Men, Intimacy, and Sexuality

ABSTRACT:

Introduction: While a connection between men, sex and intimacy may not seem a likely correlation, there clearly is a connection between these terms. A definition of terms used includes: male sexuality, normal male sexuality, intimacy, passion, emotions, vulnerability, and mindfulness.

Emotions and Intimacy: Whether discussing men and their feelings, evolutionary psychology and real men, vulnerability and power, or emotional state and sexual arousal, it is important to understand the complex nature of the male sexual response process. If men were really able to “will an erection” they would not be seeking answers to their many questions about their sexual response and that of their partner.

Male Sexuality: Physical intimacy is really a dynamic process, involving more than one person and thus it is a complex process because it is impacted by the many dynamics of the partner and the relationship. Men are often attached to their penis as part of their identity or alter-ego, and certainly it is an aspect of their self-esteem or manhood. There is a change in the sexual arousal and response process with the aging process and men need to be aware of these changes. Additionally, men and their partners need to be flexible to the potential for improving their lovemaking skills with the aging process, instead of assuming it will stay the same or “it served its purpose-procreation” and now we are done. The potential of physical intimacy to improve with the aging process is a novel idea and one that needs promotion because it will help to keep men (and their partners) feeling good about themselves and their life, if they can maintain their physical intimacy into their later years.

Conclusion: Regardless of the source of male sexual dysfunction, a solution can be found and should be found in order for the man and his partner to maintain their physical intimacy in their relationship. It is often referred to as the “cement in the relationship, not the foundation for the relationship”. The goal is really to keep people sexually active and satisfied until they take their last breath!

 

A. INTRODUCTION

            “Men, Intimacy, and Sexuality” sounds like an interesting combination of terms. One might even ask, “How could these terms be related?” “Are they related?” The answer is of course, a resounding “YES”. At no time in a man’s life is this more relevant than with the aging process. More will be said about that theory later in this chapter. Sexuality is a primal part of our personality and identity [1], it is also a topic that many people have much curiosity about and feel uncomfortable talking about. As a clinician working in the field of male and female sexual function and dysfunction for over twenty years, it has been an interesting career to learn how the mind and body must work collaboratively to “feel normal”. To “be normal sexually” is really what most people want. This is a question, which many people have unless they have done work or research on the subject. Frequently, when I am traveling and people learn of my specialty, they often talk about their personal problems, questions, and their curiosities about physical intimacy. Clinically, there are many young men (my youngest patient presenting with Male Sexual Dysfunction-MSD-was fifteen years old), also have these concerns. I try to remind people “…sex is something we all do…we are all wired the same, regardless of our country of origin, religion, or the color of our skin...it is just a part of being human!” 

            1.Definitions: In order to better understand the concepts presented in this chapter, it is good to have the current working definition of terms used so that some consistency would be presented to help prepare a context for understanding the terms and concepts presented in this chapter.

                        a. Male Sexuality-The International Society of Sexual Medicine (ISSM) [2], and the Diagnostic and Statistical Manual for Mental Health (DSM-V) [2] have worked tirelessly to define the male and female sexual dysfunctions (disorders). For the sake of this discussion, the focus will be on the male sexual dysfunctions (MSD) most commonly seen in the clinical practice, such as: orgasm disorders (premature or retarded), arousal disorders (erectile dysfunction-ED), and pain disorders (chronic prostititis or dyspareunia) [3]. With each of these disorders, there are two sources of etiology (causation), typically either organic (medical/physiological) or psychogenic (psychologically based). And, there are typically two types of disorders, either primary (lifelong) or secondary (situational) [2]. In this case, physical injury and psychological etiology would be included in the secondary or situational types of disorders.    

                        b. “Normal” Male Sexuality-Frequently, men will be concerned about whether they are a “good lover” or not. And, occasionally, they will inquire “about the size of their penis”-“am I normal?” This is not a question that a mental health clinician can answer because that is out of our area of expertise. However, we can tell men that regardless of their penis size, they can be a great lover if they learn the “mechanics of lovemaking”-this means being equally interested in their partner’s body, as much as their own body.

            I frequently tell men that if their penis is smaller than the size of a grapefruit (the size of an infant’s head) then the woman can accommodate it. While this may not answer their question about whether they are “big enough” or not, it is important to remember to focus on the process rather than the endpoint. As Bernie Zilbergeld, my mentor, used to say, “it’s not about the size of the rod, it’s about how you stir it.” [4]. Other questions men ask about sexuality is “why doesn’t my wife like to make love any more?” The best answer I can give them is my only joke, “when is it OK for a woman to fake an orgasm? When she knows that her partner is faking foreplay.” This is another way of saying the man needs to make “being a good lover a priority” instead of assuming that he is satisfying his partner. Clinically, I have learned after working in the field of male and female sexual function and dysfunction for more than twenty years, that “men turn on with their eyes, and women turn on with their ears”….women need to feel “heard” to feel safe, valued, desired, and vulnerable for physical intimacy.

                        c. Intimacy-This is a difficult concept because there are many different (and equally correct) definitions of intimacy. For this discussion, I would suggest that it refers to the emotional and physical part of the relationship of two consenting adults that allows for each of them to feel vulnerable and still safe with each other. Wikipedia defines “an intimate relationship as an interpersonal relationship that involves physical or emotional intimacy. Physical intimacy is characterized by romantic or passionate attachment or sexual activity. While the term intimate relationship commonly implies the inclusion of a sexual relationship, the term is also used as a euphemism for a relationship that is strictly sexual.” [5] Again, in this case, an additional component to “intimacy” would include the discussion about “trust” or the ability to be completely open, honest, true to yourself and with another. This implies that both parties can be loved and accepted as “who they are”, including for their humanness.  

                        d. Passion-Gender differences can be quite common for this term. Typically, men will describe some exotic, erotic encounter they had or fantasized about with a partner. However, when I ask women, they will frequently discuss some activity that involved planning, thoughtfulness, generosity by her partner, which allowed her to feel completely safe, vulnerable, and desired by her partner. Again, Wikipedia defines it as “a very strong feeling about a person or thing….an intense emotion, compelling enthusiasm or desire for anything.” [6]

                        e. Emotions-Most psychology textbooks describe emotions as a non-physical response, usually relating to feelings, perceptions, motivations, intentions, etc. However, for this discussion, we will simplify the definition to include thoughts, feelings, emotions, intentions, etc that have an impact on the physiological sexual response with a partner. Another definition of emotion is from Wikipedia as it refers to the “…subjective, conscious experience characterized primarily by psychophysiological expression, biological reactions, and mental states.” [7] A study performed in 2003 showed a correlation between negative emotional state and negative sexual response, not necessarily sexual interest [8]. Additionally, this could include the potential for people to express their feelings and fears and their impact on physical responses (or lack thereof). 

                        f. Vulnerability-This concept is truly foreign to most men because their hard wiring implies that they should be “the protector, provider type”, which is counter to vulnerable. Hence, many men have learned to “man up” regardless of their true feelings. Never is this more significant than with the aging male body and sexuality. Again, it is counter for a man to be ready for battle and be vulnerable. This may be another reason many men report they are able to “compartmentalize” so well. However, because of the evolutionary psychology, it appears that men really are more “wired to be the protector” and hence, if they lose this potential to be the “protector, provider” some fear they might lose their manhood also. The best analogy is when we think of “two bucks in the meadow” dueling it out for territorial rights. The “alpha male” rules, and the loser goes away with his head down (or dead or a limp erection). This theory will be discussed more in a latter part of this chapter.

                        g. Mindfulness-This is a newer theory in mental health relating to the concept of awareness, attention, and remembering, acceptance without judgment, and being present. [9] In order for people to practice mindfulness, there is typically a daily meditation practice. However, many people can practice mindfulness by simply slowing down their lives and getting out of auto-pilot, tuning into the present moment, and focusing on their breathing. [10] This is never more significant than in the sexual relationship because the body was wired to respond most effectively with all systems (neurological and vascular) being more relaxed in order to respond the way they were intended with physical intimacy. 

 

B. EMOTIONS AND INTIMACY

 

            1. Men and Feelings? (NOT)-It is an unfair characterization to assume that “all men do not have the capacity to express their feelings or emotions.” There are outliers in every group or situation. The reality is that because of the evolutionary wiring for most men, it is extremely difficult for them to express their feelings or emotions. One patient seen many years ago said, “I can’t tell a woman how I really feel because she’ll use it against me at some time in the future.” My response to him (and others) is to make peace with the information in that vulnerable situation so that “if she needs to use it against you (and you have already made peace with whatever information, pain, shame, vulnerability there may be), it is really more about the woman than the vulnerability in the information”. Remember that if she needs to use it against you, she is reaching for ways to empower herself by putting you down. This is not a healthy situation for either of you to be involved with, so best to get to a good mental health clinician quickly.  One of the primary goals of mental health is to empower all people to make peace with their family history, their physiological assets and deficits, to accept their being, and to learn to be “present” with every situation. It shows up most significantly in physical intimacy, especially with the aging male body. Two people deciding to take their clothes off and be intimate is one of the most intimate, vulnerable acts two people can do. Many times in youth, people just respond with hormones. However, as people age, the physiology also changes and is typically more responsive to the emotional part of the body. Hence, the  impact of a strong mind-body connection on physical intimacy increases with the aging body.    

            Never was this hypothesis more obvious than with my doctoral dissertation study. I had approximately 60 couples in the study at Stanford Medical Center in the Department of Urology. My goal was to determine if we could find a brief and effective treatment method for men (and their partners) presenting with psychogenic erectile dysfunction (PED)-meaning more psychologically based than medically or organically based source of erectile dysfunction (ED). This was when Viagra first appeared after FDA approval in America. I found that 40% of my participants had tried and failed on Viagra before enrolling in the study. [13] When I told them that Viagra was part of the equation, they were all ears. The answer was not as difficult as it sounded when people take the time to reflect on the mind-body connection to physical intimacy. I hypothesized that as men age there was a change in the mechanism of arousal as evidenced by the Massachusetts Male Aging Study (MMAS), which showed that 52% of men from 40 to 70 years old presented with some version of MSD [11]. This statistic was replicated in the men presenting to the clinic for my study. [13] The average age of my participants was 55 years old (the same as the MMAS [11,13] and the Viagra statistics [12]).  By the end of the research study, we had approximately 70% who no longer needed Viagra to help with their erectile function and sexual satisfaction of the man and his partner [13]. This success was due largely to the research protocol utilizing brief cognitive-behavior sex therapy with the couple working together to improve their emotional and physical intimacy. Again, the mind and body are connected! We also demonstrated this concept with post-doctoral research at Stanford Medical Center, utilizing functional magnetic resonance imaging (fMRI) and sexual arousal for young men and women [14, 15]. Ultimately, it would be beneficial to evaluate the aging male and female brain in the areas of brain activation (fMRI) with sexual arousal. However, those studies will have to wait until funding is available for such endeavors.

            Conceptually, it makes sense that men would have difficulty with erectile function if and when they begin to age (typically 40+) if a change in the mechanism of arousal in the brain happens spontaneously, that no one has talked about because it hasn’t been defined to date. Many men assume they will “function the same as ever”, their sexual function will be the same for the remainder of their life (they will use the same cues, methods, etc). However, since we know that erectile function is a by-product of sexual arousal [2,3], it makes sense they would need to modify their arousal, at the very least, in order for it to remain “arousing”. The old saying: “eating meat and potatoes everyday for 20 years isn’t arousing”….the same is true for physical intimacy, it needs to remain arousing for both men and women. It is just more obvious for men because their penis will not respond without sufficient arousal. I had a couple in my clinical practice many years ago who thought they would “really break out of their physical intimacy rut”. They took my advice and made love on the floor in front of the fireplace. The husband was so proud of himself for “changing it up” until his wife poked him and reminded him “it was arousing the first day and NOT after doing the same thing daily for a week.” The take away message is that “we are all human….the sooner we can accept that, the easier our life and our physical intimacy will be…we have to give ourselves permission to mix it up…. stretch out of our comfort zone.”

            2. Evolutionary psychology and Real Men-Since all humans have some “hard wiring” behaviors, it is important to remain mindful of these hard-wired gender and cultural differences. One of these hard-wired behaviors is for men to be “the protector, provider guy” in the traditional heterosexual relationship as discussed in the definitions of vulnerbility [16,17]. In the twenty-first century, it is important to remain aware that while some of the human behaviors of the past may be “hard-wired”, we have come a long way from were the cavemen were centuries ago. Hence, it is important for REAL MEN to give themselves permission not to be so hard on themselves if they are not responding the way they “think they should in a given situation”. Zilbergeld, referred to this as “trying to will an erection” in his books on male sexuality. [18,19,20] In other words, for men to think they can obtain an erection, even with Viagra or any of the PDE-5 inhibitor medications, may be too large of an expectation. It may be more beneficial for men to become aware of their own body, the impact of aging on their changing bodily functions, and their emotional state in order for them to remain truly relaxed, aroused, and ready for intimacy, including erections. 

            3. Vulnerability = Power? REALLY? This is a concept, which I have shared with patients in my clinical practice for many years. Frequently, it is a theory that most people scratch their heads because it sounds like an oxymoron. However, when we understand the mind-body connection and physical intimacy, it makes more sense. Basically, it is implying that in order for people to truly be “powerful” they must accept their own humanness, which includes their own vulnerabilities. I encourage patients to “make peace with the past…it’s just information”. None of us got to choose our genetics (family history, biochemical part of our being), nor did we get to choose the family we were born into and the resulting experiences (pleasant or not), so we need to let go of the pain, shame, embarrassment, power that history has on our lives, in order to move on and expand to reach our potential.

When we look at some of the great world leaders like the Dali Lama, Ticht Naht Hahn, Ghandi, and Martin Luther King, Jr. we see one of the things they all have in common is the acceptance of their “human vulnerabilities”. Hence, they were able to be very compassionate, kind, self-respecting, non-violent, and yet exceedingly powerful. This concept is critically important in physical intimacy because the mind and body were wired to respond sexually when the neurological and vascular systems are fully relaxed [21]. This may sound counter-intuitive because we talk about excitement as part of arousal, so there is a difference between emotional and physical excitement as part of the Sexual Response Cycle (SRC) [22] versus the ability to remain relaxed and confident during physical intimacy, which will ultimately allow the physiology to respond the way it was wired [21]. 

            4. Emotional state and sexual arousal-It is critically important for men to remember that “men turn on with their eyes, and women turn on with their ears”. Hence, women need to “feel heard” in order to feel safe, vulnerable enough to be sexually aroused by men for physical intimacy [23]. One study [24] showed that there is a positive correlation between men’s sexual function and psychoaffective state and the reverse was true. However, there did not seem to be a correlation between sexual desire and sexual intimacy and psychoaffective state [24]. This also changes for men with the aging process, and will be discussed more in another section of this chapter. For men to get in touch with their “feminine side” is not a bad thing as they reach the tender years of 40+. And, for some men much younger than 40+, this is still critically important. It has nothing to do with gender identity, it has much more to do with the awareness of who we are at our core…to get in touch with our true self, who we WANT to be. Many people go through their entire life without ever asking the question about “who am I?”…”who was I meant to be?”…”why am I here?” These are all questions that will arise as we pass the half-way mark of our life, also known as the “mid-life crisis”. This is more about the true meaning of life. This is really about coming to terms with the deep meaning for life on earth. I challenge you to hold up the mirror one day and explore “who you really are?” “who you really want to be?” “who you were really meant to be?” These are all questions that might take some time to contemplate if you are brave enough to do the work. It is amazing, that many people will say, “they have been in therapy for__ years, why am I not doing better?” I remind them that life is like a ladder, we may be in emotional pain at one time and motivated to do some work, then we will coast for some time, and life will give us another opportunity to learn, grow, and change. I hope that as humans we embrace this opportunity to learn, grow, and change and never quit enjoying and embracing these opportunities. This is because as long as we are experiencing opportunities to learn, grow, and change, we are alive, and, without these opportunities to learn, grow, and change, we are emotionally dead! Hence, the longer we can see life as offering opportunities to learn, grow, change, we will continue to be alive and have more opportunities for good sexual function and physical intimacy. My professional goal is to help people keep sexually active until they take their last breath!

            5. Gender Differences in sexual arousal. Much has been written over the past twenty-plus years about gender differences in many aspects of life. In fact, a colleague wrote a couple of books on gender differences in the brain. [25, 26] These books covered many phases of gender differences. For the purposes of this chapter, the most obvious is in the area of sexual arousal and response. This also relates to the gender differences in communication, which is a topic that has received a great deal of attention over the last several years. [27] Basically, the take away message about gender differences in the context of sexual arousal and response would relate to the fact that men are born with much more testosterone than women in the first place. [28] Testosterone is the hormone that both men and women have to fuel the sexual libido. It is not directly related to sexual function. We call it the background music in sexual response. However, with the aging body, it becomes more significant in sexual response for men and women. Another aspect of gender differences in sexual arousal and response relates to the mechanics of sexual arousal. I believe, as one of my patients told me and I haven’t found a couple to disagree to date, “men turn on with their eyes, and women turn on with their ears.” To some extent, this was shown with the initial fMRI and sexual arousal studies at Stanford, especially on the younger men and women [14,15]. In fact, another hypothesis to be proven some day would even say that as men age, this is most critical aspect of male sexual arousal and for women they could even go the other way, they could come to the place of wanting sex for the sake of sex not for emotional intimacy. I have had many women say they “don’t get much out of sex except for the connection with their partner because they know he enjoys it”. This means that men may turn on more with their emotions as they age and women may turn on less with their emotions as they age. I had a couple many years ago, who were both in their early 60’s. The husband said he “wanted his wife to be soft and gentle” and the wife said, “I just want a good orgasm and a hard F….if it’s the last thing I do before I die”, so much for romance!  

           

C. MALE SEXUALITY

            1. Man and his penis (alter-ego). My mentor, Bernie Zilbergeld, PhD wrote many books [18,19,20] on male sexuality, and he was known for referring to the man’s penis as his alter ego. One of the chapters in many of his books was, “Two feet long, hard as steel, and goes all night” [18,19,20]. This could be called the “fantasy version of male sexuality.” Never is the male attachment to his penis more obvious than when we have patients who are considering using injection therapy to assist with their erectile function [29]. I frequently hear them say, “you want me to put that needle where?” It is not infrequent that I hear couples refer to the man’s penis by a pet name, ie. “Willie”, “George”,  “Big One”, “Long John”, etc. While this may seem sweet and innocent, it is also telling of the man’s or the couple’s attachment to the male membrum (penis). Since the beginning of time, man has had an attachment to his penis because of the correlation of his manhood and his sexual response [30]. As early as 1900 BC. the Kahun Papyrus refer to the male penis as significant in the definition of male sexuality [30].

            2. Men, Sex, and Aging-FINALLY, the section of the chapter long referred to in earlier sections of this chapter. After working in the field of male sexuality for over twenty years, it became more than obvious to me, there is a potential for a change in male sexual function and dysfunction with the aging process; hence, the earlier hypotheses about the change in sexual arousal in the brain with the aging process. The potential for lowered testosterone levels (for men and women) with the aging process [25,26] has been part of the literature for many years, however, it has not been shown there is an actual difference in the mechanics of sexual arousal in the male (or female) brain with the aging process. As stated previously, the hypothesis here is that “men become more emotionally aroused with the aging process and women become less emotionally aroused with the aging process”. If this were true, there would be more activation in the prefrontal cortex of the male brain with sexual arousal, similar to the younger female brain with sexual arousal [15]. Assuming this was true, it would certainly explain why there is a high incidence of erectile dysfunction (ED) with the aging process [11,12]. As stated previously, if men are trying to use the same old arousal cues and they are not having the same arousal response, it only makes sense to try something different. However, most people are not easily motivated for “change”. This is a topic that raises huge resistance for many people, let alone men. This underscores the need for flexibility with ourselves…our relationships…and our intimacy! In the meantime, men have become accustomed to relying on one of the newer oral medications for inhibition of the PDE5 agents in the male sexual arousal [31]. In the last book by Zilbergeld [32], he researched the physical intimacy of 145 couples between the ages of 45 and 87. The conclusion was that as people age, they may have had different physical intimacy, and for the most part it was much more satisfying and meaningful than in their youth [32]. This supports the hypothesis that we need to mix it up to keep it arousing, especially as we age! Additionally, another study by Heiman et al [33] showed that as couples reach their middle years, men were more focused on physical intimacy and relationship happiness. 

Another aspect of male sexuality with aging, typically has more to do with his female partner in traditional heterosexual couples. This is referring to the typical onset of vaginal atrophy with menopause that many women experience, which causes them to have more sexual intercourse discomfort and decreased desire for physical intimacy [34]. These changes are certainly able to be treated in any clinic, they just require the patient, clinician, and partner to want to “fix” the problem.

            3. Men and Intimacy (GOTCHA!) In one study from a South American group [35], they found that both men and women preferred the emotional intimacy as the main predictor of sexual satisfaction, and that more research needs to be done in the area of physical intimacy. The take-away message from this discussion is about the opportunity for men, especially with the aging process, to become more aware of the potential for their physical intimacy to change. Hence, the need to be kind and gentle on themselves as well as with their partner, unlike the “Fifty Shades of Grey” version of “lovemaking.” [36] Additionally, it is important for men to be easy on themselves and become their own cheerleaders--to focus on the positive, instead of the negative. This whole mindset is counter to their hard-wiring because they are wired to be the “warrior, protector, provider” and be ready for danger at any opportunity. Instead, we are asking them in the context of physical intimacy, to be gentle and allow themselves to accept their “humanness”, to be mindful, to be empowered enough to be vulnerable. This may seem like a whole new paradigm of male sexual response. Unlike the days of old, where men just “got or willed an erection”, it is really suggesting that men can stretch out of their comfort zone and consider a new way of thinking and being physically intimate with a partner. Remember, we want to keep people sexually active and satisfied until they take their last breath! 

 

 

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© Linda Banner 2012