Research in partners of men with erectile dysfunction suggests that a woman's sexual difficulties can be contingent on her partner's sexual dysfunction. However, little research has been conducted in partners of men with other sexual dysfunctions, such as premature ejaculation (PE). We evaluated 139 partners of men diagnosed with having PE and 89 age-matched women whose partners did not have any sexual dysfunction. Results showed that 77.7% of PE partners had at least one sexual dysfunction, compared to 42.7% of the control group. Further research needs to be undertaken to investigate the temporal relationship between sexual dysfunctions in both partners.
Premature ejaculation (PE) is stated to be the most common sexual dysfunction seen in men, with prevalence rates in the general population reported to range between 10 and 30%.1, 2 Unlike erectile dysfunction (ED), PE is not strongly related to any illness or medical condition and therefore its prevalence in younger men is similar and consistent with that in older men.3 Despite PE being the most common male sexual dysfunction, rates of presentation at sexual dysfunction clinics are lower than that for other conditions, such as ED, possibly because men are less distressed by this condition or because they are unaware of treatment that is available.4 This is despite the fact that PE causes similar issues as ED within a relationship, namely, reduced sexual satisfaction and intimacy, and increased interpersonal difficulties.5, 6, 7, 8
Levels of female sexual dysfunction (FSD) are also relatively high, with epidemiological data suggesting rates of 20–60%.2, 9, 10, 11 A recent review of prevalence studies investigating female sexual difficulty conducted by Hayes et al.12 observed that although variation exists, patterns of sexual dysfunction were consistent across studies. The most commonly observed sexual difficulty was desire disorder (64%: range, 16–75%), followed by orgasm difficulty (31%: range, 12–64%), arousal difficulty (31%: range, 12–64%) and sexual pain (26%: range, 7–58%). However, the higher rates could be attributable to the method in which the sexual dysfunction was diagnosed, for example, through single item questions, nonvalidated questionnaires. Arguably, if distress was also taken into account as indicated by Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM-IV-TR)13 then the lower rates would probably be more realistic.
Many factors are thought to influence sexual functioning in women including age, race, education, physical and emotional health and menopause.2, 9, 10, 11 Another factor could be the sexual dysfunction of the male partner.
Studies of female partners of men with ED have found them to have higher rates of FSD compared to women whose partners do not have a sexual dysfunction.14 An investigation to assess the prevalence of FSD in female partners of men with ED attending a sexual dysfunction clinic found that 55% of the 113 women assessed reported some level of sexual dysfunction, with 35% reporting more than one sexual dysfunction.15 The mostly commonly reported problems were difficulties with orgasm, and reduced sexual desire. Of course, these figures only represent the women and partners who agreed to take part in the study and there is no indication of the timing of the onset of the men's or women's sexual dysfunction and, therefore, no clarity as to which preceded or accompanied which. However, lending support to the theory that a woman's sexual difficulties can be contingent on her partners are a number of studies showing that the sexual functioning of women with partners who have ED improved significantly when the man's ED was treated with a phosphodiesterase type 5 inhibitors (PDE5i)16 and, specifically, with sildenafil14, 17, 18 or vardenafil.19 Althof et al.20 reported improvements in women's sexual function when her partner's ED was treated with self-injection or vacuum therapy, and Cayan et al.14 reported the same with ED treatment of penile prosthesis implantation.
To date, research into the partners of men with PE has received less attention than that into female partners of men with ED. However, the literature suggests that, like the partners of men with ED, PE partners will also have increased levels of sexual difficulties. A database review by Riley and Riley4 found a high occurrence of PE (21.8%) in the partners of women presenting with sexual symptoms. PE had a particularly high occurrence in the partners of women presenting with sexual desire disorder (29.9%), arousal/lubrication disorder (42.7%), anorgasmia (47.8%) and not enjoying sex (51.5%). Additionally, a double-blind crossover trial for the treatment of rapid ejaculation in 15 couples found that treatment not only improved latency time, but also that both men and their partners had a significantly improved sexual satisfaction score, with partners also experiencing an improvement in coital orgasmic attainment.21
Given the lack of research into the prevalence of sexual difficulties of partners of men with PE, this study had two main aims, (1) to investigate the prevalence of FSD in a sample of female partners of men with PE, and (2) to compare this with levels of FSD in female partners of sexually functional men. An additional objective of the study was to validate a newly developed partner tool, the PE Partners Sexual Inventory (PEP-SI). These results will be published elsewhere.
Materials and methods
Female partners of men with PE were recruited in the United States and Spain. In the United States, the women were partners of men taking part in another study to develop a PE diagnostic tool.22, 23 Men taking part in the validation of the PE diagnostic tool either met the DSM-IV-TR classification for PE and had an intravaginal ejaculatory latency time (IELT) of less than 2 min at least 70% of the time, as measured over 4 weeks using a stopwatch, or they were diagnosed as having PE through a diagnostic interview conducted by a clinical expert.12 These experts had several years of experience in active diagnosing practice and treating men with PE, and were recognized as thought leaders, published authors or clinical study investigators. In Spain, the women partners of men were also diagnosed with PE through diagnostic interview with a practicing clinical expert. To act as a control group, an age-matched cohort of women in the United States and Spain whose partners had no sexual problems were also recruited. These women were either recruited by advertisement and self-reported that their partners did not have any sexual dysfunction, or were the partners of men taking part in the validation of the PE diagnostic tool, who were confirmed by diagnostic interview as not having any sexual dysfunction. The female partners were all currently sexually active.
A total of 228 partners were enrolled into the study. Of which, 139 women were partners of men with PE (PE partners) and the remaining 89 women were partners of men without any sexual dysfunction (control group). The average age of the PE partners was 37.8 years (range, 21–63 years), with the average age of the control group being very similar at 36.7 years (range, 19–63). PE partners (82%) were married, with the average length of their current relationship being 11.2 years (range, 6 months–40 years). The control group (61%) were married, with the average length of their current relationship being 9.1 years (range, 6 months–42 years).
The study was approved by Institutional Review Board. The men described above were given a letter to ask if they would be willing for their partner to be contacted about completing various questionnaires about her experience of having a partner with PE. All female partners were eligible to take part in the study. Men who agreed were asked to pass on a form to their partners to complete and return to indicate they were also willing to take part. Following a telephone screen, a battery of questionnaires was then sent to the partners, along with an informed consent form, to be returned by post. Women for the control group who were not recruited by the PE diagnostic study were recruited in response to an advertisement. They were also screened over the telephone to ensure eligibility and were sent the same battery of questionnaires and informed consent. Questionnaires included the following:
Abbreviated Sexual Function Questionnaire. This assesses sexual functioning over the past 4 weeks, for example, Over the last 4 weeks, how often have you had pleasurable thoughts and feelings about sexual activity? Over the last 4 weeks, how often did you have a feeling of ‘warmth’ in your vagina/genital area when you took part in sexual activity? ‘Over the last 4 weeks, how much emotional sexual arousal did you notice when you took part in sexual activity?’ (for example, feeling excited, feeling ‘turned on’, wanting sexual activity to continue). The SFQ has been validated for use not only as an efficacy tool to assess changes in sexual functioning, but also as a diagnostic tool and has been published as such.24, 25 The abbreviated version used in this study consisted of four subscales including: arousal-lubrication, arousal-sensation, desire and orgasm, with lower scores indicating higher dysfunction. For use as a screening tool, each domain has a score range indicating high probability of FSD, borderline FSD and normal sexual functioning.
To further characterize the women, a question was asked about whether the woman felt she had a sexual problem, and, if yes, whether she believed this was related to her partner's PE or was a lifelong problem.
PE Partners Sexual Inventory. This is a newly developed and validated questionnaire assessing the impact of PE on the partner's sexual satisfaction, for example, ‘Over the past 4 weeks, we had to limit the kinds of things we did during sex; …I felt pressure to achieve an orgasm; … Sexual intercourse was too quick’.26 The questionnaire consists of 17 items with increasing scores indicating higher sexual satisfaction.
Sexual Quality of Life Questionnaire-female. This assesses sexual quality of life.27 It contains 18 items with increasing scores indicating a better sexual quality of life. Example items: When I think about my sexual life, I feel close to my partner; when I think about my sexual life, I am embarrassed; when I think about my sexual life, I feel like I have lost something.
Sexual Relationship Scale. This is a newly developed and validated questionnaire to assess a person's sexual relationship with their partner, for example, ‘Sex with my partner does not feel special any more; Our sexual relationship is poor; When we have sex I feel close to my partner’. This questionnaire contains five items with increasing scores indicating a good sexual relationship with their partner.28
On the basis of the Abbreviated Sexual Function Questionnaire (ASFQ), 77.7% of PE partners had at least one sexual dysfunction, compared to 42.7% of the control group and 48.2% of PE partners had two or more diagnoses, compared with only 22.4% of the control group. The most common dysfunctions in the PE partners were problems with arousal-sensation (55.2%) and orgasm (51.9%; see Table 1). Significant differences were found between the PE partners and control group on all domains (χ2 P-values <0.0001).
When examining differences on the various sexual health questionnaires, PE partners scored significantly lower than controls across all measures, indicating that they had a poorer sexual quality of life and sexual relationship with their partners than controls, had lower sexual satisfaction and experienced more problems with desire, arousal and orgasm (see Table 2).
When asked directly, if they felt they had a sexual problem of their own, 29.7% of the PE partners answered ‘yes’ compared to only 15.1% of the no PE partners. Of the PE partners that answered ‘yes’, 23.8% of them attributed their partner's PE as the cause of their problems, 35.6% reported that their partner's PE made their problems worse and 40.5% reported that neither was the case.
Overall, partners of men with PE reported high levels of sexual dysfunction, 77.7% compared with 42.7% for partners of men with no sexual dysfunction. Additionally, nearly half (48.2%) of the women whose partners had PE experienced two or more sexual dysfunctions, compared to only 22.4% of the control group. The rates identified in the group of women whose partners do not have PE, appear to be comparable to those identified in epidemiological studies.12 When a simple one-item question was asked of the women about whether they felt they had a sexual problem the prevalence overall was much lower at 29.7%. The difference in these prevalence rates (between the ASFQ and single item) is likely due to what is being assessed—ASFQ asks about ‘sexual function’ and the single item is asking about a ‘sexual problem’. Some of the women with ASFQ scores indicating a likely dysfunction may not consider this a ‘problem’. This is the very reason why the DSM-IV-TR13 stipulates the need for a level of distress before a formal diagnosis of FSD (or a subtype) can be made.
Clearly the woman's FSD cannot be attributed to the man's PE alone, there will be other factors involved. Further studies should assess a wider range of attributes to determine the most important determining factor for the woman's FSD, for example, partners sexual dysfunction, relationship satisfaction, length of relationship or acquired vs lifelong PE.
When comparing to Greenstein et al.15 there would appear to be a difference in both the prevalence and pattern of the FSD in women of PE partners, where the highest rates of FSD are seen in the arousal sensation and orgasm categories, compared to partners of men with ED, where orgasm and desire are the largest categories of dysfunction. Riley and Riley4 found that nearly two thirds of the women presenting with sexual desire disorder, who are also partners of men with PE, had a combination of impaired arousal and diminished orgasm attainment. It is not clear from our own data whether there is a clear syndrome of FSD with particular symptom clusters that is specifically related to PE in the male partners. It does appear to be the case that problems with achieving and maintaining arousal are particularly high in this group and this may be logically linked to brevity of sexual encounters and the distraction of performance anxiety for both partners in couples struggling with PE-related disappointment.
It is also important to recognize that women (and men) commonly have more than one sexual dysfunction at the time of referral to a relevant service. In this study, nearly half of the PE partners had two or more current sexual dysfunctions. Both clinically and in research this can confound issues, as diagnostic classifications, such as DSM-IV-TR,13 tend to describe dysfunctions as individual entities rather than interrelated conditions.
The data collected in this study on FSD in the partners of men with PE did not address the temporal relationship between dysfunction in men and their partners. It would be useful and interesting to know more about this, particularly, whether there is a consistently experienced time lag between onset of male followed by female symptomatolology and also perhaps, in some cases, vice versa. If particular patterns were recognizable, this might structure advice and treatment strategies offered to couples where PE has been diagnosed and is likely to trigger secondary sexual problems in the female partner. From this data, we can clearly conclude that there is an association between sexual dysfunction in men with PE and sexual dysfunction in their female partners. Further support for this association is derived from the results demonstrating that two thirds of the women who self-reported that they had a problem of their own, felt that their partner's PE contributed to it, or caused it. However, further research needs to be undertaken to investigate the temporal relationship between sexual dysfunctions in both partners and to investigate this hypothesis specifically. Regardless of which comes first, it is clear that PE has a significant impact on a couple's sexual relationship and on her sexual function, which warrants clinician enquiry and treatment of PE. Indeed, a study assessing the impact of successful treatment of PE on the partners sexual dysfunction would be very interesting, and hopefully as successful as seen in treating women's sexual dysfunction when treating the man for his ED.14, 16, 17, 18, 19, 20
The results of the PEP-SI, SQOL and SRS indicate that the partners of men with PE have higher rates of negative emotional impact and dissatisfaction with sex. In addition, the female partners of men with PE demonstrate a lower perception of sexual quality of life and a poorer sexual relationship with their partners than the control group. These results could be reflective of a higher presence of sexual dysfunction in the women themselves, or, alternatively, could be indicative of greater difficulty with aspects of their own desire, arousal and satisfaction resulting directly from the presence of PE in their partners. It is also possible that the focus of dissatisfaction is not physiological but has much more to do with a sense of impaired intimacy and frustration with a lack of connection resulting from the male partner's preoccupation with PE and his sexual performance.
As previously discussed, further research could help clarify the temporal relationship between dysfunctions in both partners and, of particular importance here, could question the quality of sexual life retrospectively, with a focus on experience, either with other partners or with the same partner, prior to the onset of PE in men in whom presentation is secondary, that is, not lifelong. Additionally, such further research could seek to identify and clarify the relationship between the female partner's emotional dissatisfaction, their partner's PE and a general dissatisfaction with sex and the sexual relationship. Furthermore, an assessment of similarities and differences in sexual dysfunction rates in the partners of men with acquired vs lifelong PE and across a range of IELTs would also be informative.
However, this study does further reinforce the concept that sexual problems and satisfaction between two partners are highly interrelated. Of concern to clinicians working with PE should be the poor scores of PE partners on both the PEP-SI satisfaction domain and SQOL-female, as, whatever the origin of these low levels of sexual fulfillment, they may potentially introduce poor motivation or possible sabotage to any treatment regime entered into by the man with PE, with or without the clinical attendance of his partner. In relation to clinical treatment, the origin of the poor sexual fulfillment in the female partner obviously does matter, where there is an expectation that resolution of the PE itself will automatically result in greater satisfaction for her. For the small, but significant number of women who reported having their own problem independently of their partner's PE, treatments for PE may have no or even detrimental impact on the female partner's condition.
A drawback of this study is that the sample was made up of volunteers and may not be representative of more general or clinical populations. The study would need to be repeated in wider populations to verify the results and establish reproducibility.
The data presented here clearly demonstrate a high incidence of a range of sexual dysfunctions in the female partners of men with PE. Although there is an association between PE and the partners sexual dysfunction, the temporal and causal relationship between PE and FSD requires further research. Full account should be taken of the perceived low quality of sexual/emotional fulfillment represented here and the possibility that a significant part of this is accounted for by disrupted intimacy and emotional withdrawal in both partners. Such behavioral patterns, seen across the range of sexual and relationship difficulties, will have implications for the likely success of treatment strategies, of whatever sort and need to be addressed if clinicians wish to avoid setting up couples to fail sexually however effective the treatment for PE may be in its own right.
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We thank Sandra Leiblum, Cindy Meston, John Mulhall, Eileen Palace, José Pomerol, Rick Sadovsky, Ridwan Shabsigh and Miki Weider for conducting the diagnostic interviews with the male partners of the women participating in this study. We also thank Health Research Associates Inc. for coordinating the recruitment of the participants in this study. This research was funded by Pfizer Ltd, UK.
NB: The following measures—ASFQ, PEP-SI, SQOL-F, SRS, PE diagnostic tool—are all available for use upon request.
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Hobbs, K., Symonds, T., Abraham, L. et al. Sexual dysfunction in partners of men with premature ejaculation. Int J Impot Res 20, 512–517 (2008). https://doi.org/10.1038/ijir.2008.34
- premature ejaculation
- sexual dysfunction
- female sexual dysfunction
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