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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
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.)
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
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
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.
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
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.
But suppose that the medical and drug industry, as well as the urologists, who
together created an industry around the male erection, do have more insight into
the relationship between a man and his sexual organs than
the therapists have understood? The penis is a complex but well-understood organic
part of the body, and mankind can now alter how it functions, with Viagra - and
the simple truth is that most men like it that way. And if they like Viagra,
they will undoubtedly find even greater affection for Cialis, which is a once-a-day pill that will
get your cock erect on demand - a fact which literally changes the life of men
with erection problems.
This penis-centered approach to life may be something innate, or it may be something learned, but which? If it is learned, it presumably can be unlearned. In one view, a male-centered script is written by the wider culture and reinforced by most males' first sexual act. Masturbation, according to this theory, proclaims a boy's independence (from women?), and centers male sexual desire in the penis, which then imbues the penis with a central role in the definition of masculinity - so much so that a man's capacity to become erect is one of the most, if not the most, important and significant signs of masculinity and male power.
With such a powerful impetus to put the penis at the center of the concept of masculinity, it's no surprise that this organ has been subject to psychoanalysis, political analysis, and nowadays a creeping process of "medicalization" by what has been called "the erection industry"; each type of analysis can be seen as an attempt to make some intellectual and emotional sense of the over-powering, extraordinary relationship between man and his penis. Of course Freud had a major impact on society's perception of the penis, but what we term the medicalization of the penis may have an even greater impact. But just what does this mean? In essence, it refers to the way in which the penis has become an addendum to other industries - the medical industry and the drugs industry in particular. When urologists and drugs become a man's first port of call when his erection fails, then he is in the grip of those two industries, and the relationship between him and his penis has been changed. To some extent he is no longer in complete control of his own dick....he has given away some of his power to other men, and some to organizations and corporations far more powerful than he is.
The medicalized penis is only about twenty years old, and the time for which Viagra has been available is even less than that. And while science has unquestionably helped men with complete impotence or erectile dysfunction, the long-term consequences of PDE-5 inhibitors on the cellular chemistry of the penis have yet to be established. For example, is it not possible that exposure to these compounds will make the body produce abnormal levels of PDE-5? We have no way of knowing what the effect of that would be on a man's own body chemistry, nor indeed of the possible impact on his sexual behavior. In essence, a man can now hold his penis, erect or not, in his hand and he knows what relationship they have. If it is flaccid, and he wants it to be erect, then when he sees a doctor or when he takes the chemical products of the erection industry, he retains control of his penis. We have not always had this power, and we should perhaps be grateful for it: we have, in effect, the ability to override the statements that the penis can make for us about our sexual desires or wishes, and impose our own will on it.