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Evolving concepts in premature ejaculation: Implications for practice
Sexologies (2013) 22, e33—e38
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ORIGINAL ARTICLE
Evolving concepts in premature ejaculation: Implications for practice夽 M. Bonierbale 1 Interdisciplinary Association of Postgraduate Sexology, 1200, chemin de la Crete-Cauvet, 13120 Biver, Gardanne, France Available online 24 April 2013
KEYWORDS Premature ejaculation; Concept; Management; Couple; DSM
Summary The difficulties inherent in identifying a simple definition of premature ejaculation (PE) (premature for some, too quickly for others) should be seen in the light of the fact that although many genetic, neurobiological, pharmacological, psychological, urological and endocrinological factors have been proposed, and may coexist, its aetiology is unknown. Evidence-based aetiologies have found contradictory results and orient clinicians towards a more multifactorial evaluation. In addition, the role of the partner may trigger awareness of this problem among young men, or their frustration may accentuate the problem, and shows that from a clinical perspective the couple’s interaction, and the consequences of PE for them must be a strong focus. Nevertheless, a more precise differentiation between the psychological and physiological covariate implicated in ejaculation syndromes can ameliorate the application of integrated treatment approaches, which take account of relational and psychological problems that are involved in the dyadic and/or attenuate the psychological response of men affected by premature ejaculation. It is the understanding of the factors that are implicated in concepts of premature ejaculation that enable a clinical reflection of its evaluation and management. © 2013 Elsevier Masson SAS. All rights reserved.
Introduction It was around the end of the 1940s that a scientific view of sexuality emerged, distanced from moral or social judgements. Kinsey (1947) and Kinsey et al. (1948, 1953)
DOI of original article: http://dx.doi.org/10.1016/j.sexol.2013.03.002. 夽 La version en franc ¸ais de cet article, publiée dans l’édition imprimée de la revue, est également disponible en ligne : http://dx.doi.org/10.1016/j.sexol.2013.03.002. E-mail address: [email protected] 1 Psychiatrist—sexologist, president of Interdisciplinary Association of Postgraduate Sexology (AIUS).
conducted surveys on sexual behaviour, and Kinsey et al. (1953) wrote that ‘‘for approximately 75% of men, orgasm is reached within two minutes following the initiation of sexual activity, and for a not negligible number of men, orgasm is reached in less than one minute or even in the 10 or 20 seconds following penetration. Sometimes a man will be so stimulated by his imagination or by physical contact that he will ejaculate before penetration’’. This description may seem surprising today, when sexual norms are inversed and what was previously considered banal is now considered a dysfunction. This point demonstrates the impact of culture on sexual behaviour, the position of role-models, and the consequences on learning engines. Even in the 19th Century, a gentleman would rapidly fulfil his conjugal duties in order
1158-1360/$ – see front matter © 2013 Elsevier Masson SAS. All rights reserved. http://dx.doi.org/10.1016/j.sexol.2013.03.003
e34 not to disturb his wife (who, presumably, had other daily duties to be thinking about). Michel Foucault (1976) said that: ‘‘sexual life has triggered a systematic attempt to know everything about sex, that is normalised in a ‘‘science of sexuality’’, which in turn clears the way for the administration of a social sex life, more and more present in our lives’’. This observation is particularly interesting when we consider that in the 1950s in France, talking about ‘‘sex’’ was not done, neither among friends nor in the media, and that by the end of the 1970s, the sexual revolution had banished the ‘‘sexual’’ and drawn a line under puritanism. In addition, sexual practices were becoming more diverse, and age at first sex decreased by 5 years between 1968 and 1981, with the main factor implicated in changing the sexual dimension of human relationships being free speech (Jacques Marquet). This highlights that every era had its norms with regard to sexuality. This raises the question of whether the current era is experiencing liberation, or more an obligation towards an active sexuality, with its ‘‘expected results’’. From silence, modesty, inhibition and secret intimacy, a path has been forged towards more exhibition, immodesty and a liberation of mores. At the same time, we have witnessed increased liberation of women through access to pleasure facilitated by the advent of contraception. This liberation is central to new expectations and demands with regard to men, who are no longer the sole holder of knowledge about the sexuality of women, who are beginning to speak out about theirs. Sexology has contributed a great deal to these changes in the sexual order, which has been politicised by feminist achievements, illustrating the human desire to liberate the constraints imposed by nature as well as the ideologies that back it (Le Dorze, 2009).
Is ejaculation ‘‘premature’’ or has it become so? The term ‘‘premature’’ suggests that there is a ‘‘standard’’ defining the normal time for ejaculation, below which would indicate prematurity, and above which would indicate delay. What is this ‘‘time’’ before which we can say that male ejaculation is premature, and for what function? The difficulties inherent in identifying a simple definition of premature ejaculation (PE) (premature for some, too quickly for others) should be seen in the light of the fact that although many genetic, neurobiological, pharmacological, psychological, urological and endocrinological factors have been proposed, and may coexist, its aetiology is unknown. Evidence-based aetiologies have found contradictory results and orient clinicians towards a more multifactorial evaluation. In addition, the role of the partner may trigger awareness of this problem among young men, or their frustration may accentuate the problem, and this demonstrates that from a clinical perspective, the couple’s interaction and the consequences of PE for them remain a strong focus, both as a target and as a marker. Laumann et al. (1994) conducted a study in the US in which the response to the question ‘‘during the last 12 months, has there been a period of several months or more where you have reached orgasm too quickly?’’ yielded a pro-
M. Bonierbale portion of 28.5% of men reporting premature ejaculation. It is as a result of this type of evaluation of a ‘‘subjective’’ perception of premature ejaculation that it has today become the most widespread male sexual syndrome, affecting 30% of the male population. What criteria have been identified as relevant in drawing the boundaries of PE in epidemiological surveys at different points in recent history, driven by advances in knowledge and changing concepts (Giami, 2013), and how have changes over time in management of PE impacted practice in clinics today?
A ‘‘satisfactory’’ period of penetration? In early classifications of PE, the main criterion identified was the occurrence of ejaculation before the individual desired it (DSMIII). The question in Laumann et al.’s survey was based on the same presumption that a man must be able to control his ejaculation. The list of criteria that a man must fulfill in order not to be considered dysfunctional has increased; and for Colpi et al. (1986): ‘‘he who ejaculates after less than 15 movements of the pelvis following vaginal penetration is considered to be affected by premature ejaculation’’, whilst Segraves’’ (1993) looser definition states eight movements back and forth after penetration. A multitude of authors propose completely arbitrary durations, varying from one minute (Cooper and Magnus, 1984) to seven minutes (Schover et al., 1982) following vaginal penetration. By these definitions, ejaculation within 4 min following penetration would be considered premature for certain authors, but not for others. In 2008, a group of international experts brought together by the International Society for Sexual Medicine (ISSM), brought about modifications to the diagnostic and temporal criteria necessary to define premature ejaculation, stressing the importance of benchmarks such as: time from penetration to ejaculation, inability to delay ejaculation, and the negative personal consequences of premature ejaculation. This panel defined ‘‘lifelong’’ premature ejaculation as a dysfunction characterised by ‘‘ejaculation which always or nearly always occurs at or before one minute following vaginal penetration, and the presence of negative personal consequences such as distress, frustration and/or avoidance of sexual intimacy (McMahon et al., 2013).
A partner to satisfy? Masters and Johnson (1970) considered that ‘‘a man is affected by premature ejaculation if he cannot control his ejaculation long enough following penetration to satisfy his partner in at least 50% of their sexual relations’’. This point is pertinent in a clinical context when considering the repercussions for a man already vulnerable in his self-image, of a duration of penetration that he is expected to maintain, and of the performance anxiety that results. This definition was written during the midst of a surge of feminism and of the liberation of women’s sexuality. It was a time when women became ‘‘entitled’’ to sexual pleasure, at the same time not always knowing clearly what brought them to orgasm. For want of being able to express this, the woman paradoxically expected the man from whom she wished to be liberated
Evolving concepts in premature ejaculation: Implications for practice to know how to control her pleasure, and charged him with this burden (Rowland et al., 2007). It is also the time of the advent of reality TV; in an early French show focussing on ‘‘the couple’’ (Psy Show 26 Oct 1983) a journalist and a psychoanalyst feature alongside a father affected by premature ejaculation and suffering in his marriage as a result, and his wife who discusses her extramarital affairs, which she justifies by citing the necessity to ‘‘experience pleasure’’ — all with the aim of returning ‘‘to normal’’ once the man is ‘‘cured’’, somewhat paradoxically. As premature ejaculation became established as a ‘‘condition’’ or ‘‘syndrome’’, sexologists saw an increase in their consultations with men, often accompanied by an unsympathetic partner, towards whom they would have to deploy significant therapeutic efforts in order to bring down the anxiety block faced by the man; this is one of the key issues in sexotherapy. At around the same time, in 1976, Shere Hite published his first report, the Hite Report (Hite, 1977). The analysis of responses to questionnaires sent out to 3000 American women led him to conclude that the majority of women reached orgasm alone by clitoral masturbation, and were left unsatisfied by their male partners. This information, although adding to the burden on men, provided key information on the female orgasm, namely that it did not necessarily depend on penetration itself. Advanced in his field, Hite affirmed that during masturbation, women rarely ‘‘stimulate the inside of the vagina’’ and described a ‘‘clitoral system’’ not limited to the clitoral head but extending in two ‘‘bulbs’’ which begin in front of the pubic zone and surround each side of the vagina, creating waves of pleasure during excitation. These affirmations, which enabled sex therapists to thereafter endorse combining clitoral stimulation and penetration for female pleasure, might have lessened the stigma of male premature ejaculation, but paradoxically the resulting feminist counter-movement had an effect of stigmatising ‘‘clitoral women’’ which continues to this day.
A ‘‘reflex’’ to control; the ability to ejaculate at a desired moment According to Kaplan (1974, 1989) ‘‘prematurity occurs when the orgasm occurs as a reflex action; that is to say when it occurs beyond the control of the man, when a level of sexual excitation has been reached’’. For Crépault and Desjardins (1978), premature ejaculation is ‘‘the tendency in the man to experience all sexual tension feeling the need to release it as soon as possible through ejaculation; this tendency is simply the inability to control the rise of the excitatory phase or the sexual cycle’’. The stereotype of the dominant male, who is the sexual ‘‘educator’’ of women and who is the ‘‘knower’’ of the sexuality of the couple is breaking down. The impact of new male social roles on the rise in men’s complaints with regard to their ‘‘sexual efficacy’’ is not unrelated to this.
Development of classifications When, Masters and Johnson (1966) described the human sexual response cycle, with its four stages of excitement,
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plateau (full arousal, but not yet at orgasm), orgasm and resolution, this was to go on to be used as a framework by most specialists in sexual behaviour. Clinical modifications of these different stages, described and indexed into different sexual dysfunctions, were classed as: problems with excitement, plateau, orgasm and resolution. This tri-dimensional model allows premature ejaculation, dysfunctional alteration of the excitement curve, and dysfunctional alteration of the sexual response system to be described on the basis of the DSM. This model of the sexual response cycle has subsequently been updated and has supported an accumulation of knowledge regarding habitual expressions of sexuality (vasocongestive stage and stage of reflex response to orgasmic contractions [Kaplan, 1974]), allowing inadequate behaviour to be corrected. In the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV, American Psychiatric Association, 1994) symptoms and signs do not generally become diagnostic criteria unless the individual ‘‘suffers’’ or presents a ‘‘change’’ or a ‘‘deficiency’’ in important areas of functioning (social, familial, professional). Although the DSM is multi-axial, it should be noted that the symptomatic axis is often used by itself as a priority in clinical studies into medical treatments. It would be interesting to identify ‘‘responder’’ profiles while taking into account the personality axis. A select few authors, such as Tignol et al., (2001), use case studies to demonstrate that personality profiles such as the vulnerable man should not be overlooked with regard to the control of sexual excitement, where factors of vulnerability such as timidity and avoidant personality are present among the men affected by it. Other authors, such as Simonelli et al. (2008) also demonstrate the emotional dysregulation found among these men affected by PE. In the DSM-IV, premature ejaculation is ‘‘persistent or recurrent ejaculation with minimal sexual stimulation before, during, or shortly after penetration and before the person desires. 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.’’ In making an evaluation, therefore, particular aspects of the man’s sexual life are taken into account. Furthermore, ‘‘the problem causes marked distress or interpersonal difficulty’’. Thus it is necessary to pay attention to the criterion of ‘‘distress’’ in the definition of premature ejaculation, as this allows negative feelings caused by a personality, which is either perfectionist or anxious and of a depressive temperament, to be included in the inability to control the duration of penetration. Such feelings may perpetuate or exacerbate the symptoms. In day-to-day clinical practice, the clinical profile of men seeking treatment is often representative of a minority group of ‘‘pressured’’ men seeking to achieve an active sexuality which is felt to remedy a weak self-image, or indeed men lacking positive erotic anticipation, whose partners accompany them to demand what they feel they are owed and that their male partner is incapable of providing them. This can result in ‘‘hyper-concentration’’ on the man’s control of ejaculation, and follows the same pattern of hyper-attention centred on erection (and not sensual-
e36 ity) that is found in the onset and continuation of erectile dysfunction, as described by Barlow (1988). It is in this manner that a vicious circle sets in; the more the man tries to control ejaculation, the greater the chance that he will ejaculate too quickly through the deafferentation (disengaging) of sensuality experienced from the progressive building of excitement and of a quality relational experience. It has therefore long been recognised that certain ejaculations may be considered as ‘‘premature’’, ‘‘early’’ or ‘‘too quick’’, but in relation to what? Whereas the primary function of ejaculation was formerly reproduction, it has instead become for the benefit of personal and relational pleasure. One of the complexities derives from the definition of a woman’s pleasure in relation to the control of male ejaculation, and so the setting of an ‘‘arbitrary’’ time which functions to guarantee pleasure for the man ‘‘and’’ the woman should be questioned.
How to please a man affected by premature ejaculation? The classical view is that the premature ejaculator, in not feeling the building of his excitement and pleasure, cannot control his orgasm, and that control is the key to full sexuality. It is on this basis that numerous sex therapies in the 1970s and 1980s applied techniques such as that of Semans (1953), as taken up by Masters and Johnson, with the squeeze, and the stop and go of Kaplan among the most commonly used. The aim of these sex therapies is to re-teach the man to maintain a level of excitement without reaching ejaculation through using these exercises. In the squeeze, the man notices the building of pleasure and should learn to signal to his companion that he is ready to ejaculate, whereby the latter strongly squeezes the gland between her fingers in order to cut the building of erotic sensation. The man relaxes, does not ejaculate, loses his excitement and his partner caresses him sufficiently to release the muscular tension. This masturbatory stimulation is repeated at least three times in a row so that the man learns to stay in a state of sensuality without reaching orgasm. This clearly requires a compliant partner and a good therapeutic relationship. Progressively, the exercises move from passive sexuality — whereby the man is caressed and stimulated whilst he monitors to his pleasure — to him, little by little, regaining control of relations, having memorised ‘‘knowing’’ how to remain excited without ‘‘releasing’’. This is an interactive, evolutionary process between the couple. According to G. Abraham, persons in a state of sexual difficulty are hard to place in a strictly pathological context, and sexology does not treat the illness but health itself (Abraham, 2000). Here, we may say that sexual health constitutes part of the man’s self-image, the couple’s relationship, and the man’s personal resources, and that these are the objectives to be set. According to Abraham, ‘‘the quality and endurance of therapeutic results are directly linked to the envisaged goal; one must not be content with a vague improvement of sexual function; often it is necessary to ‘‘aim high’’, to advocate a thorough evaluation of the person, both in one’s relationships with others and in one’s relations with oneself.’’
M. Bonierbale Thus it is necessary to distinguish sexual ‘‘difficulty’’ linked to the context—which should be carefully evaluated in order to avoid ‘‘recurrence’’ — and ‘‘dysfunction’’, which is permanent and lifelong, accompanied by personal suffering and relational impact (Bonierbale, 2009).
Current approaches Advances in knowledge have led certain authors, such as Waldinger (2008), to a synthetic critique of psychological, unconscious, relational and/or self-taught aspects of behaviour. He refers back to other aetiologies caused by somatic factors, such as hypersensitivity of the penis gland; neurobiological factors; and problems of neurotransmission, central serotonin and the functioning of the serotonin receptors. For him, one of the major current challenges is to unite neurobiological, psychological and cultural perspectives on PE, ideally in order to achieve a definition that includes these different approaches. Until recently, however, there has been little in the way of theories of integration of these different points of view. However, Waldinger has also emphasised that the presence of PE, although a common complaint among men, is not always the result of a psychogenic or physical aetiology. Consequently, he has proposed a new classification ‘‘of premature ejaculation’’, pending the amendment of the DSM-V. According to his classification, there are four forms of PE; lifelong, acquired, naturally variable (context dependent), and pseudofunctional. He draws a distinction, particularly important for clinical practice, between the complaint and the syndrome. In the complaints we find the context-dependent variations, whereas in the syndrome there is a group of lifelong persistent complaints. These begin at sexual debut, persist with the majority of partners, manifest themselves in 90% of sexual relations with a given partner, or worsen with age. The men who complain of variable PE do not have the complete symptomatology of the subjects who have ‘‘lifelong’’ PE, and they are affected by early ejaculation only from time to time. This is reminiscent of the former clinical classifications of primary PE (lifelong), secondary PE (after a triggering event) or intermittent PE. Certain authors classify ‘‘lifelong’’ PE as ‘‘PE syndrome’’, distinguishing acquired PE from the former classification of DSM-III (Porto and Giuliano, 2013). Waldinger also introduces a temporal measure to define PE according to the intravaginal ejaculation latency time (IELT). In his view, PE syndrome is distinguished by duration of the IELT, frequency of occurrence, permanence in sexual life, aetiology, physiopathology, and treatment. For lifelong PE, this allows him to evoke a neurobiological determination justifying medical treatment to delay ejaculation. For those men, by contrast, who complain of PE but still have an IELT, which is normal (3—7 minutes) or even longer, he describes a principally psychological cause, which is perhaps even culturally defined. Thus in this case, sex therapy with counselling and pedagogic or psychotherapeutic attitudes would be a therapeutic way of clarifying these men’s complaints and of taking into account personal resources in order to teach men how to deal with them.
Evolving concepts in premature ejaculation: Implications for practice In sexology, the knowledge of all of these clinical settings means that the personalisation of therapeutic interventions is recommended. This should take into account not only the medical anamnesis and symptomatology presented by the patient, but also his personal history — lived or fantasised. This is what provides sexology’s richness and complexity, a complexity which stimulates the inventiveness of the therapist and encourages him or her to broaden to the greatest possible extent his or her field of investigations and knowledge.
What is the relevance of these different concepts in clinical practice? How is the question ‘‘is PE ‘‘premature’’ or has it become so?’’ relevant to clinical practice? It is there to remind us that the variations of the complaint may depend upon context and even on culture; this shifts the clinical focus towards evaluating the role of contextual and precipitant events, as well as motives for deciding to seek treatment (above all, in the case of ‘‘lifelong’’ PE, ‘‘why is change sought now?’’). The inability to control ejaculation, beyond possible neurophysiological factors, should not cause us to forget to consider the profile of the man seeking treatment; for instance, that of a man who lacks confidence in himself, whose control over ejaculation could be hindered by anxiety about his ability to do so, or that of a conformist who wants to adhere to models portrayed in the media. This is also not to forget the role of the partner which, at a certain point during the couple’s relationship could, through personal dissatisfaction (frustration, discovery of pleasure in an extraconjugal relationship, media), have a negative effect on the interaction and harmony of the couple. With a better understanding of these different concepts, we will be better able to set an appropriate clinical strategy. The patient’s evaluation of the duration of penetration — if this is the primary element of the complaint — is not any less subjective here. Certain men may consider themselves ‘‘quick’’ in relation to an idealised objective, and we must also listen to the partner’s perception of time to ejaculation. Thus in studies, IELT to measure PE has been set at one minute. Rowland et al. (2000, 2003) has emphasised that the primary factor to which attention should be paid is the ‘‘feeling’’ of not being able to control the time of ejaculation. How should we take into account those men who only have difficulty controlling the time of their ejaculatory response during intercourse and not during masturbation, without simply steering towards a diagnosis of relational difficulties? The impact on the couple and what is played out between them should be thoroughly evaluated; the sexual satisfaction of the partner appears low, at 61.8% versus 10.1% (other way around??), depending on whether or not the man suffers from PE (Patrick et al., 2005). In addition, a negative impact is found on the couple in the long-term, and intimacy within the couple also suffers (McCabe, 1997; Rust et al., 1988). Before any treatment is commenced, an appraisal of the couple and the persistence of emotional ties between them is fundamental; how many men who have in the past
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neglected their partner’s pleasure, when faced with a partner who wished to leave, seek medical treatment in the belief that they will retain her, despite showing no interest in her sexual pleasure before this point? Treating the connection is not treating the symptom, and first of all one must know who wants what.
Conclusions The difficulties inherent in identifying a simple definition of premature ejaculation (PE) (premature for some, too quickly for others) should be seen in the light of the fact that although many genetic, neurobiological, pharmacological, psychological, urological and endocrinological factors have been proposed, and may coexist, its aetiology is poorly defined (repetition). Evidence-based aetiologies orient the clinician towards a multifactorial evaluation, whereby the role of the partner — which may be indicative or indeed occur through her frustration — can aggravate and/or consolidate the problem. These aspects indicate that from a clinical point of view the interaction and repercussions of PE on the couple should remain a key focus of evaluation when it comes to treatment (repetition). Key ideas for evaluation: • consideration of the duration and persistence of the PE syndrome, and of the negative impact that it generates both for the man and for the couple; • confirmation by the partner of the subjective time given by the man of a duration of less than one minute from penetration to ejaculation; • signs of contextual or relational elements or organic afflictions which display potential co-morbidity should be treated as a priority (thyroid, prostate etc); • strength of the ties between the couple. Starting from these factors, the main current therapies are based on a double concept; that of combined therapy: • work on the time of ejaculation in order to delay it after penetration, by preference with medications of the SSRI group, the effectiveness and safety of which has been proven; • for daily use there is: paroxetine, sertraline, citalopram, fluoxetine, and, of tricyclic antidepressants and selective serotonin re-uptake inhibitors, clomipramine (recommendation A), outside AMM and more palliative treatments, whereby interruption is at the origin of recidivism. In these cases, combined treatment is valuable as it allows the consolidation of results through the acquisition of knowledge; • treatment on demand: ◦ tramadol, a central-action analgesic opioid, which also delays ejaculation (Bar-Or et al., 2012; Giuliano, 2012), ◦ dapoxetine; this has enriched the pharmacopoeia as, for the first time, it is an AMM for the indication of premature ejaculation (Anderson et al., 2006; McMahon et al., 2011), an SSRI with a short half-life, taken on demand, ◦ local anaesthetisation of the gland with lidocaine or prilocaine-type creams is effective and delays ejaculation, but necessitates the use of condoms to avoid
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M. Bonierbale vaginal anaesthetisation of the partner (Berkowitch et al., 1995; Atikeler et al., 2002; Henry and Morales, 2003; Busato and Galindo, 2004).
Because of the multifactorial nature of PE, it is appropriate to combine drug treatment with clinical evaluation, which will vary according to the presence of the reinforcing factors or vulnerabilities, which are detected in each sexological approach. A more precise delimitation of the interaction between the psychological and physiological covariates implicated in ejaculation can improve the application of integrated treatment approaches, which take into account the relational and psychological problems that are involved in the dyadic, and/or attenuate the physiological response in men suffering from premature ejaculation (Rowland et al., 2007).
Disclosure of interest Publication sponsored by Menarini Pharma France.
References Abraham G. Sexologie et médecine. Rev Med Suisse 2000;706:20414 http://revue.medhyg.ch/article.php3?sid=20414 Anderson KE, Mulhall JP, Wyllie MG. Pharmacokinetic and pharmacodynamic features of Dapoxetine, a novel drug for ‘‘on-demand’’ treatment of premature ejaculation. BJU Int 2006;97:311—5. Atikeler MK, Gecit I, Senal FA. Optimun usage of prilocaïne-lidocaine in premature ejaculation. Andrologia 2002;34:356—9. Barlow DH. Anxiety and its syndromes: the nature and treatment of anxiety and panic. New York: Guilford Press; 1988. Bar-Or D, Salottolo KM, Orlando A, Winkler JV, Tramadol ODT Study Group. A randomized double-blind, placebo-controlled multicenter study to evaluate the efficacy and safety of two doses of the tramadol orally disintegrating tablet for the treatment of premature ejaculation within less than 2 minutes. Eur Urol 2012;61:736—43. Berkowitch M, Keresteci A, Koren G. Efficacy of prilocaine—lidocaine cream in the treatment of premature ejaculation. J Urol 1995;154:1360—1. Bonierbale M. De la difficulté sexuelle à la dysfonction sexuelle. Sexologies 2009;18:28—31. Busato W, Galindo CC. Topical anesthesic use for treating premature ejaculation: a double blind, randomized, placebo controlled study. BJU Int 2004;93:1018—21. Colpi GM, Fanciullacci G, Beretta G, Negri L, Zanollo A. Evoked sacral potentials in subjects with true premature ejaculation. Andrologia 1986;18:583—6. Cooper A, Magnus R. Clinical and therapeutic studies in premature ejaculation. J Psychosom Res 1984;28:331—6. Crépault C, Desjardins JY. La complémentarité érotique. Ottawa: Novacom; 1978. Foucault M. La volonté de savoir T1. Bibliothèque des histoires. Paris: Gallimard; 1976. Giami A. Socio-épidémiologie de l’éjaculation prématurée. Sexologies 2013;1 [In Press]. Giuliano F. Tramadol for the treatment of premature ejaculation. Europ Urol 2012;61(4):e23—40. Henry R, Morales A. Topical prilocaine-lidocaine spray for the treatment of premature ejaculation: a proof of concept study. Int J Impot Res 2003;15:277—81. Hite S. Le rapport Hite. Collection « Réponses ». Paris: Robert Laffont; 1977.
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Further reading Psy Show: 26 oct. 1983: http://www.ina.fr/video/CPB85106010/ http://www.asblcefa.be/cefa/ viviane-et-michel-video.html. images/pdf/evolutionsocialenorme.pdf.
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ORIGINAL ARTICLE
Evolving concepts in premature ejaculation: Implications for practice夽 M. Bonierbale 1 Interdisciplinary Association of Postgraduate Sexology, 1200, chemin de la Crete-Cauvet, 13120 Biver, Gardanne, France Available online 24 April 2013
KEYWORDS Premature ejaculation; Concept; Management; Couple; DSM
Summary The difficulties inherent in identifying a simple definition of premature ejaculation (PE) (premature for some, too quickly for others) should be seen in the light of the fact that although many genetic, neurobiological, pharmacological, psychological, urological and endocrinological factors have been proposed, and may coexist, its aetiology is unknown. Evidence-based aetiologies have found contradictory results and orient clinicians towards a more multifactorial evaluation. In addition, the role of the partner may trigger awareness of this problem among young men, or their frustration may accentuate the problem, and shows that from a clinical perspective the couple’s interaction, and the consequences of PE for them must be a strong focus. Nevertheless, a more precise differentiation between the psychological and physiological covariate implicated in ejaculation syndromes can ameliorate the application of integrated treatment approaches, which take account of relational and psychological problems that are involved in the dyadic and/or attenuate the psychological response of men affected by premature ejaculation. It is the understanding of the factors that are implicated in concepts of premature ejaculation that enable a clinical reflection of its evaluation and management. © 2013 Elsevier Masson SAS. All rights reserved.
Introduction It was around the end of the 1940s that a scientific view of sexuality emerged, distanced from moral or social judgements. Kinsey (1947) and Kinsey et al. (1948, 1953)
DOI of original article: http://dx.doi.org/10.1016/j.sexol.2013.03.002. 夽 La version en franc ¸ais de cet article, publiée dans l’édition imprimée de la revue, est également disponible en ligne : http://dx.doi.org/10.1016/j.sexol.2013.03.002. E-mail address: [email protected] 1 Psychiatrist—sexologist, president of Interdisciplinary Association of Postgraduate Sexology (AIUS).
conducted surveys on sexual behaviour, and Kinsey et al. (1953) wrote that ‘‘for approximately 75% of men, orgasm is reached within two minutes following the initiation of sexual activity, and for a not negligible number of men, orgasm is reached in less than one minute or even in the 10 or 20 seconds following penetration. Sometimes a man will be so stimulated by his imagination or by physical contact that he will ejaculate before penetration’’. This description may seem surprising today, when sexual norms are inversed and what was previously considered banal is now considered a dysfunction. This point demonstrates the impact of culture on sexual behaviour, the position of role-models, and the consequences on learning engines. Even in the 19th Century, a gentleman would rapidly fulfil his conjugal duties in order
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e34 not to disturb his wife (who, presumably, had other daily duties to be thinking about). Michel Foucault (1976) said that: ‘‘sexual life has triggered a systematic attempt to know everything about sex, that is normalised in a ‘‘science of sexuality’’, which in turn clears the way for the administration of a social sex life, more and more present in our lives’’. This observation is particularly interesting when we consider that in the 1950s in France, talking about ‘‘sex’’ was not done, neither among friends nor in the media, and that by the end of the 1970s, the sexual revolution had banished the ‘‘sexual’’ and drawn a line under puritanism. In addition, sexual practices were becoming more diverse, and age at first sex decreased by 5 years between 1968 and 1981, with the main factor implicated in changing the sexual dimension of human relationships being free speech (Jacques Marquet). This highlights that every era had its norms with regard to sexuality. This raises the question of whether the current era is experiencing liberation, or more an obligation towards an active sexuality, with its ‘‘expected results’’. From silence, modesty, inhibition and secret intimacy, a path has been forged towards more exhibition, immodesty and a liberation of mores. At the same time, we have witnessed increased liberation of women through access to pleasure facilitated by the advent of contraception. This liberation is central to new expectations and demands with regard to men, who are no longer the sole holder of knowledge about the sexuality of women, who are beginning to speak out about theirs. Sexology has contributed a great deal to these changes in the sexual order, which has been politicised by feminist achievements, illustrating the human desire to liberate the constraints imposed by nature as well as the ideologies that back it (Le Dorze, 2009).
Is ejaculation ‘‘premature’’ or has it become so? The term ‘‘premature’’ suggests that there is a ‘‘standard’’ defining the normal time for ejaculation, below which would indicate prematurity, and above which would indicate delay. What is this ‘‘time’’ before which we can say that male ejaculation is premature, and for what function? The difficulties inherent in identifying a simple definition of premature ejaculation (PE) (premature for some, too quickly for others) should be seen in the light of the fact that although many genetic, neurobiological, pharmacological, psychological, urological and endocrinological factors have been proposed, and may coexist, its aetiology is unknown. Evidence-based aetiologies have found contradictory results and orient clinicians towards a more multifactorial evaluation. In addition, the role of the partner may trigger awareness of this problem among young men, or their frustration may accentuate the problem, and this demonstrates that from a clinical perspective, the couple’s interaction and the consequences of PE for them remain a strong focus, both as a target and as a marker. Laumann et al. (1994) conducted a study in the US in which the response to the question ‘‘during the last 12 months, has there been a period of several months or more where you have reached orgasm too quickly?’’ yielded a pro-
M. Bonierbale portion of 28.5% of men reporting premature ejaculation. It is as a result of this type of evaluation of a ‘‘subjective’’ perception of premature ejaculation that it has today become the most widespread male sexual syndrome, affecting 30% of the male population. What criteria have been identified as relevant in drawing the boundaries of PE in epidemiological surveys at different points in recent history, driven by advances in knowledge and changing concepts (Giami, 2013), and how have changes over time in management of PE impacted practice in clinics today?
A ‘‘satisfactory’’ period of penetration? In early classifications of PE, the main criterion identified was the occurrence of ejaculation before the individual desired it (DSMIII). The question in Laumann et al.’s survey was based on the same presumption that a man must be able to control his ejaculation. The list of criteria that a man must fulfill in order not to be considered dysfunctional has increased; and for Colpi et al. (1986): ‘‘he who ejaculates after less than 15 movements of the pelvis following vaginal penetration is considered to be affected by premature ejaculation’’, whilst Segraves’’ (1993) looser definition states eight movements back and forth after penetration. A multitude of authors propose completely arbitrary durations, varying from one minute (Cooper and Magnus, 1984) to seven minutes (Schover et al., 1982) following vaginal penetration. By these definitions, ejaculation within 4 min following penetration would be considered premature for certain authors, but not for others. In 2008, a group of international experts brought together by the International Society for Sexual Medicine (ISSM), brought about modifications to the diagnostic and temporal criteria necessary to define premature ejaculation, stressing the importance of benchmarks such as: time from penetration to ejaculation, inability to delay ejaculation, and the negative personal consequences of premature ejaculation. This panel defined ‘‘lifelong’’ premature ejaculation as a dysfunction characterised by ‘‘ejaculation which always or nearly always occurs at or before one minute following vaginal penetration, and the presence of negative personal consequences such as distress, frustration and/or avoidance of sexual intimacy (McMahon et al., 2013).
A partner to satisfy? Masters and Johnson (1970) considered that ‘‘a man is affected by premature ejaculation if he cannot control his ejaculation long enough following penetration to satisfy his partner in at least 50% of their sexual relations’’. This point is pertinent in a clinical context when considering the repercussions for a man already vulnerable in his self-image, of a duration of penetration that he is expected to maintain, and of the performance anxiety that results. This definition was written during the midst of a surge of feminism and of the liberation of women’s sexuality. It was a time when women became ‘‘entitled’’ to sexual pleasure, at the same time not always knowing clearly what brought them to orgasm. For want of being able to express this, the woman paradoxically expected the man from whom she wished to be liberated
Evolving concepts in premature ejaculation: Implications for practice to know how to control her pleasure, and charged him with this burden (Rowland et al., 2007). It is also the time of the advent of reality TV; in an early French show focussing on ‘‘the couple’’ (Psy Show 26 Oct 1983) a journalist and a psychoanalyst feature alongside a father affected by premature ejaculation and suffering in his marriage as a result, and his wife who discusses her extramarital affairs, which she justifies by citing the necessity to ‘‘experience pleasure’’ — all with the aim of returning ‘‘to normal’’ once the man is ‘‘cured’’, somewhat paradoxically. As premature ejaculation became established as a ‘‘condition’’ or ‘‘syndrome’’, sexologists saw an increase in their consultations with men, often accompanied by an unsympathetic partner, towards whom they would have to deploy significant therapeutic efforts in order to bring down the anxiety block faced by the man; this is one of the key issues in sexotherapy. At around the same time, in 1976, Shere Hite published his first report, the Hite Report (Hite, 1977). The analysis of responses to questionnaires sent out to 3000 American women led him to conclude that the majority of women reached orgasm alone by clitoral masturbation, and were left unsatisfied by their male partners. This information, although adding to the burden on men, provided key information on the female orgasm, namely that it did not necessarily depend on penetration itself. Advanced in his field, Hite affirmed that during masturbation, women rarely ‘‘stimulate the inside of the vagina’’ and described a ‘‘clitoral system’’ not limited to the clitoral head but extending in two ‘‘bulbs’’ which begin in front of the pubic zone and surround each side of the vagina, creating waves of pleasure during excitation. These affirmations, which enabled sex therapists to thereafter endorse combining clitoral stimulation and penetration for female pleasure, might have lessened the stigma of male premature ejaculation, but paradoxically the resulting feminist counter-movement had an effect of stigmatising ‘‘clitoral women’’ which continues to this day.
A ‘‘reflex’’ to control; the ability to ejaculate at a desired moment According to Kaplan (1974, 1989) ‘‘prematurity occurs when the orgasm occurs as a reflex action; that is to say when it occurs beyond the control of the man, when a level of sexual excitation has been reached’’. For Crépault and Desjardins (1978), premature ejaculation is ‘‘the tendency in the man to experience all sexual tension feeling the need to release it as soon as possible through ejaculation; this tendency is simply the inability to control the rise of the excitatory phase or the sexual cycle’’. The stereotype of the dominant male, who is the sexual ‘‘educator’’ of women and who is the ‘‘knower’’ of the sexuality of the couple is breaking down. The impact of new male social roles on the rise in men’s complaints with regard to their ‘‘sexual efficacy’’ is not unrelated to this.
Development of classifications When, Masters and Johnson (1966) described the human sexual response cycle, with its four stages of excitement,
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plateau (full arousal, but not yet at orgasm), orgasm and resolution, this was to go on to be used as a framework by most specialists in sexual behaviour. Clinical modifications of these different stages, described and indexed into different sexual dysfunctions, were classed as: problems with excitement, plateau, orgasm and resolution. This tri-dimensional model allows premature ejaculation, dysfunctional alteration of the excitement curve, and dysfunctional alteration of the sexual response system to be described on the basis of the DSM. This model of the sexual response cycle has subsequently been updated and has supported an accumulation of knowledge regarding habitual expressions of sexuality (vasocongestive stage and stage of reflex response to orgasmic contractions [Kaplan, 1974]), allowing inadequate behaviour to be corrected. In the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV, American Psychiatric Association, 1994) symptoms and signs do not generally become diagnostic criteria unless the individual ‘‘suffers’’ or presents a ‘‘change’’ or a ‘‘deficiency’’ in important areas of functioning (social, familial, professional). Although the DSM is multi-axial, it should be noted that the symptomatic axis is often used by itself as a priority in clinical studies into medical treatments. It would be interesting to identify ‘‘responder’’ profiles while taking into account the personality axis. A select few authors, such as Tignol et al., (2001), use case studies to demonstrate that personality profiles such as the vulnerable man should not be overlooked with regard to the control of sexual excitement, where factors of vulnerability such as timidity and avoidant personality are present among the men affected by it. Other authors, such as Simonelli et al. (2008) also demonstrate the emotional dysregulation found among these men affected by PE. In the DSM-IV, premature ejaculation is ‘‘persistent or recurrent ejaculation with minimal sexual stimulation before, during, or shortly after penetration and before the person desires. 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.’’ In making an evaluation, therefore, particular aspects of the man’s sexual life are taken into account. Furthermore, ‘‘the problem causes marked distress or interpersonal difficulty’’. Thus it is necessary to pay attention to the criterion of ‘‘distress’’ in the definition of premature ejaculation, as this allows negative feelings caused by a personality, which is either perfectionist or anxious and of a depressive temperament, to be included in the inability to control the duration of penetration. Such feelings may perpetuate or exacerbate the symptoms. In day-to-day clinical practice, the clinical profile of men seeking treatment is often representative of a minority group of ‘‘pressured’’ men seeking to achieve an active sexuality which is felt to remedy a weak self-image, or indeed men lacking positive erotic anticipation, whose partners accompany them to demand what they feel they are owed and that their male partner is incapable of providing them. This can result in ‘‘hyper-concentration’’ on the man’s control of ejaculation, and follows the same pattern of hyper-attention centred on erection (and not sensual-
e36 ity) that is found in the onset and continuation of erectile dysfunction, as described by Barlow (1988). It is in this manner that a vicious circle sets in; the more the man tries to control ejaculation, the greater the chance that he will ejaculate too quickly through the deafferentation (disengaging) of sensuality experienced from the progressive building of excitement and of a quality relational experience. It has therefore long been recognised that certain ejaculations may be considered as ‘‘premature’’, ‘‘early’’ or ‘‘too quick’’, but in relation to what? Whereas the primary function of ejaculation was formerly reproduction, it has instead become for the benefit of personal and relational pleasure. One of the complexities derives from the definition of a woman’s pleasure in relation to the control of male ejaculation, and so the setting of an ‘‘arbitrary’’ time which functions to guarantee pleasure for the man ‘‘and’’ the woman should be questioned.
How to please a man affected by premature ejaculation? The classical view is that the premature ejaculator, in not feeling the building of his excitement and pleasure, cannot control his orgasm, and that control is the key to full sexuality. It is on this basis that numerous sex therapies in the 1970s and 1980s applied techniques such as that of Semans (1953), as taken up by Masters and Johnson, with the squeeze, and the stop and go of Kaplan among the most commonly used. The aim of these sex therapies is to re-teach the man to maintain a level of excitement without reaching ejaculation through using these exercises. In the squeeze, the man notices the building of pleasure and should learn to signal to his companion that he is ready to ejaculate, whereby the latter strongly squeezes the gland between her fingers in order to cut the building of erotic sensation. The man relaxes, does not ejaculate, loses his excitement and his partner caresses him sufficiently to release the muscular tension. This masturbatory stimulation is repeated at least three times in a row so that the man learns to stay in a state of sensuality without reaching orgasm. This clearly requires a compliant partner and a good therapeutic relationship. Progressively, the exercises move from passive sexuality — whereby the man is caressed and stimulated whilst he monitors to his pleasure — to him, little by little, regaining control of relations, having memorised ‘‘knowing’’ how to remain excited without ‘‘releasing’’. This is an interactive, evolutionary process between the couple. According to G. Abraham, persons in a state of sexual difficulty are hard to place in a strictly pathological context, and sexology does not treat the illness but health itself (Abraham, 2000). Here, we may say that sexual health constitutes part of the man’s self-image, the couple’s relationship, and the man’s personal resources, and that these are the objectives to be set. According to Abraham, ‘‘the quality and endurance of therapeutic results are directly linked to the envisaged goal; one must not be content with a vague improvement of sexual function; often it is necessary to ‘‘aim high’’, to advocate a thorough evaluation of the person, both in one’s relationships with others and in one’s relations with oneself.’’
M. Bonierbale Thus it is necessary to distinguish sexual ‘‘difficulty’’ linked to the context—which should be carefully evaluated in order to avoid ‘‘recurrence’’ — and ‘‘dysfunction’’, which is permanent and lifelong, accompanied by personal suffering and relational impact (Bonierbale, 2009).
Current approaches Advances in knowledge have led certain authors, such as Waldinger (2008), to a synthetic critique of psychological, unconscious, relational and/or self-taught aspects of behaviour. He refers back to other aetiologies caused by somatic factors, such as hypersensitivity of the penis gland; neurobiological factors; and problems of neurotransmission, central serotonin and the functioning of the serotonin receptors. For him, one of the major current challenges is to unite neurobiological, psychological and cultural perspectives on PE, ideally in order to achieve a definition that includes these different approaches. Until recently, however, there has been little in the way of theories of integration of these different points of view. However, Waldinger has also emphasised that the presence of PE, although a common complaint among men, is not always the result of a psychogenic or physical aetiology. Consequently, he has proposed a new classification ‘‘of premature ejaculation’’, pending the amendment of the DSM-V. According to his classification, there are four forms of PE; lifelong, acquired, naturally variable (context dependent), and pseudofunctional. He draws a distinction, particularly important for clinical practice, between the complaint and the syndrome. In the complaints we find the context-dependent variations, whereas in the syndrome there is a group of lifelong persistent complaints. These begin at sexual debut, persist with the majority of partners, manifest themselves in 90% of sexual relations with a given partner, or worsen with age. The men who complain of variable PE do not have the complete symptomatology of the subjects who have ‘‘lifelong’’ PE, and they are affected by early ejaculation only from time to time. This is reminiscent of the former clinical classifications of primary PE (lifelong), secondary PE (after a triggering event) or intermittent PE. Certain authors classify ‘‘lifelong’’ PE as ‘‘PE syndrome’’, distinguishing acquired PE from the former classification of DSM-III (Porto and Giuliano, 2013). Waldinger also introduces a temporal measure to define PE according to the intravaginal ejaculation latency time (IELT). In his view, PE syndrome is distinguished by duration of the IELT, frequency of occurrence, permanence in sexual life, aetiology, physiopathology, and treatment. For lifelong PE, this allows him to evoke a neurobiological determination justifying medical treatment to delay ejaculation. For those men, by contrast, who complain of PE but still have an IELT, which is normal (3—7 minutes) or even longer, he describes a principally psychological cause, which is perhaps even culturally defined. Thus in this case, sex therapy with counselling and pedagogic or psychotherapeutic attitudes would be a therapeutic way of clarifying these men’s complaints and of taking into account personal resources in order to teach men how to deal with them.
Evolving concepts in premature ejaculation: Implications for practice In sexology, the knowledge of all of these clinical settings means that the personalisation of therapeutic interventions is recommended. This should take into account not only the medical anamnesis and symptomatology presented by the patient, but also his personal history — lived or fantasised. This is what provides sexology’s richness and complexity, a complexity which stimulates the inventiveness of the therapist and encourages him or her to broaden to the greatest possible extent his or her field of investigations and knowledge.
What is the relevance of these different concepts in clinical practice? How is the question ‘‘is PE ‘‘premature’’ or has it become so?’’ relevant to clinical practice? It is there to remind us that the variations of the complaint may depend upon context and even on culture; this shifts the clinical focus towards evaluating the role of contextual and precipitant events, as well as motives for deciding to seek treatment (above all, in the case of ‘‘lifelong’’ PE, ‘‘why is change sought now?’’). The inability to control ejaculation, beyond possible neurophysiological factors, should not cause us to forget to consider the profile of the man seeking treatment; for instance, that of a man who lacks confidence in himself, whose control over ejaculation could be hindered by anxiety about his ability to do so, or that of a conformist who wants to adhere to models portrayed in the media. This is also not to forget the role of the partner which, at a certain point during the couple’s relationship could, through personal dissatisfaction (frustration, discovery of pleasure in an extraconjugal relationship, media), have a negative effect on the interaction and harmony of the couple. With a better understanding of these different concepts, we will be better able to set an appropriate clinical strategy. The patient’s evaluation of the duration of penetration — if this is the primary element of the complaint — is not any less subjective here. Certain men may consider themselves ‘‘quick’’ in relation to an idealised objective, and we must also listen to the partner’s perception of time to ejaculation. Thus in studies, IELT to measure PE has been set at one minute. Rowland et al. (2000, 2003) has emphasised that the primary factor to which attention should be paid is the ‘‘feeling’’ of not being able to control the time of ejaculation. How should we take into account those men who only have difficulty controlling the time of their ejaculatory response during intercourse and not during masturbation, without simply steering towards a diagnosis of relational difficulties? The impact on the couple and what is played out between them should be thoroughly evaluated; the sexual satisfaction of the partner appears low, at 61.8% versus 10.1% (other way around??), depending on whether or not the man suffers from PE (Patrick et al., 2005). In addition, a negative impact is found on the couple in the long-term, and intimacy within the couple also suffers (McCabe, 1997; Rust et al., 1988). Before any treatment is commenced, an appraisal of the couple and the persistence of emotional ties between them is fundamental; how many men who have in the past
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neglected their partner’s pleasure, when faced with a partner who wished to leave, seek medical treatment in the belief that they will retain her, despite showing no interest in her sexual pleasure before this point? Treating the connection is not treating the symptom, and first of all one must know who wants what.
Conclusions The difficulties inherent in identifying a simple definition of premature ejaculation (PE) (premature for some, too quickly for others) should be seen in the light of the fact that although many genetic, neurobiological, pharmacological, psychological, urological and endocrinological factors have been proposed, and may coexist, its aetiology is poorly defined (repetition). Evidence-based aetiologies orient the clinician towards a multifactorial evaluation, whereby the role of the partner — which may be indicative or indeed occur through her frustration — can aggravate and/or consolidate the problem. These aspects indicate that from a clinical point of view the interaction and repercussions of PE on the couple should remain a key focus of evaluation when it comes to treatment (repetition). Key ideas for evaluation: • consideration of the duration and persistence of the PE syndrome, and of the negative impact that it generates both for the man and for the couple; • confirmation by the partner of the subjective time given by the man of a duration of less than one minute from penetration to ejaculation; • signs of contextual or relational elements or organic afflictions which display potential co-morbidity should be treated as a priority (thyroid, prostate etc); • strength of the ties between the couple. Starting from these factors, the main current therapies are based on a double concept; that of combined therapy: • work on the time of ejaculation in order to delay it after penetration, by preference with medications of the SSRI group, the effectiveness and safety of which has been proven; • for daily use there is: paroxetine, sertraline, citalopram, fluoxetine, and, of tricyclic antidepressants and selective serotonin re-uptake inhibitors, clomipramine (recommendation A), outside AMM and more palliative treatments, whereby interruption is at the origin of recidivism. In these cases, combined treatment is valuable as it allows the consolidation of results through the acquisition of knowledge; • treatment on demand: ◦ tramadol, a central-action analgesic opioid, which also delays ejaculation (Bar-Or et al., 2012; Giuliano, 2012), ◦ dapoxetine; this has enriched the pharmacopoeia as, for the first time, it is an AMM for the indication of premature ejaculation (Anderson et al., 2006; McMahon et al., 2011), an SSRI with a short half-life, taken on demand, ◦ local anaesthetisation of the gland with lidocaine or prilocaine-type creams is effective and delays ejaculation, but necessitates the use of condoms to avoid
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M. Bonierbale vaginal anaesthetisation of the partner (Berkowitch et al., 1995; Atikeler et al., 2002; Henry and Morales, 2003; Busato and Galindo, 2004).
Because of the multifactorial nature of PE, it is appropriate to combine drug treatment with clinical evaluation, which will vary according to the presence of the reinforcing factors or vulnerabilities, which are detected in each sexological approach. A more precise delimitation of the interaction between the psychological and physiological covariates implicated in ejaculation can improve the application of integrated treatment approaches, which take into account the relational and psychological problems that are involved in the dyadic, and/or attenuate the physiological response in men suffering from premature ejaculation (Rowland et al., 2007).
Disclosure of interest Publication sponsored by Menarini Pharma France.
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Further reading Psy Show: 26 oct. 1983: http://www.ina.fr/video/CPB85106010/ http://www.asblcefa.be/cefa/ viviane-et-michel-video.html. images/pdf/evolutionsocialenorme.pdf.