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Better dicks through drugs? The penis as a pharmaceutical target

Petra Boynton

"Dear Doctor,

I am a 44 year old male, father of three boys. My wife died four and a half years ago and I am rearing the children myself. I experienced erectile dysfunction after my wife?s death, but still had massive urges for sexual satisfaction. I was prescribed viagra and it has worked almost perfectly (face flushing, diarrhea (sic)) for me since. I have a high sex drive and enjoy regular sex/lovemaking with my new partner, (fiancée). I am concerned with two factors: (1) Are there any long term effects from the prolonged use of viagra, (four years, averaging twice daily), and what are they as I believe I may have to use it forever. (2) I have had to conceal this fact (viagra) from my fiancée through shame, and fear having to tell her about it. (a) Should I divulge my secret, or keep it forever? (b) If you suggest that I tell her my secret, What/How would be an appropriate way to do it? I would appreciate an honest and informed answer to the above dilemmas as we plan to marry next year. Thanks. Justin"

The above letter is typical of those sent to me in my capacity of sex editor at www.menshealth.co.uk. Every week I receive hundreds of emails from men of all ages, nationalities, and sexualities. Most weeks they want answers to a limited number of problems, mainly concerns about their penis size, shape, and how they should perform sexually (Boynton, 2004a). Many want to know how they can ?cure? these perceived problems, and often are like Justin (not his real name). That is, they are taking medication to assist with a sexual problem, but are receiving inadequate medical or psychosexual support; or they are self medicating after deciding they have a sexual problem they need to treat, misunderstand what sex drugs do, or are too ashamed to seek professional help.

I am gravely concerned about the number of men selecting to use drugs to ?treat? what they believe to be erectile problems, but more often is chronic insecurity caused by the way they are told they ought to be functioning sexually by the press, and by their peers. In this paper I explore the marketing of sex drugs by big-pharma companies, the problems this poses to men and their partners, and what, if anything should be done about the issue.

Current issues around men, sex and the penis

Men of all ages have been observed to be concerned about their penises (Mondaini et al, 2002). This includes worries about penis and testicle size and shape, sexual functioning and performance (Herring, 2003). Many men have missed out on basic sex education (Starkman and Rajani, 2002), and are likely to obtain their sex messages informally from friends, the Internet and porn. They may take longer than women to consult with a GP if they believe they have a sexual health problem, are afraid to talk about personal issues with their doctor (Potts, 2002, p. 146) and once at their doctors may find their GP is ill-equipped to initiate discussions about sex, or can discuss penises in terms of physiology only (Nazareth, Boynton and King, 2003; Aschka, Himmel, Ittner, Kochen, 2001; Moser, 1999). This means men are being failed through sex education and health care, whilst facing an overwhelming amount of sex content in the media that defines modern masculinity by successful sexual performance, stamina, and ?stiffies?.

Within this context, pharmaceutical companies have been aggressively targeting men via the media and academic research, creating a model of male sexual functioning that requires the penis to perform according to exacting standards (Loe, 2004; Tiefer, 2004; Marshall, 2002). It must get hard when desired, stay hard as long as required, and be able to regularly repeat this exercise (Herring, 2003; Potts, 2002). Evidence shows this model eludes most men (Nazareth, Boynton and King, 2003; Potts, 2002; Haiken, 2000), and there?s a growing voice of dissent within academia and activism suggesting that pharmaceutical companies inflate ideals of sexual performance, whilst playing on concerns about sexual stamina, to make men feel that if their penises aren?t working at (an unrealistic) ?peak? performance, they are dysfunctional, even diseased ? and require medical intervention (see Loe, 2004; Tiefer, 2004; Moynihan, 2003).

Before and since its launch Viagra has become synonymous with male sexuality, and carries a cultural subtext of sexual prowess, performance, and perfection (Tiefer, 2004; Potts, 2002). Whilst medications like Viagra, Levitra and Cialis (referred to in this paper as ?sex drugs?) can assist men with genuine erectile problems caused by diabetes, heart disease and MS (Nazareth, Boynton and King, 2003; Boynton, 2004d), media reportage and pharmaceutical company marketing have led to many misunderstandings about the effects of sex drugs, and who really needs them (Tomlinson and Wright, 2004; Loe 2004).

Marketing strategies

Earlier this year I attended a sexual functioning conference, where there were obligatory stands from the major pharmaceutical companies. At the Viagra stall an eager rep approached me and asked how my patients were getting on with the drug. I explained I wasn?t a medical doctor and didn?t prescribe, but I was a sex advisor to men, and was concerned how many of them believed that the drug was something they should take in order to overcome first night nerves, increase their prowess, or slip to their partner to make them more sexually responsive (see later in this paper). ?That?s absolutely nothing to do with us. It?s not our problem? the rep hastily replied, backing away ?we don?t have anything to do with that sort of thing at all?.

And yet that is exactly what is happening (Loe 2004). Drug companies are encouraging public discussion of their products to increase interest (Moynihan 2003; Deer, 2003; Loe 2004), and there is evidence they are aiming the drugs at younger audiences of men (Thomson, 2004,ps.44-5). The drugs have now moved from medical marvels that could save mankind, to being mandatory lifestyle enhancers. Good sex has been defined as a vital component of 21 st Century life (Tiefer, 2004), and erections and stamina are required to ensure this happens (Loe 2004, Potts, 2002).

All the major pharmaceutical companies (see Table Two) are vying to get their products into the headlines, even whilst they are still in development stage, so pharmaceutical company PR department are busy priming the press to whet our appetites for sex drugs available in inhaler format, in chocolate, that are quicker acting than the nearest rival product, and of course, will impress our partners (all these stories have appeared in the media this year). Whether the drugs are in progress or publicly available, FDA approved or an herbal alternative, the subtext of these media messages is the same. Your penis should always function perfectly, and as soon as it doesn?t, it?s time to pop a pill.

What are the common sexual problems?

The main sexual problems experienced by men are difficulties with getting and keeping an erection, problems with premature, delayed, or absent ejaculation, pain during or after sex, over or under active sex drives, or diseases of the genitals (Dunn, Crift and Hackett, 1998; Nazareth, Boynton and King, 2003; Laumann, Paik, and Rosen, 1999). These are outlined in Table One below.

Table One ? Sexual Functioning Problems That Affect Men

Common sexual dysfunctions, or issues leading to dysfunctions

Erectile Dysfunction

Premature, Delayed or Absent Ejaculation

Pain in genital area during or after sex

Lack of interest in sex

Concerns about size/shape of penis/testicles.

Problems linked to infertility or sub fertility

Sexually transmitted diseases or other diseases of the genital area

Previous sexual abuse

Hyper sexuality, or what patients may term ?sex addiction?

A lack of sexual knowledge or confidence leading to worries about sex, the body, and relationships

However, in many cases it is difficult for men, their partners, or their health practitioners to diagnose problems since many are subjective in origin, and culturally and historically determined (Tiefer, 2004; Caplan, 1987). This leaves men asking things like: how premature is premature ejaculation? What makes an ?under active? sex drive? How long should I last? How big should I be? What can I do if I?m not happy?

These concerns, along with a lack of sexual knowledge mean men are just as likely to have sexual problems caused by media fuelled anxieties about unrealistic expectations of sexual performance, penis size, shape and length, the appearance of their testicles, amount and consistency of sperm, whether circumcision is a problem, and what their foreskins ought to look like (Boynton, 2004a; Haiken, 2000; Boynton 2000) (See Box One below). Newspaper headlines (driven by pharmaceutical press releases) imply that levels of sexual dysfunction are reaching epidemic proportions (Loe, 2004; Tiefer, 2004; Boynton, 2001). The focus of this epidemic is frequently the penis - specifically erectile dysfunction, not because it is the greatest sexual problem facing men, but it is the only one where medical interventions are readily available, and aggressively promoted.

What treatment is available for male sexual dysfunction?

Many people (even those who are engaged in critically evaluating masculinities) are often unaware of the effects and actions of the sex drugs for erectile dysfunction (supplements and medication for other conditions will be discussed later). This means people are unaware of what treatment is available, and whom it suits. Table Two below includes details of pills and pellets used to treat erectile dysfunction (although injections, implants and penis pumps are also an option). Drugs are marketed to appeal to men who, through embarrassment and stigma surrounding penis problems, want to use a product that is unobtrusive, fast acting, and long lasting. Penis pumps may be as effective, but are seen as highly unfashionable, and cannot compete against the marketing machines of many pharmaceutical companies.

Given the success of treatments for erectile dysfunction it is perhaps not surprising the race is on to find a ?cure? for the newly invented ?female sexual dysfunction? (Moynihan, 2003; Tiefer, 2004). We can also expect to see similar efforts to find medical cures for premature ejaculation. Erectile dysfunction used to be seen as a largely psychological condition. Now it is portrayed as almost an entirely physical one (Tiefer, 2004). Sexual problems may have a physical origin, but given the distress they cause there will also be an element of psychological difficulty too.

However, as products are found to treat physical causes, there is greater pressure to see sex as being entirely linked within the physical body, and a new hope given through medical or surgical treatment. I have sat in on a training class given to GPs, backed by a pharmaceutical company. We were told "we used to believe erectile dysfunction was all in men?s heads. This was wrong. The problem is physical, and now we can fix it!" (see also Loe 2004; Fishman 2002). Such a view appeals in many ways to men who want a quick fix to their problem without the messiness of having to discuss emotions. Yet ignoring psychological aspects of sexual problems means many are unlikely to be fixed, and lead to men feeling more inadequate (Tomlinson and Wright, 2004).

Table Two ? Common Treatments for Erectile Dysfunction.

Product/Drug Name	Brand Name	Made By	How Works	Contra-indications
Sildenafil citrate	Viagra	Pfizer	Pill (taken orally). Blocks the enzyme that breaks down the substance that helps maintain erections. Increases blood flow to the penis.	Heavy meals can interfere with the absorption of the drug into the body. Side effects include headaches, flushing, blue-tinged vision diarrhoea or indigestion. Men using drugs containing any form of nitrate (like nitroglycerin for heart pain) should not use Viagra. A dangerous drop in blood pressure could result. Viagra also should not be used within 4 hours of taking an alpha blocker, a drug used to treat benign prostate conditions.
Vardenafil	Levitra	Bayer and Glaxo SmithKline	Pill (taken orally). An enzyme-blocker that increases the blood flow to the penis.	Should not be used by men taking nitrate drugs for angina, or medication for prostate problems.
Tadalafil	Cialis	Eli Lily	Pill (taken orally). Blocks an enzyme called phosphodiesterase-5, or PDE-5 so allows more blood to enter the penis.	Not suitable for men taking nitrates. Side effects include headaches, dizziness, nasal congestion and indigestion.
Apomorphine hydrochloride	Uprima	Abbott	Pill (taken orally). Acts on areas of the brain known to be involved in the erectile process. It works via the body's natural signalling pathways and acts to enhance the signals which allow an erection to occur.	Side effects include nausea, headaches and dizziness, Men should not take it if they have severe unstable angina, recent heart attack, severe heart failure or low blood pressure, In combination with other centrally-acting dopamine agonists or antagonists.
Alprostadil	MUSE	Vivas	Pellet placed in urethra.	Side effects in men include light-headedness, dizziness, fainting, rapid pulse and swelling of the leg veins. Some discomfort in the penis when first used. Female partners can experience discomfort and itchiness in the vagina (condoms are suggested to overcome this, and also where a female partner is pregnant). Men with abnormally formed penises, diseases that might result in prolonged erection (e.g. sickle cell anaemia or trait, leukaemia, multiple myeloma) should not use MUSE.

What do men think ?sex drugs? do?

Due to the coverage of sex drugs in the press, journalists and readers frequently misunderstand that existing sex drugs are aimed only at a minority of men with a chronic clinical condition that causes erectile problems (Boynton, 2004b). Anecdotal evidence from organisations such as the Sexual Dysfunction Association (UK), suggests men believe the drugs they hear about have aphrodisiac properties, increase their penis size, or make them a better lover. This is frequently played upon by the marketing strategies of pharmaceutical companies who use illustrations of happy heterosexual couples (Tiefer, 2004), sports or political figures such as Bob Dole (Loe, 2004), or catchphrases such as ?the mark of love? (accompanying a picture of a man?s back scarred with fingernail scratches in a "V" shape, for Viagra) to imply the medications do more than act on erections (Boynton, 2001).

Furthermore, the marketing and discussion of sex drugs, alongside a media preoccupation with having ?great (performative) sex?, means men are eager to try anything that will make them good in bed, make their penis larger, make them seem more attractive, or make it easier to get someone to sleep with them (Vares, Potts, Gavey and Grace, 2003). Marketing that plays on these issues leads to further confusion about the purpose of medication.

Why are men such easy targets?

It can be argued men are more susceptible to the marketing of sex drugs for several reasons. Firstly, many men lack comprehensive sex education when they are younger, meaning they are uncertain about how their bodies should look and behave (Singleton, 2003). And there are few sources of information for adult men to use, so many use porn as a means to find out about sex (Singleton, 2003; Boynton 2000), which can make them feel more inadequate about their penis size, shape and sexual performance. As one man wrote to me "I am a 41 year old man and realise that sex is not such a wonderful experience as it should be. Recently I watched a porn video and noticed that the guy produced an amazing amount of semen. In comparison I produce only a fraction. Could this be the reason why an orgasm is not such a great sensation for me? If so, how do I get more out of my sex life? I feel like I?m missing out somewhere".

Whilst women?s media and self-help books are not without their critics (Zimmerman, Haddock and McGeorge, 2001), they do offer a source of information about sex, even if it may be flawed. Sex for women is constructed as being a mix of the physical and the emotional, men?s sexual identities are structured around performance, stamina and size (Singleton, 2003; Zimmerman, Holm and Haddock, 2001; Loe 2004). Therefore men lack specific information about their bodies, and fill in the gaps with stories and ideas that may make them more anxious. Big-pharma companies and men?s media tend to exacerbate this by playing on sex-as-performance messages, or suggesting in former GQ editor Michael Van Meulen?s words ?real men don?t have problems?. One UK men?s magazine recently refused to support a sexual health campaign because, in their words, it was ?too heavy and might make men seem like losers?.

The marketing of sex drugs also adds to this. Placed in the role of the ?advisor?, pharmaceutical advertising or big-pharma-led magazine or news articles fill the gaps in men?s knowledge, often deliberately using male focussed events to promote their products. Within the scandal of ?Janetgate? at this year?s US Superbowl, where singer Janet Jackson ?accidentally? exposed her breast, and the public hype about this ?obscenity?, many missed that the erectile functioning drug Cialis (manufactured by Eli Lily) sponsored the whole event. The drug was shown in 60 second adverts during breaks in the game, marketed to the viewers as the ?weekend pill? (due to it?s claims to last longer than it?s rivals) with the advert clearly showing what the drug could do to enhance men?s sex lives (Loe, 2004). Whilst I am not dismissing the very real distress sexual problems can cause to men and their partners, it seems ironic that not a murmur was made about advertising penis-enhancing products, but the glimpse of one nipple caused public outrage ? and the possibility of a $550,000 fine for CBS television studios.

Self-Medication

A quick Internet search using terms like ?penis?, ?erection?, or ?sex? will inevitably bring up links to websites and sponsored links offering sex drugs (both medical and herbal, FDA approved and untested) for sale. These adverts do two things. One, they associate sex with pharmaceuticals, and two, they normalise the messages of sexual functioning as both a medical and lifestyle issue (Tiefer, 2004; Loe, 2004). In the absence of comprehensive sex education (Singleton, 2003), a fear of going to the doctor to ask about sex problems (Nazareth, Boynton and King, 2003), or a mistaken belief that the occasional lack of erection equals ?impotence?, men and their partners are self-prescribing medication. They obtain it online, through adverts in the backs of magazines or newspapers, or through health stores offering ?herbal alternatives? such as multigrain bars ?proven? to boost the libido.

Within these adverts confusion reigns about sexual problems, erectile dysfunction is muddled with premature ejaculation and lack of desire. Many websites claim their drugs can cure all these issues and make you feel horny to boot. Yet most do not adhere to the Health on the Net (HON) Code backed by the World Health Organisation, which details how health websites should operate (http://www.hon.ch/HONcode/Conduct.html), and may be promoting products that may appear benign, but can be harmful (Thurairaja, Barrass and Persad 2004).

As mentioned, I advise men on sex and relationship issues. I became aware of how serious men?s misunderstandings were about their penises after receiving letters indicating high levels of sexual anxiety and ignorance (Boynton, 2004a). Excerpts from these letters are shown in Box One.

Box One ? Quotes from letters from men asking about sexual problems

"I have a date with a girl next week. I?m worried I won?t get it up ? will Viagra help?"

"I am very short (4 inches) and it is in a curved shape when erect. I feel very low about this. What can I try to make it straighter and longer?"

"Last Saturday I got drunk and couldn?t get a hard-on. Am I impotent?"

"What drugs are there to make a woman horny?"

"When I have an erection should my penis bend upwards, point straight up?"

"How can I cure coming too soon, is there any medications I can take to stop me doing this?"

"When I see flaccid penises on the t.v. the foreskin is folded back and the head exposed. When flaccid min (sic) is small and thin and appears to have loose foreskin on the end which looks like a spout. I am slightly overweight at the moment and also a virgin. Would this explain my loose foreskin?"

"My sex drive is so high it is making me ill. My partner plans to leave me. Is there an opposite to Viagra I can take to take away my desire?"

"I cum in about 3 mins and I?m scared to have sex coz I might not last long enough. How long does a normal 16-22 year old have to last in sex?"

The problem of people self-prescribing drugs meant to treat ED, or unapproved herbal supplements can be varied. Firstly there is no guarantee what the person has brought, meaning they could be wasting their money on a placebo product, or taking something containing harmful ingredients, or too high a dosage of a pharmaceutical product (Thurairaja, Barrass and Persad 2004). Those with existing conditions such as heart disease, sickle cell, or thallassemia could risk damage or death through self-prescribing certain drugs (see Table Two). However, there is virtually no information on websites selling products or elsewhere in the media warning people they need a full health check-up from their doctor before considering self-medicating; and better still to not self-medicate if their health and sexual functioning is okay. Companies are unlikely to risk drops in profit by advocating this, and it?s unlikely health care systems would endorse such an approach.

As well as taking sex drugs to overcome perceived or real sexual problems, many men use them to counteract the effect of club drugs such as ecstasy or cocaine (which affect sexual functioning), or believe that Viagra, Cialis or Levitra combined with a club drug will enhance a clubbing or sexual experience. Self-prescription of either recreational or sex drugs carries risks, but combining them can further increase the dangers. Again, this drug combining is not being adequately tackled in drug education programmes, particularly those aimed at gay men where combining drugs like poppers and sex drugs is not uncommon ? and yet could be fatal in some cases (Solomon, Man, Gill, Jackson, 2002).

Furthermore, anxiety created around sex and performance mean increased worries for men, particularly older men or those with a new or younger partner, or when embarking on a new relationship after a bereavement or divorce (Marshall and Katz, 2002). Anecdotal evidence from therapist colleagues, and letters I?ve been sent suggest men may advise each other to ?take a sex smartie? before intercourse to ensure a ?good show?. Gay men may feel particularly under pressure to perform and look good. Problems inevitably arise if sex doesn?t happen when they expect it, and doses are repeated on subsequent dates. Certain drugs do not mix well with alcohol or rich food, but this is rarely known to men who self-medicate. This may mean they could suffer embarrassing or potentially dangerous adverse reactions to the drug (see Table Two), with them and their date being oblivious to the cause. Although to my knowledge research has not been completed on this issue, further anecdotes suggest that when people realise their partner took a sex drug, they can react negatively, feeling excluded or rejected, or worried their partner didn?t trust them enough to be honest about their sexual concerns.

As well as medicating themselves, some men believe sex drugs are aphrodisiacs, and have been tempted to use, or have used them on their partners without their knowledge or consent. Again, with frequent media discussions of the ?female viagra? it is easy to see how heterosexual men may believe the drug could solve the problem of their partner?s lack of interest in sex. Gay or bi men may feel that sex drugs are for men, so surely slipping one to a partner could only improve any subsequent encounters? Such misuses of products can, as mentioned, cause health problems, and in cases of genuine psychosexual or physiological problems, not provide any ?cure?, leading to both parties feeling further betrayed (Tomlinson and Wright, 2004), not to mention the ethics of drugging a partner for sex.

Part of the problem is linked to how these drugs are marketed and reported. On the one hand they are presented as highly medical (you get them from your doctor), but are simultaneously presented as somehow benign (you can buy them on the Internet). It is hard to believe people would make the same choices with something like chemotherapy drugs, but the sex drugs, although seen as medical, are not recognised as dangerous.

Addressing this issue

Within debates on body modification, or the pharmaceutical adventures advocated by psychonauts and others perhaps it is restrictive or prudish to suggest that the sale and promotion of sex drugs and herbal supplements should be more closely legislated. Don?t people have the right to experience sexual pleasure? If healthy men want to take drugs to increase their penile performance who are we to judge?

There is a case for greater educational, campaigning and legislative controls because the current sales and promotions of sex drugs are not targeted at well-informed men who can decide whether or not to try a sex drug (Loe, 2004; Haiken, 2000; Marshall, 2002; Vares et al, 2003). Instead, men and their partners are being made to worry unnecessarily about sexual performance and are being given incorrect media messages about how sex and the body should work (Boynton, 2004b).

Increases in sex-positive education would help overcome many problems. More importantly, reassuring men that occasional sexual problems, worries about size, and relationship difficulties are to be expected could go a long way to reducing anxiety and the need to self-medicate. Many men I hear from are reassured once they are told that it is ?normal? not be able to get it up when they are stressed, have got drunk, or are having relationship problems; and that occasional problems with getting or keeping an erection are part of life, not the sign of a dreaded dysfunction. Re-educating men to relax and not think of their orgasm as the end of intercourse (a lesson learned from heterosexual porn), can assist in reducing premature ejaculation worries, as can helping men realise the average penis length is not 10 inches and counting (Singleton, 2003; Herring, 2003; Boynton, 2004a).

The flip side of this is that men do need information when they have a genuine problem. Persistent erectile dysfunction can be a sign of heart disease, pain during or after sex should never be ignored, nor should any sudden changes in the appearance or texture of the penis or testicles (Hopcroft, Martin, and Moulds, 2004). The problem is to persuade men to go and seek help promptly from the doctor for these conditions (Hopcroft et al, 2004) ? not to treat themselves with Internet purchases, or by simply ignoring the problem, as so commonly happens currently.

And we need to educate the public about sex. The current preoccupation with sex as a perfect performance would make even the most polished porn star feel inadequate. Journalists are ill equipped to evaluate sex research, and as sex becomes more commercialised, are overwhelmed with press releases from big-pharma (Loe, 2004), along with those who want to promote their sex toys, stores, books and other services - people who may want to sell a sex product, but who may have little or no skills to assist journalists explain sex to the public (Boynton 2004b,c).

Reassuring people that sex can change through the course of a relationship, that sometimes it?s okay not to feel like having sex, and giving them the tools to communicate their sexual desires, are all a vital component of helping people have happier sex lives. Currently the feeling I get from the men I hear from is not that they are ?sex mad?, or even as stereotypes might suggest, that they love sex. No, the message I?m getting loud and clear is that men feel very threatened, frightened, and inadequate. They see sex drugs as a way to overcome these feelings, without realising it was the reporting of such products, alongside poor-quality media sex coverage and a lack of sex education, that made them feel so bad to begin with. Focusing on the penis as the only source of male pleasure and preoccupation denies men the excitement of enjoying the rest of their body, from the emotional aspects of sex, and from sharing feelings, thoughts, and desires (Tiefer, 2004, p.192; Potts, 2002).

Challenging Big Pharma

Over the past few years, many sexologists, scholars, practitioners and activists have challenged the marketing strategies of big pharma (Moynihan, 2003; Tiefer, 2004; Loe, 2004; Vares et al, 2003). This has included questioning the way sex drugs are marketed, promoted and sold (Loe, 2004; Vares et al, 2003), discussing the training of medics provided by pharmaceutical companies (Moynihan, 2003), and challenging the way sexual functioning is being made into a disease or dysfunction (Moynihan, 2003; Tiefer, 2004; Loe, 2004). The campaign FSD-Alert (aimed at challenging the medicalisation of female sexual functioning - see http://www.fsd-alert.org) has been successfully working to help women. Men need support and encouragement to realise they too are being exploited, and enabled to campaign for their sexual rights.

Although sex can be a source of problems and anxieties for many, the current medicalising of sex means our discourses of men and sex in academia and the media are now limited to penis problems, and depressing epidemiological statistics of how many people are ?sexually dysfunctional? (further increasing our anxieties and a wish to be sexually ?normal?). Sex is described in the context of the body (Tiefer, 2004; Potts, Grace, Gavey and Vares, 2004), but not the body as a source of pleasure, wonder, or spirituality (Ogden, 1999). For ?the body? read ?biology?, or better still ?biomedicine?. The only alternative for men is porn, where of course there are never any sexual dysfunctions (Faust, 1981), but completely unrealistic portrayals of the penis (Herring, 2003).

It is in the interest of pharmaceutical companies to hype up the level of sexual dysfunctions and make us anxious about measuring up (Loe, 2004; Vares et al, 2003; Haiken, 2000). It is also in their interest to control how sexual functioning is defined, marketed and taught - making medics the foremost deliverers of healthcare relating to sex ? even though this group may not wish to be the providers of this service (Moser, 1999; Boynton, 2004d).

We can challenge the pharmaceutical companies in a number of ways. Indirectly we can show our resistance by re-educating men (see next section). We can also challenge them directly by critiquing their campaigns, informing the public of the current hijacking of sex advice and information by the pharmaceutical industry (Loe, 2004), and most importantly training and questioning journalists who leap upon pharmaceutical PR stories since they offer that heady mix of science, new developments, and sex (Tiefer, 2004; Moynihan, 2003; Loe, 2004; Boynton, 2004b).

As well as directly tackling pharmaceutical companies, there are other areas to target. Those stocking herbal supplements or other ?sex products? can and should be questioned (Thurairaja, Barrass and Persad 2004). Even the top internet search engines routinely allow non-tested sex products, or adverts to buy sex drugs in the sponsored links you see running up the side of any internet search you perform. Meaning people asking about a genuine sexual problem may select a not-so-genuine store or site from a link, believing them to be trustworthy. This is unacceptable. Pressure should be put upon search engines to ensure both they, and the sites they index, are reputable and reliable.

What we can do for men and their partners

There are several things practitioners, writers, and media workers can do. We can challenge the companies who are promoting sex drugs, and affiliated groups who do not inform the public how to use medications appropriately and safely. More importantly we can campaign for better global sex education, so people learn about sex and relationships in a positive, but accurate manner. Teaching people critical reading skills (Tiefer, 2004) so they can question media messages, and specifically those about sex and relationships is vital, and ensuring those who offer sex and relationship advice are adequately qualified for the task is equally important (Boynton, 2004b,c). Given that men may have missed out on sex advice and education, offering services to provide men with a safe space to ask questions about sex may be very useful ? websites, chat rooms, or drop-in services at times that suit men and their partners could mean men are able to understand their sex lives better.

Finally we can widen the way we define sex, permitting people to see it in terms of pleasure, not just performance. Of course in many parts of the world this utopian ideal is not yet achievable, but it is possible to disabuse men of the penis myths they may currently be buying into, so they don?t feel that ?size matters?, that they should last for hours, come in pints, and worry their foreskin is ?too floppy? (just to reflect a few of the questions I had in my postbag this week!).

In a climate where sex is discussed in increasingly medical terms, and the role of culture, media, history, place, gender and sexuality is largely missed out, we need to reintroduce sex in as wide a definition possible, and help men believe that they are defined by a whole lot more than their dicks.

 

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