Viagra Falls: Talking Impotence in the Age of Zippergate

What do you think would be the bigger scandal: (1) Bill Clinton admits having sex with a 21-year-old intern, or (2) Bill Clinton admits that he is impotent? Not that he would likely admit to having ED -- Erectile Dysfunction -- as impotence is now officially called. Experts say there are as many as 20 million men in the U.S. and 140 million across the globe with ED. One study in Massachusetts found that half of all men between 40 and 70 have problems with erections. Astonishingly, and depressingly, less than 10 percent of impotent men in this country ever seek help for this condition. For most, it is better to just not talk about it.In fact, the fear of raising the subject of ED runs so deep that NBC rejected as inappropriate an advertisement for the new impotence drug Muse, which was to be shown during the Super Bowl. Instead, the network put on the air striking Nike ads of athletes appearing powerful, sexy and nude. DENIAL ABOUT IMPOTENCE IS ABOUT TO CHANGE Into this situation of "head in the sand" attitudes, failures to communicate, and fear and shame, arrives a potential silver bullet, Viagra, the world's first impotence pill. Seemingly named to associate it with the power of Niagara Falls, Viagra is the most ballyhooed of an array of new drugs (see chart) designed to help men get their penises working -- or working better as he case may be.Viagra is so potentially influential and profitable that stock prices of its owner, Pfizer, doubled in the past year and is up 21 percent in the last two months. Viagra has just been approved by the Food and Drug Administration and will be available the third week in April at wholesale prices of $7 a pill, which should translate to $8.50 or $9 retail. Viagra is one of the new boomer booster drugs, part of the developing area of male medicine -- think Rogaine -- coming to the market as the huge post-war generation's physical capacities begin to fade or break down. The king boomer himself, Bill Clinton, was, after all, just about to hit 50 when he supposodly started mixing it up with Monica Lewinsky. This new medical and drug effort to stay young has experts like author Gail Sheehy shaking their head. "I think we as Americans are already in massive denial about aging," she says. "Baby Boomers simply aren't going to have middle age. They would just refuse it. Never mind old age." The arrival of Viagra and other new drugs raise many more questions than can be answered as many people begin to explore this new sexual frontier. For example, how will the new drugs affect the quality of relationships? Problematic sexual performance is difficult to discuss, and taking a pill without expanding the conversation may not solve the problem. Writes Sheehy: "The lover of an impotent man has a special agony. She may not be able to discuss the problem with him without further deflating his ego. She may feel unfeminine, unwanted, rejected ... A potency pill may be a temporary confidence builder, but couples who have grown apart almost inevitably will need counseling to overcome anxiety and rebuild trust." Another unexplored aspect of Viagra is its potential to increase sexual response among females; there are "hints" that Viagra may also help women who have difficulty with orgasm. Psychiatrist Susan Vaughan writes: "Researchers involved in the trials on men believe that Viagra may increase vaginal lubrication and produce clitoral engorgement -- important preludes to comfortable penetration and reaching orgasm." What about homosexuals? What impact will Viagra and other impotency drugs have in the gay community, where according to Robert Bray, former communication director of the National Gay and Lesbian Task Force, impotence among gay and bisexual men remains deeply closeted. Perhaps most controversial is how Viagra will be used. Writing in the New York Times, David J. Murrow strongly suggests that it will be used "recreationally by baby boomers longing to recapture their youth. What 48-year-old man, after all, would not want to feel like a virile 18-year-old again?"California psychologist Vivian Dent thinks there may very soon be parallels between Prozac and the emerging anti-impotence pills. "Clearly, many more people use anti-depressants than are clinically depressed. These drugs, for some people, make life easier and more productive. But they can be over proscribed as a panacea, which is certainly troubling. With Viagra, I can imagine a man feeling performance anxiety, wanting to impress his lover -- a whole host of motivations -- and he's going to want a sure thing. If Viagra increases the chances of top performance, there will likely be a lot of visits to the doctor complaining of 'situational impotency.'" NEW UNDERSTANDINGS OF IMPOTENCYThere is no question that Viagra, Muse ( a drug already on the market which involves placing a tiny, rice sized pellet in the urethra) and other new drugs can have a revolutionary impact. Heretofore, men were embarrassed by their failures or came to the conclusion that impotence was simply the result of aging or surely psychological. These situations are quickly being reassessed because impotence is now considered about 80 percent physical and 20 percent psychological.Physical impotence has many causes, including diabetes, hardening of the arteries and high blood pressure. Prostate surgery can have a devastating impact on potency as well. Often drugs taken to counter other healthy problems contribute to ED. Sexual performance, of course, also is effected by stress and depression, but it is often difficult to grasp whether the cause is organic or emotional. Alcohol in excess affects potency and smoking reduces penile blood flow. Now, as claimed by Viagra testing, physical impotence can be fixed in as many as 70 to 80 percent of men when taken an hour before intercourse, when the taker is sexually stimulated. What obviously makes a drug like Viagra revolutionary is that it's a pill, meaning less discomfort, less embarrassment and no frustration of other ED strategies to combat sexual impotence -- pumps, penile inserts, injections. Getting the ruler out to see how one is measuring up can began as an early teenager and sexual performance has always been the quintessential mark of manhood. As a result, some men have gone to great lengths to make the thing work, often bruising the ego and inflicting pain. Ultimately, these intrusive approaches to solving impotence are one big reason why so many men resisted seeking help. A NEW MARKETING INSPIRED CONVERSATIONIf the fear of talking about impotency can be changed by the media, then the public conversation will definitely be altered. Any recent perusal of national new magazines indicates that a chunk of their advertising revenue is now coming from drug companies. In the media business, big advertising dollars usually mean sympathetic editorial coverage as well, and that is clearly underway. The Super Bowl aside, prepare for an avalanche of advertising for these new impotency drugs. (Some even estimate that drug company advertising will pass the billion dollar mark in 1998.) Many assume the economics of Viagra and other products are clearly connected to stimulating consumer desires. Drug companies are already counting the cash at the prospects of a hugely expanded market. Analysts are suggesting sales of $300 million for Viagra just during the remainder of 1998 and as much as $2-3 billion annually in a couple of years. That's huge bucks despite the $400 million reportedly invested in the development of the drug. Ironically Viagra was discovered by accident when it was used as a drug to treat angina, the chest pains caused by the blocking of bloodvessels that lead to the heart. Though it didn't work, researchers had a challenge getting the drug back and soon found out why: Some of the men in the drug trials were reporting having erections as one of the side effects.But the rosy predictions for Viagra appear connected to recreational use. The New York Times' Murrow quotes David Saks, a senior vice president at Gruntall & Company, predicting that: "80 percent of Viagra's sales will eventually be to men who do not really suffer from regular impotence, but will use it instead to engage in sex more frequently and insure their sexual performance."But the drug companies are covering themselves by insisting that the drugs will not be used recreationally. Joe Feczko, a senior V.P. at Phizer says, "Viagra is not an aphrodisiac. These drugs should only be used by men who are suffering from erectile dysfunction. Men will need prescriptions from their doctor." But what doctor is going to say no if a patient suggests that they are one of the 20 million men who are coming out of the impotence closet. In fact, it's likely that many men will avoid the urologist and use their regular physician for their prescriptions. BOOMER BOOSTERSThe new ED drugs are part of rapid expansion of research and development in male medicine, perhaps symbolizing the fact that male baby boomers are refusing to age sexually and otherwise in the same way as their forefathers. It's a big change for drug companies, which historically invested its research money on chronic and life threatening illnesses. Rogaine has been among the most prominent baby boomer drug. But now, competition is stiff with the full array of impotency drugs (see chart), and the first oral medicine for pattern baldness introduced by Merck and Company in December. In addition, according to the New York Times, Pharmacia and Upjohn -- makers of Rogaine -- will roll out Detrol, the first pill for overactive bladders, early in May. Bristol Myers-Squibb is developing a compound that will eliminate or fade sun spots. Drug companies are also trying to develop drugs to increase one's memory. The drug companies are looking at huge profits as these new products are rolled out. TOO MECHANICAL?The increasing influence of the profit-driven pharmaceutical culture is causing concern. Some are suggesting that the drug company attitude toward impotence, for example, has ignored the complex factors which make up a satisfactory sexual relationship. "The studies have been so mechanical -- is it hard? How big is it? How many seconds does it last?" Dr. Lenore Tiefer, a sex researcher and clinical professor of psychiatry at New York Medical Center told Gina Kolata, science writer for the New York Times. " I think of an erection as a means to an end, something suitable to a couple rather than something you measure in a lab." Sheehy, writing in Newsweek explains: "This is just what men have been searching for over the centuries -- perpetual potency ... This chemical machismo has special appeal to many boomer men performance conscious in every way and obsessed with remaining young. But men face a larger challenge to their virility. Rather than focusing on impotence in isolation, they need to be aware of all the physical and psychological passages of middle and later life. This 'MANopause' is a five- to 12-year period during which men go through hormonal fluctuations, coupled with accelerated physical and psychological changes." Greg Broerick, the Director of the Center for Male Sexual Dysfunction at the University of Pennsylvania adds, "For decades people have gone out of their way looking for a miracle drug. Well, with Viagra, it might soon be in your dad's medicine cabinet. The key here is that it will be a drug for couples."WHAT ABOUT WOMEN?If Viagra is a drug for couples so far in the expensive, aggressive push to make men whole again, women seem to have been relegated to the back seat. What effect will new found sexual prowess have on existing relationships?Psychiatrist Susan Vaughan, writing in Harpers Bazaar, notes that success of the new drug will be driven in part by women, because men will need their encouragement. But that won't come without fear. Vaughan describes the anxiety of a patient of hers , Janine, a 43-year-old women married for 17 years to Bill, 47. "If Viagra turns back the clock for Bill, and he's suddenly virile, sexy and hot to trot again, will he still want to trot with me? But would I rather that he remain impotent? Definitely not." The key role of women in treating impotence can not be ignored, and there is talk of drug companies advertising in women's magazines, encouraging them to encourage their partners.I asked a male friend in San Francisco about Viagra. His reaction: "So you're on this drug and just wailing away ... what does your partner think? 'Is it me, or is it MUSE?' How would you feel if you were with someone and they're really getting off and it's the drug, not you? I think these drugs, if used for other than a clinically diagnosed case of impotence, become a huge compensation for actually learning to talk about sex and desire and trust and love. They could become a temporary bandaid over the monotony of monogamy, which I think is a huge cause of impotence." All the attention showered on Viagra has raised this question: Will new drugs help women's sexual response, too? Since the clitoris is similar to the penis in that it becomes engorged with blood during arousal, logic suggests a an analogy. However, because of the state of sex research, one can only speculate about the effect of Viagra on women. According to Gina Kolata, "for decades the field of sex research has been a scientific backwater. The federal government kept away from sex research and serious investigators considered it career suicide to go into an area that lacked federal financing..." Remember Viagra was discovered as a fluke and scientists then had to go backwards and learn about the biochemistry and biology of erections.Thus scientists know so little little about women's arousal, how to measure it, and sexual function and dysfunction that they are stuck. "Until reseachers solve these problems, Pfizer's plans to test the effects of Viagra on women cannot begin, "Kolata adds., which raises the question of the male priority in this research. It would seem that female sex research is long overdue."In this time of supposedly female sexuality-positive attitudes, why is women's *lack* of pleasure in sex not considered a major (and commercially exploitable) health issue, and men's is?" asks Liza Featherstone, a New York journalist who specializes in sexual trends. "More power to anyone trying to have a better sex life, but I really wonder about definitions. It's interesting to me that words like impotence are not commonly used to describe women's sexual difficulties -- women who don't come or don't get wet ; it's still not even considered a real problem (they can after all, still have sex). Which I think has a lot to do with how invisible women's sexuality still is, except in direct relation to men. It reveals how much the culture is still so much more tolerant of men as pleasure-seeking beings." Kolata suggests that, if anything, sexual problems are more common in women, than men, and as in men, they get more common as women get older. Dr. Raymond Rosen, a sex researcher and professor of psychiatry at the Robert Wood Johnson Medical School suggests that much of women's sexuality remained unknown.: " What is the relationship betwen lack of desire and measure of sexual performance -- lubrication and arousal? Is it that women lose desire and then develop arousal difficulties ,or is it the other way around? " Rosen adds: women may complain about a lack of desire becasue it is more acceptable for them to say that than to say they have difficulty become aroused."Dr. Irwin Goldstein, professor of urology at Boston University School of Medicine who's survey it is which indicated that about half of men aged 40-70 had erection difficulties, thinks men and women have the same problems : a paucity of blood flowing to their sex organs. To check out women's difficulties, he surveyed 300 women whose partners had consulted him about impotence and found that 58 percent of those women were effected by sexual dysfunction including discomfort during intercourse, increased time for arousal, diminished ability to reach orgasm or diminished clitoral sensation."THE GAY COMMUNITYAnother question is whether impotence drugs will be marketed to the gay community, as advertising budgets for drug companies skyrocket. The New York Times thinks so; Morrow, indulging in some stereotypes of the gay community, writes that doctors and analysts expect Viagra to be a big hit because gays are "more comfortable with multiple partners and accustomed to the use of tools to enhance sexual pleasure." But according to Bray, "The only time impotence is addressed is usually in the context of the effect of AIDS drugs on sexual drive. Otherwise, it is a taboo subject even among gay men sensitized to open discussion of sexuality. Get a bunch of gay men together and, like all men, soon enough they'll talk graphically about every topic of sex ... except impotence." Bray continues: "One particular reason is that hyper-masculinity can be a major competitive factor in scoring sex in the gay male community. Images of tough, virile, butch, muscled, hard men are promoted to us by our media and propagated by our porn. We are pressured to conform to those images. A soft penis doesn't fit the picture of masculinity. In addition, impotence connotes aging, a definite disadvantage in a youth-obsessed gay sexual market. The fact is, if you admit to impotence you are seriously jeopardizing your chances of getting a hot date. " A NEW CONVERSATIONIt's certainly ironic that so many have been so titillated by and yakked about Clinton's White House hanky-panky and special prosecutor Kenneth Starr's Orwellian pursuit of the sexual truth, (as if it could ever be found) . But so few really want to talk about the sexual dysfunction of 20 million men.These new anti-impotence drugs are emerging smack in the middle of an unprecedented public conversation about sex, provoked by the hyper-sexualized Clinton-Lewinsky media coverage. Previously unimaginable graphic media coverage has spurred discussions about sex among millions of Americans.But again, is this discussion helpful to better communication? Public interest public relations specialist Jeff Gillenkirk observes: "America is not talking about sex as it exists as an act of love/power/fulfillment/trust/transcendance between consenting human beings, but as a silly, giggly, nervous voyeuristic naughty peek at the president with his pants down. America is incapable of talking about sex without this silliness. It is why the answer to these 20 million men is a pill. No one wants to talk about sex, so we give them a pill. The men don't want to talk to women, or men, or therapists or friends about sex, so we'll give them a pill. "Could this be changing? David Morrow thinks so: "Once a taboo topic, impotency is increasingly an accepted topic of conversation. The Internet has been buzzing ... with men inquiring when the drug would be available. Much of the interest was not limited to men who are dysfunctional. Men were also eagerly swapping news about which treatment they liked best, some of them displaying loyalty as they do with a favorite brand of liquor." But many others aren't so sure. It seems clear that the new impotence drugs have the potential to be of enormous help for many men suffering ED, and potentially for women as well. But how it will affect complex and sensitive relationships remains to be explored.Of course, the other big questions about potential recreational use and abuse remain: What is the line between impotence and uninspired penis performance? If you can guarantee a man that just swallowing a pill an hour or even 20 minutes before love making will deliver maximum performance -- hardness and stamina-wise, how long would it take before many men were taking the stuff on a regular basis. And what would that mean? Tune in, the answers to these and other questions lie ahead. Chart of Anti Impotence DrugsOn the Market:Muse by Vivus, Inc.A soft pellet, no bigger than a grain of rice is inserted -- almost dropped-- into the urethra. Within 10 minutes 80 percent of the alprostadil, a synthetic version if prostaglandin in the pellet, has been absorbed and the penis can get hard. A report in the New England Journal of Medicine says that Muse is 64.9 percent successful. Viagra ( sildenafil) by Phizer Inc.Taken orally, blocks an enzyme found mainly in the penis that breaks down a chemical produced during sexual stimulation. The longer the chemical stays around, the better chance for an erection. (No erection unless sexually stimulated.) available by April.Caverject (alprostadil) by Pharmacia & Upjohn - injected into the penis; positive results in 80 percent of users; takes 10-20 minutes to take effectIn advanced trialsApomorphine by Tap PharmaceuticalWorks completely in the brain. Version under production that dissolves under the tongue and takes 20-30minutes to work. Is said to be 70 percent affective in the psychologically impotent. Company originally aiming for 1999 FDA approval, but may move faster.Vasomax (phentolamine) by Zonagen Inc.Is an oral version of current injection drug that dilates penile blood vessels. takes effect in 15-30 minutes Trials show help of 40 percent of men with moderate impotence. Seeking FDA approval. Alprostadil gel by Macrochem a topical gel which works in 67-75 percent of users and produces response in 15-20 minutes;Invicorp by Senetek PLCAn autoinjectable ED drug in development which is reported to be effective in 81 percent of casesSources: Associated Press from Newsday 10/28/97; PR Newswire 11/10/97; London Times 2/3/98; New York Times 3/31/98