Sexual Health

Men’s sexual health is one of those topics where the medicine is mostly straightforward and the conversation is mostly impossible. The biology is well-mapped. The drugs work. The referral pathways are clear. What gets in the way is the fifteen years a guy waits before bringing it up, and then the ninety seconds his primary care doctor spends on it before refilling his lisinopril and moving on.

In clinic I see this almost weekly. A man comes in for “low mood” or “stress” or because his wife told him to, and somewhere in the third visit, when he trusts the room enough, the actual problem arrives. He hasn’t had a reliable erection in two years. Or his libido fell off a cliff at 47 and he’s been quietly assuming this is just what aging is. Or he’s been on Zoloft for eight years and nobody told him the reason he can’t finish anymore is the medication.

None of this is exotic. Most of it is fixable or at least negotiable. The piece that takes work is getting the information out of him in the first place.

Erectile dysfunction: the morning-erection question tells you almost everything

The first useful split in ED is vascular versus psychogenic, and the test for it is embarrassingly simple. Are you waking up with erections? Are you getting erections with masturbation or in non-pressured situations? If yes, the plumbing works. The problem is somewhere upstream: anxiety, relationship dynamics, performance pressure, depression, a head full of work. If no, if the morning erections have quietly disappeared over the last year or two and you can’t get one going by yourself either, then you’re looking at a vascular or endocrine problem and we need to actually work it up.

This matters because the workup splits hard at that fork. Psychogenic ED responds to sildenafil or tadalafil sometimes, but the real fix is therapy, treating the underlying depression or anxiety, and often just taking the performance loop off the table for a few months. Vascular ED is a cardiovascular signal. The penile arteries are small. They clog before the coronaries do. A 52-year-old with new-onset organic ED and a family history of heart disease needs a lipid panel and a frank conversation with his PCP, not just a Viagra prescription. ED is sometimes the first symptom of cardiovascular disease that anyone notices, by a margin of three to five years.

Then there’s the medication-induced version, which is its own category and gets missed constantly. Beta blockers. Thiazide diuretics. Finasteride. SSRIs and SNRIs, which I’ll get to. Spironolactone. A guy on three of these at once and wondering why his sex life is gone isn’t a mystery. He’s a pharmacology problem.

Low libido and the testosterone story that’s mostly oversold

Patients walk in convinced their testosterone is the issue. Sometimes it is. More often it isn’t, and the TRT clinic on the strip mall corner has done a really effective job convincing a generation of men that every problem in their forties is a low-T problem.

Real hypogonadism exists. Total testosterone under 250 ng/dL on a morning draw, confirmed on a second draw, with symptoms that fit, gets treated. But the bigger drivers of low libido in middle-aged men, in my experience, are depression, relationship attrition, sleep apnea, alcohol use, chronic stress, and antidepressants. Testosterone is downstream of most of those. You can hand a guy a tube of AndroGel and his number will go up, but if the underlying issue is that he hates his job and sleeps five hours a night and his marriage has been brittle for a decade, his libido isn’t coming back from a hormone.

I had a patient last spring, 51, came in asking for TRT. He’d done one of those direct-to-consumer panels, his free T was low-normal, and he was sure that was the explanation. He drinks three or four nights a week. Hadn’t exercised in two years. His wife had brought up separation in March. Sleeping in fragments. I told him I’d recheck his labs in three months if he cut alcohol to one night a week, got his sleep to seven hours, and started couples therapy. He was annoyed. He came back four months later with his testosterone in the high-500s and a marriage that was at least talking again. That’s what happens when you address the actual problem.

Most low-libido in middle age is a life problem wearing a hormone costume.

The SSRI conversation almost nobody is having

This is the one that bothers me most. Sexual side effects from SSRIs and SNRIs are common, well-documented, and routinely not discussed. The numbers in the literature are somewhere between 30 and 70 percent depending on the drug and how you ask. Paroxetine and sertraline are usually the worst. Escitalopram and citalopram are roughly in the middle. Bupropion and mirtazapine are the cleanest, which is why they end up being the workaround for a lot of patients.

Two things keep this buried. Clinicians don’t ask, because the visit is fifteen minutes and the depression is the headline. Patients don’t volunteer, because they’re embarrassed, or they assume it’s the depression itself, or they don’t want their psychiatrist to take them off the medication that’s finally keeping them functional. So both sides agree to not bring it up, and the patient quietly stops taking the medication six months later and ends up back in a crisis nobody saw coming.

The honest conversation, when I have it, sounds like this: yes, this medication may flatten your libido or make it hard to climax or both. There are options. We can switch to bupropion. We can add bupropion. We can lower the dose. We can try a drug holiday on weekends (sometimes works, sometimes doesn’t, and not for paroxetine). We can switch SSRIs. We can accept the tradeoff for a year while the depression heals and revisit. The point is that the tradeoff is yours to make and you should know it exists. There is also a small subset of patients who develop persistent sexual dysfunction that outlasts the medication, called PSSD, and that’s a real entity that the field has spent too long pretending isn’t real.

Premature ejaculation, Peyronie’s, and knowing who treats what

Premature ejaculation is usually treatable and almost never talked about. Topical lidocaine, SSRIs at lower doses than depression dosing (paroxetine 10-20mg or sertraline 25-50mg, often dosed on-demand), behavioral techniques. The data on SSRIs for PE is actually quite good. It’s one of the few cases where the sexual side effect is the point.

Peyronie’s disease, the curvature and plaque condition, is straight-up urology. Not psychiatry, not PCP. If a man describes new curvature, palpable plaque, painful erections, or significant change in penile shape, he needs a urologist. Same for any hematuria, scrotal masses, or testicular pain. I will sometimes co-manage the psychological piece, because Peyronie’s wrecks men psychologically, but I’m not the one driving the treatment plan.

The bigger problem is that men don’t talk

The clinical stuff above is the easy part. The harder part is that a lot of men will read this, recognize themselves, and still not bring it up at their next appointment. They’ll mention their knee, their reflux, their blood pressure. Not this. The cost of that silence is years of quietly diminished life, and depressions that get worse because the medication that was helping is also gutting something they care about and nobody asked.

If you’re sitting on something in this category, write it down before the appointment so you actually say it. A doctor who’s any good won’t be surprised and will have heard a version of it earlier the same week. The thing you’re hesitant to say is one of the most common reasons men over 40 are in our offices in the first place.