The downside of Viagra: women’s experiences and concerns.
Nicola Gavey,
Victoria M. Grace,
Tiina Vares.
First published: 3 November 2003 Full publication history DOI: 10.1046/j.1467-9566.2003.00366.x View/save citation Cited by (CrossRef): 56 articles Check for updates.
Annie Potts, Gender Studies, University of Canterbury, Private Bag 4800, Christchurch, Aotearoa, New Zealand. e-mail: annie.potts@canterbury.ac.nz.
Abstract  While much is known about the efficacy and safety of sexuopharmaceuticals used by men for the treatment of erectile difficulties, there remains a dearth of knowledge on the perspectives and experiences of their sexual partners. In particular, few studies have focused on the possible detrimental effects for women of Viagra use within a heterosexual relationship. In this paper we report on a qualitative study based in New Zealand, which involved in-depth interviews with 27 women whose partners used Viagra. A number of key dimensions were identified, three of which revealed issues and concerns for women regarding the use of Viagra by their male partners: the neglect of women by those producing and prescribing Viagra; the embodied relationship (which encompasses physical and psychosocial effects of Viagra use); and broader socio-cultural implications ( e.g. the impact of ‘the culture of Viagra’ on understandings about sexuality in older age, and on ideas about male and female sexuality). We argue that while previous medically-oriented research in this area has generally assumed an unproblematic link between Viagra use and the resumption of penetrative sex within heterosexual relationships, more attention needs to be paid to partners’ perspectives and desires, and to the specific dynamics of any given relationship. Moreover, while the publicity surrounding Viagra may potentially facilitate more positive attitudes to sexuality in older age, it may also produce a societal expectation that ‘healthy’ and ‘normal’ life for older people requires the continuation of ‘youthful’ (energetic) sex lives focused on penetrative intercourse.
Introduction.
Everybody was going on about how wonderful this thing was and . . . [when I read about some other women’s experiences] I thought oh , thank god , I’m normal ! That other people don’t – not everybody sees it as being . . . the most wonderful thing that ever happened this side of sliced bread! (the response of one 60-year-old woman in this study to the advent of Viagra).
Recently western countries have witnessed a shift towards greater interest in sexual difficulties affecting both men and women. In particular, erectile difficulties have been increasingly understood as a concern for men 1 . This trend towards recognition and acceptance of ‘erectile dysfunction’ has occurred concomitantly with a focus by the medical and pharmacological disciplines on developing physical treatments for sexual ‘problems’. The field of treatment that has proliferated most rapidly over the past 10 years is that of sexuopharmaceuticals. A variety of drugs have been demonstrated to impact on erections, but to date the drug that has had the most publicity and popularity is sildenafil citrate, commonly known as Viagra (Steers 1999). This drug became available by prescription in the United States – and in New Zealand – in 1998 2 .
While much scientific research has been conducted on the efficacy and safety of sexuopharmaceuticals used by men, and studies of a similar nature are rapidly proliferating in relation to women’s sexuality, most of these medically-oriented studies have documented the physical effects of pharmacological interventions, focusing primarily on whether drug-assisted erections restore penile-vaginal sex. For example, such investigations (frequently sponsored by the pharmaceutical industry) tend to employ the International Index of Erectile Function (IIEF) questionnaire to measure the quality of an erection with respect to whether or not ‘successful’ penetrative sex has occurred (see e.g. Lewis et al. 2001, Lamm and Couzens 1998, Whitehead and Malloy 1999). Less is known, however, about the non-physical implications – for example, the relational, emotional and socio-cultural impacts – of the advent and use of such drugs (Potts, Gavey and Grace 2001, Tiefer 1998). Even when studies have sought to investigate issues beyond the mere physical effects, they still adhere to a reductive statistical approach that fails to tease out the intricacies in any detailed manner (see, for example, the Pfizer-sponsored study by Müller et al. 2001).
Cohen et al. (2001: 442) argue that ‘medications themselves are much more than material objects with physiological effects; they are also representations that carry meanings and shape social relations as they evolve in conjunction with individuals and collectivities’. Viagra, therefore, can be viewed as a socially-embedded phenomenon that not only affects a man’s penis so that he may experience enhanced erectile capacity, but also affects his self-image, his lifestyle and his relationships with others in more personal ways. Moreover, Viagra is a device (or technology) which itself is coded with various social and cultural understandings about sexuality and masculinity (particularly, what constitutes ‘normal’ and ‘healthy’ male – and female – sexuality). Leonore Tiefer (1998: 2) has argued that ‘as a metaphor, Viagra is coming to signify positive, energetic, strong, and solving of all difficulties’.
One group upon which Viagra use impacts directly, and which to date has been relatively neglected by the medical establishment and pharmaceutical industry, is that of the sexual partners of those who take this drug. While studies are emerging which include partners of men who use Viagra, few have directly targeted women’s perspectives and experiences in any in-depth way (Bordo 1999, Potts et al. 2001). Many of the scientific reports on Viagra use continue to omit any mention of partners (see, for example, Jarow et al. 1999, Steers 1999). Moreover, when partners are included, it is more likely to be in the context of whether or not a chemically-induced erection has been sufficiently hard enough for penetration of female partners (see Hatzichristou 2002, Müller et al. 2001, Young 1998).
Regrettably, the perspective of female partners is often excluded from discourse on erectile dysfunction per se (Potts 2000, Potts et al. 2001, Tiefer 1994, although see Low et al. 2002). Despite general agreement in medical circles that the aetiology of erectile difficulties is multifactorial, and therefore that the outcome of any intervention is benefited by taking into account the different factors (physical, emotional, relational, and social) affecting any individual case (Riley 2002), most of the current pharmacological literature reviewing Viagra use by men appears to assume an unproblematic link between successful penile erection (and penetration) and user, partner and sexual relationship satisfaction (Barnes 1998). Few studies have directly assessed partners’ involvement, experiences and perceptions of satisfaction, despite claims that if the perspectives of partners are not taken into account, the long-term effectiveness of any interventions will be compromised (Barnes 1998, Holzapfel 2000, Riley 2002, Stock and Moser 2001, Tiefer and Melman 1983). For example, a Swedish study on partners’ perceptions of the effectiveness of Viagra, asked only two questions of female participants: ‘How often did your partner get an erection?’ and ‘How often did he maintain his erection?’ (Hultling 1999: 16) without questioning the significance of such erections for these women.
In this paper we explore the assumption that women automatically and unproblematically benefit from their male partner’s use of Viagra, and from Viagra-induced erections. Drawing on interviews with 27 women taking part in an independent New Zealand study investigating the socio-cultural implications of contemporary sexuopharmaceuticals such as Viagra 3 , we present an insight into the untold story of the potential downside of Viagra for women partners. This is by no means the only story to be told about women’s experiences with Viagra – but it is the one we wish to prioritise here for the reason that it is poignantly absent in so much of the discussion and promotion of the drug.
Methodology.
During April and May 2001, advertisements calling for participants for a national study on the social impact of Viagra featured on radio and in local newspapers and popular magazines throughout New Zealand. Twenty-seven women volunteered to take part in the study; ages ranged from 33–68, with the average age being 53 (33 men also took part in a complementary study on men’s experiences of using Viagra (Potts et al. forthcoming)). Participants came from a variety of socioeconomic backgrounds; the majority were Pakeha ( i.e. non-Maori New Zealanders, of European descent) and heterosexual. About one third of women were in relationships with men who were older than they were by 10 or more years. Likewise about one third of relationships were relatively new (less than five years).
Individual interviews took place in various locations throughout the country between April and September 2001. Most participants were interviewed in their homes or at the local university by a member of the research team; a small number of participants were interviewed by phone. Interviews lasted between one and two hours, and followed a semi-structured format, focusing on women’s perspectives and experiences of Viagra use by male partners. Participants were also encouraged to talk about other related issues of relevance to them and their specific relationships. Interviews generally began with women being asked to relay their own ‘story’ of Viagra use in their relationship, and then moved on to unpack specific issues and topics including: the reasons male partners came to be taking Viagra; the impact of sexual changes or difficulties on relationships, self-esteem and quality of life; the involvement of women in medical consultations and the treatment process; the effects of Viagra use on the relationship (including sexual relations); the physical effects for women of Viagra use by a male partner; their views on the implications of greater attention to sexual difficulties (and the various treatment options) for our understandings about sexuality and older people, and for our ideas and experiences of female sexuality and male sexuality. All interviews were audio-taped and transcribed in full.
The research team conducted close readings of the transcripts to identify key themes. Although we noted a great diversity of responses and experiences among participants, these broad themes were evident in some form across the full range of interviews. Individual participants’ stories and perspectives were often complex: there were few exclusively positive or negative interviews with respect to Viagra use within a relationship. For example, it was not unusual for those women who promoted Viagra as an intervention for erectile difficulties also to indicate particular detrimental effects that use of the drug had for them or their partners, or to mention some concerns they had for other women; similarly, those participants whose main motivation for taking part in this study had been to convey undesired consequences may also have discussed some less negative effects (for instance, how use of the drug may have enhanced a male partner’s self-esteem).
As we are concerned about the lack of knowledge pertaining to the less positive repercussions for women of a partner’s use of Viagra within a relationship, we concentrate in this paper on those aspects of accounts referring to such unwelcome or detrimental effects. Even though not all women emphasised such negative implications, the frequency of reference to issues of concern was sufficiently consistent to enable the identification of three key themes: the neglect of partners by those producing and prescribing Viagra; the embodied relationship (which encompasses physical and psychosocial impacts for both partners); and other socio-cultural effects of the ‘culture of Viagra’ ( e.g. the effects on societal understandings about ageing, gender and sexuality). These various issues are, of course, often inter-related and co-implicated. We argue that they raise important questions for those involved in studying, identifying and treating sexual difficulties, and prescribing sexuopharmaceuticals.
When presenting extracts from interviews in this report, we have omitted word repetitions and all speech hesitations ( i.e. all terms such as ‘um’ and ‘ah’). Quotations selected for the purpose of illustration are particularly characteristic of the discourse related to the point under discussion. In light of this, multiple excerpts from a single interview may be presented because they are particularly illustrative – chosen because of the ‘typical’ form of expression of a view on a certain issue (a view also shared by other participants). The presence of three consecutive dots [ . . . ] indicates a portion of speech has been cut. The abbreviation ‘FP’ refers to ‘female participant’. The number immediately following ‘FP’ indicates the participant’s position in the order of interviews conducted.
Issues and concerns for women Neglect of partners by those producing and prescribing Viagra.
It is perhaps appropriate to begin by drawing attention to concern expressed by participants regarding the perceived lack of interest on the part of the medical establishment and pharmaceutical industry in the specific concerns and perspectives of the sexual partners of men who experience sexual difficulties and use drugs like Viagra. Most women in our study had not been directly involved in medical consultations regarding their partner’s erectile difficulties, and some had not been included in any decisions related to choosing and commencing treatments. One woman spoke of her frustration when her husband was interviewed alone at a specialist clinic:
We weren’t interviewed together . . . because they seem to have this idea that this is a man’s problem, but it’s not a man’s problem, it’s a couple’s problem, and how the woman feels about it should come into it too . . . (FP26, 60 years).
Even for those women in the study who were involved in the medical process, this had not always been a positive experience. For instance, several women voiced dissatisfaction with the ‘quick fix’ approach of the Men’s Clinics in New Zealand 4 , and felt more effort could have been taken to ascertain broader effects of sexual difficulties on self-esteem and relationships. Some participants would have preferred to spend more time discussing treatment options other than drugs. There was also criticism of a lack of follow-up after Viagra had been prescribed, and of a perceived failure to obtain women’s perspectives, and to provide adequate information for women.
What I’ve been aware of since this drug came out was that there’s been no information for women and I think drug companies need to be held accountable . . . I think they need to be more responsible for these products and so when I saw Viagra coming out, I saw no information for women at all. It seemed to be very much looking after the blokes, I mean after all it is . . . a drug for males but . . . I mean women are such a major component of it because mostly these are men who are having sex with women . . . so that’s why I think women need to be consulted, because they’re the ones who will be being affected by this drug (FP7, 48 years).
Those who had been involved in consultations complained about the ‘clinical coldness’ of the environment and the ‘distant’ approach of practitioners (one woman’s partner had described his experience of attending a specialist clinic as ‘being on a conveyer belt’). Riley (2002: S105) draws attention to the lack of appropriate facilities and involvement of partners in the United Kingdom, claiming that many ‘andrology clinics’ are ‘environmentally unsuitable for conjoint consultation’. The experiences of some participants in our study indicate a similar situation in New Zealand.
The recent move to direct-to-consumer promotion of drugs like Viagra in New Zealand means that pharmaceutical companies may now explicitly target potential consumers (Cohen et al. 2001, Fishman and Mamo 2001). Pfizer’s 2000 advertising campaign for Viagra featured a brochure which announced: ‘Erectile problems: A man’s condition, a couple’s concern’. A search of Pfizer’s New Zealand website located a page ostensibly catering for the female partners of men who used Viagra 5 . However, the web-page primarily instructs women on how best to approach their partners about first seeking help for erectile difficulties. To date, we have not noticed any information pertaining to women’s own experiences (positive and negative) of a partner’s use of Viagra, and the various ways this may affect a relationship. Instead, the website appears to operate under an assumption that all women would benefit from – and be satisfied with – the implied changes in sexual relations instigated by Viagra use (see http://www.viagra.co.nz).
The embodied relationship.
Participants raised numerous issues about the physical and the psychosocial effects (for both partners) of a man’s use of Viagra within the context of a relationship. These include: unwelcome changes to sexual practice; tension and conflict in communication between partners; fears about men’s infidelity; and concerns about the adverse health effects of using Viagra.
Unwelcome changes to sexual practice precipitated by Viagra use.
Some have argued that, like the contraceptive pill, Viagra will simply eliminate a major anxiety associated with heterosexual intercourse, and will free couples to engage in spontaneous, worry-free lovemaking. But will the sexual script of Viagra lovemaking actually be flexible and worry-free, or will Viagra-sex be all about worshipping the penis, since no one spending upwards of $10 to have an erection will ignore it? (Tiefer 1998: 3).
As I see it with some of these erectile dysfunction treatments . . . there’s a fine line between it being helpful and being intrusive, and just taking over your life and your thinking completely , you know? (FP26, 60 years).
Changes in frequency, duration and mode of sex: Most women reported that a partner’s use of Viagra had altered some aspect of their sexual relationship. Usually such changes involved an increased frequency and/or prolonged duration of sexual relations, and/or repeated penile-vaginal sex over several hours following the use of a tablet. In some cases, Viagra use resulted in a male partner’s ability to have multiple erections over 12–24 hours. This effect was not always desired by women, who may have welcomed a closer relationship with their partners, but did not necessarily wish to have the frequency of sex – in particular, penile-vaginal sex – increased. (This is especially pertinent in light of data indicating that the average couple seeking help for erectile difficulties have not engaged in penile-vaginal sex for 2–5 years – see Riley and Riley 2000, McDowell and Snellgrove 2001).
He’d kill me for saying this, but I guess . . . the [drawback] that I notice is that, say if he takes a tablet at night before we go to bed or something then . . . we might have intercourse that night, then sometimes in the morning . . . and then if it doesn’t necessarily appeal to me I think oh no, we’re –[laughs] he’s going to try again, so that you get the two for one if you like [laughs]. Get in two for the price of one. But so I guess in some ways that could be a drawback . . . so I sometimes feel pressure that I then need to perform again in the morning (FP22, 51 years).
Even women who had a generally positive narrative about Viagra explained that a ‘downside’ or ‘drawback’ could be an undesired increased frequency of intercourse, because of pressures coming from the desire not to waste a tablet.
Increased frequency of penile-vaginal intercourse was also sometimes related to actual physical health effects for participants. Some women described experiencing pain and discomfort with repeated or prolonged intercourse: ‘Sometimes it can go on for a long time and I’m thinking oh, this is a long time, and it’s getting . . . tender’. (FP12, 60 years)
Studies have linked Viagra use by male partners to the development in older women of a urinary condition referred to as ‘honeymoon cystitis’, which is associated with prolonged sexual intercourse (Little et al. 1998, Stock and Moser 2001). Postmenopausal women may experience more vaginal dryness, which exacerbates the onset of this form of cystitis (Deeks and McCabe 2001):
He would have sex that night and again the next morning and . . . he can have more sex than I can because I get sore . . . I only ever once got thrush and once I got a bladder infection . . . I was passing blood, so I presume perhaps having sex had something to do with it . . . (FP25, 65 years).
Other identified physical effects for women of prolonged sexual intercourse include lower pelvic pain, and irritation and tearing of the vaginal wall (Levy 2001). Postmenopausal women are often advised to use lubricants to prevent such problems. Some participants, however, mentioned discomfort during repeated and prolonged penetrative sex following Viagra use, despite the employment of lubricants as a regular feature of their sexual practice.
A male partner’s use of Viagra may also impact on the mode of sexual relations within a relationship. One detrimental change, noted by several women, was that sex incorporating Viagra was more likely to involve less time spent on pleasurable activities other than penile-vaginal intercourse (although a few women reported the opposite). FP7, whose husband’s use of Viagra coincided with a decline in non-coital sex in their relationship, expressed concern for other women who were less able to be assertive about their desires and what pleased them during sex.
[Viagra use began] during a time when I was trying to impress upon him that foreplay would be a nice thing. After 20-odd years of marriage foreplay is one of those things that goes by the way, however I was trying to maintain that this was, you know, quite an important part of making love so when Viagra came along the whole foreplay thing just vanished , I mean it wasn’t even a suggestion it was: ‘OK, I’ve taken the pill, we’ve got about an hour, I expect you in that time to be acquiescent’ . . . so this concerned me because, not just for myself because I was then able to – over a long period of time, it probably took about a year – to negotiate an understanding . . . but what occurred to me was that . . . other women mightn’t have that ability and so I became quite concerned . . . (FP7, 48 years).
Riley (2002) contends that while a man’s primary motivation for taking Viagra is likely to be in order to engage in penile-vaginal sex (and this was evident in most of the accounts in our study involving men (Potts et al. forthcoming)), women may not similarly desire this. In their study of heterosexual couples affected by erectile difficulties, Riley and Riley (2000) found that over 50 per cent of women preferred sexual activities other than penile-vaginal sex ( i.e. those practices commonly referred to as ‘foreplay’) (see also Carroll and Bagley 1990 and Hurlbert, Apt and Rabehl 1993 for similar findings). Riley (2002: S106) views the tension created by partners’ differing preferences as important for practitioners to address, in case a woman ‘may not be as cooperative in helping the man regain his erectile function and may even sabotage the treatment’. We would, however, draw attention to the difficulties for women of installing the value of – and negotiating the continuance of – non-coital practices within a relationship, especially when a man’s use of Viagra precipitates a return to (more frequent) penetrative sex (and those authoritative domains such as medicine and sexology endorse this form of sex as the norm, and emphasise that an ability ‘successfully’ to complete coital sex is the measure of ‘sexual health’ for men and, to a lesser extent, for women) (Tiefer 1995, McPhillips, Braun and Gavey 2001).
Overt and subtle pressures to have sex: As mentioned, many women conveyed that they experienced some pressure to ‘make the most of a tablet’, if not for their own pleasure, then for the pleasure that repeated erections and sexual relations appeared to give their partners. Women also reported ‘putting up with sex’ when they didn’t feel like it, again sometimes for the sake of their partners. This often took the form of a subtle pressure related to their implicit assumptions about male sexuality and masculinity. Conventional male sexuality in Western culture is prevalently represented as active, strong, urgent and penis-driven (Potts 2001, Bordo 1999,Gavey, McPhillips and Doherty 2001, Tiefer 1995); traditional female sexuality is constructed in opposition to this – as passive, submissive and receptive (Ussher 1997, Potts 2002). Wendy Hollway (1989) refers to this notion of masculine sexuality, where men are viewed as having stronger sexual urges and a greater need for sex than women, as the ‘male sexual drive discourse’. This mode of representing and understanding male sexuality is prevalent in popular culture and everyday language, and also in more authoritative domains such as medicine and science. In accordance with these generally taken-for-granted ideas about ‘normal’ and ‘natural’ masculinity and femininity, some women (particularly older women, perhaps) may be influenced by ideas about a man’s ‘need for sex’, and feel it is a woman’s ‘duty’ to provide this experience for a partner (Dallos and Dallos 1997, Gavey 1992, Stock and Moser 2001).
There was a strong theme throughout the transcripts (in both studies) of men ‘needing’ penile-vaginal sex, and women agreeing that there was some obligation to meet this need in order to facilitate male wellbeing and self-esteem, and protect a man’s sense of masculinity. One 51-year-old woman, who at the time of her interview was experiencing severe discomfort during coital sex due to her own advanced illness, described feeling compelled to comply with medical literature she was reading on menopausal women and sex, which recommended that older women persevere with sexual intercourse or else, as she described it, men may lose ‘the art’.
I thought that I probably wasn’t helping by being . . . unable sometimes to . . . disguise how much discomfort I had [during intercourse] when it was considerable. [Interviewer: Did you feel like sex that way when you were in such discomfort?] . . . Probably not as much as I would normally, but I still had this idea in the back of my mind that it is not good to . . . withhold sex for long periods for somebody of his age . . . Now I guess that doesn’t apply to everybody, but . . . some of the menopause literature that I read for women really does spell it out – that you just can’t expect . . . you know, if you don’t use it, you will lose it, kind of thing (FP3, 51 years).
Her comments testify to the influence of the male sexual drive discourse, apparently even in literature for women about their own life processes. Despite her partner’s overt reluctance to engage in penetrative sex when she was experiencing pain (mentioned elsewhere in the transcript), she felt it was her ‘obligation’ to endure this for the preservation of his wellbeing.
This kind of powerful pressure to have sex against all other odds – which women arguably experience if they are positioned as ‘good’ feminine sexual subjects within a male sexual drive discourse – is potentially intensified when a male experiences erectile difficulties. It is widely accepted that difficulty producing erections causes much concern for men who experience this; the value placed in Western society on male ‘sexual performance’ means that an actual or perceived inability to conform to the ‘normal’ notions of masculine sexuality can be the source of much distress and anxiety (Bordo 1999, Buchbinder 1998, Connell 1995). Many men reportedly feel the loss of erections acutely, as a failure in themselves; the cultural emphasis placed on male sexual ‘potency’ even leading some men to consider ‘impotence’ as analogous to a form of death of the self (Candib and Schmitt 1996, Fergus, Gray and Fitch 2002, Loudon 1998, Potts 2000, Tiefer 1995). Women in our study also endured sexual relations when they didn’t feel like it out of a sense of empathy for their partners, and a desire to help men ‘restore’ confidence and self-esteem:
Now and again I’ll think oh bugger, you know, I’m too tired or . . . you’re just not in the mood or anything, but I would never hurt his feelings by saying that, never . . . [Interviewer: So what happens in those times?] Oh, you just sort of play along, I mean if you know what you’re doing you can manage that alright, yeah, but then you do have a guilt feeling a wee bit afterwards yourself but you think oh well, as long as he’s happy and satisfied well, it doesn’t hurt me if I miss out this time, no problem, it will be alright next time. [Interviewer: So what do you think would happen if you said . . . I’m not in the mood now?] I think they’d be pretty deflated, really, and I think it would be worse because of the fact that they had taken that pill . . . I’m frightened that it would hurt his feelings . . . I just think well if he’s happy, well that’s fine ’cause I can still say that the male image of not being able to function, it must be terrible for them really . . . He’s got to have that masculinity feeling, all the time, whether he performs or not, he’s got to be able to know that he can perform (FP5, 57 years).
This participant discusses her willingness to ‘play along’ with desiring sexual relations, despite feeling tired or uninterested, in order to ‘preserve’ and promote her husband’s sense of masculinity, which she feels is linked to his ability to perform sexually.
Women also experienced more direct pressure to engage in unwanted sex when men took Viagra without first negotiating with them. Such expectations, however, were sometimes resisted:
Sometimes we go to bed and I think I’ll go to sleep and then I realize that he’s making, you know, sort of like overtures . . . he’s sort of trying to get me to want sex, and it’ll be a while and then I’ll say ‘have you taken the pill’? He’ll say ‘ of course I’ve taken the pill, you know, what did you think ’? And I’ll say ‘well I had no idea . . . I’ve asked you not to take it unless we discuss it’. He said ‘well I don’t have to get your permission to take it’ . . . [Interviewer: And when that happens would there be times that you have sex where you don’t want to at all or-?] Well, there’ll be times when it happens like that when we go to sleep and we don’t speak for twenty-four hours [small laugh]’cause he’s so annoyed . . . at what it’s cost . . . and he’ll say as a matter of fact I took one last night as well and you weren’t interested so it’s cost twice as much and we haven’t had sex (FP25, 65 years) 6 .
Not wanting sex life to change at all: Contrary to the rosy pictures painted by drug company advertising of relationships rejuvenated by Viagra, there are cases where the advent of Viagra may precipitate sudden and unwelcome changes, especially if partners have in various ways adjusted positively to ongoing erectile difficulties. One woman commented that she would have been happy for life to continue in the fashion prior to her husband’s use of Viagra:
I wasn’t really too worried because we hadn’t been having sex as frequently as we had in the past, and that suited me down to the ground so to speak [laughing] and . . . oh well he felt [Viagra] was going to . . . improve his functions and make him feel happier [but] I feel that [the] ads and articles I’ve read are always stressing how wonderful Viagra is, and I don’t think it’s all that wonderful. I mean OK it’s wonderful for the man if he achieves an erection and enjoys things more, but as I say, why can’t they accept that life changes and OK if you can’t have an erection, what’s the big deal? (FP19, 66 years).
FP26 spoke of how the arrival of Viagra in her relationship required an immediate and difficult adjustment to a ‘full-on’ sex life, which she did not desire for herself. Her reluctance to convert to frequent penetrative sex prompted feelings of guilt, and created self-doubts about whether she was ‘inadequate’ and had a ‘problem’ herself:
So here we are at that stage of our life and . . . as things are quieting down in your life and you’re . . . becoming friends and yes, there’s a closeness and a friendship and yes sex did happen occasionally but quite rarely as you’re getting older, and to me that wasn’t a major problem, it was part of nature, and all of a sudden Viagra became this . . . it became a main focus in the house for a wee while . . . One day it’s . . . not an option and the next day it’s full-on. So yes, from that point of view it is something that you have to deal with. [Interviewer: Is it quite hard to get your head around thinking about?] Yes it is . . . very hard to get your head around it because if you’re not as interested you feel as though you’re abnormal . . . and letting the side down as well . . . and not supporting and not being a good wife and helping him through (FP26, 60 years).
This kind of major adjustment expected of older women who may themselves not wish for the re-establishment of frequent coital sex (or any form of sex), is generally neglected in mainstream medical reports on the ‘efficacy’ of Viagra for men and their partners.
Tensions and conflict:
Here we were with this little blue pill that was . . . creating a tension in a way that I was being seen as selfish if I wasn’t just absolutely over the moon the minute it appeared in the house . . . (FP26, 60 years).
The introduction of Viagra in relationships heralded changes in communication between partners – for some, promoting more overt negotiation about when sex would occur and when a tablet would be used; for others, resulting in a lack of negotiation, or in fraught discussions.
What I noticed in the beginning which really concerned me . . . because I saw that it was such a powerful drug and it had such a powerful effect was that . . . this made sex inevitable . Sometimes there was no discussion about whether . . . the sex act was going to take place, so it would be . . . ‘I’ve taken the pill, OK, let’s go’. And this pissed me off because it meant that [sex] seemed to be a given: ‘I’ve taken the pill, let’s fuck’ . . . What Viagra did was, for a while anyway, remove that negotiation . . . he wanted a lot more sex . . . I mean, he would be saying things like ‘OK we’ll have it now and then, you know, in another four hours we’ll do it again and then we’ll even try later on’ and I’m thinking, you know, give me a break! You know, the expectations were greater, for sure, he was being demanding, because he knew he could you see, it’s almost like . . . I have A therefore B will follow, and that really pissed me off because it took away the whole notion of any kind of . . . spontaneity or you know, the reason for the actual bonking, I mean you know, you like to think it’s an act of love, rather than just lust (FP7, 48 years).
The absence of joint decision-making about Viagra use by a new partner was a major concern for one woman, and a continuous source of conflict in their relationship:
I’ve just told [partner] that he’s got to discuss it with me, he’s not to take the pill without discussing it with me . . . usually the reason we have a row is because I’m annoyed that he’s taken the pill without discussing it with me . . . I feel it’s sort of that he’s going behind my back. He doesn’t see it like that, and even like when we’ve agreed that he won’t take it without discussing it with me, he still takes it, sometimes. He says ‘oh well, I was sure that you wanted to have it’ . . . but mostly at our age the drive for me isn’t that strong . . . (FP25, 65 years).
Negotiation around when sex occurs (and when Viagra is taken) are significant issues for women. Not all women are in a position to negotiate sex in an open or ‘equal’ way; this is the case especially for those women who may be in more traditional marriages where the husband is considered to be the authority in the family, and coital sex on demand is viewed as a ‘wife’s duty’, and also for those women who are in physically and emotionally abusive relationships. In our view, it is inevitable that Viagra will be being used by some men in order to have sex against a woman’s wishes.
Changes in men’s behaviour accompanying Viagra use also produced tension between partners. FP7 recalled how her husband of 20 years – and his friend – had become ‘predatory’ and ‘demanding’ after taking Viagra at a dinner party:
It wasn’t fun, it was such unusual behaviour from two long-term partners that it turned us right off, it was really yucky, it was quite . . . intrusive and you know, when you get with somebody and you’ve been with somebody as long as we had . . . you kind of don’t expect that sort of behaviour, it was odd (FP7, 48 years).
Stress also occurred in relationships when Viagra did not produce any significant changes in a man’s erectile capacity. One 43-year-old woman volunteered to participate in order to discuss the disappointing and sensitive aftermath of finding Viagra was not effective for her 59-year-old partner. She felt that advertisements promoting Viagra portrayed effortless and guaranteed success, and created high expectations which, when not met, contributed even more to a man’s sense of failure, and impacted further on a couple’s relationship.
Infidelities – real and imagined: Participants in both the women’s and men’s studies were concerned about how Viagra use may encourage men’s engagement in sexual encounters outside a primary relationship, without a partner’s knowledge. Such ‘infidelity’ was usually attributed to a man’s newfound sense of youth and virility associated with the restoration – and in some cases, enhancement – of erections, and, by association, masculinity. In fact, several men in our other related study reported that they were experimenting sexually with multiple partners outside their primary relationships. (We discuss this issue in detail elsewhere: see Potts et al. forthcoming.)
Health concerns: Several women expressed concern about negative side effects experienced by their partners taking Viagra, and anxiety about the more serious health risks it might pose for their partners. Women’s fears about men suffering heart attacks during or after sex sometimes impacted on their ability to relax and enjoy sexual relations:
Well, I mean it’s always in the back of your mind, you’re trying to relax and have [an] intimate time in the bedroom and in the back of your mind is . . . ‘oh, what if I have to call the ambulance and here he is with this erection?’ . . . and I know it’s silly, I shouldn’t worry about that sort of thing at a time like that . . . A lot of people don’t realize that there’s all these things going on and you’re supposed to be able to be relaxed and all these other things are whizzing round your head . . . (FP26, 60 years).
Some women were also worried that men could become physically and/or psychologically dependent on – or addicted to – Viagra for sex:
It could mess your mind, it could mess the mind of the partner . . . I could imagine that it would mess both the mind of the person using it . . . that they would then begin to think ‘well I won’t be able to perform without this’ . . . ‘my reputation will be down the drain’[laughing] . . . so I can see that . . . over a period of time . . . you could come to rely on this as a crutch to help you perform sexually as far as the guy was concerned . . . (FP21, 54 years).
Viagra may also be used as a kind of ‘prophylactic’ against a man being ‘disappointed’ by his body. As one woman explained: ‘He almost takes it as a precaution to make sure he’s not let down’ (FP22, 51 years). Another 33-year-old woman, who had initially encouraged her new partner (aged 50) to try Viagra in order to maintain his erections for longer, particularly during sex after heavy consumption of alcohol, grew concerned when she noticed he was always using the drug:
At first I thought it was great but now I’m just worried that . . . he might be getting reliant on it and I don’t know if that’s something that does happen medically or . . . Beforehand at least we were [having sex] sometimes [without Viagra] but now I think that we’re only having it when he’s actually taken the pills, and in some ways, you know, I don’t really even like thinking about that ’cause it’s like ‘God, does someone have to take a pill to have sex with me?’ (FP6, 33 years).
Moreover, it has been predicted that in the future Viagra may be routinely used by men to ‘prevent’ the very development of erectile difficulties, ‘similar to the manner in which aspirin is used to ward off heart disease’ (Marshall 2002: 139) 7 .
Broader socio-cultural implications.
Ageing and sexuality.
Historically, Western society has cultivated a negative image of older people’s sexuality, tending to reinforce the notion that active sexuality, sexual pleasure and satisfaction are reserved for the young (Kessel 2001, Schlesinger 1996, Kitzinger 1983). However, with the emergence of Viagra (and other so-called ‘lifestyle’ drugs) perceptions about ageing, older people and sexuality are changing. Katz and Marshall (2003) identify a recent societal shift to what they term ‘the new aging’, described as ‘a buoyant and optimistic cultural imagery around which marketing and consumerism have rallied’. While this may sound potentially positive and ‘liberating’ for older people, this ‘re-fashioning’ of ageing, as these authors indicate, is linked to commercial interest in capturing (the market of) a growing older population, and is ultimately contingent on men and women remaining sexually active in certain culturally sanctioned ways. Katz and Marshall (2003) point out that the desire for and ability to engage in heterosexual intercourse appears to be the ‘single indicator of positive and successful aging’. The successful marketing of products such as Viagra relies on pushing the idea of an enduring ‘successful’ sexuality (interpreted as orgasm via penile-vaginal sex) as the measure of ‘healthy’ and ‘normal’ old age; in turn, this imperative to remain ‘youthfully’ sexually active in older age buys into ‘the culture of Viagra’.
Older people, however, may resist such contemporary cultural directives, as women in our study demonstrate. Abrupt and radical changes to sexual relationships brought about by the arrival of Viagra are not always welcomed; and some participants resisted the drug’s interference in what they perceived to be a ‘normal’ ageing process. FP26 conveyed that she had been content with what she felt was a ‘natural’ decline in desire for sexual relations associated with getting older; however, with the advent of Viagra, the importance of sex was revitalised for her husband. She felt that the widespread promotion of Viagra produced an acute sense of ‘inadequacy’ and self-doubt in older people:
Up until Viagra nature took care of [differences in desire between men and women] . . . and you just got on with life and if it happened it happened, on the very rare occasions, but it wasn’t like . . . the big important thing that it seems to have become. Nature took care of it and men’s ability went down equally with women getting older, losing the same desire that they had when they were young women . . . Yes, it would definitely be different for everybody, I guess, but I think you’d probably find that . . . a large percentage of women in my age group would all say that . . . the desire decreases as you get older and . . . you know, different friends will say . . . ‘oh well maybe twice a year’, if you’re discussing things with close friends, and if it doesn’t matter, well [small laugh] doesn’t matter . . . Possibly, if I think about it, it’ll come up because Viagra has been brought up, right? Because I think Viagra has made a lot of people feel inadequate . . . everybody’s on the defensive about how often they have sex and so on, in the older age group (FP26, 60 years).
Viagra and gender inequities.
Some women articulated concern that the advent and widespread use of Viagra had reinforced societal inequities between men and women. ‘I think that a pill like Viagra really emphasises that inequality because it means that men have even more power than they did before’ (FP7, 48). This participant also felt that the marketing of Viagra disregarded or devalued differences between male sexuality (‘men get a hard-on’) and female sexuality (‘women get a wide-on’), as well as individual preferences and desires within a relationship:
. . . and then when I heard about people taking it at nightclubs and date rape taking place I though yeah I could really understand how that would happen because . . . I think they think it’s their right to have sex and that was basically what I’d seen in the early days with [my husband] . . . (FP7, 48 years).
Similarly, FP26 had noticed behavioural changes in her husband after the arrival of Viagra. She suggested that he was now more ‘romantically’ invested in the drug itself, than with her:
Once Viagra comes on the scene . . . it doesn’t seem as necessary for them [men] to show any real affection because their whole thinking is wrapped up in the Viagra. It’s almost like they’ve fallen in love with Viagra . . . they get very, very excited about Viagra, the thought of being able to take that little blue pill seems to get them very excited (FP26, 60 years).
One woman felt that the importance placed on Viagra for men was another instance of men’s sexual desires and pleasures being prioritised over women’s. She had tried Viagra herself (with little effect), and questioned why a drug for erectile difficulties had been developed ahead of any corresponding intervention for women.
I feel annoyed about that, but that’s the whole world of . . . it’s like men’s sexuality [is] catered for on many different levels and I don’t think ours is. For example . . . there hasn’t been the interest in women’s sexuality to the same degree . . . it’s OK for men to decide this is what I want and I don’t think women, as yet, still have that right to say this is what I want, please may I have it, or please give it to me . . . (FP10, 54 years).
The initial privileging, or medicalising, of male sexual difficulties by sex researchers studying the impact of drugs on sexual behaviour, indicates the operation within sex research of a cultural assumption that male sexuality is straight forward and uncomplicated (to study and to treat), whereas female sexuality is complex and mysterious (Fishman 2002). However, there may be drawbacks for women in any move towards ‘equality’ in terms of manufacturing sexuopharmaceuticals for both men and women. Not all women in our study agreed with a move similarly to pathologise women’s sexuality in older age; nor did they support the production of drugs to alter sexual desires and behaviour. Some participants had already contested their partners’ efforts to persuade them also to take Viagra in order to ‘match’ their respective desires for sexual intercourse (although some women had been interested in taking Viagra themselves) 8 .
Conclusions: foregrounding women’s concerns.
As our study clearly shows, Viagra is not simply and only men’s business. The women we interviewed reported a diverse range of experiences both in relation to their male partner’s erectile changes and in relation to their experiences of Viagra use within their relationships. In this paper, we have foregrounded women’s concerns surrounding Viagra because of the urgent need to consider this under-investigated aspect of the wider implications of sexuopharmaceuticals for men. Viagra affects more than a man’s erection. It affects the nature of the sexual relationship that he and his partner share; the frequency with which they have sex, the practices that are included in sex and, potentially, communication around sex, and both partners’ perceptions of their own sexuality. It also potentially introduces concerns for women about how this drug may affect their male partner’s health in adverse ways, and also how their own physical wellbeing may be affected. This research shows it cannot be assumed that women partners will welcome the changes brought about by Viagra. It is therefore important that women have the opportunity to be part of medical consultations and decisions regarding a partner’s treatment for erectile difficulties, otherwise the uniqueness of each relationship risks being denied in the service of ‘restoring’ a standardised (normative) idea and mode of sex.
Couples may have altered their sexual repertoires in response to erectile difficulties in ways which de-emphasise coitus in favour of non-coital activities; they may also have become more adventurous and experimental in terms of sexual pleasure (Gray et al. 2002). Women may enjoy such changes precipitated by a partner’s erectile changes, and any return to a primary focus on intercourse (especially where this may be exaggerated as a result of Viagra use) may be unwanted. Women may experience feelings of guilt and personal ‘inadequacy’ (fuelled by a perceived failure to conform to conventional ideas about heterosex and about femininity) if she does not want to engage in frequent coital sex, but still wishes to support and help her partner to feel better about himself. Those women who are not enthusiastic about a restoration of frequent intercourse within a relationship risk being labelled ‘dysfunctional’ themselves; and there may even be pressure for them to accept some form of treatment (from medical professionals, and from partners who want them to try drugs like Viagra as well).
Indeed, the women in this study mentioned various direct and indirect ‘pressures’, which they experienced once a partner commenced taking Viagra: for example, pressure to engage in sexual relations once a tablet had been taken (to avoid waste and/or for a partner’s sake); pressure to demonstrate one’s own ‘normal’ and ‘healthy’ female sexuality by supporting and privileging a man’s active sexuality based on penile penetration of the vagina; pressure to ‘match’ a partner’s enthusiasm for a revitalised sex life; pressure to try Viagra too; pressure to demonstrate a preference for intercourse over other non-coital activities. Some women were able to resist such pressures and to negotiate openly with men about when they felt like having sex, what kinds of sex they enjoyed, and when Viagra would be used; however, as one participant pointed out, not every woman is in a position to negotiate such issues in an explicit and ‘equitable’ way with a partner. There are undoubtedly women who are living in abusive relationships for whom such concerns are intensified.
Recent publicity about erectile difficulties and Viagra has drawn attention to how men and women continue to value sexual relations in older age. This has provided some opportunity to challenge negative stereotypes about sexuality and older people, and has fostered more accepting, positive images of ageing and sexuality. As women in our study have commented, however, such changes come at a cost when they are associated with the pathologising of a previously accepted ‘natural’ ageing process. Now there is a new ‘requirement’ for older people to strive to preserve those qualities conventionally associated with youthfulness (Katz and Marshall 2003, Marshall and Katz 2002). As Stephen Katz (2000: 135) puts it, older people are now encouraged to maintain ‘busy bodies’. This attitude is reinforced in drug company advertising for Viagra. The assumption that older men, in particular, might wish to ‘retire’ gracefully is fading; it is being replaced by a new – and equally problematic – expectation to retain youthful vigour and virility. This will be especially compelling for those men already invested in conventional masculinity. Fishman and Mamo (2001: 182) contend:
Prescription drugs are fast becoming popular consumer products, a capitalist fetish, where one is encouraged to think of such drugs as a means through which to improve one’s life. The biomedicalization of life itself is indicative of a cultural and medical assertion that one’s life can always be improved.
And as pharmacological treatments are developed to treat women’s sexual difficulties, which the industry hopes will be as popular and profitable as the versions designed for ‘him’, new expectations will arise for older women. Already participants have commented that they feel pressured to desire and engage in frequent and vigorous sexual activity once Viagra is on the scene for male partners. It may be, however, that similar ‘successful’ drugs created for ‘her’ ( e.g. super-lubricants, magic pills for fatigue, topical and oral treatments to combat ‘low desire disorder’) will leave women with little ‘justification’ to determine their own preferred forms of sexuality. With the technologies on hand, the moral landscape could shift in ways that leave little space to negotiate how best to compromise on differences in desire in a relationship, especially if a woman generally prefers activities other than coitus. Within a medical framework, where ‘normal’ sexual response is constructed according to a linear, goal-oriented trajectory culminating in male orgasm via coitus (Potts 2002), it seems more than likely that women’s sexual desires will be moulded to ‘match’ those of men, with ‘healthy’ sex continuing to be defined as regular penetrative intercourse.
Acknowledgements.
We are immensely grateful to the participants in this study, and to the Health Research Council of New Zealand for funding the project. We also wish to thank Roxane Vosper and Sharon McFarlane for transcribing these interviews.
To give an idea of the consumer market for sexuopharmaceuticals, erectile difficulties are estimated to affect up to 30 million men in the United States (Goldstein et al. 1998). While there are no official statistics available in New Zealand, Pfizer, the drug company which manufactures Viagra, claims on its website that ‘53% of all men in New Zealand over 40 have some difficulty getting or maintaining an erection’ ( www.viagra.co.nz ). Self-report studies in New Zealand indicate prevalence of around 30–40 per cent of adult men (White 1997).
It is important to note, that while Viagra is enjoying much publicity at present, another drug for the treatment of erectile difficulties, Uprima (apomorphine) has been released in New Zealand and may prompt a similar interest from medical professionals and consumers. This drug is promoted as working faster and having less severe side effects than Viagra (Heaton 2001). Importantly, however, many of the concerns raised by women in this paper are likely to be replicated regardless of the emergence of new and different drugs such as Uprima.
The full research project comprises several separate but related sub-studies, including women’s perspectives and experiences of Viagra use by male partners; men’s experiences of using Viagra; a reception study on depictions of Viagra in popular media and drug company advertising; and a study on the implications of sexuopharmaceuticals for women.
During the 1990s, before the popularity of oral medications like Viagra that can easily be prescribed by general practitioners (and obtained via the Internet), private clinics specialising in men’s sexual difficulties proliferated in New Zealand.
Any reference to male partners of men who use Viagra is omitted; this helps to conserve the ‘clean’ image of Viagra as a drug catering for, and used by, ‘normal’ heterosexual men for strictly medicinal purposes (see Mamo and Fishman 2001, for a synopsis of the normative and transgressive implications of Viagra advertising in the USA).
In a couple of cases, women ‘expected’ men to perform. One 56-year-old woman commented that men now had little excuse for erectile ‘failures’: ‘With Viagra, women can recycle a man . . . Either address it or get out of my bed’ (FP8). Another 68-year-old participant spoke of her frustration with a long-term partner who preferred not to take any medication for erectile difficulties and was happy with non-coital sex; however, she strongly encouraged him to try Viagra so they could resume coitus for her sake.
Indeed, the British Medical Journal recently reported that a prominent urologist, Irwin Goldstein, attending a Pfizer-sponsored medical education event, had advocated the daily use of Viagra for the prevention of impotence (see Moynihan 2003).
The debate regarding the ‘medicalisation’ of female sexuality has recently gained momentum with the publication in 2001 of Kaschak and Tiefer’s A new view of women’s sexual problems (which advocates a more holistic approach to understanding and treating sexual difficulties affecting women), and with increasing publicity relating to the involvement (investment) of pharmaceutical companies in medical research into the development of sexuopharmaceuticals for women (see, for example, the report by Moynihan in the British Medical Journal , January 2003, and the various responses to this appearing on the journal’s website).
Article Information.
Format Available.
Viagra (sildenafil); women’s experiences; erectile difficulties; relationships; ageing and sexuality; sexual pressure.
Publication History.
Issue online: 3 November 2003 Version of record online: 3 November 2003.
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Citing Literature.
Number of times cited : 56.
1 Emily Wentzell , How Did Erectile Dysfunction Become “Natural”? A Review of the Critical Social Scientific Literature on Medical Treatment for Male Sexual Dysfunction, The Journal of Sex Research , 2017 , 54 , 4-5, 486 CrossRef 2 Marie Murphy , Hiding in Plain Sight, Journal of Contemporary Ethnography , 2016 , 45 , 3, 256 CrossRef 3 Kirstin R Mitchell , Philip Prah , Catherine H Mercer , Jessica Datta , Clare Tanton , Wendy Macdowall , Andrew J Copas , Soazig Clifton , Pam Sonnenberg , Nigel Field , Anne M Johnson , Kaye Wellings , Medicated sex in Britain: evidence from the third National Survey of Sexual Attitudes and Lifestyles, Sexually Transmitted Infections , 2016 , 92 , 1, 32 CrossRef 4 Edward H. Thompson , Kaitlyn Barnes Langendoerfer , Older Men’s Blueprint for “Being a Man”, Men and Masculinities , 2016 , 19 , 2, 119 CrossRef 5 Tiina Vares , The Wiley Blackwell Encyclopedia of Gender and Sexuality Studies, 2016 , 1 Wiley Online Library 6 Colin J. Williams , Martin S. Weinberg , Joshua G. Rosenberger , Trans Women Doing Sex in San Francisco, Archives of Sexual Behavior , 2016 , 45 , 7, 1665 CrossRef 7 Gerda Fouche , Anthony J. Afolayan , Olubunmi A. Wintola , Tendani E. Khorombi , Jeremiah Senabe , Effect of the aqueous extract of the aerial parts of Monsonia angustifolia E. Mey. Ex A. Rich., on the sexual behaviour of male Wistar rats, BMC Complementary and Alternative Medicine , 2015 , 15 , 1 CrossRef 8 Camoletto Raffaella Ferrero , Chiara Bertone , Francesca Salis , Medicalizing male underperformance: expert discourses on male sexual health in Italy, SALUTE E SOCIETÀ , 2015 , 1, 183 CrossRef 9 Kimberley Thornton , Judi Chervenak , Genevieve Neal-Perry , Menopause and Sexuality, Endocrinology and Metabolism Clinics of North America , 2015 , 44 , 3, 649 CrossRef 10 Thea Cacchioni , The International Encyclopedia of Human Sexuality, 2015 , 1115 Wiley Online Library 11 Violeta Alarcão , Luis Roxo , Ana Virgolino , Fernando Luís Machado , The Intimate World of Men’s Sexual Problems: Portuguese Men’s and Women’s Narratives Explicated Through a Mixed Methods Approach, Sexuality & Culture , 2015 , 19 , 3, 543 CrossRef 12 Violeta Alarcão , Fernando Luís Machado , Alain Giami , Traditions and contradictions of sexual function definitions for Portuguese heterosexual men and women: medicalization and socially constructed gender effects, Sexual and Relationship Therapy , 2015 , 1 CrossRef 13 Paula Sequeira Rovira , La Viagra nuestra de cada día. Consumo recreacional y angustias masculinas con respecto a su potencia eréctil, Sexualidad, Salud y Sociedad (Rio de Janeiro) , 2014 , 18, 140 CrossRef 14 Susan Gledhill , Robert D. Schweitzer , Sexual desire, erectile dysfunction and the biomedicalization of sex in older heterosexual men, Journal of Advanced Nursing , 2014 , 70 , 4, 894 Wiley Online Library 15 Jane M. Ussher , Janette Perz , Emilee Gilbert , Women’s Sexuality after Cancer: A Qualitative Analysis of Sexual Changes and Renegotiation, Women & Therapy , 2014 , 37 , 3-4, 205 CrossRef 16 Janette Perz , Jane M Ussher , Emilee Gilbert , Constructions of sex and intimacy after cancer: Q methodology study of people with cancer, their partners, and health professionals, BMC Cancer , 2013 , 13 , 1 CrossRef 17 Maria Liz Cunha de Oliveira , Leidijany Costa Paz , Gislane Ferreira de Melo , Dez anos de epidemia do HIV-AIDS em maiores de 60 anos no Distrito Federal – Brasil, Revista Brasileira de Epidemiologia , 2013 , 16 , 1, 30 CrossRef 18 Jane M. Ussher , Janette Perz , Emilee Gilbert , W. K. Tim Wong , Kim Hobbs , Renegotiating Sex and Intimacy After Cancer, Cancer Nursing , 2013 , 36 , 6, 454 CrossRef 19 Nick J. Fox , Pam Alldred , The Sexuality-Assemblage: Desire, Affect, Anti-Humanism, The Sociological Review , 2013 , 61 , 4, 769 Wiley Online Library 20 Nikki Hayfield , Victoria Clarke , “I’d be just as happy with a cup of tea”: Women’s accounts of sex and affection in long-term heterosexual relationships, Women’s Studies International Forum , 2012 , 35 , 2, 67 CrossRef.
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