When the first edition of this book came out in 1993, it was difficult to find anything on the use of psychotropic drugs to treat sexual problems or on the sexual problems caused by psychotropic agents. Pre-Viagra, it was almost inconceivable that impotence and treatments for it would be talked about openly in both the academic and lay media. Among the things that have contributed most to this change of attitudes have been competition in the antidepressant marketplace and the advent of Viagra. While almost all antidepressants were known to cause some sexual dysfunction from the start, the greater frequency of this with selective serotonin-reuptake inhibitors (SSRIs), the unacceptability of this problem to people who were not used to having anything similar happen on benzodiazepines and the chance for non-SSRI-producing companies to highlight these problems combined to raise the profile of the area. This incoming tide was supplemented by something of a tidal wave with the advent of Viagra, which has firmly put the mechanics of both male and female sexual functioning on the map.
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The range of sexual difficulties
MALE POTENCY
The sexual problem in men most likely to lead to medical input and the flagship condition of the new sexual pharmacology is impotence, now rebranded as erectile dysfunction. This refers to an inability to achieve or sustain an erection. Impotence may derive from what have traditionally been termed organic and psychogenic sources, 1 although there are some grounds to think that physical and social might be better terms here.
The organic causes of impotence stem from problems with either the nervous supply to the blood vessels of the penis (neurogenic causes) or the blood vessels themselves (vasculogenic causes). The commonest vasculogenic causes involve blockage of the blood vessels by atherosclerosis, consequent on or associated with cigarette smoking, or disorders that can destroy the smooth muscle walls of the penile blood vessels, such as diabetes.
The commonest neurogenic causes stem from diseases such as multiple sclerosis or diabetes that lead to damage to the nervous supply to the sexual organs, or trauma to the spine or to the nerves serving the sexual organs. There are two neural pathways involved in mediating the erectile response and either can be damaged separately. One is the parasympathetic nervous system, which runs from the end of the spinal column and mediates reflex erectile responses, such as when the penis rubs up against material, etc. It also mediates the spontaneous erections that happen throughout the day and night in a rhythmic manner.
There is another pathway, which is part of the sympathetic system. This has been seen as a more ‘psychogenic’ pathway leading to erections at the sight of erotic material.
A number of other disorders may cause problems. There are local diseases of the penis, such as Peyronie’s disease, which involves excessive curvature of the penis (few penises are entirely straight when erect). Diseases that affect the whole body, such as liver or kidney disease, may also affect sexual functioning through an accumulation of toxic metabolites or other effects. Finally, drug treatments of various sorts from antihypertensives to analgesics may cause impotence and psychotropic drugs may either compound or minimise these problems.
EJACULATION AND ORGASM IN MEN
In men, climax usually involves an ejaculation. The extremes of pleasure – orgasm – are usually associated with this function. Ejaculation and orgasm, however, need not be tied together. There are a number of common problems affecting ejaculation and orgasm but there is a separate set of problems that can also affect orgasm, indicating that these two functions are not identical. In women, orgasm is not tied to as obvious an ejaculatory event and the differences between the two functions are more clear-cut.
Male ejaculation depends on the production of seminal fluid from the prostate gland and the mobilisation of semen from the testes. Seminal fluid is produced before ejaculation and may be noticeable on the tip of the penis during arousal, when it appears to add to the sensitivity of the penis and to facilitate intromission.
Ejaculation involves a complexly organised set of events in which the bladder neck must be closed off, seminal fluid produced and passed down the urethra to mix with semen coming from the testes, and the whole then discharged by a coordinated ‘Mexican wave’ of muscle movements. At any point along this chain of events a quite minor imbalance may compromise the whole operation.
Problems with ejaculation may involve premature, delayed or retrograde ejaculation. Premature ejaculation involves consistent ejaculation too early in sexual activity, often before entry or else within an unsatisfyingly short time of entry.
Delayed or retarded ejaculation involves an inability to ejaculate within a reasonable period of time, so that no release is achieved. With time, this makes for tension and frustration.
