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416 Ghazaleh Mosleh etal.
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14 An Evidence-Based Review of
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Medicinal Plants for Sexual Dysfunction
Management Cited by Avicenna
Elaheh Zibaee1*, Seyed Majid Ghazanfari2, Lida Jarahi3, Mina Borhani4, and
1
Department of Traditional Pharmacy, School of Pharmacy, Mashhad University of
Medical Sciences, Mashhad, Iran; 2Iranian Research Center on Healthy Aging
(IRCHA), Sabzevar University of Medical Sciences, Sabzevar, Iran; 3Department of
Community Medicine, Faculty of Medicine, Mashhad University of Medical Sciences,
Mashhad, Iran; 4Department of Pharmacognosy, School of Pharmacy, Mashhad
University of Medical Sciences, Mashhad, Iran
Abstract
Sexual health is one of the signicant aspects of health for men and women. Sexual disorders (SD) have
been a common problem in all societies at all times and aect the quality of life of individuals and their
spouses. Impotence or decreased sexual desire is introduced as a problem in dierent societies, which can
be attributed to diet, mental disorders, various diseases, and medications, as well as lifestyle. e term
“aphrodisiac” refers to substances, foods, medicines, and factors that increase sexual desire in both females and males. Aphrodisiacs are used to treat three types of disorder: libido (sexual desire, arousal),
sexual potency (eectiveness of erection), and sexual pleasure. Traditional Persian Medicine (TPM) has
paid special attention to the treatment of sexual impotence. In this chapter, aphrodisiac herbs and herbal
therapeutic methods introduced by Avicenna for treatment of these disorders are shown.
Introduction
Sexual health is one of the significant aspects
of health for men and women. Sexual disorders (SD) have been a common problem in
all societies at all times and affect the quality
of life of individuals and their spouses. Impotence or decreased sexual desire is introduced
as a problem in different societies, which can
be attributed to diet, mental disorders, various
Seyed Ahmad Emami
diseases, and medications, as well as lifestyle
(Bosch et al., 1991; Rosen and Ashton, 1993;
Monga, 1999). The levels of sex hormones,
including testosterone and progesterone, are
the most important determinants of sexual
desire in both sexes. SD include decreased or
no erection, premature or delayed or no ejaculation, sexual dissatisfaction, and decreased
secretion of sexual fluids that occur in reducing sexual desire (Bosch et al., 1991). The
1,4
*Email: zibaeeelah@gmail.com
© CAB International 2023. Medicinal Plants Used in Traditional Persian Medicine
(eds. H. Schulz, Sey
DOI: 10.1079/9781800621671.0014
ed Ahmad Emami and Farsad Nadjafi)
419
420 Elaheh Zibaee et al.
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term “aphrodisiac” refers to substances, foods,
medicines, and factors that increase sexual
desire in both females and males (Bosch et al.,
1991). Aphrodisiacs are used to treat three
types of disorder: libido (sexual desire,
arousal), sexual potency (effectiveness of
erection), and sexual pleasure (Malviya et al.,
2011). Traditional Persian Medicine (TPM) is
one of the most critical medical doctrines
with an ancient history that can help us to
recommend effective medicinal herbs in this
context. The Persian physician Avicenna has
devoted one chapter in his Canon of Medicine
(Ibn Sinā, 2015) especially to male SD. In this
chapter, Avicenna’s perspective on male SD is
reviewed, along with a brief discussion of
pathology, holistic treatment methods, and
the principles by which herbal medications
work.
Sexual Disorders in View of Avicenna
SD in men are known in TPM as da ʿf -e qow-e
bah (weakness of aphrodisiac) and enzal-e zood-
ras (early ejaculation). Avicenna has classified
male SD in 24 categories. One critical class includes low sexual desire (noqsān-o-al-bah).
Anatomy of the genital system
in semen production. The characteristics of
semen-producing foods include high nutrition value and moderate warm nature. After
the first digestion in the stomach, the food
goes to the liver, and the second digestion
takes place in the liver. The derived blood
from these two digestions goes to the arteries and passes the third digestion. Then
blood reaches the organs to perform the
fourth digestion (tissue digestion). Thus,
semen is produced in the fourth digestion
of food.
Reasons for low sexual desire
Causes of low sexual desire in the view of
Avicenna are:
1. Structural and dystemperament (su-emizāj) disorders in the organs that produce
and transmit semen (testes, semen ducts,
and penis).
2. Disorders in other essential body organs
(weakness of chief organs, d aʿf -e aʿdā-e-raeisah).
3. Semen disorders (in quantity, quality, and
movement).
4. Psychological and mental disorders (aʿrāde-nafsāni).
5. Other causes including gas (rih) deciency,
drugs, and prolonged lack of intercourse.
The male reproductive system includes the
testes, ducts, and penis:
1. Testes: Produce semen and are surrounded by
the scrotum and many veins and arteries.
2. Ducts: Two ducts (vas deferens) come
from the testes carrying semen to the penis.
3. Penis: A hollow ligament covered on both
sides by muscles that make it rm. ree
ducts in the penis lead to one valve in the
trunk. It drains urine from the bladder and
semen from the testes.
Semen, from the Traditional Persian
Medicine perspective
Semen is the fourth digestion product. Therefore, intake of foods has a very influential role
Structural and dystemperament
(su-e-mizaj) disorders in the organs
that produce and transmit semen
(testes, semen ducts, and penis)
Any defect in the testes, arteries, and semen
ducts, including excessive laxity and the
various dystemperaments in the testes and
genital system, affects the production, quality, and quantity of semen.
Main dystemperament (su-e-mizāj) disorders and their treatment principles are as
follows.
Dry dystemperament
Dry dystemperament on the genital system
makes semen very thick, compact, and challenging to move.
Sexual Dysfunction Management 421
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TREATMENT. The use of various soups, milk,
dairy products, fruits, and topical cold and
moist oils such as lettuce and pumpkin, is
helpful in these patients.
Cold dystemperament
In cold dystemperament on the genital system, patients’ semen is thick and usually has
difficulty coming out.
TREATMENT. These patients recover by con-
suming warm foods and taking moderate exercise. Foods with a warm nature such as
pistachios, almonds, cinnamon, saffron, carrot seeds, nettle seeds, ginger jam, broth with
warm spices, cooked peas, sparrow meat,
turnips, coconut, and carrot jam, and topical
warm oils such as clove and garlic are helpful
for these patients. These people should avoid
sour buttermilk and yogurt. Exercise is very
suitable for these patients.
Warm dystemperament
In the warm dystemperament on the genital
system, the patient’s skin is hot, the urine
color is bright yellow, and the semen color is
yellow. Rapid ejaculation, enlarged testes,
testicular vessels bulging, and a burning
sensation among the ejaculation are other
symptoms of these patients.
ginger jam, shrimp, leek, horseradish, watercress, artichoke, garlic, cumin, and topical
warm oils are recommended, whereas the
consumption of moisturizing foods such as be er,
pumpkin, cucumber, yogurt, and buttermilk
should be avoided.
Cold and dry dystemperament
According to Avicenna’s Canon, cold and dry
dystemperament on the genital system prevents the gas (rih ) production, and the
hot dystemperament destroys the gas (rih).
Therefore, penile flaccidity can be caused by
penile dystemperament.
TREATMENT. For the cold dystemperament
symptoms, hot spices such as onion, leek,
fenugreek, carrot seed, and hot temperament oil are recommended.
If the dry dystemperament symptoms
are observed, warm and moist foods such as
egg yolk, cow’s milk, almond milk, milk with
rice, pumpkin stew, carrot jam, and wet temperament oils such as lettuce and pumpkin
oil are suitable.
Phlegmatic syndrome
Phlegmatic dystemperament on the genital
system causes the weakness of the penile
nerves and leads to erectile dysfunction.
TREATMENT. These people tend to use cold
foods and drinks. Sekanjabin (oxymel),
lemon syrup, buttermilk, pomegranate and
its paste, milk, cucumber, purslane, barberry, plum, rice, spinach, topical violet oil,
and avoiding hot foods are helpful for these
patients.
Wet dystemperament
In the wet dystemperament on the genital
system, the semen is thin, loose, and has a
large volume.
TREATMENT. Foods with a hot and dry nature,
such as sparrow and pigeon meat, barbecue,
partridge, cinnamon, cloves, cardamom, jujube, thyme, dill, bananas, walnuts, eggs,
TREATMENT. Hot and dry nature foods, exer-
cise, avoiding cold and wet nature foods
such as buttermilk and yogurt, and topical
warm oils are helpful for these patients.
Disorders in other essential body
organs (weakness of chief organs,
daʿf -e aʿda-e-raeisah)
Weakness in brain function (daʿf -e demagh)
The brain, as the body’s central organ, controls other organs. So, any disturbance in its
function can affect the other organs’ function. These patients’ complaints are lack of
pleasure during intercourse, decreased sexual desire, and penile flaccidity.
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TREATMENT. General recommendations for
brain health include avoiding exposure to bad
smells, too many mental activities, excessive
sleep and wakefulness, excessive intercourse,
overeating, and consuming very sour foods.
Foods that strengthen the brain include
peeled almonds with candies, bird meat with
chickpeas, saffron, cinnamon, and cloves, meat
extract, lemongrass (Cymbopogon jwarancusa
subsp. olivieri (Boiss.) Soenarko), chamomile
(Chamaemelum nobile (L.) All.), basil (Ocimum
basilicum L.), lavender (Lavandula stoechas L.),
figs, apples, rose water, grapes, currants, pis
tachios, hazelnuts, and eggs. Treatment for
all kinds of brain dystemperament disorders
may be needed.
Weakness in heart function (daʿf -e qalb)
The heart delivers the necessary blood to the
organs and produces vital spirit (ruh-e-hay-
awāni). Heart weakness due to decreased
spirit and gas (rih) is associated with symptoms such as intercourse reluctance, exertional dyspnea during intercourse, erectile
dysfunction and ejaculation without an erection, pulse weakness, and decreased body
temperature.
TREATMENT. Participating in joyous gatherings,
avoiding sadness, applying good-smelling perfumes, using delicate and heart-strengthening
foods such as apples, beets, and their juice,
sweet pomegranates, grapes, rose water, bitter
gourd, spring orange juice, saffron, bird’s eggs,
and barberry and plum juice (in hot temperament) are general recommendations for heart
health. Treatment of heart dystemperament
may be necessary.
Weakness in liver function (daʿf -e kabed)
From the TPM perspective, the liver produces four main humors (khelt) in the body:
yellow bile (safrā), black bile (saudā), phlegm
(balgham), and blood (dam), and produces
natural spirit (ruh-e-tabieʿi). Therefore, liver
dysfunction can lead to infertility due to the
abnormal production of semen.
TREATMENT. General recommendations for
liver health maintenance are avoiding overeating, excessive consumption of very cold
or very hot foods, drinking icy water, water
during fasting or after bathing, intercourse
and exercise while sleeping, extreme thirst,
eating foods that are excessively sweet, eating sticky foods and consuming dense foods,
and using natural and mild sweets after
meals. Foods that strengthen the liver are
coriander, beer, pistachios, almonds, raisins,
hazelnuts, chicory, apple and pomegranate
juice, and fast-digesting meats such as
poultry and mutton. In the presence of liver
hot dystemperament symptoms, purslane,
chicory, tamarind, lemon, plum, cucumber,
pumpkin, beetroot, apple, pomegranate,
and pear should be consumed. If the liver
cold dystemperament symptoms are ob
tained, currants, cloves, cinnamon, and saffron are helpful.
Weakness in stomach function
(daʿf -e maʿdah)
The stomach is an essential organ in the
body; the digestion of food begins here, and
the gastric digestion product is delivered to
the liver. Any food maldigestion in the stomach can cause many disorders in the liver,
leading to an abnormal main humor production. Stomach weakness has symptoms such
as belching, bloating, stomach heaviness
after eating, and defecation disorders (constipation or diarrhea).
TREATMENT. The general principles of stomach
health include avoiding extreme hunger and
overeating, cramming, eating before the stomach evacuation, drinking a lot of hot or very
cold water, consuming drinks with food, consuming thick and slow-digesting foods, not
chewing food, and eating too fast. In order to
strengthen a cold stomach, warm temperament
foods such as ginger and its jam, beet jam, apple,
carrot, pistachio, almond, mint, oregano, cardamom, saffron, cinnamon, cumin, and cloves
are recommended.
Weakness in kidney function (daʿf -e kolyah)
These patients’ complaint is impotence and
ejaculation without lust.
TREATMENT. Suitable recommendations for
this group are sheep and camel milk, raisins,
Sexual Dysfunction Management 423
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carrot jam, apple juice, pear, pomegranate
and its paste, quail meat, and eggs.
Disorders in the middle organs between
the chief organs (aʿd a-e-raeisah)
and the genital system
Included in these disorders is obstruction of
the ducts between the origin and the genitals.
Disorders in particular adjacent organs
The disorders in adjacent organs include amputation of hemorrhoids and pain in the anal
area due to the nerve endings in this region.
Systemic disorders
Systemic disorders are general weakness or
systemic diseases of the body.
TREATMENT. In the treatment of body weak-
ness, fortified foods such as eggs, milk, almond, pistachios, and green beans are the
appropriate recommendations.
Semen disorders
sperm. Ejaculation is complex, and the discharge is thick. A long-time reduction in sexual activity impairs sperm production. These
patients’ complaints are poor erection and
decreased sexual desire.
TREATMENT. If the cause of gas (rih) defi-
ciency in the bottoms is due to extreme cold
dystemperament, proper treatments are
soft rubbing, grains in the food such as kidney beans and chickpeas, and onions with
salt. And if the reason for the gas (rih) deficiency is hot dystemperament, use of cold
temperament oils and foods such as pear
and milk is helpful. Suitable recommendations for the drug-use group are giving up
drugs, eating Golghand (a product obtained
by mixing rose petals and sugar) with rose
water and lemon balm every morning, fresh
cow’s milk with cantaloupe, rice with milk,
carrot jam, ginger jam, egg yolk with cinnamon, birds meat, saffron, cinnamon, and
chickpea.
Table 14.1 summarizes the reasons for
low sexual desire according to Avicenna’s
Canon of Medicine and compares them to
modern medicine.
Semen disorders include quantity, quality,
and movement disorders.
Psychological and mental disorders
Conditions such as extreme fear, depression,
anxiety, and sudden sadness are effective
triggers in infertility.
Other causes including gas (rih )
deficiency, drugs, and prolonged
lack of intercourse
Gas (rih) deficiency may be due to cold or
hot dystemperament in the distal region of
the body. Although people believe using
drugs is an effective way to cure ejaculation,
narcotics can decrease the seminal fluid
movement and disrupt the movement of
(aʿrad-e-nafsani)
Low Sexual Desire from the
Perspective of Modern Medicine
Sexual desire (libido) is a type of motivation,
need, and desire for sexual activity that is created by visual, auditory, external tactile stimuli as well as internal psychological stimuli in
cortical and subcortical areas of the brain such
as the limbic system and temporal lobe.
Sexual desire has biologic, psychological, and social components. Regarding
the biologic aspect, sexual desire, like other
instincts, is a response to a biologic need
with biologic factors such as anatomy, physiology, genes, hormonal status, general
health, nutrition, lifestyle, and age influencing it. The psychological aspect refers to
neuropsychological issues and interpersonal
relationships, whereas the social aspect refers to cultural and value issues of society
and individuals (Nimbi et al., 2020).
424 Elaheh Zibaee et al.
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Table 14.1. Reasons for low sexual desire mentioned in Avicenna’s Canon of Medicine compared to the
results of modern medicine.
Causes of low sexual
desire
Structural and
dystemperament
(su-e-mizaj)
disorders in the
organs that
produce and
transmit semen
(testes, semen
ducts, and penis)
Disorders in other
important body
organs (weakness
of chief organs,
da ʿf -e aʿda-e-
raeisah)
Semen disorders Changes in quantity,
Psychological and
mental disorders
(aʿrad-e-nafsani )
Other causes Systemic diseases
Various
dystemperaments in
the testes and
genital system
Excessive laxity
Brain Weakness in brain function
Heart Weakness in heart function
Liver Weakness in liver function
Stomach Weakness in stomach
Kidney Weakness in kidney
Middle organs Obstruction of ducts
Special adjacent
organs
Systemic disorder General weakness of the
quality, and
movement
Aʿrad -e-nafsani Psychological and mental
Gas (rih) deficiency
Intercourse time Long-term lack of
Drugs Alcohol
Avicenna’s Canon of Medicine
Cold, severe cold, dry, and
severe cold with dryness
dystemperaments
(daʿf -e demagh)
Brain trauma
(daʿf -e qalb)
(daʿf -e kabed)
function (daʿf -e maʿdah)
function (daʿf -e kolyah)
between the chief
organs (aʿda-e-raeisah)
and the genital system
Amputation of hemorrhoids
Pain in the anal area
body
Various dystemperaments
in the testes and genital
system
General weakness
In the whole body
Around the body
intercourse
Modern medicine Main causes Minor causes
Trauma
Cryptorchidism
Varicocele
Contact with gonadotoxins
Orchitis
Testicular torsion
Lack of androgen
Chromosomal causes
Idiopathic
Ejaculation dysfunction
and impotence
Hypospadias
Hypothalamic disorders
Pituitary disorders
Thyroid disorder
Brain trauma
Heart failure
Liver failure
Digestion disorders
Kidney failure
Systemic diseases of the
body
Diabetes
Hormonal causes
Pharmacologic causes
Gonadotoxins
disorders
Chronic systemic diseases
Erectile dysfunction
Time and frequency of
proximity
Contact with oxidative
stress
425 Sexual Dysfunction Management
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Causes of low sexual desire
Biologic causes
Androgen deficiency, hypogonadism, hormonal disorders, nervous system diseases, vascular system diseases, heavy alcohol drinking,
smoking, diabetes, obesity, eating disorders,
sedentary lifestyle, cancer, prostate disorder,
chronic illness, pelvic infections, fracture or surgery, and medications (like hormonal therapy,
chemotherapy, blood pressure medications,
statins and fibrates, antidepressant, antipsychotics, benzodiazepines, anticonvulsants,
H2 blockers, corticosteroids) can be listed as
biologic causes of low sexual desire.
Among the hormonal causes, free testosterone levels are an important factor on
sexual desire. Free testosterone is crucial as
it affects key receptors both centrally and
peripherally to promote a normal sexual
response and desire. Among other effective
biologic compounds, nitric oxide as a chemotactic agent can indirectly affect sexual desire. It is a potent vasodilator throughout
the body and facilitates blood flow and
lubrication to the sexual organs. Neurotransmitters such as dopamine, norepinephrine, and serotonin are three important
centrally acting neurotransmitters of the
limbic system, associated with sexual desire.
Psychosocial causes
Psychological disorders, posttraumatic stress
disorder, relationship problems, stress and
exhaustion, and low self-esteem are the main
psychosocial causes of low sexual desire
(Jayne et al., 2017).
Treatment of low sexual desire
The choice of treatment depends on the cause
of the decreased libido. Sometimes a change
in lifestyle, a discontinuation of a particular
medication, or a change in medication (such
as a reduction in dosage) can solve the problem. In general, two approaches to treatment
are suggested: medication and psychotherapy. Different treatment options for biomedical approaches (e.g., hormonal replacement
therapy or hormonal treatments, testosterone therapy) and psychological approaches
(e.g., psychotherapy, cognitive behavioral
therapy, couple psychotherapy) are available.
Pro-erection medications and the use of testosterone injections or gels are the first line
of treatment for male sexual desire problems.
There is evidence that central dopamine
neurotransmission may be important in mediating the central nervous system’s regulation of sexual desire and erections. Treatments with dopamine receptor agonists (e.g.,
bromocriptine, pergolide) may also stimulate
erections and sexual behavior (McCarthy and
McDonald, 2008).
Common drugs for erectile dysfunction
are known as phosphodiesterase inhibitors.
The enzyme phosphodiesterase (PDE) is responsible for the degradation of cGMP and
cAMP. T he isoform in penile tissue is phosphodiesterase type 5 (PDE5), which exclusively
degrades cGMP and reduces cGMP levels.
Thus, inhibition of PDE5 increases cGMP
levels, reduces intracellular calcium, relaxes
smooth muscles, and dilates blood vessels.
The use of certain drugs such as bupropion and dopamine that have other main uses
has also been suggested to increase libido.
Bupropion is a norepinephrine and dopamine
reuptake inhibitor that improves sexual desire in depressed patients as well as in patients with hypoactive sexual desire disorder
(HSDD) induced by use of serotonin specific
reuptake inhibitor antidepressants. Sildenafil
is a PDE5 inhibitor. Inhibition of PDE5 pro
motes vasodilation via the sustained effects
of nitric oxide in the vascular system. Furthermore, buspirone acts as an antianxiety
agent that binds to both serotonin and dopamine receptors in the brain. It has been studied for its potential to affect sexual function
and possible off-label use in HSDD with some
promise (Engel et al., 2019).
Pharmacologic Aspects of Medicinal
Plants for Treating Low Sexual Desire
Cited by Avicenna
This section presents scientific evidence
backing up medicinal plants mentioned in
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