A modern definition of premature ejaculation (PE)
A man has PE when he is unable to control the timing of his ejaculation during intercourse, when he routinely lasts for less than 5 minutes before ejaculating during intercourse, and when he feels dissatisfied with his sexual performance because of this.
Let us take a moment to revisit the “official” definitions of premature ejaculation as set out in the DSM IV. The DSM IV diagnostic criteria for premature ejaculation are as follows: (1) persistent and recurrent ejaculation with minimal sexual stimulation before, on, or shortly after penetration before the person wishes it; (2) marked distress or interpersonal difficulty; and (3) not exclusively due to direct effects.
Waldinger and Schweitzer analyzed two studies in 2004/2005 and discovered that the DSM IV definition actually produces a high percentage of PE diagnoses which turn out to be false positives. This is this is because the DSM IV definition is rather overweighted towards the men who complain about having PE, whilst ignoring the actual duration of their IELT. This stands for intravaginal ejaculatiry latency time (meaning the time between penetration and male ejaculation).
In practical terms what this means is that the definition set out formally in DSM IV does not take account of the fact that there is a great variability between men in how long it takes them to ejaculate. Also, there is also similar variation in how long both partners wish sex to last. This ambiguity, and the need to clarify exactly what we mean when we talk about premature ejaculation, has led to attempts to form a quantitative definition of the condition.
(This seems quite reasonable, considering that delayed ejaculation is defined by the time lag between insertion of the penis into the vagina and the man’s climax.)
There is evidence that the current average IELT is about six and half minutes in 18 to 30 year old men. If PE is defined as an IELT percentile below 2.5 that would mean a man who ejaculates in less than a minute and a half has premature ejaculation.
The problem is that many men and their partners with an IELT of less than 1.5 minutes are very happy with their sexual performance and do not regard it as a problem. On this basis they would not be defined as having premature ejaculation. Contrast this with the man who has an IELT of two minutes before he ejaculates, but believes he has poor control, is very distressed about this situation, and has some interpersonal difficulties with his partner because of it. All of this means that even though he does not fall into the conventional range of the current definition of the condition, he would still be diagnosed with PE.
Waldinger & colleagues define PE using evidence-based data to subdivide premature ejaculation into two groups, which we know as “lifelong” and “acquired”. They’ve recently proposed a third type which they call “natural variable PE”.
This term is applied to men who experience an inconsistent type of early ejaculation; this type of PE is not some of manifestation of a true pathology but simply a normal variation in the human male’s ejaculatory control.
Waldinger further proposes that normal variable PE will account for the extremely high number of men who consider themselves to be early ejaculators (that is to say between 20 and 40% of the population.) He contrasts this with the percentage of men who have lifelong and acquired PE, which he claims has never been investigated in detail, but he assumes it to be rather low at between 1% and 5% of the male population.
This approach to defining premature ejaculation is rather radical because it puts the emphasis back onto the fact that men are generally dissatisfied with their sexual performance, when in reality they may be experiencing nothing more than the natural variability of male sexual response.
If this is so, and it certainly seems likely, then it follows that the majority of men who report themselves as having PE should not be pathologised or treated with antidepressants; they should probably receive a non-invasive psychological therapy such as sexual psychotherapy or counseling.
There are almost no reports of psychoanalytic investigation of premature ejaculation, so modern therapists have a blank canvas on which to work.
One of the flaws of the very few accounts of psychoanalysis which do exist is that they tend to extrapolate from individual cases of premature ejaculation to generalized explanations such as “castration anxiety” and “hatred of women”. These are not useful in actually understanding either the etiology of quick ejaculation or how psychoanalysis might assist in its the understanding and treatment.
Lifelong acquired and normal variable premature ejaculation
Complaints of PE are expressed by four groups of men. The categorization depends on the duration of IELT, how it varies throughout life, and the personal experience of the man concerned.
Men who are defined as having lifelong PE or acquired PE usually have an IELT of less than one and a half minutes. However a minority of men with lifelong PE can last as long as three minutes. And in cases of lifelong PE, early ejaculation takes place at every experience of sexual intercourse.
By contrast, men with normal variable premature ejaculation experience considerable variability and inconsistency in the length of time for which they are able to maintain self-control before ejaculating.
Premature like ejaculatory dysfunction
This term has been proposed to explain the considerable number of men who described themselves as having PE even though they have a normal or even a long IELT duration. In a study conducted over several centers in the United States by experienced clinicians, men were defined as having PE (or not) according to DSM IV criteria.
This revealed that out of 190 men with PE, 48% were able to last at least two minutes after penetration before ejaculating, while 13% of men who complained that they had PE ejaculated between 5 and 25 minutes after penetration. The study revealed a low positive predictive value for the definition of PE according to DSM IV.
An important point here is that many men who have normal and even long IELT durations still report that they experience early ejaculation. So, while according to the DSM IV definition these men do have PE, the question arises as to whether it’s a well founded clinical judgment to define men as having PE if they can actually enjoy between 5 and 25 minutes of intercourse before ejaculating.
One of the problems in assessing such information is that nobody has any data about how accurate self-assessments of time between penetration and ejaculation actually are: particularly when they are self-reported. Even allowing for some margin of error, however, it is clear that there men fall, broadly speaking, into two categories: those with long IELT durations, and those with short IELT durations. The problem is in understanding why these men have different outcomes during intercourse.
Men with long and short IELT durations may have some differences in either their psychological make-up or their neurobiological physiology. Men who are described as having lifelong premature ejaculation are usually mentally healthy but are unable to control their ejaculation for more than 1 to 1.5 minutes.
This contrasts sharply with men who complain of premature ejaculation but have a normal or even a long IELT: they are usually able to delay their ejaculation to some degree. However, they may have psychological issues that affect their judgment of how adequate their sexual performance is in reality. Alternatively, they may have relationship issues around sexual intercourse, perhaps focusing on their partner’s different expectations of intercourse.
It seems more relevant to treat men in the latter group with some kind of counseling, or by providing sexual psychological information or engaging in psychotherapy of some kind. It is these men for whom the term “premature-like ejaculatory dysfunction” has been proposed.
It is a condition that is characterized by misperceptions about the man’s “staying power” – and often involves the belief that what is in fact a normal or even a long duration of intercourse is too short. Clearly this involves a subjective misjudgment of the man’s own performance against some standard of what he regards as normal ejaculatory performance. It’s quite clear that a condition like this is most likely to be caused by psychological, cultural or other issues within the relationship.
Premature-like ejaculatory dysfunction diagnostic criteria
1 Subjective perception of rapid ejaculation during most occurrences of sexual intercourse
2 A preoccupation with the consequences of lack of control and early ejaculation
3 The misperception around IELT which leads a man to assume that even though he is in the normal range his ability to control ejaculation is diminished
4 There is no explanation for this in terms of any other psychological dysfunction.
Waldinger claims that there is more and more evidence accumulating to suggest that lifelong PE – where the time between penetration and ejaculation is shorter than 1 to 1.5 minutes – is a neurobiological dysfunction. (And which causes psychological issues and relationship issues to arise.)
He observes that drug treatment with the SSRI dapoxetine has become fairly standard procedures for this condition. It is not clear how men with lifelong PE and men with premature-like ejaculatory dysfunction differ in emotional or physiological functioning.
But Waldinger observes that there are many men with lifelong PE who have adopted coping strategies that enable them and their partners to manage very well with a short IELT. And he does acknowledge that there are men who have serious interpersonal or emotional problems because of their ejaculatory dysfunction.
Men with long and short IELT duration may have some differences in either their psychological make-up or their neurobiological physiology. Men who are described as having lifelong premature ejaculation are usually emotionally stable but are unable to control their ejaculation for more than 1 or 1.5 minutes.
This contrasts sharply with men who complain of premature ejaculation but have a normal or long IELT: they are usually able to delay their ejaculation to some degree. However, they may have psychological issues that affect their judgment of how adequate their sexual performance is in reality. Alternatively, they may have relationship issues around sexual intercourse, perhaps focusing on the partners’ different expectations around intercourse.