High school sweethearts, my wife, and I had a healthy sexual life for many years. However, when my libido significantly decreased, I attributed it to a busy work schedule and increased weight. It brought confusion to my wife, who was used to me jumping her bones at every opportunity. When I finally discussed this with my physician, he tested my testosterone level and found it significantly low. I opted to begin testosterone replacement therapy, which revitalized our sexual health and increased our intimacy. In addition, soon after starting TRT, my body fat decreased rapidly while my lean muscle increased in response to weight training.
Sexual Health is Vital to Overall Personal Wellness
Sexual dysfunction affects more than half of men aged 40 to 70 in varying degrees. Moreover, an extensive study of 27,500 people showed that almost half of respondents had experienced at least one sexual difficulty in the last 12 months. Still, less than 20% had sought medical attention for their problem.
According to the data, it is clear that sexual health should be considered a mirror of general health, which is a prerequisite for remaining sexually active. Poorer general health reduces the period of sexually active life.
While sex drive is not essential for life, sexual wellness and satisfying sexual life are critical to most people's overall quality of life. A chronically decreased libido can affect happiness for many people by leading to personal distress and putting strain on intimate relationships.
Sexual issues such as erectile dysfunction (ED) can impact men's quality of life (QOL) and psychosocial and psycho-sexual adjustment. Studies demonstrate that men with ED report loss or diminished masculinity: a sense of no longer being a man or feeling less of a man. Moreover, men with poor sexual functioning who have more traditional masculine values have worse social functioning and increased depression.
Sexual dysfunction may cause anxiety or loss for both partners in a relationship. For example, a study found that ED can make males feel depressed, angry, socially isolated, and lacking in self-confidence, and lead to a desire to avoid their spouse. A 2016 study found that ED can make a person's partner feel confused, anxious, and undesirable. Males with ED may avoid intimacy with their partner to avoid distress. Their partner may interpret this as rejection, making them feel unwanted.
Other Factors That Influence Sexual Health
- Low testosterone (T) levels: Associated with ED, decreased libido, obesity, depressed mood, fatigue, and reduced lean muscle mass. Results from a series of T trials suggest that TRT increases all aspects of sexual activity and libido compared to placebo–levels of sexual activity and libido increased incrementally along with T blood values. In addition, an exploratory study revealed that almost 30% of men on TRT do so because of low energy and fatigue. The same study found that 52% of the men indicated that TRT boosted their energy levels.
- Mental health: Sexuality continues to be taboo, with different opinions on what constitutes normal or pathological behavior. All psychiatric diseases include symptoms that affect sexual health, such as impaired desire, arousal, and sexual satisfaction. Sexual dysfunction can deteriorate a patient’s sexual life and satisfaction, leading to decreased psychiatric medication adherence. In addition, the best mental health care includes acknowledging aspects of sexual intimacy, life desires, fears, frustrations, and self-esteem issues.
- Obesity: Studies show that obesity is associated with impairments in sexual functioning, while weight loss significantly improves sexual functioning. In a study of 2,225 candidates with obesity presenting for bariatric surgery, 12% of men reported no sexual desire, 25% of men reported no sexual activity, and 54% of men were moderately or very dissatisfied with their sexual lives. When indicated, testosterone replacement therapy (TRT) can significantly improve weight loss without compromising lean muscle. Several studies demonstrate that TRT decreases body fat and facilitates weight loss in obese patients.
- Health and lifestyle factors: Stress, poor diet, lack of exercise, smoking, drinking alcohol, drug usage, air pollution, exposure to hazardous chemicals, water contamination, and certain medications can adversely affect sexual health.
- An environment that affirms and promotes sexual health: Access to sexual health care, information about sex and sexuality, and knowledge about the consequences of unprotected sex fosters sexual well-being.
Effects of Late-onset Hypogonadism on Sexual Health
Low testosterone levels and clinical signs and symptoms of T deficiency characterize hypogonadism in older men. The prevalence of hypogonadism in men increases with age, starting in the fourth decade.
Age is significantly associated with decreased libido, as age-related mental and physical changes naturally lead to a decline in sexual desire. According to one study, libido in middle-aged men (40–60 years) is three times lower than in younger men aged 18–29.
A population-based study of 3400 men demonstrated that sexual symptoms, notably decreased libido and ED, are the most specific in identifying patients with late-onset hypogonadism. In addition, aging men with comorbidities such as metabolic syndrome, type 2 diabetes, and cardiovascular disease have a much higher prevalence of hypogonadism.
A study demonstrated that ED is increasingly prevalent with age, affecting approximately 40% of men at age 40 and almost 70% at age 70. Many studies indicate that T is essential in the central and peripheral regulation of erectile function. Moreover, erectile function can be improved by restoring T levels in hypogonadal men with erectile dysfunction (ED).
Testosterone, Sleep, and Sexual Health
Sleep disorders, including interrupted sleep, insufficient sleep, reduced REM sleep, and obstructive sleep apnea, frequently lead to low T levels and sexual dysfunction.
Insomnia is an independent risk factor for sexual dysfunction. Decreased T levels most likely explain the association between insomnia and sexual dysfunction. Specifically, studies indicate that sleep loss during the night's second half significantly reduces morning T levels. Chronic sleep restriction causes reduced T levels and could have significant implications for health and quality of life, including sexual function. In addition, men with obstructive sleep apnea are more likely to suffer from complications in sexual function.
Communication is Essential for Sexual Health
I vividly recall my first sexual education experience in the fourth grade. Teachers separated students with signed permission slips based on gender into one of two classrooms. The instructor began the course by asking us to create as many names as possible for male and female genitalia. Feeling hesitant and embarrassed, we started slowly but soon shouted what felt like profanities as the instructor wrote our responses on a chalkboard. By the end of the lecture, I remember feeling a sense of relief. I even asked a question about erections, with the answer helping me realize I wasn't alone and wasn't quite the freak I thought I was.
As a society, we struggle to talk openly about sexual topics; however, open communication is the critical foundation for effectively treating ED. Erectile dysfunction is common, affecting at least 50% of men (18 million adult men) over 50 to some extent. However, only 10 percent of men seek treatment, and about 50% discontinue treatment because they are too embarrassed to discuss their sexual health issues with a doctor. In addition, a couple's ability to effectively communicate about sexual dysfunction is critical. The inability to communicate increases anxiety about erections and sexual activity.
In addition, despite positive results and the commonality of sexual dysfunction, discussions about sexual health are uncommon in clinical encounters, believing patients may be offended. On the other hand, patients expect providers to bring up sexual health. In an extensive study of U.S. adults, sexual health was rated as a vital aspect of QOL, including participants with poor health; however, participants with poorer health reported lower sexual satisfaction. As such, sexual health should be a routine part of clinical assessment. Resources should be in place to address sexual health concerns for all patients across the lifespan in all healthcare systems that state a commitment to improving patients' overall health.
Societies transitioning to a "whole health" focus necessitates improving health care provider–patient dialogue regarding sexual health and function. Assessment of sexual health provides essential information about a patient's overall health and well-being and leads to diagnosis and treatment of sexual dysfunction.
Sexual health and a satisfying sex life are critical to the quality of life for most people. Many factors affect sexual health, including low testosterone, obesity, and lifestyle factors such as smoking and diet. The prevalence of hypogonadism increases with age, significantly affecting sexual health and wellness in older men. Testosterone therapy effectively treats hypogonadal men with sexual dysfunction, such as decreased libido and ED, and can improve sexual wellness.