A few years ago, former senator Robert Dole helped make it acceptable for men to talk about erectile dysfunction. Advertisements for sildenafil (Viagra) showed him saying, "It may take a little courage to ask your doctor about erectile dysfunction, but everything worthwhile usually does." Pfizer Inc., Viagra's manufacturer, continues to feature handsome, middle-age men with beautiful, usually younger women in advertisements for the drug, with the strong implication that the drug will enhance lives. But there are several things wrong with this picture.

First, it represents the medicalization of aging and sexuality. Men of all ages can have difficulty achieving and maintaining an erection, and the availability of a drug such as sildenafil is a breakthrough for those for whom erection is a necessity to a satisfying sexual life. But is an aging man's decline in testosterone and libido a medical condition?

Sildenafil is not the only example. Research reported in the past year has concluded that hormone replacement therapy (HRT) for menopause symptoms increases risk for adverse events including cardiovascular effects. These data have pulled the rug out from under the HRT drug market, so drug companies are betting on "male menopause," or andropause-a term used to refer to the decrease (seen by many as a "deficiency") of sex hormones in aging men. Unimed Pharmaceuticals, Inc., has been marketing a testosterone replacement gel to treat hypogonadism, which Unimed's Web site says affects up to 5 million U.S. men. I believe testosterone replacement is destined to be a replay of HRT. As pointed out in the February 26, 2003, issue of the Journal of the American Medical Association, what little research has been conducted into the side effects of testosterone replacement therapy suggests that it can stimulate prostate hyperplasia and cancer, with marginal improvements in fatigue, depression, and libido.

Second, sildenafil is marketed to men who may or may not have erectile dysfunction. I am bombarded daily with e-mail advertisements for the drug, including how to get it through the Internet. A study published in the July 5, 2002, issue of AIDS found that gay and bisexual men in San Francisco are using sildenafil as a recreational drug in combination with other illicit drugs, resulting in an alarming increase in transmission of HIV and other STIs. Pfizer's Web site now includes a statement recommending that men talk with their partners about STIs.

But it doesn't always happen. Vern Urich is a semiretired urologist in Sun City, Arizona, who teaches older adults about safer sex. About two years ago, he noticed an increase in the number of older women he treated for incontinence who also had STIs. These were mostly widowed or divorced women whose prior sexual experience had been with one partner or very few, and they had no previous need to protect against STIs. But something had changed. Some of the men in the retirement community who took sildenafil had been bed hopping, spreading STIs.

Third, ours is a conflicted society, both sex obsessed and sex denying. Sex is everywhere-on television, films, the Internet-yet our society still struggles with whether to teach young people about safer sex. And when clinicians discuss sexuality with patients, they often ignore psychological and relational aspects of sexuality. Beverly Whipple, PhD, RN, president of the Society for the Scientific Study of Sexuality, has said, "We all know that there is so much more to sexuality and sexual expression than vaginal intercourse." Will a pill that enhances erectile function fix relationship problems?

Erectile dysfunction is an important topic that nurses must understand because a variety of conditions and treatments can lead to diminished sexual function. But I question whether men's changing sexuality is a natural function of aging. Shouldn't older men try exploring dimensions of intimacy and sexuality that don't involve penile penetration? The medicalization of aging and sexuality just may prevent patients from discovering a richer sexual experience.