Impotence: it's the worst a man can get

Heard the one about the old man who is listening to an evangelist on the radio, when the evangelist proclaims, "Put one hand on your afflicted part and your other hand on the radio and you shall be healed"? So the old man puts his left hand on his penis and his right hand on the radio, at which point his wife looks over and says: "He said he was going to heal the sick, not raise the dead."

Jokes and stifled sniggers are the usual response to the subject of impotence. But beneath the faade of humour lies a widespread, serious problem. Statistics released in the UK this year (based on a survey of 2,000 men) claim that "26 per cent of the UK adult male population have experienced impotence to some degree", that "5 per cent of men are impotent all or most of the time" and that "within any two-week period in the UK, 2.3 million men suffer from erectile dysfunction". Even allowing for the fact that half of the 26 per cent group experience only "social erectile dysfunction" - minor one-off incidents - these figures come as a shock. They undermine the locker-room "up-all-night" myth of male sexuality.

Dr Geoff Hackett is the UK's first consultant in erectile dysfunction (ED) and the man behind the survey. "Impotence is a taboo that strikes at the heart of the male identity, so much so that only 10 per cent of sufferers are brave enough to tell their GPs," he says. "The problem is compounded because too few GPs take impotence seriously, tending to disregard it as a mysterious psychological problem or as part of the natural ageing process."

But although the incidence of impotence increases with age, it is not only old men who suffer. And neither is it primarily a psychological problem. Indeed, in 60 per cent of cases, the cause of impotence - defined as the inability to sustain an erection sufficient for penetration - is purely organic. Arterial disease and diabetes, which result in an insufficient blood supply to the penis, are the prime culprits, but alcohol, hard drugs, nicotine and diseases that damage the nervous system, such as multiple sclerosis, also cause ED. Contrary to popular belief, low testosterone is only a minor factor, accounting for only 3 per cent of cases.

It is the social consequences of impotence that most alarm Dr Hackett. His weekly ED clinic at the Good Hope Hospital in Sutton Coldfield, West Midlands, offers him direct contact with sufferers, some of whom have been in denial about their disorder for years.

When Dan (not his real name) went to see Dr Hackett last year, he was what Hackett describes as "a laughing depressive". To his mates, Dan, 65 and twice divorced, had a reputation as a ladies' man, being a whiz with the "willy jokes" and punctuating them with anecdotes about his own sexual prowess. But in spite of an active libido, the private truth was that Dan couldn't do it any more.

"The first time I couldn't get an erection, it took me by complete surprise," he recalls. "I felt so humiliated - I always prided myself on being the type that was so virile that I could melt condoms. My girlfriend said not to worry, that it was a temporary hitch, but it never worked and eventually we drifted apart. After that, I shied away from relationships and became isolated. I felt I had lost my manhood. How could I admit to friends that my bicycle had a flat tyre? They couldn't possibly know how inadequate I felt."

Bernard Zilbergeld, American psychologist and author of Men and Sex (HarperCollins) says that a total loss of self-esteem is par for the course for impotence sufferers. "Nothing equals the devastation wrought by the lack of an erection at the right time. Nothing except the loss of his job can make a man feel more worthless. Men have tied their self-respect to the upward mobility of their penises and when their penises do not rise to the occasion, they do not feel like men," he says.

Dr Hackett goes further, arguing that the unseen, unrecorded costs of ED include an inability to concentrate at work and marital breakdown. He gets stacks of letters that reinforce this view, like this one from a man in Nottingham: "I am 59 years, divorced. A chance of getting back together but only if I can become a lover again. Get soft erections. The specialist was kind but gave little hope. Excuse the note form, I considered it would save you time. Please help."

Another letter from a 33-year-old states: "I have been married four years and have a daughter of two. For the last year, my penis has been limp. As a result, my wife gets extremely angry. She screams at me. Now she is threatening to leave me. I have sought treatment from various physicians and psychiatrists. But it is all failure." At the end he adds: "My wife is also having difficulties getting an orgasm. So if you could send a prescription for her to come quick, it would be of further help."

That impotence is a major problem - particularly in the United States where there are more than 20 million sufferers - is beginning to be recognised by major pharmaceutical companies such as Pfizer and the aptly named Upjohn. Pfizer has announced that it is testing an impotence pill - code-named UK-92 480 - at several centres in Britain, but development is at an early stage. Upjohn's product, Caverject, released on to the market last year, contains prostaglandin E1 which when injected into a flaccid penis (£9.75 a jab), dilates the blood vessels and can give an impotent man an erection for up to 90 minutes. According to Dr Hackett, whose research into ED is being funded by Upjohn, Caverject is successful in 90 per cent of cases, whether the cause is organic or psychological.

Another GP - let us call him Rick, aged 44 - who not only helps patients with impotence but is a sufferer himself, offers a user's perspective. "Until recently, the only available drug treatment was papaverine, but the problem was that in 15 per cent of cases it resulted in priapism - prolonged erections of four hours or more. Apart from the discomfort, it is dangerous because if the blood ceases to be oxygenated, the cell tissue dies and you can end up with a chronically deformed penis. The big advance made by Caverject is that it is not only painless to inject, but it seems to have eliminated priapism as a problem. It has given me back my ability to have a safe, old-fashioned heave-ho erection. Now even my 80-year-old Dad says he wants to have a go."

Could the new treatment be a boon for the elderly? "Advances in medicine are allowing people to live longer, so why shouldn't they demand that the geriatric phase of life be made as short as possible?" argues Dr Hackett.

But Rick is more circumspect. "Sometimes a man confuses impotence with the natural wilt that accompanies ageing. I apply the following rule of thumb in treating patients: if you are 35, you should be able to hang a towel on it; if you are 55, you're doing great to get it horizontal. It seems unnecessary to give a 65-year-old something that points over his shoulder."

But some argue that drug treatment is a shallow, one-dimensional response to treating men who have plummeted to the bottom of their psyches, bereft of self-esteem and partner. Are men and their relationships so fragile that flagging erections can destabilise them to that degree?

"What worries me," says Julia Cole, a psychosexual therapist at the counselling service Relate, "is that men are being offered a quick fix. Sometimes what appears to be impotence is merely symptomatic of a loss of desire in marriage. Roughly half of the women we see with sexual problems display what is called inhibited sexual desire, a general lack of interest in sex, but until recently that was not even a recognised category among men. Somehow it's more acceptable for men to say that they're impotent than to admit that they've lost interest in sex.

"I don't take the view that it's therapy versus drug treatment because there's room for both of us and we should work together, but many doctors pooh-pooh the psychological side. Of course, if the cause is purely physical - as a result of something like diabetes - then drugs can offer enhanced quality of life and therapy is not required. But in most cases, hardening a man's willy isn't of itself going to prevent the marriage from breaking down."

Dan (the ladies' man) can't turn back the clock on his failed relationships, but since he started the new drug treatment two months ago, he appears to have found a new lease on life. "My performance is absolutely phenomenal," he says. "I go to the fridge, take out the drugs, inject myself and 15 minutes later, I'm ready to go. I can keep it up for an hour. Even in my hey-day, I could only manage 15 minutes. My girlfriend is 35 years younger than I am. If you told her I was impotent, she would never believe it."