Erectile dysfunction, erection problems or ED.
Whatever you call it, this problem strikes at the root of a man's sense of self. His penis fails to co-operate; he may want sex; he may feel desire for his partner; but he just can't get it up.
As one man said to me: "I'd almost rather be dead than lose my erection."
Having an erection is exactly what it means to be a man - at least in the eyes of a lot of us - and erection problems leave us open to panic and fear. And it's this fear that often turns a minor erection problem into a major one.
Indeed, the biggest cause of erectile dysfunction is fear.
Suppose you lose your erection for some reason. (And there are many reasons: the first time it happened to me, my penis deflated rapidly when I thought we were being watched while making love.)
You think: "This hasn't happened before. What's wrong?"
The anxiety you feel about your penis then begins to grow, until it is actually the cause of your next episode of erectile failure.
The original trigger is long since forgotten. But you get into bed again and before you know it, you're thinking: "Will it work this time?"
(It surprised me at the time, and I certainly worried about it happening again - even though we were then in no danger of being observed.)
When you do get into bed, you focus on your penis, not on what you're doing. You think: "Am I getting hard enough, fast enough? Please God, let my penis get erect!"
And maybe it does, or maybe it doesn't, but the fact is that you've established a cycle of negative expectations that attack your sexual self-confidence.
If you lose your erection again, then you have yet another failure to contend with, and your expectations around your penis become even more pessimistic.
And all the while, you're losing touch with the moment and your sexual pleasure.
Eventually you begin to anticipate failure before you've even started sex; and your erection usually deflates at the point of vaginal penetration or soon afterwards.
Obviously this is all more likely to happen if you're a worrier. Perfectionists and performance oriented men are especially liable to penis problems - so are men with little sexual experience
And when your penis isn't performing, you don't perform well as a man. You think about sex all the time; the problem takes over your life.
Things men do to get over this kind of ED
Men have a variety of well-worn strategies to deal with anxiety induced erectile dysfunction.
Unfortunately, few of these make any difference to the hardness of an un-cooperative penis:
Causes of Erectile Dysfunction
Although the kind of erectile dysfunction described above is very common, there are other causes - some physical, some emotional.
To understand these causes, you have to know a little bit about how arousal works. There are two kinds of arousal - in the mind, and in the body.
Call them "sexual desire" and "an erection", respectively. Some men get turned on by the thought of sex - in other words, they turned on mostly by their fantasy, anticipation, and the sight of sexually arousing objects.
This is fine for younger men - their penises jump to attention at the slightest provocation.
But it isn't so good for a man in his late thirties, forties, or fifties. As a man gets older, it's harder for him to get an erection just by thinking sexy thoughts - physical stimulation is needed as well. In other words, his partner has to suck or play with his penis before he becomes erect.
(By the way, see how we say "his penis has to be sucked before he gets erect" - as though the penis and the man are the same thing?)
A man who's learned to become sexually aroused by what goes on in his head may have a hard time getting aroused just by the touch of his partner - he may simply have lost touch with his body and his ability to be physically aroused.
Sidebar: young men who have premature ejaculation (PE) can become older men with erection problems. This is because a man with PE may try to stop it happening by "tuning out" his sexual feelings. (You know the old advice - don't think about your penis, think about fottball, or whatever?) And as I mentioned above, men who tune out their awareness of what's going on in their bodies become likely candidates for erectile dysfunction as they get older.
Physical problems with the penis
It's all very well offering these explanations of "mental" erectile dysfunction: such things are treatable. But there are many men out there who have real physical problems that might not be so easy to cure.
Let's be clear about this: physical causes of erection problems are rare in men under the age of 45 or 50. The exceptions are men with diabetes (the penile nerves can be damaged); circulatory problems (whether in the penis or elsewhere); and men on certain medications.
Physical causes of ejaculatory problems
Diabetes mellitus, Multiple sclerosis, Spinal cord injury, Sympathectomy, Tabes dorsalis, Proctocolectomy, Stroke, Cystectomy, Aortoiliac surgery
Drugs which can interfere with erection or ejaculation
Check your medicine packaging to see if it might be the culprit (mind you, it might still be the culprit even if it doesn't say so).
Blood pressure medicine: Beta blockers, Verapamil (Calan), Reserpine (Hydropes), Clonidine (Catapres), Methyldopa
Others include: Alprazolam, Amoxapine, Chlordiazepoxide, Sertraline, Paroxetine, Clomipramine, Fluvoxamine, Fluoxetine, Imipramine, Doxepine, Desipramine, Clorprothixine, Bethanidine, Naproxen, Nortriptyline, Thioridazine, Tranylcypromine, Venlafaxine, Citalopram
And yet more: Alcohol, Amphetamines, Metoclopramide, Opiates, Anticonvulsants, Cocaine...well, I am sure you get the idea.
Based on: Beyond Viagra by Alfred Newman, MD, published by Starhill Press, Alabama, 1999. And Principles and Practice of Sex Therapy by Sandra Lieblum, the Guilford Press, New York, 2000.
However it's not always easy to separate erection problems which are rooted in the mind from those which originate in the body.
But if a man gets an erection fairly easily when he masturbates, or during the night, the problem with his penis is not likely to be physical.
Here are some guidelines which may help to indicate if an erection problem is physical:
But even if all of the above applies, the problem can still be psychological. Only a very competent urologist or andrologist, who knows what he is doing, can sort this out.
But if the the problem is physical, what can be done? There are various erections aids and devices which serve to help a man - the Encore, for example, is a device which pumps air out of a tube to create a vacuum then around the penis, which makes it semi-erect, then uses a band which fits around the base of the penile shaft to prevent blood outflow.
There's also a vacuum device which a man can use to - temporarily - inflate his penis with blood, and cock rings of various kinds. There are some references to websites where you can purchase these items if you feel so inclined.
But perhaps the best therapy of all is Viagra, a minor miracle for many men, especially when combined with talking to a competent sex therapist.
Deep seated erectile dysfunction due to psychological issues
Some men have never had sex because their penis literally goes limp at the moment when they try to penetrate their partner. As you may well imagine, this is often due to very deep seated psychological issues. And these may need the help of a therapist. But.....
Most erection problems are simpler than that!
When you work with men who have erection problems, you often find that a bit of education at some point in their lives would have helped to prevent the problems they are facing.
The things that men need to know, but don't, are important, and they all contribute to keeping a healthy sexual attitude - and a penis in full working order!
I mentioned above the men who develop erection problems because they are out of touch with their penis. There is another group of men whose penises don't work because they have lost touch with some important stuff going on in their heads. Here's what I mean by this.
There's a widespread view - among some men and women, anyway - that a man should be a sex machine, ready, willing and able to have sex with any woman who cares to approach him, or who takes his fancy.
But life isn't like that - a man's sexual response is much more fragile, and so is the ability of his penis to maintain its erection, day in, day out.
So let's look at some of the more common beliefs which can cause erectile difficulties:
A man shouldn't be nervous about sex.
But the problem is that it's very common for a man to be nervous when he's sexual with a woman, especially if he wants to please her.
(Which is something that can happen when a man takes responsibility for his partner's sexual satisfaction.)
Anxiety about whether he can perform, or whether he's good enough in bed, is more than enough to make a man's penis wilt.
And if he can't admit to his partner that he has an erection problem, then he may well find that focusing on both his anxiety and his softening pens just makes matters worse. If he is nervous, he is more likely to ejaculate prematurely, and this will further decrease his confidence.
A man should know exactly what to do (and when to do it) during sex.
Oh dear. Again, it just isn't that simple.
Men are not mind readers, any more than women are, and they can't predict what their partners want or wish for during sex if they are not communicating it.
But a man who assumes he should know all this without being told has a serious problem during sex, for he takes on the burden of responsibility for satisfying his partner and giving her pleasure.
An erect penis is often not hard enough to bear such a load, and if she offers him no help in the practicalities of sex, he can also run into trouble - for example, suppose he can't find the way into her vagina (especially when he's in the man on top position).
He pushes his penis ineffectually at his partner's vulva. She's too shy or too inhibited to take his cock in her hand and guide it in, so eventually he gets so uptight that he loses his erection.
He then goes into a cycle of anxiety and loss of erection which makes it even harder for him to have sex....the cycle gets worse, until his confidence is so reduced that neither does his penis get hard, nor does he have the nerve to try penetrating his partner.
A man should be able to get an erect penis and keep it .....in all circumstances.
A man may well find that when he is with a woman who doesn't want sex that he loses his erection - and that's the most natural thing in the world.
Many women with sexual issues develop vaginismus - a condition where the muscles of the mouth of the vagina tighten so that penetration becomes difficult, if not impossible.
But, would you believe, men who have girlfriends with vaginismus, or girlfriends who don't like sex, may often find they can't get an erection in this situation - hardly surprising, really, though, is it?
Even so, many men would blame themselves for not being able to get erect with a woman i this situation.
But sex is not an activity which we undertake in isolation - well, not always, anyway - and it takes two people to make it successful.
True, only one of them has to have a penis - preferably an erect one - but then again, that penis wants to be enveloped by a juicy and willing vagina whose owner looks forward to receiving this male flesh.
The peculiar thing is that the female partners of many of the men in this situation actually blame them for the sexual problems.
In one case, a woman who had never had an orgasm in her life, either on her own or with her partner, blamed her male sexual partner for her problems, even though her vagina was too tight to permit his penis in!
The problem, of course is that men come to believe they are responsible for female sexual pleasure.
Another belief is that men should be able to have sex with any willing woman.
But the truth is rather different. One simple example is the man raised in a religious household with strict prohibitions on sex outside marriage.
He may well have deep seated beliefs that sex is only permissible in a faithful, committed relationship.
Little does it matter what he thinks he would like to do - fuck around, take women to bed in a series of one night stands, or whatever: if his internal conscience dictates that he should have sex in a relationship, he may well need faithfulness and commitment before he can get erect and stay erect.
As Eva Margolies so memorably says: "A man who does not listen to his penis usually finds that his penis does the talking for him anyway."
Some facts you may not know about erectile problems
This is the kind of information many men need to know - it stops them worrying about what the suddenly think of as erectile inadequacy. Did your father ever tell you these things? No? Then how would you ever have found out about them?
Men over 30, or sometimes 40, years of age often need to be physically stimulated before their penis becomes erect.
In fact, the spontaneous erections of youth may be nothing more than a memory by the time a man is 50, and at some point before that he is likely to need physical stimulation before he can become fully erect.
That's a fact of life. Like it or not, the penis responds to declining levels of testosterone in the blood by becoming less responsive to sexual thoughts and fantasy.
As we've already seem, this means that a man who is aware of his arousal both in his body and his head is likely to make this transition through mid-life more successfully than one who simply relies on his body to respond automatically with an erection to sexual stimuli.
A man does not have to have a firm, hard erection to have sex.
It is in fact perfectly possible to penetrate and thrust with a less-than-hard penis, and sex can be just as pleasurable as it would be with a full erection.
Lastly, it's important to know that a penis is never going to stay erect all the way through sex, no matter what age you are.
It can be surprising to a man when he finds that his penis, initially rigid and erect as he, say, starts to give his girl oral sex, gradually wilts and becomes flaccid again as time passes.
He can't understand this at all! After all, he has his face buried in his girlfriend's vulva! Yet this is natural. Almost all men lose their erections during sex at some point, and some level of physical stimulation will be needed in all but the most horny young men to maintain an erection over a long period of time.