Erectile dysfunction is actually very common, but little is known about how it impacts on men and what effect the treatment of erectile dysfunction can have on life quality. For a long time  - indeed, until the 1970s - many workers in this field thought that the causes of erectile dysfunction were primarily psychogenic (that is to say, based in the mind). One of the reasons for this was an authoritative study by Masters and Johnson, in which they stated that only one case of erectile dysfunction in twenty was of physical origin.

In addition, there has been little study of the emotional and psychological impact of erectile dysfunction and its treatment, both in general and in particular with Viagra, although one study of male ageing in the late 1980's remarked in passing that a man with erectile dysfunction "may be expected to be anxious, depressed and lacking self-esteem and self-confidence."

Nevertheless, some studies have observed that erectile dysfunction has a major psychological,  emotional and social effect. For example, the Sexual Dysfunction Association reported that three men in five taking part in an online survey regarded erectile dysfunction as a factor in their low self-esteem; one in three reported that his relationship had been adversely affected; and one in five said that his relationship had come to an end as a direct consequence of erectile dysfunction. There is a lot of shame attached to erectile dysfunction, which stops men with erectile dysfunction confiding in other men or looking for treatment from health care professionals.

The first simple treatment for erectile dysfunction, a phosphodiesterase inhibitor called sildenafil (Viagra), taken orally, became available in 1998. The media hype around Viagra led a lot of men to think that it was an infallible cure, but the truth is that for a lot of men, Viagra does not work, and this can compound the emotional problems caused by the erectile dysfunction in the first place.

The authors of this study looked at the impact that erectile dysfunction had on forty men attending a clinic. They investigated the men's self-esteem, and looked at how their erection problems impacted on the men's relationships and welfare. They also examined the men's expectations of Viagra as a treatment for erectile problems, and investigated how its success or failure affected their mental and emotional state. 

There were almost exactly 300 referrals to the clinic in one year, and they were divided into two groups: men for whom Viagra was successful in resolving erectile dysfunction, and the others, on whom it had no impact. "Success" was defined by the patient being able to have penetrative intercourse. "Failure", as you'd expect, meant no erection, or at least one that was not hard enough to penetrate the man's partner.  Twenty men were selected from each group.

The age range of the men was twenty two to seventy two years and the average was fifty two. All these men had Viagra prescribed at the clinic in a consultation which was neutral in tone, so as to ensure the man's expectations were not changed during the consultation. Given the men's emotional distress and sensitivity around erectile dysfunction, the authors aimed to identify and explore as many issues relating to the men's experiences as possible. The data obtained were subjected to thematic analysis, which broadly showed up as follows.

Reaction to erectile dysfunction

Most men felt emasculated by erectile dysfunction. It is unsurprising that the ability to have penetrative sexual intercourse and to satisfy one's partner sexually is regarded by most if not all men as an important and defining element of their masculinity. In some cases the man's reaction was so bad that depression followed and his relationship was seriously affected. And erectile dysfunction can also impact on a man's ability of participants to enter into new relationships: the reasoning being, if you can't have sex with a woman, "if you can't get a hard-on", why approach her in the first place?

This reduced self-confidence affected the men's sexual relationships as well as their everyday  relationships with friends and work colleagues. One observed that his impotence knocked his confidence so much that he didn't feel that he was matching up to his colleagues as a man - he reported that he "didn't feel as good as them". Other men reported feeling isolated and despondent because they believed that erectile dysfunction was a problem only for older men: for them it was an indicator of "feeling old before their time". What made this worse was that some men thought their erectile dysfunction was irreversible and they would never have sex again.

Erectile dysfunction affected the men's relationships with their partners. One in four thought they were "letting down their partners" because they could not engage in intercourse or "satisfy them sexually". [Editor's note: since when did a woman's sexual satisfaction depend on penetrative intercourse?! What a patriarchal view of relationships!] The impact of the erectile dysfunction on the men's self-esteem was clear from remarks like this: "if I can't keep an erection, I'm not going to keep a woman." Fifteen men did not or could not talk about erectile dysfunction with their partners. In their terms, they felt "belittled" by their erectile dysfunction.

Expectations of Viagra before treatment for erectile dysfunction

Most men first heard about Viagra on television or read about it in newspaper articles. As a result of this coverage, they had high expectations: many men thought they would get an instant erection and then go on to instantly be able to have sexual intercourse. Other expectations included having a "full" erection, a 100% success rate, an abnormally large erection, or an erection that lasted for a long time. 

Reactions to successful treatment treatment for erectile dysfunction

Most of the men for whom Viagra worked were happy or even elated when they got an erection. The importance of this symbol of regained manhood cannot be overstated - it is part of a man's sense of wellbeing and confidence: and, as you may infer from the remarks above, this increase in confidence is not just about being able to get erect, but also about being able to satisfy the sexual needs of one's partner.

Reactions to unsuccessful treatment for erectile dysfunction

The high expectations of Viagra obviously have a bearing on men's perception of failure. If the idea of taking one pill with a complete recovery of erectile capacity was not fulfilled, many men felt worse and believed they would never have sex again. Obviously this was a major disappointment to some men. Some men attributed these high expectations to media over-reporting of this "wonder drug." It was clear that men who felt devastated or who believed no other treatments existed had held very high expectations of Viagra, and they tended to come up with many reasons why Viagra might have been unsuccessful. Some even labeled the treatment a failure because spontaneous sex was impossible now they had to take Viagra beforehand.

Discussion

Impotence, complete erectile dysfunction, has a massive impact on men. Most men are more deeply affected than is generally realized, and their sense of masculinity and self-esteem are especially badly affected. It matters not if the origin is psychogenic, or emotional, or physical, or a mixture of these influences, the overall outcome is the same: a battered sense of masculinity, low feelings of worth to partner, low self-esteem and low sense of worth in the workplace. To ensure treatment for erectile dysfunction has been effective, a man's ability to have intercourse must be monitored. The launch of Viagra produced high, even unrealistic, expectations. When it works, men experience a renewed sense of self-confidence; when it does not, the blow is severe. With persistence, men can often succeed in regaining an erection, which is important because erectile dysfunction has a massive psychological and social impact on men, not to mention their personal relationships.