ANNA SALE: How old were you when you realized that getting erections was not something that was gonna be automatic for you? 

BRANDON: It all kind of started, you know, early twenties. So I would have been probably about 22, 23 kind of struggling with “that problem.”

This is Brandon. He’s 27, lives in Toronto. And it was around the time that he came out as gay that he realized that he had trouble getting and maintaining erections.

BRANDON: I found myself very much avoiding sex, whether it would be leaving at date early so that wasn't a possibility or making sure that we were going out somewhere. Um, so that we weren't coming back with that daunting expectation of, oh, are we, aren't we gonna go into the bedroom? And what does that look like? And am I going to be unable to get hard and to perform sexually? And I think at that point I realized to myself that, you need to do something here. 

So, Brandon talked to his doctor about it. And his doctor prescribed him Viagra. 

BRANDON: I found out that erectile drugs, uh, were very much a roll of the dice. So for me, it was you might be able to get an erection and hold one, or you might not. And there's no way of knowing.

AS: Do you feel sort of lied to by erectile dysfunction drugs about what kind of fix they offer? 

BRANDON: [Laughs] Yeah, actually, initially I did! you watch commercials all the time for Viagra and you see all these happy guys doing all these activities. That was not my experience. You know, I didn't find myself riding a Skidoo through the lake, uh, or mountain biking in the forest. No, no. None of those things happened after I took these medications. [Laughs]

I’m Anna Sale, and this is Hard.

A series from Death, Sex & Money about Viagra… 

LOUISE: It's much easier. They just have an erection.

Erectile dysfunction…

CONNOR: I just remember that, just thinking like, Christ I’ve been cursed. 

And the ways we do and don’t talk about sex, relationships and our bodies. 

OCTAVIA: I mean, like if we’re talking about if my dick broke, it did not at all. 

Brandon first emailed us three years ago. The subject line of his email was: “What happens when you’re a 24 year old gay man with ED?” 

BRANDON: The standard is, the expectation is, gay men have crazy wild sex all over the place. And whether that's, you know, out on the street, in nature, in the bushes or at home, um, homosexual gay male culture is, is very sexually charged. Um, and it's, it's everywhere and it's in your face. 

AS: Were you able to talk with anyone about how your body wasn't responding the way you wanted it to when it came to sex? About erectile dysfunction?

BRANDON: No, no, I still - I'll be honest with you really haven't. At the time I was dating. I had a boyfriend. And I did sort of express that this was something that I was working through and that if he wanted to pursue a romantic relationship, this was the qualifier. Um, because it wasn't something that I, I could change or that I had control over in that moment.

AS: Do you remember how you explained it to him? 

BRANDON: Um, yep. Very vividly, uh, three glasses of wine in and pacing around, uh, his townhouse. I just kind of came out like word vomit, "I have something to tell you, I have erectile dysfunction. I'm not okay with this. And I'm struggling immensely. If, if we're going to progress in any way, shape or form, you need to just be cool with this until I figure things out."

Brandon is still figuring it out. In addition to taking Viagra, he takes medication for depression and anxiety…which can make it more difficult to get aroused. He and his boyfriend eventually broke up, after about six months. And Brandon got back on the apps. But he says he’s had walls up when it comes to starting new relationships.

BRANDON: You frame it as a one night stand or you frame it as a hookup, then you have nothing to lose. And, and if it's somebody who I'm, I'm looking for, you know, more of a relationship with, or seeing again, again and again, um, it could be a potential deal-breaker for them.

AS: And for you, when you think about what kind of relationships you want to have in your romantic life, um, do you wish at this point in your life that you could have, uh, a more long-term relationship with, with one person? 

BRANDON: Yeah, I definitely, I would definitely prefer, uh, you know, something stable and long-term. Hopefully, maybe one day. But, but I think, you know, this, this oversexualized culture - it doesn't say anything about having sex and not being able to get an erection as okay. It's very much big hard dicks flying everywhere.

According to a survey from Johns Hopkins in 2007, more than 18 million men in the U.S. are affected by erectile dysfunction. ED can be caused by many different things… physical issues like high cholesterol and diabetes… and psychological ones like stress and depression. Sometimes a combination of both. 

And despite how common it is, the reality of ED can lead to a lot of shame and disappointment. For people affected by ED and their partners.

OCTAVIA: There is that sort of idea that if you're in your early twenties, you're going to be able to get hard fast and keep it.

DR. GOLDSTEIN: When it doesn't work, you challenge all aspects of your ego. Your self-worth.

Z: You don't flirt in the same way. You don't go on dates in the same way. 

LOUISE: I got really big hurt feelings and big feelings of rejection.

CONNOR: We were having sex and she just sort of stopped me and she goes, you're just not brave enough. [Laughs] 

The introduction of Viagra almost 25 years ago opened up new possibilities for people affected by ED. It blew open the conversation about it. And it reinforced a very specific idea of what successful sex is. 

DR. WYATT: A general that I saw said that when he wanted an erection, he wanted an immediate rock-hard erection. And I said, you know, it's not like you're saluting. 

So, we’re doing a three part series… telling the pretty wild story of how Viagra came to be… and how it’s led to some big questions about performance… and pleasure.

But to start we’re going to focus in on people’s intimate lives and relationships that have been impacted by both erectile dysfunction… and Viagra. In ways that the cheeky public conversation about the drug has never quite captured. 

LOUISE: People joke about these medications and there's just so many memes and so much pop culture reference in a joking manner. And if you think about -  the medication is for them in the plural. It's for the couple, it's for the marriage, the relationship, the partnership, it isn't just about a guy getting a boner. 

A woman we’re calling Louise is 47 and lives in New England. She's been with her husband for more than 20 years. 

LOUISE: It was never easy for him, even from the beginning to get erections. He, wasn't the kind of guy who just had them all the time.

After Viagra became available in 1998… Louise’s husband got a prescription. And for him – the drug worked well. But their insurance didn’t cover it. 

LOUISE: When these pills first came out, you know, you'd get a prescription, you'd go to pick it up, it'd be $800. And we'd say, uh, no, can we have like one pill?

AS: Huh.

LOUISE: You know? Yeah. So you kind of think about like how much is it really worth it to you? 

AS: And when he had the option of taking Viagra, how did it work when you would choose for him to take it to have time together?

LOUISE: I think it was never sort of an explicit conversation, like a commercial. "Why don't you take Viagra?" You know, it was sort of like, one of us would be hinting, like, "Hey, you wanna, you know..." and then he would take it. And one of the side effects of these medications is your nose gets really stuffy. And that's how I could tell that he had taken it.

AS: [Laughs] That's the code? 

LOUISE: Yeah. Like your nose gets really stuffy and I can hear him like, "Sniff sniff." And I would know he had taken it. 

AS: I’ve never heard that before, that is so interesting. It's like a mating call. 

LOUISE: It's very obvious.

AS: Huh. And from your point of view, your experience, when he took Viagra, what changed?

LOUISE: It's a reliable way to get an erection that doesn't involve hurt feelings if things don't work. 

AS: Oh, wait, tell, tell me why you say it like that.

LOUISE: Because if your spouse or your partner suffers from ED and you're trying to have sex and they can't get an erection, that's devastating for them. It's just like this whole emotional thing. And then of course you want to avoid it. So you don't try to do that again. It's scary for the partner of someone who has ED to initiate or to try, because there's always this risk that there - it's not going to work and then their feelings are hurt and then they're just upset and feel like they've let you down. And then you feel like a jerk for pressuring them. So when you have these kinds of medications, it kind of just takes that emotional burden off of you.

AS: Mmhm. And also gives you a little space to have your own needs and desires. 

LOUISE: Yeah. It definitely makes it so that you don't feel like a bad person asking for sex. You know, and especially now that my husband has had cancer, like it's not his fault. And I would feel like such an asshole if, you know, I was in any way criticizing his performance. Because how do you criticize someone who had cancer and had like an important part of their anatomy removed? 

Louise’s husband was diagnosed with prostate cancer a few years ago. He was in his late 40s at the time, and as part of his treatment had his prostate removed. Prostate surgery often impacts nerves in the area – for Louise’s husband, it made his ED even worse, and Viagra worked less reliably for him. According to Johns Hopkins, nearly everyone who has prostate cancer treatment has some form of erectile dysfunction afterward. 

LOUISE: I don't think there are a lot of men who are really comfortable talking about this. Um, and I know I've been in support groups for people who are spouses of prostate cancer survivors, you know, um, and there's a lot of women out there suffering, you know, with the same issue where they have a really hard time talking about it. And some people will find sex outside of the marriage. Some people will just keep trying, some people will settle for a sexless marriage. It's really complicated. 

AS: In the support group for prostate cancer survivor partners, were you able to talk about how intimacy works in your marriage? 

LOUISE: Um, I did post once and I was kind of told, well, there's lots of other ways to have sex. You should, you know, buy some sex toys. You know, really what I thought was kind of a tone deaf response. And I really didn't engage after that. And I, I left that group. The reality is most prostate cancer survivor wives are not in their forties. For someone to be diagnosed at his age is very unusual. I mean, that's a really daunting thing to be 43 years old and think about never having sex again your entire life. 

AS: Do you think about that? Do you think that's a possibility for you?

LOUISE: Sure. It definitely has been a thought in my mind. It has definitely been a possibility for me. And then, you know, sometimes I think, well, you know, there's Tinder, but I live in a really small town in a really small state and everybody knows me. There's just no way I could do something like that.

AS: Uh huh. But the idea of having a partner outside the marriage, if it was in a way that you wouldn't get caught socially has an appeal. 

LOUISE: I would, if my husband never knew, 'cause I would never want to hurt his feelings. And I am not looking for a boyfriend. I, you know, purely sex. Sure. If he didn't know about it, if it didn't have any possibility of just devastating him. Sure.

AS: Do you have that, now that we're talking about it, do you have that sense of like, you know, just like that craving, not, not, not with intimacy with your husband, but just a craving for sex? 

LOUISE: I mean, it comes and goes, I would say. A couple of glasses of Aldi wine, sure.

AS: Did you say Aldi wine, like A-L-D-I the grocery store?

LOUISE: Yeah! Winking Owl? Do you not know the Winking Owl? Two dollars and 49 cents for a beautiful bottle of Pinot Grigio? Come on now!

One more thing Louise also told me: since generic Viagra became available a few years ago, her husband has been able to take it more regularly because the cost is lower. 

LOUISE: It actually is working much better. And he actually told me the other day that he woke up in the middle of the night with a spontaneous direction, which hasn't happened in years. 

Coming up…

JOANNE: I would say, if you love him and you keep working together, you will eventually find what works for you.

We hear from a couple for whom Viagra was just one solution of many… as they tried to solve a sexual problem together. 

BOB: One of your topics is death. Okay? And let's enjoy the journey until we get there. Because we're all going to get there. 

 —

This is Hard, a series from Death, Sex & Money. I’m Anna Sale. 

Erectile dysfunction is not a new problem. It was referenced by the Ancient Egyptians and Greeks, the Old Testament, and the oldest known text in Chinese medicine. But a lot has changed in the way ED has been addressed in just the last few decades. 

For starters, what we call it has changed. In 1992, the National Institutes of Health officially recommended that the term “erectile dysfunction” be used.

That was a big shift from just two decades earlier… when this training film was made for medical students called "The Impotent Husband." 

DOCTOR: We are about to observe a conjoint marriage counseling session with a middle aged couple. The problem presented by Mr. and Mrs. Palmer is one of the most frequent encountered by physicians and counselors...

Death, Sex & Money producer Katie Bishop is here with me – she dug up this video in the course of her research…. 

KATIE BISHOP: I did – I found this on the National Institutes of Health website in their digital library… and just to paint a picture here, we're seeing a sound stage where there's a marriage counselor sitting across from a couple, a husband and wife. He looks like he's just come from the office, he's wearing a suit, she's wearing kind of a nice dress. She's chain smoking throughout the entire session. And they've come in together to talk with this marriage counselor because a few weeks prior they'd had a failed attempt at having sex. And ever since they've been having difficulties. 

MARRIAGE COUNSELOR: Now these days, let’s suppose you were to make a romantic advance tonight? What would go on in your mind? 

MR. PALMER: Failure. [Laughs]

MARRIAGE COUNSELOR: Don't want to touch it with a -

MR. PALMER: "Stop. Do not pass go." [Laughs]

MRS. PALMER: He doesn’t even want to try anymore. Why doesn't he want to try anymore? 

MR. PALMER: That's because it's, you know - you fail so many times and it’s no longer worth trying.

MRS. PALMER: But I've never held that up to you. Have I?

MR. PALMER: I didn't say you did. That's not what we're talking about. We're talking about in my feelings, my mind, well the whole situation is embarrassing.

MARRIAGE COUNSELOR: Right.

MR. PALMER: I mean, it's - let's face it. I can’t cut the mustard and that’s what we’re really talking about here…

KB: So it’s unclear to me if these are actors or an actual couple but I really believe this bickering. I think it's legit.

AS: Yeah. Yeah.

KB: And you know, the couple keeps talking together throughout the film and at the end, the marriage counselor really helps them to talk to each other about what’s been going on, and at the end they're able to be a little less angry at each other. 

MARRIAGE COUNSELOR: How do you feel now about coming in? 

MR. PALMER: It's a little better now. 

MRS. PALMER: Thank you, doctor. 

MARRIAGE COUNSELOR: But you talked with other and it helps. So that’s my commercial.

MR. PALMER: Okay. Sold. [LAUGHS]

KB: But what I thought was really interesting about this film is back in the 1970s, there just was not much understanding about how erections worked. And why they stopped working. 

DR. DAVID ROWLAND: Many people came in for treatment, but the GP or the urologist really didn't have tools or answers to address problems with erectile dysfunction. 

So I called up Dr. David Rowland, he’s an expert in human sexuality, he's also a psychologist – and he started his career back in the 1970s, right around the time when this film was made. 

DR: There was a general, uh, misconception, I think, that most of men's erectile dysfunction was created because of their anxiety. But most men's problems, at least insofar as we suspect today, most men's problems are more likely to be biologically based.

So if the husband in this film had had some sort of underlying medical condition going on – there just wasn’t a lot that doctors could do for him. 

DR: Psychosexual therapy has an important role, but it doesn't cure a problem that is biologically based. So if you think of the penis as a piece of equipment and the equipment doesn't work, you need to have something that fixes the equipment.

BOB: I think back then it was kind of looked upon as, yeah okay. You're getting older and this is going to happen and there's nothing you can do about it type thing. That’s life, guy! 

In the course of her research, Katie also met Bob. She found him on a website called FrankTalk – it's an online forum for people experiencing ED. Bob was in his early 50s when he first noticed something was different in the bedroom. It was the early '90s, before Viagra. 

BOB: Straight out, the erections wouldn't last. And that became kind of a frustration. Yes, we're getting older, but why is this happening? Within a year or so, that's when I started going to urologist, trying to find out what was wrong. Okay? The first urologist led toward being psychosomatic. In other words, it was all in my head and believe me, it was not.

I called up Bob and his wife, Joanne, at their home in Omaha. They’re now in their 70s and they’ve been married for more than 50 years. When Bob first started experiencing ED, they were recent empty nesters.

JOANNE: Well, as soon as we got rid of the two animals, um -

AS: [Laughs] You mean your kids? 

JOANNE: Yes. As soon as we pawned them off on others, um, it was okay with us but there was that frustration of Bob couldn't get it up and stay. That was the big thing. So you know, how much - I can't yell at him about it. It's not something yelling would do. And truthfully, he would always say, I feel so bad that you're not getting anything out of this. Well, if you love the guy you want to help him. 

For a while, both Bob and Joanne felt like there wasn’t much they could do. But then, in the mid-'90s, Bob started seeing a different doctor.

BOB: He was younger and basically said, no, there's, there's other options that you have, uh, in, in, in that will assist, okay? Not necessarily cure it. Viagra was just in its second phase studies. And he led me to one of the trials. And it's like, hey, you know, if I get a placebo, nothing's gonna happen. And if I get the real drug, maybe something will happen. Maybe it will help somebody else. So, it was an interesting start to the journey.

AS: Yeah. And did you notice any change in your erections? 

BOB: Yes, absolutely.

AS: When you realized that this drug was, was one that, that could help you, how did it change your sex life?

BOB: It greatly improved in most all respects, with the exception of spontaneity. And even with intimacy and touching and, and, you know, closeness, um, it would, it would take a while. So it kind of, it kind of led away from, from the, uh, uh, the timing factor.

AS: It led more to scheduling. 

BOB: Yeah, yeah. Yeah. "I'm gonna put you on the calendar for next Thursday, three o'clock?" 

Bob took Viagra… and eventually other ED drugs like Cialis and Levitra… for about seven years. But over time, Bob says, the drugs lost their effectiveness. 

BOB: You start out at 25 milligrams and you're up to 50 milligrams, then you're up to a hundred milligrams and the doctor says, you know, you can take a hundred and you can split a hundred into fifties, take 150. And that was when it's like, okay, what other alternatives do we have? 

AS: Was there a time in your, in, after you started taking Viagra after it, those drugs, after a series of drugs stopped working as well for you, when you had a conversation between you two that, you know, maybe intimacy is really important to us. Touch is really important to us as a couple, but maybe the sex life we used to have, we're just not going to have anymore in the same way. 

JOANNE: No, we didn't. We never reached that point.

BOB: No.

JOANNE: No. It's because the fact of the one doctor who said there's so much out there, there's a pump. There's different things that can be done.

Bob and Joanne tried a lot of different interventions… and then, three years ago, Bob decided to get a penile implant. It’s seen as a last resort for ED patients, and involves surgically putting a device inside the penis that can make it firm. 

ANNA SALE: And Bob, why were you, why did you want this surgery? What made you ready for deciding to take this step to do an invasive procedure?

BOB: Spontaneity?

JOANNE: No drugs.

BOB: There's, there's no drugs involved. There's no restriction rings. There's no pellets that you put, you don't want to know where. It's just, it is an unbelievable relief, I think I'll speak for myself, for me, to be able - she says, "Hey, you know, how about 1:30 today?" And it's like, okay, I can do that.

AS: Is that one of the lines that you use, Joanne? How about 1:30 today?

JOANNE: Well, here's the funny part about this. We are now back on schedules.

BOB: Yes.

JOANNE: Twice a week. We decided, well, Mondays and Fridays would work, but until hockey season began, Fridays are kind of difficult at our age to get set up for Friday afternoon and then leave at six for a hockey game for three hours. [Laughs] Um, but it's - it's to the point of yes there's spontaneity. It depends on, okay do the grandkids need us? You know, we try to do it twice a week. Uh, right now we got, let's see, it was Tuesday of this week. Oh. And on my birthday a week ago. Yes. We timed that perfectly.

BOB: Yes. Happy birthday.

JOANNE: A week ago. Yes. 

BOB: If she had said no, at any point prior to that surgery, I would have never done it, period. End of statement. 

JOANNE: The night before the surgery, he turns to me and said, number one, are you with me for future sex? Are you with me for the surgery? And I said yes on both because it’s just part of the journey.

BOB: It, it makes, it makes stuff a hell of a lot easier if you work together. And, and that's, that's where we're at right now and it makes it fun.

JOANNE: You don't have problems, Dale Carnegie says, you have situations you work through. And that work through is what we do in this marriage.

Okay, I love that quote. But a quick fact check here. We actually couldn’t find evidence that Dale Carnegie actually said those words. We asked Joanne about it and she said that Bob took a Dale Carnegie sales workshop in the ‘80s… and told us she might just be remembering the gist of one of his textbooks. At any rate… they had that idea in their back pocket when Bob entered the Viagra trials in the ‘90s.

AS: You, you got to sample Viagra before it was out in the wide broad marketplace and see what, how it would affect your intimate life. And then it becomes this cultural phenomenon where it's all anybody's talking about. Uh, all of a sudden erectile dysfunction is a term that people know.

BOB: Yes.

AS: Um, what did you make of that? All of a sudden this thing that had been secret within your, within your bedroom was now something that was much more open in the culture.

BOB: Well from, from a cultural standpoint, of course, we were very much into NASCAR. And of course, you know, there was one driver that had a whole car that had, you know, the blue pill on it. You know, I kind of took it as well, it's an awakening. Okay? Um, and guys are starting to talk about it, to think about it, instead of just accepting it. They, they were finally talking to their doctors. Like the old commercial, you know, talk to your doctor about Viagra. 

VIAGRA COMMERCIAL: Talk to your doctor about Viagra today. [NASCAR SOUNDS]

On the next episode of Hard… we’re going back to that time when Viagra entered the public consciousness… 

DOROTHY WETZEL: Viagra was going to be the first drug that was going to put Pfizer on the map.

Viagra was approved by the FDA in 1998… just a year after the FDA started allowing prescription drug companies to market directly to consumers. 

DW: You want better sex? Viagra’s a way to have better sex. 

DR. IRWIN GOLDSTEIN: Our phones did not stop ringing,

DR. CAROL BENNETT: They’d come to the urologist, they’d heard the urologist might have something that might help them.

In the next episode, we talk about the collision of medicine… science… money… and marketing… that created a Viagra explosion. 

DR. DAVID BROWN: He basically said you've wasted money for eight years, David.

DW: Was this going to be so offensive to people?

CB: It was exciting. I'd have to say.

IG: He says the words, "Oh, hell." In a British sort of accent. And takes his pants down in front of freaking everybody. And he had this massive erection.

This series was conceived, reported and produced by Katie Bishop. The original music in this series was composed by engineer Andrew Dunn with additional help from Rachel Han. The rest of our team includes Afi Yellow-Duke and Emily Botein. Special thanks to Caitlin Pierce and Alex Barron. Our intern is Gabriela Santana.

Look out for episode two in our series next week. Subscribe to Death, Sex & Money so you don't miss it.

I’m Anna Sale… and this is Death, Sex & Money from WNYC.