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If you’re at the age of 40, you’re at risk of some kind of erectile dysfunction (ED). Some 10% of you will have a complete failure of erections - more often, this affects older men. Alongside this news is the equally significant evidence of depressive illnesses. Researchers estimate that about a quarter of men will suffer some degree of anxiety or depression at some point during their lives. When this happens, the symptoms may not appear too serious and you will probably not seek treatment. This is an entirely understandable reaction. But it is always better to get a professional opinion before self-medicating.

If you seek for a treatment, your physician will advise you some. In such cases, the issue of cause and effect can become complicated. The ED may have been caused by the anxiety or depression itself, or there may have been an independent cause. But what began as a small problem can be aggravated as a side effect of the antidepressant medications you are prescribed. It is somewhat ironic that one of the factors depressing you may be your declining sexual performance, but the treatment for that depression can complete deprive you of your desire to have sex. If it gets worse, the selective serotonin reuptake inhibitors (SSRIs) antidepressants not only affect sexual performance, but may also disturb sleep patterns and cause weight gain. Not surprisingly, this prompts many patients to stop taking the medication. Thus, although treatment using one or more antidepressants is usually successful in 90% of all cases, less than one third of patients complete the course of medication, and the incidence of relapse is high.

This creates big problems for the medics trying to balance treatments for both the depressive illnesses and the ED. Because there may be adverse reactions between the different medications, you should not take Viagra, Cialis or Levitra on your own initiative if you are already taking any other medications. Your physician has a number of options:

• First way is to change antidepressant. In a number of clinical double-blind studies, Serzone (Nefazodone) and Wellbutrin (bupropion) were shown to cause fewer problems on sexual function than SSRIs. If you respond well to either of these, you may find that you feel less depressed and your sexual performance improves. Wellbutrin is also less likely to cause weight gain which may aid your choice of medication.
• With some drugs, e.g. Zoloft (sertraline) and Anafranil (clomipramine), it may be possible to change the medication regime. If you have a fairly consistent time when you engage in sexual activity, this should be timed when the drug’s level in your body would be at its lowest, i.e. you would take your daily dose after sexual intercourse.
• Then your physician may authorise you to take one of the specific ED medications such as Viagra, Cialis or Levitra. In a 2003 randomised study of ninety men suffering from antidepressant-induced ED, 54% of those treated with Viagra (sildenafil citrate) as against the placebo showed improvement. Note that only slightly over half the sample showed improvement. There are limits to the effectiveness of Viagra, Cialis and Levitra.
• There are some case reports and small clinical studies that have found some additional medications can modify the effect of the antidepressant. For example, in an off-label test, Amantadine has been shown to relieve the SSRI-induced inability to reach an orgasm in some but not all people.

All this has assumed that the ED was in fact caused by the depression or the medication to treat that depression. If there are alternative explanations for the ED, those should also be thoroughly investigated. It would compound the irony if the true cause of your ED should prove not to be the antidepressants but a condition requiring a different treatment.

There are a lots and lots of very good, qualificated and informative books on health. People get impressed by the depth of knowledge because instead of one sentence approximating how a muscle works, there are now whole chapters devoted to the thin muscle filaments containing multiple proteins. Instead of simple engineering analogies of muscles and cables, human knowledge has become obsessed by the identification of ever more complex chemical and molecular processes. This is my wood-for-the-trees moment.

Erectile dysfunction can now be described in terms of complex chemical interactions and illustrated with wonderful diagrams. There are still all kinds of analogies with hydraulic engineering, but the sophistication of the functional analysis is breathtaking. However, it is not a part of the medical books to observe and describe the entirely human context in which the erection is supposed to operate. A single male may masturbate.

Will medical treatment be asked for and a success? In part, this will be determined by the erectial disfunction. Where the relationship is socially disapproved, the man may well not seek treatment at all because of fear. A physical examination might reveal different types of sexual activity, or a chance remark in the consultation might expose the forbidden practices. This is ironic. If the parties to the relationship have a strong mutual commitment and lovingly support each other, the likelihood is that the co-operation between all involved would produce excellent medical outcomes. Well-established sexual intimacy and commitment preserve the right level of desire and motivate everyone to getting a solution that works well. Were it not for online pharmacies and their willingness to supply medications like cialis without prescription, many partnerships might never be able to get appropriate treatment of any kind.

This is two completely different cultural imperatives in conflict. Men are socially conditioned to believe that they will always be able to have an erection. Any publicly acknowledged failure means shame. Unfortunately, many partnerships do not get treatment for the underlying causes of the dysfunction. Although most will know that the dysfunction can be a symptom of diabetes and cardiovascular diseases, fear of exposure may force the couples or groups to ignore or deny the problem until it is too late for the easy treatment represented by cialis to continue on its own. By then, the chances of an effective treatment for the underlying cause may be remote. Yet they are only allowed to have erections in certain very carefully defined social situations. Step outside those situations and you are into potentially disapproved or even criminal territory.

Before urologists recognized the physical nature of impotence, medications generally fell into three categories - aphrodisiacs, surgery and mechanical treatments.

Aphrodisiacs

Lots and lots of substances have been used to increase sexual performance. Oysters, lobsters, and spices are examples. Spanish Fly, a substance made by grinding the wings of certain beetles, was a favorite of famous Marquis de Sade. In the United States it is illegal because of a tendency to cause seizures or death. Many of these substances actually simply irritate the genital organs. The user interprets this irritation as increased sensitivity, thereby giving the impression of increased performance. Rhinoceros horn has been unsuccesfully used for so long that its name has become synonymous with arousal. Unfortunately, this has led to widespread slaughter of the animals that they face extinction.

Surgery/Transplants

The idea of using animal testes to treat impotence began in the Middle Ages, when a standard treatment for “the male malady” was to place the testicles of a cock under the bed. The Malleus Maleficarum was a guide to witchcraft during that era that asserted witch’s spells caused impotence. This was a major reason witch-hunting became so widespread. Charles Edouard Brown-Sequard injected himself with an extract from the testicles of dogs that he claimed made him smarter and stronger. After ten injections, he reported improved erections, as well as a stronger jet of urine and “power of defecation.” He made no claims about the effect this had on the dogs. His “Elixir of Life” became an instant best-seller. Its 1889 launch rivaled that of Levitra, even without a famous spokesman.

Eugen Steinach in 1920 pioneered surgical treatment of impotence with a revolutionary idea-vasectomy. He believed blocking the vas deferens (the tubes semen passes through) would force maleness factors back into the bloodstream instead of letting them go to waste on the sheets. The erections probably weren’t much better, but with female partners spending less time pregnant opportunity became much more. Freud, the person most responsible for the mistaken impression that impotence was primarily psychological, set back our understanding of the disorder by decades. Taking him out of the gene pool probably did more to help the science of impotence therapy than anything else Steinach did. Many respected universities have subsequently been involved in the transplantation of animal or human testicular tissue. Swiss professor Paul Niehans treated tens of thousands of men with testicular cell injections in the early twentieth century. His procedure sometimes went straight to the root of the problem by injecting a booster shot directly into the patient’s testes.* Patients receiving the treatments included Charlie Chaplin (and you wondered why he walked that way), Aristotle Onassis, and Pope Pius XII. Chaplin was a well-known womanizer, but the Pope’s interest in this treatment remains a mystery. Another researcher in Chicago proudly stated his initial patient checked himself out of the hospital four days after surgery in order to satisfy his newfound potency. He fully understood the rule: “Never waste an erection.” Dr. Leo Stanley removed the testicles of recently executed prisoners at San Quentin in the 1920s. He transplanted them into other, more fortunate (albeit impotent) prisoners, reporting improvement in strength, well-being, and libido among the recipients. When the supply ran low, he substituted goat, ram, boar, and deer testicular tissue.

Mechanical

Hot metal rods inserted into the urethra during medieval times wasn’t able to revive erections. No one wanted a second treatment, and that wasn’t very surprising. Many types of splints have been used, including hollowed-out antlers and horns. Encouraged by finding the penis bone (baculum) in some animals, early surgeons placed rib cartilage into the penis. Although these initial attempts failed, penile prostheses have more recently proven particularly reliable.