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In the past decade there have been great advances in the treatment of impotence, which is now seen by most therapists, in most cases, as a physiological rather than a psychological problem, rejecting the medical establishment's long-held view. The word impotence itself, like "frigidity" for women, is considered suspect in many circles; the more politically correct--or at least clinical--term is erectile dysfunction, or ED, as it is commonly abbreviated. Inspired by a 1992 National Institutes of Health Conference and landmark 1994 study on the problem, the diagnosis has been defined more broadly, from the rather strict criterion of inability to get an erection, period, to the somewhat more elastic and subjective criterion of inability to get an erection adequate for "satisfactory sexual performance." This has led to a tripling of the number of men estimated to be impotent in this country--some 30 million according to the NIH, half of whom are thought to be under the age of 65. ED is associated with age; it affects about 1 in 20 men ages 40 and up, 1 in 4 over 65.
From a drug manufacturer's point of view, this burgeoning of the potential market has coincided quite nicely with the development of pharmaceutical treatments. (At least two more impotence pills are in the pipeline from different companies.) Before Viagra, the most promising therapies involved putting gel suppositories in the urethra and injecting drugs directly into the base of the penis. The downside is not hard to grasp. "You can imagine the look most patients gave when I told them they would have to stick a small needle into the most sensitive portion of their body," says University of Chicago urologist Dr. Gregory Bales. The good news is that the erections resulting from such injections can last an hour or more, even after orgasm, though depending on one's taste and circumstances, this too could be a downside. Other treatments, which involve vacuum pumps, penile implants and penis rings, are no less awkward or, to get to the heart of the matter, no more conducive to the spontaneous, unselfconscious, beautiful sex that Calvin Klein ads imply is our daily right.
The promise of Viagra is its discretion and ease of use. Doctors recommend taking the pill an hour before sex, which might lead to some wastage among overly optimistic users but shouldn't otherwise interfere too greatly with the normal course of coital events. An even greater advantage, or at least a more naturalistic one: unlike the injectable drugs, which when efficacious produce an erection regardless of context (famously proved by Dr. Giles Brindley, a leading British impotence researcher, who once demonstrated a successful experimental treatment by dropping his trousers in front of hundreds of astonished colleagues at a conference), Viagra merely paves the way for the possibility of arousal. Erections must still be achieved the old-fashioned way, whether through desire, attraction, physical stimulation, the guilty thrill of an illicit affair, page 27 of The Godfather or what have you.