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OCTOBER 2012
VOL 4, NO 6

Effectiveness of Cognitive Behavioral Therapy on Premature Ejaculation in an


Iranian Sample
Mohammad Soltanizadeh1, Hamid Taher Neshatdoust1, Mehrdad Kalantari1, Mehrdad Salehi2,
Mohammad Hossein Izadpanahi3
1

Department of Psychology, Faculty of Educational Sciences and Psychology, University of Isfahan,


Isfahan, Iran.
2
Department of Psychiatry, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran.
3
Department of Urology, School of Medicine, Isfahan University of Medical Sciences, Isfahan, Iran.
Corresponding Author: Mohammad Soltanizadeh, Faculty of Psychology and Education, University of
Isfahan, Isfahan, Iran. Postal Code: 8174673441,

Abstract
Heretofore, there have been few investigations regarding to effectiveness of cognitive behavioral therapy
on premature ejaculation in Islamic eastern cultures such as Iran. These investigations have many
methodological problems. In this research, the effectiveness of cognitive behavioral therapy on premature
ejaculation was studied using a controlled design with 3-months follow-up in Iranian sample. The sample
involved 20 men with premature ejaculation that randomly assigned in two experimental and control
groups. All participants responded to Index of Premature Ejaculation (IPE), Beck Anxiety Inventory
(BAI), Beck Depression Inventory (BDI), The World Health Organization Quality of Life (WHOQOL)BREF, Enriching and Nurturing Relationship Issues, Communication and Happiness Questionnaire
(ENRICH) and socio-demographic questionnaire. Also, they measured intravaginal ejaculatory latency
time (IELT) using stopwatch. The results of ANCOVA indicated that cognitive behavioral therapy could
improve premature ejaculation and increase IELT and men's sexual satisfaction significantly. But it didn't
show any effect on anxiety, total marital satisfaction and quality of life. The effect of therapy was kept
until 3-months follow-up. Cognitive behavioral therapy is an effective method to decrease premature
ejaculation and improve men's sexual satisfaction who suffered this disorder.
Keywords: Premature Ejaculation; Cognitive Behavioral Therapy; Sexual Satisfaction; IELT

1. Introduction
According to the results of numerous epidemiological studies (Montague et al., 2004; Rosen,
2000), premature ejaculation (PE) is likely the most prevalent sexual dysfunction. Overall, the
prevalence rate of PE falls somewhere between 25 and 40% in the global population of men
across all age groups (Lumann, Paik & Rosen, 1999; Lumann et al., 2005). Results of the
National Health and Social Life Survey (NHSLS), a large study of sexual behavior in a
demographically representative sample of adults in the United States, indicate a prevalence rate
of 29%. (Lumman et al., 1994). Similar findings are reported in the Global Study of Sexual
Attitudes and Behaviors (GSSAB), a large and survey-based study where the prevalence of
common sexual dysfunctions was studied in 29 countries stratified into seven geographic
regions. The majority of the prevalence rates reported in these seven regions were very similar to
the one reported by the NHSLS, with four of the seven regions reporting prevalence rates from
27.4 to 30.5% (Lumman et al., 2005).
Despite the predominance of PE, the creation of a standardized definition and diagnostic
criteria has been elusive. In 1970, Masters and Johnson defined the condition as the inability of a
man to delay ejaculation long enough for his partner to reach orgasm on 50% of intercourse

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attempts. The obvious criticism of this definition is its dependence on the partners ability or
likelihood to orgasm.
A precise definition of PE has yet to be formulated, although many published reports use
either the American Psychiatric Association (1994) Diagnostic and Statistical Manual of Mental
Disorders or the International Classification of Diseases (ICD-10) definition. The ICD-10 (World
Health Organization, 1993) defines PE as: an inability to delay ejaculation sufficiently to enjoy
lovemaking, manifest as either of the following: (1) occurrence of ejaculation before or very
soon after the beginning of intercourse (if a time limit is required: before or within 15 seconds of
the beginning of intercourse); (2) ejaculation occurs in the absence of sufficient erection to make
intercourse possible and the problem is not the result of prolonged abstinence from sexual
activity.
The main criteria for premature ejaculation in DSM-IV-TR (American Psychiatric
Association, 2000) include: a persistent or recurrent ejaculation with minimal sexual stimulation
before, on or shortly after penetration and before the person wishes it. The clinician must take
into account factors that affect the duration of the excitement phase, such as age, novelty of the
sexual partner or situation and recent frequency of sexual activity.
Currently, the most accepted definitions of PE come from the DSM-IV-R and ICD-10, which
both refer to PE as a condition of short ejaculatory latency that causes personal distress and is
beyond the patient's ability to control. Both definitions are echoed by the American Urological
Association (AUA), which states "PE is ejaculation that occurs sooner than desired, either before
or shortly after penetration, causing distress to either one or both partners" (Montague et al.,
2004).
Some definitions include a measure of time to define the PE. The time between vaginal
penetration and ejaculation is referred to as the intravaginal ejaculatory latency time (IELT). The
recommended IELT for diagnosing PE has varied in the literature from 1 to 2 min or less
(Rowland, Cooper & Schneider, 2001; McMahon et al. 2004). Importantly, there no widely
accepted standard for normal ejaculatory latency exists. However, a recently published study
by Patrick et al. (2005) on a large community-based population of men and their partners might
give the best estimate of normal ejaculatory latency to date. The investigators found that the
median intravaginal ejaculatory latency time (IELT), recorded using a partnerheld stopwatch,
was 7.3 min for men without PE, whereas men with PE had a median IELT of 1.8 min. In this
research we use two subjective (Index of Premature Ejaculation, Symonds et al., 2007) and
objective (IELT) measures for operational definition of PE.
PE affects the individual, his partner, the relationship, and overall quality of life (QOL). The
association between sexual satisfaction, life satisfaction, and overall well-being has been
recognized for more than 30 years (Bell, 1972; Masters & Johnson, 1970). PE has been shown to
have a significant negative psychological impact on men with the dysfunction, which typically
results in increased anxiety and loss of sexual confidence, and leads to distress and reduced
satisfaction with the sexual experience (Barnes & Eardley, 2007). McCabe (1997) showed that
men with PE had lower levels of satisfaction in all life areas assessed compared to sexually
functional men.
McCullough & Bull (2004) reported the results of 1158 men responding to a sexual health
survey. The authors found that men with PE were significantly more likely to report low
satisfaction with their sexual relationship, low satisfaction with sexual intercourse and difficulty
relaxing during intercourse. The female partners of men with PE also reported that satisfaction

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with the sexual relationship decreased with increasing severity of the mans condition (Byers &
Grenier, 2003).
To date, the cause of PE has not been conclusively determined. Not surprisingly, there are
those who advocate for an entirely biological explanation and those who insist that it is a wholly
psychological condition. Even if we were able to state unequivocally that a mans premature
ejaculation is due to biological factors exclusively, he would probably manifest a psychological
response that might further worsen the condition. Additionally, his partner may be
psychologically affected by the dysfunction, regardless of the underlying cause.
Given that psychological factors can either worsen the condition or in some cases may be
responsible for precipitating and maintaining the dysfunction, psychotherapy remains a vital
intervention to help men and their partners who suffer from rapid ejaculation (Althof, 2006).
Clinical observation and theoretical models emphasize the importance of core cognitive
structures (schemas or core beliefs) on sexual dysfunctional processes (Carey, Wincze, &
Meisler, 1993; McCarthy, 1986; Rosen, Leiblum, & Spector, 1994; Sbrocco & Barlow, 1996).
Barlow during the last two decades has developed an invaluable work on the study of cognitive
factors underlying sexual dysfunctional behaviors. Barlows (1986) cognitive-affective model
postulated that the interaction between autonomic arousal (sympathetic activation) and cognitive
interference plays a central role in determining sexually functional and dysfunctional responses.
Sbrocco and Barlow (1996) and Wiegel, Scepkowski, and Barlow (2007) further developed the
original model, indicating that schematic vulnerability is one of the main components implicated
in sexual dysfunction. Sbrocco and Barlow (1996) suggested that individuals with sexual
dysfunction have a set of sexual beliefs usually unrealistic and inaccurate and assume a rigid and
inflexible character. Whenever these demanding and unrealistic referential standards are not met,
catastrophic personal implications may arise, facilitating the development of negative self-views
(negative self-schemas) and predisposing individuals to develop sexual difficulties. Besides
Barlows theoretical model, increasing attention is being paid to the application of cognitive
approaches to sex therapy. In this regard, some therapeutic approaches with particular emphasis
on cognitive strategies and interventions have been developed (Carey et al., 1993; McCarthy,
1986; Rosen et al., 1994). Also, Nobre and Pinto-Gouveia (2009) concluded that specific faulty
cognitive constructions underlying sexual dysfunctions and encourage the development of
models and treatment approaches based on cognitive theory.
Psychological treatments depend on principles of learning and cognitive processing as the
mechanisms of change and rely on a general literature that has been well articulated and
continues to expand (e.g., Barlow, 1986). It is clear that learning new patterns, changing ones
conceptualizations, and practicing different thoughts and behaviors can lead one out of many
disorders and certain illnesses (Dobson & Craig, 1998).
Laboratory investigations of behaviorally based sex therapy support its value. There is more
research supporting the efficacy of behavioral therapy for sexual problems than any other form
of treatment, with the possible exception of medical intervention (Rosen & Leiblum, 1987;
Schover & Leiblum, 1994). More than one-half of clients show improvement after behavioral
treatment, and clients generally are thought to maintain their gain (Barlow, 1986; Hawton,
Catalan & Fagg, 1991; Schover & LoPiccolo, 1982). Typically, these studies have used carefully
trained and selected therapists operating in research clinics and offered therapy to clients without
comorbid problems.
Behavioral sex therapy rests on the theory that, once organic causes have been ruled out,
sexual difficulties are the result of a combination of factors that are amenable to change through

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relatively brief intervention. Anxiety has been emphasized as a central factor in the development
and maintenance of dysfunctional behavior (Beck & Bozman, 1995; Bozman & Beck, 1991,
Barlow, 1986). Other factors implicated are misattribution of physiological arousal (Cohen,
Rosen & Goldstein, 1985; Rook & Harnmen, 1977), cognitive distraction (Southern, 1985),
restrictive learning history and deficits in sexual technique and skill (Hurlbert, 1993).
Because of the belief by some researchers that PE is due to a learned behavior because of
performance anxiety, sex therapy became the mainstay of treatment for many years and today is
still one option for treating PE. Cognitive behavior therapy attempts to alleviate sexual
difficulties through a combination of techniques, including education (i.e., information regarding
sexual anatomy and stages of arousal), cognitive restructuring (i.e., identification of thoughts and
core beliefs that may be influencing sexual functioning), communication skills, training, and
sensate focus exercises (McCabe, 2001; Rosen, Leiblum, & Spector, 1994; Leiblum & Rosen,
1988). Sensate focus consists of a graded series of mutual body-touching exercises. The sensate
focus exercises serve to reduce performance anxiety, create pleasurable sexual experiences, and
help people become aware of sexual responses and preferences. Other common form of sex
therapy is the squeeze technique during which the patient and/or his partner squeeze the erect
penile shaft before the ejaculatory reflex is stimulated. Using this technique, the patient will learn
to voluntarily delay ejaculation while maintaining sexual excitation (Masters & Johnson, 1970).
MacCabe (2001) evaluates a cognitive behavior therapy program for people with sexual
dysfunction. He found that the treatment led to lower levels of sexual dysfunction, more positive
attitudes toward sex, perceptions that sex was more enjoyable, fewer affected aspects of sexual
dysfunction in their relationship, and a lower likelihood of perceiving themselves as a sexual
failure.
As sexual values and the meaning of sexuality depend on culture, the efficacy of
psychotherapy models may not necessarily be similar in different cultures. Therefore there is a
need for culture-specific applications of psychotherapies. Based on previous research, CBT was
effective in treating PE. Therefore, the aim of the present study was to investigate the efficacy of
CBT on PE and satisfaction of a group of Iranians with PE and is this method effective in other
countries, or therapeutic effects based on culture, family structure and the other conditions. It is
necessary to study more carefully in the countries with different cultures and family structures.
2. Method
2.1. Participants
The participants were comprised of 20 males who were currently in heterosexual
relationships. Some participants were referred by medical practitioners, others selected by an
advertisement placed in a local newspaper calling for subjects to take part in a study of
premature ejaculation in return for free treatment. Participants met the following selection
criteria: (1) 18 years age or older and married, (2) their marriage last for at least 1 year, (3)
having no history of or current psychiatric disorder, (4) no substance abuse (alcohol or drugs),
(5) free of disease, medication use, or surgical procedures that might impact sexual function, (6)
having at least one sexual relationship in a week, (7) having no other sexual dysfunction
including erectile disorder. (8) no concurrent use of other treatment for PE. Participants must
have reported a minimum 6-month history of disorder.
All participants agreed to take part in the weekly meetings and to an 8-week waiting period.
The mean age of the participants was 36.6 (SD=6.01). The socio-demographic characteristics
of the participants in the two groups are presented in Table 1 and 2. T-tests and chi-square tests
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yielded no statistically significant differences between the two groups regarding education,
wife's education, occupation, wife's occupation, socioeconomic status, child number, age, wife's
age and duration of marriage.
Table 1. Frequency of demographic variables in CBT and control groups

Groups
CBT Control

Demographic variables
Education

Wife's
Education
Socioeconomic
Status
Child Number
Occupation
Wife's
Occupation

Elementary School
High School Diploma
Post Diploma
Bachelor
Elementary School
High School Diploma
Post Diploma
Bachelor
M.A.
Weak
Average
Rich
Very Rich
0
1
2
3
Employed
Unemployed
Employed
Unemployed

1
3
2
4
0
5
1
4
0

2
3
2
3
1
7
1
0
1

3
4
3
0
2
3
5
0
3
7
3
7

2
4
3
1
3
5
1
1
4
6
3
7

2
0.476

6.333

1.2

4.367

0.22
0.0

Table 2. Mean and standard deviation of age, wife's age and duration of marriage

variables
Age
Wife's Age
Duration of
Marriage

Groups
CBT
Control
CBT
Control
CBT
Control

SD

10

38.7

6.44

10

34.5

4.99

10

33.0

5.67

10

30.7

3.83

10

11.4

8.09

10

8.1

4.74

t
1.629
1.112
1.062

2.2. Procedure
This study was designed as a randomized waiting list controlled clinical trial that have a 3month follows-up. Patients diagnosed with PE, using the Diagnostic and Statistical Manual of
Mental Disorders (DSM-IV-TR) (American Psychiatric Association, 2000) criteria. Participants
answered the questionnaire after completing a clinical assessment for sexual dysfunction
conducted by a psychiatrist and a clinical psychologist. Kappa () coefficient (Cohen, 1960) was
used to determine the inter-rater reliability of the clinical interviews. Coefficient of the
agreement between interviewers was 0.76. Besides, all participants were visited by an urologist,
in order to refuse their probable physical problems led to premature ejaculation.
All patients diagnosed with PE were asked to participate in the study. An explanation of the
purpose of the study was given by one of the researchers involved in the project and a consent
form was signed. The participants were randomly allocated to either cognitive behavior therapy

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(10 males) or control groups (10 males). Subjects in the two groups were measured pretreatment,
post-treatment, and at 3-month follow-up.
In order to measure IELT, subjects of both groups were asked to measure 3 times the interval
between penetration and ejaculation by themselves using a stopwatch before beginning the
treatment or waiting period, after treatment and 3 months after treatment or end of waiting
period.
Treatment occurred over 8 weeks, one evening per week, for approximately two hours a
session. Cognitive behavioral therapy of PE involves these components. Cognitive components
were briefly including presenting correct information about sexual function and premature
ejaculation, being familiar with CBT logic and mentioning how the thoughts and beliefs effect
on sexual function especially premature ejaculation, recognizing irrational thoughts and being
familiar with sexual myth, training the replacement of rational thoughts with irrational thoughts.
Behavioral components included training Kegel exercises to control PC muscles contraction,
sensate focus exercises including focus on nonsexual and sexual zones, using squeeze technique
during stimulation of the penis by partner to learn delay ejaculation and using this technique
during intercourse.
Because of ethical issues, waiting group received cognitive behavioral therapy after 3-months
follow-up.
2.3. Instruments
2.3.1. Index of Premature Ejaculation (IPE; Symonds et al., 2007)
IPE is a diagnostic tool based on Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition, Text Revision (DSM-IV-TR) which consists of 5 items and captures the essence
of DSM-IV-TR: control, frequency, minimal stimulation, distress, and interpersonal difficulty.
Factor analysis of the 5 items retained the one-factor solution. The reliability of the 5-item
version was good (Cronbach's alpha = 0.71; test-retest reliability = 0.73). Difference in mean
score between the time-defined population and self-reported no-PE group was highly statistically
significantly different (Symonds et al., 2007). As well as using this scale for subjective
evaluation of premature ejaculation; IELT is also used to measure the time of delay ejaculation
objectively.
2.3.2. Beck Depression Inventory-II (BDI; Beck, Steer & Brown, 1996)
The BDI-II is a self-report inventory for adolescents and adults that assesses the presence and
severity of depressive symptoms experienced during the past two weeks. The BDI-II includes 21
items each one consists of four statements reflecting varying degrees of symptom severity.
Respondents are instructed to circle the number (ranging from 0 to 3) that corresponds with the
statement that best applies to them. A rating of 0 indicates an absence of a symptom, while a
rating of 3 is indicative of a severe symptom. Ratings from the 21 items are summed to calculate
a total score, which can range from 0 to 63.
In Dabson and Mohammadkhani investigation (2007) on 354 Iranian subjects with major
depression, validity coefficient of BDI-II was 0.913. The Cronbach's alpha reliability coefficient
was 0.91. In general, the results confirmed validity and reliability of this inventory.

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2.3.3. Beck Anxiety Inventory (BAI; Beck, & Steer, 1990).


The BAI is a 21-item self-report questionnaire asks about common symptoms of anxiety, such
as feeling nervous, scared, and fear of dying, and was designed to distinguish anxiety symptoms
from depressive symptoms. Each item is rated on a 4-point Likert scale for symptom severity in
the past week, ranging from 0 (not at all) to 3 (severely). The range of total scores is from 0 to
63, with higher numbers suggesting greater degrees of anxiety. The instrument has excellent
internal consistency ( = .92) and high testretest reliability (r = .75; Beck & Steer, 1990).
2.3.4. The World Health Organization Quality of Life (WHOQOL)-BREF
WHOQOL-BREF is a 26-item instrument consisting of four domains: physical capacity (PC,
7 items), psychological well-being (PW, 6 items), social relationships (SR, 3 items), and
environmental health (EN, 8 items). The PC domain includes items on mobility, daily activities,
functional capacity and energy, pain, and sleep. The PW domain measures self-image, negative
thoughts, positive attitudes, self-esteem, mentality, learning ability, memory and concentration,
religion, and the mental status. The SR domain contains questions on personal relationships,
social support, and sex life. The EN domain covers issues related to financial resources, safety,
health and social services, living physical environment, opportunities to acquire new skills and
knowledge, recreation, general environment, and transportation (WHO, 1996). The WHOQOLBREF has well to excellent psychometric properties of reliability and performs well in
preliminary tests of validity (Skevington et al., 2004). A study by Nejat et al. (2006)
demonstrated good-to-excellent reliability and acceptable validity of this questionnaire in various
groups of subjects in Iran.
2.3.5. Enriching and Nurturing Relationship Issues, Communication and Happiness
Questionnaire (ENRICH; Olson, Fournier & Druckman, 1983).
ENRICH was designed as a multidimensional inventory, which assesses theoretically valuable
and clinically useful dimensions of marital relationships. This questionnaire has 115 items and is
scored using the Likert scale ranging from 1 to 5. This questionnaire is made of 12 subscales.
The first scale has 5 items and the rest have 10 items. The subscales are included: idealistic
distortion, marital satisfaction, personality issues, communication, conflict resolution, financial
management, leisure activities, sexual relationship, children and parenting, family and friends,
equalitarian roles and religious orientation. This questionnaire was measured according to
Iranian norms and its validity and reliability was approved by Asrar and Haghshenas (2005). In
Mahdavian's research (1997), the reliability was 0.94 using the retesting method.
2.3.6. Socio-demographic questionnaire: This questionnaire includes questions such as age,
education, length of marriage, income and socio-economic level.

3. Results
In order to study the effectiveness of CBT on PE we performed an analysis of covariance
(ANCOVA) using SPSS 17.00 (Statistical Package for Social Sciences). Before performing the
analysis, normality and equality of variance hypothesis were tested with Kolmogorov-Smirnov
and Levene test, respectively. These hypotheses were approved.

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Table 3 shows the mean and standard deviation scores for pre-test, post-test and follow-up of the
two groups used in the study.
Table 3. Summary of the descriptive data (means and standard deviations) of two groups

Variables
Depression
Anxiety
Sexual
Satisfaction
Marital
Satisfaction
Quality of Life
PE
IELT

Groups
CBT
Control
CBT
Control
CBT
Control
CBT
Control
CBT
Control
CBT
Control
CBT
Control

Pre-Test
M
SD

Post-Test
M
SD

Follow-up
M
SD

8.2

1.98

6.9

2.46

7.1

1.84

7.9

1.91

8.0

1.76

7.8

1.73

12.8

7.34

8.5

4.58

8.2

3.15

14.9

2.95

13.8

5.34

13.7

2.88

29.64

7.99

40.1

6.27

38.7

6.05

28.92

7.49

27.6

5.96

28.4

5.99

353.3

46.92

359.0

50.69

355.7

47.08

343.64

41.02

332.5

31.48

340.6

41.21

80.3

14.52

95.1

18.18

94.65

15.6

78.4

12.26

82.3

14.18

86.6

13.7

17.1

1.79

7.6

1.89

7.9

1.63

14.5

2.22

16.0

2.62

15.7

2.36

58.43

4.29

168.73

11.96

153.7

10.67

55.23

7.76

62.76

4.94

65.6

5.65

In table 4 the results of ANCOVA to compare the dependent variables between CBT and
control groups in post-test step are illustrated. In order to conduct ANCOVA, depression, anxiety
and demographic variables of subjects and pre-test scores were controlled.

Table 4. A summary of ANCOVA results to compare the dependent variables between CBT and control
groups in post-test

Dependent
Variables
Anxiety
Sexual Satisfaction
Marital Satisfaction
Quality of Life
PE
IELT

SS

df

MS

35.14
179.016
441.869
75.398
90.353
10984.002

1
1
1
1
1
1

35.14
179.016
441.869
75.398
90.353
10984.002

2.888
50.921
0.594
0.467
13.095
126.799

0.140
0.001
0.476
0.525
0.015
0.00

Eta
Squared
0.325
0.911
0.106
0.085
0.724
0.926

Observed
Power
0.300
0.999
0.097
0.087
0.822
0.999

Results of table 4 indicate that cognitive behavioral therapy could increase men's sexual
satisfaction [F=50.921, P= 0.001]. It also improved premature ejaculation [F=13.095, P<0.05]
and increased IELT [F=10984.002, P<0.0001].However it didn't have any effect on anxiety, total
marital satisfaction and quality of life.
Table 5 illustrates the results of ANCOVA by eliminating effects of pretest, anxiety,
depression and demographic variables after 3-months follow-up.

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As it is shown, there is a significant difference between sexual satisfaction [F=50.974,


P=0.001], subjective index of premature ejaculation [F=12.891, P<0.05] and IELT [F=10746.14,
P<0.0001] of control and CBT groups; and effects of therapy after passing a 3 months are still
stable. There was no change in amount of anxiety, total marital satisfaction and quality of life.
Table 5. A summary of ANCOVA results to compare dependent variables in follow-up

Dependent
Variables
Anxiety
Sexual Satisfaction
Marital Satisfaction
Quality of Life
PE
IELT

SS

df

MS

37.16
181.82
438.21
78.32
88.41
10746.14

1
1
1
1
1
1

37.16
181.82
438.21
78.32
88.41
10746.14

2.965
50.974
0.421
0.503
12.891
119.54

0.136
0.001
0.501
0.496
0.020
0.00

Eta
Squared
0.364
0.925
0.089
0.096
0.715
0.911

Observed
Power
0.328
0.999
0.082
0.099
0.803
0.999

4. Discussion
In the present study, control and the treated groups did not differ on at least the demographic
variables investigated here. Both groups were the same in educational level, wife's education,
socioeconomic status, child number, occupation status and wife's occupation status, age and age
of their wives and duration of their marriage.
Results of the current study indicated that CBT had improved men's PE. This therapy could
effect on the subjective perception of males about controlling and delaying their ejaculation. As
well as an effect on subjective perception of males, CBT could effect on objective measure of
premature ejaculation and increase IELT. Follow up of subjects after 3 months indicated that
effects of the treatment on premature ejaculation still exist. Subjects' scores in self-report
measure of premature ejaculation and IELT in a 3-month follow-up in comparison with the
pretest had a significant difference.
The reasons that cause CBT to effect on premature ejaculation are as follows. Baker and de
Silva (1988) showed that men with a sexual dysfunction especially premature ejaculation and
erectile disorder have some irrational and distorted beliefs. Such irrational beliefs have a
negative relationship with expected and desirable sexual behaviors. Besides, Barlow (1988)
believes that cognitive interference acts as a continuity factor in sexual dysfunction. McCabe
(2001) also recognized that CBT decreases sexual dysfunctions in men and women and improves
premature ejaculation.
So it seems that cognitive interference increases arousal, consequently negative feelings in
males and therefore intensifies premature ejaculation. For example, sexual stimuli aren't
perceived as they really are; therefore there may be no sexual arousal or an inhibition will
happen. In other words, attention to the thoughts creating anxiety is incompatible with a
complete attention to the sensual stimuli which are important for sexual arousal.
Since sexual situations for males with PE can cause anxiety, they avoid these situations to
deal with their anxiety. Avoidance can lead to decrease the opportunities for training ejaculatory
control and therefore PE is worsening. Cognitive behavioral therapy gives them the opportunities
to face such situations and increases their ability in controlling and delaying ejaculation.
The results indicated that CBT can improve PE without any effect on males' anxiety.
Regarding to the PE, anxiety is not the only major or accelerator factor of PE, although levels of
negative emotions in the men with PE is high (Rawland, Tai & Slob, 2003); and this factor can

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intensify it. Men with PE are prepared to have a rapid and high arousal in their sympathetic
system during sexual arousal. Anxiety is associated with increased sympathetic system activity
and therefore can affect PE. Strasberg et al. (1990) also recognized that anxiety has not a stable
role in PE and differs depending on the physical vulnerability. So lack of decrease in people's
anxiety due to therapy can be result of primary difference of people in this factor.
On the other hand, cognitive behavioral therapy of PE led to increase of participants' sexual
satisfaction, but didn't have any effect on total marital satisfaction. As McCabe (2001) mentioned
cognitive behavioral therapy not only improves sexual dysfunction but also increases a positive
view toward the sexual relation and its pleasure. Also, improvement in PE increases the spouse's
satisfaction with sexual relationship and decreases her negative feedbacks to this problem. With
improvement in men's PE, men have more confidence toward themselves to satisfy their spouse.
Their concerns regarding to this fact that their spouse may not be orgasm will decrease. These
factors lead to increase in the males' sexual satisfaction.
Total marital satisfaction involves several aspects and as therapy was only concentrated on
sexual dysfunction, so it is likely to see no change in total marital satisfaction.
We should note the certain limitations of this study. Small sample size limits the
generalizability of the results. One more limitations of this investigation was lack of dividing the
males according to the type of premature ejaculation (primary and secondary); it is
recommended to accomplish the future investigations about psychotherapies as per a factorial
plan and with considering type of the premature ejaculation.
The present study also underscores that even effective techniques of psychotherapy should be
modified according to cultural expectations, values, and gender roles.
Acknowledgements
I gratefully acknowledge all the peoples participated in this study and without whom it would
not be possible.

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