Understanding normal sexual function is necessary for understanding sexual dysfunction. To that end, the preceding chapters detailed the male sexual response at anatomical, physiological, and neurobiochemical levels. As described, erection relies on healthy vascular and neurologic tissue and genital organs, as well as an adequate male hormonal milieu. Numerous factors pertaining to the brain, spinal cord, nerves, blood vessels, smooth muscles, and hormones are crucial to a man’s optimal sexual expression and pleasure.
But there is, of course, much more to sex than a man’s ability to have an erection. Sexual functioning is a complex process that depends on age, genetic traits, character, life experience, physical capacity, sexual impulses, fantasies, inhibitions, sentiments, ideals, and motivation. Personality, attitudes toward sexuality, and past sexual experiences as well as cultural, familial, religious, and social influences contribute significantly to the character and composition of an individual’s sexual relationships. The interaction and relationship between the partners is of primary importance to sexual functioning and enjoyment.
Unfortunately, millions of men, for physical and/or psychological reasons, have lost interest in sex, cannot achieve an erection, or cannot sustain one. Fortunately, sexual dysfunction need not be permanent; once identified, it can be managed, and the sufferer can once again experience the joys of the sexual response and a sexual relationship. This chapter attempts to clarify misconceptions about male sexual dysfunction, in general, and erectile dysfunction (ED), in particular. Knowledge and understanding eases anxiety and confusion about these problems, enables objective and positive discussion, and is a vital first step toward treatment.
The majority of people usually engage in sexual activities that fall in the midrange between extremes. It is important to realize that so-called uncommon sexual behaviors or changes in a usual sexual pattern are not necessarily abnormal. Even those individuals whose behavior is either of two extremes—such as very frequent sexual encounters, or very rare encounters, for example—do not necessarily have reason for concern. (An individual who cannot accept the status of his or her sex life, however, for whatever reason, should consider seeking professional help.)
Almost all men occasionally experience episodes of sexual inadequacy that are usually of no consequence or importance. Normal men may experience a very strong sexual desire but without an erection, or sometimes an erection and even ejaculation without any sexual stimulation. These occasional anomalies may occur in times of marked anxiety, anger, or nervousness. Changes in an individual’s or couple’s standard sexual behavior may occur in an especially encouraging or facilitating situation such as a honeymoon, vacation, or romantic weekend, or conversely, in an especially discouraging or off-putting situation such as an illness, financial crisis, or other time of stress.
It must be emphasized that erection and intercourse cannot be standardized. Cultural, ethnic, social, and personal factors influence the ways different men perceive their sexual potency. To many men, the quality, staying power, frequency, and/or number of successive erections are defining characteristics. For instance, a man who is accustomed to achieving daily erections lasting 15 minutes or more may feel impotent if his frequency of erections decreases to two or three per week or if his erection lasts only about five minutes. But another man may feel completely potent if he has erections once or twice a week lasting four to five minutes.
Generally speaking, young couples in today’s world have sexual intercourse an average of two or three times a week—which means that many couples have sex more often than that and many have it less. Every couple differs in the time required for full sexual satisfaction; even separate episodes with the same sexual partner may vary in the time required. What one couple considers normal sexual functioning and behavior may be considered abnormal by another. Ultimately, a man’s potency is best gauged by the sexual satisfaction of both partners, not just by penis size, frequency or duration of erections or intercourse, or amount of time involved.
For a specific example of the continuum of normal, consider the changes in sexual response and function that occur naturally with age. As noted in chapter 4, the achievement and maintenance of erections may become inconsistent later in a man’s life and normally require more direct genital stimulation. An older man generally notices that his penile sensitivity decreases, erections are softer, orgasms are less intense, ejaculation is less forceful, and there is less volume of ejaculate (or none at all); following ejaculation, it may be several hours or even days before he can get another erection. His physiological (and emotional) need for orgasm decreases as he gets older, and his frequency of sexual intercourse usually decreases as well, to an average of less than once a month by age 75. Nevertheless, a man can enjoy so-called normal sex, regardless of his age, as long as his physical and psychological health and his interrelational circumstances allow.
A recent survey of 1,185 men aged 20–79 from Norway and the United States found, as might be expected, greater incidences of both ED and reduced sexual desire in older men. However, the men in their fifties reported similar satisfaction with their sex lives to the men in their twenties, and satisfaction greater than that was reported by the men in their thirties and forties, despite the fact that they also reported decreased sex drive and erectile and ejaculatory quality with advancing age. Analysis showed that age accounted for 22% of the variance in sex drive and 33% and 23% of the variances in erectile and ejaculatory issues, respectively, but only accounted for 3% of the variance in sexual satisfaction (Mykletun A et al. 2006).
What those results really mean is that men in their fifties and older may experience more problems with erection and ejaculation, but these problems do not seem to lessen their overall sexual satisfaction. According to psychologist Dr. Bracey, such findings are not surprising. In a British Broadcasting Corporation interview (February 21, 2006), he suggested that men in their thirties and forties may be too stressed by other things in life (such as career) to be able to fully enjoy sex, whereas men in their fifties, who may have “adjusted to what they want out of life and tend to be less hung up,” may be able to derive more pleasure from sex in their maturity.
Nowadays, to be a good lover requires adequate technical ability and lack of emotional inhibition. Beyond the body contact, fondling, and various sexual maneuvers lie the impulses, emotions, sentiments, and fantasies that shape the sexual relationship, which is an encounter between two bodies, two subconsciousnesses, two minds, and two desires. It is a repeated experience and adventure that can be highly satisfying, but sometimes threatening, as it may reveal our fragility (Salvi FM 2006). According to certain psychologists, sexuality represents a subconscious desire to experience again the pleasurable sensations experienced during childhood that were provided by the mother, with her affectionate and gentle touching and fondling of our body. A sexual relationship implies physical and emotional sharing between two persons, with the intent of providing mutual pleasure and not using the sexual partner as a sex object for selfish gratification. Sex is a unique experience, which may involve affection, satisfaction, fear, desire, intimacy, inhibition, invention, fantasy, and improvisation. It is an encounter of two bodies, two minds, and two souls trying to explore each other and to provide the ultimate mutual physical pleasure. The art of sex involves reaching beyond the pleasure of orgasm by learning how to relax, how to breathe deeply, how to manage and nurture our body, and how to free our sexual instinct from any restriction and inhibition. It also involves the desire to learn and progress sexually, to experiment with the discovery of new fantasies and experiences, and to establish a relationship that reaches beyond the physical contact to include love, sharing, and deep knowledge of our bodies and that of our partners. Sexuality as a Tantra, a tradition experienced for over a thousand years, may lead to ecstasy when the pleasure of the body combines with the pleasure of the heart and mind to reach the universal cosmic conscience.
The tragedy of sexual failure is a devastating experience, especially for men; it may affect their sense of virility, manhood, self-respect, and pride at any age and expose the man to emotional and psychological disturbances. It may open the gates of hell for millions of men, as we will see later in the book.
Sexual dysfunctions do not only afflict men. Women also experience them in the form of lack of interest in sex, low desire, poor arousal, frigidity, absence of vaginal lubrication, orgasmic inhibition, and pain during coitus. At times, sexual dysfunction may be present in both partners in a relationship.
Many people do not like the term impotence because of its negative connotation. It is also rather vague and imprecise, which is one of the reasons it has been largely replaced by other terms in the medical literature. In common parlance, erectile dysfunction is often used as a synonym for impotence, but the two terms are not actually interchangeable, as one is more strictly an erectile failure than the other. Furthermore, neither term adequately characterizes the full range of male sexual disturbances. Sexual dysfunction is a broader term that encompasses ejaculatory problems, lack of orgasm, decreased libido, ED, and other conditions that preclude normal sexual functioning or satisfaction.
For practical purposes, I define a potent (sexually functional) man as one who has a high level of desire and is able, for a majority of his sexual encounters, to achieve an erection of sufficient quality to permit penetration, intercourse, orgasm, and ejaculation. He should be able to maintain his erection for at least the minimum time necessary to satisfy both partners. Conversely, I consider a man who cannot develop an erection of sufficient rigidity or duration for intercourse to the full satisfaction of both parties to be sexually dysfunctional; more precisely, he is suffering from ED. Beyond this, there is no single standard or average that can—or should—be applied.
The most common male sexual dysfunctions are (1) ED, (2) premature ejaculation, (3) retarded or absent ejaculation, (4) inhibited sexual desire or drive, (5) absence of orgasm, and (6) deviations and perversions. Sexual dysfunction may be primary, which means that it has persisted for all of a person’s life (though it may not have been apparent until he or she became sexually active), or secondary, which means that a person who previously functioned well, sexually speaking, subsequently developed the dysfunction.
ED is the inability of a male to achieve or to maintain an erection of adequate quality and duration to permit satisfactory sexual performance and sexual gratification. It can occur in a man whose libido (sex drive) is intact (and therefore unfulfilled), or it can be associated with decreased or absent sex drive. ED is not a disease per se, but rather the clinical manifestation of one or more organic and/or psychogenic conditions. ED is not necessarily an all-or-none problem; rather, it is usually a matter of degree, ranging from minor to complete. It cuts across race, nationality, and socioeconomic factors; occurs at all ages; and varies in severity and duration from man to man. Almost all married men experience occasional episodes of ED.
Some “sexperts” contend that a man should fail in at least 50% of his sexual encounters before he is considered to have ED, but they would get an argument from men who are unsuccessful 99% of the time and would see 50% as a vast improvement. Others say that a minimum of five minutes of erection firm enough for intercourse denotes normal erectile function, but they would also get an argument, especially from men who cannot maintain an erection for 15 minutes or more—these men, though far from “impotent,” are disappointed with their sexual function and may consider themselves to have ED, however illogical that may seem to others.
Patterns of ED differ among men. Some men lose their erections when they get anxious; some can achieve erections only during foreplay; others may gain an erection only to lose it at the moment of penetration or during intercourse. Some men may have erections through masturbation, or only in deviant situations (e.g., with pornography or during unusual sexual encounters), but fail to achieve or maintain erections under normal circumstances or with their primary sexual partner—such a man is anatomically potent, but psychologically, he has ED.
The International Society of Impotence Research (Lizza EF, Rosen RC 1999) and the American Urological Association’s treatment guidelines (Montague DK et al. 2005) have both classified ED into five categories: (1) vasculogenic (arterial, cavernosal, and mixed), (2) psychogenic (situational and generalized), (3) neurogenic, (4) endocrinologic, and (5) drug induced. The etiologies, treatments, and therapeutic outcomes are different for each of these five categories as well as for primary versus secondary ED.
The prognosis for a man with ED depends on the condition’s duration, the underlying cause(s), the man’s willingness to seek medical advice and accept treatment, and the presence of aggravating conditions such as obesity, heavy smoking, lack of exercise, chronic alcoholism, drug addiction, unacknowledged homosexuality, or sexual deviations. Additional physical and psychological factors can also influence therapeutic success.
For the purpose of organizing a large body of material, this book roughly divides the physical and psychological causes of ED (chapters 7 and 8). But when it comes to ED, strict etiologic classification between organic and psychogenic is an oversimplification. ED is a multifaceted condition, and its etiology is often multifactorial. The various predisposing and contributing factors run the gamut from age, chronic health conditions, and emotional disorders to obesity, lack of exercise, and the use of certain medications and other substances. Any organic or psychological disorder that affects the brain, nervous system, vascular system, endocrine system, or genitourinary system—or, even more specifically, affects any part of the penis—can lead to a man’s inability to develop or maintain a firm erection for a period long enough for successful sexual intercourse.
Before 1980, most primary ED was considered to be psychogenic. Newer studies, however, have demonstrated that organic causes play a role in the majority of primary ED cases and that many cases—up to about 45%—involve a combination of physical and psychological factors. Recent advances in diagnostic sophistication and our understanding of erection have shown that for ED overall (primary and secondary combined), causes are purely organic or mixed in 70% to 90% and psychogenic in about 10% to 25%, according to age. In general, about 75% of ED cases in men younger than 40 are psychogenic or combined; by comparison, about 75% of ED cases in men over 60 are organic. Irrespective of its cause, most patients with ED experience emotional reactions to it—this is a natural response to what can be a devastating problem. Male sexual dysfunction can even result in psychological disturbances requiring evaluation and treatment.
In the United States alone, ED affects about 15-30 million men. About 48% of the American male population over the age of 50 may suffer from ED, with the incidence increasing with age to reach about 75% in men 70 or older. Recent statistics for American men include the following:
— A study of 2,115 men aged 40–79 revealed an overall incidence of severe ED (infrequent or no erections) of about 12%, ranging from 1% in young men to about 25% in the oldest group. (Panser LA et al. 1995)
— Longitudinal results from the 1987–1989 Massachusetts Male Aging Study (MMAS) revealed that in 1,700 men aged 40–70, the combined prevalence of minimal, moderate, and severe ED was 52%. ED’s combined prevalence was also shown to increase with age, affecting about 40% of men aged 40–49 and almost 70% of those aged 70–79. Comparing age 40 to age 70, the prevalence of severe ED rose from about 5% to about 15%, moderate ED doubled from 17% to 34%, and minimal ED held constant at 17%. An update of the MMAS showed a twofold increase in ED with each decade of life. (Feldman HA et al. 1994; Johannes CB et al. 2000)
Accurate figures for ED’s global incidence are difficult to obtain, partly because the discussion of sex is still taboo in several parts of the world. Many men deny any experience of sexual inadequacy out of embarrassment or ignorance; others simply consider it a natural, inevitable consequence of old age and don’t give it another thought. International statistics include the following:
— In Germany, the Cologne Male Study revealed a 19.2% prevalence of ED among 4,489 men aged 30–80. (Braun M et al. 2000)
— Carson et al. (2006) found that over 50% of men aged 40–70 had ED of different degrees, with about 10% complaining of complete ED, about 25% of moderate ED, and 17% of minimal ED. Furthermore, of 500 men who visited urologists for urinary symptoms unrelated to ED, about 44% had ED, and yet about 74% of those men did not discuss it with any physician out of embarrassment.
— A study of 1,688 elderly Dutch men found that significant ED, with severely reduced rigidity or no erections, was reported in 3% of men aged 50 to 54 and 26% of men aged 70 to 78. The prevalence of severely reduced or absent ejaculatory volume also increased from 3 to 35% in those age groups. (Blanker MH et al. 2001)
— A systematic review of the prevalence of ED based on 23 studies from Europe, the United States, Asia, and Australia revealed that the prevalence of ED ranged from 2% in men younger than 40 to 86% in men over the age of 80. (Prins J et al. 2002)
— Several studies involving different countries and including men aged 18–90 were reported at the Second International Consultation on Sexual Dysfunctions in 2003, with high rates of ED worldwide that increased with each decade of life. Overall, the prevalence of ED was 1% to 9% for men aged 18–39, 3% to 15% for men aged 40–49, 2% to 35% for men aged 50–59, 11% to 49% for men aged 60–69, and 22% to 79% for men aged 70 and older. (Althof SE et al. 2003; Basson R et al. 2003; Bondil P et al. 2003; McMahon CG, Meston C 2003; Meyer KF et al. 2003)
— Twenty-three worldwide studies using the Sexual Health Inventory for Men (SHIM) revealed ED prevalences of 64% in Leon, Spain; 56% in West Virginia; 54% in Porto Allegre, Brazil; and 32% in Japan. (Cappelleri JC, Rosen RC 2005)
It is estimated that in total, about I50 million men worldwide suffer from some degree of ED, and it is projected that this number will double by the year 2025, as the male population becomes increasingly older. These figures, however, doubtless underestimate the true global prevalence of ED.