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In 1998 when the Food and Drug Administration approved Viagra, pundits giddily predicted that older men would gobble the little blue pill like candy. Analysts forecast sales of at least $5 billion a year as the male population aged, and as advertising wars among what eventually became the three brands—Viagra, Levitra, and Cialis (both approved in 2003)—reminded men about the medications.
However, sales of erection medications have reached only half of initial predictions. 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. Around half of men over 50 report at least some degree of erectile dysfunction (ED). How many have used erection drugs? Some figures from recent studies:
American men: 24% (Shaeer, 2013)
Japanese: 15% (Kimura, 2012)
German, 9% (May, 2007)
27 Western country average: 7%. (Mulhal, 2008)
Only One Thing on Their Minds?
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 sex—that men are perpetually horny, and therefore, obsessed with sex and their erections. Who hasn’t heard: “Men have only one thing on their minds.” And “Men have two heads—and the little one does the thinking.” Now the stereotype of the horny man always on the prowl for sex contains more than a germ of truth. But if it’s true, why have surprisingly few older men tried erection drugs? And continued to use them?
Only Around Half of Men Refill Prescriptions
Addressing the latter issue first, there are several reasons why men don’t refill prescriptions:
• Manufacturers have exaggerated the drugs’ effectiveness. They claim the medications benefit 70 percent of users—with benefit defined as erection sufficient for intercourse. But my review of 14 studies involving 18,337 men show success rates closer to 50 percent. Men who don’t benefit don’t refill their prescriptions.
• When the drugs work, they don’t produce instant—or rock hard—erections. American men get much of their sex education from pornography. In porn, when the man unzips, out springs instant, totally firm pipe. As a result, many men believe that erections should rise to instant full firmness. Erections drugs don’t work that way. Considerable fondling of the flaccid penis is required, and when chemical erections rise, they’re often not as firm as men hoped. Men disappointed in their drug-fueled erections don’t refill prescriptions.
• Viagra et al. are not aphrodisiacs. They don’t spur arousal. 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 after around 50, arousal and erection uncouple. The myth is that men are always horny. But older men aren’t. In middle age, becoming aroused begins to takes work: an alluring partner, an erotic context (candle light, music, lingerie, etc.), and lots of whole-body massage. Viagra may aid erection. But that’s all it does. It doesn’t help men with arousal. Men who expect the drugs to turn them on often feel disappointed and don’t refill prescriptions.
• The 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 outweigh the benefits, and they don’t refill prescriptions.
• The drugs don’t repair damaged relationships. All that Viagra et al. do is increase the likelihood of erection. But many couples have unfulfilling sex—or no sex—for reasons that have nothing to do with the man’s penis. If a couple has significant relationship problems, erections by themselves don’t fix things.
At the University of Sao Paulo in Brazil, researchers analyzed 11 studies comparing the benefits of Viagra by itself versus the drug plus sex/martital therapy. In every trial, combination treatment worked better than just the drug. In one trial, researchers at the Center for Sexual Health in San Jose, California, gave 53 couples either Viagra or the drug plus eight sessions of weekly sex therapy. 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.
• Finally, the drugs aren’t cheap. If you pay retail, they run about $40 per pill. Many men think, What the hell, I’ll try an erection drug. Then they compare the costs and benefits, and decide that one prescription was enough.
Who Needs An Erection?
While many reasons explain the low rate of prescription refills, another question is more intriguing: Why do so few older men 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—or erection drugs.
After around 50, men’s sex drive mellows. Men don’t feel the same urgent need for sex that they experienced in their youth. This change requires an adjustment. But it also creates an opportunity to explore sex that’s less preoccupied with erections. Some men focus on what they’ve lost—perpetual arousal, reliable erections, and the primacy of intercourse. These men often “retire” from sex. But others focus on what they can still enjoy—pleasure that expands from the penis to the whole body.
It’s not easy for older couples to let go of intercourse. Our sexual culture is preoccupied with the old in-out. Consider the term “foreplay.” It’s what precedes the main event, which, of course, is intercourse. Hollywood, television, and pornography also focus 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 erotic pleasure and intimacy.
Quality lovemaking 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.
In addition, men don’t need erections to have orgasms. This is worth repeating: In an erotic context, if a man with a semi-firm or even a flaccid penis receives sufficient penile stimulation, he can still experience very satisfying orgasms. This is true of young men made paraplegic by motorcycle accidents, older men who lose the ability to become erect because of prostate cancer surgery—and all other older men as well.
If you’re not trying to make a baby, intercourse isn’t necessary, and as the years pass, it becomes problematic. Older men develop erection issues. Older women develop vaginal dryness and atrophy (thinning of the vaginal wall), and even with a lubricant, intercourse may feel uncomfortable. At some point, many older couples decide they’d rather be sexual without intercourse, so who needs the drugs?
Viagra and the other erection medications will, no doubt, continue to generate sales in the billions—in part because men under 50 (both straight and gay) who don’t have clinical erectile dysfunction use them for “erection insurance.” But the drugs were developed for men over 50—and almost 20 after Viagra’s approval, surprisingly few are interested.
It’s ironic. It has taken drugs entirely focused on erections and intercourse to show the world that older lovers are no longer all that interested in erections and intercourse.
References:
Althof, S.E. et al. “Self-Esteem, Confidence, and Relationships in Men Treated with Sildenafil Citrate for Erectile Dysfunction: Results of Two Double-Blind, Placebo-Controlled Trials,” Journal of General Internal Medicine (2006) 21:1069.
Banner, L.L. and R.U. Anderson. “Integrated Sildenafil and Cognitive-Behavior Sex Therapy for Psychgenic Erectile Dysfunction: A Pilot Study,” Journal of Sexual Medicine (2007) 4(4, Pt 2):1117.
Carrier, S. et al. “Treatment Satisfaction with Sildenafil in a Canadian Real-Life Setting. A 6-Month Prospective Observational Study of Primary Care Practices,” Journal of Sexual Medicine (2007) 4:1414.
Chia, S.J. et al. “Clinical Application of Prognostic Factors for Patients with Organic Causes of Erectile Dysfunction on 100 mg of Sildenafil Citrate,” International Journal of Urology (2004) 11:1104.
Conaglen, H.M and J.V. Conaglen. “Investigating Women’s Preference for Sildenafil or Tadalafil Use By Their Partners with Erectile Dysfunction: The Partners’ Preference Study,” Journal of Sexual Medicine (2008) 5:1198.
DeBusk, R.F. et al. “Efficacy and Safety of Sildenafil Citrate in Men with Erectile Dysfunction and Stable Coronary Artery Disease,” American Journal of Cardiology (2004) 93:147.
Fonseca, V. et al. “Impact of Diabetes Mellitus on the Severity of Erectile Dysfunction and Response to Treatment: Analysis of Data from Tardenafil Clinical Trials,” Diabetologia (2004) 47:1914.
Kadioglu, A. et al. “Quality of Erections in Men Treated with Flexible-Dose Sildenafil for Erectile Dysfunction: Multicenter Trial with a Double-Blind Randomized, Placebo-Controlled Phase and an Open Label Phase,” Journal of Sexual Medicine (2007) 5:726.
Kimura, M. et al. “Profiling Characteristics of Men Who Use Phosphodiesterase Type-5 Inhibitors Based on Obtaining Patterns: Data From the Nationwide Japanese Population,” Journal of Sexual Medicine (2012) 9:1649.
Lee, J. et al. “Physician-Rated Patient Preference and Patient- and Partner-Rated Preference for Tadalafil or Sildenafil Citrate: Results from the Canadian Treatment of Erectile Dysfunction Observational Study,” British Journal of Urology International (2006) 908:623.
Martin-Morales, A. et al. “Therapeutic Effectiveness and Patient Satisfaction After 6 Months of Treatment with Tadalafil, Sildenafil, and Vardenafil: Results from the Erectile Dysfunction Observational Study (EDOS),” European Urology (2007) 51:541.
May, M. et al. “Erectile Dysfunction, Discrepancy Between High Prevalence and Low Utilization of Treatment Options: Results from the Cottbus Survey,” British Journal of Urology International (2007) 100:1110.
Melnik, T. et al. “Psychosocial Interventions for Erectile Dysfunction,” Cochrane Database Systematic Review (2007) CD004825.
Melnik T. and C.H. Abdo. “Psychogenic Erectile Dysfunction: Comparative Study of Three Therapeutic Approaches,” Journal of Sex and Marital Therapy (2005) 31:243.
McCullough, A.R. et al. “Randomized, Double-Blind, Crossover Trial of Sildenafil in Men with Mild to Moderate Erectile Dysfunction: Efficacy at 8 and 12 Hours Post-dose,” Urology (2008) 71:686.
Mirone, V. et al. “Flexible-Dose Vardenafil in a Community-Based Population of Men Affected by Erectile Dysfunction: A 12-Week Open-Label, Multicenter Trial,” Journal of Sexual Medicine (2005) 2:842.
Mulhall, J. et al. “Importance of and Satisfaction with Sex Among Men and Women Worldwide: Results of the Global Better Sex Survey,” Journal of Sexual Medicine (2008) 5:788.
Ochiai, A. et al. “Efficacy of Sildenafil as the First-Step Therapy Tool for Japanese Patients with Erectile Dysfunction,” International Journal of Impotence Research (2005) 17:339.
Pickering T.G. et al. “Sildenafil Citrate for Erectile Dysfunction in Men Receiving Multiple Antihypertensive Agents: A Randomized Controlled Trial,” American Journal of Hypertension (2004) 17(12 Pt 1):1135.
Shaeer, O. “The Global Online Sexuality Survey (GOSS):The United States of America in 2011 Chapter II: Phosphodiesterase Inhibitors Utilization Among English Speakers,” Journal of Sexual Medicine (2013) 10:532.
Skoumal, R. et al. “Efficacy and Treatment Satisfaction with On_demand Tadalafil (Cialis) in Men with Erectile Dysfunction,” European Urology (2004) 46:362.
Steidle, C.P. et al. “Correlation of Improved Erectile Function and Rate of Successful Intercourse with Improved Emotional Well-Being Assessed with the Self-Esteem and Relationship Questionnaire in Men Treated with Sildenafil for Erectile Dysfunction Stratified by Age,” Current Medical Research and Opinion (2006) 22:939.
Ochia, A. “Efficacy of Sildenafil as the First–Step Therapeutic Tool for Japanese Patients with Erectile Dysfunction,” International Journal of Impotence Research (2005) 17:339.
Skoumal, R. et al. “Efficacy and Treatment Satisfaction with On-Demand Tadalafil (Cialis) in Men with Erectile Dysfunction,” European Urology (2004) 46:362.
DeBusk, R.F. et al. “Efficacy and Safety of Sildenafil Citrate in Men with Erectile Dysfunction and Stable Coronary Artery Disease,” American Journal of Cardiology (2004) 93:147.
Pickering, T.G. et al. “Sildenafil Cittrate for Erectile Dysfunction in Men Receiving Multiple Antihypertensive Agents: A Randomized Controlled Trial,” American Journal of Hypertension 17:1135.
Zinner, N. “Do Food and Dose Timing Affect the Efficacy of Sildenafil? A Randomized Placebo-Controlled Study,” Journal of Sexual Medicine 4:137.
