The Viagra Phenomenon
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02 Tiefer 065049 (bc-t) 2/6/06 1:05 pm Page 273 Abstract Contemporary constructions of sexuality can changedirection faster than a competitive ballroom dancer and it can behard to keep track of all the new developments. Regulatoryregimes abound and even proliferate yet mass media proclaimthe end of the double standard and the advent of sexualemancipation. In 1998, in yet another major twist, a newsexuopharmaceutical era was inaugurated by governmentalapproval of Viagra, a drug to treat impotence that rapidlyachieved amazing levels of global recognition. It will beimportant to sexuality studies and to sexuality policy that thistopic develops sufficient empirical and theoretical traction topursue analyses of its meanings and effects on sociocultural,political, economic and personal dimensions as they unfold overtime. One important challenge of such ‘Viagra Studies’ is toexamine the phenomenon of Viagra itself, beginning with thelegend of its discovery and the media spectacle surrounding itsapproval. This essay begins with the galloping popularity of pill-taking as an element in trajectories both of the medicalizationand demedicalization of sexuality. Although new systems ofregulation often serve to reinscribe old forms of control, andurologists’ current involvement in sexuality classification andtreatment seems to follow old paths of biological reduction andmedical authority, factors such as the Internet may shift thesexuality dance in unpredicted directions. After tracing some ofthe less-known stories behind the Viagra legend, this essayconcludes with a nod to rising coalitions of resistance.
Keywords demedicalization, medicalization, pharmaceuticalindustry, sexuopharmaceuticals, urology, Viagra Viagra, a drug to treat impotence, was approved for prescription use inmost countries of the world in 1998, but that was just the beginning.
Sexualities Copyright 2006 SAGE Publications (London, Thousand Oaks, CA and New Delhi) Vol 9(3): 273–294 DOI: 10.1177/1363460706065049 2006 SAGE Publications. All rights reserved. Not for commercial use or unauthorized distribution.
02 Tiefer 065049 (bc-t) 2/6/06 1:05 pm Page 274 Viagra rapidly became a household name and cultural metaphor as theresult of a massively effective global public relations campaign. It becamesuch a phenomenon because both the commercial forces promoting it(gigantic pharmaceutical and advertising industries) and the governmentpolicies backing that promotion were perfectly aligned with a medicalprofession and diverse public keenly interested in sex and positivelydisposed to pills. This new discursive chapter in the construction of desireand pleasure offers a gold mine for sex culture analysts interested incurrent projects of embodiment and eroticism, gender, body enhance-ment, medicalization, consumer culture, technology, expertise construc-tion, body surveillance and so on.
The story of Viagra occupies an important position in the trajectories of both the medicalization and demedicalization of sexuality (Tiefer,1998).1 On the one hand, the story figures prominently in the apparatusof biomedical sexual regulation through its connection to norms, experts,and new forms of medical management. Yet, at the same time, it partici-pates in the evolving consumerist and Internet technologies of sexualrecreation and sexual self-determination for privileged men and women ofthe ‘sex and the city’ and baby boom ‘you can have it all’ and ‘positiveaging’ generations.
We live in an age where pills are promoted and desired for health manage-ment and body regulation, especially as regards the pursuit of physical andmental improvement unto perfection (Critser, 2005; Elliott, 2003;Rothman and Rothman, 2003). People look to pills for instant and scien-tific removal of unwanted distress, whether physical or psychological. Massmedia, full of stories of new medical risks, high-tech assessment tools, andmiracle drug breakthroughs, endlessly urge the public to ‘visit yourdoctor’. Sometimes such stories actually create distress in people who visittheir doctor a little too often and are thereafter known as ‘the worried well’.
Visits to doctors, whether to report illness or to ‘check up’ on health status through health risk assessment have largely become prescription-writing opportunities (Weiss and Fitzpatrick, 2004). Prescriptions arewritten to offer treatments for illness, of course, but also for ‘irrational’reasons such as to reassure a patient that his or her complaint is beingtaken seriously or to cope with other practice demands such as tightscheduling (Weiss and Fitzpatrick, 2004).
Whereas some people buy into the traditional physician–patient relationship and dutifully comply with directives regarding the use of pills only for disease treatment, others use medications obtained fromdoctors, the Internet or friends almost casually to modulate mood, 2006 SAGE Publications. All rights reserved. Not for commercial use or unauthorized distribution.
02 Tiefer 065049 (bc-t) 2/6/06 1:05 pm Page 275 energy level, concentration, sociability, athletic and sexual performance(Harmon, 2005). News about pills and pill-taking come not only fromscience and medicine pages, but from the sports section. Competitiveathletics are constantly in crisis over which drugs are or are not permis-sible, while the idea of no-drugs professional sports seems like ananachronism (Shapin, 2005).
The result of all this pill-taking is that the pharmaceutical industry (with its nutraceutical and cosmeceutical subsidiaries)2 is the world’s mostprofitable business and plays an influential role in governmental health andbusiness policies (Angell, 2004). Such a nexus of social realities shouldencourage social and cultural theorists to examine in detail the evolvingsymbols, politics, meanings and practices around medical drugs.
Since the 1960s scholars have explored how aspects of everyday life including sexuality became more or less ‘medicalized’ over the 20thcentury, and thence viewed in terms of health and illness, normal andabnormal function, and medical management. As Conrad (2005) recentlypoints out, however, in many regions the world of healthcare has hugelychanged technologically, politically, and economically in the last 20 years,so that medicalization is now driven more by forces such as drug industrypolicy, consumer demand, managed care, and health insurance than byphysicians’ professional norms or ambitions. In those regions, however,the medicalization of sexuality lags behind that of many other areas, forexample pregnancy, alcohol intake and mood regulation. It has movedbeyond the crucial terms-setting stage of creating classification systems,but is just fully entering the phase of institutionalizing and professional-izing ‘sexual medicine’ with all the apparatus of national and internationalorganizations, conferences, training centers, scientific journals, clinics, andmedical school departments.
‘Sexual medicine’, a new subspecialty bankrolled by a pharmaceutical industry obsessed with Viagra’s blockbuster success, is rapidly emergingas the designated site of professional expertise for intimate sexual conduct.
To no one’s surprise, the new sexual medicine is thoroughly infused withsexuopharmacology – both to examine sexual side effects of mental andphysical health medications and to encourage more drugs like Viagradeveloped specifically to affect sexual desire, performance or response(Segraves and Balon, 2003).
At the same time, sexual life is being demedicalized, as nonprofessional sexual expertise explodes in popular magazines and books, on televisionand radio, from the podiums of inspirational speakers, and especially onInternet advice sites, weblogs and chat pages. Some informational sites arecovertly sponsored by pharmaceutical companies or other commercialenterprises, some are controlled by religious moralizers, and many focuson earnest healthist advice about STDs and pregnancy avoidance from 2006 SAGE Publications. All rights reserved. Not for commercial use or unauthorized distribution.
02 Tiefer 065049 (bc-t) 2/6/06 1:05 pm Page 276 Nurse Martha or Social Worker Bob. But, additionally, innumerable advicesites appear to be populist upsurges of erotic exuberance and exhibition-ism. They offer cheerful stories and optimistic news for worried babyboomers, emphasize techniques and products (webcams, sex dolls, dildos,fancy lingerie, spanking and bondage equipment) more than feelings, andfrequently refer to regular and experimental use of Viagra and other sexdrugs. A few seconds’ websearch produced the following question on sucha site: ‘I never hear about men using Viagra, Cialis, etc. for masturbation.
Is it that I’m not paying attention, or is the focus really on activities youdo with a partner?’3 Sexuality scholarship, whether empirical or theoreti-cal, needs to attend to this populist perspective.
Certain medicines, such as aspirin, penicillin, birth control pills, moodregulators (Valium and Prozac), and, now, Viagra, have become culturalicons, reaching far beyond just their impact on human physiology to shapesocial norms and practices. But the academic study of drugs and medi-cines (prescription and over-the-counter, restorative and recreational,legal and illegal) has been retarded by essentializing and moralizing prac-tices that Richard DeGrandpre has called ‘pharmalogicalism’, which hedefines as the matrix of centralized powers and discursive practices whose social functionit is to reinforce an essentialism of drugs, of angels and demons, and in doingso, to obscure the sociocultural, political and economic structures that shapeboth drug understandings and drug effects. (DeGrandpre, 2002: 76) This is abundantly true of sexuality drugs, insofar as essentializing andmoralizing themes on topics such as homosexuality, intergenerationalrelationships, women’s sexuality, and childhood sexual life have dominatedsexuality scholarship throughout the 20th century (Irvine, 2005 [1990]).
The ‘non-pharmalogical’ study of drugs and society is still in its infancy but it will have to draw on multidisciplinary insights and skills from fieldsas diverse as science and technology studies, law, physiology, health policystudies, and the sociology of business and marketing. A range of empiri-cal and analytical methodologies will be needed. Most current booksabout drugs and the pharmaceutical industry are either rah-rah self-helpbooks (by professional or self-appointed experts) or exposés by investiga-tive journalists or alarmed physicians. There have been several waves ofdrug industry exposés, usually following public scandals where a poorlystudied or poorly regulated drug caused medical tragedies that capturedmedia and public attention (Hilts, 2003). Following the thalidomidescandal of the early 1960s, for example, there were extensive hearings in 2006 SAGE Publications. All rights reserved. Not for commercial use or unauthorized distribution.
02 Tiefer 065049 (bc-t) 2/6/06 1:05 pm Page 277 the US Congress, many changes in Food and Drug Administration (FDA)operations, and a stack of reform-oriented books by journalists andphysicians in the United States (e.g., Mintz, 1965).
Recently, there has been another surge of such exposés. They have skewered lax governmental regulatory policies and aggressive pharma-ceutical industry marketing that together have created this pill-taking ageand led to scandals, including, most recently, thousands of deathsattributed to the pain-reliever, Vioxx (e.g., Abramson, 2004; Angell, 2004;Critser, 2005; Greider, 2003; Healy, 2004; Moynihan and Cassels, 2005).
These books provide useful historical, statistical, legal and corporateinsider information for political and economic analysis, but they rarely riseto make larger cultural claims about how and why drugs have come toplay such a large role in contemporary life.
Cultural studies can add important tools and perspectives for under-standing drugs in their full social context. Taussig’s (1980: 7) classicarticle stating that ‘behind every reified disease theory in our society lurksan organizing realm of moral concerns’, could provide the starting pointof an analysis of sexuopharmaceuticals. New historical studies of oralcontraceptives already include more gender analysis as they revisit drugsthat continue to be both politically and scientifically controversial (Marks,2001; Seaman, 2003). Gender and representation theory informresearchers who analyze psychotropic drug advertisements and prescrip-tion patterns (Fishman, 2004; Metzl, 2003).
Psychopharmacology history itself is getting fresh scrutiny as critics wise to the history and politics of industry–government ‘partnerships’ closelyexamine the approval process and marketing strategies behindpsychotropic drugs’ success (Healy, 1997; Valenstein, 1998). Feministanalysis of the patriarchalism of the ‘technological imperative’ at work inassisted reproduction, the workplace, and domestic activities needs to beextended to illuminate the masculinist interests behind many drugs(Wajcman, 1995). Insights from feminist health research on the unpaidcaring work in families should examine unintended consequences of drugstaken by one member of a family on others (Ehrenreich and Hochschild,2003). Works on the construction of the new flexible self will inevitablyinclude ideas about the role of sexual enhancement drugs (e.g., Elliot,2003). And this just touches some of the many cultural angles from whichscholars can and will view the new sex drugs.
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02 Tiefer 065049 (bc-t) 2/6/06 1:05 pm Page 278 A cottage industry of empirical and discursive studies is nicely complicat-ing the popular four-part industry-guided Viagra narrative of long-standing sexual suffering, innovative drug development, professionaldiagnosis and treatment, and patient satisfaction. Deconstruction andcritical analysis provide the inspiration for this new scholarship, and inter-views that go behind the advertisements and headlines add some of itsstrongest methods. Loe (2004) offered an extensive analysis of theapproval and early success of Viagra as well as its gendered promotion andreception in the United States. In New Zealand, Potts and colleagues(Potts et al., 2003, 2004) interviewed women partners of men who usedViagra, demonstrating diverse and ambivalent assessments of its value inthese women’s own sexual lives (a similar study focusing on older womenwas conducted in America by Loe).
Rubin (2004) conducted UK focus groups with men exploring layers of reaction to Viagra. Potts (2004, 2005) analyzed how Viagra has recon-figured the erotic landscape by introducing a cyborgian element with itsown associated promises and problems. Two articles in 2001 by Fishmanand Mamo (Fishman and Mamo, 2001; Mamo and Fishman, 2001)examined how the gendered promotion of Viagra reinforces dominantcultural narratives of masculinity and heterosexuality. Marshall (2002)showed how Viagra science constructs erection problems as physiologicalthrough selective inattention to issues of arousal or emotion, and how theunrelenting focus on the need for erectile rigidity is repositioningpenile–vaginal intercourse as the normative centerpiece of sexual relations.
Baglia (2005) analyzed Viagra advertisements and Pfizer promotionalmaterials in the context of current theories of masculinities. Variouswriters have discussed how Viagra use contributes to the illusion of hyper-masculinity in the porn industry (e.g., Faludi, 1995; Frammolino andHuffstutter, 2001).
My interest in Viagra Studies dates from employment in two hospital urology departments (from 1983 to 1996) observing at close hand thenature and exponential growth of urological interest in male sexualfunction. I participated in this new medical trend as a clinical psycholo-gist and researcher hired to assess and treat sexual dysfunction. I readurological journals, attended biomedical conferences, and publishedabout a dozen conventional empirical articles on male sexual dysfunctionand its management using the urology departments’ clinical data (e.g.,Melman et al., 1988; Pedersen et al., 1988; Tiefer and Melman, 1987;Tiefer et al., 1988). At the same time I was reading feminist studies andthe new social constructionism and attending feminist and sexologyconferences. I could integrate these colliding perspectives only by 2006 SAGE Publications. All rights reserved. Not for commercial use or unauthorized distribution.
02 Tiefer 065049 (bc-t) 2/6/06 1:05 pm Page 279 becoming an observer as well as a participant in the urology setting(Tiefer, 1986, 1994).
The initial success of Viagra required the stabilization of ‘impotence’ as a factual medical condition diagnosed when the penis doesn’t do what itshould. Making Viagra a blockbuster (i.e. a drug that produces at least $1billion in annual sales according to Rosen, 2005) further required thatwhat the penis should do needed to become more and more importantand demanding, so that most penises would fail or falter at some point orother and so that the incidence of ‘impotence’, or at least ‘erectileinsecurity’, would escalate. This was accomplished by cultural shifts ingender role spotlighting genital aptitude as proof of masculinity, a taleexamined repeatedly in men’s studies over the last quarter-century (Baglia,2005; Luciano, 2001; Tiefer, 1986).
Other events contributing to the Viagra ‘moment’ need to be brought under the umbrella of Viagra Studies. Sex and the City, the televisioncomedy hit series about four single, sexually active women in New York,began in the United States in June, 1998, escalating many men’s anxietyover women’s new sexual expectations and attitudes of entitlement. Oneepisode in 1999 specifically focused on Viagra,4 but its footprints couldbe tracked throughout the six years of the series. On another level entirely,1998 was the year when front page and nightly television news detailedhow President Bill Clinton was being investigated for sexual misconductwhile in office. One unintended result was an increase in the opportunityand pressure for the public to seem familiar with oral sex, adultery, semenanalysis, power imbalances and other relevant details of sexual culture.
Thus the approaching new millennium seemed suffused with both sexual panic and excitement when Viagra was approved in the US in March 1998,following a build up breathlessly charted for two years in major news maga-zines (e.g., Cowley, 1996; Leland and Murr, 1997). Viagra Studies needsthe depth and range of both empirical and discursive methods to examinethe universe of influences and effects associated with Viagra.
The official story of the development of Viagra is a narrative of scientifictriumph over ignorance and suffering that centers on discoveries abouttwo chemicals: nitric oxide (NO, a gas found in automobile emissions)and sildenafil citrate (the synthetic chemical given the brand name ofViagra by Pfizer).5 In the 1980s NO was discovered to have widespreadeffects as part of normal physiology, including relaxing the smooth musclewalls of blood vessels (Wright, 1996). NO’s effects seemed so formidablethat Science magazine named it the 1992 ‘molecule of the year’, and thediscoverers of NO were awarded the 1998 Nobel Prize in physiology.
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02 Tiefer 065049 (bc-t) 2/6/06 1:05 pm Page 280 In 1992, NO was linked to the functioning of penile blood vessels on the front page of The New York Times with an article beginning, dramat-ically, ‘Researchers say they have found the physiological explanation for thevast majority of cases of male impotence’ (Blakeslee, 1992: 1, emphasisadded). As with many such ‘breakthrough’ science stories, however, theinitial promise greatly overstated the actual deliverables, although thatwould not be known for years. Meanwhile, the hyped claims instigated arash of frustrated phone calls to urologists’ offices from men wanting toget their hands on some NO immediately.
Discourses about sex seem always to exaggerate, to breathe heavily, to amplify and elaborate. Whether academic, photographic, journalistic,cinematic, therapeutic or even scientific, sex nowadays is invariablyportrayed as consequential, urgent, and central to life satisfaction. This isan element of incalculable importance to contemporary constructions,and itself calls out for analysis. The exaggerations in the 1992 NO newsarticles merely repeated the exaggerated claim in the scientific paper theyreported, ‘In the majority of patients, abnormal vascular responsiveness isthe underlying cause of impotence’ (Rajfer et al., 1992: 90, emphasis added).
When science becomes breathless, boundaries have been crossed.
Years after the approval of Viagra, Pfizer commissioned an official history (Katzenstein, 2001). It offers the legend of how sildenafil citrate(Viagra) was developed in Pfizer Pharmaceutical Company’s UK labora-tories. Pfizer’s frequently-told tale ‘of science and serendipity’ (Katzen-stein, 2001: 80) has it that sildenafil was first synthesized in 1989 as partof its ongoing search for drugs for heart disease.6 Sildenafil causes bloodvessel dilation by inhibiting a constricting enzyme present in the smoothmuscle walls of some blood vessels and researchers thought it might behelpful with angina (chest pain caused by reduced flow of blood to heartmuscle). The legend goes that to the great surprise of the Pfizerresearchers, British test subjects taking sildenafil reported increased erec-tions and didn’t seem to mind (smile) that the drug offered no cardiacbenefit. By 1993 secret clinical trials were under way directly comparingsildenafil with placebo for the treatment of erectile dysfunction (Katzen-stein, 2001: 15).
It is worth mentioning that the official history of Viagra begins ultra- dramatically with a history-collapsing story from the Old Testament:‘Impotence has been a devastating problem since the beginning of recordedhistory. In the Bible, the Lord inflicted impotence – described as a livingdeath – on Abimelech because he wanted to have sexual relations withAbraham’s wife’ (Katzenstein, 2001: 2, emphasis added). In the Biblicalstory, God intervenes in a threatened moment of adultery by inflictingeither impotence or infertility (it is not clear which). None of the biblicaltexts I consulted mentioned the ‘living death’ part, but that construction 2006 SAGE Publications. All rights reserved. Not for commercial use or unauthorized distribution.
02 Tiefer 065049 (bc-t) 2/6/06 1:05 pm Page 281 fits right into the usual hyperbole-filled Viagra story. Impotence is (pause)a fate worse than death. Doctors often report anecdotally that men rejectneeded medical treatment for genitourinary cancers if impotence mightbe a consequence (Oliffe, 2005). Journalists following the Viagra story inthe months after its approval began listing Viagra-related deaths that werepresumably due to heart failure or drug interaction, but they seemed toimply that even death was not too high a price to pay for masculine fulfill-ment (Leland, 1998/1999).
Hyperbolic language about impotence is not new with Viagra. It has appeared in each new medical breakthrough about erections. A bookdescribing the treatment most popular before Viagra, injections ofvascular drugs into the penis, breathlessly reported, ‘After millennia ofsearching in vain for the holy Grail of sexually stimulating potions, we arefinally reaching the age of true aphrodisiacs’ (Wagner and Kaplan, 1993:17). Secure erections (pause) a fate better than paradise.
The official story thus features Nobel Prize-winning scientists, altruis- tic volunteers, desperate patients, lucky discoveries and so on, in adramatic narrative that constructs impotence as a plague of mankind sincetime immemorial awaiting the liberating touch of modern scientificpharmacology. It is a highly polished public relations fable – the onlysurprise is that it is the story told in sober publications as well as in in-house puff pieces.
Complicating this discovery legend are factors that contextualize thedevelopment of Viagra in the scientific, political, cultural and socio-economic events and atmosphere of the time. They offer an illustration ofhow society shapes science and technology. In line with what Conrad(2005) identifies as the current ‘engines of medicalization’, I have paidthe most attention to the political economic factors (Tiefer, 2000, 2004): • how impotence acquired legitimacy as a biomedical reality in urology and medicine over a period of about 20 years, • the movement of urologists into sexual health as changing biotech- nologies reconfigured surgical practices, • stagnation in sex therapy related to conservative politics, lack of • a new academic–industry partnership supporting applied science on • relaxation of government drug approval policies brought about by • health and science media’s fascination with biological sexuality, 2006 SAGE Publications. All rights reserved. Not for commercial use or unauthorized distribution.
02 Tiefer 065049 (bc-t) 2/6/06 1:05 pm Page 282 • the shift of the pharmaceutical industry towards the market potential offered by the aging baby boom generation, • removal of the prohibition on direct-to-consumer advertising of pharmaceuticals in the United States and New Zealand, • the takeover by pharmaceutical sponsorship of scientific conferences, journal supplements, and continuing education courses and so on.
These matters of political economy deserve lengthy exegesis and have been discussed in a series of recent books (e.g., Bok, 2003; Krimsky, 2003;Washburn, 2005). Some of the sexology issues have been dealt with bysociologist Janice Irvine (2005 [1990]). One might imagine that theavalanche of Viagra news coverage would also have examined these issues,but with the exception of a very few investigative stories in the businesspress (e.g., Stipp and Whitaker, 1998), most news coverage of sexuo-pharmaceuticals has been uncritical and promotional, continuing the sagaof superficial health and science journalism (Burnham, 1987).
Letiche (2002) suggests that the Viagra phenomenon caused pharma- ceutical research to adopt a new story for itself: Pharmaceutical research does not produce medicines, so much as it consumesa constant flow of chemical substances . . . In the laboratory, ‘texts’ are createdaround compounds in an attempt to make meanings that the pharmaceuticalmarket will absorb. (Letiche, 2002: 248) In the creation of Viagra, he argues that a new focus for research anddevelopment had to occur with a move from ‘life-saving’ to ‘lifestyle’ drugs: The actual breakthrough was the social imagining of the compound as an im-potency cure . . . The marketing environment was decisive in mustering supportfor what started out as an unwanted ‘side-effect’. Viagra was ‘discovered’ whenthe side effect was interpreted in light of the question: Can we manufacture itand sell it at a profit? (Letiche, 2002: 248) Complicating the Viagra legend is the task of Viagra Studies, but we canonly pursue a bit of it here. Let us return to my perspective as a psychol-ogist employed in the world of urology.
The popularity of essentialist thinking about sexuality towards the end ofthe 20th century is one of the most important factors paving the way forthe love affair with Viagra (Stulhofer, 2000; Tiefer, 1996). The trend oflooking towards biology for the ‘most basic’ explanations of complexhuman behavior, sidelined during the socially conscious 1970s and revivedby sociobiology in the 1980s, escalated in the 1990s along with the maniafor genetics and molecular biology and their magical promises. President 2006 SAGE Publications. All rights reserved. Not for commercial use or unauthorized distribution.
02 Tiefer 065049 (bc-t) 2/6/06 1:05 pm Page 283 George H. W. Bush declared the 1990s ‘The Decade of the Brain’, andpublicity about genes and physiology throughout the decade doubtlesslycontributed to the immediate and unquestioned acceptance by 1998 of amedicine for impotence and the claims that impotence had physical causes(Tyler et al., 2003).
Masters and Johnson’s (1966) physiological research on sexual response had placed genital and nongenital sexual physiology in public discussionin the 1960s. They added the use of high-technology genital measures tothe 20th century’s long-running search for the bases of gender differencesin sexuality. However, the sex therapy treatments they and othersdeveloped in that era bypassed physiological interventions in favor ofpsychoeducation and behavioral therapy (Hartman and Fithian, 1974;Kaplan, 1974; Masters and Johnson, 1970). A philosophy of learnedrather than inborn function was so deeply a part of views of sexualproblems that women with complaints about orgasm were called ‘pre-orgasmic’ rather than ‘dysfunctional’ (Barbach, 1975). Various incarna-tions of nonmedical sex therapy flourished for a decade.
Around 1980, however, the situation began to change as psychiatry swerved strongly towards a more biomedical and psychopharmacologicalmodel. The publication of a hugely expanded third edition of theAmerican Psychiatric Association’s (APA) list of mental conditions, theDiagnostic and Statistical Manual of Mental Disorders (American Psychi-atric Association, 1980), signaled two fateful developments for theconstruction of sexual life and problems. As David Healy (2002: 7) putsit, ‘1980 is [the] year in which a new biomedical self was effectively born’.
First, the APA’s new classification defined sexual problems as disorders inperforming a normative sequence of genital functions based on the allegeduniversal trajectory of Masters and Johnson’s ‘Human Sexual ResponseCycle’. Sexual satisfaction was assumed to be a subjective byproduct ofproper physical function, and improper genital function was equated withdissatisfaction and classifiable disorder (Tiefer, 1991). Other forms ofdiscontent or disappointment were downgraded to matters of style, idio-syncrasy, or perhaps culture; whatever they were, they were marginal touniversal human sexual norms.
And, second, the APA’s manual began to be used in the rapidly prolif- erating new health insurance arrangements of industry and government.
All insurance reimbursement of sexual problem treatment soon requiredthe assignment of one of the conditions listed in the APA manual, leadingto its sexual function model being taught as the only way to classify sexualproblems. That universalized sexual function sequence – desire, arousal,and orgasm – remains authoritative today (Potts, 2002; Tiefer, 2004).
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02 Tiefer 065049 (bc-t) 2/6/06 1:05 pm Page 284 During this time, a new group of biomedical sex experts was gainingauthority. In 1978, which found on the bestseller list both Shere Hite’sReport (1976) and Ehrenreich and English’s (2005 [1978]) book explain-ing why the medical model rarely served women’s interests, a group ofurologists and other physicians met in New York to discuss the physiol-ogy of erection. As one of the participants later gushed, ‘That meetingbecame the turning point, changing forever the old, erroneous way ofthinking of impotence as being exclusively a psychogenic problem’(Wagner and Kaplan, 1993: 22). This extreme claim (‘old, erroneous . . .
impotence as exclusively a psychogenic problem’) became the officialpunching bag for medicalizers as they shaped a new, mechanistic view oferection, and, by extension, of sexuality.
Claiming that their physiological science would correct the unscientific errors of the past, urologists and their allies often took a combative tone,as in a 1980 pro-endocrinology article in the Journal of the AmericanMedical Association, ‘Impotence is not always psychogenic’ (Spark et al.,1980). From these early meetings, the International Society for Impo-tence Research (ISIR) was formed in 1982, spawning regional chapters inEurope, the Asia-Pacific, and Latin America as well as half a dozenspecialty medical journals.7 A new area of ‘male sexual dysfunction’ beganto grow within the surgical subspecialty of urology with bold claims about‘the emergence of the urologist as the primary co-ordinator of care forthe patient with sexual dysfunction, whether the cause of that dysfunctionis an organic, a psychogenic or, as sometimes occurs, a combination one’(Krane et al., 1983: xiii).
To enhance their treatment repertoire (limited to surgical implants in 1980), some urologists experimented on themselves and on volunteerswith nerve-affecting drugs and penile injections. A watershed momentoccurred at the 1983 American Urological Association convention whenGiles Brindley, a British physiologist and physician, injected his penis withphenoxybenzamine just prior to his lecture and, then, dropping his pantsbefore the astonished crowd, displayed his erection.8 By the mid-1980s asmall group of physicians succeeded in finding drugs that produced erec-tions, although the pharmaceutical industry was not involved at that time.
The point was that these were well known, older compounds that had beenregistered and marketed for other purposes. No clinical trials were conducted. . . There seemed to be no hurry as the patents of these drugs were old andthe size of the market was not known with any precision. (Wagner and Kaplan,1993: 49) There were also experimental surgical procedures to correct waywardblood vessels or to install a permanent penile prosthesis if all else failed. 2006 SAGE Publications. All rights reserved. Not for commercial use or unauthorized distribution.
02 Tiefer 065049 (bc-t) 2/6/06 1:05 pm Page 285 A self-help group, ‘Impotents Anonymous’, started in 1982 by a manpleased with his penile prosthesis, sprouted chapters and meetings spon-sored by prosthesis manufacturers in which urologists answered questionsabout impotence (New York Times, 1984).
The movement of significant numbers of urologists into this new specialty was probably connected to the development of shock-wavetherapy (‘lithotripsy’) for kidney stones. The FDA first approved alithotripsy machine in 1984, rendering obsolete in one stroke a mainstayof urological surgical practice. Lithotripsy was performed on an outpatientbasis, the initial investment was substantial, and the earnings potential wasfar less than for surgery. At about the same time, noncancerous prostateenlargement, a common experience of men over 60, began to be treatedwith medications instead of surgery, removing another major source ofwork for urologists.
The attraction of specializing in men’s sexual problems (which meant erectile dysfunction, or ED) grew throughout the 1980s. When I firstbegan working in departments of urology in 1983, the field of men’s sexu-ality was not only small but marginalized, a locus of teasing and stigmafor the physicians involved. This declined as the field grew, especially afterthe executive committee of the American Urological Association (AUA)passed a legitimacy decree in 1990, ‘AUA Policy Statement: Sexualdysfunction in the male is a disease entity, the diagnoses and treatmentsof which deserve equal attention to that given other diseases’ (AUA,1993: 8). Physicians, who had earlier found professional recognition inmastery of surgical intervention and new technologies, now had to adaptto a field requiring the discussion of emotions and intimate practices.
Within a few years, however, expensive new technologies entered the diagnostic workup of ED, such that by the early 1990s, there was not allthat much doctor–patient discussion needed prior to making a diagnosisand treatment recommendation. Patients often underwent extensiveassessment of genital nerve function, hormone status and genital bloodvessels, and took nocturnal erection monitoring kits home overnight(Tiefer and Melman, 1989). The focus on the penis as the patient wasshown by the absence of wives or other sex partners as routine partici-pants in the diagnostic workup. During the 1980s the growth of managedcare began to limit insurance reimbursement for the psychotherapeuticdiscussion of emotions and intimate practices, channeling most men withsexual questions and problems towards urology.
Thus the dramatis personae, the vocabulary, and the equipment for assessing impotence were all firmly focused on biology years beforeViagra. In 1988, 10 years before Viagra, Time magazine featured a reviewof the new injection and surgical therapies under a headline that serves asthe mantra of medicalization, ‘It’s not all in your head’ (Toufexis, 1988).
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02 Tiefer 065049 (bc-t) 2/6/06 1:05 pm Page 286 Urologists were officially positioned to rescue men from the ‘old, errone-ous way of thinking of impotence as exclusively a psychogenic problem’.
The coup de grace for a contextualized view of sexual function, thoughpsychosocial sex experts failed to recognize it at the time, came in 1992,at the first (and still to this date only) National Institutes of Health (NIH)consensus conference on sexuality. Titled ‘Impotence’ and held the sameyear as the Nitric Oxide breakthrough, it was organized by the Kidney,Digestive and Diabetes section of NIH (NIDDK) and starred the newurological scientists of the penis. The outcome of this three-day event wasa 34 page document about impotence that made occasional mention offactors like culture, partners, lifestyles, sexual techniques and life-stagevariation (NIH, 1992). For the most part, it reified ‘erection’ as theessence of men’s sexuality, and called for a huge new program of researchinto physiological details and treatments. It got huge publicity.
I persuaded the editor of the International Journal of Impotence Research to devote a special issue of his journal to the NIH Report andto invite commentaries, and I supplied a list of 34 sexological experts,hoping for some trenchant critiques. I expected the sexological commen-taries to assert the importance of a contextualized understanding of sexu-ality. The editor invited many urologists to contribute as well. The finalproduct (International Journal of Impotence Research, 1993, volume 5,number 4) consisted of the NIH Report plus 35 comments. The 21urological comments were all very enthusiastic. Only 14 comments werereceived from the sexologists. Of those 14, only three took a critical pointof view and described biases, omissions, and politics in the NIH Report.
The rest said the report had good points as well as omissions, and somewere even conciliatory. I was surprised and dismayed. The biologicaljuggernaut of sex seemed a fait accompli. Five years later, when Viagra wasapproved, objectors were, predictably, practically nonexistent.
Conclusion: Sexuality studies in the era ofsexuopharmaceuticals My interest in the Viagra phenomenon has been refracted through afeminist sensibility. What will this phenomenon mean for women’s livesand sexual experiences? How will Viagra, the drug, and Viagra, thephenomenon, affect gender politics? In light of these questions, three ofthe areas that have most intrigued me in the eight years since the approvalof Viagra have been (1) the ‘Hunt for the Pink Viagra’, (2) the explosive 2006 SAGE Publications. All rights reserved. Not for commercial use or unauthorized distribution.
02 Tiefer 065049 (bc-t) 2/6/06 1:05 pm Page 287 growth of urology and nonurology clinics for ‘female sexual dysfunction’,and (3) the interaction between the business world of the pharmaceuticalindustry and sexuality drugs. Whereas the first two issues obviously pertainto women’s sexual lives, the third turns out to be no less connected.
The very well-financed ‘Hunt for the Pink Viagra’, a search to develop drugs for women that will be blockbuster equivalents to ‘original Viagra’has resulted in many different pill/patch/spray/cream products underinvestigation (Enserik, 2005). No drug has yet acquired FDA approval,9but that does not mean drugs are not being prescribed every day towomen for functional deficiencies diagnosed in sexual drive, arousal ororgasm according to the classification system adopted in 1980 (AmericanPsychiatric Association, 1980). This is because the branding of Viagra hassucceeded so thoroughly in rationalizing the idea of sexual correction andenhancement through pills that it seems inevitable and only fair that sucha product be made available for women. Feminist rhetoric of equality andchoice has been recruited by journalists and public relations promoters ofsexuopharmaceuticals to exquisite effect in this instance. Patients canacquire nonapproved drugs through off-label prescribing, a phenomenonthat has changed doctors’ prescribing practices dramatically in the pasthalf-dozen years (Buist et al., 2005). People routinely read about newdrugs in magazines and see them promoted by doctors on television longbefore they are approved. It seems only a matter of time before mostpeople will have had some experience with sexuality drugs.
The growth of diagnostic and treatment clinics for ‘female sexual dysfunction’ is an aspect of the Viagra phenomenon just getting off theground. Several such clinics opened as parts of hospital urology depart-ments between 1998 and 2001, but the two earliest (at Boston Universityand UCLA) recently closed when their directors went into privatepractice. Some private clinics have recently opened with spa and yogaservices provided along with diagnoses and treatments for women’s‘sexual health’.10 A few sexuality clinics associated with hospitals advertiseservices for women but as yet have far more to offer male patients (e.g.,‘Sexual Medicine Clinic’ at the Cornell University’s Medical School inNew York).11 The history of these clinics may parallel that of behavioralsex therapy clinics which opened in many medical center psychiatrydepartments in the 1970s only to be closed as psychiatry turned towardspsychopharmacology in the 1980s. Changing fashions in psychiatry as wellas urology are part of the Viagra phenomenon.
Finally, headlines from the world of business news closely affect sexuopharmacology. The failure to get a ‘Pink Viagra’ drug approvedseems not to be due to discursive weaknesses in the medical definitionsof women’s sexual problems, though there are plenty of those. Rather,an FDA advisory committee unanimously rejected the first medication 2006 SAGE Publications. All rights reserved. Not for commercial use or unauthorized distribution.
02 Tiefer 065049 (bc-t) 2/6/06 1:05 pm Page 288 for the new ‘female sexual dysfunction’ in December, 2004 because ofnewly heightened drug safety concerns resulting from the recent scandalover Vioxx, the pain medication accused of causing thousands ofdeaths.12 Similar coincidences and political events fill pharmaceuticalhistory (Hilts, 2003).
The women’s health movement made use of many such political moments in its struggle to affect legislation, funding, research priorities,insurance policies and health care for women in the 1970s and 1980s(Morgen, 2002; Seaman and Wood, 2000). Copying many of its tactics,in 1999 I began an educational campaign to raise awareness about howthe new sexuopharmaceutical era was riven with corrupt clinical and scien-tific practices and was promoting faulty classificatory regimes (Tiefer,2001).13 This consumer campaign to challenge the disease-mongering of‘female sexual dysfunction’ is part of a new public health advocacymovement dealing with corporate practices that affect health, such asthose in the tobacco, automobile, and food industries (Freudenberg,2005). Resistance in the sexuopharmaceutical era will employ manyfamiliar political strategies as it seeks to reveal new centers of controldisguised as forms of sexual emancipation (McWhorter, 1999).
1. ‘Demedicalization’ was notably described by Renee Fox (1977) as a growing social trend towards greater patient–doctor egalitarianism, self-care, and physician regulation. Golden (1999) sees it more as ahistorical process, signifying diminished cultural authority of medicine andthe transfer of diagnostic and treatment power to other professions. I amusing the term here to highlight the diversification and heterogeneity ofexpertise claims in the era of mass media and the Internet.
2. Nutraceuticals and cosmeceuticals are foods and cosmetics that are claimed to contain ingredients that provide health benefits. They are a part of newalternative health, wellness and anti-aging industries of rebrandednutritional supplements, some of which may contain genetically modifiedelements. Many pharmaceutical companies are developing divisions todevelop and sell these over-the-counter products.
3. (accessed 16 November 2005).
4. ‘The man, the myth, the Viagra’ (Akass and McCabe, 2004: 243).
5. An analysis of how drugs get named, including guesses about how Viagra got its name is offered on 3 January 2006); also see Katzenstein, 2001: 26.
6. The precise chronology of Pfizer’s activities is still problematic. A 2002 BBC documentary, ‘Sexual Chemistry’, reports, ‘In 1985, the drugcompany Pfizer was working on treatments for the heart complaint, angina.
Dr Ian Osterloh and Dr Gill Samuels were using sildenafil citrate to relaxblood vessels, in the hope of easing the pain of narrowed cardiac arteries’see 2006 SAGE Publications. All rights reserved. Not for commercial use or unauthorized distribution.
02 Tiefer 065049 (bc-t) 2/6/06 1:05 pm Page 289 (accessed 31 December 2005). In Pfizer’s authorized history, by contrast, itsays that ‘in 1986, Pfizer researchers decided to focus on an enzyme, PDE5, present in vascular smooth muscle cells and platelets’. They learned thatinhibiting PDE 5 might have the effects they wanted. ‘Over the course of 3years, [they] synthesized and tested hundreds of compounds [PDE 5inhibitors], and in December 1989 they found one that looked promising[sildenafil citrate]’ (Katzenstein, 2001: 10).
7. ISIR changed its name to ISSIR (International Society for Sexual and Impotence Research) in 2000 and then to ISSM (International Society forSexual Medicine) in 2004. All the national and international organizationswent through similar name evolutions and now claim to be all about ‘sexualmedicine’. They are still dominated by urologists.
8. Loe (2004) says that no one she interviewed claimed to have actually witnessed this event, but that it has attained such legendary status there isan animated recreation of it on 11 March 2006). Wagner and Kaplan offer many backgrounddetails of this event (1993: 18–29).
9. I am writing this on 7 January 2006.
10. See (accessed 11 March 2006).
11. See 12. There is much already published about the creation of ‘female sexual dysfunction’ – or FSD – (Moynihan, 2003; Tiefer, 2004) and there is agreat deal of information on March 2006) about the FDA advisory committee hearing thatvoted against Intrinsa, the first proposed FSD drug.
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Wright, P. (1996) ‘Nitric Oxide: From Menace to Marvel of the Decade. A Briefing Document Prepared for the Royal Society and Association of BritishScience Writers’, URL (accessed 6 January 2006): Biographical NoteLeonore Tiefer is a New York sexologist and clinical psychologist, well knownfor her activism in the international movement that challenges the uncheckedgrowth and influence of the pharmaceutical industry (
She holds an appointment in the Psychiatry Department at the NYU School ofMedicine and has a Manhattan private practice in psychotherapy and sextherapy. She is the author of Sex Is Not a Natural Act (2nd edition, Westview,2004) and co-editor of A New View of Women’s Sexual Problems (Haworth,2001). Dr Tiefer has been President of the International Academy of SexResearch, Secretary of the Society for Sex Therapy and Research, and a boardmember of the International Society for the Study of Women’s Sexual Health.
Address: Department of Psychiatry, NYU School of Medicine, 163 ThirdAvenue #183, New York, NY 10003, USA. [email: [email protected]] 2006 SAGE Publications. All rights reserved. Not for commercial use or unauthorized distribution.



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