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Erectile Dysfunction (ED) and Its Empirical Management through the Centuries

Male sexual dysfunction is as old as the world. The Bible attributed it to a divine curse.

The Greek physician and so-called father of medicine, Hippocrates (460—375 b.c.), attributed ED to man’s professional preoccupations and the ugliness of the female. Eighteenth- and nineteenth-century religious moralists maintained that it was caused by excessive sexual activities such as masturbation, prostitution, and promiscuity. ED has been “treated” over the years by witchcraft, exorcism, and religious counseling. Fortunately, ignorance and superstition about sexual function and dysfunction were eventually superceded (at least to some extent) by scientific examination and discovery. The mechanism of erection was first described by the famous Italian artist and inventor Leonardo da Vinci (1452—1519)—himself a sufferer of ED— who related it to the filling of the penis with blood. The physician Costanzo Varolio (1543-1575) later described the erectile function of the muscles surrounding the penis, although the very first description of these muscles is attributed to the Greek physician Galen in the second century a.d.

Chinese, Greek, Roman, and Egyptian literatures mention numerous potions to increase sexual potency. Historical remedies for ED have included the ingestion of animal testes and testicular extracts—and this is not as far off the mark as it may sound. In 1889, French physiologist Charles Edouard BrownSequard injected himself with extracts made of blood from the testicular vein, semen, and a liquid obtained from crushing the testicles of young dogs and guinea pigs. He reported an excellent sexual response to this cocktail, considered by many experts to be the birth of male hormone therapy.

LILLY-ICOS AND THE HISTORY OF HUMAN SEXUALITY

Since ancient times, men and women have been aware of their lust and basic urge to fornicate. Sexual attitudes and activities have been defined and redefined for thousands of years by countless personal, religious, ethical, societal, and ethnic influences. At a recent annual meeting of the American Urological Association, Lilly-ICOS (the manufacturer of Cialis) distributed an elegant booklet titled Sexuality: Perception and Performance throughout History, illustrating the changing image and practice of sex over time and in various cultures (Patel 2006). Following are several interesting nuggets adapted from that booklet:

Ancient Humanity

Sex was simply a natural and enjoyable act of sensual pleasure, not influenced by moral or procreational considerations, until about 9000 b.c. With the male role in reproduction unknown, the woman was the epicenter of the family. Men’s reproductive contribution was acknowledged around the time that people moved into villages with supplies of vegetation and livestock. Producing numerous offspring for more field hands was highly desirable in those agricultural societies, so a woman’s inability to conceive was a blemish that cast her in a subordinate role.

Early Egypt

Marriage with girls as young as 12 was common. Contraception was practiced with lotions and other concoctions, interruption of coitus before ejaculation, anal sex, sex with animals, and the insertion of substances such as honey and crocodile dung into the vagina to prevent sperms’ passage to the cervix.

Early Greece

Men often satisfied sexual urges by means of homosexual behavior and pederasty, especially with young postpubertal boys. Women often sought gratification through masturbation or lesbian sex. Women were considered inferior to men and classified into three groups: wives for procreation, concubines for sexual gratification, and highclass prostitutes for sexual and intellectual stimulation.

Roman Empire

Sexual liberalism, prostitution, public baths for men and women, and mythological sexual deities reflected the Romans’ “insouciant and nonchalant attitude toward sex” and widespread promiscuity, which persisted until the fall of the Empire. With the eventual domination of the Christian church, sex for pleasure (rather than procreation), homosexuality, masturbation, and contraception were condemned as sinful and were banned, sometimes by violent means.

Early India

The teachings of the aforementioned Kama Sutra (aphorisms of pleasure) focused on artha, or material well-being, and kama, or pleasure and love. Sex was considered a religious duty to be treated with respect and great consideration, an art to be acquired through practice, and an emotional act of love's expression. Along with instructions for both men and women in various sexual techniques for maximal pleasure, the manual provided lists of aphrodisiacs and modes of contraception. Indian culture’s high regard for marriage was reflected in the custom of sati, in which a widow committed suicide by throwing herself on her husband’s funeral pyre to accompany him in death.

Early Islamic World

Women who were classified as respectable ladies were admired and sheltered in harems to protect them from the so-called evils of society. These harems also provided men with the opportunity to have sex at will with numerous women. Fifteenthcentury Turks built the Grand Turk, a small city for the 300-1,200 concubines in the sultan’s harem, which gave him a vast choice of partners to choose from for his sexual gratification. A fifteenth- or sixteenth-century sex manual titled The Perfumed Garden for the Soul’s Recreathn detailed explicit methods for successful intercourse and remedies for sexual problems.

Early China

The Taoist doctrine emphasized the importance of sex for enjoying a long, healthy life and as means for the couple to complement each other and connect spiritually. Women represented the source of an inexhaustible yin essence, which men, with their easily depleted yang essence, needed to absorb to achieve harmony and prolong their lives. The man was encouraged to engage in as much sex with as many partners as possible to stockpile yin, while also conserving yang through various methods of preventing ejaculation. Several manuals on sexual techniques, positions, and foreplay were available, as well as tonics and lotions to increase sexual pleasure and methods to elongate the penis and shrink the vagina. Masturbation and homosexuality were forbidden for men but allowed for women. Later, the philosopher Confucius attacked sexual promiscuity and imposed moral views that sanctioned marriage but allowed men to have multiple wives to produce sons. Although Confucius expressed disdain for women, he insisted on the man’s obligation to fulfill the sexual desires of his wives and concubines. Confucianism’s rigid regulations persisted until the mid-seventeenth century.

Renaissance Europe

Despite the church’s prohibitions, rigid constraints, and condemnation of premarital sex (which was widespread nevertheless), this age, particularly in Italy, was marked by sexual liberalism and the dominance of sexuality in art, with nudity depicted in paintings, sculptures, and murals. A large number of illegitimate children and a high incidence of sexually transmitted diseases (STDs) were recorded, leading to the development and use of the condom.

Sixteenth- to Nineteenth-Century Japan

The “pleasure quarters” flourished with regulated prostitution, several published manuals called shunga gave specific instructions on lovemaking techniques (especially for newlyweds), and the famed Japanese geishas provided customers with incomparable entertainment in music, song, and dance.

Nineteenth-Century Europe and America

Sexual liberalism and promiscuity were widespread, nudity was again prominent in art, and prostitution was prevalent all over Europe and the United States in the 1800s. A steep increase in STDs reached about 30,000 cases in London in 1850s. This trend persisted to the next century, with gonorrhea affecting half the male population in the United States by 1914 and reaching about 100 million cases by 1970, prompting the British and U.S. governments to form antiprostitution statutes.

The Twentieth Century

Feminism and women’s liberation movements contributed to a liberal attitude toward sex unrestricted by moral or religious prohibitions. This attitude promoted the development of different forms of contraception, which allowed for sexual freedom, but was accompanied by a markedly increased incidence of STDs, including AIDS. And so the worldwide evolution and revolution of human sexuality continues...

Man’s Penile Obsession

In a healthy state, the human penis is a very efficient tool for maximum sexual gratification, procreation, and perpetuation of the species. But even when the penis is capable of doing what it is designed to do, and does it effectively, men may have any number of complaints: that it’s too short, too narrow, ugly, that it curves the wrong way—even that it’s too big or too long. In other words, those men want it to be something it is not.

Aside from the exceptions afforded by modern medical and surgical techniques, what a man is born with is what he must live with for the rest of his life. Because of their previously mentioned fascination with penile characteristics and function, however, many men try to find ways to lengthen the penis. For some, their worry and embarrassment over penile size is so great that they become sexually dysfunctional. When the object of his pride then fails to respond, it is an uncompromising witness to a man’s sexual failure. A man can fake sensitivity, caring, faithfulness, and many other human emotions—but one tiling he cannot fake is an erection.

Micropenis: Myth or Reality?

Although the size of the penis varies from man to man, it probably has less relationship, physically or structurally, to other parts of a man’s body than any other bodily component. Measurement of flaccid size may not be a valid test to assess the true length of the penis. Many men with large flaccid penises experience relatively little growth in erectness, whereas the man with a smaller flaccid penis sees a dramatic change in size on becoming erect.

Medically speaking, most so-called micropenises are actually normal sized and may simply be buried in the dense suprapubic fat (fatty tissue above the pubic bone) usually found in obese men. The procedure to lengthen these penises is relatively simple. When the suprapubic fat pad is pulled upward, the penis is usually found to have a normal length. For those men, exercise and diet alone may reduce the fat pad and provide natural penile elongation without the need for any medical or surgical treatment.

In exceptional cases, when the penis is truly small—measuring less than 1.8 inches in the flaccid state and less than 2.8 inches during erection—and especially if this is actually causing severe psychological disturbance, surgical elongation of the penis may be attempted in an effort to add about 1—2 inches to its length.

Unfortunately, several surgical techniques for lengthening and widening a short and narrow penis have proven largely unsuccessful, for example, dividing the suspensory ligaments that attach the base of the penis to the pubic bone; performing a V-Y plasty (making a V-shaped incision on the lower abdomen above the penile base, then closing the incision in a Y-shape); or taking fat from the lower abdomen and injecting it around the shaft of the penis. These techniques may commonly result in the development of inflammatory and scar tissue around the shaft, and even marked penile deformities, necessitating additional corrective surgery. (They have also led to well-publicized lawsuits, which have cost one particular urologist in California his medical license and millions of dollars in litigation.) However, as discussed in chapter 3, certain surgical procedures for penile enlargement, performed by experts, may lead to satisfactory results.

Author: K. Anthony Hanash. M.D.
Source: New Frontiers in Men’s Sexual Health