Erectile dysfunction and male sexual dysfunction in the Arab world

The population in Arab countries has a higher-than-global-average prevalence of risk factors, especially cardiovascular diseases such as hypertension, diabetes, and obesity. This has led to a significant increase in sexual dysfunction. Studies indicate that the prevalence of sexual dysfunction in Arab countries ranges from 39.9% to 66.2%, which is markedly higher than the global average due to the high prevalence of diabetes and cardiovascular diseases.

1. 1. Three main challenges in sexual health and dysfunction in Arab countries

   The first challenge is health awareness in the Arab world. Many people in Arab societies avoid addressing their sexual health entirely, often missing the opportunity for timely diagnosis and treatment.

   The second challenge stems from religious principles and sexual behavior aligned with religious views in Arab countries. Many patients spend a considerable portion of their income on ineffective medications or various treatments unrelated to medical principles, such as herbal or pseudo-medical remedies. These treatments lack scientific validation and often exacerbate the condition, wasting valuable time that could be spent on effective medical treatment.

   The third challenge is the low socioeconomic status in the community. There is insufficient awareness of erectile dysfunction issues and treatment, as well as a lack of reliable sources for studying sexual health and erectile dysfunction in Arab societies. Scientific research on this topic is scarce, leading to limited attention and lack of organization in the field of sexual health within the Arab world. Sexual health significantly affects quality of life, making knowledge and education in human sexual activity essential for healthy marital relations and managing adult and youth relationships. Therefore, reliable scientific information is essential for promoting healthy relationships and preventing serious functional and mental health problems due to a lack of knowledge. Acquiring knowledge, training, and disseminating reliable sexual health information are core principles of World Health Organization recommendations. Sexual education for children, adolescents, and adults promotes healthy marital relationships and helps prevent serious community diseases.

2. 2. Sexual dysfunction or erectile dysfunction

   Erectile dysfunction is the most common sexual health complaint encountered by therapists and sexual health professionals. It is crucial to collect complete information on a patient's sexual performance. Understanding the broad social and cultural background of sexual dysfunction in Eastern (especially Arab) societies is essential for all sex therapists, allowing them to offer proper support and effective, professional treatment. A comprehensive approach to the problem leads to successful treatment. It is important to remember that treating erectile dysfunction is not just an individual clinical issue; it is a holistic approach that affects the family and social environment.

3. 3. How an erection occurs

   The mechanism of an erection is an integrated physiological process involving smooth muscle cells with enzymes, collagen cells, internal tissues (corpora cavernosa and corpus spongiosum), the nervous system (both voluntary and involuntary), and blood vessels (arteries and veins). The latter two form the majority of the system that regulates blood flow to the right and left corpora cavernosa of the penis.

   In the non-erect state: The trabecular smooth muscles are contracted, and arterial blood flow to the corpora cavernosa is zero. Contraction of these smooth muscles keeps the surrounding veins of the corpora cavernosa open, allowing venous drainage. In the erect state: Sexual stimulation activates the parasympathetic nervous system through chemical receptors (acetylcholine, nitric oxide, and vasoactive intestinal polypeptide [VIP]), causing relaxation of smooth muscle cells, which in turn dilates the arteries and increases blood flow into the corpora cavernosa. This raises pressure within the corpora cavernosa, which increases pressure on the fascia surrounding it, compressing the veins against it and stopping blood from exiting the penis during full erection. Finally, during ejaculation, sympathetic nervous signals to the pudendal nerve cause contraction of the bulbocavernosus and ischiocavernosus muscles, resulting in ejaculation.

4. 4. How erectile dysfunction occurs

   Erectile dysfunction often results from a physical malfunction in the erection mechanism or regulatory disruptions. Problems may stem from spinal cord injuries that block nerve signals from the brain, or damage to peripheral nerves or blood vessels from pelvic or spinal surgeries. However, these issues are more common in the context of aging and chronic diseases, with atherosclerosis being the most common cause among men over 50.

   Research shows that 40% of erectile dysfunction cases are due to atherosclerosis and aging, 30% from diabetes, 15% from medications, 6% from pelvic anatomy or trauma, 5% from neurological factors, and 3% from endocrine issues, with other factors accounting for about 1%. Psychological factors and the effects of certain medications also contribute to erectile dysfunction.

   Sometimes erectile dysfunction, also known as impotence, is confused with other types of sexual dysfunction. Erectile dysfunction is defined solely as an erection disorder, while other issues are functional problems like delayed ejaculation, premature ejaculation, and lack of desire and sexual arousal.

5. 5. Causes of erectile dysfunction and contributing factors

   Erectile dysfunction (ED) arises from vascular diseases like vascular calcification, aging of body and penile tissues, nerve issues, hormonal problems, medication side effects, or a combination of these factors, including improper nitric oxide (NO) production in the penile area. Contributing risk factors for ED include high levels of LDL, high triglycerides, low HDL cholesterol, high blood sugar levels, type 2 diabetes, high blood pressure, and metabolic syndrome. Cases have also been recorded with HIV infection and certain medications used to treat other conditions.

   In addition, psychological factors such as stress, anxiety, and unstable mental and emotional states—along with the influence of the surrounding environment, social beliefs, and an individual’s cultural level—can play a role.

6. 6. Sexual Health in the Arab Community

   As previously mentioned, the lack of knowledge and awareness in Arab societies regarding sex education and marital relationships creates a confusion that complicates the clarification and treatment of the issue by sex therapists. For example, social and religious factors and personal beliefs lead to difficulty in obtaining the patient's medical history, hiding true information from the therapist, and incomplete cooperation from the patient, which stems from social and religious influences.

   A study examining married Muslim Arab men and their sexual dysfunction showed that a man's satisfaction with his sexual life, both regarding himself and his partner, is affected by his anxiety about not pleasing his partner. This anxiety arises from social and cultural contexts, such as social esteem and issues related to religious and traditional orientations.

7. 7. Cultural Norms and Expectations

   Erectile dysfunction in men makes them susceptible to emotional and psychological suffering, self-rejection, low self-esteem, and a decline or even lack of quality of individual and marital life, which can lead to negative effects on men's performance in their daily lives and social commitments. The prevalence of erectile dysfunction in Arab societies among different population groups in the same age group ranges from 0.3% to 17.0%.

   In another study among Muslim Arab men, participants indicated their beliefs about the causes of erectile dysfunction, including: masturbation, psychological factors, and the prohibition of sexual relations with women outside of marriage. These findings demonstrate the impact of beliefs stemming from social, religious, and cultural norms on understanding and treating erectile dysfunction. The influence of these beliefs reflects on the behavior and lifestyle of men suffering from erectile dysfunction.

   In general, Arab society places men at the center of dominance in all aspects. The man is the provider for the family, strong and assertive, and is dominant in the bedroom. However, in practice, there are significant gaps in the sexual therapy system among Arab communities. The disparities are, in fact, a result of imposing cultural standards that dictate rigid roles for both genders.

   Sex therapists in the contemporary Arab world must adopt a broad approach that considers the new and modern reality while respecting values rooted in Islam. The patient must receive a solution that helps them overcome an emotional and sexual problem within the understanding and integration of the duality connecting the old and the new worlds.

8. 8. Evaluation and Diagnosis of Erectile Dysfunction

   The Arab ideology places men in a position of control within the family, which has impacted the concept of sexual relations within the family. Therefore, a man feels like a failure if he cannot fulfill his primary role in sexual life, which affects his self-perception and his wife's perception of him, especially the need to have children and build a family, despite the absolute belief that reproduction is by the will of God.

   In Western society, for example, desire and intimacy achieve the concept of 'sexual relationship', unlike Arab countries where 'the firmness of erection and the ability to penetrate define sexuality,' leading most Arab men to believe that female satisfaction stems from penetration itself.

   Understanding sexual function cannot rely solely on self-assessment and information provided by the patient. For conservative Arab communities, sex is primarily viewed as a means to form a family and have children. Therefore, many Arab families, after several years of marriage and having children, do not have a sexual life.

   Sexual intercourse is the only tool for family formation and parenthood, which increases the moral and cultural importance of sexual performance. An individual experiencing sexual and functional failure will suffer from psychological disorders that lead to chronic and persistent anxiety, as in their mental world, they cannot perceive their masculine status at all.

9. 9. Medical History and Physical Examination

   Erectile dysfunction does not pose a life threat, but it must be treated professionally. It is essential to clarify and diagnose it through sexual, medical, clinical, and mental evaluation. Previously, the treatment of erectile problems was solely associated with sexual psychology. However, erectile dysfunction is a medical issue affecting an individual's overall health.

   The medical history and clinical diagnosis form an essential part of the medical encounter, as the majority of patients prefer to see a doctor rather than consult a specialist or sex therapist. Therefore, collecting the biological, psychological, and social medical history of an individual or couple is necessary to determine the causes during the diagnosis of sexual dysfunction.

   Here, the importance of questions related to the main complaint emerges, such as the severity and degree of the problem, the onset and persistence of the issue, and integrating the patient's medical history, contributing to identifying the primary causes to implement an appropriate evaluation and intervention plan.

   The evaluation process first involves assessing dysfunction from the moment it began, the evolution of the problem within the context and lifestyle of the patient, and their physical and mental health, considering cultural and social norms and traditions.

   To identify all causes of erectile dysfunction, it would be best to conduct an emotional and sexual assessment for both the patient and the partner. However, cultural and social norms and traditions limit the wife's participation in the treatment, highlighting the importance of considering the personal cultural and religious background of the patient.

10. 10. Diagnostic Tests

    There are standardized protocols and tools for diagnosing sexual dysfunction such as:

    1. IIEF Questionnaire and EHS Score: The International Index of Erectile Function (IIEF) is a globally recognized medical questionnaire used to assess sexual function in men, particularly concerning erection and sexual satisfaction. This questionnaire aids doctors in diagnosing erectile problems and monitoring the effectiveness of the treatments provided. It evaluates various aspects such as the ability to achieve an erection, sexual desire, orgasm, related problems, and overall satisfaction, with scores ranging from 0 to 30.

    On the other hand, the Erectile Hardness Score (EHS) is an evaluative tool used by physicians to determine the degree of penile hardness in men. The scale ranges from 1 to 4, where grade 1 indicates slight increase in penile size without hardness; grade 2 indicates the penis is hard but not sufficient for penetration; grade 3 indicates the penis is hard enough for penetration but not fully hard; and grade 4 indicates the penis is completely hard. This scale helps in assessing the severity of erectile dysfunction and determining the most appropriate treatment for the condition.

    The relationship between standard IIEF scores and EHS is crucial for understanding erectile function in clinical practice and research. Therefore, the evaluation between IIEF scores and EHS is necessary to achieve this goal.

    2. Nocturnal Penile Tumescence (NPT) Test: This is an important tool in diagnosing erectile problems, especially in distinguishing between psychological and physiological factors. The test results help provide targeted and personalized treatment. Utilizing this test, along with other tests and a complete medical history, allows urologists and sex therapists to determine the appropriate treatment strategy for the patient.

    3. Penile Doppler Ultrasound: This is an important tool in urology and sexual therapy, used to assess blood flow to the penis. The test is designed to diagnose vascular disorders that can lead to erectile issues. It provides information about vascular function in the penis and helps differentiate between vascular factors and other causes of erectile dysfunction.

11. 11. Treatment Approaches

    The therapeutic approach to erectile dysfunction is extensive and generally depends on the functional and psychological health of the patient and their cooperation.

    Using the Therapeutic Approach (SEMT): Sexual Experience Management Therapy

    SEMT is a therapeutic approach that focuses on improving the overall sexual experience of the patient, not just on treating specific functional problems. The approach is based on psychological, behavioral, and emotional principles, providing practical tools to enhance the sexual experience. The goal is to adapt the therapeutic program so that it is acceptable and beneficial in the personal treatment of the patient.

    Behavioral factors and habits such as physical activity and dietary habits have a significant impact on the prevention and treatment of erectile problems. Here, the importance of promoting a healthy lifestyle emerges, but it is essential to consider the personal and cultural differences among various populations within the Arab milieu. Thus, for example, a Bedouin patient will have a different worldview compared to a patient from urban or rural communities, even though both belong to the Arab world.

    It should be remembered that lifestyle is not only influenced by the community itself but also by demographic differences and common food types in their place of residence. For instance, in the Middle East, food is more diverse in vegetables and meats than in cold countries with seasonality, where excessive consumption of fats and carbohydrates is apparent, a risk factor for cardiovascular diseases like obesity. Published research has shown improvement in erectile function with minimal weight loss of 5%, which reflected an improvement in IIEF-5 scores.

    Additionally, a decrease of more than 25% in metabolic syndrome is associated with a greater chance of improving IIEF-5 scores occurring in 43% of obese men. The positive impact of low-fat lifestyle interventions and weight loss has been confirmed in numerous studies. When coupled with calorie restriction, a Mediterranean-style diet can reduce erectile dysfunction rates. Many scientific studies have shown the relationship between reducing metabolic syndrome and improving erectile function (IIEF-5) following lifestyle intervention and weight loss.

12. 12. Psychological Interventions

    Psychological therapies contribute to the success in resolving erectile problems, especially when the causes are psychological stressors. The most effective treatments include individual counseling and cognitive-behavioral therapy (CBT) alongside Viagra (Sildenafil). Psychological therapies can improve male sexual function, restore self-confidence, and achieve positive outcomes alongside counseling for the partner. Psychological interventions should be adapted to fit Arab culture. The therapeutic methods include sexual behavioral focus, incorporating techniques that reduce the pathological problems of sexual desire. Additionally, other methods recommend cognitive-behavioral therapy that gradually exposes the patient to sexual behavior while maintaining confidentiality and preventing embarrassment.

    A new care model has been developed to accommodate cultural standards in Arab communities. The program includes 12-18 monthly individual sessions for sexual psychology and cognitive-behavioral therapy that involves both partners. Behavioral therapy techniques include intimacy exercises, arousal enhancement exercises, and coping with physical stress. Furthermore, the intervention includes six cognitive enrichment sessions for couples aimed at preventing and treating additional phenomena such as premature ejaculation by improving marital communication.

13. 13. Pharmacological Treatments

    The Arab population is characterized by a fear of taking medications due to concerns about addiction or reliance on these medications, as well as fear of life-threatening side effects, noting that purchasing medications itself causes social embarrassment. The main types of medications used for erectile dysfunction are PDE5 inhibitors, Alprostadil (Prostaglandin E1), and testosterone therapy. Selective PDE5 inhibitors are the most commonly used drugs for treating sexual dysfunction. They improve the erectile response to sexual stimulation, enhance the relaxation of the corpus cavernosum, and increase blood flow, resulting in improved erections. Most studies investigating erectile dysfunction in Arab communities place it at the center of sexual dysfunction issues, making it significantly challenging to obtain positive treatment when patients do not cooperate and do not take the required medication.

    Intrapenile injections are injections used to achieve an erection, containing Alprostadil (Prostaglandin E1), which is effective in cases where the use of PDE5 inhibitors fails, thus forming a second line of treatment for sexual dysfunction based on guidelines from the European Association of Urology.

    In a study conducted in Egypt, Alprostadil was found to be as effective as Sildenafil in treating erectile dysfunction, with no significant complications. Numerous studies have examined the safety and efficacy of Alprostadil in the Arab community. However, more research is needed to clarify the distinctive comorbidities in the Arab sector that cause treatment failures. New therapeutic protocols should be enhanced to increase treatment efficacy for those suffering from sexual dysfunction.

    The third line of treatment for sexual dysfunction is surgical intervention, which involves the implantation of a penile prosthesis. This treatment is considered one of the treatment options after all non-surgical therapies have failed.

14. 14. Cultural and Linguistic Considerations in Sexual Therapy

    The world of Arab medicine faces many challenges in treatment, stemming from cultural gaps and a lack of awareness of the importance of sexual therapy, which prevents the patient from accepting and accommodating the need for treatment. Overall, the Arab patient does not view the doctor as a personal therapist, thus approaching their recommendations with limited trust.

    Furthermore, linguistic and dialectal gaps represent another challenge. A patient receiving concepts from a physician that are not in their language and medically complex concepts will not perceive that they have received reliable information, as some will not understand at all while others may find it incompatible with their cultural world and social beliefs.

    Today, approximately 400 million people speak Arabic, including in the Middle East and North Africa. Each country has its own Arabic dialect, which is similar yet different. There are identical words that have different meanings from sector to sector, and there are many dialects across each geographical area, although they are all called Arabic. This variation creates a barrier in communication between the therapist and the patient and the partner. Therefore, for example, when a patient is asked to explain their medical history and sexual performance for themselves and their partner, they may struggle to convey accurate information. Thus, even before starting treatment, there may be a lack of the required information to understand the patient's problem and complaint.

    The therapist, especially if they do not speak the patient's language or come from the patient's area, should show considerable empathy and be especially attentive to fully understand the source of the problem, while respecting the difficulties faced by the patient and their partner, in order to create trust during treatment and a safe space for interaction where all participants can engage in the therapeutic process with sincerity.

15. 15. Religious and Moral Beliefs

    The practice of sexual medicine in the Arab world faces unique challenges that must be taken into account to increase awareness among practitioners. Educational programs in sexology must consider local religious and moral backgrounds as part of public health programs. The practitioner must consider the religious and moral beliefs in Islamic Arab countries and observe and integrate various perspectives on Islamic religious practice, cultural ethics, and the treatment of pharmacological therapies for fertility and erectile dysfunction.

    The recommendations are arranged in chronological order to guide the treatment of erectile dysfunction according to accepted treatment lines and modern medicine. As a result, the Arab community maintains a lifestyle according to religious beliefs, which aim to guide the life of the believer in a religious, ethical, and legal manner, encompassing all aspects of life, including prayer, family law, criminal law, and economics. The Islamic religious movement aligns with the ethical standards of the Arab community. This approach supports Islamic principles that encourage sexual relations within marriage and emphasize the importance of reproduction and family. Sexual relations outside of marriage in Islamic law are considered 'adultery,' which means 'illicit sexual acts.'

16. 16. Conclusion and Recommendations

    When working with Arab patients suffering from erectile dysfunction, it is important for the therapist to be aware of the impact of culture on sexual behavior and treatment. Using SEMT intervention to treat a Muslim Arab patient suffering from erectile dysfunction, it is essential to understand the metaphors, symbols, and religious teachings. Therefore, the therapist must be knowledgeable about sexual concepts; for example, the Arab concept of the 'lustful male' from the seventh century continues to influence the daily language of Arabic speakers.

    Overall, erectile dysfunction can be treated through a multidisciplinary approach. Therapists, sexologists, and social workers can combine cognitive-behavioral techniques that reduce anxiety with education about the complex nature of sexual dysfunction, along with religious or spiritual metaphors that facilitate understanding and help make the therapeutic process more culturally acceptable and thus more effective. The use of religious or spiritual metaphors in treating sexual dysfunction should be examined to determine their clinical usefulness and how they can be integrated with updated cognitive-behavioral treatment approaches. Therefore, to promote healthy sexual lives in the Arab milieu, it requires Arabic-speaking psychologists and sexologists using Western psychological treatment models that can be beneficial in addressing comprehensive issues and integration. The motivational approach may serve as an element of psychological treatment for patients experiencing sexual dysfunction.

    The purpose of this study is to conduct a comprehensive examination of various significant aspects of sexual therapy for erectile problems among Arab men. During the review of available studies, it was found that interest in sexual health and the emergence of sexual dysfunction among Arab men has increased over the years.

    Innovative methods established in the field of sexual health clearly indicate that a comprehensive sexual and medical history is essential for accurate evaluation and effective treatment of Arab men. Clinical assessment, diagnosis, and physical examination of the penis are critical to ensuring optimal treatment outcomes among these populations, as Arab populations tend to trust the therapist's professionalism when 'the issue of the penis is genuinely addressed.'

    The importance of religion and culture reflects the comprehensive therapeutic approach for this segment of Arab communities. By adopting a more integrated therapeutic approach, analyzing the sexual experiences of Arab men suffering from erectile dysfunction, and combining traditional and contemporary practices by health professionals and sex therapists, a more comprehensive and effective therapeutic framework can be developed. This approach not only ensures the provision of more effective and tailored interventions but also meets the unique needs and aspirations of Arab men suffering from erectile dysfunction, ultimately aiming to enhance their sexual well-being and the quality of their intimate lives.

    I believe that health is a combination of knowledge, mind, and body. Sexual health is an integral part of overall health.

    In my opinion, it is possible to gradually reduce the impact of cultural, social, and economic beliefs on sexual health, but it will take a long time to promote and integrate this in the sector.

    This study has highlighted cultural differences in the meaning of sexual health, in the context of erectile dysfunction, especially in the Arab community, where deep social and religious beliefs influence the understanding and attitudes toward sexual health. Myths linking erectile dysfunction to supernatural forces, such as demons or magic, express a cultural narrative that has stifled open discussion and medical guidance in this field.

    Sexual health is an integral part of an individual's overall health, and it is correct and important to break these barriers. The decreasing number of direct inquiries related to sexual dysfunction in Arab communities reflects the need for a culturally appropriate and comprehensive approach to encourage people to seek help.

    To enhance sexual health among patients in the Arab community, it is very important to continue understanding the cultural and social background that prevents them from accessing treatment. Approaches such as specialized education, creating safe spaces, and open respectful dialogue may encourage more patients to seek help in this area.

17. 17. I Will Conclude with a Tale from Arab Folklore

    Juha talks about how he likens his erection to hot coffee; when passion is warm, desire increases and the erection is strong, indicating strength and emotion. He says that when the coffee cools, it loses its flavor, just like the erection—it must remain strong for a family life filled with warmth and stability. The tale emphasizes humor and folk beliefs regarding sexual situations and masculinity, using everyday comparisons such as erectile dysfunction and male impotence in Arab society.