How to win the battle with erectile dysfunction: part 1

Elderly gay couple sitting on a park bench lean in to kiss each other. One has his arms linked through his partner's arms. Love and affection.
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For many men over 50, erectile dysfunction (ED) is a growing concern — literally and figuratively.

Estimates of how common the condition is vary widely, but one trusted 1994 analysis, the Massachusetts Male Aging Study, found that around 52 percent of men over 40 experience some form of ED, from mild to complete. It also found complete ED increases from about 5 to 15 percent between ages 40 and 70.

While the actual percentage can vary at any age, depending on factors like underlying health conditions, lifestyle choices, state of mind and medication use, the data makes clear it’s a common condition.

Talking to a doctor is an important first step to addressing the physical and emotional effects of ED and to learn if there are any associated health issues.

LGBTQ Nation spoke with Perry Halkitis, PhD, MS, MPH, Dean and Hunterdon Professor of Public Health & Health Equity at Rutgers School of Public Health, and the Editor in Chief of Behavioral Medicine and Founding Editor in Chief at Annals of LGBTQ Public and Population Health, to find what causes ED, how it’s diagnosed, and what the best treatments are.

In Part 1 of our interview, Halkitis describes the physiology underlying ED, as well as the most effective treatment: ED medications, including Viagra and Cialis, also known as PDE5 inhibitors.

LGBTQ NATION: What is erectile dysfunction?

DR. PERRY HALKITIS: Erectile dysfunction is a condition that sets in for men as they get older and their testosterone level goes down, which prevents them from being able to, 1) obtain or have an erection, or 2) to maintain an erection for a sustained amount of time.

Oftentimes, this also leads to conditions that are complicated with the inability to ejaculate, and as a result of that, not experience the pleasure that they experienced during the course of their youth, or in their younger years.

LGBTQ NATION: What are the causes of erectile dysfunction in men over 50, and are they any different in straight men vs. gay men?

PH: There’s no differences at all. This is a physiological condition that develops in men over age 50, and for some, actually at younger ages, too. But 50 is the demarcation point for the later stages of life.

The main culprit for erectile dysfunction and other inabilities to perform sexually are the change in the hormone levels that take place in men as they age. When I say their hormone levels, particularly their testosterone levels. This is something that happens to both men and women, changing hormonal structure over time, because the body just doesn’t produce the hormones at the levels that they were producing them before.

We document very clearly that women stop menstruating at a certain period of time — they go through menopause. There’s less conversation about men’s hormonal changes, although in the last 10 years, there has been an uptick in that.

So this is a natural phenomenon that occurs in individuals just with an aging body, just as every other bodily system — circulatory, digestive, the skin — all experience deterioration as one ages.

Particularly, the hormonal system — the endocrine system with which the testosterone is part — also experiences a deterioration as the body begins to age more rapidly. And 50 has been the demarcation point for older adulthood, and 50 is generally the time that we see an individual begin to experience erectile dysfunction.

However, blood flow problems due to cardiovascular conditions such as hypertension that often accompany aging, as well as psychological conditions such as unmanaged depression or anxiety, are also often associated with ED. As with many health conditions, there can be multiple intersecting causal factors. It should also be noted that some antidepressants worsen ED.

LGBTQ NATION: What are some of the co-morbidities associated with erectile dysfunction? Can it be a sign you suffer from other debilitating or unknown conditions?

PH: Of course. No health condition exists in isolation. And whether you’re talking about erectile dysfunction or you’re talking about depression, or you’re talking about digestive disorders, very often these things are in sync with each other. We have a tendency to think that people have one health problem, but in fact, people tend to have multiple health problems and especially as people get older, there’s an interaction of the health of the bodily systems with each other.

Erectile dysfunction is undoubtedly related to changes in the circulatory system. That happens as people get older — your cardiovascular system changes. People develop hypertension, people develop cholesterol issues, people develop other cardiovascular ailments.

But in addition to that, the other thing that’s implicated really largely — and this is perhaps somewhat bi-directional, although some might argue causal — mental health issues including depression and anxiety that are associated with the experience of erectile dysfunction.

For men who used to be able obtain a full erection and have the sexual life that they wanted over the course of their lives, the inability to get that probably exacerbates any underlying depression that’s already there, or any underlying mental health issues that are already there.

LGBTQ NATION: If you’re having trouble achieving an erection and you’re seeking help from a doctor, how do they diagnose the condition?

PH: It starts with a conversation between doctor and patient about behavior. There can be physiological assessments, but most often doctors will prescribe treatments to their patients just based on the diagnosis that they make with the individual in conversation. Usually it’s a prescription for erectile dysfunction medications.

LGBTQ NATION: Viagra and other ED medications are in a class called PDE5 inhibitors, right? How do those work exactly?

PH: By affecting the blood pressure. What it ultimately does is it increases the blood flow to the penis. As more blood flows to the penis, it leads to the ability to obtain and maintain an erection for a period of time — with Viagra for short periods and Cialis for longer periods of time. And that is done because of a gain in the cardiovascular system affecting blood flow. This is why the conversation with a doctor is so critically important in establishing whether one can be on these medications. They affect blood pressure, and if one has hypertension or other issues it can lead to complications.

LGBTQ NATION: Are men taking Viagra and Cialis without a prescription?

PH: What we know about men is, men tend to go to the doctor much less frequently than women go to the doctor, so I can’t say to you that anybody who’s using erectile dysfunction medication is doing it through a prescription, or is doing it in the correct medical way.

We know that there is trading and purchasing erectile dysfunction medication, that people are getting from their friends and others without any diagnosis, which is a very, very, very bad idea. Because as we know these erectile dysfunction medications have implications for the cardiovascular system. And unless a doctor feels comfortable prescribing these medications based on the person’s cardiovascular system, based on the person’s experience with heart attacks and strokes and cholesterol and what have you, then it could lead to complications.  

LGBTQ NATION: What’s the success rate for PDE5 inhibitors?

PH: I mean, extremely high, extremely high success rate and this is why the drug was so popular, right? It works for most people. There are of course side effects that people report, but I think most men would say that the use of these inhibitors allows them to function the way that they would like to continue to function in their sexual lives.

In Part 2 of our interview with Dr. Halkitis, he addresses the psychological effects of ED meds, how they can be abused, and some unexpected health benefits you may not have considered.

Editor’s note: Question number two has been updated to include more information about the causes of ED

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