Healthy Life

What is sex? What is our view?
“..how I view sexuality and sexual expression. In the past, sexuality was viewed as having one purpose, and that purpose was reproduction. Today it is seen as an important aspect of health; it enhances the quality of life, fosters personal growth and contributes to human fulfilment. When the term sexuality is viewed holistically, it refers to the totality of a being.

It refers to human qualities, not just to the genitals and their functions. It includes all the qualities--biological, psychological, emotional, cultural, social and spiritual---that make people who they are. And people have the capacity to express their sexuality in any of these areas, it doesn't have to be just through the genitals.”

Whipple B .  1999 Address to the World Conference on Sexology

BACKGROUND
Why have sex? Because its good for you physically, emotionally, spiritually and there is scientific proof. Having sex twice a week is the equivalent cardio vascular exercise of jogging 60 kilometres per year. Sex increases testosterone levels which makes us stronger and more confident. It also reduces prostrate problems, lowers stress and heart problems. For women sex increases testosterone levels, protecting the heart and lungs  and keeping vaginal tissues supple, reducing irregular periods and decreasing the pain and stress of PMS. Sex is also good for your mental health with a clear link between satisfaction with sex life and psychological tests (Conrad and Milburn 2000)

WHAT CAN BE DONE?
Even though people may want a good sex life – what do they actually do about getting it. Not much! After work, stress, and being tired 30% of people don’t have the energy to think about improving their sex life. This is very likely to be people making excuses of course.

Worst of all in 1998 some 50% of Americans said that “a good sex life is something you cant work at – it either happens of it doesn’t” (p51). This is the myth of helplessness (Conrad and Milburn 2001)

Related to the poor attitude people have toward doing something about their sex life is why are having sex anyway and for what reasons? For the sexually intelligent there are a variety of reasons and the flexible approach is a more adaptable, realistic and fun and therefore smarter than a rigid approach. Sexually intelligent people have sex for different reasons at different times with the same person - lust, love, emotional, attracted and aroused etc. They also understand that its not what you do in bed that matters its what it means (Conrad and Milburn 2001)

HISTORY
Yet another sexual revolution is upon us. This time it is the chemical revolution. Pills, patches, pellets, injections and creams are being developed for all aspects of male and female sexual behaviour.

This revolution didn’t start with Viagra, although it has enjoyed a phenomenal success, but with a more important discovery. That is, the discovery of the nitric oxide pathway. This is a fundamental biological mechanism where cells communicate, surprisingly, by releasing, a gas, nitric oxide and received the Nobel prize in 1999. While Viagra was accidentally discovered earlier and released in1998 now we knew why it worked. The nitric oxide pathway regulates brain function, blood flow, and can be used to treat cancer, shock and  lung disease. Sexually, the nitric oxide pathway is one of the major links between our brains and our genitals as it increases blood flow and consequently arousal and orgasm.

Much media attention was made of the prevalence of sexual dysfunction in America as 43% of women and 33% of men (representing millions of people) report have a sex problem. 75% of participants in the sex IQ survey reported that sex is more than moderately important to them but less than 25% claimed to have a satisfying sex life (Conrad and Milburn 2001)

  Sexual dysfunction for women decreases with age and increases with age for men.

 The Journal of the American Medical Association recently published a report on a representative sample of approximately 1,500 women in the United States that revealed that approximately 64% of all women in a relationship at some point experience arousal or orgasmic dysfunction. The preponderance of those reporting such dysfunctions were fairly evenly distributed among women ranging from 18 to 59 years of age. 

The numbers worldwide are huge – 152 million men experience erectile dysfunction and with ageing populations this will increase to 322 million in the next 25 years. Erectile dysfunction increases from 12 cases per man years in the 40 to 49 year olds four fold to 46 cases in the 60 –69 year olds. The results are consistent across cultures and so is the low numbers seeking help (11%) (McKinlay 2000)

While data on the prevalence of sexual problems has been notoriously difficult to ascertain with different definitions, clinical samples, lack of controls etc  Spector and Carey have reviewed   studies and presented the following.

Laumann (1999) designed a national probability that is 97% representative of the American population and found overall the total prevalence of sexual dysfunction was higher for women than men (43% v 31%).

Women who have little interest in sex do so because they have arousal and desire problems –men don’t. That is, if a man isn’t having sex regularly its probably due to lack of opportunity whereas for women its due to a problem. Some 36% have arousal and desire problems which cause a circular effect where arousal and desire are the chicken and egg conundrum.

The effects for women on their quality of life are great with significantly more unhappiness,  and less physical and emotional wellbeing. Typically, only 10% of men and 20% of women sought medical help for their sexual problems.

Research reveals:

• The majority of couples are not satisfied with their sex life Seven years into marriage, three-quarters of couples say they are dissatisfied with their sex lives and might consider straying. 1 
• Partners seldom discuss their sexual desires According to one survey, only 41 percent of women said they have discussed their sex life with their partners or told them what turns them on. 2  So buying a sex product or video. for example has been scientifically proven to improve a couples sex life.
• 48 percent of women report difficulties in becoming aroused In a study published in the New England Journal of Medicine, 48 percent of women reported that they sometimes had difficulty becoming aroused; 46 percent reported intermittent difficulties in reaching orgasm; and 15 percent were completely unable to have an orgasm. 3  Dream Cream has a potential benefit to over 90% of women at some time in their sex lives!
• Couples don't know how to communicate about sex. Sexuality research studies conducted by leading universities across the country consistently confirm that sex is one of the most difficult topics for couples to discuss. Dr Brian Hickman at the Dream Cream web site can help improve your sexual communication skills as he has taught many couples and even used to professionally teach parents and their children how to communicate about the facts of life, periods, wet dreams etc.
• Couples who watch sexually explicit videos enjoy a more satisfying sex life. Eighty-four percent of women and 82 percent of men reported experiencing positive changes in their sexual relationships after viewing the Better Sex Video Series. 4 
• Videos can help couples learn to communicate more effectively. Therapists find videos to be a valuable communications tool, especially when dealing with difficult-to-discuss topics. One study reported that more than 90 percent of the couples who watched sexually explicit videotapes said viewing the tapes sparked communication about the issues and behaviours on the tapes. 5 

Sources:

1. Source: Kosher Sex, A Recipe for Passion and Intimacy by Shmuel Boteach 
2. Source: Marriage and Family Therapy Center, Northeast Louisiana University
3. Source: New England Journal of Medicine, 1978
4. Source: Marriage and Family Therapy Center, Northeast Louisiana University
5. Source: Marriage and Family Therapy Center, Northeast Louisiana University

Sexual Dysfunction in the United States

The myth perpetuated in popular media that everyone is having great sex is false according to a recent study reported in the Journal of the American Medical Association. Researchers from the University of Chicago asked nearly 3,000 men and women across the United States whether, in the past year, if they had gone through several months in which they:

• lacked interest in sex,
• couldn't come to an orgasm,
• climaxed too quickly
• felt pain during intercourse
• didn't find sex pleasurable
• had trouble getting aroused
• worried about their performance

The study revealed that 43 percent of women and 31 percent of men said they persistently experienced one or more of the above problems with sex.

Among other findings from the study:

• Between 22 and 28 percent of women in different age categories said they're unable to achieve orgasm during sex
• Thirty-two percent of women 18 to 30 years old said they lacked interest in sex
• The percentage of men who have trouble maintaining or achieving an erection was 7 percent among those age 18 to 20, 9 percent among those in their 30s, 11 percent among those in their 40s and 18 percent of those aged 50 to 59
• The percentage of women who have trouble becoming aroused was 18 to 19 percent among women age 18 to 39, compared with 21 percent of women in their 40s and 27 percent of women in their 50s

The study appeared in the February 10.,1999 edition of the Journal of the American Medical Association, Vol. 281, No. 6.

General Sexuality Research Trends

Frequency of Sex
A survey by Durex, a leading research firm, found the frequency of sexual interaction varies significantly from country to country. The global average for frequency of sex is 109 times per year (2.1 times per week, or once every 3.3 days). The following summary shows how individual nations compare to the national average of frequency of sexual interaction per year.

People from Thailand had the lowest average sexual frequency at 64 times per year, half the frequency of Americans.

Source: 1997 Durex Global Sex Survey

Impact of Age on Sexual Frequency 

The same study by Durex identified the most sexually active age ranges. The study concluded that people aged 20-39 make love most frequently followed by people over the age of 40 and finally, those under 20.

Source: 1997 Durex Global Sex Survey

Gender Differences in Sexual Frequency 

Durex also studied gender differences between different age groups. The study found that women are more sexually active in their teenage years than male counterparts. However, when they reach 40, men are more sexually active compared to women the same age. The greatest change of sexual frequency for males occurs during the teen years when their sexual frequency peaks. Women on the other hand, experience their most dramatic change in sexual frequency over age 40.

Source: 1997 Durex Global Sex Survey

Frequency of Sex by Relationship Status 

The status of a relationship has a major impact on the frequency of sex. Couples who are cohabiting, but not married, are the most sexually active. They make love 146 times a year compared to single people, who are not in a steady relationship and who have sex 69 times per year. Couples with children have sex more often (115 times a year) than people without children (103 times a year).

Source: 1997 Durex Global Sex Survey

Factors Most Important When Making Love

Globally, the most important factor in making love is satisfying one's partner. Thirty-four percent of respondents placed this as a top priority. Personal satisfaction ranked second (27%), followed by not catching HIV/AIDS (18%), avoiding unwanted pregnancy (16%), and avoiding sexually transmitted diseases other than AIDS (5%).

Source: 1997 Durex Global Sex Survey

Dream Cream may well be able to satisfy your partner, and that is the top priority.

Dream Cream can get things started. 

Sexual Priorities and Nationality

Different nationalities varied in the factors they rated as most important when having sex. Americans were the most selfish lovers, with 61 percent rating personal satisfaction as a top priority, followed by Russians (42%).

Canadians are the world's most considerate lovers; 51 percent rank partner satisfaction as a top priority. Mexicans follow with 50 percent, with the British at 47 percent. Respondents from Hong Kong and Poland were least likely to rate partner satisfaction as their number one priority.

Source: 1997 Durex Global Sex Survey

Age of First Sex

Globally, the average age of first sexual intercourse is 17.6 years. Men have their first sexual experience at a younger age than women (17.3 versus 17.8 years). The trend toward having sex at a younger age is accelerating with each decade. Respondents over 40 reported their first sexual experience at an average age of 18.6 years, compared to an average age of 18 years for 30-39 year-olds.

Americans are the youngest to start having sex with an average of 16.2 years, followed by Britain (16.7), Brazil (16.9), France (17) and South Africa (17.1). People in Hong Kong (18.9 years) and Poland (18.7) wait the longest to have their first sexual experience.

Source: 1997 Durex Global Sex Survey

It's ironic, but years ago it used to be that women were frigid - that was the phrase used," Dr Green said. "Now impotence is in the air. Just take a look at all those ads for the men's sexual clinics. Guys are having a tough time getting it up."

It's her belief that it is the post-1960s sexually liberated woman, uninhibited about asking for exactly what she wants, who puts men on the spot.

"I mean, men used to say, 'Wouldn't it be wonderful to have the woman do this and that', but now, when it's happening, it's just not working. Men psychologically want to feel like the hunter, not the hunted."

Dr King said the old myths about sex - such as masturbation causes blindness, men are victims of their lust or that women don't enjoy sex - have simply been swapped with new ones.

According to Dr King, new myths include the belief everybody must want and enjoy sex, 24 hours a day, seven days a week. Another is that sex is an Olympian sport where everybody goes for gold on every occasion.

Well then, just how much is normal?

According to a recent global sex survey, the amount of sex you have can vary depending where you live. A survey of 18,000 people from 27 countries carried out by condom manufacturer Durex last year found Australians pretty close to average in the world ranking table. With an average 98 sessions a year (not quite twice a week), we are ahead of New Zealand's 86 times, but well below the US (132), Russia (122), France (121) and Britain (109). As the survey is based on self-reporting, maybe the most honest nation is simply Japan, whose subjects reported having sex just 37 times a year.

Young Australian adults usually have sex for the first time at age 17 and four months, while US teenagers start a year earlier - 16 and four months.

If you're aged between 25 and 34, you're more likely to be having sex than any other age group. They set the pace at an average 113 times a year, compared with 89 times for the 16 to 20-year-olds.

But calculating the average amount of sex for couples into weekly sessions of three times a week can be misleading, said Dr King, author of Good Loving, Great Sex (Random House, $18.60).

"People can get uptight about their sense of entitlement to sex," she said. "It's a bit like salaries - everyone thinks everyone else is getting more than they are."

Instead, it's more akin to what she calls a "binge/fast" sexual frequency. Rather than a set two or three times a week, couples go for a couple or several weeks without sex, because they are busy, stressed or barely have time alone together.

But when the conditions are right, they are much more likely to be sexually active and may have sex two or three days in a row. She also points out that sex frequency changes during the relationship and that couples shouldn't use the high amount of sex they enjoy at the start as a yardstick forever after.

But married couples still come out engaging in more sex than singles, with the global survey showing that unmarried couples living together have the most sex, 146 times a year, followed by married couples (98) and then singles (49).

The most common problem seen at the Australian Centre for Sexual Health is "desire discrepancy", where one partner seeks more sex than the other. Often when men say they want more sex, they are really saying they want more love and affection. "It's easier to ask for sex than emotional comfort," Dr King said. Yet the reverse tends to be true for women, so that "while men need sex to become intimate, women tend to need intimacy to desire sex".

Author and sex educator Jo-Anne Baker, who gives sex advice on the new Australian women's website called womenzone.com.au, said the internet had "really changed the dating game".

"In the past they would never have gone to a bar, but now they can make friends in the chat rooms or meet through the dating services," Ms Baker said.

Some other trends she has seen over the past decade include the creation of an entire new genre of "erotic videos" for women, which basically are like normal movies, with a lot of sex thrown in.

She also points to the fact that department stores now sell a range of very sexy lingerie, such as corsets, g-strings and so on, which were much more specialised 20 years ago. "Madonna really made that fetish stuff mainstream," she said.

Viagra for women has also been touted as the next big thing to happen as a sex trend, but Dr King has her doubts. Despite being involved in the international clinical trials of Viagra research for women, she's wary about the concept of "pharmacological help" for women.

"Women's sexuality is a lot more complicated than popping a pill," she said. "And no amount of medication can make up for an unhappy relationship, poor sexual technique or a tired, exhausted, stressed-out woman."

Generally, women don't need to "perform" as such during sex, according to Dr King. It's more a case of women wanting pleasure, sensation and feeling.

"A pill will not provide that," she said. "Viagra simply enhances the natural process of sexual arousal. There is no pill yet that will create sexual arousal. But there is one sure aphrodisiac - love."

The question about what constitutes ideal foreplay in the global sex survey highlights the difference between men and women. The top answer for men was oral sex. For women, the top choice was split equally between touching/feeling, kissing and a romantic dinner.

Another finding from the survey was that for women, the average number of men they'll have sex with over their lifetime is 4.6. This compares with a claimed 11.7 for men.

However, almost four in 10 married people have only ever had one partner, compared with 19pc of single people.

Communication about Sex in Long Term Relationships
A study by E. Sandra Byers, Ph.D., and Harry Heinlein, M.A., of the Department of Psychology at the University of New Brunswick concluded that men initiate sexual activity more frequently than women. The study surveyed 77 married and co-habitating individuals who had been romantically involved with their partners for an average of 8.7 years. During individual sessions, participants completed a number of questionnaires to measure sexual activity over a one-week period. At the end of the day, participants indicated: (1) whether sex had been initiated on that day, and if so, by whom; (2) if sex was initiated whether the non-initiator's first response was positive or negative; (3) if sex was not initiated by either partner, whether the partner had considered initiating sexual activity. The researchers developed a number of explanations to support their findings.

Finding #1

Men and women have a different interest in sex.

• More than twice as many women as men did not initiate sex during the one-week period.

• More men considered initiating sex on days when no sexual activity took place than did women.

• The reason why women did not initiate sexual activity was NOT because they were waiting for their husband to make the first move or fearing that their sexual advances would be rejected by their partner. Women simply considered initiating sex less often than men.

The women are not waiting or rejecting but just don’t think about it as often – no wonder when 40% aren’t getting what they want from sex. 

Finding #2
Within long-term relationships, sexual initiations are usually successful in that the partner responds favourably to the sexual initiations.

• Individuals in long-term relationships are more aware of how likely their partner is to respond to sexual initiation and thus only initiate when they have an expectancy of a positive response.

• Individuals use contextual clues, predictions of past behaviour and partner's signals to decide whether or not to initiate sex.

Finding #3 
Women and men did not differ in their frequency of negative responses to sexual initiations.

• Women gave more negative responses to sexual initiations than did their male partners; however, the women also responded positively and more frequently than men.

• These results are not consistent with the traditional sexual script that puts women in the role of restrictor of sexual activity and men in the role of always being interested in sex.

• Since men are more often in the position of actor, with respect to sexual initiations, women are consequently more often in the position of reactor.

The Impact of Sex Therapy on Sexual Behaviours and Marital Communication

Couples who participated in a sex therapy program that included viewing sexually explicit audiovisual slides and movies, demonstrated changes in sexual behaviour, sexual desires, sexual communication and marital communication according to a recent study. The research studied the impact of sexual therapy on sexual behaviours and marital communication, and was conducted by the University of Texas Medical Branch.

Treatment Program
A total of 224 people, ranging in age from 25 to 34, participated in a sex therapy treatment program designed to change sexual behaviours. The treatment program, patterned after the Masters and Johnson approach, included a 2 day workshop format with individual as well as group sessions that included an initial intake interview, a self-administered sexual history questionnaire, a medical examination, and group instructional sessions led by a sex therapist. During the seminar, couples were given explicit information and audiovisual slides and movies during group instructional sessions. Couples were then asked to adjourn to their rooms for a private practice session. The study confirmed a number of findings relating to the impact of sex therapy on sexual behaviours and marital communication.

Sexual Behaviour
After attending the treatment sessions, some couples experienced:

• a narrowing of the gap between actual and desired sexual behaviours

• an increased acceptance of a wider range of sexual activities

• effective treatment in several areas of sexual dysfunction including premature ejaculation, impotence, ejaculatory incompetence, dyspareunia and sexual aversion

• a noticeable increase in sexual activity in all areas of sexual behaviour

• an increase in non-demanding activities such as viewing and being viewed nude, massaging and caressing

Communication
Couples noted the following changes after attending the workshops:

• a significant increase in reported communication before, during and after sexual activity

• an increased focus on one's own ability to communicate with a partner and not focusing on a partner's ability to communicate

• significant increase in marital communication

This study appeared in the Spring 1981 edition of the Journal of Sex and Marital Therapy, Vol. 7, No. 1.

What is normal arousal?

Women have described the sensations of orgasm as beginning with a sense of suspension, quickly followed by an intensely pleasurable feeling that usually begins at the clitoris and spreads throughout the pelvis. The genitals are often described as becoming warm, electric or tingly, and these physical sensations usually spread through some portion of the body. Most women also feel muscle contractions in their vagina or lower pelvis, often described as "pelvic throbbing".

Sex Response Cycle refers to the set of physiological and emotional changes that lead to and follow orgasm. Different researchers have constructed various models of the phases of the sex response cycle. Usually, these models include three, four, or five distinct phases, with the exact components of each phase differing across models. Helen Singer Kaplan proposed the Triphasic Concept of human sexual response involving three stages: desire, excitement, and orgasm. In his book Human Sexual Response, Lief described five sexual response phases: desire, arousal, vasocongestion, orgasm, and satisfaction.

William Masters and Virginia Johnson, prominent sex researchers and therapists, suggested that there are four identifiable phases in the sex response cycle: excitement, plateau, orgasm, and resolution. Using various instruments designed to monitor changes in heart rate and muscle tension, Masters and Johnson were able specify the bodily changes that characterize each of these phases.

The first phase, excitement, can last for just a few minutes or extend for several hours. Characteristics of this phase include: an increasing level of muscle tension, a quickened heart rate, flushed skin (or some blotches of redness may occur on the chest and back), hardened or erect nipples, and the onset of vasocongestion, resulting in swelling of the woman's clitoris and labia minora and erection of the man's penis. Other changes also occur. In the woman, the vaginal walls begin to produce a lubricating liquid, her uterus elevates and grows in size, and her breasts become larger. At the same time, the woman's vagina swells and the muscle that surrounds the vaginal opening, called the pubococygeal muscle, grows tighter. These changes prepare the woman's body for orgasm and were called the "orgasmic platform" by Masters and Johnson. Additional changes in men include elevation and swelling of the testicles, tightening of the scrotal sac, and secretion of a lubricating liquid by the Cowper's glands.

COMPETITION

Early last year, the first report on Viagra in women gloomily suggested that women were beyond the reach of medications-three in four failed to report a benefit. But that study turned out to have been flawed. Last year, Goldstein and the Berman sisters reported on 48 women who'd gone through the same routine as Paula. Overall, after taking Viagra, physiologic measurements significantly increased,-and so did subjective satisfaction.

Ito, Trant and Polan (1998) administered Larginine and other nutritional supplements to women and found after 4 weeks 73% improved their satisfaction with sex, compared to a placebo group of 37%.

Typically they include Tribulus Terrestris (a traditional Ayurvedic herb), Korean Ginseng, Milk Thistle, Ginko Biloba (circulatory stimulant), Muira Puama (unknown mechanism of effect on libido), Epimedium Sagittatum (horny goat weed increases sperm production),Damiana (aromatic herb and relaxant), Wild yam (naturally occurring DHEA)

Usually a range of minerals (Iron, Calcium and Zinc for serum testosterone) and vitamins such as A, B, E and C are included as antioxidants.

CRITICISMS

Too much of the research about women's sexual problems is funded by drug companies and narrowly conforms to their interests. There's just too much emphasis on claiming things are physical and then selling products.

The pharmaceutical companies want products they can market, which I distinguish from products that will help women with their sexuality. Their criteria for many trials exclude women with so many real-world problems -- they exclude women with psychological problems, or partner and relationship problems. They're interested in studying women with purely physical problems. So they find drugs that work on these physical problems, but then their marketing strategy, as we've seen with Viagra, is to market romance. Their strategy is not to be specific and say something works with this kind of person who has this specific kind of problem. They just say, "Use the drug, start dancing

I'm certainly not going to say these women don't know whether they feel better or not. But I am going to say it's not the first and only way to go.

On the other side of the issue are many therapists, who see the psychological aspects of this problem as most significant. Sex therapists use counselling skills when they solve sexual problems, and see products like Femprox as shortcuts that threaten both their wallets and their talk-it-out sensibilities. Lilly Tanner, Ph.D., of Miami Beach, Fla., grumbles that "women do better when they're involved in a good relationship than they do when they're putting creams on themselves. It [Femprox] is just a nonsense thing that the pharmaceuticals have come up with."

Steven Braveman (M.A., MFT) of Monterey, Calif., is apparently even more allergic to vaginal ointments. "Ninety-eight percent of pre-orgasmic women can easily have an orgasm after they work through their issues in a behavioural, therapeutic format," he fumes. "Maybe it's trauma at an early age, or a strong religious message that sexuality is evil, or they might be married to a man who is ignorant of female genitalia."

"What I fear," he continues, "what we [sex therapists] are concerned about, is that our society is medicalizing, pathologizing, an emotional or relationship problem. If women buy into the idea that they can just be pharmaceutically treated to enjoy sex, we are essentially turning them into prostitutes so that they will perform on demand. The development of these creams represents a very poor turn of events in the history of our sexuality."

Certainly an eloquent plea by the Californian, but absolutely erroneous, snorts New Yorker Kaminetsky. "That's not true!" he rails when informed of Braveman's statistic that medical intervention is 98 percent unnecessary. "What about post-menopausal women, when their bodies go through hormonal and vascular changes?" Additional physiological causes of FSAD and FSD that the urologist lists on his Web site are "nerve damage, smoking, elevated cholesterol [and] long-distance bicycle riding."

"Some people don't see the big picture," Kaminetsky says, defending his potions. "Even if the problem is psychological, if we can provide a cream that is quickly effective, why should anyone be opposed to that? I'm in the business of helping people."

After Viagra's success, it's clear that any amorous medicine is destined to become a top seller, whether patients decide to use it in conjunction with therapy or as an enhancement they can apply themselves.

REFERENCES
Bartlik B, Kaplan P, Kaminetsky J, Roentsch G, and Goldberg J.Medications with the Potential to Enhance Sexual Responsivity in Women  Psychiatric Annals 29:1 Jan 1999.

Brock G. New Horizons in Erectile Dysfunction Therapy Medscape 2001.

Gillis N. Panax Ginseng Pharmacology: A Nitric Oxide Link. Biochemical Pharmacology Vol 54, p 1-8 1997.

Laumann E, Paik A and Rosen R. Journal of the American Medical Association. Sexual Dysfunction in the United States: Prevalence and Predictors. Journal of the American Medical Association Vol 281, (6) Feb 10 1999 p 537-544.

Lee IC, Surridge D, Morales A, et al. The prevalence and influence of significant psychiatric abnormalities in men undergoing comprehensive management of organic ED. International Journal of Impotence Research 2000; 12;533-541.

McKinlay JB The world wide prevalence and epidemiology of erectile dysfunction International Journal of Impotence research. 2000 ; 12 (suppl 4) S6 – S11.

Padma-Nathan H. Challenges and Solutions in the Treatment of Erectile Dysfunction. Medscape 2001

Persky H et al Plasma testosterone level and sexual behaviour in couples Archives of Sexual Behaviour 793, p157-173 1978

Pinnock CB, Stapleton A, Marshall VR. Erectile dysfunction in the community: a prevalence study. Medical Journal of Australia. 1999; 171: 353-357.

Rosen RC, Riley A, Wagner G et al. The international index of erectile dysfunction (IIEF): a multidimensional scale for assessment of erectile dysfunction. Urology 1997; 49: 822-830.

Spector I and Carey M. Incidence and Prevalence of Sexual Dysfunctions: a critical review of the empirical literature. Archives of Sexual Behaviour. 1990, 19: p 389-408.

Waynberg J and Brewer S. Effects of Herbal vX on libido and sexual activity in premenopausal and postmenopausal women. Advances in Therapy 17(5): 255-62 2000