Will Viagra Help Men Stand Up For Themselves?

By Lawrence D. Blum, M.D.

        The first patient I ever treated for impotence had trouble standing up for himself in more ways than one. His work required him to run meetings, which he could do readily if seated, but if he were required to stand up, he became too nervous. Men with impotence do not all take the symbolism about “standing up for themselves” quite so literally, but most men with psychologically-based impotence do in fact have difficulty asserting themselves in various situations. They may be hen-pecked and afraid of their wives, frightened of authority and overly deferential to their bosses, or may “shoot themselves in the foot” in one way or another.

        A set of emotional anxieties and conflicts underlies both the sexual and non-sexual symptoms. This is hinted at in the word impotence itself. The word indicates a state of weakness, powerlessness, incapacity. The inability to have an erection is a symbolic representation of this state, a narrow definition of the broader concept. Implied also is the connection of the mind and the body. Many men have wished that the mind and the body were not so connected as they are, and that sexual function were autonomous from emotional life. In their insecurity, they have wished to perform like machines - sometimes to the distress of their partners, who have experienced them as mechanical.

        Enter Viagra. Most drugs work directly on the body, regardless of the person’s mental state. Viagra is an unusual compound, however, in that it requires sexual stimulation, a mental experience, in order to have any effect. Its effects thus resemble ordinary sexual response, in which physiologic changes follow from mental (and of course also physical) events. While helping men overcome either physical or psychological obstacles to having erections, Viagra, for better and worse, maintains a role for the human mind. In fact, one patient told me that the medication seemed to work well on an occasion on which he took the initiative, but not at all another time when his wife took the lead. In the latter instance he was disappointed that the medication could not overcome the inhibiting effects of his emotional conflicts.

        But does Viagra leave enough room for the mind? In the short time it has been available, it has obviously been a great blessing in helping men to have erections, enjoy their sexuality, and feel better about themselves. But what about the underlying conflicts in those men with psychologically-based impotence?

        My first patient, seen in the “prehistoric” days when urethral suppositories, injections, or useful pills for the treatment of impotence were not yet on the drawing board, had benefited little from behavioral therapy. Like medication, behavior therapy attempted to sidestep my patient’s mind. It paid no attention to what his true anxieties were, or, in other words, what his symptom of impotence really was about. Psychotherapy revealed that my patient was very afraid of competition with other men, and that to relieve his anxiety he tended to diminish (deflate) himself. He also proved to have frightening fantasies about women and their anatomy. As he came to understand and master these difficulties, his impotence resolved, not only sexually, but otherwise as well. He could run meetings whether sitting or standing, and he could relate to his wife in a more straightforward and less subordinate manner. The underlying problems, and not only the symptom, had been addressed.

        Suppose Viagra had been available. His erections would probably have been more reliable with the medication. But would he have learned to stand up for himself?

(This column was published in the Philadelphia Daily News, June 8, 1998.)