Why erectile dysfunction? Why now? One index of recent preoccupation with erectile dysfunction is the increased number of television and other ads by the pharmaceutical industry.

Changes in public attitudes allow for near-blanket advertising of remedies for this condition that in previous years would not be acceptable to media gatekeepers or good manners. Either there are indeed millions of men with this problem, or the drug companies are mistaken about how many men suffer from the problem.

It would be wrong to assume that the recent sweep of erectile dysfunction ads means there is some corresponding rapid increase in the disorder itself. However, our greater willingness to talk about it can have the benefit of bringing to light some of the less obvious causes for the condition.

An important idea to keep in mind about impotence is that there are primarily physiological causes for some men, but psychological explanations in other cases.

A given patient may have a condition with both aspects, yet actually benefit more from a treatment plan by a psychiatrist than a urologist.

It's time we spoke

The Mayo Clinic lists "depression, anxiety or other mental health conditions, stress, relationship problems due to stress, poor communication" as causes for erectile dysfunction. Patients may or may or may not be aware of the role such emotional issues may be playing.

Even if they sense psychological problems are a factor, talking about it to a doctor can be awkward.

Figuring out whether the problem is more psychological and emotional rather than vascular or "mechanical" may require the consulting physician to ask very personal, intimate questions.

Some men may be more comfortable thinking about their condition as a medical problem mostly involving blood pressure and stamina.

After reviewing the patient's medical history and basic physiological variables such as weight, heart rate and blood pressure, the consulting physician may suspect the fundamental problem is psychosexual or emotional.

Getting some men to open up about this can be a tricky business, and the more diverse nature of 21st Century populations can require doctors to be sensitive to a whole range of issues.

Some men will have a background in cultures that do not encourage them to divulge intimate sexual information. However, a dispassionate, clinical chat that begins with physiological rather than emotional themes could be a gentle way to eventually broach sensitive topics.

The impotence issue can be explored gradually, perhaps after general physical and emotional health issues have been explored.

There could be a role for group therapy as well. Tamara Melnick, Ph.D, and colleagues reviewed a series of studies about treating erectile dysfunction and concluded "there was evidence that group psychotherapy may improve erectile function."

Men with this problem will want to explore whether talking about their problems in a group setting, possibly in conjunction with medication, will help.

When the real reasons for impotence are not easy to divulge or even know

Men with impotence issues will need to balance considering how their physical health might affect erectile dysfunction, but should consider the possibility that the real problems lay elsewhere.

The reason for lack of getting or maintaining an erection, or for a lack of desire at all, could have everything to do with economic, family, relationship, parenting or self-esteem issues.

Some men may find themselves preferring to explain erection difficulties as stemming from primarily physiological causes; for instance, recent weight gain, recovering from illness, lower back pain or other common health concerns.

Clinicians will over time develop intuition about the respective role that physiological causes have compared to "life issues" in their patient's situations. Oftentimes there is no easy separation. Complicating matters is the lack of knowledge men may possess about their own bodies, emotions and sexuality.

The complexity of these issues may not lend themselves to a fast-food type approach where the patient walks out with a prescription for the latest ED drug.

Doctors have to be shrewd in assessing whether financial pressures, conflicts with one's partner, or coping with the death of a loved one and other intimate "existential" issues are causing the problem.  The possible contribution of such factors can be drawn out, given time and trust.

Time pressures can work against exploring the emotional side of impotence

Real tact and skill are called for here. The all-too-brief availability of the modern physician may create time pressure to not explore deeper emotional problems and just prescribe drugs after a fifteen minute consult.

Patients need to be their own advocates though, and this kind of short interaction might not allow for deeper issues to be raised.