|Year : 2014 | Volume
| Issue : 1 | Page : 24-28
Concept and understanding of premature discharge in Indian patients
BS Chavan, Abhijit R Rozatkar, Jaspreet Kaur, Preeti Singh, Chandra Bala
Department of Psychiatry, Government Medical College, Chandigarh, India
|Date of Web Publication||3-Nov-2014|
Prof. B S Chavan
Department of Psychiatry, Government Medical College and Hospital, Chandigarh
Source of Support: None, Conflict of Interest: None
Introduction: Due to lack of formal sex education in India, the unpleasant past sexual experiences and at times normal physiological activities can lead to various myths and sexual beliefs. Base on their beliefs, individuals seeking treatment for early ejaculation have their set of expectations. Premature ejaculation (PME) in Indian population thus, has personal meaning and there is no common agreement on it. Materials and Methods: With the help of semi-structured questionnaire, we surveyed the sexual activity, sexual beliefs and past sexual experiences of those seeking treatment for early ejaculation (n = 62) and compared them with an age-matched control (n = 50). Results: Those seeking treatment for early ejaculation expected more number of strokes (39.1 vs. 32.6) in lesser time (11.5 min vs. 16.3) during sexual encounters i.e. more rapid thrusting. Significantly more of those seeking treatment for early ejaculation felt that masturbation was not a normal activity and that both male and female partners must climax simultaneously for satisfactory sexual experience. Also, significantly more of those seeking treatment for early ejaculation reported their first sexual experience to be unsatisfactory. Conclusion: In the cultural context of India, those seeking treatment for early ejaculation may be distressed due to their inability to meet their own expectations in addition to distress of inability to hold ejaculation as desired. It is essential to re-educate such individuals before considering the diagnosis of PME. Various diagnostic criteria for PME have not emphasized the exclusion of cultural factors as contributors to distress of PME.
Keywords: First sexual experience, masturbation, premature ejaculation, sexual expectations
|How to cite this article:|
Chavan B S, Rozatkar AR, Kaur J, Singh P, Bala C. Concept and understanding of premature discharge in Indian patients. J Mental Health Hum Behav 2014;19:24-8
|How to cite this URL:|
Chavan B S, Rozatkar AR, Kaur J, Singh P, Bala C. Concept and understanding of premature discharge in Indian patients. J Mental Health Hum Behav [serial online] 2014 [cited 2023 Jun 5];19:24-8. Available from: https://www.jmhhb.org/text.asp?2014/19/1/24/143886
| Introduction|| |
Premature ejaculation (PME) has been a common cause for treatment seeking in sexual disorder clinics in India and elsewhere. ,,,, Index case is usually an individual in distress due to (a) Early ejaculation on vaginal penetration and (b) inability to hold ejaculation as desired. However, while making a diagnosis and formulating a management plan, clinicians also need to know if partner satisfaction, client expectation, psycho-social factors and past experiences and performance are contributors to the client's distress.
It has been more than half a century since systemic studies on this disorder have been carried out, yet a comprehensive definition still has eluded us [Table 1]. The American Psychiatric Association's definition is the most frequently quoted in research publications but has been criticized for using terms like "persistent", "minimal", "recurrent" and "shortly after" that are vague, multi-interpretable and lacking quantification. ,, Similarly the World Health Organization's definition of PME,  does quantify early ejaculation (before or within 15 seconds of beginning of intercourse) but provides no empirical evidence for the same. Other definitions listed in [Table 1] have also been challenged as being authority based rather than evidence based. This fallacy was recently addressed by a committee of experts appointed by the International Society for Sexual Medicine [ISSM]. 
PME can be conceptualized as consisting of three important constructs i.e. (1) Short intra-vaginal ejaculatory latency time [IELT], (2) a lack of perceived self-efficacy or control about the timing of ejaculation and (3) distress and interpersonal difficulty related to the ejaculatory dysfunction.  The construct of distress, especially personal distress (not partner distress or interpersonal distress) discriminates men from with or without PME.  Studies have reported that distress due to PME significantly reduces quality of life especially intimacy of individuals. , The distress perceived by the client is understood to be due to impairment in other two constructs.
In India, in the absence of any formal sex education at any level, the understanding of sexual intimacy is largely dependent on watching sexually explicit materials either visual or audio-visual and sharing experiences with peer group. , Prevailing myths regarding sexual practices like masturbation and seminal loss and the resultant set of ideas, has lead to treatment seeking for issues like perceived small size of penis and nocturnal seminal emission. ,,,, Prevailing social and religious norms in most parts of India disapprove of masturbation and sexual activity prior to marriage.
The authors have observed that most individual with poor sex education in India have set of expectations from themselves regarding their sexual performance in each sexual encounter. These beliefs include, sexual performance expected from self (in terms of number of strokes and total duration of intercourse in minutes) and partner satisfaction (simultaneous orgasm in spouse). Inability to meet their own expectations during sexual encounters compounded by their guilt for any past sexual activity, especially for masturbation, is evident in most of our patients. Individuals seek treatment for distress arising from their inability to meet their own expectations. Thus, premature ejaculation (PME) in Indian population has personal meaning.
In this exploratory survey we look for the prevalence of such beliefs in those seeking treatment for early ejaculation and compare that to a normative population. In addition to these, we also look for the role of first sexual experience (satisfactory vs. non-satisfactory) in those later seeking treatment for early ejaculation. In this study, we have attempted to elucidate additional factors for distress in individuals with PME.
| Materials and Methods|| |
Individuals who approached our Marital and Sex Clinic (MSC) (at a tertiary health centre in North India) with complain of early ejaculation were interviewed using a semi-structure questionnaire. A control group consisting of health workers, students, other hospital staff and male care-givers of patients with mental illness was also assessed using the same questionnaire.  The inclusion criteria for both the groups were: Male individuals with at least one sexual experience and consenting for participation in the study. Individuals with mental illness (except sexual dysfunctions), using any psychotropic drug or using medications for improved sexual performance and individuals where in sexual experience is limited to commercial sex worker (s) i.e. with no stable partner were excluded. Mental illness was screened by psychiatrist based on clinical interview. A total of 50 health individuals were found to be age-match with the treatment seeking group and were included in final data.
The semi-structure survey questionnaire was developed from clinical experience of the authors and information obtained from published literature. After obtaining written consent for participation, the questionnaire was administered by one of the authors (JK). The responses were analysed for statistical significance by using SPSS (Version 13.0). Chi-square and t-test were used for analysis.
| Results|| |
Sixty-two individuals approached our MSC with complain of early ejaculation. Thirty one individuals out of sixty two individuals seeking help for early ejaculation, reported it to be their only complain. Twenty five of the rest additionally complained of ill-sustained erection, while six had symptoms suggestive of Dhat syndrome (*Dhat syndrome: A culture bond syndrome characterized by nocturnal seminal emission with multiple somatic complains that are believed to be result of seminal emission). The clinical profile of patients and their partners is given in [Table 2]. Both the groups matched for their age but significant statistical difference was noted between groups on their marital status and education.
The responses to questions related to sexual activity, sexual beliefs and distress due to early ejaculation are reported in [Table 3]. Both the groups had indulged in masturbation and had similar age at the time of first sexual experience. About 58.1% of those seeking help for early ejaculation had satisfactory first sexual experience as compared to 84% in the control group. Similarly on sexual beliefs, large number of individuals seeking treatment for early ejaculation did not feel that masturbation was a normal activity. This group also reported fewer minutes required for satisfactory sexual intercourse although the number of strokes required for satisfactory ejaculation were not statistically significant. More people in the control group believed that simultaneous climax of both partner is not necessary for satisfactory intercourse. As expected, the study group reported significant distress and increased severity of their condition.
| Discussion|| |
In this study we have attempted to document the differences in sexual experiences and sexual beliefs/attitudes of persons seeking treatment for early ejaculation with an age-matched comparator group. The published studies from India on sexual dysfunction are sparse  and have largely focused on prevalence of sexual disorders, including PME, in treatment seeking population, either those attending marital and sex clinics, ,, addiction treatment centers , and those attending other psychiatry clinics including general clinics. , To the knowledge of the author, this is the only comparative study from India exploring sexual beliefs in treatment seeking population.  A similar study from this centre using the extended questionnaire has been published elsewhere. 
In our centre, we have predominantly rural and lower education class of patients seeking treatment from the sex and marital clinic while others have shown vice-versa. , Two thirds of our patients seeking treatment for early ejaculation had been married and hence had a stable sexual partner. More than ninety percent of individuals in both groups had indulged in masturbation and nearly seventy percent in each group continued to practice masturbation. However, only 17% of those in the treatment seeking group believed this to be a normal activity compared to nearly half of those in control group. More number of individuals in treatment seeking group were married and continued to masturbate. Since more of them believed masturbation as not normal, the guilt of doing so contributed to their distress.
Comparative figures from India have reported that only 50.4% of males and 38.6% of females considered masturbation as a healthy activity.  Reasons cited for masturbation not being a normal activity in both groups include: Causes physical weakness, reduces penile size, causes thinning of semen, leads to guilt, leads to impotency and few also reported it to be the cause of premature ejaculation.  In contrast, no statistical difference was noted for normalcy of nocturnal seminal emission although more subjects in treatment seeking group reported it as abnormal/pathological (63% vs. 42%).
The age of first sexual experience in our study is considerably higher than that reported in other studies from India. Aggarwal et al., (2000) reported an average age at first sexual intercourse of 17.5 years in a study on medical students in Delhi.  Indirect evidences of sexual activity among youth can be found in studies related to premarital sex. Sachdev (1998) reported that as many as 40% of male university students has experienced premarital sex.  A large study involving 51,000 youth (ages 15-24) from six states, released by Population Council and International Institute of Population Science, reported that 25% males in age group 15-24 indulged in premarital sex.  The higher age at first sexual experience in our study may probably be due to larger range of age in both groups as compared to studies that focused on adolescents and youths in the community.
Both groups in our study did not differ on age at first intercourse but significantly differed on their "satisfaction" of first sexual experience. In the study group, significantly, less number of subjects (58.1% vs. 84%) had satisfactory first experience. More importantly, unsatisfactory intercourse was twice more common those seeking treatment. Considering that "satisfaction" with sexual intercourse may be summation of multiple parameters (right partner, right time, right location, right mood, right performance etc.), the unresolved past unpleasant experience and feelings may affect the current performance (performance anxiety). Prospective studies that determine outcome of individuals with unsatisfactory first sexual experience or failed intercourse shall further enlightened the understanding on this issue.
Interestingly in our study, people seeking treatment for early ejaculation have significantly lower expectation of minutes spend in sexual intercourse but on an average expect more number of strokes during each intercourse. It appears that people seeking treatment for early ejaculation believe in more strokes per unit time i.e. more rapid thrust during intercourse. Although we did not specifically ask about rapidity of strokes,  it may be possible that individuals seeking treatment for early ejaculation have an inclination towards rapid thrusting during sexual intercourse. It is also possible that the constant fear of losing control over their erection forces them to complete the act fast. Rapidity of male thrusting has not been a subject of research but clinical practice suggests that it may play a role in determining total time spent and pleasure experienced during sexual intercourse. This hypothesis needs further research and would provide an additional evidence for etiological basis for the disorder and its possible treatment avenues.
Individuals seeking treatment for early ejaculation in our study reported that for a good sexual experience, both partners should have simultaneous climax. Because of their inability to hold ejaculation for a suitable period, they believed that their partner (s) were unsatisfied because of him. Thus, for the patient, their ability to hold ejaculation is central to satisfaction of self and their partner without understanding that women may not be able to achieve adequate arousal to climax in many sexual encounters. We have observed that in men in general, do not inquire directly about sexual satisfaction from their spouse/partner but merely assume it based on their own ability to hold ejaculation. Furthermore, both the partners do not feel that female partner has any role in helping the male to prolong the time to ejaculation. As the onus for sexual satisfaction lies entirely with the male partner, nearly all individuals who seek treatment, including those in our study group, are not accompanied by their spouse/partner. This leads to poor treatment adherence and higher drop-out. 
This study highlights that the distress of individuals complaining of early ejaculation may be due to their past sexual experiences and current sexual beliefs, part of which are cultural in origin. Since individuals did not meet their own expectations for a satisfactory intercourse, they perceive increased distress. It would be prudent to offer remedial sex education for correcting their belief system and to allay anxiety arising out of past sexual experiences. It would also make sense to defer the diagnosis until it is ascertained that the correct information has not improved their performance. An additional exclusion clause "distress arising from cultural beliefs that influence sexual activity" is hence proposed. We are currently looking at the implications of using this exclusion criterion in terms of (a) Changes in performance (b) Change in perceived distress and (c) Change in diagnosis.
This study did not involve comparison between actual performances in both groups and hence we did not use IELT for comparison. The present study did not explore the role of female partner (who may also be influenced by cultural beliefs) in attenuation/exaggeration of patient's distress and it can be area of future study. Other factors like quality of time spent in foreplay, sexual position and time since previous ejaculation could also influence the time to ejaculation.  Another limitation of the study was that we included individuals with other sexual symptoms. Presence of subclinical anxiety symptoms and level of sex education attained are other factors that could have contributed to our study findings. The study intended to compare belief systems of those presenting with complains of early ejaculation irrespective of their complain reaching a diagnosis threshold.
It is suggested that cultural relevant belief system related to sex be assessed and addressed, especially in restrictive communities before applying western diagnostic methods for sexual disorders.
| References|| |
Kendurkar A, Kaur B, Agarwal AK, Singh H, Agarwal V. Profile of adult patients attending a marriage and sex clinic in India. Int J Soc Psychiatry 2008;54:486-93.
Verma KK, Khaitan BK, Singh OP. The frequency of sexual dysfunctions in patients attending a sex therapy clinic in north India. Arch Sex Behav 1998;27:309-14.
Spector IP, Carey MP. Incidence and prevalence of the sexual dysfunctions: A critical review of the empirical literature. Arch Sex Behav 1990;19:389-408.
Laumann EO, Paik A, Rosen RC. Sexual dysfunction in the United States: Prevalence and predictors. JAMA 1999;281:537-44.
McMahon CG. Premature ejaculation. Indian J Urol 2007;23:97-108.
World Health Organization. International Classification of Disease and Death. 10 th
Revision. Geneva: World Health Organization Press; 1992.
American Psychiatric Association. Diagnostic and Statistical Manual-IV-Text Revised. Washington DC: American Psychiatric Association Press; 2000.
Masters W, Johnson V. Human Sexual Inadequacy. Boston: Little Brown and Company; 2000.
Montague DK, Jarow J, Broderick GA, Dmochowski RR, Heaton JP, Lue TF, et al.
AUA guideline on the pharmacologic management of premature ejaculation. J Urol 2004;172:290-4.
McMahon CG, Althof S, Waldinger MD, Porst H, Dean J, Sharlip I, et al.
An evidence-based definition of lifelong premature ejaculation: Report of the International Society for Sexual Medicine ad hoc committee for the definition of premature ejaculation. BJU Int 2008;102:338-50.
Althof SE, Symonds T. Patient reported outcomes used in the assessment of premature ejaculation. Urol Clin North Am 2007;34:581-9, vii.
Waldinger MD. The neurobiological approach to premature ejaculation. J Urol 2002;168:2359-67.
Althof SE, Rowland DL. Identifying constructs and criteria for the diagnosis of premature ejaculation: Implication for making errors of classification. BJU Int 2008;102:708-12.
Rowland DL, Patrick DL, Rothman M, Gagnon DD. The psychological burden of premature ejaculation. J Urol 2007;177:1065-70.
McCabe MP. Intimacy and quality of life among sexually dysfunctional men and women. J Sex Marital Ther 1997;23:276-90.
Aggarwal O, Sharma AK, Chhabra P. Study in sexuality of medical college students in India. J Adolesc Health 2000;26:226-9.
Sachdev P. Sex on campus: A preliminary study of knowledge, attitudes and behaviour of university students in Delhi, India. J Biosoc Sci 1998;30:95-105.
Kaur J, Chavan BS, Singh P, Chandra Bala. A study of factors associated with common sexual disorders presenting at marital and sex clinic. J Ment Health Hum Behavr 2010;15:105-10.
Malhotra HK, Wig NN. Dhat syndrome: A culture-bound sex neurosis of the orient. Arch Sex Behav 1975;4:519-28.
Bagadia VN, Dave KP, Pradhan PV, Shah LP. Study of 258 male patients with sexual problems. Indian J Psychiatry 1972;14:143-51.
Nakra BR, Wig NN, Varma VK. A study of male potency disorders. Indian J Psychiatry 1977;19:13-8.
Prakash O, Rao TS. Sexuality research in India: An update. Indian J Psychiatry 2010;52:S260-3.
Ramdurg S, Ambekar A, Lal R. Sexual dysfunction among male patients receiving buprenorphine and naltrexone maintenance therapy for opioid dependence. J Sex Med 2012;9:3198-204.
Arackal BS, Benegal V. Prevalence of sexual dysfunction in male subjects with alcohol dependence. Indian J Psychiatry 2007;49:109-12.
International Institute for Population Sciences (IIPS) and Population Council. 2010. Youth in India: Situation and Needs 2006-2007. Mumbai: IIPS; 2010. Available from: http://www.iipsindia.org/pdf/India%20Report.pdf
. [Last cited on 2014 Jan 01].
Avasthi A, Sharan P, Nehra R. Practicing behavioral sex therapy in India: Selection, modifications, outcome, and dropout. Sex Disabil 2003;21:107-12.
[Table 1], [Table 2], [Table 3]