1. Introduction

Premature ejaculation (PE) decreases a person’s sexual confidence and causes psychological comorbidities, which seriously affect both their health and that of their partners [1]. Furthermore, according to a recent study, both patients and healthcare professionals are hindered by cultural, religious or moral factors when addressing sexual concerns during medical consultations, which makes it difficult to provide a diagnosis and possible treatment [2]. This study aims to describe and understand the experiences of patients with attention-deficit/hyperactivity disorder (ADHD) and premature ejaculation. This could pave the way for the development of useful strategies that would enable healthcare professionals to provide these patients with better care and make them feel more comfortable in seeking help.

PE is listed in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR) [3] and is one of the most common sexual dysfunctions among the population [4, 5, 6, 7]. Approximately 30% of men over the age of 40 in Europe suffer from this sexual dysfunction [8]. However, the prevalence of PE varies significantly worldwide, with reported figures ranging from 3% to over 30%, depending on the diagnostic criteria used [8, 9]. According to the International Society for Sexual Medicine, PE consists of ejaculation that occurs consistently within 1 minute before or after penetration [5, 7]. Other studies suggest that ejaculatory latency could extend to 2 minutes or more [6]. This sexual dysfunction produces negative psychological effects on both the patients and their partners; anxiety, depression and distress are some of the symptoms that affect their quality of life, relationships, self-esteem, and confidence [1, 5].

ADHD is a mental health condition characterised by hyperactivity, restlessness, impulsivity, and attention deficit [10, 11, 12, 13] that often develops in childhood. In the Dominican Republic, the prevalence of ADHD among children stands at 7.6% [14]. However, ADHD can persist into adulthood and cause psychological and social consequences, substance abuse and family conflict [1, 10, 12, 15]. Its prevalence among adults is estimated at 2–5% worldwide [15, 16] and is higher in males than females, with a 2:1 ratio [17, 18]. Adults with ADHD often have problems concentrating, act impulsively and get distracted, resulting in higher levels of anxiety, depression and lower levels of general satisfaction in life. These symptoms have a negative impact on their daily lives, affecting their work, personal, romantic and sexual relationships [11, 19]. In terms of sexuality, scientific evidence suggests that ADHD should be considered a risk factor for sexual dysfunction [10, 15]. It has been reported that most patients with ADHD have a higher incidence of sexual dysfunction [15, 20], including PE [10, 21]. In fact, Soydan et al. [13] reported that 42% of patients diagnosed with ADHD suffered from PE. This sexual dysfunction has a negative impact on their health, leading to negative emotions during or after sexual intercourse [15]. According to the International Society of Sexual Medicine’s Guidelines, general practitioners and nurses are often the first line of contact for these patients within the healthcare system [22]. For this reason, healthcare professionals need to be able to identify PE and ensure that the patient feels comfortable seeking help [23].

There is current research highlighting ADHD as a mental disorder that affects sexual health [19] and sexual functioning [11]. In addition, a recent study suggests that these patients tend to engage in risky sexual behaviours due to their impulsivity [24]. Nevertheless, a recent review emphasises the need for further research on the sexuality of ADHD subjects [19]. For this reason, and due to the lack of qualitative studies describing the experiences of ADHD patients with sexual dysfunction, we decided to pursue this research. This study aimed to describe the experiences of men with attention-deficit/hyperactivity disorder and premature ejaculation.

2. Materials and methods

3. Results

Twenty-three participants aged 31–44 years (mean: 38.26, Standard Deviation (SD): 4.20) with PE and a history of ADHD participated in the study. Of the twenty-three participants, thirteen were married and twenty-one had children. All participants indicated that they had a female partner and fourteen identified as Catholic. In terms of educational level, sixteen had a university education. The age at which PE started ranged from 17 to 28 years (mean: 21.96, SD: 3.74) and all participants suffered from lifelong PE. All participants with ADHD were receiving pharmacological treatment. Patients under treatment for ADHD received prescriptions for daily doses of methylphenidate. The dose was response-adjusted, ranging from 27 to 36 mg per day. The socio-demographic characteristics of the participants are presented in Table 2.

Inductive data analysis was used to develop two main themes and four sub-themes, which helped to understand the experiences of participants diagnosed with ADHD who experience PE (Table 3).

4. Discussion

This study aimed to describe and understand the experiences of patients with ADHD and premature ejaculation. Following a phenomenological approach inspired by Merleau-Ponty has allowed us to understand a complex phenomenon from the perspective of the individuals embodying it. The experiences of the participants with ADHD and PE were interpreted taking into account that we access the world through our bodies [25]; the participants’ bodies cannot be separated from their presence in the world. The participants faced several challenges in relation to PE, which had an impact on their masculinity and sexual satisfaction. Recent studies on masculinity are relevant due to current social changes in society that permeate economic, political, cultural, and sexual spheres. The main objective of studies on masculinity is to identify the conflict that men experience in the face of changes to masculine identity [32].

Male sexuality is seen as a symbol of virility and masculine power. The exploration of this analytical approach has been driven by feminist studies on sex and sexuality that highlight how women are oppressed by men, thus creating an impelling force for studying male sexuality. From a social perspective, while female sexuality is repressed, male sexuality is encouraged and seen as a symbol of masculinity [33].

The study participants experienced social pressure to conform to masculine norms, which led to feelings of shame, depression and anxiety. In addition, PE negatively affected their relationships, causing sexual dissatisfaction and emotional conflict. To address this dysfunction, the participants sought to identify possible triggers, such as ADHD or excessive sexual desire, and explored various therapeutic strategies. They also turned to media sources, such as the Internet, for information and possible solutions, but to no avail. Despite the challenges in their relationships, open and honest communication with their partners played a crucial role in the process of managing PE.

The participants felt ashamed for not meeting social expectations to satisfy their partners during sex, which compromised their sense of masculinity. The contribution of women’s studies to gender approaches should not be underestimated. They have had a significant impact on current research on masculinity, given that the problems related to female sexuality highlight the need to study their gender counterpart. This includes attitudes, men’s role in society, and the personification of men’s power. Men with PE often focus intensely on their sexual performance, leading them to disconnect from their partners and not pay attention to their partners’ satisfaction [34]. This is common among those with sexual dysfunction due to health issues [35, 36]. Feminist research has highlighted how, in dominant cultural discourses, men’s sexuality has been positioned as superior to women’s [37]. However, the tides are changing, and women are no longer submissive; instead, they are demanding a pleasurable and satisfying sex life, which could lead men to feel threatened, thus accelerating the ejaculation process. The participants with PE felt stressed, dissatisfied, and fearful of their partners being unfaithful, resulting in a significant psychological burden [37, 38]. In addition, they experienced anxiety, depression, and insecurity due to their inability to satisfy their partners sexually. As for how quickly a man can achieve an erection after ejaculation, our conclusions are based on the experiences of the participants. The male refractory period varies with age; it is shortest at 20 years of age but as an individual ages, it lengthens and can last from hours to days [39]. The ejaculatory process of individuals with ADHD could be accelerated by psychological factors related to the condition, such as impulsivity and lack of attention or concentration.

These findings are consistent with previous studies on patients with PE [7, 40, 41]. Disorders such as anxiety and depression may significantly contribute to both the cause and perpetuation of PE [6, 41]. Therefore, specific care is required to manage this sexual dysfunction. The participants stated that PE had led to conflicts and difficulties in their relationships, as well as sexual dissatisfaction for both partners due to their inability to prolong sexual encounters. These ejaculation disorders hinder the pleasure of both the affected person and their partner [42, 43]. The participants also described negative experiences of sexual intercourse, which led them to have fewer and less enjoyable encounters. Similar results were observed in a previous study examining the dynamics of a couple in which one partner suffered from PE. It revealed a significant level of sexual dissatisfaction and a gradual reduction in the frequency of sexual encounters [7]. In addition, there are some studies that suggest that circumcision could have positive effects on the latency time of intravaginal ejaculation, ejaculation control, sexual satisfaction and the severity of PE [44]. Many participants tried various strategies to prolong intercourse and satisfy their partners but did not achieve the desired results. These disappointing experiences led some participants and their partners to avoid sex and be unfaithful. A recent study has shown that people who practise polygamy have a lower incidence of PE compared to monogamous men. This finding has been attributed to greater sexual experience, relationship maturity, a higher frequency of sexual intercourse and greater psychosexual comfort [45].

Most participants believed that ADHD could be a potential cause of PE. They identified distractibility, a common aspect of their daily lives, as a contributing factor. These findings are in line with recent evidence suggesting that distractibility may adversely affect sexual activity for individuals with ADHD as it reduces their enjoyment, while also highlighting ADHD as a relevant risk factor for PE [10]. Furthermore, the participants identified sexual hyperexcitation as a potential trigger for PE, corroborating previous research that established an association between the severity of ADHD symptoms and the manifestation of hypersexual behaviors [46]. Similarly, it has recently been suggested that a thorough assessment of individuals with lifelong PE about ADHD be conducted, with particular emphasis on hyperactive and impulsive characteristics [21]. Impulsivity, in general terms, is characterized by action without premeditation, impatience, a willingness to take risks, difficulty in waiting for one’s turn, an inability to maintain concentration, difficulty in delaying gratification, and a propensity for novelty seeking [47, 48]. Considering that the mastery of ejaculatory control is a developmental and structural process and given that most men naturally learn to delay ejaculation, traits such as hyperactivity and impulsivity may adversely impact this motor learning process [49, 50]. Furthermore, the participants highlighted other factors, such as work stress, sedentary lifestyles, and financial difficulties, as exacerbating the problem and leading to less frequent sexual intercourse with their partners. When treating PE, it is essential to consider the combination of physiological, psycho-behavioural, cultural, and relational factors, as all these elements play an important role [51]. The participants, motivated by their desire to satisfy their partners, tried to find solutions through communicating with their partners and friends, as well as with different healthcare professionals. For these individuals affected by PE, confiding in their partner was key to managing their condition. Recent literature suggests providing psychosexual counselling and cognitive-behavioural therapies focused on sexuality to all patients with PE, with their partners actively participating in the treatment process [52]. The participants also searched for information on the internet and sought out recommendations from friends, which led them to put various methods for dealing with PE to the test, such as the use of medication and anesthetic creams, the consumption of energy drinks and masturbation before sex. However, these strategies proved to be ineffective. Indeed, while online searches for PE are increasing, reflecting the current relevance of this condition in society [53], a study evaluating the quality of information available on the internet about PE revealed that only a few websites offered complete and comprehensive medical information about this sexual dysfunction. As a result, men are accessing information of highly variable quality [54].

When working with patients diagnosed with PE who also present with hyperactivity and ADHD, clinicians should consider specific strategies and interventions that address both the sexual aspects and symptoms associated with ADHD. It is crucial to perform a comprehensive evaluation that includes both sexual history and a detailed evaluation of ADHD, to identify how these disorders interact and affect patients’ lives. Cognitive behavioral therapies may be particularly effective, focusing on cognitive restructuring to manage the negative thoughts and impulsivity characteristic of ADHD. It is also recommended that behavioral techniques, such as ejaculation control training using stop-and-start methods and systematic desensitization, be adapted to manage inattention and hyperactivity [52]. Additionally, psychosexual counseling that focuses on information about sexual function, communication among couples, and the resolution of underlying emotional problems, could provide a framework for improving understanding and cooperation between patients and their partners. Moreover, multidisciplinary collaboration with ADHD specialists, such as psychiatrists and psychologists, is essential to ensure cohesive and effective treatment that addresses all facets of these complex disorders [52].

The characteristics of the participants were diverse in terms of age, religion, age of onset of PE, and lived experiences, thus guaranteeing variability in their responses. Although the number of participants is deemed acceptable as a result of reaching data saturation, it is crucial to acknowledge that our findings cannot be extrapolated to the entirety of men with ADHD and PE. This is due to the qualitative nature of our study, whose primary aim was to understand the experiences of the participants. The main limitation we have encountered when analysing the literature is the lack of information regarding the prevalence of PE in the participants’ country of origin, meaning that we were unable to gain an in-depth understanding of the situation as a whole. Further research estimating the prevalence of PE in the Dominican Republic would be advisable. In addition, the participants were all from the Dominican Republic, so the sample is not representative of today’s multicultural society. To have a better understanding of the phenomenon, future research should be conducted in different geographical and could include patients with PE who have male partners. It would also be advisable to use comparison groups to compare participants’ experiences with PE and ADHD.

5. Conclusions

Our findings suggest that individuals with both PE and attention-deficit/hyperactivity disorder experience heightened emotional challenges stemming from traditional masculine norms and the social pressure to conform, ultimately having a negative impact on their sexual well-being. Furthermore, they encounter difficulties in their relationships, resulting in sexual dissatisfaction for both partners. In a quest to reclaim their sexual identity and function, the participants sought assistance from healthcare professionals and explored potential triggers for this sexual dysfunction, including the influence of ADHD.

The study participants expressed gratitude for the opportunity to engage in open and nonjudgmental discussions concerning an issue they needed to address and manage with the support of healthcare professionals and their loved ones. Gaining a deeper understanding of the experiences of individuals with PE has the potential to improve the approach and efficacy of treatments for managing this condition.

Availability of data and materials

The data for this study consist of audio recordings and transcripts from the interviews with the participants. These contain confidential information (e.g., full names). The analyzed data is stored in an ATLAS.ti software project, which is required for access. Additionally, all of the data is in the possession of the lead researcher (RRR).

Author contributions

JGG and RRR—designed the research study; analyzed the data. RGA, RFC and ARO—performed the research. MRM and RAR—provided help and advice on critical review of the manuscript; wrote the manuscript. All authors contributed to editorial changes in the manuscript. All authors read and approved the final manuscript.

Ethics approval and consent to participate

The study was conducted in accordance with the Declaration of Helsinki and approved by the Ethics Committee of the Institute of Human Sexuality of the School of Medicine of the Autonomous University of Santo Domingo (Protocol number: CEI-ISH-001-2023). Participants were informed about the study’s objective and asked to provide written consent for their participation. The participants signed an informed consent form and granted permission to record the interviews before the data collection process began. The Organic Law 3/2018 of 05 December 2018, on the Protection of Personal Data and Guarantee of Digital Rights guaranteed confidentiality and anonymity.

Acknowledgment

This study has been made possible thanks to the “Programa de Ayudas para la Recualificación del Sistema Universitario Español. Ministerio de Universidades (Spanish Government)”. We would like to thank the participants who took part in this study.

Funding

This work was supported by the “Plan Propio de Cooperación Internacional 2023” of the University of Almería (reference: UAL2023_3).

Conflict of interest

The authors declare no conflict of interest.