In 2011, sex workers on Lagos's notorious Sanusi Fafunwa Street issued a warning, according to one of Nigeria's online services: "Clients who use Alomo Bitters or 'any high-power drugs like that' will either be denied service or they would be made to pay double."
Workers complained of "exceptionally powerful men who look deceptively weak but, 'when they climb on top, they just begin to work like a caterpillar'?".
Alomo Bitters is a Ghanaian alcoholic herbal product made from tropical plant extracts by Kasareko Company Limited. Some men, particularly in West Africa, also use it as an aphrodisiac.
Johannesburg-based sex therapist Elna McIntosh was therefore not overly surprised when one of her Nigerian friends in South Africa, who was on his way to Ghana for business, phoned her excitedly.
"I'm going to have great sex!" he exclaimed. "I'll be taking loads of Alomo Bitters in Ghana."
But McIntosh was perplexed, nonetheless. "Are you crazy?" she asked. "It's nonsense. There's no proof for it. And, besides, you know nothing about the side effects.
"Every country has a drug or root or something that some men swear by for good sex," she tells Bhekisisa. "But it's almost never been tested for efficacy or safety. No one even knows what dosage to take. For instance, when you take a bottle of Alomo Bitters, it's really, really bad for you."
Untested products at the local pharmacy
In South Africa, you can find many untested products on the shelves of trusted chain stores, such as Clicks and Dischem. Bhekisisa found Erex, "the one hour before" capsule that the pharmaceutical company Brunel claims is a "potent natural libido enhancer promoting a healthy sex drive and stronger erections" at Clicks in Rosebank, Johannesburg. It contains "elongifiolia extract" and "ginseng".
Erex "arousal drops" for women were sold at the same shop and promises to help to "improve desire and heighten sensation" and contains "uBangalala extract" from the roots of plants that Zulu traditional health practitioners have claimed are effective remedies for the treatment of erectile dysfunction and impotence.
According to a Brunel pharmacist, Janene Fourie, the company's Erex product sales have increased by about 10% to 15% a year since 2008. Now about 50 000 units are sold a year.
At both Clicks and Dischem, you'll also find Chinaga by GM Pharmaceuticals, "nature's ultimate sexual arousal formula" and Libido Booster, which, according to the packaging, is a "horny goat weed formula for men and women".
Not one of these products, known as complementary medicines, has undergone clinical trials. They have also not been registered with the Medicines Control Council (MCC), which is the only body in the country that has the authority to verify the contents of medicines independently and the studies proving safety and efficacy.
Complementary medicines not regulated
Since 2002, complementary medicines have merely been entered into a registry (data base) to record their existence. According to the MCC registrar, Mandisa Hela, these medicines were never regulated because of a lack of a legislative framework (although specialist clinical pharmacologist Roy Jobson argues that there has been a framework since 2002 that the complementary medicine industry ignored).
According to Jobson, "if we don't know what's in it, we can't say whether it's safe or whether it works".
The best way to get data on whether it works, Jobson says, "is to set up a trial in a controlled way, where you compare one group of people receiving the product with a group of people who are not".
For instance, Viagra, the well-known (orthodox) pharmaceutical product produced by the drug company Pfizer that is used to treat erectile dysfunction, underwent 16 years of clinical trials to test its efficacy, side effects and interactions with other medications.
According to Jobson, the leaflets accompanying complementary medicines can't be taken as truth, unless the MCC has verified them.
"The stated ingredients could be adulterated with unstated ingredients, as was the case with Simply Slim a few years ago," he says. "This slimming product [claiming to be a complementary medicine] was being imported from China. When it was tested in a laboratory, it was found to contain sibutramine, which is a schedule 5 medicine [which can be prescribed only by a doctor] and is in fact prescribed for weight loss. So no wonder Simply Slim was working beautifully.
"The problem was it was used indiscriminately and [was] available without a doctor's prescription, which is completely contrary to the idea of scheduling a medicine where you need to have a doctor check whether you don't have high blood pressure because the sibutramine could make it worse."
People embarrassed to talk about sexual conditions
McIntosh considers it dangerous to buy sexual enhancement products off the shelf but she says "there are a whole range of reasons why people find it easier. People, for instance, don't want to go to their doctors because there is the embarrassment of speaking about their [sexual] condition."
She adds: "A loss of libido or erectile dysfunction is very difficult because there can be many causes, many of which a pill can't fix. It's often to do with personality or relationship problems.
But when people find that unproven complementary medicines work, says Jobson, it's often caused by placebo effect [a perceived improvement on taking a medication that has no active ingredient in it].
According to Hela, the council has now determined that complementary medicines should be regulated and registered.
In November last year, Health Minister Aaron Motsoaledi published regulations that will require them to be registered and for the scientific data backing their claims and safety to be produced, although it might not always be based on clinical trials.
"As there are many complementary medicines that are already on the market, the MCC will register them in a phased manner starting in May this year," Hela says.
But, she says, they will have to display a label by March while they're waiting to be registered that states: "This medicine has not been evaluated by the MCC and is not intended to diagnose, treat, cure or prevent a disease".
People say sex must be spontaneous, but then the rest of their lives are planned. Where is spontaneity going to fit in here? You have to be realistic about your sex life. Plan it. How else are you going to get to it?
All those clichés in women's magazines about having a regular date night are actually true. You need to spend time with each other so you can talk.
People have affairs and then develop consequent trust issues. No amount of sexual enhancers is going to make that go away. Having emotional relationships without physical sex on the internet can also be cheating – cybersex is very explicit. Don't do it.
We thrive on touching. But when we're really angry we don't want to be touched. If your partner is angry with you, he or she is unlikely to want to be intimate. Sexual enhancers won't fix that. Working at your relationship will. – Elna McIntosch, Johannesburg-based sex therapist
Being overweight has a direct impact on sexual function, particularly for men. Obesity and cholesterol go hand in hand. Cholesterol leads to reduced blood flow to the genitals and therefore smaller and softer erections.
There is something to be said for "marathon runners make excellent lovers". Sex pushes up your pulse, so if you're starting off on a high pulse rate because you're unfit, you're going to run out of breath very quickly. Sex, particularly for men, is like doing push-ups. The fitter you are, the better the sex.
Smoking is the biggest cause of erectile dysfunction as it directly reduces blood flow to the genitals. Smoking also makes you short of breath, making sex harder.
Watch those drinks
Alcohol is a "downer" – with too much of it men often struggle to have erections. But first it's an "upper" in the sense that they feel good and uninhibited. Many people have unprotected sex, which they never intended, because of too much alcohol. It can also lead to sexually transmitted infections.
Be good to yourself
When we're down or depressed, we don't feel like sex. Do something about it: see a doctor or a therapist. Or do something to feel better about yourself – therapy doesn't always have to be face-to-face psychology. It can take on the form of going for a massage or getting your hair done. – Elna McIntosch, Johannesburg-based sex therapist
[Note this article was originally published on 14 February 2014]
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Bhekisisa means "to scrutinise" in Zulu
In South Africa, Zulu patients who would like to be thoroughly assessed by a doctor, would ask the physician to "bhekisisa" them.