Polonsky recognizes that today, practitioners are realizing that sex does not end with youth, but can extend pleasurably into old age. Aging, though, takes a toll; arousal takes longer and requires-particularly for men-more direct tactile stimulation. A couple who is unaware of this might become concerned about what has happened to their formerly good sex life, so education is needed.
Polonsky points out that clinicians have also learned exactly how the penis works: In order to have an erection, a man needs an intact vascular system, an intact nervous system and an intact hormonal system. Erectile difficulties affect 10% of American men, but that's overall; in the age group 40 to 70, organic and medication-related dysfunction become increasingly common, affecting as many as 50% to 60%, said Polonsky. With 38 million baby boomers now falling into this category, the rush is on for new medical treatments.
The National Institutes of Health estimates the number of impotent men in the United States at 30 million. According to Time magazine (May 4), when Viagra hit the market in April of this year, 36,809 prescriptions were issued during the first two weeks alone.
But Viagra shouldn't be used to circumvent dealing with relationship problems, warned Polonsky. Having "a perfect penis" may not be the whole answer, nor is vaginal intercourse the only means for satisfaction. Genitals are not mechanical devices that should be programmed like VCRs, he said; they are connected to human beings. "In this culture, we are so focused on what I call the mechanical model of sex. We need to broaden the repertoire and broaden the range," Polonsky said. "We also need to combine what is not working right with the physiology and what may not be working right in the balance of the relationship."
According to Polonsky, about 25% of men experience premature ejaculation, and for this a behavioral approach usually is effective. If not, some of the antidepressants that delay ejaculation-an otherwise unwelcome side effect-often help. Polonsky, however, has mixed feelings about using a medication in its full therapeutic dosage to gain access to its side effect.
Only in the past decade has the issue of diminished desire come to the forefront. Affecting 30% to 50% of couples, it is the problem Polonsky most frequently sees. It is more than just a matter of the early passion wearing off, he said. Often there is a mix of issues regarding intimacy, vulnerability, depression, significant physical changes or early sexual abuse.
"The therapy is often slow and complicated, and at times confounding," he said. Contrary to what the media would have people believe, treatment is slow and, in many cases, improvement is negligible.
The awareness of childhood sexual abuse and its aftermath is a new issue for women. "When I look back on some of the people I saw years ago," Polonsky said, "in retrospect, I think I probably missed the diagnosis where there were issues of sexual aversion or low sexual desire. I think that I just didn't understand, and most of us didn't back then, about the incidence of childhood sexual abuse and its repercussions. We now know that if there is a history of alcoholism, the incidence of childhood sexual abuse is something like 60% in the family."
Prescribing low doses of testosterone for women could become another new trend, according to Polonsky, because some physicians maintain that it can have a beneficial impact upon the diminished sexual desire that some women experience after menopause. He, however, is uncomfortable about "mess[ing] with a variety of hormones."
Polonsky notes that women have been taking increasing control over their own sexuality, a trend that began in the 1960s when sex came out into the open. At first, it became acceptable simply to be receptive to male overtures. Now, he avers, women are feeling sexual in their own right and free to make the advances. Not all men are comfortable with this, however, which can create conflicts in relationships.
With so much new knowledge, so many medical specialties now involved in sexuality, and more products appearing on the market every day, sexual problems are not as hopeless as they once seemed, Polonsky pointed out. Those associated with aging may be the easiest to treat.
"What the early sexual relationship was like often can predict the outcome of therapy," said Polonsky. "If it was playful and a source of joy, then it absolutely will continue with the use of some of these adjunctive therapies."