Jan 05

Photo src: thetastingnote.com

Viagra, the popular anti-impotence drug, may stop working for many patients after 2 years, the results of a study suggest.

Dr. Rizk El-Galley of the University of Alabama at Birmingham and colleagues interviewed 151 men who had filled prescriptions for Viagra. Overall, 74% reported that 25 milligrams (mg) to 100 mg of the drug enabled them to initiate and maintain erections sufficient for intercourse.

The improvement rate ranged from 50% for patients with impotence caused by diabetes, to 78% for those with no specified reason for impotence, to 100% for those with suspected leakage in their veins.

3 years later, the investigators re-interviewed 82 of the men, of whom 43 were still using the drug. Sixteen of those 43 (37%) said they had needed to increase the dose by 50 mg to achieve an adequate erection. It had taken between 1 and 18 months for the treatment to lose its effects. There was no correlation between the need to increase the dose and frequency of use.

‘In general, 81% of patients who were still receiving treatment were satisfied, and 92% were able to achieve and maintain erections sufficient for sexual intercourse in more than 50% of attempts,’ El-Galley and colleagues wrote in The Journal of Urology.

Of the 39 patients who had stopped taking Viagra, 28 had initially reported a good response. Fourteen of those patients who stopped said the drug no longer worked, and six said they had regained the ability to have spontaneous erections.

There is notable disappointment about the fading powers of the ‘blue miracle pill’ in the professional world. ‘According to my observations, Viagra only helps half of all patients with erectile dysfunction caused by physical factors’, P. Derahshani, head of the urology department of the KĂślner Klinik am Ring (Cologne, BRD) reports. A potential health-risk lies in the fact that for patients showing habituation effects, the dose can only be rised by the ones who have previously used 25 or 50mg, while for doses above 100mg, the risk of side effects such as circulatory weakness, nausea or headaches increases remarkably.

No substitute for psychotherapy or sex therapy

“One should not forget that Viagra is only indicated for erectile dysfunction for those men whose potency problems have physical causes,” the Viennese urologist Werner Reiter of the impotence clinic at the Vienna General Hospital said in an interview with the “SĂźddeutsche” (SZ). Especially in older men who smoke a lot and suffer from high blood pressure or heart disease, Viagra often loses its effect after prolonged dosing. In men with stable health, on the other hand, there is rarely a (physiological) habituation effect.
“If the impotence is caused by mental factors, Viagra will just cover up the first symptoms for a while,” warns Reiter. For long term success, these patients could only be helped with psychotherapy or sex therapy.

Health risks often underestimated

Fatally, many men ignore or underestimate the risk of self-medication. But an alarming number of 40 percent of the men who visit a doctor because of erection problems, suffer from arteriosclerosis of the coronary arteries (which may, but is not always the cause of erectile dysfunction). Impotence ‘may nevertheless be a sign of a disease or an incipient disease. However, to simply cover up symptoms and to look away from the real causes, has never worked out on the long run, neither in medicine nor in psychotherapy,” says sex therapist Karl F. Stifter. It is important to keep the whole person in mind, which in this case would mean to check for physiological causes of the erectile dysfunction before considering any medication.

Underestimated by many men is the risk of suffering a heart attack. Like most drugs that interfere with the blood circulation of the body, Viagra & Co. involve special risks for patients (sometimes unknowingly!) suffering from heart conditions. In particular, patients who are taking nitroglycerin or blood pressure lowering drugs, which also relax the smooth muscles, may not take the pills to avoid potentializing their effects. Together with medications containing nitrate (eg for angina pectoris), the drug may lead to a fatal drop in blood pressure and heart diseases in men with circulatory failure. An examination by a physician is therefore absolutely necessarily before taking them.

In fact, no other medications are responsible for as many deaths due to negligent use as the new “erection helpers”. Worldwide, 616 deaths after taking Viagra were reported during the first 3 years after its introduction alone. The easy availability of the tablets over the Internet or on the black market poses a big problem, because they are extremely inviting for self-medication, and there is a relatively high risk to purchase harmful imitations. The ‘copycat’ market of the tablets, mainly India and China, is hard to control, with all the associated risks for the end user. Often enough the tablets are also not only taken at a far too young age, but also abused as kind of a ‘lifestyle drug’, completely ignoring the impact on the cardiovascular system – and probably also the production of our endogenuous ‘drugs’ that help to build and maintain an erection, as the study mentioned above could indicate.

So there is reason to expect a massive increase of the number of ‘Viagra Veterans’ during the next years who suffer from what I’d call ‘multisystemic erectile dysfunction’: psychogenic erectile dysfunction by men who furtheron developed organically caused erectile dysfunction either from resistance against the drug or by underproduction of endogenous drugs from longterm use of the supplementary drugs). These men may well find themselves suck in a dead end once they reach an age (or have to deal with side effects of physical illnesses) involving a natural decrease of the erectile function without many remaining options to treat their impotence.
It has been proved that in the vast majority of men under the age of 50, erection problems are caused psychologically – but even (and especially) at a higher age, a medical examination is necessary before starting to take medication. If there is no clear evidence for a physical cause, in the interest of one’s health (and perhaps also to keep the “Viagra trump card” for more difficult times), it is recommended to seek counsel from a sex therapist or psychotherapist rather than to reflexively grab one of the readily available “blue pills”.

(Sources: Reuters.com; Rizk El-Galley et.al., “Long-Term Efficiacy of Sildenafil and Tachyphylaxis Effect” in: The Journal of Urology – September 2001 (Vol. 166, Issue 3, Pages 927-931); Image source: creakyeasel.com)

Dec 27

Andropause is an onset of hormonal changes in men – mostly between the ages of 40 and 50 -, which is triggered by reduced testosterone levels.

Testosterone is the primary male sex hormone and is produced in the testes. It affects all body cells and is responsible not only for sexual development, but also for the specific skin, bone and muscle structure of men. It is equally important for the production of red blood cells, which supply the body with oxygen. And after all, testosterone also plays a significant role in providing sexual pleasure and emotional balance. At around one’s middle years, however, the production of this hormone gradually drops, and so do the testosterone levels in the blood. This reduction causes problems for many affected men: in German language, the saying “die Fitness ist kraftlos und die Lenden sind saftlos” (freely translated as ‘no gas in the muscles, no fluids in the loins”) expresses the feeling when the so-called andropause kicks in: depression, irritability, loss of concentration and vitality.

Possible symptoms of the andropause include:

  • Mood disorders such as anxiety, irritability, aggression
  • Tendency to depression
  • Increased weight and body fat, increasing abdominal girth
  • Increasingly poor short-term memory
  • Decreased concentration and attention span
  • Sleep problems and / or stronger daytime fatigue than before
  • Reduced desire for intimacy and lower sex drive..
  • ..or rational desire for sex, but still, sexual apathy
  • Erectile Dysfunction
  • Less frequent and intense ejaculation
  • Osteoporosis
  • low self-esteem
  • Hot flashes and night sweats

There are, however, considerable differences of opinion among experts as to which of these symptoms actually indicate a so-called ‘male menopause’ or andropause and were initially caused by testosterone deficiency, because for each of the symptoms in the list, there could be other root causes, even if a reduced testosterone level would actually be detected in a patient. Thus, in a way, the so-called ‘testosterone replacement therapy’ is often not much more than a ‘shot in the dark’.

Testosterone replacement therapy – yes or no?

Some doctors and hospitals today offer testosterone replacement therapy without much hesitation to men, often with the particular aim of helping them to regain their desire for a satisfying love life. Even with impending cardiovascular diseases, this hormone is sometimes used for prevention, because studies have shown that testosterone has a protective effect on arteries and veins, so there are good, potential reasons to say ‘yes’ to this kind of therapy (usually in the form of tablets, gels, patches or nose sprays). However, it is important to know that a hormone replacement therapy does not help at all if one simultaneously depletes his bodies’ health and resources. It is remarkable and perhaps not entirely coincidental that many men who are looking to start a hormone replacement therapy are also often frivolous users of  ‘fitness booster medication’ (self-medicated).

Ideally, taking on an artificial testosterone substitution should increase muscle mass, bone density, libido and performance. Under certain conditions, the ‘extra dose’ testosterone may also accelerate the development of an existing prostate cancer. A preventive control (PSA control) is therefore highly advisable.

But there are also proven health tips for men, which in contrast to the artificial feeding of testosterone reliably pose no health risks and are also very well suited to raise the testosterone levels:

  • Development of more self-discipline for a healthy lifestyle – something that many men never achieved in their lives
  • Balanced nutrition (vitamins: more fruit and vegetables; low-fat: greasy, oily foods and refined carbohydrates lead to weight gain, but: obesity appears to influence the production of testosterone!)
  • The waist circumference should be less than 100 cm (see BMI test on this website)
  • Enough sleep – at least 6-8 hours per day
  • Care for a balanced mental state – if something brings you out of your balance on a reglar basis, seek necessary support through psychotherapy or coaching: optimism and a balanced state of mind help to reduce stress. On the other hand, if men are overloaded (perhaps even chronic), endocrine glands will produce significantly less amounts male sex hormones.
  • Smoke and drink less
  • Natural resources: oats and ginseng have a testosterone-like effect, and an extra portion of zinc also helps the testosterone levels: lobsters, oysters and shrimp, soybeans, wheat bran and pumpkin seeds. Casanova was known to eat 40 oysters a day!
  • Exercising also stimulates the production of testosterone: best results are achieved with intense strength training with sets of 10-15 reps, peppered with breaks of 60-90 seconds (intervals of 15-30 sec will stimulate the production of growth hormone).
  • Good sex: sexual excitement and ‘games of desire’ help to raise our hormone levels over a period of up to two days and thus counteract the natural way of deficiency. Even erotic fantasies will stimulate testosterone production in the short term, falling in love raises our testosterone for up to many months.

Men have the luxury of being able to affect their hormone levels through their lifestyle more than women, because their hormonal situation does not change so abruptly and radically with age.

In the “self test” on my website you will find a self-test for testosterone deficiency, which can allow an initial self-assessment. In case of doubt, a medical examination with blood test is recommended.

(Initially published in German language (‘Testosteron-Spiegel erhĂśhen’) in 10/2010. Image source: understandinglowt.com)

Aug 05

Am I a ‘pervert’ or simply enjoying the extraordinary? The answer to this question has seen remarkable changes over the times. Many sexual practices that might have resulted in getting burned at the stake for being possessed by ‘demons’ or being locked up in a mental ward during the last centuries are considered as nothing else than normal nowadays. However, there are indeed forms of sexual behavior that are considered as psychopathological even if moral issues are left aside. Today, sexual behavior is considered a disorder (or paraphilia) if it causes distress or impairment to the individual or harm to others. This is an important distinction to avoid pejorative positions towards more uncommon sexual interests and practices like a sexual attraction to the same sex which was still part of the diagnostic manuals until 1973.

Upcoming versions of  diagnostic manuals will further make a distinction between paraphilias and paraphilic disorders. A paraphilia by itself would not automatically justify or require therapeutic intervention. A paraphilic disorder will be the aforementioned paraphilia that causes distress or impairment to the individual or harm to others. In other words, non-normative sexual behavior will not automatically be labeled as psychopathological anymore. Cross-dressing, for example, will not automatically be classified as transvestitism anymore – unless the person is unhappy about this activity or impaired by it. Only then it would be diagnosed as ‘disorder’.
While the new generation of classifications will definitely bring improvements compared to diagnoses that were given in a pejorative way before, it will also link diagnoses closer to cultural values again, so in a society with tighter cultural norms like here in Asia, we will probably see more people diagnosed with sexual disorders once the new classifications have become standard, as these person’s behavior patterns are more prone to ‘harm’ or ‘distress’ others…

The most common paraphilias that are considered as disorders are exhibitionism, fetishism (certain objects are required to gain sexual excitement), frotteurism (urges to touch or rub against a nonconsenting person), pedophilia, sexual masochism and sadism, transvestic fetishism, urophilia (sexual excitement with the sight or thought of urination) and voyeurism. These forms of sexual deviance usually become a problem if non-consenting persons are involved, local laws are violated or if sexual arousal can only be reached by acting on the urge of the paraphilia.
Can paraphilias be cured? Many experts claim they can’t, at least not with standard methods of sex therapy. However, often enough, persons suffering from the restrictions their paraphilias impose on them can learn to manage their sexual behavior more efficiently and flexibly – at least to an extent that prevents them from breaking laws or destroying their relationships.

More articles and literature:

(This short article is part of a weekly series dealing with psychological expat problems and general mental health issues and was published in various newspapers and magazines in Thailand, 2011)

Mar 12

When I first came to Thailand, I wondered: given the healthy Thai cuisine, why are so many people – especially expats – overweight?

Take a look on any street: at least one in three expats is obese. This is a high percentage, comparable only with the ‘fattest’ States in the USA, and  is responsible for many of the health problems some expats have to deal with after living just for a few years in their new home.

But how exactly is ‘overweight’ actually defined? That’s an easy one: to calculate your BMI (Body Mass Index), you simply divide your weight in kilograms by the square of your height (or multiply your weight in pounds with 703 and divide the result by the square of your inches). At a height of 1.72m and 75kg weight, the formula would be: [75 á (1.72 m)² = BMI 25.4] (or at 150 lbs weight and 5’5″ (65″) height: [150 á 65²] x 703 = 24.96). Overweight is defined as a BMI of 25.0 or greater, obesity starts at 30.0. According to doctors, a BMI higher than 27.5 imposes major risk factors for cardiovascular disease, certain types of cancer, type 2 diabetes and joint problems.

But what makes some of us so prone to gain weight rapidly in Thailand? Alcohol is one explanation, fats another. Of course, many expats drink too much and forget (or repress) that alcoholic beverages are real calorie bombs. And, many Thai kitchens cook with too much fat, and in the past several years, the food has become too sweet and salty; while these dishes may taste good, they are no longer healthy.

But where does this tendency to eat and drink too much derive from? One explanation is that eating and drinking is a compensation option for everyday frustration and boredom. Many expats have little to fill their days, and kill time by eating and drinking, for some, a visit to the buffet can be the highlight of the week.

As a sex therapist, I have to mention the hormonal and psychological changes experienced, particularly by aging men. In their younger years it was their daily goal to have sex and workout, now that they are older the epitome of sensual delight is enjoying their lunch or dinner … unfortunately to the chagrin of their body and often enough also of their psyche. Because obesity increases the incidence  of depression, a vicious spiral might be triggered driving them to eat even more. One of the difficulties in finding a balanced diet, is that eating too much often has downright addictive dynamics. This is one reason why serious weight loss programs always involve counseling and psychotherapy as an integral part of the recovery plan. One can do a lot alone – but with some outside support, success usually comes much easier and faster.

(This short article is part of a weekly series dealing with psychological expat problems and general mental health issues and was published in various newspapers and magazines in Thailand, 2011)

Oct 28

In a global survey that was released a couple of months ago, about 10 per cent of males said that they had experienced premature ejaculation: coming too quickly is one of the commonest of all sexual problems. Not too surprisingly, especially younger men are suffering from it – as they grow older, most men will usually gain better control.

But what exactly is premature ejaculation (PE)? That’s an interesting question, as the ideas of what is ‘normal’ are differing amongst people and what doctors or therapists think is just one side of the medal after all. An American research paper stated that the average lasting time of men with PE was 1.8 minutes, while ‘normal’ men lasted an average of 7.3 minutes. However, there are men and women who are not sexually satisfied even if the man can last 5-10 minutes – and who could blame them for needing more? But according to clinical manuals, only the approximately 2.5 per cent of men who can’t last 90 seconds inside the vagina would be diagnosed with PE. Sex therapists see PE as the inability to sufficiently enjoy and play with the various levels of arousal between the start of an erection, sexual intercourse and the orgasm. Men suffering from PE are almost directly piloting towards the orgasm right from the beginning of the intercourse and have very little control over its length or intensity. In severe cases, affected men can’t have sex because they ejaculate before actually getting into the vagina.

While PE doesn’t necessarily have to be considered as a serious problem, it can make sex frustrating and even annoying for both partners. Yet, psychological pressure will often negatively affect sexual performance or even increase the problem.

Today, health professionals agree upon that PE is only caused by psychological factors, so it can usually be successfully resolved after a couple of sex therapy sessions. While there are ‘tools’ like local anesthetic gels or ‘long love condoms’, they can’t help with the roots of the problem or even further reduce sexual confidence because patients often feel increasingly dependent on the product. Also, these kinds of products often affect the sexual experience of the woman. Sex therapy will usually involve efforts to understand the psychological patterns triggering the dynamics involving PE, and the integration of techniques allowing to regain control over the sexual act. Often, ‘homework exercises’ will be prescribed in order to control the success of the therapy sessions and to achieve stable long-term effects.

(This short article is part of a weekly series dealing with psychological expat problems and general mental health issues and was published in various newspapers and magazines in Thailand, 2010)

Sep 07

Talking about ‘sex addiction’ in certain Asian cities is like talking about alcoholism during the ‘Oktoberfest’ in Munich: a firework of dirty jokes and winking confessions (‘yes, I’m an addict, too!’) are standard elements of these conversations. However, few people seem to know what sex addiction really is or means.

Sexual addiction (sometimes also called sexual dependency or sexual compulsivity) means that a person is unable to manage her sexual behavior, which is described as ‘compulsive’ in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) of the American Psychiatric Association. It is thus often also referred as ‘hypersexuality’ in many papers. Excessive sexual drive can cause distress or serious problems not only for the affected persons but also to persons associated with them. Usually they invest a lot of time and money to satisfy their obsession with various activities related to sex, and may risk losing their jobs, ruining their relationships, interfering with their social life, and putting themselves at risk for emotional and physical injury. While for many, their behavior won’t progress beyond compulsive masturbation or the extensive use of pornography or paid sex services, for others, the addiction can involve illegal activities such as exhibitionism, voyeurism, obscene phone calls, sexual harassment or abuse and especially here in Asia, violating various Asian laws like filming sexual activities or organizing sex parties. Many sex addicts spend high percentages of their money due to their lowered sexual inhibitions – basically, most of their money-making and thinking ultimately turns around satisfying their sex drive. However, sex addicts hardly gain lasting satisfaction from their sexual activities and rarely form emotional bonds with their sex partners. To many, it feels like constant hunting – without ever achieving the satisfaction of feeling full.

Unfortunately, it is also typical for sex addicts to engage in distorted thinking – justifying and rationalizing their behavior and blaming others for the problems that arise as a result of their actions. As long as possible, they will deny they have a problem and find excuses for their behavior. Thus, it usually takes a significant event like the loss of their job, the break-up of their marriage, an arrest or a health crisis, to force the addict to admit that there is indeed a problem.

While professionals are still struggling with the exact definition and diagnosis of hypersexuality / sex addiction, there is no doubt that this disorder exists. Hypersexuality is also a criterion symptom of mania in bipolar disorders and schizoaffective disorders and often linked to depression or other forms of addiction, like alcoholism or drug abuse. Treatment of sexual addiction focuses on controlling the addictive behavior and helping the person develop a healthy sexuality.

(This short article is part of a weekly series dealing with psychological expat problems and general mental health issues and was published in various newspapers and magazines in Thailand, 2010)

May 18

A large-scale impact study (n = 1046) of the Institute for Women’s Health Badem-WĂźrttemberg for frequency of sexual dysfunction in women (Female Sexual Dysfunction, FSD) and ways to treat them was recently published in the prestigious journal Journal of Sexual Medicine.

The aim of this study was to find out about the a) frequency and b) different forms of disorders of female sexual function. Also investigated was the relationship between dysfunction and hormonal contraception with the ‘anti-baby pill’, or more precisely, with different forms of hormonal contraceptives. A standardized questionnaire asked specifically about the participants’ sexual activity and possible influencing factors. Regarding a possible use of contraception, the effects of various contraceptive methods on sexual function as well as different hormonal contraceptives was compared.

The analysis shows that of the participating women, 32.4% had a risk for female sexual dysfunction: 8.7% orgasm problems, 5.8% libido issues (hypoactive sexual desire disorder), 2.6% satisfaction problems, 1.2% had decreased lubrication, 1.1% were suffering from pain during sexual intercourse and 1.0% symptoms of a sexual arousal disorder. Smoking and use of contraception had a significant impact on the prevalence of the prevalence of secual dysfunction, hormonal contraception was significantly more often associated with reduced libido and arousal than non-exclusive non-hormonal contraception or non-contraception. Other variables such as stress, pregnancy, relationship issues and a desire to have children also had a significant impact on sexual function.

The authors point out that the study could primarly detect associations, but can’t prove the causality of individual sexual problems.

(Source: Wallwiener CW, Wallwiener LM, Seeger H, Mueck AO, Bitzer J, and Wallwiener M; Prevalence of Sexual Dysfunction and Impact of Contraception in Female German Medical Students ; doi: 10.1111/j.1743-6109.2010.01742.x)

May 15

In history, the concept of sexual ‘normality’ almost continuously subjected to ethical considerations, and until today, the distinction between normality and perversion (paraphilia) is still difficult. As we can see comparing different countries in the world, cultural differences and legal systems are also influencing these artificial boundaries.

Today’s diagnostic taxonomies define various fetishes, but as also masochistic and sadistic sexual role-playing as deviances. But then, according to statistics, about 50 percent of all European men would have to be classified as having sexual disorders, preferring ‘atypical’ patterns of stimuli and triggers for sexual arousal – that way, a definition of ‘normality’ would of course be somewhat questionable and artificial. As a consequence, newer versions of the diagnostic manuals will distinguish better between pathological sexual disorders harming others (eg, acting on sexual urges with nonconsenting persons), and harmless, playful sexual deviations.

But the freedom to live as good as any sexual orientation does not automatically ensure happiness – neither of the person herself or a partner. If satisfactory sexuality can only be achieved under very limited conditions, if it conflicts with the law or if it burdens the relationship or ourselves at times, it is almost always proved to seek professional sexual advice.

(This short article is part of a weekly series dealing with psychological expat problems and general mental health issues and was published in various newspapers and magazines in Thailand, 2010)

May 14

Erectile dysfunction (ED, or the formerly called ‘Impotence’) is defined by the inability of a man to maintain an erection sufficient for intercourse in more than two-thirds of the attempts during half a year. So if it only ‘doesn’t work’ now and then, it isn’t a disorder requiring treatment. But with age, more men have to deal with ED: only one in ten 40- to 49-year-old men is affected, but among 60- to 69-year-olds it is at least one in three.

Especially in older men, physical conditions often cause or at least contribute to Erectile Dysfunction, while in men under 55, there are almost always mental triggers. ‘Magic bullets’ like Viagra or Cialis are therefore not really advisable for this younger group of men, not only out of the possible adverse consequences of long-term use, but also for the risk of a psychological dependency on the ‘power pill’.

As an Erectile Dysfunction can be indicative of heart-, cardiovascular and other serious diseases, a medical checkup is the first thing to do. If no physical causes can be found, however, a few counseling sessions with a sex therapist can often set a new pace. ‘I feel incredibly liberated,’ a client once said at the end of our sessions. Indeed, trying to improve their ‘sexual fitness’, many men can give new and more positive impetus to their own sexuality. For what could be more fair in sex than Men’s Lib? 😉

If you are interested, feel free to do the Self Test on Male Erectile Dysfunction (click here for the German version) offered on these pages.

(This short article is part of a weekly series dealing with psychological expat problems and general mental health issues and was published in various newspapers and magazines in Thailand, 2010)