Prescribing for the “swedish viagra man”

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Prescribing for the “Swedish Viagra Man”
E Johnson1, E Sjögren2 and C Åsberg3

Cultural and social studies of sildenafil tidningen. In it we noted a distinct change views with men who had stopped taking (Viagra) have shown how it influences before and after sildenafil’s 1998 intro- sildenafil, an article in Läkartidningen more than just blood flow in the penis. duction. Before sildenafil, impotent men suggested that sildenafil failed because were discussed as a heterogeneous group: of social, cultural, and relationship issues, tile dysfunction (ED) to the general pub- some had partners; others were older, sin- unwittingly bringing the discussion back lic, changing perceptions and treatment gle men; some were shy, young men with to the relationship and lifestyle causes of of impotence. It has reinforced a coital problems relating to women; others were impotence that had been prominent in imperative—the idea that all sex and men “with a secret,” although the nature the early 1990s. Despite this study, how- ever, sildenafil today still dominates the course—stressing quick, hard (youthful) lated. The treatment options for these var- erections. Moreover, it has connected ious patients differed, but the doctor was tence/ED in Sweden.
successful aging with successful sex and always supposed to be a trusted confidant successful y taking one’s medications. Yet who saw the man on several occasions, Commercial images of the Swedish
much of the critical work on sildenafil listened to him describe his feelings, and Viagra Man
comes from the North American context, discussed his concerns. Furthermore, Direct-to-consumer advertising of where direct-to-consumer advertising has the patient’s partner was encouraged to prescription medicine is forbidden in been widespread and overpowering. We be involved in these discussions because Sweden, so instead of using television have in our study asked how sildenafil has she (the partner was always imagined to commercials, pharmaceutical compa- influenced ideas about disease, sex, and be a woman) could play an important role nies provide information about drugs pharmaceutical use in a smal , peripheral in the man’s treatment.
country, Sweden, with laws against direct- to-consumer advertising of prescription appeared from the medical discourse. supporting patient advocacy groups, and drugs, with state-funded, universal health So did the term “impotence.” Instead, on informational websites.
care, and with a history of (or at least a “erectile dysfunction” was discussed— reputation for) sexual freedom. Taking an affliction of the man’s penis, a disease that populate the Pfizer-funded Swedish- a look at “downstream” effects of phar- of blood flow and tissues rather than language website pertaining to ED, we see an illness related to relationships, feel- both global harmonization and local adap- macology perspective, we wondered if ings, expectations, and disappointments. tation. Much of the information about ED the specific structural characteristics of For eight years sildenafil dominated the is similar to that found in US commercial the health-care system and the cultural Swedish medical discourse so completely material, but the “Swedish Viagra Man” landscape would influence how sildenafil that its availability determined the con- as a collective trope is a slightly different is experienced and received in Sweden.
cept of the patient (reduced to a penis) man from the one(s) found in the United States. He is, for starters, very white—even Impotent men and dysfunctioning
coming). Not until 2006, when statistics though Sweden is at this point a country showed that more than half of the men with a significant immigrant popula- We started by examining impotence and prescribed sildenafil in Sweden did not tion—and he is slightly older than the ED in the Swedish medical literature, refill their prescriptions, was this dis- analyzing the weekly trade journal Läkar- 1Swedish Collegium of Advanced Studies and Sociology, University of Gothenburg, Gothenburg, Sweden; 2Department of Accounting, Stockholm School of Economics, Stockholm, Sweden; 3Department of Thematic Studies, Gender Studies, Linköping University, Linköping, Sweden. Correspondence: E Johnson ) CLINICAL PHARMACOLOGY & THERAPEUTICS | VOLUME 89 NUMBER 1 | JANUARY 2011
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States. The Swedish Viagra Man is also convinced that subsidizing sildenafil the connection of ED to other established very connected to nature; he is presented would be a legitimate use of tax money medical conditions such as diabetes and in wilderness scenes, toughing the winter for severe ED but not for mild ED. multiple sclerosis, reflecting the subsidy cold or jumping into pristine water from However, they were also convinced that controversy and concern that the drug patients would claim to suffer from the would be unavailable to “legitimate” fortable in the uncivilized wilderness, severe form of the disease to beguile doc- which by association naturalizes both his tors into prescribing subsidized sildenafil, mercial treatment of Viagra on Pfizer’s which would not only provide subsidies Swedish website in many ways parallels for men who were not really entitled to that on the US pages—with a self-help ever, is that the Swedish Viagra Man is not them but also lead to “diagnostic bracket diagnostic quiz, a database of Viagra- alone in his affliction; he is accompanied creep.” Thus, as rationalized by both the friendly doctors, and information for by his partner. Images of smiling women Benefits Board and the court, it would be partners—there are also specific elements next to their men, couples walking along better not to subsidize the drug at al . The that are manipulated to reflect and reso- the seaside, and two sets of feet sticking decision reflects concerns about patient nate with Swedish sensibilities, e.g., the and doctor compliance with government imagined race of the user, the association site. Although the partner all but disap- policies. The clincher in their argument with Swedish forests and coastlines, and a peared from the medical discourse when was that two other drugs for treatment of Swedish survey of masculine personality sildenafil appeared in Sweden, she (there severe ED—one injected by syringe into traits. Likewise, the series of court cases is little to suggest homosexual relation- the penis and one inserted as a stick into and subsidy debates reflects the specifics ships in the material, even if the language the urethra—were already subsidized in of Swedish law and its national health- is gender neutral) is actively enrolled and Sweden. According to the Benefits Board care program.
present in the commercial material. We and the court, these two drugs are so suspect this is because sildenafil requires unpleasant to administer, as compared behind a drug, we can see that a drug her efforts to function properly. For some with taking a pill, that men with mild ED does more than cure a disease or allevi- men in some cases, sildenafil will ensure would not reasonably be expected to use ate a symptom. The mere existence of a them; this de facto limits their subsidized pharmaceutical product can influence tial sexual stimulation has to come from use to “legitimate” patients.
the medical discourse, reinforce and even construct cultural ideas and identities, and ner is a convenient ally for Pfizer.
change the practices of experts and laypeo- ple. Also, although there are very Swedish State subsidies and ED
afil use compare with its use internation- Who should pay for sildenafil? This ques- ally? There are many similarities. The Sweden, the drug has carried with it previ- tion has generated heated debate, both drug’s existence has altered the concepts ously established ideas about disease, med- in the United States (should insurance of impotence/ED, who suffers from it, ical treatments for aging, and appropriate companies pay for sildenafil but not birth and how to cure it. Sildenafil creates ster- control pil s?) and in Sweden. In 2003, the eotypical images of a Viagra Man that tive discourses that influence even as they newly formed Swedish Pharmaceuticals carry markers of class, race, and sexual- Benefits Board decided that sildenafil ity. Moreover, it has led to new laws and encounter them. Not only does the glo- would not be subsidized. Doctors could policies to regulate the practices of both balization of the pharmaceutical market prescribe sildenafil, but men would doctors and patients.
make medicines available to international sion was controversial because people in scribes behaviors or identities; it is deci- the healthy subjectivities—identities and Sweden had until then been accustomed sion makers, commercial actors, and behaviors—those medicines are prescrib- to receiving prescription medication medical experts who attach the drug to ing. This, we feel, cal s for further consid- free, beyond a basic copay level, and specific demands, images, and expecta- eration to articulate the prescribed social the decision was promptly appealed by tions to influence the behaviors of groups practices that prescription medicines carry Pfizer. During the course of the next few they are trying to govern, cajole, or cure. when they are sold on a globalized phar- years, sildenafil made its way through a Moreover, because actors in different maceutical market.
series of court cases and appeals until, in countries have different cultural starting 2008, the Supreme Administrative Court points and are working within different CONFLICT OF INTEREST
E.S. was paid approximately US$600.00 for of Sweden upheld the initial decision. institutional frameworks, they vary in undertaking a presentation for a completed Today, silden afil is still not subsidized how they use sildenafil. Thus, although research project for Pfizer AB, the Swedish sildenafil’s influence on the medical dis- subsidiary of Pfizer, Inc., the manufacturer of course in Sweden was similar to its influ- Viagra. E.J. and C.Å. declared no conflict of tion reveals that the court and the Phar- ence on the international discourse, it interest.
maceutical Benefits Board were both also involved a great deal of debate about 2011 ASCPT


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