A Summary of Research on the Effectiveness of Antidepressants and Psychotherapy Michael Conner, PsyD I n a 2002 review of research, Kirsch and Antonuccio (1) concluded that meaningful differences There is a significant gap between science and are lacking between antidepressants and placebos. In practice in the treatment of depression in America. 1998 Kirsch and Sapirstein (2) as
Bod410449 105.125Marketing Silence, Public Health Stigma and the Discourse of Risky Gay
Viagra Use in the US
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Marketing Silence, Public HealthStigma and the Discourse ofRisky Gay Viagra Use in the US Abstract This article analyzes the rise and fall of a public health ‘fact’ in the US: the assertion that gaymen’s Viagra use is inherently recreational and increases STD risk. Extending the science studiesargument that drug development and marketing entail the construction of new publics, this article showshow strategic drug marketing silences can also constitute new populations of users. It shows how Viagramarketing’s silence about gay users, which facilitated legitimization of the drug as an aid forcompanionate heterosexuality, created a cultural space for the development of health discourse about gaymen as illegitimate, recreational and risky Viagra users. Using Susan Leigh Star’s concepts of‘simplification’ and ‘complexification’, this article traces the construction and deployment of this publichealth fact, as well as its subsequent contestation. Using an arena analysis approach, this articledemonstrates how marketing discourse and public health fact-making came together in the case of gayViagra use to refresh long-standing and politically harmful American cultural associations between gaysex and sickness.
Keywords advertising, gay, medicalization, sexuality, social studies of science, Viagra In an increasingly medicalized world, people often use medical interventionsto embody particular forms of personhood. Researchers have traced theco-development of drugs and cultural ideals for embodiment, arguing that Body & Society Copyright ª The Author(s) 2011, Reprints and permissions:http://www.sagepub.co.uk/journalsPermissions.navVol. 17(4): 105–125; DOI: 10.1177/1357034X11410449 106 & Body & Society Vol. 17 No. 4 pharmaceuticals biologize social norms by making social ills tangible andtreatable (Nichter and Vuckovic, 1994; Whyte et al., 2003). Medical anthro-pologists often understand drugs as agents, which bear ‘biographies’ thatilluminate the social transformations surrounding their development and use(van der Geest et al., 1996), and serve as ‘co-performers’ of users’ attempts to‘be’ specific kinds of people (Martin, 2007). Other scholars have shown howmarketing facilitates such projects. Following guides with titles like The Art ofBranding a Condition, pharmaceutical developers consciously define sociallyundesirable bodily states as pathologies, and seek to imbue treatments with thepersonality traits that potential users might desire (Martin, 2007; Parry, 2003).
When successful, this process of marketing and development is concealed bythe naturalization of these new illnesses (Metzl, 2003).
In addition to defining new illnesses and treatments, drug development and marketing entails the constitution of new publics. While pharmaceuticalresearchers and marketers strategically define new groups of potential users,stakeholder groups may also actively define themselves through advocating fornew research or cures for particular diseases (Epstein, 1996; Nichter andVuckovic, 1994). In cases when new drugs might be controversial, drug develo-pers and marketers strive to define the group of potential users in a way thatmakes the drug’s effects seem socially positive. For example, Nelly Oudshoorn(2003) found that researchers developing a male contraceptive pill counteredfears that it would facilitate promiscuity by selecting research participantsthey viewed as responsible and ‘caring’ heterosexual men in monogamousrelationships, constructing a population of socially legitimate pill users.
Oudshoorn (2003) notes that researchers highlighted this user population’slegitimacy by defining promiscuous and irresponsible men as illegitimate users.
As this example demonstrates, construction of both legitimate and illegiti- mate users is important for public acceptance of drugs that enable potentiallycontroversial forms of embodiment. However, researchers seeking to reveal thesocial consequences of the development and naturalization of new illnesses andtheir treatments have largely focused on the ways ‘legitimate’ drug users aredefined. Critiques of the development and marketing of erectile dysfunction(ED) treatments like Viagra exemplify these efforts. ED is the relatively newmedical understanding of ‘the inability to attain or maintain penile erection suf-ficient for satisfactory sexual intercourse’ as a biological pathology (Lizza andRosen, 1999: 141). This condition has become globally known and acceptedthrough advertising, news coverage and frequent diagnosis; even in lean years,world sales of ED drugs total nearly $2.5 billion (Berenson, 2005). However,scholars have argued that drugs like Viagra function as ‘masculinity pills’, naturalizing Western cultural ideals of male sexuality as mechanistic, unflaggingand asocial by offering a medical fix for deviation from this norm (Grace et al.,2006; Loe, 2006: 31; Mamo and Fishman, 2001). Critics – and some users – ofED drugs argue that ‘sufficient’ erection is not a natural threshold, but a culturalstandard co-produced with Viagra-mediated ideals of manly sexuality (Pottset al., 2004; Tiefer, 1994). Researchers working on this topic thus strive to revealthe gendered social consequences of medicalizing difference in sexual function(Kaschak and Tiefer, 2002; Tiefer, 1995).
Here, I extend these efforts by investigating the construction of illegitimate Viagra users in the US. This article traces the definition of gay Viagra use as‘recreational’ and illegitimate by analyzing the construction and contestationof the public health ‘fact’ that gay men’s Viagra use increased their risk forsexually transmitted diseases (STDs). I explain how a marketing silence aboutgay men’s Viagra use created social space for assertion of this fact, and then showhow controversial former head of San Francisco STD prevention and controlservices Dr. Jeffrey Klausner asserted it through strategic reframing of basicpublic health research. Finally, I discuss the backlash against this fact and thework done to undermine it, as well as its ongoing social consequences.
To do so, I employ the Science, Technology and Society Studies (STS) understanding that facts are not essential truths, but context-dependent claimsthat are accepted as true after frequent use obscures the social context of theirconstruction (Latour, 1987; Latour and Woolgar, 1986; Poovey, 1998). Here,I analyze the construction and contestation of the fact of gay men’s risky Viagrause based on Susan Leigh Star’s observations about fact-making. Star arguesthat fact-making entails ‘simplification’, concealment of a fact’s social originsthrough obfuscation of the work and workers involved in making it, and thatchallenging a fact entails ‘complexification’, revealing its sociality by highlight-ing workers’ efforts to construct it (Star, 1983, 1992). Following feminist STSscholars’ calls to attend to scientific practice’s political implications in socialcontext, I will also draw connections between marketing and public healthpractices in a version of ‘arena analysis’. This approach traces power-ladeninteractions between multiple actors involved in and affected by scientificdevelopment (Clarke and Casper, 1996; Clarke and Montini, 1993; Star, 1991;Traweek, 1992). I aim to use this approach to reveal how the absence of onediscourse encouraged the production of another, by showing how strategicmarketing silence about gay Viagra users combined with stigma regarding gaymen’s sexuality, leading to the encoding of this stigma in public health knowl-edge about gay men’s bodies. Analysis of the rise and fall of this fact reveals thesocial consequences of the legitimization of controversial pharmaceuticals 108 & Body & Society Vol. 17 No. 4 through the construction of illegitimate users, as well as the mediation ofunderstandings of health, sexuality and masculinity by the US’s burgeoning‘Viagra culture’ (Potts and Tiefer, 2006: 267).
Selling Viagra and Constructing its Users In this section, I show that marketers framed Viagra as a cure for ailing hetero-sexual relationships to allay fears that the drug might fuel male promiscuity. Thisconstruction of a legitimate group of Viagra users required characterization ofother users as illegitimate, leading to the trope of the ‘recreational’ ED drug user.
While ‘recreational’ users have been framed quite differently in different coun-tries, US discourse on illegitimate use has focused on gay men. Here, I demon-strate how this resulted from strategic marketing silence around gay men’sViagra use related to the particularities of the American ‘gay niche market’.
Pfizer’s 1998 release of Viagra generated an explosion of discourse in the American popular media, as the drug was simultaneously cast as a punch lineabout failing masculinity, a wonder drug for sexual ailments, and a flashpoint forfears about unchecked manly sexuality (Loe, 2004a). Less-than-ideal erections,long seen as threats to ideal masculinity in Western cultures, have been under-stood differently over time; the recent ‘medicalization of impotence’ was accom-plished though deliberate social work including marketing (McLaren, 2007;Tiefer, 1994, 2008; Wentzell, 2008). Early Viagra marketing cast ED as explicitlybiomedical, seeking to delink it from emotional or social causes that potentialusers might see as incompatible with demonstrating ideal masculinity (Tiefer,2006). This marketing also strove to reshape existing notions of ideal manliness,casting the use of ED treatment as a manly act of ensuring successful heterosexu-ality rather than a revelation of weakness (Grace et al., 2006).
To allay fears that Viagra would encourage male promiscuity, drug market- ers initially framed it as an aid for a specific kind of sex: the heterosexual, maritalpenetrative intercourse that Western cultures have long viewed as the healthiestand most ‘normal’ form of sexuality (Rubin, 1992). This framing continued amarketing tradition of legitimizing sexual aids, like marriage manuals and sextherapy, by framing them as facilitators of socially valorized heterosexualcoupling (Marshall, 2002; Potts et al., 2004). Through advertisements showingmarried male–female couples embracing, Viagra was marketed as a ‘couple’s cure’that would strengthen the social fabric through sex (Baglia, 2005: 40). Researcherslike Barbara Marshall argue that this framing of Viagra not only reflects a hetero-normative society, but serves to further marginalize sexual difference by implyingthat only specific forms of sexual ‘function’ are functional for society (2002).
Viagra has thus been made socially acceptable in the US through its sale as a cure not simply for limp erections, but for failing relationships, families, hetero-sexuality and normative masculinity. This framing necessitated a marketingsilence regarding Viagra use for other kinds of sex. In a thorough study of Viagramarketing, Jay Baglia notes that the drug’s representatives and marketers, and thepopular press articles that give them voice, have discussed gay men’s Viagra useonly in the context of the drug’s possible side effects. Baglia documents theassociation of these negative consequences with what he calls ‘queer’ users,whose Viagra use is framed as illegitimate because it falls ‘outside the boundariessanctioned by Pfizer, by technoscientific discourse, and even by society at large’(2005: 47).
In the popular press and medical discourse, this queer use of Viagra is described as ‘recreational’. This language creates a dichotomy between queerViagra use for the pursuit of pleasure, and medically necessary use by coupled,heterosexual men. This binary construction of legitimate versus recreationalusers is central to the justification of ‘mainstream’ users’ Viagra-taking. Thismode of legitimation also helps Viagra marketing to sidestep one of the key waysof assessing the social worth of sexuality in the West: procreativity. Despite thecommonness of contraception, potentially procreative sex continues to be seen asthe most socially acceptable (Rubin, 1992). However, Viagra is most likely to sig-nificantly enhance erections in older men; if these men have female partners, theyare likely to be past childbearing age. Thus, even when targeted to heterosexuals,Viagra usually enhances non-procreative sex. Viagra marketing seeks to sidestepthis potential source of stigma by destabilizing the recreation/procreation axis ofsexual legitimacy. Rather than using procreativity as a measure of sociallyvaluable sex, Viagra marketing frames enhancement of affective heterosexualbonds as its source of legitimacy. Simultaneously, it frames illegitimate use asthat which facilitates socially devalued forms of sexuality. In this discursiveframework, ‘recreational’ sex shifts from being defined as nonprocreative sexto sex that does not support companionate, monogamous heterosexualrelationships.
While this legitimate/recreational distinction seems to operate wherever ED drugs are advertised, the type of person who embodies the illegitimate,recreational or queer Viagra user varies by national context. In the UK,illegitimate use has been linked to male and female night clubbers who use avariety of illicit drugs. Popular press articles describe recreational users as‘healthy young men and women’ who buy the drug in pubs, a concern reflectedin British public health research that traces ‘recreational’ use among ‘a sentinelpopulation of illicit drug users’ found in dance clubs (BBC, 2002; McCambridge 110 & Body & Society Vol. 17 No. 4 et al., 2006). Similarly, young, heterosexual men’s use of ‘party pill Viagra’ iscast as recreational in New Zealand (Vares and Braun, 2006: 382). However,US ‘recreational’ Viagra users have been framed almost exclusively as gay men.
While the worldwide marketing silence around ‘queer’ Viagra use was a neces-sary precondition for this characterization of gay use as illegitimate, I argue that‘the recreational user’ became conflated with ‘the gay user’ in the Americancontext due to the confluence of three cultural phenomena discussed in subse-quent sections: the specifics of gay-targeted advertising in the US; historicAmerican cultural associations between gay sex, related substances and STDs;and popular media and public health framing of gay Viagra use as physicallydangerous.
Viagra Advertising and the Limits of the ‘Gay Niche Market’ Viagra marketing in the US is a $50 million per year enterprise that includesdirect-to-consumer ads, relationship marketing techniques like magazines, anda ‘buy six, get one free’ Viagra Value Card (Arnold, 2004a, 2004b; Liebman,2003). Some similarly sized pharmaceutical ad campaigns, most notably forAIDS and depression drugs, have addressed gay consumers. For example,antidepressant maker GlaxoSmithKline sponsored gay diver Greg Louganis’‘Talk About It: Coming Out About Depression’ speaking tour (McGuire,2004). Drug companies seem willing to market drugs for conditions alreadylinked with non-hegemonic masculinities to gay consumers, since this will notdisrupt those drugs’ carefully cultivated images. However, the conspicuousabsence of any Viagra advertisement to US gay consumers suggests a deliberatedecision not to sell to the well-defined ‘gay niche market’.
The relationship of this market to notions of gay sexuality may partly under- lie this lack of targeted marketing. The American ‘gay niche market’, the market-ing term for an imagined population of gay consumers to whom advertisers maydirect specialized marketing, developed in the 1990s in concert with the expan-sion of gay-targeted media. While US cultures of same-sex sexuality have richhistories of media creation that contained advertisements, these media werelargely ‘underground’, available only to consumers ‘in the know’ for much oftheir history (Streitmatter, 1995). From the 1970s to the 1990s, gay-targeted mediaexpanded, becoming more sophisticated – and less sexualized – and attractingmainstream advertising (Branchik, 2002). For instance, The Advocate magazinebegan to package its heavily sexual classified ads under separate cover from itsmain text in order to become, according to its editor Jeff Yarbrough, ‘a little morehappy and shiny to attract advertisers’ (Sender, 2004: 46). This shift in the gay press went hand in hand with a post-AIDS crisis move toward assimilationistgay politics, which often entailed politically strategic representation of gaycommunities and identities as similar to those of heterosexuals to support callsfor equal rights (Herrell, 1991). In this context, gay marketing professionalsurged consumers out of the ‘economic closet’, and marketers developed anotion of gay consumers as wealthy, stylish and brand-loyal (Luckenbill,1998: 7; Sender, 2004). Identification of this economic market made one typeof gay identity – a white, male, middle-class identity linked to consumptionand mainstream cultural values – visible, while leaving stigmatization of othergay sexualities and radical politics unchallenged (Walters, 2001). Despite mar-keting industry celebration of selling to the ‘gay niche market’ as a progressivesocial act, this type of marketing had difficulty following gay consumers intothe bedroom or reflecting their diverse lifestyles.
Likely due to the gay niche market’s political boundaries and marketers’ strategy of legitimizing Viagra by representing it as a cure for failing heterosexualrelationships, the drug’s advertisers went to great lengths to keep silent about gayusers. A comprehensive study of the first seven years of Viagra marketing foundno mention of gay men in advertisements for the drug, or in positive news arti-cles about it (Baglia, 2005). Further, Pfizer representatives attempted to keep dis-cussions of gay men’s Viagra use out of the press. For example, the popularmedia began to discuss Viagra’s dangers soon after its release, focusing on theheart failure that could result from taking the drug with a class of heart medica-tions called nitrates (Loe, 2004b). These drugs were quickly contraindicated onViagra labeling, and Pfizer representatives worked to allay public fears about thepotential dangers of Viagra use (Online Pharmacy News, 2011).
However, Pfizer’s response to potentially dangerous interactions between Viagra and another class of nitrates, the club drug poppers (amyl and methylnitrate), was quite different. Poppers are popular with gay men, and their asso-ciation with gay sex has previously been involved in discursive linkages betweensickness and homosexuality. For example, at the height of the AIDS crisis pop-pers were believed to have immunosuppressant properties (Rubin, 1997). As JayBaglia (2005) documents, likely because of this association, Pfizer decided not toexplicitly contraindicate poppers on the Viagra labeling, instead having represen-tatives privately call prominent gay AIDS activists to suggest that they spreadthe word about the danger of combining Viagra and poppers. In 2001, when aNew York Times reporter asked Pfizer spokesman Geoff Cook whether thecompany would produce any Viagra-related educational materials for gay men,Cook said he did not know, then segued into a warning against the ‘recreational’use of Viagra (Baglia, 2005). The implication was that such materials were 112 & Body & Society Vol. 17 No. 4 unnecessary because gay use of Viagra would be inherently ‘recreational’ andthus illegitimate.
This rhetorical move conflates gay Viagra use with illegitimate ‘recreational’ use, scapegoating gay users behavior as the cause of Viagra’s side effects. Thislinkage of gay Viagra use and danger draws on and refreshes stigmatizing culturallinks between gay sex and disease. It reflects the continuing function of culturaldebates about homosexuality (like US gay marriage debates) to define the limitsof acceptable sexual practice, implicitly legitimizing non-homosexuals’ behavior(McIntosh, 1998). Since social problems and differences in American society areincreasingly medicalized, social identities are often marked as illegitimate bybeing characterized as unhealthy; this is especially true for non-normative sexualbehavior (Katz and Marshall, 2002; Marshall and Katz, 2002; Rubin, 2002). Thus,despite psychology’s formal de-medicalization of homosexuality, in popularculture same-sex sexuality frequently remains linked to biomedical pathology,most notably in the case of HIV/AIDS (Conrad and Angell, 2004). In thiscontext, associations of gay Viagra use with disease serve to define medicallymediated heterosexual sex as both socially legitimate and physically healthy.
In the next sections, I describe how in the context of US marketing silence about gayViagra users and the popular conflation of gay and ‘recreational’ use, gay Viagra-taking was also framed as a public health risk. I will focus on one particular actor,former head of San Francisco STD prevention and control services Dr. JeffreyKlausner, who was instrumental in the development, support and disseminationof this ‘fact’. In this section I present the political context that enabled Klausner’suse of ‘simplification’ in public health analysis to support this claim.
Klausner is a controversial figure in the worlds of STD prevention and gay rights. During his 1998–2009 leadership of San Francisco’s STD prevention andcontrol services, he was seen by many as gay-friendly, for example writing acolumn for gay.com and performing extensive outreach to San Francisco’s gaycommunities. However, some gay San Franciscans saw Klausner as sex-negative and homophobic. Citing examples like his unsuccessful demand thatAmerica Online post STD warnings in its gay chat rooms to stem a potentialepidemic of gay STD infection, critics argued that Klausner overstated predic-tions about gay STD risk to generate funding for prevention (Heredia, 2002).
In an extreme example, Act-Up members who accused Klausner of overstatinggay men’s syphilis risk were jailed for terrorism following a ‘phone zap’ againsthim and other officials (Conlan, 2002).
Despite such critiques, Klausner repeatedly sought resources by demanding reparations from the sellers of products and services that facilitated gay sex.
Focusing on ED drugs and their manufacturers, Klausner lobbied unsuccessfullyfor Pfizer to include STD warnings on Viagra labeling, and to provide educa-tional materials for gay men who use Viagra ‘recreationally’ (Liebert, 2003). In2004, Klausner filed a citizen petition asking that the Food and Drug Adminis-tration (FDA) re-classify all ED drugs as Schedule III controlled substances, dueto medical evidence that the use of ED drugs was linked to increases in sexualpartners, STD transmission and HIV occurrence among gay men (Roehr,2006). This change would have made users without prescriptions subject toincarceration and high fines (Bajko, 2005). In 2006, Klausner was a key partici-pant in an unsuccessful lawsuit spearheaded by the Los Angeles-based AIDSHealthcare Foundation (AHF), seeking an undisclosed amount of money fromPfizer to care for HIV patients. This claim was based on the allegation that Pfizerhad been ‘promoting Viagra as a party drug . . . leading to more infections withsexually transmitted diseases such as HIV’ (Bay Area Reporter, 2007). Despitethe drug’s explicit marketing to heterosexuals, Klausner and his co-litigantsmade use of the conflation of illegitimate/recreational and gay Viagra use toargue that such advertising had increased gay men’s HIV risk. Klausner arguedthat litigation was justified to stem ‘the promotion of Viagra for what some havecalled recreational use’, based on the claim that Pfizer’s direct-to-consumer adshad a broader target than the FDA-approved pool of legitimate ED patients(Roehr, 2007). Critics who saw the lawsuit as stigmatizing gay men’s sexualityused the marketing silence that fueled delegitimization of gay Viagra use toundermine the claim that such marketing-fueled risky gay sex existed. Aneditorial in the Bay Area Reporter argued: Pfizer doesn’t specifically market Viagra to gay men, though certainly gay men use Viagra.
Rather, the television commercials rely exclusively on images of heterosexual couples; yetwith its lawsuit, AHF would have you believe that Pfizer’s marketing campaign is directedat gay men. We don’t see that. (Bay Area Reporter, 2007) Local activists thus resisted the assertion that Viagra use was uniquely dangerousfor gay men (Roehr, 2006).
Constructing the Fact of Gay Men’s Risky Recreational Use Attempts to seek redress for Viagra-related gay STD risk depended on the claimthat the drug led gay men to have riskier sex. In this section, I examine Klausnerand colleagues’ production of this fact through public health practice. Klausner’sassertion of this fact in his public health work is encapsulated in a 2005 review 114 & Body & Society Vol. 17 No. 4 published in the American Journal of Medicine, entitled ‘Sildenafil [Viagra] Use,Sexual Risk Behavior, and Risk for Sexually Transmitted Diseases, IncludingHIV Infection’, which he co-authored with San Francisco STD Prevention andControl Services Research and Policy Associate Sean Swearingen. This reviewcasts Viagra ‘misuse’ by men who have sex with men as a public health problem,calling for interventions like those Klausner demanded elsewhere: ED druglabeling that would warn about ‘increased risk for STDs, including HIV infec-tion’, educational programs regarding this increased risk and re-classificationof ED drugs as controlled substances (Swearingen and Klausner, 2005: 575).
Here, I analyze the ‘simplifications’, acts of obscuring the social work done togenerate evidence, though which Swearingen and Klausner constructed the factthat gay men’s use of Viagra increased their STD risk. By simplifying away keydetails of the basic research that they review, especially regarding study popula-tions’ demographics and social characteristics, these authors frame all gay Viagrause as risky misuse.
Swearingen and Klausner characterize their review as an exploration of the ‘ongoing public health problem’ of ‘nonindicated’ Viagra use, and use their find-ings to make broad claims about the STD danger Viagra poses. However, thestudies they review actually examine risky sex practices in very specific popula-tions. Thirteen of the 14 reviewed studies analyze only data on men who have sexwith men (despite the fact that some reviewed publications were based on studiesthat also collected data on men having sex with women). This focus appearsdeliberate, since the review excludes pre-existing UK studies of male and femalenight clubbers’ use of Viagra and illegal drugs (McCambridge et al., 2006). Byclaiming to discuss the general health problem of ‘nonindicated’ use but focusingalmost exclusively on data regarding gay men’s Viagra use, Swearingen andKlausner imply that these are one and the same, and obscure heterosexual men’srisky behavior. Further, the reviewed studies focus on a sub-set of gay menengaged in especially risky sexual practices. Eight of the 12 US-based studiesdrew their participants from sites related to sexual risk: seven from HIV or otherSTD treatment clinics and testing sites, and one from circuit parties. All thestudies took place in cities (eight in San Francisco). Together, these studiesprovide information about Viagra use among urban US and UK gay men enga-ging in relatively high-risk behavior.
By generalizing from study populations already engaged in risky behavior, Swearingen and Klausner obscure a key finding of the reviewed studies: in moststudies that found a correlation between Viagra use and increased STD risk, itappears that many participants were using Viagra to mitigate erectile difficultycaused by illegal drug use. Among the populations studied, illegal drug use was common and only sometimes supplemented by Viagra. Methamphetamine usewas the biggest predictor of risky sex in many studies, two of which explicitlyfocused on relationships between methamphetamine use and risky sex (Breweret al., 2004; Colfax et al., 2001; Mitchell et al., 2004; Wong et al., 2004).
Another key simplification in Swearingen and Klausner’s review involves the temporal relationship between men’s Viagra use and their risky sexual activ-ity. Many of the reviewed studies gathered information on the sexual activities ofoccasional Viagra users, who had not necessarily been using it during recent riskysex. For instance, Cachay and colleagues found Sildenafil use to be a ‘significantpredictor’ of risky sex and potential STD transmission among HIV positive menin San Francisco, but their measure of Sildenafil use was whether HIV patientswere ‘subsequently receiving Sildenafil’ after their inclusion in the study, byprescription from their doctors (Cachay et al., 2004).
Swearingen and Klausner obscure the fact that the few reviewed studies that examine Viagra use in specific sexual encounters do not demonstrate that thedrug caused risky sex. Instead, these studies found that Viagra users only some-times used the drug during risky encounters. Authors of a reviewed study inwhich San Francisco gay men reported on drug use and risk behavior duringtheir most recent anal sex encounter argue that since methamphetamine canincrease sexual sensitivity but inhibit erection, some men may use Viagra tocounteract this effect: 6 percent of respondents had done so (Mansergh et al.,2004). A reviewed study of drug use and risky sex among gay members ofLondon gyms that investigated the specifics of recent unprotected sexualencounters found that men who had tried Viagra were more likely to reportunprotected sex, illegal drug or anabolic steroid use in the past six months (Sherret al., 2000). However, this study’s authors make a key point that is excludedfrom Swearingen and Klausner’s warnings about the risk of Viagra use by gaymen in general. Sherr and colleagues argue that their findings suggest: ‘some menmay have added Sildenafil to their risk-taking repertoire, rather than Sildenafilper se leading to an increase in their risk behaviour’ (2000: 2051). While the stud-ies they review characterize Viagra use as a practice that may promote risky sexwhen combined with illegal drug use, Swearingen and Klausner obscure thesespecifics to claim that Viagra alone increases risk.
Swearingen and Klausner conflate the potential risks of Viagra use with risks they implicitly attribute to all gay sex in two key ways. First, they argue thatViagra facilitates sexual risk by casting gay sex itself as inherently dangerous.
They write, ‘Although Sildenafil does not cause these [STD] infections, theincreased duration of erection, increased blood flow, and subsequent increasedmucosal susceptibility may increase the risk of acquiring these infections if 116 & Body & Society Vol. 17 No. 4 having sex with an infected partner’ (2005: 575). This statement suggests that gaymen’s erections themselves are fundamentally different and provoking of sexualdanger. Swearingen and Klausner hypothesize that Viagra-fueled gay sex mightthus be particularly risky because it facilitates ‘insertive anal intercourse in menwho have sex with men, which requires a more rigid penis than oral or vaginalintercourse’ (2005: 575). This statement overlooks the popularity of heterosexualanal sex, while making a dubious assertion about the relative rigidity of erectionnecessary for specific acts.
Second, they frame gay sex as risky regardless of whether participants practice safer sex. For instance, they present the finding that HIV positive menwho had been prescribed Viagra were more likely than men without prescrip-tions to have multiple partners per month as an indicator of Viagra-related risk.
However, they do not specify whether these men practiced unsafe sex; the simplefact that HIV positive men had sex, and that this sex correlated with Viagra use, isused to define this use of the drug as dangerously illegitimate. The review impliesthat gay sex is fundamentally dangerous misuse, so facilitating its performancewith Viagra would make participants less healthy.
A key simplification that supports this general aim is the conflation of pre- scription and non-prescription use of Viagra. In the review, the fact that somestudy subjects had been prescribed Viagra is erased, as all Viagra use studied isdescribed as ‘nonindicated’. However, many of the studies that Swearingen andKlausner (2005) argue reveal links between ‘nonindicated’ Viagra use and riskysex in fact demonstrated correlations between occasional Viagra use, often byprescription, and occasional risky sex that often occurred without Viagra. SinceHIV-related illnesses and treatments can inhibit erectile capacity, and manystudy participants were receiving HIV treatment, subjects’ perceived need forViagra is as likely to be a consequence of STD transmission rather than its cause.
Thus, the finding that men who get STDs are also taking Viagra does not neces-sarily mean that Viagra-fueled sex was the source of their infection. Many of thereviewed studies accounted for this nuance, making distinctions between pre-scription and non-prescription use (Cachay et al., 2004; Chu et al., 2003; Colfaxet al., 2001; Purcell et al., 2002; Sherr et al., 2000).
Overall, Swearingen and Klausner significantly simplify the contexts and findings of the reviewed studies to argue that Viagra use represents an ‘ongoingpublic health problem’ (2005: 576). While they briefly note the studies’ specificsand affirm that ‘definitive causal inferences regarding Sildenafil use and sexualrisk behavior and STDs cannot be made’, they analyze the reviewed findingsstrategically to conflate all gay Viagra use with the risky sex found among aparticular subset of gay, drug-abusing Viagra users (2005: 571). They argue that their findings ‘warrant a multi-faceted response to reduce the misuse ofSildenafil and its consequences, particularly among men who have sex withmen’ (2005: 571).
Other public health researchers reviewing similar data reached different conclusions, including a 2004 review by Romanelli and Smith entitled ‘Recrea-tional use of Sildenafil by HIV-Positive and -Negative Homosexual/BisexualMales’, which Swearingen and Klausner cite. Romanelli and Smith (2004) arguethat this body of research provides information on a more specific topic: theeffects of Viagra use in combination with club drugs and antiretrovirals. Ratherthan casting gay sex as a public health risk, they argue that Viagra-related dangerslie in combining the drug with contraindicated substances, or by facilitating sexduring illegal drug use. The authors also distinguish between prescription andnon-prescription Viagra use. Thus, they interpret the same studies reviewedby Swearingen and Klausner to demonstrate the risks of non-prescription Viagrause in combination with illegal drugs, in specific high-risk populations. How-ever, Klausner and Swearingen conceal these details, citing this review as supportfor the claim that Sildenafil use was associated with increased unprotected analsex between serodiscordant partners. Through such practices of simplification,Swearingen and Klausner assert that gay men’s Viagra use is a general publichealth risk.
Challenging the Fact of Risky Gay Viagra Use While this ‘fact’ provided support for Klausner’s Viagra-related activism, his useof it to support the political demands discussed previously prompted a backlashthat led to its undermining. Stakeholders in two very different arenas –physicians (many working for Pfizer to promote ED diagnosis and the sale ofViagra) and gay rights activists – sought to actively un-make this fact byrevealing the simplifications involved in its creation. This process involveddeliberate ‘complexification’, in which critics sought to highlight the socialmotives and supporting data that had been simplified away in the creation ofthe fact of risky gay use.
The political response against Klausner’s characterization of gay Viagra use entailed outright rejection of the new fact as homophobic and paternalistic bygay activists and San Francisco politicians. They sought to complexify the socialagenda surrounding this fact-making, arguing that Klausner’s argumentswere motivated by a desire to control gay men’s sexuality. Most notably,San Francisco Mayor Gavin Newsom’s HIV policy advisor, Jeff Sheehy, arguedthat STD chief Klausner’s framing of gay sex as a health risk was both 118 & Body & Society Vol. 17 No. 4 ‘AIDSphobic and homophobic’, saying that Klausner wanted ‘the dicks ofpeople with HIV in his back pocket and he wants us to ask him permission touse it [sic]’ (Roehr, 2006). Sheehy then asked San Francisco’s Human RightsCommission to investigate the matter, re-framing Klausner’s public healthfact as slander (Bajko, 2005).
Klausner’s FDA petition drew criticism on different grounds from medical professionals, who argued that classifying ED drugs as controlled substanceswould impede legitimate access (Bajko, 2005). Medical professionals who heldvarious stakes, ranging from economic interest in Viagra sales to a desire tore-focus discussion of sexual risk onto illegal drug use, also set out deliberatelyto challenge Klausner’s fact. Following Klausner’s petition, a National Institutesof Health-funded conference was held at the Bolger Center to review publichealth studies of ED treatment use, with the explicit goal of assessing the validityof the claim that ED pharmaceutical use led to risky sex and increased STDtransmission. The Bolger conference panel rejected Klausner’s fact of riskyrecreational use, arguing instead that diseases like HIV may cause sexualdysfunction and actually increase patients’ need for ED drug therapy (Rosenet al., 2006). Urologist Irwin Goldstein, long-time paid Viagra consultant andeditor of the journal in which these conference findings were published, argued:‘Health care providers should be reminded that individuals infected with HIVfrequently have erectile dysfunction from their disease or from pharmacologicagents commonly used in its treatment’ (Loe, 2004a; quoted in Roehr, 2006).
More generally, the conference panel concluded that most men use ED drugswithin stable, committed relationships, in which ‘the risk of HIV infection isrelatively small’ (Rosen et al., 2006). Here, physicians aiming to promote Viagrause employed the marketing language of the legitimate Viagra user, defendingthe drug against stigma by associating it with stable couplings.
The Bolger conference also included the voices of actors who sought to challenge Klausner’s fact for political reasons. Clearly, consultants paid by Pfizerhave particular stakes in promoting and legitimizing widespread Viagra use;Goldstein has gone so far as to recommend that all men take small doses ofViagra daily to ward off impotence (Moynihan, 2003). Yet other participantscritiqued Klausner’s fact in order to highlight what they felt to be the more press-ing risk factors for HIV transmission. For instance, Jeff Sheehy said of the panel’sfinding: ‘Once again, sound science wins out. . . . It’s speed – crystal meth – that’sthe problem’ (Roehr, 2006). Thus, a variety of medical and political actors with arange of motivations worked together to ‘complexify’ Klausner’s fact, revealingboth the submergence of basic public health data and the political designs thathad been key to its construction. Following the medical unmaking of and the political outcry against the fact of risky gay ‘recreational’ use, Klausnerwithdrew his FDA petition and issued a public apology (Roehr, 2006).
Conclusion: Arena Analysis and the Fact’s Social Consequences Here, I have traced the construction and contestation of the fact of gay men’s‘risky’ and ‘recreational’ Viagra use, in the context of strategic marketing silencesurrounding gay men’s ED drug use and long-standing American culturallinkages of gay men’s sexuality with sickness. My aim was not simply to critiquethis fact’s validity, but to reveal the social work – in the realms of politics andpublic health fact-making – involved in creating, asserting and subsequentlychallenging this fact. This study builds on science studies and medical anthropo-logical aims of understanding new medical technologies’ social consequences byinvestigating the practices of knowledge construction that enabled their develop-ment (Epstein, 1995). Research in this vein often attends to multiple actors’ par-ticipation within overlapping social arenas, in order to understand how peoplewith different motives and political commitments interact to shape technologicaldevelopment and deployment (Clarke and Montini, 1993). Here, I haveemployed this ‘arena analysis’ approach to understand the ways that marketing,public health research and politics, gay rights and pharmaceutical sales togethershaped the medical and cultural meanings given to gay men’s sexuality.
I extended this approach by including strategic silence as a key component ofthis arena; marketing silence around gay Viagra use enabled the conflation of‘recreational’ users and gay users, which was central to subsequent assertionsthat gay men’s Viagra use posed heightened STD risk.
While this study traces the making and contestation of that fact, its eventual medical undermining did not mean the end of its social influence. Swearingenand Klausner’s review continues to be widely cited, and appears to have set anagenda for US-based public health study of Viagra and STD risk; a 2011 Pubmedsearch revealed that since the year following publication of this review, over60 percent of research on Viagra and STD risk has focused on men who have sexwith men.1 Following the complexification of its findings, references to thereview often note its lack of generalizability (cf. Fisher et al., 2006). However,while the fact of gay men’s risky recreational use has been discredited, it stillappears to shape the sorts of questions that US-based public health research asksabout Viagra-related risk. More broadly, the persistence of these questionssignals the continuing pathologization of gay sexuality in American culture.
Ongoing marketing silence about gay Viagra use demonstrates the continuing conflation of gay and recreational/illegitimate use in the US. While ED drug 120 & Body & Society Vol. 17 No. 4 marketing has become more thematically diverse, it continues to avoid depictionof ‘queer’ ED drug use. Both the media attention and social fears surroundingmedically mediated erections have died down in the 13 years since Viagra’s intro-duction, and the development of competing ED drugs has enabled more diversemarketing. While newer ED drugs like Cialis have taken on the mantle of thecouple’s cure, for example using the image of older heterosexual couplesrelaxing together in bathtubs, ED drug advertising in general has begun to discusssex and drug side effects a bit more frankly (Elliott, 2006). Enabled by this shift,Viagra marketing has shifted from selling successful companionate coupling tomarketing more roguish masculinities. Revealing the persistent need to legitimizeED drugs as supportive of ideal heterosexuality, these Viagra ads have sometimesmet with social and regulatory backlash. For example, the FDA requested thatPfizer pull ads showing a man growing devil horns at the sight of lingerie, arguingthat these ads sold ‘sex’ rather than treatment for the medical condition erectiledysfunction (ConsumerAffairs.com, 2004). Yet, despite this boundary-pushingwithin ED advertising, no US marketing campaigns have aimed at gay men.
It is important to note that the marketing and public health representations of ED drug use described here are only two of a wider set of cultural representa-tions, which relate complexly to advertising and medical ‘facts’. While more andmore men are using pharmaceutical ED treatment, they are not necessarily doingso because they see themselves reflected in marketing or medical narratives aboutED. For instance, gay men have never seen themselves portrayed in the Viagramarketing, but as the studies discussed above reveal, certain groups of gay mencertainly use the drug. Similarly, straight men’s Viagra use may not match theexperiences depicted in marketing or medical discourse about ED (Potts et al.,2004). Yet, while marketing and medical messages about ED may not affectmen’s Viagra use in simple ways, the assertion of risky gay use described hereshows that these discourses both shape and are deliberately deployed in multiplesocial domains to define and intervene in people’s sex lives.
These claims in turn have broad political consequences. While the stigma of recreational use may not shape individual gay men’s consumption of Viagra, itaffects the political climate in which struggles for gay rights are fought, byrefreshing long-standing cultural associations between gay sex and sickness.
Historically, this association has facilitated specific political, social and marketagendas; extreme examples include unfounded classification of gay bars, clubsand bathhouses as vectors of STD transmission to justify lucrative redevelop-ment of the urban neighborhoods where they were located (Delaney, 1999;Rubin, 1997). The story of the assertion and contestation of the fact of risky,recreational gay Viagra use shows that while differently motivated actors can make flexible use of medical and marketing discourses in US culture, thesediscourses have very real social and political consequences.
1. Run on 21 January 2011, this Pubmed search for the terms ‘Viagra STD risk’ and ‘Viagra STI risk’ found eight articles, five of which gathered data from populations of men who have sex withmen (Brewer et al., 2006; Carey et al., 2009; Foxman et al., 2006; Mimiaga et al., 2008; Sanchezand Gallagher, 2006; Semple et al., 2009; Smith and Christakis, 2009; Tan et al., 2006).
This article is the final outcome of a project that I began as a graduate student in Gayle Rubin and EstherNewton’s ‘Queer in America’ seminar at the University of Michigan. I thank them for introducing meto the topics and approaches that are so central to my work, and for their support along the way. I alsothank the anonymous readers for their helpful comments on earlier versions of this piece.
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Emily Wentzell is an Assistant Professor in the University of Iowa Department of Anthropology. Inaddition to a focus on sexuality in popular culture, her research combines approaches from medicalanthropology, gender studies and science and technology studies to examine sexual health interven-tions’ gendered social consequences. She is currently working on two ethnographic projects basedin a hospital in Cuernavaca, Mexico. One examines older, working-class men’s use and rejection oferectile dysfunction treatments and changing ideas about masculinity, while the other focuses on theconstruction of gendered selfhood among married couples participating in an HPV transmissionstudy. [email: firstname.lastname@example.org]
ATI - EPI, RAMANTHAPUR, HYDERABAD PROCUREMENT PLAN FOR CIVIL WORKS (REVISED) CoE VTIP SCEME UNDER WORLD BANK PROJECT : VOCATIONAL TRAINING IMPROVEMENT PROJECT COUNTRY: INDIA NAME OF THE INSTITUTE: ATI - EPI, RAMANTHAPUR, HYDERABAD-500 013. 2009 - 2010 2010 Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct