Forget Bob Dole’s confession on live television. To me, the proof that Viagra has become part of the national fabric was demonstrated conclusively in a conversation I overheard at Big Steve’s Gym in Austin. Some hypermacho bodybuilders in the fifty-year-old age group—more than half of whom would be statistically likely to suffer from some degree of erectile dysfunction—were openly discussing the famous blue pill and marveling at the way it had restored the prowess of their teenage years. One remarked that he was having sex three or four times a day, thanks to his Viagra-induced erections. Another told of having sex before church, only to discover shortly before noon—as his attention began to drift during the doxology to more-temporal matters—that his erection had returned. “Shaking hands with the preacher at the door,” he confided to his companions with evident pride, “I was crossing my legs and trying to cover the damn thing up with my Bible.”
Like millions of others my age, 63, I can testify from personal experience that Viagra is everything those guys say it is. For the first time we have a pill that can restore sexual function to men suffering from erectile dysfunction (ED), or impotency, as it was known to earlier generations. Other dependable remedies have been on the market—from penile injections and inserts to the still-handy vacuum pump—but none as cheap or as easy to use as Viagra: Pop a fifty-milligram pill and in less than an hour you’re ready for action. And it’s only going to get cheaper and easier to treat impotency. Other drugs are already being tested or are awaiting Federal Drug Administration approval, including a pill called Vasomax, which was developed by Zonagen, a biopharmaceutical company located in the Woodlands, north of Houston. If all goes well, Vasomax will be on the market by the summer of 1999. At least two more potency therapies are being tested in pharmacology laboratories in other parts of the country. In a few years Viagra may become as generic as aspirin—itself once a trade name wonder drug—and hopefully as inexpensive.
Viagra’s real contribution to the common psyche is that it has coaxed out of the closet the most embarrassing of all male sexual problems. Thirty million American men have at least occasional problems achieving or sustaining a full erection, but until the avalanche of publicity brought on by the Viagra revolution, less than 5 percent had summoned the courage to consult a physician. My generation came of age at a time when nobody talked about such delicate problems. A power lifter at Big Steve’s was more likely to acknowledge that he squatted to pee than confess he had occasional trouble getting it up.
What little we knew of the problem came from reading Hemingway: Impotency was the reason Jake Barnes couldn’t connect with Lady Brett Ashley in The Sun Also Rises. It was something you got in the war or something psychological. Though seemingly remote from our own lives, impotency was the most terrifying of prospects: It destroyed the sufferer’s claim on manhood. Worse still, the condition was permanent, or so most men were taught. Our forefathers believed that poor erections were simply nature’s way of telling us that people aren’t supposed to have sex once their reproductive years have waned. And so they faded softly into the night, never dreaming that men (and women) can enjoy sex well into their nineties—with a little help from medical science and a few practical hints about romance.
Remarkably, only in the final decade of the twentieth century have we agreed that most sexual impotency—including a woman’s inability to have an orgasm—is physiological, not psychological, and that most often it should be treated as a vascular problem. The same vascular ailments that lead to heart attacks, strokes, and numbness in the legs—clogged arteries, high blood pressure, hardened vessels, and damaged nerves—contribute to sexual malfunctions by depriving the penis and the clitoris of oxygen-rich blood. A small percentage of impotency is attributable to injury or trauma-induced nerve damage, and other afflictions are indicators: Men who have had their prostate removed and people who suffer from diabetes or hypertension will more commonly experience sexual problems. ED is also made more acute by drinking, smoking, stress, and physical inactivity.
There are, to be sure, psychological aspects to the problem. “We grow up with the myth that a real man can always get an erection,” Harry Croft, a San Antonio psychiatrist, sex therapist, and lecturer told me. “When a man fails to have an erection, these myths surface. He begins to speculate on future failures and gets anxious thinking about his sexual performance.” Masters and Johnson, the sex therapist pioneers under whom Croft trained in the seventies, called this situation performance anxiety. Even after the primary causes of ED are addressed, fear of failure may continue to take the starch out of a guy.
IT TOOK ME A LONG TIME TO FIGURE IT OUT, but sex isn’t about erections; it’s about relationships. My libido has always been excessively active, even more so after I married my sex bomb wife, Phyllis, 22 years ago. Both of us had been married multiple times before, and we came together with no illusions. We each knew of the other’s adventurous past and were open and honest about our needs and desires. In acknowledging a bond of selfishness and weakness for the flesh, we advanced our own love affair in new and exciting directions. That’s the way we viewed it—as a love affair, with all the attendant risks, thrills, plateaus, and challenges the term implies. We made out on moonlit beaches, in cornfields in the shadows of interstate highways, and in darkened 747’s over the Atlantic. We had been searching separately and shamelessly for fulfillment all those years, and we found it in each other, as one finds an answered prayer.
About ten years ago I noticed that my erections were less dependable and that orgasms took longer and were less intense. I didn’t regard this as a major problem. We factored it into the act, allowing ourselves more time for foreplay and finding erotic diversions to stimulate desire and performance. I knew that part of the problem was fast living and made some concessions to a healthier lifestyle, though, in retrospect, not nearly enough. I was already being treated for hypertension, and in 1988 a mild heart attack sent me to the emergency room, where I subsequently learned that I needed quintuple-bypass surgery.
On the night before I was scheduled for surgery, Phyllis chased the visitors out of my hospital room and worked a dresser into position to block the door. Showtime! If I was going to die on the operating table, neither of us wanted me to go out horny. In a matter of minutes we were lost in passion, oblivious to the wires, tubes, and catheters that secured me to my bed. We were approaching nirvana when an alarm bell began to shriek above our heads, alerting the orderlies and nurses that my IV bag needed to be replaced. A team of medics burst through our barricade and with a show of tactful professionalism changed the IV. Then an angel in the uniform of a head nurse stood guard outside the door, in case anybody else had any bright ideas about interrupting her patient.
Bypass surgery momentarily interrupted our sexual routine, but only for three or four weeks, and things returned to normal. Nevertheless, my erectile problems got gradually worse over the next four or five years. The libido was as strong as ever, but the equipment frequently failed. Achieving an orgasm wasn’t a problem for me, but I was never sure about Phyllis. Fear of performance edged at the margins of my consciousness.
Instinctively, we began to explore new and more-inventive measures. Though we were by this time a bit long in the tooth for amour in cornfields and tourist-class seats, we discovered that we could restore the old heat by slipping out of town for romantic weekends. Long vacations were even more therapeutic. An apartment in the Marais section of Paris, a villa on the Amalfi Coast of Italy, and a hotel room in Frankfurt, Germany, with an antique bathtub as deep and as spacious as the back of a pickup are among the selections in our Love Wallow Hall of Fame.
We also addressed the fantasy factor, collecting a wardrobe of seductive costumes and giving each a name appropriate to its suggestiveness and inauguration. An early favorite was the Warden’s Daughter, a white see-through blouse with white lace panties. My corresponding outfit, a black jockstrap, was dubbed the Escaped Prisoner. A long, silk, black gown with a low-cut neckline and a split up one side became known as the Black Maria. We bought Monique’s Paris Slip in the fall of 1995, during that unforgettable week in our Paris apartment. That was the week we started calling each other Frenchy and Monique, noms d’amour that we use to this day.
Paris did something to each of us, something permanent. For the first time, we fully understood the distinction between love and sex, and romance became a continuing affair. Phyllis resisted no impulse to surprise me with exotic gifts. No longer did I wait for Valentine’s Day or birthdays to bring her flowers or scribble love notes or pathetic attempts at poetry. We shared secrets and revealed naughty episodes from our pasts. Acts of altruism were invariably rewarded—sometimes with wild monkey love, followed by candlelight dinners with wine and music, and sometimes with simpler, more subtle expressions of love: a look or a touch or an act of kindness that worked some subliminal pleasure point deeper than the libido. Lovemaking became much more than the act itself. It became a long, periodically interrupted, almost subconscious tease that went on for hours or even days. The much-celebrated climax became, in many ways, anticlimactic, the swan song of an interlude. And life was finally revealed as nothing more than a series of unbearably sweet interludes.
A FEW MONTHS AFTER WE RETURNED from Paris, I finally admitted to myself that ED was a problem that would only get worse. With some trepidation I called my urologist for an appointment. I had been reading and fling away articles on the subject, the most dramatic of which was an account of a medical conference in Las Vegas. A 57-year-old British physician had presented a paper on a new injectable drug to treat ED and then demonstrated its effectiveness by dropping his pants and displaying his fully erect organ. The full monty in Vegas was more than a landmark event, it was a cultural epiphany. The drug that caused that famous erection was papaverine, which had previously been used to lower blood pressure. Other researchers had observed that some drugs designed to treat high blood pressure and other vascular diseases could, when administered in large enough doses, cause male patients to get an erection. One such drug was alprostadil (a naturally occurring form of the hormone prostaglandin E-1), which was used to treat a rare heart defect. Another was Viagra, which was originally designed to treat angina.
The connection between the heart and the penis should not have been such a surprise. The physiology of an erection depends on a series of interacting electrical and chemical impulses, starting with up-close personal contact or some observed or remembered sexual image. Once this registers in the brain, a message is sent to the penis, causing an increase in the production of the chemical cyclic GMP, which is normally broken down and kept in check by the enzyme phosphodiesterase type 5 (PDE5). The additional cyclic GMP causes muscles in the erectile tissue to relax and the arteries to expand. As blood rushes into the newly opened spaces, the penis stiffens and expands. Simultaneously, veins that normally drain blood away from the penis are squeezed shut, facilitating full erection. After orgasm, or when arousal subsides, the equilibrium between cylic GMP and PDE5 is restored. Impotency strikes when cyclic GMP is in short supply—and when the penis has been soft for so long or the erectile tissue is so defective it can’t expand enough to close off the veins. Men who suffer from mild cases of ED can often achieve a semi-erection through arousal, but the blood drains away as quickly as it arrives: It’s like trying to fill a bathtub with the drain open.
In July 1995 the FDA approved the nation’s first drug for impotency, Caverject, the trade name for a product that consisted of a disposable needle and syringe of alprostadil. Injected into the base of the penis with a fine-gauge needle, the drug relaxes the smooth muscles surrounding the penile arteries, causing them to dilate and permit an increased flow of blood.
As expected, my initial visit to my urologist was awkward. First, a female therapist asked a lot of questions about my sex life with Phyllis. How often did we do it? How satisfactory was it? This was followed by a physical exam and finally a small-dose injection of alprostadil to determine if I would have any bad reaction to the drug. Apparently I passed the tests, because I left with a prescription for ten Caverject, at $18 a pop.
The first time I used the needle, in the privacy of my walk-in closet, I recalled my Army lessons in marksmanship: Take a deep breath, let a little out, hold it, and squeeze (don’t jerk) the trigger. It worked: I felt a tiny pinprick and after a few minutes a nearly forgotten surge of blood in my groin.
“How’s it going?” Phyllis called from the bedroom.
“Does the term Louisville Slugger ring a bell?” I replied, stepping from the closet for my debut. We both erupted into uncontrollable laughter. This spontaneous levity shattered what might otherwise have been a tense moment. It also set a precedent. After that, the Slugger became our little joke, our way of agreeing that while penile injections were not the desired beginning of foreplay, they appeared to make a most valuable contribution.
TREATING IMPOTENCY REQUIRES MORE than a pill or a needle, it requires a sense of humor. If I didn’t already know this, I certainly discovered it while researching my book HeartWiseGuy, which deals with bypass surgery, hypertension, impotency, and other ordeals of aging. Between 1995 and 1997, I tried all the ED gadgets on the market except one: the penile implant. Back in the eighties the implant was considered the gold standard, even though it required expensive and potentially dangerous surgery and did not always work as advertised. The most popular model today consists of two inflatable cylinders that are planted surgically in the spongy tissue of the penis, a fluid reservoir placed in the pelvis, and a pump affixed inside the scrotum. Squeezing the pump forces fluid into the cylinder, thereby making the penis rigid; a release valve reverses the process. But a friend who had had this model installed—on the advice of a golfing buddy who assured him that his own implant made airline stewardesses faint with pleasure—found that it indeed rarely worked as advertised. In fact, it hurt all the time. Then one morning at his office he discovered he was sitting in a pool of blood. The operation had led to an infection that ruptured his scrotum and caused him to hemorrhage. The condition was complicated by his diabetes—his doctor had not warned him that diabetics are particularly at risk with this procedure. His only recourse was to have the implant surgically removed, again at considerable expense. Later, when he decided to try Caverject, he discovered, to his horror, that the implant had destroyed the erectile tissue in his penis. It was gone and could not be replaced.
“My God!” my friend screamed at his doctor. “Are you telling me I’ll never have another erection?”
“You’re nearly seventy,” the doctor reminded him. “You’ve screwed enough.”
In November 1996 a new therapy called the Medicated Urethral System for Erection (MUSE) hit the market, with predictions that a new gold standard had been established. MUSE is a disposable catheter that inserts a BB-size pellet of alprostadil into the urethra. Essentially the same vasodilator therapy as Caverject, it spares the user the dreaded needle. But I learned, as did most others who tried it, that MUSE is less reliable than Caverject. Harin Padma-Nathan, a clinical professor of urology at the University of Southern California, reported in an article in the New England Journal of Medicine that only about 30 to 40 percent of his patients got a rigid erection using MUSE.
The simplest and most efficient therapy is the ErecAid, a hand-held pump that creates a vacuum and draws blood into the erectile tissue; the blood is dammed there with rubber tension rings attached to the base of the penis. The pump and attachments come in a carrying case about the size of a shaving kit and cost about $375. Unlike the alprostadil therapies, ErecAid does not require refrigeration and can therefore be taken on the road. Be warned, this is a clumsy piece of equipment, about as romantic as a tire jack. But here’s where the sense of humor comes in. If you incorporate the ErecAid into your foreplay, make it part of the ritual of lovemaking—think of yourself as a magician and his assistant, for example. The results are impressive. Even with Viagra in the house, the ErecAid remains a mainstay in our arsenal.
WITHOUT QUESTION, VIAGRA IS THE CURRENT gold standard. And its potential may have been barely tapped: Some scientists believe it may also improve the sexual response of postmenopausal women. Little research has been done on women’s sexual problems, even though older women have even more sexual dysfunction than men. Therapists suspect that the chief complaint, a lack of desire, really reflects women’s problems dealing with their aging bodies—vaginal dryness, the increased time needed for arousal, and difficulty reaching orgasms. Since the clitoris, like the penis, becomes engorged with blood during sexual arousal, Viagra may soon wind up on both sides of the medicine cabinet.
Viagra is a capacity drug, not a desire drug. Men still need to be aroused before anything can happen. It works by prolonging the effects of cyclic GMP—making a little go a long way—until it is sufficient to overpower the killjoy PDE5. Since healthy erectile tissue accepts only a finite amount of cyclic GMP, men with normal erectile ability won’t notice any effect from Viagra, no matter how many pills they take.
None of the ED therapies can rejuvenate an affair that has lost its spark, which calls up an extremely important issue. Men need to pay more attention to the quality rather than the quantity of sexual experiences. “Starting in puberty,” says Harry Croft, “men somehow get the idea that all a woman needs to be happy is a good, stiff member. That’s a male conceit. What women are interested in is romance, touching, caressing—sex is something that comes later. When men begin to experience problems with erection, a lot of couples withdraw from kissing and hugging and all forms of intimacy, fearing that they are making promises they can’t keep.”
Couples who have not had sex for a long time are bound to have feelings of anger and frustration that can’t be addressed by the little blue pill. Reawakening sexual desire requires a reacquaintance with romance. I read recently about a middle-aged couple who lay quietly in bed waiting for Viagra to work and eventually fell asleep. Apparently they had forgotten about foreplay. Similarly, a guy who pops a Viagra, calls his wife at the office, and demands that she hurry home for a big surprise is in for a surprise of his own: You can’t kindle the fire of love with a pill.