Let’s talk about sex, bay…. Good reader.

Historically considered taboo, the subject of sex, sexual function, sexual gratification and all things in between was largely examined through a male, heterosexual lens. The reality of sexual identity, function and experience is much more complex and multifactorial and has direct impacts on the phases of the sexual response we develop after puberty. There are a number of models that describe the sexual response in linear, cyclic and mixed phases. Generally structured as a desire, arousal, orgasm, and resolution¹.

Beyond the physiologic responses to arousals, sexual and gender identity (ie. male, female, intersex or non-binary) as well as sexual orientation (hetero, homo, a, or pan- sexual) inform the basic considerations for “sexual health.”² Layer on top of this the complex social and cultural frameworks that guide our relationship with sex. The importance of creating a healthy understanding of these complexities and factors is underpinned by the fact that sexual health is a vital piece of overall health and wellbeing.^1,2

With so many considerations it begs the question was does a “good” sex life even mean? In the simplest terms a healthy sex life would ensure an individual has an uninterrupted sexual response, is subjectively satisfied according to their sexual desire, is able to mitigate risks, can engage in ongoing consensual, mutually pleasurable, and safe sexual activity. ‘

Disorders or dysfunctional sexual responses fall into a number of categories such as sexual dysfunctions (including low sexual desire, difficulty orgasming, premature ejaculation, dyspareunia, erectile dysfunction); paraphilias (abnormally intense and persistent and often sexually compulsive disorders, affective, addictive, and impulsive) and gender dysphoria (incongruence with assigned gender.²)

For the purposes of this article, we will primarily focus on common sexual dysfunctions which can occur as the result of a primary functional disorder or more commonly secondary to other disorders. Thus, it is important to address the underlying cause of the dysfunction.

1. Sexual literacy – honest open communications including accurately and appropriately identifying anatomy. Further, sexual literacy extends into self-awareness- exploring and defining what feels good for you. Thankfully growth in the sexual wellness space includes a number of digital apps, sex educators, and sexual health researchers. All of which enable access to inclusive, evidence-based tools and practices to expand your sexual understanding.^3,4 
2. Take care of your anatomy – whatever parts you have or are going to have ensure proper care through hygiene, preparation, screening, and minimizing risky behaviours.
   • Regarding hygiene generally there is very little we need to do other than a good wash, try to avoid harsh chemical washes (unless specifically prescribed), heavily scented products (your genitals DO NOT need to smell like a floral arrangement), or tight non-breathing undergarments.
   • Preparation can mean a number of things depending on the kind of sexual activity you are engaging in – from washing your hands and cutting your nails to lubricants and tools to prevent tearing or trauma. The importance of pelvic floor health, particularly in women with a uterus is often a significant factor to causing or worsening female sexual dysfunction. Pelvic organ prolapse, dyspareunia and coital incontinence were all correlated with significant reductions in sexual satisfaction and can often be managed through pelvic floor rehabilitation.⁵
   • STI screening and use of prophylactics or barriers is important to mitigate risks or cause complications.
3. Mental Health Matters – affective disorders⁶ such as depression, anxiety, bipolar disorder and PTSD⁷ to name a few, are strongly associated with sexual dysfunctions. Barata⁶ outlined many of these associations noting that it is difficult to detangle the complex relationship between affective disorders and sexual dysfunction and paraphilias. Further complicated by the fact that many treatments and medications for such disorders may induce or exacerbate sexual dysfunctions.
4. Stress and Endocrine disorders: it’s no coincidence that stressful situations tend to shut down our sexual interest. One of the prime culprits of a dysfunction is stress. The adrenal gland produces both cortisol and many sex hormones. With chronic stress we deplete our ability to maintain the complex feedback systems that govern hormonal output. Further our sex hormones- estrogen, progesterone, androgens such as testosterone and DHEA all fluctuate.⁸ Thyroid disorders, ovarian, pituitary, and metabolic disorders can all have profound impacts on sexual health in both males and females.^8,9 Elevations in testosterone may increase sex drive, while rapid depletions in estrogen as we see during menopause can cause vaginal dryness making intercourse painful.  So be sure to address any hormone disorders and develop stress management tools.
5. Look through your medicine cabinet: As mentioned above a number of pharmaceutical and nutraceutical treatments may have side effects of impaired sexual function¹⁰. It is important to speak with your prescribing doctor to understand your options and assess any risks. (*** Please note that does NOT mean you need to come off of necessary medications, however it is an important consideration to inform your healthcare practitioner of.)

In some cases, supplementation may be appropriate to help resolve some of the underlying causes of the sexual dysfunction. Sex hormone production requires dietary fats as well as sufficient vitamin D levels (which is also needed for adequate erectile function^.11,12) In individuals with difficulty having and maintaining erections consider options that improve blood flow (similar to the mechanism of action of popular ED drugs like Viagra.) Nutrients that have been shown to improve peripheral blood flow include L-arginine¹³ which increases nitric oxide production.

Another interesting area of research is re-examining some botanical medicines that were traditionally used as sexual tonics for therapeutic potential. For example, Tribulus terrestris is being evaluated for use in hypoactive sexual desire disorder in postmenopausal women, by increasing in the serum levels of free and bioavailable testosterone¹⁴.

Adaptogens are an interesting action by certain plants that enable them to regulate hormone function- calming or stimulating depending on the current state. Some of these botanical adaptogens include: Maca root, yohimbe, ashwagandha, licorice and more.¹⁵

 References:

1. Calabrò RS, Cacciola A, Bruschetta D, Milardi D, Quattrini F, Sciarrone F, la Rosa G, Bramanti P, Anastasi G. Neuroanatomy and function of human sexual behavior: A neglected or unknown issue? Brain Behav. 2019 Dec;9(12):e01389. doi: 10.1002/brb3.1389. Epub 2019 Sep 30. PMID: 31568703; PMCID: PMC6908863.
2. APA LGBT Resources and Publications – General Audience Resources – Definitions of Terms in APA Documents Related to Sexual Orientation and Gender Diversity. http://www.apa.org/pi/lgbt/resources/index.aspx. Updated: December 31, 2014. 
3. Koepsel, E. R. The Power in Pleasure: Practical Implementation of Pleasure in Sex Education Classrooms. American Journal of Sexuality Education, 11(3), 205–265(2016). https://doi.org/10.1080/15546128.2016.1209451
4. Ferly: https://weareferly.com/
5. Verbeek M, Hayward L. Pelvic Floor Dysfunction And Its Effect On Quality Of Sexual Life. Sex Med Rev. 2019 Oct;7(4):559-564. doi: 10.1016/j.sxmr.2019.05.007. Epub 2019 Jul 24. PMID: 31351916.
6. Barata BC. Affective disorders and sexual function: from neuroscience to clinic. Curr Opin Psychiatry. 2017 Nov;30(6):396-401. doi: 10.1097/YCO.0000000000000362. PMID: 28806269.
7. Yehuda R, Lehrner A, Rosenbaum TY. PTSD and Sexual Dysfunction in Men and Women. J Sex Med. 2015 May;12(5):1107-19. doi: 10.1111/jsm.12856. Epub 2015 Apr 6. PMID: 25847589.
8. Carosa E, Sansone A, Jannini EA. MANAGEMENT OF ENDOCRINE DISEASE: Female sexual dysfunction for the endocrinologist. Eur J Endocrinol. 2020 Jun;182(6):R101. doi: 10.1530/EJE-19-0903. PMID: 32234976.
9. Brotto L, Atallah S, Johnson-Agbakwu C, Rosenbaum T, Abdo C, Byers ES, Graham C, Nobre P, Wylie K. Psychological and Interpersonal Dimensions of Sexual Function and Dysfunction. J Sex Med. 2016 Apr;13(4):538-71. doi: 10.1016/j.jsxm.2016.01.019. Epub 2016 Mar 25. PMID: 27045257.
10. Bala A, Nguyen HMT, Hellstrom WJG. Post-SSRI Sexual Dysfunction: A Literature Review. Sex Med Rev. 2018 Jan;6(1):29-34. doi: 10.1016/j.sxmr.2017.07.002. Epub 2017 Aug 1. PMID: 28778697.
11. Canguven O, Al Malki AH. Vitamin D and Male Erectile Function: An Updated Review. World J Mens Health. 2021 Jan;39(1):31-37. doi: 10.5534/wjmh.190151. Epub 2020 Jan 16. PMID: 32009309; PMCID: PMC7752519.
12. Silva T, Jesus M, Cagigal C, Silva C. Food with Influence in the Sexual and Reproductive Health. Curr Pharm Biotechnol. 2019;20(2):114-122. doi: 10.2174/1389201019666180925140400. PMID: 30255750.
13. Rhim HC, Kim MS, Park YJ, Choi WS, Park HK, Kim HG, Kim A, Paick SH. The Potential Role of Arginine Supplements on Erectile Dysfunction: A Systemic Review and Meta-Analysis. J Sex Med. 2019 Feb;16(2):223-234. doi: 10.1016/j.jsxm.2018.12.002. Erratum in: J Sex Med. 2020 Mar;17(3):560. PMID: 30770070.
14. de Souza KZ, Vale FB, Geber S. Efficacy of Tribulus terrestris for the treatment of hypoactive sexual desire disorder in postmenopausal women: a randomized, double-blinded, placebo-controlled trial. Menopause. 2016 Nov;23(11):1252-1256. doi: 10.1097/GME.0000000000000766. PMID: 27760089.
15. Malviya N, Malviya S, Jain S, Vyas S. A review of the potential of medicinal plants in the management and treatment of male sexual dysfunction. Andrologia. 2016 Oct;48(8):880-93. doi: 10.1111/and.12677. PMID: 27681645.