That little problem a man won't talk about - even if he's your doctor

Millions of men suffer from impotence, but

a new survey suggests that even those who summon up the courage to see their

GP may receive no help. Phillip Hodson reports.

The poet John Betjeman suffered: "My sex is no longer rampant." Sir Anthony Buck apparently suffered: "It took two years for the marriage to be consummated to wife Bienvenida." Even James Bond has suffered: "For an hour in that room alone with Le Chiffre the certainty of impotence had been beaten into him and a scar had been left that could only be healed by experience."

A pity they didn't live to see the current trend of impotence research and development.

This should be an exciting time for erections. There is a range of new products - at least one of them available on the NHS - or in the pipeline, to help most men. However, the conclusion of a survey of 432 patients and 194 partners, published on behalf of the Impotence Association, is significantly deflating.

The chairman of the association, Dr Alan J Riley, has estimated that up to 5 million British men suffer from some form of "erectile dysfunction" yet only 10 per cent receive any form of treatment.

We now learn that of those seeking help, one in four neglects to visit their doctor, preferring to trust to commercial alternatives such as sprays, herbs and "energy rings". Of those who do visit the surgery, 23 per cent get no treatment whatsoever. Of those who do visit the doctor and get treatment, a massive 58 per cent come away dissatisfied.

Does this matter? Well, 62 per cent of sufferers reported lowered self- esteem and some feelings of depression; 15 per cent had trouble making new relationships; 14 per cent said impotence had damaged their long-term partnerships; 10 per cent thought it had even spoiled their relationship with the doctor, while a quarter of the respondents said impotence reduced their overall quality of life by up to 80 per cent.

Allan Bennet - in his 50s - wrote to me last year to express frustration with the system: "I have had sexual difficulties for more than two years. Reluctantly, I went to see my GP having finally plucked up the courage. He asked me what I expected at my age, and did it really matter any more? I'd got my family, hadn't I? And with a magisterial wave he dismissed my concerns.

"I was so flabbergasted, I remained speechless. The doctor in question, I may add, is a Roman Catholic.

"It was only when I got home that my brain jogged back into gear. I sent him the following note:

`Dear Doctor,

`I know that you have indicated that the virility problem is not of fundamental importance to the continuation of my marriage but I can assure you that it most definitely is vital to the continued existence of my peace of mind as a man. I thought you should be informed I shall be seeing a sexual consultant in London ...' "

When you consider that good sex adds years to the life of middle-aged men such as Allan, cutting the risk of premature death by as much as 36 per cent ("The truth about sex; more of it makes you live longer", The Independent, 19 December 1997), this does amount to a legitimate health concern.

Yet time and again, for reasons of embarrassment or lack of empathy, GPs seem reluctant to be proactive or to prescribe. And as the survey suggests, patients are equally slow to face up to their difficulties, often suffering in silence as only "real" men can.

In fact, if the male sex were quoted on the stock exchange, today's price would be in trouble again. Poor educational attainments and falling sperm counts are one thing. But to pass up a National Health aphrodisiac when it is lawful and licensed seems more than perverse.

As men live longer, compete with women harder and consume more health and grooming products, impotence is, in any case, set to spread rather than diminish. Up to a third of men over the age of 45 experience some symptoms of impotence, and up to two-thirds of those aged 75 and over. Longer life span usually means more heart and hypertension problems. These may cause impotence directly, or as a result of taking medication for the conditions. The same is true of depression - a common enough feature of mid-life crisis. Both the illness, and remedies such as Prozac, can reduce libido and affect sexual performance. New drugs to counteract baldness, such as Propecia, also carry some risk of impotence.

Nor do "old" drugs such as alcohol and nicotine help. Men who consume more than 40 units of booze a week are likely to deliver little or no sexual thrill. It has been shown that smoking two high-tar cigarettes, one after the other, reduces blood-flow in the penis by about a third. And the Independent on Sunday's campaign to promote cannabis has to answer concerns that up to 20 per cent of long-term cannabis users may become impotent.

Even if you are trying to lead a drug-free, well-exercised lifestyle, there is little prospect of escape. The latest significant cause of impotence among younger men turns out to be "bicycle-riding", at least according to Dr Irwin Goldstein of Dallas, Texas (his website: http://www.nd.edu/ktrembat/ www-bike/BCY/men.bikes. html), who sees six such patients a week. He claims that hard cycle-saddles on sports bikes are responsible for reducing penile blood flow by up to 66 per cent, and even the softer versions reduce blood supply to the region by a third.

So it is just as well that we live in a period replete with remedies. Injectable prostaglandins, (blood-stream messengers) such as Caverject are a special boon for diabetes and stroke patients. Men cross their legs when you mention injections, but the sensation is said to be no more than a "small prick", according to Dr Geoff Hackett of Keele University, who ran tests for five years.

To those critics who say doctors are yet again "interfering with nature", he replied: "Spontaneous intercourse isn't very common in most 20-year- old marriages. My studies show that 39 per cent of patients with diabetes are permanently impotent. Over 50 per cent of stroke patients are impotent. And most of those with spinal damage who can't walk and have sometimes little else to live for are impotent. Not only will many of these sufferers be able to resume sexual activity, the quality of their erections is likely to exceed anything they've experienced since boyhood."

Another version of this compound (called Muse) will be available later this month in pellet form for needle-phobes.

In addition to these treatments, there is a vast array of hard or semi- hard penile rods and implants, some with external bulb-inflators, which may be fitted by a plastic surgeon, in addition to hand-applied pumps, splints and bands.

But in all this discussion of prosthetics and sexual chemistry where is the human touch?

Already we have a consumer-friendly alpha-1 blocker impotence remedy (called Erecnos) which, unlike Caverject and Muse, does not induce erection in the absence of sexual stimulation. We're about to see an orally-active compound (Sildenafil) whose trials are showing great success.

But popping a pill is never going to be the complete answer. Men, after all, are only half the equation. We already know that more than a third of the partners of impotent men have sexual problems of their own. So, despite the problems highlighted in this survey, the future still looks good for talking treatments and Relate; it is also looking good for foreplay.

Phillip Hodson is a trustee of the Impotence Association, a sex therapist and a fellow of the British Association for Counselling. The results of the survey will be published in full on 28 January. To contact the Impotence Association, write to PO Box 10296, London SW17 7ZN.