Why the market for the little blue pill is softer than expected.
In March 1998 when Viagra was first approved, Maryland anesthesiologist Ken Haslam ’56 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 novelty and adventure in his romantic life, he really didn’t need any help.
A few years later, however, Haslam became concerned when sexual thoughts no longer were enough to cause physical arousal. Tumescence took vigorous manual or oral stimulation, and even minor distractions had a wilting effect. 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.”
Haslam’s reaction is not what the experts predicted a decade ago when Viagra’s launch became the most successful of any new drug in pharmaceutical history. Pundits proclaimed that older men would embrace the little blue pill enthusiastically as an indispensable part of lovemaking. Analysts forecasted sales of $4.5 billion a year or more as the male population aged, and as couples were continually reminded about the medications by advertising wars among what eventually became the three brands—Viagra, Levitra, and Cialis (the last two approved in 2003). Social commentators even coined a new word, “viagravation,” to describe the distress women felt when partners using Viagra pressed for more frequent sex, or when men with revived equipment and confidence suddenly became interested in philandering.
However, through 2005, annual sales of the drugs reached only about half of the predictions, just $2.5 billion. That’s still a great deal of money, but older men did not flock to the drugs in anywhere near the numbers anticipated by the experts. During the first month after Viagra’s approval, U.S. doctors wrote more than 300,000 prescriptions. But seven months later, fewer than 100,000 of those men 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, researchers at Cornell’s medical school published a survey of 6,291 men in 27 countries—48 percent of whom reported some ED. How many had tried medication? A mere 7 percent.
That the vast majority of men who might benefit from these drugs don’t try them, or try them and then stop using them, contradicts a key cultural assumption—that men are obsessed with sex and intercourse. 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 get relationships. Men have relationships to get sex.”
Indeed, this stereotype contains more than a germ of truth. Most men think about sex a great deal. According to the Kinsey Institute at Indiana University, the average male teen has a sexual thought once every five minutes, compared with about every half hour for the typical man over 40. In a recent survey by Canadian researchers, almost half of men reported having sexual thoughts several times a day, but only 11 percent of women did. If so many men think about sex so frequently, why don’t more older men try the drugs? And continue to use them?
There are several reasons why men would rather not refill their prescriptions. For one, the drug industry may have exaggerated the 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 submitted to the Food and Drug Administration; in Viagra’s case, the trials involved 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 from 40 to 60 percent. In drug studies, such disparate results are not unusual. But the surprisingly low rate of prescription refills suggests that these medications may be less effective than the public has been led to believe.
Another consideration is that when the drugs work, they don’t produce instant results. American men get much of their sex education from pornography, and 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 sex therapist and UCSF clinical psychiatry professor Linda Alperstein, a former lecturer in human sexuality at Berkeley’s School of Social Welfare. “The drugs require erotic play and direct penile stimulation” for full effectiveness.
The drugs also advertise “benefits,” which men take to mean erections that are rock hard, as with porn stars. But these actors are usually in their 20s, the stage of life when erections are most firm. And in case they aren’t, these days the actors all use erection drugs. “Men who expect porn firmness might feel disappointed and figure the drugs don’t work for them,” says research psychoanalyst Paul Joannides ’76 of Waldport, Oregon, author of the popular sex manual for young adults, The Guide to Getting It On.
Viagra et al. are not aphrodisiacs. In young men, tumescence and arousal are virtually synonymous. But in middle age, the two “become uncoupled,” explains developmental psychologist Richard Sprott, Ph.D. ’94, a lecturer in the Department of Human Development at Cal State University, East Bay, in Hayward. “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. In middle age, arousal takes effort. Men who expect an aphrodisiac are disappointed.”
Then there are the side effects, which the drug industry underestimates. 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 secondary responses might outweigh the benefits.
And the drugs don’t offer the one side effect that couples might actually desire: repairing a broken relationship. At the University of São Paulo in Brazil, researchers analyzed 11 studies comparing the benefits of Viagra or other contrived stimulant versus a combination of the stimulant plus sex therapy. In every trial, combination treatment worked better than Viagra alone. In a trial at the Center for Sexual Health in San Jose, researchers gave 53 couples either Viagra by itself, or the drug plus weekly sex therapy for eight weeks. Of those using the drug alone, 38 percent expressed satisfaction. Among those who used Viagra and sex therapy, however, the figure was 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.”
Apart from the many reasons for 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? One explanation is that couples who remain sexual in older adulthood evolve away from intercourse. As a result, they no longer need erections.
After around 40, explains Sprott, 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 20s. 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.”
It is a transition that is difficult for many older couples, 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. But couples who make this transition usually discover a whole new realm of pleasure.”
Quality lovemaking, sex experts agree, has less to do with intercourse than with extended kissing and cuddling, and leisurely, playful, whole-body massage. “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.” Sex in older adulthood is less about intercourse than “outercourse,” he explains. “Outercourse is like foreplay, only there’s no intercourse after it. With creative outercourse, you can enjoy very erotic, orgasmic sex without intercourse.”
His older heterosexual clients say the drugs “feel contrived,” Alperstein says, because “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 the women have even warmed up to it. They 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 more like their female partners. 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 (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 these men are interested. How ironic that it has taken drugs entirely focused on erection and intercourse to show that as lovers age, erection and intercourse become less and less central to lovemaking.
