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Thoughts about the penis (1)

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Thoughts about the penis (2)
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Leonore Tiefer is an interesting psychologist, a sexologist with some idiosyncratic views. She wrote Sex Is [a curious title] Not a Natural Act, a collection of essays published in 1995. She maintains that male sexuality has been taken over by something she thinks of as a "medicalized" quest for the perfect male penis. And she's unhappy about it. Quite right, too. For, as  any observer of this field will know, the pursuit of perfection in the male genitals is driven by profit motives rather than medical concern. Perfection, here, is defined as the ideally functioning penis, one that can always become erect on demand. (We're not talking about enlargement procedures.) What, then, we may ask, is the role of the medical profession in stimulating desire and expectation for a perfect erection, every time?

First off, the medical profession uses somewhat dubious evidence to explain away the emotional and interpersonal causes of erectile dysfunction. And once you have started from the proposition that sex is no more than nerve sensitivity, muscle relaxation, increased intra-corporal pressure, and changes in blood flow, you soon arrive at the obvious conclusion that getting an erection is equivalent to sexual desire, and that getting an erection is a controllable process in which science can, and should, involve itself - after all, are we men not entitled to be erect whenever we want to be? Ah, well, maybe. But if sex is a process which has deep interpersonal significance, and comes from the heart, rather than the balls, then erections are only an outcome of a relationship. And when an erection fails to appear, it is often the relationship which lies at the root of the problem. To medicalize this issue and say that it can always be cured with chemicals, separates the erection from the relationship, and to some extent objectifies the woman, who in some way becomes a sex object for the man's pleasure. (Though she too may never wish to examine the relationship issues which underpin the hardness or softness of the man's penis.)

Tiefer thinks Masters and Johnson, even though they spoke of intercourse as a matter of vasocongestion (blood engorgement of erectile tissue) and involuntary muscle contractions (myotonia), understood that the patient in cases of sexual-dysfunction was the couple. How times have changed! Now, alas, the patient is the penis.

So where does this leave women? While many women really like harder and longer-lasting erections, and might therefore appear to have little to complain about when a man takes Viagra, chemically induced erections do not promote discussion of relationship issues, and - worse - men don't have to take responsibility for their erections (or lack of them) - in fact, the erection becomes a combined enterprise, a joint venture between a man, his doctor, and his Viagra.  Could it be that because urologists are mostly men, who understand that men don't want to discuss relationships, they are complicit in offering Viagra to a man who can then accept that his erection problem isn't his fault? He has a vascular problem in his penis. And that can be fixed. This medical view of erectile dysfunction certainly misses something. It helps a man feel like a man, but it does not let him explore his feelings, his talent for sex, his skills and his deficiencies in relationships. Only sex therapy can do that.

But is this radical position correct, or even justified? Between 1987 and 1989, the Massachusetts Male Aging Study provided medical checkups for over a thousand men aged between forty and seventy. This was a comprehensive study and involved psychological test as well as physical ones. A self-administered sexual questionnaire was the basis of conclusions about the men's erectile potency. But as you would guess, the MMAS concluded that most erectile dysfunction was vascular in origin, and that it was much more common than thought, affecting five percent of men at age 40 and fifteen percent of men at age 70. (I think later evidence suggests these figures have increased since, possibly due to better reporting and more openness.)

Strangely, the MMAS also led researchers to conclude that a majority of men over forty years of age have some form of impotence. This is obviously an ideal base from which to promote drugs for the impotent man, yet careful study of the MMAS has led other, more skeptical, researchers to suggest that the results of the questionnaire were predetermined by the questions, one of which was "How satisfied are you with your sex life?" In effect, if you answered this question with any answer other than totally satisfied, you were deemed to have minimal erectile dysfunction. As Tiefer observes, a rock-hard penis isn't even necessary for good sex, so this is a strange position to take. There's background to this, though: Tiefer was hired by Dr Melman, a urologist in Montefiore Medical Center, New York, to screen his erectile dysfunction patients. Unlike Tiefer, he says, very clearly, and very firmly, that men want and need an erection for good sex: it's part of their identity, part of their masculinity, part of who they are. Both they - and their wives - like the cure that Viagra offers.

Melman says that while he agrees there are men with relationship issues, and while it's true that enabling them to have an erection does not cure those relationship issues, he still has his doubts about psychosexual therapy. He's tried and failed to get data about treatment success rates from various different sexual therapists, and he still has no objective proof that such therapy actually will work in getting men back their erections. Men want results - they want an erection - and they want it fast. That's what Viagra does, and it makes it easy for doctors to satisfy that need. Does it matter? Well, maybe yes, maybe no.

It's not really the medicalizing of erectile failure that's the problem, in my view, for few people discuss their relationship in any meaningful way, with or without erections. For me, the issue is more about the medicalization of the erection, the removal of responsibility from men for their own sexual health. Pfizer - who, as you may well know, from the TV advertising they promote, make Viagra - have produced a questionnaire. This is their Male Sexual Health Inventory, which only has five questions. If a man scores less than 22 out of 25, the suggestion is made that he sees his doctor, where he no doubt puts pressure on the doctor to issue a prescription for Viagra. However, as must be obvious, there is a major difference between erectile dysfunction, which is a real problem and a mere sense of sexual dissatisfaction because your erection is not always as firm as it might be.

Where does this leave the observation that there's a lack of evidence to back-up the claims of psychosexual therapists that ED is mostly psychologically caused? Psychiatrist John Bancroft, director of the Kinsey Institute, wrote an essay entitled "Man and His Penis", subtitled with the question: "A Relationship Under Threat?" He was worried by the ignorance and avoidance of emotional and mental aspects of impotence, both the causes of it and the effects of it: he has spoken of vein grafting (revascularization), penile implants (inflatable silicone implants) and drug treatments having an overwhelming and obscuring effect on the problem. He observed that the essential foundation (my words) of a man's sexuality rested on his relationship with his penis. For example, it's certainly true that how a man sees his penis (i.e. as being large or small) often bears no relationship to its physical size: it is indeed all in the mind. And think how an erection may imbue a situation with a degree of sexuality that the penis's owner may have neither recognized nor be willing to accept. And again: the penis may totally refuse to support its owner in some sexual adventure, as if it were commenting on the rights and wrongs of what is going on. All of this certainly suggests that erectile dysfunction is not just a physical process. An erect penis  - and a flaccid penis - both tell a story about a man and his motives.

In short, I like to claim that the penis never lies. It tells the truth, whether the man behind it wants to hear this or not. Bancroft ruefully concluded that he had come to understand the importance of the relationship between a man and his penis, albeit at a time when developments in medical care seem to be rejecting it. Eleven years later, Bancroft commented that he wasn't quite as worried as he once was, even though many urologists still focus on the penis and appear not to think of the man attached to it.

Continued here