(Photographer Joe Oppedisano captures raw masculinity that fuels the imagination and the libido in his photo book “Testosterone.”)

There are four major “domains” of male sexual function:

• Sex drive
• Erectile functioning
• Ejaculatory functioning
• General sexual satisfaction

 In my research, the most common area of concern was erectile functioning.  Diminished sexual drive and general sexual satisfaction were of some concern, and ejaculatory functioning was of very little concern among the mature men who have sex with other men that I surveyed.  Perhaps the most interesting find in my research of mature men who have sex with men was that although sexual function declines with age, older men did not experience a decline in their sexual satisfaction.

Preoccupation with erectile functioning has not gone unnoticed by the health products industry. “Viagra” was a drug marketer’s dream.  Following its introduction, the brand name, “Viagra,” like “Tylenol” and “Prozac” were words taken immediately into our vocabulary. 

With its promise to men to be able to have sex any where, any time and with anyone, the use of Viagra exploded.  Clever marketing converted one of its major risks, priapism, to an apparent strength; men began to hope they might be the one to have an erection that lasted 3 hours and 59 minutes.

Erectile dysfunction(ED) affects over 52 million men.  Erectile difficulty happens occasionally to every man.  If a man fails to have an erection less than 20% of time, he does not have the clinical diagnosis of ED, but a man who fails to have one over 50% of the time, would definitely carry that diagnosis.

Erectile problems occur for a variety of reasons, including stress, fatigue, alcohol and conflict in relationships.  It also occurs more frequently with age as testosterone declines.  As one matures, sexual arousal is slower, generally requires greater stimulation, recovery time between sexual encounters is longer, and distractions like painful joints lead to erectile failure more frequently.  However, erectile failure should never be considered “normal.”

One of the major issues effecting sexual functioning is “performance anxiety.”  Men are socialized to believe that real men don’t fail at sex.  Once a man has struggled with achieving an erection, he often begins to become preoccupied with a fear of failure. This fear begins to displace the focus on pleasure, and further interferes with sexual functioning.

 Once that concern – Will I be able to get it up? – enters the mind, in most cases the struggle accelerates.  Some men, once the thought they might fail to maintain their erection, begin to try to increase the pace of the sexual encounter, the problem escalates even further.  Fear of failure often leads to avoidance of sex in a relationship.

To determine if declining testosterone levels are a factor in erectile functioning, a man should see his doctor for a physical exam, including a rectal for examination of the prostate.  In most cases, laboratory studies will be done that include:

• Testosterone level
• Thyroid function
• Luteinizing hormone (a pituitary hormone which tells the testes to produce more testosterone)
• PSA (for prostate cancer)

When testosterone is bound to protein in the blood, it has essentially no effect on the brain, so testing may include a test for the “bio-available” testosterone. 

In Part III, I will address what to do if testosterone levels are low.