‘It just didn’t enter my mind to initiate sex;’ Low sex drive in men linked to chemical imbalance | CNN

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While hanging out with his college roommates, Peter (not his real name) realized he felt differently about sex than other heterosexual men.

“I’ve never been somebody who was interested in pornography, but I’d laugh along with their jokes,” said Peter, now 44, who is British. “Of course I never mentioned that … as a man, you’d be kicked out of the herd.”

As he developed “proper, serious relationships” with women, Peter discovered he didn’t have the sexual drive many of his partners did.

“I would make excuses around getting tired or feeling stressed, that kind of thing,” he said. “It wasn’t an issue with attraction to my partner. It just didn’t enter my mind to initiate sex.”

In 2021, Peter saw an ad recruiting male volunteers for a new study on hypoactive sexual desire disorder, or HSDD. Researchers planned to inject the study’s participants with kisspeptin —a naturally occurring sexual hormone — to see if it increased their sex drive. Kisspeptin plays a key role in reproduction; without adequate levels of the hormone children do not go through puberty, for example.

In a long-term, committed relationship with a woman he says has a higher sexual appetite, Peter signed up, intrigued by the thought that a biological imbalance might help explain his behavior.

In the week after the final session, Peter said, something amazing occurred.

“All of a sudden, I wanted to initiate intimacy. I can only presume it was driven not by my mind remembering something, but my body wanting something,” he said. “I did initiate sex more and it improved things with my partner incredibly.”

Experts believe HSDD affects at least 10% of women and up to 8% of men, although those numbers may be low, said Stanley Althof, a professor emeritus of psychology at Case Western Reserve University School of Medicine in Cleveland, Ohio and executive director of the Center for Marital and Sexual Health of South Florida.

“Men are embarrassed to go to the doctor to begin with, and you’re supposed to be a macho guy,” said Althof, who was not involved in the kisspeptin study.

“So it’s difficult for men to say, ‘Hey, I’ve got a problem with my sex drive.’ That’s why the majority of male patients I see with HSDD are sent in by their partners.”

To be diagnosed with the disorder, a person must have no other issues that might cause a change in libido, such as erectile dysfunction or premature ejaculation.

“Losing interest due to performance issues is common, but HSDD is its own thing,” Althof said. “It’s an absence of erotic thoughts and a lack of desire for sex that has to be present for six months. It also cannot be better explained by another disorder or other stressors: It can’t be due to depression. It can’t be due to a bad relationship. It can’t be due to taking an antidepressant.”

One more key point: A man or woman must have clinically significant distress to have HSDD, said clinical psychologist Dr. Sheryl Kingsberg, a professor in reproductive biology and psychiatry at Case Western Reserve University, who was also not involved in the kisspeptin study.

“Some people aren’t bothered by their lack of interest in sex, so we wouldn’t treat them for HSDD,” said Kingsberg, who is also chief of behavioral medicine at MacDonald Women’s Hospital and University Hospitals Cleveland Medical Center.

“The women coming into my office are deeply distressed,” she said. “They tell me ‘I used to have desire but it’s gone. I could be on a desert island with no pressures, but I just don’t have the appetite. I want it back.’ Those women have HSDD.”

Dr. Waljit Dhillo, a professor in endocrinology and metabolism at Imperial College London, has been studying the relationship between low sexual desire and the hormone kisspeptin for years, first in animals, then in people.

Prior studies by Dhillo of healthy men with no libido problems found giving them kisspeptin boosted levels of testosterone and luteinizing hormone, which is important for gonad function.

His newest study, published in the journal JAMA Network Open in February, enrolled 32 men with verified HSDD. Peter was one of them.

“So many people say to themselves, ‘It’s just me. I’ve got a problem.’ But actually, HSDD may be how your brain is wired,” said Dhillo, who is a dean at the United Kingdom’s National Institute for Health and Care Research Academy in Newcastle upon Tyne.

“The biology is telling us there’s increased activation of inhibitory areas in the brain — the same areas that tell us it’s not OK to walk around in public naked — and those areas are switching off sexual desire. How can we tackle that? We give a hormone that would naturally give you increased sexual desire, essentially hijacking the normal system.”

The men participating in the new study visited Dhillo’s lab twice. On each occasion, they were fitted with a device to objectively measure arousal, given an injection and asked to watch pornography while their brains were scanned via functional magnetic resonance imaging (fMRI).

Neither the subjects or the researchers knew if that day’s injection was kisspeptin or a placebo.

“It was extraordinarily surreal, lying there with something resembling a hangman’s noose around your bits and watching a mixture of ’70s to modern-day pornographic images and videos,” Peter said. “You’d get about five or six seconds of one type of image or video, rate your arousal for the researchers, and then move on to the next.”

Brain scans showed a significant dual effect after the kisspeptin injection, Dhillo said. Activity in the areas of the brain that inhibit behavior slowed, while areas of the brain connected to sexual interest lit up.

“As a group, the men had a 56% higher sexual response to sexual images after the kisspeptin than the placebo,” Dhillo said. “And we found no side effects at the very, very small dose that we are using.”

Peter noticed a difference immediately after finishing the treatments. His sex life was so robust, in fact, that it wasn’t long before his partner was pregnant with their first child.

As published, the study did not follow the men long-term to see if the effects of kisspeptin lasted. For Peter, however, its impact has been life-changing.

“I have found there’s been a lasting effect for me,” he said. “I do find I have a much better sexual appetite even now some years after the treatment.”

Even the arrival of a baby boy didn’t deter his new interest in sex.

“The cliche is when you have kids, your sex life takes a bit of a hit,” he told CNN. “But that hasn’t been the case for us. In fact, we’re pregnant with our second child, due in July.”

While Peter had a positive long-term result, it’s too soon to say kisspeptin injections were the reason, Althof said.

“When you hear dramatic results like Peter’s, I would be cautious in saying that is the typical outcome. While it’s wonderful that it happened for him, these fMRI studies are difficult to interpret and not conclusive,” he said.

“Sexual desire is very complicated — I say it’s a combination of brain function, hormones and love, wine and roses,” Althof added. “This study is promising, but it needs replication in larger groups.”

And even if future research does confirm kisspeptin’s benefits, medical treatment is not a substitution for healthy communication about sex between partners and with health care providers, Dhillo said.

“These are society’s taboos, but actually, the more we talk about real (sexual) issues that affect real people, the more we find it’s actually quite common,” he said.”If you’re not troubled by low libido, it’s not an issue at all, but if you are troubled by it, this can lead to marital breakdown, unhappiness and reduced quality of life.”

Study: Climate change is killing our sex drive

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Asthma, cancer, erectile drugs sent from abroad make up are most confiscations, despite opioid claims | CNN

For years, the FDA has defended its efforts to intercept prescription drugs coming from abroad by mail as necessary to keep out dangerous opioids, including fentanyl.

The pharmaceutical industry frequently cites such concerns in its battle to stymie numerous proposals in Washington to allow Americans to buy drugs from Canada and other countries where prices are almost always much lower.

But the agency’s own data from recent years on its confiscation of packages containing drugs coming through international mail provides scant evidence that a significant number of opioids enters this way. In the two years for which KHN obtained data from the agency, only a tiny fraction of the drugs inspected contained opioids.

The overwhelming majority were uncontrolled prescription drugs that people had ordered, presumably because they can’t afford the prices at home.

The FDA still stops those drugs, because they lack U.S. labeling and packaging, which federal authorities say ensure they were made under U.S. supervision and tracking.

The FDA said it found 33 packages of opioids and no fentanyl sent by mail in 2022 out of nearly 53,000 drug shipments its inspectors examined at international mail facilities. That’s about 0.06% of examined packages.

According to a detailed breakdown of drugs intercepted in 2020, the lion’s share of what was intercepted — and most often destroyed — was pharmaceuticals. The No. 1 item was cheap erectile dysfunction pills, like generic Viagra. But there were also prescribed medicines to treat asthma, diabetes, cancer, and HIV.

FDA spokesperson Devin Koontz said the figures don’t reflect the full picture because U.S. Customs and Border Protection is the primary screener at the mail facilities.

But data obtained from the customs agency shows it likewise found few opioids: Of more than 30,000 drugs it intercepted in 2022 at the international mail facilities, only 111 were fentanyl and 116 were other opioids.

On average, Americans pay more than twice the price for exactly the same drugs as people in other countries. In polling, 7% of U.S. adults say they do not take their medicines because they can’t afford them. About 8% admit they or someone else in their household has ordered medicines from overseas to save money, though it is technically illegal in most cases. At least four states — Florida, Colorado, New Hampshire, and New Mexico — have proposed programs that would allow residents to import drugs from Canada.

While the FDA has found only a relatively small number of opioids, including fentanyl, in international mail, Congress gave the agency a total of $10 million in 2022 and 2023 to expand efforts to interdict shipments of opioids and other unapproved drugs.

“Additional staffing coupled with improved analytical technology and data analytics techniques will allow us to not only examine more packages but will also increase our targeting abilities to ensure we are examining packages with a high probability of containing violative products,” said Dan Solis, assistant commissioner for import operations at the FDA.

But drug importation proponents worry the increased inspections targeting opioids will result in more uncontrolled substances being blocked in the mail.

“The FDA continues to ask for more and more taxpayer money to stop fentanyl and opioids at international mail facilities, but it appears to be using that money to refuse and destroy an increasing number of regular international prescription drug orders,” said Gabe Levitt, president of PharmacyChecker.com, which accredits foreign online pharmacies that sell medicines to customers in the U.S. and worldwide. “The argument that importing drugs is going to inflame the opioid crisis doesn’t make any sense.”

“The nation’s fentanyl import crisis should not be conflated with safe personal drug importation,” Levitt said.

He was not surprised at the low number of opioids being sent through the mail: In 2022, an organization he heads called Prescription Justice received 2020 FDA data through a Freedom of Information Act request. It showed that FDA inspectors intercepted 214 packages with opioids and no fentanyl out of roughly 50,000 drug shipments. In contrast, they found nearly 12,000 packages containing erectile dysfunction pills. They also blocked thousands of packages containing prescription medicines to treat a host of other conditions.

Over 90% of the drugs found at international mail facilities are destroyed or denied entry into the United States, FDA officials said.

In 2019, an FDA document touted the agency’s efforts to stop fentanyl coming into the United States by mail amid efforts to stop other illegal drugs.

Levitt was pleased that Congress in December added language to a federal spending bill that he said would refocus the FDA mail inspections. It said the “FDA’s efforts at International Mail Facilities must focus on preventing controlled, counterfeit, or otherwise dangerous pharmaceuticals from entering the United States. Further, funds made available in this Act should prioritize cases in which importation poses a significant threat to public health.”

Levitt said the language should shift the FDA from stopping shipments containing drugs for cancer, heart conditions, and erectile dysfunction to blocking controlled substances, including opioids.

But the FDA’s Koontz said the language won’t change the type of drugs FDA inspectors examine, because every drug is potentially dangerous. “Importing drugs from abroad simply for cost savings is not a good enough reason to expose yourself to the additional risks,” he said. “The drug may be fine, but we don’t know, so we assume it is not.”

He said even drugs that are made in the same manufacturing facilities as drugs intended for sale in the United States can be dangerous because they lack U.S. labeling and packaging that ensure they were made properly and handled within the U.S. supply chain.

FDA officials say drugs bought from foreign pharmacies are 10 times as likely to be counterfeit as drugs sold in the United States.

To back up that claim, the FDA cites congressional testimony from a former agency official in 2005 who — while working for a drug industry-funded think tank — said between 8% and 10% of the global medicine supply chain is counterfeit.

The FDA said it doesn’t have data showing which drugs it finds are unsafe counterfeits and which drugs lack proper labeling or packaging. The U.S. Customs and Border Protection data shows that, among the more than 30,000 drugs it inspected in 2022, it found 365 counterfeits.

Pharmaceutical Research and Manufacturers of America, the trade group for the industry, funds a nonprofit advocacy organization called Partnership for Safe Medicines, which has run media campaigns to oppose drug importation efforts with the argument that it would worsen the fentanyl epidemic.

Shabbir Safdar, executive director of the Partnership for Safe Medicines, a group funded by U.S. pharmaceutical manufacturers, said he was surprised the amount of fentanyl and opioids found by customs and FDA inspectors in the mail was so low. He said that historically it has been a problem, but he could not provide proof of that claim.

He said federal agencies are not inspecting enough packages to get the full picture. “With limited resources we may be getting fooled by the smugglers,” he said. “We need to be inspecting the right 50,000 packages each year.”

For decades, millions of Americans seeking to save money have bought drugs from foreign pharmacies, with most sales done online. Although the FDA says people are not allowed to bring prescription drugs into the United States except in rare cases, dozens of cities, county governments, and school districts help their employees buy drugs from abroad.

The Trump administration said in 2020 that drugs could be safely imported and opened the door for states to apply to the FDA to start importation programs. But the Biden administration has yet to approve any.

A federal judge in February threw out a lawsuit filed by PhRMA and the Partnership for Safe Medicines to block the federal drug importation program, saying it’s unclear when, if ever, the federal government would approve any state programs.

Levitt and other importation advocates say the process is often safe largely because the drugs being sold to people with valid prescriptions via international mail are FDA-approved drugs with labeling different from that found at U.S. pharmacies, or foreign versions of FDA-approved drugs made at the same facilities as drugs sold in the U.S. or similarly regulated facilities. Most drugs sold at U.S. pharmacies are already produced abroad.

Because of the sheer volume of mail, even as the FDA has stepped up staffing at the mail facilities in recent years, the agency can physically inspect fewer than 1% of packages presumed to contain drugs, FDA officials said.

Solis said the agency targets its interdiction efforts to packages from countries from which it believes counterfeit or illegal drugs are more likely to come.

Advocates for importation say efforts to block it protect the pharmaceutical industry’s profits and hurt U.S. residents trying to afford their medicines.

“We have never seen a rash of deaths or harm from prescription drugs that people bring across the border from verified pharmacies, because these are the same drugs that people buy in American pharmacies,” said Alex Lawson, executive director of Social Security Works, which advocates for lower drug prices. “The pharmaceutical industry is using the FDA to protect their price monopoly to keep their prices high.”

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Pleasure Quest: In Search of the Elusive Orgasm

Instead of climaxing, Eva* used to cry.

From the first time she had intercourse, at 17, the buildup of emotion and sensation would often trigger a bout of tears. Other times, she felt as though orgasm was an almost-sneeze – “this very fast semi-climax, and then it was over. When I would hear about women who had multiple orgasms, amazing orgasms, I just couldn’t imagine.”

Eva, now 70 and retired from a long career in the film industry, kept her inability to reach orgasm a secret cloaked in shame: “Sometimes I’d almost whisper it at the end of a medical appointment.” For decades, she asked friends: “‘Who do you see? Who do you talk to?’ Nobody knew how to get answers or information.”

Eva may have been isolated, but she wasn’t alone. Studies estimate that 10%-15% of women have never had an orgasm, and nearly half report some degree of anorgasmia – absent, infrequent, unsatisfying, or painful orgasm.

Despite that prevalence, female sexual pleasure hasn’t earned nearly the same spotlight as male virility. Viagra commercials punctuate prime-time TV, but female orgasm remains a taboo topic, not only at the dinner table but even in clinical circles.

Lisa Valle, DO, is an obstetrician/gynecologist in Santa Monica, CA, who graduated from medical school in 2001. Her professors taught cursory lessons on sexually transmitted infections, but “the orgasm issues are typically a missed thing.”

Myths About Female Arousal

In 2016, Valle opened a practice dedicated solely to women’s sexual health; her clients range from teen girls who can’t insert a tampon without pain to women in their 90s who want more sexual pleasure.

Many women, even those who know their bodies well, lack information about the physiology and psychology of orgasm, Valle says. Movies, and particularly the porn industry, often perpetuate myths about female arousal and pleasure.

“[In a movie scene], he kissed her neck and all of a sudden she’s having an orgasm. It’s just not realistic,” she says.

In truth, women need arousal, which takes time, in order to reach the balance of excitement and relaxation required for orgasm. That involves hormones, lubrication, blood flow, pelvic floor muscles – they can’t be too tight or too loose – a clitoral hood that easily retracts, and a behind-the-scenes network of vestibular bulbs and perineal sponge.

It’s a common myth that orgasm “is all about the clitoris,” says Ellen Heed, PhD, a somatic psychologist with a specialty in sexological bodywork and a practice based in Ashland, OR. Actually, it’s a “reproductive-system response” in which a woman’s erectile tissue becomes engorged, round ligaments lift the cervix, and neurons in the brain fire in response to arousal.

“Women think orgasm is supposed to be spontaneous,” Heed says. “It can be. But we have to learn about it.” 

What’s Behind Orgasm Challenges

Eva tried. She used vibrators and sex toys, including “some kind of a stick with a feathery thing on it to tickle your G-spot.” She attended weekend workshops on tantric sex and massaged estrogen cream on her clitoris each morning. “None of this was turning into an orgasm,” she said.

She also began reflecting on a sexual, medical, and social history that included a traumatic incident at age 8 – a male relative masturbated in front of her – along with three abdominal surgeries, a series of yeast and fungal infections, and a C-section when she was 35.

All of those can affect a woman’s ability to orgasm, according to experts. That’s why Erica Marchand, PhD, a Los Angeles psychologist with a focus on sexuality and relationships, always refers clients with anorgasmia for a full physical evaluation.

Scar tissue from prior surgeries, C-sections, or episiotomies may impede orgasm. So can the hormones in birth control pills and the ingredients in some psychiatric medications. Endometriosis, urinary tract infections, and yeast infections can affect pelvic floor muscles.

Physical therapist Stephanie Prendergast co-founded the Pelvic Health and Rehabilitation Center, with locations in northern and Southern California and New England; her focus is on pelvic pain and sexual dysfunction.

“An orgasm is a rapid muscle contraction, a combination of voluntary and autonomic,” she explains. “In a normal, functioning pelvic floor, we should be able to control the muscles. In pelvic floor dysfunction, we can’t. People don’t realize that’s why they may have orgasm challenges.”

From Manual Therapy to Emotional Work

After doing a thorough history and a physical evaluation – “we’ll examine everything from the ribs down,” she says – Prendergast does manual therapy, including trans-vaginal work, to restore movement and reduce pain in muscles, tissues, and nerves. Women may need core exercises to restore weakness in the pelvic floor or gentle stretching to relax those muscles.

“Once we see that their physiologic function is there, we need to help them become orgasmic again,” Prendergast says.

That often involves emotional work as well. Childhood learning and beliefs about sexuality – as well as unwanted sexual experiences, sexual violence, or trauma – play a huge role in women’s ability to reach orgasm, says Marchand. “I talk to people about their mindset about sex and pleasure: What did they learn when they were younger about sex? How do they feel about themselves and their bodies? Is pleasure something that feels OK?”

Valle, as part of her initial assessment, asks clients about anxiety and depression, medication and surgeries, stress, and sleep patterns. She uses the “Q-tip test” to check for sensitivity and pain in the vulva, vagina, and clitoris. She might refer women to an endocrinologist, a pelvic floor physical therapist, or a sex therapist who specializes in trauma.

And she works to counter the cavalier advice traditionally dispensed by doctors who fail to understand the complexity of female orgasm. Valle keeps a running list of the unhelpful suggestions her patients have received: Drink some wine. Try lidocaine. Go on vacation. Just relax. 

Some Feel Shut Out of ‘the Orgasm Club’

Shame and secrecy compound difficulties with orgasm. “If someone was shamed or told their whole body was wrong, or that any kind of desire was ungodly or indulgent … then finding permission to be embodied at all is something we have to come to before even talking about orgasm,” says Heed.

And when a woman can’t achieve orgasm, she may isolate herself further by not discussing it, even with friends. “Women feel like they don’t belong to the orgasm club, and that feels sad, intimidating, helpless, hopeless. Like they’re missing out on something,” Heed says.

For years, that was the case for Jennifer Anderson, a 36-year-old technology trainer. From the time she became sexually active at age 17, her focus was always on pleasuring her male partner.

“If he was satisfied sexually, then I’d done my job. When we were having sex, my mind would race about things that were not sex-related. I had a mental block about being aroused. I struggled with partner orgasms for as long as I can remember.”

She tried “dirty talk” during sex with her husband. Sex toys. Watching porn together. It wasn’t until she struck up a romantic and sexual relationship with a woman at work – eventually separating from her husband – that Anderson began to reach orgasm regularly.

“With a female partner, things were way different,” she says. “I feel more self-satisfied, knowing about this whole new world of sexuality and sexual pleasure.”

A Crash Course in ‘the Big O’

Health practitioners say there are strategies that work to help women with anorgasmia. Heed, the somatic psychologist, might recommend “orgasmic meditation,” in which a woman uses lube and strokes her clitoris as a mindfulness practice, learning about and experiencing the sensations.

Marchand developed the “Big O Masterclass,” a 10-week online course for women struggling to achieve orgasm. The self-paced curriculum includes work on sexual beliefs, arousal, stimulation, and partner dynamics. Nearly 2,000 women have taken it since the course’s 2018 launch.

Attention to female orgasm is not just a matter of individual pleasure, Marchand says. Orgasm “is a matter of equity and equality. It feels like a social justice issue to me.” The good news, she says, is that “most of the time, orgasm is a learnable skill.”

That’s true for Eva, who struggled with orgasm for nearly all her adult life. Her current partner, a man she began dating 2 years ago, is patient and open to trying new strategies to help both of them find pleasure in sex.

“It’s the best relationship, the most connected and sweet, that I’ve ever had,” she says. And while she still faces obstacles to sexual ease – arthritis, a knee replacement, the hormonal changes that come with aging – Eva also notes a renewed sense of motivation.

“We haven’t had a lot of intercourse, but I feel like there’s progress. I’m hopeful. I’m in the middle of it. I feel like I’m on a journey that might get me there.”

*Some names have been changed to ensure anonymity.

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