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With time to reflect on their own needs, as well as that of the family, one finds that there can be as much ambivalence about the desire for a second child as for the first baby, again particularly in those women who had no problems conceiving the first time. Couples do not appear in surgeries or clinics until the first child is about to start school at four or five years old. It is as though there is a sudden panic at the realization that their first child has nearly left home and maybe they have left it too late. It can be seen here how bereavement becomes one of the emotions felt by a woman in this situation, often leading to mounting tension within the relationship.

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Just as the patient may not make her decision without being influenced by those around her, neither does the doctor work in isolation. Someone has to carry out the abortion, nurse the patient and, in the hard-pressed NHS, possibly make the decision as to which patient is most deserving of a hospital bed. This is obviously easier in one of the private charitable organizations dedicated to providing an efficient abortion service. Although no-one may complain at an extra patient attending the antenatal clinic, an extra abortion on an operating list may cause exasperation. This author is unfortunately aware that her counselling is more relaxed when she has plenty of beds at her disposal than when an admission would involve several telephone calls. If a woman decides to continue her pregnancy, this doctor sometimes wonders if she is relieved because she has made the best decision for her patient, or because she has saved a bed. One is aware of the warm glow in the staff (and oneself?) whenever a patient changes her mind and keeps the baby, and how in some quarters this is regarded as a success. Helping to prevent a woman from having an abortion she will live to regret is obviously a favourable outcome but it is a very limited measure of success. A decision to continue with the pregnancy may not necessarily be in the woman’s best interests.

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Continue with the program as outlined in weeks 1 through 3, and follow these suggestions to remove the stress of “trying.” Instead, explore different, nongenital ways of pleasing yourself and your partner. Breast touching is off limits, too. The idea is to relax and enjoy the pleasure of being close without any expectation that intercourse will take place.

Make time for this as often as you can, at least 30 minutes, five times a week. Don’t try to squeeze this into your busy day; actually schedule time for this, make it a priority. To make sure you and your partner both enjoy these sessions, alternate being in charge, so that each of you acts as the “leader” and neither feels left out.

Obviously, it’s important that you discuss the program with your lover so this change doesn’t come out of nowhere.

Weeks 7 through 9: Continue with the Previous Suggestions

Feel free, however, to add genital and breast touching. Continue to avoid intercourse. Just enjoy yourself. If you don’t get an erection, don’t worry. Explore your partner’s body and let her make new discoveries about yours. If you get an erection and ejaculate quickly, try the stop-start or squeeze techniques, described later in this chapter.

Weeks 10 through 12: Continue with the Program

If your erections have returned, at this point you may enjoy intercourse. If you lose your erections quickly or find impotence still a problem, go back and repeat the instructions, beginning with weeks 4 to 6.

Some important advice: Don’t expect immediate success. Don’t let a “failure” (or several) stop you. If the program works for you, great! If it doesn’t, professional sextherapy may help. Some couples find it difficult to follow a program without a professional’s direction and support.

Here are some other self-help techniques that can improve potency.

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An example of this problem is Zachary, a 53-year-old diabetic who had been divorced for many years. He was convinced his potency problem was to blame for his nonexistent social life. If he got himself into an intimate situation with a woman, he was afraid he would be “discovered.” Zachary was convinced that once his potency was restored his problems interacting with women would be over. He could not admit to himself that his social difficulties were long-standing and preceded his potency problem.

Unfortunately, Zachary kept his hopes of a personality transformation completely private. He told his doctor that he wanted the surgery so he could have intercourse again. In terms of his health and general physical condition, Zachary appeared to be a good candidate for the operation. And as far as his doctor knew, he had realistic expectations.

The operation went without a hitch. During the recovery, however, Zachary complained of a great deal of pain. After several weeks, the pain subsided, but he was still displeased. He referred to the implant as “that thing.” Nothing was right. Finally, quite upset, he let his hidden expectations come to light. He had expected the implant to take away his social ineptness and fear of women and make him a different man. Instead, after the operation he was the same man, except he was able to get an erection. And he was bitterly disappointed.

After several months, Zachary demanded to have his implant removed. He resisted all advice to get psychological and sex therapy to help him with his problems. Looking back on Zachary’s situation, it’s clear that he would have fared much better if counseling had helped him first develop his social skills, overcome his shyness and become more comfortable around women. Then his decision to get an implant would have been based on a desire to have intercourse—not on a wish to change his personality.

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It is the latter application that is particularly interesting. Benign prostatic hyperplasia, or BPH, is a common enlargement of the prostate gland. Very prevalent in men past forty, its exact cause is not fully known. While it is not cancerous—nor does it lead to the disease—a man can have both BPH and prostate cancer simultaneously. And although BPH doesn’t affect sexual performance directly, its urinary symptoms can get in the way of sexual activity.

Situated in the front of the rectum and just below the bladder, the prostate completely surrounds the top portion of the urethra, the channel through which both urine and semen pass from the body. A reproductive organ the size of a walnut, the prostate’s major function is to produce part of the fluid portion of semen. During orgasm, muscles in the prostate quickly contract, pushing the prostate fluid through special ducts into the urethra, where it mixes with other fluids that help carry sperm out through the tip of the penis.

While the prostate itself plays no role in the urinary system, disorders of the organ often cause urinary problems due to the gland’s close proximity to the bladder and urethra. Enlargement of the prostate, due either to BPH or cancer, will often constrict the urethra where it runs through the prostate, contributing to bladder-relieving problems.

All symptoms of BPH are linked to urination. As the prostate enlarges, the flow of urine through the urethra is obstructed. Frequent urination, a difficulty starting the action, a weak stream, and dribbling at the end of urination are typical symptoms. Until recently, surgery was the only option. It has now fallen out of favor for several reasons. For one, it often failed to provide relief. For another, it often led to chronic incontinence. Cases of TURP (transurethral resection of the prostate) surgery could lead to an increased risk of death from cardiovascular disease. On top of all that, it is estimated that as many as 15 percent of men go on to develop ED following surgery.

Now, however, there are prescription drugs that will effectively shrink the prostate or relax the muscle tissue that constricts the urethra. Unfortunately, the drugs designed to control BPH often bring about ED or a loss of libido in many men. Finasteride (Proscar) is one such medication.

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Take the time to make a list of the things he does—or doesn’t do —that could potentially be harming his health. Talk to him about these issues, calmly and rationally Discussing one or two at a time will make it more manageable. Remind him that ED is often a symptom of a physical problem or underlying medical condition that might need to be treated.

Anticipate his denials, as well as his defense mechanisms. It’s unlikely that he will agree with you, especially at first. He might very well feel overwhelmed, worried, and upset that you are crossing his personal boundary. But persevere. His health, as well as your relationship, is at stake. And, of course, once he is willing to discuss his problem, your shared problem, then it is time to bring up the fact that he can be helped. But do keep in mind that one conversation is not likely to get him to pick up the phone and make a doctor’s appointment. Both of you have to want help. And for the pills to function optimally, both of you have to want them to work—physically and emotionally.

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Cigarettes have a similar effect. Diabetic men may be particularly susceptible to the negative effects of smoking on erection. One study evaluated 30 diabetic men, all with erection problems. Ten smokers were instructed only not to smoke. Ten smokers were given medication to improve blood flow, and also told to cut out smoking. And 10 nonsmokers took medication.

Those who quit smoking and took their medication did the best. Almost half of the men treated this way, when retested for sleep erections, were found to be normal.

And three out often diabetic men who did nothing but quit smoking found themselves with adequate erections.

It is important to realize that, without proper tests and evaluation, you cannot assume that your disease is the cause of the problem. Certainly for some diabetic men erection problems are not linked to their disease, as was demonstrated by a study done at Loyola University’s Sexual Dysfunction Clinic. Out of 27 diabetic men with erection problems who underwent sex therapy with their wives, 22 were able to have intercourse just a few weeks after beginning treatment. (Some experienced this welcome change in just the first two weeks.) While it is true that this particular group of diabetic men may have been in better control of their disease than some others, clearly the study director, Domeena C. Renshaw, M.D., is correct in stating that “diabetic impotence is not always due to diabetes.” If a man convinces himself that he will develop sexual problems, he may talk himself into having them, physical factors or no. For many patients, sex therapy can be very helpful whether they have a physical condition to blame or not. And men who get partial erections due to physical problems can learn how to get the most out of what they have.

While there are no magic potions to cure diabetes-caused potency problems, there are some treatments that are frequently effective. Penile implants, penile shots, medications, and sex therapy (all discussed in later chapters) have been used with good success. And in the future, some medicines may be able to improve the way damaged nerves work and possibly help some diabetic men. Currently under investigation, these drugs are not commercially available. Trials at several major medical centers are underway to test just how effective they are.

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