|Title:||Imagining Impotence in America: From Men's Deeds to Men's Minds to Viagra|
|Publication Info:||Ann Arbor, MI: MPublishing, University of Michigan Library
This work is protected by copyright and may be linked to without seeking permission. Permission must be received for subsequent distribution in print or electronically. Please contact email@example.com for more information.
Imagining Impotence in America: From Men's Deeds to Men's Minds to Viagra
vol. 17, no. 1, 2008
Issue title: New Directions in Medical Anthropology
Imagining Impotence in America: From Men’s Deeds to Men’s Minds to Viagra
Department of Anthropology, University of Michigan
Introduction: constructions of impotence
Penile erections, and their occasional failure to meet ideal standards, may seem timeless. However, the nature of those standards, as well as understandings about, embodiments of, and even the physical factors underlying erections and their lack, are not. While less–than–ideal erections are currently understood within the medical framework of erectile dysfunction, an ostensibly objective pathology treatable through medical means, this way of understanding non–normative erections is culturally and historically contingent. In the United States over the last century, non–normative erections have been hegemonically defined as medical yet behaviorally based conditions, then as psychological problems, and now as an entirely biomedical condition. Each of these understandings of impotence has been shaped by competing medical and mental health specialties that had economic and professional stakes in defining and offering cures for the condition. Pharmaceutical corporations’ involvement in shaping and treating erectile dysfunction has also recently shifted men’s experience of impotence from private pathology to inclusion in a mass-marketed medical experience.
Each way of conceptualizing non–normative erections has deeply affected men’s lives and their senses of embodied masculinity. A key similarity between the various conceptions of impotence is their strict delineation of normal and abnormal erections and sexual practice; such boundaries have been central to the constitution of hegemonic masculinities. Each construction of impotence has marked certain men as behaviorally, psychologically, or physically deviant, and provided hope for attaining ideal erection and masculinity to some men while denying it to others. While the recent shift from psychological to biological explanations for less–than–ideal erections provides medical aid and support to many men, it simultaneously obscures the sociocultural aspects of impotence, most centrally the role of the cultural in its definition and construction as a disease, as well as in the construction of masculinity itself.
In this paper, I use the professional medical and psychological literature to trace shifts between the three hegemonic understandings of impotence that held sway in the United States between the late 1800s and the present: impotence as a behaviorally based medical condition, as a symptom of psychological distress, and finally as the biomedical pathology “erectile dysfunction.” I end with a description of current social constructionist scholarship on today’s medicalized understanding of impotence, and discuss further possibilities for the cross-cultural study of impotence and masculinity informed by the history of impotence understandings in the United States.
Turn-of-the-century medical discourse
Modern medical narratives generally figure biomedical understanding of erectile dysfunction as revolutionary by asserting that understandings of impotence have progressed teleologically from incorrect psychological ideas to correct medical ones. To make this argument, they tend to ignore the historical period before psychoanalysis in which impotence was viewed as a medical condition, albeit a very different one from erectile dysfunction. Bringing previous medical understandings of impotence back into the picture demonstrates that ideas of impotence in the U.S. have not in fact progressed linearly, and that the differences between turn-of-the-century medical ideas and modern ones illustrate not technological progress, but the embeddedness of medical thinking in broader cultural discourses. While physiological understandings of erections are relatively similar in medical texts of the late 1800s and today, theories about the etiology of impotence betray quite different cultural contexts that produced key distinctions in understandings and embodiments of impotence.
The authoritative medical text of impotence’s previous biomedical incarnation in America was Dr. Samuel W. Gross’s 1881 book, A Practical Treatise on Impotence, Sterility, and Allied Disorders of the Male Sexual Organs. Gross grounded his work in fertility promotion, urging doctors to identify and treat disorders of the male genitalia before performing surgery on wives in “unfruitful marriages” (1881:viii). Acknowledging that “erection may fail or cease under the influence of excitement, depressing, or other emotions or mental preoccupation, is a fact with which everyone is familiar,” Gross focused on “inability to copulate or perform the sexual act” that he saw as medically grounded (1881:59, viii). Gross argued that urethral lesions, or “strictures,” were the most common cause of impotence, and that they usually had a behavioral etiology (1881:viii). For Gross, socially inappropriate sexual conduct, including masturbation, “sexual excess,” stimulation that did not lead to ejaculation, and gonorrhea (a consequence of inappropriate sexual partnering) physically damaged the urethra, which then had to be unblocked with a series of implements (1881:21, 28). Gross also recommended “moral treatment” to ensure that the patient would cease the behavior that had led to his stricture (1881:41). While Gross recognized that impotence could be temporarily caused by mental stress, or could occasionally result from congenital physical defects or nerve damage, he characterized it largely as a physical problem caused by excessive or morally questionable sexual activity.
Later works employed Gross’s understanding of impotence while elaborating on the ramifications of sexual incontinence. A doctor writing in 1897 portrayed the physical and behavioral as intimately linked, noting that, “true [physical] impotence...will always present the history of masturbation” (King 1897:68). The mental served as a compounding factor in the behavioral etiology of impotence: masturbation and improper seminal emissions “have not only weakened the organs, but have first suggested the fear of impotence in the mind of the patient, which, when dwelt upon and the fear confirmed by failure, had produced the physical state” (King 1897:77). Impotence was not considered to be a condition of sexual deficiency, but of excess; too much sex, or the morally and physically incorrect kind of sex, physically damages a man’s genitals.
Doctors, then as now, viewed impotence as a profoundly distressing medical condition, the stress of which could exacerbate the physical problem. Retired Army Surgeon General William A. Hammond wrote in 1883 that, “no cause is...so destructive to the happiness of the average man as the loss of his virile power...his peace of mind is interfered with to an extent that no other disease is capable of causing” (1883:93). While physicians did not view emotional distress as the cause of true impotence, which they differentiated from situational impotence occurring when “the mind is intensely engaged with engrossing subjects of a character foreign to the animal passion,” some did expand on the category of “psychical” (psychological) impotence, although in a behaviorally focused way very different from the psychoanalytic discourse that would later take hold (Hammond 1883:93).
Hammond (1883) spent a large portion of his book detailing case studies that illustrate the ‘perversions’ described by Kraft-Ebbing, explaining how inverts, shoe fetishists, and other practitioners of deviant behavior were impotent by virtue of failure to be aroused by heterosexual intercourse. For Hammond, the mental phenomenon of perversion was inextricably linked to the physical sexual behavior understood to cause impotence. Hammond’s prurient catalogue of mental impotencies demonstrates how the condition was understood as a medical symptom linked with varying degrees of behavioral deviance. He highlighted this point by including the purportedly factual case study of a French shepherd who masturbated so excessively and with such dangerously unorthodox objects that he eventually split his penis into two (Hammond 1883:95). Hammond used such cases to argue for sexual continence by threatening permanent physical damage (as well as, quite probably, to encourage book sales).
The cures proposed for impotence in 19th century America combined the medical, the behavioral, and the moral. Elaborating on Gross’s excision of strictures, later doctors suggested probing, electrocautery, hydrotherapy, and surgical removal of “all sources of irritation” including tight foreskins and “irritable” rectums. Doctors also prescribed rest, abstinence, and eschewal of even “exciting books, like detective stories,” and urged sexual moderation following the cure (King 1897:106–126). Authors also advised their fellow doctors to “quiet the nervous fears of the patient” in order to allay worries that could produce transient impotence (King 1897:106).
A shift to psychological etiology
The understanding of impotence as a medical problem resulting from inappropriate sexual behavior was supplanted by a psychological etiology in the first decades of the 1900s. While specific behaviors were previously understood to create physical damage that led to impotence, the popularization of psychoanalysis engendered conceptions of impotence as a symptom of psychological distress. American popularizations of Freudian theory and the much–discussed writings of Havelock Ellis cast the desire for sex not as a physically dangerous behavior, but an innate psychological drive that should be gratified (albeit in very specific, socially sanctioned ways) (D’Emilio and Freedman 1997:224). This conceptual turn superseded the medical discourse that had presented sex as an optional behavior to be performed in rational moderation, paving the way for psychoanalytic understandings of impotence to become hegemonic.
As the crystallizing fields of sexology and psychoanalysis made the sex drive a positive and naturalized concept, sex came to be understood in part as a social entity, particularly important in cementing male–female relations. More centrally, though, sex began to be seen as definitive of the individual psychological self (D’Emilio and Freedman 1997). This understanding spawned a typology of selves; for instance, people who engaged in same-sex sexuality were now not individuals who performed a certain behavior, but homosexuals, specific and unique types of people (D’Emilio and Freedman 1997:225). Impotence, though not a definitional element of character, likewise became a deeply rooted element of the psyche rather than a behavioral condition.
A 1913 practical handbook of mental diseases designed for medical students and practicing doctors demonstrated the initial changes in the medical understanding of impotence produced by reconciliation of medicine and psychoanalysis. “Sexual disturbances,” including “irritable weakness,” the weak erectile response to local friction, were framed as “part and parcel” of general neurasthenia caused by physical and mental exhaustion (Dercum 1913:173). The sexual symptoms of this hybrid mental and physical condition became psychologically salient precisely because sex had become more central to selfhood; while they were physically no different than nervous stomach symptoms, because sexual disturbances “are sexual, their importance becomes exaggerated in the patient’s mind and their significance misinterpreted” (Dercum 1913:173). Neurasthenic sexual disturbances were not couched in sexual behavior as earlier doctors believed: “the physical consequences of masturbation or modifications of the sexual act...are not as grave or baneful as they are commonly supposed to be...the effect of a sexual transgression is not so much physical as mental” (Dercum 1913:181).
Using the analytic language of repression, the author explained that patients dwelled psychologically on their sexual symptoms, brooding themselves into an exhausted, neurasthenic state and reinforcing their physical condition. By virtue of their centrality to new models of the self, sexual problems necessarily had psychological consequences that led to physical symptoms and even influenced symptoms of non–sexual etiology. This theory directly refuted the previous idea that sexual behavior itself caused impotence: “Because of the peculiar relation which the sexual functions bear to the moral and social life of the individual, the patient is apt to [wrongly] ascribe his nervous exhaustion, with its train of depressing symptoms, to...masturbation...or other sexual misconduct” (Dercum 1913:173).
Purely psychoanalytic explanations of impotence soon became dominant, and in the first decades of the 1900s, even hybrid medico–analytic understandings defined impotence as a largely mental phenomenon, with the exception of rare and obvious cases of physical deformity, injury or nerve damage. While different branches of psychoanalysis and psychiatry varied in their specific understandings of impotence, consensus held that a talking cure aimed at the psychological processes and unconscious conflicts underlying impotence, rather than physical medical intervention, was the appropriate treatment. The concept of anxiety, which became central to Freud’s developmental theories with the 1926 publication of Inhibitions, Symptoms, and Anxiety, was broadly adopted as a key psychological factor in impotence, and remains so today in understandings of “performance anxiety.” Alfred Adler’s concept of the inferiority complex, later transmuted into the discourse of “self-esteem,” also became important to thinking about impotence. The inferiority complex became a central topic of conversation in the 1920s and 1930s, and was central to the marketing of cosmetics and the new field of cosmetic surgery in the burgeoning U.S. consumer culture (Haiken 2000). This discourse would also be employed in the marketing of sexuopharmaceuticals after the turn to biomedical understandings of impotence.
Wilhelm Stekel’s two-volume work Impotence in the Male (1959) was influential in American psychoanalytic treatment of sexual disorders, and goes further than many analytic perspectives in its sweeping implication of the social in the psychological problems that underlie impotence. Initially published in 1927 and reprinted through 1959, Impotence in the Male asserted that “impotence is a social disorder” (Stekel 1959:12). Stekel argued, in quite florid language, that institutions like marriage, war, and religion restrain and repress men in ways that foster psychic impotence. “Civilized” society, for Stekel, forces men into psychic imbalance: “The hypertrophic cultivation of the ‘will-to-power’ has brought in its wake a situation wherein the majority of civilized men have neither time nor energy left to love” (1959:5).
Stekel cast impotence as purely psychosocial, explicitly refuting the earlier medical idea that sexually incontinent behavior caused impotence. He wrote that men came to him believing that “sins of their youth” were to blame, while in reality “analysis will always disclose the psychic origin of this impotency” (Stekel 1959:46). Furthermore, all impotence was “psychic impotence,” and even those occasional cases involving physical problems were largely of a psychological nature: “In rare cases of psychic impotence, the psychic inadequacy to love goes hand in hand with a physical one” (Stekel 1959:10). Stekel figured impotence as a psychosocial tragedy spawned by civilization gone awry, that, while rooted in both the social and the mental, had clear consequences for individual self-definition. “Impotence impresses its stamp upon a man’s whole personality. He loses his feeling of self-regard, his energy, his whole pleasure in productive activity. He has the bitter conviction: You are not a man!” (Stekel 1959:7).
The 1959 preface to Impotence in the Male, written by psychiatrist Emil A. Gutheil, extols the currency of Stekel’s insights. Calling only for “larger statistical samples” to validate Stekel’s claims and case study descriptions with more scientific support, Gutheil says that Stekel’s concept of impotence as “one of the cultural diseases of our age...[which] will remain the inalienable property of scientific psychiatry” (1959:iii). Gutheil also re-asserts the idea that “practically all cases of impotence can be traced to psychic inhibitions and will respond to rational psychotherapy” (1959:iii). However, his emphasis on the language of science is indicative of a broader cultural trend towards scientific inquiry posed as objective and rational. The allure of scientific advancement, rooted in the advent of technologies like television, the space race and the multiplicity of new home appliances that fueled a now–powerful consumer culture, as well as the currency of teleological narratives of progress, underlay a backlash against psychoanalysis in the 1960s.
The backlash against analysis
The backlash against psychoanalysis was fueled by trends within the discipline. Stekel’s indictment of society as a whole is more characteristic of early psychoanalytic discourse than later. While culture and the social realm were often cited as the sources of psychological conflict in early psychoanalytic work (Freud’s Totem and Taboo is a prime example), through the 1940s, 1950s and early 1960s, psychoanalysis shifted to promoting a healthy adjustment to unproblematized social norms, a move embedded in the focus on normativity in post-war American culture (Connell 1995:11). This psychoanalytic focus on normalization, created in but also constitutive of a cultural focus on fact–based science, certainly laid the groundwork for the concept of the universal normative body on which biomedical disease models of impotence would later rely.
Empirical sexological work also contributed to this shift toward “objective” science. Zoologist Alfred Kinsey’s Sexual Behavior in the Human Male (1948), an encyclopedic study of over 6000 American men’s self-reported sexual behaviors and experiences, played a pivotal role in the shift from analytic to biomedical understandings of sexuality. While Kinsey stated that his work would be useful to physicians, psychiatrists, and psychoanalysts alike, his understanding of sexuality as a concrete and quantifiable entity engendered a new type of scientific approach to the topic. Kinsey’s claim to present “data about sex which would represent an accumulation of scientific fact completely divorced from questions of moral value and social custom” (1948:3) engendered the notion that sex could be understood as an objective entity disconnected from mind or culture.
Kinsey found that impotence played a minor role in American men’s sexual lives. While men commonly reported transitory impotence that they understood to be caused by emotional or mental preoccupation, impotence as an ongoing condition was reported only rarely by young men, though it was generally understood to be and experienced as a common outcome of old age (Kinsey 1948:237). Aside from an argument against the older and still-lingering medical concept of impotence as “the penalty for excessive sexual exercise in youth,” Kinsey devoted a section of less than four pages, headed “Old Age and Impotence,” to the topic, which presented impotence as a natural consequence of aging (1948:238). However, Kinsey’s provision of the rationale for objectively scientific understandings of sexuality would be central to the later biomedicalization of impotence that radically altered understandings of the condition.
Drawing from assertions that conditions dealt with by psychoanalysis could be understood though objective science, a cultural narrative of psychoanalysis as unscientific, self-indulgent, urban, and slightly morally questionable arose in the mid-1960s and heavily influenced popular understandings of impotence. Psychoanalysis itself was figured as emasculating, in that it made men dependent on everlasting therapies associated with talk rather than action, did not make linear progress, and promised no immediate and scientifically verifiable cure. An excellent example of backlash literature is Dr. Edwin Hirsch’s 1966 Impotence and Frigidity, which promotes Hirsch’s quack yet results–oriented science of “psychomatics” over psychoanalysis. In chapters such as “Why Psychoanalysis has Failed in the Treatment of Psychological Impotence,” Hirsch figures psychoanalysis as not only an ineffective cure, but as a cause of male impotence, insofar as it, along with men’s passive acceptance of women’s liberation, contributed to a culture of wishy-washy men (1966:57). A statement in the chapter on “The Emasculation of the American Male” sums up the idea that psychoanalysis has turned virile men impotent:
Unscientific logic is largely responsible for the mistaken idea that 99 percent of impotence is due to psychic causes...the diagnosis of ‘psychic impotence’ is readily pinned onto the man who agrees that his flesh is free of disease. Powerful as is such reasoning, the ‘paralyzed’ or ‘dead’ phallus is the end result of psychomaterialistic factors which may be readily recognized. [Hirsh 1966:61]
This passage demonstrates how the backlash against psychoanalysis began to engender a conceptual turn against psychological etiologies for impotence.
Back to the body
Medical approaches to “self-esteem” issues, such as cosmetic surgery, men’s hair grafting, and other forms of “psychiatry with a scalpel” were well-established and growing ever more profitable at the time of this backlash (Haiken 2000:394). A dramatic post-war proliferation of doctors and subsequent competition between medical specialties, together with the nascent medicalization of ‘self-esteem’ issues, paved the way for the medicalization of impotence. While psychoanalytic theories of the etiology of impotence remained entrenched, urologists began to assert that the condition fell within their realm of expertise, since, no matter what its etiology, it physically affected the uro-genital tract.
The 1959 book Sexual Impotence in the Male, written by a professor of urology, was an explicit call to action for the medical specialty to claim impotence as its territory. Author Leonard Wershub wrote that, “the object of the book is to impress the physician with the need of greater interest in the subject of sexual impotence in the male” (1959:vii). Wershub polled urologists to discover what proportion of impotence they diagnosed as physical versus mental, and found that they identified only about 10% of impotence as physical in nature. This estimate reflected the enculturation of urologists of the time in the psychoanalytically oriented discourse of psychological impotence.
Although he subscribed to the prevailing contemporary understanding of impotence as largely mental, Wershub asserted that the condition nevertheless fell with the “urologist’s domain” (1959:5). He elaborated on all the possible organic and “quasi-organic” causes of impotence that urologists could treat medically, and exhorted urologists to train themselves to treat the 90% of impotent men who were psychologically afflicted (Wershub 1959). Wershub stated:
I do not believe that even when the urologist has ruled out all possible organic pathology, the psychiatrist should then take over...the urologist...can evaluate critically the role of organic impotence and non-organic (functional) impotence without resort to elaborate psychiatric methods which are time consuming and expensive. [1959:7]
He argued that urologists must familiarize themselves with the religious, ethical, and moral problems linked to impotence, have open conversations with their patients, and ultimately “convince such a patient that he is not impotent” (Wershub 1959:79). Since “the effects of psychic and emotional factors on illness are being more and more recognized,” Wershub exhorted urologists to incorporate brief and non–analytic versions of the talking cure into their practice (1959:5).
By the late 1960s, medical books still couched psychologically grounded understandings of impotence in ever more biomedical approaches. Common tactics included adopting Wershub’s renaming of “psychic impotence” as “functional impotence” in order to sever the condition’s ties with psychoanalysis, and elaborating on the physiological aspects of erection. For example, a 1968 text written by a psychiatrist included the following disclaimer: “although in a small minority of cases of impotence the condition may be symptomatic of a neuro–endocrinological disease, in the vast majority of cases the condition is ‘functional’” (Johnson 1968:22). The author spent much of the book engaging in a detailed review of the neural and endocrine bases of erectile function, asserting that physical causes of impotence should be sought in patients without “a neurotic constitution and/or recent relevant psychic experiences” (Johnson 1968:28). While writing within a hegemonic understanding of impotence as largely psychological, the author participated in the emerging shift to medical characterizations of impotence. In this context, the social was now figured as the backdrop for a biological drama rather than the site of a psychological problem, as demonstrated by the assertion that “sexual behavior is learnt and is organized within a genetically determined neuro-endocrinal framework” (Johnson 1968:18).
Shifting psychological models
While medicalization of impotence was a central effect of the backlash against psychoanalysis, the backlash also engendered a related shift within the field of psychological understandings of impotence from psychoanalytic to behavioral approaches. The turn to scientific objectivism that enabled medical doctors to stake claims on impotence was in part fueled by the psychologically oriented work of William H. Masters and Virginia E. Johnson, heirs of Kinsey in their focus on gathering scientifically ‘objective’ sexual data. Masters and Johnson led the post–backlash shift in psychological understandings of impotence with a new program of behavioral sex therapy presented in their 1970 book Human Sexual Inadequacy. They argued that “impotence is not a naturally occurring phenomenon” (Masters and Johnson 1970:187). For them, impotence was psychosocial rather than physical, although physical factors such as premature ejaculation or loss of an erection could plant seeds of doubt in a man’s mind that engendered psychological impotence (Masters and Johnson 1970:163). Dismissing the nascent medical claims over impotence, they argued that while “every sexually inadequate male lunges toward any potential physical excuse for sexual malfunction,” even when physical factors affect male sexual response, they are almost always secondary to psychological factors (Masters and Johnson 1970:187). Importantly, though, Masters and Johnson introduced the idea of the biologically objective “sexual response cycle,” which promoted the concept of a universal, normal, and biomedically intelligible body which would contribute to the medicalization of impotence.
In the wake of complaints about the lengthy and diffuse nature of psychoanalysis, Masters and Johnson promoted a systematic and results–based program of behavioral therapy centered on sexual exercises for couples. While shades of the psychoanalytic model of impotence remained in their understanding of the etiology of sexual dysfunction, they expanded on social rather than wholly individual psychological discourses. They argued that while sexual problems have been thought to originate in family dynamics, “the natural social associations of the adolescent as he ventures from his security base” are also key (Masters and Johnson 1970:137). They figured anxiety as the central factor in sexual dysfunction, and argued that insecurity was the key element of marital sexual dysfunction (Masters and Johnson 1970:9).
Almost all the sex therapies that have followed Masters and Johnson make use of their basic concept of sexual dysfunction and their program of treatment. However, later iterations of these ideas reflected their embeddedness within expanding medical discourses of erectile dysfunction. For example, a 1979 book on sex therapy expanded on Masters and Johnson’s concept of anxiety as a key problem, but couched it in biology. The book began, like medical books on the topic, with a discussion of the physiology of sexual response. The author argued that, at base, all sexual dysfunctions “are caused by a single factor: anxiety” (Kaplan 1979:24). While drawing on psychoanalytic language to note that sexually related anxiety can have oedipal symptoms, Helen Singer Kaplan cast anxiety as an ultimately biological process: “The physiological concomitants of anxiety are always the same, no matter what its source” (1979:24).
As medical models of impotence grew hegemonic, later books on sex therapy acknowledged the new understanding of erectile dysfunction as usually physical, while asserting that it also had psychological ramifications. All About Sex Therapy, written in 1983, stated that problems with erection are caused by “a combination of physical and psychological factors...the influence of physical factors on erections can be a matter of degree” (Kilman and Mills 1983:91). This book, while promoting behavioral therapy and noting that medical intervention may not solve all a man’s problems, discussed the cost and availability of penile prostheses and noted that men are largely happy with them (Kilman and Mills 1983). A 1981 book written by the founder of the American Association of Sex Educators, Counselors, and Therapists stated that good sex therapies must begin with a medical examination by a physician, be short-term, diminish anxiety, and provide missing sexual knowledge (Schiller 1981:46). Throughout the 1980s and 1990s, in the context of a tightening medical hold on the topic of erectile dysfunction and increasing control over patient use of services by managed-care health plans that would not pay for lengthy psychotherapies, sex therapists promoted brief treatments centered around education and removal of anxiety and misinformation, and claimed legitimacy by including biomedical descriptions of sexual response in their work.
The medicalization of impotence
Development of a series of biomedical treatments for impotence, beginning in the early 1970s, enabled physicians to stake a stronger claim on the condition by offering unique physical treatments; these medical interventions fueled the shift from conceptions of impotence as a largely psychological problem to a largely physical one. The introduction of penile implants in 1973, the vacuum pump in 1983, pharmacological penile injections in 1995 (and similarly acting urethral suppositories in 1997), and finally oral drugs beginning with Viagra in 1998 encouraged the medicalization of impotence as the pathological physical entity erectile dysfunction (Katzenstein 2001:7). The advent of these treatments enabled the institutionalization of biomedical impotence treatment; for example, the 1982 founding of the International Society for Impotence Research coincided with the development of injectible pharmaceuticals for erection. The American Urological Association’s 1993 assertion that “sexual dysfunction in the male is a disease entity” cemented the medical professionalization of impotence treatment (Tiefer 1995:160). The advent and marketing of new technologies and professional entities also fueled a flood of popular press articles that introduced the new term “erectile dysfunction” to readers, popularizing it as a biomedical concern in the context of presenting new scientific information to readers.
Medical texts on impotence/erectile dysfunction (ED) looked quite similar throughout the 1980s and 1990s. Written in highly technical medical language, these books invariably began with the physiology of erection or sexual response, locating impotence/ED firmly in the body. Some books went so far into the scientific realm as to combine laboratory animal and human data on erectile function, figuring the human mind only as a variable: “Human data will be emphasized where available, as the human psyche as well as certain anatomic variations make extrapolation of animal data to man very difficult in some cases” (Jonas and Thon 1991:3). Authors limited discussion of the mental aspects of erectile dysfunction to an obligatory chapter or two on behavioral or sex therapy, which generally called for interdisciplinary treatment in which the secondary psychological ramifications of the physical problem of impotence could be treated.
The expansion of physicians’ roles in treating erectile dysfunction was a key topic in this literature. In a 1983 work, which appeared early on in the advent of impotence-related technologies, a urologist wrote that:
the emergence of the urologist as the primary coordinator of care for the patient with sexual dysfunction, whether the cause of that dysfunction is an organic, a psychogenic, or as sometimes occurs, a combined one. In one sense, this is merely a reaffirmation of the historical role of the urologist as a specialist in diseases of the male genital tract. In another sense, it recognized the importance that prosthetic surgery has recently assumed in the treatment of impotence. [Krane et al. 1983:xiii]
Later books noted that the series of medical treatments available enabled urologists to invariably offer men with erectile dysfunction a biomedical treatment. Importantly, authors discussed medical treatments as appropriate for dysfunction of any etiology. A urologist writing in 1991 noted that since “almost all patients with psychogenic impotence or erectile failure due to neurological cause will respond to ICP [penile injection]; it is a valuable outpatient or office procedure” (Kirby, et al. 1991:143).
The increasing ubiquity of medical models of and treatments for impotence entailed a shift in the statistics offered about the prevalence and nature of the condition. While Kinsey understood erectile dysfunction in the non–elderly to be a relatively insignificant problem, doctors of the 1980s, 1990s, and today see it as an epidemic, a shift clearly influenced by the more general pathologization of physical aging in the context of medical consumer culture and drug company marketing campaigns. A 1991 book estimated that erectile dysfunction affects one in ten men, while another from the same year argued that the older estimate that 90–95% of impotence was psychologically grounded was not valid; recent medical studies showed organic factors in 20–85% of cases and (often secondary) psychological factors in 38–74% (Kirby, et al. 1991; Jonas, 199:210). A book about Viagra sponsored by its manufacturer, Pfizer, stated that 30 million men have erectile dysfunction, which “to some degree affects more than half of all men aged 40 to 70” (Katzenstein 2001:3). Furthermore, “it’s now known that some 80% of ED cases stem from physical problems...and for the 20% of men whose ED results from anxiety or some other psychological problem: Try telling them that their anguish is less intense than if their problem had arisen from a physical cause!” (Katzenstein 2001:50). Erectile dysfunction was presented as a medical epidemic that deserved to be treated, even for the few cases of psychogenic ED, with medical technology.
A specific type of narrative about the history of erectile dysfunction treatment became ubiquitous in the impotence-related medical literature of the past few decades. These books almost always discuss earlier “misconceptions” about the psychological nature of impotence, and contrast prior psychological approaches with effective and technologically advanced medical therapies. For example, a 1991 author stated:
Over the last decade there has been phenomenal progress—gone forever is the Freudian attribution of erectile dysfunction exclusively to psychogenic factors...consistent male erectile dysfunction is more likely than not to be the consequence of primary organic pathology...This modern concept has been associated with advances in the field, in the areas of basic research, diagnostic evaluation and therapeutic options. [Kirby et al. 1991;v]
Although a few very recent works take a more moderate tone, noting the shift from ideas of a largely psychogenic to largely physical nature, and asserting that “erectile failure is commonly due to a complex interaction between psychological and physical problems,” most works characterize psychological ideas of impotence as misconceptions (Eardley and Krishna 2003:2).
Recently, under the influence of marketing campaigns for oral pharmaceuticals for erectile dysfunction, the focus on medical treatment has shifted from urologists to primary care physicians. A 2003 book written by urologists notes that Viagra has radically changed the way erectile dysfunction is treated, since more, younger, and physically healthier men are seeking treatment from non–specialist physicians, who are rapidly training themselves to administer the appropriate drugs (Eardley and Krishna 2003:71). A Pfizer-produced book on Viagra includes tips for primary care doctors about prescribing Viagra, and specifically encourages doctors to broach the topic of ED with male patients visiting for other reasons. This book even includes a list of questions that doctors can ask to start these conversations, including, “Do you want to talk about Viagra?” “Do you find that your erections are not as firm as you would like?” and “Many of my male patients who smoke (or have diabetes or take antihypertensive drugs, etc.) have difficulty with erections—how about you?” (Katzenstein 2001:59).
This history of changing understandings of impotence, and its recent reconfiguration as the medical pathology erectile dysfunction, show that what is currently considered a concrete biological entity is a cultural construction embedded in contingent biology. While an elderly man with infrequent erections was considered medically normal through the 1950s, he now has a disease condition. The ‘invert’ of the 1890s, psychically impotent because he could not become erect through arousal with a woman, is now medically normal if he can get consistent, rigid erections with a man. Despite their historical contingency, these shifting cultural classifications are lived as truths, and produce phenomenologically real, deeply felt and often agonizing lived experience. Furthermore, different conceptions of impotence produce different mental effects and promote specific body practices (such as medication, surgery, and specific sexual practices) that in turn concretely influence the physical event of erection. Ideas of impotence can not only shape thinking about and the social meaning of erections, but influence their bodily expression and the biopractices used to mediate them.
Erectile dysfunction in the U.S. is thus lived today as a medical epidemic, in which more and more, younger and younger men are driven by the mass marketing of sexuopharmaceuticals to seek classification within and medical treatment for the pathology. Erectile dysfunction as a disease taps into the construction and embodiment of gender in a basic way, and a group of scholars have studied the lived experience, cultural construction, and social consequences of erectile dysfunction treatment in the Anglophone West, identifying and critiquing gendered medical systems that simultaneously construct and confine.
Sexologist Leonore Tiefer inaugurated the social study of medicalized impotence in the mid-1980s, identifying the medicalization of male sexuality as a growing phenomenon (1986). Tiefer sought to denaturalize sex and sexual pathology, using a social constructionist approach to analyze the social consequences of men’s medical sexual enhancement in the pre–Viagra world (1995). She critically examined the economic incentives for physicians and mass media to promote medicalization of sexual dysfunction, as well as the active role that individuals play in medicalization. Tiefer wrote:
Increasing importance of lifelong sexual activity in personal life, the insatiability of mass media for appropriate sexual topics, the expansionist needs of specialty medicine and new medical technology, and the highly demanding male sexual script...interact to produce a medicalization of male sexuality and sexual impotence that limits many men even as it offers new options and hope to others. [1995:141]
Tiefer argued that medicalized erections reinforce phallocentric practices and understandings of sexuality, since focus on the erection as central to sex makes it seem as if becoming erect is all that counts. Such phallocentrism limits men by circumscribing their ideas of sex, yet also “operates to preserve male power” more generally by excluding and subordinating women’s sexual contributions (Tiefer 1994:364). Ironically, Tiefer herself proposed that the NIH officially replace the term ‘impotence’ with ‘erectile dysfunction’ as a destigmatization measure; this shift in terminology has instead been co-opted to cement the shift to a purely biomedical understanding of non–normative erections, and has been particularly useful to marketers of new sexuopharmaceuticals (1995:161).
Following the advent of Viagra, a small but rich body of scholarship has built on Tiefer’s insights to document the social consequences of the ED epidemic in the Anglophone West. One key focus has been the growth and ramifications of the ED industry, which Barbara Marshall argues valorizes and then sells the opportunity to perform phallocentric, heteronormative embodied masculinity (2002:138). Content analyses of ED drug marketing have demonstrated this process, showing how marketing images pose the drugs as vehicles for hegemonic masculinity and ideal heterosexual romance (Baglia 2005; Wienke 2006). Elizabeth Haiken (2000), a historian of cosmetic surgery, has located ED treatment in the context of cosmetic medical interventions marketed to allay masculine anxiety, such as penile lengthening surgery, male–oriented cosmetic surgery, and surgical and pharmacological treatments for hair loss.
Other researchers have interviewed male ED drug users and their sexual partners to shed light on the social ramifications of ED treatment, finding that these medical treatments are often used as ‘masculinity pills,’ but are sometimes subsequently rejected as users craft new, less phallocentric or mechanistic ideals of masculinity (Loe 2004, 2006:31). For instance, Annie Potts interviewed Viagra–takers and their partners in New Zealand, finding great diversity in people’s experiences of both erectile dysfunction and its medical treatment; some completely supported, and others wholly rejected “the idea that erectile difficulties were ‘abnormal’ or ‘dysfunctional’” (2004c:492). Potts argues that individuals’ complex stories challenge the medical model of impotence, as well as the idea that sexual difficulties are concrete disease entities that can unproblematically be fixed with the proper medical treatment. They note that, “there is no standard experience of a ‘functional’ erection, even less so a ‘dysfunctional’ erection” (Potts 2004c:497). Studies of prostate– cancer–related sexual difficulty and its consequences for individuals’ performances of masculinity have come to similar conclusions (e.g., Fergus et al. 2002; Gray et al. 2002; Oliffe 2005).
More theoretical analyses argue that ‘Viagra culture’ makes sense within a broader Western tradition that understands bodies, particularly those infused with masculinity, as machines (Loe 2004; Mamo and Fishman 2001; Marshall 2002; Potts 2000; Tiefer 2006). Many such studies incorporate critical examinations of technoscience and approaches like cyborg theory to frame medical mediation of sexual function as an example of the broader trend of technological intervention influencing possibilities of and ideas about the capacities and ideal functions of gendered bodies (Croissant 2006; Potts 2004a, 2004b, 2005). These discussions of technologized embodiment are often contextualized in the broader pathologization of aging that shapes medicine, bodily norms, and social expectations today (Marshall 2006; Marshall and Katz 2002).
This body of work thoroughly analyzes the ways that particular strains of western thought—understandings of bodies as machines, mechanistic and phallocentric hegemonic masculinity, and widespread medicalization of and technoscientific mediation of a growing list of bodily states deemed non-normative—enabled the popularization of ED as a diagnosis and ED treatment as a medication for masculinity. Many of these works also demonstrate the agency of individual ED patients and their sexual partners in negotiating, adopting, or rejecting ideals of masculinity that require pharmacological mediation. However, these analyses share particular boundaries. Likely because of the difficulty of finding ED-treatment users willing to participate in interviews (see Loe 2004), these studies rely on a relatively homogenous group of men categorized only as “Viagra users”, and are thus unable to make comparisons based on race, class, sexuality, location, or other sociodemographic variables. For instance, only one study has attempted to examine the link between economic status and erectile dysfunction; it found that men of lower socioeconomic status were more prone to erectile dysfunction, but could not explain why (Aytac 2000:777). This state of affairs falls problematically into line with the biomedical models of impotence’s erasure of links between the embodiment of masculinity in sexual performance and broader socioeconomic, political, and historical trends.
Social studies of ED have been limited almost completely to the Anglophone West. Researching the relationship of ED treatment and masculinity outside this narrow cultural and geographic scope, in contexts shaped by diverse traditions of medicine and masculinity, has the potential to shed new light on dialectic relationships between technoscience and gender. For instance, medical anthropologist Marcia Inhorn encountered impotence in her ethnographic work on infertility and in vitro fertilization (IVF) in Egypt. Inhorn presents impotence as a salient but largely unaddressed fertility problem, arguing that IVF doctors often fail to realize that “infertility may be a proxy for ‘troubled sex,’ and that this problem is ignored to the extent that wives of impotent husbands undergo fertility treatment rather than reveal the condition” and cast public doubt on their husbands’ masculinity (2002:348). Understanding why medicalization of impotence flourishes in some cultural settings, but is rejected, or is supplanted by the proxy medicalization of sexual partners as demonstrated in Inhorn’s research, would reveal much about the preconditions that make medicalization of masculinity a usable cultural strategy.
Studying ED outside the Anglophone West would also enable the study of globalization’s effects on interactions between gender and medicine. Through global sales networks, technologies developed in one site based on local conceptions of health come to mediate people’s bodies, understandings of health, and norms of embodiment in other sites. A growing literature on global pharmaceuticals characterizes drugs as vehicles of ideology that are both encoded with projected uses in their sites of development, and reinterpreted in subsequent local construction and negotiation of illness identities, social relations, and symbolic processes (Lakoff 2005; Nichter and Vuckovic 1994; Petryna et al 2006; van der Geest et al. 2002). Further, these global pharmaceuticals may carry quite complex social meanings from their sites of development. Jonathan Metzl (2003) argues that, in the case of anti-depressants in the United States, a seemingly revolutionary shift from psychological to biological treatments that was hailed within medicine and the popular press served to conceal great continuity in the gendered social goals of treatment for depression. It is thus likely that the apparently radical historical shifts between the three medical conceptions of impotence in the United States discussed in this paper have concealed enduring, relatively consistent ideas about ideal masculinity. For instance, despite their differences, these understandings of impotence all figured penile erections as the epicenter of masculinity and manhood. The most exciting new directions for ED research, then, are to examine the cross-cultural flow of ED treatment technology, to examine which understandings of masculinity and medicine are imported along with these technologies, and to discover how these globally spreading, or other local, ideas about gender and health make ED intelligible as a ‘disease of masculinity.’
Aytac, Isik A., Andre B. Araujo, Catherine B. Johannes, Ken P. Kleinman and John B. McKinlay
2000 Socioeconomic Factors and Incidence of Erectile Dysfunction: Findings of the Longitudinal Massachusetts Male Aging Study. Social Science and Medicine 51:771–778.
2005 The Viagra Ad Venture: Masculinity, Media and the Performance of Sexual Health. New York: Peter Lang Publishing.
2006 The New Sexual Technobody: Viagra in the Hyperreal World. Sexualities 9(3):333–344.
D’Emilio, John, and Estelle B. Freedman
1997 Intimate Matters: A History of Sexuality in America. Chicago: University of Chicago Press.
Dercum, Francis X.
1913 A Clinical Manual of Mental Diseases. Philadelphia: W. B. Saunders Company.
Eardley, Ian, and Sethia Krishna
2003 Erectile Dysfunction: Current Investigation and Management. London: Mosby.
Fergus, K., Gray, R. and Fitch, M.
2002 Sexual Dysfunction and the Preservation of Manhood: Experiences of Men with Prostate Cancer. Journal of Health Psychology 7(3):303–316.
Gray, R. E., et al.
2002 Hegemonic Masculinity and the Experience of Prostate Cancer: A Narrative Approach. Journal of Aging and Identity 7(1):43–62.
Gross, Samuel W.
1881 A Practical Treatise on Impotence, Sterility, and Allied Disorders of the Male Sexual Organs. Philadelphia: Henry C. Lea’s Son and Co.
Gutheil, Emil A..
1959 Introduction: Impotence in the Male. In Impotence in the Male: The Psychic Disorders of Sexual Function in the Male. Wilhelm Stekel. Pp. iii-iv. New York: Liveright Publishing Corporation.
2000 Virtual Virility, or, Does Medicine Make the Man? Men and Masculinities 2(4):388–409.
Hammond, William A.
1883 Sexual Impotence in the Male. New York: Bermingham and Co.
Hirsch, Edwin W.
1966 Impotence and Frigidity. New York: The Citadel Press.
Inhorn, Marcia C.
2002 Sexuality, Masculinity, and Infertility in Egypt: Potent Troubles in the Marital and Medical Encounters. Journal of Men’s Studies 10(3):343–359.
1968 Disorders of Sexual Potency in the Male. Oxford: Pergamon Press.
Jonas, U., and W. F. Thon
1991 Erectile Dysfunction. New York: Springer-Verlag.
Kaplan, Helen Singer
1979 Disorders of Sexual Desire and Other New Concepts and Techniques in Sex Therapy. New York: Simon & Schuster.
2001 Viagra: The Remarkable Story of the Discovery and Launch. New York: Medical Information Press.
Kilman, Peter R., and Katherine H. Mills
1983 All About Sex Therapy. New York: Plenium Press.
King, William Harvey
1897 Spermatorrhea, Impotence, and Sterility. New York: A. L. Chatterton and Company.
Kinsey, Alfred C.
1948 Sexual Behavior in the Human Male. Philadelphia: W.B. Saunders Company.
Kirby, R. S., Culley C. Carson, and G. D. Webster
1991 Impotence: Diagnosis and Management of Male Erectile Dysfunction. Oxford: Butterworth-Heinemann.
Krane, Robert J., M. B. Siroky, and I. Goldstein
1983 Male Sexual Dysfunction. Boston: Little, Brown and Company.
2005 The Anxieties of Globalization: Antidepressant Sales and Economic Crisis in Argentina. Social Studies of Science 34(2):247–269.
2004 The Rise of Viagra: How the Little Blue Pill Changed Sex in America . New York: New York University Press.
2006 The Viagra Blues: Embracing or Resisting the Viagra Body. In Medicalized Masculinities. D. Rosenfeld and C. Faircloth, eds. Pp. 21-44. Philadelphia: Temple University Press.
Mamo, Laura and Jennifer Fishman
2001 Potency in All the Right Places: Viagra as a Technology of the Gendered Body. Body and Society 7(4):13–35.
Marshall, Barbara L.
2002 “Hard Science”: Gendered Constructions of Sexual Dysfunction in the “Viagra Age.” Sexualities 5(2):131–158.
2006 The New Virility: Viagra, Male Aging and Sexual Function. Sexualities 9(3):345–362.
Marshall, Barbara L. and Stephen Katz
2002 “Forever Functional”: Sexual Fitness and the Aging Male Body. Body and Society 8(4):43–70.
Masters, William H., and Virginia E. Johnson
1970 Human Sexual Inadequacy. Boston: Little, Brown and Company.
Metzl, Jonathan Michel
2003 Prozac on the Couch: Prescribing Gender in the Era of Wonder Drugs. Durham: Duke University Press.
Nichter, M., and N. Vuckovic
1994 Agenda for an Anthropology of Pharmaceutical Practice. Social Science and Medicine 39(11):1509-25.
2005 Constructions of Masculinity Following Prostatectomy–induced Impotence. Social Science and Medicine 60(10):2249–2259.
Petryna, Adriana, Arthur Kleinman and Andrew Lakoff
2006 Global Pharmaceuticals: Ethics, Markets, Practices. Durham: Duke University Press.
2000 “The Essence of the Hard On”: Hegemonic Masculinity and the Cultural Construction of “Erectile Dysfunction.” Men and Masculinities 3(1):85–103.
2004a Deleuze on Viagra (Or, What Can a “Viagra-body” Do?). Body and Society 10(1): 17–36.
2004b Viagra Cyborgs: Creating ‘Better Manhood Through Chemistry.’ In Sex and the Body. A. Potts, N. Garvey, and A. Weatherall, eds. Palmerston North: Dunmore Press.