How Did Erectile Dysfunction Become "Natural"? A Review of the Critical Social Scientific Literature on Medical Treatment for Male Sexual Dysfunction

The effects and safety of testosterone replacement therapy for men with hypogonadism: the TestES evidence synthesis and economic evaluation

Background

Low levels of testosterone cause male hypogonadism, which is associated with sexual dysfunction, tiredness and reduced muscle strength and quality of life. Testosterone replacement therapy is commonly used for ameliorating symptoms of male hypogonadism, but there is uncertainty about the magnitude of its effects and its cardiovascular and cerebrovascular safety.

Aims of the research

The primary aim was to evaluate the safety of testosterone replacement therapy. We also assessed the clinical and cost-effectiveness of testosterone replacement therapy for men with male hypogonadism, and the existing qualitative evidence on men's experience and acceptability of testosterone replacement therapy.

Design

Evidence synthesis and individual participant data meta-analysis of effectiveness and safety, qualitative evidence synthesis and model-based cost-utility analysis.

Data sources

Major electronic databases were searched from 1992 to February 2021 and were restricted to English-language publications.

Methods

We conducted a systematic review with meta-analysis of individual participant data according to current methodological standards. Evidence was considered from placebo-controlled randomised controlled trials assessing the effects of any formulation of testosterone replacement therapy in men with male hypogonadism. Primary outcomes were mortality and cardiovascular and cerebrovascular events. Data were extracted by one reviewer and cross-checked by a second reviewer. The risk of bias was assessed using the Cochrane Risk of Bias tool. We performed one-stage meta-analyses using the acquired individual participant data and two-stage meta-analyses to integrate the individual participant data with data extracted from eligible studies that did not provide individual participant data. A decision-analytic Markov model was developed to evaluate the cost per quality-adjusted life-years of the use of testosterone replacement therapy in cohorts of patients of different starting ages.

Results

We identified 35 trials (5601 randomised participants). Of these, 17 trials (3431 participants) provided individual participant data. There were too few deaths to assess mortality. There was no difference between the testosterone replacement therapy group (120/1601, 7.5%) and placebo group (110/1519, 7.2%) in the incidence of cardiovascular and/or cerebrovascular events (13 studies, odds ratio 1.07, 95% confidence interval 0.81 to 1.42; p = 0.62). Testosterone replacement therapy improved quality of life and sexual function in almost all patient subgroups. In the testosterone replacement therapy group, serum testosterone was higher while serum cholesterol, triglycerides, haemoglobin and haematocrit were all lower. We identified several themes from five qualitative studies showing how symptoms of low testosterone affect men's lives and their experience of treatment. The cost-effectiveness of testosterone replacement therapy was dependent on whether uncertain effects on all-cause mortality were included in the model, and on the approach used to estimate the health state utility increment associated with testosterone replacement therapy, which might have been driven by improvements in symptoms such as sexual dysfunction and low mood.

Limitations

A meaningful evaluation of mortality was hampered by the limited number of defined events. Definition and reporting of cardiovascular and cerebrovascular events and methods for testosterone measurement varied across trials.

Conclusions

Our findings do not support a relationship between testosterone replacement therapy and cardiovascular/cerebrovascular events in the short-to-medium term. Testosterone replacement therapy improves sexual function and quality of life without adverse effects on blood pressure, serum lipids or glycaemic markers.

Future work

Rigorous long-term evidence assessing the safety of testosterone replacement therapy and subgroups most benefiting from treatment is needed.

Study registration

The study is registered as PROSPERO CRD42018111005.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 17/68/01) and is published in full in Health Technology Assessment; Vol. 28, No. 43. See the NIHR Funding and Awards website for further award information.

'Manopause': sexual response changes as a threat to ageing manhood

When men root manhood in sexual performance, their inability to get and maintain an erection (i.e. erectile dysfunction) may pose a threat to ageing men's ability to enact masculinity. Using data from the 2015-2016 National Social Life, Health and Aging Project (NSHAP) - a nationally representative survey of the USA - this study finds that age and erectile dysfunction interact: men who report 'trouble getting or maintaining an erection' have a higher odds of reporting anxiety before sex. However, this effect gradually declines as the sample of men with erectile dysfunction ages (from ages 49 to 95). Additionally, men who do not report erectile dysfunction have the same odds of sex-anxiety throughout the sample, regardless of their age. The change in sexual performance may cause distress for men, as they feel unable to maintain their dominant masculinity in old age. While previous studies have shown that age and gender interact to affect men's sexual health in mid-life and later-life, this study adds to the feminist gerontology literature by providing indirect evidence that changes in sexual response may become gradually less anxiety-inducing, and thereby, less threatening for men as they age.

Social Perceptions of Masculinity and Sexual Esteem Are Impacted by Viagra Use, Testosterone, and Sexual Performance

Sexual behaviors play a role in the social construction of masculinity. Moreover, this stereotype has been capitalized upon by pharmaceutical companies, as well as those that sell products not approved by the U.S. Food and Drug Administration, for purposes of marketing sexual medicines. Stereotypical notions of masculinity, however, also emphasize the importance of self-reliance, which may cause some to look unfavorably upon the use of sexual medicine. Consistent with this notion, a male target was viewed as more masculine when his female partner consistently reached orgasm, unless he had no history of erectile dysfunction (ED), but was taking Viagra anyway (Experiment 1; N = 522). In addition, when his partner consistently reached orgasm, ratings of his sexual esteem were also lower if he used Viagra than if he did not, but only if he had no history of ED. In Experiment 2 (N = 711), although there was no effect of a male target's use of testosterone, social perception of his masculinity and sexual esteem increased as his "natural" levels of testosterone increased. In addition, exploratory analysis revealed that if the male target had low (but not normal or high) "natural" levels of testosterone, ratings of his masculinity were higher if his female partner consistently had an orgasm, which suggests that female orgasm served to "rescue" masculinity. Because expectations about drugs drive their use, it is important to address preconceived notions about the use of sexual medicines for purposes of enhancing masculinity and sexual esteem, as the social perception of their use is much more complex.

Communicating male sexual dysfunction: The medicalization and psychologization of sexual experiences in Chinese online medical consultations

Previous research shows that men who experience erectile or sexual dysfunction may feel uncomfortable discussing their sexual experiences in face-to-face clinical encounters. Part of the reason is the stigma and embarrassment associated with discussing private sexual matters. This study examines how e-patients, or more precisely advice-seekers, and doctors communicate about sexual dysfunction in online medical consultations (OMCs). We conducted a Theme-Oriented Discourse Analysis of relevant OMCs on CH Doctor, a Chinese medical consultation website, to understand how individuals with perceived sexual dysfunction articulate their conditions and how doctors on the platform respond and provide recommendations to these individuals. Our analysis reveals that OMCs afford advice-seekers a place to openly discuss their sexual health issues and gain empowerment from doctors who assist in mitigating the associated social stigma. Upon detailed discourse analysis, however, we find that individuals seeking advice often interpret their sexual experiences as symptoms of illness that requires medical intervention. In response, doctors tend to validate these advice-seekers' preliminary self-diagnoses by treating their conditions as medical issues and characterizing them as psychosocial problems caused by stress and anxiety. Aligning with a critical sociological perspective that views sexual dysfunction as socially constructed problems referenced against dominant norms of sexual functioning, we argue that the medicalization and psychologization of certain sexual behaviors by doctors and advice-seekers discursively reinforce and legitimize essentialist views of hetero-coital sexual interaction. Such views reify penile-vaginal intercourse and ejaculation as the only standard, successful, and desirable form of sexual activity. This may further induce fear and anxiety among adult men whose sexual behaviors do not realistically align with these norms.

Men's Feminist Identification and Reported Use of Prescription Erectile Dysfunction Medication

We analyzed data from the 2018 Sex in Canada survey (n = 1,015 cisgender men) to examine the association between feminist identification and reported use of prescription ED medication (EDM) during men's last sexual encounter. Feminist-identified men were substantially more likely to report EDM use than non-feminist men, even after controlling for alcohol use before sex, erection difficulties, sexual arousal, sexual health, mental health, and physical health. One explanation is that feminist men may use EDM to bolster their masculinity when it is otherwise threatened by their identification as feminist. Another is that non-feminist men may be less likely to use prescription EDM because they view accessing healthcare services as a threat to their masculinity. It is also possible that feminist men are more likely to use EDM because they wish to maintain an erection to better please their partner. Lastly, feminist men may be more honest about EDM use than non-feminist men, even though rates are similar. Regardless of the exact reason, therapists can use these results to tailor sexual health messages to clients based on feminist identification. Future work could employ qualitative methods to understand why feminist men report higher rates of EDM use than non-feminist men.

The Role of Information in Later-Life Sexuality: An Invitation for Further Exploration

Despite the key role of information in realizing, questioning, or respecting one's sexual health, individuals' engagement with information about sex and sexuality remains understudied, particularly in older adult populations. Beginning with current understandings of later-life sexuality to contextualize how older adults may need, use, and manage information about their sexual lives and practices, this forum article follows with what is currently known about older adults' sexuality-related information needs and practices. We conclude with an invitation for collaboration between gerontologists and Library and Information Science scholars and professionals as a means to step outside the medicalization of older adults' sexuality and bolster our understandings of how information and later-life sexuality are mututally shaping.

Identifying the outcomes important to men with hypogonadism: A qualitative evidence synthesis

OBJECTIVE

Men with male hypogonadism (MH) experience sexual dysfunction, which improves with testosterone replacement therapy (TRT). However, randomised controlled trials provide little consensus on functional and behavioural symptoms in hypogonadal men; these are often better captured by qualitative information from individual patient experience.

METHODS

We systematically searched major electronic databases to identify qualitative data from men with hypogonadism, with or without TRT. Two independent authors performed the selection, extraction, and thematic analysis of data. Quality of eligible studies was assessed using the Critical Appraisals Skills Programme and Grading of Recommendations Assessment, Development and Evaluation-Confidence in the Evidence from Reviews of Qualitative research tools.

RESULTS

We analysed data from five studies published in nine reports that assessed a total of 284 participants. Published data were only available within North America, with no ethnic minority or other underserved groups included. In addition to sexual dysfunction, men with MH experienced adverse changes in physical strength, perceptions of masculinity, cognitive function, and quality of life. The experience of MH appeared dependent on the source(s) of educational material.

DISCUSSION

We propose a patient-centred approach to clinician interactions rather than focusing on discreet MH symptoms. Current evidence about the experience of MH is limited to North America and predominantly white ethnicity, which may not be broadly applicable to other geographic regions. Broadening our understanding of the MH experience may improve the targeting of information to patients. In addition, a multidisciplinary approach may better address symptoms neither attributable to MH nor alleviated by TRT.

A Psychosocial Approach to Erectile Dysfunction: Position Statements from the European Society of Sexual Medicine (ESSM)

INTRODUCTION

Although erectile dysfunction (ED) involves an interaction between physiological and psychological pathways, the psychosocial aspects of ED have received considerably less attention so far.

AIM

To review the available evidence on the psychosocial aspects of ED in order to develop a position statement and clinical practice recommendations on behalf of the European Society of Sexual Medicine (ESSM).

METHOD

A comprehensive, narrative review of the literature was performed.

MAIN OUTCOME MEASURES

Specific statements and recommendations according to the Oxford Centre for Evidence-Based Medicine 2011 Levels of Evidence criteria were provided.

RESULTS

A multidisciplinary treatment, in which medical treatment is combined with a psychological approach, is preferred over unimodal treatment. There is increasing evidence that psychological treatments of ED can improve medical treatments, the patient's adherence to treatment, and the quality of the sexual relationship. The main components of psychological treatment of ED involve cognitive and behavioral techniques aimed at reducing anxiety, challenging dysfunctional beliefs, increasing sexual stimulation, disrupting sexual avoidance, and increasing intimacy and communication skills in a relational context. When applicable and possible, it is strongly recommended to include the partner in the assessment and treatment of ED and to actively work on interpartner agreement and shared decision-making regarding possible treatment options. To ensure a better integration of the biopsychosocial model into clinical practice, developing concrete treatment protocols and training programs are desirable.

CONCLUSION

Because the psychosocial approach to ED has been underexposed so far, this position statement provides valuable information for clinicians treating ED. Psychological interventions on ED are based on existing theoretical models that are grounded in empirical evidence. However, the quality of available studies is low, which calls for further research. The sexual medicine field would benefit from pursuing more diversity, inclusivity, and integration when setting up treatments and evaluating their effect. Dewitte M, Bettocchi C, Carvalho J, et al. A Psychosocial Approach to Erectile Dysfunction: Position Statements from the European Society of Sexual Medicine (ESSM). Sex Med 2021;9:100434.

Sexual Dysfunction and Gun Ownership in America: When Hard Data Meet a Limp Theory

Although there has been no direct empirical evidence linking sexual dysfunction (SD) with gun ownership, speculation has been widespread and persistent for decades. In this paper, we formally examine the association between SD and gun ownership. Our primary hypothesis, derived from the psychosexual theory of gun ownership, asserts that men experiencing SD are more likely to personally own guns than other men. To test this hypothesis, we used recently collected data from the 2021 Crime, Health, and Politics Survey (CHAPS), a national probability sample of 780 men, and binary logistic regression to model gun ownership as a function of SD. Our key finding is that men experiencing SD are no more likely to own guns than men without SD. This interpretation was supported across several indicators of SD (performance anxiety, erection trouble, and ED medication) and gun ownership (personal gun ownership, purchasing a gun during the pandemic, and keeping a gun in one's bedroom). To our knowledge, we are the first to have directly tested the association between SD and gun ownership in America. Our findings are important because they contribute to our understanding of factors associated with gun ownership by challenging the belief that phallic symbolism and masculinity somehow drive men with SD to purchase guns. Our results also remind us of the perils of gun culture rhetoric, which, in this case, function to discredit gun owners and to further stigmatize men with ED. We conclude by calling for more evidence-based discussions of SD and guns in society.

Medicalization Defined in Empirical Contexts - A Scoping Review

BACKGROUND

Medicalization has been a topic of discussion and research for over four decades. It is a known concept to researchers from a broad range of disciplines. Medicalization appears to be a concept that speaks to all, suggesting a shared understanding of what it constitutes. However, conceptually, the definition of medicalization has evolved over time. It is unknown how the concept is applied in empirical research, therefore following research question was answered: How is medicalization defined in empirical research and how do the definitions differ from each other?

METHODS

We performed a scoping review on the empirical research on medicalization. The 5 steps of a scoping review were followed: (1) Identifying the research question; (2) Identifying relevant studies; (3) Inclusion and exclusion criteria; (4) Charting the data; and (5) Collating, summarizing and reporting the results. The screening of 3027 papers resulted in the inclusion of 50 empirical studies in the review.

RESULTS

The application of the concept of medicalization within empirical studies proved quite diverse. The used conceptual definitions could be divided into 10 categories, which differed from each other subtly though importantly. The ten categories could be placed in a framework, containing two axes. The one axe represents a continuum from value neutral definitions to value laden definitions. The other axe represents a continuum from a micro to a macro perspective on medicalization.

CONCLUSION

This review shows that empirical research on medicalization is quite heterogeneous in its definition of the concept. This reveals the richness and complexity of medicalization, once more, but also hinders the comparability of studies. Future empirical research should pay more attention to the choice made with regard to the definition of medialization and its applicability to the context of the study.

Declining Sexual Activity and Desire in Women: Findings from Representative German Surveys 2005 and 2016

We estimate (1) sexual activity and sexual desire in women living with and without a partner across the age range in Germany and (2) changes over 11 years. A representative survey of 1345 (response rate: 65%) women between 18 and 99 years from 2016 was compared to a survey of 1314 women age 18-91 from 2005 (response rate: 53%). Sexual activity was assessed as having been physically intimate with someone in the past year; frequency of sexual desire was rated for the past 4 weeks. In 2016, the great majority of women living with a partner were sexually active and indicated sexual desire until the age of 60, which decreased thereafter. Compared to 2005, fewer women cohabited with a partner. Across the age range, women living without a partner reported considerably less sexual activity and desire. The overall proportion of women reporting partnered sexual activity decreased from 67% to 62% in 2016, and absent sexual desire increased from 24% to 26%. Declines of sexual activity and desire affected mostly young and middle-aged women. The decline of sexual activity and desire seems to be due to a reduced proportion of women living with a partner. There was also a generation effect with younger and middle-aged women without a partner becoming less sexually active and experiencing less desire compared to the previous survey. While surveys were methodologically comparable, interpretations are limited by the absence of longitudinal data.

Sexual Rehabilitation After Prostate Cancer Through Assistive Aids: A Comparison of Gay/Bisexual and Heterosexual Men

The use of assistive aids in sexual rehabilitation after prostate cancer (PCa) was examined in 124 gay, bisexual, and other men who have sex with men (GBM) and 225 heterosexual men. GBM were significantly more likely to use assistive aids (79% versus 56%), to try multiple assistive aids (M = 1.65 versus M = 0.83) including medication, penile injection, penile implant, vacuum pump, and nonmedical sex aids, and to seek information about sexual rehabilitation on the Internet, through counseling, or in a support group. There were no differences between the groups in satisfaction with the use of assistive aids. However, use of aids was a significant negative predictor of sexual functioning for GBM and a significant positive predictor for heterosexual men. Interview accounts described satisfaction with assistive aids in terms of maintaining erectile functioning and relationships. The majority of men in the study also described hindrances, both physical and social, resulting in discontinuation of assistive aids, including perceived artificiality, loss of sexual spontaneity, side effects, failure to achieve erectile response, cost, and lack of access to information and support. It is concluded that the specific needs and concerns of GBM and heterosexual men regarding sexual rehabilitation after PCa need to be addressed by clinicians.