Treatment of Premature Ejaculation: Alleviating Sexual Dysfunction, Disease Mongering, or Both?

by Brian D. Earp / (@briandavidearp)

An interesting new paper, “Distress, Disease, Desire: Perspectives on the Medicalization of Premature Ejaculation,” has just been published online at the Journal of Medical Ethics. According to the authors, Ylva Söderfeldt, Adam Droppe, and Tim Ohnhäuser, their aim is to “question the very concept of premature ejaculation and ask whether it in itself reproduces the same sexual norms that cause some to experience distress over ‘too quick’ ejaculations.” To prime the reader for their project, they begin with a familiar story:

a condition previously thought of as a variant within the normal range, as a personal shortcoming, or as a psychological issue is at a certain point cast as a medical problem. Diagnostic criteria and guidelines are (re-)formulated in ways that invent or widen the patient group and thus create or boost the market for the new drug. Those involved in developing the criteria and the treatment are sometimes the same persons and, furthermore, cultivate close connections to the pharmaceutical companies profiting from the development. Sufferers experience relief from personal guilt when they learn that their problem is a medical and treatable one, whereas critics call out the process as disease-mongering.

Something like this pattern has indeed played out time and time again – methylphenidate (Ritalin) for ADHD, sildenafil for erectile dysfunction, and more recently the development of flibanserin for “hypoactive sexual desire disorder” (see the excellent analysis by Antonie Meixel et al., “Hypoactive Sexual Desire Disorder: Inventing a Disease to Sell Low Libido” in a previous issue of JME). Having set up this narrative, Söderfeldt, Droppe, and Ohnhäuser turn their attention to the case at hand—the “medicalization” of premature ejaculation (PE).

The begin by noting that certain selective serotonin reuptake inhibitors (SSRIs), normally used to treat depression (itself the “medicalization of sadness” on some accounts), have been known since at least the 1990s to sometimes delay ejaculation as a “side-effect.” They then call attention to a 2004 application by Johnson & Johnson for FDA approval of dapoxetine for on-demand—as opposed to off-label—“treatment” of PE.

Rather than digging into debates over medical evidence concerning the efficacy of the drug, they jump right to a set normative questions touching on the medicalization of sexual experience and behavior. As they note, ethical discussions concerning the prescription of Ritalin and sildenafil (among other pharmaceutical innovations) centered on questions about what we see as “normal” behavior—and on how adding drugs to the mix might change those perceptions in ways that are potentially concerning.

But with few exceptions, according to Söderfeldt et al., the introduction of dapoxetine as a “treatment” for PE “has not yet elicited reactions of that sort.” They see this as surprising, because PE is to a large extent “a diagnosis that reflects cultural standards and is contingent on normative social behavior.”

According to the DSM-V, PE consists of always or almost always ejaculating within about one minute after vaginal penetration, thereby causing distress. Thus, Söderfeldt and colleagues note,

premature ejaculation is always conceived of in relation to vaginal penetration. Any sexual activity apart from heterosexual coitus is left out of the equation, which essentially separates the condition from the patient’s body: the diagnosis is made not based on how he reacts to stimulation per se, but on the position of his penis at the moment of ejaculation and shortly before. Nevertheless, those currently involved in the science of PE maintain that it is an organic dysfunction, perhaps hereditary in nature.

Such “organic” approaches to defining sexual “disorders” do often fail to engage with surrounding social norms—and variations in subjective preferences—that bear on intimate behavior. As Julian Savulescu and I noted in a recent paper, a comparatively short interval between certain types of stimulation and the onset of ejaculation is “neither inherently pathological nor even necessarily problematic.” Rather,

the character, intensity, and expression of people’s sexual drives and capacities range widely even without the influence of medication. Whether a given alteration to those factors is likely to frustrate, or facilitate, one’s relationship goals … will depend upon the type and degree of alteration, the means by which it is achieved, the nature of the relationship and the relationship goals themselves, etc.—all considered within the context of other possible means by which those goals could be achieved, the sexual and other preferences of the couple in question, and their shared values.

Of course, many men do experience distress over their ejaculatory latency. If, all things considered, the use of a drug to delay ejaculation in response to certain types of stimulation will help a couple fulfill their sexual goals, then perhaps the drug should be made available to them. Importantly, however–at least in principle–this does not necessarily require first pathologizing their current situation.

That said, as Söderfeldt et al. convincingly argue, “methods seeking to prolong the duration of vaginal penetration” do seem to confirm, or at least play into, “the underlying idea that sustained coitus is required [for satisfying] sexual interactions. Extension of the sexual repertoire and liberation from the coital imperative have the potential to improve the sexual lives of many more than those who experience relief from SSRI- enhanced IELTs.”

Target article

Söderfeldt, Y., Droppe, A., &  Ohnhäuser, T. (2017). Distress, disease, desire: perspectives on the medicalisation of premature ejaculationJournal of Medical Ethics, online first. 

References and related reading 

Earp, B. D., & Darby R. (2017). Circumcision, sexual experience, and harm. University of Pennsylvania Journal of International Law, in press.

Earp, B. D., Sandberg, A., & Savulescu, J. (2015). The medicalization of love. Cambridge Quarterly of Healthcare Ethics, 24(03), 323-336.

Earp, B. D., & Savulescu, J. (2017). Love drugs: Why scientists should study the effects of pharmaceuticals on human romantic relationships. Technology in Society, online first.

Gupta, K. (2012). Protecting sexual diversity: Rethinking the use of neurotechnological interventions to alter sexuality. AJOB Neuroscience, 3(3), 24-28.

Meixel, A., Yanchar, E., & Fugh-Berman, A. (2015). Hypoactive sexual desire disorder: inventing a disease to sell low libido. Journal of Medical Ethics, 41(10), 859-862.

Wakefield, J. C., & Horwitz, A. V. (2009). The medicalization of sadness: How psychiatry transformed a natural emotion into a mental disorder. Salute e Società. Fascicolo 2, 2009, (2), 1000-1018.