This article focuses on the articulation between male health and sexuality in Brazil. In recent decades there has been a marked medicalization of sexuality centered on the development of new technologies, diagnostic categories and intervention methods, including the creation of public policies in the Brazilian public health system. This process is best exemplified by a set of initiatives pursued under the banner of “sexual health as a portal to men’s health”. The core idea is that men, who would normally not look after their health, will be attracted to the health system via the treatment of erectile dysfunction. The public and political campaigns focusing on acceptance of the relative new diagnoses of erectile dysfunction and andropause (or androgen decline in the aging male) illustrate how, in the last two decades, a new focus on masculinity has taken shape via the pharmacologization of sexuality.

Keywords: male sexuality, medicalization, sexual health, public health, erectile dysfunction

In recent decades in Brazil there has been a marked medicalization and pharmacologization of sexuality centered on the development of new technologies, diagnostic categories and intervention methods, including the creation of public policies. This phenomenon is related to the emergence of a scenario characterized by certain key elements, namely medications, medical societies, the pharmaceuticals industry, the media, consumers, and events that range from the prescription of medications in the doctor’s surgery to the running of campaigns and formulation of policies in the Brazilian public health system. This trend is best exemplified by a set of initiatives pursued under the banner of “sexual health as a portal to men’s health”. The core idea is that men, who would normally not look after their health, will be attracted to the health system via the treatment of erectile dysfunction.

This paper is the outcome of a research project about gender differences in the recent medicalization of ageing and sexuality focused on the creation of the categories of menopause, andropause and sexual dysfunction. The goal was to map out the formulation and propagation of diagnoses relating to the ageing of men and women and how these tie in with sexuality–related phenomena, taking gender relations as the point of reference. The research investigates how these new diagnoses have appeared in the field of medicine in Brazil in recent decades. This socio–anthropological study articulates different qualitative research techniques, such as participant observation, interviews and documental research. Articles in scientific journals have also been analyzed, as have the websites of medical societies, news reports, television programs and publicity material, as well as the ethnography of medical conferences and campaigns, and interviews with professionals from the related areas. A broad range of sources is essential to capture the full extent of the processes studied and the intricacy of the sociotechnical networks set into play.

It is important to highlight that only recently have research efforts been put into historically mapping out differentiated interests on the part of medical science towards men and women, both in its theoretical reflections and daily practice. At first sight, it is clear that women have received far more attention in the field of medicine than men, who have only started receiving special attention in the last few decades thanks to the creation of new diagnoses and pathologies.^1–4

In Brazil it was only at the turn of the twenty–first century that the state started to make consolidated new investments into the medicalization of men. A prime example of this phenomenon is the creation of the National Policy for Comprehensive Men’s Healthcare, launched officially by the Brazilian government in August 2009. What stands out in this new scenario is the strength of the political lobby and influence in civil society of urologists, as seen in a number of public and media campaigns. This has resulted in a new emphasis on the notion of sexual health⁵ and the more widespread acceptance of the relative new diagnoses of sexual dysfunction and andropause (androgen decline in the aging male), in close articulation with the efforts of the pharmaceutical industry to encourage the consumption of medications associated with these “dysfunctions” in the Brazilian market.⁶

The aforementioned national policy was formulated in response to a number of interests. But undoubtedly key amongst the agents who collaborated in its creation was a group of high–profile urologists represented by the Brazilian Society of Urology (Sociedade Brasileira de Urologia, SBU). Since 2004 the SBU had been conducting campaigns and exerting pressure on sectors of the government, elected representatives, health boards and other medical associations with the purpose of getting a policy of this nature passed. In 2008 the initiative was cemented with the signing of a technical cooperation agreement between the SBU and the Ministry of Health geared towards the provision of male healthcare via the public health system, providing guidance for doctors and conducting public information campaigns, the first of which, on erectile dysfunction, was conducted from July to September of 2008. Rather than contributing to the more in–depth discussions about the national policy^6–9 and the corresponding development of special healthcare for men already the target of a number of studies^10–14, the objective here is to give primary attention to the associations between sexuality and medicalization.¹⁵ To do so, I take an increasingly widespread slogan that has been used at recent events involving the medicalization of male health, at least in the communications made by urologists and their associations. The slogan in question is: “sexual health as a portal to men’s health”. The aim is not to identify the origin, authorship or primary intent of this phrase, but to perceive how repeatedly it is used and what specific overtones it lends to the articulation between sex, health and medicalization.

In 2008 it was common to see this idea being conveyed in different situations, including press reports, articles prepared by pharmaceuticals companies, medical conferences and public events. In high–circulation magazines aimed at a general readership, like Veja and Isto é, the topic was addressed in leading articles,¹⁶ such as one in the Special Section of the March 19^th edition of Veja entitled “The Blue Revolution: Ten years after the launch of Viagra^®, the specter of impotence no longer haunts men”. It explains that one of main benefits brought about by Viagra^® is the greater ease of diagnosing high blood pressure and diabetes, of which erectile dysfunction can be a symptom. The article highlights the publicization of the subject of erectile dysfunction and the use of Viagra^® as a gateway to healthcare for men.¹⁷ In the July 9^th issue of Isto É, an article discusses the creation of the National Policy for Comprehensive Men’s Healthcare; highlighting the argument that erectile dysfunction could have a negative impact on men’s lives and could also indicate the presence of cardiovascular and other diseases.¹⁸ In a newspaper report in O Globo on August 17^th, 2008, the same tone can be seen in the statements given by urologist José Carlos de Almeida, then the president of the SBU, saying that erectile dysfunction was not the cause of a problem but essentially the consequence of other diseases.¹⁹

At medical conferences the subject was also highlighted, not just in the talks but also in the publicity materials prepared by the drugs companies.²⁰ Bayer Schering Pharma, in a special bid to be seen as the “first laboratory with a portfolio focused on men’s health”, distributed a document entitled “Sexual health as a portal to men’s health” at the International Congress of Endocrinology in Rio de Janeiro in 2008 and at the 10^th Congress of the Latin American Society of Sexual Medicine in Florianópolis.²¹ It contained a set of three articles: “Sexual health as a portal to men’s health”, by Ricardo Meirelles, professor of endocrinology at PUC–Rio and chairman of the Department of Female Endocrinology and Andrology of the Brazilian Metabolic Endocrinology Society; “Testosterone deficiency and erectile dysfunction as components of metabolic syndrome”, by Farid Saad, honorary professor at Hang Tuah University, Indonesia; and “The role of testosterone replacement therapy in male sexual and somatic health”, by Svetlana Kalinchenko, lead researcher of the Department of Andrology and Urology, Russian Research Center for Endocrinology, and head of the Russian chapter of the International Society for the Study of the Aging Male. On the back cover of the document “exclusively for medical practitioners”, in which the association between sexual performance, youth and men’s health was reinforced, there was an advertisement for Nebido^®, a three–monthly injection of testosterone indicated for the treatment of androgen decline in the aging male (ADAM).

In the National Information Campaign on Men’s Health promoted by SBU as of August 2008, the focus was also on erectile dysfunction, with the justification that it was a key indicator of disease, since it could be related to heart disease, high blood pressure and diabetes. The SBU website noted that erectile dysfunction is the top of the agenda because it is a disease marker. The problem affects around 50% of men over 40 years of age. Fewer than 10% seek their doctor. The entity wants to prevent self–medication.²² The same tone can be seen in the videos produced by SBU at the time. It was the topic chosen for the first program of the online television channel, TVSBU, which consisted of a talk on erectile dysfunction given by an eminent urologist, Sidney Glina, in which, amongst other things, he noted that other diseases were the root causes of erectile dysfunction. In the series of programs called Healthy Citizen, the link between erectile dysfunction and other diseases was again mentioned, this time by Antônio Barbosa de Oliveira.²²

Finally, the same thrust could be seen in the events leading up to the launch of the National Policy for Comprehensive Men’s Healthcare. Such was the case of the 4^th Forum on Public Policy and Men’s Health held by the Social Security and Family Committee of the Chamber of Deputies in Brasilia on August 7^th 2008. The public session was entitled “Men’s health, urological aspects and the Unified Health System, circumstances and prospects”. One of the key speakers was once again Sidney Glina, whose presentation was on “Erectile Dysfunction–Approach and Treatment. Should the Unified Health System distribute medications free of charge?” He presented erectile dysfunction as a public health issue and a disease marker by drawing on a number of bibliographical references, epidemiological data and international documents, and noted that the treatment of erectile dysfunction could be a gateway for men to the health service.²³

Based on the above observations, it could be argued that a new wave of medicalization of male sexuality is particularly apparent in the promotion of the diagnosis of sexual dysfunction²⁴ and andropause or ADAM.²⁵ The assumption is that sexual activity is a precondition for a healthy life and that erectile function is what defines virility throughout a man’s life. It is precisely in this context that Viagra^® (sildenafil citrate), a medication for achieving and maintaining erection, was brought out by Pfizer, indicating the existence of an incipient molecular science of sexuality.^1,26

To assure the success of the new medication, it was necessary first to portray erectile dysfunction as a problem that can affect men of any age, and then to make sure the drug was already available to resolve or prevent the problem. In this sense, Viagra^® is part of a rapidly expanding market for a far broader set of lifestyle drugs designed to improve individual performance. Meanwhile, Pfizer has also worked hard to make erectile dysfunction an acceptable topic of public discourse, with the result that demands for its treatment rise.^27–31

In the wake of Viagra^®, some new testosterone–based medications for the treatment of andropause have been brought out, which are also associated with combatting sexual dysfunctions. Such is the case of Nebido^®, developed by Bayer Schering Pharma, which has also been promoted in large–scale campaigns in Brazil.

It can be concluded that the emphasis on sexual health as a gateway or entrance point for men to healthcare services is linked to a series of factors and recurring references. A constant has been the argument that men do not usually take care of their own health, a task that is often seen as a female responsibility. However, one thing men will always be concerned about is their sexual performance, expressed in terms of erectile function. By proposing to treat this, urologists have arguably found a way to get men treated for other diseases. But for this strategy to work, urologists will have to be a more consistent, representative presence in public health services.

Another phenomenon is that men’s sexuality has been essentially reduced to erectile function, which only goes to corroborate the idea that male sexuality is synonymous with having an erection, and almost exclusively addressed in heterosexist terms. This effectively precludes any other perception of male sexuality.

The public and political campaigns focusing on erectile dysfunction and andropause illustrate how, in the last two decades, a new focus on masculinity has taken shape via the pharmacologization of sexuality. This has been either through the use of drugs to achieve erection or the prescription of testosterone. Although a degree of critical perception can now be noted, especially with the publication of data that call into question the efficacy and safety of such therapies, it can be supposed that medicalization has won the day, both in medical practice and in the lay representations that are taking root. In the specific case of the conjunction of ageing and sexuality, it should be noted that the promotion of the new drugs and resources has gone hand–in–hand with the absolutely unquestioning promotion of modes of behavior centered on the veneration of a young, healthy, sexually–active body.

This article presents partial results of the Project “Gender differences in the recent medicalization of ageing and sexuality: the creation of the categories of menopause, andropause and sexual dysfunction” (with funding from Conselho Nacional de Pesquisa – CNPq/Brasil). Some of the data analyzed here were discussed previously in Rohden, F. “Capturados pelo sexo: a medicalização da sexualidade masculina em dois momentos”. Ciência e Saúde Coletiva, v.17, p.2645 – 2654, 2012.

The author declares no conflict of interest.

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