We often talk about the role of the brain during sexual activity. While the genitals may seem more involved with the “action,” the brain is a great coordinator. It takes in sexual stimuli (like a provocative smile or a touch), processes them, and sends messages to the genitals to start getting ready, either through erection or vaginal lubrication.
But there’s more to the brain and sex than these physiological processes. The brain also filters our emotional and psychological responses to sex. It analyzes questions like:
· Do I trust my partner?
· Will my partner or I become pregnant?
· Does my partner have a sexually-transmitted infection?
· Is this a safe place to have sex?
· If I can’t perform sexually, what will my partner think?
· Will sex hurt?
· Will my spouse find out I’m having an affair?
· Do I really want to have sex with this person right now?
The list could go on. Such anxieties – and more formally diagnosed anxiety disorders - can have an impact on our sexual function. That’s what we’ll be talking about today.
What is anxiety?
We’ve all felt anxious at times. Life events like starting a new job, getting married, or having a baby can all be anxiety-inducing. But so can smaller-scale events like asking for a raise at work or handling a dispute with your neighbor.
Sometimes, these feelings of apprehension occur in situations that wouldn’t make the average person anxious. The feelings can start to interfere with daily life.
In that case, a person might be diagnosed with an anxiety disorder, such as generalized anxiety disorder (excessive anxiety), panic disorder (episodes of great fear), social anxiety (fear of social situations and judgement by others), or posttraumatic stress disorder (PTSD – anxiety triggered by a traumatic event).
The relationship between anxiety and sex, however, can be circular.
Feeling anxious can impair your sexual function. For example, if you’re concerned about your partner’s fidelity, you might find yourself focused on that during sex, making it more difficult to relax and stay in the moment.
Conversely, if you have a medical condition that can make sex uncomfortable, such as endometriosis, the anticipation of pain can dampen your sexual desire or lead you to avoid sex altogether.
How can anxiety impact sex?
The brain works in many mysterious ways and anxiety’s effects on sexual function can take many forms. Here are some of the more common ones:
Anxiety can make us less interested in sex. For example, if a woman suspects that her partner is unfaithful, she may feel inadequate, angry, and less inclined to have sex.
Sometimes people are so worried about pleasing their partner that their performance suffers. Men might have trouble getting an erection or might ejaculate before they want to. Women might have trouble relaxing enough to allow penetration.
· Pain. Pain is a common sexual problem, especially for women. Unfortunately, the expectation of pain can become so intense that it blocks out any pleasure.
· Trouble with orgasm. The effects of anxiety can have a cumulative effect, making it more difficult to reach orgasm.
· Avoidance. People may be so anxious about sex that they shy away from dating, relationships, and sex.
What can people do?
If you think anxiety is interfering with your sex life, there are several steps you can take:
· See your doctor. Sometimes, people feel awkward about seeing a professional for anxiety and try to manage it on their own. But there’s nothing wrong with asking for help. Your doctor can refer you to a mental health specialist who will come up with a treatment plan tailored just for you.
· Consider couples counseling. If you feel anxious about some aspect of your relationship, you might see a specialist who focuses on couples therapy. You and your partner can learn to work through your issues constructively and come up with strategies to improve life at home. You can also learn better communication skills.
· Try sex therapy. Sex therapy is another type of counseling, but it focuses more on sex itself. It can be a helpful option for people with performance anxiety or sexual fears.
· Be up front with your partner. Lots of couples have trouble discussing sex. Sometimes, we just need to take a deep breath and start the conversation. Be honest about how you’re feeling. Your partner might be thinking about the same issues and feel relieved that you brought them up. Also, be open with your partner about what feels good to you and ask for what you want sexually.
· Focus on the intimacy. Your fears and anxieties can take a lot of your mental energy and keep you from just enjoying sex for what it is – a connection between two people at one moment in time. Try to focus on what’s happening. Use your senses – what sorts of touch, sounds, and smells are you experiencing? Are they pleasant? Put your attention there.
· Say “no” if you want to. If you don’t want to have sex with a certain person or at a certain time, you do not have to. You have every right to say “no.” This is also true if you and your partner disagree on sexual practices, like condom use.
Ali finally talked to his doctor about his erection problems. He’d been struggling for a while, but he had been too embarrassed to say anything. Then his wife Lila showed him an article about erectile dysfunction (ED) and how common it was, especially for older men. She went with him to his appointment and, with her support, he had a new prescription for a phosphodiesterase type 5 inhibitor, something his doctor called a PDE5i.
So far, it was going pretty well. He took his pill when he and Lila were starting to feel amorous, and in about a half hour, he was ready to go. Sure, they couldn’t be as spontaneous as they used to be, but that was a small price to pay for a better sexual relationship. Dina said she was enjoying their intimacy again, too.
There was just one problem.
There were times when the medicine didn’t work so well. Last week, they had their first barbeque of the season. Dina made amazing cheeseburgers, and Ali had two. Later, after a dip in the pool, they headed to the bedroom, but he couldn’t get an erection. Dina said not to worry about it, but he hated disappointing her.
Did something change with the meds?
Not necessarily. Sometimes, foods and beverages affect the way ED drugs work.
What are PDE5 inhibitors?
PDE5 inhibitors are a class of drugs designed to treat ED. They work by increasing blood flow into the penis when a man is sexually stimulated. Good blood flow is essential for a firm erection.
Four of the most commonly-prescribed PDE5 inhibitors are sildenafil, avanafil, tadalafil, and vardenafil. Viagra is now available in generic form as well.
Men who take PDE5 inhibitors still need to be sexually stimulated for an erection to occur.
How might foods interact with PDE5 inhibitors?
Foods might limit the effectiveness of PDE5 inhibitors in two ways.
the type of food might delay the erection. Some men find that their ED drugs take longer to work after they have eaten fatty foods, like Ali’s two cheeseburgers mentioned above.
ED drugs, like Sildenafil and Vardenafil, work better on an empty stomach. If a man takes them with food, the stomach needs to do double duty: digest the meal and process the pill.
Men might consider taking their pill and enjoying their sexual activity before they eat. But all men are different, so it might take some trial and error to figure out what you can eat – and how much – around that time.
What about alcohol?
Lots of men have trouble getting erections after consuming alcohol, especially in excessive amounts. Some people even call it “brewer’s droop.” Alcohol can dehydrate you, which interferes with blood flow to the penis.
The effect can be similar for men who take ED drugs. Even though PDE5 inhibitors are meant to help with blood flow, using alcohol can work against the process.
If you discover that you have trouble with erections after alcohol, even when taking an ED drug, you might want to reconsider your alcohol intake.
When should I seek help?
If your ED medications aren’t working as well as you thought they would – and you’re taking them exactly as prescribed – call your doctor. You might need to change medications or adjust the dose. Also, remember that not all men respond to ED drugs. Fortunately, there are other ED treatment options, so don’t give up hope. Patience is key; eventually, you will find the solution that works best for you and your partner.
You probably know it’s important to keep your blood pressure under control. High blood pressure (also called hypertension) can lead to all sorts of health problems, including coronary heart disease, heart failure, stroke, and kidney failure.
But did you know that high blood pressure can cause problems in your sex life, too?
What is High Blood Pressure and How Can it Affect Sex?
As blood travels through your arteries, it exerts a certain amount of force along the arterial walls. This force is blood pressure. The higher your blood pressure, the more force your blood exerts against these walls.
Over time, high blood pressure can damage the linings of your blood vessels, leading to plaque buildup and atherosclerosis – hardening of the arteries. When this happens, blood has a harder time flowing to essential parts of the body.
Since blood flow to the penis is an important mechanism for erection, many men with high blood pressure develop erectile dysfunction, which means they can’t get or keep an erection firm enough for sex.
Men with high blood pressure might have problems with ejaculation and desire, too.
Reduced blood flow to the genitals can also be an issue for women, interfering with desire, arousal, vaginal lubrication, and orgasm.
Anxiety over high blood pressure and its associated health problems can affect with the sex lives of both men and women, especially if it weakens relationships. Couples may have less desire for sex. Or they may not feel sexually satisfied.
Sexual Side Effects of Blood Pressure Medications
Unfortunately, medications used to treat high blood pressure can cause sexual problems themselves. For example, diuretics (water pills) can reduce blood flow to the penis and lower levels of zinc, which a man’s body needs to make testosterone. Beta blockers are another type of blood pressure drug that can have sexual side effects.
If you think your medication is causing sexual problems, don’t hesitate to talk to your doctor. It might be possible to adjust your dose or change the drug you take. Don’t make any changes without a doctor’s guidance, however.
Manage Your Blood Pressure
There are many steps you can take to lower your blood pressure and keep it at a healthy level. Sometimes, all it takes is changing your lifestyle a bit:
Eat a healthy diet that includes fruits, vegetables, and whole grains. You might also consider fat-free or low-fat dairy products, fish, and nuts. Keep red meat, added sugars, and alcohol to a minimum.
Cut back on salt and sodium. The National Heart, Lung, and Blood Institute recommends no more than one teaspoon of salt each day. Check the sodium content of the foods you eat. Remember, processed foods tend to be high in sodium.
Keep your weight under control. Being overweight increases your risk for high blood pressure.
Exercise regularly. Talk to your doctor about a fitness plan that’s right for you.
If you smoke, quit. Avoid secondhand smoke as well.
Reduce your stress levels. Blood pressure can rise when we’re excited or stressed. Find ways to relax and try not to overextend yourself with commitments. Ask your friends and family for help if you need to.
Your doctor can help you with these strategies and suggest others tailored to you. If you need medication, be sure to take it as directed.
Platelet-rich plasma (PRP) therapy refers to injections used to reduce inflammation and promote tissue healing. Athletes sometimes have PRP to speed up the healing of sports injuries. PRP has also been used for hair loss, cosmetic surgery, and osteoarthritis.
Some practitioners claim that PRP injections into the penis or the vagina can improve sexual function and satisfaction. This use is considered experimental and has not been widely studied.
P Shots and O Shots
For men, the injection is called the “Priapus shot” or “P shot” and is thought to improve erections and increase penis size.
For women, PRP therapy is called the “Orgasm shot” or “O Shot.” Practitioners claim that the shot leads to heightened libido, better vaginal lubrication, and more intense orgasms. Again, these claims are not evidence based.
The process involves separating platelets from a patient’s own blood and injecting them directly into the genitals.
What are platelets?
When a person has a cut, scrape, or other type of bleeding wound, platelets – small blood cells – work to stop the bleeding by clotting the blood. Proteins in platelets also contribute to wound healing.
Some scientists believe that injecting platelets from a patient’s own blood into a wounded area could help it heal more quickly.
In 2017, researchers reported on a small study of nine men with erectile dysfunction (ED). Each participant received one PRP injection in addition to a standard ED treatment (medication or vacuum therapy). The men’s scores on an ED assessment did get better, and none of the men had serious side effects.
The authors wrote that “PRP may represent a safe and viable option as a supplementary therapy for penile rehabilitation.” But they added that more research is needed.
This small study had no control group. Therefore, the only true result was that PRP therapy did not cause significant harm because all patients underwent typical erection therapies in addition to the PRP.
Currently, regulatory agencies have not approved PRP therapy for the treatment of sexual dysfunction.
Nevertheless, some practitioners market PRP therapy with promises of better sex. These claims should be considered with caution. There have been no large randomized controlled trials to show efficacy.
In 2018, the Sexual Medicine Society of North America (SMSNA – an ISSM-affiliated society) released a position statement on ED restorative therapies, including PRP therapy. The organization encourages further research so that clinicians can fully understand the pros and cons of therapy, as well as its long term safety.
People considering PRP therapy for sexual dysfunction are encouraged to see their healthcare provider for advice on standard treatments that are backed with solid scientific evidence. In some cases, patients see sexual improvements by making lifestyle changes, addressing an existing health condition (such as diabetes or heart disease), changing medications, counseling, or communicating more openly with a partner.
Bill took a deep breath, looked at his wife Judy, and finally told his urologist, “Okay. I’ll get the implant.”
It wasn’t something he necessarily wanted to do. But he had been dealing with erectile dysfunction (ED) for a few years now and no other treatments seemed to be working out. Because he took heart medication, he couldn’t take the pills he saw advertised on TV. And the vacuum device, which was far from romantic, didn’t seem right for him either.
He didn’t like the word “prosthesis” when it referred to his manhood. It made him think of artificial limbs. But he knew that an implant was just that – a device designed to give him an erection when he wanted.
He and Judy were in their fifties - still young - and still had a long sex life in front of them. He wanted to be more spontaneous with their lovemaking. He wanted to feel confident, like he did early in their marriage. And he wanted to keep Judy satisfied. She was patient, but he knew he was disappointing her every time.
Bill had heard that penile implants had a high satisfaction rate. He’d also heard that sex would probably still feel the same as it did before he had ED. But he was nervous. He knew that after getting the implant, there was no turning back. So he wanted to make sure he was doing the right thing.
Many men getting implants share Bill’s concerns. Penile implantation is a big decision. Today, we’ll talk about men’s experiences with implants and some things to keep in mind if you’re considering one.
What kind of implant?
Bill’s urologist recommended a 3-piece inflatable implant, which is currently the most common type. These implants have three components:
Cylinders that are surgically implanted into the shaft of the penis. These cylinders replace the corpora cavernosa – the spongy tissue that typically fills with blood and gives an erection its firmness.
A reservoir filled with saline fluid. This fluid fills the cylinders on demand, similar to the way blood once filled the corpora cavernosa.
A pump placed in the scrotum. When a man wants an erection, he can activate the pump by squeezing it, sending the saline fluid into the cylinders. Similarly, when he no longer desires an erection, he can deactivate the pump, returning the saline fluid to the reservoir until next time.
Another type of implant, but less commonly used, involves malleable rods placed in the shaft. The man can move his penis to an erect position as he chooses.
Why do men like their implants?
In December 2015, The Journal of Sexual Medicine published a study on men’s satisfaction and dissatisfaction with penile implants. The researchers interviewed 47 men with an average age of 61 years and asked them to share their thoughts.
Overall, 79% of the men were “fairly” or “very” satisfied. The main reasons they gave were:
Improved sexual performance. Men could get erections, penetrate their partners, and feel sexually satisfied.
Improved self-esteem, confidence, and male identity. “It was a giant step I took in my life, and I'm glad I took it,” one man said.
Improved relationships. One participant remarked, “My general relationship with my wife is much better now.” Others said they were happy that they could please their partners.
Improved urination. Some men said their urinary function was better with the implant.
Why are men dissatisfied?
While the majority of men were satisfied, there were some who were not. Here are some of their reasons
Unmet expectations. Some men found that the implant did not “feel” the way they thought it would.
Shortening of the penis. In some cases, the penis was shorter than it was before. Two men were not able to have intercourse. [Note: A small 2014 study of penile shortening showed that 70% of men experience some degree of shortening after penile implantation, usually in the range of 0.5 centimeters to 1.5 centimeters. However, over half the men in the study didn’t notice.]
Feeling “artificial.” One man said, “It is always artificial. It takes time to inflate, it always disturbs.”
Malfunction. After a while, some men with inflatable implants had trouble activating their devices. It is possible for pumps to malfunction, although this is rare. A urologist should give instructions on how to keep the device in good working order.
Should you get an implant?
That’s a question only you, your partner, and your doctor can answer. As the study suggests, the majority of men are satisfied with their choice. But men should be prepared – and have realistic expectations – before surgery. If you have any questions or concerns, be sure to let your andrologist know.
For centuries, men and women have searched for foods, herbs, and other substances that could enhance their sexual experiences. The U.S. Food and Drug Administration (FDA) defines “aphrodisiac” as “any product that bears labeling claims that it will arouse or increase sexual desire, or that it will improve sexual performance.”
In 2015, scientists analyzed approximately fifty medical studies on popular products marketed as aphrodisiacs. Overall, they concluded that more trials are needed before doctors can recommend any substances. They also noted that some products could be unsafe and cause dangerous interactions with drugs one is already taking
The study identified some products that should be avoided completely due to harmful side effects:
The following products didn’t have enough data to support their use:
Horny goat weed
The authors added that there is not enough evidence to support the use of vitamins, minerals, and vaginal tightening products as aphrodisiacs.
The authors did find evidence to support the use of these products as aphrodisiacs.
However, patients should be aware that these products can still interact with other medications. For example, ginseng can interfere with anticoagulant medications, which help prevent blood clots. In addition, people with hormone-sensitive cancers, such as breast cancer, should not use ginseng.
Patients should always consult with their doctor before trying any supplement or over-the-counter product. They should also notify their doctor about any products they are currently using.
It’s important to remember that sexual desire, arousal, and performance depend on a wide range of factors. A person’s overall health, psychological well-being, and emotional state can all be involved. For example, medical conditions like diabetes and heart disease can impair a man’s erections. Women going through menopause might have trouble with vaginal lubrication. Fatigue, stress, anxiety, and relationship problems can make people less interested in sex.
If you are having a sexual issue, be sure to see your doctor. Medical treatment and sexual therapy may be needed, but your healthcare provider can tailor your treatment to your specific needs.
Mind if I smoke?
It’s not a question you hear much nowadays. Still, almost 18% of adults in the United States smoke cigarettes, according to the Centers for Disease Control and Prevention (CDC). And more men smoke than women.
Most people are aware that smoking is bad for their health. Smoking is linked to cancer, heart disease, respiratory disease, and a host of other illnesses.
What men might not know, however, is that smoking can also lead to erectile dysfunction (ED). Studies have shown that men who smoke are more likely to develop ED. And the more a man smokes – both quantity and duration of time - the worse his ED tends to be.
The good news is that quitting smoking can help restore erections. Let’s look at this relationship more closely.
How does smoking cause ED?
First, let’s go over the physiology of erections.
When a man is sexually stimulated, his brain sends signals to the penis to trigger an erection. Smooth muscle tissue relaxes and arteries widen, allowing the penis to fill with blood. When enough blood flows in, veins constrict to keep it there until the man ejaculates (or the stimulation stops). Then the veins open and blood flows back into the body.
As you can see, blood flow is critical for a good erection. Blood is what gives the penis the firmness needed for sex. When blood flow is compromised, so is the erection.
Smoking tobacco releases chemicals that interfere with this process. This can happen in a few ways.
Hardening of the arteries (atherosclerosis). Chemicals can damage the lining of blood vessels, making it difficult for blood to flow into the penis.
Damage to smooth muscle tissue. When this tissue can’t relax properly, blood flow becomes impaired.
Decreased nitic oxide. Smoking interferes with the body’s production of nitric oxide, a compound needed for erections.
Other health conditions, like diabetes and heart disease can contribute to ED, too. If you’re having erection problems, it’s important to have a full checkup with your doctor. But quitting smoking definitely can’t hurt.
Tips for Quitting
Ready to quit? Here are some tips to consider:
Talk to your doctor. He or she can give you personalized advice and refer you to a smoking cessation program in your area. Your doctor can also monitor other medical conditions that might be contributing to your erection problems and guide you toward making healthy lifestyle choices, like exercising and eating well.
Manage stress. For many people, stress and anxiety are smoking triggers. It may be easier said than done, but try your best to manage stress. If you need help, don’t hesitate to ask for it. For example, if you need a hand caring for children, see if a friend can babysit once in a while. If work is overwhelming, talk to your boss about possible changes. There are times when we need a healthcare professional to help us through stressful times. That’s okay, too. Your doctor can put you in touch with a therapist or counselor.
Get support. Tell your friends and relatives about your goal. They can cheer on your progress and encourage you when you’ve hit a rough spot. You might also consider a formal support group of people who are facing the same challenges you are.
Set mini-goals. Break your goal down into reasonable mini-goals. Instead of saying, “I’ll go 24 hours without a cigarette,” try going an hour, then two, then three.
Celebrate your successes. If you’ve met one of your mini-goals, pat yourself on the back! Quitting smoking is difficult, so reward yourself by going out with friends, catching a movie, or any other activity you enjoy.
Be Kind to Yourself. If you don’t meet a mini-goal, don’t beat yourself up. Give yourself credit for trying and resolve to tackle it again tomorrow.
Try technology. There are a number of free and low-cost smartphone apps for Apple and Android devices designed to help users quit smoking. Some will keep track of how many cigarettes you haven’t smoked and how much money you’ve saved. Some offer tips and words of encouragement, too.
Quitting smoking should make you feel better overall. You’ll feel good about yourself knowing that you’ve taken an important step toward better health – and possibly better sex!
What is testosterone deficiency?
You have probably heard about testosterone in light of men’s sexual health. Produced by the testes, this hormone drives libido, gives men their physical characteristics (like facial hair), and helps maintain muscle mass.
Some men’s bodies don’t make enough testosterone. This situation, called hypogonadism, can happen when there are problems with the testes or the part of the brain that triggers testosterone production. Hypogonadism can also be a result of chemotherapy, radiation therapy, inflammation, infection, and obesity.
In addition, men’s bodies make less testosterone as they get older. In fact, testosterone levels drop from 1% to 3% each year after a man’s 40th birthday. As a result, some – but not all – men start to have symptoms like low sex drive, fatigue, moodiness, erectile dysfunction (ED), and diminished muscle mass.
How is testosterone deficiency diagnosed?
Two criteria must be present for a man to be diagnosed with testosterone deficiency:
His testosterone levels must be lower than 300 ng/dL. Two total testosterone measurements taken on two different occasions are recommended. Because men’s testosterone levels fluctuate throughout the day, early morning measurements are the rule of thumb.
The man must exhibit symptoms of low testosterone, like the ones mentioned above – low libido, low energy, depression, ED, etc.
If a man meets only one of these criteria, then he does not have testosterone deficiency.
What is testosterone replacement therapy (TRT)?
Testosterone replacement therapy (TRT) is prescribed to some men with testosterone deficiency. This synthetic form of testosterone is typically administered through gels, patches, or injections.
What are the Recommendatios for TRT?
Clinicians should inform testosterone deficient patients that low testosterone is a risk factor for cardiovascular disease. Note: In 2015, the U.S. Food and Drug Administration (FDA) issued an advisory, expressing concerns that men who take testosterone might be at higher risk for heart attack and stroke. (Read more here.) However, the link to such events was considered controversial.
Clinicians should inform patients of the absence of evidence linking testosterone therapy to the development of prostate cancer. Note: There have been concerns that testosterone therapy might lead to prostate cancer, but this link has not been proven. However, testosterone can fuel the growth of existing prostate cancer cells, so TRT is not usually recommended for men with prostate cancer.
The long-term impact of exogenous testosterone on spermatogenesis should be discussed with patients who are interested in future fertility. Exogenous testosterone therapy should not be prescribed to men who are currently trying to conceive. Note: Testosterone is important for sperm production, but the synthetic form used in TRT might interfere with this process. Sometimes, sperm counts increase after men stop TRT, but this cannot be guaranteed. Men may decide to bank their sperm before starting therapy.
Clinicians should discuss the risk of transference with patients using testosterone gels/creams. Men are advised to wash their hands thoroughly after applying testosterone to the skin to avoid transfer to another person. They should also cover the application area before sex. (For example, if testosterone is applied to the shoulder, wearing a T-shirt can reduce the risk of transferring the gel or cream to a partner.)
Testosterone levels should be measured every 6-12 months while on testosterone therapy. Note: While on TRT, it’s important for men to see their doctor regularly for follow-up appointments so that testosterone levels can be assessed, and treatment can be adjusted, if necessary.
Sexual performance anxiety and erectile dysfunction (ED) are both troublesome issues, and it’s possible for a man to have both. But they do have some clear differences.
A man with sexual performance anxiety has worries about his sexual function or his ability to please his partner sexually. He might have questions like these:
Will I be able to get a firm erection?
Will I ejaculate too quickly?
Will I have an orgasm?
Does my partner find me attractive?
Is my penis big enough?
Am I sexually skilled enough?
Will my partner reach orgasm?
What will happen if my partner is not sexually satisfied?
Men who use pornography can develop sexual performance anxiety if they compare their real-life experiences to what they see in adult films and videos. Usually, such depictions are not realistic, but men may feel nervous or inadequate if they don’t perform the same way.
Sometimes, a man may become so concerned about his performance that he develops erectile dysfunction (ED). The anxiety triggers the production of stress hormones (such as epinephrine and norepinephrine) which can narrow blood vessels in the penis and make it difficult for blood to flow in and form an erection.
Erectile dysfunction (ED) occurs when a man cannot get and maintain an erection firm enough for sex. As noted earlier, ED can be a result of performance anxiety.
But health situations can affect erections, too. Here are some examples:
High blood pressure
Cancer treatment (such as prostatectomy – removal of the prostate gland)
Medication side effects
Attention deficit (especially in young men)