Erections are a growth industry. In 1996, American men spent $25 million on drugs designed to transform middle-aged torpor into teenage turgor. That's a significant sum considering the only medication approved by the Food and Drug Administration had to be injected in the penis with a needle. In 1997, after the feds OK'd a plastic plunger delivering the same drug sans syringe, the market surged to $200 million. If you include non-pharmaceutical therapies such as vacuum pumps and surgical implants, the number expands to $700 million. That's a lot of hard cash, yet more -- a lot more -- is coming.
On March 27, the FDA approved Viagra, a little blue pill that, according to its manufacturer, Pfizer Inc., has created a forest of wood in up to 80 percent of the 4,000 impotent men tested in their clinical trials. The sound of trees rising is beautiful music to stock analysts, no doubt thinking of the 30 million American men who are said to have erectile dysfunction. And as baby boomers age, that number will soar. Like teeth, penises weren't designed to last 80 years.
Thus, predicts David Saks of Gruntal & Co., Viagra will be the most profitable drug ever -- and early reports show he's probably right. In the week ending April 10, nearly 40,000 prescriptions were written at a retail price of about $10 a pill. One Net-savvy physician, Michael Thomas of Milwaukee, was selling Viagra scrips on his Web page at $50 per "consultation," until criticism forced him to require in-person office visits. Even without the Internet, Pfizer could gross $4 billion yearly from the drug. One thing is certain: Wall Street has placed its bet. In the past year Pfizer's stock -- now selling at an all-time high -- has more than doubled. On Thursday, the company is expected to announce a two-for-one stock split.
The man behind that growth is Dr. Ian Osterloh, a diffident Englishman with narrow shoulders, a receding chin and a complexion the color of typing paper. When we met, not long before Pfizer submitted Viagra for approval, he was sipping tea and waiting to take the podium at a medical conference. The discovery of Viagra, he said, is a tale of the unexpected.
"We were experimenting at our research center in Sandwich [England] with treatments for hypertension and angina. We thought a phosphodiesterase inhibitor [which Viagra is] might be effective." Viagra surprised Osterloh and his fellow researchers twice: It didn't lower blood pressure but it did raise erections. A follow-up study caused even more excitement -- first among the research subjects, then Pfizer, now investors.
Viagra is poised to dominate the impotence market much the way Prozac and similar pills have taken over the treatment of depression. But unlike Prozac, Viagra has a huge potential for black-market sales. At one testing site, a burglar stole a shipment of pills. Osterloh blames (guess who?) the media.
"This is not a 'superstud drug,'" he said. "It is a serious medication for a serious disease. It is not intended for healthy, functioning men." But sensational news coverage, he complained, has given the false impression that Viagra is for "regular guys" who want "a little extra performance."
"That," Osterloh said, "is what you get in your motorcar after it has been properly serviced."
Osterloh was annoyed when I asked if he'd taken the drug himself. "Certainly not," he said. But the history of impotence research is filled with men who've experimented on themselves. An unforgettable example occurred at the 1983 meeting of the American Urological Association in Las Vegas. There, British physician Giles Brindley demonstrated beyond charts and graphs that a drug he'd been experimenting with was effective. He did this by stepping in front of the podium and dropping his trousers. Moments earlier, Brindley had injected himself. So there it was, standing proud before a room full of strangers: the, uh, "evidence." Farther down the Strip, Siegfried and Roy were making a white Bengal tiger disappear, and two circus aerialists -- one sitting on the other's shoulders -- were traversing a tightrope without a net. But even in Vegas they'd never seen a show like this.
Within weeks, doctors were prescribing injections, even though the medication was not FDA-approved for that purpose until two years later.
The mainstream press, especially the New York Times (which ran four
pieces on Viagra in the week after its approval) has been a consistent booster of this erection industry, gushing over every new treatment -- and the new treatment emphasis. Once impotence was thought to be a psychological problem, the turf of sex therapists and shrinks. Now urologists, backed by the media, say the problem isn't in your head -- it's in the vascular system inside your penis.
This shift has moved the focus from the couple (Masters and Johnson's great insight) to the male organ. Treatment is based on an assumption of pathology. Many erectile-dysfunction specialists don't even do a diagnostic work-up on the patient's penis -- nor did Osterloh recommend one when he spoke on March 27 at Pfizer's press conference announcing Viagra's approval by the FDA. Instead, most urologists give a general physical exam, take a sexual history, then offer the patient drugs.
Sure, these medications work, technically speaking, just as a doctor can prescribe a sedative to make an insomniac sleep. But does the fact that the drug works mean the problem is solved?
The answer to that, of course, depends on how you define the "problem." The 1994 Massachusetts Male Aging Study, the survey urologists cite to prove their assertion that impotence is a problem (of varying severity) for half the male population between the ages of 40 and 70, didn't merely ask respondents to rate their erections. It asked, "How satisfied are you with your sex life?" Surveyors created a "mild ED" category (ED = Erectile Dysfunction) for men who have erections, but worry that they're not getting quite as hard, or lasting as long, as they used to.
(And how many men over 40, even those who have a regular sex partner, don't worry about that?)
It's only when you count these men that the
number of "impotent" men reaches 30 million. Dr. James Barada of Albany, N.Y., a member of the American Urological Association's Treatment Guidelines Committee, is one of a small but growing number of urologists concerned about this "inflation" of the patient pool. "There's a
difference between erectile dysfunction, which is a real disease,"
Barada said, "and erectile dysphoria, which is a vague sense of
dissatisfaction. I worry the line is getting blurred."
Of course, the issue of sexual "satisfaction" is important, even if it is of questionable value in determining how many man really suffer from impotence. After all, only a dunderhead would deny that sex for humans -- for better and worse -- is at least as much a psychological process as it is biological. But these
truths are of little interest to most urologists. When Brindley
dropped his pants in Las Vegas, he did more than give new meaning to the term "scientific presentation." He achieved the first major breakthrough in what Dr. Leonore Tiefer, professor of psychiatry at New York Medical Center, has called "the pursuit of the perfect penis." This penis is impervious to Freudian insights, couples counseling and feminist criticism. It is a sexual tire that can be reinflated at will by drugs, no matter how many times it has gone flat in the past -- or why. The
ultimate male fantasy has come true: a penis that's hard on demand. And, best of all, you don't have to talk to your wife, girlfriend or lover -- or, even worse, a shrink -- about your "relationship." The only relationship that matters is the one between you and your dick.
Science has rewired that connection, but the price tag for this new
power tool is hidden. Men joke about being sex machines; the reality may not be so funny. When the penis becomes a mere engineering problem, the psychic vault of attitudes and anxieties that make up the "masculine mystique" is at risk of losing something important: its mystery, with consequences for eroticism, manhood and gender relations that the wood salesmen -- and buyers of Pfizer stock -- haven't pondered at all.
With urologists, roughly 99 percent of whom are men, now
dominating the discourse on sexual functioning, an important group is rarely heard from -- women. Sure, most women appreciate a firm,
hard erection. But a firm, hard erection attached to an inept,
insensitive lover is hardly the answer to anyone's problem. Not
surprisingly, this is an issue you don't hear addressed at urological conventions.
Even so, nothing is likely to stop the Viagra juggernaut. American men have been reeducated to see aging and the loss of youthful vigor not as a natural process, but as a disease. Sure, life is hard, doctors tell us -- it's supposed to be. And we have the drugs to keep it that way.