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Abstract While it was once assumed that sexual function and virility naturally declined with age, the sexual capacities of the aging body have more recently been aligned to new performative standards, particularly for men. This article explores the history and contemporary dimensions of this new culture of virility. The first section reviews shifting scientific and cultural narratives of the sex/age problematic. The latter part of the article explores how the robust post-Viagra ‘men’s health’ industry has expanded the medicalization of masculinity and male sexuality in later life, particularly via the recuperation of the ‘male menopause’ as ‘androgen deficiency in the aging male’. As the aging male body is opened up to new manifestations of dysfunction and disorder, attention is drawn to emerging understandings of risk, health and surveillance in relation to sexual function.

Keywords aging, health, masculinity, sexuality, Viagra

Barbara L. Marshall Trent University, Canada

The New Virility: Viagra, Male Aging and Sexual Function

Introduction Over the last century, a variety of expert discourses – including psychiatry, gerontology, sexology, endocrinology, and urology – have been central in the construction and reconstruction of sexual lifecourses. Traditionally, the assumption that sexual function and virility naturally decline with age grounded the efforts of the sexological sciences to help men manage and adjust to what was considered a finite bodily resource. However, late in the 20th century, as the sexual capacities of aging men were opened up to new biomedical treatments and consumerist lifestyle projects, what were previously considered to be ‘normal’ changes in sexual capacities associated with bodily aging became pathologized as sexual dysfunctions. While not entirely responsible for this reconfigured understanding of the

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Sexualities Copyright © 2006 SAGE Publications (London, Thousand Oaks, CA and New Delhi) Vol 9(3): 345–362 DOI: 10.1177/1363460706065057

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aging male, the success of the blockbuster drug Viagra (sildenafil citrate) in securing a particular understanding of sexuality and sexual function across the lifecourse cannot be underestimated. As a site of convergence between the ‘biomedicalization of aging’ (Estes and Binney, 1989; Gilleard and Higgs, 1998) and that of sexuality (Tiefer, 1996), the recon- ceptualization of what might have been considered normative experiences related to bodily aging as dysfunctions which demand correction means that masculine vitality itself has increasingly become framed as a biochem- ical problem in both medical and popular discourses. John Hoberman (2005: 71), in his history of testosterone, credits the ‘Viagra boom’ with being the catalyst for reviving scientific interest in the sexual effects of testosterone on aging men which had for years been ‘suppressed by old taboos and the timidity of potential sponsors’.

This article explores the contemporary bodily configuration, still in the making, of the virile, sexually-fit aging male. I analyze scientific and clinical texts on aging and sexuality, as well as health promotion and marketing initiatives directed at older men, to trace both the history and contemporary dimensions of the new culture of virility. The first part of the article reviews shifting scientific and cultural narratives of the sex/age problematic in men over the course of the 20th century. The varying significance accorded to changing sexual capacities is illustrated from early assertions of the natural waning of sexual powers with age to the more contemporary emphasis on continued sexual functionality as a marker of successful aging. The latter part of the article explores how the newly robust ‘men’s health’ industry has expanded the medicalization of masculinity in later life, particularly via the recuperation of the ‘male menopause’ as ‘androgen deficiency in the aging male’, and has framed emerging understandings of risk, health and surveillance in relation to sexual function.

Rejuvenation and the aging male: From fringe to mainstream Historically, aging was viewed as a process of de-sexualization, and both medical and moral authorities in the late 19th and early 20th centuries extolled the virtues of the post-reproductive, post-sexual life. Popular author Sylvanus Stall (1901: 59), suggesting that it was nature’s course to diminish sexual power in men once their peak reproductive fitness had passed, reminded his readers of the benefits of accepting and adjusting to sexual decline, promising that ‘the stress of passion will be past, the imagination will become more chastened, the heart more refined, the lines of intellectual and spiritual vision lengthened, the sphere of

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usefulness enlarged’. The conviction that men’s sexual powers naturally declined with age could lead only to a counsel of acceptance, and advice similar to Stall’s was widely repeated in the early 20th-century literature. For example, Frederic Sturgis (1930: 312) advised that ‘Where old age is the cause of impotence, there is, alas! no remedy, except to submit as gracefully as possible to the decrees of fate, and by carefully husbanding the sexual resources to prolong the usefulness of the genital organs as far as possible’.

Not all early 20th-century scientists embraced the counsel of graceful acceptance of decline. Some contended that the secret to masculine vitality – and the secret to forestalling its loss in the aging process – lay in the sex glands themselves. While there has certainly been a long-standing belief that masculine virility, valor and vigor are rooted in the testes, assump- tions of the testicular basis of masculinity came to the fore in the organ- otherapy and rejuvenation experiments of the late 19th and early 20th centuries. Sengoopta (2001: 644) calls the 1920s the ‘decade of the testicle’ as it was then that ‘physiological and clinical research on testicu- lar functions came together in what, for a time, seemed to be a spectacu- larly successful synthesis’. Austrian scientist Eugen Steinach, after a period of experimentation with testicular transplants, became famous for the ‘Steinach operation’. This was essentially a vasectomy which supposedly let the body reabsorb testicular fluid instead of discharging it, hence reaping the benefits of its invigorating power (Sengoopta, 2003). By the 1920s, other scientists around the world, such as Harry Benjamin and Peter Schmidt, had taken up Steinach’s theories and were conducting their own trials with surgical rejuvenation (Schmidt, 1929).

Relatively few men actually underwent the procedures advocated by the rejuvenation enthusiasts, and what success those who did may have claimed is now suspected to be largely a placebo effect (Cussons et al., 2002). By the 1930s, surgical rejuvenation was largely discredited as a medical practice and was consigned to the fringes of quackery (Fishbein, 1932; Jaheil, 1992). But as commentators such as Susan Squier (1999) and John Hoberman (2005) have noted, the ideas of rejuvenation and life-extension retained both cultural and medical significance throughout the 20th century. In particular, the public imagination was captured by the idea that science could forestall, or even reverse, the effects of age on the body.

Sexual rejuvenation in aging men was a subject of some ambivalence, even for its promoters. While organotherapy and rejuvenation unequivo- cally linked masculine vitality and vigor to glandular secretions, interest in rejuvenation therapies was largely motivated by worries about declines in masculine productivity, not virility. To be sure, restoration of sexual function was part of the promise of rejuvenation, but this was treated as

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almost a side effect of the restoration of general masculine vigor. Steinach himself stressed the non-sexual benefits of rejuvenation, seeking to ward off not only the physical disorders of age (cancer, heart disease, hyper- tension) but also the ‘paralyzing fatigue, disinclination to work, failing memory, indifference and depression, all of which hinder or preclude progress and every kind of competition’ (cited in Hirshbein, 2000: 285). In a spirited defense of rejuvenation science, Paul Kammerer (1924: 185) argued that: ‘If reawakened manhood, a by-product of rejuvenation, occasionally is criticized as an immoral disadvantage of rejuvenation as a whole, then the simultaneously reawakened love of, and ability to work, should be considered a sufficient compensation’. Similarly, in reviewing the literature on rejuvenation therapies, George Ridley Scott (1953: 9–10) suggested that ‘much of the hostility towards rejuvenation has been engendered through its association with sex’ and countered almost apolo- getically that ‘there is no way of extending the physical and mental powers of the individual into advancing years without coincidentally keeping the sexual and endocrinal glands functioning’.

This ambivalence towards sexual rejuvenation of aging men continued as hormone therapy moved into mainstream medical practice via testos- terone treatment for the ‘male climacteric’ in the 1930s and 1940s. While notions of a male climacteric as a parallel process to the female menopause had circulated in the medical literature since the early 19th century, it was not until August Werner’s reintroduction of the concept to mainstream American medicine in 1939 that it had a clinical presence (Werner, 1939). Yet Werner, though arguing that the climacteric ‘is due primarily to a function of the sex glands’ (1939: 1441), and asserting that, as a result, ‘man is subject to varying degrees of sexual function’ (Werner, 1946: 194), did not view the restoration of sexual function as a central goal of testosterone therapy. In other words, even though sexual dysfunction might be a key symptom of the climacteric, it was not the main concern in treating it. Although potency might inadvertently be stimulated by testosterone therapy, Werner (1945: 710) insisted that it should not be given for this purpose, and in fact suggested that ‘it is perhaps better for older men if this phase of the reaction does not result’. This emphasis on the non-sexual aspects of restoring masculine vitality is reiterated in a discussion of Werner’s work by Charles Dunn, who reminded readers that

the male climacteric is an important syndrome because it occurs chiefly in men with important responsibilities, men who require sustained energy, physical and mental throughout the day to perform competently their assigned responsibil- ities . . . The true climacteric patient is more concerned with constitutional rehabilitation than he is with sexual stimulation. (Dunn, 1945: 710)

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The specter of immorality still cast a shadow over sexual rejuvenation of aging men, reiterating the long-held assumption that old age should be a time of asexuality (Marshall and Katz, forthcoming). If acceptance of the male climacteric as a clinical disorder, and its treatment with hormone replacement therapy, was to be accepted in mainstream medical practice, then the emphasis had to be placed on the non-sexual aspects of treat- ment. Despite this, the concept never really caught on. Rather than as a medical disorder, the ‘male climacteric’ was viewed as a period of psycho- logical or emotional upheaval – a ‘mid-life crisis’ (Featherstone and Hepworth, 1985; Hepworth and Featherstone, 1998). Ironically – at least from the perspective of those such as Werner – it took the post-Viagra re- centering of sexual function and its restoration to revitalize the concept of male menopause as a medical disorder in the late 20th century.

Positive aging and the re-sexualization of the aging male Ambivalence towards the importance of sexual function in medical discourse around aging and masculinity illustrates the dilemma in which the emerging sciences of aging and sexuality found themselves in the early to mid-20th century. On the one hand, sexual science had enshrined sexual decline as an inevitable aspect of bodily aging. On the other hand, the new professional discourse of gerontology emphasized vitality, activity and independence, challenging previously negative stereotypes of later life (Katz, 1996). Discourses of ‘positive aging’ in sexology and gerontology did find some common ground in the mid-20th century as shifting etiolo- gies of sexual dysfunction resulted in their agreement that psychological, rather than organic, factors were central (Marshall and Katz, 2002). Sexual decline was no longer characterized as a ‘natural’ consequence of bodily aging for which graceful acceptance was the appropriate response. Aging men were increasingly told that it was their anxiety over their supposed loss of sexual function – their fear of loss of potency – that was causing their premature sexual decline. In addition, men were told that to cease having sex would itself hasten aging. Common wisdom by the middle of the 20th century was that continued sexual activity, and especially sexual intercourse, was a healthy and necessary component of successful aging.

In the 1980s new developments in urology effected a decisive change in understanding the sexual capacities of the aging body. Specifically, urological research reconceptualized the male erection as a vascular, physiological event after it was demonstrated that erections could be induced by chemical injection, severing the mechanism of erection from any sort of emotional arousal or tactile stimulation (Brindley, 1986; Virag,

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1982). Impotence – which by the 1990s was referred to as ‘erectile dysfunction’ – became a treatable, physiological disorder. The effect of this move was to see sexual decline as neither the inevitable by-product of bodily aging nor the result of psychological difficulties. Erectile dysfunc- tion resulted from ‘modifiable, para-aging phenomena’ (Feldman et al., 1994: 54). Reversing the old belief that psychological distress acted to produce physiological sexual dysfunction, it was now argued that, left untreated, physiological sexual dysfunction had serious emotional and psychological effects. As one of the many mass-market books on male sexual function to emerge in the wake of Viagra put it: ‘no malfunction of the human apparatus – not even cancer or heart disease – can be more painful to the male ego or catastrophic to the male psyche than sexual impotence’ (Melchiode and Sloan, 1999: 17). These catastrophic effects, coupled with the reportedly epidemic rates of men suffering from erectile difficulties, and the expected increase in incidence given aging populations in western societies, transformed age-related sexual dysfunction into a serious public health problem demanding redress.

By the late 1990s, scientific and commercial interests converged in reconceptualizing sexual disorders as requiring biotechnical, rather than therapeutic, fixes, and sexual-function products were now added to the legitimate marketplace of products geared to aging consumers (Katz and Marshall, 2003). In contrast to the manner in which the restoration of sexual function was treated as an almost regrettable byproduct of rejuvenation in the first half of the 20th century, there was nothing coin- cidental or apologetic about the central place accorded to sexual function in the emerging arsenal of anti-aging products and related health promotion discourses.

The discourses of positive aging have contributed to the unmooring of sexual decline from the limits of the aging body, in part as a means of redressing negative, ageist stereotypes. One of the problems with the discourses of positive aging, however, has been the assumption that successful aging really means not aging. As Stephen Katz (2001/2002: 27) asserts, ‘the ideals of positive aging and anti-ageism have come to be used to promote a widespread anti-aging culture, one that translates their radical appeal into commercial capital’. Against this landscape, the concatenation of masculinity, sexual functionality and successful aging stands out. While the negative association of aging and active sexuality is, of course, ageist, the reversal of this association will not necessarily be liberating if narrow sexist (and heterosexist) sexual stereotypes are reasserted in the process (Marshall and Katz, forthcoming). As a number of critical analyses have demonstrated, restoration of aging male sexuality via the rehabilitation of the erection with Viagra (and its successor drugs) has been premised on a narrow and limiting understanding of both ‘sex’

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and ‘masculinity’ (Loe, 2001; Mamo and Fishman, 2001; Marshall, 2002; Potts, 2000). Masculinity, at least as it is portrayed in pharmaceutical advertising and ‘men’s health’ promotion around erectile dysfunction, ‘remains anchored in the erect penis across the lifecourse’ (Marshall and Katz, 2002: 63). Calasanti and King (2005: 16) summarize the impact of the new culture of virility on aging men: ‘Sexual functioning now serves as a vehicle for reconstructions of manhood as “ageless” . . . To the extent that men can demonstrate their virility, they can still be men’.

Aging women, of course, have long been subject to biomedical restora- tion of their ‘femininity’ via hormone replacement therapy. Nelly Oudshoorn (1997) has suggested several reasons why, at least until recently, the problems of the aging male were not medicalized to the same degree as those of women. First, the success in defining female menopause as a treatable hormone deficiency gave a clear motive for the hormone replacement industry to target women. Gynecological clinics were able to facilitate both research on and treatments to their clientele, while parallel institutions were not available for men. Oudshoorn argues that men’s more passive attitudes towards seeking treatment for health problems and the continued marginalization of men’s health in the organizational struc- tures of institutionalized medicine were key factors in undermedicalizing the male menopause, in comparison to women’s. As she puts it, ‘health problems can only be classified as illness and be medicalized if there exists a cultural climate and a medical infrastructure that actively transforms health complaints into diseases’ (Oudshoorn, 1997: 143). This ‘active transformation’ is evident in the post-Viagra years, as both the cultural climate and medical infrastructure have absorbed the assumption of a biochemical basis for sexual dysfunction (Marshall, 2002). The clinical and market success of Viagra was pivotal in paving the way for the develop- ment of a lucrative men’s health industry and for the construction of the aging male body as a site of biomedical intervention. An expanded range of institutional and discursive structures have not only accommodated, but nurtured, the medicalization of masculinity in mid- and late life. Professional associations, journals, conferences and clinics focusing on men’s sexual health and aging have proliferated. The pharmaceutical industry has worked hard to legitimate and publicize the disorders for which they have a potential treatment by sponsoring and disseminating research favorable to their products. That there is profit to be made here cannot be denied: according to industry reports, the therapeutic areas of male sexual dysfunction and male menopause are expected to lead the way in expanding the already $17 billion dollar world market in pharma- ceuticals for ‘men’s health’ (Biotech Week, 2003). By the late 20th century, the aging male body was understood as a series of functional subsystems amenable to constant monitoring and biotechnical intervention. While

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Viagra was seen as the solution to malfunction in one of these subsystems (vascular flow to the penis), the problems of the aging male were now increasingly opened up to diagnosis and treatment. By the turn of the 21st century, the concept of the male climacteric, menopause, or ‘andropause’ as an organic disorder was poised to undergo a renaissance, but this time with the restoration of sexual virility at its center.

‘If you think you can Viagra your way out of this one, think again’: The return of testosterone According to the report of the Third International Conference on the Management of Erectile Dysfunction, held in 2003: ‘Although it is now possible for almost all men with ED to regain their erections, getting those men to use their erections regularly is more complicated’ (Nehra et al., 2003: S3). With a reported 50–60 per cent of men discontinuing medical treatments for erectile dysfunction, attention has increasingly turned to the problem of waning sexual desire. As one newspaper feature put it: ‘If you think you can Viagra your way out of this one, think again: It and similar drugs might help with the mechanics, but not with desire; testos- terone is what fires the libido’ (Werland, 2004: 9).

As discussed in an earlier section of the article, the concept of the ‘male climacteric’ or ‘male menopause’ as an organic disorder never really caught on in mainstream medicine. However, from the late 1990s to the present, the male menopause, now referred to as ‘andropause’, or ADAM (androgen deficiency in the aging male), has circulated widely through both the clinical and popular health literatures.1 Here, the andropause is reconceptualized as an age-related physiological disorder treatable with testosterone therapy. Despite a mass of contradictory scientific evidence on the existence of the disorder and both the efficacy and safety of testosterone therapy, it is reiterated that ‘andropause is a fact, not a fiction’ (Nicholls, 2003: 99), and ‘andropause is a testosterone deficiency that develops gradually over a number of years in all men aged 50 and older’ (Anderson et al., 2002: M796). The ADAM questionnaire (Table 1) developed by a team at the University of St Louis and at Organon, one of the key manu- facturers of pharmaceutical testosterone products, has been widely promoted as a clinical screening tool that identifies ‘a symptom complex associated with the age-related decline in testosterone that may be amenable to therapeutic intervention’ (Morley et al., 2000: 1241).2

The foregrounding of erectile dysfunction as a key symptom of andropause appears more related to the post-Viagra willingness of men to present with this disorder than it does to any evidence linking erectile dysfunction to low testosterone levels. Dunsmuir (1999: 138) confirms

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that ‘much of the lay public equates the male menopause with erectile failure’, in spite of the fact that several studies of men presenting at clinics with erectile dysfunction show that the incidence of low testosterone in this group is small (Johnson and Jarow, 1992; T’Sjoen et al., 2003). Indeed the Massachusetts Male Aging Study, which is cited so ubiquitously to establish the relationship between age and erectile function, found no significant correlations between the latter and testosterone levels (Feldman et al., 1994). Yet the ADAM questionnaire treats a positive response to the question about erectile dysfunction as immediately identifying the respondent as ‘at risk’ for androgen deficiency (Morley et al., 2000).3

Significantly, marketing the new virility has revived some very old configurations of masculinity. A doctor with a men’s clinic recounts a typical success story of modern treatment modalities. Here, a 40-year-old man presented complaining of erectile dysfunction and low libido. After he ‘treated the erectile dysfunction and prescribed oral testosterone for the man’s low libido’ the patient returned after six weeks:

He was vibrant. He had quit his job and gone into business for himself – some- thing he said that he always wanted to do but never believed in himself enough to follow through . . . The man’s marriage was wonderful and his sex life was great. He had a great sense of vitality and a positive attitude towards life. (Powell, 2000: D2)

Not only is treatment for erectile dysfunction (presumably with Viagra) coupled with treatment for diminished libido (testosterone), but sexual decline and its reversal are linked, just as in the early 20th-century reju- venation movement, with the restoration of masculine productive power more generally. Not unlike the ‘feminine forever’ message with which women were bombarded by proponents of hormone replacement therapy

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ADAM (Androgen Decline in the Aging Male) Questionnaire

1. Do you have a decrease in libido (sex drive)? 2. Do you have a lack of energy? 3. Do you have a decrease in strength and/or endurance? 4. Have you lost height? 5. Have you noticed a decreased ‘enjoyment of life’? 6. Are you sad and/or grumpy? 7. Are your erections less strong? 8. Have you noted a recent deterioration in your ability to play sports? 9. Are you falling asleep after dinner?

10. Has there been a recent deterioration in your work performance?

Source: Morley et al. (2000).

Table 1. The ADAM Questionnaire

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in the 1960s, the newly remedicalized menopause for men reasserts a chemical basis for masculinity itself. Decline in sexual function, sports performance, work success – these all become markers of the equation of aging with demasculinization,4 and all become treatable in a program of virility maintenance.

The new virility: Risk factors, surveillance and sexual health A number of commentators on health and medicine in contemporary western societies have argued that individuals are increasingly being enrolled into programs of self-surveillance and risk management. For example, Anthony Pryce, drawing on Deborah Lupton’s (1999) analysis of ‘risk’ in late modernity, has suggested that the medical gaze now reaches beyond the walls of the clinic:

Surveillance is relocated through the individual citizen’s reflexive observation of their ‘self ’ for signs of contamination, disease or dysfunction within cultures increasingly constructed as morally, socially, environmentally and biologically dangerous or ‘risky’. The recruitment and self-examination by the ‘active patient’ is central to governmentality and the construction of a new health citizenship. (Pryce, 2000: 104)

Similarly, Andrew Webster (2002) notes that new discourses of health and illness have created the ‘worried well’ as a significant market. It is not difficult to see these trends as evident in the new discourses of men’s sexual health. The widespread publicity given to the ‘epidemic’ of sexual dysfunction, coupled with the close cultural association between sexual virility and masculinity, has fostered an environment of amplified risk for many men, promoting self-surveillance and monitoring. And no longer is sexual dysfunction just a concern for men in their old age, but anxiety over the prospect of sexual decline is fostered at increasingly younger ages. As Margaret Gullette (1998: 17) notes, ‘everyone has been getting older younger’.

While the original disease model of erectile dysfunction focused on clearly discernable age-related physiological factors relating to impaired vascular function, the efficacy of Viagra in producing erections regardless of the etiology5 has expanded the parameters of the disease. The Viagra user is no longer just an older man who, due to a physiological problem, is unable to get or keep an erection most of the time, but is just as likely to be a younger man, with no identified organic disorder, who worries about his erections being less reliable than he thinks they should be. This is clearly reflected in the marketing campaigns for Viagra (and its succes- sor drugs). Originally marketed to an older audience (with Bob Dole as

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the initial spokesman in North America), erectile dysfunction drugs have been pitched to ever younger markets. One widely-used print advertise- ment for Viagra in the United States features a man, appearing to be in his early 40s, telling us that he knows ‘a lot of guys have occasional erection problems’, but that he chose not to accept his by seeing his doctor and asking about Viagra.

The downloading of risk and anxiety about age-related changes in sexual capacities to younger and younger men is borne out by research on whom those prescriptions are going to. A study of prescription claims data in the US in the first five years of Viagra’s availability found that younger men (aged 18 to 45) were the fastest growing group of users (Delate et al., 2004). Similarly, the renewed medicalization of the male menopause has meant medicalizing mid-life, rather than late-life, masculinity – according to two reports cited by the National Institute of Medicine, most testos- terone prescriptions were given to men in the 45–65 age group, not to men over 65, where decreased levels of circulating testosterone are most evident (Liverman and Blazer, 2004: 25). The construction of ever- younger aging males as ‘active patients’ occurs against an expanded horizon of risk, increasing responsibility of both the individual and the health professional to undertake virility surveillance, and an expansion of the very concept of ‘sexual health’.

The transformation of erectile dysfunction and low libido into organic disorders originally linked them with other bodily disorders which act as risk factors – for example, diabetes, prostate cancer, obesity and hypo- gonadism. However, age, as the most clearly articulated risk factor puts all men at risk. The specter of sexual dysfunction has also been taken up by various health promotion discourses in terms of lifestyle factors that may increase the risk of sexual dysfunction. These include both official campaigns, such as Health Canada’s anti-smoking campaign (‘Tobacco use can make you impotent’), and unofficial ones, as in ‘People for the Ethical Treatment of Animals’ (PETA) promotion of vegetarianism (‘Eating meat can cause impotence’). When the popular magazine Men’s Health ran a feature educating men on how to assess their risk for develop- ing erectile dysfunction (McDonald, 2000), the highest-risk case study was a 31 year old who currently has sex every day. While he doesn’t have problems yet, we are told his ‘poor diet, sedentary lifestyle and family history will eventually catch up to him’, and that if doesn’t start to exercise and eat right, his ‘sex-life expectancy’ has only about 10 years to run. The message here is not only one of constant vigilance, even where no immedi- ate problems are apparent, but also one of equating the loss of erectile power with the end of life itself. Thus, the onus is on the individual to take responsibility for managing risk through new regimes of bodily disci- pline which must start long before the onset of ‘old age’.

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In addition to preventative lifestyle changes, men are exhorted to continually monitor and assess their sexual function, and to take remedial action where necessary.

Pfizer’s ‘three steps to better erections’ plan illustrates well the construction of the active patient in this respect. In brochures and on web sites,6 men are instructed to assess their erectile capacity (by filling out a short form of the International Index of Erectile Function), compare it to a standardized model (via their score on that quiz) and seek action by visiting their doctor and asking for a starter pack of Viagra. This process is replicated for those worried that they might be suffering from andropause – take a quiz, go to your doctor, actively ask about a treat- ment. Not only is the individual increasingly enrolled into regimes of self- surveillance, but physicians are also increasingly called upon to be more pro-active in diagnosing sexual dysfunctions in their patients. A number of recent articles in periodicals directed at front-line family physicians encourage ‘proactive sexual health interviews’ (Nusbaum and Hamilton, 2002) and suggest that information about sexual function should be ‘actively solicited as part of the routine medical history’ (Lightner, 2002). Also suggested is the use of questionnaires to identify symptom complexes – either physician administered or left in the physician’s waiting room for the patient to self-administer (MacIndoe, 2003). It is no wonder that the pharmaceutical industry has invested so heavily in developing the myriad questionnaires, indices and scales aimed at diagnosing dysfunctions.

The concept of ‘sexual health’, once focused on sexually transmitted disease and reproductive concerns (Giami, 2002) has now broadened out to (and perhaps become primarily focused on) a concern with mainten- ance and enhancement of sexual desire and performance. Sexual function has now come to dominate many uses of the concept of sexual health – for example, one of the newer indices on the block, the Male Sexual Health Questionnaire, deals only with erections, ejaculations and sexual satisfaction (Rosen et al., 2004). A brochure entitled ‘Men’s Sexual Health’, distributed in physicians’ waiting rooms, has four pages on erectile dysfunction and its treatment, two pages on loss of sexual desire linked to androgen deficiency, and two pages on prevention of STDs.7 Thus three-quarters of the brochure conceptualizes ‘sexual health’ as ‘sexual function’. Given that health ‘has become a duty as much as a right of citizenship’ (Porter, 2002: 201; see also Crawford, 1980 and Tiefer, 1997), seeing sexual health primarily in terms of meeting some standard- ized model of sexual function makes it a moral imperative. A critical aspect of being a responsible late modern citizen is to take charge of one’s health – including one’s sexual health – by adopting particular sorts of lifestyles, and by the consumption of appropriate forms of expertise and products.

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Conclusions The success of Viagra in securing a new regime of compulsory tumescence is an exemplary case of the manner in which bodies are reconstructed as sites for biomedical intervention and incorporated into consumerist ‘lifestyle’ projects. A reinvigorated sense of masculinity as a life-long project is configured by the new biology of the body which has emerged in relation to pharmaceutical therapies geared towards functionality and performativity. The post-Viagra expansion of the ‘men’s health’ industry, which promotes a standardized model of sexual function as its raison d’etre, has an ever-expanding kit-bag of therapies for an ever-younger aging patient. Not only sexual function, but masculine vitality itself, is presumed to be at stake here, as anxieties over aging are crystallized in terms of biochemical demasculinization. Yet qualitative research with older men (and women), demonstrates that:

there is no standard experience of a ‘functional’ erection, even less so a ‘dysfunc- tional erection’; there appears to be no necessary relationship between a particu- lar type of erection and a satisfying sexual relationship; and there is no definitive view of what constitutes ‘normal’ masculinity or ‘being a man’ in relation to erectile ‘functionality’. (Potts et al., 2004: 498)

Perhaps the recognition that ‘manhood changes’ (Calasanti and King, 2005: 5), rather than diminishes with age can be the starting point for challenging the post-Viagra culture of virility.

Acknowledgements This article draws on and extends work done in collaboration with my colleague Stephen Katz, and I am grateful to him for both his expertise and his permission to use jointly developed ideas here. I would also like to thank Annie Potts and three anonymous reviewers for their helpful comments. Research for this article was supported by a grant from the Social Sciences and Humanities Research Council of Canada.

Notes 1. As a rough measure of the increase in clinical interest, a search in Medline

from 1980 to 2003, using ‘male menopause’, ‘andropause’ and/or ‘male climacteric’ as keywords, found that 1998 was the first year with more than five citations, and the numbers climb steadily each year to 29 citations in 2003. For an extended discussion of the history of the male climacteric and its revival as the andropause, see Marshall (forthcoming).

2. In addition to its promotion to family physicians as a clinical screening tool (MacIndoe, 2003), the ADAM questionnaire is reproduced in advertisements for testosterone supplements in popular magazines such as Men’s Health and Golf, in newspaper and magazine stories (see, for example, Kirkey, 2003; Toronto Star, 2002), and hundreds of health-information web sites.

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3. A ‘positive’ questionnaire result is defined as a ‘yes’ answer to questions 1 or 7, or any other three questions. According to the authors of the study validating the questionnaire, ‘The most common affirmative answer for individuals with low BT [blood testosterone] was in response to question 7 pertaining to the strength of penile erections’ (Morley et al., 2000: 1240). Yet there is no scientific evidence which links these two factors in any causal relation.

4. The manner in which the testosterone narrative for men bundles together sexual function with other cultural referents of masculine vigor may be contrasted with that for women, for whom testosterone treatment is being explored as a libido enhancer (Fishman, 2004; Tiefer, 2004). For both men and women, improved libido and enhanced sense of well-being are claimed as benefits, but women treated with testosterone are not hailed (or assessed?) for their improved sports performance or business competitiveness. See Marshall and Katz (forthcoming) for a more extended discussion of how distinctly gendered sexual identities are being reasserted in contemporary discourses of sexual rejuvenation.

5. Clinical research demonstrates that Viagra has the highest efficacy in cases of erectile dysfunction for which there is no identified organic cause (Shabsigh, 1999; Steers, 1999). See Marshall (2002) for further discussion of how the disease parameters of erectile dysfunction have expanded.

6. See, for example, www.viagra.com/steps/index.asp (accessed March 2006). 7. The corresponding brochure entitled ‘Women’s Sexual Health’ was entirely

focused on sexuality in the ‘transition years’ (i.e. perimenopause and menopause) and discussed hormone therapy to deal with sexual difficulties (both estrogen and testosterone – the latter only available to women on off-label prescription). Thanks to Andrea Tone for passing these brochures on to me.

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Biographical Note Barbara Marshall is a Professor of Sociology at Trent University, where she teaches and writes in the areas of social theory, the body, technology and sexuality. She continues to explore the historical and contemporary intersections of gender, sexuality, age and biomedical technologies, both on her own and in collaboration with her frequent co-author, Stephen Katz. Address: S103 Lady Eaton College, Trent University, 1600 West Bank Drive, Peterborough, Ontario, Canada K9J 7B8. [email: [email protected], website: www.trentu.ca/sociology/bmarshall]

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