Impotence.

Gay men have always been open about discussing sex--with other gay men, at least. When it comes to chatting about impotence, however, they maintain an uncharacteristic silence--especially in front of a straight doctor.

"There are not many gay urologists," says Mark Litwin, an assistant professor of urology and public health at the University of California, Los Angeles. "A gay man may be uncomfortable talking about gay sexual issues to a doctor he perceives is not open to his sexuality."

Regardless, some gay men, like some straight men, suffer from impotence. "I'm not sure how many gay men deal with this openly," says Phil (not his real name), a gay man in his 40s who has suffered from impotence for two decades. "I come across a lot of men who clearly have issues, who aren't getting erections or have difficulty with it. I want to say, I know what you're going through."

When Phil goes out on a date, he takes along a needle filled with a vasodilator, a new drug that in ten to 15 minutes produces an erection that can last up to several hours. Usually he injects the drug in private, out of sight of his partner. "It's awkward filling up these insulin needles, carrying that with you, and being prepared to inject yourself," he says. "But I still prefer that over being flaccid."

Phil sought help, but it didn't come easy. At the university hospital where he went for treatment, he was counseled before being given the drug. "They clearly had been dealing with married couples," he says. "I lied and told them I had an ongoing partner, because to them the whole issue of sex with anonymous people was not something they could deal with. I'm not sure they would have let me have the injections if I had told the truth."

Phil's fears are not unfounded. Litwin says that patients suffering from HIV-related impotence are all too often turned down for testosterone therapy. "I can tell you plenty of horror stories of urologists telling patients, `You have HIV, so you shouldn't be having sex anyway,'" Litwin says. "That's sad, not the least because your relationship with your partner is a source of solace for people with HIV. It's far beyond our purview as physicians to decide who is worthy of getting erections."

Fear of such judgmental reactions--or just plain old embarrassment--prevents many gay men from discussing their impotence, so they suffer in silence. "When you think about it, it's about virility and manhood," says Gary Cohan, an openly gay physician at Pacific Oaks Medical Group in Los Angeles. Compounding the problem is the emphasis on potency in many gay erotic images. (Yet even the most fabled erotic images may not be what they seem. According to one source, the use of vasodilators is common in the gay porn industry.)

Litwin says there's no reason to live in frustration. "It's unfortunate because there are so many wonderful treatments available nowadays. Ten years ago the only thing we could recommend was a psychiatrist or a penile implant."

Still, says Phil, vasodilators are not exactly the wonders some might think. While the drugs produce an erection, they do not fan excitement. "It has nothing to do with desire for the other person," he says. Moreover, the resulting erection is so hard that it can be uncomfortable. Once, Phil had to have his penis drained because the erection was so prolonged as to become dangerous, a possible side effect of vasodilators.

Yet, says Phil, the drug is worth the inconvenience. "After that first lover, from about the time I was 21 to my late 30s, I didn't have many sexual partners at all," he says. "I didn't have much sex whatsoever because I felt embarrassed when I wouldn't get an erection. I was quite depressed about the whole thing."

The organic causes of impotence range from poor arterial flow to low testosterone levels, the latter a common problem among men with HIV. Impotence can also be a side effect of drug use. "We're in the middle of a speed epidemic," notes Ron Stall, an epidemiologist at the Center for AIDS Prevention Sciences at the University of California, San Francisco. "Guys who use speed a lot and over a long period of time can have a hard time getting it up."

Often, however, the problem has a psychological component. "The younger the patient, the more it is related to factors that are nonphysical," says Litwin. "If there is any stress or anxiety in the system, that trumps any erection."