Sexuality

Since antiquity, history and literature are replete with references to the waning of male virility, in all its ambiguities, with age. The seemingly inexhaustible repertoire of remedies to stave it off testifies to the ubiquity of this human fixation. In particular, the decline in male sexuality in old age, being both emblematic and problematic, it is not surprising that aphrodisiacs are among the most ancient and ubiquitous of folk remedies. The modern educated layman, however, having lost faith in rhino horn and tiger penis, appears now bedazzled by the misty allure of hormones, the contemporary folkloric embodiment of the fabled aphrodisiac. And for hormones, our social organization dictates that doctors remain its monopolistic dispensers.

Systematic sociological studies of human sexuality were pioneered by Kinsey in mid 20th century followed by more recent comprehensive national data from the UK (Wellings et al 1994), USA (Laumann et al 1994) and France (Messiah & Pelletier 1996). Their focus has been on men under 60 years leaving an incomplete picture. As an observational methodology, such research aspires to high standards in representative sampling; its limitations are in its lacking independent, objective validation of findings. It is hardly surprising that uncorroborated self-report (to strangers) of the most emotive, and hence least likely to be reliably reported, aspect of human behaviour would produce glaring discrepancies. For example, * 50% of men but only * 5% of women over the age of 80 report ongoing sexual activity with a partner (Laumann et al 1994). If these facts are dubious, more subtle motivations and manifestations must be well beyond reach. Bedevilled by its subjectivity and imperilled by proximity to social mores, the prospects for more objective research into male sexual activity in the general population seem remote. Yet large lacunae in understanding of male sexuality remain, among them the role of prostitution which, given its ubiquity and pervasiveness, is remarkably little studied. If prostitution is the oldest profession, then use of its services must be the oldest male pastime. While the sociology of prostitutes is widely studied, their male clients remain obscure and ignored. It is hard to imagine that studies of such a ubiquitous and pervasive facet of male sexuality would not enlighten the understanding of male sexuality.

By contrast, medical complaints of male sexual dysfunction undoubtedly increase with age. While all functional aspects of male sexuality — libido, potency and ejaculation — are reduced in older men, the major impact of ageing is the exponential increase of erectile dysfunction with age (Ayta et al 1999). The last decade has seen a major paradigm shift in understanding of male sexual dysfunction. This includes a public relations makeover in nomenclature (impotence becoming erectile dysfunction), a shift in beliefs about causation (from prevailing Freudian psychoanalytic beliefs on psychosomatic causation, to erectile dysfunction being due to organic neurovascular disorders of cavernosal hydraulics) and development of the first effective pharmacotherapy.

The development of vasoactive cavernosal pharmacotherapy was inaugurated by the accidental discovery of papaverine effects during vascular surgery and soon surpassed by the equally fortuitous discovery of oral sildenafil during clinical drug evaluation for other purposes. Both are striking instances of Pasteur's dictum of chance favouring the prepared mind rather than outcomes of goal-oriented research. Stemming from recognizing the vasculogenic basis of most age-related erectile dysfunction, important issues arising include the role of erectile dysfunction as a sentinel presentation of cardiovascular disease, the potential for primary and secondary prevention strategies based on cardiovascular disease pathogenesis (Ayta et al 1999) and elucidating the pathogenic mechanisms of the most frequent iatrogenic cause of erectile dysfunction, anti-hypertensive drug therapy (Feldman et al 2000). While the lucrative new pharmaceutical market for vasoactive drugs will ensure expanding options for treatment of individuals with erectile dysfunction, the high and increasing prevalence means the prospective impact on public health policy and financing is daunting (Ayta et al 1999).

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