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Erectile Dysfunction and Damaged Blood Vessels
Part I: Dispelling a common myth
Judging from annual growth in the sales figures for VIAGRA®*, for instance, it is clear that the American consumer public takes it pretty much for granted now that most cases of erectile dysfunction (ED) do not have a psychological basis. In fact, TV commercials for CIALIS®, another prescription medicine to correct that condition, tell us that it could be caused by a problem with “blood flow.” [*2003 to 2014: 1.93 billion U.S. dollars]
“Blood flow” is a far cry from allegations that one so afflicted was likely embroiled in what Dr. Zygmund Freud believed to be an Oedipal Complex… the emotionally unhealthy “mother” thing treatable only with extensive couch-surfing.
We are witnessing a welcome paradigm shift from couch surfing and, as the makers of CIALIS® would have you know, to somewhat less expensive and less time consuming, and demonstrably effective parallel bathtub surfing.
Even though few in the viewing public could explain what “problem with blood flow” actually means, it is for most of them a relief to know that it is not “in your head.” For, the belief that one’s ED has a psychological basis often led to self-blaming conclusions such as “I am not a man anymore,” or “maybe I don’t really find her as attractive as I now should.”
But, from an individual health and longevity point of view, they would be far better off if it were “in your head”: A problem with blood flow is not an advantage over obscure emotional issues — a problem that they’d better do something about because it is far more than an erection that is at stake here. Medicine now tells us that faltering erection may be a warning — like the canary in the coal mine* — that their very life may be at stake.
[* Meldrum, Gambone, Morris , et al. (2011) The link between erectile and cardiovascular health: the canary in the coal mine. Am J Cardiol., 108(4):599-606.]
It is taking some time for rank and file medicine to catch on that ED is most often due to a blood vessel impairment, and for the mental health profession to jump on the band wagon. For instance, according to the Merck Manual currently on line:
Etiology of Erectile Dysfunction
There are 2 types of ED:
Primary ED, the man has never been able to attain or sustain an erection
Secondary ED, acquired later in life by a man who previously was able to attain erections
Primary ED is rare and is almost always due to psychologic factors or clinically obvious anatomic abnormalities.
Secondary ED is more common, and > 90% of cases have an organic etiology. Many men with secondary ED develop reactive psychologic difficulties that compound the problem. Psychologic factors, whether primary or reactive, must be considered in every case of ED. Psychologic causes of primary ED include guilt, fear of intimacy, depression, or anxiety. In secondary ED, causes may relate to performance anxiety, stress, or depression. Psychogenic ED may be situational, involving a particular place, time, or partner. (My emphasis in bold type.)
Despite the overwhelming evidence that ED “may be a problem with blood flow,” we witness an overwhelming tendency to cling to outmoded psychological etiology for most of which there is, in fact, not the slightest shred of scientific evidence. Of course it stands to reason (pardon the pun) that a man who experiences faltering erection would have some performance anxiety: This illustrates once again the dictum that if one is to put the horse before the cart, he needs to know what a horse looks like.
The traditional Psychology/Psychiatry folks don’t do any better:
The common term “erectile dysfunction” (ED) is “Male Erectile Disorder” in the current Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association. It is said to be a persistent or recurrent inability to attain or to maintain an adequate erection to completion of the sexual activity. It is a disturbance causing marked distress or interpersonal difficulty, an ED not better accounted for by any other diagnostic categories except mental retardation and personality disorder, and one that is not due exclusively to the direct physiological effects of a substance, e.g. a drug abused, a medication, or a general medical condition (APA—DSM-IV-TR, 2000). (My emphasis in bold type.)
The definition assigns etiology to other than medical causes thus seemingly excluding vascular/vasculogenic ED, now considered, as noted in the quotation “> 90%” from the Merck Manual above, to be the most common form found among American men.
It should be noted that the recommendation to include diagnostic criteria for a medical basis of ED in subsequent editions of the DSM is made in the Journal of Sexual Medicine*. You can find this discussion detailed in Chapter 1 of my book. [* Segraves RT. (2010) Considerations for diagnostic criteria for erectile dysfunction in DSM V. J Sex Med., 7(2 Pt 1):654-660.]
Thus, the myth that ED is caused most often, or at least in large part, by hypothetical psychological issues, albeit dealt a mighty blow, it lingers on. In some measure, the more or less successful psychopharmacology treatments for psychological disorders contributes to the myth: The discovery that neurotransmitters gone awry may feature in psychopathology and that correction by prescription drugs that target these can result in resolving psychological problems can, by analogy, support the tenacious belief that even though ED has a psychological etiology, it still can be corrected by drugs. For all they knew, at first, VIAGRA could be an anxiolytic that reduces “fear of failure.” After all, VIAGRA is vaguely linked to neurotransmitters — the stuff of drug treatments for emotional disorders.
Putting the horse before DesCartes: In most cases, emotional/psychological problems do not cause ED; ED causes emotional/psychological problems.
I urge you to read my book, Erectile Dysfunction as a Cardiovascular Impairment where I document in detail the scientific evidence that in most cases, ED is caused by blood vessel disease and not emotional issues.
In the next blog (No. 2) I will report how early studies of erectile function in the bull retractor penis led to understanding that the neurotransmitter acetylcholine is principally involved in the relaxation of penis blood vessels and muscles required for erection.
About the Author
Robert Fried, Ph.D is an Emeritus Professor, Doctoral Faculty in Behavioral Neuroscience, at City University of New York (CUNY); Emeritus, American Physiological Society (APS) (Cardiovascular and Respiration Div.)
Formerly, Director, Rehabilitation Research Institute (RRI), ICD – International Center for the Disabled, New York, NY.
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