From Christmas 2008 - Ten years of Viagra
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Roxana Whelan on dilemmas of men's sexual health.
A man has a quick consultation. You deal with the problem and hand over a prescription but he hovers. 'Actually there's something else, doctor… err, I'm seeing this lady and, well, I'm having problems. I was wondering, err, you know those tablets…?'
This scenario has become more familiar over the last ten years because of new therapies for erectile dysfunction, greater media attention, and hence greater public awareness of the problem.
The issue of men's sexual health is not often covered in Christian medical publications. Triple Helix ran an article  on Viagra when it was first licensed in 1998, but since then the issue has hardly been considered. We frequently read about abortion, contraception and teenage sex, but rarely about male sexual dysfunction.
A US study showed that 52% of men aged 40-70 experienced some degree of erectile dysfunction (ED), while 10% experienced complete erectile dysfunction.  Premature ejaculation is also common, affecting up to 40% of men  while hypoactive sexual desire affects 15%. 
We know men consult doctors less frequently than women do.  Reasons include busyness and lifestyle stress, but also embarrassment, reluctance to admit to problems, and fear. Sexual problems carry a particular taboo. Visiting a doctor about a sexual problem not only introduces an embarrassing topic but acknowledges that all is not well in the bedroom. This can feel like an admission of guilt, failure or weakness, or even a threat to one's masculinity. There is also a common belief that nothing can be done anyway.
The advent of the contraceptive pill and the legalisation of abortion in the 1960s have led to a radical change in attitudes towards sex and relationships. In 1960 the marriage rate for men was 62 per 1,000 (62 out of every 1,000 single men married each year). This had dropped to 28 per 1,000 by 2000. By contrast the divorce rate in 1960 was 1.7 per 1,000 married men, rising to 12.7 per 1,000 by 2000.  The age at first marriage has also risen. People are more likely to have sexual relationships before marriage and to start new relationships at various stages of life.
Viagra (sildenafil) celebrates the tenth anniversary of its British licence this year. Previous therapies were unappealing, ineffective, or little known. Some unlicensed therapies were helpful, while recreational drugs were often used to enhance performance. Viagra's arrival made a big splash; seductive advertising in the medical press was paralleled by provocative headlines nationally. People became aware not only that erectile dysfunction was common, but something could be done about it. That something could be as simple as taking a tablet obtained on prescription.
On the one hand was a sense that 'everybody's doing it', yet on the other the taboo remained. To obtain Viagra a man had to admit to his doctor there was a problem. Fuelled by demand, many private clinics and providers sprang up, and the internet became a common source of supply. The blue diamond-shaped tablet became recognised across the globe, a symbol of sexual freedom and rejuvenation for men, as the contraceptive pill had been for women. A problem which had been hidden under the bed-clothes for years suddenly came into the limelight and competitors brought other oral treatments onto the market.
Christian doctors will meet a range of men requesting Viagra or similar treatments, or asking for help with sexual problems. Each man will have his own situation. Some will be married, some cohabiting, some in a new relationship, some having an affair. Some will be in homosexual partnerships. Some will be engaging in casual sex. Some may even be perpetrators of abuse.
So what is the dilemma? Is there a dilemma at all? Is erectile dysfunction purely a medical problem which needs to be managed with the best available treatment, whatever the context? Or is there an ethical and moral dimension too?
By its very nature, a sexual problem has several dimensions. Erectile dysfunction is not merely the inability to achieve an erection. Emotionally, it often causes anxiety and loss of self-esteem, and socially, it affects the man's relationship, often leading to awkwardness and insecurity. The partner's response may be loving and accepting, or there may be tension and arguments. The security of the relationship may become conditional on the man's performance. Erectile dysfunction may not only be the cause but the manifestation of emotional problems, relationship difficulties, or spiritual issues such as guilt.
As doctors we need to explore not only what is happening physically but what is happening emotionally, socially and spiritually. Is the relationship compatible with the patient's value system, or is it a source of guilt? Is it a healthy relationship? Is there pressure to have sexual intercourse? We may be able to tease out other issues which need addressing. There may be a mental health problem which requires treatment. There may be issues which would be helped by counselling. There may be problems within the relationship which need to be tackled, possibly with the help of a third party such as Relate.  The man may need to think carefully about whether he is in the right relationship.
Having explored these issues, the problem may persist and we have to decide: are we going to prescribe or not? What would God have us do in these situations? In the Bible we read that sexual intercourse is given by God to unite a man and a woman within marriage: 'For this reason a man will leave his father and mother and be united to his wife, and they will become one flesh'.  The Ten Commandments forbid adultery,  and both Jesus 0 and Paul  endorse this. Does this mean we should decline to prescribe Viagra and the like to men who are not married?
We know many of our patients have different beliefs, and hence different lifestyles, from our own. Jesus taught we should not judge others.  He demonstrated this with the woman caught in adultery, but then told her to 'go now and leave your life of sin'.  Paul specifically taught that we should not judge those outside the church.  The GMC guidelines on Personal Beliefs and Medical Practice  state that we should not impose our personal beliefs on patients, nor should we allow our beliefs to prejudice their care. But we are required to obey God rather than men.  The dilemma is this: is a prescription in certain circumstances tantamount to condoning sin? Or does failure to prescribe constitute passing judgment?
There are no easy answers, and the decision will ultimately be a matter for each doctor's conscience.  It will also depend on the individual situation. For a man in a consenting adult heterosexual relationship, it could be argued we should respect his lifestyle choice and provide treatment for his medical problem. We could argue that those in long-term relationships are living 'as if married' and should be treated as such. While most Christians would view homosexual partnerships as wrong,  we must be careful not to judge the couple. And we must be aware of GMC guidelines and recent legal changes on discrimination. Where we feel unable to prescribe, patients are entitled to a second opinion if they are unhappy with our decision.
We also have a duty to protect both our patients and others. Somebody requesting Viagra for a series of casual relationships is putting his physical and emotional health at risk, and may spread sexually transmitted infections to others. Somebody having an extramarital affair is harming his wife. One would have strong grounds for saying 'No' in these situations. A man having intercourse with a minor of either sex is acting illegally, and we should take appropriate action.
Whether or not we eventually prescribe in these situations, we may be able to introduce some of God's values within the consultation. One useful question is 'How important is sex within your relationship?' This gently challenges the assumption that it is all-important. Encouraging couples to shift the focus away from sex and to spend more time talking or enjoying each other's company in other ways can be helpful. It may be necessary to challenge the attitude of a partner whose love has become conditional on sexual performance.
Finally we turn to the case of married men with erectile dysfunction. Often they are more reluctant to come forward and discuss their problems. Yet here we need to affirm God's gift of sex within marriage,  encourage them to talk, and at least to consider therapeutic options. We need to communicate that this is an important issue worth exploring.
Men's sexual problems are common, and present in various scenarios. While we should uphold the Bible's teaching about sex within marriage, we need to respect our patients and not to judge. Individual doctors will draw the line in different places about prescribing medication for erectile dysfunction. In all situations, we should bear in mind our patients' emotional and spiritual needs as well as their medical ones, and also the wellbeing of other parties.
1. Anon. Viaggro. Triple Helix 1998;
2. Travison T et al. The Natural
Progression and Remission of Erectile Dysfunction: Results from the Massachusetts Male Aging Study.
Journal of Urology January 2007;241-246
3. Ejaculation Problems: Factsheet.
Sexual Dysfunction Association. May 2007.
4. Brosman S. Erectile Dysfunction.
5. Kapur N et al. Primary care consultation predictors in men and women: a cohort study.
BJGP 2005; 55(511):108–113
6. Benson H. UK Marriage Statistics, taken from Office of National Statistics.
7. Relate: the relationship people.
8. Genesis 2:24
9. Exodus 20:14
10. Matthew 19:4-9
11. 1 Corinthians 6:15-20
12. Matthew 7:1-5
13. John 8:1-11
14. 1 Corinthians 5:12-13
15. Personal Beliefs and Medical Practice. General Medical Council 2008
16. Acts 5:29
17. Romans 14
18. Romans 1:26-27Article written by Roxana Whelan