Healthy Skepticism Library item: 457
Warning: This library includes all items relevant to health product marketing that we are aware of regardless of quality. Often we do not agree with all or part of the contents.
Publication type: news
Tuller D
Gentlemen, Start Your Engines?
T he New York Times 2004 Jun 21
Full text:
Do half of American men over 40 need a pill to make their sex lives complete?
About six million American men have taken Viagra for erectile dysfunction since it was introduced by Pfizer in 1998, and about a million have taken its newer competitors, Levitra and Cialis, according to the makers of the drugs.
But the companies have a grander vision: 30 million potential customers, mostly among the roughly 60 million men over age 40.
Even as the companies battle ever more fiercely over the existing market, they are all promoting the idea that the consumer base can extend well beyond men who have the classic symptom of the disorder formerly known as impotence, a persistent and complete inability to have or sustain an erection sufficient for sexual intercourse.
That problem is most often caused by neurological conditions, disorders that interfere with circulation, like hypertension, diabetes or heart disease, and treatments like prostate surgery. For many sufferers, the drugs, which all work to unblock a circulatory glitch, have been a godsend.
But those patients account for only one chunk of the 30 million.
That figure is an extrapolation made by an advisory panel of the National Institutes of Health from several studies conducted before the introduction of Viagra. The most cited is a survey in Massachusetts of 1,290 men from age 40 to 70. Its finding that 52 percent suffered from erectile dysfunction is posted on the Web sites of the drug makers and appears frequently in their material on the subject.
What is not generally spelled out is that about 80 percent of those classified as having erectile dysfunction in the study were categorized as having only a moderate or minimal problem, or that the factors examined included any single instance of difficulty having or keeping an erection within the previous six months. The study also included questions that opened the door to more emotional and subjective factors, like the men’s ratings of their satisfaction with their sex life and of their sexual relationships with specific partners.
The drive to redefine erectile dysfunction, also known as E.D., as a quality-of-life issue for significantly younger men facing normal age-related changes is as plain as the shift to the younger celebrities and models now being used to advertise the drugs.
The response of the drug makers is, essentially, what’s wrong with that?
“The face of E.D. now is a younger, seemingly much healthier guy,” said Leonard M. Blum, vice president for sales and marketing at the Icos Corporation, which along with Eli Lilly & Company jointly markets Cialis, “so the spectator is wondering if we’re now trying to say to every man out there who hits age 40, `Well, congratulations, now it’s time to start taking your E.D. medications.’ But to those who think we’re targeting the worried well,” he said, “I want to say that we didn’t create E.D. Plenty of men and couples suffer tremendously because of it.”
Critics say that the drug companies are trying to advance the idea that anything less than erectile perfection is unacceptable.
“Just because someone can’t always have an erection on demand doesn’t necessarily mean it’s a problem,” said Dr. Leonore Tiefer, an associate professor of psychiatry at the New York University School of Medicine, who has been a vocal critic of the way the drugs are marketed. “The advertising and promotion have become disengaged from any notion of a medical condition or a disease. Now you take these drugs because you’re less perfect than you want to be. It’s like teeth whitener.”
That quest for instant perfection rose a notch recently when a British company, Vectura, announced that it was testing an inhalable erectile dysfunction drug that it claimed could work in as little as eight minutes.
Some researchers have also raised questions about the data behind the figure of 30 million men extrapolated from the Massachusetts study. An article published last year in The International Journal of Impotence Research found that the study’s estimate that 35 percent of men from age 40 to 70 have moderate to severe erectile dysfunction was “considerably higher” than those of the 13 other epidemiological studies it reviewed, which covered various age groups in different countries and found prevalence rates ranging from 5 to 20 percent.
The drug companies say that their own research on erectile dysfunction prevalence is in line with the Massachusetts study and deny that they use the numbers to exaggerate the need for erectile dysfunction medications. “Most men who are 45 or 47 don’t have the same erections they had when they were 18, and if they’re fine with that, nobody should judge it,” said Dr. Janice Lipsky, director of marketing at Pfizer. “But I can tell you from the bottom of my heart that there are still men who really do want to go to their doctors but can’t imagine bringing it up.”
Dr. Michael Kimmel, a sociology professor at the State University of New York at Stony Brook who has written extensively about masculinity and gender issues, said he thought the emphasis on the problem’s purported ubiquity could have more than one effect.
“Using the 30 million figure is like saying, `You’re not alone, guys,’ which can be extremely reassuring,” he said.
“On the other hand, it helps to create a market that is infinitely larger than the market that might have existed otherwise.”
Pharmaceutical executives, as well as many urologists and other medical experts, agree that erectile dysfunction exists along a broad continuum from very mild to severe.
But they say that only a small percentage of the men who need pharmaceutical help have asked for it, and point to the experience of those who have to bear out what a difference treatment can make.
Curtis Palmer, a 58-year-old retired professor of industrial management from Evansville, Ill., suffered from severe erectile dysfunction after undergoing prostate surgery, a common cause of the disorder.
Viagra, he said, has not fully restored his functioning but has helped enormously. “When you have erectile dysfunction, you look at your wife and it’s like looking at art, because you’re stimulated by the visuals,” said Mr. Palmer, who recently celebrated his 38th wedding anniversary. “But as far as doing anything about it, you can’t.
Something feels broken. And your relationship is the casualty.”
Other men who have taken the medications, however, clearly fall into the camps of those with moderate or even minimal problems.
A 51-year-old Northern California man, who preferred to remain anonymous, said that he generally had little problems getting an erection. But after he separated from his wife, he was sometimes concerned about how he would perform with other partners and tried medication when he went on vacation with a new girlfriend.
“It was kind of cool because I could almost snap my fingers and it was like I was 17,” he said. “There might be an occasion where I’d take the drug again for the performance enhancement if I were with someone new and was overly nervous. It isn’t the same as when you were 35. It can fail or go away and you have to not panic.”
Dr. Ridwan Shabsigh, director of the New York Male Reproductive Center at Columbia-Presbyterian Medical Center, compared the situation for men with a modest decline in sexual function to that of someone with a mild hearing impairment.
“If everybody is quiet and the room is quiet, they can hear,” said Dr. Shabsigh, who like many urologists has served as a consultant or adviser to the makers of erectile dysfunction drugs. “But if there’s any noise, they will need a hearing aid. I think mild E.D. patients might sometimes use the treatment and sometimes not. But that is still a medical use and would by no means be what some people call recreational use.”
Mr. Blum of Icos pointed out that many other health conditions formerly accepted as part of the aging process were routinely treated with medication. “It used to be normal that a man reached a certain age and was expected to have high blood pressure, or a woman was expected to have osteoporosis,” he said. “Now we realize that just because a person’s getting older, they don’t need to go into physical decline.”
But even some urologists who generally consider themselves strong supporters of pharmaceutical intervention say they are concerned that the drugs are now viewed as the all-purpose solution to sexual problems – whether their basis is emotional or physical – and are being overprescribed.
Dr. Arnold Melman, chairman of the urology department at Montefiore Medical Center in the Bronx, said that the publicity about the medications had persuaded many men who have suffered in silence to seek treatment. However, he added, some patients who complain of erectile dysfunction actually experience normal erections during sleep but suffer from psychological or relationship problems that inhibit sexual functioning.
Many of them would benefit more from seeing a counselor or sex therapist than from medication. “When I started doing this in the early 70’s,” he said, “95 percent of people with E.D. were considered to have a psychological problem.
Now the pendulum has swung the other way.
“I think the truth is somewhere in the middle, he said.
“But it’s easier to give a pill than to do the right thing all the time.”
In fact, according to a new study conducted in New Zealand, the changes the drugs can bring to the bedroom – and to relationships – can be far more complicated than advertisements might suggest.
The study, which will be published in the August issue of the journal Social Science & Medicine, drew on lengthy interviews with men who were taking Viagra and women whose sexual partners did.
For a number of men, the drug had restored their sense of masculinity along with their erections. Some men praised the drug for in a sense “rewiring” their penis, and talked about using Viagra as a means of restoring their ability to have sex without a pharmaceutical aid, with one man comparing the process to regaining the use of an atrophied muscle.
But study participants of both sexes also discussed more troubling changes as well, like an increase in opportunity and temptation for men to have sex outside the relationship, a rise in women’s suspicions of infidelity, whether warranted or not, and pressure on the women to have unwanted intercourse – in some cases, so that a pill would not be “wasted.”
Others reported that the use of the drug had not diminished men’s anxiety about performance, but increased it, leading to a fear of psychological dependence on the pill. “I know without it, I run the risk of it falling over [and] so I guess I’m probably a bit frightened of not taking it,” said one man.
“He’s addicted to it,” said one woman of her husband.
For some observers, the issues raised by the drugs rise to the level of philosophical questions about the nature of sex itself. Dr. Kimmel, the Stony Brook sociologist, thinks that many men – and their partners – might benefit from reducing the focus on a rock-hard erection as the essence of male sexuality.
The shift, he said, might actually improve a couple’s sex life by encouraging them to expand their sexual repertoires, explore other parts of their bodies and discover new ways to give each other pleasure. In fact, he added, some women might be less concerned about erections than their partners think.
“These drugs reassert the very phallocentric focus of the definition of sexuality,” Dr. Kimmel said. “In doing that, they frame what in our culture counts in sex and what doesn’t count. And what doesn’t count is anything that’s not penile-vaginal penetration, like touching, kissing, licking and stroking.”
