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ORIGINAL
ARTICLE
The
premature
ejaculation
‘disorder’:
Questioning
the
criterion
of
one
minute
of
penetration
夽
P.
Kempeneers
a,b,∗,
M.
Desseilles
b,caDépartementdessciencesdelasantépublique,universitédeLiège,Liège,Belgium
bCliniquepsychiatriquedesAlexiens,rueduChâteau-de-Ruyff,68,B-4841Henri-Chapelle,Belgium cDépartementdepsychologie,universitédeNamur,Namur,Belgium
Availableonline9July2014
KEYWORDS Premature ejaculation; Ejaculationlatency; Aetiology; Treatment; Cognitivebehavioural therapy; Sextherapy; Selectiveserotonin reuptakeinhibitors
Summary The currenttrend isto reservethe diagnosis ofpremature ejaculation (PE)for caseswherepenetrationlastsforaboutoneminuteorless.The rationaleisthatthe aetiol-ogyisprimarilybio-constitutional,andthatlong-termpharmacologicaltreatmentistheonly viableoption.However,theliteraturecontainslittlescientificevidencetosupportthis argu-ment.Infact,agoodnumberofindividualswhosufferfromoverlyrapidejaculationpresent withpenetrationdurationexceedingoneminute,andevensevereformsofPEhaveresponded favourablytopsycho-sexologicaltreatment.Moreover,althoughcertainbiologicalvariablesare knowntoinfluenceejaculationlatencytime,nothingindicatesthattheyplayanexclusiverole ofpsychosocialetiologicalfactorsinseverePE.Therefore,itwouldbe‘premature’tobasea PEdiagnosisonamaximumpenetrationdurationofoneminute,whichshouldinsteadbe con-sideredaseveritygradient.Giventhatdesiredcriteriaforpenetrationdurationoftenexceed biologicalnorms,itwouldbeinappropriatetoproposethatonlythemostsevereformsofPE haveconstitutionalorigins.Inanycase,theconstitutionisrelativelyflexible,andcanrespond toadaptivelearning.An adaptivelearningapproachwouldundoubtedlybemoredifficultto applyinseverecases,butnotimpossible.Theissueofwhethertousepharmacologicalversus psycho-sexologicaltreatmentcouldbesidesteppedbymovingbeyondthesinglecriterionof ejaculationlatency.
©2014ElsevierMassonSAS.Allrightsreserved.
DOIoforiginalarticle:http://dx.doi.org/10.1016/j.sexol.2014.06.005.
夽 Laversionenfranc¸aisdecetarticle,publiéedansl’éditionimpriméedelarevue,estdisponibleenligne:http://dx.doi.org/10.1016/
j.sexol.2014.06.004.
∗Correspondingauthor.
E-mailaddress:p.kempeneers@ulg.ac.be(P.Kempeneers).
http://dx.doi.org/10.1016/j.sexol.2014.06.004
e60 P.Kempeneers,M.Desseilles
Qualifying
ejaculation
‘prematurity’:
two
opposing
viewpoints
Everybody, or almost everybody, agrees that premature ejaculation(PE)maybeconsideredasexualdysfunctionif threecriteriaaremet:ejaculation:
• occursrapidly;
• isfelttobeoutsidetheman’scontrol;
• generatesafeelingofdistress,oratleastdissatisfaction. Beyond this common ground, however, conceptions diverge, mainly concerning the criterion of rapidness
(Bonierbale,2013;Kempeneersetal.,inpress).
Inschematicterms,therearetwomainopposing view-points:
• on the one hand, there is what is known as the ‘‘subjectivist’’view.Initsmostextremeform,thisview proposes theindividual’s wishes, or subjectivity, asthe onlyrelevantreferent:anejaculationisconsidered pre-maturewhenitregularlyoccursbeforethemanwantsit to,andthatisall.Rapidnessisthereforereducedtolack ofcontrol.ThisviewpointiswellexpressedinworksbyDe
Carufel(2009)andMetzandMcCarthy(2003),among
oth-ers.Inthissense,PEwouldaffectapproximately15to30% ofthemalepopulation(Laumannetal.,2005;Levinson,
2008;Parketal.,2010;Porstetal.,2007);
• ontheotherhand,thereisthe‘‘objectivist’’view,which seeks toobjectively determine ejaculation rapidnessin termsof regularoccurrenceat belowamaximum pene-tration duration.Various authorshave proposed various benchmarks, ranging from 15seconds (WHO, 1994) to sevenminutes(Schoveretal.,1982).Currently,thetrend is to retain a one-minute maximum threshold. In this sense,lessthan5%ofthepopulationwouldbeaffected
(APA,2013;Janninietal.,2013;McMahonetal.,2008).
Intrinsic to thesetwo schools of thought are opposing idealtypesofnormality:
• a purely subjectivist approach would be to regard as normalaman’stotalvoluntarycontroloverhisown ejac-ulation.Pushedtotheextreme,thisconceptionbecomes akindofbiologicalutopia;
• apurelyobjectivistapproachwouldbetojudge normal-itybasedonstatisticsalone,withthepotentiallyharmful effect of delegitimising the notion of ‘‘disorder,’’ and consequentlythetherapeuticintention,beyondthe piv-otalvalue.
Ejaculation
and
its
timing:
observational
data
Thegeneralpopulation
Thefirst investigationtouse objectivemeasuresof pene-tration time in the general population was conducted by
Waldinger et al. (2005) in several national samples. The
mediandurationofcoituswas5.4minutes,withdifferences acrosscountriesrangingfrom3.7minutesinTurkeyto7.6in
the United Kingdom. A secondinvestigation by Waldinger
etal.(2009)reportedsimilarresults:4.4minutesinTurkey,
10intheUnitedKingdom,andsixforthetotalsample.
Individualdesires
Incomparisontothefindingsof Waldingeretal.,asurvey conducted by Montorsi (2005) revealed that the respon-dentsestimatednormalpenetrationdurationat13minutes on average for Americans and 9.6for Europeans. Else-where,CortyandGuardiani(2008)surveyed34experienced American and Canadian sexologists and found that what was deemed ‘‘desirable’’ duration, that is, from seven to 13minutes of penetration, exceeded the statistical norm of three to sevenminutes, which was considered ‘‘adequate’’ duration. This is probably not unconnected to the widespread opinion that achieving an orgasm requireslongertactilestimulationforwomenthanformen: five to 15minutes on average for women versus four to sevenminutes for men (Nagoski,2010). In short, when it comes to penetration duration, the reference standards clearly exceed the statistical standards. What could —at leastintheWesternworld—beconsideredabiologicalnorm appearstoberatherunsatisfactoryfrombothahedonicand asocioculturalperspective.Thereisnoshortageofmenwho wouldliketodelaytheirejaculationlongerthanusual,just astheywouldliketobealittletallerandsmarterthanthe average. Leaving aside the distressstemming fromoverly rapidejaculationwouldbeingtooshortornotsmartenough countasa‘disorder’?This isnotjusta biologicalissue;it is alsopsychological, sociocultural, and relational(Giami, 2013).Thus,whereasejaculation canoftenbedelayedby meansofchemicalorbehaviouraltherapy, psychosexologi-calcounsellingcanprovideadditionalhelpthroughtraining inhowtodealwiththelimitationsofone’scondition.This summarizestheavailabletreatmentoptions.
PEinmen
In a stop-watch study in a sample of 110men who con-sultedforPEdysfunction,Waldingeretal.(1998)observed that 90%of individualspresented aprimary(lifelong)and generalised form involvingejaculation within one minute of penetration, with99% withintwo minutes.A regularly citedstudybyMcMahon(2002)inover1000Australianmen treated for PE produced similar results. However, asthis studyisincludedinthescientificdatabaseintheformofan abstractforaconferenceposterpresentation,the method-ologicaldetailsremainunknown.
Inthewakeofthesetwostudies,agroupofexpertsfrom the International Society for Sexual Medicine (ISSM) pro-posed reserving the primary and generalised PE diagnosis for individualspresenting ejaculationlatencyofaboutone minuteorless(McMahonetal.,2008).Voiceswereraisedto persuadetheAmericanPsychiatricAssociation(APA),author oftheseminalDiagnosticandStatisticalManualofMental disorders,tointegratethisceilingvalue intotheirmanual
(Segraves,2010).They wereevidentlyconvinced, because
theDSM-5,publishedinMay2013,nowmakesthisdistinction (APA,2013).
ApartfromMcMahon’sstudy,forwhichonlytheabstract isavailable,thestudybyWaldingeretal.(1998),basedon a one-minute pivotal value, provides little solid corrobo-ration.Some studiesevenfound contradictoryresults,for instance,twostop-watchstudies,oneintheUnitedStates
(Patricketal.,2005),theotherinEurope(Giulianoetal.,
2008), each investigating 200men diagnosed with PE. It appearedthatover40%ofejaculations,althoughreported aspremature, actually occurred two minutesafter pene-tration. Nevertheless, it is notablethat, unlike the study byWaldinger etal.,thesetwo studiesdid notexclusively addressprimaryandgeneralisedformsofPE.
If we can agree withAlthof etal. (1995), Pryor et al.
(2006), and Rosen et al. (2007) that the self-estimates
reportedbymensufferingfromPEreflectactualpenetration duration,wemustalsocitetworecentstudiesthat contra-dicttheobservationsofWaldingeretal.Oneinvestigation
byMcMahonetal.(2012)intheAsia-Pacificregionshowed
that, of 816men diagnosed with PEbased on the prema-tureejaculationdiagnostictool(Symondsetal.,2007),74% reportedejaculationlatenciesexceedingtwominutes,and almost90%reportedlatenciesexceedingoneminute.Ina study conductedin Belgium by Kempeneers etal. (2013), 26%of341subjectswithprimaryandgeneralisedPE diag-nosis (DSM-IV-TR criteria) reported penetration durations exceedingtwominutes,andabout50%reporteddurations exceedingoneminute.
Determination
of
the
problem
and
the
treatment
In the domains of mind and behaviour, the concepts of ‘health’and‘disorder’aredefinedasmuchinsocialas bio-logicalterms,andtherationaleforatreatmentisintimately relatedtotheconceptionoftheproblem.
When adequate training and proper sexual education areofferedas‘treatments’toindividuals withcomplaints ofrapid ejaculation—an estimated 15to30% ofthe pop-ulation— this does not pose ethical problems. Economic problems, maybe,butnot somuchethical, andless ethi-callydisturbingthanif,forexample,trainingandremedial courseswereofferedtoindividualssufferingfromnot feel-ingasintelligentastheywouldlike.Althoughthereremains the largerissue of the legitimacyof social normalisation, thesetypesof‘soft’treatmentsareperceivedasnotreally liabletoharmthebeneficiaries.Thus,theyprovidea reason-ablygoodfitwithabroadconceptionofa‘problem’thata goodnumberofindividualsexperience,aconceptionbased essentiallyonindividualsuffering.
Itisquiteanotherstorywhenweconsider pharmacologi-caltreatmentsandtheirtrailofmedium-andlong-termside effects. Here, behavioural and mental normalisation can entailbiologicalcostsforindividualusers,costs thatmust beweighed againsttheexpected benefits.Todaywe hear regulardenouncementsofthelarge-scaleuseof psychotrop-ics —which include active agents used to treat PE— due totheassociatedbiologicalcosts,whichrepresentaheavy price to pay for the ‘‘cult of performance’’ (Ehrenberg,
1998;Frances,2013).Itwouldthereforeappearpreferable
tolimitthesetreatments,andconsequentlythediagnosis, tocases that areuntreatable by the ‘softer’ methods. In
thisperspective,apotentiallytoxictreatmentshouldtarget onlythepartoftheproblem—the‘real’problem—thatis attributabletoabiologicalabnormality,totheexclusionof problemswithpsychosocialcauses.Accordingly,the recog-nitionof an essentiallybiological problem would indicate thetherapeuticuseofdopingagents.
Should
primary
severe
PE
be
considered
a
neurobiological
disorder?
Why?
How?
With
what
limitations?
HowdidtheISSMandtheAPAendupdeterminingamaximum threshold of one minute of penetration as the diagnostic criterionfor PE, basedonsuch paltryscientific evidence? Itishard nottohypothesisethat thisconsistentviewwas adopted in ordertojustify apharmaceutical approachto theproblem.
Fromapharmaceuticalindustryperspective,the estab-lishment of a ceiling duration would certainly have the disadvantage of delegitimising therapeutic intervention beyond the pivotal value (Waldinger, 2008), but it would alsohavetheadvantageofjustifyingpharmaceutical inter-ventionwithinthislimitation,andevenmoresoiftheform of PE is defined as a biological abnormality, and if phar-macologicaltreatment isdesignatedasthesoleoptionfor improvingthesituation.Thisispreciselytheviewdefended bytheISSM’sexpertgroup.Shouldweconsiderthisamere coincidence?Mostoftheexpertsareawareoftheprofitsto begainedbythepharmaceuticalindustry.
However,thechoicetorelateprimaryPE(characterised byejaculationlatencyoflessthanoneminute)toa neurobi-ologicaldysfunctionisbasedonasyllogism.Epidemiological studies cited by the group of experts indicate that many bodily diseases (e.g., osteoporosis, diabetes, and cardio-vasculardiseases) affect approximately0.5to2.5%of the population.Insofarasthethresholdvalueofoneminute ofpenetrationreducestheproportionofmenconcernedto aboutthesamenumber(<5%,seeabove),thesevereform ofPEbecomestheoreticallyequivalenttoabodilydeficiency
(McMahonetal.,2008).
This syllogistic logic does not by itself prove that the conclusion is wrong. Evoking other arguments to support theirproposal,theauthorsciteaseriesofstudiesthatpoint tothecontributionofbioconstitutionalfactorstoPE.They refertoJernetal.(2007),whoassessedheritabilityratesof PE,alltypescombined,at28%inaseriesofFinnishtwins;
toCoronaetal.(2011),whosuggestedapotentialimpact
ofthehormonalenvironment;andtoJanssenetal.(2009), who,inasampleofPEsubjectspresentingpenetration dura-tionsoflessthanoneminute,notedthatcarriersoftheLL variant ofthe 5-HTTLPR geneinvolved in serotonin trans-portation were characterised by evenshorter ejaculation latenciesthancounterpartcarriersoftheSSandSLvariants. However,nothingin thesestudies,or inany otherstudies toourknowledge, allowsconcluding thatthese biological factorsplayanexclusiveorevenaleadingroleinprimary PEwithejaculationlatenciesoflessthanoneminute.The reductionof this clearlysevere formof the problemto a neurochemicalimbalanceremainscompletelyhypothetical atthispoint.
e62 P.Kempeneers,M.Desseilles Consistent with the perception of severe primary PE
attributabletoabioconstitutionaldeficiency,thelong-term useofserotonergicagentstodelaytheejaculationreflexhas oftenbeenpresentedastheonlyviabletreatment (Althof
et al., 2010; Porst, 2012; Waldinger, 2007). Yet at least
threeclinical trials appearto have refuted thisproposal. Thus,DeCarufelandTrudel(2006),DeSutteretal.(2002),
andKempeneersetal.(2012)foundthatsubjectsaffected
byparticularlyshortejaculation latencymayalsorespond favourably to sexual behavioural therapy. It is true they showedlessimprovementincomparisontoPEsubjectswith penetration duration exceeding one minute (Kempeneers
etal., 2012), but therewere improvements nonetheless.
Similarfindings were obtained for medication treatments
(Waldinger,2007),suchthatattheendoftheday,latencies
shorterthanoneminuterepresentaseveritygradientofthe disorderthatlimits,nottosayeradicates,theeffectiveness ofanytreatmentwhatsoever.
By
way
of
a
conclusion
Inthelast10to15years,manystudieshavebeenpublished toclarifyandhighlightthebiologicaltenetsofPE.Although the knowledge has been advanced, much remains to be explained(Bonierbale,2013).Inthewakeofthisprogress,a goodnumberofclinicaltrialsofpharmacologicaltreatments forthisproblemhavebeencarriedout,particularlyon selec-tive serotonin reuptake inhibitors (SSRIs). In comparison, thevolume ofpublications on psychological and sociocul-turalaspects is insignificant, withclinical trialsof sexual behaviouralapproachesaccountingforbarely1000subjects, sometimes contradictory findings, and methods that are uncertainand often difficult tocompare between studies
(BernerandGunzler,2012;Jern,2013;Kempeneersetal.,
inpress;Melniketal.,2011).Thisdisproportionofavailable
information,which has arguablybeencommercially influ-enced,hascontributedtodrawpublicandclinicalattention tobiologicalandchemotherapeuticcomponentsofthe prob-lem, to the detriment of psychosocial and sex therapy components.Thishasnodoubtfosteredtheperceptionthat PEisreducedtoabodilydeficiency.
Thestate of the knowledge doesnot allow concluding thatsevereformsofprimaryPEstemfroma neurobiologi-calproblemthatcanbetreatedbymedicationsalone.While fully supporting the presence of bioconstitutional factors liabletoincreasetheriskforPEanditsseverity,wemustalso recognisethe enormous plasticity ofthe biological condi-tion.Intermsofpenetrationtime,thebiologicalnormsare inanycasebelowsocioculturalnorms,suchthatlegionsof ‘biologicallynormal’menmust learnhowtocontroltheir excitement in order toprolong coitus beyondtheir natu-rallimit.Andmany managetodoso,withor withoutthe helpofa sextherapist. Thelogicis notdifferentfor men who present a priori penetration times of less than one minute. Itcould bemore difficult for these mento learn newbehaviours,butnotimpossible.
Two therapeutic strategies areavailable: usechemical agentsto acton nervetransporters,or applybehavioural therapy to achieve better control of sexual excitement. Itappearsthat thedecision touseeither of these strate-gies cannot be based on a priori penetration duration.
In addition, they can be viewed as fully complementary
(Kempeneersetal.,inpress).
Strictly speaking, due to the potential side effects, a medicationstrategyshouldnotbeproposedasthefirst-line treatment,andprobablyevennotformenpresenting ejac-ulatorylatencytimesoflessthanoneminute.Intime,the developmentofeffectiveself-treatmentinstrumentsshould make sexual therapy moreaccessible asafirst-line
treat-ment (De Sutter et al., 2002; Kempeneers et al., 2012;
Kempeneers etal.,inpress).Moreover,oncetheirusehas
been clarified, and because the aim is to relieve suffer-ing,itwouldbeunfortunateifmedicationtreatmentswere prohibitedwhenpsychosexologicaltreatmentprovestobe ineffectiveorimpossible,evenwhendealingwith penetra-tiontimesconsidered statisticallynormal.Finally, itcould bebeneficialtocombinethetwotreatment types, partic-ularly for severe forms of PE that are resistant to either approachseparately.Althoughtheirsynergisticeffectshave beenestablished(Lietal.,2006; Yuanetal.,2008),they remainunderexplored.
Disclosure
of
interest
Theauthorsdeclarethattheyhavenoconflictsofinterest concerningthisarticle.
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