Delayed ejaculation is listed among the sexual dysfunctions in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5 : 302.74) [37]. It is characterized as a marked delay or infrequency of ejaculation occurring in about 75–100% of partnered sexual activity, accompanied by a desire not to delay the ejaculation—indicating that the delay is neither intentional nor wanted. In addition, the DSM-5 definition assumes that the condition is accompanied by clinically significant distress and that it has persisted for at least 6 months. The International Classification of Diseases ((ICD-10 Version 2016: www.​who.​int/​classifications/​icd/​en/​) [38], the standard diagnostic tool used to monitor the incidence and prevalence of diseases and other health problems, also includes a code for delayed ejaculation under the nomenclatures of “inhibited orgasm” and “psychogenic anorgasmy ;” (F52.3, Orgasmic Dysfunction: Inhibited Orgasm [male][female]), the latter suggesting a condition of orgasmic absence distinguished by its psychological origin. Neither the DSM-5 nor ICD-10 classification is fully inclusive, comprehensive, or clear in meaning. For example, DSM-5 neither temporally defines “delay” nor specifies situations of inadequate arousal or severe relationship distress in the classification. ICD-10, on the other hand, does not elaborate upon its coding categories to differentiate orgasm from ejaculation, or inhibited orgasm from psychogenic anorgasmy; and it too provides no temporal parameters for “delay,” stating only that orgasm “does not occur or is markedly delayed.” To its credit, DSM-5 includes relevant qualifiers such as “acquired” or “lifelong” (see Sect. “Lifelong vs. acquired DE”), and “generalized” or “situational,” along with designation of “mild, moderate, or severe.” In addition, DSM-5 notes the importance of considering five other factors: (1) partner, (2) relationship, (3) individual vulnerability (e.g., history of abuse), psychiatric comorbidity (e.g., depression), and stressors, (4) cultural/religious influences, and (5) medical factors. The relevance of these risk/qualifying factors were discussed in detail in Sect. “Etiology, Physiology, and Pathophysiology,” of this chapter (see Table 16-2).

There are no clearly specified parameters as to when a man actually meets the conditions for DE, as operationalized criteria do not exist. Perhaps a simplified strategy is to use an approach that parallels that of another male orgasmic disorder—namely premature ejaculation—in which three criteria are considered: ejaculatory latency, self-efficacy, and level of distress or bother [1, 39]. The first criterion regarding ejaculatory latency for men with DE can be based on findings that the median ejaculation time for most men is around 6–10 min (standard deviation = ± 3–4) [40, 41]. Therefore, those men who meet the following three criteria might be considered candidates for a DE diagnosis .

The above characteristics, together with the fact that a man and/or his partner are sufficiently concerned or upset by the condition that they have decided to seek help for the problem, are grounds for considering a DE diagnosis.

Delayed ejaculation has not attracted the same level of attention in the media as erectile dysfunction (ED) and premature ejaculation (PE) . No FDA approved medication is available for the treatment of DE (as is the case for ED), and unlike PE , pharmaceutical companies have not vigorously studied and pursued biomedical treatments for delayed ejaculation. As a result, men whose sexual relationships are disrupted by their difficulty or inability to ejaculate remain somewhat hidden from view, receiving little or no attention from the popular press and, more disconcertingly, from close and sustained investigation by the research community [11, 42]. As a result, we know little about the etiology of DE based on large study samples—for example, whether these men have always had difficulty reaching ejaculation or whether they typically develop the problem after a period of more typical ejaculatory latencies; we have little empirically based information regarding etiological factors for those men who have had a lifelong problem with reaching ejaculation; we have little understanding of the level of distress these men experience about their condition—for example, whether the difficulty or inability to reach orgasm results in levels of distress comparable to men experiencing erectile dysfunction [43] or premature ejaculation [44, 45]; and we have little insight into how the problem affects their sexual relationship.

On the other hand, sufficient numbers of men do seek help for DE to suggest that the inability to ejaculate imparts a number of psychobehavioral consequences, including diminished sexual satisfaction, low self-efficacy, and a lack of self-confidence [13, 16]. Furthermore, such men typically report a history of unsatisfying sexual relationships and, in some instances, a preference for masturbation over intercourse [14, 46]. In those instances where procreation and having a family are among the couple’s goals of sexual intercourse, delayed and/or inhibited ejaculation may be particularly troubling and frustrating to one or both partners.

Similar to men with other types of sexual dysfunction, men with DE indicate high levels of relationship distress, sexual dissatisfaction, anxiety about their sexual performance, and general health issues—significantly higher than sexually functional men. In addition, along with other sexually dysfunctional counterparts, men with DE typically report lower frequencies of coital activity [13]. A distinguishing characteristic of men with DE—and one that has implications for treatment—is that they usually have little or no difficulty attaining or keeping their erections—in fact they are often able to sustain erections for prolonged periods of time. But despite their good erections, they report lower levels of psychosexual arousal, at least compared with sexually functional men [33].

Comprehending the array of factors that account for variation in latency to ejaculation following vaginal intromission is key to understanding any sexual problem. As with many other biobehavioral responses, variation in ejaculatory latency is under the influence of both biological and psychological-behavioral factors. One contemporary way of conceptualizing the interaction of these systems has been proposed by those who study evolutionary psychology [47]. The ejaculatory latency range for each individual may be predisposed or biologically set (e.g., via genetics), but the actual timing or moment of ejaculation within that range depends on a variety of contextual, psychological-behavioral, and relationship-partner variables [16, 48]. Such thinking is clearly supported by the fact that ejaculatory latency in men with ejaculatory disorders (either premature or delayed ejaculation) is often quite different during coitus than during masturbation [49].