A retrospective–present-day analysis on acquired premature ejaculation

Abstract

Background

Men with acquired premature ejaculation (APE) develop the condition after a period of normal ejaculatory function. This is the first article to focus on the developmental course of APE.

Aim

To retrospectively detail the developmental course of foreplay duration, ejaculatory latencies over multiple partnered sexual activities, and changes in PE symptomology in men with APE from age of sexual debut to the present.

Methods

From March 2024 through February 2025, 411 volunteers, aged 18-80 years, responded to an online sexual health and behavior questionnaire posted on multiple social media platforms. These men also met the preliminary qualifying criteria of having PE based on responses to an abridged Premature Ejaculation Diagnostic Tool (PEDT) and meeting other inclusion criteria. Of these, 77 men (mean age = 40 years, range 19-66) met the criterion of having APE as their symptoms developed only after an extended period of normal ejaculatory control.

Outcome

Significant changes in partnered ejaculatory latencies from the men’s sexual debut to the present are reported.

Results

Sexual debut typically occurred around age 19, with PE first reported on average at age 31. Overall, vaginal and anal ejaculatory latencies (EL) at sexual debut were 5.98, 5.01, and 4.7 min, respectively, but the overall, vaginal and anal ELs at the present time were 1.86, 0.97, and 0.75 min (P < .001). Foreplay duration of approximately 12-13 min remained unchanged over the lifespan despite large decreases in ELs. Nearly 34% of the participants reported that their symptomology continued to worsen after it first appeared.

Clinical Implications: The data highlight the major differences between present-day partnered sexual behaviors and time spent in foreplay and masturbation compared to sexual activities earlier in life. It suggests that under specific circumstances men have the ability to delay ejaculation.

Strengths and Limitations

The strength of this article is its developmental perspective in terms of examining the men’s past and present sexual behaviors. The major limitations are the retrospective–present-day methodology and recruitment via social media, which could lead to sample biases and reliance on men’s recall.

Conclusions

This study both confirms the presumed developmental course of ELs in men with APE and adds new insights regarding these men’s sexual experiences, including the comparability of their ELs with men having lifelong PE, the relationship between ELs and types of partnered sexual activity, and the lack of association between foreplay duration and EL. It also documents that one-third of men with APE experienced continued deterioration of their condition with age.

Introduction

Premature ejaculation (PE) first appeared in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM III) published in 1980.¹ Since then, PE has commonly been defined by (1) a short ejaculation latency (EL) during penetrative sex; (2) a lack of ability to delay or postpone ejaculation; and (3) negative consequences such as distress, bother, or concern.^2-7 Most professional societies have further recognized two subtypes of PE, lifelong (LPE) and acquired (APE).^2-8

LPE is assumed to begin at the man’s sexual debut and remains fairly constant throughout his lifetime. The etiology of LPE is thought to be primarily biological in origin, with an added psychological and relational burden.^3,9 APE, on the other hand, arises after a period of normal ejaculatory function, with suggested etiologies that include biological (eg, prostatitis, erectile dysfunction), psychological (eg, anxiety, depression), and relational (eg, discord, partner dysfunction) factors. While the same three broad diagnostic criteria noted above have been used to diagnose both LPE and APE subtypes, the EL inclusion criteria have been inconsistent for both men with LPE and those with APE. For men with APE, one definition specifies ≤3 min,⁶ a second ≤2-3 min,² and a third ≤2 min.¹⁰ Furthermore, EL thresholds for APE in most definitions have not been aligned with the thresholds for men with LPE,^2,4 with the rationale for this disparity based primarily upon expert opinion and two empirical reports.^11,12

Rationale and objectives

Not only do such variations in diagnostic criteria highlight the fact that clear and reliable data regarding the lifetime course of men with APE are lacking, but they also create confusion and inconsistencies in both research protocols and clinically based diagnostic procedures. Specifically, consistent and uniform diagnostic criteria are necessary for making accurate estimates of PE prevalence, supporting investigations into the etiology of the dysfunction, assessing the impact on patients and partners, creating validated patient-reported outcomes (PROs), assisting with regulatory authority oversight, and ascertaining which men might benefit from specific treatment interventions.¹³

Furthermore, men with APE have garnered far less attention from the research community than men with LPE, leaving significant gaps in the understanding and experiences of these men. For example, at what age do their PE symptoms typically begin? Do their symptoms worsen as they continue to age? Is the duration of their foreplay modified as they begin to experience PE symptomology? Are the short ELs associated with PE symptomology manifested over various types of partnered sex, and do they also occur during masturbation? And do the EL patterns for various types of partnered sexual activity show consistency from sexual debut (when PE symptomology is absent) to the current time (when PE symptomology is present)?

The above questions could be best addressed with a longitudinal study design; however, such designs are generally impractical and/or impossible for tracking lifespan changes in APE, where risk factors along with predictability of the onset of symptomology have not been empirically documented. On the other hand, a retrospective versus current-time approach, as used in the present study, provides an alternative strategy for garnering insights into the questions outlined above, particularly regarding the developmental course of APE. To address these issues, the aims of this study were to:

1. Characterize APE men by their level of sexual desire and interest in sex, partnered sex and masturbation frequencies, relationship and sexual satisfaction, medical comorbidities, and erectile problems (Aim 1);

2. Better understand the relationship between men’s sexual debut and the age of onset of PE symptomology, and to document further changes—either improvement or deterioration—of their condition with aging (Aim 2);

3. Determine lifespan changes in foreplay duration and ELs of men with APE men (Aim 3);

4. Characterize the ejaculatory response both for different types of partnered sex and for masturbation in men with APE (Aim 4).

Methods

Participants

From March 2024 through February 2025, 928 volunteers, aged 18-80 years, responded to an online sexual health and behavior questionnaire posted to several platforms, including subreddit sites (see Appendix A for a complete list), prematureejaculation.help and morarimedical.com. Figure 1 details the categorization of participants that completed the survey. Of the initial respondents, 409 met the following criteria: 18 years of age or older, “often reaching orgasm or ejaculation very quickly, before you want to,” producing a full complement of responses on the major study variables, residing in one of the countries listed in Appendix B, and able to respond to questions posed in English. We excluded men who “never had any type of sexual activity with a partner which typically led to orgasm, e.g., oral sex, vaginal intercourse, anal intercourse, and mutual masturbation.” Individual cases were further inspected for inconsistent, out-of-range, or errant responses (eg, >3 or more SD), and those cases were also excluded when they clearly did not meet the criteria for PE.

Figure 1.

Flowchart for categorizing participants.

Survey instrument

The 47-item questionnaire was initially subjected to face validity review and assessment of completion time by 19 men, either individually or in small focus group sessions (mean age = 40.2 years) and subsequently modified as necessary based on their feedback. Experimenter-derived self-report items assessed health status, medication use, anxiety, interest in and (separately) importance of sex, general relationship satisfaction, and sexual relationship satisfaction. The questionnaire included abridged versions of the International Index of Erectile Function (IIEF)¹⁴ and the Premature Ejaculation Diagnostic Tool (PEDT),¹⁵ with the latter instrument including only the three items assessing ejaculatory control, the construct considered most central to PE.^15-18 The 3-item PEDT had been validated and utilized in previous research, demonstrating good psychometric properties, including test–retest reliability of 0.85 and internal consistency (Cronbach alpha) of .75¹⁹ (Supplementary Table S1). The remaining PEDT items, which were related to bother/distress, were assessed as a separate construct, as informed by best practices in survey construction.^20,21 Masturbation latency was assessed with modified PEDT questions that had also been employed in previous research and demonstrated good test–retest reliability (0.74) and internal consistency (0.86). The masturbation PEDT also demonstrated divergence from the partnered sex PEDT, which attests to its utility as a validated and cohesive index for differentiating ejaculatory control during masturbation from ejaculatory control during partnered sex (Supplementary Table S1). Consistent with the focus on PE symptomology over the lifespan, participants provided retrospective and current information about their PE symptomology, as described below.

Defining a group of men with PE

Only men who indicated that they frequently ejaculated before desired were considered as candidates for this study, with the final determination contingent upon respondents’ scoring >10 on the abridged PEDT, thus being classified as “definite PE.” Participants were further categorized into either LPE or APE subtypes based on their responses to a follow-up question using phraseology similar to that appearing in professional definitions of the subtypes.^2-5 Specifically, men who indicated that their condition had persisted throughout their entire, or nearly their entire, sexual life were classified as having LPE; those who reported the onset of symptoms only after a period of typical or normal ejaculatory function were categorized as having APE. For this analysis, only participants in the APE classification who met the criterion for “definite” PE were included, thus yielding a final sample of 77 men (mean age = 39.6 [median = 38.0], SD = 10.8, range = 19-66). Preliminary power analysis had determined that for a .05 significance level, a moderate effect size, and power (1 − β) set at .80, about 20-30 cases were adequate for making within-group comparisons (https://researchmethods  resources.nih.gov/). Thus, with over 70 participants, this analysis was well powered.

Subset of items pertaining to men with APE

Men in each PE subtype were asked more specific questions to assess lifespan changes in their ejaculatory and sexual response. Items pertaining to men with APE included their age at their sexual debut for partnered sex, their current age, and the age at which they first noted their PE symptomology. Participants also estimated the length of their foreplay and three separate ELs at both their sexual debut and currently: the first represented an omnibus index of their estimated EL for all types of partnered sex combined (eg, oral, penetrative vaginal/anal, manual stimulation); the second EL was specific to vaginal intercourse; and the third was specific to anal intercourse. EL estimates were recorded on an analog scale extending from −0.5 (ie, before penetration) to 9.5 min after the onset of orgasm-intended stimulation or penetration. If the respondent exceeded the 9.5 limit on the analog scale, they estimated their EL manually on the next line, rounded to the nearest 0.5 min.

Procedure

The study received approval from the IRB at Valpariso University, USA (VUIRB#24-2: 02.06.24). The online distribution of the survey and collection of data followed best practices, including approximately 15 (±5) min for survey completion, guaranteed anonymity, safeguards to prevent multiple submissions, embedded attention checks designed to eliminate participants who responded inconsistently throughout the survey, and no incentives or compensation for participation.^22,23 Seventy-seven percent of the participants who began the survey completed it. Informed consent was obtained by participants checking boxes attesting to (1) their current age being ≥18 years and (2) their informed consent before accessing the questionnaire. Respondents could voluntarily end participation at any time without a penalty by closing the webpage.

Statistical analyses

Analyses consisted of descriptive statistics (means, frequencies) and repeated measures ANOVAs to detect differences between current and past PE experiences, between different types of partnered sexual activities, and between masturbation and partnered sexual activities. Analyses were conducted using SPSS (IBM Corp, Released 2020, IBM SPSS Statistics for Windows, version 27.0, Armonk, NY: IBM Corp).

Results

Demographic, health, and sexual functioning parameters (Aim 1)

Of the 77 men with APE, 82% reported having some college experience or a higher education degree. Six percent had no current sexual partner, 75% had one sexual partner, and 20% had multiple partners. Healthwise, 28% of the sample reported having a health issue related to sexual functioning (eg, high blood pressure, diabetes, cardiovascular/heart disease, metabolic disorder, or lower urinary tract symptoms-LUTS), 6% were taking medication, 28% struggled with anxiety or depression throughout their lifetime, and 33% reported erectile dysfunction (Table 1).

Table 1.

Demographic, health, and sexual variables of interest in the men with APE.

Variable	Mean or percentage yes
Current age	39.6
Medical issue related to sexual function (%)	28
Medication use (%)	6
Anxiety/Depression over lifetime (%)	28
Anxiety/Depression last 12-24 months (%)	13
Erectile dysfunction (%)	33
Sex rated as very or extremely important (%)	89
Interest in sex—extremely interested (%)	86
Overall relationship—Mostly Satisfied (%)	77
Sexual satisfaction—high to very high (%)	18

Also in Table 1, the importance of sex was rated “very to extremely important” by 89% of the respondents, and sexual desire/interest in sex was rated “extremely interested” by 86%. On average, most men engaged in partnered sex weekly or biweekly, while masturbating, on average, 2-3 times weekly. About 77% were “mostly to very satisfied” with their overall relationship, but on a comparably scaled item, only 18% rated their “sexual satisfaction as high to very high.” These patterns were generally consistent with other studies on PE conducted by this research group.^19,24-26

Measures specifically assessed in relationship to premature ejaculation

Changes over the lifespan: sexual debut, PE onset, and the current situation (Aim 2)

The mean age of the group’s sexual debut was 18.6 years (±3.36). It was not, however, until age 31.5 yrs (± 10.83), on average, that the men with APE self-identified as having PE; that is, men were not symptomatic for about 13 years. While most men (61.4%) indicated that their PE symptomology stayed about the same as they continued to age, 36.8% reported that it had worsened, whereas only 1.8% indicated an improvement in functioning.

Lifespan changes in foreplay duration and ELs of men with APE (Aim 3)

At sexual debut, men reported an overall mean EL of 5.98 min (± 3.44), a mean vaginal sex EL of 5.01 min (± 2.80), and a mean anal sex EL (n = 23) of 4.83 min (±3.54). As shown in Figure 2, ELs were generally around 5-6 min. In contrast, ELs at the current time (after the onset of PE) were much shorter, with men reporting a mean overall EL of 1.86 (±1.24) min, a mean vaginal sex EL of 0.97 min (±0.94), and a mean anal sex EL of 0.75 min (±1.46). Statistical comparisons using ANOVA between sexual debut and current overall, vaginal, and anal ELs were all significant (P < .001). To better capture the magnitude of the changes from sexual debut to the current time, we note that the mean overall EL was shortened by about 4.12 min, the mean vaginal EL by 4.04 min, and the mean anal EL by 4.08 min, representing percentage decreases in EL of 69%, 81%, and 84%, respectively.

Figure 2.

Change in ejaculatory latencies, initial (at sexual debut) versus current times.

Despite these significant and large (based on effect size) changes in mean ELs from sexual debut to the present time, no significant change in foreplay duration occurred from sexual debut (12.65 ± 7.07 min) to the current time (13.31 ± 7.93 min), P = .474.

Differences of ELs across varying types of sexual activities (Aim 4)

At both sexual debut and the current time, the type of sexual activity (overall, vaginal, anal) affected the men’s ELs in a consistent manner. Regarding partnered sexual activity at both time points, ELs were longest for overall activity, significantly shorter for vaginal intercourse (P < .001), and shortest for anal intercourse (P < .001 compared with overall). The average masturbation EL for the current time was 4.11 min (±16.3), that is, significantly longer than all the partnered sex (overall, vaginal, anal) ELs at the current time (P ≤ .002 for all comparisons). Because of the disparity between mean and median for masturbatory EL, we recognize that it is a skewed distribution. We therefore compared medians using the Wilcoxon sign test, with no change in H₀ rejection and only very minor changes in P-values, as shown in Table 2. This EL pattern aligned well with the parallel finding that while the PEDT scores for partnered sex all fell within the “definite PE” range (mean ± SD), PEDT scores for masturbation were within the normal range (mean ± SD), although near the cusp of “probable PE.”

Table 2.

Means, medians, SDs, and tests of significance for acquired premature ejaculation: sexual debut versus currently and masturbation versus partnered sex.

	Sexual debut		Currently
	Mean (SD) in minutes	Median in minutes	Mean (SD) in minutes	Median in minutes
Overall EL	5.98 (±3.44)	5	1.86 (±1.24)	2
Vaginal EL	5.01 (±2.80)	5	0.97 (±0.94)	1
Anal EL	4.83 (±3.54)	4	0.75 (±1.46)	0
Masturbation			4.11 (±16.3)	3
Tests of significance
ANOVA for sexual debut vs currently
Overall EL	P < .001
Vaginal EL	P < .001
Anal EL	P < .001
Wilcoxon sign test for sexual debut vs currently
Overall EL	P < .001
Vaginal EL	P < .001
Anal EL	P < .001
Wilcoxon sign test—current partnered sex vs masturbation
Overall EL vs masturbation EL	P < .001
Vaginal EL vs masturbation EL	P < .001
Anal EL vs masturbation EL	P < .004

Discussion

To our knowledge, this is the first article to report specific sexual/ejaculatory responses for different types of sexual activities in men with APE using a retrospective–current approach that enables a lifespan perspective. We begin our discussion by noting that 13 years passed between men’s sexual debut and their development of PE symptoms. Yet the precipitating or triggering events or factors that intervened between sexual debut and the onset of symptomology remain largely unexplained. Although several factors are suggestive, including the fairly high rates of ED (33%) and anxiety/depression over the lifetime (28%), these rates were not out of line with other studies on men with PE^19,24 and, interestingly, not significantly different from a group of men with LPE drawn from the same online sample.²⁵ It is noteworthy that the men reported having satisfactory relationships (mean = 3.96/5.0, ±1.10) but low sexual satisfaction (mean = 2.75/5.0 ± 0.91), highlighting the negative impact of the dysfunction on the man and possibly the partner. Furthermore, the finding that one-third of the men with APE reported continued deterioration over time suggests that the condition may be further exacerbated by the aging process and/or by a developing or ongoing chronic disease (eg, cardiovascular, endocrine, LUTS²⁷) and/or worsening performance anxiety. At this time, a clear understanding of this continued deterioration does not exist, for example, whether the progression is gradual or punctuated, whether it can be explained by identifiable factors, whether and how men attempt to remediate the problem, and what consequences it has for the sexual lives of both the man and his partner. In an attempt to garner insight into these processes, follow-up analysis will adopt a multivariate approach in order to identify potential covariates (such as erectile functioning and level of sexual interest) that can help explain the observed changes in ELs over time.

Lifespan changes in foreplay and ELs

This study is also the first to empirically document the significant reductions in partnered ELs among men reporting APE through retrospective analysis. In our sample, all the partnered-sex ELs showed large reductions since sexual debut, including an approximately 80% reduction for vaginal and anal sex—those ELs were, on average, 58 and 45 s for vaginal and anal sex, respectively, each with an SD of around 1-1.5 min. Such statistical parameters suggest that about 85%-90% of the men with APE in our sample ejaculated within 2 min of penetration, well below the International Society of Sexual Medicine-ISSM-recommended threshold of 3 min.⁶ The ISSM threshold was based primarily on expert opinion,⁶ with two ancillary studies cited to support the 3 min determination.^11,12 Yet, careful inspection of those two studies actually reveals stronger support for a 2 min threshold than the existing 3 min threshold, as both studies indicate that the great majority of men with APE ejaculated within 2 min of vaginal penetration.^11,12

Notably, the ELs for APE men in our study were equal to or shorter than those of a comparison group of LPE men drawn from the same online community sample.²⁵ In this respect, the current study contributes to a sizable and growing body of evidence that supports a single EL threshold of approximately 2 min for men with either APE or LPE.^25,28 Indeed, a 2 min threshold would typically capture over 85% of men with APE and LPE during either vaginal or anal sex.^11,12

Regarding foreplay, a widely held clinical belief has been that men with PE avoid or minimize foreplay because it may lead to a high level of pre-penetration arousal and exacerbate the rapid ejaculation. This study offers no support for this assumption, as no reduction in foreplay time occurred as men developed PE symptomology. This somewhat surprising result was, however, not unique to men with APE, as similar foreplay durations were characteristic of men with other PE subtypes, including LPE and intermittent PE.^25,26 In addition, other studies have reported findings that closely align with the notion that foreplay duration in men with PE does not necessarily correlate with their rapid ejaculation. One study, for example, found foreplay duration to be similar for men with and without PE²⁹; another found that most men with PE reported that increasing foreplay duration had little or no effect on their ELs.³⁰

Although an empirically supported explanation for the lack of correlation between foreplay duration and ELs awaits further study, we posit that rapid ejaculation in men with PE may be tied more to partner-specific factors such as postpenetration penile stimulation and possible concomitant sexual performance anxiety^31-33 than to pre-penetration arousal derived from foreplay. Alternatively, an explanation offered by several respondents was that foreplay in men with PE is aimed primarily at arousing the partner in preparation for a sexual encounter that might otherwise be unusually brief in duration. For such men, the attentional focus on the “mechanical/technical task” of arousing the partner may temporarily attenuate their own arousal potential. Such hypothetical explanations highlight the need for further exploration of how foreplay in men with and without PE problems affects their ELs.^34,35

Comparison of ELs across different types of sexual activities

The finding that different types of sexual activities yielded consistent differences in ELs suggests that the ELs of PE men may be sensitive to different types of penile stimulation. Undoubtedly, men have greater control over their ejaculatory response during masturbation than during penetrative sex, which not only provides a feasible explanation for their longer ELs during the former activity but also is in sync with multiple studies now reporting a similar pattern.^19,30,36 Furthermore, the finding that different types of partnered sexual activities can modulate ELs in our study is consistent with the recent finding that various sexual intercourse positions and/or types of stimulation may improve ELs in some men with PE.^30,37 Although the gains in ELs were relatively small, they reiterate the important role that stimulus parameters (eg, intensity and rhythm) may play in ejaculatory response and, coupled with the potential for sexual performance anxiety to exacerbate dysfunctional responding during partnered sex, suggest that greater attention to the behavioral and psychological components of sexual engagement are worth exploration not only in psychosexual therapeutic settings but also in situations involving presumed pathophysiological origins for the APE.^31,38,39 Finally, the similarly short EL patterns across vaginal and anal intercourse, as well as overall partnered sex, reinforce the growing view that PE should not be evaluated solely with vaginal ELs. Comparable ejaculatory control across partnered sexual activities supports a more inclusive, behaviorally grounded conceptualization of PE, relevant not only to nonheterosexual men, about two-thirds of whom do not engage in penetrative sex, but also to heterosexual couples who may prefer or require nonpenetrative options during partnered sex.⁴⁰

Limitations

The major limitation of this study is the retrospective–present -day methodology and recruitment via social media, which could lead to sample biases and reliance on men’s recall. Although the sequencing of items in the survey was designed to maximize recall accuracy, retrospective assessment can be influenced by current cognitions about sexual experiences. However, in prestudy focus sessions, participants did not report significant difficulty recalling their EL or the duration of foreplay during their early sexual experiences. In fact, the men were confident of their recall ability. One explanation for their confidence is the well-known “primacy-recency” effect, a phenomenon by which individuals generally remember their first (early) experiences and last (most recent) experiences quite readily, relative to the interim experiences. Further confidence in the recall data is evident in the patterns of EL responses that were consistent with expectations regarding PE subtypes, with men who identified as having APE showing significant and meaningful differences in the early versus current ELs, and men who identified as having LPE showing no differences in early versus current ELs.²⁵ Nonetheless, we acknowledge that we have no objective method for assessing the accuracy of their recall.

The sample intentionally recruited men primarily from countries where social and legal tolerance protect sexually diverse individuals and behaviors, as stipulated by our IRB (see Appendix A), so the extent to which our findings apply to populations outside this catchment area is unknown. This restriction was enacted to protect men who practice particular sexual activities (and in so doing suggest a particular sexual orientation) that might result in persecution, prosecution, and other ill consequences (ie, blackmail). However, we note that while several early studies found regional and cultural differences in PE prevalence, careful review of the literature suggests otherwise, with recent empirical support suggesting consistency in PE characteristics across global regions.⁴¹

Regarding other limitations, the number of men engaging in anal sex was 23, so caution regarding the ELs for this specific type of sex is warranted. In addition, we relied on estimated ELs rather than clocked ELs, although at least three studies have noted the interchangeability of these measures.^42-44 And although we adhered to best practices regarding online survey distribution and data collection, biases in education, age, socioeconomic category, and other demographic characteristics are inevitable in nonprobability sampling procedures that rely largely on social media. To assess whether our sample exhibited undue bias, we compared sample statistics for PE men in this study with PE and non-PE men drawn from two other online datasets. In doing so, we found no substantive differences in the distribution of men in probable versus definite PEDT categories, in their average levels of ejaculatory control, or in their reported levels of dysfunction-related distress. Finally, the study might have reached an even more powerful conclusion had we been able to report that the changes in EL from sexual debut to the current time had occurred as a function of changes in erectile functioning, medication use, and other personal factors over the lifespan. Although such variables were assessed at the current time, there was no retrospective assessment of these risk factors, and therefore changes in these measures could not be explored as possible covariates for the changes in the ELs.

Conclusion

This study demonstrated, among other things, that the distribution of anal and vaginal intercourse ELs for men with APE were generally under 2 min, with mean values of 1 min or less representing an 80%-90% reduction since sexual debut, parameters that are well below the ISSM-recommended cutoff time of 3 min. In this respect, the ELs of men with APE were comparable to those of men with LPE. This study contributes to the growing body of evidence suggesting that a 2-min threshold would apply equally well to both PE subtypes. Results further indicate that ELs vary with the type of sexual activity, with men with APE demonstrating greater control over ejaculatory response during foreplay and masturbation than during penetrative sexual behaviors. Such patterns reiterate the relevance of various cognitive/behavioral strategies that focus attention on the man’s state of arousal and manage stimulatory intensity and rhythms in the treatment of PE, either alone or in combination with available pharmacotherapies.

Appendix A. List of subreddits

• r/takemysurvey/

• r/SampleSize/

• r/PrematureEjaculation

• r/sex

• r/sexover30/

• /r/menshealth/

• /r/OneY/

• r/NoFap

• r/askgaybros/

• /r/erectiledysfunction/

• r/lgbtstudies/

Appendix B. List of countries

• Australia

• Austria

• Belgium

• Canada

• Denmark

• Finland

• France

• Germany

• Ireland

• Italy

• New Zealand

• Norway

• Portugal

• Spain

• Sweden

• Switzerland

• United Kingdom

• United States

Funding

None declared.

Conflicts of interest

There are no disclosures for D.L.R. or P.C.-L. S.E.A. is a member of the Medical Advisory Board for Kandence Bio.

Ethical approval

The research was approved by the IRB of Valpariso University (VUIRB 24-2, 02.06.2024)