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CHICAGO - The scenes in his examining room "can be comical" to Dr. Robert Garafolo.
Teenage boys regularly try to talk him into writing a prescription for Viagra by explaining erectile dysfunction that doesn't exist. It is the antithesis of machismo.
"There is nothing wrong with them, so I hear a lot of stories about anxiety or (failed) behavior," said Garafolo, director of youth services at the Howard Brown Health Center in Chicago and an adolescent physician with a practice at Children's Memorial Hospital.
But Garafolo stops chuckling about the same time he says "no" and realizes the teens sitting across from him will likely get their prescriptions filled on the Internet. Or maybe they will buy some of the "blue diamonds" (the pill's color and shape) at a party or local club.
Viagra, the older man's drug, has earned a place among hard-partying youth. It has gone recreational practically without anyone noticing.
"A tremendous amount of younger men take it in hopes to enhance performance and endurance," Garafolo said.
"One thing that is remarkable is it has all happened without anybody paying much attention," said Dr. Abraham Morgentaler, a Harvard Medical School physician and researcher in sexual dysfunction.
Here's the problem: Teenage boys and 20-something guys are taking Viagra with "club drugs" such as Ecstasy. Although Ecstasy can boost energy and provide the desired high, it lessens a male's ability to have an erection. Alcohol does the same thing to a man's sexual abilities.
Adding the Viagra for a "sextasy" drug cocktail restores virility because the prescription drug's main biological action is to increase the nitric oxide production needed to encourage blood flow to the penis.
The result is that a lot of young guys-and more than a few in their 30s, 40s and beyond-are suddenly more able to have sex when it is least advisable. Viagra works for four to six hours, which only extends the time to make unwise late-night decision, such as not using a condom.
Forget the Viagra jokes that are so prevalent that Internet sites are devoted to the genre.
There clearly is a dark side to how the popular drug is used. The arrival of Viagra competitors Levitra and Cialis, which you can't miss if you watch any sporting event on television, especially pro football, will serve to cast an even longer shadow.
"It's a prescription for danger," Garafolo said. "It is becoming fairly well documented that using Viagra can put a man more at risk for sexually transmitted diseases, including HIV and AIDS."
For instance, one study of 844 men conducted at San Francisco's STD clinic found that Viagra users had an average of 5.4 sexual partners in the last two months compared with 3.5 partners among non-Viagra users. Plus, more men received the drug from a friend or acquaintance than from a health practitioner.
The San Francisco study, conducted by Dr. Jeffrey Klausner, showed that gay and bisexual men are four times more likely to use Viagra recreationally than are heterosexual men. Of those gay and bisexual Viagra users, 43 percent mixed it with Ecstasy and 28 percent with methamphetamines (known as "poppers," which can potentially lead to an unsafe drop in blood pressure if a male has any undiagnosed cardiovascular troubles).
Nonetheless, Garafolo insisted, he sees plenty of "straight" adolescents who are using the drugs. In some cases, he said females are encouraging Viagra use for their male partners.
Gay men are simply ahead on the social learning curve. Garafolo agreed that ignoring the heterosexual misuse of Viagra is similar to society's wrongheaded tendency to link HIV/AIDS only to gay men.
"It is a fallacy to consider it as strictly a gay issue," said Garafolo, who sees mostly gay patients at the Howard Brown center and many heterosexuals at his Children's Memorial practice.
Morgentaler said hundreds of heterosexual men come to his Men's Health Boston practice. And he's also keenly aware of the street buzz about Viagra.
"College-age students take Viagra to parties or get offered it," Morgentaler said. "Guys who hear about a friend's marital or girlfriend problems will half-joke that maybe the friend needs some Viagra to `spice things up a bit.' Viagra has left the realm of a medically prescribed drug."
For its part, representatives of Pfizer, the makers of Viagra, have stated "the product is for men with erectile dysfunction" and that the company has "opposed recreational use from day one."
Morgentaler said he is always "reluctant to prescribe Viagra to anyone who doesn't truly need it," but that typically won't stop patients from regularly asking for "a six-pack." Those guys are not asking for beer. Viagra comes in a convenient sample pack of six, which Pfizer provides to doctors as a way for patients to try the drug.
"It's a stroke of (advertising) genius, evoking two great images of American maleness," Morgentaler said. "The first, of course, is the six-pack of beer. The second refers to the highly desired set of abdominal muscles."
One problem with Viagra use is that some men-usually older males-might unwittingly mix nitroglycerin heart medicine and the sexual function drug. This combination can create potential blood pressure irregularities. It's most likely when a man is handed a sample pill from a friend (who maybe got the six-pack from his doctor) or uses an online pharmacy for his supply (answering a mere few general health questions).
What's more, Morgentaler sees a growing number of men , including guys in their 20s and 30s, creating another problem. They take Viagra figuring to be sexual supermen early in a relationship. Then the question is, once the relationship blossoms, does the man keep taking Viagra-or Levitra or Cialis-for the rest of his love life, whether he needs it or not?
Is it love or is it Viagra?
"The guys taking Viagra think their girlfriends will be furious if they find out the man is taking it and not telling them," Morgentaler explained. "But they worry that not taking it will cause the women to notice a dropoff in performance."
The drop in performance might be real or imagined. Dr. Laurence Levine, a urologist who sees more than 7,000 men in his Rush University Medical Center practice, said Viagra and its competitors will delay orgasm. That helps men with premature-ejaculation problems.
Another possible plus is that Viagra will improve what Levine called "erection refractory."
"Twenty minutes later the man is back up and ready to go," said Levine, who was involved with the early studies about Viagra.
Dr. Ira Sharlip, a San Francisco physician and spokesman for the American Urological Association, calls it the "sexual athlete" phenomenon.
"But Viagra and its competitors won't turn a normal erection into a supernatural erection," Sharlip said. "It is most useful for men with at least mild erectile dysfunction."
In any case, researchers have found that men will not develop any physical dependence on Viagra-or any loss of normal function if they stop using it-but he considers psychological dependence a separate matter.
"Increasingly more men are not willing to take a chance on subpar performance," Levine explained.
That troubles Levine. He has treated young men with self-confidence issues who "regain spontaneous erections" by strategic use of Viagra. Once the patient achieves normal function, Levine recommends using Viagra only "half the time" rather than in all circumstances. This modified dosing helps the man gain confidence in his own body's abilities.
Morgentaler has seen so many cases of Viagra getting mixed up in relationship problems that he has written a new book, "The Viagra Myth: The Surprising Impact on Love and Relationships" (Jossey-Bass, $24.95). His message is clear: Viagra won't fix age-old issues in relationships, such as growing apart or lack of trust.
"As a group, men are so focused on performance issues, we must look like idiots to women," Morgentaler said. "The reality is Viagra is a medicine that in concept helps with performance. The myth is that a pill that improves blood flow to the penis can solve personal relationship problems.
"It can't. What's left to manage our relationships is the old-fashioned tools of communication, respect and accepting each other's differences."
(c) 2003, Chicago Tribune. Distributed by Knight Ridder/Tribune News Service.