The Viagar Myth

Menstuff® has compiled the following information on performance anxiety and viagra.

Performance Anxiety & Viagra: A Chapter From the "Viagra Myth"
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Performance Anxiety & Viagra: A Chapter From the "Viagra Myth"

"This emphasis on sexual performance is a big issue for men. But it is also a double-edged sword..."

In Chapter Two of The Male Myth, we explored the ways in which men strive for an ever-harder erection, even if this means taking a medication like Viagra to help them. This emphasis on sexual performance is a big issue for men. But it is also a double-edged sword, because the dark side of a successful performance is the possibility of failure. When the erection fails because of nervousness, it is called performance anxiety, or sometimes, psychogenic impotence.

Unfortunately, many men have experienced at least one episode of performance anxiety at some point in their life. This also means, of course, that a large number of women have been present for the event as well, though their perception of the experience is usually quite different.

The failure to obtain an adequate erection because of performance anxiety can be an excruciating experience, as any honest man will testify. “I felt like a total wimp loser. How could I face her again. It was just devastating,” men have told me.

The “Viagra Myth” is that a little blue pill can solve all erection problems, rendering the disappointment and frustration of performance anxiety a thing of the past. If only it were true. The stories that follow illuminate this aspect of the “Viagra Myth” and its relationship to performance anxiety.

The Popsicle-Stick Splint

Sitting around drinks one day, a group of friends found the conversation turning to sex. Trudy, a woman in her late thirties, said, “See that waiter over there? Once when I was single, I brought home a guy who looked just like that. He was this gorgeous Italian who spoke with an adorable accent. When he took his clothes off, I thought I had died and gone to heaven. Everything was great until he goes to put on a condom. Then it was ‘Pfffft,’ like someone had stuck a pin in a balloon, and the whole evening was a loss, no matter what I did. What a waste of manhood!”

Judy spoke up. “I’ve had that same experience a few times. What is it with guys? They get all excited as if the only thing they care about in the whole world is going to bed with you, and then when you finally get them alone, they can’t finish what they started. The first time it happened to me, I couldn’t figure it out. Had I done or said something wrong? Had he discovered some repulsive physical flaw of mine that had turned him off so completely?”

Deanna jumped in. “I know exactly what you mean!” The women were all enjoying themselves now, sharing stories of false male bravado and their underlying frailties, while the men at the table listened silently, gamely pretending to be unaffected personally by any of the stories.

"I understand now that it’s got little to do with me and all to do with men and their performance issues,” she continued. “And I know I’m supposed to be understanding. It’s just that I don’t always feel like being understanding. What I feel like saying to them is, ‘You’ve been working it all night, and I’m ready for you now. If your equipment isn’t responding properly, why don’t you just get some popsicle sticks and tape them to your penis like a splint so you’ve got something hard enough to go inside me. You weren’t so shy when you got me here all butt-naked!’ ”

The women were all screaming with laughter at this point, and people were staring at the table to see what the commotion was about. Deanna turned to the men at the table, challenging them as a group. “So tell us, O great warriors of the bedroom, what is a woman to do if her man can’t get it up?”

The four men at the table glanced sheepishly around at the others, none particularly interested in volunteering to be the lightning rod for this kind of attention. Finally, Paul spoke up: “I know I speak for all the men here when I say that nothing of this sort would ever happen with any of us!”

“Hear, hear!” yelled the other men laughing, with beer mugs clinking and high-fives all around. “No, seriously,” said Trudy. “What does a woman do in that situation to help the guy out? We never know what to do. We’re afraid to be too passive, yet we don’t want to put more pressure on you guys by being too aggressive either. If we just roll over and go to sleep, we’re afraid you’ll feel rejected, and we’ll make the situation even worse.”

“Needless to say, I have no personal experience with this problem myself,” offered Ken, “but I have a ‘friend’ who told me about something that happened to him a long time ago. Of course, it only happened the one time in his entire life.”

“Sure. A good friend, right, Ken?” teased Judy.

“He was a teenager when it happened,” Ken continued, “and it was the first time he was trying to have sex with this particular girl. They were at her home, and her parents were out for the evening. Just as he was about to go inside her, he heard a noise and thought her parents were coming home. It was a false alarm, but by now it was too soft to go in. It was like trying to play pool with a limp noodle.”

“What did the girl do?” asked Trudy.

“She tried everything, but to tell you the truth, once the penis went soft, it didn’t matter what she did. It was as if she wasn’t even in the picture anymore, except as the target where he needed to hit a bull’s-eye.”

“I know that feeling where the guy just disappears into his own brain,” said Judy. “Once this guy is walking around my bedroom with his head hanging after things weren’t, um, progressing, and he’s just talking to himself as if I weren’t even in the room. I got fed up, waved at him, and said ‘Yoo-hoo! Remember me?’ ”

“It wasn’t about you anymore, Judy. It was all about the guy’s penis at that point,” explained Laurence, as if he had some personal insight into the experience.

“Exactly!” said Deanna. “One more example of the misguided male thought process. They just think too much when it comes to their penis. I learned to just jump on a guy when I first start in with him so that he doesn’t have time to think about it and get nervous.

Thank goodness Viagra is around now to help the weaker sex.” “Amen to that!” exclaimed Mark, who had been strangely quiet up to this point, and everyone laughed.

The Male Performance Imperative

Ours is a society focused on performance. We look up to those who have what Ernest Hemingway, himself the heavyweight champion of supermacho authors, called grace under pressure, like Mayor Giuliani of New York City after the terrorist attacks on the World Trade Center, or President Kennedy staring down the Russians during the Cuban missile crisis.

We even treat our best athletes as heroes, particularly those who are “clutch performers”—those men and women who come through at times of greatest pressure: the one who takes the last shot as the game is on the line and the scoreboard ticks off the last seconds.

At the other end of the spectrum are those individuals who perform poorly under the hot lights of observation. These poor men and women, sometimes no older than boys or girls, are said to “choke.” Bill Buckner was an otherwise decent Boston Red Sox player who botched an easy play during the World Series in 1986, and the Red Sox went on to lose a championship that had appeared all sewn up for them.

Although Bill Buckner must have excelled throughout his life in order to make it to such a high level in baseball, he was reviled afterward in Boston and is remembered now only as the player who choked, “a loser.” It is a narrow view of life when one sees only two possibilities with any opportunity: to be the hero or to be the goat. Yet this is often how men see themselves. “If I succeed, I’m a winner: if I fail, I’m a loser.” Boys grow up with fantasies of being in do-or-die situations.

This is what propels fantasies of heroic wartime rescues, critical athletic moments where there is one last chance for success, and even comic book scenarios. When I was a child, I used to imagine that I was Superman trying to avert global disaster as a huge meteor hurtled toward earth. This boyhood “training” can create pressure-cooker situations out of ordinary circumstances.

A woman may not understand why her husband becomes so agitated and sweaty as he fights traffic trying to get to the airport on time. But she never incorporated into her essence the unspoken rule governing a variety of male actions: success is critical because “the fate of the universe hangs in the balance.” A woman may be upset if the couple arrives late to the airport because of the practical problems that stem from this, but she may be stunned by the man’s reaction, as if he has failed in his manly duty and is thus a “loser.”

One of the few human endeavors that fails to improve with concentration and determination is creating an erection. “Relax, relax” is easy to say, but completely counterintuitive for a man when things are going wrong sexually.

Moreover, the moment a man has any doubt that he is performing well sexually, he is likely to panic at the inevitable thought that his penis might not work at all on this occasion and that he will be unable to complete what he sees as an all-important event.

A Woman’s Power to Heal

When a man and woman have gone through the buildup leading to a sexual encounter and the penis fails to respond or, even worse, the erection disappears just before “the moment of truth,” it is disappointing to the woman as well. While the man tries to figure out how to deal with this embarrassing situation, the woman must deal with her own set of issues. Not only may she feel frustrated, but she may even feel as if she needs to play the part of an amateur psychologist in order to salvage the situation, by helping the man achieve an erection again or feel okay so that they can try again another time. As Laurence said, this may not be easy for the woman to do once the erection has failed, because the man may be so focused on his own drama.

But some women tell remarkable stories about how a failed erection moved their relationships forward. “I knew Sean as a friend for quite some time before we started dating, and I really cared for him,” began Bonnie, “but the first time we went to bed together, I could tell he was nervous, and it just didn’t work out. I was disappointed, naturally, but I felt worse for Sean. He always acted like this cool, tough guy, but he seemed so sad the way he was sitting on the edge of the bed.

“Finally, I took his arm and pulled him toward me, saying ‘I’m so cold. Please come close and keep me warm.’ When he lay back down, I snuggled into him and told him all the things I liked about him. When I told him I thought he was really sweet, he looked up at me and said, ‘Really?’ like he couldn’t believe it. Then I told him I didn’t need to have sex with him that night, but I did want to be able to lie close to him and to feel his hands and body on me.

“We had a wonderful night. Sean was tender with me in a way I had never imagined he could be. He had always been kind of macho when we had kissed before, as if he was playing a role right out of some gangster movie, but not that night. He was like a sweet puppy dog, kissing me all over. It didn’t take long before he had a great erection, but I was enjoying Sean so much that I wouldn’t let him put it in for the longest time. When I finally let him, it was fantastic for both of us. Sean still acts tough in public and around his buddies but never with me. We got engaged a couple of months later. “I think Sean just needed to hear that I liked him for who he really was, and then the penis took care of itself.”

As Bonnie’s story so nicely demonstrates, if the goal of sex is intimacy rather than performance, then the absence of a firm erection need not interfere with lovemaking. Indeed, in some cases, it may provide an opportunity for different types of pleasurable interactions, both physical and emotional.

“It’s All in My Head”

When men hear the term psychogenic impotence, they often translate it into casual language: “Oh I get it. You think it’s all in my head.” Although this is true, because the problem is all in their head, it doesn’t mean they are crazy. People have this idea that a man with a psychological cause for his impotence must have had a strange relationship with his mother when he was four years old, or that he needs to be dressed up in women’s clothing in order to achieve an erection. Those cases do exist, but they are quite rare.

All it really means is that the anxious thoughts are getting in the way of the body’s usual response to a sexual situation. Instead of the blood vessels within the penis filling up with blood, the adrenaline release that accompanies anxiety makes the blood vessels constrict, like a kinked hose, and the penis then fails to become firm.

It amazes me how evolution has created the wonderful biological system that we call the human body. One of the strongest responses in the body is the reaction to fear, called the fight-or- flight response. My colleague, Dr. Alan Altman, has a nice way of explaining how the fight-or-flight response applies to male sexuality. Imagine if, as a caveman, you were confronted suddenly with a saber-tooth tiger.

Your choices are two: to battle it out (“fight”) or to run away (“flight”). Adrenaline is released throughout the body to help in this situation by increasing the heart rate and blood pressure, which helps to pump oxygen to the brain and the large muscles of the arms, legs, and torso.

But having a stiff penis would only get in the way with either running or fighting. Part of the fight-or-flight response is thus to make sure that the penis stays soft. Since anxiety is a trigger for the fight-or-flight response, this explains why being nervous in a sexual situation leads to poor or absent erections.

The medical world is still a little confused about psychogenic impotence. Although Viagra has been shown to be particularly effective for men with a “shy penis,” many physicians still believe that men should work through this problem on their own rather than take medication for it.

I recently lectured to a group of 120 Danish physicians who were visiting the United States and described two cases to them. One was a married man in his sixties who had progressive difficulty with erections over several years and had high blood pressure as well as diabetes, both of which can contribute to erectile dysfunction on a physical basis. The second case was a young, healthy single man who was unable to achieve an erection with a new partner because of anxiety and who then continued to have difficulty for several weeks.

When I asked how many of the audience would offer to treat the first man with Viagra, every hand went up. When I asked about the second man, only three hands were raised. This response surprised me somewhat, since the young man has a better chance of a successful result with Viagra than the older man did. But this episode reinforced my impression that the medical community is still resistant to the idea that healthy men should take any form of medication to help with sex.

Their attitudes instead are that the man should somehow work it out on his own, as if he just hasn’t tried hard enough. Or maybe it just wasn’t meant to be. But in any case, nearly all of these doctors thought that they shouldn’t be getting involved in such cases.

I disagree entirely with this attitude. Men with psychogenic impotence suffer greatly from their inability to have satisfying sexual relationships. It is wonderful that we live in an age where there is a safe and effective medication that may help. Nevertheless, as we shall see, sometimes Viagra works, and sometimes it doesn’t.

When Does It Work, and When Does It Not?

Here are two examples of recent cases where I’ve tried to use Viagra for men with performance anxiety.

Matt was forty-one and had been dating Melissa, age thirty-four, once or twice a week for almost two months.

Matt told me this story plainly, always maintaining eye contact with me. “Melissa was so sexy, and she would get me so excited. But she had a thing about going ‘all the way.’ She wanted to be sure, she said, before she gave herself to me. That’s how she put it—‘gave herself to me.’ I was feeling like it was all a little silly and even thought about ending our relationship, but Melissa finally said,

‘Okay, in three Saturdays, we’ll do it.’” She kept talking about it and e-mailing me about it: ‘Be ready for me!’ she would say. “When the day finally came, I was ready. Or so I thought.

Melissa was to come meet me at my apartment at 10:00 A.M. I was waiting for her in my best pajamas. I figured we were going to go straight to bed and get busy. But she was dressed in nice clothes and had put on makeup, like we were going out to dinner at a fine restaurant. I tried to take her into the bedroom—I’d been waiting and waiting, after all, just for this moment—but she wasn’t ready yet.

“ ‘Can I have a drink first?’ she asked me.

“ ‘But it’s only ten o’clock in the morning!’ I exclaimed.

“ ‘Please,’ she asked again. ‘Do you have any red wine?’ “After a drink and some frustrating small talk, I tried getting her into the bedroom again, but she wouldn’t go. She made some comment about my not having gotten dressed yet. So even though it was only about 11:00 A.M. on a Saturday, I went into my room, changed into a suit and tie, and came back out to the living room. She smiled, told me I looked nice, and asked for another glass of wine. After another twenty minutes or so, she took my hand and led me to the bedroom. I figured, ‘What the heck, women are weird, but I’m finally learning how to play the game right.’ Was I ever wrong on that last score!

“We step into the bedroom, and Melissa starts to take off my tie and undo my shirt. I’m starting to get excited now. She won’t kiss me yet, though, which was odd, because that was the one thing she’d always been happy to do with me. I start to try to take off her shirt, and she stops me, saying, ‘Not yet. It’s too bright in here.’

“It’s true; it was bright. It was daytime, after all, and a sunny day too. My blinds didn’t block the sun too well, but that had never bothered me. But it sure bothered Melissa. So picture this: we both end up balancing on the radiators, taping blankets over the windows in my bedroom to cut out the daylight! I’m standing there in my underwear, and she’s still wearing her nice clothes.

“Finally it was dark. So then she wanted a candle. I go into the kitchen to get a utility candle and light it. Now she’s happy. She pulls off her clothing, and she is absolutely ravishing. I’d never seen her naked before. She pulls me onto the bed. I’d been waiting for this moment for so long. But I couldn’t get it up. Nothing. Zilch. Nada. After all that buildup too.”

“So, what happened?” I asked.

“Well, she worked on me for a long while. I felt stupid. I felt like my body had betrayed me. I’d been an athlete in school and could always rely on my body. But that day, it let me down. I felt like I didn’t really want to be there. I would have preferred to go for a run and work up a sweat. Finally, she says, ‘I think you need a bath to relax you.’

“She gets me into the bath. Brings in the candle. Starts soaping me with a washcloth. It felt good. She gets in the tub behind me and washes my back. Before you know it, I get a little hard. Melissa climbs around, straddles me, and gets me inside. We had sex that way, even though I was never completely firm.

“It wasn’t a complete failure, you know, but it was embarrassing. I liked thinking of myself as a sexually successful guy, but I was pathetic that day. She said, ‘Don’t worry about it,’ but I felt lousy.

“We’ve tried to do it a few times since then, but it’s never been good. Sometimes I’m hard enough to go inside, but I’m thinking the whole time about whether I’m going to lose it completely. Most of the time, it won’t get up at all. Even weirder is that I can ejaculate sometimes, even though my penis isn’t hard. Is that normal?” “It can happen,” I answered. “Ejaculation has a separate set of controls from erection and can take place even when the blood vessels in the penis don’t fill up all the way.”

“I know I’m not impotent, Doctor. I got freaked out when this happened and worried that something had happened to my body. I know it doesn’t sound too nice, but I was going crazy, and so I called up an old girlfriend and visited with her a couple of times.

Everything worked out great. I don’t like her as much as I do Melissa, but she and I had always been in tune with each other sexually. She never made me put up with that first-time crap. Anyway, that’s how I know this is all mental for me.”

“Well, it seems you’ve made an accurate diagnosis for yourself. How can I help you?” I asked.

“Doctor, I’m really sweet on Melissa, despite our problems. And maybe I just want to know that I can get it right sexually with her. I don’t know. But I was wondering if you thought Viagra might help me out with her.”

I went over the rest of his medical history and gave him an examination. Everything was in order. I prescribed Viagra. Matt came back to see me the following month. He smiled when I walked into the room.

“How are you, Matt?” I asked.

“Great, Doctor. Thank you for the Viagra. It worked! The ship has been righted! I used it only a few times, and then I figured I didn’t need it anymore. I’m back to normal. Now that the sex is okay, though, I have to figure out whether Melissa is right for me in other ways. I just received a job offer in Seattle, to start in another two months, and Melissa and I are trying to decide whether she should come out to be with me.”

Matt was the best kind of Viagra cure. Once he regained his confidence in his own ability to have sex, he didn’t need the medication at all anymore. Unfortunately, it doesn’t always work out that way.

A Viagra Failure

William was a thirty-year-old muscular man whom I’d originally met when he did some contracting work on my house. One day, long after the job was completed, he called me at the office and told me he was having sexual problems with a new girlfriend. His regular doctor had prescribed Viagra, but it hadn’t helped.

I was surprised, since sudden difficulty with erections in a healthy man is almost always a psychological problem, and as we saw with Matt, Viagra is usually effective in that situation. I wondered if William was taking the Viagra properly.

“William,” I said over the phone, “I’m about to leave town and won’t be able to see you in the office for at least a week. In the meantime, let’s see if we can’t get things working for you right away. This sounds situational, related to something going on between you and your new friend Julie. Viagra usually works for this, so let’s make sure you’re taking it properly. What dose are you taking?” “I started with one pill, 50 milligrams, and then when it didn’t work, I took two of them, 100 milligrams, the next time.”

“How many times have you taken 100 milligrams?”

“About four or five times now.”

“Do you give the medicine time to get into your system?”

“Yeah. I do what my regular doctor told me to do: I take it at least one hour before we try to have sex.”

“Good. Do you take it before or after meals?”

“I haven’t paid any attention to food,” said William. “Is that important?”

“Yes, it is. If you take Viagra with anything in your stomach, even alcohol, it can slow down how quickly the medicine is absorbed. It may not work as well, or it may just take a lot longer before it starts to work. Some guys who take it after a heavy dinner don’t notice any effect until the next morning.”

“I didn’t know that,” he said.

“Tell you what,” I said. “Why don’t you try the Viagra a few times again, 100 milligrams, and call me next week. If things aren’t right, we’ll make arrangements to see you in the office. Pay attention to the food issue. My suggestion is that if you guys are going out for the evening, you take the Viagra about thirty to sixty minutes before you start eating and drinking. It stays in your system for a good six hours, so if you took the pill at 6:00 P.M., for example, you’re probably all set until midnight or so.

“I really think that you’re just freaked out by the whole thing right now, and that if you have one or two successes with Viagra, you won’t need it anymore.”

I hadn’t had time to get into too much detail on the phone with William, but he did tell me that he and Julie had been successful sexually twice, then not at all. There was no question in my mind that there was nothing wrong with William on a physical basis and that the problem stemmed from something that had happened between William and Julie.

William was young and healthy, and had normal erections right up until the moment of his difficulties. When a man starts having troubles suddenly, there are only a few possibilities as to what may be causing it: new medications or increased dose of a medication, new major medical events such as surgery, or a bad accident—or the problem is situational.

By situational, I mean there’s something about the man’s situation that isn’t right. It may be anxiety or feeling awkward. Perhaps he is angry at his partner. Perhaps the woman is angry at the man and thus not providing the usual sexual signals that give the man the encouragement he needs.

In any case, I was confident that Viagra would work for William. A study presented at the national urology meeting showed that 40 percent of men who said that Viagra didn’t work for them could have success if they were instructed properly in its use.

The biggest issue is to take it on an empty stomach. Because William hadn’t paid attention to this, I thought there was an excellent chance of success if he took the dose before meals.

William called me again the next week. “It’s no better,” he said. “I did exactly what you told me, but I don’t notice anything different with the Viagra. It’s like trying to stuff a marshmallow through a keyhole.”

“Let’s see if there’s anything physically wrong,” I told William over the phone. I arranged for him to undergo some tests and then to see me afterward.

William came to my office the next week. We shook hands again. “Thanks for seeing me,” he said. “It’s strange to see you as my doctor, but it’s cool. This is hard stuff to be talking about, but at least I know that I can trust you.”

“I know it’s a little strange, but it’s okay,” I said, smiling. “This is what I do,” and I invited him to sit down. “William, you’ve told me a little on the phone, but why don’t we start by having you tell me what’s been going on with you and Julie.”

“There’s not much to tell,” he said. “I met Julie about two months ago, and we hit it off right away. Sex was fine the first two times we did it, but the third time we got together, my penis never came up at all. I can’t explain it. I wasn’t nervous or anything. It just didn’t happen. We’ve tried a million times since then, with and without Viagra, and I’m never really hard with her. Every once in a while, I get semi hard, enough to get in, but it’s a disaster. It just doesn’t want to get hard.”

“Was there something different that third time with Julie?” I asked.

“Not that I can think of.”

“Are you taking any medications at all?”


“Have you had any injuries around the penis or between your legs, like falling on the crossbar of a bicycle, or something like that?”


“Have you woken up with an erection in the morning or in the middle of the night since you’ve started seeing Julie?”

“No, Doctor, and that’s part of what’s making me crazy. I’m afraid there’s something wrong with me. Everything is just different!”

“Can you masturbate and get a firm erection that way? Recently, I mean.”

“I’ve tried, Doctor, I’ve tried. It kind of works that way. Not great, but it’s there. I’ve done it with and without Viagra. But it’s almost as if the penis doesn’t have the same feeling anymore, like it’s dead. I’m afraid there’s something wrong down there.”

I gave William a physical examination. He was in great shape, very muscular, and with an all-over tan he achieved by going to the tanning salon on a regular basis.

“William, there’s something I’m not getting here. Your physical examination is normal. I’ve looked over your test results too, and everything is in order. In fact,” I said, showing him a graph, “this is the nighttime test you took with the bands on your penis that record any erections. Each night, the body tries to achieve several erections, associated with dreams. You can’t be nervous when you’re asleep, so we get, in a sense, a picture of your ‘pure’ erection.

If you look here, you can see that you had four erections each night, with some of them lasting as long as forty-five minutes. Most important, you had excellent rigidity during those erections.”

“I don’t get it. What does this mean?” he asked.

“It means that when your brain isn’t thinking about how you’re doing, your penis is able to achieve excellent erections. The blood vessels and nerves in your penis are just fine, but not even Viagra can give you an erection if your mind says no.”

“So there’s nothing wrong with me physically, is that what you’re saying?”


William sat back in his chair, reflecting on this information. “I guess that’s a good thing.” He was quiet for a moment. “So this is all in my head? Is that what you’re saying?” he said more calmly. “Yes. Tell me again what happened that third time with Julie. I think that’s where the secret lies. I’m certain there was something different that third time. What do you remember about that night?”

William looked down at his open hands, sighed, and looked up at me. “Can I be honest with you?” he asked. He gulped. “Truth is, I kinda feel like I’m out of my league with Julie. She’s aggressive sexually in a way that I’m not used to. One night when we had first started seeing each other, I was driving her home and she starts unbuttoning my shirt while I’m driving on the highway, rubbing her hands all over my chest while nibbling at my neck. It was amazing we didn’t drive into a tree.

“That third night that things didn’t work out? We were having drinks, and she asked whether I’d ever been with more than one woman at a time. I’ve never done anything wild like that. In fact, I don’t think I’m very wild at all. I asked her back if she’d been with more than one guy, and she tells me about this party she’d been to a few years back. She’d been drunk and took a nap in one of the bedrooms. Two guys came in to talk to her, and she ended up doing it with both of them at the same time.

“I think she thought it would get me excited, but it bothered me. I don’t think I’m a prude, but I didn’t want to hear about her with other guys, especially doing stuff like that. I could never do that. I’d be too nervous. Listening to her made me feel like I was an uptight stiff.”

William paused. He flexed his chest muscles and arms, stretched, and looked up at me with a sheepish smile. “This is probably the kind of thing you were getting at, isn’t it?” he asked. “Have you ever considered the possibility that Julie might be spending time with you because she likes you?” I asked. William laughed loudly. “That’s too obvious! No, I never even considered that. I have this crazy idea that a woman would be interested in me only if I have something special to offer, like my Harley motorcycle or big biceps from working out at the gym. She still tells me stories about sex with other guys and asks me about my experiences. I’ve always loved sex, and it’s always felt exciting to me at the time, but my stories all seem dull compared to hers. And I feel weird telling them in the first place. I don’t think it’s right for us to talk about sex with old lovers. Maybe I am uptight. Julie acts as if it’s important to be open about this stuff, but it gives me the willies. What do I do about it?”

“Have you ever told her that?” William shook his head no.

“Tell her to stop. Tell her it makes you crazy to think about her having sex with other men. She should be flattered. But the important thing is that you need to do what it takes so that you can be comfortable with her.” I let this sink in before I continued. “Let me get something straight, William. Apart from the sexual stuff, do you like Julie?”



“We have a great time together, Doctor. We’re always laughing. We like to do a lot of the same things.”

“Good. Does she know you’re here with me today?”

“No way.”

“Does she know you’ve tried Viagra?”


“Okay. Here are my recommendations. First of all, tell her you came to see me. Let her know this has been important enough for you so that you decided to see a specialist. It will free you from the pressure of keeping a secret. Give her a chance to be your ally instead of your obstacle. Next, it is critical that you have sex only when you are feeling like having sex.”

“I don’t get what you mean. I always feel like having sex.”

“I don’t believe that. In fact, I bet you almost never really, truly feel like having sex with Julie anymore. Most guys in your situation have lost that loving feeling. But I am also sure that there are some times that you do feel at least a little aroused by her. Those are the times you should try.

“It’s a funny thing about Viagra,” I continued. “A lot of guys think that Viagra will give them the erection they want, no matter the circumstances. But it’s not true. A man needs to be sexually excited if Viagra is going to work. Viagra does not work for men who feel that sex is a chore!”

The next morning, my secretary came to my office to tell me that William was waiting to see me. William was smiling from ear to ear. “I’m sorry to bother you, especially without an appointment,” he blurted out, “but I had to tell you what happened. After I left your office, I went to find Julie. I told her I didn’t want to hear anything anymore about any other guys. I told her it freaked me out to hear about that stuff. I even told her that it made me feel inadequate, like I wasn’t wild enough for her tastes.”

William paused to catch his breath. “It was amazing what happened afterward. She started crying and telling me over and over that she was sorry. She said she was just trying to impress me, because she figured I’d been with a lot of women. She said she liked the fact that I hadn’t been so wild, that maybe she could trust me, unlike previous men in her life. She said she just liked spending time with me. She snuggled up next to me so tight while she was talking and crying, and I got this terrific hard-on. We ended up having an incredible day and night of sex. And guess what?” William raised both arms straight to the ceiling as if signaling a touchdown. “No Viagra,” he shouted.

“William, you’re cured!”

Learning from Viagra

The male preoccupation with sexual performance can create enormous anxiety, which may make it impossible for the penis to function at all. When this happens, men tend to see their failure in dramatic terms and may feel that their inability to achieve an erection at one given time means that they are a loser or inadequate. The next time a man tries to have sex, he is likely to be worrying if the penis will respond properly, which may make the situation even worse.

Viagra can be an effective treatment for many men with this type of erection problem. If there is sexual excitement present, Viagra will help the penis achieve good rigidity. Matt was a great Viagra cure because he needed to take it only a few times before he regained confidence in himself sexually. Many men say that just feeling their penis becoming hard makes them more excited, and Viagra may help in this way too.

Some single men who are on the dating circuit use Viagra every time they start a new sexual relationship in order to avoid the frustration and embarrassment that they may have experienced in the past with a “shy penis.” Although this is not a standard medical indication for the use of Viagra, I have no objections to prescribing it for this situation.

It makes perfect sense to me. But I also recommend that if these men want to continue the relationship, a time comes when they should tell their partners that they’re taking Viagra and why, so they can talk through some of the issues or anxieties and see if continuing this medication is really necessary in the long run.

The Viagra Myth is that a pill can solve all our sexual problems.

But life is more complicated than this. William had lost his sexual feeling when he was with Julie, and Viagra couldn’t help him because the feeling just wasn’t there. Instead of feeling aroused, he felt as if he needed to get over a hurdle. Sex was a challenge, and he approached it the way he would a weight machine at the gym: with hard work. Once William was honest and open with Julie and she responded favorably, the sexual feeling came back, and he didn’t even need Viagra.

Curiously, some women have found that the man’s inability to achieve a firm erection provides an opportunity for a different type of connecting: one in which the man is more vulnerable and in some ways more accessible to them emotionally. Being accepting of the man, whether or not he is “performing well,” can unleash in him a flood of warm, positive feelings, which is likely to cause warmth and firmness in the penis as well.


Men too frequently see sex as a performance rather than as a shared activity with their partner. Unfortunately, this creates pressure for a man, which may make it difficult for him to achieve an erection. This is called performance anxiety or psychogenic impotence.

A number of things can contribute to an occasional failed erection, including stress, alcohol, recreational drugs, fatigue, and relationship problems.

If a man has failed at achieving an erection one time, it is inevitable that the next time he tries, a part of his brain will be busy assessing whether the penis is hard enough and wondering if it will work properly. Naturally, this process interferes with sex and makes it even more difficult to achieve a good erection. If a man fails a few times in a row, he is likely to lose all confidence in his ability to perform sexually.

Men tend to think too much about their penis. Many women have learned that if their male partner is in the dumps about his psychogenic erectile dysfunction, they will do well to jump straight to penetration before he has time to think himself out of his erection!

Viagra can be an effective “jump-start” for many men who have psychogenic erectile dysfunction.

Viagra does not solve the underlying issues in relationships that may precipitate the difficulty in lovemaking. The best solution is often to clear the air by discussing what feels bad to each person.

A failed erection may turn out to be an opportunity for a different kind of physical and emotional intimacy that may truly benefit a relationship.

Source: Abraham Morgentaler, M.D., F.A.C.S., is an associate clinical professor at Harvard Medical School and director of Men's Health Boston. An expert in the field of male sexual function and dysfunction, he is the author of The Male Body: A Physician's Guide to What Every Man Should Know About His Sexual Health (1993) and has published in such prominent medical journals as The New England Journal of Medicine, The Lancet, and The Journal of the American Medical Association. This is a chapter from his latest book, The Viagra Myth.  

Petite Pink Pill Promotes Female Libido

To its detractors, flibanserin, a pink pill targeting female libido and made by Sprout Pharmaceuticals, is just another example of disease mongering. Disease mongering refers to the practice of pharmaceutical companies and others "pathologizing" aspects of the human condition in order to make a buck. For example, halitosis or bad breath only became a condition that needed treatment after Listerine was developed to "treat" it.

However, to its supporters, female sexual interest/arousal disorder is a very real disease, and flibanserin can help. These supporters cite the distress caused by a diminished or nonexistent sex drive.

What is female sexual interest/arousal disorder?

Female sexual interest/arousal disorder refers to a reduction or absence of sexual interest in a woman that lasts 6 or more months and causes distress or interpersonal difficulties. Moreover, such disinterest is unattributable to another disease (think diabetes or depression) or drug (think antidepressants). It's important that this loss of sexual desire causes distress or difficulty because, otherwise, it's not really a problem. After all, lots of people have a long-standing disinterest in sex that doesn't cause personal problems, and this is fine.

Researchers posit that female sexual interest/arousal disorder involves complex brain circuitry controlling reward processing. Specifically, this condition affects frontostriatal pathways and neuronal projections of the insula, amygdala, hypothalamus and ventral striatum.

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In women with such sexual interest and arousal issues, sexual motivation and pleasure are adversely affected. Of note, aberrant reward processing slices into other psychiatric disorders including depression, schizophrenia, substance abuse, dementia, eating disorders and other sexual disorders.

Interestingly, researchers have discovered changes on functional MRI that suggest macrocircuit anomalies attributable to female sexual interest/arousal disorders. For instance, women diagnosed with this disorder exhibit abnormal activation in the brain's cortical and striatal regions.

How does flibanserin work?

It's really difficult (impossible) for scientists to measure specific neurotransmitter levels in different parts of the brain. However, using microdialysis techniques and nodes within brain networks, researchers postulate that flibanserin increases the release of both dopamine and norepinephrine and reduces the release of serotonin in women with reduced sexual interest and desire. More specifically, flibanserin can distinguish between serotonin receptors and stimulate serotonin 5HT1A receptors while blocking serotonin 5HT2A receptors in the prefontal cortex thus increasing the downstream release of dopamine and norepinephrine. Apparently, these combined neurotransmitter effects help better regulate reward processing and increase feminine libido.

Of particular note, flibanserin works on neurotransmitters not hormones. Although hormones have proven effective in boosting libido, adverse effects make them too risky as treatment. Moreover, flibanserin is not "female Viagra." Viagra works by increasing blood flow to the genitals using a completely different mechanism and affecting a different site of action (genitals vs. brain).

Results from 2 clinical trials titled BEGONIA and DAISY (ah, names of flowers ... how cute!) suggest that flibanserin can increase feminine libido. Combined, these randomized and placebo-controlled trials examined 3548 women with sexual interest and arousal disorder. After 24 weeks of once-daily treatment with 100 mg flibanserin, satisfying sexual events, sexual desire and distress caused by low sexual desire were measured using various (subjective) questionnaires. Researchers observed that in participants taking flibanserin--as compared with those taking placebo--there was an increase in number of satisfying sexual encounters and level of sexual desire and a decrease in distress caused by low sexual desire.

Serious adverse events in these trials occurred in fewer than 1 percent of participants, and none of these serious events were attributable to flibanserin treatment itself. Less serious adverse effects included dizziness, nausea, fatigue and sleepiness (most common).

Another randomized- and placebo-controlled trial named SNOWDROP (I'm seeing a pattern, here ... another flower name!), examined 949 postmenopausal women with female sexual interest/arousal disorder (technically hypoactive sexual desire disorder--a DSM-IV-TR term that has since been modified to sexual interest/arousal disorder in DSM-5). Much like the other trials, results indicate that fibanserin improves sexual desire, number of satisfying sexual events and reduces sexual distress all while causing few adverse effects. Specifically, 37.6 percent of women on flibanserin versus 28.0 percent of women taking placebo reported satisfying sexual events.

Although in some of these studies researchers attempted to include participants taking antidepressant medications, antihypertensives, triptans and some antifungals, one major limitation of these studies is sampling bias. In other words, because issues with sexual arousal and desire are pervasive and affect all types of women, it was hard to test whether flibanserin works in everyone.

Citing concerns about safety and efficacy, the FDA has refused to approve flibanserin twice--rejections with which its maker, Sprout Pharmaceuticals, and others take issue. From a medical treatments perspective, I definitely sympathize with the FDA's concerns. After all, flibanserin tools with several neurotransmitters and considering that many of the women who will take the drug will also be taking other drugs that further alter neurotransmitter levels--like antidepressants and anxiolytics--it's best to take a cautionary stance.

I honestly don't know what to think of flibanserin. On the one hand, I'm sometimes suspect of pharmaceutical companies and their intentions. I understand that if approved, flibanserin may be overprescribed to certain women like those who experience no distress related to a paucity of sexual desire or arousal. On a related note, everything about Sprout's marketing of flibanserin screams manipulation including the pill's pink color and floral-monikered clinical trials. On the other hand, I'm a man with a penis and all its associated circuitry--I have no idea what it feels like to be a woman with female sexual interest/arousal disorder.

Selected Sources

Article titled "Efficacy and safety of flibanserin in postmenopausal women with hypoactive sexual desire disorder: results of the SNOWDROP trial" by JA Simon and co-authors published in Menopause: The Journal of The North American Menopause Society published in 2013.

Article titled "Mechanism of action of flibanserin, a multifunctional serotonin agonist and antagonist (MSAA), in hypoactive sexual desire disorder" by SM Stahl published in CNS Spectrums in 2015.

Article titled "Improving prospects for treating hypoactive sexual desire disorder (HSDD): development status of flibanserin" by J Thorp, Jr, and co-authors from BJOG published in 2014.

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