Psychosocial aspects of the problem are dealt with at length: is the ed linked to a particular partner (how do you ask that clearly and yet discreetly?), or is it connected with tiredness? Was there any unpleasant psychosocial event associated with the first occurrence of the problem? What are conditions like at work and what are the prospects, or are there perhaps worries that subconsciously demand too much attention? Has something happened to the permanent partner to make her/him less attractive? Are there nocturnal and morning erections and are you able to masturbate as before? How is your appetite for sex?
What does the man actually think about the situation and how is his partner reacting?
In the first volume of his Essais the great French philosopher Michel de Montaigne (1533–1592) went into these problems at length.
Montaigne wrote in a fluid, improvised style, with a string of associative leaps. He tells of a friend of his who had heard a man say that he lost his erection the moment he wanted to penetrate a woman. He was so overcome with shame at his flaccid member that the next time he was in bed with a woman he couldn’t put it out of his head, and the fear that the same disaster would befall him again was so great that it prevented his member from becoming erect. From that moment on he was unable to achieve an erection, however much he desired a woman. The shameful memory of each setback tormented and dominated him more and more.
Montaigne’s friend had become impotent when he lost his unshakeable rational control over his penis, which in his eyes was an essential component of normal masculinity. According to the philo -
sopher Alain de Botton, Montaigne did not blame the penis: ‘Except for genuine impotence, never again are you incapable if you are capable of doing it once.’ Because of the frightening idea that we have complete mental control over our bodies, and the terror of deviating from the normal pattern, the man could no longer perform. The solution was to adjust the pattern, and render the event less traumatic by accepting that the loss of power of the penis was an innocent blip in one’s love life.
Montaigne took the unforeseen caprices of the penis out of the dark recesses of unspoken shame.
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Montaigne knew a nobleman from Gascony who could not maintain his erection with a woman, who fled home, cut off his penis and sent it to the lady in question ‘to make amends for his insult’.
Montaigne had better advice:
Married folk have time at their disposal: if they are not ready they should not try to rush things . . . It is better . . . to wait for an opportune moment . . . Before possessing his wife, a man who suffers a rejection should make gentle assays and overtures with various little sallies; he should not stubbornly persist in proving himself inadequate once and for all.
Examination of patients with erection problems
In the physical examination we check whether there is a normal pattern of male hair growth, we listen with the aid of a stethoscope to see if there are any indications of vascular constriction, and if necessary we test reflexes, and feel the penis and the scrotum.
Physical examination of a man with ed does not generally provide any information that was not already perfectly obvious. Nevertheless there are plenty of men who believe that their complaint is the first symptom of a serious disease, and unfortunately this is occasionally the case. In young men the danger is multiple sclerosis and in older men serious cardiovascular disorders. Other diseases which are known to cause erection problems are long-term high blood pressure, leukaemia, serious kidney diseases, hyper- or hypothyroidism, diabetes, underdeveloped or bilaterally damaged testicles, hyper- or hypoactivity of the hypophysis, overactive adrenal glands, amytrophic sclerosis (also an ailment of the spine), spinal cord lesion, serious epilepsy, hernia of the back, Parkinson’s disease and, last but not least, inflammation of the prostate.
If cancer requires the removal of the prostate, bladder, or rectum, this also leads in most cases to ed. Because the surgeon has to keep a margin of healthy tissue around the tumour in order to ensure a lasting recovery by the patient, it is inevitable that some nerves involved in erection will be damaged. It is hence extremely important that the patient should be informed of this before the operation. Radiotherapy can also cause ed.
Additional examinations
Under normal circumstances every man has nocturnal erections, the duration and hardness of which are related to age. Usually a man has 144
a i l m e n t s o f t h e p e n i s such erections between three and five times a night for between twenty and thirty minutes as part of dreaming. In ed with a physical cause, nocturnal erections occur scarcely if at all. The first quantitative data on erectile capacity were obtained a few decades ago from test subjects’ sleeping for a number of nights with a so-called erectiometer around the penis. These meters were nothing more than a felt strip with graduated markings. The following morning it was possible to check whether there had been nocturnal erections and if so how strong. The test was also carried out with the perforated edge around a sheet of stamps. If the following morning the border was found to be torn, this was more or less conclusive evidence of a nocturnal erection. Nowadays university hospitals have very sophisticated equipment for registering nocturnal erections, and thus determining whether an erectile problem has a psychological basis.
The blood supply and drainage can be assessed with the aid of duplex scanning. In this context duplex means simply that two examinations, namely echography and Doppler, are combined. The duplex measurement is carried out both at rest and after an intrapenile injection with a vasodilatory substance. This measurement is important in checking whether the ed is caused by arteriosclerosis. Using the echograph the arteries in the penis can be located, after which the flow can be measured with the aid of the Doppler sound signal. There is a light-hearted limerick on the Doppler effect:
There was an old German named Brecht
Whose penis was seldom erect.
When his wife heard him humming
She knew he was coming –
An example of Doppler effect!
Only a minority of men with ed look for the cause in the psychological field. Mourning is often suggested, especially by widowers who after a while enter into a new relationship. A similar problem of course affects widows and divorced women, who also have to wait and see whether things click sexually. The snag is that the new partners – probably wrongly – expect to share the same bed as soon as possible, and under those circumstances a widower feels under pressure to prove his potency. The man has cared for years for a wife with failing health and after she dies he falls into an emotional black hole, and naturally the same would apply to a widow. Sadly, starting a new sexual relationship is by no means always easy for bereaved partners.
When it finally comes to sexual intercourse even young men may fail to come up to the mark, as illustrated in the following limerick: 145
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There was a young fellow named Bliss
Whose sex life was strangely amiss,
For even with Venus
His recalcitrant penis
Could never do better than t
h
i
s
.
In most cases ed at a young age is an expression of shyness, though occasionally there is a serious underlying psychological problem.
ed can also be indirectly caused by young women: some are easily distracted, become bored when the experience turns out to be less exciting than they thought, or feel a mounting sense of rebellion. In such cases their deprecatory and sometimes insulting remarks can cause their young lover’s penis to go limp. This happens especially if the man involved feels he has to give a terrific performance, while feeling extremely unsure of himself. Sometimes he is frightened of hurting his partner, and occasionally he imagines the hymen as a sort of drumskin, dense and stretched taut, which has to be perforated, causing excruciating pain when coitus is first performed.
Apart from that there are
quite frequently anxieties regarding one’s own sexual organ. One of the most common expressions of this is so-called pseudophimosis. The sufferer has never been taught how to observe proper penile hygiene, including thorough cleaning of the glans, so that with a strong erection and even more when entering the narrow vagina, he experiences a slight pain and a great deal of anxiety.
The result is an abrupt termination of this first sexual approach and a disinclination to take any further initiatives. If a patient does not spontaneously raise the subject, but simply states that though he achieves a good erection, his organ becomes flaccid the moment the penis is introduced into the vagina, there are good grounds for a physical examination. If the man is asked to roll back his foreskin, he appears to try very hard but still does not manage to do so. If one tries to help him, one’s offer is rejected. After some persuasion and with some trepidation he allows the doctor to expose the glans. At this point the person involved is quite frequently close to fainting. A large quantity of smegma shows that the foreskin has not been properly cleaned. Afterwards the man is urged to roll back the foreskin daily and wash his member with soap and water. This is the quickest way to overcome his fear of the vulnerability of his exposed glans. After this he will no longer find it difficult to entrust his precious organ to his partner.
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a i l m e n t s o f t h e p e n i s Experience shows that resentment at adultery by the female partner can also become a malignant growth that eats away at potency.
Adultery itself also quite frequently leads to ed. The Italian feminist Pia Fontana writes about an impotent adulterer in the story ‘The Diary’, in which she describes how the protagonist, Elsa, seduces the married cardiologist Riccardo. They had met at the house of friends, after which she made an appointment at his surgery, not because of an ailment, but with something else in mind. This only becomes clear to Riccardo at their second meeting. Elsa is able to bring him to a pitch of excitement, while at the same time realizing that making love surrounded by the usual metal cabinet full of files, a wrinkled cloth screen, a treatment table covered with a strip of white paper and the inevitable photo of wife and two children, is bound to be a terrible experience.
Elsa goes exploring and discovers a blue tiled bathroom. That’s where it will have to be, she thinks, turning on the hot tap: He caressed her, licked her, lay on top of her, and then something embarrassing happened – embarrassing for him, that is, since Elsa didn’t find it all that strange: despite everything Riccardo couldn’t get it up. Well, it’s nothing exceptional, but it was a nuisance, for both of them . . . He tried, tried again, but he just couldn’t do it. And he was really in the mood, perhaps too much in the mood, or perhaps there was something else.
Elsa becomes irritated by his failure, while Riccardo repeatedly apologizes and maintains that he is completely under her spell:
‘Why do you keep on trying?’ said Elsa. ‘It’s really not that important to me, you know.’ She dried herself with strips of paper – from the treatment table – there was a whole roll in the cupboard.
Riccardo can’t stop apologizing, and as Elsa leaves the practice, she reflects that he is a nice, interesting man. She smiles at the thought of his failed attempts, but the two of them never have a second chance.
Divorce, tensions at work and suppressed homosexuality are also well-known causes of ed. It is estimated that in America between 2 and 4 million people are married to a homosexual or bisexual partner –
usually without knowing it. Between 20 and 30 per cent of gay men and women go into heterosexual marriages despite being aware of their own sexual proclivities: 95 per cent of married homosexuals were aware of their sexual preferences before marriage and 90 per cent had had homosexual experiences. Most believed that marriage would ‘cure’
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them. According to an article in the New York Times, 15 per cent of American married couples in which one partner comes out as homosexual, remain married.
An illustration from my own practice: a well-groomed 53-year-old man attends the surgery for erection problems. His physical condition is good, though he suffers from diabetes and has to inject himself with insulin twice a day. Diabetes suggests a physical cause for his complaint, but not every ailment suffered by a diabetic patient is neces sarily caused by diabetes. The patient has been married for nineteen years, by his own testimony happily. After a number of tests have been carried out it gradually becomes clear that his problem is not so much one of erection as of arousal. The man has nurtured homosexual feelings for years, but does not want to act them out. However, he wouldn’t dream of divorce. He lives in a rather remote little village, and by his testimony coming out openly would be absolutely impossible. The patient feels very negative about referral to a psychologist-sexologist. The suggestion of establishing secret homosexual relationships in town is also dismissed out of hand. He does, though, make it clear that he would like to continue to be monitored every three months. The background to this wish only becomes clear when I have talked things through with an experienced female sexologist in a peer group discussion. She explains that for the man in question visiting a male urologist may count as a kind of sexual contact, which at least offers him the opportunity to speak frankly and openly about his feelings.
It is known that in the course of history some political leaders had potency problems while involved in a power struggle, particularly if the outcome was still uncertain. Mao Zedong was a well-known example. ‘When his power climbed to great heights in the early 1960s, he seldom complained of impotence,’ wrote his personal physician in a biography of the Great Helmsman. From an early age Mao was determined to remain healthy as he grew older and to remain sexually active until he was 80. However, pride came before a fall, and his personal physician was ordered to give him regular injections of an extract of ground deer antlers, which traditional Chinese medicine considers a potency-enhancing substance. There is no evidence as to whether the injections helped.
Like Mao, the majority of men with erection problems believe they have a physical ailment. The lack of an erection is equated with being ill. In the first instance therefore people want to be examined, and their organ is presented for cure or repair, preferably with pills or injections, or if necessary through an operation by the urologist, traditionally the plumber among doctors. Today the crux of the matter is increasingly:
‘What’s wrong with my body, and can the fault be repaired?’ It’s very 148
a i l m e n t s o f t h e p e n i s rare for a man unable to get an erection to say: ‘Stands to reason, I don’t really feel like it.’
In the 1980s the previously mentioned psychologist Bernie Zilber -
geld was considered one of the authorities on male sexuality. In his books he gives a compelling sketch of the still current image of the erect penis: ‘It’s two feet long, hard as steel, and can go all night.’ To support that assertion he quotes extensively from popular literature, for example from The Betsy (1971) by Harold Robbins, one of the world’s best-selling authors:
Gently her fingers opened his union suit and he sprang out at her like an angry lion from its cage. Carefully she peeled back his foreskin, exposing his red and angry glans, and took him in both hands, one behind the other as if she were grasping a baseball bat. She stared at it in wonder.
C’est formidable. Un vrai canon.
Partly because of these overblown images many men shrink to anxious bullocks whose members refuse to behave every day like a cross between a baseball bat, a raging lion and a cannon.
Occasionally someone is prepared to admit that his potency problem is connected with his partner: she bores him, there’s no curiosity, no mystery any more, the excitement has gone. Getting into a sexual rut becomes the cause of ed. In this area it is obviously not only the vagina that has the right to strike – the penis does too. Sexologists call this the
‘Coolidge phenomenon’, after the American president Calvin Coolidge, who features
in the following anecdote:
One day the president and his first lady visit a state farm. Soon their guided tour splits in two. At the chicken run Mrs Coolidge asks the farmer how often a rooster mates. ‘Scores of times a day, ma’am,’ replies the farmer. ‘Be sure to tell the president that,’ says Mrs Coolidge. When the president comes along and is told about the rooster, his question is: ‘With the same chicken every day?’ ‘Oh no, Mr President, with a different one every time.’ Coolidge nods and says: ‘Be sure to tell my wife that!’
Exclusive sexual relations with the same partner can be an advantage.
In 1994 the psychologist W. Zeegers published The Sunny Side of Sex: The After-Effects of Satisfying Sexuality. In the book he compares the sex lives of couples, whom he divides into three categories: couples who always do the same thing in bed, couples who try to make each session 149
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of lovemaking something special and couples who invite others to share sex. They were selected on the basis of their own assessment that they enjoyed a satisfying love life. It was scarcely surprising that the various couples experienced sexuality differently: the way in which their experiences differed turned out to be much more interesting. With people who had a sex life with little variation things always went well: the partners never felt that any particular session was exceptional. It was naturally inconceivable for them that it might ever go less well.
They never fantasized during lovemaking. Within this group there was clearly both love and intimacy, and apart from that each partner knew that the other would never do anything odd – it was just all very familiar.
Cultural influences
Our views on impotence are completely bound up with the time and culture we live in. The ancient Chinese, for instance, never saw the phenomenon of impotence as a significant problem. When the penis no longer became hard enough, the method of ‘soft’ entry was recommended, as described by Jolan Chang in The Tao of Love and Sex. If a man is experienced and dextrous enough, according to this old Chinese method, he can manoeuvre even a completely limp penis inside a woman. According to the Tao one must not attempt penetration when the vagina is not moist. If necessary, vegetable oil can be used as a lubricant. The key to the success of this soft penetration method is the man’s dexterity. As soon as the penis has been manoeuvred into the vagina, he must make a ring round the base of the penis with his fingers with the aim of keeping the tip as stiff as possible. You might conclude that soft entry is a sensible technique for men with erection problems, but that a potent man will have no need of it. According to the Chinese tradition, however, this is definitely not true. ‘Soft entry is not just for the beginner or the problem case. It is an integral part of the Tao of Love,’ writes Jolan Chang. However, there is a snake in the grass. Soft entry and deferred ejaculation in fact serve only male self-interest. Men who want to live to a great age must according to the prescripts of the Tao replenish their weakening yang, the male essence, which is the source of strength, energy and a long life – with yin shui, the water of yin, or the vaginal secretions of young women. Because yang is essential for the health and energy of the man, he must not harm it. This is why a Taoist seldom ejaculates during coitus. Instead he tries to keep his strength up with the secretions of his female partners. The more yin shui he absorbs, the more the essence of the man is strengthened, which is partly why there must be very regular intercourse!
Manhood Page 18