“My cousin and I were driving in the car one day and my mouth started moving before my brain knew what it was saying,” says Angus Barge, a 30-year-old who lives in London. “And I basically told him that for the previous six months I’d been struggling to get it up.” Erectile dysfunction (ED) affected more than just his romantic life, says Mr Barge. He lost confidence and had trouble concentrating at work because he was preoccupied with the problem. After a long silence, Mr Barge’s cousin, Xander Gilbert, told him that he had been struggling with the same thing on and off since he was a teenager.
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Their experience is not unusual. Surveys of men in America, Germany and Spain have found that around 20% suffer from ED at some point in their lives. Women can struggle with sex too. Surveys suggest that around half of British women experience sexual difficulties that had lasted for more than three months in a given year. In Canada, researchers found that nearly 40% of women and 30% of men aged 40-59 had some sort of sexual problem, such as low desire, pain during sex, erection problems or difficulty reaching an orgasm.
No laughing matter
Getting help is tricky. Overstretched health services struggle to provide quick treatment. Many doctors end up prescribing drugs like Viagra to men whose problems are psychological, not physical, because there is nothing else they can do. A mix of embarrassment and ignorance means many of those suffering from sexual dysfunction never seek treatment in the first place. In France, for example, only a quarter of people with sexual problems contact a doctor. Mr Barge says he scoured the internet for solutions to his problem, trying various pills and supplements to no effect.
Sexual problems remain cloaked by shame and embarrassment, rather as mental-health ones did two or three decades ago. Patients are often reluctant to seek treatment; many doctors see the problem as trivial. Even in the liberal countries of western Europe, sex education mostly focuses on preventing diseases or unwanted pregnancies. Even dedicated sexual-health clinics tend not to have much to offer those struggling to have satisfying sex. Fortunately, that is beginning to change.
Sometimes sexual problems can be an early hint that something is wrong elsewhere in the body. ED is often a purely psychological issue, especially in younger men. But in many cases it is at least partly caused by a narrowing of the genital arteries. That makes it an early warning sign of possible heart trouble. Suffering from ED is as good a predictor of heart disease as a history of smoking or a family history of coronary artery disease.
Sometimes the issues are simply distressing rather than potentially fatal. A clutch of British universities runs a decadal sexual-health survey called Natsal, one of the biggest in the world. In the most recent survey, completed in 2012, 7.5% of sexually active women reported painful sex, with a quarter having symptoms “very often” or “always” and for at least six months.
Not all problems are strictly medical in nature. Discordance in sexual desire is a common problem. The most recent instance of Natsal also found that 38% of men and 49% of women with a partner said that the amount of sex in their lives was “about right”. Nearly all of the rest, both men and women, said they wished for more. In many cases a gap between partners is related to differences in the level of enjoyment derived.
That matters. Besides being miserable for the individuals involved, sexual dissatisfaction is a big reason why marriages and long-term relationships break down. Data from places as diverse as America, Denmark and India suggest that problems with physical or emotional intimacy are a leading cause of between 20% and 50% of divorces. (Which in turn often make adults poorer and children less happy.)
As Mr Gilbert found, sexual problems can affect work, too. A study published in 2019 examined 52,000 men in countries including Brazil, China, Germany and Spain. It found higher rates of absenteeism from work in men with ed (7.1% compared with 3.2% over a six-month period), as well as substantially lower productivity when they were in the office.
Embarrassment—on both sides of the doctor’s desk—means that sexual problems often go untreated. Even in the Netherlands, where people are more open about sex than in most other countries, patients want the doctor to open the discussion, says Woet Gianotten, a Dutch sexologist and emeritus professor at the University Medical Centres of Utrecht and Rotterdam. But medics can often themselves be reluctant. Many, says Dr Gianotten, assume that if the patient does not mention a sexual problem all must be well. Kristen Mark, who teaches a course on sexuality to medical students at the University of Minnesota, says that a lot of time in the course is devoted to practising plain speaking. “If they are talking to a patient we don’t want them to have this awkward look on their face as if that’s the first time they’ve ever said the word ‘vulva’.”
If embarrassment can be overcome, there are plenty of treatments available. Some doctors recommend a few sessions of “mindfulness”, a trendy sort of meditation that helps to refocus the mind away from whatever is causing anxiety. The patent on Viagra, a popular medicine for erectile dysfunction, expired in 2020, meaning cheaper, generic versions of the drug are now widely available. In women, menopause is a frequent cause of sexual problems. Women in rich countries have had access to hormone-replacement therapy for many decades. Besides treating hot flushes and insomnia, it can also help relieve the sexual symptoms of menopause.
Different levels of sexual desire, meanwhile, are often related to differences in the level of enjoyment derived. Another sexual-health survey, this time for Indiana University, found that, in America, men have orgasms in consensual sexual encounters about 85% of the time, compared with 63% for women. The reasons for the gap are complex but much has to do with misplaced ideas about what “normal” or “good” sex is, says Dr Mark. Since talking frankly about sex is difficult, many people absorb tropes from Hollywood or the porn industry. Unsurprisingly, these do not translate well to real life.
Letting the light in
Despite the prevalence of sexual problems, very few countries have made their treatment part of routine primary care. France stands out for its attitude to post-natal women. Childbirth can wreak havoc with a woman’s pelvic-floor muscles. Among other problems, that can stop them having sex for a long time after giving birth. French women are entitled to appointments with a pelvic physiotherapist, starting just six weeks after birth. The Netherlands allows disabled people, such as those with paralysis, to request sessions with specially trained sex workers. (In the past the cost of the service was covered by social insurance but after cuts to social spending it is no longer free.)
Some governments are beginning to focus on promoting pleasure as much as treating the lack of it. In many cases, this new approach was prompted by the covid-19 lockdowns. Single Dutch people were allowed to meet with a “sex buddy” when contact between households was restricted. Irish health authorities gave their citizens recommendations on masturbation. Colombia’s health ministry dispensed guidance on the use of sex toys and consensual cybersex.
For those who prefer not to take sex tips from bureaucrats, the sex-toy industry offers another avenue for relief. Savvy marketers are positioning their products as “wellness devices”, in an attempt to escape the industry’s grubby aura and to align with shifting attitudes among customers. Perhaps as a result, it is growing fast. PwC, a consultancy, reckons about 25-30% of adults in America, Britain and France use sex toys. A third bought their first device in the past three years. Walgreens, an American chain of chemists, and Boots, its British subsidiary, now offer dildos and vibrators on their websites, alongside ibuprofen and false eyelashes. PwC puts the size of the global market at $19bn in 2021, up from $11bn in 2016, making it roughly as big as the market for hair-styling products.
Apps are another popular option. Mr Barge’s and Mr Gilbert’s heart-to-heart led them to found Mojo, an app that provides exercises, education and support groups for those with erectile dysfunction. Mr Barge reckons that many users whose issues are psychological see an improvement within six weeks or so. A Spanish startup, Myhixel, offers app-based therapy for premature ejaculation. Germany has approved an app to treat vaginal pain made by HelloBetter, a startup, which users can pay for with their medical insurance.
Information can be particularly hard to come by in poor countries, which often have stronger taboos around sex. An Indian website called Agents of Ishq, started by Paromita Vohra, a film-maker, is one attempt to fill that gap. It features humorous video skits, comics and other entertaining materials that cover things like consent for sex and masturbation (including an annual masturbation poetry contest). It also publishes stories about sex and desire submitted by ordinary people. Many of the comments, she says, are along the lines of “Oh, I’m not alone…somebody else also feels that way.”
Some experts, meanwhile, think the problem might be better addressed with prevention rather than attempts at curing problems after they arise. Although most teenagers in rich countries attend sex-education classes at school, the focus tends to be on avoiding bad things, such as diseases or unwanted pregnancies. Discussion of pleasure is often conspicuous by its absence. In poor places, the subject is often not discussed at all.
At the very least, says Mojo’s Mr Barge, sex education in schools should aim to be realistic, and to cover health, pleasure and potential problems. It should aim to remind teenagers that “sex isn’t like it is in films and it doesn’t always go right. And even as young, healthy people, you’re going to have problems and that doesn’t mean you’re broken. It’s perfectly normal for sex not to go to plan.” ■
This content was originally published here.