03wienke.pmd

MALE SEXUALITY, MEDICALIZATION,
AND THE MARKETING OF CIALIS AND
LEVITRA1
Chris WienkeDepartment of Criminology, Sociology, and GeographyArkansas State UniversityState University, AR 72467(cwienke@astate.edu) New treatments for male impotence have proliferated since Viagra’s popularemergence on the market in 1998. Two such therapies recently received FDAapproval for prescription use: Cialis and Levitra. This paper examines themarketing campaigns for Viagra’s competitors and asks whether these treat-ments offer a different discourse on impotence. Using advertising and promo-tional materials, the study focuses on the major discursive themes related tothe promotion of these drugs. The study finds that while the marketing cam-paigns for Cialis and Levitra employ most of medicine’s traditional discourseson impotence, they emphasize several additional discursive strategies to helppromote these drugs in the competitive impotence treatment market. The au-thor suggests that these promotional themes have important implications forthe medical project of constructing the “sexually functional” male body. Inconclusion, the author argues that these new drugs and the discourses theycirculate introduce new standards for sexual functioning and medicalize areasof male sexuality not previously seen as requiring medical repair.
Introduction
The introduction of Viagra, the first oral treatment for impotence, has changed the way men view problems with sexual performance.
Sexuality & Culture, Fall 2005, Vol. 9, No. 4, pp. 29-57.
Sexuality & Culture / Fall 2005
Today, men are more inclined to define and treat their performanceproblems as medical problems than ever before, thanks in largepart to Viagra. Perhaps as a result of Viagra’s success, as both apharmaceutical product and as a cultural phenomenon, there is anow a burgeoning range of rival therapies for the treatment of im-potence. Two such therapies recently received FDA approval forprescription use: Cialis, an impotence treatment drug developed bythe pharmaceutical companies Eli Lilly and Icos Corporation, andLevitra, another pharmaceutical option being launched by Bayerand GlaxoSmithKline.2 Like Viagra, both drugs treat impotenceby increasing blood flow to the genitals under conditions of sexualarousal, thereby enabling the achievement and maintenance of a“normal” erection.3 Their advent thus reflects an increasinglymedicalized way of thinking about men’s sexual problems and theirtreatment. Medicalization occurs when areas of life not previouslyconsidered medical are redefined as problems requiring medicalanalysis and management (Conrad & Schneider, 1980). Impotence,or what health experts call “erectile dysfunction,” has become onesuch example, with impotence medication exemplifying this trend(Mamo & Fishman, 2001).
At present, Viagra, the blockbuster drug marketed by Pfizer Phar- maceuticals, dominates the impotence treatment market, vastly out-selling alternative therapies, including penile implants, vacuumpumps, injectibles, and urethra suppositories. The drug, which an-nually generates 1.5 billion in sales for Pfizer, has been used byover 20 million men worldwide, easily making it one of the mostpopular prescription drugs in recent history (Doonar, 2003). Avail-able for prescription use only since 1998, Viagra has already be-come a household word synonymous with treating impotence.
However, with new drugs now entering the market, Viagra’s statusas the treatment of choice appears less certain. According to indus-try analysts, the emergence of Cialis and Levitra marks the firstserious challenge to Viagra’s control over the anti-impotence mar-ket4 (Gannon, 2003). Whether the makers of Cialis and Levitra canmount a challenge strong enough to rival Viagra will depend onthe marketing strategies they use to sell these products. Both drugmakers have begun to market their products aggressively through Marketing of Cialis and Levitra 31
direct-to-consumer advertising,5 and plan to match or outspendPfizer’s $90 million advertising budget for Viagra (Howard, 2003).
This paper analyzes the marketing campaigns for Cialis and Levitra to see what kinds of promotional strategies are emphasizedand whether they offer a different medical discourse on impotence.
The study focuses on the major discursive themes related to thepromotion of these drugs and considers how they contribute to theproject of medicalizing male sexuality. I develop this focusthrough a discourse analysis of educational and promotionalmaterials about Cialis and Levitra. The materials analyzed in-clude advertising and Internet promotional literature as well asmedia coverage in popular periodicals. Analyzing such materi-als is one way of sorting out the strategies used by drug makersto market these products. This approach also illuminates the dis-tinctive logic used to medicalize this particular aspect of male sexu-ality. As sources of medical-pharmaceutical knowledge, these textsconstitute marketing sites for potential consumers. Through ana-lytical readings of these materials, the paper will shed light on thesecond wave of pharmaceuticals to enter the male sexual consumermarket.
I begin this paper by examining the historical shifts in construc- tions and treatments of impotence, and the rise of medicalization asthe sociocultural model of choice. Then, after a brief description ofthe data collection process, I present the findings from my analysisof websites, advertisements, and media coverage of Cialis andLevitra. Here I argue that while the marketing campaigns for Cialisand Levitra employ most of medicine’s traditional discourses onimpotence, they emphasize several additional discursive themes tohelp promote these drugs in the competitive impotence treatmentmarket. My findings reveal four general themes regarding the pro-motion of these drugs, which I identify as (1) technological ad-vancement; (2) natural sex enhancement; (3) symbolic appeals tohegemonic masculinity; and (4) nonmedical, lifestyle usage. I sug-gest that these promotional themes have important implications forthe medical project of constructing the sexually functional malebody. In conclusion, I argue that these new drugs and the discoursesthey circulate introduce new standards for sexual functioning and Sexuality & Culture / Fall 2005
medicalize areas of male sexuality not previously seen as requiringmedical repair.
Impotence and Medicalization
Historical and sociological investigations of impotence reveal how medicalization has transformed unacceptable erectile perfor-mance into a subject for medical analysis and management (Hall,1991; Mumford, 1992; Tiefer, 1994). Although men have beenconcerned about impotence for centuries, only recently, with therise of sexology in the nineteenth century, has it been explicitlydefined and categorized as a medical problem.1 Prior to the latenineteenth century, impotence was often treated as an unwelcomeexperience, an unacceptable behavior, a personal trouble, an ir-regularity, even a sign of perversion. The focus was more on thebehavior than on organic sexual differences. For example, in the1800s, “an anonymous writer in the Lancet gave warnings againstadvising men with ‘questionable powers’ to marry . describingthem as ‘as a rule, inexpressibly nasty’” (quoted in Hall, 1991:115). This writer, like others at the time, attributed this behavior tothe effects of long-continued masturbation and previous excessiveintercourse, both of which violated the codes of sexual respectabil-ity and the ethic of self-discipline (Hall, 1991). Only when impo-tence became redefined as a medical problem did people come tosee it as a distinct, pathological condition associated with individualidentity. When the focus shifted from the behavior to the individualman, impotence was no longer considered a perverted act. It wasnow considered a psychological or physical sickness that requiresmedical attention.7 The pathologization of impotence that emergedat the turn of the century provides one instance of how the institu-tions of science and medicine have medicalized and controlled de-viant male bodies and sexualities (See Foucault, 1979).
The construction of impotence as a medical problem was, until recently, thought, in most instances, to be a psychological problemand thus the domain of sexology, psychiatry, and therapeutic inter-ventions that emphasize treatment for the couple. In recent years,however, the diagnosis and subsequent treatment of impotence has Marketing of Cialis and Levitra 33
moved to the physiological domain as biomedical experts isolatedthe physical mechanics of erectile functioning. In the followingquote, Leslie Horvitz, a medical writer for Insight Magazine, re-flects this shift in emphasis, while at the same time framing impo-tence in a way that is very different from the terms used by theanonymous author of the 1800s quoted above: The penis contains two chambers, called the corpora cavernosa, filled withsmooth muscles, fibrous tissues, veins, and arteries. To achieve an erection,the smooth muscles must relax, allowing blood to fill the open spaces andexpand the penis. Any illness or disorder that interferes with the normalfunction of the circulatory system can lead to impotence . [including]heart disease, stroke, diabetes, kidney disease, chronic alcoholism, athero-sclerosis, and vascular disease. Smoking is a particularly grave factorsince it impedes circulation over time . [Impotence] also can occur be-cause of injury . [and is] linked to prescription drugs for ailments such ashypertension and depression (1997: 39-40).
One result of this shift in medical thought has been the develop- ment of a range of technologies designed to treat erectile dysfunc-tion, from injections to erection pills to aphrodisiacs like Yohimbinehydrochloride to surgical implants. Indeed, the technologically-en-hanced erection has become the leading edge of America’s multi-billion dollar impotence treatment industry. Initially, biomedicaltreatments were limited primarily to prosthetic implants—a type ofsurgery that enables erections with or without sexual stimulationand removes physical sensation. However, such treatments havebeen prone to malfunction and re-operation; thus few patients haveopted for surgical treatments (Tiefer, 2001). By the 1980s, penileinjections (a type of therapy that produces an erection by chemicalmeans) became common, although later studies showed high drop-out rates among patients using this method (2001). Today, Viagra,the first oral medication to be approved for impotence, has becomethe treatment of choice. The drug, which costs approximately $8per pill, is reasonably inexpensive compared to other treatmentmethods, and, given in pill form, is also less painful and invasive touse.8 Although access to Viagra legally requires a physician pre-scription, public demand for it has resulted in loose medical regula-tion (Carpiano, 2001). In fact, the diagnosis of impotence hasrecently become an almost entirely self-assessed condition, based Sexuality & Culture / Fall 2005
on a 15-item impotence-evaluation instrument (Marshall, 2002).
The instrument, which was developed by the Center of Sex andMarital Health in New Jersey, is used widely by both specialists(urology) and primary care physicians (the family doctor). With theadvent of Internet pharmacies, which sell Viagra and other medica-tions, medical-pharmaceutical treatments have become even easierto obtain. Such sites provide patients a way to bypass direct contactwith physician intervention (Marshall, 2002). In doing so, they elimi-nate the need for face-to-face counseling, allowing patients to avoidaddressing other possible causes of their condition and other plau-sible treatment options (Carpiano, 2001).
Social researchers have attributed the current wave of medicalized impotence and its treatment to a range of social and economic fac-tors. According to Tiefer (1994), the contemporary investment inthe biomedical construction of impotence derives from an indirectcoalition among urologists, medical-pharmaceutical industries, massmedia, and various entrepreneurs. These groups have actively pro-moted a medical view of impotence at the expense of other viableconceptual frameworks, such as political, feminist, and social con-structionist (Gagnon, 1977; Segal, 1990; Parker, Barbosa, andAggleton, 2000). Cultural norms of masculinity, combined withphallocentric9 constructions of sexuality, have also contributed tothe rise of medicalized impotence. Within Western culture, imagesof manhood are closely tied to ideals of sexual potency and theability to achieve an erection (Zilbergeld, 1992). At the same time,sexual socialization teaches men to view intercourse as the primarycomponent of sexual activity, and anything else as foreplay,afterplay, or special needs (Tiefer, 1994; Fracher & Kimmel, 1995;Potts, 2000). Therefore, when men encounter erectile problems,they may feel like their masculinity is threatened and their sexualityis unnatural or deviant. Medicalized impotence offers men an ex-planation for their problems that lessens cultural stigmatization,thereby relieving men of blame and individual failure even in theface of impotence (Tiefer, 1994). The availability of technologicaltreatments, in turn, offers men the tools in which to manage sexualconformity and to preserve masculine power and confidence (Loe,2001). Consequently, men (and their partners) have become a re- Marketing of Cialis and Levitra 35
ceptive audience to quick-fix technological solutions as opposed tosocial or psychological remedies (Tiefer, 1994; Fracher & Kimmel,1995; Carpiano, 2001). Indeed, as Meika Loe (2001; 2004) hasargued, the popularity of Viagra and other treatment technologiesis in part a response to a crisis of masculinity in modern societies,stemming from the gains of women’s liberation and female sexualempowerment. Richard Carpiano (2001) also attributes the popu-larity of these medicalized treatments to cultural and personal cri-sis, arguing that public demand for impotence medication played abigger role in creating the Viagra craze than the medical field itself(See also Hepworth & Featherstone, 1998).
Today, the pharmaceutical industry is the main driving force be- hind medicalized sexual problems and the rise of sexual medicine.
Many factors have contributed to this, not the least of which are therecently deregulated pharmaceutical industry, the increasingprivatization of biomedical research, and the growing commercialappeal of “lifestyle” drugs10 (Tiefer, 2004). These developmentshave created a favorable climate for drug companies to promoteand produce sexual medicine. While several medicalized therapieshave emerged to “manage” women’s sexual problems, themedicalization of male sexuality continues to be the focus of sexualresearch, product development, and marketing (Loe, 2004). Therecent launch of Cialis and Levitra exemplifies this continuing trend.
Hailed as viable alternatives to Viagra, these drugs have the poten-tial to become the next blockbuster treatments for erectile prob-lems.
As a social researcher with an interest in male sexual medicalization, I wanted to examine the marketing campaigns forCialis and Levitra to see if these treatments offer a different dis-course from Viagra on medicalized impotence. To this end, I con-ducted a discourse analysis of texts offering promotional informationabout Cialis and Levitra. Discourse analysis involves a close read-ing of texts to explore the production and distribution of knowl-edge in society (Mamo & Fishman, 2001). I use advertising, Sexuality & Culture / Fall 2005
promotional materials, and media coverage in newspapers andmagazines because these texts constitute marketing sites for poten-tial consumers. In other words, these are the kinds of texts thatconsumers might read as they attempt to make sense of impotence,its treatment, and the availability of treatment options.
The materials analyzed include the official web sites for Cialis and Levitra, print and television advertisements,11 and over 150newspaper and magazine articles on Cialis and Levitra, spanningthe time when knowledge of these drugs first broke to the immedi-ate aftermath following their FDA-approval in 2003. I analyzedthe media coverage precisely because the mass media routinelypublicize and promote new medical technologies for men’s sexualproblems12 (Tiefer, 1994). As Teifer (1994: 368) writes, “By quot-ing medical ‘experts,’ using medical terminology, and by swiftlyand enthusiastically publicizing new devices and pharmaceuticals,the mass media legitimize, instruct, and model the proper construc-tion and discourse. People underline and save ‘sex health’ articles,and . bring in such material . [during patient-doctor visits].” Iused Lexis-Nexis to locate articles offering information on Cialisand Levitra, specifically searching for those that offered details onpharmaceutical marketing strategies. I eliminated several types ofarticles from my final sample because the coverage made too sparsemention of the drugs to be of value or because they representedsyndicated columns repeated in other newspapers under new head-lines.13 Of the roughly 150 articles collected in my initial search, 46were selected for in-depth analysis. My sample included businessnews, commentaries, and science and health reports.14 In my analysis, I adopt Stuart Hall’s (1980) argument that the meanings encoded into texts, such as advertisements or Internetpromotions, contain a preferred reading. As readers, we can “makesense” of texts precisely because they suggest a certain set of pos-sibilities to us, encouraging us to locate an intended or preferredreading of the texts and the encoded meanings contained withinthem (White & Gillett, 1994). While texts cannot guarantee thedecoding of those meanings, readers are unlikely to be able to ig-nore the preferred reading. As Duncan notes, “responsible textualstudies do not assert without absolute certainty how particular texts Marketing of Cialis and Levitra 37
are interpreted. But they suggest the kinds of interpretations thatmay take place, based on available evidence and likely interpreta-tions of a particular text. Ultimately these interpretations must bejudged on the basis of the persuasiveness and logic of theresearcher’s discussion” (quoted in White & Gillett, 1994: 23).
My analysis of websites, advertisements, and media coverage of Cialis and Levitra reveals four general themes regarding the pro-motion of these drugs: (1) technological advancement; (2) naturalsex enhancement; (3) symbolic appeals to hegemonic masculinity;and (4) nonmedical, lifestyle usage. In the first section below, Iargue that the materials about Cialis and Levitra construct thesedrugs as state-of-the-art technologies that promise users optimalerectile results. Next, I argue that these texts promote a presump-tion about what is natural about male sexuality, and represent Cialisand Levitra as technologies that return men to a “natural” state ofsexual intimacy. In the third section, I explain how the imagery ofprofessional sport is used in advertising texts to promote a sym-bolic link between these drugs and hegemonic masculinity. Finally,I argue that these materials construct Cialis and Levitra as lifestyledrugs for the improvement of male sexual satisfaction, whether ornot users have “legitimate” sexual health problems. In outliningthese discursive themes, I draw on exemplary texts and discusshow each theme, to varying extent, contributes to the medicalizationof male sexuality. I suggest that, taken together, these themes workto reposition the medical boundaries of the “sexually functional”and “dysfunctional” male body.
“We’re Not Talking Your Daddy’s Viagra”: Cialis and Levitra asTechnological Advancements The marketers for Cialis and Levitra employ most of biomedicine’s discursive strategies, portraying men’s sexuality in biomedical terms,defining the causes of impotence as physiological, and toutingmedical intervention as the proper response to impotence. At thesame time, however, marketers have advanced several additionalstrategies to construct their products as superior alternatives to otherimpotence technologies, especially Viagra. One way marketers have Sexuality & Culture / Fall 2005
promoted Cialis and Levitra as preferable solutions is by appealingto modernist assumptions about technological advancement. Themarketers for both drugs base the superiority of their products ontheir ability to outperform competing technologies in all areas ofsexual functioning. To legitimate this claim, marketers have publi-cized the results of clinical studies15 that validate their drugs as fasteracting, longer lasting, and having fewer side effects than Viagra,the current treatment of choice. By making these clinical differ-ences central to their promotional campaigns, marketers have dis-cursively established Cialis and Levitra as state-of-the-arttechnologies while simultaneously constructing competing tech-nologies as obsolete.
For example, unlike Viagra, which enables erections for a lim- ited period of time (usually between two to four hours), marketerssuggest that Cialis, after ingested, remains effective in the body forup to 36 hours. Because of its relatively long lasting results, adver-tisers have already labeled Cialis “the weekend pill.” As one mediareport explains, the drug “can be taken on a Friday and its effectsmay still be felt on Sunday morning” (Foley, 2002). The makers ofLevitra, on the other hand, have distinguished their drug fromViagra by marketing it as faster acting. Clinical tests have shownthat Levitra takes effect within 15 minutes after ingestion, com-pared with 40 to 60 minutes for Viagra.16 This difference is impor-tant, marketers claim, because it “allows you a certain level ofspontaneity” (quoted in Gannon, 2003). In addition, both drugs areclaimed to produce fewer side effects than Viagra, which someusers complain causes abnormal vision, headaches, indigestion anddiarrhea, and work even after eating a full meal while Viagra worksbest on an empty stomach.
The theme of technological advancement was evident in most media stories on Cialis and Levitra. Such stories not only toutedCialis and Levitra as “new and improved” erectile dysfunction prod-ucts but also depicted competing products as outdated technolo-gies. For example, in addition to repeating findings from clinicalstudies, media stories often included testimonials by men who havetried different treatment options. An early 2003 article from theChicago Sun-Times illustrates how this literary device adds legiti- Marketing of Cialis and Levitra 39
macy to the marketing theme of technological advancement. In thearticle, the author tells the story of Manfred Weber, a Viagra userwho plans to switch to Levitra: “After more than 40 years of mar-riage, ‘things weren’t working so well anymore,’ he says. He triedViagra a few times, but it gave him headaches. After taking Levitrain a clinical trial, the headaches stopped. ‘It brought my wife and Icloser to each other again,’ says Weber, 65. With that trial over, heis biding his time with an occasional Viagra until Levitra is ap-proved in this country” (Fuhrmans, 2003). The author of anotherarticle also uses a testimonial of man who prefers the new treat-ment options over Viagra, in this case Cialis. In one of his quotes,the unnamed man appears to be parodying the tagline for a recentViagra ad (“Let’s just say [Viagra] works for me”). He says, “I willstick to Cialis because unlike Viagra it works for 24 hours—thatcertainly works for me. It’s great” (emphasis added; Young, 2003).
In media stories such as these, where individual accounts of satis-fied customers are found, the media collaborates in publicizing andpromoting the marketing theme of technological advancement: itcompares new treatment options with Viagra and finds them to bepreferable solutions precisely because they offer men the possibil-ity of a “better” sexual performance.
In addition to testimonials, several media stories also included accounts from marketing researchers hired to oversee product fo-cus groups. Such accounts explicitly reflected marketers’ claimsabout technological advancement. A recent article on Cialis inBusinessWeek illustrates the use of this strategy. In the article, theauthor relates the story of a researcher who was hired by Eli Lillyto gauge consumer reaction to Cialis. During one of the focusgroups, the participants, whose husbands all suffered from impo-tence, were asked to watch a prospective TV commercial for thedrug. The voice-over in the ad advised: “Introducing Cialis. Youcan take Cialis anytime and have up to 36 hours to respond to yourpartner, without planning or rushing.” The researcher observed thegroup from the other side of a one-way mirror, while the group’smoderator tried to flesh out the main source of the group’s interest.
As the researcher observed their reactions, she saw one of the par-ticipants leap out of her chair and shout “Thirty-six hours! Yeah!” Sexuality & Culture / Fall 2005
According to the report in the article, the researcher had never seena focus group in her 15-year career of monitoring such groups getas excited as they did about a product. “It was a marketer’s dream,”she says (Arndt, 2003). Apparently, what makes the drug “amarketer’s dream” is that even participants in focus groups recog-nize it as a technological breakthrough that extends the male body’ssexual capacities.
In this account, as in others provided to journalists by industry representatives, Cialis and Levitra are depicted as progressive dis-coveries in the scientific search for solutions to a sexual health prob-lem. This theme, which is reflected in media reports andmanufacturer publicity, contributes to the medicalization of malesexuality in at least two ways. First, it provides a justification formedicalization. The emphasis is placed on the novelty, sophistica-tion, and advantages of these technologies. There is little in thesematerials that offers men an alternative to the scientific discourse ofmedicalized impotence. Instead, the new treatments are portrayedas sophisticated additions to the reining paradigm of medical man-agement. Second, the materials that reflect this theme extendmedicalization into previously undiagnosed areas of male sexual“health.” The specific sexual concerns emphasized in these mate-rials are extended to include the timing of erectile response, theduration of erectile readiness, and the side effects of erectile inter-ventions. By emphasizing the efficacy of Cialis and Levitra in pro-ducing faster-acting and longer-lasting erections with fewer sideeffects, these texts broaden the clinical framing of male sexual func-tioning to include the ability to respond immediately to sexual urges,to respond to sexual urges without planning or rushing, and to func-tion sexually with few unwanted health effects. In this way, themedia and marketers collaborate in medicalizing areas of male sexu-ality not previously requiring medical help.
Sex the Natural Way: Cialis and Levitra as Nature’sEnhancements In playing up these technological advantages, the narratives sur- rounding these products simultaneously play on cultural assump- Marketing of Cialis and Levitra 41
tions about what is “natural” about men’s (and women’s) sexuality.
In addition to enhanced performance, the marketing campaigns forthese drugs center on their products’ ability to simulate a “natural”sexual response unencumbered by time or rational calculation.
Unlike Viagra, which takes effect up to an hour before (and stopsbeing effective a few hours after) sex is planned, marketers forCialis and Levitra promise results that mimic the “natural” sexualcycle, which is spontaneous, worry-free, and uninhibited by exter-nal considerations. In doing so, marketers have discursively estab-lished a link between nature and technology. The marketing impliesthat, through these drugs, users will return to a natural state of sexualintimacy. Of course, the very idea of “natural” sex invoked in themarketing of these drugs is itself a sexual script, shaped by societaland cultural assumptions (Gagnon, 1977). Associating sex withspontaneous feeling is thus a discursive strategy that constructs sexas natural.
The emphasis on Cialis and Levitra as technological-enhance- ments for natural sexuality was apparent in the media coverage ofthese drugs. Media stories routinely quoted medical experts andpharmaceutical spokespersons in the promotion of this theme. Thefollowing quotes from Carole Copeland, a spokeswoman for EliLilly and Icos, were found in the New York Times and the BostonGlobe: “Men tell us that, when they take other pills, they feel likethey’re on a stopwatch and that adds to the pressure they alreadyfeel. They would like a treatment that would disconnect taking atablet from intimacy” (quoted in Harris, 2003a). Cialis, on the otherhand, “offers a longer window of opportunity for intimacy, andthat’s what men and their partners say they miss most when theyhave erectile dysfunction: those special moments that just comenaturally” (quoted in Goldberg, 2003). Viewed in such terms, itwould appear that Cialis restores control to the body and its bodilyfunctions in ways that Viagra and other technologies do not. WithCialis, control returns to the body because the drug acts throughthe body’s natural processes of arousal. A recent news report onLevitra reflects a similar sentiment regarding the relationship be-tween control and nature, noting that “Viagra users are as con-trolled by the clock as a prisoner during conjugal visits: You have Sexuality & Culture / Fall 2005
to wait two hours after a meal before taking it, then wait anotherhour for it to kick in, then hustle up and get your business donewithin four hours, before the little warden says visiting hours areover. Levitra, by contrast, doesn’t interact with food, and workswithin 20 minutes” (McDougall, 2003).
The advertisements for these drugs also emphasize the theme of technology as an enhancement for natural sex. This theme wasparticularly apparent in the ads for Cialis. In a promotional cam-paign entitled “Choose the moment,” marketers for Cialis have cre-ated a number of television spots with scenes of couples snugglingand slowly caressing “to emphasize cozy, tender, or playful mo-ments” (Arndt, 2003). A soundtrack of easy, laid-back jazz accom-panies these visual images. In addition, the scenes in the ads arelengthened so that the camera seems to linger with each couple, asubtle reminder that with Cialis there is no hurry. The voice-overadvises: “When the moment is right, you’ll be ready.” A similarrepresentation appears on the first page of the Cialis website. Thecaption reads, “Cialis is here. Will you be ready?” Accompanyingthe caption is an image of a middle-age couple bathing side by sidein adjacent bathtubs—a signifier for romantic activity. Below therepresentation appears a heading entitled “What is Cialis?” underwhich a description of the drug is provided: “Cialis is a prescrip-tion medication . shown to improve erectile function . up to 36hours following dosing.” (www.cialis.com, 2004). A recent onlinead for Cialis makes the fusion of technology and nature even moreexplicit, claiming that the drug “works twice as fast as Viagra .
[and] lasts 9 times longer . so you’ll never miss the moment again.”The visual accompanying the written text features a younger het-erosexual couple, without clothes, gently holding and caressingone another. The reader is unable to tell whether the sexual “mo-ment” has begun or ended. The image thus enhances the meaningbehind the textual message: unlike Viagra, Cialis works in waysthat reflect the body’s “natural” urges, freeing couples to engage inspontaneous, worry-free lovemaking.
Marketing these drugs as enhancements to natural sex may seem contradictory, given that it is only through technological assistancethat “natural” lovemaking is made possible. The spontaneity prom- Marketing of Cialis and Levitra 43
ised by drug makers depends on the use of technology, along withthe medical assumptions that inform that use. The physiologicaleffects of these drugs may produce the feeling of flexible, trouble-free lovemaking, but only within the confines of technological sur-veillance, regulation, and control. To reconcile this apparentcontradiction, the marketers for Cialis and Levitra have reified theirtechnology “as more natural than natural” (Mamo & Fishman,2001: 22). When sexually aroused, the body sometimes loses con-trol (impotence), causing a breakdown in the sexual script of natu-ral sexuality. With Viagra, control is restored to the body, but in anunnatural way, restricted by time and other considerations. Cialisand Levitra, on the other hand, incorporate technology within the“natural” body in a seamless way, such that it is difficult to tellwhere the body leaves off and the technology begins. Through thisconstruction, the use of technology becomes the natural act (Mamo& Fishman, 2001: 21-22).
The link between technology and nature in these marketing ma- terials has other important implications for the medicalization ofmale sexuality, specifically with regard to constructions of sexualfunctioning. The materials suggest that sexual functioning involvesmore than the mere ability to attain and maintain an erection for thepurpose of sexual intercourse. Rather, it involves doing so natu-rally according to the body’s organic cycle of sexual arousal. Bymarketing these drugs as technologies capable of facilitating a “natu-ral” sexual response, these texts present a new guideline for assess-ing functional male sexuality and its reparable deviations. Here“natural spontaneity” becomes a boundary point between sexualfitness and sexual deviation.
“Tackling Men’s Health”: The Marketing of Cialis and Levitrathrough Popular Sport With the possible exception of sex, few cultural idioms are in- voked as often in advertisements aimed at men as that of the worldof professional sport (Renson & Careel, 1986; Grove et al., 1989).
Corporate advertising campaigns for products ranging from beer toshaving cream regularly use sport to appeal to men. At the same Sexuality & Culture / Fall 2005
time, professional sport provides advertisers an ideal setting forreaching large male audiences. Sporting events, especially televisedones, attract millions of male viewers each week (Sage, 1998). Giventhis advertising tradition, it should not be surprising to find that theimpotence treatment industry has turned to professional sport as aplatform for marketing its products. Viagra’s sponsorship of MajorLeague Baseball is one such example. In fact, Pfizer recently phasedout its previous Viagra spokesman, former presidential candidateBob Dole, in favor of Rafael Palmeiro, the Texas Ranger firstbaseman who recently hit his five hundredth home run. Pfizer alsosponsors a Viagra car on the NASCAR racing circuit, and duringmany of the races provides a van where fans can receive free test-ing for erectile problems.
The marketers of Cialis and Levitra have continued this trend through sponsorships of other professional sport leagues and throughcampaigns headed by other sport celebrities. The makers of Levitra,for example, recently secured a $20 million package with the Na-tional Football League, which will air television advertisements forthe drug during games, and have hired Mike Ditka, the ex-NFLplayer and coach, as a spokesman. In addition to exclusive leaguesponsorship, the Levitra makers have cut individual deals with anumber of NFL teams. The makers of Cialis, on the other hand,were recent benefactors for a racing yacht in the America’s Cup,and have sponsored NCAA Men’s Basketball and the ProfessionalGolf Association. At present, Cialis does not have a sport celebrityspokesperson.
As a cultural medium, sport is ideal for advertising because it is one of the few sites in which a large number of men are regularlyassembled, but it is the symbolism of sport which inscribes prod-ucts in advertisements with cultural meaning. This is true in themarketing campaigns for impotence treatment drugs. In the case ofCialis and Levitra, marketers are using the symbolism of sport toappeal to “hegemonic masculinity”: the socially dominant concep-tions, cultural ideals, and ideological constructions of what is ap-propriate masculinity (Connell, 1987). Competitive sport, especiallycontact sports like football, embodies many of the valued charac-teristics of hegemonic masculinity. These include physical strength, Marketing of Cialis and Levitra 45
skill, aggression, control, force, athleticism, and heterosexuality(Messner, 1992). In this way, then, sport is not just a cultural me-dium but a masculine medium, in which “the combination of skilland force” in athletic experience becomes a defining feature ofmasculine identity (Connell, 1987: 85). Marketers of products likeCialis and Levitra depend on such symbolism to sell their products,thereby appealing to potential users’ aspirations to attain or main-tain hegemonic masculinity (Mamo & Fishman, 2001: 23). In dis-cussing Levitra’s sponsorship of the NFL, a spokeswoman forBayer explains: “We are talking to men in a language they canunderstand.” This language is evident in a number of recent advertisements for Levitra. As part of a promotional campaign entitled “TacklingMen’s Health,” the advertisements feature the football legend, “Iron”Mike Ditka.17 Known for his toughness, aggressive manner, andunrelenting resolve, Ditka publicly symbolizes all that is valued incurrent constructions of hegemonic masculinity—the highly skilledand powerful body, the supposedly virile heterosexuality, and com-petitive achievement. Ditka’s presence, like Dole’s before him, isintended to destigmatize erectile dysfunction. However, unlike hispredecessor, whose image appeals primarily to older men, Ditkaprojects a more phallic-like image. In the ads, Ditka speaks franklyabout his own difficulties with sexual health and his attempts toovercome them. At the same time, he uses his experiences in pro-fessional sport to connect with the targeted audience. The ads, whichrun the tagline “Stay in the Game,” compare Levitra’s use for erec-tile dysfunction to the physical sacrifices involved in athletic com-petition, including playing through pain and injuries. In one of theseads, Ditka advises, “Any coach will tell you that you need to stayin the game.” The statement, which should be familiar to anyoneacquainted with the values of competitive sport, reflects a core les-son in traditional athletic socialization: sport involves physical sac-rifice, even at the expense of pain. Within sport, physical sacrificeis glorified as a legitimate, even necessary means to achieving indi-vidual and team goals. Athletes are taught to play in pain, to sacri-fice their bodies for particular pursuits, and that to do so iscourageous and manly (Sabo, 1995). This unrelenting emphasis Sexuality & Culture / Fall 2005
on physical sacrifice in sport has contributed to the normalizationof pain and the subsequent provision and legitimation of pain medi-cation (i.e., “painkillers”), an occurrence that, in effect, medicalizesmasculinity in competitive action (Messner, 1992).
In the ad for Levitra, marketers have established a new twist on this old lesson: just as athletes need to manage physical discomfortto remain competitively active, men with erectile dysfunction needto manage sexual discomfort to remain sexually active. This twistdeftly constructs Levitra as a legitimate, and perhaps necessary,recourse for male sexual action. In this way, Levitra becomes onemore tool in the project of managing functional masculinity. Likepainkillers for athletes, Levitra medicalizes masculinity. The drugtransforms the limits of the male body so that men can be “men”again.
Another ad featuring Ditka aired exclusively during the 2004 Super Bowl, an event that regularly reaches 60 to 70 percent of thehouseholds watching television (Sage, 1998). In the ad, Ditka dis-cusses the differences between football and baseball, a subtle re-minder that Levitra sponsors the former, and Viagra the later. HereDitka compares erect manly-men to football, able to play in anyweather conditions, as opposed to baseball, with fragile playerswho do not even play when it rains. “Baseball needs Levitra,” saysDitka. The ad, which suggests an attempt by marketers to distin-guish their drug from Viagra, uses a sport analogy to transmit amessage about Levitra and its competitive rival. Apparently, Levitra,like football, is tough and enduring, while Viagra, like baseball, issensitive to external conditions. This distinction discursively posi-tions Levitra as the more masculine of the two products, and itsmedical effects as more potent.
In sport-theme ads like this one, the imagery of sport is used to symbolically link erection products to hegemonic masculinity. Theads, which appeal to men’s aspirations to attain or maintain hege-monic masculinity, essentially promise consumers masculineachievement through the use of a pill. As in the example above, theads attribute masculine characteristics to these products, essentiallyconstructing them as tools for assembling masculinity (Loe, 2001: Marketing of Cialis and Levitra 47
115). Here masculine identity itself becomes attainable with thehelp of medical intervention.
Making Sex Better: Cialis and Levitra as Lifestyle Products A recent television advertisement for Levitra features a young man, looking barely 30, trying to throw a football through a tire.
Initially, he misses, hitting the tire’s side. However, after Levitra ismentioned, he shoots the ball straight through the tire again andagain, and is joined by an attractive young woman, presumably hiswife. The voice-over says, “Sometimes you need a little help stay-ing in the game. When you’re in the zone, it’s all good.” The ad,which has aired repeatedly over the past half year, accomplishesseveral things in transmitting a message about Levitra. First, it ef-fectively symbolizes the sexual activity for which the product isdesigned to treat with no taint of obscenity or pornography. This isexpressed through the image of a man penetrating a tire with a ball.
Second, and perhaps more importantly, the ad reflects an attemptby the makers of Levitra to market the drug to a youthful, presum-ably “healthy,” male demographic, men who, according to oneadvertising executive, “just need a little help with [their] aim.” It isthrough the imagery and message of ads like this one that Levitra isconstructed as a lifestyle drug. Such ads are intended to appeal notonly to men with impotence but also large segments of the malepopulace, whether or not they have bona fide medical problems.
The construction of Levitra as a lifestyle product, as opposed to a remedy for a health-related problem, represents a shift in the mar-keting of impotence treatment technologies. For example, in Pfizer’sinitial advertising campaign, Viagra was marketed to mature audi-ences as a medical treatment for erectile failure caused by age-re-lated conditions (Marshall & Katz, 2002). In the original print andtelevision advertisements, the company featured spokesman BobDole and images of white-haired couples dancing. Pfizer insistedat the time that it was not trying to encourage recreational use amongotherwise healthy men. By contrast, GlaxoSmithKline and Bayer,the co-marketers of Levitra, boldly admit their attempts to expandthe impotence treatment market through appeals to recreational use.
Sexuality & Culture / Fall 2005
Unlike Pfizer, whose initial goals for Viagra were to treat impo-tence by helping men achieve penetration and ejaculation, Levitra’ssellers stress the goal of sexual satisfaction (Harris, 2003b). “We’vedone a lot of research on trying to understand what men want,”says Nancy Bryan, vice president for marketing at Bayer. “Andwhat they want is to improve the quality of their erections, toget one that’s hard enough and lasts long enough for a satisfy-ing sexual experience” (quoted in Harris, 2003b). Another re-port explains: “the ads [for Levitra] have come a long way sincethe Bob Dole days . That ad, with all of its Freudian implications,says everything you need to know about where the male sexualrevolution is heading. ED—‘erectile dysfunction’—is old news.
EQ—‘erectile quality’—is now the name of the game”18(CBSNEWS.com, 2004).
Perhaps the most obvious illustration of this marketing strategy, wherein impotence drugs are repackaged for nonmedical uses, isfound on Levitra’s website. Although the opening page for thiswebsite describes Levitra as a medical treatment for erectile dys-function, in subsequent pages the website either opts for the term“erectile quality” (EQ) to describe the condition for which the drugis intended to treat, or else uses this term interchangeably with themedical term “erectile dysfunction” (ED). This apparent shift interminology reflects a continuing trend in the medical-pharmaceu-tical construction of male sexuality (Marshall & Katz, 2002). Asstated in the introduction to this paper, until recently, the term “im-potence,” a psychological diagnosis, was used by medical profes-sionals to describe the condition in which the male is unable toattain and maintain an erection sufficient for satisfactory sexual in-tercourse. Under this construction, the condition is understood as apsychological problem, and thus treatable with psychotherapeuticinterventions. With the “discovery” of the physiological origins ofthe condition, however, impotence became “erectile dysfunction,”a biomedical diagnosis, and thus treatable with pharmaceutical in-terventions (Mamo & Fishman, 2001). Replacing the term “impo-tence” with “erectile dysfunction” in the medical sciences wasintended to reposition the condition as a physiological disorder andto lessen the pejorative stigma traditionally associated with it (Tiefer, Marketing of Cialis and Levitra 49
1994). The term “erectile quality,” on the other hand, is entirely amarketing construction designed to appeal to larger segments ofthe public, not just those medically diagnosed.
A definition of EQ appears on page 2 of Levitra’s website under a heading entitled “What is erection quality (EQ)?”: In market research, men identified three things as essential elements ofachieving a satisfactory erection, including: The ability to attain an erec-tion; erection hardness; [and] the ability to maintain it for satisfactory sex.
Taken together these make up erection quality (EQ). Many men have been,or will be, concerned with the quality of their erections at some point intheir life. It may be an occasional difficulty in getting or maintaining anerection; it could be an erection that is just not as hard as it once was; or itmay be a consistent inability to achieve an erection (www.levitra.com).
Defined in these terms, EQ is a sexual condition that exists both within and beyond the medical category ED. By implication, Levitramay be viewed as a pharmaceutical treatment that works not justfor medically diagnosed health conditions but for life-limiting con-ditions, however defined. The following four pages of the websitedescribe “How an erection works,” the “Things that can affect yourerection quality,” “How Levitra may help improve your erectilefunction,” and how “Maintaining your erection quality (EQ) is partof maintaining your overall health” (www.levitra.com). Readingthrough these pages, it becomes obvious that the focus of Levitra isnot necessarily on the medical condition it has been authorized totreat, but on how the effects of that treatment will affect other as-pects of one’s life (Mamo & Fishman, 2001); hence the term “erec-tion quality.” Subsequent pages of the website include a section on “Talking to your doctor” about EQ, which provides helpful hints on what tosay during, and how to prepare for, a doctor visit, and a section on“Information for partners,” which, among other things, informspartners what men want in order to enjoy sex, to which the websiteresponds: “They want consistent, reliable erectile quality.” In be-tween these sections appears an “Erectile Function Questionnaire”in which readers are able to assess their erectile quality accordingto industry-specified standards, using it to gauge whether or notthey exhibit signs of erectile problems. However, as I discovered in Sexuality & Culture / Fall 2005
filling out the form even scores which indicate no sign of erectileproblems, may not necessarily mean that there is no problem. Inresponse to my results, the website read: “Your [score] . indicatesthat you have no signs of erectile dysfunction (ED). While youmay not be having problems with your erectile function, you maystill want to talk with your doctor if you have any concerns aboutyour erectile quality (EQ)” (www.levitra.com). The evaluation maythus provide the reader with reassurance regarding the normality ofhis erectile function (as in my case), but it also leaves room forspeculation, especially in light of Levitra’s efficacy at improving“erectile quality.” The reader is left to decide for himself whethererectile normality is sufficient, or whether his already erect erectionrequires further “improvement.” As lifestyle drugs, Cialis and Levitra promise life-enhancing re- sults. In particular, they promise sexual satisfaction in the form of apill. The marketing of Cialis and Levitra as lifestyle drugs rein-forces a medical-pharmaceutical model of male sexuality, with theemphasis of that model on penile erectility. The promotional mate-rials represent erectility as a phenomenon capable of enhancementand improvement through technological intervention. Conversely,these texts reconfigure the intended user of erectile interventions.
The intended user “is now configured not just as the man who, forwhatever reason, is unable to get or keep an erection most of thetime, but includes all those whose erections could be `improved’”(Marshall & Katz, 2002: 61). By repackaging these drugs for lifestyleuse, marketers widen the application of their products to includeareas of sexuality not previously considered in need of improve-ment, expanding their market in the process.
Conclusion
Pharmaceutical company interest in male sexuality has grown rapidly since Viagra’s popular emergence on the market in 1998.
Spurred by Viagra’s success, pharmaceutical companies are nowon the look out for the next miracle drug that can be manufactured,marketed, and sold to men. Today, Viagra, the pill that revolution-ized impotence treatment, faces competition from two new entrants Marketing of Cialis and Levitra 51
to the market, Cialis and Levitra. Although both drugs work inmuch the same way as Viagra, they promise to take male sexualityto a new level of performance and functionality. By pushing malesexuality beyond the limits of previous technologies, these drugsintroduce new standards for functional sexuality and create newmedically treatable deviations.
In some ways, the introduction of Cialis and Levitra reflects an old medical theme. As with Viagra, these drug makers rely on mostof medicine’s discursive strategies in marketing their products. Theirmarketing campaigns defend the legitimacy of impotence as a medi-cal problem, uphold prevailing medical claims about the causes ofimpotence, and justify medical intervention as the proper response.
In other ways, however, the marketing campaigns, in their attemptto distinguish these products from other technologies, offer a newdiscourse on impotence, medicine, and male sexuality. As this pa-per has shown, this discursive move is significant because it essen-tially repositions the clinical boundaries of the sexually functionaland dysfunctional male body. These drugs and the discourses theycirculate promise to alter the male body and its sexual functioningin ways that Viagra and other technologies do not. Cialis and Levitraare constructed as technologies that enable the male body, or atleast parts of it (the penis), to become sexually functional in waysthat surpass the effects of other technologies. The sexually func-tional male body is now configured as a body that responds imme-diately when needed, responds without planning or rushing, workslike nature (spontaneous, worry-free, uninhibited by external con-siderations), exhibits the ideals of masculine physicality, and is al-ways sexually satisfied. Anything less is sexually dysfunctional andin need of medical repair.
As I have argued, the materials analyzed for this study represent Cialis and Levitra and their reported bodily-altering effects in sev-eral ways. First, they represent Cialis and Levitra as state-of-the-arttechnologies that offer users an optimal sexual performance. Usersare promised fast-acting erections, lasting long durations, with fewside effects. Second, these texts represent Cialis and Levitra as tech-nological enhancements to natural sex. The marketing materialspromise a return to natural, worry-free intimacy through the con- Sexuality & Culture / Fall 2005
sumption of these products. This marketing strategy plays on cul-tural assumptions about what is natural about men’s sexuality. Inaddition, these campaigns use the imagery of sport to symbolicallylink these drugs to hegemonic masculinity. Here the messageemerges that one can attain masculinity in the form of a pill. Fi-nally, they construct these drugs as lifestyle products that can en-hance sexual satisfaction, whether or not users have bona fidesexual health problems. In this way, the marketing not only en-courages medicalization for legitimate sexual problems, but advo-cates the medical approach for nonmedical concerns. Altogether,these themes work to expand the domain of sexual fitness and thereach of medical repair.
In the years ahead, therapies that promise to solve men’s sexual concerns, enhance their sexual performance, or make sex “betterthan the real thing” will continue to flood the marketplace (Mamo& Fishman, 2001: 29). Indeed, several new therapies are already indevelopment and could be available within two to three years, in-cluding a nasal spray, which works through the brain, stimulatingsexual arousal; a topical cream, which has no major side effects,other than initial burning, stinging, or tingling; and a pill that dis-solves under the tongue, which bypasses the digestive system, block-ing the release of the adrenaline that obstructs sexual arousal (Allen,2003). With the increase in such therapies, it is likely that pharma-ceutical drug development and marketing will play an even largerrole in promoting medicalization, subjecting further areas of malesexual life to medical control and regulation. It is thus imperativethat social scientists consider the implications of this newest stagein the medicalization of male sexuality. In addition, researchers willneed to consider whether medical discourses that have been shapedby media forms are reshaped through informal discussions amongmen, between partners, and within patient-provider relationships.
Earlier versions of this paper were presented at the American SociologicalAssociation Annual Meeting 2004 and the Humanities and Social Sci-ences lecture series at Arkansas State University in 2004.
Marketing of Cialis and Levitra 53
Until 2003, Viagra’s patent protection prohibited FDA approval for simi-lar pharmaceutical products.
As Leonore Tiefer (1994) explains, the medical profession implicitly de-fines a normal erection “as ‘hard enough for penetration’ and lasting ‘un-til ejaculation,’ informally, that means a few minutes. Anything less is‘impotence’”(p. 372).
Already available in Europe, these drugs have taken significant marketshare from Viagra. In Germany, for example, Cialis has taken a 27% share,while Levitra has 14% of the market (Teather, 2003).
Due to federal changes in the regulation of pharmaceutical advertising,drug companies can now advertise their products directly to consumersthrough mainstream magazines and television commercials. Previously,pharmaceutical advertising campaigns were limited primarily to physi-cian and health care provider-oriented journals, or to physicians directlythrough promotional information, drug samples, and gifts. Today, themajority of pharmaceutical advertising money has shifted to “direct” ad-vertising to consumers themselves (Mamo & Fishman, 2001: 17).
The history of impotence is similar to the history of (male) homosexuality(see Foucault, 1979; Weeks, 1977), in that “the impotent man” as a type ofperson or as a matter of identity was literally invented in scientific dis-course only in the late nineteenth century: “The word impotent is used todescribe the man who does not get an erection, not just his penis. When aman is told by his doctor that he is impotent or when the man turns to hispartner and says he is impotent: they [sic] are saying a lot more than thatthe penis cannot become erect” (quoted in Tiefer, 1987, p. 165).
In other words, the phenomenon marked as “impotence” may in fact be auniversal experience, even if it may not always be marked as such, ifmarked at all. But coupling the phenomenon marked as “impotence” withidentity (and pathology) is historically specific, socially constructed, anda relatively recent occurrence.
Administered orally, the drug takes effect between 40 to 60 minutes afteringestion, and remains effective for two to four hours.
The term phallocentrism refers to penis-/phallic-centered sexuality inwhich intercourse, vaginal or anal, is the objective of the sexual encoun-ter (Potts, 2000).
10. Lifestyle drugs treat life-limiting rather than life-threatening conditions.
Examples include hair loss, memory loss, skin problems, and mild aller-gies. Such drugs generally promise to make life better in some way (Mamo& Fishman, 2001).
11. The advertisements for this study were selected nonrandomly using a convenience sampling procedure. This involved selecting a sample ofwhatever ads were available between 2003 and 2004. In this case, the adswere selected primarily from mainstream American news magazines andnetwork and cable television outlets. These outlets were targeted pre-cisely because they reach large consumer audiences. For the sake of con-venience, I decided not to analyze ads outside of the United States,although this would be a fascinating project, particularly given the con- Sexuality & Culture / Fall 2005
trasts that are likely to exist across national contexts. Further work isneeded on cross-national differences.
12. According to Tiefer (1994), medicalized information about sex allows the news media to discuss topics that might otherwise be considered taboo orsalacious. Instead, sexual subject matters become newsworthy and thusappropriate for publication or broadcast.
13. Because I used Lexis-Nexis to guide my search, my sample included articles from both national and international sources. A number of thesearticles were drawn from European sources. Unlike the United States, theuse of direct-to-consumer advertising for pharmaceuticals is legally pro-hibited in Europe; thus media coverage constitutes a primary means ofreaching European consumers. However, it is unclear whether differentstandards for drug regulations affect the media coverage that is obtainedfrom news sources outside of the United States. Nevertheless, most ofinternational news on Cialis and Levitra did appear to offer the sameinformation as that found from American sources.
14. Articles from the following periodicals were selected for in-depth analy- sis: The Age (Melbourne) (one article); Boston Globe (two articles); Bos-ton Herald (two articles); Brand Strategy (one article); Business Week(one article); Chicago Sun-Times (one article); Daily Telegraph (London)(one article); Daily Telegraph (Sydney) (one article); Financial Times(London) (one article); The Gazette (Montreal) (one article); The Guard-ian (four articles); The Independent (London) (two articles); Los AngelesTimes (one article); The Mirror (one article); Newsday (New York) (onearticle); New York Times (four articles); The Observer (one article); OttawaCitizen (two articles); Pharmacy New (Australia) (one article); Philadel-phia Magazine (one article); Pittsburgh Post-Gazette (two articles); Se-attle Times (five articles); Straits Times (Singapore) (one article); SundayTelegraph (London) (one article); Sunday Times (London) (two articles);The Times (London) (one article); The Toronto Star (one article); USAToday (two articles); Washington Post (one article).
15. According to Adele Clarke and her colleagues (2003), the use of random- ized clinical trials has become the “gold standard” for the legitimizationof biomedical claims.
16. Interestingly, some sex therapists see Viagra’s delayed effect as a potential benefit, in the belief that it promotes anticipation and foreplay (Marshall,2002: 150-151).
17. Cialis’s makers have made no plans to hire a sport celebrity, preferring instead to emphasize the pill’s longer duration.
18. Rather than raising questions about the direction of impotence treatment marketing, most media accounts seem so superficial and uncritical theyappear to condone it. One exception, an article entitled “Sex enhancers’competition gives rise to ridicule,” was published in the Boston Herald.
After illustrating how the campaigns for the new drugs promise “optimalperformance . Enhancement . That extra edge.” the author writes “Andso billions are about to made off male ‘edge’ insecurity” (Eagan, 2002).
Marketing of Cialis and Levitra 55
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