Be careful what you wish for, I think as my husband reaches again for his new toy. Tragically, it's not a Ferrari or the latest Mac laptop — it's his Penis 2.0—the new, pharmaceutically enhanced model.
I married an older man, and lucky for us both, the only part on him that's given out is his knees. But since I was writing about erectile dysfunction (ED) drugs, I wanted him to help me out. Would he try one? The little blue pill enables older men to sexually respond like 18-year-olds. "Wouldn't that be interesting," I asked him, "journalistically speaking?"
John was skeptical. "What if I take this and things never work without the pill again?" he asked. I pointed out that the label of a leading brand, Viagra, does not list physical dependence as a side effect (although it does mention headaches and an upset stomach). True to promise, when John used Viagra, everything was perfectly fine. But to my chagrin, it was perfectly fine a lot.
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And therein lies a problem I wonder whether the makers of Viagra and its pharmaceutical cousins Levitra and Cialis foresaw. While men of a certain age are undoubtedly thrilled to have their sexual potency restored, maybe their wives' enthusiasm is a bit more subdued?
What at first glance seems an obvious win-win situation for both husbands and wives can have a raft of unintended consequences. Don't get me wrong: Viagra is a wonder drug. Since the early '90s, when researchers testing a new heart medication called Sildenafil discovered that it had a startling side effect in men, erectile dysfunction drugs have become more than a billion-dollar industry.
One study conducted by Express Scripts, a pharmacy benefit management company, found that nearly 20% of all American men over age 45 have tried them. And since, according to the National Institutes of Health, approximately 5 percent of 40-year-old men and from 15 to 25 percent of 65-year-old men experience ED (for reasons ranging from narrowing of the blood vessels with age to high blood pressure, diabetes, obesity, and neurological problems), these drugs have been a godsend to millions.
ED drugs can also, indirectly, be lifesavers. Thirty-four to 70 percent of all men who take antidepressants experience sexual dysfunction as a side effect, and of those who have this problem, almost 90 percent stop taking the antidepressants so their sex lives can go back to normal.
But ED drugs are so readily available, so much a jokey part of the cultural landscape, that few of us really know how they work and what the potential dangers are. This leads to misuse — not so much life-threatening as knuckleheaded.
Essentially, ED drugs work like this: What gives a man an erection is blood flow to the penis. The vessels dilate, and blood flows in. There is an enzyme that counteracts the dilation. ED drugs inhibit that enzyme, allowing dilation to occur more easily and last longer. They can also diminish a man's refractory time, meaning that after orgasm he can more quickly get an erection again.
The one thing most people know about Viagra and its cohorts is that they are not supposed to be used by men who take nitroglycerin, a common medication for heart patients that also dilates the blood vessels. But ask around. That little piece of knowledge has translated into "Viagra is bad if you have a heart condition."
Not so, says Arthur S. Agatston, MD, a cardiologist and associate professor of medicine at the University of Miami Miller School of Medicine and Prevention editorial advisory board member. In fact, Dr. Agatston says, because Viagra keeps the blood vessels from becoming "sticky" and helps blood flow through them smoothly, not just in the penis but throughout the body, in the future, many of us—women included—may end up taking some small amount of Viagra daily, the way we take baby aspirin, which has the same nonsticking effect on blood itself.
So when a man takes Viagra, he has to avoid anything that dilates the blood vessels, not just nitroglycerides. Drinking, lying in the sun — both are problematic. Viagra won't give him a heart attack, but, taken with too much alcohol, it could make him pass out, Dr. Agatston says.
Perhaps more damaging than ignorance of the physical ramifications of ED drugs is ignorance of their potential interpersonal blowback. When not discussed frankly, Viagra can cause a lot of misunderstanding and hurt between couples. "There is something about a hard erection that is extremely important to a man's identity," says Steven Lamm, MD, an internist in New York City and author of The Hardness Factor. "And of course most couples would prefer that the man be able to have one. But there are some who may have adjusted to life without sex. Perhaps the woman doesn't really want it anymore, for one reason or another. And for those couples, the introduction of an ED drug can throw them seriously out of sync."
That leads to what is perhaps the biggest complicating factor: the reality that a woman's postmenopause genital health can put her physically at odds with her partner's newfound, drug-assisted prowess. As women age, their hormonal balances change. Reduced estrogen levels often mean less sexual desire but also decreased vaginal elasticity and lubrication, and thus more potential for sex to be painful.
The problem can be especially daunting for older women who are widowed or divorced or just beginning to date after years of being alone or with one man. Certainly this was the case for Marjorie P., a 60-something woman who complained about the drugs on a 50+ Web site: "Men have been saved from their middle-age sexual issues by Viagra and Cialis. They can be thirty again, while I have to deal with the sexual issues of being my age. It's put the world on 'tilt.'" Andrea D., a twice-divorced physician from Santa Monica, CA, and an over-50 dater, put it more bluntly. "Viagra has been liberating for men, but unless a woman is taking hormone therapy, she may have vaginal dryness and really not be that interested in the kind of driving, pounding intercourse he's now capable of."
There is also fallout from the erroneous belief that Viagra causes not just greater blood flow but also greater desire. The hormone testosterone is the driving force behind libido; a man with little or no testosterone will not have any desire to have sex, Viagra or no. Moreover, even with normal amounts of testosterone, "Viagra does not just instantly give a man an erection," says Abraham Morgentaler, MD, associate clinical professor of urology at Harvard Medical School and author of The Viagra Myth.
"You have to be in a sexual situation, you need to have desire and intent, in order for the drug to work." Dr. Morgentaler tells the story of a patient who was very upset because Viagra didn't do the trick for him. "He said, 'Doc, I followed your directions exactly. I took the pill an hour in advance. Then I watched a baseball game on TV and waited.' The man's wife was in the other room, waiting too; neither of them realized that the drug would be effective only if they were together, doing what couples do."
The misunderstandings cut all ways: Some women think ED drugs make men amorous and that their presence isn't required. "What a lot of women need to be turned on is the feeling that they're desired," adds Virginia A. Sadock, MD, director of the program in human sexuality at New York University Langone Medical Center. "So with Viagra, they think, Oh, it's not me he wants; it's the Viagra talking. In my practice, I spend a lot of time reassuring them that this isn't the case — and I tell men they must reassure the women too."
Another big issue for many women: ED drugs drastically shorten the interval between climaxing and achieving another erection. Men look at this differently than women do. For them, it's not a bug, it's a feature. And for the woman?
"We want maybe twenty or thirty great minutes of sex," says Susan K., a mother of two in Connecticut. "We don't want an interminable two hours." Not to mention the fact that prolonged intercourse, particularly without sufficient lubrication, can do damage. It can lead to vaginal abrasions and even tearing and can expose a woman to risk of getting yeast infections and — particularly for a woman who is dating or divorced — to sexually transmitted diseases.
There are, too, single women who worry that men with new-and-improved sexual abilities will be less likely to commit to marriage, and wives who worry that their husbands will be more apt to look outside the marriage for sex.
"A partner's Viagra use is now another reason some women give when I ask why they've come to see me," says Miami plastic surgeon Lee Gibstein, MD, who has performed breast implants, face-lifts, and even vaginal rejuvenation on women concerned about turning back the clock.
Which is not to say that Viagra hasn't ever led to straying—but not for the reasons women think. "I've seen problems when a wife or partner objects to ED drugs on the grounds that sex should be natural and spontaneous," says Dr. Morgentaler. So if the man is unable to have erections on his own, and the woman shoots down the idea of a pill, then the guy is really stuck. The relationship can get into trouble, because one person wants sex and the other doesn't or only wants it on her terms.
So how can you make sure, if ED drugs come into your marriage, that they help rather than hamper your relationship?
"Couples really need to talk about what each partner in the relationship expects," says New York couples counselor Jane Greer, PhD, author of What About Me?: Stop Selfishness from Ruining Your Relationship. "The drug can highlight problems about which member of the couple puts him or herself first, which one is thoughtful and which isn't — creating all sorts of conflict."
Adds Andrea, whose own Viagra dating experiences and the experiences of similarly aged friends have ranged from excellent to Emergency Care Needed:
"You have to be crystal clear about what works for you and what doesn't. Because even with someone you really, really adore ... sometimes you just want to get back to reading your book!"
Moreover, women need to stop lying about what they like and don't like to protect the male ego, because that's a recipe for sexual dissatisfaction. "Women can cheat themselves out of good sex because they don't take responsibility for their own feelings, both physically and emotionally," says Dr. Sadock. This means: If you need to buy lubricant to make sex more comfortable, do it; if you need to tell him you're perfectly happy having intercourse for a few minutes, do that too.
After my husband's little panic about never being able to function without the wonders of pharmaceuticals again, well, it took only a week before he was back to his old self. But here's the interesting thing. He told me at the time that he threw out the Viagra. Last night, I noticed it was still in his drawer. I guess it's nice to have an insurance policy.
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