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Genital-prioritized attentional bias in lifelong premature ejaculation: behavioral evidence from eye-tracking and machine learning

International Journal of Impotence Research (2026) Cite this article

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Abstract

Lifelong premature ejaculation (LPE) involves altered responses to sexual cues. Neuroimaging has identified attention-related neural abnormalities in LPE, but behavioral evidence for attentional bias remains limited. Using eye tracking, we compared visual-attention patterns in 35 heterosexual men with LPE (andrology outpatient clinic, Henan Provincial People’s Hospital) and 38 heterosexual healthy controls (HCs) (online advertisements on official platforms of Henan Provincial People’s Hospital and Xidian University), from Nov 2023 to Jun 2024. Participants freely viewed three categories of sexual images (bikini-clad, nude, intercourse). Gaze metrics—first fixation order (FFO), fixation count (FC), and proportion of dwell time (PDT)—were extracted within predefined areas of interests (AOIs; face, chest, genital) for each stimulus category, yielding 27 candidate eye-tracking features per participant (3 categories × 3 AOIs × 3 metrics). We then applied sequential backward selection (SBS) with support vector machine (SVM) to select the most discriminative feature subset. An SVM classifier trained on the selected features distinguished LPE from HCs with 82.2% accuracy (AUC = 0.78). Compared with HCs, LPE showed earlier genital orienting (FFO: nude 4.2 ± 1.5 vs 6.0 ± 2.2, p < 0.001; intercourse 3.8 ± 1.5 vs 4.9 ± 1.9, p = 0.004) and more genital fixations (FC: bikini-clad 4.2 ± 1.6 vs 3.3 ± 1.2, p = 0.006; intercourse 7.9 ± 3.1 vs 6.1 ± 2.0, p = 0.008), indicating a genital-prioritized attentional bias. Anxiety and depression scores were higher in LPE (SAS: 34.1 ± 6.4 vs 29.4 ± 5.8, p = 0.003; SDS: 34.8 ± 7.6 vs 29.5 ± 6.8, p = 0.003), but no eye-tracking features correlated with these symptoms. Earlier genital orienting correlated with greater LPE severity (FFO vs PEDT: nude r = −0.47, p < 0.001; intercourse r = −0.36, p = 0.002). This study provides the first behavioral evidence of a genital-prioritized attentional bias in heterosexual men with LPE, offering novel mechanistic insight into its neurocognitive underpinnings.

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Fig. 1: Schematic overview of the eye-tracking paradigm.
The alternative text for this image may have been generated using AI.
Fig. 2: Overview of eye-tracking data collection, feature extraction, and feature selection procedure.
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Fig. 3: Classification performance based on selected eye-tracking features.
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Fig. 4: Scatterplots showing correlations among FFO, PE severity, and emotional symptoms.
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Data availability

The data that support the findings of this study are available from the corresponding authors upon reasonable request.

Code availability

The code used for feature extraction and machine-learning analyses is available from the corresponding authors upon reasonable request.

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Funding

This study was supported by the Henan Provincial Medical Science and Technology Tackling Program Joint Co-construction Project (No. LHGJ20210054).

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Authors and Affiliations

  1. Engineering Research Center of Molecular and Neuro lmaging of Ministry of Education, School of Life Science and Technology, Xidian University, No. 2 South Taibai Road, Xi’an, 710071, China

    Weilu Chai, Zhichao Liu, Jiahui Xu & Minghao Dong

  2. Xi’an Key Laboratory of Intelligent Sensing and Regulation of trans-Scale Life Information, School of Life Science and Technology, Xidian University, 266 Xinglong Section of Xifeng Road, Xi’an, 710071, China

    Weilu Chai, Zhichao Liu, Jiahui Xu & Minghao Dong

  3. Department of Andrology and Energy Medicine, Henan Provincial People’s Hospital, People’s Hospital of Zhengzhou University, Zhengzhou, 450000, Henan, China

    Jinxing Liu, Xin Chen & Xiangsheng Zhang

  4. Department of Ophthalmology, The First People’s Hospital of Xianyang, 10 Biyuan Road, Xianyang, 712009, China

    Rui Pei

  5. Faculty of Psychology and Education Sciences, University of Porto, Porto, Portugal

    Nicoletta Cera

  6. Research Unit in Medical Imaging and Radiotherapy, Cross I&D Lisbon Research Centre, Escola Superior de Saúde da Cruz Vermelha Portuguesa, Lisbon, Portugal

    Nicoletta Cera

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  1. Weilu Chai
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Contributions

WLC and ZCL curated and analyzed data, implemented code, and prepared visualizations; JHX assisted with data curation and code; JXL with curation and validation. ZCL, JHX, XC, and RP conducted the investigation. WLC, ZCL, and MHD developed methodology. MHD and XSZ conceived, supervised, and administered the study, provided resources, and MHD secured funding. Validation was provided by WLC, JXL, XC, RP, and NC. WLC drafted the manuscript, which WLC, MHD, and NC revised and edited. All authors read and approved the final manuscript.

Corresponding authors

Correspondence to Xiangsheng Zhang or Minghao Dong.

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Competing interests

The authors declare that there are no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

Declaration of generative AI and AI-assisted technologies in the writing process

During the preparation of this work the author(s) used OpenAI's GPT-4 solely for linguistic refinement. After using this tool/service, the authors reviewed and edited the content as needed and take full responsibility for the content of the publication.

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The present study was approved by the Ethics Committee of Henan Provincial People’s Hospital and conducted in accordance with the Declaration of Helsinki. Written informed consent to participate was obtained from all participants.

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Written informed consent for publication of the anonymized participant image shown in Fig. 2A was obtained from the participant.

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Chai, W., Liu, Z., Xu, J. et al. Genital-prioritized attentional bias in lifelong premature ejaculation: behavioral evidence from eye-tracking and machine learning. Int J Impot Res (2026). https://doi.org/10.1038/s41443-026-01288-7

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