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In the end, "sex is complicated".

May marks the mid-point of spring, a welcome respite from a long, cold, harsh, and difficult winter for many. In some cases this winter was quite strange, with the effects of global warming becoming more evident. I was driving in Boston in mid-January, usually the coldest time of the year, with the air conditioner on because the temperature was so warm, while in Santa Monica, California, snow was falling on the beach. Spring has brought a relief for some and further strange weather for others. Many of us live in places where the only certainty to the weather is its uncertainty —predicting weather is complicated. So how does that thought apply to the field of sexual medicine and The Journal of Sexual Medicine ( JSM )? At a recent international meeting, I found myself sitting in the hotel lobby bar in deep conversation with a dear friend from the pharmaceutical industry who announced, in confidence, retirement from our field. I was shocked! “And what about the other half of the dynamic duo?” There was confirmation that both members of the team were leaving. This information was shared shortly after the announcement from a different company of the sale of its rights to a sexual medicine drug to its former partner resulting in the release of its entire workforce. Another company had just undergone reorganization and laid off or reassigned numerous employees, including a close colleague who had been in the field since the beginning of the oral pill clinical trials. I asked my friend about these actions and the response was quick and without much reflection. “The sexual medicine market did not grow as expected.” When asked why, the answer was more cryptic. “Oh many reasons. In the end, though, sex is complicated.” The somber hotel lobby bar conversation did not fit with the hopes of the spring season and the exponential growth of interest in sexual health publications our editorial team has observed with the expansion of your JSM. We shook hands and parted ways, but our conversation stayed with me. Yes, sex is complicated, but that is why the JSM publishes so many high-quality multidisciplinary research investigations in sexual medicine [1–13]. And that is why there is a need for the many societies studying sexual medicine and why more research, more funding, and more education are all needed. Sexual dysfunctions are genuine, common, relevant, distressing, and complicated human bio-psycho-social conditions. The only certainty to sexual health is its uncertainty—there is more to healthy sex than taking a pill. Worldwide sales of safe and effective oral medications indicated for the treatment of men with erectile dysfunction have exceeded 3 billion dollars annually—that is not an insignificant sum. Expenditures in terms of scientific research as well as professional and lay education have been enormous and have helped empower men to freely discuss sexual health concerns with their physicians. I believe this to be unlike any other time in history. Unfortunately, as a result of financial analysts’ predictions that the industry would have grown even faster and yielded even more financial rewards, we are witnessing the current downsizing and reorganization within the pharmaceutical industry. What is very clear, however, is that Pandora’s box has been opened by the development of an oral pill, and the desire by men and women for treatment of their sexual problems is not going to disappear. “Sex is complicated” simply means we need to know more, not do less. Stroberg and colleagues [2] looked at the specific reasons for discontinuation of phosphodiesterase type 5 (PDE5) inhibitors. The study— entitled “Is sex only for the healthy and wealthy?” —concluded that less than half of the PDE5 inhibitor users continued using the medication. While one factor associated with discontinuation was impaired health, another was cost. There was a large disparity in PDE5 inhibitor usage based on household income. Just because a drug is effective does not guarantee it will be cost-effective for the patient. Sexual function and dysfunction involve the couple, which does not make sex any less complicated. A recent JSM publication [5], co-authored by associate editor Annamaria Giraldi, examined the frequency and determinants of sexual desire in men and women. This article boldly highlights some of the complications of sex. For all age groups, there is more sexual desire in men than in women, and this 523