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    Senior Member Phlegethon's Avatar
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    Post Wishin' and hopin'

    Wishin' and hopin'

    October 25, 2003


    Having found that men's sex problems were mainly in the body, not the mind, scientists stepped in with Viagra. The debate now is how to help women fight the failings of their sexual anatomy, writes Bettina Arndt.

    A grunt or groan was quite normal. But the earthy cries emerging from a woman Dr Stuart Meloy was treating for back pain suggested that, this time, his spinal cord stimulation device was causing quite a different reaction. He asked her what was the matter. "You'll have to teach my husband to do that," came her answer.

    It was two years ago that Meloy stumbled on the spinal nerve pathways that control orgasm, through this fortuitous accident. Since then, the North Carolina surgeon has been conducting clinical trials on a remote-controlled, matchbox-sized signal generator, which is implanted in the patient's buttocks. His discovery may add a tiny piece to a puzzle coming together through a flood of international sex research in the past 20 years.

    Until recently, the focus was on the male sexual equipment, as research shed new light not only on nervous systems, but blood supply, hormones, bio-chemicals, everything that makes the whole process work - or not. As far as male plumbing is concerned, critical pieces in the puzzle have been identified. But the spotlight has swung to female sexual anatomy and a controversy has erupted. It is fuelled by critics who fear the complexities of the female sexual response will be distorted, as researchers, funded by the drug companies, search for a female Viagra.

    Underlying the furore is the critical question: does women's sexual equipment last a lifetime or, as with men, gradually show signs of wear and tear? The big story for men has been the fragility of the system. Sadly, the penis has turned out to be the canary in the mineshaft, heralding a range of physical problems that affects its performance long before other parts of the body. So trouble getting erections or keeping them can be the first sign of conditions such as heart disease, high blood pressure, cholesterol problems, even diabetes.

    "About three-quarters of all erectile dysfunction have an organic cause," says Chris McMahon, director of the Australian Centre for Sexual Health in Sydney. This conclusion embarrasses those of us who were in the sex therapy business 20 or 30 years ago. Then, we were taught impotence was in the mind, that 95 percent of erectile problems were caused by performance anxiety.

    Millions of men around the world invested in behaviour therapy, trying in vain to cure the mind, when it was the body letting them down. And, as a Sydney sex therapist, Dr Rosie King, points out, this only added to their problems: "Those poor guys not only failed at sex, but they failed at sex therapy, which is a terrible double whammy for a man's self-esteem."

    Then, the problem was we simply didn't know enough about what causes erections and what stops them happening. But along came Giles Brindley, the British physician who, in 1983, rocked a room packed with several thousand American urologists by dropping his pants and proudly displaying outstanding evidence of a drug-induced erection. Brindley, who was later knighted not for his service to erections but for his bio-engineering skills, had injected his penis with 33 different drugs before trying papaverine, the smooth muscle relaxant that proved so effective in adding the much-needed backbone.

    While Brindley's stunt opened the door to the widespread use of injectable impotence drugs, it also provided a diagnostic tool for detecting exactly how the equipment worked and when it was faulty. It had long been known that erections were all about blood flow. But the scientists hadn't figured out what kept the blood there. Now they realised that the smooth muscle relaxants mimic the body's erection methodology, relaxing tissue in the spongy bodies in the penis that suck up the blood like thirsty sponges and, in doing so, flatten the exit veins, trapping blood inside.

    Soon, urologists were using smooth muscle relaxants to test patients' erectile blood flow, with the penis wired up to machinery such as the aptly named DICC (Dynamic Infusion Cavernosometry and Cavernosography), which measures blood pressure in the penis and detects specific blood-flow problems. Here came the critical evidence that erection problems come down to blood flow - problems with arteries letting blood in, or veins allowing it to escape, or the capacity of tissues in the spongy bodies to expand and contract. It's not that mental processes aren't important - performance anxiety can put even the healthiest penis out of action - but, in most older men, the equipment starts to show signs of wear and tear.

    A far smaller group - perhaps 3 to 5 per cent - have nerve damage, often as a result of surgery or radiation to the prostate gland, bladder, rectum or large intestine. Diabetes can also damage nerve endings in the penis and other "wiring" problems can result from injuries to the spinal cord, or brain or neurological disease.

    But blood-flow problems remain the main game. We're talking big numbers here, with 50 per cent of men over 60, and about three-quarters of men over 75, having erection problems. The initial reaction to the discovery that blood flow was the main culprit was to try to fix it using revascularisation surgery, but this proved tricky. "It wasn't a great success," says McMahon, explaining that blood-flow problems often re-emerged after the surgery.

    And then along came the miracle of Viagra, an oral medication that also promotes relaxation of smooth muscle cells, enhancing blood flow and causing erections even in many men experiencing blood-flow problems. "It works really well with the typical ageing male who just can't get an erection and the men whose impotence is due to anxiety, but not when there's a severe disorder," says Dr Michael Lowy, from the Sydney Centre for Men's Health. For men whose equipment is in really bad shape, injectables are often better, he says, while some prefer to use an inflatable prosthesis.

    The billions of dollars being spent around the world on Viagra and similar oral medications, such as Cialis and Levitra, have raised concerns about the influence of such drugs on the fundamental relationship between a man and his penis. As John Bancroft, a British psychiatrist and Kinsey Institute director, explains, the traditional role of the penis has been to tell its owner the truth, whether or not he wants to hear it. "And how often does the penis resolutely refuse to support its owner in a sexual encounter, as if to say 'You have no business doing this - count me out of it'?" he wrote, in a paper titled Man and His Penis: A Relationship under Threat.

    "Now man can hold his manhood in his hand, confident in knowing who is in charge," writes David Friedman, in his cultural history of the penis, A Mind of Its Own (The Free Press, 2001). Friedman, despite some qualms, ultimately defends the medicalised penis as a giant leap for mankind. To argue that older men don't need rock-hard erections - a line taken by some therapists - is to deny human nature, suggests Friedman; "if not human nature, then male nature".

    New knowledge and technology have fundamentally changed the whole equation. And this applies to more than erection problems. While therapists have helped some men with premature ejaculation, there remains a group with a lifelong battle with ejaculation control. "Until about five years ago, everyone was convinced these men had performance anxiety," says McMahon, who is writing a major review on the topic for the World Health Organisation. He says there is evidence that some of these men may have "an inherited problem with sensitivity of the serotonin receptors in their brains", which is why anti-depressant drugs such as Aropax or Zoloft slow down their responses.

    While this radical rethink has taken place in our understanding of the intimate parts of the male anatomy, what about the fair sex? "We still haven't scratched the surface when it comes to the female sexual anatomy and response," says McMahon. But like many of his colleagues, he's convinced the underlying similarities in pelvic anatomy - similar erectile tissue, blood flow, nervous system - must mean that similar equipment failure is bound to occur.

    In January this year, an Australian journalist, Ray Moynihan, wrote an editorial for the British Medical Journal, criticising drug companies' involvement in "inventing" a "new" disease - female sexual dysfunction (FSD). He attacked the companies for sponsoring seminars in which female sexual problems were renamed and redefined. A Sydney gynaecologist, Dr Jules Black, wrote to Moynihan agreeing that drug companies (aided by urologists) were "trying to create a new disease where one doesn't exist and are homing in on territory already well covered by serious sexual scientists for decades".

    But most Australian sex experts question whether this territory is well covered. They say it is a nonsense to suggest female sexual dysfunction is new (and neither is the term FSD, which has been used in the sex therapy field for more than 30 years). "It's rubbish," says Melbourne University professor Lorraine Dennerstein, the new president of the International Society for the Study of Women's Sexual Health. "I have women who think their problems are pretty real and describe them graphically to me. What am I supposed to do, tell them 'You are imagining this'? I don't think so." She explains that therapists have struggled for decades to help women with problems included under the FSD label - desire, arousal, orgasm and pain - and, as with male erectile problems, they haven't been all that successful.

    The best evidence on the prevalence of such problems locally comes from the Australian Study of Health and Relationships, published by La Trobe University earlier this year. The survey found that many women do indeed have FSD - 20 per cent have pain during intercourse, 55 per cent lack of sexual interest, and 29 per cent are unable to come to orgasm (for at least one month in the past year). An astonishing 71 per cent of women have one or more of these problems.

    Comparing women in their 30s with those in their 50s, there's a 15 per cent increase (from 27 to 42 per cent) in the proportion having orgasm problems. Now it is possible that that big increase could be traced to psychological or relationship factors - the hazards of living with middle-aged, impotence-prone men, loss of sexual confidence and other mid-life crises. But it is also likely that, as with men, women start to experience problems with their sexual equipment as they age.

    Helen O'Connell is a Melbourne urology surgeon who is surprised to find herself with an international reputation for unearthing the true glories of the clitoris. Five years ago, O'Connell published research on female sexual anatomy - involving dissection of female cadavers - which showed anatomy books don't do justice to the clitoris. Rather than simply the small visible "head", the clitoris is a much larger structure, which wraps around the vagina and urethra and includes a mass of erectile tissue that, like the penis, swells with blood when aroused. O'Connell has been working this year with colleagues in Michigan to study magnetic resonance images of the female pelvis.

    O'Connell's research shows clearly that the erectile tissue in the clitoral structures "is very similar, or almost completely identical, to male tissue" and looks like it will respond in the same way as male tissue. This means it is likely that as women age, they will develop blood-flow problems similar to those affecting the penis. "I do think there's going to be a significant organic component to arousal problems which has been overlooked," says O'Connell.

    But how big a component has yet to be determined. Recent work has shown diminished pelvic blood flow can lead to thickening and fibrosis of the vaginal wall and clitoris's smooth muscle tissue. Work is under way on the effect of high blood pressure and cholesterol on genital blood flow, techniques are being developed for measuring sexual response in women, and there is research being done on biochemical reactions controlling smooth muscle relaxation and on the role of hormones such as oestrogen in blood flow to the vagina and clitoris.

    With many more women than men having surgery in the pelvic region, work on nerve damage that occurs during such surgery may be even more important. O'Connell says there is little description in anatomy texts of the nerve supply to female sexual structures. "This is the backdrop for the training of pelvic surgeons. It is no wonder there has been relatively little emphasis on female nerve-sparing surgery in gynaecology, urology and other branches of pelvic surgery."

    In the huge debate created by Roy Moynihan's article - the British Medical Journal website had more than 80 pages of feedback - some of the angriest comments came from women who had lost sexual response after this type of surgery. "As one who has suffered female sexual dysfunction after a hysterectomy, I can reassure you that it is a real physical problem that can have devastating consequences," wrote one woman.

    But there were equally outraged responses from women who had always had sexual problems: "It is a point of great stress for women when they are repeatedly told their problem is in their relationship, when they know it is not," wrote a middle-aged woman, "who has experienced FSD all my adult life".

    These problems are real and distressing, says Rosie King, who believes we are also likely to find that many women will experience a loss of sensitivity in the genitals as they age, and will need more effective stimulation in order to respond. She stresses the importance of the psyche in influencing women's responses: "Compared to men, female sexuality is not as robust in dealing with the vicissitudes of life."

    And that's where Susan Davis, the research director at the Jean Hailes Foundation in Melbourne, takes issue with the recent FSD definitions. She argues that it is inappropriate to include female sexual desire problems in the list of "dysfunctions" when they are so clearly based in the psyche and so often stem from relationship issues. "Sexual disinclination is not a disease," she says, expressing her concern that drug companies are trying to create a market for women.

    King suggests that since drugs such as Viagra have proved so helpful to men with psychological as well as physically based erectile problems, women's sexual lives may also be improved if they could be aided, pharmacologically, to enjoy a less fragile response. But this is clearly the area of real controversy. There's no question the wave of research into the female sexual response is being financed by drug companies in the hope of profits from pharmaceutical solutions to these problems. But, while Moynihan and colleagues see this as a conspiracy, many, like O'Connell, believe we reap the benefits.

    "Since drug companies have started putting more and more money into research and development, it seems to have had a huge impact and most of that has been positive. There's been such a growth in recent years in knowledge; knowledge that really helps people. I don't think those things occur in a vacuum."

    And that's the bottom line. Much of the critical information we have acquired in recent years about our sexual equipment has been through research sponsored, at least in part, by the pharmaceutical industry. Yes, they have a vested interest in the outcome but so do we all. With men's sexual lives having been dramatically improved by recent discoveries about their bodies, female sexuality deserves similar attention.



    Bettina Arndt was one of Australia's first sex therapists.
    And all my youth passed by sad-hearted,
    the joy of Spring was never mine;
    Autumn blows through me dread of parting,
    and my heart dreams and longs to die.

    - Nikolaus Lenau (1802-1850)

    Real misanthropes are not found in solitude, but in the world; since it is experience of life, and not philosophy, which produces real hatred of mankind.

    - Giacomo Leopardi (1798-1837)

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    Phlegethon, you should really consider studying to become a sex therapist.

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    Quote Originally Posted by Sigrun Christianson
    I have no failings.
    If only I got a nickel everytime I heard a woman say something along those lines!

    Last edited by Taras Bulba; Wednesday, November 19th, 2003 at 06:14 AM.

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    Senior Member Ominous Lord Spoonblade's Avatar
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    Quote Originally Posted by Pushkin
    If only I got a nickel everytime I heard a woman say something along those lines!
    If only I had a nickel for everytime someone said "if only I had a nickel for everytime..." :giggle
    I envision a world where people dawning long white robes and elaborate headdresses run rampant down the streets, waving their arms in the air while screaming "we've gone mad, we've gone mad", like defrocked monks breaking the silence of ages past.

    Spoonblade: Sharper than a knife and twice as deadly.

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    Quote Originally Posted by Vanessa
    If only I had a nickel for everytime someone said "if only I had a nickel for everytime..." :giggle
    Oh fine, be like that!

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    Senior Member Phlegethon's Avatar
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    Quote Originally Posted by Loki
    Phlegethon, you should really consider studying to become a sex therapist.
    You don't really believe someone has to study for that job, do you?

    Hey Nessy, cool new avatar, although you are way too young to have seen the original Mentors line-up play live.
    And all my youth passed by sad-hearted,
    the joy of Spring was never mine;
    Autumn blows through me dread of parting,
    and my heart dreams and longs to die.

    - Nikolaus Lenau (1802-1850)

    Real misanthropes are not found in solitude, but in the world; since it is experience of life, and not philosophy, which produces real hatred of mankind.

    - Giacomo Leopardi (1798-1837)

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    Senior Member Ominous Lord Spoonblade's Avatar
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    Quote Originally Posted by Phlegethon
    Hey Nessy, cool new avatar, although you are way too young to have seen the original Mentors line-up play live.
    Thanks, I knew you would appreciate it

    Oh El Duce was long dead before I started listening to any music like that hahaha. You've seen them live?
    I envision a world where people dawning long white robes and elaborate headdresses run rampant down the streets, waving their arms in the air while screaming "we've gone mad, we've gone mad", like defrocked monks breaking the silence of ages past.

    Spoonblade: Sharper than a knife and twice as deadly.

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    Senior Member Phlegethon's Avatar
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    Quote Originally Posted by Vanessa
    Oh El Duce was long dead before I started listening to any music like that hahaha. You've seen them live?
    Yep, in 1984 or so.

    El Duce still made it into the annals of rock and roll for the coolest way to die. Getting run over by an Amtrak train while totally drunk is better than suffocating in your puke like Jimi Hendrix, John Bonham and Bon Scott.
    And all my youth passed by sad-hearted,
    the joy of Spring was never mine;
    Autumn blows through me dread of parting,
    and my heart dreams and longs to die.

    - Nikolaus Lenau (1802-1850)

    Real misanthropes are not found in solitude, but in the world; since it is experience of life, and not philosophy, which produces real hatred of mankind.

    - Giacomo Leopardi (1798-1837)

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