Understanding health care practitioners’ criteria regarding the decision to treat men with premature ejaculation

Abstract

Background

The extent to which health care practitioners (HCP) follow clinical practice guidelines (CPG) regarding diagnostic criteria can affect treatment outcomes, yet little is known about the factors HCPs take into consideration regarding their decision to treat men with symptoms of premature ejaculation (PE), a field where professional definitions vary considerably.

Aim

To describe HCP priorities regarding the use of PE diagnostic criteria in their decision-to-treat and, further, to assess whether HCP characteristics regarding specialization, professional identity, and experience impact decision-making priorities.

Methods

A total of 228 professionally-trained medical and mental health specialists responded to online and in-person invitations to complete a survey regarding their criteria and approaches for deciding whether to treat men with complaints of PE. Included were items pertaining to professional identity and experience, along with analyses of 5 items focusing on the use of professional guidelines for diagnosing PE, the role of ejaculatory latency (EL), ejaculatory control, and bother/distress, the method of assessing bother/distress, and understanding the role of anxiety in the diagnostic process.

Outcome

HCPs’ priorities regarding diagnostic criteria for PE, including whether professional identity, specialization, and clinical experience might have affected their priorities.

Results

Among the respondents, 42.5% identified with a mental health/therapy background; 57.5% with a medically-oriented background. Overall, 66.7% of HCPs used professional guidelines 70% of the time or more, with 33.3% using them half the time or less; 75% preferred either ISSM and DSM-5 guidelines. Furthermore, 61.6% indicated that the decision to treat did not consider EL at all, as long as other PE symptoms were present; and only 13.6% used a 1 min threshold. Bother/Distress and anxiety were explored in-depth by 81.5% and 78.5 of respondents, respectively. HCP characteristics regarding professional identity, specialization in sexual health, and clinical experience with PE had only weak effects on diagnostic strategies.

Clinical Implication

HCPs demonstrated a patient-centric rather than a criterion-centric approach regarding their decision to treat men with PE symptomology.

Strengths and Limitations

This study provided a rare in-depth view regarding the priorities of HCPs in their strategy for accepting patients for PE treatment. Limitations included a sample that was selective, not only due to the forums and networks from which they were drawn but also in terms of their Western geo-cultural origin.

Conclusion

Consistent with a patient-centric approach, HCPs dealing with men with PE generally follow the spirit of the professional diagnostic guidelines although not specific criteria within the guidelines.

Introduction

Clinical practice guidelines (CPG) aim to standardize evidence-based, high-quality care. Yet, despite decades of guideline development and dissemination, real-world adherence remains inconsistent. While adherence to guidelines improves outcomes, deviations increase the risk of complications, treatment resistance, and reduced effectiveness; diagnostic errors account for an estimated 6%-17% of adverse medical events.^1–3 Yet, publishing and disseminating guidelines rarely changes practice, and even structured feedback yields only modest improvements.^4,5 Guideline adherence is affected by factors at multiple levels: the health care practitioner (HCP), the patient, the utility of the guidelines, and the organizational environment.

Regarding HCPs, limited awareness or knowledge, lack of agreement with recommendations, low confidence in applicability to individual patients, and cognitive overload and time pressure all affect CPG adherence.^6,7 Furthermore, gaps between HCPs’ attitudes and behaviors regarding CPGs are common: although many HCPs endorse the guidelines in principle, they often deviate from them in actual practice.^8,9 Regarding patient factors, health literacy, expectations, illness complexity, treatment suitability, and sociocultural context may all influence HCPs’ decisions to either adhere to or deviate from guidelines.^10–13 Regarding the guidelines themselves, poorly-formatted, overly complex, confusing, seemingly rigid, or insufficiently individualized guidelines are considered less useful, particularly in high-pressure clinical environments.⁷ Finally, an organizational environment that promotes targeted training and the use of decision-support tools improves diagnostic and therapeutic accuracy.^14–16 Even then, however, when HCPs perceive guidelines as restrictive or misaligned with clinical realities, they prioritize flexibility and individualized assessment over adherence to specific guidelines.^9,17,18 Understanding criterion-adherence to CPGs related to premature ejaculation (PE) is critically important to improving diagnostic accuracy and ensuring consistent, evidence-informed management of this condition.

Diagnostic criteria for premature ejaculation

Premature ejaculation (PE) is characterized by ejaculating before desired during partnered sex and often results in shame, embarrassment, and diminished sexual satisfaction for the man and his partner.^19–24 Currently, at least six different sets of diagnostic criteria have been delineated by various professional organizations or groups.^25–30 All criteria share three common elements: (1) ejaculation upon minimal stimulation, operationalized by a short ejaculation latency (EL); (2) a lack of ability to delay ejaculation; and (3) dysfunction-related negative consequences such as bother, distress, and anxiety. Most professional definitions also distinguish between lifelong and acquired PE subtypes, reflecting different developmental pathways related to biological, psychological, relationship, and/or pathophysiological factors.^{25,26,28–30}

Nonetheless, major inconsistencies persist across definitions. EL thresholds vary considerably: LPE is defined as ≤1 minute in some guidelines^25,27 but ≤2 minutes in others,^26,30 while APE thresholds range from ≤3 minutes²⁵ to 2-3 minutes^26,30; two prominent definitions specify no EL threshold at all for either PE subtype.^28,29 Frequency or consistency of occurrence criteria are similarly heterogeneous: some definitions specify occurrence “on all/nearly all” occasions (eg, ^25–27,30), whereas ICD-11 recognizes PE as either “episodic or persistent”²⁸ and the European Urological Association (EUA) is mute on the issue.²⁹ The point about “regularity” is relevant because several studies have examined men who experience a form of PE that seems episodic or intermittent (IPE).^21,31–34 Such conflicting criteria not only impede the use of standardized protocols for PE research, but also render diagnostic procedures both confusing and inconsistent. Inconsistency may further contribute to diagnostic uncertainty and reduce adherence to strict (often varying) guidelines. Consequently, HCPs may dismiss or disregard either general or specific aspects of the criteria as being vague, debatable, and even doubtful.

Do HCPs actually use the diagnostic criteria for PE?

Accurate assessment of PE is essential for estimating prevalence, guiding treatment, and supporting research on risk and causal mechanisms.^19,35,36 Nevertheless, a recent 15-year review of research studies found that EL criteria were applied inconsistently across studies and, in some cases, EL criteria were omitted altogether, with focus more on ejaculatory control and distress.^37,38 Clinical practice shows a similar trend^32,39–41: clinicians acknowledge EL but prioritize loss of control, distress, and interpersonal impact when diagnosing and treating PE.^25,42 Thus, HCPs often manage men whose self-reported EL exceeds formal thresholds but whose impairment and distress match PE, using clinical judgment and context-sensitive assessment rather than fixed cutoffs.^{25,37,43–45} Overall, while formal criteria guide definitions, research and practice favor a flexible, patient-centered approach, supporting a balance between empirical validity and clinical utility beyond strict latency cutoffs.^44,46,47

Training, professional education, and the use of diagnostic criteria

HCP diagnostic accuracy and therapeutic decisions are shaped by training, clinical exposure, and familiarity with evidence-based standards. Specialty training influences focus: sexual medicine specialists may follow guidelines more consistently than non-specialists^29,33; urologists emphasize biophysical measures, while mental health clinicians prioritize psychological dimensions.^24,48 Structured, ongoing professional education can improve diagnostic accuracy, guideline alignment, and evidence translation,^49–51 and strengthen patient-centered communication and shared decision-making.^51–56 Along with cultural competence, which helps HCPs recognize the role of diverse beliefs and comfort levels surrounding sexual dysfunction and its treatments,^57,58 targeted education can play an important role in helping HCPs understand both the value of diagnostic criteria and their limitations.

Rationale and goals of the study

The understanding and use of diagnostic criteria play an important role in HCP’s decision-to-treat men with PE and manage their symptoms. At the same time, the diagnostic criteria must make sense within the context of the patient-clinician dialog, and should correspond to the priorities and goals of both the patient and HCP. Yet, within the field of sexual medicine, professional definitions for PE have conflicting criteria, rendering diagnostic procedures for treatment both confusing and inconsistent, particularly for those less familiar with the historical roots of the inconsistencies. Furthermore, such inconsistencies convey a lack clarity and confidence among professionals regarding the appropriate characterization of PE, a situation that might lead researchers and HCPs to dismiss or disregard the criteria altogether. Indeed, such concerns might be overcome, in part, through focused training, specialization, and clinical experience: as HCPs develop deeper understanding of the overarching characteristics of PE, they will improve their diagnostic protocols and increase the probability of better outcomes.

In this study, we were interested in better understanding the role of diagnostic criteria in HCPs’ decision to treat men approaching a clinic with symptoms or complaints of PE. Specifically, in this cross-sectional online survey of HCPs, our goals were:

1. To describe HCP priorities regarding the use of PE diagnostic criteria in their decision-to-treat, including the relevance of EL and dysfunction-related distress (Aim 1);

2. To understand how professional training, specialization in sexual health, and clinical experience treating PE affect response patterns regarding the goal above (Aims 2a-c);

3. To gain deeper insight into HCPs thought-processing, attitudes, and decision-making by analyzing qualitative data based on optional response elaborations following each question (Aim 3).

Method

Participants

Of those meeting eligibility requirements of 18+ years, providing informed consent, professionally qualified, and actively treating men with PE, the completion (or near completion) rate for the survey was 80.4%. For those respondents that answered the first content question related to the goals of the survey itself, the completion or near-completion rate was 100%, yielding a final sample size of 228 for most items. Preliminary power analysis determined that for a 0.05 significance level, a moderate effect size, and power (1-β) set at 0.80, about 40 cases per grouping represented an adequate size for cross-group comparisons.

Survey development

As a literature search turned up no relevant studies and/or assessment instruments on this topic as it relates to PE, we constructed a brief survey intended to delve into the perspectives of HCPs from various medical and mental health backgrounds on their use of professional definitions and guidelines in the diagnosis of PE. As part of the survey development, 9 practitioners drawn from a variety of medical and mental health backgrounds reviewed various versions of the survey for purposes of determining alignment of the questions with the survey goals, item face-validity and relevance, structure and content of the questions and response options, and approximate completion time. In addition, a pilot test on 30 initial HCPs helped to further identify remaining issues with clarity, face-validity, content-validity, sequencing of items, adaptive and conceptual flow of the survey, and opportunities for elaboration.

Preliminary questionnaire items gathered information regarding global residence, professional training/identity, specialization in sexual health care or medicine, and experience treating men with PE, including the number of years in PE practice and the typical number of patients seen each year (Table 1). The body of the questionnaire included items pertaining to three domains: the use of professional definitions/guidelines by HCPs in the decision to treat a man with purported PE; the criteria used by HCPs to assess when treatment was successful, met its goals, or should be ended; and the role of adjunctive issues related to the treatment of PE, including partner involvement, interdisciplinary collaborative efforts, the likelihood of success, and satisfaction with available treatment methodologies, including pharmacotherapies. The present study dealt only with the first domain, namely decision-to-treat information, and extracted the results of 5 of the 20 items pertaining to this section of the questionnaire. These items took one of two formats: four questions dealing with decision-to-treat criteria permitted one response option; the fifth question dealing with areas of clinical investigation permitted multiple responses (see Tables 2 and 3). Each item invited respondents to elaborate upon, qualify, or explain their response; and where appropriate, “other” response option with elaboration was included.

Table 1.

Distribution of professional experience items related to the treatment of men with PE.

Variable	N	%	Variable	N	%
Men treated/year			Years treating Men
Less than 5	49	21.6	Less than 5	59	25.9
About 5-10	60	26.4	About 5-10	65	28.5
About 11-20	40	17.6	About 11-20	48	21.1
More than 20	78	34.4	More than 20	56	24.6

Table 2.

Use of and preference for professional definitions for PE.

Question	Response options	Frequency	Percent (%)
Verify that patient meets diagnostic guidelines?	Not regularly, < 30% of time	33	14.5
	About half the time, 30-70%	43	18.9
	Most of the time, > 70%	152	66.7
	Total	228	100.0
Which guideline primarily followed?	ISSM	105	46.1
	DSM	67	29.4
	ICD	24	10.5
	EAU	9	4.0
	Andrology Assn or other (eg, combination)	6	2.7
	Not sure, or do not follow guidelines	15	6.6
	Total	226	100.0

Table 3.

Frequencies and percentages for key clinical perspectives on premature ejaculation (PE).

Question	Response options	Frequency	Percent (%)
Decision-to-treat when man presents treatment	treat only if reported EL ≤ 1 min	30	13.6
	treat only if reported EL ≤ 2 min	31	14.0
	treat only if reported EL is under about 3 min	24	10.9
	treat if EL is frustratingly short, without considering EL	72	32.6
	treat if EL is frustratingly short, even if in a normal range	64	29.0
	Total	221	100.0
Primary way of assessing level of distress	Assumed by man’s presentation at clinic	42	18.4
	Mainly PROs or scales	26	11.4
	Intake procedure/clinical interview	160	70.8
	Total	228	100.0
When assessing distress, explore other sources of anxiety?a	General anxiety	179	78.5
	Depression	157	68.9
	Relationship anxiety	196	86.0
	Performance anxiety	209	91.7
	Rather focus on ejaculatory control, latency, satisfaction	10	4.4

^aRespondents rank ordered response options, with only the highest ranked option presented here.

Procedure

The distribution and collection of data via the online questionnaire—approved by the Institutional Review Board of Valparaiso University, USA, VUIRB#24-2, 02.06.24—followed best practices for online surveys.^59–63 Informed consent was obtained by participants’ checking boxes attesting (1) to their current age of ≥18 years, and (2) to their informed consent before accessing the questionnaire. As informed, respondents could voluntarily end participation without penalty by closing the webpage. No funding or involvement occurred from any outside organization, commercial or otherwise, and no benefit was realized by any commercial or professional organization, or respondent linking to the survey.

Information about the questionnaire and its purpose was distributed through the authors’ personal and professional networks, with a posted link to the online survey opening April 1, 2025 and continuing through December 1, 2025. Three methods were used to distribute the survey. First, an email list from an international educational platform dedicated to sexual HCPs (IOSS) was utilized to disseminate an e-newsletter, inviting individuals to respond to the survey. Second, individual invitations were sent by email to sexual HCPs by the authors, selected based on personal-professional networks. Third, announcements were made at professional conferences and workshops inviting attendees to access and complete the questionnaire.

Data analyzes

Quantitative analyzes

Initial analysis generated frequencies for response options for each item. A secondary analysis was aimed at understanding how professional identity/training, specialization in sexual health, and experience in treating PE were related response patterns, as determined by t-tests, chi square, or other measures of association. These analyzes utilized IBM SPSS (Version 27.0; IBM Corp, 2020).

Qualitative analyzes

About 10% of respondents provided elaboration of their item responses. Given the modest volume and brief format of these data, the qualitative findings were used to contextualize and deepen interpretation of the quantitative response patterns rather than to stand as an independent qualitative dataset.

Open-ended responses to the five questions were analyzed using an inductive qualitative content analysis approach. Because the qualitative material consisted of brief optional written elaborations linked to fixed-response items, the analytic aim was not theory generation but the systematic identification of recurring clinical meanings, decision principles, and interpretive patterns across responses. The analysis was conducted manually by the researcher and proceeded in several explicit steps to enhance transparency and consistency of interpretation.

First, all open-ended responses were compiled item by item and read repeatedly in full to achieve immersion in the data and to gain an overall sense of the range and tone of clinicians’ comments. During this familiarization phase, preliminary analytic notes were made regarding recurring concepts, contrasts, and clinically meaningful expressions. Second, responses were segmented into meaning units, defined as words, phrases, or sentences expressing a distinct idea relevant to clinicians’ diagnostic reasoning or treatment decision-making. Third, these meaning units were assigned initial open codes that stayed close to participants’ own wording whenever possible. In the next step, codes were compared across responses and iteratively grouped into higher-order categories on the basis of conceptual similarity. Category labels and definitions were refined through repeated movement between the raw text, the provisional codes, and the emerging category structure. Earlier-coded responses were revisited whenever new codes or categories were introduced, so that coding decisions were applied consistently across the dataset rather than only in a linear fashion. To strengthen consistency in interpretation, the developing coding structure and representative excerpts were reviewed by a second researcher, with attention to whether category labels accurately reflected the underlying text and were meaningfully distinct from one another. Disagreements or ambiguities in interpretation were resolved through discussion and return to the original responses until a shared interpretation was reached.

Results

Description of the sample

The active sample consisted of 228 professionals. Respondents were drawn primarily from Central, Southern, and Western Europe (68.3%), with the remainder scattered across other world regions (Supplementary Table S1). Respondents’ professional backgrounds represented the spectrum of disciplines linked to sexual health (Supplementary Table S2). Broadly classified, 97 (42.5%) identified with a mental health/therapy background; 131 (57.5%) identified with a medically-oriented background. Also, 187 (82.4%) identified as sexual health/medicine specialists, 40 (17.6%) identified as non-specialists. Regarding the two items assessing treatment experience, HCPs indicated a range of experiences, from less than 5 years to more than 20, and from less than 5 patients per year to more than 20 (Table 1), with respondents spread fairly evenly across categories.

Frequency responses to each question in the overall sample (aims 1,3)

On two items related to the use of published professional diagnostic criteria (Table 2: variables VERIFY and GUIDELINES), 66.7% used them more than 70% of the time, 18.9% used them about half the time, and 14.5% used them less than 30% of the time. The most preferred diagnostic criteria were ISSM and DSM-5, accounting for 75.5% of the respondents, with 17.2% using ICD, EAU, or andrology-based criteria, and 6.6% foregoing the use of professional criteria. Qualitative responses highlighted the fact that clinicians who favored ISSM often viewed it as the most clinically relevant and practice-oriented framework for PE, aligning well with psychosexual and multidisciplinary treatment contexts. DSM, by contrast, was more frequently described as a background or a complementary reference, used alongside client experience rather than as a rigid diagnostic approach. Several respondents explicitly noted that DSM criteria were conceptually helpful but insufficient to capture the complexity of PE in clinical practice. In addition, several respondents noted that sharing diagnostic labels or strict criteria with clients could reinforce shame or inadequacy, preferring instead to use guidelines internally while adopting more client-centered therapeutic language that helps “normalize” their condition by minimizing shame, embarrassment, and stigmatization.

Respondents’ results regarding their use of specific PE diagnostic criteria are presented in Table 3 (variables LATENCY, DISTRESS, ANXIETY). The first question (LATENCY) dealt with HCPs’ criteria regarding their decision to treat men presenting with PE, specifically with regard to their EL—one of the stated criteria for all PE definitions. Of the 228 HCPs, 61.6% indicated that they did not consider EL at all, so long as the patient/client was frustrated or dissatisfied with his current ejaculatory response. The remaining 38.4% considered EL as relevant information: 10.9% used a 3 min threshold; 14.0% a 2 min threshold; and 13.6% a 1 min threshold. From qualitative data, a strong consensus emerged that distress and perceived loss of control were more clinically meaningful than a time-based EL threshold, even among the roughly 38% of HCPs who used explicit latency thresholds as a factor in their decision. That is, EL was rarely viewed as a stand-alone criterion and was instead considered in combination with clinical history.

Of all the respondents, 81.5% assessed distress (DISTRESS)—also a criterion for a PE diagnosis—via an in-depth clinical session or via PROs; 18.4% assumed the man’s presentation at the clinic was sufficient reason to assume dysfunction-related distress. Consistent with the emphasis on assessing distress, various types of anxiety (ANXIETY) were explored by 78.5% or higher of HCPs, with performance anxiety reaching nearly 92%. However, 4.4% of respondents, mainly those assuming the patient’s distress by their help-seeking behavior, focused on other PE symptoms, including ejaculatory control, latency, and sexual satisfaction. Qualitative responses revealed that some clinicians conducted comprehensive assessments that focused on sexual history, partner dynamics, psychological functioning, and social context, which reinforce the perceived complexity and contextual nature of PE-related distress.

Role of HCP characteristics on response patterns

Does professional identity/training affect the use of PE diagnostic criteria? (aim 2a)

Professional identity/training (medical practitioners [MEDP] vs mental health practitioners [MHP]) was significantly associated with two items related to PE diagnostic criteria. Regarding LATENCY, MHPs were less likely to require short EL of 1-2 min and more likely to accept a client whose EL—though somewhat typical—was a source of frustration (Kendall’s tau = -.134; P = .034), although the effect size was small. Regarding DISTRESS, MEDPs were more likely to accept presentation at the clinic as evidence of distress and less likely to explore the issue either through PROs or in-depth clinical interviews (Kendall’s tau = -.304; P < .001), a moderate effect size.

Does identifying as a specialist affect the use of PE diagnostic criteria? (aim 2b)

Non-specialists were slightly more likely to adhere to specific EL criteria (LATENCY) than specialists, although the effect size was small (Kendall’s tau = -.125; P < .003).

Does greater experience treating men with PE affect the use of PE diagnostic criteria? (aim 2c)

A composite variable representing professional experience was created by combining two correlated variables (r_s = 0.41): the HCP’s years of experience treating PE and their estimated annual PE patient load. Only one item (DISTRESS) reached significance: HCPs with more experience were more likely to assume that clinic presentation was sufficient evidence of distress; those with less experience were more likely to conduct in-depth intakes or interviews to assess distress (Kendall’s tau = -.127; P = .034).

Correlations among items

Intercorrelations among items having an underlying ordinal scale (VERIFY, LATENCY, DISTRESS) were assessed with Kendall’s tau. Greater VERIFY was weakly-moderately correlated with higher exploration of DISTRESS (Kendall’s tau = .231, P < .001). And greater VERIFY was weakly correlated with using stricter EL criteria (LATENCY) in practitioner’s decision-to-treat (Kendall’s tau = .168, P = .004). These weak correlations strengthen the assumption that various questions were not merely tapping into the same construct but were in fact assessing different aspects of the decision-making process within the clinical setting. At the same time, they demonstrate that HCP responses showed at least some patterns of predictability across items.

Discussion

Although the parameters defining PE have been discussed and debated for over three decades, few studies have adopted a clinical perspective offering insight into HCPs use of, adherence to, and perspectives on the diagnostic criteria that guide their decision-to-treat potential clients. The perspective of HCPs is particularly relevant, given the inconsistent and conflicting criteria for PE across existing professional definitions^26–30—inconsistencies that not only confuse the diagnostic process, but also reduce confidence in the utility and benefit of applying guidelines that lack consensus.^7,9,11–13

In our study, about 2/3 of HCPs used professional guidelines “most of the time” to verify PE in men seeking treatment, while nearly 1/3 were lax about their approach, relying on them about half the time or less. Over 75% of respondents reported using either the ISSM or DSM guidelines for PE; the remaining 25% used a variety of other professional definitions. These patterns suggest that significant percentages of HCPs may rely largely on clinical judgment rather than specific diagnostic criteria in their decision to treat. They further indicate that no particular set of professional guidelines is viewed as a gold standard for treatment—with patterns suggesting that HCPs disciplinary training may influence their preference for specific definitional criteria.^24,29,33,48 Similarly, qualitative responses illustrate flexibility in using guideline-informed but pluralistic viewpoints, with clinicians selecting frameworks that best fit their professional background, healthcare context, and client-centered clinical philosophy. Interestingly, given the irregular use of professional criteria among HCPs, along with the inconsistencies across professional definitions, the pool of men being treated for PE likely includes some who most definitely have it, others who might have it, and some who may not have it all.^64,65

Further insight into HCPs’ attitudes regarding their decision-to-treat is evidenced by questions that addressed two specific PE diagnostic criteria: ejaculatory latency (EL) and bother/distress. Regarding EL, less than 40% of HCPs viewed EL (at any threshold) as a critical factor in their decision to treat; the majority (60%) focused on men’s frustration/distress about their impaired sexual response. In the qualitative responses, EL was framed as contextual and relational, not absolute, with some HCPs explicitly stating that if a client/couple experienced significant distress, reduced sexual confidence, or relational strain, treatment was warranted regardless of whether diagnostic criteria are technically met.

In fact, these patterns reveal an interesting paradox: the majority of respondents (75%) relied on ISSM or DSM guidelines for the diagnosis of PE—both of which stipulate a qualifying EL of about ≤1 min. Yet only 13.6% of HCPs indicated that this criterion was critical to their decision-making, illustrating the large disconnect between formal guidelines and actual practice.^9,17,18 Regarding bother/distress, 70% of HCPs explored this criterion as part of the clinical intake or interview, while another 11% relied mainly on PROs. Slightly under 20% assumed that a dysfunction-related visit to the clinic was sufficient evidence for bother/distress. Many HCPs explicitly differentiated between diagnostic PE and PE-like presentations, offering psychoeducation, counseling, or psychotherapy when ELs were normal but distress was high. In this respect, our data suggest that HCPs encounter patients who present distress and seek treatment despite having EL values within the “normal” range; yet it remains unclear how these cases are being managed in practice and which approaches are most effective. Because this scenario is common in routine care (62% of respondents did not consider EL a deciding factor; 82% and 79% routinely assess distress and anxiety), clinical education should provide explicit guidance and training on assessment, communication, and evidence-based management for such individuals to ensure patient-centered, effective care.

Furthermore, the finding that over 4 of 5 HCPs explore sources of general and/or relationship anxiety, and that 9 of 10 explore performance anxiety, is testament to the strong role that patients’ negative feelings play regarding HCPs’ decision to treat.^66–68 In their qualitative responses, clinicians described tailoring treatment based on consensual goals, realism of expectations, and broader sexual functioning. For some men, success involved learning control; for others, it involved normalization, acceptance, or expanding sexual repertoires beyond penetration. A substantial proportion of qualitative comments elaborated on broader psychological vulnerabilities. Clinicians frequently mentioned shame, low self-esteem, perfectionism, and chronic self-criticism, often describing these as pre-existing traits rather than consequences of PE alone. A smaller but still clear subset of responses addressed developmental, trauma-related, and neurodevelopmental factors, including early sexual learning under conditions of secrecy, childhood adversity, attachment style, and ADHD. Finally, while less frequent than psychological and relational themes, biopsychosocial and physiological contributors (eg, pelvic floor functioning, autonomic arousal, medication effects) often appeared across qualitative responses, usually framed as interacting with—rather than replacing—biopsychosocial explanations. In brief, HCP responses indicated consensus that distress in PE is best understood as multilayered, with sexual performance anxiety and relationship dynamics at its core, embedded within broader psychological, developmental, and contextual factors. In this respect, both medical and mental health practitioners—via training, ethical responsibility, and professional experience—understand their primary role and motivation as one of patient care and well-being rather than as gatekeepers who decide who should or should not be offered treatment.^43–45

Role of HCP characteristics

Although our sample showed considerable variability regarding respondents use of and/or adherence to professional diagnostic criteria, HCP characteristics accounted for only a small amount of this variability. That is, unlike some research on non-sexual ailments,⁴⁹ evidence that disciplinary training, specialization, and professional experience predicted patterns of professional criteria usage regarding PE was weak. Specifically, MHPs were slightly more likely to focus on distress factors and less likely to use strict EL criteria; non-specialists indicated slightly greater reliance on using various EL cutoffs than specialists, an understandable action, given that non-specialists need to rely on expert sources due to their limited professional experience; and HCPs with more experience were slightly more likely to assume that dysfunction-related presentation at a clinic was sufficient evidence of distress; those with less experience were more likely to conduct in-depth interviews to assess distress. Although significant, these relationships were weak, in each case accounting for under 2% of the variance in responding. In fact, such minimal differences reassure potential clients that a PE diagnosis is generally not dependent on the HCP professional characteristics or experience. Such patterns further emphasize HCPs’ patient-centric approach (vs criterion-centric) when dealing with men’s PE problems.^{51–56,67–69} Furthermore, although our data do not assess whether the flexibility regarding adherence to PE diagnostic criteria reflects other (non-HCP) issues such as clinical judgment, definitional variability, or uncertainty about guideline applicability, our findings echo known barriers to guideline adherence (eg, perceived as being too restrictive or misaligned with clinical realities^9,17,18): that typically lead clinicians to prioritize flexibility and individualized assessment over adherence to specific guidelines. Such patterns reiterate the general importance of clinician training in applying context-sensitive decisions, and setting shared, outcome-focused goals.^53–55

Limitations

We tapped an HCP population that was undoubtedly selective, not only due to the forums and networks from which they were drawn—groups often interested in issues surrounding sexuality and thus motivated to participate—but also in terms of geo-cultural origin. Thus, our results may be limited in their generalization to primary care physicians or other HCPs who may not be part of sexual health networks, although our study uncovered no meaningful differences in diagnostic strategies between non-specialists and specialists. Perhaps more to this point is whether our findings generalize to those HCPs who practice in world regions having strong histories of traditional medicine, alternative treatment pathways, and religious/cultural values that rely on non-science explanations for disease.⁵⁸

Although we assessed the roles of EL and bother/distress in HCPs’ decision-making, in this analysis, we did not include the role of ejaculatory control, typically considered an important dimension of PE.^47,70 In a forthcoming study, we examine in detail the role of this factor in patient’s stated concerns at clinic presentation as well as HCPs’ objectives regarding therapeutic outcomes and criteria for satisfactory treatment.

Conclusions

HCPs dealing with men with PE generally follow the spirit of the professional diagnostic guidelines although not specific criteria within the guidelines. The vast majority consider distress and/or other negative fallout as critical to their decision to treat men complaining about rapid ejaculation. Although respondents showed a full range of use and adherence to clinical guidelines, minimal variation could be attributed to HCP characteristics. As is often expected regarding issues surrounding sexual problems, HCPs generally adopted a strong patient-centric approach rather than diagnostic-centric approach.

Author contributions

Conceptualization: PKS, ZM, DR; Methodology: DR, PSK, ZM; Data Collection: PSK, DR, ZM; Data Analysis: DR, ZM; Visualization: PSK, DR, SM; Writing: DR, ZM, PSK; Writing, Editing, and Review: DR, ZM, PSK.

Funding

None declared.

Conflicts of interest

The authors report no conflicts of interest.

Copyright permission

All work, including tables, is original and therefore does not require permissions.

IRB approval

This project was reviewed and approved by the Institutional Review Board at Valparaiso University, USA (VUIRB:#24-2, 02.06.24). All respondents checked a box attesting to their informed consent prior to accessing the survey.