control subjects, found that the men who prematurely ejaculate were equally accurate, and, in some cases, more accurate when their self-ratings were compared with objective measures of physiological arousal.

In summary, there is no definitive notion about the cause of premature ejaculation. Perhaps the most consistent research finding is simply that premature ejaculation is typical of younger, less experienced men and men who have sex infrequently. In a sense, however, these negative research findings do guide treatment, as they tell clinicians that a purely symptom-focused, behavioral retraining procedure is usually all that is needed to resolve this disorder. In premature ejaculation, there do not seem to be complex psychological or physiological conditions underlying the disorder that need to be addressed for treatment to succeed.