By Thomas Kouo

Male virility is rapidly becoming a popular topic in mainstreamCulture. Viagra and "Smiling Bob" are widely advertised on television, and impotence is no longer an issue too shameful to be discussed by the men it impairs. The abbreviation 'ED' has replaced the unfortunate term 'impotence' as the common name for nearly all sexually- related male health complaints. According to a recent study, "6:30 disease"-or yang-wilt, as it is called in traditional Chinese medicine-was shown to be present to some degree in half of all men over 40.

I was recently approached by a clinical supervisor at the Pacific College of Oriental Medicine's Senior's Clinic, located in downtown San Diego, about a patient who had visited her private practice. She took me aside and asked if I would be willing to treat this patient whose chief complaint was erectile dysfunction. In any of the other clinics where I work such a request would not be out of the ordinary, however, male fertility patients at the senior's Clinic are rarely, if ever, encountered.

The case history was that of a 78- year-old male (I'll call him "Bob") who had undergone multiple groin surgeries, including, it seemed, a penile implant. According to his history, the Viagra Bob had taken had failed to produce an erection. I agreed to try and help Bob, though I was told that his was a complicated case, and to keep my eyes open for nuances and subtleties that may make the case more clear. It was a Monday, and we scheduled him for an appointment the following week.

The patient was 78 years old and impotent, and I found myself pondering the irony of that complaint. Impotence seems like a natural part of the aging process. I started to wonder if I would actually be able to help Bob. What could I do? Then, with one single question, I knew how I was going to approach Bob and his condition. I began to see that the important question to ask was not the what or the how of his impotence, but the why.

We must expand our view of impotence to include the why at the very deepest of levels. It is not enough to address the physical and social ramifications of this condition. We must discover the meaning behind male fertility, its importance, and its place in the male psyche and spirit. Just as pain is a communication from the body that there is a problem or injury, ED can be a communication from the spirit that the man is lost. There was meaning behind this, and I had a feeling that Bob and his condition were going to teach me a great deal about being human.

Evidence of society's evolution is present in nearly every facet of American life. Gender roles have surely evolved. Roles are no longer as clearly defined as when men were the breadwinners and women maintained the household. By today's standards, these out-of-date views of life are considered archaic, and yet I believe that men in general are still holding on to the past. Since we have not truly changed, we are not evolving at the pace of our culture. Men look at women in the workplace and see them in the roles that males have historically occupied themselves. From the positions where men once ruled, they are now looking laterally and upwardly and finding women as their peers and superiors.

Women have spent years struggling for the opportunity to compete on equal playing fields with men in the work arena, and they are now starting\ to crack the ceiling of male-only working hierarchies. Women have earned their way into the breadwinner's circle. Rarely do you see men struggling for opportunities to work in the home. Where does this leave them? They are not quite sure. Who are they? What are they? How does one express a destiny that is not understood? It seems that there is an inverse relationship between the cloudiness of men's gender role and the incidence of reported male impotence. As with most things, this relationship is not an absolute.

There are many facets of male sexual health. The body-mind-spirit paradigm can be the outline that reveals countless factors that warrant consideration. While this can be a source of endless frustration in seeking out the source of pathology, it also gives male virility its resiliency. Biomedicine's main concern is with the physical aspect of male sexual response and offers "Smiling Bob" as its champion. The mental and psycho-spiritual aspects of male fertility are now acknowledged as viable components to male fertility, but few remedies are offered via secular medicine.

In Chinese medicine, the inability to achieve or sustain an erection falls primarily under the influence of the Liver and Kidney organ patterns. The Liver channel courses through the loins, and serves to activate the area and ensure the smooth flow of qi. The functional aspect of the male erection is governed by the Kidney's yang, while Kidney jing (yin) fosters the erection with its purpose of reproduction. In the purest sense, an erection serves the purpose of conception, or the combination of jing that is able to develop into a vessel that is touched by the and can contain shen.

How do we work in reverse to use these affected channels and organs to seek out the source of a man's affliction? If the Kidney and Liver are the primary affected organs and channels, how do these manifest in the totality of being?

Men tend to define themselves by their utility. This is the realm of the Kidneys, specifically the Kidney's yang. Women tend to define themselves more through their relationships as nurturers. This is their yin nature. As men age, their yin declines as a function of diminishing vitality. Yang also declines as a function of age.

Women find that with their yin's prevalence and subsequent decline, the relative amount of yin as compared with yang decreases, leaving them with an unbalanced yin/yang relationship in which yang begins to dominate. This is why women tend to become more like men as they age. Conversely, men feel the decline in yang more than that of their yin since they are so heavily disposed toward yang by nature. This leaves them with a relative yin prevalence, which explains why older men can be so nurturing and lovable.

Destiny, or one's life purpose, is governed by the zhi, which is ruled by the Kidney organ. Although not absolute, like the dao, it is the Grand Ultimate as far as human life is concerned. It is fitting that destiny is governed by the same organ in which the source of all yin and yang resides.

Impotence can be seen as the failure of a man to manifest his destiny. In the past, men knew what their purpose was. They brought home the bacon, they fixed the plumbing, they planted their seed. It then follows that as one's purpose wanes or becomes uncertain, so does the Kidney organ decline, as least to some extent.

Within the Liver organ resides the hun. This can be likened to our connection with heaven. It is the interaction between the hun and po that initiates life. The hun is that part of our nature which we call divine. This divinity (part of the dao), paired with the po (which corrupts the hun), delineates our lifespan, and that is what offers us infinite possibilities. Likewise, the smooth flow of qi and blood is what allows the human body, mind, and spirit to operate at an optimal level.

Impotence can be seen as a function of a man's inability to get in touch with heaven. As man retreats into himself, he fails to see the greater power that gives spark to his destiny (Kidney), which is put into action through the desire and passion provided through the shen (Heart). Perhaps a change in perspective can help to offer balance for men as we relate to ourselves and to our place in the universe.

As I met with and listened to Bob, I thought about how his ability to achieve an erection would change his life. I asked him how long his condition had been present and what he expected from acupuncture. He claimed that he had no expectations from acupuncture, but wanted to get back the part of his life that had been missing for so long. I listened to Bob and looked into his eyes. His plea's underlying message was all but hidden, though present in a small, glistening spark in the corner of his eye. He wanted to feel like a man again.

Following our intake, I diagnosed Bob with a wood/earth disharmony with damp-phlegm confounding the three jiao qi dynamic, qi and blood stagnation in the lower jiao, and an underlying Kidney organ deficiency. I initially treated him with the following points: Ling Gu, Da Bai, Yin Tang, Zhongwan Ren-12, Qihai Ren-6, Guanyuan Ren-4, Huiyin Ren-1, Sanyinjiao SP-6, Rangu KD-2, Baihui Du-20, and Fenglong ST-40.

Electrical stimulation was performed with Guanyuan Ren-4 connected to Sanyinjiao SP-6 on the right leg, and Huiyin Ren-1 connected to Rangu KD-2 on the left leg. Ling Gu, Da Bai, and Fenglong ST-40 were needled bilaterally. The electrical stimulation was done for 20 minutes at a moderate level measured by patient verbal response. Total needle retention time was 25 minutes.

My rationale was to help his body regain its strength and functioning, I sought to harmonize the dynamic between the three jiao. I also wanted to strongly move qi and blood while gently tonifying to minimize the damage. On a spiritual level, I sought to address heaven, earth, and man to facilitate communication between the three and to ease the pathway for heaven's will and earth's nurturing into man's expression. I chose Ling Gu, Da Bai, Yin Tang, Zhongwan Ren-12, and Qihai Ren-6 in order to do this.

One of the major obstacles evident in Bob was the presence of phlegmdamp. I chose Fenglong ST-40 to address this phlegm-damp, as well as to open the chest and relieve the Pericardium organ. I hoped that by opening this thoroughfare the Heart and Kidney organs would be able to reestablish communication, serving to stabilize the shao-yin axis, and (if I may be excused for a rather crude metaphor) to provide the "spark" to his plug.

I chose to address the impotence directly with Guanyuan Ren-4, Huiyin Ren-1, Sanyinjiao SP-6, and Rangu KD-2.

I chose Sanyinjiao SP-6 because it is the intersecting point of the three yin channels of the leg (the Spleen, Liver, and Kidney channels). It also moves Liver qi, treats sinking of central qi, and controls the external genitalia. I chose Rangu KD-2 since it is the fire point of the Kidney channel. The direction of fire is upwards and Kidney yang can be supplemented through its fire point. Bob reported no improvement with his ED, but he did experience a marked increase in energy and his ease of physical activity.

At the supervisor's request, the treatment was modified for the following visit to specifically omit Sanyinjiao SP-6. I chose Guanyuan Ren-4, Huiyin Ren-1, Fenglong ST-40, Shaofu HE-8, and Taichong LIV-3. Electrical stimulation was performed in the same manner as before, connecting Guanyuan Ren-4 and Huiyin Ren-1. All points not of the Ren vessel were needled bilaterally. Bob reported no improvement in his ED but claimed to experience an increased feeling of well-being following the treatment.

To date, Bob has undergone two treatments using the same point prescription, and will continue until he has had five treatments using the same protocol, with minor adjustments. After this initial period, a complete assessment will be performed with a possible change in treatment strategy depending on Bob's progress and presentation.

Thus far, he has reported no change in his ED since the onset of treatment. Despite this, he has remained hopeful and compliant with his treatments. His positive attitude and optimistic outlook provide him a better chance to overcome the circumstances that are causing his ED. Perhaps hope is all that we will sit with in the end, all things considered- not a bad place to be. OM