Bill Monaghan was familiar with Zoloft before he started experimenting with it off-label. He'd been prescribed the drug in elementary school to treat a "bad case of OCD," but weaned himself off the selective serotonin reuptake inhibitor (SSRI) through exercise.
More than a decade later, the South Jersey resident was looking to get back on an SSRI for a different reason: He was finishing too quickly during sex.
"It literally drove me insane," said Monaghan, now 25. "Basically, I was thinking about my penis all fucking day."
SSRIs, a class of antidepressants, treat depression or anxiety disorders by limiting serotonin reabsorption, ultimately increasing the amount of serotonin available for the body's use. They also come with a slew of side effects—one of which is decreased libido and difficulty achieving orgasm. For most, it's an annoyance, but for men like Monaghan, it was an opportunity.
Monaghan went to a urologist, and then a slew of psychiatrists who put him on "a lot of shit" that he says he "didn't need to be on," but not Zoloft. Finally, he found a psychiatrist who appreciated his straightforwardness.
"I actually had papers printed out," Monaghan said. "I was like, 'Here's the medical abstracts of off-label uses of medication that I read up on and I want to experiment with it on myself. Look, I have OCD so the insurance will cover it and blah, blah, blah. We can kill two birds with one stone but this is what I want to do.' I was like, 'I'm not going to try to get you to prescribe me something and lie to you.' I was completely honest and up front."
The doctor put him on Paxil, the trade name for an SSRI called paroxetine and, over the course of the following months, Monaghan went from lasting 30 seconds to more than ten minutes.
Patrick Jern, a psychologist and professor at Abo Akademi University in Finland, said SRRIs effects on ejaculation seemed like a breakthrough for sexual medicine. "It was prescribed off-label for a lot of years to treat premature ejactulation," he said, "and it's actually rather successful."
But while few doctors disagree about the fact that SSRIs delay ejaculation and curb sex drive, some are wary about their role in sexual medicine. Most SSRIs have a bunch of negative short-term side effects (weight gain, fatigue, nausea) and unknown long-term side effects. Still, there are dozens of threads on forums like Reddit filled with men lauding the impacts of SSRIs on their sex life.
"Honestly I feel like a monster now for the length of time I can last," wrote one user, who was prescribed an SSRI called Cipralex solely for premature ejaculation. "I can give this girl some monster orgasms and it feels amazing knowing that I can truly satisfy this girl."
The drug impacts his mood, he said, but he deemed the tradeoff for his boosted confidence worth it.
"I've had a lot of people close to me come up to me and mention that I look depressed and not myself," he said. "This is the only reason I'm contemplating pulling back on them a little bit but it's just difficult because I'm so happy how I'm able to perform in bed now. Obviously the right decision would be to get off of them entirely but it just seems like my performance is too good to be true to stop them now."
Jern, the psychologist from Finland, performed a study on men who'd taken dapoxetine to treat premature ejaculation. He found that 70 percent ultimately stopped using the drug, typically citing the side effects, with half of those who discontinued use reporting nausea and nearly a quarter reporting diarrhea.
Dapoxetine is notable because it's the only SSRI with a marketing permit in many countries for treatment of premature ejaculation. Like Viagra (which was also popularized through its side effect—it was originally developed to treat hypertension), dapoxetine can be taken on-demand, about an hour before sex, and clear the system shortly thereafter.
The drug has not, however, been approved by the FDA for this usage in the United States (because its application is still pending, the FDA could not provide further information). Despite the lack of approval, other drugs containing the same chemical compound as dapoxetine have surfaced in the United States. In October 2015, the FDA recalled the drugs Rhino 7 3000 and Rhino 7 Platinum 3000, both over-the-counter sexual endurance supplements which were found to contain dapoxetine.
"Studies have shown that antidepressants increased the risk of suicidal thinking and behavior in children, adolescents, and young adults when compared to placebo," the FDA wrote in a release announcing the recall. "Therefore, consuming these products presents a health risk which could be life threatening."
Pharmaceutical companies can't market their drugs for anything other than their intended use, but doctors can prescribe off-label use at their discretion. Dr. T. Mike Hsieh, a urologist and professor at the University of California San Diego, says he sometimes prescribes SSRIs for patients with premature ejaculations, but only in the most dire cases and after a thorough screening.
"If a couple who's trying to conceive but the guy can't last—during foreplay the guy ejaculates—how is he supposed to try to conceive with his wife?" Hsieh said. "So there are definitely specific instances, in addition to maintaining a healthy sex life. I do use SSRIs and I do use all the topical numbing applications to try to help these guys out, but what I do is try to screen them for any kind of underlying depression or bipolar disorder and then, if there's any concern, I would have them see a psychiatrist first to make sure they're clear."
Hsieh is concerned about the SSRI use, however, because a vast majority of his patients—many of them college students—are struggling with perception rather than an actual physical issue.
"When a college kid comes in and says they can last 20 minutes, you're like, listen, because the medication really only helps a guy get from about half a minute to two and half minutes," Hsieh said. The average length of sexual penetration is hard to nail down, but studies show ranges from three minutes to about seven.
Hsieh believes this uptick in young men who think they're suffering from premature ejaculation is the result of an increase in the availability of porn.
"They don't understand that a lot of those guys, porn actors, they're getting injections and various things to keep their erection up for the film," Hsieh said. "But naturally when a 15-year-old or a 20-year-old college kid starts watching these movies they start comparing their own performance to what they see on the film. Obviously, they all feel they are very inadequate. So even though, I think, it's been reported that as high as two-thirds of men have premature ejaculation, but if you really put a strict definition on it, then it's probably a smaller amount of people."
Even the SSRI use itself, Hsieh said, might not be helping a sexual problem that's strictly physical.
"SSRI has been used to treat anxiety so maybe part of the effect is that it also calms the guys down a little bit," he said. "Some guys don't really have erection problems, but if you give them a little bit of viagra they feel like, 'Oh, now I'm ready to go.' So there's that weird placebo effect or anti-anxiety effect and I think that probably contributes to it."
Even Monaghan, who's a vocal supporter of SSRIs when used correctly and whose SSRI of choice, paroxetine, has lower discontinuation rates according to Jern's study, warns against misuse.
"Don't just go get these pills," he said. "They're powerful mental drugs and if you don't have a problem and you take them you can actually create a problem."
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