Under normal circumstances every man has nocturnal erections, the duration and hardness of which are related to age. Usually a man has 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:

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

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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.

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’ 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 necessarily 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 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 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.