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Epidemiology

Confessions from the alcove

Erectile dysfunction may be the first sign of coronary diseases

Some of the most intimate secrets of men and women are coming out from underneath the sheets. In Brazil, one in every two men over 40 years old is subject, with lesser or greater intensity, to a normally embarrassing situation called, in medical language, erectile dysfunction, or, in the ordinary sense, impotence. Almost half of these cases consist of slight forms, which ought not awaken any greater concern as they are passing episodes, that can be turned around spontaneously, without any greater organic or psychological repercussions. The problem lies with the other half: the moderate or serious cases, which really could need treatment, for representing “a sentinel for other diseases”, in the words of Edson Duarte Moreira Júnior, a physician-epidemiologist of the Oswaldo Cruz Foundation (Fiocruz) in Salvador. Since 1998, he has been working on researches that dimension the scope and the consequences of this and of other male sexual problems in Brazil and in the world.

Were it not enough by itself, for causing psychological upsets that can foster depression, besides potentially corroding conjugal, family and social relationships, the more severe cases of incapacity for an erection may reflect deficiencies of the circulation of the blood – if not treated in time, they may lead to a heart attack. “Erectile dysfunction can be the first sign of coronary diseases”, warns urologist Archimedes Nardozza, a professor from the Federal University of São Paulo (Unifesp). The explanation is simple: the arteries of the penis, relatively small in comparison with the coronaries, which irrigate the cardiac muscle, may make erection difficult, even with low quantities of fat blocking the arrival of blood into the compartments of the penis called cavernous bodies, which led to an erection as they fill up.

The risk of a man with impotence showing an accumulation of fat in the arteries is up to 2.5 times greater than that of a sexually normal man, according to a survey carried out in São Paulo with 287 participants (137 with dysfunction and 150 without). “And the severer the erectile dysfunction is, the greater the risk of coronary problems”, comments cardiologist Juarez Ortiz, the coordinator of this study, which came out in October 2005 in the Arquivos Brasileiros de Cardiologia [Brazilian Cardiology Archives] magazine.  On January 23 of this year, the Archives of Internal Medicine magazine published a similar work, signed by James Min, of the University of Chicago, United States, comparing the general state of health of 121 men with erectile dysfunction with that of another 100 without it. In this work, 44% of the men with dysfunction showed coronary problems, found in only 17% of those who were sexually normal.

The American study went a little further and showed a relationship between the most common male sexual disorder with lower activity and physical resistance. According to this work, incapacity for erection could be even more effective than the risk factors habitually evaluated, such as cholesterol levels, blood pressure or family history, for an early indication of when the arteries have lost their capacity for carrying blood in the quantity and at the speed needed for the good working of the heart.

This association can be understood, because the reasons that lead to the difficulty for an erection are the same that led to coronary diseases: obesity, hypertension and diabetes. In these two studies, diabetes was at least 2.2 times more frequent, and hypertension 1.5 times, in men with erectile dysfunction than those in the other group. The association between coronary problems and the incapacity for an erection also emerges from one of the largest epidemiological survey in this field ever done in a country: the Avaliar project. In a task force, 4,377 doctors interviewed 71,503 men with a minimum age of 18 years in 380 cities from 24 states in Brazil. Carried out between August 2002 and January 2003, Avaliar showed that the incapacity for an erection – slight, moderate or severe – went up from 47% in men with normal blood pressure to 73.5% in those with severe hypertension, and from 48.2% in men of normal weight to 60.7% in obese men.

From this numerical aridity, one conclusion emerges that may be very useful. “To prevent erectile dysfunction, it should be enough to act on the risk factors for coronary diseases, like obesity, hypertension, a sedentary life and diabetes”, Nardozza says. In isolation, he recalls, diabetes is the main cause of this male debility, by virtue of its two effects: it damages both the blood vessels and the nerve endings in the penis. That is why men with diabetes are those that benefit least from the medicines against erectile dysfunction, in chemical terms called phosphodiesterase inhibitors. By containing the action of the phosphodiesterase enzyme and keeping the nitric oxide in circulation for longer, this compound stimulates the flow of blood and dilates the arteries of the penis, but cannot do anything against nerves destroyed by the excess of sugar in the organism.

The difficulty for an erection is regarded as a consequence of the gradual blockage of the blood vessels, but it may also be both a cause and a consequence of depression, the most common psychic imbalance with which it is associated. A study published in the Journal of Affective Disorders in 2004 shows clearly this two-way relationship. A team coordinated by Alfredo Nicolosi, a researcher from the Institute for Biomedical Technologies, in Milan, Italy, interviewed 2,417 men in Brazil, Italy, Japan and Malaysia. Of this total, 2% showed an already-diagnosed depression, but 21% showed depressive symptoms, such as prolonged sadness without a real reason. Depression was more common amongst the younger men who showed erectile dysfunction and nurtured a greater expectation of a normal and healthy sex life.

Women
It is estimated that in the whole world 150 million men over 18 years old suffer from the slight, moderate or severe forms of erectile dysfunction. In Brazil, about 11 million individuals live who in the 12 months prior to the survey, for at least two months running, showed a difficulty for erection. The slight form predominates, which corresponds to 26.6% of the total and in the majority of cases should not be a cause for concern, for being transitory and not affecting health. But the moderate form is equivalent to 18.3%, and severe form to 3.5% of the total – these two are in fact worrying, for the possibility of signposting circulatory or cardiac problems. According to Moreira Júnior, 1 million new cases of this kind of male sexual disorder should arise in Brazil every year. But the lack of an erection, he reminds us, can only be considered a sexual disorder when it makes life difficult or hinders conjugal or social relations.

It is not just the incapacity for an erection that sounds like a threat to virility. In statistical terms, one in every four men should show in the course of his life at least one sexual disorder – from the lack of desire to premature ejaculation, not always with more serious consequences for health. Amongst women, one in every five may face the lack of desire or orgasm – and two in five may be struck by some kind of difficulty connected with sexuality, something that also does not go so far as being necessarily pathological. With small variations, this picture is to be seen in other countries as well, according to studies that became more frequent after 1998, when the first oral medicine against erectile dysfunction, Viagra, appeared.

The blue pill and, next, its competitors, Cialis and Levitra, besides their more evident benefits, took out of the alcove the sexual problems – to start with, only the men’s, with, with time, women’s too. By replacing the painful treatments hitherto adopted, based on elastic bands or injections applied into the penis, these medicines have made it possible for men to recognize their frustrations and throw themselves once again into a quest for desires that they had left aside. The incapacity for having or for maintaining an erection in a satisfactory manner during a sexual relation then ceased to be seen merely as an occasional accident, which ought only worry men over 70 years old. A totally different scenario was constructed, in which the difficulty in hardening the male sexual organ has emerged as a phenomenon disseminated all over the world, despite ethnic, geographic or cultural  diversities, more common and severe with the advance of age.

These discoveries are part of the Global Study of Sexual Attitudes and Behaviors, probably the most wide-ranging survey ever done in this area, with the same methodology for gathering information applied to 13,882 men and 13,618 women, interviewed in 29 countries. This work was funded by the manufacturer of Viagra, Pfizer, which also sponsored Avaliar, without imposing limitations on the autonomy of the researchers – it was an unconditional grant, as attested in the scientific articles in which the results obtained were made public. The studies about the situation of each country – and Brazil is one of the first countries to publish its results – began to come out last year, after the stage of global analysis of the results obtained.

The interviews, which recorded the population trends in each country, indicate that 28% of the world’s men and 39% of its women show some sexual problem, considering only the moderate and severe forms. Studies of this kind, psychiatrist Jair Mari, a professor from Unifesp, reminds us, are usually essentially descriptive, “lacking the medical, social and cultural context”. They do not take into consideration the simultaneous occurrence of other organic imbalances or the use of medicines that could be associated with the difficulty for an erection, nor the life stories or the circumstances that could explain it, much less intriguing behaviors of women like Séverine, the central personage of Belle de Jour, a film from 1967, directed by Luis Buñuel. Interpreted by Catherine Deneuve, Séverine loves her husband, but only manages to liberate herself sexually with the men she encounters every afternoon in a brothel.

To avoid inflated figures and alarmist results, Moreira Júnior stresses, though, that this survey sought to take into consideration the simultaneous occurrence of other problems of health and personal circumstances, such as unemployment or the death of relatives, which may interfere temporarily with the sex life. According to him, the questionnaires were prepared and analyzed, not only by physicians, but also by statisticians, sociologists, anthropologists and psychiatrists.

Parallel universes
Many results still have to be interpreted, but they already quantify potential sources of dissatisfactions in the sex life, like premature ejaculation, found in 14% of men worldwide. With representatives from populations from the most varied cultures and ethnic origins, these surveys also make known the dimensions of the problems of female sexuality, the causes and consequences of which – the researchers themselves recognize – are still less studied than the masculine ones.

Amongst women, the lack of sexual interest is the most common complaint, reported by 21% of those taking part in these studies, while the incapacity for reaching an orgasm and the difficulties of vaginal lubrication showed up in equivalent proportions, each one of them to be found in 16% of the female public. Oddly enough, the most common difficulties in women were the least common in men: only 9% of the men reported a lack of interest for sex, less than twice that observed in the female public. Amongst the women, 15% commented that sex was not a pleasurable activity – only 6% of the men gave the same reply.

Gynecologist Eleonora Bedin Pasqualotto, a professor from the University of Caxias do Sul, in Rio Grande do Sul, attributes these differences to the contrasting visions of men and women about their own bodies and the sexual roles they believe they must perform. “Women give more attention than men to the perception of themselves, they usually let themselves be carried away by stereotypes of female beauty and value the whole body”, she says. When they feel fat or ugly in front of the mirror, even if they are not, they may draw away from their partner, rein back desire and merely cultivate the memories of the long nights of love. “Men, though, seem not to be taken aback when they see themselves in the mirror, even though the transformations brought about by age are already evident, and are only worried about their sexual performance.”

The obsession with sexual performance helps one to understand why, in Brazil, men buy 1.18 million pills a month against impotence. Brazil is one of the largest consumer markets in the world of these medicines, criticized for feeding in men, even those who are starting their sex life, the fear of failing at a moment when, they believe, erection is an obligation, a pressing proof of masculinity. On a board set up in front of a pharmacy at the entrance of the State University of Campinas (Unicamp), the first medicines announced to a predominantly young public are precisely those against impotence. For some time, their consumers have no longer the men who really need treatment against erectile dysfunction. Mari, though, suggests more care: “Premature and prolonged use may generate insecurity and psychological dependence”.

Prejudices
In a study published last year in the Clinics magazine, Eleonora Pasqualotto comments that, in women, the manifestations that could been seen as sexual dysfunctions may, in actual fact, signpost dissatisfactions with life itself or with the conjugal relationship, besides expressing a psychic defense mechanism resulting from traumatic sexual experiences. Furthermore, she reminds us, social prejudices still seem to persist, likewise leading to the blockage of desire and difficulty to respond to sexual stimuli. With the birth control pill, women distanced themselves from the fear of getting pregnant every time they had a sexual relation, but they have not freed themselves from the weight of the social stigmas and of a model of social behavior according to which the sexual initiation of men is stimulated and reinforces virility, whereas in women it is curbed – if not, it will lead to debasement and promiscuity.

The result is anxious men and dissatisfied women. Amongst the representatives of 29 countries, Brazilian men showed the second highest level of premature ejaculation (30%), which reflects the concern with performance and with sexual stereotypes, ranking behind only the Spaniards (31%). It was an unexpected result, the effects of which can already be outlined: “Men are frustrated, but they get used to premature ejaculation”, Moreira Júnior says. “Women are much more frustrated.”

Premature ejaculation is not the only reason for female discontent. Brazilian women are the ones that proved most unsatisfied with the duration of the preliminaries to the sex act: until now, 22% of Brazilian women, almost twice the world average, would like the preliminaries to last longer. Worldwide, almost all the participants (92% of the men and 91% of the women) consider physical contact and caresses as very important, even without a sexual relation.

For Moreira Júnior, these results are important for two reasons: for showing that women are expressing their frustrations, and for indicating that men, as a consequence of the macho culture, are not as concerned as they ought to be in fully meeting the women’s expectations. They also suggest, for Jair Mari, a narrow vision of the sex act, focused on penetration, with little attention to erotic games and to the possibility of exploring the partner’s body. “People lose the opportunity of developing sexually that way”, he says.

Even though the quality may be no great shakes, the quantity calls attention. According to these studies, Brazil is the country in which sex is practiced most frequently: 74% of the people from 40 to 80 years old have sexual relations at least once a week – the world average is 50%. “We have to see first of all whether the Brazilian are not also those who lie most”, says Moreira Júnior. “It’s hardly probable.” According to him, the data is trustworthy because the interviewers made interviewees feel relaxed and emphasized the importance of honest replies.

The results could initially be explained by the fact that Brazil is a country with a younger population than that of the Northern Hemisphere, such as the United States and the countries of Europe, which accounted for the major part of the interviewees. The researcher from Fiocruz believes that a more consistent interpretation ought to take into consideration as well the weight of the culture, the history and the climate. “In tropical countries”, he says, “there tends to be a greater cult of the body, which is more on view, fostering sensuality and sexuality”.

One taboo overturned with these international surveys is that sexual activity does not come to an end with the gray hair of the parents or grandparents: according to these surveys, 69% of the men and 40% of the women keep themselves sexually active after the age of 60. “Sexual activity diminishes with age, it’s natural, but it doesn’t disappear abruptly, as people usually believe”, he comments. “Perhaps some people do not have more sexual relations after the age of 60 simply because they no longer have partners.”

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