Colby was in his 20s — far too young, according to some, to struggle with this particular thing — when he noticed an issue: When he wanted to get intimate, he couldn’t stay hard.
The now-33-year-old, who, like everyone else in this story, asked Vox not to publish their last name so he could speak more openly about his sex life, was unsure if his issues were truly physical or if they stemmed from something else. He saw a doctor who did some blood work — his testosterone levels, while still normal, were slightly low. A specialist put him on testosterone, but Colby was concerned about negative long-term side effects, and eventually wanted to try something else: Viagra.
His doctor wasn’t so sure. You’re only 28. We don’t think you need it, Colby remembered his doctor telling him. But if you want to try it and see how it works for you, let us know. They wrote him a script.
When considering the stereotypical Viagra patient, the mind conjures up an image of a man decidedly older than his 20s, after all. But that picture is changing.
Why I reported this
Earlier this year, I sat in a bar with a handful of dudes in their 20s and 30s who had taken, or had friends who took, erectile dysfunction meds — drugs most commonly prescribed to men decades their senior. One 27-year-old told me the side effects of his hair loss medication impacted his ability to get an erection. The way he saw it was he’d rather have hair and need Cialis than lose his hair and get a boner with ease. I’ve been thinking about his comment ever since.
Studies vary when it comes to how many adult men under 40 seek out medications for erectile dysfunction, but some estimates are as high as 39 percent. In a major medical journal, one pediatric urology practice reported a 31-fold increase in adolescent males who experienced erectile dysfunction between 2014 and 2024. According to the urologists and the very sincere, very open men I spoke to, younger guys are taking dick pills for a multitude of reasons: genuine erectile dysfunction, sure, but also to optimize their day-to-day as well as their sex lives. The fact that these drugs are cheaper and more accessible — and less embarrassing to get — only makes them more appealing.
I, like so many women in America, have been horrified and dismayed as details surrounding some young men’s behaviors and attitudes toward women and sex became public. When reporting this story, however, I found nearly the opposite to be true: The guys I spoke with were earnest and vulnerable when it came to their struggles and their willingness to enhance their pleasure.
Urologist Amy Pearlman said there is an increased awareness that is leading more guys to seek treatment — whether or not they really need it. “A lot of the guys who come in are not coming from a place of deficiency,” she told Vox. “There is abundance.”
Colby and Viagra weren’t a perfect match, he told me. The side effects — vivid dreams, terrible headaches — turned him off. But Cialis? Why not give it a try? He’s been on it ever since.
“Do I think Cialis would be something that I’ll probably keep on hand?” Colby said. “Yeah.”
The sex lives of young people — young men, in particular — are full of contradictions. Gen Z craves sex, but is too afraid of rejection to date. Porn is easily accessible and highly consumed, but isn’t an accurate representation of real sexual encounters. The female orgasm gap persists. Young men say they distrust health information shared by influencers, yet admit to trying wellness trends or self-diagnosing based on what they’ve seen online. Young women are moving further left, but 21 percent of Gen Z men think “a real woman should never initiate sex” (compared with just 7 percent of baby boomer men). More people are speaking openly about the poor state of men’s collective mental health, but the restrictive masculinity norms at the root of it are stubbornly persistent.
The increased acceptance of drugs once reserved for older men, drugs once mired in so much stigma, speaks to a culture that is awkwardly navigating these shifting expectations. Are men getting more comfortable addressing their problems directly — and finding a genuinely healthier relationship with sex? Or just finding new ways to meet the old pressure to perform?
ED pills are cheap and accessible
There has never been a better time to get into dick pills. Over the last decade, more generics have hit the market and have brought the cost way down. Sildenafil, the generic version of Viagra, was first made available in the US in 2017, and tadalafil — generic Cialis — hit the market a year later.
Around the same time, direct-to-consumer telehealth platforms like Hims, Ro (formerly Roman), and BlueChew launched, offering these drugs at an even lower cost — and all without a trip to the doctor. The typical Hims patient, per New York magazine in 2021, is a man in his 20s or 30s, keen to score generic Viagra. These websites are intentionally discreet and eliminate deeper diagnostic conversations with medical providers — for better or for worse. Customers need only answer a few simple questions before they’re offered a prescription, even if they don’t meet the diagnostic criteria for ED.
These companies offer a seductive vision: One Hims TV spot is sleekly filmed — soft lighting, young, attractive actors cuddling in the grass — and doesn’t mention the words “erectile dysfunction” once. “Searching for the simplest way to treat ED?” a nonjudgmental voiceover asks. The whole production seems to beckon young men into a warm embrace. Erectile dysfunction is passé. You are youthful, and it’s okay if you struggle to stay hard. Good-looking people, like you, discreetly shop for health treatments online. These medications aren’t just about sex; they’re for your health. They are for you.
And that means that more men are asking their doctors for them, too.
Pearlman, the Florida urologist, told me that she treats many men under 40 — and even some teenagers — who just want “to make it a little easier to get erections when they want them.”
“The reality is there’s nothing wrong with optimizing,” she said. “I don’t need a patient to plead their case that they’re suffering…to warrant a medication that I would consider to be one of the safest medications ever available to people. And what a blessing it is that it’s so accessible and cost-effective and has so many reasons that it could help people.”
Young men may also be pill-curious simply because the meds are hard to avoid. Unregulated sexual performance “supplements” that promise increased stamina but may just actually be massive doses of bootleg Viagra or Cialis laced with printer ink or drywall have lurked in plexiglass cases in the gas station, but many men — reasonably — were perhaps too scared or embarrassed to buy them. Now, though, higher-quality options are everywhere. Direct-to-consumer platforms like Hims have funneled millions of dollars into advertising — on subways, television, and podcasts — on the one hand, helping to destigmatize and normalize men’s sexual health, and on the other, perhaps nudging suggestible young people into thinking they have a problem.
The growing interest in dick pills speaks to Hims’ megaphone in particular. “I do think that the power and talent, just in terms of marketing and communications, and the budget of a company like Hims for getting the word out and educating the public about a medical condition dramatically dwarfs the marketing talent, the budgets, and communication abilities of conventional private practices, health systems,” Peter Stahl, senior vice president of men’s sexual health and urology at Hims & Hers, told Vox.
Once ED becomes fodder for commercial breaks on your favorite TV shows and podcasts, you might not consider the medication out of the realm of possibility for you.
Some doctors see these telehealth sites as a net benefit given that they bring more men into the healthcare system. As children, both boys and girls commonly visit a pediatrician, but once they become adults, women are more likely to regularly visit their primary care physician or their OB-GYN.
Telehealth offers a third option besides googling symptoms or going to a doctor’s office. Online healthcare is “now the gateway to men’s health where people — at a superficial level — get to learn about how these medications help them, but they don’t know why,” said Justin Dubin, a urologist and director of men’s sexual health at Baptist Health South Florida. Dubin sees this as a net positive, he told Vox. If men are asking questions about their boners — Why are these pills so effective? What’s going on with my body? — and it gets more guys to the doctor, that’s a good thing.
The side effect effect
Since being diagnosed with depression and PTSD a few years ago, 31-year-old Alexander (a pseudonym) cycled through a series of antidepressants until he finally found one that helped him. Mentally, he was feeling better, but his sex drive took a nosedive, a common side effect of some SSRIs. His doctor prescribed Viagra.
About one in six American adults take antidepressants, which are among the most prescribed medications in the country. Depending on the drug, anywhere from 20 percent to 70 percent of people taking an antidepressant reported sexual dysfunction. Other medications particularly popular among young men, like those treating hair loss, have also been linked to lower libido and an inability to get hard.
Ironically, the same direct-to-consumer platforms selling erectile dysfunction medications also prescribe antidepressants and hair loss treatments — the very drugs that cause ED. “I think it is notable that the same companies are marketing those two drugs together,” Kristen Mark, a professor and the director of the Eli Coleman Institute for Sexual and Gender Health at the University of Minnesota Medical School, told Vox.
Another man, 35-year-old Tristan, was prescribed an ADHD medication in his late 20s, which he said made it hard for him to get an erection. Since then, he’s taken Cialis daily, and it’s not only benefited his sex life, but his overall mood, too. “I have a much better pump at the gym,” he told me. “I would be really bummed if there was some medical reason later on in life that I had to stop taking it,” he said. He plans on taking it for the rest of his life.
The anxious generation
For many young men, the issue may not be physical at all, but mental. Unlike older patients — who are generally more likely to have ED — whose impotence stems from high blood pressure, obesity, diabetes, and high cholesterol, younger men’s issues in the bedroom tend to stem from anxiety and depression.
The sense that there’s pressure to perform is giving more men anxiety. “We see that far and above any other reason, ED is diagnosed in younger populations because of performance anxiety,” Mark said. They may not have any underlying health conditions preventing them from getting an erection, but young guys can get in their heads with new partners, especially if there are any lingering negative feelings from a bad breakup, past trauma, or heightened stress and anxiety.
Charles Welliver, director of men’s health and an associate professor of urology at Albany Medical Center, finds his younger patients’ mental block typically stems from a specific event, like the end of a relationship. He’ll prescribe them Viagra to help them regain confidence, he said, a little nudge to get back out there. While he notes there’s little evidence these medications can cause physical dependence, men may become mentally reliant on them. “Psychological dependence is a different situation where guys think they need it to perform,” Welliver told Vox.
Inexperienced and perhaps operating under the unrealistic expectation that they must perform like the guys they’ve seen in porn, some of young men’s formative sexual experiences may be thwarted by fear or latent misogyny.
“It’s an age-old story you can see in movies or TV of the guy that’s a young teenager and trying so hard to perform for the pretty girl, and then it just doesn’t happen,” Colby said. As teens and 20-somethings forge their sexual identities, their views are shaped by the content they consume online and the experiences of their peers. If their favorite podcaster is touting a supplement likening an erection to a flagpost, they might suspect they’re lacking in some way, should they get nervous during a first sexual encounter, despite it being incredibly normal and common. Using medication as a mask of masculinity in lieu of addressing deeper insecurities may prevent young men from developing intimacy.
“This performance anxiety piece is certainly not going to be solved by just continuing to take Cialis or Viagra,” Mark said. “They need better coping mechanisms for addressing that anxiety in the moment, and they’re not getting any of that by just taking a drug.”
Some of those self-soothing strategies, according to Mark, include remaining present, feeling connected to your partner, and taking a break if you’re too in your head. It’s important to understand where the performance anxiety is coming from. “Think about what is it about this setting that I am here for? Why am I doing this?” Mark said. “Focus in on how that feels for you, rather than just pressing on.”
These conversations and practices are decidedly less likely in the context of casual sex. The familiarity and comfortability to discuss your sex life is among the many virtues of long-term relationships. Few men would consider pausing a hookup to interrogate their emotional hang-ups. Popping a pill is easier than talking to your situationship about your nerves. It’s hard to stay in the moment and relax when you’re thinking about how the stranger in your bedroom is judging you or will reject you outright if you can’t perform.
These anxieties may simply be a product of youth, something to outgrow with time and wisdom and experience. Vulnerable conversations about sex can be less taboo among friends and within couples as you age; there comes a realization that porn isn’t real, that sex doesn’t necessarily mean penetration, and that the other person’s (or people’s) pleasure is probably more important than your own.
Ultimately, ED pills will only go so far if the problem is in your head. Colby, the 33-year-old who was prescribed Viagra and Cialis, said he once had a hookup tell him to drive her home because he couldn’t get hard. “You can take all the medication that you want, but if you’re mentally not in a relaxed state, medication’s not going to do shit for you,” he said.
The quest for optimization
Sometimes the desire for dick pills doesn’t stem from lack or insecurity or a side effect, but simply to get, and give, more of a good thing.
In the biohacking corners of the internet, Cialis is touted as an effective pre-workout supplement, giving men like Tristan, the 35-year-old who takes it to offset his ADHD medication’s side effects, a temporary boost in muscle swelling after a lift. “It is improving blood flow throughout your body, and that’s why you’re seeing the benefits,” Dubin, the Baptist Health doctor, said. “That’s why many men say that they do get a better pump at the gym, they feel a little bit better.” (The good news for frequent and off-label users of ED medications is that doctors said they are safe for prolonged use in men without cardiovascular disease and are difficult to misuse.)
In the endless pursuit of masculine self-optimization, testosterone replacement therapy has become a trendy touchpoint, something of a catchall for overall enhancement. Research has shown TRT does have some benefits: the treatment has been shown in research to improve vascular function, mood, muscle strength, bone density, and sexual function in healthy men. According to doctors, some patients come in either associating their ED with low testosterone or are concerned their levels are low. But low testosterone isn’t always a contributor to ED, Raevti Bole, director of the Center for Male Fertility at the Cleveland Clinic, told Vox — which means taking T might not do anything for erections. With that in mind, doctors are much more likely to prescribe an ED drug to younger men than to put them on testosterone.
Maybe you don’t care about T, your mental health is fine, and you just want to get the most out of sex. Every now and then, when the mood strikes him, 39-year-old Jake attends a sex party. “Straight guys have fantasy football leagues,” he told Vox. “Gay guys fulfill their fantasies at regular scheduled orgies.” If he paid to get in, which he often does, he wants to maximize his time, money, and enjoyment. So he asked his doctor for a little assistance — not that he needed it. He just wanted an enhancement. Jake was prescribed three months’ worth of Cialis. “You can always walk,” he said, “but it’s more fun to fly.”
Jake only needed a handful of pills for his recreational use, and now, suddenly, he was flush with Cialis. He certainly wasn’t going to use them all, so, rather than let them go to waste, he decided to spread the wealth. “I’ve been handing them out to straight men supportively to be like, we can talk about your life. It’s so fine if you need this,” Jake said. He’s given pills to baristas, coworkers, and patrons at the bar where he works. (A note: sharing prescription medication, including Viagra and Cialis, is illegal and can be dangerous, especially if the recipient has underlying health issues or takes other drugs that interfere.) If he can, in some small way, spark a conversation about intimacy, about common biological experiences, that’s a win. If he could facilitate a fun, sexy time, even better.
If some men don’t feel quite ready to have earnest conversations about their sex lives, maybe they need a wink and a nudge from someone like Jake.
But perhaps more than anything, maybe young men could use a reminder that they don’t need the stamina of a porn star or to be expected to perform at a moment’s notice. A reminder they can be vulnerable and masculine, anxious and deserving of intimacy. With age and a willingness to be open with their partners, they may come to discover they don’t actually have erectile dysfunction; they just get nervous with a new partner, or they don’t actually feel like having sex after a stressful day at work. You know, normal parts of the human experience that don’t necessarily need to be pathologized or cured. In fact, it could be empowering.
It’s a balance Jake is still navigating himself. As he approaches his 40s, casual sex is losing its luster. Hookups aren’t like they were in his 20s when he could perform regardless of whether he found the person attractive. “Now, my emotions are getting in the way, which I think isn’t wrong,” Jake said. Sure, Cialis helps move things along, but to what end?
“Maybe I should be asking myself, ‘Jake, are you doing this more for him than for you?’” he said. “Are you fulfilling other people’s desires more than you’re fulfilling your own?”
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