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06 Marshall 065057 2/6/06 1:05 pm Page 345 Abstract While it was once assumed that sexual function andvirility naturally declined with age, the sexual capacities of theaging body have more recently been aligned to new performativestandards, particularly for men. This article explores the historyand contemporary dimensions of this new culture of virility. Thefirst section reviews shifting scientific and cultural narratives ofthe sex/age problematic. The latter part of the article exploreshow the robust post-Viagra ‘men’s health’ industry has expandedthe medicalization of masculinity and male sexuality in later life,particularly via the recuperation of the ‘male menopause’ as‘androgen deficiency in the aging male’. As the aging male bodyis opened up to new manifestations of dysfunction and disorder,attention is drawn to emerging understandings of risk, healthand surveillance in relation to sexual function.
Keywords aging, health, masculinity, sexuality, Viagra Over the last century, a variety of expert discourses – including psychiatry,gerontology, sexology, endocrinology, and urology – have been central inthe construction and reconstruction of sexual lifecourses. Traditionally,the assumption that sexual function and virility naturally decline with agegrounded the efforts of the sexological sciences to help men manage andadjust to what was considered a finite bodily resource. However, late inthe 20th century, as the sexual capacities of aging men were opened upto new biomedical treatments and consumerist lifestyle projects, whatwere previously considered to be ‘normal’ changes in sexual capacitiesassociated with bodily aging became pathologized as sexual dysfunctions.
While not entirely responsible for this reconfigured understanding of the Sexualities Copyright 2006 SAGE Publications (London, Thousand Oaks, CA and New Delhi) Vol 9(3): 345–362 DOI: 10.1177/1363460706065057 06 Marshall 065057 2/6/06 1:05 pm Page 346 aging male, the success of the blockbuster drug Viagra (sildenafil citrate)in securing a particular understanding of sexuality and sexual functionacross the lifecourse cannot be underestimated. As a site of convergencebetween the ‘biomedicalization of aging’ (Estes and Binney, 1989;Gilleard and Higgs, 1998) and that of sexuality (Tiefer, 1996), the recon-ceptualization of what might have been considered normative experiencesrelated to bodily aging as dysfunctions which demand correction meansthat masculine vitality itself has increasingly become framed as a biochem-ical problem in both medical and popular discourses. John Hoberman(2005: 71), in his history of testosterone, credits the ‘Viagra boom’ withbeing the catalyst for reviving scientific interest in the sexual effects oftestosterone on aging men which had for years been ‘suppressed by oldtaboos and the timidity of potential sponsors’.
This article explores the contemporary bodily configuration, still in the making, of the virile, sexually-fit aging male. I analyze scientificand clinical texts on aging and sexuality, as well as health promotion andmarketing initiatives directed at older men, to trace both the historyand contemporary dimensions of the new culture of virility. The first partof the article reviews shifting scientific and cultural narratives of thesex/age problematic in men over the course of the 20th century. Thevarying significance accorded to changing sexual capacities is illustratedfrom early assertions of the natural waning of sexual powers with age tothe more contemporary emphasis on continued sexual functionality as amarker of successful aging. The latter part of the article explores how thenewly robust ‘men’s health’ industry has expanded the medicalization ofmasculinity in later life, particularly via the recuperation of the ‘malemenopause’ as ‘androgen deficiency in the aging male’, and has framedemerging understandings of risk, health and surveillance in relation tosexual function.
Rejuvenation and the aging male: From fringe tomainstream Historically, aging was viewed as a process of de-sexualization, and bothmedical and moral authorities in the late 19th and early 20th centuriesextolled the virtues of the post-reproductive, post-sexual life. Popularauthor Sylvanus Stall (1901: 59), suggesting that it was nature’s courseto diminish sexual power in men once their peak reproductive fitness hadpassed, reminded his readers of the benefits of accepting and adjustingto sexual decline, promising that ‘the stress of passion will be past, theimagination will become more chastened, the heart more refined, thelines of intellectual and spiritual vision lengthened, the sphere of 06 Marshall 065057 2/6/06 1:05 pm Page 347 usefulness enlarged’. The conviction that men’s sexual powers naturallydeclined with age could lead only to a counsel of acceptance, and advicesimilar to Stall’s was widely repeated in the early 20th-century literature.
For example, Frederic Sturgis (1930: 312) advised that ‘Where old ageis the cause of impotence, there is, alas! no remedy, except to submit asgracefully as possible to the decrees of fate, and by carefully husbandingthe sexual resources to prolong the usefulness of the genital organs as faras possible’.
Not all early 20th-century scientists embraced the counsel of graceful acceptance of decline. Some contended that the secret to masculine vitality– and the secret to forestalling its loss in the aging process – lay in the sexglands themselves. While there has certainly been a long-standing beliefthat masculine virility, valor and vigor are rooted in the testes, assump-tions of the testicular basis of masculinity came to the fore in the organ-otherapy and rejuvenation experiments of the late 19th and early 20thcenturies. Sengoopta (2001: 644) calls the 1920s the ‘decade of thetesticle’ as it was then that ‘physiological and clinical research on testicu-lar functions came together in what, for a time, seemed to be a spectacu-larly successful synthesis’. Austrian scientist Eugen Steinach, after a periodof experimentation with testicular transplants, became famous for the‘Steinach operation’. This was essentially a vasectomy which supposedlylet the body reabsorb testicular fluid instead of discharging it, hencereaping the benefits of its invigorating power (Sengoopta, 2003). By the1920s, other scientists around the world, such as Harry Benjamin andPeter Schmidt, had taken up Steinach’s theories and were conducting theirown trials with surgical rejuvenation (Schmidt, 1929).
Relatively few men actually underwent the procedures advocated by the rejuvenation enthusiasts, and what success those who did may haveclaimed is now suspected to be largely a placebo effect (Cussons et al.,2002). By the 1930s, surgical rejuvenation was largely discredited as amedical practice and was consigned to the fringes of quackery (Fishbein,1932; Jaheil, 1992). But as commentators such as Susan Squier (1999)and John Hoberman (2005) have noted, the ideas of rejuvenation andlife-extension retained both cultural and medical significance throughoutthe 20th century. In particular, the public imagination was captured bythe idea that science could forestall, or even reverse, the effects of age onthe body.
Sexual rejuvenation in aging men was a subject of some ambivalence, even for its promoters. While organotherapy and rejuvenation unequivo-cally linked masculine vitality and vigor to glandular secretions, interest inrejuvenation therapies was largely motivated by worries about declines inmasculine productivity, not virility. To be sure, restoration of sexualfunction was part of the promise of rejuvenation, but this was treated as 06 Marshall 065057 2/6/06 1:05 pm Page 348 almost a side effect of the restoration of general masculine vigor. Steinachhimself stressed the non-sexual benefits of rejuvenation, seeking to wardoff not only the physical disorders of age (cancer, heart disease, hyper-tension) but also the ‘paralyzing fatigue, disinclination to work, failingmemory, indifference and depression, all of which hinder or precludeprogress and every kind of competition’ (cited in Hirshbein, 2000: 285).
In a spirited defense of rejuvenation science, Paul Kammerer (1924: 185)argued that: ‘If reawakened manhood, a by-product of rejuvenation,occasionally is criticized as an immoral disadvantage of rejuvenation as awhole, then the simultaneously reawakened love of, and ability to work,should be considered a sufficient compensation’. Similarly, in reviewingthe literature on rejuvenation therapies, George Ridley Scott (1953: 9–10)suggested that ‘much of the hostility towards rejuvenation has beenengendered through its association with sex’ and countered almost apolo-getically that ‘there is no way of extending the physical and mental powersof the individual into advancing years without coincidentally keeping thesexual and endocrinal glands functioning’.
This ambivalence towards sexual rejuvenation of aging men continued as hormone therapy moved into mainstream medical practice via testos-terone treatment for the ‘male climacteric’ in the 1930s and 1940s. Whilenotions of a male climacteric as a parallel process to the femalemenopause had circulated in the medical literature since the early 19thcentury, it was not until August Werner’s reintroduction of the conceptto mainstream American medicine in 1939 that it had a clinical presence(Werner, 1939). Yet Werner, though arguing that the climacteric ‘is dueprimarily to a function of the sex glands’ (1939: 1441), and assertingthat, as a result, ‘man is subject to varying degrees of sexual function’(Werner, 1946: 194), did not view the restoration of sexual function asa central goal of testosterone therapy. In other words, even though sexualdysfunction might be a key symptom of the climacteric, it was not themain concern in treating it. Although potency might inadvertently bestimulated by testosterone therapy, Werner (1945: 710) insisted that itshould not be given for this purpose, and in fact suggested that ‘it isperhaps better for older men if this phase of the reaction does not result’.
This emphasis on the non-sexual aspects of restoring masculine vitality isreiterated in a discussion of Werner’s work by Charles Dunn, whoreminded readers that the male climacteric is an important syndrome because it occurs chiefly in menwith important responsibilities, men who require sustained energy, physical andmental throughout the day to perform competently their assigned responsibil-ities . . . The true climacteric patient is more concerned with constitutionalrehabilitation than he is with sexual stimulation. (Dunn, 1945: 710) 06 Marshall 065057 2/6/06 1:05 pm Page 349 The specter of immorality still cast a shadow over sexual rejuvenation ofaging men, reiterating the long-held assumption that old age should be atime of asexuality (Marshall and Katz, forthcoming). If acceptance of themale climacteric as a clinical disorder, and its treatment with hormonereplacement therapy, was to be accepted in mainstream medical practice,then the emphasis had to be placed on the non-sexual aspects of treat-ment. Despite this, the concept never really caught on. Rather than as amedical disorder, the ‘male climacteric’ was viewed as a period of psycho-logical or emotional upheaval – a ‘mid-life crisis’ (Featherstone andHepworth, 1985; Hepworth and Featherstone, 1998). Ironically – at leastfrom the perspective of those such as Werner – it took the post-Viagra re-centering of sexual function and its restoration to revitalize the conceptof male menopause as a medical disorder in the late 20th century.
Positive aging and the re-sexualization of the agingmale Ambivalence towards the importance of sexual function in medicaldiscourse around aging and masculinity illustrates the dilemma in whichthe emerging sciences of aging and sexuality found themselves in the earlyto mid-20th century. On the one hand, sexual science had enshrinedsexual decline as an inevitable aspect of bodily aging. On the other hand,the new professional discourse of gerontology emphasized vitality, activityand independence, challenging previously negative stereotypes of later life(Katz, 1996). Discourses of ‘positive aging’ in sexology and gerontologydid find some common ground in the mid-20th century as shifting etiolo-gies of sexual dysfunction resulted in their agreement that psychological,rather than organic, factors were central (Marshall and Katz, 2002). Sexualdecline was no longer characterized as a ‘natural’ consequence of bodilyaging for which graceful acceptance was the appropriate response. Agingmen were increasingly told that it was their anxiety over their supposedloss of sexual function – their fear of loss of potency – that was causingtheir premature sexual decline. In addition, men were told that to ceasehaving sex would itself hasten aging. Common wisdom by the middle ofthe 20th century was that continued sexual activity, and especially sexualintercourse, was a healthy and necessary component of successful aging.
In the 1980s new developments in urology effected a decisive change in understanding the sexual capacities of the aging body. Specifically,urological research reconceptualized the male erection as a vascular,physiological event after it was demonstrated that erections could beinduced by chemical injection, severing the mechanism of erection fromany sort of emotional arousal or tactile stimulation (Brindley, 1986; Virag, 06 Marshall 065057 2/6/06 1:05 pm Page 350 1982). Impotence – which by the 1990s was referred to as ‘erectiledysfunction’ – became a treatable, physiological disorder. The effect ofthis move was to see sexual decline as neither the inevitable by-product ofbodily aging nor the result of psychological difficulties. Erectile dysfunc-tion resulted from ‘modifiable, para-aging phenomena’ (Feldman et al.,1994: 54). Reversing the old belief that psychological distress acted toproduce physiological sexual dysfunction, it was now argued that, leftuntreated, physiological sexual dysfunction had serious emotional andpsychological effects. As one of the many mass-market books on malesexual function to emerge in the wake of Viagra put it: ‘no malfunctionof the human apparatus – not even cancer or heart disease – can be morepainful to the male ego or catastrophic to the male psyche than sexualimpotence’ (Melchiode and Sloan, 1999: 17). These catastrophic effects,coupled with the reportedly epidemic rates of men suffering from erectiledifficulties, and the expected increase in incidence given aging populationsin western societies, transformed age-related sexual dysfunction into aserious public health problem demanding redress.
By the late 1990s, scientific and commercial interests converged in reconceptualizing sexual disorders as requiring biotechnical, rather thantherapeutic, fixes, and sexual-function products were now added to thelegitimate marketplace of products geared to aging consumers (Katz andMarshall, 2003). In contrast to the manner in which the restoration ofsexual function was treated as an almost regrettable byproduct ofrejuvenation in the first half of the 20th century, there was nothing coin-cidental or apologetic about the central place accorded to sexual functionin the emerging arsenal of anti-aging products and related healthpromotion discourses.
The discourses of positive aging have contributed to the unmooring of sexual decline from the limits of the aging body, in part as a means ofredressing negative, ageist stereotypes. One of the problems with thediscourses of positive aging, however, has been the assumption thatsuccessful aging really means not aging. As Stephen Katz (2001/2002:27) asserts, ‘the ideals of positive aging and anti-ageism have come to beused to promote a widespread anti-aging culture, one that translates theirradical appeal into commercial capital’. Against this landscape, theconcatenation of masculinity, sexual functionality and successful agingstands out. While the negative association of aging and active sexuality is,of course, ageist, the reversal of this association will not necessarily beliberating if narrow sexist (and heterosexist) sexual stereotypes arereasserted in the process (Marshall and Katz, forthcoming). As a numberof critical analyses have demonstrated, restoration of aging male sexualityvia the rehabilitation of the erection with Viagra (and its successor drugs)has been premised on a narrow and limiting understanding of both ‘sex’ 06 Marshall 065057 2/6/06 1:05 pm Page 351 and ‘masculinity’ (Loe, 2001; Mamo and Fishman, 2001; Marshall, 2002;Potts, 2000). Masculinity, at least as it is portrayed in pharmaceuticaladvertising and ‘men’s health’ promotion around erectile dysfunction,‘remains anchored in the erect penis across the lifecourse’ (Marshall andKatz, 2002: 63). Calasanti and King (2005: 16) summarize the impact ofthe new culture of virility on aging men: ‘Sexual functioning now servesas a vehicle for reconstructions of manhood as “ageless” . . . To the extentthat men can demonstrate their virility, they can still be men’.
Aging women, of course, have long been subject to biomedical restora- tion of their ‘femininity’ via hormone replacement therapy. NellyOudshoorn (1997) has suggested several reasons why, at least untilrecently, the problems of the aging male were not medicalized to the samedegree as those of women. First, the success in defining female menopauseas a treatable hormone deficiency gave a clear motive for the hormonereplacement industry to target women. Gynecological clinics were able tofacilitate both research on and treatments to their clientele, while parallelinstitutions were not available for men. Oudshoorn argues that men’smore passive attitudes towards seeking treatment for health problems andthe continued marginalization of men’s health in the organizational struc-tures of institutionalized medicine were key factors in undermedicalizingthe male menopause, in comparison to women’s. As she puts it, ‘healthproblems can only be classified as illness and be medicalized if there existsa cultural climate and a medical infrastructure that actively transformshealth complaints into diseases’ (Oudshoorn, 1997: 143). This ‘activetransformation’ is evident in the post-Viagra years, as both the culturalclimate and medical infrastructure have absorbed the assumption of abiochemical basis for sexual dysfunction (Marshall, 2002). The clinical andmarket success of Viagra was pivotal in paving the way for the develop-ment of a lucrative men’s health industry and for the construction of theaging male body as a site of biomedical intervention. An expanded rangeof institutional and discursive structures have not only accommodated,but nurtured, the medicalization of masculinity in mid- and late life.
Professional associations, journals, conferences and clinics focusing onmen’s sexual health and aging have proliferated. The pharmaceuticalindustry has worked hard to legitimate and publicize the disorders forwhich they have a potential treatment by sponsoring and disseminatingresearch favorable to their products. That there is profit to be made herecannot be denied: according to industry reports, the therapeutic areas ofmale sexual dysfunction and male menopause are expected to lead the wayin expanding the already $17 billion dollar world market in pharma-ceuticals for ‘men’s health’ (Biotech Week, 2003). By the late 20th century,the aging male body was understood as a series of functional subsystemsamenable to constant monitoring and biotechnical intervention. While 06 Marshall 065057 2/6/06 1:05 pm Page 352 Viagra was seen as the solution to malfunction in one of these subsystems(vascular flow to the penis), the problems of the aging male were nowincreasingly opened up to diagnosis and treatment. By the turn of the 21stcentury, the concept of the male climacteric, menopause, or ‘andropause’as an organic disorder was poised to undergo a renaissance, but this timewith the restoration of sexual virility at its center.
‘If you think you can Viagra your way out of thisone, think again’: The return of testosterone According to the report of the Third International Conference on theManagement of Erectile Dysfunction, held in 2003: ‘Although it is nowpossible for almost all men with ED to regain their erections, getting thosemen to use their erections regularly is more complicated’ (Nehra et al.,2003: S3). With a reported 50–60 per cent of men discontinuing medicaltreatments for erectile dysfunction, attention has increasingly turned tothe problem of waning sexual desire. As one newspaper feature put it: ‘Ifyou think you can Viagra your way out of this one, think again: It andsimilar drugs might help with the mechanics, but not with desire; testos-terone is what fires the libido’ (Werland, 2004: 9).
As discussed in an earlier section of the article, the concept of the ‘male climacteric’ or ‘male menopause’ as an organic disorder never really caughton in mainstream medicine. However, from the late 1990s to the present,the male menopause, now referred to as ‘andropause’, or ADAM(androgen deficiency in the aging male), has circulated widely throughboth the clinical and popular health literatures.1 Here, the andropause isreconceptualized as an age-related physiological disorder treatable withtestosterone therapy. Despite a mass of contradictory scientific evidence onthe existence of the disorder and both the efficacy and safety of testosteronetherapy, it is reiterated that ‘andropause is a fact, not a fiction’ (Nicholls,2003: 99), and ‘andropause is a testosterone deficiency that developsgradually over a number of years in all men aged 50 and older’ (Andersonet al., 2002: M796). The ADAM questionnaire (Table 1) developed by ateam at the University of St Louis and at Organon, one of the key manu-facturers of pharmaceutical testosterone products, has been widelypromoted as a clinical screening tool that identifies ‘a symptom complexassociated with the age-related decline in testosterone that may beamenable to therapeutic intervention’ (Morley et al., 2000: 1241).2 The foregrounding of erectile dysfunction as a key symptom of andropause appears more related to the post-Viagra willingness of men topresent with this disorder than it does to any evidence linking erectiledysfunction to low testosterone levels. Dunsmuir (1999: 138) confirms 06 Marshall 065057 2/6/06 1:05 pm Page 353 ADAM (Androgen Decline in the Aging Male) Questionnaire 1. Do you have a decrease in libido (sex drive)?2. Do you have a lack of energy?3. Do you have a decrease in strength and/or endurance?4. Have you lost height?5. Have you noticed a decreased ‘enjoyment of life’?6. Are you sad and/or grumpy?7. Are your erections less strong?8. Have you noted a recent deterioration in your ability to play sports?9. Are you falling asleep after dinner? 10. Has there been a recent deterioration in your work performance? Source: Morley et al. (2000).
that ‘much of the lay public equates the male menopause with erectilefailure’, in spite of the fact that several studies of men presenting at clinicswith erectile dysfunction show that the incidence of low testosterone inthis group is small (Johnson and Jarow, 1992; T’Sjoen et al., 2003).
Indeed the Massachusetts Male Aging Study, which is cited so ubiquitouslyto establish the relationship between age and erectile function, found nosignificant correlations between the latter and testosterone levels (Feldmanet al., 1994). Yet the ADAM questionnaire treats a positive response tothe question about erectile dysfunction as immediately identifying therespondent as ‘at risk’ for androgen deficiency (Morley et al., 2000).3 Significantly, marketing the new virility has revived some very old configurations of masculinity. A doctor with a men’s clinic recounts atypical success story of modern treatment modalities. Here, a 40-year-oldman presented complaining of erectile dysfunction and low libido. Afterhe ‘treated the erectile dysfunction and prescribed oral testosterone forthe man’s low libido’ the patient returned after six weeks: He was vibrant. He had quit his job and gone into business for himself – some-thing he said that he always wanted to do but never believed in himself enoughto follow through . . . The man’s marriage was wonderful and his sex life wasgreat. He had a great sense of vitality and a positive attitude towards life.
(Powell, 2000: D2) Not only is treatment for erectile dysfunction (presumably with Viagra)coupled with treatment for diminished libido (testosterone), but sexualdecline and its reversal are linked, just as in the early 20th-century reju-venation movement, with the restoration of masculine productive powermore generally. Not unlike the ‘feminine forever’ message with whichwomen were bombarded by proponents of hormone replacement therapy 06 Marshall 065057 2/6/06 1:05 pm Page 354 in the 1960s, the newly remedicalized menopause for men reasserts achemical basis for masculinity itself. Decline in sexual function, sportsperformance, work success – these all become markers of the equation ofaging with demasculinization,4 and all become treatable in a program ofvirility maintenance.
The new virility: Risk factors, surveillance andsexual health A number of commentators on health and medicine in contemporarywestern societies have argued that individuals are increasingly beingenrolled into programs of self-surveillance and risk management. Forexample, Anthony Pryce, drawing on Deborah Lupton’s (1999) analysisof ‘risk’ in late modernity, has suggested that the medical gaze nowreaches beyond the walls of the clinic: Surveillance is relocated through the individual citizen’s reflexive observationof their ‘self’ for signs of contamination, disease or dysfunction within culturesincreasingly constructed as morally, socially, environmentally and biologicallydangerous or ‘risky’. The recruitment and self-examination by the ‘activepatient’ is central to governmentality and the construction of a new healthcitizenship. (Pryce, 2000: 104) Similarly, Andrew Webster (2002) notes that new discourses of healthand illness have created the ‘worried well’ as a significant market. It isnot difficult to see these trends as evident in the new discourses of men’ssexual health. The widespread publicity given to the ‘epidemic’ of sexualdysfunction, coupled with the close cultural association between sexualvirility and masculinity, has fostered an environment of amplified risk formany men, promoting self-surveillance and monitoring. And no longeris sexual dysfunction just a concern for men in their old age, but anxietyover the prospect of sexual decline is fostered at increasingly youngerages. As Margaret Gullette (1998: 17) notes, ‘everyone has been gettingolder younger’.
While the original disease model of erectile dysfunction focused on clearly discernable age-related physiological factors relating to impairedvascular function, the efficacy of Viagra in producing erections regardlessof the etiology5 has expanded the parameters of the disease. The Viagrauser is no longer just an older man who, due to a physiological problem,is unable to get or keep an erection most of the time, but is just as likelyto be a younger man, with no identified organic disorder, who worriesabout his erections being less reliable than he thinks they should be. Thisis clearly reflected in the marketing campaigns for Viagra (and its succes-sor drugs). Originally marketed to an older audience (with Bob Dole as 06 Marshall 065057 2/6/06 1:05 pm Page 355 the initial spokesman in North America), erectile dysfunction drugs havebeen pitched to ever younger markets. One widely-used print advertise-ment for Viagra in the United States features a man, appearing to be inhis early 40s, telling us that he knows ‘a lot of guys have occasionalerection problems’, but that he chose not to accept his by seeing hisdoctor and asking about Viagra.
The downloading of risk and anxiety about age-related changes in sexual capacities to younger and younger men is borne out by research onwhom those prescriptions are going to. A study of prescription claims datain the US in the first five years of Viagra’s availability found that youngermen (aged 18 to 45) were the fastest growing group of users (Delate et al.,2004). Similarly, the renewed medicalization of the male menopause hasmeant medicalizing mid-life, rather than late-life, masculinity – accordingto two reports cited by the National Institute of Medicine, most testos-terone prescriptions were given to men in the 45–65 age group, not tomen over 65, where decreased levels of circulating testosterone are mostevident (Liverman and Blazer, 2004: 25). The construction of ever-younger aging males as ‘active patients’ occurs against an expandedhorizon of risk, increasing responsibility of both the individual and thehealth professional to undertake virility surveillance, and an expansion ofthe very concept of ‘sexual health’.
The transformation of erectile dysfunction and low libido into organic disorders originally linked them with other bodily disorders which act asrisk factors – for example, diabetes, prostate cancer, obesity and hypo-gonadism. However, age, as the most clearly articulated risk factor putsall men at risk. The specter of sexual dysfunction has also been taken upby various health promotion discourses in terms of lifestyle factors thatmay increase the risk of sexual dysfunction. These include both officialcampaigns, such as Health Canada’s anti-smoking campaign (‘Tobaccouse can make you impotent’), and unofficial ones, as in ‘People for theEthical Treatment of Animals’ (PETA) promotion of vegetarianism(‘Eating meat can cause impotence’). When the popular magazine Men’sHealth ran a feature educating men on how to assess their risk for develop-ing erectile dysfunction (McDonald, 2000), the highest-risk case studywas a 31 year old who currently has sex every day. While he doesn’t haveproblems yet, we are told his ‘poor diet, sedentary lifestyle and familyhistory will eventually catch up to him’, and that if doesn’t start to exerciseand eat right, his ‘sex-life expectancy’ has only about 10 years to run. Themessage here is not only one of constant vigilance, even where no immedi-ate problems are apparent, but also one of equating the loss of erectilepower with the end of life itself. Thus, the onus is on the individual totake responsibility for managing risk through new regimes of bodily disci-pline which must start long before the onset of ‘old age’.
06 Marshall 065057 2/6/06 1:05 pm Page 356 In addition to preventative lifestyle changes, men are exhorted to continually monitor and assess their sexual function, and to take remedialaction where necessary.
Pfizer’s ‘three steps to better erections’ plan illustrates well the construction of the active patient in this respect. In brochures and on websites,6 men are instructed to assess their erectile capacity (by filling out ashort form of the International Index of Erectile Function), compare it toa standardized model (via their score on that quiz) and seek action byvisiting their doctor and asking for a starter pack of Viagra. This processis replicated for those worried that they might be suffering fromandropause – take a quiz, go to your doctor, actively ask about a treat-ment. Not only is the individual increasingly enrolled into regimes of self-surveillance, but physicians are also increasingly called upon to be morepro-active in diagnosing sexual dysfunctions in their patients. A numberof recent articles in periodicals directed at front-line family physiciansencourage ‘proactive sexual health interviews’ (Nusbaum and Hamilton,2002) and suggest that information about sexual function should be‘actively solicited as part of the routine medical history’ (Lightner, 2002).
Also suggested is the use of questionnaires to identify symptom complexes– either physician administered or left in the physician’s waiting room forthe patient to self-administer (MacIndoe, 2003). It is no wonder that thepharmaceutical industry has invested so heavily in developing the myriadquestionnaires, indices and scales aimed at diagnosing dysfunctions.
The concept of ‘sexual health’, once focused on sexually transmitted disease and reproductive concerns (Giami, 2002) has now broadened outto (and perhaps become primarily focused on) a concern with mainten-ance and enhancement of sexual desire and performance. Sexual functionhas now come to dominate many uses of the concept of sexual health –for example, one of the newer indices on the block, the Male SexualHealth Questionnaire, deals only with erections, ejaculations andsexual satisfaction (Rosen et al., 2004). A brochure entitled ‘Men’s SexualHealth’, distributed in physicians’ waiting rooms, has four pages onerectile dysfunction and its treatment, two pages on loss of sexual desirelinked to androgen deficiency, and two pages on prevention of STDs.7Thus three-quarters of the brochure conceptualizes ‘sexual health’ as‘sexual function’. Given that health ‘has become a duty as much as a rightof citizenship’ (Porter, 2002: 201; see also Crawford, 1980 and Tiefer,1997), seeing sexual health primarily in terms of meeting some standard-ized model of sexual function makes it a moral imperative. A critical aspectof being a responsible late modern citizen is to take charge of one’s health– including one’s sexual health – by adopting particular sorts of lifestyles,and by the consumption of appropriate forms of expertise and products.
06 Marshall 065057 2/6/06 1:05 pm Page 357 The success of Viagra in securing a new regime of compulsory tumescenceis an exemplary case of the manner in which bodies are reconstructed assites for biomedical intervention and incorporated into consumerist‘lifestyle’ projects. A reinvigorated sense of masculinity as a life-longproject is configured by the new biology of the body which has emergedin relation to pharmaceutical therapies geared towards functionality andperformativity. The post-Viagra expansion of the ‘men’s health’ industry,which promotes a standardized model of sexual function as its raisond’etre, has an ever-expanding kit-bag of therapies for an ever-youngeraging patient. Not only sexual function, but masculine vitality itself, ispresumed to be at stake here, as anxieties over aging are crystallized interms of biochemical demasculinization. Yet qualitative research witholder men (and women), demonstrates that: there is no standard experience of a ‘functional’ erection, even less so a ‘dysfunc-tional erection’; there appears to be no necessary relationship between a particu-lar type of erection and a satisfying sexual relationship; and there is no definitiveview of what constitutes ‘normal’ masculinity or ‘being a man’ in relation toerectile ‘functionality’. (Potts et al., 2004: 498) Perhaps the recognition that ‘manhood changes’ (Calasanti and King,2005: 5), rather than diminishes with age can be the starting point forchallenging the post-Viagra culture of virility.
AcknowledgementsThis article draws on and extends work done in collaboration with my colleagueStephen Katz, and I am grateful to him for both his expertise and his permissionto use jointly developed ideas here. I would also like to thank Annie Potts andthree anonymous reviewers for their helpful comments. Research for this articlewas supported by a grant from the Social Sciences and Humanities ResearchCouncil of Canada.
Notes1. As a rough measure of the increase in clinical interest, a search in Medline from 1980 to 2003, using ‘male menopause’, ‘andropause’ and/or ‘maleclimacteric’ as keywords, found that 1998 was the first year with more thanfive citations, and the numbers climb steadily each year to 29 citations in2003. For an extended discussion of the history of the male climacteric andits revival as the andropause, see Marshall (forthcoming).
2. In addition to its promotion to family physicians as a clinical screening tool (MacIndoe, 2003), the ADAM questionnaire is reproduced in advertisementsfor testosterone supplements in popular magazines such as Men’s Health andGolf, in newspaper and magazine stories (see, for example, Kirkey, 2003;Toronto Star, 2002), and hundreds of health-information web sites.
06 Marshall 065057 2/6/06 1:05 pm Page 358 3. A ‘positive’ questionnaire result is defined as a ‘yes’ answer to questions 1 or 7, or any other three questions. According to the authors of the studyvalidating the questionnaire, ‘The most common affirmative answer forindividuals with low BT [blood testosterone] was in response to question 7pertaining to the strength of penile erections’ (Morley et al., 2000: 1240).
Yet there is no scientific evidence which links these two factors in any causalrelation.
4. The manner in which the testosterone narrative for men bundles together sexual function with other cultural referents of masculine vigor may becontrasted with that for women, for whom testosterone treatment is beingexplored as a libido enhancer (Fishman, 2004; Tiefer, 2004). For both menand women, improved libido and enhanced sense of well-being are claimed asbenefits, but women treated with testosterone are not hailed (or assessed?)for their improved sports performance or business competitiveness. SeeMarshall and Katz (forthcoming) for a more extended discussion of howdistinctly gendered sexual identities are being reasserted in contemporarydiscourses of sexual rejuvenation.
5. Clinical research demonstrates that Viagra has the highest efficacy in cases of erectile dysfunction for which there is no identified organic cause (Shabsigh,1999; Steers, 1999). See Marshall (2002) for further discussion of how thedisease parameters of erectile dysfunction have expanded.
6. See, for example, (accessed March 2006).
7. The corresponding brochure entitled ‘Women’s Sexual Health’ was entirely focused on sexuality in the ‘transition years’ (i.e. perimenopause andmenopause) and discussed hormone therapy to deal with sexual difficulties(both estrogen and testosterone – the latter only available to women on off-label prescription). Thanks to Andrea Tone for passing these brochureson to me.
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Biographical NoteBarbara Marshall is a Professor of Sociology at Trent University, where sheteaches and writes in the areas of social theory, the body, technology andsexuality. She continues to explore the historical and contemporary intersectionsof gender, sexuality, age and biomedical technologies, both on her own and incollaboration with her frequent co-author, Stephen Katz. Address: S103 LadyEaton College, Trent University, 1600 West Bank Drive, Peterborough,Ontario, Canada K9J 7B8. [email:,]


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