The Viagra Craze

By BRUCE HANDY

Besides its phony name, funny shape and unappetizing color, what's not to like about Viagra, the new pill that conquers impotence? Could there be a product more tailored to the easy-solution-loving, sexually insecure American psyche than this one? The drug, manufactured by Pfizer, went on sale three weeks ago, finally giving talk-show hosts something other than Bill Clinton and Pamela Lee to crack smarmy jokes about.

Spurred, perhaps, by just that sort of publicity, would-be patients have been besieging urologists' offices and sex clinics--men both genuinely dysfunctional and merely dissatisfied, skulking around in hopes of achieving "better" erections through chemistry. Already, a kind of Viagra connoisseurship is beginning to take hold. "The hundreds are absolutely incredible," says a very satisfied user, referring to the drug's 100-mg maximum-strength dosage, "and the effect lasts through the following morning." What else can one say but Vrooom! Cheap gas, strong economy, erection pills--what a country! What a time to be alive!

"We've always been waiting for the magic bullet," says Dr. Fernando Borges of the Florida Impotency Center in St. Petersburg, where he has been working with sexually dysfunctional patients for 21 years. "This," he says, "is pretty close to the magic bullet." The very day Viagra became available, Dr. John Stripling, an Atlanta urologist, churned out 300 prescriptions with the help of a rubber stamp he had had the foresight to purchase. At the Urology Health Center in New Port Richey, Fla., which participated in the drug's clinical trials, the waiting time to see a doctor for a Viagra consultation is a month. Not that this has stopped motivated patients. "We've been inundated with emergencies," says Dr. Ramon Perez. "Pain in the kidney. Blood in the urine. But when they get in here, they just want to ask us about Viagra. It's amazing. These people have been impotent for three years, and they cannot wait another few days."

"It's the fastest takeoff of a new drug that I've ever seen, and I've been in this business for 27 years," says Michael Podgurski, director of pharmacy at the 4,000-outlet Rite Aid drugstore chain. After a brief lag, the drug is now being prescribed at the rate of at least 10,000 scripts a day, outpacing such famous quick starters as the antidepressant Prozac (which went on to become one of the biggest-selling drugs in America) and the baldness remedy Rogaine (which has been something of a disappointment after its initial blaze of popularity).

The run on Viagra has been abetted by the likes of David Michael Thomas, a Milwaukee, Wis., osteopath who advertises his services on the Web at www.penispill.com and who allegedly prescribed Viagra to some 700 patients after cursory $50 telephone examinations. At a license-suspension hearing in front of Wisconsin regulatory officials last week, Thomas agreed to stop the practice. (Normally a diagnosis of impotence involves a rigorous physical exam, blood tests and an extensive sexual history.) Other entrepreneurs have been offering prescriptions directly over the Internet.

Even supporters of the pill worry about hyped expectations. "People always want a quick fix," complains Dr. Domeena Renshaw, a psychiatrist who directs the Loyola Sex Therapy Clinic outside Chicago. "They think Viagra is magic, just like they thought the G spot worked like a garage-door opener." In the wake of fen/phen and Redux, the diet-drug treatments that were pulled from the market last year after it was learned that they could damage heart valves, caution would be advisable with Viagra. But so far the side effects seem comparatively slight and manageable: chiefly headache, flushed skin, upset stomach and curious vision distortions involving the color blue. Pfizer, leaving nothing to chance, has even requested and received the Vatican's unofficial blessing for Viagra. All in all, a happy ending for American men, their partners and especially Pfizer stockholders, who have seen the value of their shares jump nearly 60% this year alone.

Yet there's something unnerving about Viagra too, not so much on the face of it (the drug's merits appear to be manifold; doctors think it might even improve the sexual response of postmenopausal women) but in the broader philosophical implications. Is sexuality, like the state of happiness or male-pattern baldness, just one more hitherto mysterious and profound area of human-beingness that can be pharmaceutically manipulated, like any other fathomable construct of enzymes and receptors? Another looming question: Since Viagra is taken--at prices ranging from $8 to $12 a pop--not on a day-in, day-out basis but only when one actually wants to have sex, will HMOs and other insurers soon be telling us how much sex is reimbursable? Sufficient? Normal? Necessary?

And what about the impact on the freighted social interactions we euphemistically refer to as dating? "I bet that within a year, you'll see women's-magazine articles saying, 'How to Tell If It's You or Viagra,'" says James R. Petersen, who has written the Playboy Advisor column for the past 22 years. He adds, "I think Viagra is going to be as monumental as the birth-control pill." No less an authority than Bob Guccione, publisher of Penthouse magazine, believes the drug will "free the American male libido" from the emasculating doings of feminists. And not only that. According to Guccione, "the ability to have sex by older men will make them healthier and live longer. It will fool the biological clock when men are still active in the later years. It is a very significant effect of the drug that many haven't contemplated." There isn't any actual scientific evidence to back up Guccione's claims, but he does do a nice job of illuminating two important subtexts of Viagra's appeal: the chimeras of undiminishable power and perpetual youth.

Of course, the overt appeal is pretty compelling too.

In the past decade there have been great advances in the treatment of impotence, which is now seen by most therapists, in most cases, as a physiological rather than a psychological problem, rejecting the medical establishment's long-held view. The word impotence itself, like "frigidity" for women, is considered suspect in many circles; the more politically correct--or at least clinical--term is erectile dysfunction, or ED, as it is commonly abbreviated. Inspired by a 1992 National Institutes of Health Conference and landmark 1994 study on the problem, the diagnosis has been defined more broadly, from the rather strict criterion of inability to get an erection, period, to the somewhat more elastic and subjective criterion of inability to get an erection adequate for "satisfactory sexual performance." This has led to a tripling of the number of men estimated to be impotent in this country--some 30 million according to the NIH, half of whom are thought to be under the age of 65. ED is associated with age; it affects about 1 in 20 men ages 40 and up, 1 in 4 over 65.

From a drug manufacturer's point of view, this burgeoning of the potential market has coincided quite nicely with the development of pharmaceutical treatments. (At least two more impotence pills are in the pipeline from different companies.) Before Viagra, the most promising therapies involved putting gel suppositories in the urethra and injecting drugs directly into the base of the penis. The downside is not hard to grasp. "You can imagine the look most patients gave when I told them they would have to stick a small needle into the most sensitive portion of their body," says University of Chicago urologist Dr. Gregory Bales. The good news is that the erections resulting from such injections can last an hour or more, even after orgasm, though depending on one's taste and circumstances, this too could be a downside. Other treatments, which involve vacuum pumps, penile implants and penis rings, are no less awkward or, to get to the heart of the matter, no more conducive to the spontaneous, unselfconscious, beautiful sex that Calvin Klein ads imply is our daily right.

The promise of Viagra is its discretion and ease of use. Doctors recommend taking the pill an hour before sex, which might lead to some wastage among overly optimistic users but shouldn't otherwise interfere too greatly with the normal course of coital events. An even greater advantage, or at least a more naturalistic one: unlike the injectable drugs, which when efficacious produce an erection regardless of context (famously proved by Dr. Giles Brindley, a leading British impotence researcher, who once demonstrated a successful experimental treatment by dropping his trousers in front of hundreds of astonished colleagues at a conference), Viagra merely paves the way for the possibility of arousal. Erections must still be achieved the old-fashioned way, whether through desire, attraction, physical stimulation, the guilty thrill of an illicit affair, page 27 of The Godfather or what have you.

Loyola psychiatrist Renshaw offers the instructive example of a couple who came to see her the day after the man had taken Viagra for the first time: "They went to bed to wait for something to happen and fell asleep while they were waiting. They forgot to have foreplay. They expected an instant erection." The next night, after Renshaw gently reminded them about the importance of stimulation, they had intercourse for the first time in three years.

During the drug's clinical trials, which as a rule tend to have rosier outcomes than real life, Pfizer reported a 60%-to-80% success rate, depending on the dosage (compared with a 24% success rate for placebos). The anecdotal evidence is even more compelling, if one can put up with a certain amount of crowing. Earl Macklin, a 59-year-old security guard in Chicago, has suffered from impotence on and off for 10 years as a result of diabetes. The first two times he tried Viagra, it produced minimal results; the third time he was able to have intercourse with his girlfriend for the first time in their four-month relationship. "I've been using it every day since then," he says (four days later) with a conspiratorial chuckle. "It makes me feel like I'm in my 30s again." Macklin's insurance company has notified him that it won't be reimbursing him, so, he says, "I'll limit myself to 20 pills a month."

Tom Cannata, a 43-year-old accountant from Springfield, Mass., has been taking Viagra for the past three years as a trial subject. He was suffering from partial impotence brought on, he believes, by years of bicycle riding (an activity, it should be noted, that is not universally held to be a cause of impotence). Cannata was able to achieve erections but felt that they "should have been stronger and much longer-lasting." Viagra worked for him the first time and has worked ever since. "Not only is the frequency of our sex greater," he says, "but for me it is much more intense than it was without the medication. The quality is so much better. Much firmer, stronger erections. And the orgasm is much more explosive." So pleased has Cannata been with the results that he was inspired, he says, to go out and buy a sports car not long after beginning the drug--indicating, perhaps, a soon-to-boom, Viagra-inspired market for souped-up cars, Aramis, oversize stereo equipment and other accoutrements of the virile life-style.

Some patients TIME queried had no reaction to Viagra whatsoever. Others have had more ambiguous experiences. Consider Irving Mesher, a 73-year-old retired New York City firefighter, who currently lives at a family-owned nudist resort in Pennsylvania's Pocono mountains. He describes himself as "sexually motivated" and "very active." Thanks to injection therapies (prostate-cancer treatments six years ago left him "semihard"), he has been having sex--by his account--as often as three or four times a week with several girlfriends in their 20s. Still, he was eager to try Viagra. Taking a 50-mg dose the first time, he was pleased with the results: "About as hard as it can get." However, a subsequent experiment with a 100-mg pill backfired, having no beneficial effect, as did a return to 50 mg. Mesher nevertheless plans to continue with Viagra, inspired, perhaps, by the example of his 70-year-old best friend Frank, who took the drug last week and "turned into a monster." The two are planning to invite several friends to a Viagra party.

As Mesher's story suggests, and many doctors insist, more isn't necessarily more with Viagra. Known to chemists by the less evocative name of sildenafil (the word Viagra, redolent of both "vigor" and "Niagara," had been kicking around Pfizer for years, a brand name in search of a product), the drug began life as a heart medication designed to treat angina by increasing blood flow to the heart. Sildenafil, it turned out, wasn't so good at opening coronary arteries, but happy test subjects did notice increased blood flow to their penises, a side effect brought to Pfizer's attention when the test subjects were reluctant to return their leftover pills. The medication works by suppressing the effect of the naturally occurring enzyme phosphodiesterase type 5 (PDE5), which causes an erection to subside after orgasm by breaking down the body chemical known as cyclic GMP. It is cyclic GMP that initiates the muscular and vascular changes that lead to an erection in the first place. While PDE5 is always present in the penis, cyclic GMP is produced only during arousal. The catch in impotent men is that they may not produce enough cyclic GMP to temporarily "win out" over the PDE5. Thus the efficacy of Viagra: by strong-arming PDE5, it allows a little bit of one's cyclic GMP to go a long way.

One more nugget of possibly boring but crucial biochemistry: the erectile tissue in the penis has a finite number of receptors for cyclic GMP. This means that a normally functioning man with adequate levels of the chemical shouldn't get any more bang for his buck by gobbling Viagra; the variations anyone feels in his or her sexual response are due to factors outside the drug's purview. At the same time, Pfizer hasn't done any testing of the drug on nonimpotent men to prove the point, but it's hard to imagine that biochemical nitpicking is going to stop people from experimenting. Certainly it will be hard for wet blankets and smarty-pants to compete with the siren calls coming out of sex clinics around the country from men "feeling 18 again."

"If you can have an erection naturally, you probably won't need Viagra," says Thomas Burnakis, pharmacy clinical coordinator at Baptist Medical Center in Jacksonville, Fla. "It's not going to make your erection harder or last longer. But I can guarantee you that if you walk in and say, 'Doc, I'm having trouble keeping my flag up,' most physicians are not going to insist on testing. What's to keep you from using it? Absolutely nothing. And just as with fen/phen, while a lot of doctors said they would not give that drug, a lot of clinics were prescribing it. It's going to be a moneymaking procedure. They'll give a cursory exam, charge you for that and write the prescription"--a prediction that has already been borne out on the Internet. According to Pfizer, there's no evidence that overeager users could develop a physical addiction to Viagra. But as for a psychological addiction, that is uncharted territory.

It is because of the potential for abuse and, more to the point, the traditionally seedy associations that cling to impotence remedies (witness the ads in the back of low-rent men's magazines for spurious Spanish fly, hard-on creams and the like) that drug companies have only recently turned their attention to sexual dysfunction. This would account for the tone adopted by Pfizer chairman and CEO William Steere even as he figuratively licks his chops over the potential market in "aging baby boomers." He is careful to point out that "quality-of-life drugs are gene-based just like those for serious medical conditions. In areas like impotence, aging skin, baldness and obesity, the science is just as profound as if you were working in cancer, asthma or anti-infectives." In other words, Viagra is sober stuff and not at all akin to Sy Sperling's Hair Club for Men.

Along related lines, a brochure for Pfizer employees points out that while "jokes and puns are often used in conversation about sexual health topics...you can redirect humorous remarks to more appropriate discussion by not joining in the humor and pointing out the seriousness of the subject matter, reminding the people with whom you speak that ED is a significant medical condition that affects the lives of millions of men and their partners." This is true, of course. It also speaks to the tricky questions of taste and exploitation that Pfizer will have to navigate in marketing the drug. So far, without an official launch or virtually any promotion, Viagra is doing fine. But why hold back? Advertisements will begin appearing in medical journals in about six weeks, followed by consumer ads this summer. A company spokesman says they will be "tasteful and emotional, emphasizing [impotence] as a couple's condition." One can imagine.

At any rate, it's an emphasis that should remind us that human sexuality is far too rich and complex for the entire subject to be balanced on the delicate fulcrum of an erection. As with the debate in psychiatry between traditional talk therapists and their more pharmacologically minded colleagues, controversy over Viagra and its cousins may well provoke a rift among sex researchers. Raymond Rosen, a professor of psychiatry at the Robert Wood Johnson Medical School in Piscataway, N.J., makes the obvious but necessary point that Viagra will not be the final word on sexual dysfunction or dissatisfaction: "There's a danger that we could lose sight of the fact that a lot of sexual problems relate to poor relationships or poor self-esteem or anxiety, depression or other factors." Or as Petersen, the Playboy adviser, puts it, "You can take an angry couple and give them Viagra, and then you have an angry couple with an erection." Oddly, that's reassuring.

--Reported by Edward Barnes and Lawrence Mondi/New York, Wendy Cole/Chicago, Greg Fulton/Atlanta and Arnold Mann/Washington

Discuss Viagra with the experts online Thursday, April 30, 7 p.m. ET, at time.com

With reporting by Edward Barnes and Lawrence Mondi/New York, Wendy Cole/Chicago, Greg Fulton/Atlanta and Arnold Mann/Washington