Man with Capital "M": masculinity ideals (re)constructed in pharmaceutical marketing

Abstracts

In this article we examine advertising material for erectile dysfunction drugs in order to analyse the discourses of pharmaceutical marketing. Embedded within a cycle that both contributes to, and feeds from, existing notions, advertisements directed towards doctors deploy new ideas related to nosological categories, while at the same time re-enforcing traditional gender/sexuality paradigms. Male sexuality, traditionally represented as "wild" and "unruly", is (re)normalised. The biomedicalized "new man", sexually potent, confident and stiff, is a hybrid of body and technology, found in the dissolving boundary between nature and culture.

Biomedicalization; Masculinities; Gender; Sexuality; Advertising

Neste artigo utilizamos material publicitário de drogas para tratamento da "disfunção erétil" para analisar os discursos do marketing farmacêutico. Num ciclo de realimentação, as propagandas voltadas aos médicos veiculam novas concepções relacionadas a categorias nosológicas, enquanto reforçam noções tradicionais de gênero/sexualidade. A sexualidade masculina, tradicionalmente representada como "selvagem", "incontrolável", é (re)normatizada. O "novo homem" biomedicalizado, sexualmente potente, confiante e rígido é um produto híbrido corpo-tecnologia, na fronteira esfumaçada entre natureza e cultura.

Biomedicalização; Masculinidades; Gênero; Sexualidade; Propaganda

Man with a Capital 'M'. ideas of masculinity (Re)Constructed in Pharmaceutical Marketing

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ABSTRACT

In this article we make use of marketing material for medication for the treatment of 'erectile dysfunction' to analyse pharmaceutical marketing discourses. In a feedback cycle, the advertisements, intended for doctors, both carry new conceptions related to nosological categories, at the same time as traditional notions of gender/sexuality. Masculine sexuality, traditionally represented as 'wild', or 'uncontrollable', is (re)normatised. The 'new man', biomedicalised, sexually potent, confident, and rigid, is a hybrid body/technology product at the vague frontier between nature and culture.

Key words: Biomedicalisation (biomedicalization); masculinity; gender; sexuality; advertising.

The time has come to show the capital M at the heart of every Brazilian Man.

(Advertising for the medication Helleva®, produced by Cristália Laboratories).

INTRODUCTION

In this article, we will analyse advertising material and announcements aimed at doctors, of four pharmaceutical companies, for the treatment of so-called "masculine sexual dysfunctions". The material was collected in ethnography undertaken in two congresses, one for sexology and the other for sexual medicine.

Until the end of the 1990s, the medical treatments available for impotence, such as injections in the penis right before intercourse or penial implants, all had in common an invasive character. The attempts at establishing direct connections between the serum levels of testosterone and masculine sexual dysfunctions were inconclusive. In 1991, the launching of sildenafil citrate

Some decades prior, the classic studies of Masters and Johnson had constructed a model of comprehension of human sexual activity, the "cycle of sexual response", conceived as 'psycho-physiological', placing in one side the psychogenetic causes and the organic causes, such as diabetes, on the other. From a practical point of view, the mode of intervention available, only involved the 'psycho' element or compartment (Masters & Johnson, 1966, 1970; Giami, 2009b, p.640). In 1977, Helen Kaplan reelaborated this model and proposed a version that is used up until the present day as a reference: a cycle composed of three successive psycho-physiological phases, that is, desire, excitation and orgasm (Kaplan, 1977). These studies caused a dislocation of standard ideas of impotence and frigidity to that of 'sexual dysfunction', by way of the discrimination and normatisation of the 'phases of the sexual response cycle'. This movement configures what Faro (2009a, p. 10-11) conceived of as the "psychomedicalisation" of sexuality.

The public injection of phenoxibenzamine by Dr. Giles Brindley into his own penis at a urology conference, in 1983, has been a performance transformed into the origin myth in the history of interventions into impotence (Rohden, 2009, p. 98; Marshall & Katz, 2002, p. 54). Beyond the conspicuous erection, it has reinforced the concept of male arousal as a 'physiological event', disassociated from the psychological component of sexual desire. We can understand this bizarre 'inaugural moment' as a landmark signifying the biomedicalisation of masculine sexual activity. One sees, throughout the 1980s, an increase in the amount of research and scientific articles about masculine sexual dysfunctions and their treatment, which implied an important inflexion for the field of clinical sexology. In the first place, the psychogenic conception of impotence was downplayed in favour of a predominantly organic conception. As such, it has been necessary a change in the diagnostic category itself that, according to the analysis of Lakoff (2005), needed to become "operationable". The category of impotence, with its heavy symbolic weight and tendency to absorb the subject as a whole, was gradually abandoned in favour of the term 'erectile dysfunction', defined as

The persistent incapacity to attain or maintain sufficient rigidity in the erection to have sexual relations. The degree of erectile dysfunction is variable and can be situated between a partial reduction of penial rigidity and an incapacity to maintain an erection, and the total absence of erection. This definition is limited to the erectile capacity of the penis and does not include libidinal problems, and problems with ejaculation or orgasm. (Krane et al., 1989, apud Giami, 2009b, p. 641).

The increase in the number of studies about masculine sexuality during the 1980s within a generally medicalised framework (Giami, 2009b; Faro, 2008), contributed in a marked fashion to the construction of a technological frame conducive to biomedicalisation.

The development of pharmacological technologies destined for the 'resolution' of a new nosological category (ED) has a double aspect: to simultaneously respond to the constructed and consolidated demand of this very category as a 'medical problem' to be 'resolved', clearly showing the circularity of the process of medicalisation/biomedicalisation. We would be, therefore, facing the co-construction of technologies and consumers: new molecules, and 'real' or 'potential' patients with ED. This contemporary focus on the male and the reduction of masculine sexuality to the erection embody the process of biomedicalisation of sexuality in the late 20^th century.

By way of a more general problematisation that mixes sexuality and age as fundamental dimensions of the modern subject, Barbara Marshall and Stephen Katz (2002), amongst others, highlight the importance of lifestyle cultures at the end of the last century. These cultures, by emphasizing health, activity, and the avoidance of ageing, were part of a broader process, which gave birth to a vast field of studies and interventions regarding the penetrative capacity of the masculine sexual organ. According to the authors, the great novelty is that one goes from a conception that admits the decline of sexual life across the passage of time, and in which one even judges negatively sexual activity in old age, to another, in which one is obliged to have good sexual performance until the end of one's life. Beyond this, sexual activity is advocated as the very necessary condition for a healthy life, and erectile capacity would define virility throughout the course of masculine life (Marshall & Katz, 2002; Marshall, 2006).

The important argument raised by the bibliography regarding this theme is that it was initially necessary to transform erectile dysfunction into a problem, in order to show that this could affect any man, at any stage of life. Equally, according to this logic, it was emphasised that a drug capable of 'resolving' or 'preventing' this difficulty was already available. In this sense, Viagra would be part of the group of so-called life-style drugs or comfort medicines, intended to improve individual performance; a market clearly in expansion. Furthermore Pfizer also invested in promoting the idea of erectile dysfunction as an acceptable topic for public discussion, which would lead to a greater search for treatment on the part of patients (Lexchin, 2006).

According to Meika Loe (2001) the development of this new material and cultural technology was related to the propagation of an idea of masculinity in crisis, illustrated especially through the metaphor of the erection. The notion that the erection, a symbol of virility and masculine identity, is effectively unstable and subject to various types of mishaps seems to increasingly gain attention. Furthermore, it is precisely to combat this lack of control or uncertainty regarding the masculine body that the industry offers a resource like Viagra, which would guarantee the expectation of an always improved performance (Grace et al, 2006).

As Brigeiro and Maksud point out, Viagra was launched in Brazil on the 1^st of June, 1998 and "no other medicine had been dealt with by the Brazilian print media with the same level of interest and variety of approaches, being dealt with in diverse sections and columns" (Brigeiro & Maksud, 2009, p. 74). The analysis of the advertising campaigns for Viagra in various countries has shown how the medication transformed itself into something intended to improve sexual performance without restriction to a specific group.

The idea of a 'crisis of masculinity' has been used to explain, not just the emergence of erectile dysfunction as a medical issue, but also the 'incredible success' of the drugs produced to treat it.

At the same time, the medicalisation of reproduction (and of the female body) led to the release onto the market of the birth control pill, a biotechnological event that had profound consequences in the transformations mentioned above. According to Loe, the pill, by removing obstacles that sustained a double sexual morality, transformed women into "critical consumers of masculine performance" (Loe, 2004, p.13), increasing the anxiety of heterosexual men regarding the traditional definitions of masculinity. Developing further this line of inquiry, Loe affirms that the new reproductive technologies from the middle of the 20^th century were precursors for sexual pharmacology. According to Loe, the new oral contraceptives served as catalysts and barometers of the changes in social attitude regarding science, technology, and medicine. By having as their objective a body and lifestyle transformation of its users (and not a cure for a disease), they could be considered the first lifestyle drugs in the field of sexuality. For this author, the Viagra era represents the emergence of a masculinity recovery movement based on a drug, and the re-emergence of the male body as a locus of confidence and control through an intense investment (financial and scientific) in the restoration or improvement of "masculine sexual potential" (Op. Cit.).

The strictly organic definition of sexual potency, leaving aside affective, social, or moral definitions, removes it from the struggles regarding definitions of gender. It is as if urologists (and the pharmaceutical industry) had provided the disorientated men a way by which masculine potency, by being translated into purely physical terms as erectile potency, could be 'improved'. In this manner, masculine (re)empowering necessarily implies the biomedicalisation of masculine sexuality, resulting in important transformations in the very definition of this sexuality.

A new facet of this phenomenon, especially visible in the Brazilian case, is the way ED is being used as a 'decoy' for public policy in programs of prevention for chronic conditions in men (Carrara et al., 2009). This issue was made explicit by the then Health Minister José Gomes Temporão, whose declaration on the matter produced innumerable, highly significant jokes.

Rohden (2009) points out the role of the gender differences in the configuration of the field of sexual medicine, considering that the prevailing perspective reduces the sexual experience of men to the anatomic-physical norm of erection, most of the time considered only in the context of heterosexual relations. In the masculine case, the model of Masters & Johnson, according to which sexuality is viewed as the combination of bio-psycho-socio elements and as something that has to do with the couple, is left aside. Men are presented as individualised beings by way of a description of their corporal economy, and deprived of interiority (when compared to women). When it comes to women, the description tends to include relational issues, especially those regarding the moral-affective quality of the couple. Beyond this, in their case, a paradoxical key for our comprehension is added. If, on one hand, there is an insistent reference to the supposed complexity of feminine sexuality, which would be more influenced by affective and relational issues, on the other hand there is the constant recourse to the masculine model, be it "basic" research about feminine sexuality or as the standard for investments in diagnosis and treatment of the female 'dysfunctions'.

In this article, via the analysis of the advertising of drugs for ED intended for doctors, we propose to explore what certain forms of biomedicalisation reveal about the (re)construction of masculinity.

As Elaine Rabello shows,

(...) [A]dvertising does not create values, but rather uses those that are already circulating in the society and reformulates them for presentation to the public through advertising. Owing to this, the media becomes a useful vehicle for the comprehension of what the society legitimates as a desirable lifestyle. In this way, it is of interest to the pharmaceutical industry to give a name and a substrate to the desire for total wellbeing and performance through the process of reification, attributing materiality to a brand or product which, being swallowed, can enter the body (the stage of the experiences of wellbeing and productivity) and "produce" the desired "health" effects, thanks to science, to technology, and thanks to who, obviously, makes all of this available in the form of a product (Rabello, 2010, p. 31).

In the same way the presuppositions regarding masculinity inform the marketing of drugs for ED, the distinct substances whose 'actions' manifest themselves differently in terms of the promised erection indicate what would be the 'desirable' attributes for 'adequate' masculine performance. This performance would possibly be the summation of all the attributes associated to these substances. At the same time, the number of requirements for such a qualification shows it to be an unattainable ideal: 'complete' masculinity which, according to these parameters, reveals itself in the final analysis to be a mission impossible to achieve. One of the roles played by the marketing consists precisely in the incessant incitement of the search for this ideal, with many very often unsubtle promises.

MATERIAL AND DISCUSSION

Our empirical data was constituted by leaflets obtained in observations undertaken in the two congresses, one of sexology and the other of sexual medicine; the XI Brazilian Congress of Human Sexuality, Recife, 2007 and the X Congress of the Latin American Society of Sexual Medicine, Florianópolis, 2009, respectively. The second event is part of the implantation and development of sexual medicine, an area that has sought to affirm itself as autonomous in relation to sexology. In the field of studies/interventions into sexuality, it situates itself in the most radical stream of the biomedical paradigm, and has established a hegemonic relation with clinical sexology:

One can perceive that the supporters of sexual medicine, in the great majority urologists, tend to apply pressure to what until then had functioned as a more dispersed field in terms of definitions and demarcations of boundaries, in order to transform it into a body with clearer frontiers between the different attributions and functions (doctors practice medicine, psychologists practice psychotherapy, educators practice/orient sexual education). From this point of view the designation "sexologist" or "sexology", which seems to refer naturally to the period of implantation of the field and to a moment of greater dispersion of definitions and frontiers, is abandoned in the name of more precise designations, which concentrate specialties also clearly demarcated (Russo et al, 2011, p. 134).

Russo et al. (Op. cit.) propose a map of the studies and interventions into sexuality, which helps to contextualize the congresses studied in these ethnographies. The authors suggest that sexology and sexual medicine, that have a medico-psychological perspective in common, correspond to parts of a more ample aggregate that gathers different kinds of knowledge and of interventions into sexuality. This broader field is also composed by approaches centred on political activism and by studies developed by the social/anthropological sciences. Sexology appears as a term which has been losing prestige, with the tendency to be superseded, and refers to a field which structured itself along two subfields, clinical and educational sexology. While the educational subfield positioned itself in the interface between the three approaches of the field of knowledge and interventions regarding sexuality, having conceptions now more political and social, now more biological, clinical sexology, just as with sexual medicine, characterises itself by the naturalising presuppositions of the medico-psychological vision (Op. cit., p.134).

Congresses and events play an important role in the constitution and institutionalisation of this field, especially because it is an area that tends to be ignored in undergraduate and graduate courses.

Information packs in couché paper were obtained, with four colour printing and quite luxurious productions. There was a fairly constant pattern in these packs: on the first page was an attention grabbing headline, with a strong border, graphics on the next page and, on the last page, information in small lettering with diverse bibliographical references.

We worked with the advertising of four drugs: Viagra^® (sildenafil citrate) of Pfizer, Cialis^® (tadalafil) of Eli Lilly from Brazil, Levitra^® (vardenafil) of Bayer Schering Pharma, and Helleva^® (lodenafil carbonate), of Cristália Chemical Products and Pharmaceuticals Ltd., whose slogan transformed itself into the epigraphy of, and inspired the title of this study. The informational material of Levitra included advertising for Nebido^®. Cialis, Levitra, Helleva, and Viagra are drugs for ED. Nebido, with a testosterone base, aims at treating hypogonadism or 'androgen deficiency in the aging male' - ADAM.

The anatomical illustrations of penises were accompanied on the opposite page by the specification of the "Scale of Hardness of the Erection (SHE): 1^st Degree - severe ED: thick penis but not rigid; 2^nd degree - moderate ED: rigid penis, but not sufficient for penetration; 3^rd degree - mild ED: partially rigid, but still able to penetrate; 4^th degree - without ED: penis totally rigid".

One of the brochures for Viagra (entitled "Hardness is the aim") illustrated, in a manner so as to leave no margin for doubt, the 'degree of hardness of the erection' (Figure 2). Rectangles of an increasing size, arranged from left to right, contained the following images: 1^st degree - water; 2^nd degree - sand; 3^rd degree - braided straw, and 4^th degree - a blue wooden board, with the wood grain drawn in.

By contrast, BSP also distributed copies of urologists' papers, with authors' photos and a complete bibliography, in which clinical cases were presented. One of these leaflets, although dealing exclusively with the use of Levitra, nevertheless had an advertisement for Nebido at the end: a double page spread in which the term ADAM featured prominently, accompanied by an asterisk in which the acronym was spelled out didactically as "androgenic deficiency of the ageing male". Another leaflet, dealing with diabetes, discussed the lowering of testosterone levels, recommending Nebido while also featuring an advertisement for the drug. A different brochure entitled "Sexual health as a gateway for male health" dealt exclusively with testosterone deficiency, for which the 'tried and true' therapeutic choice was Nebido.

Comparing Pfizer and PSB's materials, the simplicity of the former when compared to the complexity of the latter is noticeable, which included detailed academic format articles. A hypothesis for this difference is that Pfizer was manufacturing a product that was already in a stage of stabilisation

Beyond a strategy of 'scientifically' legitimising the efficacy of the drugs, there was a battle underway for dominance of the market, in which a drug's 'qualities' were compared to those of its competitors. Pfizer's talking points were 'hardness', and the fact that Viagra was the first drug approved for ED, as we can see in the slogans found in their promotional brochures: "Hardness is important" and "Only Viagra is Viagra" were added to the image of the blue rhomboid pill strangely balanced on one of its corners, that is, 'standing up'. Various double-entendres and ambiguous images were scattered throughout the promotional material: "Viagra, sildenafil citrate. A solid relationship with hardness"; a stone sculpture of an embracing couple. The predominant colour used was blue, a 'masculine' colour and the colour of the marketed pill, indicating that with extreme hardness everything becomes 'blue'.

Cialis is currently the bestselling iPDE5

Commensurate with the stage of diffusion, the emphasis of Levitra's campaign was on its "novelty" in establishing a "new level of efficacy for ED treatment" in this way prolonging the "duration of sexual intercourse". In one of the drug's brochures a pie chart, divided in four segments, specified and standardised the ideal duration: "1-2 minutes (too short); 3-7 minutes (adequate); 10-30 minutes (too long); 7-10 minutes (desirable)". This last slice was slightly detached from the rest, to prevent any possible misinterpretation of the chart (Figure 5).

If Pfizer subtly emphasised Viagra's status as the first ever treatment for ED ("Only Viagra is Viagra"),

Another BSP brochure established the equation "Couple's satisfaction = longer duration of sexual intercourse = new parameter for efficacy". In a pedagogic illustration of the process of creating a technological framework favourable to several of their products, their slogan emphasised how "Levitra® prolongs the duration of sexual intercourse up to three times longer in patients with ED both with or without comorbidities" (our emphasis). As a bonus, was the promise that the drug would have a '3 in 1' role: by satisfying its claim of prolonging "up to three times longer the duration of sexual intercourse" (our emphasis), a 'too short' episode of intercourse of 1-2 minutes, following the previously mentioned pie chart on the desired length for sexual intercourse (Figure 5), would reach the 3-6 minute 'adequate' band, nearly arriving at a 'desirable' intercourse of 7-10 minutes. From this, we can hypothesize that, at this stage of the drug's promotion, it could also reach premature ejaculators. Even those in the 'adequate' band could be 'upgraded' to 'desirable', in a potential use of Levitra as an enhancement or lifestyle drug (Azize, 2006).

Following the logic of their competitors' avant-garde advertisements, Helleva

When compared to the promotional material for Viagra and Levitra, both quite discreet in their promises for a conspicuous masculinity, Helleva was quite explicit: "It is time to show the capital M at the heart of each and every Brazilian Man" was the slogan that accompanied the capital H,

According to the graphs that compared the rate of absorption of the drug when taken on an empty stomach or when taken with alcohol, use in conjunction with alcohol or food would not interfere with the drug's absorption. On the contrary, the performance of the drug would actually improve in these cases. This was presented as an advantage, in stark contrast with Viagra, which needs to be taken on an empty stomach to be effective.

The image of a cake with white icing and colourful sugar chips, with a capital H instead of the traditional birthday candle (or the cherry on top), found in the third page of Helleva's brochure is pregnant with meanings: it can be related to the association between the use of Helleva and celebration, the possibility of having a sexual feast after a gastronomic one, the feast of having your capital M (capital H in the original) optimised and not be let down at the 'key' moment.

Presenting the drug as innovative was compatible with Helleva still being in its promotional phase, while being the "first synthetic product developed in Brazil" which would give the drug a certain seniority and credibility in Brazil. Cristália's main slogan is "Innovation is in our DNA. Cristália is the Brazilian-owned pharmaceutical company that invests more in research, development, and innovation", a slogan that features prominently on their website, alongside the information that the company received the FINEP

In a public announcement published in the O Estado de São Paulo newspaper, Temporão

Thus, the collaboration between Cristália/FIOCRUZ suggests that, if the project to which Carrara et al. referred was to be implemented, Helleva could be the chosen drug. The National Policy of Men's Health could significantly help turn this possibility into a reality, helping to promote and popularise Helleva on the Brazilian market.

FINAL REMARKS

We are dealing with a broader uninterrupted feedback cycle of which the studied material represents an 'instant', an example. The cycle departs from lay and traditional presuppositions of gender and sexuality which, translated in medical terms (medicalisation), transform themselves into normatised domains that can and, especially, should be 'corrected'. The functions 'corrected' by the biomedical interventions produce new expectations, models, and possibilities, that is to say, new bodies reconfigured by pharmacological technologies (biomedicalisation). New bodies also produce new norms and ideals which, appropriated by the lay public, construct parallel pathways of drug consumption by way of self-prescription. As much the medical prescriptions as self prescribing reinforce biomedicalisation, since they work from the understanding of a bodily activity codified in medical terms and which, in this manner, is open to pharmacological interventions. This cycle produces a technological frame in which the use of pharmaceuticals stops being merely 'acceptable' and becomes 'desirable'. Each new medication is integrated into this cycle, reinforcing the technological frame in which 'men's health' and 'masculinity' are constantly reconstructed and resignified.

One seeks the legitimation of products and of the 'necessity' for their use through the invocation of 'scientificity', backed up by scientific articles that reveal the dissolution of the boundaries between academic production, research, and industrial development.

As Alain Giami shows, in the absence of critical medical training regarding themes related to sexual function, "the pharmaceutical industry controls in an almost exclusive manner the information and the training of doctors" (Giami, 2009b, p. 69). In this way, in respect to the prescriptions for ED, doctors occupy a similar place to lay people, partly consequent on an academic education which does not include the critical evaluation of scientific articles (Camargo Jr., 2003).

In Brazil, the advertisement of this type of medication (the so-called ethical drug) is forbidden, it can only be advertised to doctors (in congresses or in scientific publications). That explains in part the fact that this propaganda, directed toward professionals, makes use of the normal marketing arsenal. In other words, one uses with the doctor common sense images and conceptions similar to the ones used with lay-persons. One has the impression that the industry intends to 'sell' the product to the professional for their personal use. In other terms, despite the aim of the advertisement being to instigate the doctor to prescribe, its language and the images used make it seems that the real aim is to sell the medication itself.

The colloquial language used in all the information packs, for "exclusive circulation amongst doctors", grabbed our attention. In the advertising kits for Cialis, we note on the last page, in capital letters, the recommendation "Don't forget to speak with your patient", explaining in detail what to say:

+ With Cialis your patient does not need to schedule to take the tablet immediately before sexual relations.

+ Cialis has up to 36 hours of efficacy, that is to say, your patient can take it at lunch on Friday and will be safe to have sexual relations, at any time, up until Sunday morning.

+ Cialis can be taken with fatty foods and alcoholic drinks in moderate quantities.

+The erection only occurs through sexual stimulation.

+It is not recommended for a patient who is using organic nitrates. (Cialis Information pack, p.4)

Backed up by the absence of critical medical training regarding the theme, the choice of topics to be 'clarified' seemed to place the agency of the professional in second place. The ready made explanation which the laboratory suggests the doctor should provide the patient presupposes a professional that is no more than an intermediary between the industry and the consumer.

According to Azize, the discourses which circulate "between the lay public, the pharmaceutical laboratories, and biomedical professionals (promote) the idea of a 'super-health', generating a new objective and new uses for the medications", constructing what the same author calls "lifestyle medications" (Azize, 2006, p.121). Regarding our specific object, the pharmaceuticals for ED, Faro points out that:

Pro-sexual drugs offer an enhancement for sexuality, something that would make the body function better, which would bring completion to sexual function. It is not an illness that can be cured by a medication, but a function, which will be potentialised with a pill (Faro, 2009b, p. 18).

At the same time in which the drugs 'guarantee' performance, they produce a diversity of anxieties, present or future, in relation to the 'quality' and duration of an erection. As Chris Wienke carefully analysed, the self-response questionnaire on the Levitra site carries to the inevitable conclusion that, if the person does not have any of the listed problems, they may still "wish to speak with their doctor about some worry regarding their erectile quality" (Wienke, 2006, p.62).

The advertising for Viagra makes plain, including visually, an ideal of masculinity which requires (to be attained with absolute security) the use of pharmaceuticals, as shown in the graphic in which the fourth stage of erection ("completely hard and totally rigid") is represented by the unappealingly obvious blue wooden board. That is to say, the advertising simultaneously exploits masculine insecurity and 'expectations', by offering a 'magic pill', reinforcing the idea of a male sexuality always ready for sex, translated in the readiness of the "completely hard" penis to penetrate. In this sense, we arrive at the point of an 'optimised' masculinity. The '4^th stage of erection' assumes, automatically, as Vares and Braun show, "all male sexuality (…) codified as always potentially suboptimal and capable of being improved" (Vares & Braun, 2006, p.328). In other terms, "the presentation of Viagra operates a paradoxical relationship in which one has to overcome the loss of virility without demolishing its symbolic content (to the contrary, while reinforcing it)" (Brigeiro & Maksud, 2009, p.79). The desirable duration of the normalised erection should be between 7 and 10 minutes, no more and no less. The equation "Satisfaction of the couple = greater duration of sexual relation = new parameter of efficiency" shows the notion of sexual relations as heteronormative ("Get better at having sex with your partner")

'Responsible masculinity' is used by the BSP campaign, which is in agreement with the already mentioned National Policy of Men's Health. It is what the first phrase of the advertising material for Levitra indicates: "THE EVOLUTION in Masculine Health". On the interior page, the idea is reinforced: "Bayer was the first laboratory with a portfolio focused on masculine health. With advanced research Bayer Schering Pharma offers effective treatments for the health of men as well as innovative preventative solutions". The 'responsible man' takes care of his physical and economic health, according to our national product, Helleva, which declares that: "Big results, small costs, just how a man likes it". In a clear paradox with the strategy of the Ministry of Health of using ED as a hook to talk about other conditions, such as hypertension and diabetes, the advertising material of Helleva underlines, amongst its qualities, the fact of being still more efficient "after meals rich in lipids and also after the consumption of alcohol".

The pharmacological effect of a guaranteed and sustained erection produces 'confident masculinity': "It's time to show the capital H that's at the heart of every Brazilian man". The implicit conception of male sexuality centred on the erection as unstable leads to the notion that without medication all male sexuality is uncertain. The resolution of this 'fragility' is sought in a concrete solution: a pill that will eliminate uncertainty. "Confidence stamped on the box" and also "Security with a capital H". Or, according to Eli Lilly: "Freedom of choice which only Cialis offers", "Cialis is highly effective for up to 36 hours". Without questioning the equation masculinity = erection, one starts by managing the fragility, guaranteeing the erection. Male sexuality, traditionally represented as 'wild', 'instinctive', and 'uncontrollable' is normatised and rationalised. Paradoxically, it is by way of sophisticated pharmacological technology that one offers to men the return of their 'primordial' characteristics, of their 'true sexual nature', of their 'liberty' and 'confidence'. Molecules and behaviours are mixed in a naturalised continuum. Constructing a masculinity in whose centre is the maintenance of the sexually potent man, confident, rigid and effective, we find a hybrid product as much body as technology, 'super-natural', on the definitively misty border between nature and culture.

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• Faro, L. As disfunções sexuais femininas no periódico. Archives of Sexual Behavior. Dissertação de mestrado em Saúde Coletiva, Instituto de Medicina Social, UERJ, Rio de Janeiro, 2008.
• __________. Contornos da medicalização da sexualidade feminina no século XXI: disfunções sexuais femininas num periódico científico. Trabalho apresentado no 33º Encontro Anual da ANPOCS, Caxambu, 2009a. Disponível em: http://www.encontroanpocs.org.br/2009/. Acesso em: 15/12/2009.
• __________. A medicalização das disfunções sexuais femininas no contexto da farmacologização da sexualidade. Trabalho apresentado no XIV Congresso Brasileiro de Sociologia, Rio de Janeiro, 2009b. Disponível em: Acesso em: 22/06/2010.
• Fleck, L. Genesis and Development of a Sientific Fact. Chicago and London, The University of Chicago Press, 1979.
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• __________. Da impotência à disfunção erétil. Destinos da medicalização da sexualidade. Physis. Revista de Saúde Coletiva vol. 19, nº 3, Rio de Janeiro, 2009b, pp.637-658.
• Grace, V.; Potts, A.; Gavey, N. & Vares, T. The Discursive Condition of Viagra. Sexualities, vol. 9, nº 3, London, Thousand Oaks e New Delhi, SAGE Publications, 2006, pp.295-314.
• Kaplan, H. A nova terapia do sexo Rio de Janeiro, Nova Fronteira, 1977.
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• Lexchin, J. Bigger and Better: How Pfizer Redefined Erectile Dysfunction. Plosmedicine, vol. 3, nº 4, 2006, pp.1-4.
• Loe, M. Fixing broken masculinity: Viagra as a technology for the production of gender and sexuality. Sexuality and culture, vol. 5, nº 3, 2001, pp.97-125.
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• __________ & Katz, S. Forever Functional: Sexual Fitness and the Ageing Male Body. Body & Society, vol. 8, nº 4, London, Thousand Oaks and New Delhi, SAGE Publications, 2002, pp.43-70.
• Masters, W. & Johnson, V. Human sexual response. Boston, Little, Brown, 1966.
• __________. Human sexual inadequacy. Boston, Little, Brown, 1970.
• Mulhall, J., et alii Erectile Dysfunction: Monitoring Response to Treatment in Clinical Practice - Recommendations of an International Study Panel. Journal of Sexual Medicine, nº 4, 2007, pp.448-464.
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• Rabello, E. T. Representações sociais mobilizadas pela propaganda televisiva de medicamentos: intersecções entre ciência, saúde e práticas de consumo. Dissertação de mestrado em Saúde Coletiva. PPGSC do Instituto de Medicina Social UERJ, Rio de Janeiro, 2010.
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• __________. Diferenças de gênero e medicalização da sexualidade na criação do diagnóstico das disfunções sexuais. Revista Estudos Feministas, vol.17, nº 1, Florianópolis, 2009, pp.89-109.
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• Tiefer, L. The Viagra phenomenon. Sexualities, vol.9, nº 3. London, Thousand Oaks and New Delhi, SAGE Publications, 2006, pp.273-294.
• Vares, T. & Braun, V. Spreading the Word, but What Word is That? Viagra and Male Sexuality in Popular Culture. Sexualities, vol. 9, nº 3, London, Thousand Oaks and New Delhi, SAGE Publications, 2006, pp.315-332.
• Wienke, C. Sex in the Natural Way: The Marketing of Cialis and Levitra. In: Rosenfeld, D. & Faircloth, C.A. (eds.) Medicalized Masculinities. Philadelphia, Temple University Press, 2006, pp.45-64.

^[1]

Livi Faro^I; Lilian Krakowski Chazan^II; Fabíola Rohden^III; Jane Russo^IV

^[2]

In a dialectical movement, this set of advertisements carries new nosological categories, while at the same time reinforcing and reconfiguring traditional ideas about gender and sexuality, constructing in this manner a consumer market for diverse biomedical technologies and professional services aimed at "resolving" new "pathologies".

^[3]

by Pfizer, with the commercial name Viagra

^®, represented a watershed in diverse ways. Amongst them, the consolidation of the process of defining 'erectile dysfunction' (ED) as a physiological phenomenon, the possibility of access to a non-invasive 'solution' of easy administration, the gradual amplification of the very concept of erectile dysfunction - with the consequent expansion of the consumer market - and, last but not least, a series of reconfigurations of masculine sexuality and of masculinity.

^[4]

Various authors are discussing in diverse manners how much the emergence of medications for ED on the market contributes to the medicalisation - or biomedicalisation - of masculine sexuality.

^[5]

We wish to underline the distinction between medicalisation and biomedicalisation. The first has to do with codification, in medical terms, of the most diverse aspects of human life (Conrad, 2007). The term 'biomedicalisation' has been used to emphasise the expansion and reconfiguration of processes of medicalisation driven by the technological innovation of biomedicine (Clarke et al., 2003, p. 164). The prefix 'bio' indicates the transformations that such technologies produce in biological processes of human and non-human life. For Clarke et al (Op. Cit., p. 182), biomedicalisation involves not only control, but also transformation of bodies, of health and life, with the production of drugs being one of its key elements. To the extent that it involves the stimulation of the consumption of pharmaceuticals, biomedicalisation necessarily implies the co-construction of technologies and consumers. For our theme, that involves direct pharmacological intervention in sexuality, the term biomedicalisation presents itself as more precise.

^[6]

Though it had been promoted in its initial phase for an older demographic in the context of heterosexual unions, it began to be suggested for increasingly younger men, who began to appear in the advertising material without any conspicuous partner (Marshall & Katz, 2002, p. 61). However, as Vares and Braun (2006) point out, what was behind this whole advertising phenomenon was the creation of a feeling of masculine vulnerability that would motivate the search for control and an improvement of potency and sexuality as a whole. If a certain bodily and mental unpredictability was very frequently associated with the feminine body and reproductive processes (Rohden, 2001), now the masculine body, seen as more stable and "naturally" potent, also began to be conceived as a suspect for instability.

^[7]

The point of emergence of this supposed crisis would be the social and cultural transformations which occurred in the post-war era, especially in the 1960s and 1970s. The social position of women underwent profound changes, with important consequences for the family. The change in the status of women and the emergence of the gay movement advocating the rights of homosexual men and women had represented a strong blow to hegemonic masculinity,

^[8]

leading to a confusion regarding what defines (or ceases to define) masculinity. The traditional conceptions around the white, educated, heterosexual male were put in check.

^[9]

^[10]

^[11]

In this sense, it is worth citing the tests and the use of Viagra to treat problems relative to excitation in women and, subsequently, the great investment in the use of testosterone to resolve the problem of the so-called hypoactive sexual desire in women, a hormone that since its discovery was conceived of as eminently masculine, in contrast to oestrogen (Oudshoorn, 1994). In this new phase then, to have a satisfactory sexuality, women need to make use of what would symbolically represent a process of masculinisation.

^[12]

The advertisements

^[13]

Along with the most explicitly propagandistic material, Pfizer and Bayer Schering Pharma (BSP) distributed flyers with scientific 'content'. Pfizer had a pamphlet of 20 pages, entitled "Erectile Dysfunction: recommendations for treatment in clinical practice", that consisted in a simplification of the article published in the Journal of Sexual Medicine (Mulhall et al., 2007) with many tables, graphics, and illustrations of the penis in the 'four stages of rigidity and erection' (Figure 1).

^[14]

, only needing to emphasise that their product was simply 'superior' to the others. This was also the case of Cialis,

^[15]

whose promotional material was not even distributed during the 2009 conference, even though its manufacturer, Eli Lilly, was the

bronze sponsor of the event. In the case of BSP, this company was trying to open up markets for Levitra, a drug that was still in its promotional stage, while at the same time attempting to build, through the notion of ADAM, a technological support base for Nebido. In the case of Nebido, the process of medicalisation is reinforced by the use of the drug, the 'need' for which is produced by the construction of a nosological category. Cristália, in turn, had chosen not to emphasise in a 'scientific' way the virtues of their product, focusing instead on the 'Brazilian' specifics: it was, apparently, time to "

Show the capital M at the heart of every Brazilian Man".

^[16]

The series of brochures each had a catchphrase attributing agency to the hardness featured on the cover: "

Hardness is the aim"; "

Hardness makes the difference"; "

Hardness keeps relationships in balance" (

Figure 3). The cover slogan was repeated on the second page of the brochure, while the third page exhibited results that backed the content of the slogan in a simplified, schematic manner. Following Anvisa's

^[17]

regulations,

^[18]

all catchphrases and slogans were, without exception, accompanied by a small number that directed the reader towards the back cover of the leaflet, in which international bibliographical items or drug information were cited as supporting references. Curiously enough, even though all these brochures were directed at doctors, references to any kind of dysfunction or disease were not the primary focus.

^[19]

drug in Brazil. Its promotional material calls our attention through its use of the plus sign and the catchphrase "

a lot more" (

Figure 4). Compared to Viagra's "stone", the visual layout of Cialis' information pack is flowing, as if to capture the idea of a "

Freedom that allows the patient to live in a more spontaneous way without time constraints". The catchphrase "

A lot more" was repeated throughout the brochure: "

Much more efficacy than our competitors", "

Cialis offers many more hours of freedom to choose the right moment". 'Freedom' was the second most used term: "

Freedom that allows the patient to live in a more spontaneous way and without time constraints", "

Cialis offers much more freedom to choose the right moment". As an alternative to the 'completely rigid' Viagra, "

with Cialis your patient does not have to plan his intake of the medication for right before intercourse". The big promise lies in this sentence: "

a much longer active period than its competitors", guaranteeing up to 36-hours effectiveness.

^[20]

BSP assumed the status of being "

the first laboratory with a portfolio focused on men's health". Clearly, BSP's advertisement strategy established a dialogue with that of Pfizer while promoting the construction of a technological framework that also included Levitra and Nebido, affirming that "

ED is more than just a potency problem" (our emphasis). BSP's selling point, within this context, was that "

for men with ED, the duration of sexual intercourse is as important as maintaining potency", while "

93% of men consider the duration of the erection an important factor". These sentences were followed by a table exhibiting the results of a survey on "

What is important for men during intercourse?". In the survey, 93% of men surveyed said that both "

Erection rigidity" and "

Duration of erection" were important, coming second only to "

Ease of attaining an erection" and "

Improving sexual relationship with their partners". Amongst the least mentioned concerns for the men surveyed was "

Duration of action of the drug", cited by 88%.

^[21]

Contrary to the images in Pfizer's brochure, all of them quite allusive, BSP's images were mostly 'objective': graphs, photographs of the article's authors or drug packaging. The only images that were not so objective pictured a flame to the left of the trademark Levitra^®, alongside an enigmatic twenty inscribed within a circle and the slogan "Register that mark", to which one could question: 20 what? Years, milligrams, minutes?

^[22]

was presented as the "

First synthetic product developed in Brazil", emphasising the novelty of its packaging: "

Cristália brings to Brazil a Swiss mechanism of holographic safety" described as an

"exclusive system against counterfeiting (

…

) a 3D hologram of four different colours in the blister packaging, using the same technology as that usedto print money". For Helleva, looks are not deceitful: "

Confidence stamped on the packaging", protected by 'Swiss technology', in a reference to that country's iconic association with 'safety' and with being a trustworthy holder of bank deposits. None of the promotional material of the international pharmaceutical companies appealed to that sort of legitimacy, highlighting a local concern with the circulation of counterfeited medicines.

^[23]

^[24]

posing solitary and imposing on the cover of the leaflet. This metaphorical image was also present throughout the pages of the brochure: "

with a capital H", "

Safety with a capital H".

[25]

The recurring use of the word 'capital' refers to a certain masculine fixation with penis' size, with a double reason to be proud: for being a 'man with a capital M',

^[26]

and for being Brazilian. This idea was reinforced by the information given on the second page of the brochure for being the first synthetic drug developed in Brazil, partially leading to the (almost) inevitable conclusion that it would be the drug of choice for 'Brazilians'.

^[27]

^[28]

Helleva's promotional material is explicit with regards to the construction of an economically responsible though festive masculinity: "

Big results, small expenses, just the way Men like it". Aimed at the "Brazilian people": "

Less expense, more accessible: 40% discount on the price of Helleva"; "

30% discount in Helleva purchases with your Bem

Cristália card".

^[29]

technological award in 2007, and has established collaborations and partnerships with several Brazilian public universities, the Santa Casa de Misericórdia of São Paulo, FIOCRUZ, Butantã Institute, INCOR and Zerbini Foundation.

^[30]

The established partnership with FarManguinhos/FIOCRUZ, linked to the Brazilian Ministry of Health, points to the likelihood of a public/private partnership in Helleva's production. As Carrara

et al. (2009) argue

^[31]

declared that the Ministry of Health was analysing the possibility of offering treatment for erectile dysfunction through the public health system, including the provision of drugs. The government was examining the financial impact of this initiative (

Op. cit., p. 676).

^[32]

In the advertising material, the strategy becomes visible in the pamphlet for Viagra, which, with big letters and plenty of illustrations, gives a schematic summary of the article published in a renowned medical journal, as well as in the information packs of the BSP that reproduce scientific articles written by professors from renowned medical schools, presenting clinical cases and their 'solution' and, finally, by the recurrent presentation of all the pharmaceuticals as 'the first' in some respect, or 'the last' in another respect so as to denote 'innovation'. The underlying idea of 'scientific progress' equates the innovative aspect with something implicitly 'scientific', adding value to the product. This notion is especially present at the moment of diffusion. To the extent that the medication is established, it begins to present the quality of having been 'the first', as a propagandistic and legitimating feature.

^[33]

Thus, the marketing directed at doctors (the focus of this analysis) takes centre stage in the construction of a key element for the consumption of these pharmaceuticals: the doctor's prescription. The final users, the consumers 'themselves', will use the medication be it via the doctor's prescription, or by self-prescription, instigated by the marketing subtly present in the media.

^[34]

and centred on penial rigidity: "

Hardness is the aim", as Pfizer informs us. BSP elaborates even further: "

ED is more than just a problem of potency

"

, pointing out the creation of a new norm - duration, - amplifying, in this way, the definition of ED and, consequently, the number of potential consumers.

Publication Dates

• Publication in this collection
  11 July 2013
• Date of issue
  June 2013

History

• Received
  27 July 2011
• Accepted
  25 Apr 2012