Sexual problems in gay men

Why are these important?

It may be very difficult for a gay man to admit to having any problems with sex. After all, our sexuality is part of what makes us gay men. It is a myth that we are all sexual athletes, always ready for sex and always able to perform at a moment’s notice. But because this false view exists, we tend to measure ourselves against it.

If something goes wrong, some men feel they are ‘letting the side down’ if they ask for help. Asking for help with a sexual problem is the same as asking for help with any other medical problem and our needs are as important as anyone else’s.

What is erectile dysfunction?

Erections are funny things. When we were sixteen they seemed to happen all the time, even when they were not wanted. As we get older they don’t always appear, even when we want one most. Almost every man experiences a time when their erection is less strong than they would like, but sometimes it becomes a problem.

Erectile dysfunction (ED) is when you are unable to get or keep an erection suitable for sexual intercourse or another chosen sexual activity. If your erection is never OK (either with a partner or with masturbation, and is never there when you wake up), then it is likely to be a physical problem (in the body). If your erections are fine except with a partner, then it is more likely to be a psychological problem (in the mind). Often people have a combination of physical and psychological issues, which together cause problems.

Physical causes of ED include diabetes, multiple sclerosis and problems with the blood supply to the penis (importantly this may mean the blood supply to the heart will also be affected in the future, so if you have ED, it is wise to see your GP for a general health check.) Occasionally there is a problem with the male hormone, testosterone, especially

in older men. Drugs, both ‘prescribed’ and ‘recreational’, are a common cause of erectile difficulties (see our factsheet ‘Erectile dysfunction’).

Having a psychological problem with sex does not mean that there is anything else wrong with your mental health. Help is available for both the physical and psychological causes of sexual problems.

What are the medical treatments for ED?

There are drugs that can help with erection difficulties. Oral treatments (tablets) are called phosphodiesterase (pronounced phos- pho- di- es- ter- ase) inhibitors (PDE5i). They include sildenafil (Viagra®), tadalafil (Cialis®), vardenafil (Levitra®) and avanafil (Spedra®). They work for many men but will not cause an erection unless the man is mentally AND physically stimulated (see our factsheet ‘Oral treatment for erectile dysfunction’).

Men who have less firm erections may find their condom slips off. A PDE5i may help prevent this (and make sex safer) by producing a firmer erection.

You should not take a PDE5i if you are taking a medicine that contains nitrates, because this combination can cause the blood pressure to drop too low. Such medicines include sprays for angina, some tablets for the heart and the recreational drugs known as ‘poppers’ (Amyl nitrite)). Because ‘poppers’ may be used in a confined environment (such as a sauna) by someone other than the PDE5i user, the effect of the chemical spreading through the environment could potentially affect the PDE5i user. PDE5i should only be prescribed by a doctor who will take your health and other medications into consideration. Do not buy medicines online – they may be fakes!

A drug called alprostadil (which is the same as a chemical that the penis produces naturally when it becomes erect) can be injected into the shaft of the penis. This allows more blood to flow into the penis and get trapped there, which helps you get and keep an erection. Injection therapy is very successful in those men who do not respond to tablets. Two alprostadil products are currently available for injection – Caverject® and Viridal®.

Invicorp is another type of injection therapy used to treat ED. It contains two active ingredients (aviptadil and phentolamine mesilate); one increases blood flow to the penis to get an erection while the other traps the increased amount of blood in the penis to keep the erection. Invicorp may work well for men who have found little success with other ED treatments and some may find it less uncomfortable to use than alprostadil injections.

Another option is to insert a pellet (MUSE®) that contains alprostadil into the urethra (the tube through which you pass water) after urinating. The pellet dissolves and gives you an erection.
Alprostadil can also be used topically as a cream (Vitaros®) which is applied to the penis.
For more information on injection, urethral and topical treatments for ED, see our factsheet ‘Injection, urethral and topical treatments for erectile dysfunction’.

Vacuum pump devices draw blood into the penis to get an erection, and it is trapped there with a special ring at the base of the penis to keep the erection. These devices suit some people well (see our factsheet ‘Vacuum pump treatment for erectile dysfunction’).

Testosterone replacement therapy (TRT) may be required if you are found to have low levels of this hormone (see our factsheet ‘Testosterone deficiency’).

Surgically implanted devices, which strengthen the penis from inside, are available for the very few people for whom producing an erection is not possible in any other way.

What are ejaculation problems?

Difficulties controlling when you ejaculate or ‘come’ are increasingly common. Ejaculating too quickly is called ‘premature ejaculation’ (PE) and when it takes longer than you would like it to it is called ‘delayed ejaculation’ (DE). DE has been considered a rare problem, but it is being seen more often in gay men referred to specialist clinics.

Retrograde ejaculation is where you may not see any fluid (semen) after orgasm. If this happens, you may also have noticed that when you first pass water after intercourse it is cloudy. This is because the semen is being expelled backwards into the bladder. Anejaculation is when you get the sensation of ejaculation but you don’t ejaculate at all.

For more information, see our factsheet ‘Ejaculation problems’

What are problems with sexual desire?

A lack of sexual desire (or ‘sex drive’) is often described as a loss of libido. Occasionally ‘going off’ sex has a physical cause, such as low testosterone. If so, it can then usually be treated by a doctor. But if the initial tests are ok, it may be best treated by sex therapy (see the following section on ‘Sex therapy). If you have a regular partner it is often useful if he goes to some of the clinic visits with you.

What is sex therapy?

Sex therapy is talking therapy where an individual or couple work with an experienced therapist to assess and treat their sexual and/or relationship problems. Together they will identify factors that trigger the problems and design a specific treatment programme to resolve or reduce their impact.

Sex therapy is considered highly effective in addressing the main causes and contributing factors of sexual difficulties. And it helps people to develop healthier attitudes towards sex, improve sexual intimacy, become more confident sexually, and improve communication within the relationship.

Sex therapy can also be used in combination with other forms of treatment. Your GP or another health professional on the NHS may be able to refer you for sex therapy (depending on area), or you can contact a therapist directly and pay privately. It is important to make sure that they are qualified and are registered with an appropriate professional body. You can find more information on sex therapy in our factsheets ‘Sex therapy’ and ‘How to find, choose and benefit from counselling support.’

What about recreational drug use and sex?

There are increasing concerns about the link between ‘club drug’ use and high-risk sexual behaviours in a small number of gay men. This includes ‘chemsex’.

In the UK, the term ‘chemsex’ is used to describe consensual sex while under the influence of psychoactive drugs, mostly among gay men. This mainly involves the use of mephedrone, gamma-hydroxybutyric acid (GHB), gamma-butyrolactone (GBL) and crystal methamphetamine (crystal meth). These drugs may be used alone or in combination to fuel sex sessions lasting several hours or days with multiple partners.

There are serious health implications with this type of behaviour. You may become physically or psychologically dependent on the drugs. You may require treatment for mental health effects and/or drug treatment to support detoxification. You may take an overdose by mistake. Different drugs may interact with each other or with alcohol. Not sleeping or eating for days may harm your general health and wellbeing. Injecting drugs increases the risk of contracting HIV and hepatitis C, and unprotected sex (particularly with different partners) increases your risk of these and other sexually transmitted infections (STIs).

Gay men who are worried about their mental or physical health following ‘chemsex’ may delay or avoid accessing professional support due to fears of being judged or the person they see having a lack of knowledge about this practice. If you don’t want to talk to your GP, you can ask them to refer you to a sex therapist or a substance misuse treatment service or you can contact these yourself. See the previous section on ‘Sex therapy’ for more information on this. You can find information about local drug treatment services on the Frank website www.talktofrank.com Genito-Urinary Medicine (GUM) clinics/departments may also be able to help you, particularly if you are worried that you might have caught a STI (see the following section on ‘Where can you get help for sexual problems’?).

Where can you get help for sexual problems?

Most people with sexual problems are advised to seek help from their GP first, but many Genito-Urinary Medicine (GUM) clinics/departments can offer help. They should at least be able to direct you towards whatever services are available. Their details can be found on the British Association for Sexual Health and HIV (BASHH) website www.bashh.org

Finding good quality care that is also ‘gay friendly’ can be difficult. If you choose to find a sex therapist through gay media, make sure they are qualified and are registered with an appropriate professional body (see the previous section on ‘Sex therapy’)

What is the Take Home Message?

Sexual problems may be a warning sign of other health problems – heed the warning and get checked out

Where can you get more information?

The Sexual Advice Association is here to help. We cannot give individual medical advice, but we can answer your questions on any sexual problems and put you in touch with local specialist practitioners. We also have a number of factsheets and booklets on sexual problems and related issues for men and women that can be downloaded from our website or requested. Please feel free to email us or phone our Helpline (our contact details are at the bottom of this page).

You can also visit the NHS Choices website at www.nhs.uk for information and advice on many different health and lifestyle topics.

Further reading

Download our booklet ‘Sex and the heart’ and/or our factsheet ‘Explaining sexual problems to your GP’

Donate

By donating to the Sexual Advice Association, you will know that you are helping improve the lives of people living with sexual problems. If you are interested in donating, please click here or contact us for more information (details at the bottom of this page).

Thinking About Sex Day: February 14th

Launched by the Sexual Advice Association, Thinking About Sex Day (TASD) is designed to encourage everyone to think about the physical and psychological issues surrounding sexual activity.

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