DSM-5 Write-Up No. 2
Category: Delayed Ejaculation
Sexual dysfunctions include delayed ejaculation, erectile disorder, female orgasmic disorder, female sexual interest/arousal disorder, Genito-pelvic pain/penetration disorder, male hypoactive sexual desire disorder, premature (early) ejaculation, substance/medication-induced sexual dysfunction, another specified sexual dysfunction, and unspecified sexual dysfunction. Sexual dysfunctions are a heterogeneous group of disorders that are typically characterized by a clinically significant disturbance in a person’s ability to respond sexually or to experience sexual pleasure. An individual may have several sexual dysfunctions at the same time. In such cases, all the dysfunctions should be diagnosed.
The essential feature of delayed ejaculation is a marked delay in or inability to achieve ejaculation or marked infrequency of ejaculation on all or almost all occasions of partnered sexual activity, despite the presence of adequate sexual stimulation and the desire to ejaculate. To qualify for a DSM-5 diagnosis of delayed ejaculation, the symptoms must have persisted for a minimum duration of approximately 6 months and must cause clinically significant distress in the individual. The partnered sexual activity may include manual, oral, coital, or anal stimulation. In most cases, the diagnosis will be made by self-report, although for men in heterosexual partnered relationships, it is frequently the female partner’s distress that motivates treatment seeking. It is common for men who present with delayed ejaculation to be able to ejaculate with self-stimulation, but not during partnered sexual activity. The definition of “delay” does not have precise boundaries, as there is no consensus as to what constitutes a reasonable time to reach orgasm or what is unacceptably long for most men and their sexual partners. Although the definitions of delayed ejaculation apply equally well to both heterosexual and homosexual orientation, most of the research focus has been based on the concept of intravaginal latency, and therefore male-female intercourse. The findings from those studies document that the majority of men’s intravaginal ejaculatory latency time (IELT) range is approximately 4–10 minutes.
The man and his partner may report prolonged thrusting to achieve orgasm to the point of exhaustion or genital discomfort and sometimes even injury to himself and/or his partner before finally ceasing. Some males may report avoiding sexual activity because of a repetitive pattern of difficulty ejaculating. Delayed ejaculation is associated with highly frequent masturbation, use of masturbation techniques not easily duplicated by a partner and marked disparities between sexual fantasies during masturbation and the reality of sex with a partner. Males with delayed ejaculation typically report less coital activity, higher levels of relationship distress, sexual dissatisfaction, lower subjective arousal, anxiety about their sexual performance, and general health issues than sexually functional men.
The prevalence of delayed ejaculation in the United States is estimated at 1%–5% but has ranged as high as 11% in international studies. However, variation in syndrome definitions across studies may have contributed to differences in the prevalence of the DSM-5 disorder.
Development and Course Genetic and physiological.
Another medical condition or injury and/or its treatment. Lifelong delayed ejaculation begins with early sexual experiences and continues throughout the course of an individual’s life. Acquired delayed ejaculation begins after a period of normal sexual function. A number of biomedical, psychosocial, and cultural factors can contribute to the predisposition to or maintenance of lifelong or acquired delayed and either subtype can be generalized or situational in nature. The prevalence of delayed ejaculation increases with age. As males age, they are more likely to have progressively more of the following changes in ejaculatory function, including, but not limited to, reduced ejaculatory volume, force, and sensation, and increased “refractory time.” Refractory latency increases for male’s secondary to surgical, medical, and pharmaceutical complications, as well as aging.
Risk and Prognostic Factors
Ejaculatory latency is an end point consequence that is determined by a range of factors. A large number of psychosocial factors increase the probability of an individual experiencing delayed ejaculation, with depression and relationship dissatisfaction being predominant contributors. Numerous medical conditions may lead to delayed ejaculation, including procedures that disrupt sympathetic or somatic innervation to the genital region such as radical prostatectomy for cancer treatment. Neurological and endocrine disorders, including spinal cord injury, stroke, multiple sclerosis, pelvic-region surgery, severe diabetes, epilepsy, hormonal abnormalities, and sleep apnea, as well as alcohol abuse, bowel dysfunction, cannabis use, and environmental factors, may be associated with delayed ejaculation. Additionally, medications that inhibit α-adrenergic innervation of the ejaculatory system (e.g., tamsulosin) are associated with delayed ejaculation, as well as antihypertensive agents, antidepressants (e.g., selective serotonin reuptake inhibitors), and antipsychotic drugs.
Age-related loss of the fast-conducting peripheral sensory nerves and age-related decreased sex steroid secretion may be associated with an increase in delayed ejaculation in males as they age. Reduced androgen levels with age may also be associated with delayed ejaculation.
Sex- and Gender-Related Diagnostic Issues
By definition, the diagnosis of delayed ejaculation is only given to males. Distressing difficulties with orgasm in women would be considered under female orgasmic disorder.
Functional Consequences of Delayed Ejaculation
Delayed ejaculation is often associated with considerable psychological distress in one or both partners. Difficulty with ejaculation may contribute to difficulties in conception and lead to significant fertility assessment, as the lack of ejaculation is not often spontaneously discussed by individuals unless there is direct inquiry from their physician.
A major diagnostic challenge is Substance/medication use. Dysfunction with orgasm. F52.21 differentiating between a delayed ejaculation that is fully explained by another medical condition or injury (or its treatment) and a delayed ejaculation attributable to a variety of proportionally different biomedical-psychosocial and cultural factors that determine the symptom(s). A number of medical conditions or injuries, along with their treatments, may produce delays in ejaculation independent of psychosocial and cultural issues. Delayed ejaculation must be differentiated from a number of urological conditions (especially other ejaculatory disorders), including retrograde ejaculation or anejaculation, which is typically the result of etiologies ranging from hormonal to neurological and/or anatomical abnormalities, including ejaculatory duct obstruction and other urological disorders. A number of pharmacological agents, such as antidepressants, antipsychotics, α sympathetic drugs, alcohol, and opioid drugs, can cause ejaculatory problems. In such cases, the diagnosis is substance/medication-induced sexual dysfunction instead of delayed ejaculation. It is important in the history to ascertain whether the complaint concerns delayed ejaculation or the sensation of orgasm, or both. Ejaculation occurs in the genitals, whereas the experience of orgasm is believed to be primarily subjective. Ejaculation and orgasm usually occur together but not always. For example, a male with a normal ejaculatory pattern may complain of decreased pleasure (i.e., an hedonic ejaculation). Such a complaint would not be coded as delayed ejaculation but could be coded as other specified sexual dysfunction or unspecified sexual dysfunction.
There is some evidence to suggest that delayed ejaculation may be more common in severe forms of major depressive disorder.
American Psychiatric Association.
(2022). Diagnostic and statistical manual of mental
disorders: DSM-5-Tr. APA Publishing.
Boland, R., Verdiun, M., &
Ruiz, P. (2021). Kaplan and Sadock's synopsis of Psychiatry. Wolters
Mitra, P., & Jain, A. (2022).
Dissociative Identity Disorder. New York University School of Medicine.
Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK568768