Michael Perelman says there are a host of options out there, including alternative therapies, but it all depends on your sexual tipping point.

Question: What are the differences between Viagra, Cialis, and Levitra?

Michael Perelman: I am privileged, actually, to be an advisor to all three of these companies and there are remarkable similarities between these drugs because they are all in the same class of medication and they all work in the same way. Essentially they help blood accumulate in the penis by diminishing the outflow; it does not go back to the rest of the body quite as fast as it might otherwise. We walk around normally flaccid as men, without an erection, because there is an enzyme, phosphoridesterades [ph?] that degrades the potential for erection normally, so these drugs all block that enzyme. So it is as if you have pulled the plug in the bathtub and then you stuff it up with Kleenex and it kind of goes out more slowly. So if you have water coming in and the water is going out more slowly, the bathtub gets filled up quite nicely, and, in fact, would even overflow. So how do these drugs work? The drugs all work very similarly in that they affect that enzyme. Cyalis has a longer duration of action. What that means is it lasts from 24 to 48 hours verses the other drugs last a less long period of time. Because each of these molecules is unique, even though they are part of the same class of drugs, they have slightly different side effects. So while Levitra and Viagra would remain within the system, within the body, a shorter amount of time than Cyalis, in many cases that would be desirable and in some cases that would not be desirable, so this is important that the patient have a conversation with his physician as to really what’s best for them, and there are reasons to consider one drug over another as what to try first. In fact, Cyalis, for instance, has just been approved for daily dosing, so smaller amounts of the drug are used on a daily basis, almost like a male vitamin, to keep a certain level of arousal, capacity for arousal I should say in place with less side effect, and yet the other two drugs that are used on what is called a PRN basis and as needed basis, or do not last in the body as long a period of time. So the side effect profile, which is something that you do not see advertised on television and discussed in a serious way, is more, again, the stuff of late night jokes, long-lasting erections. The other aspects or side effects are something that you need to discuss with your physician, and that will help determine which drug is best for you, and that can be a trial and error experiment with some guidance from your doctor as to this notion of duration of action. Do you want a drug that has more availability for more spontaneity or do you want a drug that you know is going to work for you that you are comfortable using? And in that sense, Viagra, having been first to market, is many people’s choice only because, like Kleenex, we do not think of a facial tissue, we frequently will use the name Kleenex, the same has been true for Viagra, but there are definite advantages and sometimes superiority to the other drugs. It’s a complex answer to what would seem to be a simple question, but that’s why each person who is unique, go back to the sexual tipping point model, needs to discuss this with their physician.

Quesiton: What are the drawbacks to taking these drugs?

Michael Perelman: I think the biggest downside to these drugs is they can provide men with an erroneous sense of their level of arousal, which can cause its own problems.  So you take a drug like this and you find your body more responsive than it was, and that is a very good thing, but sometimes, for some men, this can cause difficulty in their relationships because they are really not being sensitive to their partner’s level of arousal.  So if she is responding normally for her, that may not be as quickly as it now is for him, being pharmaceutically enhanced, and that can cause some tension.  It changes the equilibrium in their relationship.  So relationship problems can sometimes occur as a consequence of the use of these drugs, and that’s really where I think there is a lot of opportunity for mental health professionals like myself, to help people learn how to learn these drugs in a way that enhances their life, if spontaneously that doesn’t happen already.  And we know half the people using these drugs are really very content and continue using these drugs; but we also know that half the people who try them choose not to continue using them for a variety of reasons, some of those reasons being side effects; some of those reasons being lack of efficacy, it does not work as well as they hoped; sometimes, though, it’s the negative impact it has on the relationship.  And then, finally, if a man thinks he is more aroused than he really is, he may find that it’s difficult to reach orgasm because he really is not that turned on to begin with.  He is pharmaceutically assisted in obtaining and maintaining his erection, and most of us, as guys, sort of think, well, if I have an erection, I must be turned on, but in reality, that’s not true, being turned on, if you will, is a very complex psycho physiological process; it is in the mind and the body again, back to that sexual tipping point.  So you are turned on, you think, because you have an erection, and yet you’re really not as turned on as you might be so you have difficult reaching orgasm, and that can become very distressing, both to the man and his partner, and I have seen a slight increase in that particular problem both with our aging population and with men using these drugs.

Question: Can alternative therapies cure sexual dysfunction?

Michael Perelman: Sure.  I try and find, you know, really a lot of what I do, I think of myself sometimes as a  detective.  I am asking questions, detailed questions, about whatever the presenting problem is that someone suggests to me that they are concerned about.  And it’s in the asking of these questions I find the most amazing answers and solutions because we have a society that, in general, has not looked at this in detail in this kind of precise way.  While men, we kidded around sex, for years, you know, locker room jokes, and women would talk to their friends perhaps even more than men did about their sex lives, detailed questions and answers, which is the way that you solve any problem, was not done.  So, in my office, I ask very specific questions.  It is not out of prurient interest, but the way you solve problems is you find out what is going on.  I am also going to find out what else helps you relax, so if historically you have taken walks or you have jogged, and that helps you feel good and keep in shape, I am going to encourage you to do that.  If meditations works for you historically, I’ll encourage you to go back to that, because frequently, if somebody is having a central problem, they become depressed and anxious and they stop doing a lot of things that have been helpful and healthy to them.  So when I talk about things like this, people will frequently say, “Oh, I’ve done that already, it didn’t help.”  But we’ll talk about you have to get all ten of your ducks lined up facing the same direction, you can’t just try getting a good night’s sleep, oh, that didn’t make a difference, and cutting down on your alcohol, that did not make a difference, you need your cut down on your alcohol, be more careful, be more in tune with what you are experiencing.  Now, an interesting movement within mental health in general is this whole notional of mindfulness, sort of an integration of East/West philosophy, and the same thing can be true of sex.  If you think again of that sexual tipping point, sexual fantasy, which could be erotic thoughts about others, but it could just be remembering the best time that you had with your wife two years ago.  It does not have to be about other people.  Sexual fantasy can also be being in the moment and eroticizing your experience, being aware of what you are feeling that feels good and being able to screen out distraction so, you know, the siren goes off on the car that just got bumped outside, you hear the garbage truck going by, you know, some kids are laughing or a dog is barking, that you are able to keep your focus on the sexual experience and not be distracted, and there are all kinds of ways of learning how to do that that are really very similar to other ways we learn how to discipline and control our mind.  It’s just people don’t think about that as necessary, because when they were younger, they did not have to think about all these things, it just worked in much the same way as when I was younger I didn’t have to stretch before I played tennis, it did not matter; but now I better do that or I am going to get hurt.