Prescribing Masturbation: An Idea Whose Time Has Come (Again)

Should vibrators be available on prescription and covered by healthcare plans?

Masturbation is the most ubiquitous expression of good sexual health. Despite this, not a moment of my medical training was devoted to the topic. Whilst masturbation is no longer explicitly considered a disease entity or the cause of disease, the idea that masturbation is pathological or immoral persists. For example, childhood masturbation continues to be called ‘gratification disorder’ by pediatricians, whilst the endurance of the term masturbation itself which literally means defilement by hand harks back to a 19^th century notion that the act was ‘Forbidden by God, [and] despised by men.’ Nevertheless medicine has enjoyed a complex relationship with masturbation regarding it both as a cause of disease and as a cure. Whilst the evidence for the therapeutic uses of masturbation is not robust, I can’t help but feel that since medicine has done so much to malign masturbation, we now have a moral obligation to promote it. The time has come once more for us to prescribe masturbation.

The Medicalization of Masturbation

Whilst medical men had remarked upon masturbation on occasion since the time of Hippocrates, the belief that masturbation was not only a vice but also a disease did not take hold until the 18^th century. With the publication of Onania in 1759 the stage was set for masturbation to establish itself as a pathological process that posed a looming threat to humanity. The belief in the deleterious effects of masturbation on human health was not unanimous; however, such was the popularity of this text that there appeared to be sweeping consensus of the dangers of masturbation. By the 19^th century, masturbation had become associated with consumption, scrofula, feeble mindedness, insanity, a diminution of vision, and syphilis. If in the 18^th century, masturbation would be seen as both a moral vice and a cause of maladies physical and spiritual, in the 19^th century the Swiss physician Samuel Tissot expunged all discussion of the moral and spiritual and secured the place of masturbation as the cause of many maladies, with a “scientific” basis. In addition to the usual complaints experienced by men, Tissot proclaimed that female masturbators could also experience hysteria, jaundice, ulceration and prolapse of the uterus, and clitoral rashes. His ‘scientific’ theory was that masturbation led to disease through unnatural loss of ‘la liqueur séminale’ and secondly through the mental activity required which effectively damaged the brain. Quite how the former ‘scientific’ theory explained the ill effects of masturbation in women is unclear.

Antimasturbation fervor was at its greatest in America. Treatments including cold baths, tying of the hands, even applying carbolic acid to the penises of young boys were all enthusiastically used in the treatment of this ‘disgusting and revolting’ act. The Michigan-based physician Alonso Garwood documented a case of an orphan boy from a poorhouse who he raised as his own with a particularly severe compulsion to masturbation, and noted in the Northwestern Medical and Surgical Journal:

After using every moral means in my power, I tried cold bathing, restricting his diet to plain unstimulating food, whipping him as hard as I dared to without injuring the child, blistered his penis till it was all over raw, and as a dernier resort tied his hands. All these efforts were entirely abortive; whilst his penis was raw, he indulged as much as ever, and did not seem to regard the soreness. And when his hands were tied, he would bring on a seminal discharge by friction against his clothes, between his thighs, or between his abdomen and bed clothes, and at last he obtained such command over the abdominal, perineal and glutial muscles, in connection with the force of imagination, that he could produce a discharge sitting on a chair in my presence when there was no motion perceptible.

The desire of self gratification appeared to be constantly in his mind, and I am convinced that he would forgo any and everything else, even death itself, before he would quit the practice. Giving up all hopes of effecting a cure, and his presence becoming so disgusting and repulsive, I laid the case before the superintendents of the county and the board of supervisors, accompanied with the request, that they would destroy the indentures, and receive him again as a pauper, which they did accordingly.

Incidentally, although clitoridectomies were occasionally performed to curtail excessive female sexuality, the available medical literature almost entirely refers to males. It is almost as if the notion that women could obtain sexual pleasure without penetration was too offensive to male sensibilities.

Female masturbation did not go unremarked, however. Even in Onania, the author remarked "to imagine that Women are naturally more modest than Men, is a Mistake" and noted that “Female masturbators suffer from imbecility, fluor albus [leucorrhoea], hysteric fits, barrenness and a "total Ineptitude to the Act of Generation itself." The psychiatrist Richard von Krafft-Ebing in his Psychopathia Sexualis cites the case of two sisters who masturbated from childhood, regarding them as ‘most revolting’ and notes that hot iron treatment to the clitoris failed to temper their enthusiasm for the practice. He further notes a case of a woman who started masturbating in childhood, noting with horror that she ‘continued to practice masturbation when married, and even during pregnancy. She was pregnant twelve times.’ Krafft-Ebing believed that ‘since woman has less sexual need than man, a predominating sexual desire in her arouses a suspicion of its pathological significance.’ The Swiss psychiatrist Eugen Bleuler is noted to have smelt the hand of one of his schizophrenic female patients, for evidence of masturbation, presumably believing a causal connection.

Epidemiology of Masturbation

Given the prevalence of masturbation, and the rarity of many of the conditions it was ascribed to, it is not surprising that the view that masturbation caused so many ills did not go unchallenged. The Scottish surgeon John Hunter was among those to point out that one would expect a tendency for impotence to be more common if it were truly caused by masturbation. More recent epidemiological surveys shed light on the frequency of masturbation in various populations.

In a British Study of 11 161 participants, 73% of men and 36.8% of women reported masturbating in the 4 weeks prior to telephone interview. In striking contrast, whilst men who reported masturbation were less likely to report vaginal sex during the same period, women were more likely to report vaginal intercourse. Conversely, both men and women reporting same-sex sexual partners were more likely to report masturbation. Similarly in a study of Australian Adolescents aged 15-18, 58.5% of boys reported ever having masturbated, compared with 38.3% of girls. Further, a US cross-sectional survey of adolescents aged 14-17 found that whilst prior masturbation increased with age in females, recent masturbation did not. This contrasted with males where 67.6% of the 17 year olds reported recent masturbation, compared with 42.9% of 14 year olds. The gender disparity of masturbation epidemiology is not new. The Kinsey studies, which were the first to systematically outline sexual behavior in men and women, found that whilst 92% of men reported masturbation to the point of orgasm at some point in the life course, only 58% of women did. This prevalence figure for women was still more than was expected during the sexually conservative 1950s, and this finding was one among many that meant the publication of sexual behavior in women was much more controversial and condemned than the previous publication delineating sexual behavior in the human male. According to data pooled from the online dating website Ok Cupid!, from a sample of 78200 users, 21% Jewish women claimed to have never masturbated, compared with 9% of Jewish men. In contrast, 7.5% of women identifying as agnostic claimed to have never masturbated, along with 5% of agnostic men. Further, 18% of Muslim women, and 17% of Hindu women reported having never masturbated, far higher than male counterparts of the same religion. In sum, there exists a significant gender disparity in masturbation, and this is across cultural bounds.

Masturbation on Prescription?

Since the time of Hippocrates the treatment of hysteria in women has involved massage of the genitalia by the physician or midwife. Despite this therapy, it appears that women themselves were never encouraged to bring themselves to orgasm by stimulating their own genitalia. In fact, this was something that was explicitly discouraged on the grounds that it was deleterious to health as discussed above. Quite why the hands of the physician or husband should be therapeutic, but the woman’s own hands should be viewed as toxic to her own genitalia is inexplicable. Inexplicable but for the implication that women were incapable of arousing themselves without men. The social historian Rachel P. Maines talks of the androcentric model of sexuality, which she notes has been the predominant model in the history of sexuality. The androcentric model of sexuality recognizes preparation of orgasm, penetration, and male orgasm as the constituents of sexual activity. Female orgasm, though expected, is incidental and irrelevant. Safe for a few reports by medical men, female masturbation is but a footnote in the history of masturbation, and female masturbators are caricatured as morbid, pathological and deranged.

By the end of the 19^th century, the first medical vibrator was devised, which effectively reduced the effort and manpower needed to manually stimulate the genitalia of ‘hysterical’ women. It seems likely that not only was female sexual pleasure not a goal of electromechanical stimulation, it was not even conceived of as a side-effect. If orgasm was the result of penetration in the prevailing worldview, it was not going to be achieved in this way. Little did the inventors know that not only could vibrators facilitate orgasm, they would often be far superior to penetration.

Vibrators as medical devices?

Today, vibrator use is exceedingly common. In one cross-sectional study of women who have sex with women, over three-quarters reported vibrator use, and over a quarter within the past three months. In another cross-sectional study of over 1000 participants, this time males, 44.8% reported vibrator use, either in solo or partnered sexual activities, 10% having done so in the past month. Vibrators are often recommended in the treatment of both male and female sexual dysfunction. There has been a proliferation of devices available on the market. There is a dearth of data available on which vibrators may be best for whom. Clinical research has been particularly captivated by the move to comparative effectiveness, which aims to test out different interventions against one another, on multiple outcomes in order to answer questions such as which performs better in different groups, or for different conditions. Could this sort of methodology be applied to vibrators? The answer is a resounding yes, but at what cost? A multitude of questions are generated. Should vibrators be registered and regulated as medical devices? Who will pay for the head to head comparisons of different vibrators? Should vibrators be available on prescription and covered by healthcare plans? Perhaps most concerning, do we want to risk remedicalizing masturbation and the vibrator? The answer then is not that vibrators should once again be medical devices and tested as such, but that we need more comparative data in the form of Consumer Reports and other such methodologies than can better help inform women’s choices. There appears to be a relative dearth of impartial information out there on this topic and it is not surprising. Even today, the notion of women’s sexual pleasure, especially without men appears to offend our sensibilities. Recently the Mayor of Boston’s office rejected Trojan’s request for a permit to give away free vibrators in Boston’s City Hall Plaza. Whilst we may have advanced in our attitudes towards masturbation, taboo and stigma persist.

Prescribing Masturbation: the moral imperative

There is a paucity of research investigating the efficacy of masturbation as a therapeutic treatment or as a public health intervention. Although it had been suggested that promoting masturbation may reduce HIV and STI transmission, particularly in endemic regions, the evidence supporting this is weak. On the other hand, masturbation is an important expression of good sexual health, a way for individuals to acquaint themselves with their bodies, and to relieve stress. Given how much the medical establishment has done to demonize masturbation, and denounce it as the cause of all disease and degeneration, the time has now come for us to promote masturbation. As most men masturbate, seeking to redress to the gender inequalities in masturbation would be a logical starting point. Clinicians should first seek permission to discuss the topic with women, whilst remaining culturally sensitive. They can then address any misconceptions or barriers that exist in women who do not masturbate, suggesting it as a possible activity to add to the repertoire of good sexual health. At the same time, clinicians should be mindful to explore attitudes, beliefs and concerns about masturbation without extolling the virtues beyond the evidence base. Sexual health screenings and well woman checks could provide opportune moments to discuss this, and education and counseling about masturbation can be incorporated into comprehensive preventive care and thus covered by health insurance plans.

Incorporating education about masturbation into healthcare will be challenging because taboos surrounding the discussion of masturbation persist. Arguments will be made that broaching this topic in a clinical consultation constitutes an unnecessary and unwanted intrusion of the personal sphere, and would be uncomfortable for patients and clinicians alike. Such criticisms are untenable. Given how ardent practitioners of the past were to denounce masturbation as the harbinger of disease and debility, without a shred of supporting evidence, it seems perfectly reasonable that clinicians of today might respectfully enquire whether their patients would like to talk about masturbation as part of a wider discussion of sexual wellbeing. The real challenges are not around archaic notions of sin or taboo. Rather, the challenge to redress gender inequalities in masturbation is the entrenched androcentric view that women either cannot or should not be capable of sexual satisfaction without penetration. Masturbation then, is not just a tool for sexual wellbeing, but an expression of autonomy and liberation and a challenge to the persisting attitudes that, like female orgasms, women are not only incidental but irrelevant.