the `magic bullet’
The first thing to know about Viagra, the little blue erection pill, is that every man alive can recall at least one occasion when they’d have really liked to pop one. The second thing to know is that if you don’t believe the first thing, you soon will.
Viagra is expected to be licensed for use in South Africa in about three months’ time. For those in the dark about men’s penile fragility, the hunger for Viagra will turn on the lights. But the estimated three to five million South African men who are more than passingly familiar with the bleak, isolating misery caused by persistent impotence, or “erectile dysfunction” to use its formal title, surely already know that tumescence, sweet tumescence, may be just a few weeks and a precious prescription slip away.
If demand for the “blue diamonds” is anything like it has been in the United States, the queues will stretch into the streets. Following its launch in April, Viagramania seized the nation. In mid- May prescription rates topped 300 000 a week, eclipsing even those of the fabled anti-depressant, Prozac. Rhetoric inspired by Viagra has had a born again quality, as if God himself had raised the American penis proudly to the top of the sexual flagpole.
One satisfied Viagra-user, quoted in Time magazine, described the 100mg, maximum-strength dosage as “absolutely incredible – the effect lasts through the following morning! What else can one say but `Vrooom!’ Cheap gas, strong economy, erection pills. What a country! What a time to be alive!”
The lust for the drug seems to have blurred competing shades of American moral opinion in a great, public shedding of male inadequacy, guilt and shame. Among those who’ve “come out” to share the good news about their new lives with Viagra are Robert Dole, the crusty old Republican ex-presidential candidate, and Hugh Hefner, the veteran publisher of Playboy magazine. From the younger generation, comic actor Jim Carrey has attributed his renewed marital bliss to the “magic bullet”.
But when the drug arrives in South Africa it will face several difficulties. Foremost of these is likely to be its cost. A single pill is being sold for between $12 and $15 in the US. And medical aids are unlikely to pay for the tablet.
In Britain, debates are already raging over who will foot the bill for Viagra. The drain on its National Health Service (NHS) drugs bill could be enormous – perhaps 1-billion, when the total annual budget for all drugs is around 5-billion. It will force difficult decisions on British health authorities, which will have to assess how much of the stuff they can afford and what other drugs they’ll have to ration in order to afford it.
The result may be that in some parts of the country Viagra will be more easily obtainable, creating fears about angry patients not wanting to hear the word “no”, and even of black markets – an Italian imitation is reported to have already appeared.
The men who hope Viagra is their saviour see things differently. How many there actually are is difficult to say, partly because many sufferers will not have identified themselves before. There remains every incentive for men to keep their problem to themselves, perhaps the strongest argument for the disorder’s seriousness. In a culture which sets such store by masculine “performance”, admitting to impotence, even to a doctor, can be more than just embarrassing: it can feel like an admission of complete masculine failure.
Reticence is heightened by the unappealing nature of existing treatments. Penises are coaxed upright through the use of vacuum pumps, implants and, most shuddersome of all, drugs injected directly into the base. Even the most recent, the insertion of a gel pellet called Muse into the bladder, compares badly with the promised blessings of Viagra. You just swallow it. One hour later the chemicals are in position, but the penis does not leap straight to artificial attention.
Instead, the pill’s effects are activated by erotic arousal: whatever turns you on is meant to turn the drug on too. Around 70% of clinical trialists reported firmer, longer-lasting erections, and many users report stronger orgasms and quicker recovery from earlier ones. There are side- effects – headaches, flushes, upset stomach and a blue tinge to vision – but these are not severe enough to prevent it getting a South African licence. Nor, at least initially, will they put too many men off.
Yet the Viagra phenomenon is about a great deal more than providing suffering men with the erections of their dreams. It is also about decidedly unsexy subjects like the skills and responsibilities of health care professionals. It is, too, about the many complex and often troubling issues surrounding male desire, indeed modern masculinity itself. And, of course, it is also about women.
Viagra has relevance for them in two important ways. One is that the drug seems able to do an equivalent job for them, though much more research is needed before it can be licensed for women’s use. The possible effects on fertility, pregnancy and foetal health are as yet unknown, though Pfizer, Viagra’s manufacturer, has run tests on post-menopausal women, and an American urologist has reportedly conducted a trial on 10 younger women (all of whom have had hysterectomies) and reported improved lubrication, with some reaching orgasm for the first time.
The second way that Viagra is relevant to women is, of course, that they are the ones required to adapt to the relaunch of their male partners’ libidos. As the US has seen, some do so with delight, others are less cheerful. It would be helpful to know more, and it seems significant that half the human race has so far hardly been invited to take part in the great, frothy, phallic funfest that the Viagra saga has mostly been depicted as so far.
The more sober story behind Viagramania might be told from that brittle moment when a man lowers his eyes to his doctor’s surgery floor and describes – confesses, perhaps – to the loss of his erection. In fact his disclosure is a reason for good cheer.
Most impotence sufferers do not even get this far. Dr Ian Banks, a general practitioner (GP) based in Northern Ireland and a member of the British Medical Association’s (BMA) GPs’ committee, says most try all manner of ways to solve their problems before they tell their doctor: “They’ll write to agony aunts, health columnists on men’s magazines, anything else first,” he says. “They don’t want to talk about it at all if they can help it. They don’t go to the pub with a bunch of lads and say, `Hey, you’ll never guess, I couldn’t get it up last night.’ Women will talk to each other about these things. Men won’t.”
This is confirmed by Ann Craig, director of the Impotence Association in Britain, which offers advice through a telephone helpline. Its confidentiality provides an opportunity for men to open up, though there are still those who cannot bear to do their own talking. That’s why about 15% of the callers are women: wives, girlfriends, even the mothers of young men still in their teens. “It’s very, very sad,” says Craig. “Some of them would die rather than talk to anyone.”
The virtue of the media fuss over Viagra has been to drag impotence from the shadows – it is no longer unmentionable. In itself this has probably already had a loosening effect on men’s self-ruinous reticence – in May, the Impotence Association helpline received a staggering 35 000 calls.
Dr David Smart, a Johannesburg urologist involved in local clinical trials to have the drug certified by the Medicines Control Council, says: “Viagra has been such a talked-about point and men will probably go to their GP, who is someone they know and are comfortable with, to solve their impotence.” But, says Smart, “Erectile problems don’t happen in a vacuum, they’re always in the context of a relationship.”
Although the media attention lavished on Viagra is likely to make it the first line of approach, Dr Paul, South Africa’s most famous sexologist, cautions that sexual problems have residual effects on relationships. “You have to look at sexual problems holistically.” Often, he says, these problems are rooted in relationships and there has to be some adjustment. When the man becomes sexually active again, the woman also has to readjust.
But the hysteria surrounding the so- called “love drug” has also created an air of expectation which will beget disappointment. Viagra has been written up as if it were the ultimate quick fix from Planet Eros, but it will not do the trick for every man.
The Impotence Association calculates that it will help no more than half. Pfizer did not include men who were already taking other medications in its trials, yet erectile dysfunction can be a side-effect of many other drugs, including those prescribed for diabetes, angina and other heart conditions, and Viagra will often not be compatible with those.
It is no use at all to men who lose their erections following a prostectomy (the removal of the prostate) or, it seems, to those in the 30% whose condition is ascribed to psychological rather than physical causes. There will also be Viagra failures which just can’t be explained, and it will be back to the needle or the vacuum pump.
There are also fears that some doctors will prescribe inappropriately. Viagra’s ubiquity and its alluring brand name, so suggestive of vigour and gushing glory, will encourage men to visit their GPs: how much easier to declare, “Doctor, I need Viagra”, than to tip-toe awkwardly around the subject first.
Yet investigating erectile dysfunction can be a tricky business. In the first place, how can a doctor tell if and to what degree a man is impotent? For the patient, demonstrating the difficulty is not quite so straightforward as revealing a rash or opening wide and saying “aah”. All in all, as Banks puts it, “Impotence can be a can of worms. It might be down to too much smoking and drinking, it might be down to stress, it might be about problems in a relationship.”
Banks fears Viagra might be used as an excuse for doctors not to trouble themselves with opening up that can of worms – especially male doctors. “When male patients and male doctors interact, it’s always loaded down with all the baggage of being a man, not wanting to go into intimate things too deeply. A lot of male doctors will like the quick fix aspect too. The temptation will be just to write the prescription the patient already thinks he needs.”
But, says Smart, “We’ll probably see in time Viagra being used as a screening test. If it doesn’t work on some guys, then they can go into the system for tests.”
In Banks’s view any such issues go to the heart of how the medical profession deals with “the genuine, serious problems of men’s health, especially their sexual health”. The Viagra “hysteria”, as he terms it, characterised by triumphal tales of restored machismo and youth, has in his view ruined a great opportunity to debate the issues properly. These issues aren’t just to do with tablets and biology, but with the aspects of masculinity in most urgent need of reform.
Viagramania fixes attention on how sexual gusto is one of the crucial props upon which men’s self-esteem leans. The most partisanly conservative interpretation of Viagra’s cultural significance has come from Bob Guccione, publisher of Penthouse magazine. “Feminism,” he has pronounced, “has emasculated the American male, and that emasculation has led to physical problems. This pill will undercut the feminist agenda. It will free the American male libido in much the same way the Pill did.”
For Guccione, as for Hefner, the Viagra story seems to be a kind of restoration tale of how the love drug saved King Willy: the guys get their erections and the sisterhood backs down. Might there be something in it? Not as much as Guccione thinks. His remark contains a heap of glib assumptions. In the first place, what does he mean by “feminism”, by “emasculation”, and just what kind of freedom does he believe the male libido should enjoy?
In the first case, he seems to make the common error of defining feminism, a broad and divided church, as a handful of celebrity authors myopically obsessed with the phallus as the literal, fundamental agent of female oppression.
If so, he fails to grasp that most feminist thinkers of the past 30 years have been concerned with seeking an equitable new settlement between men and women. That may mean taking issue with the ways men behave, but that is not at all the same thing as casting them as irredeemable monsters or turning them into cowering eunuchs.
The feminist conspiracy Guccione evokes is the paranoid delusion of big baby boys. But his comment helps frame the key question about Viagra’s effect on Western life: will it change male sexuality and sexual attitudes for better, or worse?
Lynne Segal, professor of gender studies at Middlesex University, explores the context of this question in Slow Motion, her insightful study of men and masculinity. She discovers a realm of paradox. On the one hand, there is the male bonding language of sexual and sexist denigration, the relentless derogatory dialogue about “cunts”, “pricks” and “queers” or the sniggering office contests to see who can sleep with the new secretary first.
“Calling up images of male sexual performance serves to consolidate and confirm masculinity, and to exclude and belittle women,” Segal writes. But, on the other hand: “Whatever the meanings attached to `the act’ of sexual intercourse, for many men it confirms a sense of ineptness and failure: the failure to satisfy women … For many men it is precisely through sex that they experience their greatest uncertainties, dependence and deference in relation to women – in stark contrast, quite often, with their experience of authority and independence in the public world.”
Can Viagra be part of the solution to these simultaneously frail and destructive aspects of male sexuality? Segal’s initial reaction to Viagramania has been dismay. “It seems to illustrate a lack of change in masculinity. For 30 years, feminist sexual politics has challenged the idea that a big, firm erection is all there is to sex, yet that seems to be the message with Viagra. It doesn’t really seem to be about pleasure through sexuality, but about men confirming their idea of masculinity.”
Leonore Tiefer, a New York clinical sexologist and author of the meaningfully titled Sex Is Not a Natural Act, professes herself “conflicted and ambivalent” about Viagra’s impact in the US. “We’re in the honeymoon phase at the moment – it’s like the Holy Grail has arrived in the bedroom – but like all honeymoons it will come to an end.” There are signs of this already, as sales have fallen to levels which might be described as merely staggering.
Some users have discovered that their medical insurance does not cover the drug. There have also been some 40 Viagra-related deaths. Pfizer puts these down to over-exertion by men who were already in weakened physical conditions, but the company faces the first Viagra lawsuit, from a 63-year-old man who had a heart attack after using the drug.
Then there is the less dramatic, but immensely sobering, discovery by some who have used the drug that penetration is not the panacea they had hoped it might be – that an erection was not the solution to all their sex-related problems, or simply that they and/or their partners didn’t want to do it that much anyway.
For Tiefer, like Banks, the highs and the lows of Viagramania have smothered opportunities for grown-up public discourse about sexual dynamics, health and need. “In some ways it’s a great thing,” Tiefer says. “It’s like a marvellous cultural experiment which can give us a lot of knowledge, a lot of information. The trouble is it’s been pushed out there like it’s just another product, when it’s so much more than that. It’s been handled a bit like nutrition labels on food – not everyone knows what to do with the information. With Viagra, people need some deeper sexual understanding so they can evaluate what the pill can actually do for them.”
This understanding, Tiefer argues, can only come from a fuller embrace of sex education throughout society. Her therapy work yields endless evidence of its absence, especially among men. “I could give you many, many examples of couples where all the guy wanted was an erection, believing this would solve his problem. He may not even anticipate it with jubilation. He’ll say he feels he’s under pressure, that he’s supposed to keep on doing it even though he’s old. His wife may expect it and an orgasm too.
“And, of course, he thinks he’s not as good as the other guys anymore, though he won’t actually say that. What he might say is something like, `Since I got this problem I can’t go into a bar.’ So I say, `Why’s that?’ and they say, `I dunno.’ He doesn’t know how to make those connections. He’ll be sitting there with his arms folded while his wife will be describing, feeling and expressing. This is a game he’s never learned to play because, of course, it is perceived as a weakness in male terms.”
Such stories make it tempting to suspect Viagramania has some characteristics of what sociologists identified decades ago as “the medicalisation of social problems”. The textbook example is the widespread prescription of Valium and Librium to women suffering from depression. This, it is now generally conceded, was the ultimate “quick fix” non-solution, enabling doctors and others to ignore the possible social reasons why woman were depressed in the first place – a classic case of a treatment not really being a cure.
It would be wrong to conclude from this analogy that Viagra is a con. Even those most irked by the media frenzy and most concerned about the flawed grounds on which it might be prescribed have faith in the drug’s potential. It may not work for all men, but it will work wonderfully for many and, hopefully, their male or female partners too.
However, as Ann Craig of the Impotence Association says, “Viagra is not a panacea. If there are problems within a relationship, curing the impotence won’t automatically make those problems go away. Sex isn’t everything, it’s just sometimes it seems that way. People here have been reading and hearing about Viagra every day. It’s making some men think they should be superstuds and doing it at least three times a week. But plenty of people are quite happy just doing it once a month.”
Such wise voices may struggle to be heard above the loud and lustful grunting set to mark the British debut of what has been dubbed “Pfizer’s riser”. The company is now working furiously to build on its success by developing a Viagra pill for women. Already we’ve heard the first female testimonials from the frontline of ecstasy: something about a clitoris fit to burst.
Meanwhile, we await the full significance of Viagra for men. Will it simply be a case of Old King Willy on his throne? Or will Viagra help men learn the wild, weird and tender mysteries of truly making love?