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The Second Sexual Revolution
Viagra was just the beginning. Soon we will all be medicated and wired for high-performance romance. By JACK HITT
Drawing by Tom Tomorrow
t was only two years ago that Bob Dole went on "The Larry King Show" to discuss his prostate-cancer operation. During a commercial break, so the story goes, King leaned over to ask his old friend, confidentially, how he was dealing with the operation's grimmest side effect, impotence. Dole cheerfully informed the talk-show host that there was a new drug, Viagra, and miraculously, it had cured the problem. King asked Dole if he would discuss it on the air, and Dole said sure, why not?
The world was about to become a very different place. Viagra would cycle through the expected paces of pop-culture acceptance with stunning speed. Leno and Letterman got an entire summer's worth of monologues off the subject. For a while the papers regularly pumped out clowning (and possibly true) stories about the drug -- there was Frank Bernardo, 70, who left his wife, declaring, "It's time for me to be a stud again"; there was also Gen. Sani Abacha of Nigeria, who died in the midst of a Viagra-fueled encounter with two women in his magisterial bed.
But the jokes are over. Viagra's sales topped $1 billion in the first year, and Pfizer is now the second-largest drug company in the world. The drug's use has leveled off, but consider the
level: nearly 200,000 prescriptions are filled each week, and 17 million Americans have used the drug. Viagra has been embraced by the well off (4 percent of the total population of Palm Beach County has a prescription), but not only by the well off. Not long ago, Wal-Mart and Kmart had a Viagra war that drove the per-pill price down from $10 to $7.80.
Jack Hitt is a contributing writer for the magazine.
And so, no one talks about it anymore.
Welcome to the lull. It's as if a freak 20-foot swell crashed on the beach, leaving a few new gullies. It's over. Go back inside. Everything is back to normal. Everything except that tsunami on the horizon.
At this moment, there are at least a dozen new Viagra-like medicines and devices currently in clinical trials. Many of these drugs are for men, but this time around, there are just as many for women -- specifically, for a new phylum of illness, female sexual dysfunction, which will soon cycle through the same paces as "erectile dysfunction," setting the word "frigidity" alongside impotence in our dictionary of merry old archaisms. "Our knowledge of sexual health is in revolutionary mode," says Dr. Irwin Goldstein, a Boston University urologist and pioneer in the field.
With $1 billion in sales for Viagra, the research pressure is intense, yielding paper titles like "The Ejaculatory Behavior in Sexually Sluggish Male Rats. . . . " Scientists, doctors and pharmaceutical companies are racing to discover newer and better drugs. Who doubts they will improve the lives of those who suffer from the newly discovered sexual disorders now showing up in the medical journals? But these drugs will also have, some say, an "enhancing" effect on normally functioning people. More important, the temptation for anyone to obtain these drugs will be more easily satisfied than ever before, since the family of pharmaceuticals inspired by Viagra is entering the market at a time when medicine is decentralizing, slipping the reins long held by doctors. There is already telling evidence that these new sex drugs may well do for medicine what porn did for the Internet -- constitute the killer ap that reshapes the industry in an age of patient choice and turboconsumerism.
hough most of us are inculcated with the belief that the totality of sex is unknowable, maybe even divine, once you've spent some time with the new sex researchers, you learn that the actual mechanics of it all aren't that lofty. Compared to a kidney or a lung, our genital rig is basic stuff, the corporeal equivalent of a 1968 VW Beetle engine. Ensure that the "hormonal milieu" is properly gauged and that there is enough blood flow, and the engineering work is pretty much done -- for men and women alike. (Then there needs to be passion, romance and love perhaps, but urologists continue to leave these areas of research to poets and musicians. So far.)
"Not to discount psychological aspects," said Goldstein, who was a member of the team that treated Bob Dole, "but at a certain point all sex is mechanical. The man needs a sufficient axial rigidity so his penis can penetrate through labia, and he has to sustain that in order to have sex. This is a mechanical structure, and mechanical structures follow scientific principles." Goldstein, seated in his office at Boston University Hospital's Sexual Health Clinic, poked his forefinger into the palm of his hand and explained that the "typical resistance" posed by the average vagina is a measurable two pounds. The key is to create an erection that doesn't "deform" or collapse when engaging that resistance.
Sexual Healing: Soon, a variety of remedies for sexual dysfunction -- and ways to enhance sexual performance -- will become available to men and women. From left to right:
Testosterone patch: This device, made by Procter & Gamble, delivers testosterone to the pelvic region. But it's not for men only. Several companies are working on a version for women whose testosterone production and sex drive have decreased after hysterectomies or other sex-organ surgery.
Viagra: The Granddaddy of pharmaceutical sex medicine, the little blue pill was introduced to the market in 1998. Its popularity has helped to make its producer, Pfizer, the second-largest drug company in the world.
Prostaglandin E-1 cream: To stimulate blood flow to the genital area, Vivus is developing a topical cream for women that contains this ingredient. It is intended to alleviate arousal and orgasm dysfunction and enhance vaginal lubrication.
Alprostadil cream: NexMed is working on its own topical cream for women, similar to prostaglandin E-1. It is also developing a topical therapy for male impotence.
Clitoral device: Beyond pills or hormonal creams, one company is taking a nonpharmacological approach to treating women with sexual dysfunction. UroMetrics is developing the Eros Clitoral Therapy Device, a small pump with a cup, about the size of a thimble, that fits over the clitoris. It is designed to stimulate blood flow to the organ, thereby enhancing sensation and lubrication and enabling its user to achieve orgasm more easily.Photograph by
Clang for The New York Times
"I am an engineer," noted Goldstein, who in fact collaborated with Boston University's department of aerospace engineering in formulating his theories. "And I can apply the principles of hydraulics to these problems. I can utilize medical strategies to assess, diagnose and manipulate things that are not so straightforward in psychiatry."
That's something new. For most of the 20th century, any sexual complaint was treated on the couch, not in the lab. Only comparatively recently has impotence been understood to be an organic disease -- potentially identifiable and treatable with medicine.
The change is part of a cultural shift that dates back to the birth control pill, when mostly young people were liberated to experiment with sex fearlessly outside of marriage. Many moral conservatives continue to condemn the era for unleashing the Pandoran epidemics of teenage pregnancy, sexually transmitted disease and moral decline. But this telling of the story ignores a more subtle and significant shift. Average folks -- young and old, liberal and conservative -- began to accept that sex was not a biblical imperative whose sole aim is procreation, but a lively part of good health -- something to be enjoyed, like great food and laughter, well into old age. This is the revolution that Bob Dole has joined at the barricades.
The distinction is not just medical; it's metaphysical. Psychological problems carry with them the full freight of personal responsibility. But a physical problem seems more like a cosmic error, something unrelated to a person's actions. It's no flaw in your manhood or womanhood if your sexual organs don't work. It's a "disorder" -- and by being labeled as one, it becomes something detached from your own true self and easier for a patient to emotionally confront and for a doctor to treat.
Breaking through the wall of the patient's superego, though, was only half the challenge for researchers like Goldstein. Medical approaches to sexual problems have been thwarted by another obstacle: there wasn't anything medicine could do about them. "Unless you have a treatment, you don't have a condition," Goldstein said. "If there is nothing for me to say except, 'See a psychiatrist,' then what is the rush to accurately describe and research your condition?"
For the longest time the only treatments were for men, and they were practically medieval. Outside the opaque world of aphrodisiacs, medicine had come up with only one solution for male impotence: the penile implant, a surgical procedure developed by urologists in 1973.
"I can remember," Goldstein said of the slow progress. "It was 1983, when a doctor named Giles Brindley came up with the first drug-induced erection. At a urology meeting, he was wearing sweat pants. He excused himself for a minute and went to the men's room and injected himself. When he came back, he lowered his pants to show us a stunning and natural erection. He walked down the aisle and let us touch it. People couldn't believe it wasn't an implant."
Goldstein noticed a look of considerable distress on my face, and added something that he thought might comfort me: "It was a bunch of urologists."
Not long after Dr. Brindley's performance, a company based in California, Vivus, perfected an erectile suppository called MUSE (medicated urethral system for erection). Although it is effective, it requires that the suppository be inserted in the tip of the penis. Pfizer's truly great breakthrough with Viagra was inventing an erectile treatment that didn't make the average person double over in horror.
As the cures have become more user-friendly, the discourse among the general population has become more comfortable, too. The morning I was meeting with Goldstein, a patient showed up and allowed me to join his consultation on the condition that I would not publish his name.
The patient, a Dominican-born social worker in his 30's, was accidentally kicked in the groin years ago. The damage was severe. A beefy, rounded man, he sits on the examination table sidesaddle, his ankles crossed coyly. Both he and his Rubenesque wife curl their shoulders inward and keep their heads bowed, as if in shame. It's clear that the ripple effect of this simple injury has affected every part of their lives and marriage.
When Goldstein asks the patient what happens when he makes love to his wife, he says, "I don't know." He looks at me with the same tepid smile and pinched eyes that Bob Dole has in that magazine ad. "I don't know," he repeats. It's fascinating to watch Goldstein work this tiny room, this miniature stage, trying to determine just what mix of clinical authority and just-us-guys informality will make this doctor-patient interview work. He has the uncanny ability to radiate locker-room crassness and professional etiquette almost in the same sentence. He's dressed in a crisp gray pinstriped suit, but he possesses a soft casual voice that lopes amiably around his words, like Donald Sutherland's. One wall of his office is covered with half a dozen sheepskins, proving his professional bona fides to anyone who needs that. Over his door is a walrus penis bone, two feet long -- a conversation starter for a certain kind of person. The wall plate of his light switch is a cartoon of a doctor and the switch itself doubles as the doctor's . . . well, funny stuff for an altogether different kind of person.
The formal "make love" query isn't working, so Goldstein tries again: "When you lie down naked to fool around with your wife, describe what happens." The social worker's eyes pinch harder. I involuntarily curl my shoulders -- as if to acknowledge our common genomic humanity. (I feel certain my face resembles, at this time, the Greek mask of tragedy.)
"It takes a long time, a long time to get ready, you know," he says quickly, as if he fears Goldstein might become even more "street" in his queries. Again, he looks at me. "A long time, you know." I nod furiously and make a noise similar to a kitten coming upon a saucer of milk.
Goldstein says: "Here's what's happening. Normally when you get an erection, the blood flows like this." He walks to a sink and turns the spigot on full blast. "Now what's happening is this." He slows the flow to a trickle. "Everything works. It's just taking too long. One of your arteries to your penis is blocked. The good news is we can fix that with a penis bypass operation." He punches in a video showing a highly magnified surgery, the screen all liquidy pinks. We watch as doctors take a redundant piece of artery from the stomach and then use it to bypass the damaged artery in the penis. "I've done 600 of these operations. You have a highly significant chance for a full recovery."
The patient laughs involuntarily -- the kind of irrepressibly giddy laughter that accompanies extremely good fortune on par with winning $100million or being selected by NASA to fly to the moon. The wife laughs. It's absolutely infectious. I start laughing. It is a small celebration of unadulterated laughter. This news puts everyone in the peppiest mood. We all shake hands, awkward but well meaning, like passing the peace in church.
"I am going to prescribe Viagra for him," Goldstein told me back in his office. "Not for sex. But as a sleeping pill." Goldstein explained that the average male gets five erections per night in his sleep. "Our belief is that the night erection is the battery recharging time. Your penis is guaranteed to have one and a half to three hours of erection time every night. You know how doctors now recommend taking a single aspirin a day to prevent heart attack? I predict one day there will be evidence to support a medication -- something like Viagra -- that enhances erections. Call it erectogenic."
ypotheses and fresh ideas seem commonplace in this new field now that Bob Dole has made the world safe for sexual-health research. Some of them are simple. For instance, Goldstein has made it a minicrusade to banish the standard bicycle seat, which crushes the main nerve cluster leading to the genitalia and, Goldstein believes, accounts for the relatively high incidence of sexual dysfunction among bikers. But a great deal of the cutting-edge discoveries are occurring for women. Last year, the Journal of the American Medical Association published a study reporting that 43 percent of women experience some kind of sexual dysfunction. Just a few weeks ago, the Network for Excellence in Women's Sexual Health was organized to help doctors and health care professionals who want to enter this emerging field.
A lot of the revelations about women stem directly from studies on men. Women also have four or five nightly clitoral "erections," Goldstein said, which are crucial for the maintenance of their sexual health. Yet even among these researchers, the presumption still persists that men's sexuality is mere hydraulics and that women's sexuality is more complex. "We're being forced to realize that men aren't so simple either," Goldstein said, "because of what we've learned about women."
Take, for example, the case of a Boston professor who participated last year in a clinical trial to measure Viagra's efficacy on women and spoke to me only on the condition of anonymity.
Though most of us are taught to believe that the totality of sex is unknowable, the mechanics of it aren't lofty. Compared to a kidney, our genital rig is the corporeal equivalent of a 1968 VW beetle engine.
"Female sexual dysfunction is a very real problem for some people," the 55-year-old told me, recalling the day in 1994 when she learned she had breast cancer. She endured a lumpectomy, an oophorectomy (removal of ovaries) and finally a hysterectomy. When it was over, she said, "it was as though my mind was capable of being sexual but it was disconnected from my body. There was no there there. I felt like I had been neutered."
Admitting to a "a strong libido," she went to her doctor to find out what she could do. He told her "more or less, women at your age don't care about sex anymore." So she read up, asked around and soon heard about the Boston University clinic run by Goldstein and his two partners, Jennifer Berman, a urologist; and her sister Laura Berman, a sex therapist.
The doctors selected the professor for the early trials, in part because her problem is complex. Viagra achieves its effect by increasing blood flow to the genitals, but that would not be enough. According to the Bermans, the pathways connecting the professor's desire (she felt it cerebrally) with her physical arousal (she felt nothing genitally) had been interrupted. Such communications are facilitated by hormones, specifically the right levels of estrogen and testosterone. She began testosterone cream applications accompanied by an estrogen ring inserted in the vagina like a diaphragm for slow release of the hormone. While this adjustment helped reconnect the brain with the genitals, there still wasn't enough blood flow during stimulation to regularly effect an orgasm. So Viagra, too, was tested.
"The combination was so successful," she said. "With Viagra I have orgasms, much more intense orgasms."
Shaping the brave new world of sexual medicine: From left, Jennifer Berman, urologist; Laura Berman, sex therapist; and Irwin Goldstein, urologist. Photograph by Clang for The New York Times.
This case reveals just how detailed sexual disorder studies have become in a fairly short time. In fact, in the October 1999 issue of the journal Urology, the three partners at the Boston clinic broke down the four basic kinds of female sexual dysfunction that either are or will soon be treatable. The professor's basic condition is known as Sexual Arousal Disorder. (It even has an Oprah-ready acronym.) Sexual thoughts occur, but they aren't communicated to the genitals.
The other ailments are Orgasmic Disorder which includes inorgasmia (inability to have orgasm) and the unnamed condition of "muffled" orgasms. The third new subdisease is Sexual Pain Disorder, which includes vaginismus (involuntary muscle spasms) and dyspareunia (general genital pain). The final one is Hypoactive Sexual Desire Disorder, more or less the opposite of the professor's condition, in which the genitals may or may not work but it hardly matters because the patient lacks libido and the usual sexual thoughts or fantasies that precede a sexual encounter.
Many of these conditions overlap and are often accompanied (or caused) by emotional problems like depression. "It's more of an algorithm," Berman said. But in the overwhelming majority of her patients' cases, she added -- and there's a furious debate embedded in the rest of this sentence -- the organic disorder precedes the emotional ones.
This is not to say psychological sex problems don't exist. "There is no drug," Laura Berman said, "that will restore a satisfactory sex life to a woman who hates her husband." But she estimated that only about 20 percent of her patients have purely psychogenic problems; for the other patients, there is a raft of new procedures to measure their sexual health.
In many clinics, a typical female patient would first submit to a photoplethysmography. According to James Yeager, chief research scientist with the drug company NexMed, the device is a "black box with wires coming out of it with a kind of penlight that is inserted in the vagina." The woman then stimulates herself while a photo cell in the penlight measures the change in redness of the vaginal tissue and then calibrates blood flow. There are drawbacks to this procedure, which are obvious, and if they're not, send me a postcard and I'll drop you a line. I'm moving on.
At the Boston University Hospital clinic, genital blood flow is measured with a "high-frequency laser duplex Doppler," Laura Berman said, "which is like a sonogram." Then the clinicians also measure vaginal pH (using a digital pH probe), the structural architecture of the organ or "vaginal compliance" (using a Schuster balloon) and finally, clitoral and labial vibratory threshold (using a biothesiometer). "We record these measurements at baseline and after sexual stimulation with a standardized 15-minute erotic video and vibrator," the authors write in their Urology article.
With men, the entire process is quite similar. In the old days, men were outfitted with a "penis cuff" -- a wraparound device like a petite blood-pressure gauge. Today, a sonogram is more accurate and yields a photograph mapping out the geographies of blood flow. Once the doctors examine the differentials in these measurements, a diagnosis follows and, when appropriate, medical treatment.
iscovering those treatments is the province of researchers, and one of the most pre-eminent of them is Goldstein's colleague and Laura Berman's sister, Dr. Jennifer Berman, one of the nation's few female urologists. Berman agreed to see me under extraordinary circumstances. Only three days before, she had given birth to her son, and the birth was difficult. Still, amazingly trim in her slacks and sailor's peacoat, Dr. Berman said she was happy to come to her office since she also wanted to check on the status of a new grant application for a major research program, which she was eager to explain.
"When I was trained in urology," she said, walking briskly down the street to her lab, "I was struck at the lengths surgeons went to, when operating on men, to preserve the nerves and blood vessels that are connected to the penis. But when we operated on the female pelvis, we just cut everything out. And I would ask, 'Where are the nerves?' And you know what? No one even knew.' She said this, strangely, not with anger but with an explorer's excitement. "So we need fresh cadavers. They're about $3,000 each. You know, if you look in any anatomical text, there are 20 pages on male sexual anatomy and 2 pages on the female. And there are conflicting reports as to how one should describe the female anatomy. We know there is a major plexus of nerves along the cervix but how they connect to the clitoris and vagina is not understood at all. In men, we know that there is a cluster of nerves along the lateral side of the prostate. That's why there's a special operation."
I didn't say anything for a while. It wasn't the usual male-feminist discomfort, although it's never easy being the sole representative of the sex when one of those grotesque inequities pops into view. No, rather, it was an acknowledgment of the air of frontier desperation that characterizes so much of this research: so many obvious things to do, so many cultural obstacles. I imagine there was a similar feeling surrounding anatomy in Dickensian England, when early surgeons robbed graves to find corpses to practice on. Or in the early days of organ transplantation (in the 60's), when doctors would occasionally get caught slipping really nice kidneys from the nearly dead. These dissonances occur in medicine when doctors have sneaked ahead of the culture in redefining something holy -- the sanctity of the dead, respect for the living and now: the mystery of sex.
Berman led me into a modern brick building, where we passed through a number of security checks. We stepped into a recovery room, where two surgeons were working on one of Dr. Berman's projects. Five white New Zealand rabbits had just undergone oophorectomies to surgically induce menopause. A sixth was feeling the anesthesia take effect. Her head was flopped forward, now too heavy to lift. Her eyes had gone slack.
The organ chamber at the urology lab of Boston University, where rabbit vaginas are tested by researchers. Photograph by Clang for The New York Times
Afterward, Berman will test a new treatment. A lot of Sexual Pain Disorder is caused by "inadequate secretion in the vaginal canal," Berman said. So she will administer an agent that will naturally switch on the body's mucosal membranes to start producing lubrication.
In another wing of the lab, she opened a refrigerator and pulled out a tray holding a few dozen capped test tubes.
"These are rabbit cervixes that were removed after the drug test," she said. "They'll be tested to see if there's been an increase in mucosal activity."
She then showed me an "organ chamber." In outsize tubes are clips that hold stretched segments of the smooth muscle from the clitorises, vaginas and penises removed from animal specimens or discarded human tissue after surgery.
"I can do any kind of smooth muscle test," Berman said. "The tissues are placed in these chambers and you look at how they respond to drugs. I can show you how tissue contracts or relaxes. I can stimulate it electronically and look at the reactions in the presence or absence of different drugs. And it's all recorded here." She pointed to a needle scratching across an unscrolling cylinder of paper, like a seismograph.
These tests represent the experiments now being conducted in university labs and corporate R-and-D facilities all over the country. The cumulative lesson of much of this research is leading to two categories of treatments -- hormone therapy, which restores desire, and various drugs, which amplify the sensation of arousal. Many companies are researching hormone medicines. Solvay already markets one called Estratest. Organon is in trials with a treatment called tibolone, which is believed to increase desire. Dr. Glenn Braunstein, an endocrinologist at Cedars-Sinai Medical Center in Los Angeles, is working on a "testosterone patch" under grants from the marketing giant Procter & Gamble.
But the real gold rush is occurring in the other field of research -- creating a drug to increase blood flow to the genitals. And just as Viagra as a pill was a kind of psychological breakthrough, the researchers looking for other blood-flow solutions want something simple -- a tablet or perhaps even better, a quick-acting cream that is stabilized at room temperature so that women can carry it in a purse like lipstick or men can just toss it into a shaving kit. The competition is furious among small firms, each with a blood-flow drug -- some for men, some for women -- that are anywhere from one to five years from getting to market. Herewith a sampling, complete with active ingredients:
* Vivus: prostaglandin E-1 cream.
* MacroChem: a gel, using a version of prostaglandin E-1 called Topiglan.
* NexMed: alprostadil, a variant of prostaglandin cream.
* Tap Pharmaceuticals: an apomorphine treatment formulated into a small tablet placed under the tongue.
* Pentech Pharmaceutical: ditto.
* Zonagen: phentolamine, in tablets and suppositories.
* Pfizer: Viagra for women (sildenafil).
* Palatin Technologies: a peptide molecule derivative called PT-14; in the earliest test stages.
* ICOS Corporation: a tablet code-named IC351. (That's all they would reveal.) Bill Gates, who may be telling us something, owns almost 13 percent of the company.
Infomercials have shifted from vegetable slicers and wrinkle tonics to "natural" aphrodisiacs. There is scarcely a tree left standing in the rain forest whose bark hasn't been stripped and tested for the alternative-health industry. The Internet is teeming with unsolicited ads for products with vaguely homonymic names, though none of them come close to Pfizer's allegedly unintended melding of "vital" and "Niagara" to generate the best product name since Coke. Some long-touted aphrodisiacs are now being tested, too. A derivative of chili peppers is in legitimate trials. Does this count as a drug?
NitroMed, a company based in Massachusetts, is working on a mixture of an old passion powder called yohimbe (stripped from the inner bark of the Corynanthe yohimbe tree in tropical West Africa) combined with an amino acid called L-Arginine to see if the two can work effectively as a vasodilator -- that is, a chemical that increases blood flow. Then there are the nondrug inventions. A company called UroMetrics is working on a vacuum device, fitted with a small cup the size of a thimble, and intended to draw blood directly to the clitoris. It might be easy to dismiss this as a sex toy, except that it's also in trials for Food and Drug Administration approval, and UroMetrics intends to distribute it only as a medical device via prescription.
While cruising the Patent Office's Web site (www.uspto.gov), I discovered that Vivus's claim to prostaglandin E-1 cream has been challenged by a Tennessee doctor named Michael Wysor. According to his patent attorney, Michael Ebert in New York, Wysor may have filed his invention after the original patent was granted to Vivus, but he believes there are technical challenges that support his claim.
Wysor, who ran two sexual-health clinics, in Knoxville and Johnson City, that have since gone bankrupt, has just finished a book proposal on erectile dysfunction. He has tried his cream on women informally, but refused to elaborate on his methods. That's just how crowded the field has become. Garage inventors are in on it.
The pace of change inside this small research world also means that almost no one is stopping to reflect on the implications of the drugs that are marching -- and there really is no stopping them now -- toward the marketplace. When I spoke to Leland Wilson, the C.E.O. of Vivus, about his company's new prostaglandin cream, he happily suggested that most women would be able to experience orgasm after just a few minutes of vaginal intercourse. Such a development seemed fraught with truly significant implications -- both good and bad -- but obviously fraught. When I pressed him to imagine some of the implications, he sputtered through several change-of-subject tactics.
"That is beyond the realm of medicine," he said. There was a quality to the conversation reminiscent of Werner von Braun, who supposedly once said, "I send the rockets up; where they come down is not my business."
"I find it simply incredible this whole thing is happening," said Leonore Tiefer, a psychologist at the New York University School of Medicine and pretty much the only critic of all this research I could find.
"There is no such thing as 'female sexual dysfunction,"' she added. "It's a social construction invented to benefit the drug companies." Tiefer believes that a kind of "magical thinking" infects the way most of us imagine our sexuality. That it can always be better, and that we resist the natural changes that define the arc of a well-lived life: "That's where this disorder comes in and says, 'If there is a change' -- and invariably there is a change in life -- then change is bad.' Ah, a problem! So we invent a universal model, a normative view of sex. If you don't get wet for X period of seconds from Y pressure of stimulation, then you have a problem."
When we operated on the female pelvis,' says one doctor, 'we just cut everything out. And I would ask, "Where are the nerves?" And you know what? No one even knew.'
Tiefer was evasive when I asked her about the existence of real medical conditions being cured by these new drugs. "What about the placebo effect?" she asked, when I offered up the Boston professor's case as an example. Tiefer believes the medicalization of sex gives people an out -- a way to avoid the root cause of their sexual problems. "I don't see many women depressed about the blood flow to the genitalia. They are depressed about many other things about sex, but not that. This research should be done, of course, but with a few dollars, by a few people, in a few places. But it should not be this Boeing of sex research."
Not surprisingly, many researchers dismiss Tiefer's ideas as rear-guard propaganda to protect the sex concession that therapists have held for so long. Fears that the medical establishment will big-foot the psychologists' business is not an imaginary concern these days. The central theme of Peter Kramer's "Listening to Prozac" is the observation that, in the treatment of depression, drug therapy has driven talk therapy right out of business.
"Every disease pharmacology has attacked in the last 50 years," Vivus's Wilson said bluntly, "has at some point been treated by psychologists, and as soon as pharmacology discovers the real organic reason for the disease and a method for treating it, then psychologists moved on to treat something else. That's exactly what's happening here." Precisely because "psychologists have never successfully treated sexual dysfunction in anybody," Wilson said, "business" was the real source of much of the current professional "squabbling." But not all of Tiefer's critics dismiss her apprehensions.
"There is a fear that Viagra might be used like Prozac," Laura Berman said, "as a sort of Band-Aid approach to therapy. And it's a risk, especially in men, that you might be treating the symptoms, not the problem."
But Tiefer also believes that the medical model of research is just too reductive: "They don't look at sex in a robust way. It's the narrowest possible view: does it twitch once or twice? O.K., then, twice is statistically more significant than once. Good girl."
"Viagra does make sex into a very goal-oriented act," Berman conceded. "The question is, What is sex in general? Is the goal to have an orgasm? Or is it to make yourself vulnerable to someone, communicate with them, share yourself with someone? Sex is often the mirror of the larger relationship. So now we have the possibility of the four-minute encounter. What does that do to intimacy?" She paused for a moment, and it was possible to see her concern metamorphose into a new argument: "Maybe a couple would be better off if they combined four-minute sex with a two-hour conversation over wine." This research, she concluded, suddenly finding her voice, will ultimately allow for different choices. "You will also be able to have hours of sex with multiple orgasms," she added, offering up a future of "quickies and slowies, and a whole range of options."
hoice. You wonder, what took so long? The language of the marketplace that has conquered every other domain in contemporary life has at last found a vehicle to enter the bedroom. "This work," Berman said, "is putting something mysterious and uncontrollable under our control. It can be a liberating and exciting shift, or a confining one, depending."
And that's where Viagra and its progeny are truly revolutionary. They enable us to control our own sexual health, pushing the idea of sexuality far beyond the lab or the couch. The Tiefer debate presumes that these medical inventions will stay under the strict control of doctors, that the old rules of the medical-industrial complex still apply.
But the Golden Age of the A.M.A. is over. The appearance of Viagra has taken place at a time when medicine itself is in the process of decentralizing and allowing market forces to guide many decisions. Increasingly, patients are told to take charge of their own health care; politicians debate a "patient's bill of rights." H.M.O.'s themselves are built on the idea that individuals will decide the general direction of their care. Doctors are increasingly called health care "providers" as drugs are now marketed directly to patients. Viagra was one of the first new drugs introduced to the world alongside the slogan: "Ask your doctor about. . . . "
In this loosey-goosey environment, Viagra has already slipped into the recreational underground -- far beyond the reach of both psychologists and doctors. Club kids in the big cities use it as a party drug. The practice of poly-pharmacy, taking a couple of different rave drugs, say, Ecstasy or Special K, kills the sex drive. For heavy partiers, Viagra solves the problem; it allows a night of Dionysian dancing to end the way it used to.
Viagra has also found its way into gay subculture. "You have to realize that a lot of men come out of the closet when they are 30 or even 40, and then go nuts," said Eston Dunn, the health education coordinator for the Gay and Lesbian Community Center in Fort Lauderdale, Fla. "If you're heterosexual, you discover your sexuality at 15, and then you go nuts. That's why a lot of older gay men behave like 15-year-olds. In many ways, they really are 15, and a lot of them turn to Viagra to keep up with their own newfound enthusiasm." In the gay party scene, Dunn said, "you used to hear that cocaine lines were put out with straws. Now it's Viagra, like jelly beans in little candy dishes."
The third group using Viagra on the sly is nonimpotent heterosexuals. I found out about this niche accidentally one night at my own dinner table. An old acquaintance stopped over for the night. He's an ambitious man, in his late 30's, the chairman of a well-regarded department of a prestigious university. On about our third glass of wine, he leaned over and asked, "So have you tried Viagra?"
I bolted back. "No, no," he said. "I mean for fun." But I was confused. Pfizer's official pronouncements state clearly that Viagra doesn't really "work" on potent men. My friend, who would not allow his name to be used, said he wasn't talking about the stated effect of Viagra. Although he did in fact get what he thought were unflagging erections, there is another side effect of Viagra. Beside maximizing blood flow, for the three to five hours that the drug is in the body, it also blocks the enzyme that stymies erections just after orgasm.
"My girlfriend always knows when I use it," explained my friend, who has tried the drug roughly 15 times in the last year. "Instead of this carefully choreographed single episode, suddenly I'm a nuclear reactor of love. Definitely. Multiple orgasms in one night." (So female drugs eliminate foreplay, shortening sex, and male drugs lengthen intercourse, extending sex. Once again, men and women pass like ships in the night.)
Pfizer makes it plain that the company does not agree with this kind of cavalier use of Viagra. But Pfizer is being somewhat disingenuous. Just look at the ads for Viagra. The originals in 1998 and 1999 featured what were clearly old men. One image was a barrel-chested fellow with whitening hair wearing a big winter sweater stretched across the healthy bulk of a well-lived life. He is standing in a meadow, hugging his wife, a women in her 60's looking quite good in a pair of jeans. The slogan reads, "Let the Dance Begin."
The new ad, which I clipped in January from a national magazine, has a trim fellow who could be a character on "Friends." He has a mop of brown hair above a smooth forehead. He's embracing a young woman in a white blouse, tossing her mane of pretty red hair. He might be 35, maybe. The slogan reads, "Take the First Step." More elaborate versions speak of a new disease: "If you're not satisfied with your sex life due to poor erections during recent months, talk to your doctor. You may be suffering from mild E.D. -- and Viagra can help."
"Not satisfied with your sex life" -- now there's a market segment. And what is "mild" E.D.? It's not really defined and could encompass just about any complaint imaginable. Perhaps it's what my friend was describing. He wanted his "maximum" erections to last for as long as he wanted to spend in bed with his lover. Viagra, he said, "lets me do this for hours without ever having to even think about it." And how did he get his prescription? He told his doctor that since he practices safe sex, he'd have less "trouble keeping a condom on" if his penis maintained a maximum blood-flow erection. His "provider" wrote the prescription.
The appeal Viagra has for some of these subgroups has meant that the blue pill is showing up in the underground drug economy. There have been numerous drug busts reported in which Viagra was found individually packaged among cocaine, Ecstasy and pot -- ready for dealers to market. In England, according to several published reports, the drug goes by the street name "poke."
I'm skeptical of the "poke" lingo, in part because the street is probably the most inaccessible place to get Viagra. Why go to some dingy corner in a bad part of town when the Internet is filled with sites that sell it easily and cheaply. Of course, the authorities have tried to crack down on the practice of selling pharmaceuticals online. A family-practice doctor in Ohio named Daniel L. Thompson was charged in July with 64 felonies, including 17 counts of drug trafficking for providing Viagra and other prescriptions over the Internet. And in December, President Clinton called on the F.D.A. to take measures to stop the practice. But controlling the Web is futile, as I discovered one day last winter when I typed "Viagra and aphrodisiac" into a search engine and was offered hundreds of choices. The Web sites sound like jokes: drugman.com and mywebdr .com and viagraguys.com. I opted to get my fix from a Web site called kwikmed .com.
After I signed on -- I waited while this message scrolled by: "Brought to you by Tide Detergent" -- I was instructed to fill out an online medical interview. I was asked obvious questions, like "Are you taking any heart medication?" I told the truth and said no. I was asked only a couple of private questions, but I admitted to no dysfunction whatsoever. Only one question was devoted to ascertaining my "problem." So I wrote: "Life is not as good as it should be" -- a philosophical statement I have pretty much always lived by. When I clicked the box marked Send, I instantaneously received a message back saying my doctor had "approved me for Viagra," unless of course my credit card didn't clear. The next morning, at the crack of the workday, barely 12 hours after I had clicked the send button, the FedEx guy appeared with an envelope that rattled when he handed it to me. In a brown bottle were 10 of the famous blue diamond-shaped pills. The crooked label looked as if it had been produced on an Officemax printer. My doctor was someone named "A. Guzman."
As we permit more and more market forces to take command of the health care industry, it shouldn't surprise anyone that the new drug dealer will not be found in the shadows, offering sinsemilla under his breath. He's already sitting right on our desks, his cursor winking at us. As I started to cruise the Internet looking for this underground world, it quickly became clear that, like the culture at large, Viagra had almost instantaneously colonized this frontier, too. One or two hyperlinks from Viagra, and I came upon a book called "Better Sex Through Chemistry."
With the enraged pace of daily life, who doubts that a drug-enhanced four-minute sexual encounter among harried day traders could become the norm?
"The idea of exotic herbal aphrodisiacs has been around forever," said the book's co-author, John Morgenthaler, when I reached him on the telephone. "But people thought they were akin to eating raw oysters. A neat idea, but really just the placebo effect." Viagra, in his mind, changed all that. Morgenthaler's book, and a 1999 sequel, "The Smart Guide to Better Sex From Andro to Zinc," chronicles the new levels of proof that hard science is bringing to the reputations of some of the old folklore remedies. This is evidence-based medicine at its simplest, separating the wheat from the chaff with double-blind placebo-controlled tests. Many of the old remedies hold no interest to researchers -- like camel hump fat or jackal bile or dong chong xia cao, a Chinese fungus that grows on dormant worms. (One day, naturalists may credit Viagra for saving the rhinoceros, now on the cusp of extinction due to the popularity of its supposedly aphrodisiacal horn.)
Other traditional remedies, like yohimbe, are being seriously considered. But the rethinking of sex caused by Viagra, according to Morgenthaler, merely signals a much bigger change that the drug is effecting.
"Viagra has opened the subject and legitimized the idea of enhancement drugs," Morgenthaler said. "This is the way it works with Western medicine: first there is this idea that if you have a 'disease' then you need a medicine to treat it. Then some forward-thinking doctor says, 'Why wait for the disease to start?' So we get to talking about 'prevention.' The third step is, 'Why be disease-oriented at all?' Let's just enhance ourselves beyond normal and average." This new era will be brought about by the consumerization of medicine, Morgenthaler noted. By allowing patients to have more of a say in what "medicine" means, we are redefining its purposes.
"What is cosmetic surgery?" Morgenthaler asked. "Isn't it just medicine bent entirely toward enhancement? The other breakthrough area is sports medicine. It's almost entirely about enhancement." Two years ago, Mark McGwire of the St. Louis Cardinals revealed that he was a regular user of an enhancing drug called androstenedione. Many critics weighed in to denounce the corrosive effect of a role model proclaiming the virtues of a drug. Morgenthaler, however, sees McGwire as a brave pioneer, like Dole -- someone who has come out of the closet to speak honestly about the brave new worlds these medicines hail.
"There really is an obvious parallel here," said Rachel Maines, author of the highly regarded book "The Technology of Orgasm." Her sober account of the industrial history of the electric vibrator shows how it was invented by a doctor, Joseph Mortimer Granville, in the 1880's and was used exclusively by doctors as a sexual-medical device to better cure hysteria in women by effecting a "hysterical paroxysm." The machine had the added benefit of moving patients more quickly through the office by shortening the old manual method of inducing a paroxysm to an industrial-age 10 minutes. The earliest vibrators easily stayed within the bounds of medicine since "they were steam-powered and you had to keep shoveling coal into the engine," Maines said. But eventual refinements in the machinery meant the vibrator "was democratized -- it started with doctors and then slowly became available to everyone."
When I raised with Goldstein the possibility of these new drugs spilling over into the general population, he was outraged. He hardly believed me when I told him I had Viagra in my hands less than a day after going online to find it. When I insisted that it was that easy to obtain, he simply asserted that the government should do something about it. When I told him that I had talked to people who were enjoying Viagra recreationally and that the drug had another life below the surface of medicine's officialdom, he shrugged and said, "It's not right."
Instead he gave me a lecture, outlining the future as he saw it: "When you go to medical school, you can go into ob/gyn, urology, general surgery, endocrinology, cardiology, gastroenterology -- but can you find a department of sexual medicine? No. But sexual medicine will find its place in medical schools. There will be a sexual medical specialty with multidisciplinary inputs from many fields. Why? Because all human beings have only several things in common. When they get thirsty, they drink. When they get hungry, they eat." He paused for a minute. "And all are very interested sexual beings. This is the principle upon which I am dedicating my academic career."
No doubt sexual medicine will one day be taught at medical schools. But in permitting that to happen we have defined a certain kind of pleasure as a branch of health (although perhaps not as radically as, say, the Netherlands, where government-financed prostitutes are made available to people with disabilities). Still, the pressure is on to improve something that was once understood to be a lucky side effect to procreation.
The generation that will first sample all these drugs and creams and pills as they come off the R.-and-D. conveyor belts in the next few years is the same one that, in the pop history of America, broke ground by smoking pot in the 1960's and 70's for enlightenment and set off the sexual revolution. It is the same generation whose interest in long-term health gave us jogging and workout spas; the same generation that is perpetually accused of being permanent adolescents; the same generation that has accelerated this economy into overdrive. Does anyone believe that regulation will prevent this same generation from employing drugs, in the words of Leonore Tiefer, "to maintain a 20-year-old vagina to go with their husband's 20-year-old penis"? The underground markets of John Morgenthaler and the Main Street clinics of Irwin Goldstein are not two choices. They are flip sides of the same coin -- an inevitable result of the impulse to bring the wonderful world of chemistry into the bedroom.
My bottle of Viagra sits on the second shelf of my medicine cabinet, unopened -- a totem of the future. But what's in it? Medicine? Preventive therapy? Enhancement pills? Recreational drugs? The marketplace will let us know soon enough. I look at the little brown bottle every morning and see the name of my new provider, A. Guzman -- a genie of turboconsumerism heralding the conquest of choice over the last redoubt of privacy.
February 20, 2000
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