|PRESCRIPTION FOR DEBATE
Will Viagra change the way Americans view sexual health?
May 15, 1998
in this forum:
What liabilities do doctors face if Viagra causes long-term side effects? Can Viagra help a low libido? How successful would a blue "sugar pill" be? Can Viagra be habit forming? Are insurance companies guilty of a double standard? Aaron Gaudio of Corvallis, OR asks: Viagra as far as I understand, was not developed in order to cure sexual frustration, but rather to cure sexual impotence. Arenít doctors misusing the instruments of their profession by granting so many prescriptions to people who are not clinically impotent? What possible liabilities do these doctors face should Viagra be found to cause long-term side effects?
Ira Sharlip responds:
A 55 year old man was in my office today with a typical story of erectile dysfunction (ED). He's in good health but he's experiencing a decline in his erections. He's still able to have intercourse but not with the confidence he used to have. Of course, he asked about Viagra. It is likely that Viagra will improve the quality of his erections. So why shouldn't he use Viagra, as long as he can afford it and as long as he understands the known risks of the drug? I don't believe that I am "misusing" an instrument of my profession by prescribing this drug to a patient who may not be "clinically impotent."
Viagra was judged to be clinically safe by the FDA when that government agency approved it on March 27, 1998. The known side effects of Viagra are lightheadedness, dizziness, headache, nausea, facial flushing and temporary visual disturbances. As with any other drug, currently unknown long term side effects may show up with widespread use over many years. There is no reason to expect that physicians will face† greater liabilities with Viagra than we do with any other new drug.
Richard Coorsh from HIAA responds:
†† With regard to the first question, as insurers, we're expert on questions pertaining to health care financing, but we must defer to experts in the medical community with regard to the safety of Viagra, and to experts in the legal community with regard to liability questions.†† The question as to whether there may be an overabundance of prescriptions reflects a genuine concern, shared by insurers, that prescriptions should be issued only for Viagra's government-approved use.
Paul Wolpe responds:
Almost all medications are used by physicians for multiple purposes.† The question is not necessarily what the drug was developed for (it was originally developed for chest pain) but for whom it may be useful. Anecdotes are already flying around the Internet and informal networks from people who do not have organic impotence but believe Viagra is giving them firmer erections, longer lasting erections, etc.
The problem is that all men have occasional impotence, due to stress, alcohol, etc.† Just the belief that a pill can overcome that may give the psychological boost needed to achieve erection.† The question of whether these men are clinically impotent or not is more difficult than it first appears; they may not have ORGANIC impotence and still be impotent due to psychological factors.† Does Viagra help that?† The evidence is not in.
Eileen Palace responds:
Historically, physicians and clinical diagnoses have referred to medically-based or "organic" erectile dysfunction versus psychologically-based or "psychogenic" erectile dysfunction. Based on these traditional distinctions, treatment approaches have been adopted accordingly (medical versus psychological). There are numerous problems with this approach. First, organic-psychogenic, medical-psychological, and mind-body are false dichotomies. The "mind" is the "body" - it is your brain, and therefore your psychological and physical health are interactive and inseparable. My research has shown that cognitive (thought) processes increase genital blood flow within 30 seconds (Palace, 1996). That is, women with sexual dysfunctions who significantly change their expectations after seeing deceptive feedback showing more physical arousal that they anticipated, raised their actual physiological response to the level of the deceptively high feedback within 20 seconds. These findings demonstrate how quickly the "mind" can alter the "body." Similarly, Rubinow (1992) found that expectancy may cause differential sensitivity to gonadal steroids in premenstrual syndrome. Social experience and learning which change cognitions and behavior, cause very real changes in biological and physiological functioning (termed biological plasticity). A physiological problem, therefore, is unlikely to exist without creating psychogenic problems (self-esteem, self confidence, avoidance of intimacy, conflict with partner and misunderstanding). These psychogenic components further hinder biological erectile capacity in a downward spiral.
It is important for the consumer to understand that even if a physical problem is found (for example, vascular leakage), this does not mean that the physical symptom was the cause of the election problem. You need to account for the psychological impact of the physical problem on the individual, and more importantly, on the relationship. In my research, I have found that medically-based treatments can decrease effectiveness over time if the cognitive factors that often block its effects are not addressed. Further, treatment of the physical component may provide a physical component cure (an erection), but no relationship in which to use it.
Finally, even if a pure organic cause is found, this does not mean that a purely physical treatment will be the most effective. The results have been found with antidepressant medications versus cognitive-behavior therapy. The combination is slightly more effective for short and long term outcome. For example, I see many patients diagnosed with prostate cancer and vascular leakage who successfully used penile injection and other medical interventions to achieve erection. After seeking therapy and acquiring improved interpersonal skills, communications skill, problem-solving skills, sexual techniques, etc., they found that they could achieve election with no medical intervention. Of course, This does not mean that the physical problem was resolved. But it does suggest that it was not the only component in the turbine of factors that effect erection, and that the cognitive, affective, and interpersonal factors contribute to, and may outweigh the influences of the vascular leakage.
The differentiation of medical and psychological etiologies is not very useful. Rather, I think optimal sexual functioning results from replacing mind-body dichotomies with integrated behavioral medicine approaches. These strategies identify the common pathway for cognitive processes (such as strong emotion and reactions to stress) to affect physical functioning, and conversely, physical functioning to affect psychological well-being. It is the "marriage" of "mind and body" that makes for effective sexual health, and addresses the physical component with interventions such as Viagra, combined with the cognitive component such as cognitive, behavioral, and interpersonal sex and couples therapy.