Are We Overlooking the Power of the Placebo in Sexual Medicine?

Abstract

The advertisements offering different treatments for sexual problems with spectacular results are placebos in light of their broader definition, which encompasses the entire ritual of the therapeutic act, encompassing both the inert substance and the psychosocial context surrounding the patient and the therapy. This is especially relevant for sexual disorders, given the stigma and shame associated with them. It is time the physicians working in the field of sexual medicine recognize their importance and incorporate them in their treatment regimens.

Are We Overlooking the Power of the Placebo in Sexual Medicine?

It is a ubiquitous sight in India, of the walls adjacent to the railway lines or the hoardings around the rail and bus stations, showing a hapless young man in the throes of despair, and the advertisement asking why there should be anxiety before one’s marriage (Shaadi se pehle ghabrahat kyun?), going on to suggest that the application of a particular oil or use of a specific tablet or a capsule is all that is needed to fix the problem. It is further asserted that the medicine mentioned above has the power to correct “childhood mistakes” (Bachpan ki galtiyan), referring ostensibly to masturbation. Such advertisements are usually designed to be colorful and eye-catching. Similar advertisements appear on pornographic websites as well. Furthermore, the results of such treatments are often portrayed as being analogous to a galloping horse or a well-built man with a chiseled body and prominent, upturned mustaches (which are culturally accepted as associated with masculinity).

These common sights raise interesting questions. First and foremost, why are these products and their advertisements limited almost exclusively to sexual problems? Do all these products qualify to be labeled as “placebo”? And, most importantly, is there a message in this for the mental health professionals working in the field of sexual medicine?

Against this backdrop, it is pertinent to first review the definition and basic construct of a “placebo.”

Historical Perspective: Tracing the Construct of a “Placebo”

The word “placebo” was in use long before it began to be used in the field of medicine. The first recorded use of the word “placebo” in English dates back to the 13th century, when it referred to the vespers for the dead in the Roman Catholic Church. In fact, “placebo” is the first word in the first line of the first antiphon, Psalm 114:9. ¹

One of the earliest pieces of evidence of the effectiveness of the placebo found in the annals of medicine is Plato’s cure for headaches, which consisted of a certain leaf and a charm to go with it. If one uttered the charm at the moment of its application, the remedy made one perfectly well, but without the charm, there was no efficacy in the leaf. ²

Placebos have been variously described as “deceptive,” “controversial,” “ethically tenuous,” “a source of debate and confusion,” and “belonging to the grey zone,” among others.^3,4

Traditionally, a “placebo” is defined as an inert substance that has no inherent pharmacological activity. ⁵

The concept of a “placebo” has evolved over time, and it is now viewed in a broader context, rather than being limited to an inert substance with no pharmacological action. The term “placebo” encompasses the entire ritual of the therapeutic act, encompassing both the inert substance and the psychosocial context surrounding the patient and the therapy. ⁶

This also includes the verbal communication between the treating physician and the recipient. Thus, it is present to a variable extent in all therapeutic encounters and may be used to benefit the patients. At the same time, it also provides a ready avenue for unscrupulous “healers” of all types.

The key question is whether the advertisements described earlier, the treatments that they promise to deliver, and the unqualified doctors who pose as “sex specialists” qualify to be labeled as “placebo.” Considering the facts discussed above, the answer appears to be in the affirmative.

The “Placebo” Effect has a Neurobiological Basis

Research in the area of the placebo effect has delineated neurobiological correlates of the placebo effect. There is evidence that placebo administration results in “true”—or non-artifactual—neurobiological changes in the brain that resemble the effect of drugs. ⁷

Available data suggest that placebo administration can cause immunosuppression, striatal dopamine release, and endogenous opioid release. Furthermore, there is evidence that placebo effects in depressive and anxiety disorders are correlated with altered activity in the ventral striatum, orbitofrontal cortex, rostral anterior cingulate cortex, and the default mode network. ⁸ Hence, brain mechanisms of expectation, anxiety, and reward are all involved in the placebo response.

Research also suggests that neurochemical changes following the administration of a placebo mimic those associated with a variety of learning phenomena, such as Pavlovian conditioning, cognitive, and social learning. ⁸

The Possible Neurobiological Correlates of Response to Sexual Disorders

The potential mechanisms are still unexplored, though a subject of active research.

The neural substrate for the placebo effect in sexual disorders has been proposed to be the dopaminergic system, as it has a positive association with sexual arousal. The dopaminergic hypothesis is supported by the fact that dopamine agonists have been used over the years in the treatment of erectile dysfunction. ⁹

There is limited evidence to suggest that endogenous opioids, which are released on the raising of expectation (brought about by a placebo), influence sex drive in humans and animals. This could be another mechanism by which placebos exert an effect on sexual functioning.^10,11

The Effect Size of the Placebo

The earliest evidence of the effect size of the placebo effect was provided in a research article published in the Journal of the American Medical Association (JAMA), “The Powerful Placebo,” in which it was concluded that the placebos had a high degree of therapeutic effectiveness. ¹²

A brief overview of the evidence available with respect to the placebo response rates in sexual disorders is of interest. In a meta-analysis of 63 trials to assess the efficacy of phosphodiesterase-5 inhibitors in patients suffering from erectile dysfunction, the effect size in the placebo arm showed a small to moderate improvement of erectile function (Hedges’ g score: 0.35). ⁸

The effect size in patients having premature ejaculation is not as significant as seen in patients with erectile dysfunction, and as per the available data, the typical placebo intravaginal ejaculatory latency time response shows a 1.6-1.7-fold increase over the baseline. ¹³

Placebo-controlled studies for female sexual dysfunction have found a substantial average increase in sexual function scores after eight weeks of treatment with a placebo. ¹⁴

So, the strongest evidence in this regard is available for patients suffering from erectile dysfunction and female sexual dysfunction.

The Unique Socio-cultural Perspective of Sexual Problems

Sexual problems are hidden under veils of stigma in our society. This is deeply ingrained across our socio-cultural landscape, driven by societal norms, and amplified by both offline and online environments. This stigma continues to prevail even in today’s era of digitization. To have a sexual problem is embarrassing and looked down upon by society. It is associated with weakness of the body and mind. This widely held belief has its roots in the lack of knowledge about sexual health.

Factors contributing to sexual stigma include cultural norms, religious beliefs, and a lack of awareness about different aspects of normal sexuality.

The psychological impact on individuals includes feelings of shame, guilt, and self-doubt, with implications for mental health and well-being.

These societal beliefs provide fertile ground for unscrupulous elements to emerge, and most of them, unknowingly, prescribe a placebo in one form or another.

Sexual stigma and shaming practices are pervasive issues in Indian society, deeply rooted in cultural norms, religious beliefs, and patriarchal values. ¹⁵

The societal attitudes are reinforced by Bollywood and regional cinema that perpetuate narrow depictions of sexuality.

Educational taboos on sex are another significant challenge faced by educators in addressing sexuality in the school curriculum. Furthermore, workplaces in India tend to avoid discussions on sexuality and gender diversity, contributing to the perpetuation of stigma.

The Significance of the “Placebo” in Sexual Medicine

Most physicians construe placebos in conventional terms of being nothing more than biologically inert substances that, in clinical trials, must be controlled for to assess the specific effects of new (drug) interventions. Against this backdrop, the core question for mental health professionals working in the field of sexual medicine is whether we are under-utilizing the power of the placebo in our clinical practice. This under-utilization could be driving the market of unscrupulous “sex specialists,” and, in the process, depriving many patients of appropriate and research-based treatments.

The mental health professionals working in the field of sexual medicine must give serious consideration to increasing the use of placebos in treating our patients to provide the best possible outcomes for them. The time has come to reclaim our patients and save them from the cobweb of misinformation and inappropriate treatments.