Using Ecological Momentary Assessment to investigate associations between ejaculatory latency and control in partnered and non-partnered sexual activities

Description of and Relationships among Potential Variables Supported for the Diagnosis of Delayed Ejaculation

The lack of empirically based diagnostic criteria for delayed ejaculation (DE) not only undermines confidence in the reported prevalence rates for this sexual dysfunction, but it has also resulted in a lack of validated patient reported outcomes (PROs) for assessing this condition. The current study was designed to describe and evaluate six face-valid variables previously shown to discriminate between men with and without DE for their utility as diagnostic measures for DE. A sample of 1285 men (mean age = 37.8, SD = 12.7) free of erectile problems and premature ejaculation completed an online sexual health survey that included potential questions intended for use in the diagnosis of DE. Questionnaire items included ones reflective of previously proposed diagnostic constructs related to DE: ejaculation timing/latency, ejaculation efficacy/control, and negative effects of DE. Results indicated that five of the six proposed items showed moderate intercorrelations, suggesting that each constituted a distinct (i.e., non-redundant) though relevant criterion related to the diagnosis of DE. Based on the level of interrelatedness, the better items representing each construct were included in commonality analysis to assess their unique contributions to the diagnosis of DE. Perceived lack of ejaculatory efficacy/control contributed the largest portion of the variance to the diagnosis of DE (58%), with bother/distress (an index of the negative effects of DE) contributing the second largest portion (25%), and ejaculation timing/latency contributing only a small portion of the variance (6%) to the diagnosis of DE. The relevance of these findings to developing a patient report outcome (PRO) for diagnosing DE that considers both empirically supported questions/items and an appropriate balance of items regarding the three constructs was discussed.

Are the Criteria for the Diagnosis of Premature Ejaculation Applicable to Gay Men or Sexual Activities Other than Penile-Vaginal Intercourse?

Introduction

The criteria for premature ejaculation (PE) have generally been limited to the diagnosis of heterosexual men engaging in penile-vaginal intercourse and therefore the applicability of PE diagnostic criteria to gay men and to activities beyond penile-vaginal intercourse has yet to be explored in depth.

Aim

To compare the prevalence of PE in gay and straight men and to assess whether PE-related diagnostic measures (ejaculatory control, ejaculation latency [EL], and bother/distress) can be applied with confidence to gay men or to men engaging in sexual activities other than penile-vaginal intercourse.

Methods

Gay and straight participants (n = 3878) were recruited to take an online survey assessing sexual orientation, sexual function/dysfunction (including specific PE-related measures), sexual relationship satisfaction, and various other sexual behaviors during partnered sex or masturbation.

Outcomes

Comparison of ejaculatory control, EL, and bother/distress across gay and straight men, as well as across different types of sexual activities.

Results

A slightly lower PE prevalence among gay men became undetectable when other predictors of prevalence were included in a multivariate analysis (aOR = 0.87 [95% CI: 0.60–1.22]). Gay men with PE reported longer typical ELs (z_U = -3.35, P < .001) and lower distress (z_U = 3.68, P < .001) relative to straight men, but longer ELs and lower distress were also associated with anal sex.

Clinical Translation

Clinicians can feel confident about using existing criteria for the diagnosis of PE in gay men but should be aware of potentially longer ELs and lower PE-related bother/distress—probably related to the practice of anal sex—compared with straight men.

Strengths and Limitations

Although well-powered and international in scope, this study was limited by biases inherent to online surveys, the lack of a sizable sample of bisexual men, and a lack of differentiation between men with acquired vs lifelong PE.

Conclusions

Irrespective of sexual orientation, gay and straight men with PE reported shorter ELs, lower satisfaction, and greater bother/distress than functional counterparts. While PE-related diagnostic criteria (ejaculatory control, EL, and bother/distress) are applicable to gay men, accommodation for longer ELs and lower bother/distress in gay men should be considered.

McNabney SM, Weseman CE, Hevesi K, et al. Are the Criteria for the Diagnosis of Premature Ejaculation Applicable to Gay Men or Sexual Activities Other than Penile-Vaginal Intercourse?. Sex Med 2022;10:100516.

Premature Ejaculation Measures During Partnered Sex and Masturbation: What These Findings Tell Us About the Nature and Rigidity of Premature Ejaculation

Men with premature ejaculation (PE) during partnered sex (as defined by poor ejaculatory control) show significantly reduced PE symptomology during masturbation, but the reasons for this disparity are not clear. This study investigated the other two PE-related diagnostic criteria, namely ejaculatory latency (EL) and bother/distress, in order to explore possible explanations for this disparity between types of sexual activity. Specifically, 1,447 men with either normal or poor ejaculatory control were compared on EL parameters, bother/distress, and sexual satisfaction/pleasure during both partnered sex and masturbation. Results indicated that men with PE reported longer ELs during masturbation than partnered sex, in contrast with men without PE who reported shorter ELs during masturbation. Bother/distress was lower for both groups during masturbation, but bother/distress in men with PE during masturbation was comparable to that of men without PE during partnered sex. Minimal difference in these patterns was found across lifelong and acquired PE subtypes, whereas men with PE with comorbid erectile dysfunction appeared to represent a distinct group. These findings have implications for PE management or treatment as well as for the overall conceptualization of PE as a pathophysiological condition.

Do the diagnostic criteria for premature ejaculation apply to non-straight men and to sexual activities other than penile-vaginal intercourse?

Professional standards committees have generally applied the diagnostic criteria for premature ejaculation only to situations involving (presumed) heterosexual men having penile-vaginal intercourse. This paper reviews the existing evidence supporting expansion of the criteria for use among non-straight men engaging in sexual activities that do not include vaginal intercourse. In brief, estimated ejaculation latencies appear similar across men identifying with different sexual orientations, and various partnered sexual activities (oral, vaginal, and manual) tend to be well correlated. In contrast, masturbation latency patterns are different between men with and without premature ejaculation, and ejaculatory control and bother/distress may be less critical to gay men than straight men during partnered sex. Finally, it should be noted that existing patient report outcomes (PROs) require modification for use with non-straight men.

Diagnostic Criteria for Premature Ejaculation: Clarifying the Role of “Ejaculatory Control” and “Bother/Distress”

“Ejaculatory control” and “bother/distress” are key criteria for diagnosing men with premature ejaculation (PE), yet compared with ejaculatory latency (EL), these constructs have received only minimal attention. In addition, they have not been characterized in men having different sexual orientations or subtypes of PE. This study aimed to characterize relationships among ejaculatory control, bother/distress, and EL; to assess differences across men having different sexual orientations, PE status, and PE subtypes (i.e., lifelong vs. acquired); and to determine the importance of ejaculatory control to men’s sexual partners. In total, 1071 men and sexual partners of men rated their ejaculatory control and bother/distress and estimated their EL; these measures were compared across sexual orientation, PE status, PE subtype, and male and female partners of men. Results revealed a monotonic though slightly curvilinear relationship between ejaculatory control and bother/distress. These PE criteria differed significantly between PE and non-PE men, to a lesser extent between gay and straight men, and not at all between men having lifelong vs. acquired PE. Female and male partners of men affirmed the importance of ejaculatory control during partnered sex, indicating lack of control as a potential reason for ending a relationship.

A Practical Guide to Analyzing Time-Varying Associations between Physical Activity and Affect Using Multilevel Modeling

There is growing interest in within-person associations of objectively measured physical and physiological variables with psychological states in daily life. Here we provide a practical guide with SAS code of multilevel modeling for analyzing physical activity data obtained by accelerometer and self-report data from intensive and repeated measures using ecological momentary assessments (EMA). We review previous applications of EMA in research and clinical settings and the analytical tools that are useful for EMA research. We exemplify the analyses of EMA data with cases on physical activity data and affect and discuss the future challenges in the field.

A Longitudinal Assessment of Associations Between Women's Tendency to Pretend Orgasm, Orgasm Function, and Intercourse-Related Pain in Different Partner Relationship Constellations

The aim of the present study was to investigate how women's tendency to pretend orgasm during intercourse is associated with orgasm function and intercourse-related pain, using a longitudinal design where temporal stability and possible causal relationships could be modeled. The study sample consisted of 1421 Finnish women who had participated in large-scale population-based data collections conducted at two time points 7 years apart. Pretending orgasm was assessed for the past 4 weeks, and orgasm function and pain were assessed using the Female Sexual Function Index for the past 4 weeks. Associations were also computed separately in three groups of women based on relationship status. Pretending orgasm was considerably variable over time, with 34% of the women having pretended orgasm a few times or more at least at one time point, and 11% having done so at both time points. Initial bivariate correlations revealed associations between pretending orgasm and orgasm problems within and across time, whereas associations with pain were more ambiguous. However, we found no support in the path model for the leading hypotheses that pretending orgasms would predict pain or orgasm problems over a long period of time, or that pain or orgasm problems would predict pretending orgasm. The strongest predictor of future pretending in our model was previous pretending (R ² = .14). Relationship status did not seem to affect pretending orgasm in any major way.

Reexamining the Definitions of PE and DE

Evidence-based definitions improve clinical practice and research. Nonetheless, the International Society of Sexual Medicine (ISSM) and the American Psychiatric Association's (DSM-5) definitions regarding lifelong and acquired premature ejaculation (PE) and delayed ejaculation (DE) require reexamination. Existing Intravaginal Ejaculation Latency Time (IELT) evidence, the ISSM position papers, and articles both supporting and critiquing the ISSM's definitions were reviewed. Disproportionately, the findings from those studies document that the majority of men's IELT range is approximately 4 to 10 minutes. Such robust quantitative evidence should become the basis for determining the temporal criterion when defining both PE and DE. Any bilateral deviation from that majority's ∼4- to 10-minute IELT range should meet the qualification for the temporal diagnostic criterion. However, for a man to be diagnosed with a disorder, a licensed health-care clinician (HCC) must also determine that the man suffers from "lack of control" and "distress." Diagnosis would include subtyping Lifelong or Acquired, Global or Situational, similar to the ISSM guidelines and specifying mild, moderate, or severe-similar to DSM-5 requirements. "Control" and "distress" should trump latency and convey greater weight in the diagnostic process. Loosened latency criteria could result in false positive diagnoses; however, requiring a licensed HCC to evaluate control and distress reduces that risk.

Psychosexual therapy for delayed ejaculation based on the Sexual Tipping Point model

The Sexual Tipping Point(®) (STP) model is an integrated approach to the etiology, diagnosis and treatment of men with delayed ejaculation (DE), including all subtypes manifesting ejaculatory delay or absence [registered trademark owned by the MAP Educational Fund, a 501(c)(3) public charity]. A single pathogenetic pathway does not exist for sexual disorders generally and that is also true for DE specifically. Men with DE have various bio-psychosocial-behavioral & cultural predisposing, precipitating, maintaining, and contextual factors which trigger, reinforce, or worsen the probability of DE occurring. Regardless of the degree of organic etiology present, DE is exacerbated by insufficient stimulation: an inadequate combination of "friction and fantasy". High frequency negative thoughts may neutralize erotic cognitions (fantasy) and subsequently delay, ameliorate, or inhibit ejaculation, while partner stimulation (friction) may prove unsatisfying. Assessment requires a thorough sexual history including inquiry into masturbatory methods. Many men with DE engage in an idiosyncratic masturbatory style, defined as a masturbation technique not easily duplicated by the partner's hand, mouth, or vagina. The clinician's most valuable diagnostic tool is a focused sex history (sex status). Differentiate DE from other sexual problems and review the conditions under which the man can ejaculate. Perceived partner attractiveness, the use of fantasy during sex, anxiety-surrounding coitus and masturbatory patterns require meticulous exploration. Identify important DE causes by juxtaposing an awareness of his cognitions and the sexual stimulation experienced during masturbation, versus a partnered experience. Assist the man in identifying behaviors that enhance immersion in excitation and minimize inhibiting thoughts, in order to reach ejaculation in his preferred manner. Discontinuing, reducing or altering masturbation is often required, which evokes patient resistance. Coaching tips are offered on how to ensure adherence to this suspension, manage resistance and facilitate success. Depending on motivation level, masturbation interruption may be compromised and negotiated. Encourage a man who continues to masturbate to alter style ("switch hands") and to approximate the stimulation likely to be experienced with his partner. Success will require most men to be taught to learn bodily movements and fantasies that approximate the thoughts and sensations experienced in masturbation. Fertility issues, as well as patient/partner anger are important causational factors, which often require individual and/or conjoint consultation. Drug treatment would benefit men particularly with severe DE, regardless of concomitant psychosocial-behavioral and cultural complications. When and if a safe effective medication for DE becomes available, this author's transdisciplinary perspective supports appropriate medication use when integrated with counseling. This approach emphasizes the utility of a biopsychosocial-cultural perspective combined with special attention to the patient's narrative. Treatment is patient-centered, holistic and integrates a variety of therapies as needed.