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Viagra and the staff of life

Like GPs everywhere I have had to deal with numerous enquiries about Viagra, the new wonder drug for what we used to call impotence, but now every schoolboy knows as 'erectile dysfunction'. By contrast with the popular image of lusty swingers demanding enhanced 'recreational' sex, all but one of the men requesting Viagra in my surgery was over 60 and most were over 70. The younger man had become impotent as a result of a surgical procedure that went badly wrong. Most of these men have significant medical problems - diabetes, high blood pressure, coronary heart disease.

I have long been impressed at the commitment of many of my older patients to continuing sexual activity. Much of the public debate - and all the rather childish jokes - expresses the familiar disgust of adolescents at the discovery that their parents are still having sex. Yet whereas in films and on television the only people who have sex are young and nubile, in the real world people of all ages, shapes and sizes, and people with all sorts of disabilities, have active and fulfilling sex lives. The high level of demand for established treatments for impotence - involving injections into the penis, implants or vacuum devices - which are often painful, uncomfortable and unsatisfactory, indicates what men are ready to endure to sustain some sort of sexual performance.

There is something very positive and life affirming about the sexual impulse. The word intercourse implies both an intimate and a social experience. The quest for Viagra, in my patients at least, expresses an admirable determination to achieve pleasure and an equally admirable aspiration to give pleasure.

There is also a sort of cosmic justice in the fact that people who do not seem to conform in a single particular to conventional stereotypes of sexual attractiveness can not only find a mate, but enjoy a high level of sexual fulfilment with them. Furthermore, though people's sexual activity is governed by a range of social codes and influenced by market forces, there is still a private sphere in which sex can be enjoyed with considerable freedom from outside interference.

In a society that seems increasingly to regard masculinity as a pathological condition, it is not surprising that a drug which claims to enhance it - at least where it is impaired - has provoked a hostile reaction. Announcing his decision to ban Viagra from prescription on the NHS, health secretary Frank Dobson raised the spectre of 'people waving their potency at a disco'. Given the age of my patients requesting Viagra this seems an unlikely scenario, though one is an accomplished ballroom dancer. In Dobson's febrile imagin- ation the image of the priapic male links the elderly man taking Viagra to the youth/yob culture which seems to strike terror into the heart of the New Labour government.

Agony aunt Clare Rayner has characterised protests at the ban on Viagra as 'childish howls of frustration from a menacing mob of elderly but immature blokes who want to recapture an illusory lost youth'. This is not just nonsense, but offensive too. My patients just want to have sex with somebody. What is childish or immature about that? And what is menacing about an elderly man who wants to restore his declining potency? It is difficult to imagine any context in which Rayner might be confronted by a mob of frustrated old men howling and demanding Viagra, though she clearly has a rich fantasy life.

It is striking that in a society saturated with sexual imagery, the erect penis is still the ultimate pornographic image, just as penetrative sex, its natural function, seems to be widely regarded as a mode of violation rather than a source of mutual satisfaction. Whereas in some cultures the male erection is celebrated as the staff of life, in our culture its connotations of impulsiveness and creativity, and its symbolic associations with being assertive and taking risks, are regarded in a generally negative light.

The prevailing animosity towards Viagra has not, however, stopped politicians and doctors from using it to advance their own agendas. Ministers and senior NHS administrators emphasise the exemplary value of the government's first ban on a drug which is widely acknowledged to be safe and effective, in bringing the issue of rationing health service spending to the centre of public attention. Banning Viagra opens the way to banning more treatments, in a transparent and open way, of course. Some doctors claim a privileged position in the rationing process as the only people with the requisite skill to diagnose erectile dysfunction. I reckon my patients are better judges of whether or not they can get it up.

I would recommend a more radical approach: the deregulation of the pharmaceutical industry and the de-medicalisation of sex. Viagra has exposed the way that a network of restrictive practices and monopolistic arrangements enables drug companies to make vast profits at the public expense. Why not give free rein to market forces and watch the price of Viagra - and many other drugs - fall? Instead of allowing doctors to dictate who should have Viagra, let the customer decide whether or not they need it, and let them buy it over the counter - together with contraceptives, post-menopausal hormone replacement, treatments for obesity and depression, blushing and other non-medical problems.

Inspired by the gloomy conviction that a drug that enhances sexual performance must be too good to be true, commentators have leapt with glee upon early reports of fatalities attributed to Viagra in the USA, and other side-effects, notably retinal damage (provoking yet more naff jokes). When I told one of my patients that, even if Viagra was available he would not be able to take it together with his treatment for angina, he immediately took the bottle out of his pocket and threw it with a flourish in the bin. 'It might kill me', he said, 'but what a way to go!'.

Dr Michael Fitzpatrick

Reproduced from LM issue 115, November 1998

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