Psychological or physical?
Not only patients but doctors too consider it important to decide whether the erection problem is caused by psychological or physical factors. Why is that? In the case of a patient with a duodenal ulcer not much attention is usually given to underlying psychosocial problems. A prescription for medication to inhibit or neutralize stomach acid is soon written out, and constitutes what is known as symptomatic treatment. In the case of ed, however, the patient does not get off so lightly: the experts must, as far as they can, determine whether the problem is psychological or physical in origin. That is probably why many men are ashamed to reveal their erection problems. Research by gps showed that over 85 per cent of men with an erection problem needed help, but only 10-15 per cent had actually sought help. Once he has gone to his gp the man with ed who does not react, or does not react positively to an erection pill prefers to be referred to a urologist rather than to a sexologist. The former works with various types of apparatus, syringes and needles, or may decide on an operation. For many men that is obviously less threatening than having to talk to a sexologist about all kinds of details of their failed love life. Men have a relatively strong tendency to rationalize. Research into gps’ treatment methods showed that a consultation in which the erection problem is first broached lasts on average thirteen minutes, and in only 10 per cent of cases is the partner present.
The patient can, in the best-case scenario, expect the following questions: is the problem in getting an erection or in maintaining it? If an erection can be achieved, the blood supply is probably adequate. How long does the erection last? Does the erection disappear before or during coitus, and how long has the problem been going on? Is it affected by the position of the body? (In terms of coital position men are vulnerable in the missionary position: the moment they start making coital movements relatively more blood is channelled away towards their legs, which can be at the expense of the blood supply to the penis – certainly if there is hardening of the arteries. In a nutshell: ‘It’s a choice between sex and legs.’ Other questions probing the cause of the erectile dysfunction include: are there any apparently unrelated physical ailments? What about the use of medication, alcohol, tobacco and drugs? Urologists also often use a questionnaire.
What is the situation among non-Western men? Is ed more common among them? Do they deal with the problem differently? According to gps, Muslim men often broach sexual problems via a physical complaint. An erection problem may be presented as pain in the penis, knee or abdomen. The complaint is probably expressed in a veiled way because discussing psychosocial and sexual problems with an outsider is taboo in Islamic culture, while ‘being ill’ is accepted. Turks and Moroccans also generally expect to be prescribed drugs. Injections are more highly valued than tablets, powders or suppositories. With Turkish men potency and fertility are crucial for their sense of self-worth, vitality and pride. Consequently erection problems can be seen as a loss of vitality or even as the approach of death.
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 philosopher 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.
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.