Impotency, or the state of being impotent, is a condition that prevents males from maintaining an erection throughout the sex act. Culturally, it has acquired the connotation of a general inability to have sex, particularly to carry a sex act to completion. Because the medical condition of impotence does not necessarily imply that ejaculation is impossible, the term largely has been replaced in medical discourse with erectile dysfunction (first used in 1974 by H.S. Kaplan in The New Sex Therapy), which treats erectile ability rather than ejaculatory ability as the central issue. Although the medical difference between the terms is minimal, they differ greatly in regard to cultural significance. In nonmedical usage impotence often means a general lack of ability or effectiveness, a lack of strength or virility, a condition of weakness or powerlessness. The fundamental qualities of masculinity in essence are negated by impotence. Impotence is the negatively valued aspect of the metaphorical connection between a man's sexual ability and his general agency in society.
CAUSES AND CURES
The most common physiological causes of erectile dysfunction are diabetes and vascular disease, although there are many other contributing factors, including neurological malfunction, inflammation, and drug use; these conditions may cause or worsen other conditions. When there is a gradual onset of erectile dysfunction, it is likely to be physiological in origin, but when there is a sudden onset, the cause is often psychological. The availability and aggressive marketing of medications to treat erectile dysfunction beginning in the 1990s has contributed to the general belief that the condition is primarily physiological. Medical data suggest, however, that 50 percent of cases probably are psychological in origin and thus are unlikely to respond to pharmacological treatment except when there is a placebo effect. It is unclear how many men whose symptoms persist in spite of medication seek further attention, although the assumption is that many do not.
Before the use of oral medications, treatment for impotence or erectile dysfunction was complicated and invasive. In the 1970s the first penile prostheses or implants were introduced. Although effective, they require surgery as well as manual control, such as inflation with a pump, and often produce an erection that is noticeably artificial in that it is excessively rigid, with little of the pliability or flexibility typical of erections (Wand and Lewis 2001). In the 1980s intracorporal injections were developed to aid erection and, although generally effective, were never a popular choice with patients. They were inconvenient, requiring injection no more than twenty minutes before intercourse, and many patients who injected themselves complained of pain in the penis (Shabsigh 2001). Later in the 1980s vacuum pumps were introduced. They had fewer negative side effects but were less reliably able to produce a lasting erection and all but eliminated the possibility of spontaneity in sexual activity. All these treatments are focused on the treatment of a physiological inability to achieve or maintain an erection and do not take into account the possibility of psychological causes of sexual dysfunction.
Some work has been done to identify common problems in men who have erectile dysfunction, such as Levine and Althof 's (1991) three-part schema of contributory problems: performance anxiety, antecedent life changes such as divorce and bereavement, and developmental vulnerabilities. Little progress has been made in treating conditions that arise from those problems, however, and it generally is recognized that research on psychological causes is far behind research on physiological ones.
Like most sex-based conditions, impotence has a counterpart in female sexual function. Frigidity is defined as a severe aversion to sexual activity or the inability to achieve orgasm during intercourse. Although similar in some respects to impotence, it is linked specifically to the pleasure obtained from sexual activity, whereas impotence is understood as the inability to engage in or sustain a sexual act. In simplistic terms, frigidity is linked to desire and impotence is linked to physical function. This division, however, ignores the possibility of male sexual function being linked to desire; it assumes an omnipresent desire for sexual activity in males that is not related to their ability to function sexually.
THE HISTORY OF IMPOTENCE
Impotence historically has been understood as a physical problem: In ancient Greece the penis was thought to inflate with air during erection, and the inability to achieve or maintain an erection was thought to be linked to that process. During the Renaissance the problem was believed to be related to the musculature of the penis (Zorgniotti and Lizza 1991). Although impotence had cultural significance, attempts to explain the condition medically guaranteed that the connection between the physical condition and ideas of masculinity were understood as metaphorical in nature.
In the late nineteenth century the practice of urology developed, placing the study of impotence in the purview of medical professionals. However, early urology largely connected impotence with gonorrheal infection and excessive masturbation, thus figuring it as a preventable condition acquired through personal behavior. The public fascination with the work of Sigmund Freud in the early twentieth century changed the nature of many sexually based conditions in public discourse. Complicated psychological concepts such as the Oedipus complex were simplified for mass consumption and generally were misunderstood. One result was that impotence became linked primarily to issues of identity and masculinity; the metaphorical connection between the condition and the overall maleness of the individual became much more concrete. Although medical research on impotence progressed rapidly after World War II, the popular belief that impotence is fundamentally an issue of masculinity ensured that it rarely was discussed publicly and that an individual would be unlikely to admit to being impotent.
Impotence was repathologized in the late twentieth century, emerging under the name erectile dysfunction. That term came into common parlance in the early 1990s, when sildenafil began to be marketed under the brand name Viagra as a treatment for the condition. The availability of a pharmacological treatment allowed for the understanding of impotence as being based in pathology, a dysfunction of the body outside the control of the individual. It thus became a neutrally valued condition rather than a source of shame or embarrassment. The marketing campaign targeted primarily middle-aged men and used the former Senate majority leader and presidential candidate Bob Dole as a spokesperson. Culturally, Dole was perceived as asexual: He was a man of advanced years, was partially physically disabled from a wound sustained during World War II, and occupied a position of respect in the U.S. government. His power was substantial yet was completely outside the realm of the sexual. By appearing in advertisements for Viagra, Dole established himself as a sexual entity and even gained respect in that arena. By extension, middle-aged men who received treatment for erectile dysfunction became seen as reclaiming virility at an age when it was unexpected. A kind of prowess was indicated by the desire to have sex even when that desire was not matched with the ability to do so. Viagra and other similar medications have become commonly used recreational drugs; although this has not been proved medically, they are thought to enhance sexual function in individuals who do not have erectile dysfunction.
Although taking medication to combat erectile dysfunction has become both possible and fashionable, little attention is paid to the fact that a great many cases are not physical in nature and thus not treatable with pharmaceuticals. Nonpathological conditions, that is, those requiring psychological treatment, remain negatively valued and are usually what is meant by the use of the word impotence. The term erectile dysfunction is used almost exclusively to refer to medically treated conditions. If it is treatable medically, the condition is seen as one of the body and its failures but is not linked in any specific way with identity. When the cause is not pathological, impotence is linked symbolically to the nature of masculinity and therefore is stigmatized. The vast majority of medical literature acknowledges the possibility of psychogenic causes of impotence but does not offer any particular treatment or course of action when this is the case. Instead, the most common organic causes of erectile dysfunction (diabetes and vascular disease) are discussed at length. Even studies that propose taking a patient history that might help evaluate psychogenic causes indicate that the answers given "are by no means completely reliable but only suggestive" (Lakin 1988, p. 28). Thus, even when a psychogenic cause is indicated, doctors are encouraged to be suspicious of those findings.
CHANGES IN THE DISCOURSE
In the post-Viagra era the discourse surrounding the condition changed. The primary shift was in terminology, from impotence to erectile dysfunction. The renaming of the condition effectively released it from its negative connotations, allowing it to be discussed openly between doctor and patient without embarrassment. At the same time the range of sexual activities associated with erectile dysfunction and impotence expanded in scope. The conditions had been understood almost exclusively as an inability to complete vaginal intercourse with a woman. Later they were recognized as an inability to maintain an erection until orgasm regardless of the specific sexual act or the sex of the partner.
see also Frigidity.
Kaplan, Helen Singer. 1974. The New Sex Therapy: Active Treatment of Sexual Dysfunctions. New York: Brunner/Mazel.
Lakin, Milton. 1988. "Diagnostic Assessment of Disorders of Male Sexual Function." In Disorders of Male Sexual Function, ed. Drogo K. Montague. Chicago: Year Book Medical Publishers.
Levine, S.B., and Stanley Althof. 1991. "The Pathogenesis of Psychogenic Erectile Dysfunction." Journal of Sex Education & Therapy 17(4): 251-266.
Metz, Michael E., and Barry W. McCarthy. 2004. Coping with Erectile Dysfunction: How to Regain Confidence and Enjoy Great Sex. Oakland: New Harbinger.
Shabsigh, Ridwan. 2001. "Intracorporal Therapy." In Male Sexual Function: A Guide to Clinical Management, ed. John J. Mulcahy. Totowa, NJ: Humana Press.
Steidle, Christopher P. 1998. The Impotence Sourcebook. Los Angeles: Lowell House.
Wang, Run, and Ronald W. Lewis. 2001. "Penile Implants: Types and Current Indications." In Male Sexual Function: A Guide to Clinical Management, ed. John J. Mulcahy. Totowa, NJ: Humana Press.
Zorgniotti, Adrian, and Eli F. Lizza. 1991. Diagnosis and Management of Impotence. Philadelphia: B.C. Decker.
Brian D. Holcomb