The Ins and Outs of Gay Sex (26 page)

T
hey had been together for close to thirty years, and soon it would be over.
Fred, the younger of the two and muscular even into his sixties, was now little more than skin covering bones.
His wig lay in his lap like a little dog.
He saw me staring at it.
“I can put this on if it bothers you,” he said.

I smiled.
“Whatever makes you comfortable.”

“To tell you the truth, nothing makes me comfortable these days.”

“If there’s anything I can do …” My voice trailed off.

“There is something.”
He reached for his partner Harry’s hand and held it tight.
“We haven’t been intimate for a long time, what with the treatments and all.
Harry says it’s not important, but it is.
I tried the other night.”
Harry started to say something, but Fred cut him off.
“You don’t know everything!
I wanted to see if it would get hard again.”

“And?”
I asked.

“Nothing.”

“That’s probably from the radiation destroying your nerves,” I said, sounding too clinical when my heart was aching.

“We don’t have much time together.
And I want to be intimate again.
I love him.
It’s important to me.
Important to us.
Can you help us?”

Most if not all men experience sexual dysfunction at some point in their lives.
Whether it is that first encounter when you shot your load at the first touch of his hand or the night you couldn’t get it up no matter how hard you tried, it’s going to happen.
Isolated episodes are nothing to worry about:
They’re normal.
Sexual dysfunction becomes a problem when it is the rule, not the exception.
The problem facing men is that we’ve been taught that sexual dysfunction is in our head (the one above our neck), and like all psychological illnesses, we find it profoundly embarrassing.
It becomes even more of a problem for gay men who may have been taught that the very nature of their sexuality is a psychological disorder.

Researchers estimate that over 30 million men in this country are impotent and approximately another third suffer from premature ejaculation.
And these figures may underestimate the true magnitude of the situation, because less than 10 percent of impotent men seek treatment.

If there’s a problem, why won’t we speak up?
For men in general, sexual dysfunction hits us at the root of our manhood.
If we can’t perform, we’re not true men.
For gay men anxiety heightens even more.
If our sexuality is an aberration, then what right do we have to ask for help when it doesn’t work?
Homophobic feelings are compounded by our fantasy image of the ideal gay male:
pumped-up pecs, washboard abs, silky hair, chiseled face, huge cock that’s always hard—the essence of virility.
But if we’re gay and impotent, then we better not speak up.
Wrong!

Over the years doctors have made great strides in treating male sexual dysfunction.
First and foremost, we’ve learned that over 80 percent of impotence in men over fifty results from a
physiological,
not a psychological, abnormality—most commonly caused by poor blood flow into the penis.
This is a highly correctable problem.

We can break down sexual function into three areas:
erection, ejaculation, and orgasm.
Although these three areas are intimately related, they are not inseparable.
They result from completely different physiological responses, and as such each can exist independently of the others.
While it’s difficult to imagine, you can have an orgasm without an erection or ejaculation, ejaculation without an orgasm or erection, and an erection without ejaculation or an orgasm—did I cover all the possibilities?
Sexual dysfunction becomes easier to treat because each factor does not depend on the others.
So if you’re having a problem, talk to your doctor.
Don’t be embarrassed.
It’s your right to enjoy your sexuality.

Impotence encompasses both a failure to ejaculate or attain an erection.
It affects only 5 percent of men in their forties but rises dramatically to affect 60 percent of men in their seventies.
Impotence was never discussed much in the gay community:
First it was taboo for so long and then AIDS turned our attention from these other less-threatening health issues.
As men live longer productive lives, impotence becomes a significant problem facing the gay community—and the magnitude of the problem will continue to grow.
Men who have sex with men need a stiffer erection to penetrate a partner’s anal sphincter.
What might not seem a problem for a man attempting vaginal intercourse can mean impotence if he prefers anal sex.

Physiological causes of impotence can be divided into four main categories:
vascular, neurological, hormonal, and drug induced.
Vascular insufficiency represents the most common cause by far.
When any part of the body rests, its requirements for oxygen and nutrients decline.
The minute your body begins to work, whether digesting food or lifting
something heavy, blood flow increases dramatically to meet energy demands.
If your arteries are narrowed by atherosclerosis (hardening and blockage), they may be able to carry enough blood to meet resting requirements but not enough to allow for work.
(Think of people with heart problems.
They are fine at rest, but when they exert themselves they develop chest pain—angina—because blocked arteries can’t bring enough oxygen to their heart.
) When your penis goes to work, it’s in the form of an erection.
If your arteries are blocked to any significant degree, you won’t get enough blood into your erectile tissue to make it stand at attention.

Impotence related to vascular insufficiency usually results from blockage in large arteries in the abdomen and pelvis (aorta or iliac arteries), the main arteries in the penis, or their smaller tributaries.
Any disease that promotes atherosclerosis increases your risk for this form of impotence.
Thus high blood pressure, diabetes, elevated cholesterol levels, and smoking are the most common culprits.

Vein abnormalities also can cause impotence.
If your veins cannot constrict and keep blood from leaving erectile tissue (a condition known as leaky veins), your erection will not happen, will be soft, or will not last long enough for you to climax.
Men with this problem sometimes benefit from cock rings, which function like tourniquets helping veins hold in blood.

Nerves to the penis are also vital in producing an erection.
They send impulses to the penis telling arteries to open so more blood rushes in and veins to constrict to keep the penis filled.
These nerve impulses originate in either the brain or lower spinal cord, so a man paralyzed from a high spinal cord injury can still get hard.
Any disease that damages nerves can cause impotence.
Diabetes, spinal cord trauma, multiple sclerosis, and herniated discs are the most
common.
Neurological diseases affecting the brain, most notably Parkinson’s disease, also can lead to impotence.

Hormonal problems are another cause of impotence, especially in HIV-positive men.
If the testosterone level falls, as frequently seen with HIV, libido decreases and so does the ability to get hard.
Thyroid disorders and pituitary tumors (prolactinomas) also cause impotence.
Men who take steroids or estrogen (looking for that fuller figure) frequently become impotent.
Fortunately, hormone levels (including testosterone) can be measured, and readily replaced with medications.

Diabetes, caused by the body’s failure to produce the hormone insulin, which keeps blood sugar under control, damages both arteries and nerves.
It is the commonest cause of impotence, and an estimated half of all male diabetics experience some sexual dysfunction.
Unfortunately, keeping blood sugar under tight control may not protect a person from impotence.

Although I have mentioned many diseases that predispose men to impotence, please don’t think that just because you have one of them you are doomed to sexual dysfunction.
Being predisposed to something is not an absolute, and with adequate care you may be able to avoid any problems.

Drugs, both prescribed and abused, are also frequent causes of impotence and are responsible for almost one-fourth of all cases.
The most common classes of drugs that produce impotence are antihypertensives (those used to treat high blood pressure), heart medications, psychiatric medications, tranquilizers, and depressants (narcotics, barbiturates, alcohol, cocaine, and marijuana).
Drugs are a likely cause for impotence especially if the onset of your problem can be tied to the start of a new medication.
(See
Table 7.
1
for a list of common offenders.
)

TABLE 7.
1
DRUGS THAT MAY CAUSE IMPOTENCE OR EJACULATORY PROBLEMS
^*

Medically prescribed therapies also can cause impotence.
Medications can be altered, but other treatments may be unavoidable or even lifesaving.
Pelvic, spinal cord, and brain surgery, particularly if done to cure cancer, can result in impotence.
(Radical prostate surgery and some types of colon surgery are the biggest culprits.
) Cancer radiation treatments to the pelvic region (again prostate and colon cancers are common) can lead to impotence as well.
If prostate cancer spreads to other parts of your body, pharmacological (Lupron) or surgical castration, both obvious causes of impotence, often is necessary to slow the disease.
(See
Chapter 9
.
) If you need pelvic surgery or radiation, be sure to ask your doctor if there is a chance you will be left impotent.
When you consent to treatment, you’re focusing on a bigger problem—the cancer.
Once treatment ends and you’re cancer free, impotence may not seem like such a trivial matter.
New medications combat impotence, but they don’t always work.

A doctor first must determine the reason for your impotence before it can be treated effectively.
Although you may feel humiliated by the process, it is usually painless.
I urge you to hang in there, for if a cause is found and the treatment is successful, your life will improve dramatically.
Most impotence evaluations start like all other trips to the doctor:
with a thorough history and physical exam.
The doctor searches your history for clues to causes of your problem.
(Are you depressed?
Did you recently begin a new medication?
Do you have blocked arteries in other parts of your body?
Any neurological problems?
) A physical examination provides your doctor with tangible evidence that further pinpoints the cause.
(Shrunken testicles, diminished pulses, a prominent thyroid, visual disturbances, a tremor, to name just a few.
)

Blood tests check various hormone levels and blood sugar.
A nocturnal penile tumescence (NPT) test helps your doctor distinguish between psychological and physiological impotence.
Men normally experience three to five erections each night during rapid-eye-movement (REM) sleep.
Expect your NPT to be normal when psychological problems cause impotence.
If, however, there is a physiological basis for your impotence, nocturnal penile erections are also diminished.

I bet you want to know how doctors measure nocturnal erections.
(And, no, they don’t get into bed with you!
) They use a portable, take-home machine called the Rigiscan.
You attach its Velcro loops to the base and tip of your penis before going to sleep.
During the night the Rigiscan records your erections, which doctors later analyze for frequency, duration, and rigidity.