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Viagra was supposed to change the world. Did it?

WASHINGTON—When Viagra came on the market nine years ago, Time magazine worried that it signaled "the end of sex as we know it." Playboy predicted a sexual revolution "as monumental as the birth control pill." Adweek forecast demand for Viagra so massive that "not one dollar need ever be spent advertising it."

It certainly hasn't worked out that way.

Prescriptions for erectile dysfunction drugs, which sparked a veritable gold rush to doctors' offices initially, have been steady worldwide for three years despite massive promotional campaigns. Revenues for Viagra were once forecast at $5 billion a year. In 2006, revenues totaled just $3 billion for Viagra and rivals Levitra and Cialis combined.

"The market's about as big as it's going to get," said Jason Napodano, a biotech stock analyst at Zacks Equity Research in Chicago.

So the first finding about how erectile dysfunction drugs changed American life is: less than expected. Rather than spark a second sexual revolution, sexologists say, Viagra and its cousins merely advanced substantially a long-under-way trend toward enhanced and open sensuality.

The drugs made erection problems widely discussable for the first time. They made chemically assisted sex acceptable among law-abiding people. They enhanced the potential for sex among older Americans. For younger ones, the drugs reportedly made dating life more ardent, stressful and sex-centered.

For promiscuous gay men, the drugs probably made pleasure riskier: Surveys show that users have more sex and sexually transmitted diseases. For women, sex therapists say, the drugs made intimacy more intercourse-centered and more time-regimented.

The makers of erectile dysfunction drugs won't address most changes in sexual lifestyle, although clinicians say they see them all the time. "Our approach is to focus on ED as a serious medical condition," said Rob Perry, a spokesman for GlaxoSmithKline, which along with Bayer promotes Levitra in the United States.

But believing that people take erectile dysfunction drugs only for medical reasons is like believing they drink wine only to help their hearts, according to Edward Shorter, a University of Toronto medical historian. "They can't advertise it as a sex drug for rock hard erections so they say it's for erectile dysfunction," said Shorter, the author of the surprisingly academic book "Written in the Flesh: A History of Desire."

He's not anti-ED drug—"I say bravo to them"—but he thinks that the strictly medical argument hides the drugs' real utility: "For at least the last half-century, people have been intent on turning sex into a really sensual experience, and this helps that."

Whether that's the whole truth or just part of it, the drugs indisputably helped millions of men by making their erection problems mentionable.

"That was a very big deal," said Dr. Judy Kuriansky, a longtime sex counselor on radio, based in New York. "Before Viagra, a lot of men with erection problems were angry and withdrawn in their relationships. They didn't want sex; their partners didn't know what was going on; the women blamed themselves, and it was a mess."

Today, "talking about erection problems is no more stigmatized than talking about feeling depressed," according to Kuriansky.

Yet for every man with erectile dysfunction who's sought treatment, several more never have, surveys determined, and that more than anything suppressed the market for the drugs and the ballyhooed revolution.

And those who did try the drugs had mixed results. Here's what happened.

First, consider men with erection problems. ED drug makers say there are 30 million of them in the United States, 52 percent of men ages 40 to 70. Those numbers, however, rely on a survey that counted every man who said he wasn't "always able to get and keep an erection good enough for sexual intercourse."

The best estimate is that a fifth or sixth of men with erectile dysfunction now take the drugs, which usually work.

"We live in a privileged generation," said Dr. Fernando Borges, founding urologist at the Florida Impotency Center in St. Petersburg. "I see more wives with smiles on their faces, and husbands, too, because they feel less pressure to perform."

An AARP sexuality survey of men and women 45 and older backs him up. Men treated for erectile dysfunction reported that they had more and better sex. In addition, 56 percent of the men said it had improved their relationships. Virtually all the rest said that treatment—mostly but not always with drugs—neither helped nor hurt their relationships.

The increased sexual satisfaction extends to their partners, according to a recent study sponsored by Pfizer Inc., the maker of Viagra.

Divorce is an occasional side effect, however. Sometimes rekindled interest in sex leads men to stray. Other times, wives find pills in pockets. "It's been good for business, kinda," said Mel Hoover, a private detective in Tacoma, Wash.

For a second large group—younger men who take the drug simply to enhance performance—results are more mixed. Their number is unknown, but clinicians say they're seeing more of them.

Dr. Abraham Morgentaler, a Boston urologist who teaches Harvard Medical School students, thinks that many are responding to pressure from sexually ardent women. Such women have become more numerous and aggressive in recent years, especially in urban areas, said Morgentaler, the author of "The Viagra Myth: The Surprising Impact on Love and Relationships."

"They feel as entitled to sexual satisfaction as men, and they're as knowledgeable about it and aggressive about it," he said.

"I think guys feel pressure to perform that they never felt before," he continued. "It's not unusual to have a guy in his 20s or 30s come in, who's by all accounts functionally normal, and say, `It's crazy out there, Doc. I need help.'"

One new and adverse side effect for these men is stress, if they take erectile dysfunction drugs secretly. As many as half don't tell their lovers, one study found.

A third very large group consists of men who tried the drugs but only briefly.

About half of men for whom erectile dysfunction drugs are prescribed don't renew their prescriptions, surveys indicate.

ED drug makers wouldn't comment. "We just don't discuss strategic research or marketing," said Perry of GlaxoSmithKline.

One popular explanation for nonrenewals is the dumb lovers theory. By that scenario, the husband takes his Viagra, sits down to watch TV and his wife tells him to come upstairs when he's aroused.

That won't happen without foreplay or fantasizing, experts know, because the drugs aren't aphrodisiacs; they simply make penises stay hard once inspired.

The drugs produce erections roughly 4 out of 5 times when the problem is psychological, according to their makers, 2 out of 3 when it's organic. Alcohol or a heavy dinner can add to the failure rate, however. And side effects, such as headaches and nausea, can be discouraging.

But larger proportions of people keep taking other drugs that work less well, have worse side effects and make less dramatic cases for themselves.

So what's really going on?

Therapists say failure is likeliest with the first pill, when the pressure is greatest. That's especially true for couples who haven't had sex for a long time or aren't drawn to their partners, said Dr. William Petok, a psychologist and sex therapist who practices in the Baltimore area.

"You've got to be attracted to the person you're with, and a pill doesn't do that," he said.

The drugs' makers ignore that real-life complexity, said Dr. Stephen Levine, a psychiatrist and sex therapist who teaches at the Case Western Reserve School of Medicine in Cleveland. "They don't consider that your wife might be sick or incontinent. Or that you might recognize that you have no desire to make love to your wife and would really like to change partners. Or that you're still mad at her for saying no so many times. Or that she doesn't find you attractive or is too savvy to your past."

In short, erectile dysfunction isn't the whole issue when it comes to intimacy problems. It's simply the piece of the problem that medicine has learned how to fix.

"Almost everybody I see is a Viagra failure," said Dr. Barry McCarthy, a Washington psychologist and sex counselor for couples. Many give up on sex entirely after erectile dysfunction drugs fail, McCarthy said, attributing to Viagra and its kin the perverse side effect of creating nonsexual marriages.

Dr. Irwin Goldstein, a urologist and ED treatment pioneer who directs sexual medicine at Alvarado Hospital in San Diego, agreed that the drugs had proved less popular than expected. He added, however, that "the real problem with sexual dysfunction isn't men—it's women," citing a survey that found 43 percent of women sexually dysfunctional vs. 31 percent of men. Other studies show lower percentages but the same disparity.

Goldstein predicted a flood of interest from both sexes once effective treatment for women is available.

At that point, the dance wouldn't just begin. It'd be a tango.

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(McClatchy researcher Tish Wells contributed to this report.)

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To review the AARP's sex survey, go to www.aarp.org/research/family/lifestyles/2004(underscore)sexuality.html

For a feminist critique of erectile-dysfunction drugs and the drug industry's "medicalized" approach to sex, go to www.fsd-alert.org

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(c) 2007, McClatchy-Tribune Information Services.

CARTOON (from MCT Photo Service, 202-383-6099): MED-VIAGRA

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