Barbara L Marshall. Generations. Volume 32, Issue 1. Spring 2008.
In August of 2007, media attention was raptly focused on a new study out of the University of Chicago, which showed that while sexual activity declines with age, many older people enjoy a variety of sexual activities well into late life (Lindau et al., 2007). “Sexed-up seniors do it more than you think” proclaimed the headline on the website of NBC-News. “Senior partners: Still randy” declared Canada’s Globe and Mail (Agrell, 2007). Both the study itself and the media coverage of it illustrated well what appears to be a new cultural consensus on sexuality and aging. While historically sex has been seen primarily as the province of the young, more recently the maintenance of active sexuality as a marker of normal aging has also been garnering attention.
The University of Chicago study not only suggested that sexuality was important across the lifespan, but also dearly linked sexuality with overall health and urged that increased medical attention be paid to late-life sexuality. The lead author suggested in an interview that she “would like to see physicians begin asking patients if they are sexually active, how their sex lives are going, or if there is anything preventing them from having sex” (Agrell, 2007). In a reversal of long-held beliefs mat older people just shouldn’t be sexy, the onus is now on all of us to remain sexy. While certainly the positive image of elder sex promoted here is most welcome, implicit in the extensive media coverage of such research is an underlying view of those who choose to opt out of active sexuality as they age as victims of a pathology and a subtle reiteration of a message of risk and decline in the absence of appropriate intervention.
It is against this backdrop that I explore in this article the medicalization of aging men’s sexuality, in particular the rise of a post-Viagra ”men’s health” industry. This new addition to the aging enterprise has expanded the medicalization of masculinity and male sexuality in later life, particularly via the recuperation of the “male menopause” as a hormonaly treatable disorder. Finally, I explore how hormonal and other pharmaceutical therapies aimed at promoting masculine virility are deployed against the background of new understandings of risk, health, and surveillance in relation to aging men’s sexual function.
New Views of Age and Sex
Masculine life-courses have shifted in terms of aging and sexual function (Gullette, 1997; Marshall, 2006,2007; Marshall and Katz, 2002, 2006). Victorian narratives of the “spermatic economy” (Haller, 1989) held that masculine vitality was a fixed resource that needed to be prudently managed if it were to be enjoyed into late life. If masculine vitality were squandered, sexual decline could occur at any age. Even with careful husbandry, however, the waning of the sexual impulse with age was treated as part of nature’s wisdom, and counsel in the art of graceful acceptance was widespread. It was not until the early twentieth century that the idea of age-related midlifb sexual decline took hold and was fashioned as a target for therapeutic intervention. Today, aging men are expected to remain “forever functional” (Marshall and Katz, 2002), and, as Calasanti and King (2005, p. 16) summarize it, “sexual function now serves as a vehicle for reconstructions of manhood as ‘ageless.”
In contemporary medicine, sexual health in aging men has become a “canary in the mine” indicator of their general health in mid to late life. “Sexual Health Is the Portal to Men’s Health” (Shabsigh, 2006) was the tide of the keynote speech at the Fifth World Congress on the Aging Male, held in Austria in 2006. A recent editorial in the Journal of Men’s Health and Gender similarly proclaimed that “… sexual health is one of the gates to men’s health in general!” (Meryn, 2006, p. 318). Yet the concept of sexual health, once defined as reproductive health and absence of sexually transmitted disease (Giami, 2002), is now narrowly focused on sexual performance and desire.
In other words, sexual health has become equated with sexual function and defined by the desire and ability to have intercourse. Erec tile dysfunction, for example, is seen as a key indicator of other underlying conditions such as cardiovascular disease and diabetes (Kirby, 2004, p. 255).
The press release for last year’s North American Congress on the Aging Male was headlined “Failure to treat sexual dysfunction can pose serious risk for aging males” and warned that “leading research scientists and clinicians from around the world are reaching the consensus that failure to treat decreased sexual function in aging males may actually put them at greater risk for heart disease and cancer” (Canadian Society for the Study of the Aging Male, 2007). The assertion (reviewed later in this article) that erectile dysfunction is an important warning sign of underlying disease is contradicted by widespread campaigns encouraging men to self-diagnose sexual dysfunctions and request specific pharmaceutical treatment. What is clear is that the clinical and market success of Viagra, introduced to the North American market in 1998, was pivotal in creating new institutional structures and health-promotion discourses around men’s sexual health and in constructing the aging male body as a site of biomédical intervention. Viagra solidified a turn to understanding the aging male body as a series of functional subsystems amenable to constant monitoring and biotechnical intervention. While Viagra was seen as the solution to malfunction in one of these subsystems (vascular flow to the penis), the problems of the aging male are now increasingly opened up to diagnosis and treatment.
The market for erectile dysfunction drugs, while perhaps not as massive as the most optimistic estimates originally suggested, is huge, and is buoyed by the continual promise of new and better drugs on the horizon (a quick search of the U.S. clinical trial registry shows thirtytwo trials in progress for erectile dysfunction). New indications in the clinical literature suggest a move toward treating erectile dysfunction as a chronic disease, with daily (rather than on-demand) administration of erectile drugs such as PDE-5 inhibitors (like Viagra, Cialis, and Levitra) (Montorsi et al., 2006). lhe market is also buoyed by renewed interest in using existing drugs for newly reconstructed disorders. Chief among these is the rediscovery of the socalled male menopause, or andropause, now understood as “androgen deficiency in the aging male” or “late-onset hypogonadism.” According to the pharmaceutical information company IMS Health, testosterone prescriptions in the United States doubled from 2000 to 2004 and are now estimated to be a $400-million-dollar-a-year business. Taken together, according to industry reports, the therapeutic areas of sexual dysfunction and male menopause are expected to lead the way in expanding the $17 billion world market in pharmaceuticals for “men’s health” (Bioteeh Week, September 10, 2003).
Androfause: Arb Aging Men The New Women?
The medicalization of the male menopause was well under way by the late twentieth century, apparently undeterred by mistakes made in the medicalization of women’s menopause, where “on the basis of questionable evidence and scientific fallades … many claims were made about the wonders of estrogen replacement” (ODonnell, Araujo, and McKinlay, 2004, p. 509). This is not the first time that the male menopause has been construed as a treatable hormone deficiency. A series of articles in American medical journals in the 1930s and 1940s investigated the “male climacteric” and treatment of it with injections of testosterone. While attributed to a deficiency in the sex glands, the male climacteric was seen as only clinically significant in a small proportion of aging men. Furthermore, while sexual dysfunction was viewed as a key symptom, it was not the main concern in treating the disorder. Although potency might inadvertently be stimulated by testosterone therapy, it was not to be given for this purpose, and at least one researcher suggested that “it is perhaps better for older men if this phase of the reaction does not result” (Werner, 1945, p. 710).
The idea of a hormonally treatable male menopause failed to gain much attention from mainstream medicine in subsequent years. Rather than a medical disorder, the “male climacteric” became viewed as more of a period of emotional adjustment, or midlife crisis (Featherstone and Hepworth, 1985; Hepworth and Featherstone, 1998). It was not until sexuality came to be viewed as the key to men’s midlife problems in the late twentieth century that the male menopause, or andropause, was reconceptualized as a medical condition. In the post-Viagra climate, with its intentionally heightened public awareness of the risk of sexual decline with aging, the notion of andropause as a widespread “disorder” now circulates through the scientific literature, the clinic, and the general public by way of citation, marketing, and mass media.
Since the late 1990$, mainstream journals, especially those focused on urology and impotence research, have been peppered with articles on the diagnosis and treatment of andropause. There is a significant gap, however, between andropause as a symptom complex, and androgen deficiency—or hypogonadism—as a biochemical state. Because testosterone is only approved in the U.S. for the treatment of hypogonadism (not andropause per se), there is a huge commercial motive in construing andropause as a form of hypogonadism. Hypogonadism itself is a relatively rare condition—there is, however, a large and growing market of men in mid and later life. If the increase in prescriptions for testosterone supplements is any indication, it would appear that this strategy has been successful.
The research on andropause and its treatment with testosterone remains controversial, and there is more disagreement than agreement on definition, diagnosis, and treatment Researchers and clinicians generally agree that many older men report symptoms such as erectile dysfunction, decline in libido, and decrease in strength and energy. They also agree that there is a moderate and gradual decline in testosterone as men age, but that many men remain within the “normal” range for younger men.
More contentious are issues such as whether declining testosterone levels have clinical significance, whether they may be caused by confounding factors such as obesity or inactivity, whether testosterone supplements result in dear benefits, and if so, whether or not they outweigh the potential risks. Controversies remain over measurement of bioavailable testosterone, what constitutes normative and/or deficient levels.
Further complicating the picture are studies suggesting that a significant proportion of men who have been identified as having mildly low testosterone levels show normal levels upon retesting, and that even some healthy young men may have abnormally low testosterone levels during any given twenty-four-hour period (Bhasin et al., 2006, p. 1998). A recent analysis of a number of studies suggests that the effects of testosterone supplementation on sexual function may be quite modest and may in fact diminish over time (Isidori et al., 2005). Data from the Massachusetts Male Aging Study show that low libido is a poor predictor of low testosterone levels (Travison et al., 2006).
It is no wonder that the National Institutes of Health concluded that “the growth in testosterone’s reputation and increased use … has outpaced the scientific evidence about its potential benefits and risks” (liverman and Blazer, 2004, p. 11). Despite these debates, the existence of the andropause has now become widely discussed and is given credibility in a number of circles in which controversial and contested theories become presented as scientific fact.
Pharmaceutical companies actively promote an appearance of consensus on the existence, definition, and treatment protocols for clinical entities such as andropause, or “symptomatic late-onset hypogonadism.” Some of the strategies include websites, health promotion brochures, and support to professional and patient groups organized around specific disorders. As has been demonstrated in other areas of pharmaceutical research, such as mat on antidepressants, the placement of industry—written articles in key clinical journals is one way of manufacturing the appearance of consensus (Heaty and CattdL, 2003). Such articles in mainstream clinical journals now include studies that survey physician knowledge about particular disorders.
For example, Solvay, manufacturer of Androgel, a testosterone product, has sponsored two studies of primary care physicians’ knowledge of andropause (Anderson et al., 2002; Pommerville and Zakus, 2006). These studies take as their premise such assertions as “Andropause is a testosterone deficiency that develops gradually over a number of years in all men aged 50 and over” and “The causes, symptoms and treatment options for andropause have been well documented.” The studies then proceed to score primary care physicians’ responses as “correct” or “incorrect” on a range of questions regarding the nature of, and treatment options for, the disorder. Given the manifest lack of scientific consensus on such matters, such an exercise can only be seen as one in the service of public relations rather than public health.
Mainstream media stories resulting from pharmaceutical company press releases highlight public education campaigns or new products. Mostly, these articles take the form of relatively uncritical “good news” stories. Mainstream press stories on the andropause, tor example, followed a familiar script, which suggested that while the existence of male menopause had been a subject of controversy in the past, there was now a scientific consensus that it is a “real” disorder treatable with hormone therapy. Stories of miraculous transformations (weight loss, muscle gain, better sex, better mood) resulting from testosterone treatment generally over-shadowed any brief nods to possible risks and cautions from more skeptical doctors and scientists. In many stories, the libido-enhancing benefits of testosterone are added to the presumably already accepted benefits of erectile drugs. As one article put it: “If you think you can Viagra your way out of this one, think again: it and similar drugs might help with the mechanics, but not with desire: testosterone is what fires the libido” (Werland, 2004).
In another story, a doctor with a men’s clinic recounts a “typical case,” a 40-year-old complaining about erectile dysfunction and low libido. Six weeks after the doctor treated the erectile dysfunction (presumably with Viagra or a similar drug) and prescribed testosterone, the patient returned, “It was vibrant,” the doctor writes. “He had quit his job and gone into business for himself …The man’s marriage was wonderful and his sex life was great. He had a great sense of vitality and a positive attitude towards life” (Bowell, 2000).
Sexual decline and its pharmaceutical reversal are linked here with the restoration of masculine vitality more generally. Not unlike the “feminine forever” message promoted to women by those selling hormone replacement therapy in the 19605, the newly remedicalized climacteric in men reasserts a hormonal basis for masculinity itself.
Risk and Surveillance
All this bears witness to the dose cultural association between sexual virility and masculinity and fosters an environment of amplified risk for many men. No longer is sexual dysfunction just a concern for men in old age: Anxiety over the prospect of sexual decline is fostered earlier, in midlife. As Margaret Gullette (1998, p. 17) notes, “everyone has been getting older youngerf The Viagra user is not just an older man who is unable to get or keep an erection, but is more likely to be any man who worries about his erections being less reliable than he thinks they should be. A study of prescription-claims data in the U.S. during Viagra’s first five years on the market found that younger men (ages 18 to 45) were the fastest growing group of users. Medicalization of the andropause has also meant medicalizing not only late-life masculinity, but also midlife masculinity.
According to the U.S. National Institute of Medicine, most testosterone prescriptions were given to men in the 45-65 age group, not to men over the age of 65, where decreased levels of circulating testosterone are most evident (Liverman and Blazer, 2004, p. 25). lliis construction of ever-younger aging males as “active patients” occurs against an expanded horizon of risk, increasing the responsibility of both individuals and health professionals to undertake virility surveillance.
The specter of sexual dysfunction has become central to a variety of health-promotion discourses that target lifestyle factors that might put individuals at risk. These factors include both official campaigns, such as Health Canada’s warning labels on cigarettes (“Tobacco use can make you impotent”), and unofficial ones, such as the promotion of vegetarianism (“Eating meat can cause impotence”) by People for the Ethical Treatment of Animals (PETA). The onus is on individuals to take responsibility for managing their risk of sexual dysfunction through various regimes of bodily discipline (including diet and exercise), which must start long before the onset of old age.
Direct consumer advertising, permitted in the U.S., also enrolls the individual as a key agent in the diagnosis and treatment of bodily disorders. With the aid of widely circulated quizzes and indexes, men are encouraged to screen themselves and consult their doctors. For example, Pfizer, manufacturer of Viagra, promotes a plan for “three steps to better erections.” Men are instructed to assess their erectile capacity (via a short quiz), compare it to a standardized model (via their score on that quiz), and seek action by visiting their doctor and requesting a starter pack ofViagra. Studies show that when patients ask their physicians for a prescription for a specific medication, they are likely to get it (Kravitz et al., 2005).
Responsibility for diagnosis and management of erectile dysfunction also has largely shifted from urologists to primary care physicians. Oral PDE-5 inhibitors such as Viagra, Cialis, and Levitra are considered frontline therapies, and more invasive testing to determine underlying causes of erectile dysfunction tends to be reserved for cases in which these erectile medications do not work. At least one critic suggests that primary care physicians “prescribe them like aspirin to virtually any man who asks” (MacNeil, 2005, p. 46). This use of these drugs would seem to fly in the face of claims that erectile dysfunction is an important warning sign of more serious health concerns.
The self-diagnosis and treatment-seeking process is replicated by those worried that they might be suffering from andropause. The “ADAM” (androgen deficiency in the aging mak) quiz is featured on a number of websites sponsored by pharmaceutical companies as well as in full-page advertisements in magazines such as Aim’s Health and GeIf. According to the quiz, men who experience such concerns as decreased libido, lack of energy, grumpiness, weakened erections, decline in sports or work performance, and after-dinner sleepiness should see their doctors to investigate testosterone therapy.
In case individuals are negligent in screening themselves, doctors are encouraged to engage in “pro-active questioning about a patient’s sexual relations during routine consultations” (Kirby, 2004, p. 256). They are encouraged to monitor their patients for signs of sexual decline by conducting “proactive sexual health” interviews (Nusbaum and Hamilton, 2002) and by “routinely asking about libido, sexual function and stamina” (Maclndoe, 2003, p. 52).
This environment of accelerated surveillance for signs of sexual dysfunction in part reflects the sense in which sexual health, like health in general, becomes “a duty as much as a right of citizenship” (Porter, 2002, p. 201). Health, as the author Leonore Tiefer (1997) has put it, is the “new morality,” and sexual health is no exception here.
Toward a Critical Perspective
What is needed is a move toward a critical perspective on the medicalization of late-life masculinity. I have reviewed some developments in the late twentieth and early twenty-first centuries that have opened up the sexual capacities of aging men to new biomedical remedies and lifestyle projects. While not entirely responsible for these developments, the success of Viagra and similar drugs in securing a particular understanding of sexuality and aging masculinity should not be underestimated. In the post-Viagra culture of virility, changes in sexual capacities associated with bodily aging are assumed to be, not normal, but tamer, pathological sexual dysfunctions that require treatment. The burgeoning “men’s health” industry has expanded the range of discursive and institutional structures that both accommodated and nurtured the medicalization of the aging male body. Illustrating both the biomedicalization of aging (Estes and Binney, 1989) and the medicalization of sexuality (Tiefer, 1996), aging male bodies have been made and remade at the intersections of science and culture.
This medicalization of masculinity is not mitigated by a critical men’s health movement in the way in which a feminist health movement originally critiqued the medicalization of women’s health and contested the widespread portrayal of aging as defêminization. Michael Fitzpatrick (2006) argues that the contemporary men’s health movement lacks any radical impulse, with the following result: Tar from challenging medical authority, they [the men’s health movement] urge men to submit themselves to it on a greater scale than ever before” (p. 260).
Thus what passes for a men’s health movement lacks a critique of cultural standards of masculinity, particularly as these intersect with a critical perspective on aging. This situation makes it all the more important for academics and practitioners to cast a critical eye on the convergence of science and industry in fashioning aging as a crisis of masculinity.