A condition in which a man is persistently or recurrently unable to obtain or maintain an erection of sufficient rigidity to have intercourse. It can have a partly physical basis or can be a form of unconscious sex avoidance.

What causes it?

Most impotent men believe that there is a physical cause for their impotence but this is probably not so, and psychosexual therapy can often do much to cure them. However, there is little doubt that zinc deficiency, for example, is much more common than is realized and this provably contributes to the problem. There are scores of causes for impotence-here are just a few of them.

• Any painful condition of the penis, such as a tight foreskin.

• Diabetes is a common cause-about half of all middle-aged insulin-dependent diabetics have sexual problems, the most troublesome of which is impotence.

• Any arterial disease that produces a reduced blood supply to the penis is a well-recognized cause.

• Certain diseases of the nervous system such as multiple sclerosis and paralysis.

• Certain operations, including prostatectomy and pelvic surgery for cancer.

• Certain hormone deficiencies.

• Psychological illnesses such as depression.

• Alcohol.

• Zinc deficiency.

• Smoking.

• Drug abuse.

• Medical drugs, especially those for high blood pressure, and anti-depressants.

• Various psychological reasons, including: the man unconsciously thinking of his partner as his mother; guilt about sex; such a degree of anxiety that he is unable to relax and let an erection occur; a fear of women and their ‘purity’; a fear of VD or unwanted pregnancy (this is especially common in extramarital impotence); misperceptions of women’s sexuality generally; and many more.

• Earlier failures-leading to the belief that he will always fail.

• Old age. As men age they tend to become less potent. Few men in their nineties are potent.

• Any of the reasons that cause a loss of sex drive.

• Doubts about the relationship with the partner.

• Hostility towards the woman (often not recognized consciously).

• Fear of being detected (in the parental home or in a public place, for example).

• Tiredness, either mental or physical.

• Latent homosexuality-the man would unconsciously rather be with another man and not his partner.

• Fear of hurting his partner, especially after a baby or an operation on the woman.

• An over-demanding woman.

• Stress-from, for example, work, money, home, business problems, or worries about children and parents.

Clearly these causes are many and complex and will often need to be sorted out with the help of a professional who is expert in the area.

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The most commonly used methods for the reduction of sexual phobias stem from the de-sensitization paradigm (Salter; Wolpe). This method is a series of controlled exposures to the phobic stimuli and attempts to change the phobic reaction either by reducing its intensity or by increasing the self-control behaviors. With each such exposure, the power of the phobic reaction diminishes until it completely disappears.

Although the efficacy of this procedure has been well demonstrated experimentally and clinically, the theory underlying it is not so clear. It has been explained in terms of counter-conditioning, self-control concepts, extinction, cognitive variables, and in still other terms. The issue is far from resolved. Indeed, Goldfried and Davison opine that in this area greater confusion exists today than it did years ago. Rather than discussing this, we will present the methods specifically involved.

In its most classical form, systematic desensitization has certain characteristics:

1. The disturbing situation must be approached in a gradual, step-by-step manner. The aim is to keep the elicited disturbance at each step sufficiently low so that the person may learn to counter it. The series of graded situations used in this approach is called a “hierarchy.” The situations used may be imagined, may be simulated or may be actual life situations.

2. A counter-anxiety behavior must be applied at each step of the hierarchy. Although deliberate muscle relaxation is probably the most widely used behavior for this purpose, many others are available. Brady has used medication to counter the tension. Bass has used the feeling of sexual excitement to counter the anxiety. The aversion relief method has already been mentioned. Wolpe states that any response-inhibiting anxiety, including assertive responses, can be used in desensitization.

The patient is first presented with the lowest (least anxiety-provoking) item of the hierarchy. When he or she experiences any disturbance, the item is removed and the counter-anxiety element (e.g., relaxation) is introduced. The item is repeated until it no longer elicits any disturbance whatever. At this point, the next item of the hierarchy is introduced.

The self-control method of desensitization (Goldfried) also utilizes hierarchies and relaxation. Here relaxation is thought of as a coping technique, as self-control of the physiological reactions of anxiety (Goldfried and Merbaum). Instead of removing the hierarchy item when an anxiety response is elicited, the person is kept in the situation and is encouraged to cope until the anxiety diminishes.

We have tried both the classical and the self-control methods with the in-vivo-desensitization treatment of vaginismus. Here the hierarchy consists of objects of various sizes to be placed in the vagina. In the classical method, the patient removes the object at the first indication of discomfort and then relaxes. With the self-control method, the patient allows the object to remain while learning to cope with the anxiety. The number of patients involved was far too low to indicate whether one method was superior to the other. However, when both procedures were presented, several of the patients had definite preferences for one or the other.

Desensitization using imagined stimuli has the advantages of convenience, flexibility, and greater control of the stimuli. The stimulus scenes used in imagery desensitization may be very creative, and professional literature abounds with examples. A rather typical hierarchy that we have found useful is the one reported by Lazarus for the group desensitization of women with the common complaint of frigidity. The items he used were: embracing, kissing, being fondled, undressing, and foreplay in the nude, awareness of the husband’s erection, intromission, and changing positions during coitus.

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Diagnosis

To apply the term diagnosis to homosexuality raises the same problem as applying it to red hair, left-handedness, or limb amputation, all of which are conditions not usually considered syndromes. All are conditions that are self-declared and do not need a diagnostic workup. In consensual homosexuality the evidence may be observed or the person may report it verbally. Without such direct evidence, there may be no way of inferring it from other aspects of behavior.

When homosexuality is not expressed in action, the only evidence may be the person’s report of homosexual imagery in dreams, daydreams, and fantasy, or of responding erotically to homosexual images and percepts. In some instances, the only evidence, initially, may be symbolic and disguised; overt homosexual imagery, under the inhibiting pressure of guilt, embarrassment, or shame, may be unable to manifest itself directly. Its place is taken by erotic apathy, inertia, or depression, or by some symbolic sexual substitution.

There are no known or measurable somatic correlates of homosexuality which are important diagnostically. In particular, measures of circulating hormonal levels are noncontributory. However, homosexuality may occur in the presence of other syndromes such as hypogonadism, Klinefelter’s (47, XXY) syndrome, and others.

Differential Diagnosis

Extreme cases of effeminate male homosexuality or virilistic lesbianism need to be differentiated from:

transexualism

transvestism

The most common error in differential diagnosis is to confuse homosexuality with:

bisexualism

The next most common error is to confuse homosexuality with accompanying or derivative symptoms or syndromes of behavioral disability such as:

psychosomatic stress reaction

anxiety neurosis

paranoid schizophrenic reaction

body-image neurosis or psychosis

delinquent or criminal character or conduct disorder

masochism, sadism, pedophilia, or other paraphilia

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Studies of sex stereotypes have demonstrated repeatedly that men and women are viewed very differently; in fact, they are viewed as polar opposites in many personality attributes (Broverman, Vogel, Broverman, Clarkson, and Rosenkrantz). In achievement-oriented traits men are thought to be competent and strong, and women are thought to be incompetent and weak. Whereas men are described as independent, active, competitive, self-confident, and ambitious, women are described as dependent, passive, uncompetitive, unconfident, and unambitious. Men and women also are described differently in qualities of warmth and expressiveness, with women being rated more positively: they are described as tender, understanding, concerned with others, and comfortable with their feelings, whereas men are described in opposite terms.

It seems that little has changed since 1957 when McKee and Sherriffs found that when subjects were asked to generate images of men and women, males were characterized by (a) rational competence and ability and (b) vigor, action, and effectiveness. Women, on the other hand, were characterized by (a) social skills and (b) warmth and emotional support. Then, too, characteristics most commonly ascribed to men were those essential to achievement but those most commonly ascribed to women were those associated with nurture and affiliation.

The traits associated with women and men are not only different, but they are seen as differentially desirable. Although each is credited with a number of positive traits, subjects of both sexes concur that those associated with men are more valued than those associated with women (Rosenkrantz, Vogel, Bee, Broverman, and Broverman). Simply put, achievement seems to be more highly valued in our society than nurture or affiliation. A great deal of evidence supports this point. Smith found that as age increased, children of both sexes increasingly indicated a preference for the traits of males rather than of females. Fernberger found that college students cast male rather than female characters in fictional situations requiring intelligence and “all-around superiority.” Finally, McKee and Sheriffs found that a typical man is believed to possess a greater number of desirable characteristics than a typical woman.

Looking at the world around us it is apparent how stereotypical views are passed on and maintained. The images of men presented in children’s textbooks, for instance, are consistently active, curious, and independent; girls, however, are depicted as dependent, showing little initiative, and constantly in need of help from boys (Weitzman, Eifler, Hokadin, and Ross). Similarly stereotyped presentations) of men and women can be found in television commercials. In a recent study in which the roles of men and women in these commercials were compared, only 14% of the women were found to be in authoritative positions as compared to 70% of the men. Moreover, when they agreed to buy a product, men were shown to be motivated by potential social and/or career advancement, but women were shown to be motivated by the increased satisfaction of their families or men in their life (McArthur and Resko).

It is not difficult to see how stereotyped conceptions of what women are like are transmitted. But to what extent are these conceptions accurate reflections of reality? Are men and women actually as different as is commonly assumed?

Until recently it was generally accepted that the biological differences between men and women were paralleled by distinct psychological differences. In fact, several reviews of the literature focused on the nature of these sex differences (Garai and Scheinfeld; Maccoby; Tyler). The areas in which functioning was thought to differ was broad: intellectual ability, dependency, passivity, self-esteem, cognitive style, and perception. In some cases reported findings depicted males more favorably; in others, they depicted females more favorably, but the notion of differences was upheld.

However, in 1974, Maccoby and Jacklin, in their exhaustive book, The Psychology of Sex Differences, carefully examined the available data and concluded that many of the presumed differences between males and females are based on myth, not on reality. They found no support for the view that women lack the motivation to achieve nor that they are less intelligent than men. Patterns of task persistence and risk-taking behavior were found to be quite similar to both sexes. Also challenged were the alleged differences in the social needs often attributed to men and women. According to Maccoby and Jacklin, females have not been found to be more sociable, more dependent on others, or more oriented toward social stimulation and reinforcement than have males.

Additionally, a considerable body of literature examines women’s feelings toward and behavior at work. Results from many of these studies also contradict the notion that women are different from men. Women have been reported to have similar vocational interests (Diamond), leadership abilities (Day and Stogdill), and problem-solving abilities (Matthews) to men’s. In many areas directly related to achievement men and women are more alike than different. Yet, despite this fact, the view that crucial differences exist between the sexes persists.

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The “problem” of paternity is an issue in ethnography which can be traced back to Australian observations in the 19th century and to the pioneering works of Malinowski in the Trobriands. In this matrilineal society the husband is not regarded as the father of his wife’s children. Trobrianders are ignorant of “physical fatherhood” (Malinowski). Linton’s Marquesan informants would admit to understanding paternity (“physical fatherhood,” in Malinowski’s terms) but preferred to connect their genealogies to those of household heads, who were not necessarily “blood” relatives (Linton). The Trobriand theory of maternity without paternity is diametrically different from that of the Mehinaku child who has many fathers, as many as mother will acknowledge having had sex with during pregnancy, and the child will relate to these men, more or less, as “fathers” (Gregor). Through “multiple paternity” the Mehinaku believe that pregnancy is a sort of “collective labor project.” When a child is born, every man who regularly had sexual intercourse with the mother may be regarded as the father.

The consequences of this for the social organization of the Mehinaku are considerable, for “multiple paternity” requires children to acknowledge the paternal status of certain men in the village, even if they are instructed to address them as “papa” only when the husband is not within hearing distance. Likewise, the incest taboo generally is extended to prohibit sexual contact between persons related through maternal affairs, just as persons related through marriage are prohibited as sexual or marriage partners (Gregor). Apparently the Mehinaku are not rigid about all this and allow that if a certain man had sexual relations with a child’s mother only “a few times,” he is only a “little bit” the child’s father, and the child may be allowed to have sexual relations with and even marry this person’s children (Gregor).

The area of fertility and infertility is one of the few in the cross-cultural literature that seems to be controlled primarily by women. Even among the sexually repressed Irish islanders of Inis Beag, men are thought to be more naturally libidinal than women (Messenger). However, assuming that a woman is in some control over the men with whom she has intercourse, she can either increase or decrease the total number of instances of sexual intercourse, the number of various partners in intercourse, or the number of occasions of intercourse allowed any one partner. The perceived consequences of these strategies all will be different, given the ideology of the group, but at least in this domain a woman has the upper hand. She hypothetically can control her fertility and equally important to people like the Mehinaku, she can extend her children’s kinship system to include men and their relatives, who will relate to these children at the expense of her designated husband.

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Messenger reported of the Inis Beag that “there is much evidence to indicate that the female orgasm is unknown—or at least doubted, or considered a deviant response”. In the Tepoztlan village in Mexico, wives are not expected to be passionate, and husbands refrain from arousing their wives sexually, assuming that the passive and frigid wife will be faithful (Lewis).

Mangaian women, by contrast, have a great deal of premarital experience and develop orgasmic response as a matter of course. Female orgasm is highly valued: “The really important aspect of sexual intercourse for either the married man or the more experienced unwed male is to give pleasure to his wife or woman or girl—the pleasure of the orgasm” (Marshall). Davenports East Bay Melanesian group likewise took for granted the woman’s experience of orgasm in marital coitus. They believed firmly that, once engaged in fore-play, there was nothing to prevent a woman from having orgasm if intercourse followed (Davenport).

The evidence suggests that, in general, young females take longer in coitus to reach orgasm than young males do. Therefore, in repressive societies, in which even marital sex is furtive and hurried, characterized by attitudes antagonistic to sensuality and pleasure, the incidence of female orgasm is predictably low. If sexuality is openly valued and enjoyed, emphasizing prolongation and satisfaction for both partners, the orgasmic potential of women is more likely to be realized.

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“I had a very good sexual relationship with my wife,” says Russell, a 69-year-old widower who was married for 26 years. “In fact, there was a period of several months when I was in my late 40′s when my sex drive actually increased. I don’t know what to attribute this to. I really didn’t notice any difference as I’ve aged—I’ve always enjoyed it.”

The belief that you will lose your sexuality as you age, however, can have a powerful negative effect. And thinking that your active sex life will continue as long as you so desire can have a correspondingly positive influence.

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Just a few years ago, most physicians were taught that the vast majority of impotence cases were caused by psychological factors. Now that we know more about erection and researchers have begun studying the effects of illness on erection, it’s thought that at least 50 percent of all impotence has a physical cause or a physical contributing factor. But this information has been slow in reaching many physicians and other health care professionals already in practice. Doctors who don’t specialize in erection problems may remain ignorant of the new information.

For example, one internist who sees a lot of elderly patients told us she thought most cases of impotence were caused by psychological problems. And although sexuality was a concern of her patients, she didn’t think much could be done to help men with erection problems.

Thinking like that can cause a lot of needless unhappiness and confusion. Take, for example, Bill’s experience. About a year ago, he began having a problem with potency. At the age of 49, happily married for the second time, Bill felt secure in his relationship with his wife, Janice. Still, he sometimes could not get an erection, although he felt very aroused and wanted to make love. Bill had never had a problem with sex before, and he was puzzled and troubled. So was Janice.

They didn’t know what to do. Bill felt rather uncomfortable about asking anyone about his problem. But, in what he regarded as a fortunate circumstance, he became ill and had to go see his family doctor. There, he mustered his courage and told the doctor matter-of-factly: “I can’t get an erection like I used to.” The physician responded, “Well, you’re not as young as you used to be.” And that was that. Bill was too embarrassed to say anything else. But he was angry: 49 was far too young to put sex on the shelf. He didn’t think Janice wanted to live without sex, either. Bill believed there had to be more to his problem, and after some anxious and uncomfortable weeks he decided to find another doctor.

Bill was right to doubt his doctor. His age was no explanation for the changes he was experiencing. It would be normal for it to take Bill a little longer to get an erection than it did ten years before. But even with direct stimulation and allowing plenty of time, Bill just could not get an erection.

Fortunately, Bill searched persistently until he found a urologist who specialized in sexual potency. The doctor was able to find—and treat—the cause of his difficulty.

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Some of the problems that affect the skin are the result of the way it has been treated in the past. Your skin may have been exposed to many noxious agents, including chemicals from household and industrial products, infections, and sunlight, which is perhaps the agent that has the greatest negative effect on the skin. Some problems of the skin are the outcome of underlying conditions affecting the body in general and some conditions are limited to the skin alone.

With aging there is a thinning of the skin as well as some loss of elasticity. Repair of damage takes longer, resistance to injury and infection decreases, and the ability to adjust to extreme changes in temperature becomes impaired. All these factors lower the protective effect of the skin. Some of the changes may not be under your control but other changes may be modified by the way you treat your skin.

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