Sex & Relationships

Boner in a Bottle: The Plusses and Pitfalls of ED Drugs

From a biological point, Viagra works best if you really need it. The pharmaceutical companies don’t like to say this -- naturally, they want you to think every man needs it.

After a couple of glasses of Dewar’s the other day, my next-door neighbor, who’s 41, leaned my way and out of the blue started gushing about Cialis. We’d been talking about basketball, and suddenly, bingo, Tony was off and running, weaving and bobbing, describing the nonstop sex he had had for 36 hours. Meanwhile, Sandra, his wife, the woman he presumably had the sex with, was chatting up my wife in the kitchen 20 feet away about the neighborhood real estate market, as our three kids were killing each other in the bedroom, playing Nintendo.

Tony seemed to be in an extreme state of post-coital bliss. He kept crowing about the best sex he’d ever had. And the thing about Tony is, he and I never talk anything personal. Tony, I think, needed to proclaim what Cialis had done for him, for his wife, for the whole world.

Chalk it up to a newfound sense that men can and should have great sex for the rest of our lives. Call it our national erection, a god-given mandate that the trio of ED drugs out there -- Viagra, Levitra, and Cialis -- were placed on earth to bring peace and goodwill to our horny world.

Tony, mind you, is a serious sports guy. I doubt he’s ever asked for salad dressing on the side. Nor has he ever ironed a shirt, consumed an asparagus spear, or entertained thoughts of enrolling in a Bikram Yoga class.

But as word of the power of ED (erectile dysfunction) drugs spreads, even the most macho of our brothers is taking these sex pharmaceuticals for a spin and then boasting to anyone who’ll listen. Chalk it up to the New New-Age Guy.

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ED drugs are for the worried well. They’re accessories to modern life. Like Starbucks and digital cable. Starbucks sells high-priced caffeine by the vente and we gladly pay for it. Verizon FiOS gives us TV on our terms. Plastic surgery shapes and contours everything from noses and breasts to bellies to glutes. So why should ED drugs be any different? Aren’t they what life in the 21st century is all about? Sex -- how we want it and when we want it. It’s what we deserve. Even though we might not need these drugs, they sure make us feel good.

Everyone seems to have an ED-drug favorite -- sort of like beer (Miller vs. Bud) or trucks (Chevy vs. Ford). And maybe like with beer and trucks, these pills seem to work so well that many men don’t want to go without. To many guys in their mid-40s and older, the pharmaceutical ménage a trois is pretty much a rock-solid insurance policy against penile deflation due to age, anxiety, smoking (which constricts blood flow), diabetes, sleep deprivation, even (some say), alcohol and marijuana.

The Big Three are also touted to perk up limp members nailed by anti-depressants. Men who take drugs for stomach ulcers, high cholesterol, coronary artery disease, and high blood pressure (particularly diuretics) often have problems getting erections, but drug-makers say these penis-uppers can cure even the droopiest of dog tails. And if premature ejaculation hounds you, studies show these drugs can make you last longer. There’s more: Urologists say these pharmaceuticals can shorten the so-called refractory period, so you can come back sooner for more.

Where’d these powerful, popular drugs come from and how’d they jumpstart such a national craze?

Remember way back in 1998, when Viagra was launched as the world’s first drug to help get an erection? Viagra’s TV huckster was none other than 75-year-old Bob Dole, who broke all kinds of taboos by lecturing to millions of Americans that he was impotent from prostate cancer and that Viagra helped him have sex again. The image of Bob Dole having sex was bad enough, but the mention of impotence -- what man out there wanted to cop to that?

In the annals of ad history, that first Viagra commercial is right up there with the Energizer Bunny. “That ad was all about introducing ED (erectile dysfunction) to the public, and selling ED,” says Meika Loe, the author of The Rise of Viagra: How the Little Blue Pill Changed Sex in America.

It didn’t take the marketing geniuses at Pfizer Inc., which makes Viagra, long to get smart. They changed the pill’s raison d’etre from impotence to a condition they popularized -- ED. Forever banish that horrible word, impotence. The ad was “was effective marketing -- it taught the public to think that sexual problems are no longer severe, shameful, and rare -- but they are more common,” says Loe.

Above all, Pfizer sought to keep it simple: ED. Mention erectile dysfunction when and only when the FDA required it. The idea was to make two letters, ED, as popular as OK. Got it?

But there was more to firing up Viagra. Bob Dole had to go. How often does a 75-year-old guy want to have sex, anyway? More importantly (at least from the drug companies’ perspective): How many years did Bob Dole have left to buy drugs? Not to be left out of the equation: The image of Bob and Elizabeth Dole having sex. Talk about turn-offs, even if you’re a Republican.

Bob Dole was just too old to be the poster boy for a drug that could turn a limp penis into one you could spin plates with. If Pfizer was going to recoup the millions it had invested in its diamond-shaped blue pill, it would have to attract a much younger and more diverse customer, says Loe, who teaches medical sociology at Colgate University. The younger the buyer, the more sex he’s probably getting (or at least hoping he’s getting), and the more years he’d have to buy the pills. Provided that the drug works and works well, Pfizer could have on its corporate hands satisfied customers who’d be popping Viagra for the rest of their lives. Everyone wins: horny guys getting more than they ever expected and contented stockholders clucking atop growing nest eggs.

Besides the pill popper’s age, the ads changed other pre-conceived notions of who should be taking these penis risers. Loe notes that the ads subtly expanded the pharmaceutical’s market base. All kinds of ethnic men began touting Viagra, from letter carriers, to athletes, to a man in a wheelchair, so the message was that not just aging, wealthy white men have ED. The strategy went further, leaving ED in the dust and shifting from a medical reason for taking Viagra to simply taking it to improve your lifestyle, your masculinity, your sex life, and therefore your relationships.

The idea transformation was thus complete: An erection in a bottle for everyone -- including the women we love.

Witness today’s ads and commercials. The guys pimping ED drugs look in their mid-thirties, busily throwing footballs (swish!) through tire swings. And the woman, they’re a long way, baby, from Elizabeth Dole. These women have sly, come-hither smiles that say, “C’mon, sweetheart, I’m all yours, whenever you want (it).” They might be talking about “a quality experience when the time is right,” but the subtext is more like, “My man and I are animals in the sack!”

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Levitra (made by GlaxoSmithKline and Bayer) and Cialis (from Eli Lilly & Co. and Icos Corp.) were introduced in late 2003, but both are coming on strong. Hard stats are difficult to come by, since there are so many free samples out there, and many men fill a prescription or two, then stop using the drugs or use them irregularly (50 percent of Viagra prescriptions are not refilled); black-market, Internet, and counterfeit sales of ED drugs are, by nature, unregulated. Thus far, though, Viagra is still the market leader with a little less than 50 percent of the worldwide market, followed by Cialis (40 percent) and Levitra (10 percent).

The drugs are the latest sex toys for men in their middle years, increasingly popular among men (and even some women) ages 18 to 45. That’s why 39-year-old homerun king Rafael Palmeiro and racecar driver Mark “Start your engines” Martin were spokesmen for two of the drugs. That’s why Viagra, Levitra, and Cialis ads are everywhere there are men -- from NFL, NBA, NHL, and Major League Baseball games to PGA tournaments, the America’s Cup in sailing, and NASCAR races.

The surging popularity of ED drugs has changed how men and women look at aging, sexuality, masculinity, femininity, marriage, dating, and relationships. They also have had a profound effect in how we talk (or don’t talk) to each other.

Take the fidgety guy not used to dating, perhaps coming off a divorce, who worries that he won’t be able to get an erection. Or the guy who the moment his girlfriend suggests he wear a condom, his erection goes poof. Many men who pop these penis boosters don’t want to cop to any pharmaceutical intervention. Why ruin the mystique? Talk about impressing your new girlfriend with news that it was a pill -- not she -- that transformed your shrimpy penis into a pulsating pole. Then there’s the issue of what happens when a guy decides to go cold turkey after several amazing lovemaking sessions. Imagine this scenario:

She (suspiciously): “Hey, what happened to you last night?

He (sputtering): “Whaddayamean?”

She (getting up to leave): “All my girlfriends were waiting in line to take a whirl with you. But now I realize you’re just like my husband!”

Which brings up the real issue of psychological dependence. “If a guy takes one of these pills and after sex the woman says, ‘Wow, that was great!’ what’s the guy going to do the next time?” asks Abraham Morgentaler, a Boston urologist and author of The Viagra Myth: The Surprising Impact on Love and Relationships. “Those four words might be the most dangerous four words a man can ever hear.”

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The conundrum here is that while many middle-aged men might not need the drugs, the lovemakingcan be better with them, says Morgentaler and Ira Sharlip, a spokesman for the American Urological Association. The reason? Because men are freed from worry that their erections might fail, they slow down, become more confident, spend more time on their partners’ needs, all the while prolonging sex. So, the drugs finally (the one woman who’s reading this article is now saying) allow men to spend more time on foreplay, and in turn, can transform an ordinary lover into a Caring Sensitive Man who’s also a Major Stud. With the issue of keeping it up out of the way, the pills can allow a man to be more natural (some irony, huh?) in terms of communicating, pleasuring his partner, and radiating a greater sense of ease during sex.

“When sex is restored in a relationship, it’s a marvelous thing,” says Morgentaler, a clinical associate professor of urology at Harvard Medical School. “These drugs, under the best of circumstances, can restore a whole array of relationship issues that stem from the man feeling incomplete because of the possibility of ED.”

The three drugs are slightly different, even though they ultimately aim to do the same thing. They do not replace desire, so if you pop a pill, don’t worry about getting an erection looking at sheep, fine-leather boots, or your mother-in-law (unless you have sexual desire for any of them). Viagra can take an hour to kick in, and for some men, it will not work on a full stomach (ditch the romantic candlelight dinner). In exceedingly rare cases, men who take Viagra have reported that for a while they see the world with a bluish tint. (Great. My fantasy: making love to a blue-eyed woman with blue nipples.) Each of the drugs can cause flushing since the pills are vasodilators, which means they open up your arteries and send blood coursing through them. If you take nitrates (for instance, nitroglycerin) for angina, then you should not mix them with any of the penis-hardening agents.

Levitra claims to work faster than Viagra, in as little as 15 minutes, but like the two others drugs, can cause headaches (“Sorry dear, I have a headache and an erection”). Viagra and Levitra say their effects last four hours, but on occasion, men report results for up to 12 hours. Cialis doesn’t start working for an hour, but once it kicks in, the manufacturer says it’ll keep working for 36 hours, so even after you ejaculate, many men stay hard for more rounds.

The correct dosage is up for grabs. Most urologists suggest first experimenting with the smallest first. Since all doses, from the smallest to the largest, of the drugs cost about the same, many cost-conscious users get the highest dose and then crack the pills (and for that reason, the manufacturers make all three drugs very difficult to split) and save the other halves for another spin. You don’t have to go to a urologist for samples; drug reps leave millions of samples with internists, general practitioners, probably even your wife or girlfriend’s OB-GYN.

Last year, 40 percent of the ED pills men took were free samples, researchers estimate. The drug makers’ latest beef is that men are asking their physicians for samples, and when the sample packs are used up, the men don’t fill the prescriptions (that’s the drug companies’ problem, not ours). Some insurance providers pick up the drugs’ tab, some don’t. Out of pocket, the drugs average about $12 per pill from the corner pharmacy (depending on quantity), and less over the Internet (but beware of cyberspace rip-offs).

Apart from the terrifying image of calling your doctor at 3 a.m. to report that your erection won’t go away (which is really exceedingly rare, and if it happens, a bucket of ice works great), the obvious downside is whether your partner wants to get intimate as often as you probably will. The drugs have led to changing how aging men and women view their roles as partners and the necessity of sex to ensure continued affection toward each other.

Because it (usually) takes two to have sex, a new kind of casualty post-ED drugs is now known as the Viagra Wife. While not yet in the Oxford English Dictionary, this is an increasingly common malady showing up at neighborhood canasta games and in divorce courts -- aging wives accustomed and satisfied, thank you, with their naturally ebbing desire, now confronted with husbands raring to hop in the sack after Jeopardy every night. And if not with their wives, then with the woman who lives around the corner. No wonder wives (and the neighbor lady) are sore.

The Viagra Wife is far from a media invention, but very real and often very angry these days, says Lonnie Barbach, a San Francisco therapist and author of Going the Distance: Finding and Keeping Lifelong Love. “Some women in their fifties stopped having sex a while ago. They may have lost their sexual urge because of menopause, because of aging, because of a host of reasons. And now a guy says out of the blue, ‘I want to have sex!”’

Excuse me?” is often her bewildered response, says Barbach.

The issues here are complex, but Barbach says that for many men a diminution of sex leading to infrequent or nonexistent lovemaking, often translates to a lack of touching between partners. “The guy might say, ‘Don’t touch me, don’t excite me,’ so as a women you pull back.” This becomes a pattern until the man comes home with a pack of Viagra tabs, pops one, gets an erection, and says, “Let’s go!”

It may or may not come as a surprise that the three ED pharmaceuticals have become the recreational drugs of choice among hard-partying college dudes, who might cop the drugs from their fathers’ medicine cabinet. But physicians say men in their 20s and 30s don’t need an assist in the first place. Like youth, these drugs are wasted on the young.

But who can blame guys out there seeking something to help them in the sack? The strange alliance of the Women’s Movement, the Cosmogirl, Sex in the City, Desperate Housewives, and Paris Hilton may share responsibility in prompting the New Woman to have demanded a higher level of sexual performance from her partner. Some women have come to expect a sexual athlete in bed. So what’s a mildly neurotic guy to do other than pop a pill to get an invitation back?

Barbach and Morgantaler say they have heard loads of tales from their patients of this new breed of Female Sexual Predator. So have I. One of my wife’s friends is Jennifer, a 34-year-old attorney, who makes no effort to hide her weekend bar crawls in search of “boy toys,” as she calls them. Jenn is not shy about discussing size, duration, and stamina. “Some women, especially younger women, are looking at the performance issue rather than creating a relationship,” says Barbach. “They want to try different things, they want to experiment.”

This is a problem?

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Before you rush off to your physician for a free sample package, slick back your hair, and go trolling for Female Sexual Predators, you should know there are several things that these drugs won’t do.

The drugs won’t initiate an erection on its own. They will do absolutely nothing for a normal, healthy young man. No way will they make an erection larger or longer than it’s been in the past. Your penis is your penis, usually till death do you part. Learn to accept it, care for it, pay attention to it.

That’s Long Island therapist Joel D. Block’s advice. “When you’re young, it might not be a good idea to listen to your penis. But as you get older, the penis has a lot of wisdom. The penis talks to you. If you do take a pill, take it temporarily -- until you work out the situation that is causing you to take it in the first place. From a biological point, Viagra works -- but it works best if you really need it. The pharmaceutical companies don’t like to say this. They want every man to think the drug will make him into a stud -- or that every man needs it. You very well might get a little boost with the drug. Will the sex be necessarily better? It might. It might not.”

For now, there’s Viagra, Levitra, and Cialis to choose from, but others assists may be on their way. In Europe, you can buy Uprima, manufactured by TAP Pharmaceuticals, designed to be taken under the tongue for very fast action (15 minutes or less). Uprima functions differently from the trio of ED drugs in that it doesn’t work on the hydraulics of an erection. Instead, it sends signals to the brain, which in turn, transmit impulses to your penis to begin to process of building an erection. The drug gets mixed reviews from American urologists and the FDA, and it’s unlikely to be available in the U.S., but can be purchased over the Internet.

Then there’s always the old standby, the herb yohimbe, made from bark of a West African tree, but you have to take it three times a day for at least a month (talk about spontaneity), and even then, only 15 percent of users say it works. One of the side effects is sweaty palms. No wonder. You’re so uptight after not having sex for so long that you start sweating whenever a woman looks your way.

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The fact is that Americans today expect drugs to cure everything, so why not a remedy for a drooping dong? Pharmaceuticals have become part of our culture, whether it be Ritalin for our kids, Lipitor or Zocar for our hearts, Prozac for our depression, Ambien for our sleeplessness, Flonase for our sinuses, Ativan for our nerves, Prevacid for our heartburn. This, of course, is what drug companies want: that we buy and buy often. With ED drugs, it’s certainly easy enough.

Viagra samples come in six-packs (just like beer and abs -- two other models of American machismo). Even the names of the drug trio are not-so-subtle reminders of pleasures to come. Viagra sounds like Niagara -- a never-ending, powerful release of liquid. Levitra sounds like levitate (as in, to rise); le is the masculine pronoun and vie means life in French. Levitra reminds me of a Parisian bar where you walk in and within 10 minutes you’re having sex on the bathroom floor with a French chick who doesn’t shave under her arms, but is drop-dead gorgeous. I haven’t figured out Cialis yet, except that it’s pronounced “See Alice,” although I’m afraid to ask who Alice is or what she wants, even though I know she doesn’t live here any longer.

So do you pop one or not? It’s not a safety issue for most men out there; physicians agree the pills pose little health risk. What’s a guy to do? Do you buy into Mike Ditka’s macho challenge or that fetching brunette with the great eyes urging you to “stay in the game”?

Joel D. Bloch, the author of Sex Over 50andSecrets of Better Sex, takes the middle road. “I don’t have an issue with experimenting with Viagra or the other ED drugs. I’m not against using them on occasion. I’m against relying on them or demeaning yourself by believing you absolutely need them to function. Again, some men do, but fewer than the medical community would have you believe.”

But Tony, can you keep down the racket? Do you have to wake up the whole neighborhood every night?

A version of this story first appeared in the Sunday Chicago Tribune.

Stephen G. Bloom, a professor of journalism at the University of Iowa, is the author of Postville: A Clash of Cultures in Heartland America, Inside the Writer's Mind, The Oxford Project (with Peter Feldstein), and Tears of Mermaids: The Secret Story of Pearls.