The Journal of Sexual Medicine, 2023, 20, 426–438

https://doi.org/10.1093/jsxmed/qdad008
Advance access publication date 13 February 2023
Original Research

Characteristics of men who report symptoms of delayed

ejaculation: providing support for empirically derived
diagnostic criteria
David L. Rowland, PhD1 ,* , Drew R. Attinger, BS1 , Abigail L. Morrow, BS1 , Ion Motofei, MD2 ,
Krisztina Hevesi, PhD3
1 Department of Psychology, Valparaiso University, Valparaiso, IN 46383, United States
2 Department of Psychiatry, Carol Davila University, 020021 Bucharest, Romania
3 Institute of Psychology, ELTE Eötvös Loránd University, H-1053 Budapest, Hungary

*Corresponding author: Department of Psychology, Valparaiso University, Valparaiso IN 46383, United States. Email: david.rowland@valpo.edu

Abstract
Background: Little is known regarding the demographic, sexual, and relationship characteristics of men with symptoms of delayed ejaculation
(DE).
Aim: To identify differences between men with and without DE symptomology to validate face-valid diagnostic criteria and to identify various
functional correlates of DE.
Methods: A total of 2679 men meeting inclusion criteria were partitioned into groups with and without DE symptomology on the basis of their
self-reported “difficulty reaching ejaculation/orgasm during partnered sex.” Men were then compared on a broad array of demographic and
relationship variables, as well as sexual response variables assessed during partnered sex and masturbation.
Outcomes: Outcomes included the identified differences between men with and without DE symptomology.
Results: Men with DE—whether having comorbid erectile dysfunction or not—differed from men without DE on 5 face-valid variables related to
previously proposed diagnostic criteria for DE, including ones related to ejaculation latency (P < .001); self-efficacy related to reaching ejaculation,
as assessed by the percentage of episodes reaching ejaculation during partnered sex (P < .001); and negative consequences of the impairment,
including “bother/distress” and (lack of) “orgasmic pleasure/sexual satisfaction” (P < .001). All such differences were associated with medium
to large effect sizes. In addition, men showed differences on a number of functional correlates of DE, including anxiety, relationship satisfaction,
frequency of partnered sex and masturbation, and level of symptomology during partnered sex vs masturbation (P < .001).
Clinical Implications: Face-valid criteria for the diagnosis of DE were statistically verified, and functional correlates of DE relevant to guiding
and focusing treatment were identified.
Strengths and Limitations: In this first comprehensive analysis of its kind, we have demonstrated widespread differences on sexual and
relationship variables relevant to the diagnosis of DE and to its functional correlates between men with and without DE symptomology during
partnered sex. Limitations include participant recruitment through social media, which likely biased the sample; the use of estimated rather than
clocked ejaculation latencies; and the fact that differences between men with acquired and lifelong DE were not investigated.
Conclusion: This well-powered multinational study provides strong empirical support for several face-valid measures for the diagnosis of DE,
with a number of explanatory and control covariates that may help shed light on the lived experiences of men with DE and suggest focus
areas for treatment. Whether or not the DE men had comorbid erectile dysfunction had little impact on the differences with men having normal
ejaculatory functioning.
Keywords: delayed ejaculation; inhibited ejaculation; sexual dysfunction; erectile dysfunction; relationship satisfaction; partnered sex; masturbation.

Introduction be lifelong or acquired, and while its etiology is uncertain, it

Delayed ejaculation (DE), an umbrella nosologic term that
often includes the complete absence of ejaculation, represents
the difficulty or inability of men to ejaculate during partnered
sex. DE has been defined by the DSM-5 as “a marked delay in
ejaculation” or “marked infrequency or absence of ejaculation
. . . present in 75% or more of partnered sexual encounters
and persistent over at least the last 6 months . . . [and the
experience of)] clinically significant distress”.1 The ICD-11
offers a similar definition, identifying “male delayed ejacula-
tion” as the “inability to achieve ejaculation or an excessive
or increased latency of ejaculation, despite adequate sexual
stimulation and the desire to ejaculate . . . which has occurred
episodically or persistently over . . . at least several months,
and is associated with clinically significant distress”.2 DE can
likely involves physiologic/somatic, pathophysiologic, and/or
psychological origins.
Although its prevalence is uncertain, DE was initially
reported at fairly low rates in the literature, typically around
3% to 5%.3-5 More recent clinical and community samples
have placed the prevalence substantially higher, by some
estimates closer to 7% to 15% of men.6-8 For example, one
recent community sample reported that the percentage of
men indicating a strong “desire to ejaculate sooner” during
partnered sex was around 7% to 8%,9 nearly identical to
results from the National Health and Social Life Survey in the
United States.10 Others, however, note that in the absence of
clear diagnostic criteria, the rate of DE may be underreported
and therefore even higher.11

Received: November 16, 2022. Revised: December 15, 2022. Accepted: January 3, 2023
© The Author(s) 2023. Published by Oxford University Press on behalf of The International Society of Sexual Medicine. All rights reserved. For permissions,
please e-mail: journals.permissions@oup.com.
The Journal of Sexual Medicine, 2023, Vol 20, Issue 4
Furthermore, prevalence rates are undoubtedly affected
by other factors, including how the DE population is
defined. For example, DE may be a lifelong problem, or
it may be acquired later in life.12 Many men with DE—
estimated at 10% to 30%—also show signs of erectile
dysfunction (ED),13,14 yet studies reporting prevalence have
not always controlled for this comorbidity. Specifically, for
men with comorbid ED, the problem may be a lack of
sufficient rigidity to reach ejaculation rather than difficulty
or inability to ejaculate. In contrast, men without ED who
complain of DE are often capable of getting and keeping
firm erections yet find it difficult or impossible to ejaculate
during partnered sex,15 suggesting either a high ejaculatory
threshold or, despite good erections, insufficient arousal for
ejaculation.
Differentiating characteristics of men with DE
Identifying differences in sexual and relationship functioning
between men with and without DE has received sporadic
attention. Ironically, studies have been more successful at
identifying characteristics that do not differentiate men with
and without DE, including ones such as age, body mass
index,16 testosterone levels,16,17 genetic predisposition,18
and alexithymia (ie, the diminished ability to feel and/or
express emotions).19 Nevertheless, 3 characteristics have
emerged that do appear to distinguish men with DE from
men without DE: higher negative emotionality (bother/dis-
tress) related to sexual activity,16,20-22 lower relationship
quality/satisfaction,15,16,23 and insufficient arousal to reach
ejaculation.15,23 Regarding this last characterization, men
with DE report lower arousal to erotic stimuli despite
having laboratory-assessed erections comparable to men
without DE,15 a finding further supported by a small-sample
functional magnetic resonance imaging study suggesting that
abnormal neurotransmitter activity in specific brain regions
may signify sexual arousal deficits to erotic stimulation
in men with DE.23 A similar interpretation of inadequate
arousal has emerged from reports that some DE men who
masturbate very frequently may accustom themselves to
stimulus conditions that do not generalize well to partnered
sex.5,20,24
Rationale and goals
The lack of empirical studies and consequent dearth of evi-
dence regarding descriptors of men with DE have highlighted
the need for further study of men who report this condition.
Such information is critical for 2 reasons. First, it may help
specify variables most relevant to the definition and diagnosis
of DE, including ones manifested during partnered sex.25
Second, it may help identify covariates related to the func-
tional (sexual) impairment relevant to understanding the lived
experiences of the patient/couple and to developing effective
treatment strategies.26,27
Against this backdrop, we explored differences between
men reporting difficulty reaching ejaculation/orgasm and men
with normal ejaculatory function during partnered sex on a
broad array of demographic, sexual, and relationship vari-
ables. Specifically, the study pursued 3 goals:
Aim 1: To identify differences on potential face-valid diag-
nostic variables for DE between men with and without DE
427
symptomology, including those with comorbid ED and those
without ED.
Aim 2: To ascertain that identified differences in face-valid
diagnostic variables were robustly linked to partnered sex.
Aim 3: To identify correlates related to the functional
impairment associated with DE.
Methods
Participants
Participants were recruited through voluntary self-selection
from July 2019 through February 2020 to complete a sur-
vey pertaining to sexual health and behavior. The sample
was recruited through 2 approaches. The first group was
recruited from the United States and other English-speaking
countries (n = 699) and included men who responded to the
research homepage, postings on several reddit.com forums,
or any of the unpaid social media (eg, Facebook) and pub-
lic announcements. The second group was recruited from
Hungary and included men who responded to comparable
forum posts, unpaid online/public announcements, or the
Hungarian research webpage (n = 3243). A final group (data
not in this study analysis) consisted of men attending a major
university in Hungary (n = 134) who volunteered to take an
anonymously coded pencil-and-paper version of the ques-
tionnaire to enable test-retest reliability analysis on specific
questionnaire items after 4 to 6 weeks.
The completion rate for the survey was 81% of those
who initially opened it (active n = 3142). Among those com-
pleting the survey, men were excluded from the analysis if
they had never had a sexual partner; identified as “asex-
ual” or transgender/nonbinary; reported having premature
ejaculation (PE); chose not to ejaculate during partnered sex
or masturbation; or showed inconsistency in responding, as
determined by 6 embedded “attention checks” in the survey
(eg, responding on 1 survey item in a manner that was
inconsistent with a response on a similar item). The final
internet-based sample consisted of 2679 men ≥18 years of age
(mean [SE] = 37.5 [0.253], range = 18-85): 633 (23.6%) from
English-speaking countries and 2046 (76.4%) from Hungary.
Survey questionnaire
During the survey development process, 7 focus groups
were convened. Two groups included men in the United
States (n = 10; mean age, 32.4 years), and 5 groups included
men from Hungary (n = 79; mean age, 2.7 years), the latter
consisting primarily of university students in several profes-
sional and academic disciplines. Group members reviewed
the questionnaire items, commented on their relevance and
clarity of phrasing, and suggested wording changes and
additional response categories.28 Focus groups also appraised
item face validity and assessed the time required for survey
completion. For Hungarian respondents, the questionnaire
was translated to Hungarian by a professional translator and
subsequently back-translated to English to ensure preserva-
tion of meaning. Because items drawn from standardized
assessment instruments embedded in the survey had already
been validated in Hungarian, these translated items were
used, with minor wording changes to fit the requirements of
the present study (eg, modifying “intercourse” to “partnered
sex”).
428
The first part of the 55-item survey queried about demo-
graphic and health characteristics, such as the respondent’s
age, education, anxiety/depression throughout the previous
6 months, and any chronic medical conditions related to sex-
ual functioning. The second portion examined participants’
sexual histories during the previous 12 to 24 months, includ-
ing sexual orientation, self-reported interest in sex, general
relationship satisfaction, and sexual relationship satisfaction.
This section also evaluated the estimated ejaculation latencies
(ELs) as well as frequencies of partnered sex, masturbation,
and pornography use during masturbation. The third sec-
tion addressed common sexual dysfunctions in men during
partnered sex and masturbation and consisted of relevant
items from the abridged version of the International Index
of Erectile Function (IIEF-5)29 and the Premature Ejaculation
Diagnostic Tool (PEDT),30 as well as questions aimed at
assessing DE.
Major organizing variable of interest
The organizing variable in this study was whether or not
men indicated “difficulty reaching orgasm/ejaculation during
partnered sex,” a face-valid defining characteristic of men
with DE. The sample of men without DE (NON-DE) excluded
men having PE. The sample of men with DE was defined in
2 ways: the first group included all men indicating difficulty
reaching orgasm (ALL DE); the second group included men
indicating difficulty reaching orgasm but not experiencing ED
(PURE DE).
Assessment of DE
As no patient-reported outcomes have been validated for
assessing DE,7 we selected an experimenter-derived item from
the questionnaire to assess DE symptomology. Specifically,
respondents were asked about their “difficulty reaching
orgasm during partnered sex,” with responses scaled 1 to 5
such that higher scores represented greater difficulty. For this
item, 1 and 2 represented no/mild DE; 3, moderate DE; and 4
and 5, moderately severe to severe DE—with the 4-5 category
(ie, ≥75% of the time) used to define DE for comparisons
across DE and NON-DE groups. This percentage (75%)
aligns with the DSM-5 criterion for DE.1 Test-retest reliability
for this item was 0.70 to 0.73 depending on the specific
grouping analyzed.
Control covariates
Two concomitant sexual problems were assessed to better
define the study groups: (1) PE was assessed so that men with
this problem could be removed from the study sample, and
(2) ED was assessed so that men with this problem could be
studied in relation to their DE status.
Premature ejaculation
PE was assessed to ensure that the “normal ejaculatory func-
tioning” group did not include men with PE. We used 3
of the 5 items from the PEDT30 focusing on ejaculatory
control, the construct most central to PE.31 Two items related
to “bother/distress” were not included as they represented
consequences of PE. Consistent with the diagnostic categories
for the PEDT,30 for the included items (scaled 1-5, with higher
scores representing greater probability of PE), scores of 13
to 15 represented definite PE; 9 to 12, probable PE; and ≤8,
The Journal of Sexual Medicine, 2023, Vol 20, Issue 4
no PE. Those with definite PE were removed from the study
sample. Internal reliability for these 3 items ranged from 0.80
to 0.85,32 and test-retest reliability was 0.85.
Erectile dysfunction
ED was assessed during partnered sex to identify men who
were to be removed from the sample to generate the PURE
DE group (those without concomitant ED). Four IIEF-5
items specifically related to erection29 were used; an item
focusing on satisfaction during intercourse was not included.
Consistent with the scoring rubric for the IIEF-5, lower scores
indicated greater ED, and men with scores <10 (moderately
severe to severe ED) were removed for the PURE DE group.
Internal reliability for the 4 items was 0.89, and test-retest
reliability was 0.86.
Classes of outcome variables
See Table A1 for detailed descriptions of items and variables.
Face-valid diagnostic criterion variables for DE (aim 1)
Based on previous reports and reviews, we identified 5 survey
items that closely corresponded to proposed face-valid crite-
ria suggested for the diagnosis of DE. These included ones
related to EL, difficult or absent ejaculation despite the desire
to ejaculate, and bother/distress.7,11,12,33,34 Corresponding
items from our survey consisted of the following:
EL AVG: estimated average EL during partnered sex
EL MIN: estimated minimum EL during partnered sex
% EPISODES: percentage of sexual episodes leading to
orgasm/ejaculation during partnered sex
PLEASURE/SATISF: (lack of) orgasmic pleasure/
satisfaction during partnered sex
BOTHER/DISTRESS: negative emotional response,
including bother/distress, related to sexual difficulty during
partnered sex
Covariates related to the health and functional/sexual
aspects of DE (aim 3)
Demographic and health-related variables included age, edu-
cation, sexual orientation, ongoing problems with anxiety/de-
pression (≥6 months) as a proxy for general psychological
health/functioning, and having medical issues (with a list
provided) that could affect sexual functioning.
Sexuality-related variables included sexual interest, use of
erotic materials during masturbation, frequency of partnered
sex and (separately) masturbation, estimated EL AVG and EL
MIN during masturbation, % EPISODES leading to orgasm/e-
jaculation during masturbation, PLEASURE/SATISF during
masturbation, BOTHER/DISTRESS related to sexual diffi-
culty during masturbation, and difficulty reaching orgasm/e-
jaculation during masturbation. Variables represented single
items, with the exception of SEXUAL INTEREST, which was
constructed from a question from the overall IIEF35 (“...rate
your sexual desire/interest”) and supplemented with a ques-
tion on the “importance of sex.” Responses on these 2 items
correlated well (rs = 0.71), so they were combined to gener-
ate the SEXUAL INTEREST composite. Test-retest reliability
was 0.85.
Sexual and overall relationship satisfaction was assessed
separately on rating scales from 1 (not satisfied at all) to 5
The Journal of Sexual Medicine, 2023, Vol 20, Issue 4
(very satisfied). Specifically, respondents were asked, “How
satisfied are you with the SEXUAL aspects of your relation-
ship?” and “Beyond sexual issues, how satisfied are you with
the OVERALL aspects of your current relationship?”
Procedure
Ethics approval was obtained from the Institutional Review
Boards at the authors’ institutions in the United States and
Hungary. The online distribution of the survey and collection
of data followed best practices: approximately ≤20 minutes
for survey completion, guaranteed anonymity, safeguards to
prevent multiple submissions, embedded attention checks,
reporting of internal consistency for standardized assessment
scales for the study sample, and offering no incentives
for participation.36-40 Before accessing the questionnaire,
participants checked boxes attesting to their current age
≥18 years and to their informed consent. Respondents could
voluntarily end participation at any time by closing the
webpage.
Analytic strategy
In a preliminary cleaning of the data, several differences
on variables were noted regarding national origin (origin
of data), but because few such differences were related to
the outcome variables in this analysis, this measure was not
investigated further. For aims 1 and 3, we compared individual
or composite variables between each DE group (ALL DE or
PURE DE) and the NON-DE group using t-tests or, where
appropriate, nonparametric Mann-Whitney tests. Due to the
number of comparisons, α was set at 0.01 (2-tailed; 0.005 for
1-tailed face-valid diagnostic items). For aim 2, a 2-way mixed
model analysis of variance was applied to ascertain that the
characteristic differences were indeed typical of, or specific to,
partnered sex vs masturbation. Analyses were carried out with
SPSS (version 25.0: IBM).
Results
Differences between the non-DE and DE groups on
face-valid diagnostic variables (aim 1)
All face-valid diagnostic variables showed significant differ-
ences between the NON-DE group and either DE group
(Table 1). Specifically, during partnered sex, EL AVG, EL
MIN, % EPISODES ending in ejaculation, PLEASURE/SAT-
ISF, and BOTHER/DISTRESS all differed significantly (P
< .001), with effect sizes ranging from moderate to large
(η2 = 0.07-0.20).
Characteristics strongly related to partnered sex
(aim 2)
The 5 face-valid diagnostic variables were assessed during
partnered sex and masturbation. Two-way mixed model
analyses of variance restricted to the NON-DE and PURE
DE groups (within-subject factor = type of sexual ACTIVITY;
between-group factor = GROUP: PURE DE vs NON-DE)
showed group differences on all variables (P < .001). That is,
NON-DE men reported shorter EL AVG and EL MIN, higher
% EPISODES ending in ejaculation, greater PLEASURE/SAT-
ISF, and lower BOTHER/DISTRESS (Table 2). Significant
ACTIVITY differences also occurred for all variables (P <
.001): during masturbation (relative to partnered sex), men
429
showed shorter EL AVG and EL MIN, higher % EPISODES
ending in ejaculation, lower PLEASURE/SATISF, and lower
BOTHER/DISTRESS. Significant GROUP × ACTIVITY
interactions were found for all analyses (P < .001), indicating
that differences in DE symptomology between the PURE
DE and NON-DE groups were greatly intensified during
partnered sex yet quite minimal or negligible during mastur-
bation (Table 2). Illustrations of interaction effects (Figure 1)
for 3 key variables—EL MIN, % of EPISODES ending
in ejaculation, and BOTHER/DISTRESS—are provided to
demonstrate these patterns.
Covariates related to functional/sexual aspects of
DE (aim 3)
Two demographic/health variables showed differences
between groups (Table 1). Specifically, more men in the
DE groups reported anxiety/depression than in the NON-
DE group (P < .001), and the bisexual orientation group
showed a higher percentage of DE (27%) as compared
with the straight or gay groups (both around 14%,
P = .001).
A number of sex-related variables—all but 1 related to
masturbation—showed group differences as well (Table 1).
Specifically, the frequency of partnered sex was significantly
lower in the DE groups (P ≤ .002). Four masturbation-related
variables—frequency of masturbation and EL AVG, EL MIN,
and difficulty reaching orgasm/ejaculation during masturba-
tion—differed significantly between the NON-DE group and
either DE group (P ≤ .005). For all the preceding variables,
effect sizes ranged from small to medium (η2 = 0.01-0.08). For
2 variables associated with masturbation—% EPISODES end-
ing in ejaculation and BOTHER/DISTRESS associated with
masturbation—the ALL DE group differed significantly from
the NON-DE group (P ≤ .003), but the PURE DE group did
not meet the 0.01 criterion (P = .011 and .016, respectively).
In addition, sexual and overall relationship satisfaction each
differed significantly between the NON-DE group and either
DE group (P ≤ .002) (Table 1), although effect sizes were
fairly small.
Discussion
In this first comprehensive analysis of its kind, we have
demonstrated widespread differences on sexual and relation-
ship variables between men with normal ejaculatory function
and men indicating difficulty reaching ejaculation/orgasm, the
primary symptom of DE. Although several such differences
had been iterated previously,15,16,20-23 most reported here are
new, including ones for possible consideration as face-valid
diagnostic criteria for DE. We have further demonstrated that
these differences are robustly related to partnered sex and, not
surprising, much less pronounced or even negligible during
masturbation.25
Previous studies have suggested that men without DE differ
from men with DE on negative emotionality related to sex-
ual response and on relationship satisfaction.15 Our findings
not only affirmed these differences but identified a multi-
tude of other behavioral- and sexual response–related vari-
ables that distinguish men with and without DE. Surprisingly,
these differences were largely independent of whether or not
the DE group included men with ED, explained perhaps
 430

Table 1. Comparison of NON-DE vs DE groups (ALL and PURE) on demographic, sexual, and relationship variables.a

NON-DE ALL DE PURE DE

Variables Mean (SE) No. Mean (SE) No. P valueb Effect size,c η2 Mean (SE) No. P valueb Effect size,c η2
Demographic/health
Age 37.5 (0.267) 2254 37.4 (0.750) 352 .831 — 37.0 (0.789) 310 .668 —
Education 2.97 (0.033) 2269 2.88 (0.078) 355 .325 — 2.86 (0.085) 313 .232 —
Sexual orientationd NA 2272 NA 342 .000 — NA 302 .001 —
Medical issue, % yes 19 2269 22 355 .402 — 21 313 .379 —
Anxiety/depression, % yes 18 2324 32 355 .000 — 31 313 .000 —
Sexuality related
Interest in sex 8.34 (0.031) 2323 8.13 (0.090) 354 .020/.155 .011 8.20 (0.094) 312 .106/.372 .011
Frequency
Partnered sex 6.21 (0.034) 2266 5.71 (0.106) 341 .000/.000 .017 5.92 (0.108) 301 .000/.002 .008
Masturbation 5.83 (0.040) 2268 6.11 (0.107) 341 .011/.002 .011 6.12 (0.116) 301 .021/.003 .010
Pornography use 3.95 (0.033) 2269 4.15 (0.076) 341 .028/.033 .005 4.11 (0.084) 301 .123/.089 .005
Partnered Sex
EL AVGe 4.92 (0.035) 2181 6.32 (0.107) 337 .000/.000 .097 6.22 (0.111) 297 .000/.000 .081
EL MIN 6.42 (0.117) 2119 10.66 (0.458) 281 .000/.000 .076 10.45 (0.492) 250 .000/.000 .071
% EPISODES 10.10 (0.031) 2204 7.78 (0.032) 341 .000/.000 .238 8.16 (0.184) 300 .000/.000 .201
BOTHER/DISTRESS 2.90 (0.037) 2260 4.11 (0.087) 342 .000/.000 .128 3.99 (0.094) 302 .000/.000 .114
PLEASURE/SATISF 5.34 (0.016) 2212 4.94 (0.056) 312 .000/.000 .080 4.99 (0.057) 281 .000/.000 .071
Masturbation
EL AVG 4.16 (0.032) 2245 4.61 (0.088) 340 .000/.000 .015 4.63 (0.094) 301 .000/.000 .015
EL MIN 4.38 (0.078) 2095 5.44 (0.230) 307 .000/.000 .012 5.36 (0.242) 270 .000/.000 .010
% EPISODES 10.49 (0.030) 2206 10.27 (0.092) 341 .011/.002 .013 10.29 (0.100) 301 .024/.016 .011
BOTHER/DISTRESS 2.57 (0.021) 2063 2.76 (0.062) 286 .004/.003 .040 2.72 (0.065) 254 .014/.011 .036
PLEASURE/SATISF 4.86 (0.019) 2261 4.82 (0.052) 337 .478/.624 .008 4.83 (0.055) 299 .545/.737 .008
Ejaculation difficulty 2.34 (0.016) 2184 2.84 (0.063) 339 .000/.000 .086 2.82 (0.067) 299 .000/.000 .081
Sexual and overall relationship
Sexual satisfaction 3.55 (0.027) 1842 3.17 (0.078) 248 .000/.000 .024 3.30 (0.079) 223 .001/.001 .016
Relationship satisfaction 3.99 (0.024) 1787 3.74 (0.065) 246 .000/.000 .022 3.79 (0.068) 219 .005/.002 .018

Abbreviations: ALL DE, all men indicating difficulty reaching orgasm; DE, delayed ejaculation; NON-DE, men without DE; PURE DE, men indicating difficulty reaching orgasm but not experiencing erectile
dysfunction. For variable abbreviations, see Table A1. a Shaded variables represent proposed face-valid diagnostic criteria for DE. Dashes indicate that effect sizes for these variables were not assessed. b Comparisons
were made with t-tests (first P value) and Mann-Whitney tests (second P value). Overall interpretations were minimally affected, with Mann-Whitney tests generally producing slightly higher P values. c Interpretation
of effect size (η2 ) is as follows: 0.01 = small, 0.06 = medium, 0.14 = large. d No data are presented, as a cross-tabulation table of sexual orientation by DE category was generated but not included. Chi-square analysis
on the percentage of respondents with DE in each category of sexual orientation (straight, bisexual, gay) indicated that the bisexual category had a significantly higher percentage than either of the 2 other categories
(straight, gay). e EL AVG is a categorical average (see Table A1), representing an interpolated average of about 9 minutes. In contrast, EL MIN represents actual minutes (6.42).
The Journal of Sexual Medicine, 2023, Vol 20, Issue 4
The Journal of Sexual Medicine, 2023, Vol 20, Issue 4
Table 2. Comparison of NON-DE vs PURE DE groups on 5 face-valid diagnostic variables, showing the patterns across partnered sex and masturbation.a
Mean (SD)
Variable comparison NON-DE
EL AVG
Partnered 4.92 (1.62)
Masturbation 4.18 (1.51)
EL MIN
Partnered 6.30 (5.20)
Masturbation 4.36 (3.57)
% EPISODES
Partnered 91.0 (1.47)
Masturbation 95.0 (1.36)
PLEASURE/SATISF
Partnered 5.33 (.75)
Masturbation 4.86 (0.92)
BOTHER/DISTRESS
Partnered 2.77 (1.73)
Masturbation 2.57 (0.95)
Abbreviations: NON-DE, men without delayed ejaculation; PURE DE, men indicating difficulty reaching orgasm but not experiencing erectile dysfunction.
For variable abbreviations, see Table A1. a All group (NON-DE vs PURE DE) and activity (partnered sex vs masturbation) differences were significant at P
< .001. All interaction effects were also significant (P < .001), indicating how differences between NON-DE and PURE DE groups were intensified during
partnered sex (relative to masturbation).
by the fairly low comorbidity rate (about 12%) between
the dysfunctions in our sample. Specifically, the exact same
partnered sex variables and 4 of 6 masturbation variables
for both DE groups (ALL DE and PURE DE) were signif-
icantly different from the NON-DE group. Of the 6 mas-
turbation variables, only 2—% EPISODES ending in orgasm
and BOTHER/DISTRESS during masturbation—showed sig-
nificant differences for the ALL DE group but not for the
PURE DE group. The slightly greater effect size of the ALL
DE group, representing a greater difference with the NON-
DE group, is perhaps not surprising, given that some of these
men likely suffered from multiple sexual dysfunctions (ED
and DE).
Face-valid diagnostic variables (aim 1)
Previous reports and reviews have proposed concepts/vari-
ables for consideration in the diagnosis of DE,7,11,12,33,34
and for the most part, these have been analogous to ones
used in the diagnosis of PE. Specifically, diagnostic criteria
for PE have typically included 3 constructs: (1) a problem
with the timing of ejaculation (for PE, too short a latency),
(2) a lack of self-efficacy in that the man is unable to effect a
more desirable response (for PE, delaying ejaculation through
ejaculatory control/modulation), and (3) bother/distress as a
consequence of the sexual impairment.1,2,12 Analogous con-
structs proposed as face-valid indices for the diagnosis of DE
have included (1) a problem with the timing of ejaculation (for
DE, too long a latency), (2) a lack of self-efficacy regarding the
response (for DE, difficulty reaching ejaculation and/or unable
to ejaculate sooner), and (3) bother/distress as a consequence
of the sexual impairment.
In our empirical approach to identifying possible variables
that might be part of a DE diagnosis, we first queried men
about their “difficulty reaching ejaculation/orgasm during
431
PURE DE
6.22 (1.92)
4.63 (1.64)
10.16 (7.51)
5.13 (3.77)
71.5 (3.20)
92.9 (1.73)
4.74 (1.35)
4.83 (0.98)
3.87 (1.63)
2.72 (1.03)
partnered sex” as a way of defining NON-DE and DE
groups. This item indicated a lack of ejaculatory control
or ability to modulate the timing of ejaculation, and in
our assessment, it captured the core symptomology of DE
in the same manner that a lack of ejaculatory control
has been identified as the core characteristic of men with
PE.41,42
Then, using this construct as our reference, we verified
differences between NON-DE and DE groups on 5 face-valid
items corresponding to the 3 previously proposed criteria
for diagnosing DE.43,44 Specifically, estimated average and
minimum ELs—which represent a problem with the timing
of ejaculation—differed significantly between NON-DE and
DE groups, as did the items “distress/bother” and “lack of
orgasmic pleasure/satisfaction,” as measures related to the
negative consequences of DE. In addition, the percentage of
time (episodes) reaching ejaculation during partnered sex,
as a face-valid self-efficacy measure representing the man’s
capacity for reaching orgasm and correlated with “difficulty
reaching orgasm” (rs = −0.41), was different between NON-
DE and DE groups. Thus, this analysis not only provided
empirical support for the use of 5 face-valid items relevant to
the 3 proposed criteria for diagnosing DE but also determined
that these 5 variables carried some of the largest effect sizes
of all those tested. For these analyses, 2 items were related to
the timing of ejaculation: 1 to difficulty reaching ejaculation,
a measure of ejaculatory control or ability to modulate the
timing of ejaculation, and 2 to the negative consequences
of DE.
Robust relationship to partnered sex (aim 2)
In this study, the 5 face-valid variables corresponding to
DE diagnostic criteria were assessed during partnered sex
and masturbation. All such variables demonstrated much
432 The Journal of Sexual Medicine, 2023, Vol 20, Issue 4

Figure 1. Two-way mixed model analyses of variance from Table 2, including only 3 variables: minimum ejaculatory latency (EL MIN), percentage of
sexual episodes leading to orgasm/ejaculation during partnered sex (% EPISODES), and higher negative emotionality related to sexual activity
(BOTHER/DISTRESS).

greater differences between NON-DE and DE groups dur-
ing partnered sex than during masturbation, indicating that
partnered sex intensifies DE symptomology and, furthermore,
the use of these face-valid variables within the context of
the couples’ relationship represents an appropriate strategy
for a DE diagnosis.25,45 As noted previously,25 we attribute
the greater symptomology during partnered sex, in part, to
a combination of (1) the performance demands associated
with partnered sex and (2) the greater control that men have
over the type, rhythm, and intensity of stimulation during
masturbation.
Covariates related to functional/sexual aspects of
DE (aim 3)
Beyond the 5 face-valid items relevant to the proposed criteria
for DE, other covariates differentiated NON-DE from DE.
These measures elaborate on the functional consequences,
components, and correlates affected by the impaired sexual
response. Understanding such supplemental information
aligns with the goals of the ICD companion effort, the
International Classification of Functioning, Disability, and
Health, which not only attempts to characterize a mental/-
sexual health disorder in terms of its severity and impact on
The Journal of Sexual Medicine, 2023, Vol 20, Issue 4
the functioning of the man and his partner26,46,47 but can
be instrumental in guiding appropriate strategies and focal
points for treatment.26,47
Our study identified several such functional correlates
and treatment focal points. For example, men with DE
symptomology reported a greater incidence of anxiety/de-
pression, a well-known difference associated with most
sexual dysfunctions in men and women,48,49 as well as lower
overall relationship and sexual relationship satisfaction, also
characteristics of men and women experiencing a sexual
problem.50,51
In addition, the lower frequency of partnered sex and
the higher frequency of masturbation seen in the DE group
might warrant exploration as part of a remediation strategy.
Specifically, in our study, men with DE generally reported
more positive associations with masturbation than partnered
sex—for example, as a group, they reported less negative
emotionality, greater sexual pleasure and satisfaction, shorter
ELs, and less difficulty reaching orgasm during masturba-
tion (relative to partnered sex). For these men, masturbation
activity might become preferred over partnered sex activity,
a situation having the potential to exacerbate their dysfunc-
tional response during partnered sex. Specifically, as these
men become increasingly conditioned to arousal conditions
associated with self-stimulation, they may find partner-related
stimulation inadequate to reach arousal levels sufficient for
ejaculation.5,24
However, considering the positive and successful experi-
ences with masturbation that men with DE have, one strat-
egy for improving their sexual efficacy may lie in specific
therapeutic coaching (eg, enhanced couples’ communication)
that aims to align their arousal conditions during mastur-
bation more closely with those involved in partnered sex.25
A closer alignment between masturbation stimulation and
partner-related stimulation has, for example, been associ-
ated with lower orgasmic difficulty during partnered sex in
women.52
Finally, we note 2 other findings from this study. First, men
with a bisexual orientation showed a higher prevalence of
DE than either gay or straight men. Whether this finding is
merely coincidental is not clear; we have been unable to find
other studies reporting a similar pattern and, at this point,
offer no plausible explanation. The finding does, however,
reiterate the importance of analyzing sexual minority data
in studies related to sexual dysfunction.32 Second, variables
that did not differ between the NON-DE and DE groups—
some reported previously—were also notable, such as age,15
education level, sexual interest, frequency of pornography
433
use during masturbation,20 and orgasmic pleasure/satisfaction
during masturbation.
Limitations
Several limitations need to be noted. For one, although we
followed best practices for online survey distribution and
collection of data36-40 and reported internal reliability values
for the embedded assessment scales, research strategies that
rely heavily on public and social media for recruitment are
subject to biases in education, class, social media access,
and other factors. Second, we did not use clocked ELs in
this study, a procedure that would have been impractical
for a study of this type and sample size. However, we note
that 3 large-scale studies have concluded that estimated and
clocked ELs can be used interchangeably53-55 and, as implied
by another analysis, clocked ELs may in some instances be
a less reliable/valid measure of EL, given the well-known
principle that “the observer always influences what is being
observed”.56 Third, although we differentiated between ALL
DE and PURE DE (those without concomitant ED), this study
did not explore differences between men with lifelong and
acquired DE, an issue that awaits future analyses. Finally, we
acknowledge that our study lacked non-Western participants,
so we caution against extrapolating our findings to larger
worldwide populations until such diverse samples can be
investigated.
Conclusion
This well-powered (β > 0.99), multinational study is the first
to provide strong empirical support for 5 face-valid mea-
sures for the diagnosis of DE, with a number of explana-
tory and control covariates that may help shed light on
the lived experiences of men with DE and suggest focus
areas for treatment. Results of this study will facilitate the
development and acceptance of more standardized criteria for
diagnosing DE.
Funding
None declared.
Conflicts of interest: None declared.
Data availability
Interested researchers may make reasonable requests to review
the output files from our analyses.
Table A1. Outcome variables and response options for this study.a
Variable names
Demographic variables
Age
Educational attainment
Sexual orientation
Medical issue(s)
Anxiety/depression
Sex-related variables
Interest in sex
Frequency of partnered sex
Frequency of masturbation
Frequency pornography use
434
Description in survey questionnaire Response categories
What is your current age? Self-reported years
Highest level of education completed? 0 = Less than high school
1 = High school or equivalent
2 = Skill certification/technical degree
3 = Some college
4 = Bachelor’s degree
5 = Graduate/postgraduate study
What is your sexual orientation? 0 = Not attracted to either sex/asexual
1 = Sexually attracted only to women
2 = Primarily attracted to women, but also somewhat to men
3 = Attracted to both men and women about equally
4 = Primarily attracted to men, but also somewhat to women
5 = Sexually attracted only to men
6 = Other (please describe)
Do you have any of the following ongoing medical issues: high blood pressure, diabetes, 0 = No
cardiovascular disease, or lower urinary tract problems? 1 = Yes
Are you currently suffering from ongoing/persistent (>6 months) anxiety or depression? 0 = No
1 = Yes
Rate your overall level of interest in and/or desire for sex (ie not distinguishing whether with a 1 = Not at all interested
partner or through masturbation). 5 = Very interested
Considering your history with your current or most recent (primary) sexual partner, about how 1 = Never
often do you or did you have sex with your partner? 2 = Almost never
3 = Less than once a month
4 = About once a month
5 = About one time every two weeks
6 = About one time every week
7 = 2-3 times per week
8 = 4-6 times per week
9 = About once a day
10 = More than once a day
About how often do you masturbate? 1 = Almost never
2 = Less than once a month
3 = About once a month
4 = About one time every two weeks
5 = About one time per week
6 = About 2-3 times per week
7 = About 4-6 times per week
8 = About once a day
9 = About 2-3 times per day
10 = More than 4 times per day
About what percent of the time do you use erotic materials when you masturbate? 0 = Never
1 = Rarely or less than 15% of the time
2 = About 15-40%
3 = About 40-60%
4 = About 60-85%
5 = Very often or more than 85%
The Journal of Sexual Medicine, 2023, Vol 20, Issue 4
(Continued)
Table A1. Continued.
Variable names
Typical ejaculatory latency
(EL AVG)
Shortest ejaculatory latency
(EL MIN)
Frequency of partnered sex
ending in orgasm
(% EPISODES)
Sexual dysfunction
(BOTHER/DISTRESS)
Orgasmic pleasure
(PLEASURE/SATISF)
Typical ejaculation latency in
masturbation (EL AVG)
Shortest ejaculatory latency in
masturbation (EL MIN)
Description in survey questionnaire Response categories
If you have partnered sex, about how long does it take for you, on average, to reach orgasm, from 1 = Less than 1 minute
the time that you begin penile stimulation (ie when you initially start trying to move toward 2 = 1-2 minutes
orgasm)? 3 = 3-5 minutes
4 = 6-10 minutes
5 = 11-15 minutes
6 = 16-20 minutes
7 = 21-25 minutes
8 = More than 25 minutes
9 = I have partnered sex but can seldom reach orgasm
10 = I have partnered sex but choose not to ejaculate
If you reach orgasm during partnered sex, estimate the typical shortest time in minutes for Self-reported minutes
ejaculation, from the time you begin penile stimulation that moves you toward orgasm.
Estimate how often sex with a partner typically ends in (or ended in) orgasm for you. If you have 0 = 0%
not had any sexual activities with your partner, or if you choose not to reach orgasm, select NA 1 = 10%
(not applicable). 2 = 20%
The Journal of Sexual Medicine, 2023, Vol 20, Issue 4
3 = 30%
4 = 40%
5 = 50%
6 = 60%
7 = 70%
8 = 80%
9 = 90%
10 = 100%
When you have (or have had) sex with your partner, if you have any difficulties with sex, such as 0 = N/A: I nearly always reach orgasm with my partner, so this is
finding it very difficult to reach orgasm, does (or did) this bother, upset, or frustrate you, or make not a problem
you feel guilty? 1 = Almost never
5 = Almost always
When you have (or have had) sex with a partner, how pleasurable or satisfying would you rate 0 = N/A: I generally choose not to ejaculate during partnered sex
your typical orgasm? 1 = Not satisfying
5 = Very satisfying
If you masturbate, about how long does it take for you, on average, from the time you begin penile 1 = Less than 1 minute
stimulation (ie when you initially start trying to move toward orgasm)? 2 = 1-2 minutes
3 = 3-5 minutes
4 = 6-10 minutes
5 = 11-15 minutes
6 = 16-20 minutes
7 = 21-25 minutes
8 = More than 25 minutes
9 = I have partnered sex but can seldom reach orgasm
10 = I have partnered sex but choose not to ejaculate
If you reach orgasm during masturbation, indicate a usual range for orgasm/ejaculation in minutes, Self-reported minutes
from the time you begin penile stimulation (ie when you initially start trying to move toward
orgasm)?
(Continued)
435
 436

Table A1. Continued.

Variable names Description in survey questionnaire Response categories

Frequency of masturbation Estimate how often masturbation (alone, without your partner present) ends in orgasm for you by 0 = 0%
ending in orgasm (% selecting one of these options. 1 = 10%
EPISODES) 2 = 20%
3 = 30%
4 = 40%
5 = 50%
6 = 60%
7 = 70%
8 = 80%
9 = 90%
10 = 100%
Masturbation dysfunction When you masturbate, if you have any difficulties with getting or keeping an erection, ejaculating 0 = N/A: I always or nearly always reach orgasm during
(BOTHER/DISTRESS) too quickly, or finding it difficult to reach orgasm, does (or did) this bother, upset, or frustrate you? masturbation
1 = Almost never
5 = Almost always
Masturbation orgasmic pleasure During masturbation, how pleasurable or satisfying would you rate your typical orgasm? 0 = N/A: I do not reach orgasm during masturbation
(PLEASURE/SATISF) 1 = Not satisfying
5 = Very satisfying
Difficulty reaching orgasm During masturbation, do you ever have difficulty reaching orgasm? 0 = N/A: I masturbate but choose not to ejaculate/orgasm
during masturbation 1 = Almost never
5 = Almost always
Sexual/overall relationship
Sexual relationship satisfaction How satisfied are you with the sexual aspects of your current primary sexual relationship? 1 = Not at all satisfied/low quality
5 = Very satisfied/high quality
Overall relationship satisfaction Beyond sexual issues, how satisfied are you with the OVERALL aspects of your current primary 1 = Not at all satisfied
relationship? 5 = Very satisfied/high quality
a Item abbreviations are in parentheses. Shaded items represent proposed face-valid diagnostic criterion variables.
The Journal of Sexual Medicine, 2023, Vol 20, Issue 4
The Journal of Sexual Medicine, 2023, Vol 20, Issue 4 437

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