Impotence is the inability to obtain an erection which is hard enough to achieve vaginal intercourse or the inability to maintain such an erection for long enough to ejaculate inside the vagina.

It may manifest itself by either: the inability to get an adequate erection; or getting one but losing it, without ejaculation, at the point of or soon after attempting intercourse.

Conditions often mistaken for impotence

1. Premature ejaculation: the inability to control or delay ejaculation.
   
   This condition could easily be mistaken for impotence in two ways:
   
   • first, by failing to get an erection soon after losing one prematurely, before the system is fully recovered;
   • and second, by losing an erection on or soon after vaginal entry, because ejaculation could not be delayed.
     

In both conditions the erectile difficulty occurs after ejaculation.

1. Delayed or inhibited ejaculation: due to an excessive control of ejaculation.
   
   This condition is often referred to, even in some books, as a form of impotence. It is however a different condition which responds to a different type of treatment.
   
   
2. Lack of desire.
   
   The false image of men as being always ready, always willing and always interested in sex delayed the recognition of the fact that men do go off sex as well as women.
   
   The man who has lost interest in sex or is too frightened of sexual intimacy may not be able to get an erection because he is not aroused enough to get one.
   
   He may also get an erection but lose it, without ejaculation, because he is too bored or distracted by more interesting things.
   
   It is difficult sometimes to seperate men who have erectile problems because they have lost interest in sex from those who have convinced themselves that they are "not interested in sex" to save themselves the humiliation of trying to get an erection and failing.

How common is it?
Impotence is much more common than is generally realised. One in ten of adult men suffer from persistent erectile difficulty, not just the odd failure.

This means that at least three million British men and 10 million American men suffer from impotence.

It is closely related to age and general health. the risk of becoming impotent increases steadily with age, with a sharp rise at the age of 65. In one study, 34 per cent of men attending the outpatient clinics of a general hospital were suffering from impotence. The most common single factor in all of them was "taking drug medication".

Is it all in the mind?
It was thought until recently that the majority of cases of impotence are caused by psychological factors. This led to giving the impotent man dismissive and uhelpful advice like "Don't worry", "It's all in the mind", "Just relax, have a drink and it will go away" or "Just leave it and it will correct itself".

Some couples were subjected to intensive and lengthy courses of psychotherapy and sex therapy, which might have helped a few cases but left many more with some understanding of their problem but still as impotent.

With the vast improvement in diagnostic methods and more sophistication in the whole approach to the problem, it is now realised that physical factors may be the main cause, or at least one of the contributing factors, in at least half of all cases.

False unhelpful beliefs
Sex is a taboo subject around which there are many strongly held beliefs that are passed from one generation to the next without their usefulness being questioned. Here are some examples:

"A real man should always be ready with an erection"

"Only women show emotions"

"It is the man's responsibility to start, orchestrate and finish love making and any failures should be attributed solely to him"

"If a man loses an erection, he loses everything"

Men who accept these false beliefs unquestioningly put themselves under unreasonable pressure, take responsibility for responses which are out of their control and talk themselves, unjustifiably, into being failures. No wonder that when they are put under enough pressure they lose their erections.

Poor communication

Sex is a form of communication. Couples who cannot talk to each other are not likely to be able to make love to each other.

Men who cannot communicate feelings like fear, uncertainty or vulnerability will find it difficult to share with their partner some of their anxieties about their sexual performance. By keeping these worries to themselves, these get blown out of all proportion, and these men become very vulnerable to losing their erections.

Men who cannot express and resolve feelings of anger, frustration or hostility towards their partner may use their penis as a weapon in marital conflict. Holding back erections could be an aggressive act which some shy and timid men resort to in order to express their anger towards their more domineering partners.

Physical vulnerability

Some minor physical impairments, which may not be enough in themselves to cause problems could, if combined with stress, cause erectile failure. These vulnerabilities could be either:

1. Constitutional - some men are born with a particularly sensitive vascular system which tends to react to stress by restricting the blood supply to the penis, causing impotence. This mechanism is similar to that which makes men with a particularly sensitive lining of the stomach develop peptic ulcers under stress.
   
   
2. In the form of minor vascular or neurological impairments - as in mild degrees of atherosclerosis, diabetes or hypertension.

Drugs, alcohol, smoking, obesity and long periods of sexual abstinence are all physical factors that make it harder to get an erection or to maintain it.