Impotent men used to have to grimace and bear it. But, argues David Nolan, the fuss about the development of a new 'cure' is not entirely good news

Stiffening up

One reason why Viagra has attracted so much attention is that previous cures for impotence were often awkward, painful and impractical. Who would not choose a simple tablet when the alter-natives involve surgery, injections or implants, silicone rods, inflatable cylinders, vacuum pumps, and penile supposi-tories? The insertion of a large hypodermic needle into the penis is only a turn-on for couples with very peculiar tastes. Previous treatments also tended to deliver an erection which lasted for hours - hardly appropriate for a quickie in the toilet at a dinner party.

As a drug which treats an organic medical problem Viagra is to be welcomed. What is not so welcome is the way it has been hailed as a symbol of our times. Just as Prozac symbolised the 'nervous nineties' and Ecstasy stood for the atomised generation X, so Viagra is already becoming an icon to the wilted, crisis-ridden masculinity that is supposed to be a feature of the current day and age.

Camille Paglia's comments to Time magazine were predictable: 'The erection is the last gasp of modern manhood. If men can't continue to produce erections, they're going to evolve themselves right out of the human species. They need [Viagra] to bolster themselves. They need it to stiffen their erections. It's like the steel that they would get if they were at war.' Penthouse publisher Bob Guccione's comments were less expected. 'Feminism has emasculated the American male and that emasculation has led to physical problems. [Viagra] will free the American male libido much the same way that the Pill did.'

Within days of attaining a licence from the US food and drug administration, Viagra had become a channel for an outpouring of euphoria and anguish about the state of America's manhood.

The universal acclaim is all the more surprising - even the Vatican has supposedly bestowed its unofficial blessing on Viagra - given that it is not without side effects. In our risk-conscious times, new drug launches are often accom-panied by prophesies of doom. Not this one - potential adverse reactions have been treated as a joke. One UK doctor who tried it out said that it made him look like a bull frog with bulging eyes, but confirmed he is still willing to issue prescriptions at about £18 a tablet, albeit on a 'named patient basis' (which means he is not responsible for any side effects) as Viagra is not yet licensed in the UK. And he is not the only person who has suffered adverse reactions. About 10 per cent of the trial group had a variety of side effects including headaches (and we know what they do to sex), nausea, facial flushing and diarrhoea. About three per cent said that after taking the pill they had difficulty distinguishing between the colours blue and green and their vision was affected by a blue haze.

The most astounding fact in the Viagra story, though, is the extent of the demand for it. More than 113 000 prescriptions were issued in the second week it was on sale, 'dozens of times higher than typical for successful newly launched drugs' (Time, 4 May). Prescriptions in the USA have now levelled off at 40 000 a day. You would never have guessed there were so many men in need of chemical stimulation.

Men's sexual health groups have claimed that another benefit of the drug is that it has helped to bring impotence out of the closet. I am not so sure. Over the past few years, men's sexual problems have featured ever-larger in medical journals and the general media. Whereas conventional wisdom used to be that women had sexual problems while men just had sex, today men too have become a subject of psychosexual scrutiny. Articles in men's health magazines are as likely to be about men's confessions of sexual insecurities as about their prowess. By Viagra's launch impotence was already a major issue, typically reported as a condition that affects all men at some stage. Perhaps in future we will be advised that we will all need to reach for Viagra at some time.

There is also a very modern obsession in men's magazines with the quality of the sex their readers are having. Gone are the days when it was 'how much and how often with how many women'. Now it is all about the level of enjoyment - both for the man and his partner. First men were encouraged to consider the quality of their partner's orgasms; now they are encouraged to examine the quality of their own. Today it is not enough for a man to have sex - he has to have wonderful sex, and give wonderful sex. He must allow himself to be judged on his performance and he must judge himself - not just as an erotic athlete but as a caring man. A fuck is no longer just a fuck, but a whole statement of being.

Sexual counsellors now advise that the fear of failure after a lost erection may send a man into a spiral of despair from which there is no escape. Is it any wonder that an increasing number of men claim to be daunted by the prospect and feel they need a little chemical support?

Even the definition of impotence seems to have changed. According to the British Medical Journal, impotence was traditionally defined as 'the inability to achieve or maintain an erection sufficient for sexual intercourse', until in 1994 the US national institute of health called for a reclassification. Now it is renamed 'erectile dysfunction' (ED) and defined as an 'inability to get an erection adequate for satisfactory sexual performance', which immediately qualified three times as many men to join the category 'victims of ED'. This is not surprising - it is impossible to define what constitutes 'satisfactory sexual performance'. The category now presumably includes those who can fuck for 10 minutes but would prefer to fuck for an hour. Consequently, the UK Impotence Association claims one in 10 men experience erectile dysfunction. US sources claim between 10 and 30 million American men experience ED, making it 'one of the most common chronic conditions in Western countries' (Lancet, 1998, 351: 1368).

Impotence has been universalised. The normal lows that accompany the highs of sexual activity have been turned into a clinical condition.

There are, of course, some organic reasons for impotence in a small minority of men: diabetes, age, prostate problems, strokes and certain prescription drugs. Viagra is a welcome treatment in these cases. But most of us should be able to accept problems in the performance department - and confront them - without a trip to the pharmacy. Most men at some stage will experience some form of sexual failure. That is normal. The advent of Viagra turns that normality into a problem, a condition. A rare event becomes problematised and medicalised, forcing men into an unnecessary relationship with their doctors over something that may not happen again for years.

In a world of emasculated men Viagra was bound to succeed. Now, however, the manufacturer has announced tests involving 500 women in England. Apparently boosting blood flow to the vagina may increase a woman's sensitivity in the same way it does for men. But the prospect of coping with hordes of rampant Viagra-impregnated women may deal a crushing blow to the already fragile male psyche and render men unable to get it up at all, Viagra or not. *

How Viagra works

Viagra is the citrate salt of sildenafil - a phosphodiesterase 5 (PDE5) inhibitor. By blocking the PDE5 enzyme, which is found mainly in the penis, Viagra enhances the effects of nitric oxide, a chemical compound produced during sexual stimulation. This is turn allows another chemical, cyclic GMP, to last longer. The longer cyclic GMP lasts the better the chance of increased blood flow around and to the penis, and therefore the better the chance of an erection.

Viagra does not itself cause an erection but enhances the response to sexual stimulation. This means that the drug will not give non-impotent men a better erection.

Viagra costs between $8 and $12 a pop and is expected to be licensed in Britain in the autumn.