Medication for the healthy?

Modern Western culture does not restrict medication to the medically ill. Herbals, dietary supplements, and over-the-counter drugs, as well as highly publicized medications for sexual function such as Viagra (sildenafil) and Cialis (tadalafil), have blurred the categorical boundary between the sick and the well. An extensive review and discussion of the practice of taking such substances is beyond the scope of this book. It is important, however, for the clinician to carefully review the reported effects on sexual function of a substance used by a patient, as available at MEDLINEplus, and to have a clear view of what the substance purports to do in the area of sexual functioning. The distinction between an aphrodisiac and a drug to enhance physiological response is key in this regard.

For example, Cheap Viagra Australia and Cialis are not aphrodisiacs. They do not increase one’s desire for sex; they augment erectile activity and usually require stimulation—physical and psychic—to be effective. Testosterone, on the other hand, acts on the libido without significantly increasing erectile response. Thus, if a healthy man has erectile dysfunction and a normal testosterone level, there is no reason to give him exogenous testosterone for the erectile dysfunction. In a double-blind, placebocontrolled crossover study, Raul Schiavi and colleagues reported that there was no effect on erectile functioning when testosterone was administered to men with erectile dysfunction. Only a slight increase in ejaculatory frequency was noted, and this was not connected with the participants’ self-reports of any increased sense of sexual desire.
The question of medication use by the healthy to enhance sexual function most often arises in connection with the process of healthy aging. The normal aging decrements in function versus the limitations caused by a disease process is a complicated and controversial subject. For an approach to this question, I look at the question of the aging body and sex.


From the perspective of a healthy, albeit aging, body, the ability for sexual activity resembles that for any other physical activity. In this view, sexual functioning is similar to jogging, swimming, hiking, and climbing stairs: the more one has done this in the past, the better one is able to do it now and in the future. There may be a general decline in motivation, speed, and endurance, but if essential health is a quality of the aging body, the ability to perform physical activities will remain essentially intact. In the sexual realm, at least for healthy men, a parallel decline in the sensory/neural and autonomic functioning of the genitals is part of the aging process. Erections are slower to attain, briefer in duration; seminal ejaculate is less; and orgasmic pleasure is satisfying but less intense than in earlier years.

Will a healthy older person be able to function sexually? The simple answer is, “The past is prologue,” as research studies on sex and aging have taught us. At least for elderly married men, past patterns of sexual activity are strong indicators of sexual vitality in older age. The more complex answer is, “It depends.” Whether or not an older person is interested in sex and is sexually active depends on a number of factors other than physical health. Availability of a partner, quality of the relationship, history of sexual expression (or lack thereof), competing interests or commitments (e.g., chosen celibacy) are some of the factors that predict sexual activity in an aging person. These factors are best understood in the life story and behavior perspectives, and I return to examine them in later chapters.

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One carefully designed study captures many of the issues involved in sex and healthy aging in men. Raul Schiavi, at the time a psychia trist and sex researcher at Mt. Sinai School of Medicine in New York City, recruited a sample of men (ages 45 to 75) carefully screened to minimize the effects of disease or medications as confounding factors in sexual functioning. Seventy-two heterosexual couples were interviewed, the spouses separately, about their sexual lives together. The men participated in nocturnal penile tumescence (NPT) sleep studies in which erectile tumescence (erection) was monitored with strain gauges attached to the penis. Much to the surprise of the investigators, a high proportion of the men above 65 who failed to have full erections during sleep were, by their own and their partner’s independent reports, able to have intercourse regularly and were quite satisfied with their sexual lives.

The strong suggestion in this finding is that compromised physiological status (abnormal NPT) can be overridden by the physical and emotional stimulation of a spouse. The relationship of sex and aging is a complex phenomenon, not given to simple single-cause explanations. While disease processes and “normal” decrements in function are factors to be reckoned with, in real life, many factors enter into the picture. Other perspectives, especially the life story perspective, with its emphasis on value and meaning, need to be employed at this point to give due regard to the complexity of the lives involved.

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