Erectile dysfunction is fast on the ascent among otherwise healthy men, affecting an estimated half of those in their thirties and giving rise to an influx of pharmaceutical quick fixes. But as little blue pills become ever more prevalent, might the hard truth be that the problem is in our heads?
Now 30, he first experienced “the internal panic” at university. The girl he was cavorting with had started telling him not to worry before he realised what was going wrong. “I guess I was struggling,” he says. “Out of nowhere, she tells me that this guy her friend is seeing ‘has it all the time’. She diagnosed me, there and then. It was the absolute worst thing to hear. I fancied her a lot. I couldn’t stop panicking. Then I really couldn’t get it up.”
The frisson fizzled out. They didn’t have sex, and he never saw her in a romantic capacity again. That was in 2009, when he was barely out of his teens. A decade later, John, who requested that we don’t use his real name, still carries the shame. “It’s not something you really go to the doctor for. Why would you? They’ll only give you Viagra, which I can get myself. And who wants to talk about it?”
Who, indeed? But experts believe that John is just one figure in a crowded room of men suffering in silence. Erectile dysfunction (ED), once considered an older man’s malady, is reportedly skyrocketing among millennials. Researchers claim that one in four new ED patients are now under 40, and a recent study by Co-Op Pharmacy found that, out of 2000 men surveyed, half of those in their thirties had difficulty achieving or maintaining an erection – more than men in their forties or fifties.
In medical terms, this makes little sense. Millennials are healthier, fitter, more nutritionally switched on and far less likely to suffer from heart disease than their fathers. Thirtysomethings run more, drink less and, by and large, don’t smoke. If there was a checklist of ways to avoid ED, an average member of this generation would tick every box. But doctors are even encountering people in their teens suffering from ED. So, if we are seeing a rise in healthy men unable to get it up, what is getting us down?
Last year, Viagra celebrated its 20th birthday. Since the little blue pill was approved for use in 1998, it has made manufacturer Pfizer more than $24bn in the US alone. Pfizer’s US patent expires in 2020 but, a couple of years ago, the company negotiated a deal for generic and alternative options to be sold – a development that has transformed the ED economy. In effect, our erections have been commodified.
Among the first to get a firm grip on them was the US start-up Hims – a wellness and lifestyle company that trades on modish, shareable images and humorous memes, and sells everything from vitamins to sildenafil, the active ingredient in Viagra. Its branding screams “young”, and those cries have evidently fallen on receptive ears. Last year, Hims was worth more than $700m and was reportedly fast approaching unicorn status: a valuation of $1bn.
Chasing similar success, other companies followed. While the Therapeutic Goods Administration last year rejected an application to make sildenafil (Viagra) available without prescription, it can be purchased online. Meanwhile, in the UK, Viagra went over the counter – and everything changed. “We’re one of a handful of UK brands that launched last year, selling these medications,” says Riccardo Bruni, co-founder of Many, a UK-based online men’s pharmacy. “There’s a clear market for these drugs, for young as well as older men.” It’s hard to argue with the business model. Many has some notable investors, including Richard Reed, the co-founder of smoothie company Innocent Drinks.
Crucially, acquisition is simple. To order drugs from the site, all you have to do is fill out a consultation form, which is appraised by Many’s pharmacist. But not all meds start-ups have an in-house pharmacist, and the ease of online transactions has drawn criticism. For example, some medical professionals warn that, though many of these drugs can stave off the symptoms, they won’t necessarily fix the underlying problems. After all, the causes of issues such as ED can be complex – exactly the reasoning behind the TGA’s retention of the status quo.
To understand why something is broken, it’s useful to know how it works. While an erection might seem simple enough – arousal plus stimulus equals go time! – it is the result of an intricate process requiring the harmonious interplay of chemistry and the nervous system, involving multiple biological instruments that are each prone to hitting a bum note.
First, there’s the penis’s capacity to retain blood. Failure here is common, and this is known as the inability to maintain an erection. There can also be hitches getting the blood there in the first place – often tied to cardiovascular issues ormetabolic syndrome. Physical trauma to the groin, or nerve compression (as a result of too much cycling, say), can have an effect, too.
So, is there an epidemic of young men getting kicked where it hurts? “I have guys – some as young as 18 – telling me things like, ‘My dick’s broken,’” says GP Nick Knight. “They’ve had one or more experiences of not being able to get an erection, and they’re worried. This is becoming common.” But nine times out of 10, looking for a physical explanation for ED in a young man is barking up the wrong diagnostic tree. “Their penises aren’t broken. That’s more likely in older men, who might smoke, have diabetes or be on medication. It’s something else.”
Popular culture often presents ED as a joke. For this, we can, in part, thank the ill-considered “sad man with his head in his hands next to his disappointed wife” image on cigarette packets and medical pamphlets in recent years. These depictions have perpetuated the narrative that to be unable to achieve an erection somehow makes you less of a man – regardless of whether you’re a 20-a-day smoker, seriously ill – or just an anxious young man.
That’s doubly problematic when you consider what many experts believe is the true cause of ED’s rise. “It simply cannot be a coincidence that there is also an epidemic of mental health issues in young men,” says Knight. “I’d be fascinated to know, of those people presenting with ED, how many are also suffering from a mental health problem,” hesays. “I would wager the number is high.”
Knight would be given poor odds if the bookies had an eye on the clinics. “There has definitely been an increased uptake of psychosexual therapy services,” says Kate Moyle, a counsellor specialising in this area. “Young men make up a large proportion of those seeking advice, and we are also seeing high numbers struggling with erectile dysfunction and rapid or delayed ejaculation.”
That is important. Your psyche holds your penis as if by a marionette string. As soon as you start to over-analyse things, it can be game over: stress and anxiety are the ultimate mood killers. “Men I see often describe feeling that they are very much present in their heads, but not in their bodies, or that they struggle to focus when it comes to sex,” says Moyle. Sex requires a degree of mindfulness to be enjoyable and, indeed, possible. But the younger generation – one wracked by comparison and inadequacy, and the Instagramification of happiness – is often too neurotic to zone in.
The mental health connection has always interested me,” says Bruni. “You just have to look at the medication. We sell Priligy, a premature ejaculation medication, which is so similar to many antidepressants as to be almost indistinguishable. It regulates serotonin, which, when imbalanced, can cause you to come too quickly. That tells you everything you need to know about the link between your mental state and sex.”
So, what are we unhappy about? “Performance anxiety is exactly what it says on the tin. It’s the fear of performing badly: not lasting long enough, not being hard enough, not satisfying your partner,” says Moyle. “And if the focus is on these goals, then it is not on our enjoyment.”
has been agonised over since time immemorial. To get to the root of the problem, experts have been asking what, exactly, has changed? Two minutes on Google and one theory will rise as surely as morning glory: the impact of our unbridled access to hardcore pornography.
THE PORN ULTIMATUM
Since the online proliferation of porn, erections have become totemic, thrusting their way into the collective imagination of a generation of men more worried about sex than any before it. One sexual health clinic has reported a 100 per cent rise in referrals for those seeking treatment for porn addiction. Many experts see this as the root cause of millennial sexual dysfunctions.
“Porn is incredibly desensitising to intimacy,” says Knight. “Some men aren’t getting the same kicks from real sex as they are when masturbating with porn. I often ask patients, ‘How much do you watch?’ And, ‘Do you think it might be having an impact?’”
It has certainly had an impact on Kevin – also not his real name – who believes that his porn use contributed to the collapse of a long-term relationship. “I don’t think I was ever a real porn addict,” he says. “But I did probably use it a bit too much and have done since I was a teenager. My last girlfriend didn’t catch me using it or anything like that, but I do think it’s the reason why I have this recurring problem in relationships – a super-quick honeymoon period when I want loads of sex, then I can’t get hard after a few weeks. I think porn has made me bored on some kind of deeper level.”
That boredom has resulted in a particularly millennial type of ED – one that is “cured” by the excitement of a new partner, who can match the thrill that Kevin, now 29, more regularly gets from opening a new tab on RedTube. But then the feeling quickly subsides, and he is no longer able to become aroused by that partner. “I was with my ex for three years. We had sex maybe three times during the last two. I could get it up for porn, but not for her. I felt guilty all the time, and it made me lash out. It was a nightmare.”
The almost limitless choice offered by internet porn can evidently dampen your ability to enjoy “normal” intercourse. “It sets the bar too high,” says Knight. “Nothing will do it for you any more.” In response, websites such as Your Brain on Porn and ED forums on Reddit have emerged – communities built around t he shared experience of a disorder dubbed “porn-induced erectile dysfunction”.
The former group, in particular, has been on a mission to raise awareness about what it considers to be a clear link between porn use and sexual dysfunction: “Other than the advent of streaming porn in 2006,” it argues, “no variable related to youthful ED has appreciably changed in the last 10-20 years.”
But this view is not without its critics. There are statisticians who prescribe a healthy dose of caution even when appraising such seemingly irrefutable “facts”. One of those sceptics is Dr Justin Lehmiller – erstwhile teacher at Harvard and currently a research fellow at the Kinsey Institute – whose work on sex and psychology has been published in every major journal on human sexuality.
Lehmiller’s intention hasn’t been to debunk the numbers, so much as pour cold water over the hysteria. “Some people are looking at data points that aren’t high quality,” he says. “I have no strong personal opinion. I’m a scientist. What I have is more of a hypothesis. It’s not just about porn. There are more people on antidepressants, there’s more body anxiety, and there are more sexual communication difficulties. Blaming porn alone is ideological.”
It’s a sentiment echoed by Moyle. “There is some validity in the porn theory, but pornography isn’t the sole problem. Reports of stress and anxiety in younger people are at an all-time high. But sexual problems remain undiscussed. This can contribute to more anxiety. It’s a vicious cycle of dysfunction and anxiety.”
That cycle of shame and dysfunction is what has led many men to the back alleys of the internet, choosing to buy knock-off Viagra from the dark web and fake pharmacies. Embarrassment, it seems, overrides caution.
THE ONLY WAY IS UP
This is where start-ups such as Many have been able to muscle in on the action. It’s a millennial solution to a millennial problem, with mainstream tech offering the benefits of the illegal route – discretion, next-day delivery – but with the safety and legitimacy of a genuine – and 24/7 – pharmacy.
Some experts, including Lehmiller, believe that easy access to these medications isn’t inherently helpful, as it increases the temptation to seek a pill instead of investigating the true causes of our problems. Yet there’s a degree of unrealistic expectation here. The statistics don’t lie: men are putting themselves at risk by buying unregulated meds every day. It’s hardly likely – in fact, it’s improbable – that they’ll all suddenly run to the doctor just because they’ve been told to.
So, could this new wave of start-ups provide a solution for people like John, at least in the short term? “The thing that annoys me most is this exaggerated acceptance: ‘We get why you’re sad about ED. Come and talk to your doctor about it,’” John says. “It’s bullshit, really. I’m not going to sit down and talk to someone when it’s simpler to sort it out myself.” John estimates that he has taken somewhere in the region of 50-100 illegally procured ED meds in his adult life. When asked if he knows about the risks – excessive doses due to inaccurate labelling of active ingredients, contamination with toxins, fake drugs – he sweats bullets . “No,” he says. “I didn’t know that.”
In this respect, companies such as Many have the potential to do a lot of good. “Of course, we make buying these drugs easier,” says Bruni. “And we understand the concerns around the products we sell, but what we sell is regulated. We’re also trying to be a part of this conversation for the better.
“Men can pathologise a thing that’s normal – like not being able to get it up from time to time. We’re not for those men. We never push pills on people who don’t need them, and our consultation only allows people who do to buy them.”
SHADES OF GREY
Perhaps what we need, most of all, is a new classification that isn’t as binary as “ED or no ED”. “Maybe young men have the wrong idea of what ED is,” says Lehmiller. “If the penis isn’t doing what they want it to do every time, they think there’s a problem. But it’s normal for men not to always maintain an erection.”
In a way, that’s just life. “Sometimes, life is just hard. It’s stressful, and you’re tired, and you can’t go to the gym,” says Knight. “No drug or therapy can make all of that go away, and they can even be counterproductive.”
Curiously, where he does see the benefit of medication is as Viagra for the ego. “I might see a young guy and give him one or two pills, and that’s it. You have it once, then it’s stuck in your head. A couple of times on Viagra and boom! You’ve got your confidence back.”
Erectile dysfunction among healthy men, it seems, could be all in the mind: another side-effect of our many mental health issues, alongside anxiety, depression and body dysmorphia. It’s a jungle in there.
“We are starting to talk about many of these things,” says Moyle. “We’re just not there yet when it comes to sex.”
Society’s shifting attitude to mental health, then, offers the best lesson: to break down the stigma, first we must challenge the judgments we make in our own minds. And until we do that?The statistics suggest the bedroom downturn will only continue.
What tablets should you take to help your erectile dysfunction?
There’s no shame in a pill prop but you need to know what you’re taking. Umar Malick, Many’s pharmacist, spills on pills
The original ED medication produced by Pfizer. It works by increasing blood flow to the penis and should take effect within 30 minutes.
Sildenafil citrate is the active ingredient in Viagra. Unbranded varieties work in exactly the same way, but tend not to carry the price tag of Viagra.
The brand name of Viagra’s main competition. It can last for up to 36 hours, which explains why it is sometimes colloquially referred to as “the weekend pill”.
Unbranded Cialis. It’s as effective, but costs half the price. Some men find tadalafil has fewer side effects than sildenafi.
Works slightly faster than Viagra and lasts for up to five hours. Note that this drug is taken in smaller doses than Viagra.
The active ingredient in Levitra. It also tends to be less affected by food, whereas fatty meals make it harder for Viagra to enter the bloodstream.