THERE ARE CURRENTLY MORE than a million websites that discuss orgasms and health, so we know there’s certainly a lot of interest in this topic. Overall, orgasms are evidently good for our health, even though they are not particularly effective at burning calories. An orgasm itself burns only two to three calories. However, a person can burn another fifty or more calories during the physical activity that leads to orgasm. One way to relate sexual activity to various forms of exercise is to compare “metabolic equivalents” (METs). One MET is defined as the amount of energy required to just sit quietly, which is about one calorie per kilogram (1 kilogram = 2.2 pounds) of body weight per hour. At this rate, a person who weighs 160 pounds would burn about 70 calories in one hour while sitting quietly or sleeping, which would be about 1,700 calories in twenty-four hours. Having sex with your partner uses about 5 METs. Having sex with someone who isn’t your usual partner uses about 9 METs. Playing basketball also uses about 9 METs. Playing tennis uses 6 METs. Skiing uses 8 METs. Walking one mile uses 2.3 METs, and walking three miles uses 4.3 METs.
Research studies reviewed in a paper prepared by the Planned Parenthood Federation of America found that masturbation and partnered sexual activity may benefit many aspects of health and well-being, including longevity, immunity, reproductive health, and pain management. Some researchers have suggested that sexual activity may be correlated with a reduced risk of two of the leading causes of death in the western world: heart disease and cancer.
One study claimed that a steady and active sex life diminishes the negative physiological effects of aging and the risk for some diseases. Another study, which included 918 men between forty-five and fifty-nine years of age, probed the question in depth. The men were given a physical examination, including taking a medical history, measuring blood pressure, electrocardiogram, and cholesterol tests, and were asked about their frequency of orgasm. At a ten-year follow-up, it was found that the men who had reported having eight or more orgasms per month were twice as likely to be alive as the men who had less than one orgasm per month. The researchers concluded that “sexual activity seems to have a protective effect on men’s health.”
In the same group of 918 men, the researchers found that those who reported a high frequency of sexual intercourse were only half as likely to die of a heart attack (myocardial infarction, or MI—a blockage of blood flow to the heart muscle) as men who reported a low or intermediate frequency of orgasm.
There are not as many studies of women, but a study published in 1976 compared the sexual lives of 100 women hospitalized for heart attack (MI) with those of a group of 100 women of comparable age who were hospitalized for other reasons. Some of the questions about sexual life included the occurrence of “frigidity” (a 1970s term that is now considered obsolete). “Frigidity” was defined as a long-term lack of enjoyment of sexual intercourse, or a current inability to experience orgasm during intercourse, which created emotional dissatisfaction, or a current absence of orgasm, sexual enjoyment, and/or sexual intercourse due to a partner’s illness or erectile dysfunction, which also created emotional dissatisfaction. The study found that the women with MI were more likely to be sexually “frigid” and sexually dissatisfied than the women hospitalized for other types of illness.
There is some evidence that male orgasms may protect women! Actually, the evidence is that pregnancy may afford a long-term protective effect against breast cancer. One researcher proposed in 1994 that a woman’s immune response that protects against breast cancer may be triggered by antigenic proteins in her partner’s sperm. The possible sperm effect was supported by a later study that found a woman’s risk of breast cancer was associated with the number of lifetime male sexual partners she had: the more sex partners, the lower her risk of breast cancer. Although much less common, men also can have breast cancer. One study found that men with breast cancer have a lower frequency of orgasm than a comparison group of healthy men.
For men, two studies have provided evidence that the higher the frequency of ejaculations over many years, the lower the incidence of prostate cancer. In an Australian interview study of more than 2,000 men under the age of seventy, those who recalled having an average of four or more ejaculations per week during their twenties, thirties, and forties had a significantly lower (by one-third) risk of developing prostate cancer than men who reported an average of fewer than three ejaculations per week during the same age period. There was no association of prostate cancer with the number of sexual partners, suggesting that infectious factors did not account for the difference (it’s well established that the greater the number of sexual partners, the higher the likelihood of acquiring a sexually transmitted infection, or STI).
In a questionnaire study of more than 50,000 American men ages forty to seventy-five, researchers found that the group of men who experienced many orgasms (at least twenty-one per month) were much less likely to have prostate cancer than the group who experienced moderate to low numbers of orgasms (seven or fewer per month). The researchers speculated that ejaculations may clear the prostate of potential carcinogenic substances and that psychological stress reduction resulting from ejaculation could reduce the release of “stress-related substances” (which could be related to eventual development of cancer) from the nerves that supply the prostate.
Orgasms may also serve as a sleep aid. It’s well known that many men feel sleepy after experiencing an orgasm, and this seems to be less so in women, but one study found that many women use orgasm to induce sleep. The study reported that 32 percent of women who reported masturbating in the previous three months did so to facilitate falling asleep.
People experiencing pain may find that orgasms can offer some relief. In the 1970s researchers discovered that vaginal and cervical stimulation in laboratory animals blocks behavioral and brain responses to pain, a finding that led to similar studies with humans. The human studies showed that vaginal self-stimulation produces an increase in pain thresholds (ranging from 40 percent to more than 100 percent; an increase in pain threshold of 100 percent means that the woman has become half as sensitive to the pain). However, these women do not “go numb.” Their sense of touch is not diminished, just their reaction to pain. A later study found that pleasurable stimulation of all areas of the genitals elevates pain thresholds. The most effective area for increasing pain threshold when stimulated is the area of the G spot. Orgasm produces the greatest increase in pain thresholds. This effect has not been measured in men, although anecdotal evidence that men become insensitive to pain at the time of orgasm has been described for many years.
YES, THERE IS RESEARCH evidence that sexual activity and orgasm can reduce stress. A study of 2,632 American women found that 39 percent of those who masturbated reported doing so to relax. When a person experiences orgasm, the hormone oxytocin is released from nerve cells in the hypothalamus (a region of the brain) into the bloodstream. Low levels of oxytocin in the blood are correlated with a relatively high incidence of tension and anxiety disorders, whereas higher levels are correlated with reduced responsiveness to stress.
In addition to the physiological role of orgasm in reducing stress, orgasmic pleasure in a mutually loving relationship can benefit the mental health of the partners and the quality of the relationship. But we must note that if individuals attempt to stimulate orgasms specifically to achieve relaxation afterward, this may place the partners under performance pressure—which could intensify stress rather than reduce it.
In rare cases, individuals have been forced to have orgasms by a sexual abuser or during a sexual assault. Following such abuse or assault, it’s possible that orgasmic sensations intensify the individual’s stress rather than providing a sense of relief. People who experience increased stress when having an orgasm should see a sexuality counselor or psychosexual therapist (ideally, one who is experienced in dealing with victims of sexual abuse).
WHEN A FORMER VICE PRESIDENT of the United States, Nelson A. Rockefeller, died of a heart attack during a sexual encounter in a hotel with a much younger woman, it triggered great interest among the public. People wanted to know whether “death in the saddle” was common or rare. The answer is that it is rare. In one study of 5,559 cases of sudden death in men, fewer than 20 deaths occurred during a sexual act. In general, it seems that the exertion associated with sexual activity is more the culprit than is the actual orgasm.
According to one medical examiner, “death in the saddle” follows a pattern in which “the deceased [man] is usually married; he is with a non-spouse in unfamiliar surroundings after a big meal with alcohol.” (Unfortunately, so far, most scientific articles on the incidence of “death by sex” focus on men.) One study reported that 70 percent of twenty coital (sexual intercourse) deaths recorded had occurred during extramarital intercourse. This suggests that added stresses could have been involved in these deaths. The researchers cited another study in which coroners estimated that “acute coronary insufficiency resulting from coitus is a fact, but the incidence rate is no more than three out of every 500 subjects with heart disease.” The researchers concluded that “it is obvious that coital death is a rare occurrence, and that reports of coital death of a middle aged, middle-class, male patient with heart disease who engages in sexual activity with his wife of 20 or more years in their own bedroom is even rarer.”
In a more recent review, the same researchers caution that the increases in heart rate and blood pressure that occur during intercourse might “precipitate the fracture or erosion of a vulnerable atherosclerotic plaque with subsequent thrombus (clot) formation and arterial occlusion.” However, they cite a survey of more than 1,700 patients in which “sexual activity was noted to be a potential triggering event prior to MI in only 1.5 percent of patients.” These authors concluded that “absolute risk caused by sexual activity is considerably low: one chance in one million healthy individuals. Cardiac rehabilitation and exercise training programs can reduce incidence of chest pain (angina pectoris) during sexual activity.” One medical heart expert recently recommended a gradual increase in sexual exertion after a heart attack. The recommendation is to resume sexual activity slowly, over a period of six or more weeks, starting with gentle caressing, then mutual genital manipulation, and eventually intercourse, as long as no medical symptoms, such as chest pain, occur as exertion increases.
YES. SOME MEN AND women suffer from “pre-orgasmic headache,” which is characterized by a dull ache in the head and neck associated with muscle contraction in the jaw muscles that increases with sexual excitement. An “orgasmic headache” has also been described—a sudden severe (“explosive” or “thunderclap”) headache that occurs at orgasm produced by masturbation or intercourse. Some, but not all, men and women who have orgasmic headaches also suffer from migraines. The orgasmic headache is said to last for minutes, hours, or even days. To be on the safe side, when experiencing such severe headaches, the individual should see a doctor to rule out the possibility of an aneurysm (ballooned, locally weakened blood vessel) or a burst blood vessel supplying the meninges (the membranes that form a capsule around the brain and spinal cord).
Another type of headache associated with orgasm has been described as “ice-pick-like,” with the pain felt in the face. Someone who experiences this type of headache should be tested for possible epileptic activity or compression of, or stretching of, the spinal cord, which may be related to prior trauma, a tumor, or a congenital condition. Another possible cause of this type of orgasmic headache is constriction of blood vessels that convey blood to the meninges.
Some physicians suggest that orgasmic headaches are similar to headaches after exercise, which are related to a temporary rise in blood pressure, muscle spasm of the neck or scalp, or dilation of blood vessels in the meninges. Orgasmic headache also has similarities to headache after the procedure known as a “spinal tap,” which may be due to reduced pressure of the spinal fluid after the sample of fluid is removed.
Relief from orgasmic headache has been obtained with a class of drugs known as triptans. Triptans (which are also effective against migraine headaches) are reported to reduce the duration and severity of orgasmic headaches and even to prevent orgasmic headaches when they are taken thirty minutes before intercourse. Propanolol (a type of drug known as a beta-blocker) and calcium-channel blockers are other headache medicines that can be effective in preventing orgasmic headaches.
THERE IS SURPRISINGLY LITTLE research on this widely discussed issue. The scientific literature through the 1990s is a barren shelf, but a medical discussion of “blue balls” was started with publication of a case report in the major medical journal Pediatrics in 2000. The authors (two physicians) wrote that “‘blue balls’ is a widely used colloquialism describing testicular and scrotal pain after high, sustained sexual arousal unrelieved because of lack of orgasm and ejaculation. It is remarkable that the medical literature completely lacks acknowledgment of this condition.” The authors described a case of a fourteen-year-old who came to the emergency room with testicular-scrotal pain that had persisted for more than an hour. The boy reported experiencing the pain previously, when he was petting with his girlfriend; on neither occasion did he ejaculate and on both occasions the pain started immediately after stopping foreplay. An examination found that the boy had no current or prior relevant pathology, and the pain subsided after an hour in the emergency room. On subsequent telephone follow-up, he revealed that he’d started having sexual intercourse with his girlfriend, with no further episodes of testicular-scrotal pain.
The authors of this report suggested that the pain in cases of this sort might result from the lack of orgasmic resolution, which could lead to insufficient draining of blood from the genitals and/or increased pressure in the epididymal tubes, through which sperm and fluid are normally transported away from the testicles. “The treatment is sexual release,” the authors wrote, “or perhaps straining to move a very heavy object” (a straining procedure known as the “Valsalva maneuver”).
This report stimulated a letter to the editor of the journal, which read: “we wonder whether the authors’ suggestion that ‘straining to move a very heavy object’ is the first choice . . . As this condition is coming to light in a highly respected pediatric journal, perhaps we should resurrect the advice of former Surgeon General Jocelyn Elders and teach masturbation in the schools. This novel idea, which led to her removal from office, should have been implemented yesterday.” Jocelyn Elders, M.D., was appointed U.S. surgeon general by President Bill Clinton and served for fifteen months in his administration, until she was forced to resign in 1994 as a direct result of suggesting that schools should consider teaching masturbation to students as a means of preventing sexually transmitted diseases.
In response to the letter’s suggestion that sexual release is an effective treatment for blue balls, another letter appeared: “What are the ethical implications of such a statement? Will young men demand sexual satisfaction of their partners as essential medical therapy? Do the authors condone self-treatment? What about potential adverse effects of treatment, such as blindness and palmar hypertrichosis [hairiness] (personal communications, our mothers)? What are the ethical and/or medical responsibilities for the health care team in treating young men in an urgent care setting? And if treatment is rendered, are there appropriate diagnostic and treatment codes for billing purposes?”
The authors of the original article responded in yet another letter to the editor of Pediatrics: “A 70-year-old retired college professor told us . . . [that] in the 1940s a practicing physician taught him and his fellow eighth-graders about sexuality, including ‘lover’s nuts.’ The doctor told them that masturbation was at times a legitimate medical treatment.” They continued: “In no way should the pain of blue balls be an excuse to inappropriately advance a sexual relationship. As part of sexual education, we might teach that sexual urges are natural, abstinence is a real choice, and sexual decisions ought never to be based on coercion or exploitation.” They concluded with the droll pun: “blue balls is real, and a cure is coming.”
In a subsequent commentary on the dialogue, an engineer, L. N. Ludovici (in a letter with coauthor J. Arndt) wrote: “I have had a vasectomy and noticed that I no longer get blue balls with prolonged sexual excitement if there is no release by ejaculation. Instead, I feel pain along the path of the vas deferens down to the point where it is sealed off. Indeed, with palpation of the vas deferens, it feels swollen. If blue balls were caused by blood engorgement in the testicles I would still get it since the vasectomy did not cut the blood vessels. I conclude that blue balls is caused not by blood engorgement, but by seminal fluid engorgement. I theorize that since the fraction of the seminal fluid that is produced outside of the testicles has nowhere to go, it backs down the vas deferens into the normally connected testes and swells the whole system to the point of pain.”
Until someone undertakes a more serious analysis of blue balls syndrome, it will most likely remain a controversial, and much discussed, phenomenon.
MOST OFTEN, ORGASM REMAINS intact for men and women who have been diagnosed with or have been treated for and survived cancer. However, it is a common complaint of cancer survivors that they find it difficult to restart their sexual life after they have been treated for their cancer. After treatment, orgasm may become delayed or more difficult to experience for reasons related to medications or the emotional adjustment to cancer, or both. The medications and emotional adjustment can also lead to a common sexual problem for people with cancer: loss of desire for sexual activity. The loss of desire seems to affect men and women equally. In general, cancer patients undergoing treatment and recent cancer survivors commonly find rigorous physical activities fatiguing, which may also reduce interest in engaging in sexual activity.
Other cancer-related sexual problems commonly experienced are erectile dysfunction in men and dyspareunia (pain during vaginal intercourse) in women. These problems could be due to treatments such as radiation therapy to the genital area or surgical procedures such as hysterectomy and bilateral salpingo-oophorectomy, in which the uterus, cervix, ovaries, and fallopian tubes are removed.
Surgical procedures related to cancer may affect the nerve and blood supply to the genital region, interfering with stimulation of arousal and erection in men, lubrication and vaginal and cervical sensation in women, and orgasm in both men and women. In the case of dyspareunia, a course of dilation therapy (in which the woman uses a graded series of dilators, from finger size to penis size, for daily massage of the vaginal opening and walls to ease penile penetration), use of lubricants, and use of sedatives may help the woman become more comfortable with vaginal intercourse.
As a result of total hysterectomy (removal of the uterus and cervix), women may experience changes in genital sensations due to pain or to loss of sensation and numbness, as well as a decreased ability to experience orgasm. Premature ovarian failure as a result of chemotherapy or pelvic radiation therapy is also often a preliminary to sexual disorders, particularly when hormone replacement is inadvisable (“contraindicated”) because the growth of the cancerous cells is hormonally sensitive. Premature ovarian failure resulting from chemotherapy or radiation precipitates the onset of menopausal symptoms due to the sudden loss of estrogen and androgen normally produced by the ovaries. These symptoms include vaginal atrophy (shrinkage), thinning of the vulvar tissues and vagina, loss of tissue elasticity, decreased vaginal lubrication, hot flashes, increased frequency of urinary tract infections, mood swings, fatigue, and irritability. When not contraindicated because of cancer risk, physician-prescribed replacement of the ovarian hormones—by hormone patch, pill, or injection—can diminish and control these symptoms.
Men who undergo treatment for prostate cancer (chemical, surgical, and/or radiation) may experience ejaculation that is delayed, inhibited, or “retrograde” (the ejaculated fluid goes into the bladder rather than out through the urethra, due to failure of the urethra’s internal sphincter). In some cases, ejaculation may not occur at all. Among men with prostate cancer who have received anti-androgen therapy (“chemical castration,” which is done to decrease the normal prostate-stimulatory effect of androgens), about 80 percent report a profound decrease in sexual interest, typically accompanied by erectile dysfunction and difficulty experiencing orgasms.
Relationship problems, such as a change of “power” between partners, may also occur following a cancer diagnosis and treatment. With the new role for one partner as caretaker of the partner with cancer, the personal interactions may change dramatically, creating tension and conflict in the couple’s emotional and sexual relationship. In a common misconception, the partner of the cancer patient erroneously believes that if he or she overstimulates or puts too much pressure on the partner with cancer, this will cause a relapse (return) of the disease. So he or she withholds such stimulation or does not make sexual requests. Such overly cautious behavior might lead to weakening of the couple’s emotional and sexual relationship.
Depending on the type of cancer and its severity, surgeons have developed nerve-sparing procedures that allow them to remove cancerous tumors and other structures while minimizing damage to sexual function. For example, for men with colorectal cancer (cancer of the colon and rectum), development of surgical techniques that spare the hypogastric and pelvic plexus nerves has allowed patients to largely retain erectile and ejaculatory function and orgasm. Similar nerve-sparing surgical procedures can also be used in the case of prostate cancer, depending on its location and severity. We are surprised that the medical literature seems to offer only a few reports of nerve-sparing surgery for women who undergo hysterectomy.
A HYSTERECTOMY (THE REMOVAL OF the uterus and, in a total hysterectomy, the cervix and the uterus) may affect a woman’s ability to experience orgasm in three main ways. First, hysterectomy eliminates or reduces pain and excessive menstrual bleeding. If the pain and bleeding were negatively affecting a woman’s enjoyment of sex, then the hysterectomy could improve her sexual experience. Second, the surgery can affect the sensations from the sexual organs directly by damaging blood and nerve supplies, or the medication that follows the surgery can interfere with the neurotransmitters in the brain that control sexual feeling and the ability to have an orgasm. So, there is the potential for a decline in sexual sensations and desire. Third, any surgery can have a profound psychological impact.
The nerves that convey sensation from the clitoris are likely to remain undamaged by hysterectomy, so clitoral sensation is unlikely to be affected. However, the nerves that convey sensation from the vagina are more likely to be damaged by the surgery, and this could reduce the woman’s ability to experience orgasm. In the case of a total hysterectomy, in which the cervix is also removed, cervical sensation is eliminated, and for some women, both vaginal and cervical stimulation are an important component of their orgasmic experience.
The many studies that are available on the effects of hysterectomy on a woman’s sexual experience don’t paint a clear picture of the outcomes, mainly because they fail to report on women’s preferred regions of genital stimulation, and the different regions can be differently affected by the surgery.
HYSTERECTOMY MAY BE THE most commonly discussed surgery affecting female genitals, but there are many other surgeries that may affect a woman’s ability to experience orgasm. These other “pelvic surgeries” include, but are not limited to, oophorectomy (removal of the ovaries), cystectomy (partial or complete removal of the urinary bladder), vulvectomy (which might involve the removal of the top layer of the vulval skin affected by cancer or, in severe cases, the entire vulva and deep tissues, including the clitoris), and abdomino-perineal resection (a radical surgical procedure in which the anus, rectum, and sigmoid colon are removed to treat cancer located very low in the rectum or in the anus, close to the sphincter—the muscle that keeps closed and opens the anus). If the surgeon is successful in retaining adequate blood supply and preserving healthy nerves, the effects of these surgeries on sexual activity and orgasm may be minimal. Conversely, disturbance in the function of the blood or nerve supply could lead to a sexual disorder. If you are to undergo surgical treatment of this sort, it’s important to inform your surgeon beforehand about the importance to you of retaining your sexual function. The surgeon will then take extra care when working on these nerves, veins, and arteries.
IN SOME CASES, YES. Removal of the prostate gland (prostatectomy) is one of the most common male pelvic surgeries. This surgery can damage nerves and blood vessels and, at a minimum, removes an important male sex organ. The risks associated with prostate surgery include occasional or total loss of erection, loss of ability to ejaculate, expulsion of urine at orgasm (“orgasm-associated incontinence”), painful ejaculation, and sexual desire disorder (decrease or loss of sexual desire). Men may be at least as affected psychologically by prostate surgery as women are by hysterectomy, because the effects of prostate surgery can be more externally evident—possibly affecting erection, penetration, and ejaculation.
Men with an intact prostate who experience pain at the point of ejaculation or immediately afterward may have prostatitis (an inflammation of the prostate gland that develops gradually), benign prostatic hyperplasia (enlargement of the prostate gland, which occurs with age), or ejaculatory duct obstruction. These are medical conditions that may be treatable with medication, but they may require surgery.
Men facing prostate surgery should be frank with their doctors, asking questions about the potential consequences involved in the surgery. Recent improvements in surgical techniques have greatly reduced the risks to men’s sexual functioning.
THERE ARE MANY OTHER forms of surgery in men that can profoundly affect orgasm. These include abdomino-perineal resection (in which the anus, rectum, and sigmoid colon are removed), cystectomy (partial or total removal of the urinary bladder), vesiculectomy (partial or total removal of the seminal vesicles), urethrectomy (removal of the urethra), orchidectomy (removal of one or both testicles), and penectomy (partial or total removal of the penis).
FAILURE TO DEVELOP AN erection obviously can mechanically prevent a man from experiencing orgasms from vaginal intercourse. If, despite lack of erection, the man has penile sensation, surgical implants can make the penis sufficiently rigid for orgasms to be stimulated through intercourse.
There are two major types of surgical implant. One type is a semirigid, malleable rod (like a goose-neck lamp) that makes the penis rigid (two rods are implanted). The penis can be raised or lowered by bending the rods, although the circumference of the penis does not change. The other type consists of two inflatable cylinders that are implanted in the penis. A reservoir of liquid is implanted in the abdomen or scrotum, and a pump is implanted in the scrotum. When the pump is squeezed, the liquid from the reservoir fills the two cylinders and the penis becomes erect. Squeezing a release bar near the pump returns the fluid to the reservoir when an erection is no longer desired. The advantages of the surgical implants are a long-lasting effect and a high degree of satisfaction among men who have them. The disadvantages include irreversibility, invasiveness, and the potential for surgical complications and mechanical failure.
Prosthetic devices for producing penile erection. The two main types of surgically implanted devices designed to enable penetrative intercourse are the malleable rods (lower left) and the hydraulic pump plus inflatable rods (upper and lower right). The malleable rods can be bent into an erect position when desired, supporting the penis. In the pump-and-reservoir devices, inflatable rods are implanted in the penis, the pump is placed in the scrotum, and the hydraulic reservoir is implanted into the scrotum or nearby. The pump is activated manually, inflating the cylinders in the penis to produce an erection. The nonsurgical suction device, with constriction band (upper left), is shown for comparison. (Adapted from image courtesy Dr. Gorm Wagner)
Another type of surgery in men with erectile dysfunction involves the blood vessels. According to Thomas Lue, young men who have inadequate penile blood flow can be treated surgically to increase arterial inflow and decrease venous outflow, enabling them to experience erections and orgasms from vaginal intercourse.
THERE ARE REPORTS OF “hypersexuality” produced by some types of brain damage. The basis for the hypersexuality may be a combination of loss of discrimination of appropriate sexual objects, loss of social inhibitions, and increased sexual desire.
There was a report in 1955 of a nineteen-year-old man with temporal lobe epilepsy that was resistant to medication. He underwent surgical removal of parts of his brain (anterior portion of the temporal lobes, anterior portion of the hippocampus, and the amygdala, on both sides of his brain). After the surgery, “He picked up objects . . . the same object again and again . . . [and] displayed to the doctor, with satisfaction, that he had spontaneous erections followed by masturbation and orgasm . . . became exhibitionistic . . . wanted to show his sexual organ erect to all doctors . . . [and] showed indifference [to women] in contrast with his behavior before the operation . . . Homosexual tendencies . . . were soon noticed . . . [and he practiced] self-abuse several times a day.”
Two surgeons in the 1940s noted increased sexuality in about 25 percent of their patients who had undergone frontal lobotomy, a procedure mainly used to treat depression or psychosis before the advent of effective medications. The controversial physicians Walter Freeman and James Watts, who performed more than 500 frontal lobotomies in the 1940s, commented that “it would seem that the postoperative inertia manifested by some patients reduces the tendency of the individual to seek sexual gratification. On the other hand, the suppression of the restraining forces may lead to a freer expression of the personality along sexual lines.” In the latter case, in which an effect of the surgery was to relax social inhibitions, patients were described as making inappropriate advances to members of their own and the other sex and masturbating in public. With the introduction of antidepressant and antipsychotic drugs after the 1950s, frontal lobotomy became obsolete.
There are several reports of hypersexuality after surgery that encroached on the septal region of the patient’s brain. The behavior patterns were similar to those occurring after frontal lobotomy: socially inappropriate sexual advances to others, masturbation in public, demands for sexual intercourse many times a day—all behavior patterns that were not present before the surgery.
Different parts of the brain excite and inhibit sexual activity in humans, normally maintaining a balance between the two tendencies. However, when specific regions of the brain are damaged by trauma or surgery, an imbalance can occur that results in an increase or decrease in sexual motivation and behavior. Specifying the brain regions affected by the trauma or surgery is not precise enough to conclude exactly which brain regions control which sexuality functions or to predict the ways in which sexuality might be affected by an individual case of brain trauma or surgery.
Women and men with spinal cord injury suffer problems of bowel and bladder control, spasticity (uncontrollable, powerful contractions of leg and back muscles), and, depending on the level of the injury, the possibility of sudden elevation of blood pressure with associated severe headache. The reduced genital sensation that results from the damage to the sensory pathways from the genitals to the brain adds to the distress. Sexual desire, however, is often unaffected in people with spinal cord injury.
We give here just a short and necessarily oversimplified account— oversimplified because there are many individual differences, depending on physical, physiological, emotional, and interpersonal factors.
In men, complete spinal cord injury blocks signals passing from the brain down the spinal cord to the genitals (complete means that there is no voluntary motor control or sensory awareness below the injury site). For these men, sexual arousal such as by “psychogenic” factors—erotic visual, verbal, thought, fantasy—or any stimulation originating in the brain rather than in the genitals cannot be transmitted to the genitals. If the complete spinal cord injury is near the base of the spinal cord, which is just below the last rib, erection, ejaculation, and orgasm in response to physical stimulation of the penis may also be blocked, due to damage to the nerves that carry genital sensation to the spinal cord. However, if the damage is higher up in the spinal cord, erection in response to physical stimulation of the penis may be possible, even if ejaculation and orgasm are blocked. If the spinal cord damage is still higher, near the level of the upper ribs or above, then erection and ejaculation in response to physical penile stimulation may be possible, although orgasm may be blocked.
There are many exceptions to these generalizations. If the spinal cord injury is incomplete, sensory pathways from the genitals to the brain may be variably intact or damaged. Some reports describe men with spinal cord injury who experience orgasm from genital stimulation. It may be possible to induce ejaculation, if not by manual penile stimulation, then by vibrator or by electrical stimulation with a rectal probe. Viable sperm may be obtained by these methods, which can be used to impregnate the partner, at least by in vitro fertilization.
Even in cases of complete spinal cord injury in which genital sensory awareness is absent, caressing of other sensate body regions can elicit orgasms, such as stimulation of the hypersensitive skin region near the level of the spinal cord injury, in the “right” way by the “right” person. Other potentially erogenous body regions above the level of the injury include the nipples, ears, lips, tongue, face, and neck.
For women who have a severed spinal cord near the level of the nipples or above, research shows, surprisingly, that stimulation of the vagina and cervix (whose sensory nerves connect to the spinal cord below the site of injury) can induce orgasm. These women have no sensation of the clitoris, vulva, and labia, because of their injury. But the pair of vagus nerves convey enough sensory activity from the cervix and vagina directly to the brain (outside the spinal cord) to stimulate orgasms. The vagus nerves travel near the intestines, along the esophagus (the tube that connects the mouth to the stomach), up through the chest and neck, and into the brain. We don’t know whether every woman with a complete spinal cord injury will have a functional vagus nerve pathway. But for a woman with spinal cord injury who desires sexual stimulation, it’s worth exploring whether she still has sensory awareness to physical stimulation of the deep vagina and cervix.
ERECTILE DYSFUNCTION (ED), PREVIOUSLY called “impotence,” has numerous causes and many treatment options. The dysfunction can be lifelong or situational. The cause may be organic, psychological, mixed, or unknown. “Complete erectile dysfunction” is defined as the total inability to obtain or maintain erections during sexual stimulation, as well as the absence of nocturnal (nighttime) erections. There are also lesser degrees of ED. To produce an erection, certain penile blood vessels dilate, allowing extra blood to be pumped into the penis, which causes the penis to expand. The outgoing blood vessels are squeezed partially shut as the penis becomes engorged with blood, causing less blood to flow out. The increased inflow combined with the decreased outflow of blood results in an erection. In ED, there is insufficient blood flow into the penis (and, sometimes, too much outflow). The lack of a “backup of blood” results in a penis that is either flaccid or insufficiently rigid.
Before the U.S. Food and Drug Administration (FDA) approved Viagra (sildenafil) in 1998, very few men with ED reported this problem to a physician or sex therapist. Today, Viagra, Levitra (vardenafil HCl), Cialis (tadalafil), and related medications are commonly prescribed, and many men feel comfortable telling their doctor they have a problem related to erection. Doctors have also become more comfortable asking their patients about their sex life, something that may have been viewed as inappropriate in years past.
It was long believed that about 80 percent of cases of ED were psychological in origin, and many, if not most, women believed it was their fault if their partner had ED, because the woman felt she was no longer attractive or sufficiently sexually arousing. However, we now know that a large majority of cases of ED are due to medical factors related to the man.
Erectile dysfunction can be associated with a wide range of medical conditions and psychological problems caused by depression, relationship difficulties, and even employment changes. Physiological bases for ED include vascular problems as a consequence of high blood pressure, diabetes and diabetes-related nerve damage, elevated levels of cholesterol and other lipids, multiple sclerosis, Parkinson disease, various surgical procedures, even prolonged bicycle riding, and side effects associated with prescription or nonprescription drug use. Smoking, alcohol, and stress can also contribute to ED.
In recommending a treatment, doctors must consider the needs and priorities of the man and his sex partner(s), which will be influenced by cultural, social, ethnic, religious, and national factors. Men with ED and their partner(s) should select the best treatment for their sexual concerns, after receiving appropriate education that includes information on sexuality and all treatment options. In evaluating the various treatments for ED, a family’s traditions, ethnicity, and socioeconomic conditions, as well as the man’s and his partner’s preferences, expectations, and psychological status, must be carefully weighed. This is a couple’s issue, not just one man’s issue.
Depending on the underlying reasons for the ED, the following treatments are among the individual’s and couple’s options.
There are four major components of sex therapy for ED: (1) anxiety reduction and desensitization; (2) cognitive-behavioral interventions; (3) increased sexual stimulation; and (4) interpersonal assertiveness and couple’s communication training. Men with ED and their partners are often resistant to psychological interventions, because of the potential implication that the problem is “all in his head” or that the man is purposefully avoiding sexual intimacy.
For some cases of ED, a combined approach might work best. Men with ED or their partners frequently have other sexual or relationship concerns, psychological distress, or partner conflict, and these can best be addressed with a combination of medical and sex therapy interventions.
In some cases, cognitive-behavioral therapy could be useful. During this form of therapy some exercises are assigned to the person to help him gain confidence and a sense of control over his body. One of these exercises is to slowly stimulate the penis to an erection (by self-stimulation or by the partner). As soon as an erection is produced, the stimulation should be stopped. Then, after a few seconds, when the penis is semi-erect or flaccid, the stimulation should begin again and the same process repeated. On the third occasion, the stimulation could be continued with hand or oral stimulation to bring the person to orgasm and ejaculation. This is an effective psychological exercise that demonstrates to the man that he can produce an erection whenever, and as many times as, he desires, and he need not “use it or lose it.” Performed in conjunction with a caring and loving relationship, this technique can be very effective. It is one of the techniques that are widely used in combination with other exercises to help men with psychosexual bases for their ED, such as performance anxiety.
Researchers in Europe found that if men with ED went on a special exercise program, this was just as successful in improving erection capacity as taking Viagra. This research group found that more than 80 percent of the men who exercised reported better erections, compared with 74 percent of those taking Viagra and 18 percent of the placebo group (the group taking a pill that looked like Viagra but contained only inactive ingredients; use of a placebo group is standard procedure in well-controlled clinical studies). The exercise program was aimed at improving blood supply around the pelvic region, buttocks, and upper leg muscles by means of squatting and leg lifts. In another study of men who followed an exercise program to strengthen their pelvic floor muscles, erections were highly improved. This success with exercise is especially true if the ED is due to mild leakage in the veins that drain the penis, in which case the penis does not sufficiently maintain a backup of blood to keep an erection.
Several over-the-counter products are available for treatment of ED, but most of them have not been tested in adequately controlled research studies and the results published in professional journals. One product that has been appropriately studied and positive results reported is ArginMax for Men. It contains gingko biloba, Korean ginseng, American ginseng, l-arginine, and vitamins. A 1994 study reported that this product improved men’s ability to maintain an erection during intercourse and improved their satisfaction with their overall sex life, compared with men who received a placebo.
Medical treatments for ED can be divided into three major categories:
Oral pharmacological agents. Several oral pharmacological agents are approved for this use, of which the most commonly used are the PDE-5 inhibitors (phosphodiesterase type-5 inhibitors, a name that refers to their mechanism of action). Viagra, Levitra, and Cialis are PDE-5 inhibitors. These drugs do not produce sexual desire; instead, they facilitate erection of the penis in response to cognitive (psychogenic) or physical sexual stimulation. Basically, these drugs open the blood vessels that supply the penis and thus allow more blood to enter. Men may experience side effects from these drugs, including headache, facial flushing, and visual problems. Furthermore, the blood vessel–dilating effect of these drugs can add to the blood vessel–dilating effect of nitroglycerine-type drugs—including illegal drugs such as “poppers” (amyl nitrate)—to produce a dangerous and sometimes fatal drop in blood pressure.
Other oral products are available, but the PDE-5 inhibitors are the most commonly used. Some other types of drugs are currently under clinical investigation.
Local (nonsurgical and mechanical) therapies. Injection of Alprostadil (a prostaglandin) through a fine needle directly into the corpora cavernosa (the spongy erectile tissues that form the body of the penis) is one treatment that brings about a rapid erection. The drug is self-injected, or injected by a partner. Alprostadil relaxes smooth muscles, dilating arterial blood vessels and so improving blood flow into the penis. The drug can also be applied in the form of a semi-solid pellet that is inserted, with a special applicator, directly into the urethra (the channel in the penis that conveys the ejaculate and urine). Some men report pain with this method, and there are rare cases of low blood pressure and dizziness. It’s recommended that if the female partner is, or may be, pregnant, a condom should be used with this type of therapy. Some research suggests the pellet method is not as effective as the injection method.
Vacuum constriction devices (VCDs) are widely available, including over the counter (without a prescription) in some countries. They consist of a plastic cylinder with a pump attached. The man places the cylinder over his penis and pumps the air out, drawing blood into the penis and creating an erection. A plastic ring, which is supplied with the VCD, is then placed around the base of the penis to maintain the erection. Although VCDs are cumbersome to use, they are nonpharmacological and may appeal to some men who prefer to avoid taking medications.
Surgical treatments. Surgical implants in the penis are among several surgical procedures for the treatment of ED (see, earlier in this chapter, “Are there surgeries that can improve a man’s chance of experiencing orgasm?”). Non-invasive treatments should be attempted first.
VIAGRA AND SIMILAR DRUGS (Cialis, Levitra) that are used to treat erectile dysfunction—the PDE-5 inhibitors—have also been tested for use in treating women with sexual disorders.
Although the effectiveness of Viagra on women’s sexual desire and orgasmic response remains controversial, most studies show that this drug increases blood flow into the clitoris. The side effects, as in men, are relatively minor, but there are health risks associated with taking any drug, and PDE-5 inhibitors in particular. The manufacturer of Viagra discontinued testing it in women, and the FDA has not approved it for use in women. Certainly, no one—men or women—should take these drugs without careful consultation with their doctor about the risks and potential benefits.
WHEN THE VAGINA IS inadequately lubricated, it can feel itchy and irritated. Vaginal dryness may make some activities uncomfortable, and it can make vaginal intercourse less pleasurable. It can cause pain or light bleeding with sexual intercourse, and it may cause urinary frequency or urgency because of the thinning of the lining of the urethra and the vagina. During menopause, vaginal dryness is a common cause of discomfort or pain for the woman, and perhaps for the man, during vaginal intercourse. Burning and pain during vaginal intercourse can begin long before a gynecologist is able to detect changes in vaginal tissue. Of course, vaginal dryness can greatly reduce a woman’s pleasure and interfere with her ability to experience orgasm.
Vaginal dryness is a common condition that can affect women of all ages, although it occurs most often during and after menopause. It can also be caused as a side effect of drugs such as antihistamines and decongestants, which are taken to dry up the mucous membranes in the nose. In relation to menopause, reduced estrogen levels are the main cause of vaginal dryness. Estrogen, a hormone secreted mainly by the ovaries but also by the adrenals, helps keep the vaginal tissue healthy by promoting normal vaginal lubrication, and it helps keep the tissue elastic and normally acidic. These are natural defenses against vaginal and urinary tract infection. Estrogen levels decrease around the time of menopause, and the vaginal lining becomes thinner and more fragile. Reduced vaginal lubrication may also occur as a result of childbirth, breastfeeding, treatment for cancer, surgical removal of the ovaries, and smoking.
Douching, the process of cleaning the vagina with a liquid preparation, disrupts the normal chemical balance in the vagina and may cause inflammation. This can cause the vagina to feel dry and irritated. Most health care professionals recommend that women should not douche.
Medical diagnosis of vaginal dryness is made by a pelvic examination performed by a health care practitioner. A sample of cervical cells or vaginal secretions may be taken for microscopic examination. Low estrogen levels, which may be the basis for vaginal dryness, can most reliably be determined by a blood test for FSH (follicle-stimulating hormone). For women who are still menstruating, estrogen levels in the blood vary with the time of the menstrual cycle, and tests for estrogen are not as reliable as measurement of FSH levels in blood, which increase as estrogen levels decrease.
There are several self-care and medical treatments that can help reduce vaginal dryness. If the vaginal dryness is due to a lack of adequate estrogen and if the following self-care measures don’t correct the problem, vaginal estrogen therapy may be ordered by prescription.
The most commonly used water-based lubricants are Astroglide and K-Y jelly. They lubricate the vagina for several hours and are safe for use with latex products such as condoms and dental dams. Vaginal moisturizers such as Replens last longer than lubricants. They may decrease dryness for up to three days with a single application. Women should probably avoid many of the other products that claim to help, as very few have been properly tested and evaluated.
Oil-based products such as Vaseline or massage oil may produce vaginal dryness. They should not be used with latex condoms and other latex products because they can cause deterioration of the latex. It’s advisable to avoid other products that have not been studied through standard scientific research procedures. The vagina may become irritated by application of vinegar, yogurt, hand lotions, soaps, and bubble baths, and by other douches.
Vaginal dryness has been shown to be reduced by ArginMax for Women. In an adequately designed research study with 77 women, the results showed an increased satisfaction with overall sex life, in addition to a reduction of vaginal dryness.
There are several forms of estrogen therapy:
Although the ability of estrogen to stimulate growth of uterine tissue could promote uterine cancer, the amount of estrogen absorbed into the body by the three methods listed above is too low to stimulate significant growth of uterine tissue and is therefore unlikely to be cancer-promoting. Orally administered or higher doses of estrogen, however, can produce undesirable uterine stimulation. To counteract that effect, progesterone, which inhibits uterine growth, is added to the higher-dose estrogen treatments to prevent the growth of uterine tissue.
PREMATURE, RAPID, OR EARLY ejaculation (usually called PE) is one of the most common male sexual disorders. According to some studies, this condition affects one in three men between the ages of eighteen and fifty-nine. Initially, the criterion of PE was the experience of a short latency (one to two minutes) from vaginal penetration to ejaculation. This criterion is now considered inadequate and has been replaced: PE is now defined as a consistent inability to intentionally delay ejaculation.
One of the most common causes of PE involves psychological factors, particularly anxiety. There is commonly an element of distress in both partners. Men who worry about the sexual satisfaction of their partners may have an increased tendency to experience PE.
Although we don’t have a full understanding of the neural processes that enable a man to control the timing of his ejaculation and orgasm, the findings from many studies suggest that the neurotransmitter serotonin is involved in this process. This conclusion is based on the frequent observation that men taking SSRI antidepressants (selective serotonin reuptake inhibitors), which increase the level of serotonin in the brain, complain of anorgasmia—indicating that serotonin may delay orgasm. Men taking these same antidepressants for treatment of PE seem to increase the latency—the time it takes to ejaculate—from less than one minute to between two and six minutes.
Although SSRIs have been reported, anecdotally, to be effective in correcting PE, no oral or topical agents, including SSRIs, have been approved by the FDA for the treatment of this problem. One of the criticisms associated with the use of most SSRIs for the treatment of PE is that they can produce side effects such as dry mouth, nausea, drowsiness, and anorgasmia. It’s advisable to consult a psychiatrist or an experienced general practitioner before using any form of antidepressant drugs (including SSRIs) for PE. Some men report that they find one type of SSRI more effective than others. It’s important to consult a physician before changing the type or dose of SSRI, or stopping it altogether.
In about one-third of cases, men with PE also show some degree of erectile dysfunction, which typically results in PE without full erection. In these cases, treatment with drugs such as Viagra can be beneficial. Men with PE are often successfully treated with behavioral therapy, including the “stop-start” or “squeeze” techniques, which are based on the idea that PE results from insufficient attention to pre-orgasmic levels of sexual tension.
When PE is associated with a high level of anxiety, moderate amounts of alcohol or a benzodiazepine are reported to be effective in delaying ejaculation. In other cases, the application of a local anesthetic to the glans of the penis (the rounded part at the tip) may significantly prolong ejaculation latency without affecting the quality of orgasm. These local anesthetics, such as lidocaine or prilocaine spray, are typically applied fifteen minutes before intercourse.
Men suffering from PE that is affecting their sex life might be helped by an assessment by a psychosexual therapist, who could then direct them to the most appropriate path for treatment. Sometimes just a course of behavioral psychosexual therapy is sufficient; sometimes medical treatment is necessary. Some of the techniques that are recommended for overcoming PE are: (1) desensitization of the penis, to control the level of excitement elicited by different stimuli from the partner; (2) the squeeze technique, in which the underside of the glans is compressed by the fingers; (3) exercises contracting the muscles of the pelvic floor; and (4) the stop-start technique, in which the penis is stimulated to the point right before ejaculation, then stimulation is stopped for a couple of seconds, then it is repeated. The third time, the man can ejaculate.
Finally, men with PE might simply wear a condom. The condom can prevent oversensitivity of the penis in contact with the vaginal warmth and texture, so the man can enjoy the penetrative sex for a longer time before ejaculating.
NO SEXUAL ACTIVITY—AT LEAST, activity involving two or more people—is completely safe. But there are levels of safety, and you can participate in safer sex, taking precautions during sexual activity that can help you avoid acquiring or transmitting an STI. Everyone engaging in sexual activity should understand that STIs are passed around from person to person because the “germs” take advantage of our desire to have sex. The bacteria and viruses that “travel with passion” include genital herpes, HPV (the virus that causes genital warts), HIV, chlamydia, gonorrhea, syphilis, hepatitis B and C, and several others. You can greatly decrease your chances of getting these diseases if you choose to behave in a “safer” manner. It is always important to practice safer sex, and it is extremely important if you and your partner don’t know each other’s HIV status, have not known each other for a long time, or have been involved in risky health behavior patterns such as having one or more sexual partners, injecting drugs, or sharing needles. Individuals who have had blood transfusions in the past few years, or who are intimate with someone who has, should also be extra cautious. If your partner has been, or may have been, with another partner in the past year, it’s wise to use extra protection.
The best way to reduce the possibility of spreading disease when engaging in sexual activity is to avoid the exchange of bodily fluids. Latex condoms, when properly used, greatly reduce (but do not eliminate) the risk of transmitting and receiving an STI. Improper use includes exposing the condom to oils, which break down the latex (oils include Vaseline, massage oil, and many hand creams), and using a condom more than once. However, too many people don’t use condoms—and the results of such decisions can be devastating. The reasons people avoid condom use are many. Some men believe that if they use condoms, their partner might think they are having sex with other partners behind her back. Others think that it’s unnatural and “impure” to have sex with a barrier. Some couples don’t want to interrupt sex to put on the condom. And of course, condoms significantly reduce the pleasurable sensation of direct contact between bare penis and vagina.
Oral sex is much safer when a man wears a condom (unlubricated, to avoid the bad taste). Some couples may prefer dental dams. Dental dams can be used when a woman wants to experience an orgasm from oral sex. The dental dam covers her vulva and clitoris, limiting her exposure to a man’s saliva and oral blood. Dental dams and male condoms that are designed for protected oral sex are available in various colors and even different tastes to give more flavor to a couple’s sex life.
The first FDA-approved female condom is made of polyurethane, which does not disintegrate with oil-based lubricants. The female condom is usually supplied with lubricant and, like the male condom, should be used only once. Some couples prefer the female condom because it can be inserted hours before sex and so won’t interfere with the sexual encounter.
New products are now being developed, called microbicides, which are being tested in animals and humans. These are products that protect against both pregnancy and STIs, including HIV. Women can use these products with a diaphragm or with the Softcup (a feminine hygiene product—not itself a contraceptive—known as a menstrual cup), which can be worn for up to 12 hours. Women do not report any change in their orgasmic responses with these products.
Many men participating in studies on condom use and sexual pleasure report that their pleasure decreases when they use condoms, but women don’t report the same experience. In fact, some studies show that women whose partners use condoms have more positive attitudes toward sexuality and engage in a higher frequency of sexual activity. This might be because using a well-lubricated condom makes it much easier to penetrate the vagina, which is especially helpful when women experience pain at the beginning of penetration.
Some studies report condom slippage when participants used supplementary lubricant on their condoms for oral and vaginal sexual encounters, so it’s advisable to build up the level of supplementary lubricant you use gradually as you become more confident about how to use a condom in this way.
The other benefit of using condoms is that they can help reduce anxiety related to making a mess or impregnation. For a woman, it can help her overcome her fear of contracting an STI or becoming pregnant and may help her relax more, which may help her to experience orgasm. Using a condom may also help her overcome her dislike of pleasuring her partner orally, for fear of ending up with a mouthful of seminal fluid or smelling genital odors.
PROBABLY YES. ORAL SEX, often performed to stimulate an orgasm, is broadly defined as any contact between mouth, lips, and tongue of one person with another person’s vulva, penis, or anus. The exact level of risk associated with oral sex is not completely known for each STI because it is very difficult to reliably identify the transmission route of an infection (which may have occurred weeks, months, or years before diagnosis). In one study, 8 of 122 HIV-infected patients (7 percent) were deemed likely to have contracted HIV through oral sex. Researchers in England have also presented conclusive evidence that transmission of HIV can occur from oral sex where the virus travels from penis to mouth, mouth to penis, and vagina to mouth. This risk of acquiring HIV during oral sex is highest for people who have other risk factors such as bleeding disorders, dental problems (loss of a tooth or bleeding gums), and illegal drug use. There is also research showing that the hepatitis B virus can be transferred through oral sex. Some researchers believe that herpes and gonorrhea infections are often transmitted as a result of oral sex. (For safer sex during oral sex, see above, “How do I have an orgasm while practicing safer sex?”)
ORGASMS ARE PROBABLY NOT affected very much by our everyday diet. However, since antiquity and in practically all cultures, and still today, there has been a belief that certain foods stimulate sexual desire and performance. In the classical world, men who ate fish, especially salmon, herring, and carp, were thought to have remarkable sexual potency. Other products of the sea, such as ambergris (whale vomit, used as a base for expensive perfumes) and shark fins, were eagerly sought in some cultures as aphrodisiacs. We have found no scientific data in support of the sexual performance–improving effect of the fish diet for men. However, a recent study showed that feeding boars a high diet of omega-3 oil, prevalent in some fish, lengthened the duration of their ejaculation from an already impressive average of 5 minutes 44 seconds to an even more impressive 6 minutes 29 seconds!
Plants, including many herbs, contain a large number of biochemicals that may influence sexual response and orgasm. Since medieval times, garlic, anise, cinnamon, onions, and carrots, among others, have been recommended to cure “anaphrodisia,” the lack of sexual interest. However, only a very few of these plant derivatives have been tested in humans and found to have positive effects. One such biochemical is yohimbine, obtained from the tree Corynanthe yohimbe. Other herbal products found to have positive effects on sexual response include extracts of Ginkgo biloba (maidenhair tree). These extracts contain many potentially active agents known as glycosides, flavonoids, and terpenolactones, which may affect brain regions involved in sexual response. The effect of ginkgo biloba on sexual arousal in men is exerted through relaxation of the smooth muscles of the penis, facilitating erection by increasing blood flow into the penis. Ginkgo biloba has also been reported to counteract the inhibitory effect of antidepressant medication on sexual response, including orgasm, in men and women.
Ginseng is another herbal product that has been reported to improve sexual response. “Ginseng” is a generic term for several plant species belonging to the genus Panax. Ginseng contains many biochemicals, including steroids, saponins, and ginsenosides, that may alter the functioning of several of the neurotransmitters—nitric oxide (NO), acetylcholine, and opioids—that are involved in sexual response. Ginseng stimulates penile erection by the pathway that uses nitric oxide as neurotransmitter. The effect on penile erection of these herbal therapies has been confirmed by some studies.
Although no clear information exists on the positive or negative effects of the components of our normal, everyday diet, there is evidence that obesity in men is one cause of erectile dysfunction. Obese men with ED can regain their sexual activity after two years of adopting a “Mediterranean-style” diet, which is rich in fruits, vegetables, nuts, whole grains, and olive oil. The adoption of this type of diet by obese women for a two-year period significantly improved their scores on a rating scale called the “Female Sexual Index.” However, whether the diet directly affects a person’s sex life or affects weight, which in turn affects sex life, is difficult to evaluate.