It was the drug that transformed the sexual landscape. Before Viagra, impotence meant shame and often the collapse of all but the most committed relationships. The discovery of its startling ability to restore men's faded sexual function triggered a social revolution as monumental as that caused by the contraceptive pill.
Today Viagra -- launched in the US 10 years ago this month -- is the world's most ubiquitous medical brand name. Type it into Google and a search throws up more than 4 million references: 10 times more than Prozac and 20 times as many as Botox, its nearest competitors.
The drug has also spawned its own catalog of jokes and become a byword for efficacy and impact. Nicole Kidman's nude scene in the play The Blue Room was famously described as "pure theatrical Viagra," for example, while in the US the Survivor TV series was labeled "CBS' Viagra," a magic pill that made the network virile.
But just how much of all this publicity is hype? Has the "wonder pill" really lived up to its promise? Has it been a universal force for good?
From the financial perspective there can be little doubt. In the decade since Viagra first went on sale, more than 30 million men in 120 countries have been prescribed it. In addition, many millions more have bought it illegally on the Internet, or taken a few from their mates in bars for recreational use.
Indeed, the take-off of Viagra was one of the fastest that a new drug has ever seen. Almost immediately after its launch in the US, it was being prescribed at the rate of at least 10,000 a day.
In Atlanta, urologist John Stripling wrote out 300 prescriptions on the day it became available.
And there is no doubt much of this proliferation has been to the good of men and women, as Graham Jackson, a consultant cardiologist in London and an expert on sexual problems, explained.
"More than 20 percent of breakdowns of relationships are caused because a man has erectile problems. It can cause agony for a man when he cannot perform as he feels he should," he said.
"A lot of partners are kind and supportive. A few are cruel. And when you have huge great men crying like babies in your clinic, you get pretty desperate for something that will put their problems to right as soon as possible. Viagra has done that in a great many cases that have come to my clinic, I am glad to say," Jackson said.
Certainly, the drug has brought joy to many relationships. However, it has also had -- in many cases -- a destructive impact.
"Now men have a drug to help them get it up and get going, they have also shown a worrying tendency to get up and leave -- for younger women," as one sex counselor put it.
In the process, Viagra has become the third party in many marriage splits, increasingly cited in celebrity divorce cases, most recently with Wendy and Johnny Kidd, parents of supermodel Jodie and makeup guru Jemma.
"Older men are more able to perform again, so they're going elsewhere -- to younger, greener pastures," said New York divorce lawyer Raoul Felder, who recently acted for the wife of a 70-year-old man who began cheating on her days after taking Viagra.
In Florida's retirement communities, rates of sexually transmitted diseases among elderly men -- who have started visiting prostitutes after taking Viagra -- are soaring, it emerged recently.
Nor is this phenomenon restricted to the US.
"I have seen an exponential rise in divorce cases sparked by Viagra-fueled adultery,' said James Stewart, of the London law firm Manches.
So widespread and common is the use of Viagra that male clients now talk to him about taking it as openly and willingly as they would admit to taking Disprin for a headache, he said.
"The problem is that Viagra widens the age period in which men can commit adultery and that is the catalyst for most relationship breakdowns. On the other hand, Viagra has saved as many, if not more, marriages than it destroys," Stewart said.
"If a couple's sex life is bad, then that can give rise to all sorts of other problems. By improving a couple's intimate relationship, Viagra strengthens the marital bond," he said.
This point was backed by David Ralph, a consultant at the University College London's Institute of Urology.
"Viagra has transformed the lives not only of millions of patients with erectile dysfunction but the lives of their partners as well," he said.
In addition, media coverage means that after generations of taboo and refusing to talk about sexual failure, erectile dysfunction has become a subject that can be discussed openly, a point stressed by the author Erica Jong.
"Impotence was the great secret. Now suddenly, you can't go to a dinner party without having people talk about erections," she said.
This disappearance of sexual reticence has been particularly beneficial for the general health of the population, and is one of the major benefits of the Viagra revolution, say doctors. In making men less afraid to talk about their sexual problems, it is becoming easier to make diagnoses of more serious illnesses, as Ralph pointed out.
"The circulation problems that create erectile dysfunction can also be a sign of vascular blockage and diabetes," he said.
This point is supported by Jackson, who said that erectile problems are often the first symptoms of a general failing of a man's blood circulation and that this could go on to trigger heart attacks or other cardiac problems.
"So if men are more willing to come forward, then we can pick them up more speedily. That is why it is important that men don't just take Viagra -- or its partner drugs Levitra or Cialis -- when they first experience erectile problems but consult their doctors," he said.
"If they don't tell their GP [general practitioner] and just take Viagra to compensate, they will be heading into danger. To be fair to the drug companies involved, however, they have gone to great lengths to make sure these drugs are administered by GPs," he said.
Nevertheless, the widespread availability of Viagra has posed its own problems, not just for patients suffering circulation problems but for men of all ages who use it as a recreational drug.
"Viagra is spawning a nation of men who are dependent on the drug, particularly young men who develop the expectation that they should be able to just pop a pill and have sex, regardless of how they feel emotionally," psychotherapist Paula Hall said.
Talk show host Jerry Springer was one of the first to go public with a claim of dependency, while over-use of Viagra was blamed for turning the 66-year-old Earl of Shaftesbury from a kindly old man to someone who stalked the Riviera nightclubs for high-class prostitutes, it was claimed during the trial of his murderers two years ago.
Last year, the AIDS Healthcare Foundation launched a lawsuit accusing Pfizer of recklessly advertising Viagra, and turning it into a "party drug" whose use is fueling the AIDS epidemic. There are also concerns about those taking the drug on a non-prescription basis, but there is no documented evidence of any major loss of life involving recreational use.
"That is one of the great things about Viagra," Jackson said. "It has no really life-threatening side effects."
Roger Kirby, director of the Prostate Centre, London, agreed.
"Nothing much happens if someone without erectile dysfunction takes the drug," he said.
Indeed, Viagra can even make some illegal drugs safer, he said.
"For example, cocaine is a very dangerous drug because it causes coronary arteries to close and can sometimes give you a heart attack," Kirby explained. "Viagra has the opposite effect and so can help the cocaine user."
Such an effect is generally accidental, however. Most clubbers take cocaine-Viagra mixes -- known as "coconut pokes" -- to get high while still being able to perform sexually. Protection against heart attacks is not the prime concern here, needless to say.
Nor would it be correct to assume that the drug lacks significant side-effects, as consultant gynecologist David Glenn has warned. His research indicates that the drug is linked to infertility.
"Men who use it recreationally for long periods could be building up trouble for themselves in later years. They could find it difficult to father children," he said.
"We need to do a lot more research on the subject to find out. In the meantime, young men need to be careful. Viagra could have a cumulative impact on their fertility and on their chances of fathering children in the future," he said.
Another key issue concerns the idea that a drug that restores sexual ability to a man is sufficient on its own to put a threatened relationship back on track, as Susanna Abse, director of the Tavistock Centre for Couple Relationships, said.
"I regularly sit opposite couples who tell me that their problem is caused by his inability to get or to maintain an erection and that they think the answer is so simple. It would seem a straightforward course of Viagra is all that they need. But when I suggest it, they either refuse to try it, or they do try it and it still doesn't work," she said.
"The problem is that erectile dysfunction can become a defense for a couple against having to share sexual intimacy. It can be very frightening when the curtain is whisked away and you are forced to confront that issue," she said.
In general, however, Viagra has been a success story both for its manufacturer, Pfizer -- which has made more than US$2 billion from the drug, it is estimated -- and for users, many of whom have regained lost sexual prowess and have had their marriages and relationships revitalized.
"We've always been waiting for the magic bullet and this is pretty close," David Ralph said. "The one, accidental discovery leading to the wonder drug that is Viagra has transformed the lives not only of millions of patients with erectile dysfunction but the lives of their partners and their families too."
Or as Rafael Wurzel, a US physician, has put it: "Viagra opened the door to an honest and uninhibited discussion about issues pertaining to sexual dysfunction, for men, for women, and for couples. I think it has been wonderful."
Others, however, have taken a more jaundiced view of this new sexual revolution, of course -- as one letter, published by the syndicated Ann Landers advice column in US newspapers, made abundantly and poignantly clear: "I am 62 years old and the mother of six grown children and I was thrilled when my 64-year-old husband began to slow down about two years ago. So now what happens? A pill called Viagra is invented and the old goat is back in the saddle. I do love my husband but I believe I have earned a rest. Besides, these pills cost US$10 a piece. Last week he had four."
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