In March 1998 when Viagra was first approved, Maryland anesthesiologist Ken Haslam, M.D. (Cal B.S. 1956) was 64, single, and dating. “I was meeting lots of women. It was exciting. And for me, new relationships lead to great sex. I heard about Viagra, of course. But with all the excitement in my life, I didn’t need any erection help, so I didn’t try it.”
A few years later, however, Haslam became concerned about his erections. Sexual thoughts no longer caused a stirring between his legs. Raising an erection took effort, vigorous manual or oral stimulation. His erections were not as firm as they’d once been. And minor distractions wilted them. As a doctor, he recognized mild erectile dysfunction (ED), normal for men over 60, but still annoying. “So I tried Viagra, 50 mg. It worked. It worked well.”
Today, at 75, Haslam still leads an active sex life, and he still uses Viagra—but for only about 10 percent of his lovemaking. “There’s more to sex than an erection,” he explains. “Erection is not the goal. Shared intimacy is, a close, loving relationship. I’ve had wonderful sex and great orgasms without an erection. Occasionally it’s fun to use Viagra. But most of the time, I don’t even think about it.”
Viagra-Vation
Haslam’s reaction is not what the experts predicted a decade ago when Viagra became the most successful new-drug launch in pharmaceutical history. Pundits proclaimed that older men would embrace the little blue pill the way type 1 diabetics use insulin, as an indispensable part of daily life. Analysts forecast sales of $4.5 billion a year or more as the male population aged, and as advertising wars among what eventually became the three brands—Viagra, Levitra, and Cialis (both approved in 2003)—heated up and continually reminded men and couples about the medications. Social commentators even coined a new word, “viagra-vation,” to describe the distress women felt when partners using Viagra pressed for more frequent sex, or when men with newly restored erections suddenly became interested in philandering.
However, through 2005, sales of erection medications reached only about half of the predictions, just $2.5 billion annually. That’s still a great deal of money, but older men did not flock to the drugs in anywhere near the numbers the experts anticipated. During the first two months after Viagra’s approval, U.S. doctors wrote 275,000 prescriptions. But seven months later, only one-third of those men—fewer than 100,000—had obtained refills. According to Pfizer, maker of Viagra, as many as half of men over 40 experience some ED, but only about 15 percent of them have even tried erection drugs, let alone become regular users.
Recent research makes the Pfizer estimate look optimistic. In 2007, German researchers surveyed 3,124 older men. Forty percent of them had some form of ED. Of that group, 96 percent could name an erection drug, but only 9 percent had used one. And last year [2008], researchers at Cornell’s medical school surveyed 6,291 men in 27 countries. Almost half—48 percent—reported some ED. How many had tried an erection drug? A mere 7 percent.
Only One Thing on Their Minds?
In other words, the vast majority of men who might benefit from erection medications don’t try them, or try them and then stop. This flies in the face of a key cultural assumption about men and sex—that men are perpetually horny, and therefore, obsessed with erection. Who hasn’t heard: “Men have only one thing on their minds.” “Men have two heads—and the little one does the thinking.” “Women have sex to gain relationships. Men have relationships to gain sex.”
Now this stereotype contains more than a germ of truth. Most men think about sex a great deal. According to the Kinsey Institute at the University of Indiana, the average male teen has a sexual thought once every five minutes, while the typical man over 40 has one about every half hour. But if that’s true why don’t more older men try the drugs? And continue to use them?
Addressing the latter issue first, there are several reasons why men would rather not refill their prescriptions:
- The drug industry may have exaggerated effectiveness. The makers of Viagra, Levitra, and Cialis say the drugs benefit about 70 percent of users. That figure comes from the pre-approval studies they submitted to the Food and Drug Administration, in Viagra’s case, trials involving approximately 3,000 men. But a review of 14 recent studies involving more than six times as many participants—18,337 men—shows effectiveness results ranging from 0 to 89 percent. Most results cluster in the ballpark of 70 percent, but several trials show success rates ranging from 40 to 60 percent. In drug studies, disparate results are not unusual. But the surprisingly low rate of prescriptions refills suggests that erection drugs may be less effective than the public has been led to believe.
- When the drugs work, they don’t produce instant erections. American men get much of their sex education, if not most, from pornography. In porn, the man unzips and out flops a telephone pole. After years of viewing porn, many men come to believe that erections are supposed to rise instantly to full firmness. In men under 30 they often do. “But in older men, they just don’t,” explains San Francisco sex therapist Linda Alperstein, L.C.S.W., a former lecturer in human sexuality at the Cal School of Social Welfare. “The drugs require erotic play and direct penile stimulation. Men expecting instant erections may feel disappointed.”
- Erection medications may not produce firm erections. When erection drug advertising promises “benefit,” many men expect what they see in porn, erections that are rock-hard. But the actors in porn are usually in their twenties, the stage of life when erections are firmest. And just in case, these days, they all use erection drugs. “Even with the drugs, middle-aged erections are not as firm as the ones men see in porn or recall from their youth,” says Paul Joannides, Psy.D., of Waldport, Oregon, author of the best-selling sex manual for young adults, The Guide to Getting It On (Cal BA 1976). “Men who expect porn firmness might feel disappointed, and figure the drugs don’t work for them.”
- Viagra et al. are not aphrodisiacs. In young men, erection and arousal are virtually synonymous. When young men feel aroused, they raise erections, and when they have erections, they feel aroused. “But in middle age, arousal and erection become uncoupled,” explains developmental psychologist Richard Sprott, Ph.D., a lecturer in the Department of Human Development at Cal State University, East Bay, in Hayward (Cal Ph.D. 1994). “You can take a pill and get hard, but you may not feel aroused. This astonishes many men. It goes against all their previous experience, and it defies gender role expectations. The myth is that men are always horny. But older men aren’t. In middle age, arousal takes effort. It becomes work. Viagra may give you an erection. But that’s all it does. It doesn’t help men become aroused. Men who expect an aphrodisiac are disappointed.”
- They drug industry underestimates side effects. In Viagra’s pre-approval trials, side effects were mild and uncommon—headache (16 percent of users), stomach upset (7 percent), and nasal congestion (4 percent). Some post-approval studies have reported similar findings. But others have documented much higher rates of side effects—40 percent of users. This issue remains unresolved, but for some men, the side effects might outweigh the benefits.
- Cost may be an issue. Many health insurers don’t cover erection medications. Cost can be $10 to $20 per pill.
- The drugs don’t repair damaged relationships. All that Viagra et al. do is increase the likelihood of erection. But many couples have unfulfilled sex—or no sex—for reasons that have nothing to do with the man’s penis. “If the intimacy in a relationship is broken,” Joannides explains, “if the couple lives in an erotic void or has other festering relationship problems that ruin sex, the most perfect erection in the world isn’t going to fix things. The couple needs sex therapy.”
At the University of Sao Paulo in Brazil, researchers analyzed 11 studies comparing the benefits of Viagra by itself versus the drug plus sex therapy. In every trial, combination treatment worked better than Viagra by itself. In one trial, researchers at the Center for Sexual Health in San Jose, California, researchers gave 53 couples either Viagra by itself or the drug plus weekly sex therapy for eight weeks. Using the drug alone, 38 percent of couples expressed satisfaction. But among those who used Viagra and sex therapy, the figure was almost twice that, 66 percent. “The evidence is clear,” Joannides says. “There’s more to good sex than a stiff penis. Erection drugs work best combined with sex therapy focused on the relationship.”
Older Men: Sexually More Like Women
While many reasons explain the low rate of prescription refills, another question is perhaps more intriguing: Why do so few older men—less than 10 percent—try erection drugs in the first place? Because couples who remain sexual in older adulthood evolve away from vaginal intercourse. As a result, they no longer need erections.
After around 40, Sprott explains, sex changes: “Men’s testosterone production gradually falls, so men’s sex drive becomes tempered. They mellow. They don’t feel the same urgent need for sex that they experienced in their twenties. This change requires a major adjustment. But it also creates an opportunity to explore sex that’s less preoccupied with the genitals. Some men focus on what they’ve lost—perpetual arousal, reliable erections, and the primacy of intercourse. But others focus on what they can gain, pleasure that expands from the genitals to the whole body.”
“For many older men and couples, this transition is difficult,” Alperstein says. “People need time to grieve what they’ve lost. Our sexual culture is so focused on intercourse. Take the word ‘foreplay.’ It’s what comes before the main event, which, of course, is intercourse. And Hollywood sex and pornography are largely focused on intercourse. So it takes real effort to move beyond an intercourse-based sexual worldview. But couples who make this transition usually discover a whole new realm of pleasure.”
Quality lovemaking, sex experts agree, has less to do with rock-hard erections and piston-like intercourse than with extended kissing and cuddling, and leisurely, playful, whole-body massage that includes the genitals, but is not fixated on them. “The first thing older couples need to know,” says Haslam, who teaches workshops on sex after 40, “is that men don’t need erections to have orgasms. I’ve had wonderful orgasms without one, thanks to manual stimulation or oral sex. The second thing they need to know is that sex in older adulthood is less about intercourse than ‘outercourse.’ Outercourse is like foreplay, only there’s no intercourse after it. Outercourse includes mutual pleasuring with fingers, lips, tongues, and sex toys. With creative outercourse, you can enjoy very erotic, orgasmic sex without intercourse.”
“My older clients tell me that the drugs feel contrived,” Alperstein explains. “They’re all about intercourse. But if you’re not trying to make a baby, intercourse isn’t necessary, and as the years pass, it becomes problematic. The man probably has erection issues. The woman is probably postmenopausal, and even with a lubricant, intercourse may feel uncomfortable. At some point, many couples decide they’d rather be sexual without intercourse, so who needs the drugs?”
Compared with young men, young women tend to take longer to become aroused. This often causes conflict. Many young women complain that sex is over for their young lovers before they’ve even warmed up to it. Young women also tend to be less genitally focused than young men and more excited by playful whole-body sensuality. This, too, can cause conflict. She wants to kiss and cuddle and maybe try a foot massage, meanwhile, he has only one thing on his mind.
But as men age, men’s and women’s sexual sensibilities converge. Men become sexually more like women. They need more time to become aroused, and as erection and intercourse become more problematic or impossible, whole-body sensuality becomes more attractive. “Compared with young lovers,” Sprott explains, “older couples are more sexually in synch. Couples who appreciate this can enjoy richer, more fulfilling sex at 65 than they had at 25—even without erection and intercourse.”
Viagra and the other erection medications will, no doubt, continue to generate sales in the billions—in part because men in the porn industry pop the pills like candy, and because men under 50 (both straight and gay) now use them for “erection insurance.” But the drugs were developed for men over 50—and a decade after Viagra’s launch, surprisingly few of them are interested. It’s ironic. It has taken drugs entirely focused on erection and intercourse to show the world that older lovers move beyond erections and intercourse.
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