Sexual Dysfunction in Male

Overview of Sexual Dysfunction in Male

Male sexual dysfunction (MSD) affects 10–25% of middle-aged and older people, and female sexual dysfunction occurs with similar frequency.

Demographic changes, the popularity of newer treatments, and greater awareness of sexual dysfunction by patients and society have led to increased diagnosis and associated health care expenditures for the management of this common disorder.

Because many patients are reluctant to initiate discussion of their sex lives, physicians should address this topic directly to elicit a history of sexual dysfunction.

Types of Sexual Dysfunction in Male

Sexual Dysfunction may Classified in to 4 categories

Sexual Desire Disorder or Hypoactive sexual desire disorder

• Decreased libido is characterized by a lack or absence for some time of sexual desire or libido for sexual activity or of sexual fantasies.

Causes:

• Decrease in the production of testosterone in men
• Ageing
• Fatigue
• Medications (such as the SSRIs) or psychiatric conditions, such as depression and anxiety.

Sexual Arousal Disorder

Sexual arousal disorders were previously known as impotence in men, though these have now been replaced with less judgmental terms.

Impotence is now known as erectile dysfunction.

For people of all genders, these conditions can manifest themselves as an aversion to and avoidance of sexual contact with a partner.

In men, there may be partial or complete failure to attain or maintain an erection, or a lack of sexual excitement and pleasure in sexual activity.

There may be physiological origins to these disorders, such as decreased blood flow or lack of vaginal lubrication. Chronic disease can also contribute, as well as the nature of the relationship between the partners.

Additionally, the condition post-orgasm illness syndrome (POIS) may cause symptoms when aroused, including adrenergic-type presentation; rapid breathing, paresthesia, palpitations, headaches, aphasia, nausea, itchy eyes, fever, muscle pain and weakness and fatigue.

Duration

From the onset of arousal, symptoms can persist for up to a week in patients.

The etiology of this condition is un known, however it is believed to be a pathology of either the immune system or autonomic nervous systems.

It is defined as a rare disease by the NIH but the prevalence is unknown. It is not thought to be psychiatric in nature, but it may present as anxiety relating to coital activities and thus may be incorrectly diagnosed as such. There is no known cure or treatment.[1][3]

Erectile dysfunction

Erectile dysfunction or impotence is a sexual dysfunction characterized by the inability to develop or maintain an erection of the penis.

Causes:

• Damage to the Nervi erigentes which prevents or delays erection, or
• Diabetes
• Cardiovascular disease, which simply decreases blood flow to the tissue in the penis, many of which are medically treatable.
• Psychological or physical. Psychological erectile dysfunction can often be helped by almost anything that the patient believes in; there is a very strong placebo effect.
• Erectile dysfunction from vascular disease is seen mainly amongst older individuals who have atherosclerosis.
• Vascular disease is common in individuals who have diabetes, peripheral vascular disease, hypertension and those who smoke. Anytime blood flow to the penis is impaired, erectile dysfunction is the end result.

Other causes

• Drugs Individuals who take drugs that lower blood pressure or antipsychotics, antidepressants, sedatives, narcotics, antacids or alcohol can have problems with sexual function and loss of libido.
• Hormone deficiency is a relatively rare cause of erectile dysfunction.
• In individuals with testicular failure, as in Klinefelter syndrome, or those who have had radiation therapy, chemotherapy or childhood exposure to mumps virus, the testes may fail and not produce testosterone. Other hormonal causes of erectile failure include brain tumors, hyperthyroidism, hypothyroidism or disorders of the adrenal gland.

Orgasm Disorder

• Anorgasmia

Anorgasmia is classified as persistent delays or absence of orgasm following a normal sexual excitement phase in at least 75% of sexual encounters. The disorder can have physical, psychological, or pharmacological origins. SSRI antidepressants are a common pharmaceutical culprit, as they can delay orgasm or eliminate it entirely. A common physiological culprit of anorgasmia is menopause; one in three women report problems obtaining an orgasm during sexual stimulation following menopause.

• Premature Ejaculation

Premature ejaculation is when ejaculation occurs before the partner achieves orgasm, or a mutually satisfactory length of time has passed during intercourse. There is no correct length of time for intercourse to last, but generally, premature ejaculation is thought to occur when ejaculation occurs in under two minutes from the time of the insertion of the penis. For a diagnosis, the patient must have a chronic history of premature ejaculation, poor ejaculatory control, and the problem must cause feelings of dissatisfaction as well as distress the patient, the partner or both.

• Historically attributed to psychological causes, new theories suggest that premature ejaculation may have an underlying neurobiological cause which may lead to rapid ejaculation.
• Post-orgasmic Disorder

Post-orgasmic disorders cause symptoms shortly after orgasm or ejaculation. Post-coital tristesse (PCT) is a feeling of melancholy and anxiety after sexual intercourse that lasts for up to two hours. Sexual headaches occur in the skull and neck during sexual activity, including masturbation, arousal or orgasm.

Other factors

• In men, post orgasmic illness syndrome (POIS) causes severe muscle pain throughout the body and other symptoms immediately following ejaculation. The symptoms last for up to a week.
• POIS may involve adrenergic symptoms: rapid breathing, paresthesia, palpitations, headaches, aphasia, nausea, itchy eyes, fever, muscle pain and weakness and fatigue.
• The etiology of this condition is unknown; but it may present as anxiety relating to coital activities and thus may be incorrectly diagnosed as such. There is no known cure or treatment.
• Dhat syndrome is another condition which occurs in men. It is a culture-bound syndrome which causes anxious and dysphoric mood after sex, but is distinct from the low-mood and concentration problems (acute aphasia) seen in post orgasm illness syndrome.[1][3]

Sexual pain Disorder

• In men, structural abnormalities of the penis like Peyronie’s disease can make sexual intercourse difficult and/or painful. The disease is characterized by thick fibrous bands in the penis that lead to excessive curvature during erection.
• It has an incidence estimated at 0.4–3% or more, is most common in men 40–70, and is of uncertain cause.
• Risk factors include genetics, minor trauma (including that occurring during cystoscopy or transurethral resection of the prostate), chronic systemic vascular diseases, smoking, and alcohol consumption.
• Priapism is a painful erection that occurs for several hours and occurs in the absence of sexual stimulation. This condition develops when blood gets trapped in the penis and is unable to drain.
• If the condition is not promptly treated, it can lead to severe scarring and permanent loss of erectile function. The disorder is most common in young men and children. Individuals with sickle-cell disease and those who use certain medications can often develop this disorder.

Causes:

• Anxiety Disorder
• Panic disorder
• Aging
• Prostatic Trouble
• Injury to spinal cord

Sign & Symptoms of Sexual Dysfunction in Male

Diagnosis

• Detail history of patient regarding Surgical history, Chronic illness, other metabolic diseases such as DM, Hypertension, Hyperthyroid, Hypothyroid, etc.
• Physical Examination
• Systemic Examination
• Any sign of Anaemia, Blood Pressure, Cardiovascular Diseases, Thyroid examination, Neurological Examination.

Genital Examination

• Bulbo cavernous reflex
• Size of penis, scrotum, Testis.

Investigation of Sexual Dysfunction in Male

• Serum Prolactin
• Serum Testosterone
• Gonadotropins
• CBC
• Blood sugar level
• Lipid Profile
• Thyroid profile
• PSA [Prostate Specific Antigen]

Treatment

• Therapies currently employed for the treatment of ED include oral PDE-5 inhibitor therapy, injection therapies, testosterone therapy, penile devices, and psychological therapy.
• In addition, limited data suggest that treatments for underlying risk factors and comorbidities—for example, weight loss, exercise, stress reduction, and smoking cessation—may improve erectile function.
• Decisions regarding therapy should take into account the preferences and expectations of patients and their partners. [3]

ORAL AGENTS

• Sildenafil, tadalafil, vardenafil, and avanafil are the only approved and effective oral agents for the treatment of ED.
• These four medications have markedly improved the management of ED because they are effective for the treatment of a broad range of causes, including psychogenic, diabetic, vasculogenic, postradical prostatectomy (nerve-sparing procedures), and spinal cord injury.
• Several oral medications like Viagra, Cialis and Levitra have become available to help people with erectile dysfunction and have become first line therapy. These medications provide an easy, safe, and effective treatment solution for approximately 60% of men. In the rest, the medications may not work because of wrong diagnosis or chronic history.

ANDROGEN THERAPY

• Testosterone replacement is used to treat both primary and secondary causes of hypogonadism.

VACUUM CONSTRICTION DEVICES

• Vacuum constriction devices (VCDs) are a well-established non-invasive therapy.
• They are a reasonable treatment alternative for select patients who cannot take sildenafil or do not desire other interventions.
• VCDs draw venous blood into the penis and use a constriction Ring to restrict venous return and maintain tumescence.
• Adverse ejaculation. Additionally, many patients complain that the devices are cumbersome and that the induced erections have a non-physiologic appearance and feel.

INTRAURETHRAL ALPROSTADIL

INTRACAVERNOSAL SELF-INJECTION

SURGERY

• Surgical implantation of a semirigid or inflatable penile prosthesis.

Homeopathic Treatment of Sexual Dysfunction in Male

Homeopathy treats the person as a whole. It means that homeopathic treatment focuses on the patient as a person, as well as his pathological condition. The homeopathic medicines selected after a full individualizing examination and case-analysis.

which includes

• The medical history of the patient,
• Physical and mental constitution,
• Family history,
• Presenting symptoms,
• Underlying pathology,
• Possible causative factors etc.

A miasmatic tendency (predisposition/susceptibility) also often taken into account for the treatment of chronic conditions.

What Homoeopathic doctors do?

A homeopathy doctor tries to treat more than just the presenting symptoms. The focus is usually on what caused the disease condition? Why ‘this patient’ is sick ‘this way’?.

The disease diagnosis is important but in homeopathy, the cause of disease not just probed to the level of bacteria and viruses. Other factors like mental, emotional and physical stress that could predispose a person to illness also looked for. No a days, even modern medicine also considers a large number of diseases as psychosomatic. The correct homeopathy remedy tries to correct this disease predisposition.

The focus is not on curing the disease but to cure the person who is sick, to restore the health. If a disease pathology not very advanced, homeopathy remedies do give a hope for cure but even in incurable cases, the quality of life can greatly improved with homeopathic medicines.

Homeopathic Medicines for Sexual Dysfunction in Male:

The homeopathic remedies (medicines) given below indicate the therapeutic affinity but this is not a complete and definite guide to the homeopathy treatment of this condition. The symptoms listed against each homeopathic remedy may not be directly related to this disease because in homeopathy general symptoms and constitutional indications also taken into account for selecting a remedy.

Medicines:

Agaricus

• It is a best acting medicine in MSD.
• Furthermore, External itching of sexual organs.
• Frequent continued erections; additionally great desire for an embrace, with slight ability and insufficient seminal emission, every embrace followed by great debility and languor.
• Profuse night-sweats also sometimes burning itching of skin, complaints after sexual debauchees.
• Lastly, In women itching and irritation of pudendum, with strong desire for sexual intercourse; great selfishness, forgetfulness and indifference; very strong bearing-down feeling.

Agnus Castus 

• Diminished sexual instinct, after an embrace he feels easy and light.
• In detail, Complete prostration and impotence.
• Semen watery also deficient; penis so relaxed that voluptuous fancies excite no erections.
• Testes cold, swollen, hard also painful.
• Impotence, with gleet, especially with those who frequently had gleet; additionally pollutions from irritable weakness with prostatorrhoea; prostatic juice passes with hard stool.
• Premature old age in young person from abuse of sexual functions, with melancholy, apathy, mental distraction, self-contempt, general debility, also Spermatorrhoea of old sinners, though impotent,

Anacardium 

• Basically Sexual debility; nervous prostration following sexual emissions.
• Moreover, Weakness of memory and general temporary feebleness of brain- force; hypochondriasis, sullen mood, dread of labor.
• Difficult digestion; weakness of stomach, relieved by eating, but all the symptoms return in a few hours.
• Frequent urging to stool without being able to accomplish anything; discharge of prostatic fluid with the stool, also after emission of urine.

Argentum Metallicum

• Effects of onanism; seminal emissions; almost every night, without erection.
• Atrophy of penis.

Argentum nitricum

• Erections, but they fail when coition is attempted; embrace is painful, as if urethra were put upon a stretch and is sensitive at orifice.
• Want of sexual desire, the genital organs having shriveled; frequent nightly emissions, sometimes with lascivious dreams.

Aurum Metallicum

• Testes mere pendent shreds, either frequent nightly emissions or nightly erections without emission, or nightly erections and pollutions, without subsequent weakness.
• Discharge specifically of prostatic fluid from a relaxed penis, with settled suicidal melancholia in MSD.
• Lastly, Sterility from lowered vitality of the parts with great mental depression.

Baryta Carb

• Diminution of sexual desire also great weakness of the genital organs in persons addicted to the excessive use of stimulating drinks.
• Numbness of genitals; erections while riding, with impotence in MSD.
• Cloudy urine with yellow sediment; heaviness in small of back and loins.
• Small retracted testicles with pulsations between shoulders.
• Hypertrophy especially of prostate; sweat about scrotum.

Belladonna

• Increased sexual desire, with great inclination to masturbation.
• Nocturnal emission of semen, during relaxation of penis.
• Sexual desire decreased, weakness and relaxation of genitals; nymphomania, especially during pregnancy.

Berberis

• Suppressed sexual desire; during coition too weak also too short thrill, ejection too soon.
• Coldness and numb feeling in prepuce and glans; scrotum shrunken, cold, with pressure in testicles; too speedy ejaculation of semen, the desire is weak also soon passes away.
• Swelling and stitching-tearing pains in spermatic cords, pain extending down into testicles and especially to the epididymis.
• All in all, Suppressed sexual desire in women, with long-delayed thrill and often cutting and stitching in the parts during coition; vagina painful to touch.

Bufo Rana

• Longs for solitude, to give himself up to his vice; quick ejaculation, without thrill, with spasms and painful uneasiness of the limbs.
• Frequent nocturnal emissions, followed by debility; slow emission, or entirely absent; aversion to coitus; impotency.
• Imbecility with loss of all decency; masturbation or coitus causes convulsions, simulating those of epilepsy, usually followed by profound sleep; inclination to touch the genitals.

Calcarea Carb

• Bad effects of early masturbation, night- sweats follow every emission, or after marriage, every coitus is followed by weakness of mind and body.
• Increased sexual desire provokes emission, but unusual weakness follows indulgence, and ejaculation is tardy; burning and stinging while semen discharges during coition pressing pain in head and back.
• Lassitude and weakness in lower extremities; sweats easily.

Calcarea Phos

• Erections while riding in a carriage, without sexual desire; shooting through perineum into penis.
• Voluptuous feeling, as if all female genitals were filling up with blood, she feels all parts pulsating, with increased sexual desire; nymphomania just before menses and in young married people.

Cannabis Indica

• Satyriasis, erections while riding, walking, and also while sitting still, not caused by amorous thoughts.
• Violent painful erections; sexual desire increased in both sexes.

Cantharis

• Seminal emissions at night, followed by a disagreeable burning heat all over body.
• Great anxiety, heaviness, inability to sleep for the rest of the night; nightly emissions followed by shivering lasting for an hour or two and sleeplessness for that night.
• Partial blindness for an hour or two after an emission.
• Great despondency, inability to apply himself to work and thus life becomes a burden.
• Frightful satyriasis, violent painful priapism, discharge of blood instead of semen.
• Over sensitiveness of all female parts; pruritus, with strong sexual desire; itching in vagina; pernicious consequences of masturbation.

Carbo Veg

• Onanism during sleep; frequent pollutions without any sensation.
• Continual erections at night, without any voluptuous sensations of fancies.
• Seminal discharge too soon during coitus, followed by roaring in head; prostatic discharge while straining at stool.

Coffea

• Excessive sensitiveness about genitals especially vulva, with voluptuous itching; would like to rub or scratch, but parts are too sensitive.
• Male sexual organs much excited without seminal emission and with dry heat of body.
• Nocturnal emissions followed by great languor and irritability.

Conium

• Premature dementia, atrophy of testicles.
• Bad effects from suppressed sexual desire or from excessive indulgence.
• Painful seminal emission instead of the normal pleasurable thrill.
• Sexual desire without erection or with an insufficient one, pollutions, with subsequent excitement of the sexual desire, even when merely dallying with women.
• Discharge of prostatic juice during every motion, without lascivious thoughts.

Hyoscyamus

• In both sexes sexual desire excessive, lascivious, exposes pudenda.
• Excited sexual desire without excitement of the fancy; masturbation with smutty talk.
• Specifically indicated medicine for Sexual dysfunction.

Lachesis

• Onanism, with epilepsy.
• Nocturnal emission, with a thrill of delight.
• Excessive sexual desire, with constant erection at night; emissions, with profuse night-sweats; emissions, with cheerful disposition and feeling of ease on waking, succeeded by an increased mental concentration; semen has a pungent smell.

Lycopodium

• Mental, nervous and bodily weakness due to Sexual dysfunction.
• Impotence; penis small, cold and relaxed; erections feeble.
• Falls asleep during an embrace, excessive and exhausting pollutions; desponding, grieving, extremely sensitive.
• Weakness of memory; pale, wretched complexion.
• Weak digestion; the old man’s balm, strong desire, but cannot get up an erection.

Natrum Mur

• Deficient nutrition and dirty, flaccid, torpid skin.
• Genital organs smell badly and strongly; feeling of weakness in sexual organs,
• Sexual instinct dormant, with irrational emission during an embrace.
• Frequent nocturnal emissions in spite of frequent embraces; after sexual excesses physical weakness, even paralysis.
• Scrotum relaxed flabby, emission of prostatic fluid without erection when thinking of sexual things.

Nux Vomica

• Bad effects from early masturbation.
• Headache, backache, difficulty in walking due to Sexual dysfunction .
• Frequent involuntary emissions at night, especially towards morning.
• Bad effects from sexual excesses and abuse of liquors; easily excited desire, but during an embrace the penis becomes relaxed; increase of smegma.

Picric Acid

• It is best indicated medicine in MSD.
• Violent, strong, and long-lasting erections, with fear it would rupture the penis, followed by profuse seminal emissions.
• Great sexual desire; violent erections all night, preventing sleep.
• Great weakness and heaviness of lower limbs; impotence.
• Penis relaxed and shrunken; coldness of genitals.

Platina

• Satyriasis, sexual desire excessive, with violent erections, especially at night.
• Nymphomania, worse especially in the lying-in state.
• Either Tingling or titillation from the genitals up into the abdomen.
• Painful sensitiveness and continual pressure in the region of the mons veneris also genital organs.
• Besides this, Masturbation in young boys who have been seduced into it, embrace with little pleasure and very brief.
• All in all, Constant erections at night without seminal emissions, or often without amorous dreams.

Sarsaparilla

• Painful seminal emissions specifically at night; painful emissions, excited even in daytime without sexual feeling.
• Lascivious dreams with erections wake him up, with headache, prostration and vertigo.
• In detail, Inclination to coitus, with restless sleep and frequent emissions, spermatic cords swollen.
• Sexual excitement makes them ache and sensitive; besides this bloody pollutions; offensive odor about genitals.

Selenium

• Seminal weakness, with erethism also nervous exhaustion.
• Voluntary or involuntary seminal emissions are followed by irritability, mental confusion, headache.
• Almost paralytic weakness of spine.
• Involuntary escape of prostatic fluid, dribbling of semen during sleep and after stool also urination.
• Aggravation during the relaxation; impotence, lewd thoughts, but physically unable; erections slow, insufficient.

Diet & Regimen

For Sexual Dysfunction in Male

Diet:

Why it matters: A healthy diet supports optimal hormone levels, blood flow, and energy levels – all crucial for sexual function.

Focus on these:

Fruits and vegetables: These provide essential vitamins, minerals, and antioxidants that protect against cell damage and support healthy blood circulation, which is vital for achieving and maintaining an erection. Good choices include berries (antioxidant-rich), citrus fruits (vitamin C for circulation), leafy greens (nitrates for blood vessel function), and cruciferous vegetables.

Whole grains: Opt for whole-grain bread, pasta, brown rice, quinoa, and oats over refined grains. They provide sustained energy and fiber, which can help regulate blood sugar and improve cardiovascular health, important for overall sexual function.

Lean protein: Include poultry, fish, beans, lentils, tofu, and low-fat dairy in your diet. Protein is essential for hormone production, muscle health, and energy levels.

Healthy fats: Incorporate avocados, nuts, seeds (chia, flax, hemp), and olive oil. These fats are crucial for hormone production, including testosterone, which plays a key role in libido and erectile function.

Foods with potential benefits:

Watermelon: A good source of citrulline, an amino acid that converts to arginine in the body. Arginine helps relax blood vessels and improve blood flow to the genitals, potentially aiding in achieving and maintaining an erection.

Oysters: High in zinc, which is essential for testosterone production. Testosterone plays a key role in libido and sexual function.

Dark chocolate: Contains flavonoids, antioxidants that may improve blood flow and reduce blood pressure, potentially enhancing sexual function.

Leafy greens: Good sources of nitrates, which can enhance blood vessel function and improve circulation

Regimen:

Manage stress: Chronic stress can significantly impact sexual function by increasing cortisol levels, which can interfere with testosterone production and libido.

Stress reduction techniques: Include exercise, yoga, meditation, deep breathing exercises, and spending time in nature.

Exercise regularly: Aim for at least 150 minutes of moderate-intensity or 75 minutes of vigorous-intensity aerobic activity per week, along with1 strength training exercises two or more days a week.2 Exercise improves cardiovascular health, boosts energy levels, enhances body image, and reduces stress, all contributing to better sexual function.

Pelvic floor exercises: Kegel exercises can strengthen the muscles involved in ejaculation and may help with premature ejaculation.

Prioritize sleep: Lack of sleep can affect hormone levels, including testosterone, and lead to fatigue, low mood, and decreased libido. Aim for 7-9 hours of quality sleep per night.

Improve sleep hygiene: Establish a regular sleep schedule, create a relaxing bedtime routine, and optimize your sleep environment (dark, quiet, and cool).

Maintain a healthy weight: Obesity is linked to various sexual dysfunctions, including erectile dysfunction and low libido. Losing even a small amount of weight can have a positive impact on sexual function.

Limit alcohol and quit smoking: Both smoking and excessive alcohol consumption can negatively affect blood flow, damage blood vessels, and contribute to sexual health problems like ED.

Communicate with your partner: Open and honest communication about your needs, desires, and concerns can strengthen intimacy, reduce performance anxiety, and improve your sexual relationship.

Seek professional help: If you’re experiencing persistent sexual dysfunction, consult a doctor or therapist. They can help identify underlying causes, such as hormonal imbalances, medical conditions (like diabetes or heart disease), or psychological factors (like anxiety or depression), and recommend appropriate treatments or therapies.

Possible treatments: May include medication (like PDE5 inhibitors for ED), hormone therapy, therapy or counseling, or other interventions.

References use for Article Sexual Dysfunction in Male

1. Harrison-s_Principles_of_Internal_Medicine-_19th_Edition-_2_Volume_Set
2. Homoeopathic Therapeutics By Lilienthal
3. https://en.wikipedia.org/wiki/Sexual_dysfunction
4. Kumar, B. N. A., Mallanna, S., Raj, G. S., & Prasannakumar, D. R. (2014). Prevalence, typology and clinical correlates of sexual dysfunction among men with alcohol dependence syndrome. Indian Journal of Medical Research and Pharmaceutical Sciences, 4(3), 79-85.
5. Tiwari, S. C., Pandey, A., Singh, J. V., Pandey, N., & Pandey, A. R. (2018). Prevalence and correlates of sexual health disorders among adult men in a rural area of North India: An observational study. Journal of Family Medicine and Primary Care, 7(3), 515-521.  
6. Kaplan & Sadock’s Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry,  11th Edition, Benjamin J. Sadock, Virginia A. Sadock, Pedro Ruiz, 2015, Wolters Kluwer.
7. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5), 5th Edition,  American Psychiatric Association, 2013, American Psychiatric Publishing.
8. Campbell-Walsh Urology, 11th Edition, Alan J. Wein, Louis R. Kavoussi, Andrew C. Novick, Alan W. Partin, Craig A. Peters,  2015,  Elsevier.
9. The Merck Manual of Diagnosis and Therapy, 20th Edition, Robert S. Porter, Justin L. Kaplan, 2018,  Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc.
10. Smith’s General Urology, 18th Edition,  Emil A. Tanagho, Jack W. McAninch,  2013,  McGraw Hill Professional.
11. The 5-Minute Clinical Consult,  26th Edition,  Frank J. Domino, Robert A. Baldor, Jeremy Golding, Nancy P. Southall,  2023, Wolters Kluwer.
12. The Oxford Textbook of Sexual Health,  3rd Edition,  David L. Rowland, Mark A. Barratt, 2019, Oxford University Press.
13. The New Male Sexuality,  Revised Edition,  Bernie Zilbergeld, 2000,  Bantam Books.