At this point there is still a lot of controversy over the exact role of testosterone in producing a normal erection, but it's rather clear that it does have the major role in providing for normal sexual desire and sex drive. Clearly, in the definition of impotence, the degree of difficulty or dissatisfaction with one's erection is in the eye of the beholder, or at least in the mind of the beholder. The only thing I could tell him was that he must be much more Americanized than he realized because his sexual function was in line with most American males over thirty years of age. He was in excellent medical condition and had no evidence of any underlying medical problem to cause any physical problems. His primary complaint was that he could only have one ejaculation per evening and once he had an ejaculation, he had tremendous difficulty obtaining another erection that evening.

On further questioning, I found that he had recently married an American woman and they were very happy in their marriage except for his obvious disappointment with his ability to perform in the bedroom. I'm reminded of an; Iranian patient who came to see me about two years ago very distraught over his inability to have "normal" erections. In some Middle East countries men are expected to perform with multiple orgasms and multiple erections in one evening. This definition always reminds me of the variability in different cultures around the world as to the sexual prowess expected of the male. Obviously, what might be satisfactory erections for one individual might cause a major problem for another. Urologists currently define impotence as the inability to initiate and maintain an erection adequate for normal intercourse. The urological community refers to impotence as erectile dysfunction, and in this work the two terms are used interchangeably. These individuals may have absolutely no problem achieving an erection, but just no desire to do so. On the other hand, patients experiencing significant depression, from whatever causes, invariably will complain of the loss of sex drive. Sometimes this is a natural process of aging.