Provocative Wave for Men

Little Blue Pills:Viagra Use and Gay Men

By Walter Armstrong

Hard-ons come and hard-ons go but a man's fear of losing his erection at crunch time never wavers. That fact, along with allied fantasies of power, control, and possessing a dick to die for, explains the phenomenal success of Viagra and other erectile-dysfunction (ED) drugs. Originally approved to treat impotence, the little blue diamond-shaped tablets have become, in less than a decade, a multibillion-dollar performance-enhancing product, a cultural icon and household name, and one of the most popular, controversial—and its critics say, most destructive—drugs in the gay community. This is quite a feat for a pharmaceutically crude compound. Viagra cures no devastating disease, boasts no breakthrough science. It neither brightens your mood nor sharpens your thinking nor strengthens your memory. It doesn't stimulate the neurochemistry of your brain like crystal meth, Ecstasy, and other primo party drugs, and won't make you dance till dawn, fuck for days, become one with the universe or see God. Contrary to common belief, it won't even make you horny. All Viagra does is increase the flow of blood into your penis for a few hours, ensuring an erection. But that barely begins to describe the appeal of the effect. "On Viagra my dick feels literally as hard as a rock," said Justin M. (not his real name). "It has a whole different quality to it from my natural erection. It's like a baseball bat—like something separate from the rest of my body."

Confessions of an Addict

Justin M. is a 35-year-old gay men who lives in New York, is educated, successful, and articulate, and describes himself as "addicted to" or "dependent on" the little blue pill. He first tried it in 2000. "I had a gay doctor who prescribed it liberally," he said. "I don't remember making up any excuse about condoms and having trouble staying hard or anything. I just told him I wanted to try it because I was curious." In fact it was less curiosity than a rational consumer choice. Justin M. had a special set of needs that he believed Viagra could meet: "I was having sex outside my relationship"—he and his longtime boyfriend had hit a dry spell—"and it was the kind of thing where I'd meet someone online, I only had an hour or so, I might be feeling nervous or ambivalent, and I wanted to make the most of it." Although he never has trouble maintaining an erection, the boost from Viagra upped Justin M.'s confidence. Performing at peak level under pressure is clearly something Justin M. prizes. "I'm exclusively a top—and I want to be as good a top as possible," he said. "I was answering these ads online from guys who were power bottoms. My role was to go the distance and then some. I wanted to be Supertop." Taking Viagra on his way to the stranger's apartment was the ticket to becoming Supertop, like Clark Kent switching outfits in his phone booth. But at some point Justin M.'s responsible recreational use of Viagra began to go wrong.

Viagra Takes a Public Hit

The abuse of Viagra by gay men is an old story, but it made new headlines last week when Los Angeles' AIDS Healthcare Foundation (AHF) filed a lawsuit against Pfizer for "promoting Viagra as a party drug...leading to more infections with sexually transmitted diseases such as HIV." The group is asking the court to force the drug giant not only to replace its direct-to-consumer marketing with a "responsible use" campaign but, more to the point, to hand over an unspecified sum directly to AHF, the largest provider of services to people with HIV in California. Calling AHF "a victim of Pfizer's irresponsibility," the organization's head, Michael Weinstein, said, "We estimate that a majority of new infections in this country are related to the use of crystal meth, and the majority are also using Viagra." (The CDC begs to differ. Not even a majority of new infections among men who have sex with men are associated with Viagra.) Joining AHF is San Francisco Department of Public Health's STD chief Dr. Jeffrey Klausner, an archenemy of Viagra. "The promotion of Viagra for...recreational use must be stopped," he said. "Litigation is sometimes the only means available to the public to reverse unfair practices." Pfizer predictably denied that it pushes its drug for recreational use, pointing out that Viagra ads and labels warn against STDs, including HIV. Less predictable was the immediate pushback from gay advocates and researchers. "The idea that people on speed are having wild sex with Viagra because they saw a halftime commercial during the Super Bowl is ridiculous," former San Francisco AIDS policy adviser Jeff Sheehy said. "I don't like direct-to-consumer TV ads, but the rest [of the suit] is just extortion." There are calls for investigations into AHF's funding practices, and some demands that "homophobic" Klausner resign. How could one little blue pill cause so many people to see red?

Let's Take a Few Steps Backward

Like many prescription drugs, Viagra was discovered by accident. In the late '80s, male volunteers in trials for an experimental angina treatment reported a peculiar side effect—increased erections during sexual arousal. Researchers were more than happy to take a second look at the compound, called sildenafil citrate, since it was looking pretty useless in preventing heart attacks. They found instead that it was remarkably effective at prolonging erections. It increases blood flow into erectile tissue by blocking an enzyme called phosphodiesterase type 5 that would otherwise cause all those spongy muscle cells to deflate. (That's why Viagra, and its competitors, Cialis and Levitra, are known as PDE5-inhibitors.) A new drug that extends erections had blockbuster written all over it, and Pfizer wasted no time in winning approval for the first-ever impotence treatment in 1998. But "impotence" being a downer of a word, the company renamed the medical condition "erectile dysfunction" for labeling purposes. Then it flooded the market with bright blue, diamond-shaped pills that bore the subliminally suggestive name of Viagra ("vital" plus "Niagra" promising the ultimate orgasm), topped off with a TV ad blitz featuring the losing presidential candidate, former Sen. Bob Dole; a 77-year-old Pelé, the Brazilian soccer phenom; and other famous seniors. Sales topped $1 billion in its first year. Who knew erectile dysfunction was such a neglected diagnosis? Of course, a growing number of prescriptions were for guys, like Justin M., who were neither old nor impotent. The little blue pill fast became a mainstay in the medicine cabinets of gay men with HIV, many of whom suffered under a load of libido-killing symptoms ranging from low testosterone to the side effects of antidepressants. Some HIV-negative guys, who tend to have the same gay docs as their poz brothers, soon got in on the act. The most common reason given, when one was required, for why they needed a script was condoms—and how hard they make it on hard-ons. At a time when condom fatigue had been fingered as a cause for the rise in unsafe sex in the gay community, there was a certain logic to the idea that widespread use of Viagra among gay men just might turn the anti-latex tide.

Survey Says: It Depends Who You Ask

Measuring the actual extent of recreational Viagra use among gay men is difficult, though not for lack of trying. Many surveys have been conducted, especially in big cities, but few are scientific because they were designed by researchers with a Viagra-as-villain bias. The most notorious example is a 2004 survey trumpeting that one in six gay men uses Viagra, although the fact that the questions were asked at a sex resort went unmentioned in the many news reports. "It's like going to a Broadway show and concluding that one in six gay men like musical theater," said Gay Men's Health Crisis' Noel Alicea. More counting has been done in San Francisco's gay community than anywhere else in America, not least because of Dr. Jeffrey Klausner, who has a mission to end Viagra's use as a lifestyle drug. Before his endorsement last week of AFH's lawsuit against Pfizer, Klausner's boldest move had been petitioning the FDA to list the ED drugs as controlled substances, making them easier to track and harder to prescribe. In response, AIDS advocate Jeff Sheehy opined that the STD maven was angling to keep "the dicks of people with HIV in his back pocket—and he wants us to ask him permission to use it." To dramatize what he sees as a conspiracy of commercial, sexual, and moral irresponsibility implicating Pfizer and the city's gay doctors, gay sex establishments, and gay Viagra users, Klausner often recalls how shocked he was on the day in 2002 when he discovered empty sample packages of Viagra on the floors of a local sex club. A San Francisco study of gay men "in bars and on street corners" in 2001 found that 10 percent had used Viagra—among poz guys, more than 40 percent. By 2005, a phone survey had found that one third of all Frisco homos had recently used Viagra—and that men who had HIV, men who had more sex partners, men who had more unprotected anal sex, and men who took more party drugs (or some or all of the above) were more likely to pop Vitamin V. The largest national study confirmed these general trends. Of some 1,200 gay men interviewed at bars and nightclubs in 10 states in 2005, 11 percent reported recent Viagra use. More than half had used it while on a second party drug. Twice as many had had unprotected anal sex while on Viagra, and rates of HIV infection were significantly higher.

Vroom Vroom: Straight Guys Like It Too

Of course, gay men are by no means the only men playing with Viagra. Straight men in their twenties, thirties, and forties were quick to deploy the drug to deal, as the media put it, with the anxieties of dating a postfeminist wave of demanding women—dubbed the "Samantha complex" in reference to Sex and the City. TV ads began reflecting this new younger face of the exploding Viagra market, abandoning tasteful white-haired couples with slogans like "Let the Dance Begin" for NASCAR drivers declaring, "Gentlemen, start your engines!" and thirtysomething dudes with the brand logo's blue V behind their heads like a pair of devil horns—and the slogan "Get back to mischief!" When Levitra, made by Bayer and GlaxoSmithKline, hit the market in 2003, it seized on sports metaphor for the hard sell, purchasing the most expensive ad time in TV and proceeding to run, during National Football League games, including the Super Bowl, images of a man trying to toss a pigskin through a tire. "When you're in the zone, it's all good," quipped the hip voiceover. (ED ads have since been banned from prime time.) Hot on the heels of Levitra came Cialis, Eli Lilly's extended-version of sildenafil that lasts for up to 36 hours and seemed made to order for sexual bingeing. The pill's street name was The Weekender. And the street was where more and more PDE5-inhibitors were passing hands, from online pharmacies and local dealers listing in web site classifieds to nightclubs, sex clubs, and college frats. Ravers and circuit queens began supplementing the Ecstasy and Special K—which juiced their all-night dancing but left their penises limp—with Viagra for a reliable morning-after stiffy. "Those of us really close to the street see what's going on," Alan Brown, who runs the Electric Dreams Foundation, a national group that promotes health and safety in gay nightlife, observed in 2001. Viagra, he explained, is a "prolonger," considered a natural companion to the "disinhibitors." These disinhibitor/prolonger combos were packaged and sold under names like Sextasy, Rockin' and Rollin', and Trail Mix. The consequences of this combustible mix could not have been more obvious. By allowing guys already addled by drug and drink to pop a pill—and, half an hour later, a woody—Viagra upset the sexual ecology of the party scene. Thousands of folks whose minds had been chemically reduced to primary process are now able to close the evening's entertainments with a fuck—condoms and other cares cast to the winds. They still stagger, float or fall into oblivion, only now they exchange sexual fluids on the way.

Common Side Effects and Drug Interaction Problems

As a chemical compound, however, Viagra itself has proved surprisingly safe. By far the three most common complaints associated with Viagra use are flushing in the face, headache, and heartburn. Cases of priapism, a too-much-of-a-good-thing that can be very painful, have been reported, as have vision problems—a "blue haze"—related to the drug's effect on the blood vessels in the retina. Red flags arise when Viagra interacts with other drugs, two of which are common among gay men. Poz guys on protease inhibitors, in particular ritonavir, are advised to limit their Viagra use to one 25-mg dose every two doses because the HIV med slows down the body's metabolism of the ED drug, causing an 11-fold pileup in the blood. Poppers, an accessory of some gay sex, are another no-no: The nitrates, like Viagra, dilate blood vessels, and the double whammy can cause blood pressure to plummet, leading to dizziness, heart attack or stroke.

Big Wood, No Arousal

For Justin M., the red flags had nothing to do with Viagra's side effects or interactions. Supertop was HIV negative, religious about condoms, and an only occasional partier who steered clear of crystal meth. Moderation is his middle name, except when it comes to the little blue pill and its rock-hard results. His frequency of Viagra use increased from once a month to once a week—though because his hookups were often limited to an hour, he often used only a quarter of a pill. Still, any booty call with a stranger might require a pick-me-up, and so might sex with his boyfriend. That was a warning signal. "I began feeling like my regular erection was not sufficient—that without a Viagra hard-on, something was missing," he said. "It was partly the conditions I was putting myself in—the hookups, the time-frame, the need to be a supertop. But the more I used it, the more dependent I became on it." The sense of control and power the drug gave him, not to mention the desire and pleasure his performance inspired in his partners, proved habit-forming. But there was a darker development. "Viagra changes the way you think about your penis," Justin M. says. "You objectify it to the point where it seems detached, separate from your body, with no connection to what is going on inside your head." With minimal sensation or sentiment, his body could spring a fierce woody, like strapping on a dildo—and almost as lifeless. He began to wonder if Viagra had fundamentally, even permanently, altered his connection to his penis. "I decided that if I was going to keep having sex like that, I would do it without Viagra," he said. "There comes a point where you value your natural response—your mind is aroused and that's what hardens your penis." Justin M.'s hard lesson about hard-ons has moved him into the anti-Viagra camp, though he is no zealot. "I think the widespread access to it is a bad thing. It's unconscionable that my doctor dispensed it like candy," he said. "No, I would not recommend it to anyone. Instead I would tell them, 'If your dick is not hard, there's a reason for it—explore that. There's beauty in being connected to your body and to sex.'" Justin M.'s advice may fall on deaf ears. When it comes to sex, gay men have shown a high tolerance for acting but little taste for thinking. Our history is chockfull of stories of men who came out in order to find their sexual identities only to lose themselves, and often their lives, in sex.

Tina: An Enemy We Can All Agree On

The current curse on our house is, of course, not Viagra but crystal methamphetamine, which most experts agree is fueling viral hotspots likely to keep HIV burning in the gay community for many years. Gay men who use meth are four times more likely to have HIV and five times more likely to have syphilis than those who are not Friends of Tina. Gay men who use meth and Viagra together are six times more likely to have STD bugs. And many non-addicts circle in and out of those moving feasts. Some public health officials like Klausner have fixed on Viagra as the lynchpin in the complex of desires and chemicals, behaviors, and addictions that link meth use to HIV infection. "The predominant problem that we see in San Francisco is that widespread use [of Viagra] among gay men...increases their ability to have more sex partners, particularly in multiple partner environments, and reverses the chemical impotence associated with methamphetamine and crystal use," Klausner said. And given the stranglehold that crystal has on its addicts, not to mention being easy to manufacture and hard to interdict, Viagra has emerged not only as the lynchpin but, from a drug enforcement standpoint, the weakest link in the system. In that sense, it is a kind of scapegoat. And certainly it has the sympathy of its many fans. Whether practical or rhetorical, Klausner's blacklisting of a medical treatment is provoking a backlash from many gay men who are in no mood to hear moral sermons from a straight man. Ironically, the same week that Weinstein and Klausner launched the lawsuit, Pfizer admitted for the first time that it may seek approval for an over-the-counter version of Viagra. It's a long-shot strategy to beat the cheaper generic versions just around the corner. And a new generation of PDE5-inhibitors, including topical creams and gels that are easier to apply and faster acting, are also in the works. As for Justin M., what he wants from Viagra has nothing to do with cheaper, easier, or faster. Although he still packs a quarter of a tab in his wallet, he looks forward to the day when he can throw his crutch away. "I carry a Viagra around with me just in case—in case drinking, or some situation, arises," he said. "I want to be sure I can rise to the occasion, ha ha." But Justin M. isn't laughing—he's mourning. A bit like a former meth addict who finds sober sex boring compared to the intensities of crystal-fueled bingeing, he regrets ever having tasted the pharmaceutical fruit of knowledge. The rock-hard baseball-bat fantasy-made-flesh is gone, and Supertop's own flesh no longer satisfies. But for a man as self-aware as Justin M., the odds are in his favor. "There are dangers to the drug—there's a price you pay," Justin M. says finally, "and it's not necessarily the HIV-STD-crystal meth stuff you read in the headlines." In fact, it's the stuff in your head. About Walter Armstrong: Walter Armstrong is a freelance writer and editor in New York who served as the editor-in-chief of POZ magazine for six years. Armstrong has also worked at Rolling Stone, Men's Journal, Us, GQ, OutWeek and numerous other magazines.