Viagra: A Tale of Two Pills

© Jennifer L. Pozner

Erections and sexual dysfunction are in the headlines again, and this time, thanks to the miracles of modern medicine, we're not even talking about Bill Clinton.

Ever since the FDA's April approval of Viagra, the little blue pill giving insurance companies a headache, the media have been infatuated with male impotence and its potential cure. U.S. pharmacists dispensed more than 215,000 Viagra prescriptions within the first four weeks of availability, sending manufacturer Pfizer Inc.'s stocks soaring and journalists buzzing. Everyone from porn magazine editors to former presidential hopefuls have expounded upon the supposed sociocultural impact of a wonderdrug clinically proven to, shall we say, make man's best friend stand up and salute the flag.

1996 republican presidential candidate Bob Dole, 74, praised the erection inducer on "Larry King Live." A participant in Viagra's clinical trials, the former Senate Majority Leader pronounced it a "great" and "effective" drug. When pressed by reporters for her appraisal, Elizabeth Dole tittered in approval: "Let me just say - he was in the protocol, and it is a great drug." (It's safe to assume the American public could have lived without that image.)

To shed light on our nation's psycho-sexual mindset, TIME.com offered a page of reflections from such cultural geniuses as Penthouse publisher Bob Guccione, who believes that male erectile dysfunction is more a symptom of women's demands for justice than men's increasing age or declining health. To Guccione, Viagra promises to cure not only impotence but women's uppity behavior, as well. "Feminism has emasculated the American male, and that emasculation has led to physical problems. This pill will take the pressure off men. It will... undercut the feminist agenda," Guccione said, most likely with his fingers crossed.

Antifeminist spinmistress Camille Paglia affirmed Viagra as the greatest strengthener of modern manhood since the shotgun - "It's like the steel that they would get if they were at war," she told TIME. Entrenched beneath her misguided bluster, Paglia may finally be onto something: Viagra does speak to a war being waged over sexual health. But the real struggle - that over health care funding - is being fought on an economic battlefield and women, not men, are in need of ammunition.

A Tale of Two Pills

From Business Week to Newsweek, reporters, doctors, health insurance monitors and stock market analysts have engaged in active and often indignant debate over one key question: who should be financially responsible for erections? The hype over Viagra funding proves how poorly the health insurance industry responds to women's medical needs as opposed to those of men, and how little notice the press and the public give to this disparity.

Viagra’s benefits are physiological (potency pill poppers get to experience sexual gratification and release) and psychological (a Viagra high replaces patients’ performance anxieties with the pumped-up gusto of "manly men"). Its effects are felt primarily by the individual drug user (and, perhaps, his partner). By contrast, contraceptive care provides individual women with a great modicum of reproductive control, and allows a greater chance at economic independence (young and low-income heterosexual women denied access to contraception are far more likely to be forced into public assistance and/or poverty than those to whom this basic health care requirement is attainable).

The dangers of Viagra are becoming increasingly glaring: as of June 9, the FDA received 16 reports of death among men who took the drug, and though no direct evidence links the fatalities with the pill, at least seven of these (mostly elderly) men died during or after intercourse. Oral contraceptives, on the other hand, are among the safest and most effective of any existing prescriptive medications.

And, as always, there’s the money. Viagra costs roughly $10 per single dose. Oral contraceptives cost women approximately $30 for a full month. Every public dollar spent on contraceptive services prevents $4 in public expenditures on unwanted or unplanned pregnancies. Every dose of Viagra subsidized by private or governmental insurers saves men from sexual frustration and… drumroll, please… the embarrassment of hearing their wives and girlfriends say, "That’s OK, honey, it happens to every guy, once in a while." In short, Viagra is a costly, potentially risky drug which allows impotent men more sexual pleasure in their personal lives, while oral contraception offers a generally safe, cost-effective, socially beneficial solution to America’s unintended pregnancy rate (which, at 60%, doubles that of other developed nations).

Yet despite these contrasts, nearly half of approximately 300,000 men who seek renewed sexual vigor via Viagra each week are being fully or partially reimbursed by their health insurers. Additionally, insurers are reimbursing up to 73 percent of impotence patients using less sexy treatments such as Caverject, which requires an injection in the urethra. Medicaid programs in at least 10 states now "guarantee satisfying sex for the impotent poor." States such as Arkansas, Florida and Maryland subsidize 4 to 6 medicinal erections per month, while Utah covers 10 (to help men "approach normality," said Duane Park, Utah’s Medicaid drug utilization reviewer). Viagra seekers in Montana must merely cover a $2 copayment typically required for prescription medications.

Compare the erection-in-a-bottle with the basic contraceptive needs of all heterosexually active women who do not wish to become pregnant. While many health insurers are guaranteeing free or low-cost romps to men, they are by and large denying most women the contraceptive coverage that is a fundamental health care necessity for 20 - 30 years of their adult lives (the alternative being, on average, a potential 8 - 15 pregnancies in a woman’s lifetime). According to the Alan Guttmacher Institute, 33 million American women are in need of contraceptive services and supplies, yet most women using birth control pay for it themselves. The American College of Obstetricians and Gynecologists (ACOG) notes that two-thirds of U.S. women of childbearing age rely on private, employer-related plans for their health coverage. While 90% of these health plans cover prescription drugs and devices, a large majority exclude prescription contraceptives from coverage. Only 33 percent of large group health plans cover the birth control pill. Other contraceptive methods are even less financially accessible. Is it any wonder that women of childbearing age pay 68% more in out-of-pocket medical expenses than their male counterparts?

Whose Well-Being Are We Talking About?

By early May, Alabama's Medicaid program had already paid for $23,000 worth of Viagra prescriptions, and was beginning to fear the drug would overburden the program. Republican State Representative and Medicaid Oversight Committee leader Ron Johnson opposed his state’s move to revoke blanket coverage, responding to the AP: "The sex drive being what it is in some people, it may very well have a lot to do with the mental well-being of a person."

Could it be? Among a political party with the combined sexual verve of a chastity belt, might there finally be a Republican who understands that the libido is not an evil force but rather a normal, healthy part of human existence?

Don’t count on it. Johnson’s comment may be pronoun-free, but his message is gender-specific. Clearly, men are the people taking Viagra, and it’s men’s mental well-being about which Johnson worried. If he was truly concerned with the influence of sexuality on people’s well-being, Viagra-proponent Johnson would go on the books demanding funding for contraception in order to assure women’s rights to fulfilling sex lives.

Sadly, thats not happening with Johnson or with health insurers, because of a simple, age-old double standard. Men supposedly need sex due to biological urges; impotence is considered a medical disease, hence its cure should be funded. Women, thought to have lower sex drives, are assumed to bear the reproductive risk (we play, we pay). Since pregnancy is not a "disease" and reproductive control is considered "optional" or "recreational," health insurers do not consider themselves bound to cover contraceptives.

"This insurance exclusion makes no sense," said Dr. Luella Klein, Director of Women?s Health Services in a May ACOG press release. "Contraception provides great savings to the health care system, yet it is the individual woman who is shouldering the burden of this cost savings to insurers," she said. It’s certainly not a bottom-line issue: according to a report in the American Journal of Public Health, a fifteen percent increase in the number of oral contraceptive users in a health plan would provide enough savings in pregnancy costs alone to provide oral contraceptive coverage for all users in the plan.

In attempt to rectify what they consider a discriminatory imbalance, the ACOG has endorsed a bill now pending in Congress (S 766/HR 2174) which would require any insurers who cover prescription drug benefits and outpatient services to cover all FDA-approved contraceptive drugs and devices.

Viagra has begun to rally public attention behind the issue of sexual health care. If this attention can be channeled into support for the ACOG bill, the irony will be far more exciting than the effects of any pill.

When freelance writer Jennifer Pozner considers that the Pope issued his stamp of Papal approval for Viagra yet is still condemning sexually active women who attempt to practice contraception, she doesn’t know whether to laugh or scream. So, she does both.

This article originally appeared in Sojourner: The Women’s Forum, July 1998

Write your elected officials and urge them to support legislation to require health plans to treat birth control equally with other prescription medications.

Feminist Women's Health Center