After Viagra, tackling another sexual taboo
By Carey Goldberg, Globe Staff
Published: May 8, 2005

Some specialists call it the last taboo since the start of the Viagra era. Even with public talk of impotence now commonplace, that new openness does not stop the cringes at the mention of an even more common male sexual problem: premature ejaculation.

But that may be about to change. With promising pills for the condition on the horizon, drug-company money is helping support an array of research on premature ejaculation.

Sexual-medicine specialists, who estimate that 20 to 30 percent of men of all ages have the condition, are working on defining it in a scientifically more rigorous way, refining existing treatments such as the use of antidepressants, and testing the new drugs.

''The new wave of research is not just about drug development," said Stanley Althof, a psychology professor at Case Western Reserve University School of Medicine. ''It's also about trying to understand what's at the basis of these problems and develop new and better treatments."

It will be months before the US Food and Drug Administration is expected to decide on approval for the farthest along of the drugs, a Johnson and Johnson compound called dapoxetine that is similar to antidepressants such as Prozac -- which often cause delays in orgasm. But the new drug acts faster and its effects fade much more quickly. Pfizer, too, is working on a pill, as are several other, smaller companies, researchers say.

Major questions remain: Will dapoxetine and the other drugs be approved? If so, how popular will they be, given that studies show that premature ejaculation generally bothers men much less than impotence does?

Still, some specialists foresee a not-so-distant time when premature ejaculation becomes part of public discourse, much as erectile dysfunction did when Viagra came along in the late 1990s, accompanied by ads with prominent patients such as Bob Dole and an influx of men into doctors' offices to request the little blue pill.

In the most recent sign of expanding research on premature ejaculation, this month's Journal of Sexual Medicine describes a study in which hundreds of wives used stopwatches to time their husbands in bed. The study, the largest of its kind, aimed to define the boundary between normal and premature ejaculation.

Sponsored by Johnson and Johnson, the study found that the average premature ejaculation lasted about two minutes during intercourse, while the average ejaculation lasted about seven.

It also surprised researchers by finding that among men whose ejaculations lasted under three minutes, emotional responses varied greatly, said Althof, one of its authors. Some felt distress and lack of control, key elements of a diagnosis of premature ejaculation; others were unbothered.

Later this month, at the annual American Urological Association conference, researchers are scheduled to present a half-dozen papers on dapoxetine sponsored by Johnson and Johnson, and several more on other aspects of premature ejaculation.

The papers include a report on a clinical trial of dapoxetine that, according to the abstract on the association's website, found that the drug could add a couple of minutes to a premature ejaculation patient's staying power. That may not sound impressive at first, but in fact it meant a doubling or tripling of times that originally averaged about one minute.

Johnson and Johnson has not tested dapoxetine in men without premature ejaculation because it is not intended for them, said Usman Azam, the company's vice president of Urology Research and Development.

But sexual-medicine specialists say that the Prozac-generation antidepressants often delay orgasm even in people with normal timing, so it is likely that dapoxetine, which is closely related, will do the same.

That does not mean, they caution, that demand for drugs to combat premature ejaculation will necessarily extend far beyond the patients who really need them, to the legions of men who occasionally wish their erections could last longer.

If the drugs' side effects resemble those of antidepressants, they can be fairly extensive, from nausea to, ironically, loss of sexual desire. The abstract on the clinical trial reports that when men took a middling dose of dapoxetine, 20 percent felt nauseated and nearly 7 percent got headaches. It mentioned no loss of desire.

Some even question how many men who definitely have premature ejaculation would want to resort to a drug.

''If we use the population studies that say more men have premature ejaculation than erectile dysfunction, the Wall Street people will say, 'This is a billion-dollar-a-year market, it's a no-brainer,' " said Dr. James Barada of the Albany Center for Sexual Health, who has worked on clinical trials both for dapoxetine and the Pfizer drug.

''But the reality is, a lot of people are not distressed," he said.

Survey data from 1992 on American sexuality indicates that premature ejaculation affects men quite differently from impotence. Unlike impotent men, those with premature ejaculation show no significant drop in general happiness or physical satisfaction in their relationships, according to the National Health and Social Life Survey, a study of more than 3,400 American adults.

''We have this crude measure of general happiness and the fact that it doesn't affect physical pleasure -- these are indications to me that it just simply doesn't shake the timbers quite the way erectile dysfunction is likely to do," said Edward Laumann, the University of Chicago sociology professor who led the study.

Of course, Laumann noted, once a drug for premature ejaculation comes out, and a man can ''now do something about it, he'll be under a greater social expectation to do something about it."

Dr. Irwin Goldstein, a sexual-medicine specialist, said that when a man has premature ejaculation, his partner often is more affected. ''This really is a disorder of the partner," he said. ''It's a couples issue -- the guy, because he ejaculates, may not necessarily view this as a problem."

For some men, however, premature ejaculation is in fact a serious problem, and such sufferers may well benefit from new drugs, specialists say.

Ian Kerner, a sex therapist in Manhattan who openly talks of his own premature ejaculation problem, says he long felt like a ''sexual cripple." Among his patients, he said, are single men who stop dating because of the problem.

In the Freudian era, Kerner noted, psychiatrists attributed premature ejaculation to unconscious fears of castration or other psychological complexes. Then came the Masters and Johnson era, when therapists emphasized techniques that couples could work on together.

Now, he said, the understanding of premature ejaculation is more biological: its causes are clearly connected to the action of brain messengers like serotonin and dopamine, and drugs can help on that level. In recent years, he said, despite the side effects, the most effective treatment has been what is known as ''off-label" prescriptions of antidepressants, when the drug is not used for its original purpose.

But chemical solutions must be combined with communication between sex partners, he and other specialists emphasized. ''What I wouldn't want to see is being in an age where, just like you pop a pill to get an erection, you pop a pill to last longer," Kerner said. ''It's not just about taking a pill, it's about engaging in meaningful dialogue around your intimate life."

The American Urological Association has been working to spread understanding of premature ejaculation. Last year, it published guidelines for physicians on treating it with antidepressants and topical anesthesia, noting that such use was not officially approved by the FDA but did often seem to help.

How big a step forward dapoxetine and its competitors will be remains to be seen.

''Is it an effective therapy compared to placebo? Yes," said Barada of the Albany Center for Sexual Health. ''Is it going to benefit those who have the condition? Yes. Is it going to be a one-size-fits-all cure for premature ejaculation? I don't believe any medicine does that."

Carey Goldberg can be reached at goldberg@globe.com.