Cover image for Beyond viagra : a commonsense guide to building a healthy sexual relationship for both men and women
Beyond viagra : a commonsense guide to building a healthy sexual relationship for both men and women
Melchiode, Gerald A.
Personal Author:
First edition.
Publication Information:
New York : Henry Holt, [1999]

Physical Description:
248 pages ; 22 cm
General Note:
"An Owl book."

Includes index.
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RC889 .M379 1999 Adult Non-Fiction Central Closed Stacks

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Explores underlying psychological and emotional stresses affecting sexual dysfunction and details when the drug should be prescribed.

Author Notes

Gerald Melchiode, M.D., is a professor of psychiatry and lecturer at the University of Texas Southwestern Medical Center in Dallas and has been a therapist in human sexuality for more than thirty years. Bill Sloan is a former award-winning reporter for the Dallas Times, and a Pulitzer Prize nominee.

Reviews 2

Booklist Review

Psychiatrist Melchiode was a consultant to Pfizer early in its development of Viagra, and though "excited and optimistic" about it, he is no cheerleader for it. With award-winning reporter Sloan's aid, he reviews the history of the drug and its major uses, contraindications, and side effects. He then suggests steps to take should Viagra not work. He examines basic sexual relations between men and women, emphasizing the need for cooperation, information, and understanding. Faced with a sexual dysfunction, a physician must identify and evaluate the real problem and then make a diagnosis. (Medical education, however, is deplorably weak in teaching about sex; physicians, therefore, have an obligation to learn on their own.) Next, it may be good to call in a psychiatrist or another specialist. Melchiode cites specific medical histories to personalize and clarify major problems and possibilities. --William Beatty

Library Journal Review

The National Institutes of Health estimates that 20 million men suffer from sexual dysfunction. As more Americans seek prescriptions for Viagra from their physicians, it is important to realize that potential solutions to this problem go beyond pills. A therapist specializing in human sexuality for 30-plus years, Melchiode (psychiatry, Univ. of Texas Southwestern Medical Sch.) participated in early trials of Viagra. He does an excellent job of addressing sexual problems within the context of relationships, as well as the issues involved in determining whether Viagra is the therapy of choice. Further, he deals with other important topics, such as sexuality and aging, the stance of managed-care providers with respect to Viagra, women's attitudes toward the drug, and Viagra's impact on society as whole. An appropriate choice for consumer health collections and public libraries.ÄLinda M.G. Katz, Allegheny Univ. of the Health Sciences Lib., Philadelphia (c) Copyright 2010. Library Journals LLC, a wholly owned subsidiary of Media Source, Inc. No redistribution permitted.



Chapter One Waiting for Viagra Viagra.     Few words in medical history have entered the mainstream of our vocabulary more quickly or forcefully. To those familiar with the Latin languages, its correct pronunciation would seem to be Vee-AH-grah, but the manufacturer prefers to call it Vy-AH-grah, and the newscasters say Vy-AG-rah, to rhyme with "Niagara."     Regardless of how you pronounce it, though, the definition of Viagra is still the same. It's the first effective oral treatment ever discovered for male impotency and one of the most sought-after pills in the annals of pharmacology.     Amazing as it seems, just a year ago almost no one in this country had ever heard or read the word Viagra . Now some version of it seems to be on everybody's lips. Doctors from coast to coast have been swamped with patients clamoring for it. Within two weeks after it was introduced in drugstores, some forty thousand prescriptions a day were being written for it, a record that no previous drug had come within a mile of matching, and total 1998 sales were projected at over $1 billion. Fueling the demand were innumerable newspaper and magazine articles, radio talk shows, and TV news programs.     Viagra is literally changing our world before our very eyes--and with good reason.     True "miracle drugs" have come along only a few times in recorded history, but this little blue pill, approved by the U.S. Food and Drug Administration in late March 1998 after years of testing in America and Europe, seems to merit this definition. Viagra temporarily "cures" male impotency in the vast majority of men who take it--predictably, painlessly, in a matter of minutes, and with almost no observable side effects.     By the time it became available by prescription in April 1998, I had already had a close relationship with Viagra and its U.S. manufacturer for a number of months. As a practicing psychiatrist specializing in the treatment of male sexual disorders, I was among a select few doctors who prescribed the drug for patients prior to its general availability. I was also asked by Pfizer Inc., the giant pharmaceutical company that markets Viagra, to serve as a consultant to help familiarize the rest of the nation's medical community with the drug.     Because of this experience, I can now say that both as a pharmaceutical agent and a social trendsetter, Viagra is everything it's cracked up to be. And for better or worse, it has the potential to be much, much more.     "It really works and it takes only one pill to do the trick," says a sixty-two-year-old user who participated in a hospital-based Viagra testing program. "Within forty-five minutes, I had an erection like I haven't had since I was thirty or so--and my first one in months. It almost made me feel like a kid again."     Not even the widely hailed antidepressant Prozac has generated such overwhelming interest on the part of the public. Viagra is a cinch to become the most widely consumed prescription drug in at least three decades. It's also well on its way to becoming the most abused prescription drug in history. But this is only the tip of the iceberg. The real impact of Viagra goes far beyond these immediate effects. Its introduction is a cultural landmark that will, in all likelihood, alter social patterns, sexual mores, and basic human relationships for generations to come. It has already rerouted America's entire approach to male impotency--and to sex itself, for that matter. It has done so rapidly, dramatically, and probably forever.     As Newsweek observed some six months before the drug's release, if Viagra makes enough of the nation's thirty-eight million baby boomers feel like "virile teenagers" again, it could touch off another sexual revolution.     The prediction has proved highly accurate. This revolution could be even more far-reaching and profound than the one triggered by the appearance of the birth-control pill in the late 1960s. By the turn of the century, the drug will be available around the world, and it will be followed by other oral impotency medications. A Long Time Coming Civilization has waited an incredibly long time for Viagra and the other oral drugs for male impotency that are sure to follow it. By the time the first U.S. prescriptions for Viagra were written, the ailment known in medical circles as erectile dysfunction had quietly reached epidemic proportions. And despite all our other medical advances, no single treatment for impotency had yet even come close to yielding satisfying results.     Before Viagra, the only sure way for an impotent man to get and maintain an erection was with penile prostheses, vacuum pumps, hypodermic needles (ouch!), or urethral implants. They took most of he spontaneity out of the sex act, produced erections that wouldn't go away for hours (or sometimes even days), often hurt like hell, and in some instances were downright dangerous.     At best, these were ugly alternatives to a sexually lifeless existence, but they were the only "quick fixes" we had. Almost overnight, Viagra has changed all that.     It couldn't have happened at a more propitious time. There is compelling evidence that male sexual dysfunction is more widespread today than at any previous point in human history--and yet it is certainly nothing new. As far as we know, impotency has been affecting certain men since the dawn of time. Until the past few decades, however, the subject was so shrouded in secrecy and shame that medical science had developed little solid information about it.     Today, the National Institutes of Health estimate that twenty million American men suffer from it, and Pfizer sets the figure even higher--at thirty million. When partners of the dysfunctional males are included, this means that up to sixty million men and women in this country are directly victimized by this "masculine" disorder. And even this vast number may not reflect the full magnitude of the problem, since many men affected by poor sexual performance have historically been too embarrassed to seek treatment. Definitions of Impotence Before we go any further in discussing how to treat impotence, we need to define the term--or, more specifically, the terms --involved.     Impotence, impotency, and erectile dysfunction are basically interchangeable names for the same problem. They simply mean that, at least part of the time, a man is unable to obtain an erection sufficiently rigid for sexual intercourse. The traditional lay term for this condition is impotence, while medical people more frequently refer to it as impotency . Both terms imply a degree of permanence that could be a deterrent to effective treatment. Erectile dysfunction is a more recent term that may sound somewhat less ominous to the patient. It is now widely used by physicians in an effort to describe more clearly what the other terms mean.     Sexual dysfunction is a broader term that can include not only erectile failure but a variety of other problems in both men and women. (Yes, a surprising number of women suffer from sexual dysfunction, too, and many are unaware of their problems, because they are less obvious than men's. Viagra offers intriguing possibilities for helping sexually troubled women, and these are the focus of a chapter later in this book.)     Of all male sexual disorders, erectile dysfunction is by far the most common, but the degrees of dysfunction vary widely from patient to patient, and several systems have been established for differentiating among them.     The authoritative Massachusetts Male Aging Study (MMAS) used a three-tier definition to calculate how many of the study's subjects suffered some form of diagnosable erectile dysfunction: • Minimal dysfunction meant that a man was usually able to get and keep an erection sufficient for sexual intercourse. • Moderate dysfunction meant that a man could sometimes get and keep a good enough erection for sexual intercourse. • Complete dysfunction was defined as meaning a man could never get and keep an erection sufficient for sexual intercourse.     The MMAS study also found that 52 percent of the 1,290 men, aged forty to seventy, who participated in it were affected by one of these three phases. The minimal category accounted for 17.2 percent of the men, the moderate category for 25.2 percent, and the complete category for 9.6 percent.     If these findings can be extrapolated to the general population, they mean that more than half of all men in this age group are affected by some degree of erectile dysfunction. If the old adage that "misery loves company" actually holds true, simply realizing this fact should provide some measure of reassurance for the legions of sexually impaired men in this country. Ancient Times Versus Modern I've seen firsthand--and tried to alleviate--the demoralizing, ego-destroying psychological impact of impotency on hundreds of male patients during the relatively enlightened era of the past thirty years. In many of them, the precise cause of the problem was elusive and difficult to pinpoint. Impotency may be purely physical in nature, or it may be totally psychological. Other times, it may be a complex combination of both.     There are many triggers for impotency, and despite all our research, there is still much to be learned about it, even today. I can only imagine the hopelessness and silent torment suffered in earlier times by men who found themselves sexually "dead," with no prospects of effective treatment, much less a cure.     It seems probable, however, that male impotency was a much less common condition in the ancient world than it is in the modern one. One reason for this is that not nearly as many men survived to reach what we now refer to as "middle age"--the over-forty period when male sexual dysfunction is most prevalent. Just a couple of hundred years ago, a man was considered "old" when he reached his fifties, an age that now falls within our definition of the "prime of life." In the mid-nineteenth century, for example, a typical man in this age group had spent decades working twelve-hour days and six-day weeks, usually at hard physical labor. Under the circumstances, he could easily blame a flagging sex drive on sheer fatigue. And the lack of effective birth-control measures often made it prudent to reduce or curtail sexual activity at that point in life, anyway.     This is in sharp contrast to our attitudes and practices today, when many men are starting second families in their fifties and when millions of men and women are obsessed with the "cult of youth," of which sex is viewed as an indispensable part. In movies, television, and every other modern entertainment and communications medium, sex and sexuality are inseparably linked with youth, glamour, and success. In this atmosphere, losing your ability to have sex can seem as crushing as losing a limb or an eye--possibly even more so.     Barry W., a fifty-seven-year-old salesman who came to me after prostate surgery left him impotent, expressed it this way: "The operation saved my life, but it also left me feeling like a big part of that life was gone forever. Sometimes it was as if I wasn't even the same person I'd been before." Longer Life, Higher Risk We're living far longer than our forebears. A baby boy born today has a life expectancy of about seventy-three years, and a healthy man in his mid-fifties can expect to live to eighty or beyond. That's the good news. The bad news is that as men age, their odds of developing sexual dysfunction gradually increase. Diseases such as diabetes, prostate cancer, hypertension, and atherosclerosis often trigger a loss of sexual function, and so do many of the drugs and surgical procedures used to treat these ailments. As in Barry's case, once-fatal diseases are now often held in check, and the life span is extended, but as a consequence the patient's sexuality can be damaged or obliterated completely.     Even in the absence of any disease or other identifiable cause for erectile dysfunction, the aging process itself affects sexual response. Some men in their seventies have fathered children, and some men have maintained an active sex life into their eighties. But for many others, the desire for sex fades years earlier with no identifiable physical cause.     It can be argued, however--and, in fact, has been demonstrated in studies of elderly populations--that continuing to engage in sex, even on an infrequent basis, benefits the general health of older people and is associated, in particular, with a healthy prostate in older men. Viagra clearly puts these benefits within the reach of millions of men in their sixties, seventies, eighties, and beyond, but the social consequences of so many men continuing sexual activity into old age aren't nearly so easy to predict.     Population studies show that by 2020, about 20 percent of all Americans will be over sixty-five. As the baby-boom generation of the 1940s and '50s enters middle age and the nation's population grows steadily older, more and more men will be living with degenerative-disease processes that can produce additional millions of cases of impotency. Medical authorities quoted on a recent edition of ABC's 20/20 estimate that erectile dysfunction will affect more than 50 percent of all American males between the ages of forty and seventy.     This is a stunning statistic. What it means is that once a man enters this age group, his odds of developing erectile dysfunction are at least as high as his odds of avoiding it. If this doesn't constitute an epidemic, I don't know what would.     But what it also means is that within a couple of decades, the market for Viagra and other anti-impotency and erection-enhancing drugs--just among the elderly--will be gargantuan.     Meanwhile, the very pressures and excesses of modern life also contribute immeasurably to the impotency problem. The abuse of alcohol and/or illegal drugs is frequently an underlying cause of male sexual failure, and recent studies show that men who smoke cigarettes are seven times as likely to develop erectile dysfunction as nonsmoking men. Millions of Americans of both sexes suffer from clinical depression, which robs them of their zest for life and their interest in sex. In either partner in a relationship, severe untreated depression can mean the end of sexual intimacy.     Each of these factors contributes to the prevalence of sexual dysfunction. Each represents another reason why the modern world has waited so desperately for Viagra and the "magic bullet" it represents. But the factors cited above are some of the easier ones to identify. There are other, far more complicated problems that often lie buried far beneath the surface. And instead of offering a quick, painless solution to these problems, the improper use of Viagra or other oral impotency medications could actually make them worse. A Fly in the Ointment? This is why, as exciting as Viagra's track record has been thus far, some sex therapists, marriage counselors, and sociologists are urging caution. They warn that widespread use of the drug could become a sort of "Trojan horse" for sexually troubled men and their mates. Without a sound system of controls, some experts fear that Viagra could end up damaging as many relationships as it benefits--conceivably even more.     The causes of psychologically induced impotence are often deep-rooted and obscure. They usually relate to much more than merely the physical act of sex itself. No pill, no matter how effective, can magically make up for the loss of romantic feeling and the erosion of affection that frequently set the stage for male impotence. It can do nothing, for example, to rekindle desire in a wife embittered by the idea that her husband is no longer physically attracted to her or angered by his refusal to admit his problem and seek treatment. (Indeed, even the promise of a "potency pill" that helped up to 92 percent of the men involved in European studies may not be enough to persuade some American males to swallow their pride--and a perceived threat to their manhood--long enough to consult a physician about their sexual difficulties.)     It's important to understand that, in the vast majority of cases, men's sexual failures don't take place in isolation. They almost always affect at least one other person. Typically, when a man begins having difficulty getting erections, his partner doesn't know the cause or how to deal with it. Her first impulse may be to blame herself for not being sexy or attractive enough anymore. Then, as the man grows more worried about his difficulty, he tends to make matters worse by avoiding intimate contact with his wife. He often withdraws from her, both physically and emotionally.     Over time, the partner's self-blame often turns to frustration. She urges the man to seek help, but the thought of telling a doctor about his problem is too humiliating for him to bear--so he does nothing. Gradually the woman's suppressed resentment and bitterness grows, while the husband tries to ignore the problem and his own nagging sense of failure and guilt. Sometimes, the relationship falls apart, but many couples reach some sort of compromise in which they continue to live together but with very little physical contact, very little affection--and no sex.     Now imagine this scenario: Suddenly, a marvelous pill comes along that promises to restore the man's sexual prowess. The man is excited and eager. All he wants is a physician willing to write a prescription for the pill. Forty-five minutes after he swallows his first one, he's raring to go. But what about his partner?     "Not so fast," his wife responds. "What about all these years I've been asking you to do something--see a doctor or a marriage counselor--and you've only buried your head deeper in the sand? What about all the times you've avoided me? Now you're all worked up again and demanding sex, but why should I feel any affection toward you? Why should I say, `Oh, fine, let's get it on!' and just forget all the rest?"     The point is that even a "magic bullet" can be used to shoot oneself in the foot. Simply taking a pill and getting an erection isn't going to erase all the hidden scars, negative undercurrents, and stored-up antagonisms that can mar and threaten a relationship.     The penile prostheses that some men had implanted beginning in the 1970s produced what could be termed a perpetual erection, and the vacuum pumps and injections that came later also made sex a mechanical possibility. But oddly enough, many of the men who tried these devices never employed them for sexual intercourse with their partners. In fact, the partners were seldom even included in the decisions to use the devices in the first place, and they were understandably turned off by them. The devices and the kind of sexual activity they made possible seemed too mechanical, awkward, inconvenient, and unnatural. It was devoid of the feelings of warmth, closeness, and spontaneity that most of the men and their partners really wanted.     To ensure that Viagra doesn't become just another turnoff for many women, it should be used with reason and in combination with effective counseling when needed. Unquestionably, Viagra produces a natural-feeling erection and allows completely natural sex. But this time medical technology mustn't overlook the importance of the partner. Indiscriminate overuse of the drug simply to embellish a "macho stud" image could be disastrous. It could lead to increased infidelity and promiscuity, additional weakening of the already-beleaguered family unit, and further unraveling of our social fabric. The Changing Female Role Once upon a time, we lived in a world totally dominated by males. Before the twentieth century, masculine rule of major social, political, and economic systems was virtually absolute and seldom challenged. Men made all the important decisions, and women were simply expected to follow along. As I'm sure you've noticed, times have really changed!     In the thirty or so years since the emergence of the women's movement in this country, a massive shift in the balance of power has taken place--in government, business, science, education, religion, and elsewhere. But in no area of society has the new posture and status of women been more keenly felt than in marriage, childrearing, and other key personal relationships.     Countless women have abandoned their traditional roles as homemakers and mothers in search of equality and fulfillment. Today, they compete boldly with men in the world at large, often outperforming their male counterparts. Many women make more money than their husbands. Many hold positions as top managers and executives. They demonstrate their independence daily in hundreds of corporate boardrooms--and, perhaps even more significantly, in tens of millions of bedrooms.     It isn't the purpose of this book to debate the pros and cons of this socio-economic phenomenon. History will ultimately determine the full effect of the changing female role on Western civilization. I also don't mean to imply that it's wrong for women to take a more active, demonstrative role in sex, whether it be in letting their partners know what they like and don't like, or in helping their partners work through sexual difficulties. For every impotent man in a committed relationship, his problem is very much a woman's problem, too. But at the same time, it would be a mistake to ignore the new assertiveness of women as it relates to the current epidemic of male sexual dysfunction.     The old image of the male as the perpetual aggressor or pursuer in romantic and sexual encounters no longer holds true. Younger women, especially, have ripped up the double standard that prevailed for thousands of years and tossed it to the winds. Many of them show no more qualms than men about initiating intimacy with attractive members of the opposite sex. Whether men can admit it or not, this challenge to the traditional male role makes many of them apprehensive and uncomfortable.     On average, until the recent past, boys tended to become sexually active at an earlier age than girls, but this, too, is changing. Surveys show that nearly one in every five girls under the age of fifteen is sexually active. Girls as young as thirteen, responding to questions on one such survey, expressed the belief that "if you know a boy for a few hours and like him, it's okay to have sex with him."     While the fear of AIDS and the HIV virus has served as a strong deterrent to casual sex among more mature men and women in recent years, adolescents often seem to ignore the threat. Meanwhile, the effectiveness and availability of birth-control pills (many parents readily admit supplying the pills for their sexually active teenage daughters) have also loosened traditional sexual restraints among adolescent girls.     These factors, coupled with the rise of feminism and the demand that women enjoy the same sexual prerogatives as men, have created a whole "new morality" where casual sex is concerned. As any qualified sex therapist can tell you, aggressive sexual behavior by women triggers performance anxiety in a sizable percentage of men. This can lead directly to erectile dysfunction, particularly in men accustomed to more traditional partners and relationships. Even young, healthy males can be affected. A "Scary" Experience Consider the plight of Greg C., a recently divorced businessman in his early forties. Greg had been married for nearly twenty years to a shy woman with little interest in sex, but after his marriage ended, he found himself frequenting singles bars again in search of female companionship.     "I wasn't prepared at all for the way things have changed out there," Greg admitted. "To me, it was really scary."     The first time Greg found himself in an intimate situation with a younger woman he had met in a bar, it had been several months since he'd last had sex. Initially, he became strongly aroused, but when the critical moment came and his partner grew more demanding, he was totally unable to perform. To make matters worse, the woman ridiculed him, which left Greg ashamed, chagrined, and emotionally wrecked.     "These younger women can come on pretty strong," he said. "They don't like to take `no' for an answer--and they sure don't like it when the guy they're with can't get it up!"     After several similar experiences, Greg consulted a urologist, and when tests showed no physical basis for his problem, the urologist suggested he talk to a psychiatrist.     For most healthy men of Greg's age in situations like these--at least 80 percent, based on reports so far--Viagra can provide a quick, dependable rescue. It works in about forty-five minutes and its effects last for several hours. It can be taken randomly at any time a man contemplates having sex. Side effects are mild and minimal, and most men have none at all.     Even so, some physicians may be hesitant about prescribing Viagra for men in Greg's circumstances. In my view, it isn't the physician's role to make moral judgments or try to dictate how the patient should use the drug. If the patient's problem is diagnosed as erectile dysfunction--and to me that means not being able to obtain an erection sufficient for intercourse on at least several occasions--the physician should try to help him overcome the problem. I do believe, though, that if the problem is found to be psychological, the drug therapy should be accompanied by counseling in which both partners participate. And it would be pretty unrealistic to expect one of Greg's partners--former partners, I should say--to come along with him to a psychiatrist's office.     In counseling, it was pointed out to Greg that a singles bar is one of the unlikeliest places to find a partner for a meaningful, long-term relationship and that church groups, adult education classes, volunteer organizations, professional societies, and health clubs offer better prospects.     Eventually, though, Viagra was prescribed for Greg, and it worked like a charm. He soon regained his confidence and found he could perform adequately without the drug, although he admitted carrying a spare pill in his pocket "just in case." Hundreds of thousands of other men with the same sort of problem will undoubtedly use Viagra with similar results within the next year.     I only wish that all instances of erectile dysfunction could be "cured" as simply as Greg's, but unfortunately, that isn't the case. For those who are less interested in the superficial thrill of casual sex than in protecting and preserving lasting, meaningful relationships, overcoming impotency can still be a lengthy, meticulous undertaking. It's also one in which the patient's partner is often as important a participant as the patient himself.     That's why I firmly believe that both Viagra and this book are every bit as much for women's benefit as they are for men's. It's More Than a Game Today's American society is saturated and suffused with the concept of recreational sex. Beginning in adolescence or earlier, sexual messages, stimuli, and innuendo bombard us relentlessly from every side. Free-and-easy sex is the universal theme of movies, television programs, and other media products. It has become our national pastime--a game played every day and every night by countless millions of men and women.     Viewed simplistically, Viagra's arrival only adds new excitement and more players to the game. Thanks to this pill, millions of unfortunates who were once trapped on the sidelines by sexual dysfunction can now become full, eager participants again. Not only that, but they can play longer and harder (literally) than ever before. This is why Viagra is in huge demand by men who merely want to enhance their sexual performance rather than relieve serious impotency. Although Viagra is definitely not an aphrodisiac, merely thinking about the drug can serve as a psychological sexual stimulant for many men.     It's easy to see why a burgeoning black market has already sprung up for Viagra and why it's likely to grow steadily more lucrative in the months ahead. Even when purchased through regular, proper channels, the drug is expensive--eight to twelve dollars per pill at retail. But sexual experimenters are often willing to pay several times that much for the chance to try Viagra. Like most other drugs available only by prescription in the United States, Viagra can be purchased over the counter in Mexico. And although stocks of the drug are currently limited, the laws of supply and demand will soon make it available in every Mexican pharmacia to anyone who has the money to pay for it.     "It's going to become an abused drug," said Dr. E. Douglas Whitehead, director of the Manhattan-based Association for Male Sexual Dysfunction, in an interview with the Wall Street Journal several months before Viagra was approved by the FDA. "People are going to get it under whatever pretenses they wish.... There's going to be a black market."     The temptation to regard Viagra merely as a handy new device for improving one's "score" in the game of recreational sex, and to misuse the drug for this narrow purpose, is fraught with danger--both to the individual and to American society as a whole.     The often-tragic consequences of the national sex game are graphically illustrated by the soaring numbers of divorces, single-parent families, teenage pregnancies, sexually transmitted diseases, battered spouses, sexually abused children, and sex-related violent crimes. Many observers share my concern that widespread abuse of Viagra could add immeasurably to this toll. In the hands of serial sex offenders and child molesters, for instance, it could become a national catastrophe.     The worst tragedy of all would be for this revolutionary new medicine to be treated as a "dirty joke" by a large percentage of the public. To those afflicted with it, erectile dysfunction is anything but comical. And to those who have lost the power to offer their partners the ultimate expression of intimacy and romantic love, sex is much more than just a game.     For the impotent male, attempting to overcome sexual failure can assume the dimensions of a life-and-death struggle. Judging from my years of experience, I honestly believe that no malfunction of the human apparatus--not even cancer or heart disease--can be more painful to the male ego or catastrophic to the male psyche than sexual impotence. It is, as my patient Barry W. observed, as if a vital part of you has been taken away.     Relieving this soul-wrenching condition and repairing all-important human relationships that support our whole social structure represent Viagra's noblest possible contribution. Yet some will inevitably view it as just another titillating touch of spice in the game of recreational sex; to think otherwise would be to ignore human nature.     With this in mind, both the medical profession and the general public need to recognize that even Viagra has its limitations. We must also realize that its indiscriminate overuse can have dark, destructive implications. Only by doing so can we ensure that Viagra will be a boon to humanity, rather than a curse. Finding the Right Answers Whether you happen to be male or female, young or old, rich or poor, straight or gay, in a committed relationship or not, this book is designed to explain what you need to know about Viagra--objectively, not as a testimonial for it or similar drugs to come. The following chapters explain what Viagra is, how it was discovered, and how it works. They reveal who should (and shouldn't) take it, what it can (and can't) do, its proven benefits, and its potential dangers. They detail its possible future applications as a sex-enhancing drug for women and a life-extending medicine for the aged. They project the future effect of the vast social changes Viagra has already put into motion.     But at the same time, the book is also intended to serve a broader, more comprehensive purpose. In addition to examining the phenomenon of Viagra, I want it to serve as a commonsense guide to human sexuality and human relationships in general. The introduction of a revolutionary oral agent for overcoming impotency offers a golden opportunity for us to drag the discussion of male--and female--sexual problems out of the shadows where it has lurked for so long. The Viagra phenomenon has created an ideal environment for shedding new light on some of the most enigmatic and misunderstood disorders known to science.     The following chapters will examine impotency and its causes in simple, straightforward language that every man and woman can understand. They will show that while certain similarities exist, no two cases of male impotency are exactly the same. Like sets of human fingerprints, each has slight, subtle variations based on the personal circumstances and deep-seated feelings and needs of the individuals involved.     My intention is to give women a broader, clearer understanding both of impotency itself and the myriad ways that men react to it. I also want to help women understand how Viagra may benefit them in the near future, In turn, I want to give men better insight into the feelings of fear, resentment, insecurity, and betrayal that male sexual dysfunction can touch off in the women it robs of affection and intimacy. And I want men to realize that even the sudden restoration of sexual performance with the help of a drug like Viagra can have a serious emotional downside for their partners. I saw real-life examples of just such a downside within the first few weeks after I began prescribing Viagra.     Finally, I want to show that, despite the eternal differences between the sexes, men and women may actually be closer together sexually than they realize, and that effective communication and mutual consideration are the most important keys to a satisfying intimate relationship.     Our challenge now is to use Viagra within this context in order to maximize its benefits and minimize its risks. Our mission is to find the right answers that have been denied us until now, while refusing to accept wrong answers, no matter how easy and enticing they may seem.     My hope is that this book will help its readers move toward these ends and toward happier, more fulfilling, more loving relationships.     Beyond the immediate phenomenon of Viagra lies a world that will be vastly and irrevocably different in its social customs, public attitudes, and sexual practices. This world can be infinitely better--or infinitely worse--than the one in which we've lived until now.     It's largely up to us to determine which way it goes. Copyright © 1999 Gerald Melchiode, M.D., and Bill Sloan. All rights reserved.