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Internationally renowned, Dr. Michael Perelman is Co-Director, of the Human Sexuality Program, New York Presbyterian Hospital. He is a Clinical Professor of Psychiatry, Reproductive Medicine, and Urology at Weill Medical College, Cornell University. A National Institute of Health Fellow, he received his MS, M.Phil. and Ph.D. degrees in clinical psychology from Columbia University--where he wrote the first sex therapy doctoral dissertaion in Columbia's history in 1976.
Dr. Perelman's clients, experience common sense advice filtered through the wisdom of over 30 years of clinical practice. Dr. Perelman has been invited to present his Sexual Tipping Point model at professional meetings around the world and has published widely in the professional literature. He is frequently quoted and often featured by the media.
Besides private practice, Dr. Perelman serves on multiple professional society,editorial, and industry Advisory/Directors Boards. He is the Past-President of the Society for Sex Therapy and Research. His research interests are integrating the use of sexual pharmaceuticals with sex counseling to provide better risk/benefit for men and women suffering from sexual problems.
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.
Michael Perelman says there are a host of options out there, including alternative therapies, but it all depends on your sexual tipping point.
Higher education faces challenges that are unlike any other industry. What path will ASU, and universities like ASU, take in a post-COVID world?
- Everywhere you turn, the idea that coronavirus has brought on a "new normal" is present and true. But for higher education, COVID-19 exposes a long list of pernicious old problems more than it presents new problems.
- It was widely known, yet ignored, that digital instruction must be embraced. When combined with traditional, in-person teaching, it can enhance student learning outcomes at scale.
- COVID-19 has forced institutions to understand that far too many higher education outcomes are determined by a student's family income, and in the context of COVID-19 this means that lower-income students, first-generation students and students of color will be disproportionately afflicted.
What conditions of the new normal were already appreciated widely?<p>First, we understand that higher education is unique among industries. Some industries are governed by markets. Others are run by governments. Most operate under the influence of both markets and governments. And then there's higher education. Higher education as an "industry" involves public, private, and for-profit universities operating at small, medium, large, and now massive scales. Some higher education industry actors are intense specialists; others are adept generalists. Some are fantastically wealthy; others are tragically poor. Some are embedded in large cities; others are carefully situated near farms and frontiers.</p> <p>These differences demonstrate just some of the complexities that shape higher education. Still, we understand that change in the industry is underway, and we must be active in directing it. Yet because of higher education's unique (and sometimes vexing) operational and structural conditions, many of the lessons from change management and the science of industrial transformation are only applicable in limited or highly modified ways. For evidence of this, one can look at various perspectives, including those that we have offered, on such topics as <a href="https://www.insidehighered.com/digital-learning/blogs/rethinking-higher-education/lessons-disruption" target="_blank">disruption</a>, <a href="https://www.nytimes.com/2020/02/20/education/learning/education-technology.html" target="_blank">technology management</a>, and so-called "<a href="https://www.insidehighered.com/sites/default/server_files/media/Excerpt_IHESpecialReport_Growing-Role-of-Mergers-in-Higher-Ed.pdf" target="_blank">mergers and acquisitions</a>" in higher education. In each of these spaces, the "market forces" and "market rules" for higher education are different than they are in business, or even in government. This has always been the case and it is made more obvious by COVID-19.</p> <p>Second, with so much excitement about innovation in higher education, we sometimes lose sight of the fact that students are—and should remain—the core cause for innovation. Higher education's capacity to absorb new ideas is strong. But the ideas that endure are those designed to benefit students, and therefore society. This is important to remember because not all innovations are designed with students in mind. The recent history of innovation in higher education includes several cautionary tales of what can happen when institutional interests—or worse, <a href="https://www.insidehighered.com/news/2016/02/09/apollos-new-owners-seek-fresh-start-beleaguered-company" target="_blank">shareholder</a> interests—are placed above student well-being.</p>
Photo: Getty Images<p>Third, it is abundantly apparent that universities must leverage technology to increase educational quality and access. The rapid shift to delivering an education that complies with social distancing guidelines speaks volumes about the adaptability of higher education institutions, but this transition has also posed unique difficulties for colleges and universities that had been slow to adopt digital education. The last decade has shown that online education, implemented effectively, can meet or even surpass the quality of in-person <a href="https://link-springer-com.ezproxy1.lib.asu.edu/article/10.1007/s10639-019-10027-z" target="_blank">instruction</a>.</p><p>Digital instruction, broadly defined, leverages online capabilities and integrates adaptive learning methodologies, predictive analytics, and innovations in instructional design to enable increased student engagement, personalized learning experiences, and improved learning outcomes. The ability of these technologies to transcend geographic barriers and to shrink the marginal cost of educating additional students makes them essential for delivering education at scale.</p><p>As a bonus, and it is no small thing given that they are the core cause for innovation, students embrace and enjoy digital instruction. It is their preference to learn in a format that leverages technology. This should not be a surprise; it is now how we live in all facets of life.</p><p>Still, we have only barely begun to conceive of the impact digital education will have. For example, emerging virtual and augmented reality technologies that facilitate interactive, hands-on learning will transform the way that learners acquire and apply new knowledge. Technology-enabled learning cannot replace the traditional college experience or ensure the survival of any specific college, but it can enhance student learning outcomes at scale. This has always been the case, and it is made more obvious by COVID-19.</p>
What conditions of the new normal were emerging suspicions?<p>Our collective thinking about the role of institutional or university-to-university collaboration and networking has benefitted from a new clarity in light of COVID-19. We now recognize more than ever that colleges and universities must work together to ensure that the American higher education system is resilient and sufficiently robust to meet the needs of students and their families.</p> <p>In recent weeks, various commentators have suggested that higher education will face a wave of institutional <a href="https://www.businessinsider.com/scott-galloway-predicts-colleges-will-close-due-to-pandemic-2020-5" target="_blank">closures</a> and consolidations and that large institutions with significant online instruction capacity will become dominant.</p> <p>While ASU is the largest public university in the United States by enrollment and among the most well-equipped in online education, we strongly oppose "let them fail" mindsets. The strength of American higher education relies on its institutional diversity, and on the ability of colleges and universities to meet the needs of their local communities and educate local students. The needs of learners are highly individualized, demanding a wide range of options to accommodate the aspirations and learning styles of every kind of student. Education will become less relevant and meaningful to students, and less responsive to local needs, if institutions of higher learning are allowed to fail. </p> <p>Preventing this outcome demands that colleges and universities work together to establish greater capacity for remote, distributed education. This will help institutions with fewer resources adapt to our new normal and continue to fulfill their mission of serving students, their families, and their communities. Many had suspected that collaboration and networking were preferable over letting vulnerable colleges fail. COVID-19's new normal seems to be confirming this.</p>
President Barack Obama delivers the commencement address during the Arizona State University graduation ceremony at Sun Devil Stadium May 13, 2009 in Tempe, Arizona. Over 65,000 people attended the graduation.
Photo by Joshua Lott/Getty Images<p>A second condition of the new normal that many had suspected to be true in recent years is the limited role that any one university or type of university can play as an exemplar to universities more broadly. For decades, the evolution of higher education has been shaped by the widespread imitation of a small number of elite universities. Most public research universities could benefit from replicating Berkeley or Michigan. Most small private colleges did well by replicating Williams or Swarthmore. And all universities paid close attention to Harvard, Princeton, MIT, Stanford, and Yale. It is not an exaggeration to say that the logic of replication has guided the evolution of higher education for centuries, both in the US and abroad.</p><p>Only recently have we been able to move beyond replication to new strategies of change, and COVID-19 has confirmed the legitimacy of doing so. For example, cases such as <a href="https://www.washingtonpost.com/education/2020/03/10/harvard-moves-classes-online-advises-students-stay-home-after-spring-break-response-covid-19/" target="_blank">Harvard's</a> eviction of students over the course of less than one week or <a href="https://www.nhregister.com/news/coronavirus/article/Mayor-New-Haven-asks-for-coronavirus-help-Yale-15162606.php" target="_blank">Yale's apparent reluctance</a> to work with the city of New Haven, highlight that even higher education's legacy gold standards have limits and weaknesses. We are hopeful that the new normal will include a more active and earnest recognition that we need many types of universities. We think the new normal invites us to rethink the very nature of "gold standards" for higher education.</p>
A graduate student protests MIT's rejection of some evacuation exemption requests.
Photo: Maddie Meyer/Getty Images<p>Finally, and perhaps most importantly, we had started to suspect and now understand that America's colleges and universities are among the many institutions of democracy and civil society that are, by their very design, incapable of being sufficiently responsive to the full spectrum of modern challenges and opportunities they face. Far too many higher education outcomes are determined by a student's family income, and in the context of COVID-19 this means that lower-income students, first-generation students and students of color will be disproportionately afflicted. And without new designs, we can expect postsecondary success for these same students to be as elusive in the new normal, as it was in the <a href="http://pellinstitute.org/indicators/reports_2019.shtml" target="_blank">old normal</a>. This is not just because some universities fail to sufficiently recognize and engage the promise of diversity, this is because few universities have been designed from the outset to effectively serve the unique needs of lower-income students, first-generation students and students of color.</p>
Where can the new normal take us?<p>As colleges and universities face the difficult realities of adapting to COVID-19, they also face an opportunity to rethink their operations and designs in order to respond to social needs with greater agility, adopt technology that enables education to be delivered at scale, and collaborate with each other in order to maintain the dynamism and resilience of the American higher education system.</p> <p>COVID-19 raises questions about the relevance, the quality, and the accessibility of higher education—and these are the same challenges higher education has been grappling with for years. </p> <p>ASU has been able to rapidly adapt to the present circumstances because we have spent nearly two decades not just anticipating but <em>driving</em> innovation in higher education. We have adopted a <a href="https://www.asu.edu/about/charter-mission-and-values" target="_blank">charter</a> that formalizes our definition of success in terms of "who we include and how they succeed" rather than "<a href="https://www.washingtonpost.com/opinions/2019/10/17/forget-varsity-blues-madness-lets-talk-about-students-who-cant-afford-college/" target="_blank">who we exclude</a>." We adopted an entrepreneurial <a href="https://president.asu.edu/read/higher-logic" target="_blank">operating model</a> that moves at the speed of technological and social change. We have launched initiatives such as <a href="https://www.instride.com/how-it-works/" target="_blank">InStride</a>, a platform for delivering continuing education to learners already in the workforce. We developed our own robust technological capabilities in ASU <a href="https://edplus.asu.edu/" target="_blank">EdPlus</a>, a hub for research and development in digital learning that, even before the current crisis, allowed us to serve more than 45,000 fully online students. We have also created partnerships with other forward-thinking institutions in order to mutually strengthen our capabilities for educational accessibility and quality; this includes our role in co-founding the <a href="https://theuia.org/" target="_blank">University Innovation Alliance</a>, a consortium of 11 public research universities that share data and resources to serve students at scale. </p> <p>For ASU, and universities like ASU, the "new normal" of a post-COVID world looks surprisingly like the world we already knew was necessary. Our record breaking summer 2020 <a href="https://asunow.asu.edu/20200519-sun-devil-life-summer-enrollment-sets-asu-record" target="_blank">enrollment</a> speaks to this. What COVID demonstrates is that we were already headed in the right direction and necessitates that we continue forward with new intensity and, we hope, with more partners. In fact, rather than "new normal" we might just say, it's "go time." </p>
Sallie Krawcheck and Bob Kulhan will be talking money, jobs, and how the pandemic will disproportionally affect women's finances.
Scientists uncovered the secrets of what drove some of the world's last remaining woolly mammoths to extinction.
Every summer, children on the Alaskan island of St Paul cool down in Lake Hill, a crater lake in an extinct volcano – unaware of the mysteries that lie beneath.
Manly Bands wanted to improve on mens' wedding bands. Mission accomplished.
- Manly Bands was founded in 2016 to provide better options and customer service in men's wedding bands.
- Unique materials include antler, dinosaur bones, meteorite, tungsten, and whiskey barrels.
- The company donates a portion of profits to charity every month.
These new status behaviours are what one expert calls 'inconspicuous consumption'.