The pills can solve your problem, while not really solving it at all. Photo: Getty
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What happens when you go to the doctor and say you can’t get an erection

It is estimated that only a third of men with erectile dysfunction seek treatment. This is what happens if you do.

So, what happens when you go to the doctor and say that you are chronically unable to get an erection?

Well, if you have a female doctor, she’ll look sort of surprised, and tell you, very kindly, that you could have requested an appointment with a male doctor; she’ll seem to think that that would have in some way been less embarrassing. In response, you’ll shrug and explain that, by this point, it’s all the same to you, embarrassment-wise.

You’ll learn that most cases of erectile dysfunction (ED) occur in men over 40 (maybe up to 52 per cent of over-40s have suffered from the problem). You’re not over 40. You’ll learn that ED is associated with a portfolio of serious medical conditions, including diabetes, neurological disease, liver disease, kidney disease, testosterone deficiency, low thyroid hormone, urinary problems and coronary artery disease. But you don’t have any of those. Nor do you smoke, do drugs, or drink heavily. “Good for you”, the doctor might say.

These medical conditions, you’ll be told (quite rightly), make it very important that anyone who does experience ED consults a doctor. But, of course, you already knew that it was very important to consult a doctor – because ED, in addition to being a signifier of various lethal illnesses, prevents you from having penetrative sex. Which is a crap state of affairs.

So then you’ll be asked to drop your jeans and pants and get on the couch, and you’ll obediently do so, wondering if you’re supposed to take your trousers off all the way or if it’s OK to leave them, as you have done, around your ankles, and then the doctor will pull aside the curtain and say, “Oh, I should have said, lie down on the couch, please,” because you’ve been attempting a sort of nonchalant lean against the couch instead, which when you think about it is pretty stupid, because it suggests that the doctor is going to either bend double or drop to her knees to examine your knob, and obviously she isn’t, so you climb on the couch and recline, somehow, unbelievably, feeling even more stupid and awkward than you felt thirty seconds ago (you know, when you sort of rolled your eyes and said, ‘Well, I’ve got, um, chronic, erm, erectiledysfunction, basically”).

The doctor will then frowningly inspect your limp member, viewing it from above, lifting it to view it from below, poking interestedly at the surrounding regions, and then sliding your foreskin back and forth like a cricketer adjusting the rubber grip on his bat.

Then she’ll say, “Well, that all seems fine”, and for the first time that day you’ll feel pretty good about yourself.

Why don’t more ED sufferers go in for this diverting pastime? What’s keeping them from confronting the problem?

“Some men just hope it will get better and go away,” says Victoria Lehmann, a sexual and relationship therapist at the Sexual Advice Association (formerly the Impotence Association). “Women attend GP surgeries for contraception and have developed a language to talk about sexual issues. Men, on the other hand, visit doctors less, so going to make an appointment or seeing a doctor for the first time and talking about something so intimate and private can be extremely difficult. The media can still portray men as strong and virile, which makes men feel vulnerable and anxious when they are not being able to engage in successful sexual activity.”

Doctors themselves don’t always help matters. GPs have been given additional training on how to take a sexual history and are broadly aware of treatments available, but – thanks to time restrictions, embarrassment and a lack of confidence in their own expertise – many avoid going into these issues in depth.  

As you hastily re-trouser yourself and the doctor disposes of her rubber gloves, there’s a palpable sense of relief that the worst is over. For the doctor, that’s true. For you, it is not.

The doctor – who is young, and very kind – prescribes (a) bonk-pills, (b) an appointment with a specialist at an out-of-town clinic and (c) counselling. She’s unfamiliar with the NHS’s rules on bonk-pill allocation (they seldom prescribe Cialis or Viagra on the health service unless you have a physical cause for your condition, but, she smiles, in a case like yours – seeing as you are so UTTERLY impotent! – they’ll make an exception). When you take the prescription to the Lloyds round the corner, you’ll find that she’s recklessly over-prescribed; the senior pharmacist, who happens to be a man, will have to usher you into a secret little cubicle to explain that they’re not allowed to give you that amount of Cialis for £7.85 (which could have kept a stud-farm in hard-ons for a year), and amends the scrip to grant you a tenth as much. You leave with the packet in your pocket and dread in your heart. Next stop, the Specialist.

The Specialist turns out to be a very tall, very impressive Dutchman. Again the business with the couch (the frowning scrutiny, the waggling back and forth, the cricket-bat routine, the that-all-seems-fine). He asks you if you’ve been on holiday. You wonder if he’s making small-talk, even though he didn’t really say it like it was small-talk, and you answer, haltingly, with something about a long weekend in York, and he says that it often, you know, helps, a holiday, and you say “oh”, because it’s never helped you. The Specialist sends you off for some blood tests (which will come back a few days later, as you knew they would, clear), and gives you a scrip for more pills, and shakes your hand and says good-bye, and off you go. You’ll later be told that he has written “seems anxious” on your notes. You will respond to this information with a hollow laugh.

Now nothing remains but the Counsellor. Many ED clinics refuse to provide psychosexual counselling on the NHS, forcing sufferers to go private or go without. It’s representative of a generally patchy ED provision across the health service. But you got lucky – so off you go, to your first appointment with the Counsellor. 

Remember, you do all of this on your own – not because you lack kind friends or a supportive partner, but because you know (you insist) it’s your problem, this; it’s your illness, your failing, yours to deal with. It’s not something anyone else needs to worry about. So, quite voluntarily, you do it on your own. You feel lonely, of course, but that’s only fair, because this is all your problem.

Anyway, it’s the Counsellor you’ve really been pinning your hopes on, because you’ve known all along, for these past twenty years, that this, your problem, your impotence, is a form of anxiety – even though you’re not an anxious person, not a real worrier, not uptight or embarrassed about sex (a late bloomer, sure, shy sometimes, yes, but there are later bloomers and shier men, you’re quite sure, who don’t struggle so pitiably to maintain an erection in bed). Somewhere inside you there’s a strung-out little Numskull who just can’t get it together to pull the lever marked “boner”.

There isn’t room in one article to explore the sexual anxieties to which the average man is prey. 

“In general, men believe that they ought to be good lovers and please their partners,” says Victoria Lehmann. “They cannot fake an erection or ejaculations. Men worry about the size of their penis and are concerned if they ejaculate too quickly or not all and whether their erection remains hard enough for their partner to enjoy sex. This puts enormous pressure on a man to perform well.”

You’ve never really been all that aware of this sort of pressure – but that, of course, doesn’t mean it hasn’t been there.

So you go to counselling. And the counselling is fine, and the counsellor is lovely though her office is tiny and dowdy and, you feel, inadequately soundproofed, and you have several hour-long sessions, and you speak openly and frankly and without shame about your erectile dysfunction, and you don’t really learn anything you didn’t already know but it’s still nice to get it all out in the open. She recommends a book by some American MD, and you read the relevant chapter, and it brings you to sorry tears of recognition, even though you never cry at anything, ever - and you think, tentatively, that maybe, if you were to write openly about your experience of impotence, it might help someone out there, and maybe even help you, too.

Then your counsellor transfers to another hospital, far away, and although before she goes she gives you the option of switching to another counsellor, you both sort of feel that this counselling thing has run its course, so you don’t book any more sessions, and the counselling peters out – and you’re left with the pills.

The pills work. Seriously. Those things work.

So your problem has sort of been solved but also not really been solved at all. There’s still prescription fees and awkward appointments, every time, every fucking time with a different GP, for repeat scrips. And there’s still, deep inside, something wrong, something not working.

And the funny and terrible thing is that you can’t tell anyone about this (oh, except the life insurance agents with whom you will have several hilariously painful conversations). You’re not the sort of person who gets embarrassed about this stuff, you’re a liberal and down-to-earth and foul-mouthed person, and you know none of this is your fault, so why should you feel awkward? – and yet you can’t talk about it, because, even if you’re not embarrassed, your friends will think you are, or ought to be, and so they’ll be embarrassed, and so you won’t say anything (once, when drunk with a mate, you’ll mention it fleetingly, testingly, and he’ll tell you, in alarmed tones, that you’re pissed, and that you mustn’t say any more, because you’ll regret it in the morning if you do).

How can this be helped? Can it be helped?

More flexible, accessible health-service support would, of course, be a good start. Advertising and online resources – targeted not only at ED sufferers but at their partners too – would help with the development of the vocabulary and social protocols we need in order to promote more open discussion of the problem. And celebrity endorsement might seem tacky, but it can give men and their partners “permission” to discuss their symptoms. Providing these things shouldn’t be left to pharma companies and their shills (hello, Pelé!); “A pill will make it all better” is not the message ED sufferers really need to hear.    

In the meantime, we remain locked in to the taboo – so much so that, when you do come to share your experiences of erectile dysfunction, writing a wry second-person article on the subject for a magazine with a readership of thousands in a bold bid to normalise psychosexual health problems, you’ll still feel the need to adopt a pseudonym.  

That is what happens when you go to the doctor and say that you are chronically unable to get an erection.

David Vernon is a pseudonym.

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Air pollution: 5 steps to vanquishing an invisible killer

A new report looks at the economics of air pollution. 

110, 150, 520... These chilling statistics are the number of deaths attributable to particulate air pollution for the cities of Southampton, Nottingham and Birmingham in 2010 respectively. Or how about 40,000 - that is the total number of UK deaths per year that are attributable the combined effects of particulate matter (PM2.5) and Nitrogen Oxides (NOx).

This situation sucks, to say the very least. But while there are no dramatic images to stir up action, these deaths are preventable and we know their cause. Road traffic is the worst culprit. Traffic is responsible for 80 per cent of NOx on high pollution roads, with diesel engines contributing the bulk of the problem.

Now a new report by ResPublica has compiled a list of ways that city councils around the UK can help. The report argues that: “The onus is on cities to create plans that can meet the health and economic challenge within a short time-frame, and identify what they need from national government to do so.”

This is a diplomatic way of saying that current government action on the subject does not go far enough – and that cities must help prod them into gear. That includes poking holes in the government’s proposed plans for new “Clean Air Zones”.

Here are just five of the ways the report suggests letting the light in and the pollution out:

1. Clean up the draft Clean Air Zones framework

Last October, the government set out its draft plans for new Clean Air Zones in the UK’s five most polluted cities, Birmingham, Derby, Leeds, Nottingham and Southampton (excluding London - where other plans are afoot). These zones will charge “polluting” vehicles to enter and can be implemented with varying levels of intensity, with three options that include cars and one that does not.

But the report argues that there is still too much potential for polluters to play dirty with the rules. Car-charging zones must be mandatory for all cities that breach the current EU standards, the report argues (not just the suggested five). Otherwise national operators who own fleets of vehicles could simply relocate outdated buses or taxis to places where they don’t have to pay.  

Different vehicles should fall under the same rules, the report added. Otherwise, taking your car rather than the bus could suddenly seem like the cost-saving option.

2. Vouchers to vouch-safe the project’s success

The government is exploring a scrappage scheme for diesel cars, to help get the worst and oldest polluting vehicles off the road. But as the report points out, blanket scrappage could simply put a whole load of new fossil-fuel cars on the road.

Instead, ResPublica suggests using the revenue from the Clean Air Zone charges, plus hiked vehicle registration fees, to create “Pollution Reduction Vouchers”.

Low-income households with older cars, that would be liable to charging, could then use the vouchers to help secure alternative transport, buy a new and compliant car, or retrofit their existing vehicle with new technology.

3. Extend Vehicle Excise Duty

Vehicle Excise Duty is currently only tiered by how much CO2 pollution a car creates for the first year. After that it becomes a flat rate for all cars under £40,000. The report suggests changing this so that the most polluting vehicles for CO2, NOx and PM2.5 continue to pay higher rates throughout their life span.

For ClientEarth CEO James Thornton, changes to vehicle excise duty are key to moving people onto cleaner modes of transport: “We need a network of clean air zones to keep the most polluting diesel vehicles from the most polluted parts of our towns and cities and incentives such as a targeted scrappage scheme and changes to vehicle excise duty to move people onto cleaner modes of transport.”

4. Repurposed car parks

You would think city bosses would want less cars in the centre of town. But while less cars is good news for oxygen-breathers, it is bad news for city budgets reliant on parking charges. But using car parks to tap into new revenue from property development and joint ventures could help cities reverse this thinking.

5. Prioritise public awareness

Charge zones can be understandably unpopular. In 2008, a referendum in Manchester defeated the idea of congestion charging. So a big effort is needed to raise public awareness of the health crisis our roads have caused. Metro mayors should outline pollution plans in their manifestos, the report suggests. And cities can take advantage of their existing assets. For example in London there are plans to use electronics in the Underground to update travellers on the air pollution levels.

***

Change is already in the air. Southampton has used money from the Local Sustainable Travel Fund to run a successful messaging campaign. And in 2011 Nottingham City Council became the first city to implement a Workplace Parking levy – a scheme which has raised £35.3m to help extend its tram system, upgrade the station and purchase electric buses.

But many more “air necessities” are needed before we can forget about pollution’s worry and its strife.  

 

India Bourke is an environment writer and editorial assistant at the New Statesman.