The Disease of an Erection or the Erection of a Disease: The commodification of the 21st Century biomedical male

A Little Blue Pill…

A man in his late 50s is dancing with a woman of the same age. He dips the woman down across his body, controlling her movement with his arm beneath her back. Both are smiling as he hovers over her, purportedly affirming their roles in this (tired) dance of the sexes; with the male leading and in control, and the female hanging vulnerably in a horizontal position, completely supported by her Rock of Gibraltar. Her fate appears contingent upon the facile support of her graying Lancelot to keep her large, but purportedly fragile, body afloat.

This scene is describing an advertisement for the male ‘potency drug’, Viagra. The message is clear; in a happy heterosexual relationship the man is strong, supporting, and dominant, the woman is vulnerable, trusting, and passive, the sex is youthful and the relationship is blissful, all thanks to this little blue pill. The subtext is that Viagra not only makes erections strong, but also brings couples closer together and is beneficial (and probably necessary) for your relationship: strong erections build strong relationships. Hence, Viagra preserves these traditional stereotypes of hegemonic masculinity and femininity as what a (heterosexual) couple should desire.

Since Viagra (sildenafil) was launched by Pfizer pharmaceutical in 1998, over 17 million men are reported to have received prescriptions. Pfizer reported sales in 2001 of 1.5 billion U.S. dollars. (Moynihan 2003). Biochemically, Viagra produces vasodilation in the penis, allowing it to fill with blood unhampered (Arky & Davidson 1999). A full page of precautions, contraindications, and adverse reactions regarding Viagra appears in the fifty-third edition of the Physician’s Desk Reference, but few physicians (or patients) seem concerned.

The “Problem”?

Before the advent of Viagra, abatement in male sexual performance was understood to be a natural and normal progression of aging. Adapting to this natural progression was viewed as a positive adaptation (Potts, et.al. 2006). However, many drug companies and affiliated researchers and clinicians did not agree with nature after Viagra was born. According to Sadir (2005:1) “if you can’t get it up because you’re pissed, stressed out, simply not in the mood or no longer find your partner attractive, you are actually suffering from a disease. And like all diseases, it must be cured. The cure is to swallow a pill and have sex no matter what, anywhere, anytime. This has now become the norm.” Once we label this condition as dysfunctional and pathological, we have branded males who do not meet this criteria, (in the American culture of hyper-vigilant physical perfectionism), as damaged goods in need of repair. Populations that were previously considered normal, now require biomedical discourse and intervention (Fishman and Mamo 2001). Hence, normality has become “pathologized” (Marshall 2006: 345).

Erectile Disorder is identified as the “inability to attain or maintain penile erection sufficient for satisfactory sexual intercourse” (Potts 2006). This definition leaves room for broad interpretation in both individual and clinical diagnoses and thereby provides liberal freedoms for clinical management. However, diagnostic criteria are not cast in stone and are subject to frequent change. Hence, not only should the elderly male now maintain his erection, he should ultimately be able to perform more effectively than in his youth (Potts 2006).

Erectile dysfunction increases with age from a prevalence of 39% among men 40 years old to 67% of men age 70 years old (Potts, et. al., 2006). Hence, if a prevalence of 67% is found in men age 70, are 67% of men experiencing an abnormal pathology or are the remaining 33% “abnormal”? Should active sexuality over the entire lifespan be the criterion by which overall sexual health is assessed? (Potts, et. al., 2006)
According to Lauman, Paik and Rosen (1999) sexual “problems” are cited as being most prevalent in young women and older men. The authors conclude that this “problem warrants recognition as a significant public health concern” (ibid:544). Really? Can erectile dysfunction be compared to HIV/AIDS, Tuberculosis, smoking, or even obesity in terms of “significant public health concerns”? Or does the mere label of significance, appearing in the pages of the Journal of the American Medical Association (JAMA), render erectile dysfunction a serious public health concern?

Dickenson (2007) asserts that if the agenda of research is a function of corporate requirements, then “the scientific method has itself become a commodity”. The corporate-sponsored creation of a disease is hardly a novel occurrence (Moynihan, 2003). 1997 marked a turning point in the United States Pharmaceutical industry, as regulations were relaxed and the FDA allowed pharmaceutical companies to advertise their wares directly to consumers via printed material and television (Fishman & Mamo, 2001). Self-improvement became synonymous with swallowing a pill and suddenly everyone was in need of intervention. The psychopharmaceutical industry boomed, as mood stabilizers such as Prozac and Paxil were understood to be as essential as daily vitamins.

“Medicine, and its concomitant industries, is a social institution that is both informed by and produces culture through its products and discourses” (ibid:182). Biomedicine, as practiced in the United States, is a function of the American mythology of the hero at the frontier. Advancement at all costs is the message of this mythos, and it doesn’t hurt if that advancement generates some wealth in the process. We live in an age when lungs remain breathing and hearts continue beating autonomously via technological intervention, whilst the brain, in essence, has long since died. Hence, why then would biomedicine abandon the flaccid male?

Science in the Boudoir or Curious Bedfellows…

Biomedicine has infiltrated our daily lives with an accumulation of social life being designated as pathological. What once were considered appropriate functions of a changing body (such as baldness, Pre-Menstrual-Syndrome and menopause) have become medicalized social problems. Social issues are redefined as medical, with medical practitioners designated as the purveyors of cure (Rosenfeld & Faircloth 2006). Furthermore, why should we overhaul our psyche or lifestyle, when it is far more time and energy efficient to pop a pill? In the biomedical model, the human body is not conceived as capable of regaining a natural homeostasis without the necessary good of medical intervention.

Moynihan (2003) reports that drug companies have tried the same approach to “female sexual dysfunction”. In May 1997, pharmaceutical companies sponsored a meeting in the U.S. between clinicians, drug companies and researchers (with close ties to drug companies), in order to agree on a definition of female sexual dysfunction. In October 1998, a “closed session” conference produced a new classification for female sexual dysfunction detailing “disorders of desire, arousal, orgasm, and pain” (ibid: 45). 18 of the 19 members of this committee had financial interests with a total of 22 different drug companies. Internationally, female sexual dysfunction was introduced in Paris in 1999, as part of the first international conference on erectile dysfunction, which was also primarily sponsored by several pharmaceutical companies. However, the turning point in the validation of this new diagnostic category was a February 1999 Journal of the American Medical Association (JAMA) article “Sexual Dysfunction in the United States: prevalence and predictors” (Laumann, Paik, Rosen, 1999). The authors proclaimed that the total prevalence for sexual dysfunction in women in the U.S. was 43%. Overnight, a pathology affecting nearly half the population of American women was christened by two researchers with close ties to Pfizer Pharmaceutical (Moynihan, 2003). According to Sardar (2005), the treatment targeted for this new pathology, a device that can be implanted under skin to trigger a female’s orgasm, has already received United States Food & Drug Administration (USFDA) approval. Within a decade it may be normal for any woman to produce this bionic orgasm at the touch of a button.

Sexuality does not originate and terminate at the genitals. Hence, addressing sexual issues as a purely physical dysfunction that can be cured via pharmaceuticals in order to alter sexual functioning can be misleading and may obfuscate symptoms that are co-morbidities to physical or psychical disorders (i.e., depression, diabetes, vascular pathologies, etc).

Unlike other medical systems (such as Traditional Chinese Medicine), the biomedical model bisects the mind from the body by virtue of the Cartesian binary system from whence it came. Is a system with a mind-body division really best suited for addressing issues such as sexuality, which clearly involve both domains and their interplay? Furthermore is a drug that accentuates the division between feeling and function, the best intervention for a condition that demands their union? This singular focus on the promotion of genital function results in a gross disservice to patients and a perversion of intent by denying the importance of complex physical, social, and personal aetiologies (Moynihan, 2003). However not all clinicians follow these trends in diagnoses and treatment. Dr. David Duval, M.D., emphasizes, “one of the main problems I have with prescribing Viagra is that you overlook underlying causes. Providing one with, for example, an erection can in essence be harmful by thwarting people from investigating underlying causes for symptoms. I find patients are so afraid to understand themselves and their bodies that all I really end up providing is a kind of Band-Aid covering up the real issues”.

The dominant myth of male sexuality portrays men as possessing “omnipresent sexual desire” (Fishman & Mamo, 2001:184). In this manner, a Viagra can take away from a more egalitarian intimacy that often naturally evolves between the aging male and his partner, in which “the pleasures of mutuality become more significant; the importance of non-penetrative and even non-genital sexual pleasures is acknowledged; and men are encouraged to expect, accept and adapt to ‘natural’ changes in sexuality associated with growing older” (Potts, et.al. 2006). However, these manufactured mores raise the bar of expectation for men ever higher. Consider how the toxic demands that the heroine induced-like figure of Kate Moss haunted a generation of young women. Now men are subject to the objectification that was previously the sole dominion of women. What is most threatening about the commodification of the body, is that it reduces an individual to an object (Dickenson, 2007).

This “equal right” of objectification is not sought by all. Potts, et.al. (2006:315) argue that sexual pleasure in mature men does not necessarily include “penile performance, penetrative sex and normative ideas about potent masculinity”. Potts, et.al (2006) interviewed 33 men between the ages of 33 and 72 and found that many did not desire what Viagra depicted men as desiring. As part of the natural aging process, men reported that when they reduced their “penis-centered”, focus, and did not define their masculinity by virtue of the tumescence of their member, they focused more on pleasing their partner, mutuality of enjoyment of sexual relations with partners, less emphasis of the sole import of achieving orgasm, and a less urgent, more prolonged, and relaxed intimacy. Some men even reported preferring this new way of relating to partners. It may be understood as a difference between performing and simply being. You can witness this distinction in body language. The strutting male with a mating ritual-like puffed-out chest is not exactly ‘being’, as much as engaging in a performance, seeking praise to bolster his battered self-image. By thwarting this natural shift into greater mutuality in intimacy as males age, Viagra may be understood to “buttress existing systems of social inequity. Viagra is manufactured to preserve a particular masculinity and to maintain a specific cultural order” (Hartley, 2006: 425).

The effect of Viagra on a man’s partner has been utterly absent from this discourse. Potts, et.al. (2003) observed in their interviews that Viagra resulted in a double-edged sword for the female partners of heterosexual men. Prolonged and more frequent coitus was not sought by all women queried. Women spoke of feeling pressured to “perform” due to the male partner’s attitude of getting the most “bang for his buck”, if you will, out of his pill. Women also spoke of how the “Viagra state” resulted in reduced engagement in foreplay or any activity other than coitus. The women interviewed echoed one another, stating that in some ways the utilization of Viagra mechanized their sexual relations with their partner. In sum, the women demonstrated how the utilization of Viagra affects more than erections; Viagra affects the nature of relationships.

Conclusion…

Clearly there are men who suffer from organic dysfunction that deleteriously affects their sexual lives and can benefit from Viagra. This is not an attempt to negate or denigrate the value of a pharmacotherapy that can benefit a population. Viagra does have its place as a therapeutic sexuopharmaceutical.

Rather, this is an attempt to question the ethics of a drug company benefiting by preying on the fears of the worried well. Obviously, drug companies, and the researchers and clinicians affiliated with them, need to be monitored for accuracy in creating true diagnostic and pathological categories in the absence of an agenda of profit. Viagra and the sexuopharmaceuticals which treat sexual functioning often take away the ability to progress through the passages of life without remorse and neurotic adaptation.

The medicalization of masculinity has been largely ignored by feminists due to the fact that males have a long tradition of medicalizing the female body. However, the one action does not condone the other. Clearly, the sexual bodies of both men and women are now aggressively being commodified. What is the affliction that Viagra is really treating? Sardar (2005) posits that it is the perceived loss of male power. Or could this commodification be understood as the inability of 21st century consumers to perceive themselves as anything but impotent without some kind of medical intervention in the face of life’s uncertainties?

Paul Kadetz has just completed his MSc in Medical Anthropology at Oxford. He is a licensed acupuncturist, Board Certified Nurse Practitioner, and has an Master’s of Public Health (MPH) in International Health and Development. His articles have most recently been published in Disaster Medicine and Public Health, The Yale Journal Of Public Health, The American Public Health Association and he completed a chapter for the upcoming book; Displaced City: Hurricane Katrina and the Unequal Recovery of New Orleans, edited by Fussell and Elliott for Sage Publications. He is currently completing In My Backyard, a book about the equity of the recovery of Post-Katrina New Orleans. Google him for more information!

Footnotes

¹ Concurrent illnesses and diseases.

Further Reference

Arky, R, Davidson, C. (1999) Physician’s Desk Reference. 53rd Edition. Medical Economics Company.
Dickenson, D. (2007) Do We All Have ‘Feminized’ Bodies Now? From: Property in the Body –
Feminist Perspectives. Cambridge University Press.
(http://www.amazon.co.uk/Property-Body-Feminist-Perspectives-Cambridge/dp/0521687322/ref=sr_1_1?ie=UTF8&s=books&qid=1221947913&sr=8-1)

Duval, D. Interview. September 9, 2007.

Fishman, J, Mamo, L. (2001) What’s in a disorder: A Cultural Analysis of Medical and Pharmaceutical Constructions of Male and Female Sexual Dysfunction. Body & Society. 7(2):179-193.
(http://www.haworthpress.com/store/ArticleAbstract.asp?sid=4MCU226ECRCF9KK996VHH85EEET33E11&ID=37863)

Hartley, H. (2006) Review: The Viagra Adventure- Masculinity, Media, and the performance of Sexual Health. Journal of Sex & Marital Therapy. 32:425-431.
(http://www.ingentaconnect.com/content/routledg/usmt/2006/00000032/00000005/art00007)

Laumann, E, Paik, A, Rosen, R. (1999) Sexual Dysfunction in the United States: prevalence and predictors. JAMA 228:537-544.
(http://jama.ama-assn.org/cgi/content/abstract/281/6/537)

Marshall, B. (2006) The New Virility:Viagra, Male Aging and Sexual Function. Sexualities. 9(3):345-362.
(http://sexualities.sagepub.com/cgi/content/abstract/9/3/345)

Moynihan, R. (2003) The making of a disease: female sexual dysfunction. BMJ. 326. 4 January 2003. 45-47.
(http://www.bmj.com/cgi/content/full/326/7379/45?ijkey=vggM9BCGJ/)

Potts, A, Gavey, N Grace, V, Vares, T,. (2003) The Downside of Viagra: Women’s Experiences and Concerns. Sociology of Health & Illness. 25;(7):697-719.
(http://www3.interscience.wiley.com/journal/118836414/abstract)

Potts, A, Grace, V, Vares, T, Gavey, N. (2006) ‘sex for life?’ Men’s counter-stories on ‘erectile dysfunction’, male sexuality and ageing. Sociology of Health & Illness. 28;(3):306-329.
(http://www.ingentaconnect.com/content/bpl/shil/2006/00000028/00000003/art00003)

Rosenfeld, D, Faircloth, C. (2006) Medicalized Masculinities. Temple University Press.
(http://www.amazon.co.uk/Medicalized-Masculinities-Dana-Rosenfeld/dp/1592130984/ref=sr_1_1?ie=UTF8&s=books&qid=1221947231&sr=8-1)

Sardar,Z. (2005) It’s just mechanics. The New Statesman. Retrieved on 9/7/07 from: http://www.newstatesman.com/print/200501010019