For most of the men I see, above baseline is the start of the conversation, not the end of it. The honest question — the one most rushed consultations cannot reach — is not is this working? but is this any good?
In medicine we use the word baseline a great deal. It means the lower edge of normal function — the threshold below which intervention is warranted. We measure cardiovascular function from baseline. We measure renal function from baseline. And, increasingly, we measure sexual function from baseline.
That's the problem. Baseline is not a destination. It's a floor.
Three composite encounters across the lifespan. Names and details changed; the patterns are common.
A man in his late twenties is worried about erectile dysfunction. He has been worried for eighteen months. Examination is unremarkable. Bloods are fine. Function, in the sense the medical literature uses the word, is intact. What he is actually describing, when we slow the conversation down, is that sex does not feel the way he expected sex to feel. The map he was given does not match the territory of an actual partnered encounter. Jack Morin's old erotic equation names what is missing: attraction plus obstacles equals excitement. Desire feeds on anticipation, on distance, on the slowly-crossed gap; the sexual conditions of his early adulthood have given him a great deal of destination and very little journey. The smoke is I think there's something wrong with my body. The fire is I do not know what I want, or how to ask for it, or what to do with the gap between. He has already been on a telehealth platform once. Generic tadalafil sits in his bathroom cabinet. His vascular system is not the problem.
A man in his late thirties has come in because the tablet is now necessary every time. The median age of men prescribed daily PDE5 inhibitors through the telehealth platforms is around thirty-seven, not seventy, and he fits the profile precisely. Two children under five. A demanding job. A partner whose desire has not, in his account, returned to where it used to be since the second baby. A five-question online assessment, a three-month supply by post, no examination, no conversation. He is here now because the anxiety around whether tonight he has the tablet on him is, itself, the problem. What no one has yet asked him, in plain language, is what is actually happening between him and his partner. The libido mismatch, he assumes, is hers. The script he has internalised tells him she is broken; medication will fix him; he will compensate. The script Esther Perel has been writing about for two decades tells him something else: the very conditions that make a long partnership safe — proximity, predictability, the laundry, the schedule, the children — are the conditions that make eros harder to find. Domesticity asks for transparency; desire asks for distance. They are not the same instrument. His partner does not need him to be more reliably erect. She needs him to be more reliably interested.
A man in his late sixties is two years out from a radical prostatectomy. Continent. Cancer-free. Erectile function did not return. He has tried daily tadalafil; he has tried on-demand sildenafil. He has used the vacuum erection device. He has paid privately for a course of low-intensity shockwave therapy at a clinic up the line. He has now started intracavernosal injections. All of these work, in the sense the medical literature uses the word. None feel like anything he wants to do. His wife of forty-one years has told him, gently, that she would rather be held in bed than be the audience to a pharmacological project. He has not believed her. Mohit Khera has been writing about sexspan — the years of healthy sexual functioning, set alongside lifespan and healthspan, with the argument that sexspan should be lengthened the way the other two are. The frame is useful. It can also be misread. Sexspan is not the years your body still has erections in it. It is the years in which eros is alive in your life, which is a different and longer measure. The medical pathway has offered him three more options up the ladder of intervention. No one has yet sat with him in the foreclosure he is grieving — the foreclosure of one specific kind of sex — and helped him notice that the rest of his erotic life, including the wife who is asking to be held, is not foreclosed at all.
Three different decades. Three different presenting complaints. One conversation, repeated.
What unites them is not pathology. The first contains no medical pathology at all; the second contains a chemical answer to a relational question; the third contains a real anatomical loss that has been treated as the only loss worth naming. What unites them is the absence — in their lives, and in the medicine they have so far been offered — of an intelligent adult conversation about a domain that is medical, psychological, relational, cultural and embodied at the same time, and that almost no one in their lives is willing to hold whole, for long enough.
That conversation is the work. And the Australian data is sobering. Fewer than one in ten primary care clinicians routinely asks about sexual difficulties; around four in five cases that come up are raised by the patient. The patient who does not raise it gets nothing. Most, on this evidence, do not raise it.
It does not mean abandoning the medicine. The medicine is the foundation. Erectile dysfunction precedes cardiac events by three to five years on average; a man presenting with new ED has just handed you a window into his coronary arteries. Hormonal pathology is real and worth investigating. Genuine sexual dysfunction — PSSD, vulvodynia, hypogonadism, pelvic floor injury, post-surgical neurovascular damage — gets treated as such, with the rigour the diagnosis deserves.
It means refusing to stop where the medicine stops.
Three things shift when pleasure is taken seriously as a clinical destination rather than a private matter the patient should sort out on their own time.
First, the diagnostic frame widens. Erectile difficulty is not only a cardiovascular window; it is also a window into the man's sleep, his fitness, his anxiety load, the shape of his current relationship, and the partner who is half of the system in the room. The female partner, in heterosexual practice, is not the silent half of the equation. She is the equation, with him. Her libido, her arousal, her pain, her grief, her own ageing body — the conversation that does not register her registers half of what is actually happening.
Second, the goal of the conversation changes. It stops being restoration to function and becomes what would you actually want this to feel like? That question is harder, slower, and considerably more useful. It is also, in my experience, the question almost no patient has been asked, and the question many of them have been waiting their whole adult life for someone to ask.
Third, the silences in the room change. Foreskins. Faked orgasms. The depression-libido double bind on SSRIs. What changes for a couple after the third child. What changes after radiotherapy. Coercive control inside relationships that look fine from the outside. The clinical reputation worth building is not built on saying outrageous things. It is built on the absence — in the room, in the consultation — of judgment, of hurry, of flinching.
What it is, on the days it is working: a slower conversation. A longer appointment. The body taken seriously as more than a problem to be fixed. The partner taken seriously as more than a passive beneficiary. The man trusted as the intelligent adult he already is. The small, durable joy that turns up when someone is finally given room to say what they have been carrying alone.
Sexual health challenges are real. They are largely unspoken. They require physicians who do not flinch, and who can name them.
The baseline is a floor. The work is everything above it.