April 27, 1998

A silent, embarrassing affliction sweeps Indian bedrooms, with men from all age groups and social classes desperately turning to doctors for cures.

By Madhu Jain, Subhadra Menon and Ramesh Vinayak

Lalit Bhasin is the kind of man most men envy. Just a year ago he would have thought so too. At 39, the suave, successful banker had a well-turned out wife and two precocious children, swung a mean club on the golf course. But a few months ago, things began to go wrong in the bedroom. The worst thing that could happen to a man happened to him: he became impotent. "It drove me nuts," confesses Bhasin. "I had money, but without my virility I was only half a man."

He didn't see a connection but whistle-stop work schedules and jetting round the globe chasing deals and dreams had sapped his sexual vitality. And so began a nightmarish odyssey: rounds of quacks and charlatans. It took Rs 25,000 and a great desperation before Bhasin finally summoned courage to seek medical help.

Bhasin's ordeal is not unique. In fact, it has become particularly common. The proverbial headache is getting to be the male preserve. One out of every 10 Indian males could be impotent, according to a survey of 1,500 men done in Delhi by the Alpha One Andrology Centre at Aashlok Hospital. "Impotence is a silent epidemic that is sweeping across the nation, the average victim being a middle-aged male otherwise healthy and successful," says the centre's director, urologist Vikram Sharma. Big city hospitals estimate that one out of every five to eight patients is impotent -- or, as the politically-correct term goes, suffers from erectile dysfunction (ED). A recent seven-year study by the Marital and Psychosexual Clinic at the Post-Graduate Institute of Medical Education and Research (pgimer), Chandigarh, concluded that 77 per cent of its 464 new patients suffered from ED or premature ejaculation -- or both. And so, in clinics across the nation, amazed doctors watch as determined wives, mothers, even mothers-in-law, drag in their men. Women no longer content with lying back and being mere baby machines want satisfaction. Borne on the beams of unseen satellites, images of a loud, new female sexuality are displacing traditional roles of silent fertility. They see hard bodies and seemingly endless energy.

"The meta message coming from the media is that you have to have a huge erection and keep it for a long time," says Radhika Chandiramani, clinical psychologist. "The young man often fantasises about what an erection should be like, compares it with the real situation, after which anxiety sets in and that is the most deflationary thing that can happen."

As the traditionally boorish, sexually self-centred Indian male is called upon to prove his mettle, he's getting a bad case of performance anxiety. Like Sanjay Lal, a small-time Delhi doctor in his early 30s. His problem is a transformed wife who demands more creativity in the bedroom. When they married six years ago, Ranjana was a small-town girl barely able to string together two sentences in English. But she soon found a Professor Higgins in her female boss (an IIM graduate) in the multinational company where she works as a secretary. The two women discussed their sexual lives, and their conversations began to resound in the Lal bedroom. The fights began: she resented the fact that he never asked her where she wanted to be touched and her language took on the intonations of her other role model: the revenge-seeking heroine in the popular afternoon soap Shanti. For someone brought up in the-man-knows-best environment, this was crippling for Lal. He stopped making love.

This new female demand is particularly -- and poignantly -- difficult to meet, given the hectic pace of the daily treadmill of life. The pressures of competition, the race to earn more money and consumerism are all drives that relegate sex to the back-burner. The winds of liberalisation, in a sense, are chilling Indian bedrooms. Nitin Bose, a 42-year-old executive, narrates with frustration how unceasing ambition and a pursuit of the good life put him out to pasture -- sexually. His love life was reduced to an infrequent tension-filled 10-minute tryst after an exhausting 16-hour day. Two children and six years into his marriage, Bose's mind and body finally gave up. He just couldn't do it any more.

Anecdotal evidence confirms that the affliction plagues urban and rural India, the rich and the poor, the young -- and yes, even older men in search of sexual reawakening.

D. Narayana Reddy, a consultant on sexual medicine at the Dega Institute in Chennai, says that he now sees at least 15 patients a day; back in 1982, he had just 37 patients for the whole year. Rajiv Gupta, a consultant psychiatrist in Ludhiana, says that the number of his patients reporting impotency has increased three to four times in the past decade. Dr Prakash Kothari, head of the sexual medicine department at Mumbai's KEM Hospital, says that impotence has increased by 15 per cent a year in the past two to three years. In Lucknow, A. K. Agrawal, head of the department of psychiatry at the King George Medical College, says: "There is a growing fear of impotence among rural and urban people here." It's a trend in line with what happens to men in the developed world. In the US, the National Institute of Health estimates that as many as 30 million men suffer from ed. That staggering figure has given rise to a market for impotence cures that runs into billions of dollars.

India, the cures mushroom on the pavements, restricted only by the imaginations of those who create the formulations. Street-corner quacks have always plied Indian males with elixirs. But driven by the exploding demand for magic potions, street medicine has gone mainstream: packaged and over-the-counter in chemist shops in their new quasi-pharmacological avatars (See box). The remedies are wild and varied. From "rooster's flesh fried in crocodile semen" (a recipe from the classic ayurveda text Charaka Samhita) to more prosaic repackaged roots like 303.

The street experts and "sexologists" with gloriously luxuriant moustaches have clinicians and doctors worried. Harjeet Singh, a leading Lucknow psychiatrist, is convinced that the "so-called sexologists" are a major factor in the increasing fear about impotency. "An average patient ends up paying Rs 25,000 to Rs 40,000 without having an erection," says Singh. "Since they spend huge sums of money on advertisements, pamphlets and hoardings to lure customers, they must be recovering it from the hapless patients."

Are more and more men getting impotent? Or, are they just more open about it and seeking help? Doctors and psychiatrists are divided on this. Reddy believes that a larger number of men are seeking help because we now live in more liberated times: "Social taboos are disappearing and there's a greater awareness in the younger generation." On the other hand, Ajit Avasthi of pgimer says quite unequivocally: "What we are diagnosing is not even the tip of the iceberg."

Impotency cuts across age groups and classes. At the Alpha One Centre, the youngest patient is 18 years old, the oldest 72. Last week, a 75-year-old businessman walked into the Out-Patient Department of pgimer and, without batting an eyelid, narrated his problem to Dr S.K. Sharma, who heads the urology department. "I want sex," he told Sharma, "but my organ has lost its erection." He had already done the rounds of quacks and spent a minor fortune in search of the elixir of love. Finally, he went away happy, after the installation of the Vacuum Erection Device. Another Rs 15,000 -- but all for love.

The changing age profile surprises doctors. Dr Achal Bhagat, psychotherapist at Delhi's Indraprastha Apollo Hospital, observes a gradual shift from the younger men coming in for premature ejaculation and ED to men in their 30s and even older. "There has been a marked increase in the age group of 45-69," he says.

So what is this typical patient like? He's likely to be around 40-45 years old and in a second relationship -- the first not having worked out. He is also likely to be fairly successful, smokes, drinks a bit, may chew paan masala and is a little tubby. He's had a good sex life, but lately he isn't so sure. "While in the 30-year-old and the 45-year-old there may be some loss of libido, this 60 -year-old has no loss of libido, only a loss of erection," says Bhagat.

There are two kinds of impotency: primary and secondary. Primary impotence occurs early in sexual life, whereas men who cannot achieve erection after a certain age suffer from what is called secondary impotence. Whether primary or secondary, ED falls into two categories -- physical and psychological. Physical impotence is when the patient has some defect or is suffering from a disease. It could be damaged blood vessels leading to insufficient blood supply to the penis. It could be a nerve damage because of a spinal injury or diabetes. It could be due to drugs taken for depression, hypertension, an allergy or a cardiac condition.

Drug-induced impotence could account for as much as 25 per cent of the total cases of ED, says Dr Mandeep Bajaj, endocrinologist at the Apollo Hospital. Hormonal imbalances -- like the creeping presence of Prolactin, a hormone for lactation in women sometimes found in men -- could also lead to the inability to have an erection. So could excessive alcohol consumption or smoking. According to international health protocols, smoking just two cigarettes can lead to a decreased ability to have an erection. Such physical causes of impotence, however, are completely curable (see box on treatment options).

A major emerging worry is diabetes. Studies by Dr S.M. Sadikot, a consulting endocrinologist and andrologist at the Jaslok Hospital and Research Centre in Mumbai, have shown that at least 28 per cent of male diabetics complain of total ED, while more than 45 per cent suffered from a significant degree of the problem. According to Bajaj, there is a 30 per cent to 75 per cent higher prevalence of impotence amongst diabetic men compared with the general population. The diabetic suffers from a combination of damage to the blood vessels and nerves because of high blood sugar. Impotence may often be the first symptom of diabetes and requires preventive management. Bajaj sees an earlier onset of diabetes in India because of altered lifestyles which are increasingly sedentary, encourage high-fat diets and fast foods.

Sometimes, it's all in the mind. While Dr Rupin Shah, director of the Centre for Male Reproductive and Sexual Medicine at Mumbai's Bhatia General Hospital, maintains that "almost two-thirds of all cases of impotence in India stem from psychological causes", Sadikot insists that the reverse is true. "A precise understanding of the physiology of erections and their nervous, vascular and hormonal control makes us realise that in the vast majority of cases (70 per cent-75 per cent), the cause is organic (physiological)," says Sadikot. Doctors are putting their minds together to resolve the mind-or-matter debate. The new speciality of andrology uses a battery of specialists: psychiatrists, urologists, endocrinologists, surgeons, neurologists and gynaecologists.

The most damaging aspect of impotence is that it creates a vicious cycle of anxiety and depression, which in turn aggravates the problem. Newly weds especially are susceptible to what is called "honeymoon impotence". India, according to Shah, is "the country of unconsummated marriages". Every week, he counsels at least five new couples who haven't ever had sexual intercourse. He estimates that 45 per cent of all men who have a sexual problem are impotent.

Stress and depression are also major psychological triggers. The stereotype of the business executive who comes home mentally and physically exhausted. Love in the time of the stopwatch can kill desire. Indeed, as Dr Jitender Nagpal, consultant psychiatrist at Delhi's Vidyasagar Institute of Mental Health, observes, if the romantic aspect of sex goes missing in these hurried times, the quality of the sexual lives of couples will suffer. "They end up being spectators to each others' anguish rather than performers," says Nagpal. There's also an impotence of convenience. Loss of erection in the late 20s and 30s, say psychiatrists, can become a vehicle to express anger and difficulties in a marriage. It could be "situational impotence". "Impotence is definitely a problem where marital conflicts remain unresolved," says Reeni Singh, a family and marital therapist with the Sampark Counselling Centre at Delhi's Modi Hospital. "For instance, if there is tension between the mother-in-law and the daughter-in-law, some husbands tend to become impotent." Add to this the fear of having contracted aids. Typically, after an indiscreet sexual encounter a man may worry so much about picking up the disease that often he is unable to perform later.

What surprises doctors the most is not just the openness about a subject that was once considered taboo, but also who's bringing in the men. Wives often bring their husbands, but now an increasing number of mothers and mothers-in-law are taking their sons and sons-in-law for treatment. "Earlier, barely 5 per cent of women would reluctantly accompany their husbands to a sexologist," says Dr Raj Brahmbhatt, consultant with the Family Planning Association of India, "but today, one in every five ED cases is actually brought in by the wives." Previously, after two children, people were content to kiss their sex lives goodbye. Now, thanks to the media, they're still interested at 60.

So the mamas have also become players. An old woman from rural Punjab actually took her son-in-law to Ludhiana's M.D. Memorial Hospital and did most of the talking to Dr P.P.S. Gill, about how the newly married man was unable to have an erection. In another instance, a mother dragged her 20-year-old son, who had been married just the day before and could not "perform", to urologist Dr Rohit Bhargava. "Mothers even ring up and ask about how the therapy is going," says Bhagat.

What compounds the problem are the various myths surrounding impotency -- most of them deep-rooted and ingrained in society (see box on Exploding Myths). Much of this arises from a simple fact. "For a man," says Brahmbhatt, "his ego lies in his penis." For most men, the guilt of masturbation during adolescence could become a trigger for impotence. It stems from a general ignorance about the subject, lack of proper sex education and a generally conservative society.

As a result, the myths persist. For instance, a lot of people believe that impotence is something one has to accept as part of ageing. Erection, say doctors, has nothing to do with age, at least in the physiological sense. If you retain normal testosterone levels and adequate blood supply, there is no reason why you can't have one even at 60 or 70. "What does change is the attitude to sex and sharing, which often reduces the frequency of erection," says Sharma. In some older men, a lowering of testosterone levels can also create impotence. "You need all the right hormones in the right amounts for sexual desire and erection," says Dr R. Ahlawat, urologist at Apollo Hospital. After 40, most males show hormonal decline, although the rate can vary from person to person. Hormone replacement therapy can work for such people, but doctors warn that in some cases it can lead to prostate cancer.

For Vivek Nair it wasn't as simple as hormones. Defective vessels restricting blood flow to his penis had made the 27-year-old teacher impotent. Nair despaired over the fact that he could never have a normal sex life until he reached the right doctor. A surgical implant solved his problem. Today, diagnosis is fast, decisions for the kind of treatment regime are taken quickly, and within days the patient is normal. Such implants are just one of the many options available for treating physical impotence. And each one has its merits and demerits. Sharma of Alpha One explains, "The most sophisticated implant enables a patient to manipulate the timing and duration of the erection by just pressing a synthetic sac placed in his scrotum." This regulates the flow of a saline solution into the two cylinders of the prostheses and erection takes place. Of course, this treatment is not always affordable as it can cost anywhere between Rs 1.75 lakh and Rs 2 lakh.

Which is why doctors have long been hoping for an oral drug that can cure impotence. "Can't I just pop a pill and be fine, doctor?" is a question Indian physicians have to answer very often. Recently, the US Food and Drugs Administration cleared a drug called sildenafil, trade name Viagra, developed by the pharmaceutical giant Pfizer, to cure impotence. But it may be months before it is available here, subject to approval by the Drugs Controller of India. More importantly, a dose for a single erection will cost about Rs 500. "We are cautiously optimistic about the drug and its side-effects and potential for misuse would have to be kept in mind," says Sharma. Popping a pill to become potent would be wishful thinking for most Indians, at least for now. Meanwhile, the only way out might be a combination of physiological and psychological therapy. The shrinking world may have some bearing on impotency but it is also part of the cure: already, enterprising men in Mumbai are getting their relatives in the US to send them Viagra, while others are seeking the wonder drug through the Internet. But the ultimate aphrodisiac still remains elusive. Superman will have to wait.

Names of patients have been changed to protect their identities.

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