Speaker 1: Courage, something shared by countless Americans, those that risked their lives,
Speaker 1: those that battle serious illness. When I was diagnosed with cancer,
Speaker 1: I was primarily concerned with ridding myself of the cancer,
Speaker 1: but secondly, I was concerned about post operative side effects
Speaker 1: like a rectile dysfunction ED, often called impotence. You know,
Speaker 1: it's a little embarrassing to talk about ED, but it's
Speaker 1: so important to millions of men and their partners that
Speaker 1: I decided to talk about it publicly. And after all,
Speaker 1: it can be associated with many conditions, including prostate surgery,
Speaker 1: high blood pressure, diabetes, or even smoking. The point I
Speaker 1: want to make is that there are many treatments available
Speaker 1: for ED, so my advice is to get a medical checkup.
Speaker 1: It's the best way to get educated about ED and
Speaker 1: what can be done to treat it. It may take
Speaker 1: a little courage, but I've always found that everything worthwhile does.
Speaker 2: I mean, none of it was wrong.
Speaker 1: I love it. It's because it sounds more like a
Speaker 1: p s A than an advertisement. It does.
Speaker 2: It totally sounds like I mean, they don't even say
Speaker 2: the name of the medicine, right, but it's very under
Speaker 2: the radar.
Speaker 1: Uh huh. So that was from the infamous, really historic
Speaker 1: Bob Dole commercial from nineteen ninety eight. Bob Dol, Bob Dol.
Speaker 2: Bob Dol. Do you know that was one of my
Speaker 2: brother's first words.
Speaker 1: Was he born near like in the year leading up
Speaker 1: to a presidential election or what? I don't know.
Speaker 2: I just remember during the presidential election. I'm pretty sure
Speaker 2: it was my youngest brother. It might have not even
Speaker 2: been him, but sitting there saying Bob Dol, Bob Dol,
Speaker 2: Bob dol, So it could him been the one who
Speaker 2: was nineteen ninety I don't know.
Speaker 1: That's someone who's watching too much TV and too many
Speaker 1: political commercials, right.
Speaker 2: Bob Dohl, Bob Dol, Bob Dol. Anyways?
Speaker 1: Oh yeah, yes, Well, Hi, I'm Aaron.
Speaker 2: Welsh, and I'm Aaron on an update and this.
Speaker 1: Is this podcast will Kill You.
Speaker 2: And today we're talking about viagra. We are can we
Speaker 2: say trade names? We're talking about Sildena, Phil, We're.
Speaker 1: Talking about I mean, my part is mostly about biagra.
Speaker 1: Period Biographs is also not the first trade name that
Speaker 1: we would have said on this podcast.
Speaker 2: Launched the Whole Allergies episode talking about EpiPens, like.
Speaker 1: Yeah, exactly, epineph and auto injectors. Right, too much to
Speaker 1: say any episode, it's gonna be a great episode. I
Speaker 1: am so excited for this one. There's just it's a
Speaker 1: it's a rich topic. Yeah, who knew? Who knew?
Speaker 2: Yeah?
Speaker 1: We should have? We did, we did, they did, That's
Speaker 1: why we picked it. Yeah, but before we get into
Speaker 1: all of that, Aaron, what time is it? It's quarantin
Speaker 1: any time it is? And what are we drinking this week?
Speaker 2: Nothing other than little Blue pills? Yep, it makes sense.
Speaker 1: It makes sense. Pills, p I L s just one
Speaker 1: L just because because it's beer. It's a beer drink.
Speaker 1: It's a pill drink even and lemonade and blue curse out.
Speaker 2: Sorry sorry, but not that sorry, because it clever.
Speaker 1: I mean, we had to do the name and then
Speaker 1: the recipe was based on that, and so there you go.
Speaker 2: Enjoy it or don't. Yeah, anyways, you'll find the full
Speaker 2: recipe so you can decide for yourself for that quarantine
Speaker 2: and the non alcoholic. We'll do it plusy Brita on
Speaker 2: our website This podcast will kill You dot com and
Speaker 2: on all of our social media channels.
Speaker 1: And on our website you can find all sorts of goodies,
Speaker 1: including button not limited to transcripts, links to our bookshop
Speaker 1: dot org affiliate account, our goodreads lists, music by Bloodmobile,
Speaker 1: links to a first hand account, form, a contact us form,
Speaker 1: so many forms so show notes, Patreon, merch merar, repin'
Speaker 1: the shirt and our new shirt today which I just
Speaker 1: am still in love with so much so and other things.
Speaker 1: Check out our website. This podcast will kill you dot com.
Speaker 2: If you haven't already, please remember to rate, review, and
Speaker 2: subscribe on whatever podcaster you like to listen to so
Speaker 2: that you don't miss our new episodes, and because it
Speaker 2: helps us get up in the charts, which helps new
Speaker 2: listeners find our podcast. So thanks, we appreciate it.
Speaker 1: Aaron, can we get started? We can today's topic.
Speaker 2: Right after a short break.
Speaker 1: Still.
Speaker 2: Dentaphil is the medicine that we're talking about today, and
Speaker 2: it is of course most famous for its use as
Speaker 2: a treatment for erectile dysfunction under the trade name viagra,
Speaker 2: but that is not its only use, so I want
Speaker 2: to give credit up front that this is also an
Speaker 2: important medication that is used for the treatment of things
Speaker 2: like pulmonary hypertension in both adults but also tiny babies.
Speaker 2: Off label use, and that's a condition where the pressure
Speaker 2: in your blood vessels and your lungs is too high
Speaker 2: and it can make it really difficult to breathe. In babies,
Speaker 2: this is often because they're born premature. But I'm saying
Speaker 2: that now because that's mostly the last time I'm going
Speaker 2: to talk about it, because its use in other contexts
Speaker 2: is really overshadowed, of course by its fame as viagra.
Speaker 2: So to understand the use of this medication in the
Speaker 2: treatment of a rectile dysfunction, we have to start by
Speaker 2: talking about erections. What are they, how do they work,
Speaker 2: what is happening when they don't work, and why does
Speaker 2: viagra help?
Speaker 1: So we all love the questions that we should be
Speaker 1: asking exactly.
Speaker 2: There is the potential, as evidenced by multiple like twenty
Speaker 2: to fifty page papers on the detailed biochemical reactions and
Speaker 2: the neurobiology and endocrinology of what's happening in a penile erection.
Speaker 2: There's the potential to go into way too much detail,
Speaker 2: But for this episode I will link to all of
Speaker 2: those papers so people who want to dig deep can
Speaker 2: What we need to understand is really the broad strokes
Speaker 2: of what an erection is a penile erection is the
Speaker 2: end result of a pretty complex neurovascular process, which means
Speaker 2: that it involves a real web of our peripheral nerves
Speaker 2: as well as our brain and spinal cord. It involves
Speaker 2: both sensory and motor nerves, and both are sympathetic and parasympathetic,
Speaker 2: so those autonomic nervous systems. It coordinates through tactile, auditory, visual,
Speaker 2: and other stimuli, and involves a pretty wide range of
Speaker 2: neurotransmitters as well as hormones. And all of this has
Speaker 2: to coordinate with our vascular system, which is what deals
Speaker 2: with blood flow in and blood flow out. And we
Speaker 2: don't have to get deep deep into the details to
Speaker 2: understand how this works and how viagrass soldeniphil can affect
Speaker 2: this process, but we do need to understand the anatomy
Speaker 2: of a penis. So anatomically, the penis has some pretty
Speaker 2: specialized tissue creatively called a rectile tissue. Wow, okay, I know,
Speaker 2: such creative naming. So if you were to look at
Speaker 2: the interior of a penis, like in cross section, to me,
Speaker 2: it kind of looks like a fly with like an
Speaker 2: open mouth, going like ooh, okay, because like imagine a fly,
Speaker 2: a big fly eyes, but then they have like a
Speaker 2: human mouth going like, oh my.
Speaker 1: Gosh, I don't like that image, but continue, but it's
Speaker 1: in your brain now.
Speaker 2: So in cross section, it has these two big round
Speaker 2: almost really they're like tubes that are full of this
Speaker 2: spongy type of tissue that's called the corpora cavernosa.
Speaker 1: And each of these.
Speaker 2: Corpora cavernosa has an artery that flows through the center,
Speaker 2: and then these two sponges are surrounded by a pretty
Speaker 2: dense fibrous tissue that forms a sheath like a sword
Speaker 2: with a sheath. Right, it's a firm area, and that
Speaker 2: is what looks like the fly eyes, like this pair
Speaker 2: of big wide eyes. And then beneath that, like on
Speaker 2: the dorsal underside of that, if you're looking at a
Speaker 2: cross section, there's another tissue, spongy tissue tube called the
Speaker 2: corpus spongiosum, and inside this tube is the urethru where
Speaker 2: pa is going to come out as well as ejaculate
Speaker 2: is going to come out, and that's what looks like
Speaker 2: the mouth of the fly. This is surrounded by a thinner,
Speaker 2: fibrous sheath of tissue and then the whole thing is
Speaker 2: surrounded by a lot of different smooth muscle, not skeletal muscle,
Speaker 2: but smooth muscle.
Speaker 1: So just like a lot of different types of tissue
Speaker 1: all laggered together.
Speaker 2: A lot of different types of tissue in these three
Speaker 2: pockets of spongy area, okay, with a lot of smooth
Speaker 2: muscle tissue all up in there. And smooth muscle is
Speaker 2: the type of muscle that we have all of our bodies.
Speaker 2: It's what surrounds our arteries or is part of our arteries.
Speaker 2: It's what's in all of our internal organs, except for
Speaker 2: our heart, which has its own specialized kind of muscle.
Speaker 2: But unlike most other smooth muscle in our bodies, the
Speaker 2: smooth muscle that surrounds the corpora cavernosa in the penis
Speaker 2: is tonic contracted, which means that it's always a little
Speaker 2: bit though not one hundred percent completely, but it's a
Speaker 2: little bit clamped down contracted, rather than relaxed. And what
Speaker 2: that does is it allows for only enough blood flow
Speaker 2: through to keep the tissues of the penis healthy without
Speaker 2: allowing too much blood in. So what happens in an
Speaker 2: erection through again this complex series of neurotransmitters, hormones, blah
Speaker 2: blah blah. Is that this smooth muscle starts to relax
Speaker 2: and that causes the dilation of those arteries in the
Speaker 2: corpus cavernosa in those flies eyes, and that allows for
Speaker 2: increased blood flow. That blood flows out of the arteries
Speaker 2: into those tissues and fills up all of this spongy
Speaker 2: potential space. These are called sinusoids, and they're basically like
Speaker 2: chambers in those spongy tissues. And as those tissues begin
Speaker 2: to expand, they actually compress the veins in the penis,
Speaker 2: which are all located outside of that fascial tissue or
Speaker 2: in between layers of fashion, but outside of those sponges.
Speaker 1: So it's like let more blood in and prevent blood
Speaker 1: from leaving.
Speaker 2: Exactly exactly, and that traps the blood in those sinusoids
Speaker 2: in the sponge you have very little venus outflow. And
Speaker 2: the more that that process continues through this kind of
Speaker 2: positive feedback loop, then eventually you have a really significant
Speaker 2: increase in the pressure inside of the penis, and then
Speaker 2: you have a contraction of nearby muscles called the issio
Speaker 2: cavernosis muscles, and these are muscles like in the pelvic floor,
Speaker 2: not smooth muscles, but skeletal muscles, and that provides a
Speaker 2: further rigidity, so you have that's how you end up
Speaker 2: with the rigidity of an erection. Does that make sense? Yeah,
Speaker 2: that's it. That's all it is, right. I can make
Speaker 2: it as simple as.
Speaker 1: That more blood in, less blood out erection.
Speaker 2: Erection, and to do that you first need a relaxation
Speaker 2: of that smooth muscle. So then if we understand that,
Speaker 2: then we can understand that there's a lot of ways
Speaker 2: that this process could go wrong, and that end result
Speaker 2: is called a rectile dysfunction. And for this I'm going
Speaker 2: to just rely on nih definitions limited though they may be.
Speaker 2: A rectile dysfunction is the condition in which somebody cannot
Speaker 2: either achieve or maintain an erection that is firm enough
Speaker 2: for a satisfactory sexual experience. That's the literal definition. And
Speaker 2: there isn't one underlying cause of a rectile dysfunction. Erectile
Speaker 2: dysfunction is an end result, right, It's as satisfying sexual
Speaker 2: ability or the inability to have this satisfying sexual experience
Speaker 2: because the erection is not as firm as either it
Speaker 2: used to be or as you want it to be.
Speaker 2: Now again, there's limitations to this, and one thing that
Speaker 2: I'm not probably doing a good enough job in this
Speaker 2: whole episode is going into the nuances of how we
Speaker 2: define sexual health in general, right, or.
Speaker 1: What is the satisfactory sexual experience exactly? Right?
Speaker 2: Yeah, yeah, yeah, right, So like that is that is
Speaker 2: beyond the scope of this. But if we're sticking with
Speaker 2: this definition, then what we're looking at really is that
Speaker 2: erection itself. And there's a lot of different things that
Speaker 2: can end up causing a rectile dysfunction or a lot
Speaker 2: of different risk factors that end up relating to this.
Speaker 1: Right.
Speaker 2: There are of course psychosocial issues, like we said, like
Speaker 2: what is healthy sexual function? What does it mean to
Speaker 2: that individual? What's considered disorder? But you accept that I've
Speaker 2: got a disorder or I feel like there's a disorder.
Speaker 2: There's a lot of different things that can end up
Speaker 2: causing this. There's things like neurologic issues, whether that's a
Speaker 2: spinal cord injury or peripheral nerve damage or either like
Speaker 2: demielinating disease like MS or a whole host of other
Speaker 2: chronic diseases that can cause nerve issues. There's also endocrine
Speaker 2: issues like low levels of testosterone. There's also vascular issues,
Speaker 2: and vascular issues likely account for the majority of a
Speaker 2: rectile dysfunction, though it's a little hard to get great
Speaker 2: stats on this, but a lot of papers estimate like
Speaker 2: seventy percent or so. And vascular disease is not one thing, right,
Speaker 2: There's a whole bunch of risk factors that lead to
Speaker 2: vascular disease that can lead to a rectile dysfunction. Diabetes,
Speaker 2: high blood pressure, high cholesterol. All of these affect the
Speaker 2: lining of our blood vessels, which is going to affect
Speaker 2: blood flow, which is necessary for an erection. Aging in
Speaker 2: general causes oxidative stress and endothelial dysfunction, and then of
Speaker 2: course the hospital can do it to you, which it
Speaker 2: sounds like was what happened in our first hand account
Speaker 2: because someone had treatment for cancer.
Speaker 1: I was like, what do you mean.
Speaker 2: Treatment for something like prostate cancer or other operations or
Speaker 2: medications that can sometimes cause erect how dysfunction?
Speaker 1: Okay, Aaron, real quick, age? Why Like, I know you
Speaker 1: mentioned oxidative stress blah blah blah, but like, why what
Speaker 1: is the aging? Why does the aging process lead to
Speaker 1: higher rates of ED? Aaron This is.
Speaker 2: A question that made like I already was, I wondered this,
Speaker 2: but looking at the statistics, I wonder even more because okay,
Speaker 2: this is jumping ahead. But statistically people say that anywhere
Speaker 2: from like fifty to one hundred percent of people with
Speaker 2: a penis over age seventy have a rectile dysfunction. Okay, again,
Speaker 2: meaning that they're not having a satisfying sexual experience because
Speaker 2: they're not able to achieve or maintain an erection.
Speaker 1: Which real quick again, does that definition include frequency? Is
Speaker 1: that every time? Is that just once in a month?
Speaker 1: Is that once in a week? Like, it doesn't include
Speaker 1: any of that? It doesn't matter, right because it is subjective.
Speaker 1: It is it is a subjective experience that is meeting
Speaker 1: criteria for this dysfunction or disorder. Right, it's giving me
Speaker 1: menopause vibes.
Speaker 2: Where we're calling this a disorder because it is causing
Speaker 2: impact on your life, which is valid, But is it
Speaker 2: a disorder like evolutionarily? Maybe not?
Speaker 1: Right, I don't wait for it, just wait for it.
Speaker 1: There's more where that came from. We'll get you to it.
Speaker 2: I can imagine, because again it is very individual, like
Speaker 2: what is the satisy finding sexual experience for one person
Speaker 2: is not the same as for another person. For some people,
Speaker 2: it might not even include an erection, it might not
Speaker 2: even include orgasm. Like, there's so much nuance to this.
Speaker 1: What's the end goal here for Yeah, exact fixing, fixing, this, fixing, fixing.
Speaker 2: This, fixing, this and this in the case of erectile dysfunction,
Speaker 2: is just the firmness of the erection.
Speaker 1: But there is a real relationship between age and ED.
Speaker 1: So what is going on mechanistically? Like, what is the
Speaker 1: basis for this physiologically?
Speaker 2: Great question. I don't have a one single answer for you.
Speaker 2: I don't have like an aging equals this. There's a lot.
Speaker 2: There's the fact that as we age, all of those
Speaker 2: other risk factors go up. Cholesterol goes up, blood pressure
Speaker 2: goes up, the rates of diabetes go up. Aging also,
Speaker 2: like I said, already is thought to be independently associated
Speaker 2: with things that end up causing endothelial dysfunction, which is
Speaker 2: blood vessel dysfunction. Is it just that there's a lot
Speaker 2: of different factors. I don't think that there's one thing
Speaker 2: that aging causes that leads directly to a rectile dysfunction.
Speaker 2: I think it's a whole host of issues.
Speaker 1: I just have so many questions, but keep going.
Speaker 2: I don't know that I'm going to answer any of
Speaker 2: your questions. But out of all the different things, be
Speaker 2: they neurogenic, be they vascular, be they psychological, be they hormonal,
Speaker 2: Very often the first thing that is used for treatment
Speaker 2: is one thing, and that is viagra. So, no matter
Speaker 2: the cause, that's not usually investigated, first thing, often not
Speaker 2: even second thing, the treatment is a blanket viagra for
Speaker 2: all your woes.
Speaker 1: And so what percentage of cases of ED does viagra
Speaker 1: actually help with?
Speaker 2: Most papers I read estimated sixty to seventy percent.
Speaker 1: Wow, okay, it's pretty high.
Speaker 2: It's pretty high. Why is that? How does it work?
Speaker 2: Let me tell you, sildentiphyl viagra. It's a phosphodiesterase or
Speaker 2: PDE inhibitor. What does that mean. PDE is an enzyme.
Speaker 2: It's not one enzyme. It's a whole group of enzymes.
Speaker 2: And these enzymes are present on a whole bunch of
Speaker 2: our tissues throughout our bodies. But there's one in particular
Speaker 2: that viagra is very strongly like. It really only works
Speaker 2: on this one type of phosphodiastorse called PDE five and
Speaker 2: this particular phosphodiasterorate enzyme happens to be present in very
Speaker 2: high concentration in the corpus cavernosum of the penis. That's
Speaker 2: spongy tissue that's responsible for the majority really of an erection.
Speaker 2: So through this again very complicated series of biochemistry, the
Speaker 2: end result of blocking PDE five, which is what sildentiphil
Speaker 2: and other similar drugs do, It blocks the action of
Speaker 2: this enzyme and that results in this cascade of events
Speaker 2: that causes increased relaxation of that smooth muscle, So that
Speaker 2: allows for blood flow into the corpus cavernosum to start,
Speaker 2: and that allows the further steps of an erection to
Speaker 2: take place. That whole cascade of things can happen if
Speaker 2: you have relaxation of that smooth muscle and increased blood
Speaker 2: flow m H. And that's that's it. It can be
Speaker 2: as simple as that.
Speaker 1: What about other ed drugs.
Speaker 2: So Cialis is the trade name for tadalaphil, which you
Speaker 2: can tell by the A fill at the end that
Speaker 2: it's the same type of medication. It has like a
Speaker 2: different half life and blah blah blah, but it's still
Speaker 2: a PDE five inhibitor. So it acts in the same way.
Speaker 2: And there's a few other drugs that are really similar,
Speaker 2: just like different versions essentially but acting on the same
Speaker 2: end time. So all of those work in a very
Speaker 2: similar way. There are other medicines that are used. Some
Speaker 2: of them are like injectable medicines that you inject directly
Speaker 2: into the penis. Some of them are you can put
Speaker 2: them in other ways. A lot of them still like
Speaker 2: predominantly we target this phosphodiestors pathway. The other ones might
Speaker 2: target different PDEs, so PDE one instead of five or whatever,
Speaker 2: but that's predominantly what they're doing is targeting this pathway.
Speaker 1: Aaron, you said injectibles, and then you said and then
Speaker 1: put them in in other ways and you just try
Speaker 1: to skape right by that. Can you go back to that.
Speaker 2: It wasn't that exciting of other ways? I just mean
Speaker 2: like sublingual orkay, yeah, injectable. I don't think that there
Speaker 2: are any that are just topical though, I think that
Speaker 2: that's been tried. Yeah, Okay, not that exciting. So yeah,
Speaker 2: that I mean that that is honestly, that's the that's
Speaker 2: the basis of it. That's how viagra works, and that's
Speaker 2: why it works. Interestingly, sildeniphil still requires the initial steps
Speaker 2: of erection, which includes sexual arousal, so you still need
Speaker 2: first this neurologic input.
Speaker 1: Before you get.
Speaker 2: That relaxation of the smooth muscle from sildentophil, because it's
Speaker 2: not like direct. The way that it happens is like
Speaker 2: the build up of certain like precursors and then the
Speaker 2: blocking of calcium and blah blah blah. So sildenophil itself,
Speaker 2: viagra itself does not cause an erection. It also doesn't
Speaker 2: affect libido or sexual desire. All it does is allow
Speaker 2: for increased blood flow so that in the context of
Speaker 2: an erection it can be firmer and or lasts longer.
Speaker 1: Just opens the blood floodgates but waits for the signal
Speaker 1: from yeah.
Speaker 2: It like it makes the floodgates easier to open. It
Speaker 2: allows for there to just be like a gentle push
Speaker 2: instead of like a big shove like of a heavy door.
Speaker 1: Okay, So I have a bunch of questions. Okay, all right,
Speaker 1: you always see her on the commercials. If you have
Speaker 1: an erection lasting longer than four hours, et cetera, seek
Speaker 1: medical criapism. Right, Why is that happening. And second to
Speaker 1: that is kind of similar to that is like, what
Speaker 1: are some of the other side effects that we see
Speaker 1: with use of sildentophil and why do we see those things?
Speaker 2: Great question. So, of course any medicine has the risk
Speaker 2: of side effects. Most common side effects with viagara are
Speaker 2: things like headache or flushing. You can have some dizziness
Speaker 2: or like stomach upset, also, weirdly, nasal congestion. I don't
Speaker 2: actually know why that one happens. Most of these have
Speaker 2: to do with the fact that because this is acting
Speaker 2: on smooth muscle, and while it is specific to PDE
Speaker 2: five and that is mostly found in the penal tissues,
Speaker 2: it's also found in some other places. So this can
Speaker 2: cause relaxation of smooth muscle other places and then potentially
Speaker 2: drop your blood pressure and that might trigger some of
Speaker 2: these other symptoms. Really importantly, we see this happen if
Speaker 2: somebody is also taking a medicine that has nitrites in it,
Speaker 2: like nitroglycerin, which someone might take if they have angina,
Speaker 2: or like that pain in their chest that's from their
Speaker 2: heart having blockage. Basically, if viagra and a nitrite is
Speaker 2: taken together, these drugs actually interact with each other and
Speaker 2: then cause really severe drops in blood pressure, like potentially deadly,
Speaker 2: really problematic to take these two medicines together. Otherwise, viagra
Speaker 2: and similar medications are actually pretty safe most all the time.
Speaker 2: When priapism happens, so that like prolonged direction, that can
Speaker 2: be very dangerous because again with an erection, you're having
Speaker 2: a lot of blood flow through the arteries into the
Speaker 2: penis and very little blood outflow, so that pressure can
Speaker 2: really build up and end up. If it lasts for
Speaker 2: too long and you don't have enough blood outflow, you
Speaker 2: can increase the pressure so much that you can start
Speaker 2: to damage tissue in the penis. So priapism is very serious.
Speaker 2: That generally only happens if somebody takes too much of
Speaker 2: this medication, Okay, at the doses that it's usually recommended.
Speaker 2: It's very very very rare to have priapism as a
Speaker 2: side effect. It's usually from doubling up on doses, or
Speaker 2: it didn't seem like it worked, so I took extra,
Speaker 2: et cetera.
Speaker 1: And how is priapism treated?
Speaker 2: A lot of times if it needs to be, it
Speaker 2: is treated by physically removing the blood from the penis
Speaker 2: with a large syringe. Any other questions.
Speaker 1: That's it. Yeah, it's not great.
Speaker 2: It's not great. There's other kind of trying to calm
Speaker 2: yourself to reduce that blood flow, because again, there's a
Speaker 2: lot of like nervous system input that's going into this.
Speaker 2: So if you can try and reverse some of that psychologically,
Speaker 2: sometimes that can help a lot with making that direction
Speaker 2: D two mess.
Speaker 1: This is called how do you just be like, Okay,
Speaker 1: don't think about this erection, don't think about this direction
Speaker 1: that I've had for three and a half hours. Like, understandably, it's.
Speaker 2: Very hard, it's very difficult to do. So, yes, so
Speaker 2: that's viagra, Erin, that's how it works. That's how you
Speaker 2: get an erection, and how you that's how it works. Erin,
Speaker 2: tell me how we figured this out. I cannot wait
Speaker 2: to hear the story, like the story of viagra.
Speaker 1: Oh, there are so many stories to tell, Erin, and
Speaker 1: I can't wait to get to them all. Right after
Speaker 1: this break, step up to the plate, let the dance begin.
Speaker 1: Love life again. This is the age of man, this
Speaker 1: is the age of viagra. And of course, lest we
Speaker 1: forget ask your doctor.
Speaker 2: Sorry your face, I cannot.
Speaker 1: Oh yeah, really trying to embody all of these commercials.
Speaker 2: You're doing such a sad job, literally such a good job.
Speaker 1: When viagra hit the market in nineteen ninety eight, it
Speaker 1: sent shockwaves around the world. Late night talk shows made
Speaker 1: countless jokes. Cultural commentators wrote article after article about how
Speaker 1: viagra would transform sex and relationships. Millions of men made
Speaker 1: long overdue appointments with their doctor. Hey, anyway you get
Speaker 1: in the door is great. Fizer counted their millions, and
Speaker 1: other drug companies got to work trying to create their
Speaker 1: own blockbuster drug. The impact that viagra has had is huge.
Speaker 1: It changed the way drugs are marketed. It contributed to
Speaker 1: the medicalization of sex. It opened up discussions about a
Speaker 1: formerly taboo subject, sex and older adults. It highlighted gender
Speaker 1: bias in drug production and insurance coverage and research. I
Speaker 1: don't think the world had seen a drug like it
Speaker 1: before in terms of how much controversy and discussion it prompted.
Speaker 1: Its release reminds me actually a lot of the chatter
Speaker 1: and hype around ozebic and related drugs, which we should
Speaker 1: really do an episode and this sort of like this
Speaker 1: will save us or this will be the end of us.
Speaker 1: Extreme perspectives like everything is so like, whoa, this is
Speaker 1: the end of relationships. Oh, this is the age of
Speaker 1: a new era, you know, like that kind of thing.
Speaker 2: Wow, yeah, nineteen ninety eight. I don't think I realized
Speaker 2: it was so recent. Oh yeah, yeah, okay, I can't wait.
Speaker 1: And it just slipped into like our cultural consciousness like right, yeah.
Speaker 2: It's weird, weird, okay.
Speaker 1: But before there was ozempic, there was viagra, and before
Speaker 1: there was viagra, there was nothing. That's the story that
Speaker 1: you've likely heard, and the story that Peiser seems to
Speaker 1: love to tell. Nearly every publication that references the origins
Speaker 1: of viagra uses the word serendipity or one of its synonyms. Okay,
Speaker 1: as the story goes, Pfiser was testing out a new
Speaker 1: drug for a heart condition and stumbled up to greatness
Speaker 1: by utter chance. That might be part of the story,
Speaker 1: but it's certainly not all of it. The truth is
Speaker 1: that the hunt for an erectile dysfunction cure hadn't long
Speaker 1: been underway. And I'm not talking about like herbal extracts
Speaker 1: or animal glands, which like millennia people have been using
Speaker 1: those or trying those out. I mean that there had
Speaker 1: been since at least the nineteen seventies and nineteen eighties,
Speaker 1: a real concerted effort in medicine to create a medication,
Speaker 1: a device, or a surgery to treat what had long
Speaker 1: been known as impotence but was getting rebranded as a
Speaker 1: rectile dysfunction. The history of impotence is a separate topic entirely,
Speaker 1: but relevant to this discussion is what people thought caused
Speaker 1: it throughout that history, and that was your brain. For
Speaker 1: much of modern medicine, impotence, as it was then known,
Speaker 1: was considered a condition primarily of psychogenic origin, meaning it
Speaker 1: was caused by your brain. Anxiety, stress, depression, your wife's frigidity. Yeah,
Speaker 1: that was one of the leading causes. Rigidity, frigidity, cool, cool,
Speaker 1: And accordingly, it was treated by the folks who dealt
Speaker 1: with your brain, psychologists and psychiatrists. This notion replaced the
Speaker 1: previous dominant concept that impotence was a normal part of aging,
Speaker 1: and it began the shift in seeing impotence as something
Speaker 1: to treat, as something to manage, as something to cure.
Speaker 1: It redefined what quote unquote normal looked like. People did
Speaker 1: recognize that there were some cases of impotence that seemed
Speaker 1: to have a physical or organic origin. But the most
Speaker 1: commonly cited statistic, which by the way, no one can
Speaker 1: really figure out where the statistic came from up until
Speaker 1: the nineteen seventies or even the nineteen eighties, was that
Speaker 1: at least ninety percent of cases of impotence were psychological
Speaker 1: in origin. Yeah. Compare that to today, which is basically
Speaker 1: the reverse. Quote. Current medical consensus on a rectile dysfunction
Speaker 1: is ten to thirty percent psychogenic and seventy to ninety
Speaker 1: percent organic. Quote.
Speaker 2: And I don't know where they're getting those numbers.
Speaker 1: Either, Pfizer, all of it.
Speaker 2: Yeah, all of it is very interesting and doesn't even
Speaker 2: get into like female sexual dysfunction, which shows is still
Speaker 2: considered psychogenic and entirely in the rain. Right.
Speaker 1: Yeah, but cool. What happened to cause this reversal? Yeah,
Speaker 1: it wasn't viagra, or at least it wasn't Viagra alone,
Speaker 1: since the tides began to turn at least a decade
Speaker 1: or two before the drug came on the scene. It
Speaker 1: was Viagra's predecessors that helped to transform impotence into a
Speaker 1: rectile dysfunction. Devices, surgical treatments, or even injectable medications that
Speaker 1: were developed and tested in the nineteen seventies and nineteen
Speaker 1: eighties showed that for at least some a rectile dysfunction
Speaker 1: could be treated with medical rather than psychological intervention alone,
Speaker 1: and this led to a shift in who treated a
Speaker 1: rectile dysfunction as it was beginning to be known, from
Speaker 1: therapists to urologists, as well as increased interest in the
Speaker 1: physiological basis of erections and ways to induce them via medication,
Speaker 1: which brings me to the story of Professor GS. Brindley. Okay,
Speaker 1: have you heard this story?
Speaker 2: Nope?
Speaker 1: Okay, name doesn't sound familiar. Nope, Okay should it?
Speaker 2: It's going to add by the end of this I
Speaker 2: won't forget it.
Speaker 1: Yeah, I think that's sort of how I feel. It's
Speaker 1: now scarred into my brain. Nothing could have prepared me
Speaker 1: for this. Oh dear, how might we set the stage? Yeah? Truly?
Speaker 1: The year nineteen eighty three, the location Las Vegas aka
Speaker 1: Sin City, the occasion the annual meeting of the American
Speaker 1: Neurological Association hot stuff. On this fateful day referenced in
Speaker 1: every history of Viagra article and book, Professor G. S.
Speaker 1: Brindley made his way to the lecture hall, where he
Speaker 1: was scheduled to give an evening talk titled something along
Speaker 1: the lines of Vasoactive Therapy for a rectile dysfunction, Something innocuous, unremarkable.
Speaker 1: The audience was not substantial, around eighty or so people,
Speaker 1: mostly urologists, who dragged their partners along for one last
Speaker 1: lecture before the evening reception began. The first sign that
Speaker 1: something was amiss appeared even before the lecture began. The
Speaker 1: audience watched as the fifty seven year old Brindley climbed
Speaker 1: the stairs to the lectern dressed in a blue tracksuit,
Speaker 1: not at all professional attire for this kind of meeting.
Speaker 1: It's not ecology, after all.
Speaker 2: I'm very nervous right now.
Speaker 1: You should be. And this track suit stood in sharp
Speaker 1: contrast to those in the seats who were in their
Speaker 1: evening best. If the lecture had followed a normal course,
Speaker 1: perhaps no one would remember the blue track suit. But
Speaker 1: from the very first slide it was apparent that this
Speaker 1: was anything other than a normal talk, because the very
Speaker 1: first slide was a penis. Yeah, okay, it's a urology meeting.
Speaker 1: Penis picks are to be expected. That's not abnormal, right,
Speaker 1: But This wasn't just any penis. This was Brindley's penis.
Speaker 2: Brindley's penis, I knew it.
Speaker 1: And not just one slide, but multiple dozens. Yeah, lot
Speaker 1: his own pen well, Brindley explained to his stunned audience
Speaker 1: he had no other choice. His hypothesis was that if
Speaker 1: you injected vasoactive agents like papaverine and pantolamine into the penis,
Speaker 1: you could induce an erection, But lacking easy access to
Speaker 1: an appropriate animal model, he decided to test it out
Speaker 1: on himself.
Speaker 2: Uh huh.
Speaker 1: It doesn't end here, unfortunately, because while a picture may
Speaker 1: be worth one thousand words a live demonstration, but you
Speaker 1: can't put a price on that.
Speaker 2: No, you really can't. That's why you need a tracksuit.
Speaker 1: Mmm. Brindley was worried that the audience wouldn't believe that
Speaker 1: the erection featured in these pictures was induced by the
Speaker 1: injection alone, and so prior to the lecture, he had
Speaker 1: injected himself with popuvererin and deliberately wore his loose tracksuit
Speaker 1: so that he could pull his pants tight against himself,
Speaker 1: which is exactly what he did after stepping out from
Speaker 1: behind the podium. As to what happened next. Let me
Speaker 1: read you this quote from one of the audience members. Quote.
Speaker 1: At this point, I and I believe everyone else in
Speaker 1: the room was agog I could scarcely believe what was
Speaker 1: occurring on stage. But Professor Brindley was not satisfied. He
Speaker 1: looked down skeptically at his pants and shook his head
Speaker 1: with dismay. Unfortunately, this doesn't display the results clearly enough.
Speaker 1: He then summarily dropped his trousers and shorts, revealing a long, thin,
Speaker 1: clearly erect penis. There was not a sound in the room.
Speaker 1: Everyone had stopped breathing. The sense of drama in the
Speaker 1: room was palpable. He then said, with gravity, I'd like
Speaker 1: to give some of the audience the opportunity to confirm
Speaker 1: the degree of two messens. With his pants at his knees,
Speaker 1: he waddled down the stairs, approaching, to their horror the
Speaker 1: urologists and their partners in the front row. As he
Speaker 1: approached them, four or five of the women in the
Speaker 1: front rows threw their hands up in the air and
Speaker 1: screamed loudly. The screams seemed to shock Professor Brindley, who
Speaker 1: rapidly pulled up his trousers, returned to the podium and
Speaker 1: terminated the lecture.
Speaker 2: He didn't realize that maybe this was inappropriate until people screamed,
Speaker 2: I mean, okay, So I have so many thoughts on this,
Speaker 2: so many thoughts on this.
Speaker 1: I was processing this story for days. It's so many,
Speaker 1: it's so many.
Speaker 2: You're at a conference, a meeting, and you I mean,
Speaker 2: I don't have the right.
Speaker 1: This is a guy who doesn't have friends to tell him, Hey, man,
Speaker 1: maybe not.
Speaker 2: You can't drop trow on stage at a scientific conference.
Speaker 1: I mean, and let's be real. You shouldn't need to
Speaker 1: have friends who are your moral guideposts like that, Like
Speaker 1: that should be something that you know to not do right.
Speaker 2: You can't do that.
Speaker 1: You cannot, you cannot do that. But he did, Okay,
Speaker 1: he did. And so what can we take away from
Speaker 1: Brindley's lecture One? And this is the thing that's most
Speaker 1: often referenced when you know this is mentioned in any
Speaker 1: article or book about viagra, is that his demonstration showed
Speaker 1: that you could induce erections with a vasoactive compound. This
Speaker 1: was fifteen years before viagra came on the market, and
Speaker 1: so this is why the story is often mentioned because
Speaker 1: it's like, oh, this is proof that people had been
Speaker 1: working on medications for a rectile dysfunction long before Peiser
Speaker 1: got into the game, and sort of the same physiological
Speaker 1: basis was used as like how to induce an erection? Yep, okay, fine,
Speaker 1: that's the first thing. But the second thing that we
Speaker 1: can take away and this is the thing that I
Speaker 1: didn't see mentioned in any articles or books that included
Speaker 1: the story is excuse me, but like what what?
Speaker 2: Yeah?
Speaker 1: What?
Speaker 2: Like?
Speaker 1: How was this allowed to happen? How was this not
Speaker 1: disciplined afterward? And who has no one commented on how
Speaker 1: messed up this was?
Speaker 2: Yeah?
Speaker 1: Like, not only that, but people generally write about Brindley
Speaker 1: as this quirky, eccentric guy whose lecture was unique, dramatic,
Speaker 1: paradigm shifting, and unexpected. This is a quote right from unique.
Speaker 1: It is difficult to imagine that a similar scenario could
Speaker 1: ever take place again. End quote. I mean, I yeah, certainly,
Speaker 1: hope not no kidding. I mean it's the same thing
Speaker 1: we see time after time with certain people getting away
Speaker 1: with anything if their work is seen as valuable, right, like.
Speaker 2: Literally exposing your erect penis to an entire room without consent, yes,
Speaker 2: or even warning. I mean not even warning much, not.
Speaker 1: Even warning, not like, hey, what you're about to see
Speaker 1: is pictures of a penis on whatever, Like that's yeah,
Speaker 1: we can even Okay.
Speaker 2: I would honestly expect it at a Eurologic Society conference,
Speaker 2: though I would still expect in the eighties some kind
Speaker 2: of warning like in the eighties. I guess you're.
Speaker 1: Right today, I think that's generous of you. Yeah, sorry, yeah,
Speaker 1: but it's just it's it's amazing. Like the article where
Speaker 1: I pulled these quotes from is titled how not to
Speaker 1: Communicate New Scientific Information, and it was written in two
Speaker 1: thousand and five, and it's still Brintley is like, what
Speaker 1: a quirky guy. This was so unforgettable. Wow, he goes
Speaker 1: down in history as a really eccentric dude.
Speaker 2: So wait, sorry, this is an article about how not
Speaker 2: to communicate things. Are they lifting him up as an
Speaker 2: example of good job?
Speaker 1: Or like it's mostly like cheeky, like wow, what a guy.
Speaker 1: I can't believe he did this. What a scoundrel. So
Speaker 1: I mean the reflection still not there. I mean two
Speaker 1: thousand and five was twenty years ago, but still yeah,
Speaker 1: all right, okay, so I've already given enough airtime to Brittanley,
Speaker 1: Let's get back to viagra. The nineteen seventies and nineteen
Speaker 1: eighties saw a number of developments that set the stage
Speaker 1: for Viagra's introduction. Injections with phasoactive compounds that gave people erections,
Speaker 1: a rectile dysfunction perceived as a deviation from the norm
Speaker 1: rather than a normal part of aging, and the switch
Speaker 1: in thinking of a rectile dysfunction's cause from psychogenic to organic.
Speaker 1: All of these things opened the door to reframing ed
Speaker 1: as a medical condition that affected quality of life and
Speaker 1: thus was a therapeutic target. It's true that Phiser didn't
Speaker 1: set out to make an erectile dysfunction drug, but this
Speaker 1: reframing made it possible for them to seize the opportunity
Speaker 1: when it presented itself, which it did in nineteen ninety two.
Speaker 1: Phiser had for a few years been working on a
Speaker 1: medication to treat angina, experimenting with a few different compounds,
Speaker 1: including one called saltentiphil citrate, which had been synthesized by
Speaker 1: fire in their sandwich labs in the UK. Essentially, they
Speaker 1: were looking for an alternative to nitrates, which worked in
Speaker 1: the short term but became less effective over time as
Speaker 1: tolerance developed. Early studies showed that sildenophil dilated the blood vessels,
Speaker 1: lowering blood pressure, a good thing because it meant sending
Speaker 1: more blood to the heart, but it could also lower
Speaker 1: blood pressure too much when used in combo with nitrates,
Speaker 1: as you mentioned, Aaron, and that was a common prescription
Speaker 1: for their intended consumer group. Plus the short half life
Speaker 1: of sildenophil meant you had to take it three times
Speaker 1: a day, which was not ideal, and it was associated
Speaker 1: with a few adverse events like indigestion, headache, and erections,
Speaker 1: specifically more frequent and longer lasting erections, and that's how
Speaker 1: it was described like erections were labeled or were described
Speaker 1: as an adverse event. Despite what later versions of the
Speaker 1: story would have you believe, there was no light bulb
Speaker 1: moment where Pfizer scientists proclaimed finally an erection drug. Initially,
Speaker 1: this side effect was just kind of noted down along
Speaker 1: with the rest of them, and even if someone did
Speaker 1: spend a few minutes of thought on it, sildoniphil didn't
Speaker 1: seem like it would be the best ed drug. The
Speaker 1: increased erection didn't happen until a few days after taking
Speaker 1: the drug, which you had to do three times a day,
Speaker 1: and the clinical trial involved young men, so there was
Speaker 1: no reason to think that it would have the same
Speaker 1: effect in older men who had ED along with vascular disease. Okay,
Speaker 1: so if you wanted an erection on Saturday, you'd have
Speaker 1: to start taking the meds on Wednesday and not skip
Speaker 1: one of your three daily doses.
Speaker 2: Interesting, yeah, based on their studies as an based.
Speaker 1: On right, right, because this was not like at this point,
Speaker 1: sildoniphil had not been tested specifically for exrections.
Speaker 2: Right right, right right.
Speaker 1: But even with all these odds stacked against sildeniphil, researchers
Speaker 1: still thought it might be worth a shot. They had
Speaker 1: the molecular action of sildenophil mostly figured out, so they
Speaker 1: reasoned that maybe seldenophil in the absence of sexual stimulation
Speaker 1: equals no erection, but sildenophil plus sexual stimulation equals erection.
Speaker 1: And so Pfizer put together a couple of pilot studies
Speaker 1: in nineteen ninety three and nineteen ninety four testing sildenophil
Speaker 1: for the treatment of ED. They recruited volunteers with ED
Speaker 1: gave them sildenophil or placebo, put them in a private
Speaker 1: room with erotic materials, and then monitored their erections using
Speaker 1: a device called the Ridgie scan. Yes that's the actual name.
Speaker 2: Rigie Scan.
Speaker 1: Love Reggie Scan. A note on the Ridgie scan. Sixty
Speaker 1: percent rigidity was considered successful, which corresponded to the amount
Speaker 1: of rigidity for vaginal penetration. So quite a heteronormative measurement.
Speaker 2: There, not surprising, it's not at all. I just thought that,
Speaker 2: how this function is ormative?
Speaker 1: Interesting? Yeah, the results of these pilot studies were promising.
Speaker 1: Sildenophil seemed to work, and what was even better was
Speaker 1: that it worked after a single dose. This opened the
Speaker 1: door to larger clinical trials involving thousands of individuals, which
Speaker 1: were also successful. Participants allegedly didn't want the trial to end,
Speaker 1: so Pfizer got permission to keep them enrolled in a
Speaker 1: long term trial. This is from someone affiliated with Pfizer,
Speaker 1: so you know, grain of salt. In fact, actually a
Speaker 1: lot of the papers, a lot of the papers both
Speaker 1: about the history but especially about the effects of viagra
Speaker 1: or sildenophil, are like you can look and you're like, oh,
Speaker 1: Pfiser Labs. Yeah, oh yeah, Pfizer, Oh, Pfizer, Siser Fresher. Yeah.
Speaker 1: There did seem to be a few worrying side effects
Speaker 1: which you touched on a little bit aarin, but by
Speaker 1: and large it seemed relatively smooth sailing for Pfizer and
Speaker 1: Sildenophil in large art because its safety had already been
Speaker 1: assessed in previous years. So in nineteen ninety seven, Peiser
Speaker 1: filed a new drug application for Viagra as it was
Speaker 1: now known with the FDA. The FDA gave Peiser Priority
Speaker 1: Review status, which is used for drugs that quote represent
Speaker 1: major advances in treatment or fulfill a significant medical need.
Speaker 1: And wow, okay. Within a year, the FDA approved Viagra
Speaker 1: for treatment of a rectile dysfunction, and the first oral
Speaker 1: medication for ED landed on the market in nineteen ninety eight.
Speaker 1: Viagra's launch was anything but a quiet slipping onto the market,
Speaker 1: and it drastically changed the marketing landscape for pharmaceuticals. You
Speaker 1: might think that an erectile dysfunction drug kind of sells itself,
Speaker 1: but in fact, at the time similar medications or devices
Speaker 1: were considered kind of CD, and so Pfizer had to
Speaker 1: carefully strategize their marketing campaigns, and one way they did
Speaker 1: this was to make it clear that viagra was for
Speaker 1: only certain kinds of people, essentially the straight, married, middle class,
Speaker 1: older white men that they featured in their early ads,
Speaker 1: many of which didn't necessarily say or focus on erectal
Speaker 1: dysfunction or viagra outright, or if they did, they made
Speaker 1: it very clear that a rectal dysfunction was entirely a
Speaker 1: medical issue, not a psychogenic one. These ads also portrayed
Speaker 1: viagra as a relationship drug, promising to restore happiness, as
Speaker 1: well as masculinity as narrowly defined in these ads. Pfizer
Speaker 1: was also one of the first to use celebrity spokespeople
Speaker 1: like Bob Dole in advertisements and paid consultants like urologists
Speaker 1: to appear on daytime talk shows or in commercials, and importantly,
Speaker 1: these consultants didn't readily reveal their connection to the company,
Speaker 1: instead portraying themselves as un by experts whoa shade. This
Speaker 1: direct to consumer advertising seems super familiar to us now,
Speaker 1: although still bizarre and icky and dystopian, Like I don't
Speaker 1: have regular TV and so when I'm like in a
Speaker 1: hotel and they're commercial after commercial after commercial.
Speaker 2: For every single commercial is for a drug, and it
Speaker 2: really drives me crazy. It's horrible, especially because very much
Speaker 2: like the ad for viagra, where they didn't even say viagra,
Speaker 2: Like now they all say the drug, but a lot
Speaker 2: of times they won't say the condition. Even so it'll
Speaker 2: make everyone who's listening think, well, I need to go
Speaker 2: talk to my doctor about this medicine. I have no
Speaker 2: idea what it's for, no idea what it's treating, but
Speaker 2: everyone on the TV needs it and they're so happy.
Speaker 1: Right look at me, I can eat yogurt happily again, Like.
Speaker 2: Right, look at me, I'm playing in the sunshine fly
Speaker 2: height what pushing my grandchildren on a swing?
Speaker 1: Like it's just yes, uh, we laugh so we don't cry.
Speaker 1: But yeah, at the time that Viagra was released, this
Speaker 1: sort of direct to consumer marketing was super new. The
Speaker 1: FDA had only lifted the ban on these types of
Speaker 1: ads six months before the drug was released.
Speaker 2: Also, they used to be banned and then they were lifted.
Speaker 2: I'm so curious. We need to do a whole episode
Speaker 2: on that.
Speaker 1: We yeah, we really, we really really need to. The
Speaker 1: World Wide Web, which was relatively new in nineteen ninety eight.
Speaker 1: Also provided another avenue for people to gain more information
Speaker 1: about viagra and to try to buy the drug online
Speaker 1: without a prescription. Viagra was the butt of a million
Speaker 1: and one late night talk show jokes. It made appearances
Speaker 1: in storylines on TV shows, and soon everyone knew the
Speaker 1: name of this drug.
Speaker 2: Yeah.
Speaker 1: Many men took the logan ask your doctor to heart,
Speaker 1: and there were some reports that visits to doctors' offices
Speaker 1: actually increased for some groups of men who made their
Speaker 1: first appointment in years to ask about viagra. Erectile dysfunction
Speaker 1: went from a disorder treated in the nineteen sixties by
Speaker 1: psychiatrists to then be treated by specialist psychologists to one
Speaker 1: treated by general practitioners. Within the first three months of
Speaker 1: its release, Viagra made four hundred and eleven million dollars
Speaker 1: in sales.
Speaker 2: Is that in nineteen nineties dollars.
Speaker 1: I believe so Yeah, Holy guacamole, and two point seven
Speaker 1: million prescriptions were written in the first three months.
Speaker 2: Wow.
Speaker 1: It became the fastest selling drug in history, grossing over
Speaker 1: one billion dollars in its first year and netting seven
Speaker 1: point four billion in total sales for Pfizer in its
Speaker 1: first five years. I am aghast, I know agg I'll
Speaker 1: just like the audience in Brindley's lecture. Some commentators sung
Speaker 1: the praises of viagra, like Bob GUCCIONI, which I don't
Speaker 1: know if I'm saying that right. The publisher of Penthouse
Speaker 1: who wrote that quote, feminism has emasculated the American male,
Speaker 1: and that emasculation has led to physical problems. This pill
Speaker 1: will take the pressure off men, it will lead to
Speaker 1: new relationships and undercut the feminist agenda. And QUI I'm
Speaker 1: going to lose it. I'm gonna lose it. Uh, less
Speaker 1: sexist and more reasonable. People pointed out that viagra had
Speaker 1: made sex, especially for older adults, more of an open
Speaker 1: topic of conversation, and it reduced the stigma attached to
Speaker 1: erectile dysfunction, but there were some many even critics of
Speaker 1: the drug, mostly centered around fears of how viagra would
Speaker 1: change relationships, lead to addiction or recreational use. From an
Speaker 1: article in Time before Viagra's release, quote, doctors are concerned
Speaker 1: that an anti impotence pill could be subject to widespread abuse.
Speaker 1: Reports indicate that some Hollywood bedroom athletes have already tapped
Speaker 1: into an underground market for an injectable erection drug. The
Speaker 1: danger is that otherwise healthy men will take seldentifhil to
Speaker 1: bolster their sexual performance and then become psychologically addicted, unable
Speaker 1: to achieve an orgasm without it. End quote. Bedroom athletes, athletes,
Speaker 1: A Hollywood bedroom athlete love that what. Prior to Viagra's release,
Speaker 1: Pfizer anticipated this opposition and quote sent a delegation to
Speaker 1: the Vatican to find out how the Roman Catholic Church
Speaker 1: would respond to the pill. The Vatican gave its blessing
Speaker 1: on the basis of Viagra's contribution to improving family relations.
Speaker 1: End quote and barf. I get the Pope approved, Pope approved. Yes,
Speaker 1: the Pope's seal of approval stamped on every blue pill.
Speaker 2: Oh my god, I have so many feelings I can't
Speaker 2: express them.
Speaker 1: I mean, I not enough time in the world for
Speaker 1: me to process all of the thoughts and feelings.
Speaker 2: I have the Pope approved viagra.
Speaker 1: Improving family relations.
Speaker 2: Yeah, family relations, that's what viagra improves.
Speaker 1: Absolutely aarin. Others drew attention to the manner in which
Speaker 1: Peiser had branded a rectile dysfunction, accusing them of creating
Speaker 1: a disease or problem, and then inventing and marketing a
Speaker 1: solution classic capitalism. Then there was the question of normal.
Speaker 1: Even before viagra, medicine had sought to create a baseline
Speaker 1: for what was considered normal and what wasn't in terms
Speaker 1: of erections, arousal, masculinity, femininity, aging, sexuality, relationships, and bodies
Speaker 1: in general. By constructing boundaries around what is quote unquote
Speaker 1: normal or acceptable, medicine can other people and make them
Speaker 1: feel like there is something wrong with them and they
Speaker 1: should be striving to achieve that normal. We've talked about
Speaker 1: this before in our Menopause episode, sort of the medicalization
Speaker 1: of a normal part of aging and some of the
Speaker 1: issues that come with that. But like we also said
Speaker 1: in our Apause episode, that doesn't mean that we should
Speaker 1: completely reject these drugs that might make some people's lives
Speaker 1: a little easier, a little better, or a lot better.
Speaker 1: Just because something is a normal part of the aging
Speaker 1: process doesn't mean that we can't or shouldn't do something
Speaker 1: about it if we want to, and if it doesn't
Speaker 1: harm us, right, if.
Speaker 2: It's causing problems in your life, like you seem, like
Speaker 2: we talked about with menopause, like is that totally a
Speaker 2: normal part yes, is some of it very uncomfortable and
Speaker 2: impacts your quality of life? Yes, do something about it.
Speaker 2: Same thing with Edah.
Speaker 1: Absolutely, yeah. And so I want to push back a
Speaker 1: bit on this idea that a rectile dysfunction is solely
Speaker 1: a problem invented to sell a solution. Yeah, because clearly
Speaker 1: millions of people around the world have benefited from the
Speaker 1: use of viagra and related drugs and have reported that
Speaker 1: their quality of life has improved because of them. And
Speaker 1: the last criticism that I want to discuss is not
Speaker 1: about viagra itself, but about what Viagra highlighted when it
Speaker 1: came to gender bias in medicine and what is considered
Speaker 1: medical necessity. Ah.
Speaker 2: Yep.
Speaker 1: Within a few months a Viagra's release in nineteen ninety eight,
Speaker 1: most major American health insurance carriers covered it. Also wow, Yeah,
Speaker 1: well because there were a few lawsuits pending, and so
Speaker 1: they quickly were just like, all right, we see this,
Speaker 1: we see this coming in our future, let's just cover it.
Speaker 2: Within a few months, do you know how many insurance
Speaker 2: companies still won't cover ozempic and other similar I mean
Speaker 2: wigovy more like not ozempic, but the ones that are
Speaker 2: marketed just for weight less. That's a whole nother thing.
Speaker 1: It's a whole other thing.
Speaker 2: Yep, wow, okay, all right, cool cool.
Speaker 1: But this was not the case for birth control pills.
Speaker 1: Right when Viagra came out, most people still had to
Speaker 1: pay for it out of pocket. The year Viagra was
Speaker 1: released nineteen ninety eight, women paid sixty eight percent more
Speaker 1: out of pocket health expenses compared to men because most
Speaker 1: reproductive health services were not covered.
Speaker 2: Well, Aaron, birth control is not approved by the Pope, right.
Speaker 1: It's absolutely not.
Speaker 2: It's very much not.
Speaker 1: The reasoning was that viagra is a medical drug intended
Speaker 1: to treat a legitimate medical condition, while birth control was
Speaker 1: and is seen as a quote unquote lifestyle drug. Oh
Speaker 1: my god, and therefore optional. I'm never mind the fact
Speaker 1: that many people use birth control to treat medical conditions,
Speaker 1: never mind the fact that birth control was approved by
Speaker 1: the FDA in the first place to treat menstrual disorders.
Speaker 1: Viagra also brought to light other differences. For fifteen years
Speaker 1: after its initial release, the birth control pill could only
Speaker 1: be prescribed to married women, who often had to obtain
Speaker 1: their husband's permission. Only in nineteen seventy two were unmarried
Speaker 1: women allowed to obtain the pill. Can you imagine any
Speaker 1: law prohibiting an unmarried man from getting viagra or requiring
Speaker 1: that he get his wife's permission right so that she
Speaker 1: knows what he's up to? M hm, and I acknowledge
Speaker 1: that it's a bit apples and orange comparison. Here is it, though,
Speaker 1: But swap out viagra with male birth control and the
Speaker 1: point remains. And finally there's the sheer existence of viagra,
Speaker 1: which was made possible only by years of studying the
Speaker 1: decline and erections over a man's life. Similar studies in
Speaker 1: women happening at the same time were few and far between,
Speaker 1: tinged with sexist assumptions, and kind of came to the conclusion, well,
Speaker 1: who even knows? There's just too much going on here?
Speaker 1: Women are just too complicated. The switch from impotence is
Speaker 1: a psychogenic disorder to a rectilenction is an organic condition
Speaker 1: happened lightning fast. Compare that to the long, long tradition
Speaker 1: of women being told that it's all in their head.
Speaker 1: Even when it comes to quote unquote female viagra, it's
Speaker 1: the same thing. Quote is it a mind or body problem?
Speaker 1: End quote. Read the cover of a two thousand copy
Speaker 1: of Newsweek. In early studies of vasoactive drugs for female
Speaker 1: sexual dysfunction, participants were required to see a sex therapist first.
Speaker 1: Who quote evaluates the context in which the patient experiences
Speaker 1: her sexuality, her self esteem and body image, and her
Speaker 1: ability to communicate her sexual needs to her partner. End quote.
Speaker 1: Oh it's hormonal. Oh it's about blood flow. Oh it's
Speaker 1: all in her head. Oh it's about her partner. Oh
Speaker 1: it's about the general state of the world. Oh. Maybe
Speaker 1: it's a combination of all of them, and we'll never
Speaker 1: figure it out. How about arousal is not the same
Speaker 1: for everyone? But part of the issue seems to stem
Speaker 1: from the fact that the study of female sexual dysfunction
Speaker 1: takes the blueprint from male a rectile dysfunction. Researchers are
Speaker 1: looking for a direct parallel What is the female equivalent
Speaker 1: of an erection? But what if there isn't one in
Speaker 1: these studies? What is the outcome that the researchers are
Speaker 1: looking for and how are they measuring it? Is it
Speaker 1: vaginal lubrication, is it clatoral engorgement, is it perceived arousal?
Speaker 1: Is it orgasm? Or is it some mix? Why has
Speaker 1: it taken so long to develop a female viagra. Great question,
Speaker 1: let's tell that story someday.
Speaker 2: Also erin it hasn't changed. I mean, first line on
Speaker 2: up to date for female sexual arousal disorder is see
Speaker 2: a sex therapist, right, And.
Speaker 1: It's never considered like, oh, a rectile dysfunction is so
Speaker 1: simple because we've been studying it for so much longer
Speaker 1: and we've put so much more funding into answering this question.
Speaker 1: But female arousal, female sexual dysfunction is so complicated because
Speaker 1: we don't really care about it, and we haven't cared
Speaker 1: about it. It's such a mystery.
Speaker 2: It's also like it doesn't just service to everyone because like, yes,
Speaker 2: therapy is great.
Speaker 1: And that's exactly what I have here. Yeah, because what
Speaker 1: viagra did is that it reduced male arousal to one dimension, right,
Speaker 1: and it led many researchers to do the same for
Speaker 1: female arousal. This is not good for anyone, right, Like,
Speaker 1: and I think that this is a really undertold part
Speaker 1: of the story where it's like viagra is great and
Speaker 1: if it works for you, whether you're whether the ultimate
Speaker 1: cause of a rectile dysfunction is psychogenic and viagra is
Speaker 1: working because it's whatever helping.
Speaker 2: You overcome easier than you're less in your own head.
Speaker 1: Whatever it is, right, whatever it is, but it's like,
Speaker 1: shouldn't we consider the whole picture instead of being like,
Speaker 1: it's blood flow, right, it's blood flow. It's blood flow,
Speaker 1: and for women, I don't really know, it doesn't seem
Speaker 1: to be just blood flow for you. So sorry, best
Speaker 1: of luck. I think this is why the story of
Speaker 1: viagra is so fascinating to me, is because of all
Speaker 1: of these dimensions. Is because of the huge legacy that
Speaker 1: it has had on marketing, on sexuality, on the way
Speaker 1: that we talk about drugs, and I'm like blockbuster drugs,
Speaker 1: I mean everything, And so I'm really curious, Aaron, what
Speaker 1: you can tell me about viagra today.
Speaker 2: I don't know, not much. I think we've covered it all,
Speaker 2: but I'll try and wrap us up right after this break, Aaron.
Speaker 2: We already talked about a lot of the statistics when
Speaker 2: it comes to the prevalence of a rectile dysfunction, which
Speaker 2: again mirrors one hundred percent in those over age seventy
Speaker 2: fifty or more percent. As you like, it increases, it's
Speaker 2: estimated to increase with each decade, usually over age forty
Speaker 2: so starting from like forty to fifty percent around age
Speaker 2: forty and kind of going up from there. Exactly how
Speaker 2: are these statistics determined, It's a little bit unclear from
Speaker 2: all of the papers that I read, and that is
Speaker 2: not too like we've mentioned, undercut the importance of a
Speaker 2: rectile dysfunction in a person's sexual health, because we already
Speaker 2: underappreciate sexual health, especially in US healthcare, like it is
Speaker 2: just ignored across the board for a lot of people,
Speaker 2: and viagra and similar medications are often seen as this
Speaker 2: kind of easy fix, a blanket fix for any kind
Speaker 2: of a rectile dysfunction. When is that the fix for everyone?
Speaker 2: Maybe not. There's also statistics that I saw in a
Speaker 2: number of papers that I don't know where these came from,
Speaker 2: and they weren't good. But also that estimate that a
Speaker 2: large proportion of people who maybe have a rectile dysfunction
Speaker 2: or are suffering in some way with their sexual function
Speaker 2: don't actually ever access even a drug as ubiquitous as viagra.
Speaker 2: So there's again just a lot of it comes down
Speaker 2: to the way that we communicate about sexual health and
Speaker 2: the taboos that are still in existence about sexual health.
Speaker 2: Even though viagra has become sort of the butt of
Speaker 2: so many jokes and is so easy to come by
Speaker 2: these days. It's also estimated that in the US, the
Speaker 2: the cost of treatment for a rectile dysfunction is fifteen
Speaker 2: billion dollars a year.
Speaker 1: How much do we.
Speaker 2: Spend on female sexual health? Almost nothing, probably in comparison.
Speaker 1: I have a question, did you come across any studies
Speaker 1: looking at the effects of viagra on women?
Speaker 2: Great question, I didn't. I know that they do exist.
Speaker 1: I didn't.
Speaker 2: I probably should have spent more time looking for them specifically.
Speaker 2: But I know that they do exist, and I know
Speaker 2: that there are other there are other medicines that are
Speaker 2: targeting like female sexual dysfunction specifically. The one that I
Speaker 2: know of the most is not like a vasodilator. It
Speaker 2: doesn't work in that way. It's more closely related to
Speaker 2: like the SSR rise. It like works I think in
Speaker 2: relation to seratonin, which is another neurotransmitter that is very
Speaker 2: much involved in like the a rectile process as well.
Speaker 2: But yeah, it is an area much less explored.
Speaker 1: Okay, but in terms of like women taking viagraph women taking.
Speaker 2: Viagra, it is a thing that has been done. I
Speaker 2: don't know the stats on it. Oh okay, yeah, yeah,
Speaker 2: I don't know the stats on it. There are, though,
Speaker 2: also a lot of other treatments for rectile dysfunction aside
Speaker 2: from viagra. There's similar medicines like the sialis or tadalaphil
Speaker 2: and others, some of which are now approved to take
Speaker 2: on a low dose daily basis rather than an as
Speaker 2: needed basis, which is how viagra has always been taken
Speaker 2: and marketed. There are also other things like vacuum devices
Speaker 2: which use negative pressure to stimulate blood flow that helps
Speaker 2: the process along. There's injectable medications, there's suppository medications. There's
Speaker 2: other surgical interventions, especially depending on the cause of the
Speaker 2: rectile dysfunction to begin with, and you might need a
Speaker 2: surgical intervention. Some of these are like semi rigid all
Speaker 2: the time. Some of these have pumps that you physically
Speaker 2: pump up when you need but there aren't, as far
Speaker 2: as I could tell, at least as of twenty nineteen,
Speaker 2: any new oral medicines that are targeting like very novel
Speaker 2: biochemical pathways to treat a rectile dysfunction. There's also a
Speaker 2: lot of supplements and nutraceuticals that are at your own
Speaker 2: risk entirely unregulated see our Supplements episode. And then there's
Speaker 2: newer therapies like shockwave therapy or PRP. All of these
Speaker 2: very I don't know. I have a couple of papers
Speaker 2: if you want to go in detail on what the
Speaker 2: evidence of these are. They're all still very much in
Speaker 2: trials and not anything that's available on the market, But
Speaker 2: there is still a hefty amount of research going on
Speaker 2: on new and better ways to treat a rectile dysfunction.
Speaker 1: It's a profitable business. It really really is one thing
Speaker 1: that I want to add just I know that someday
Speaker 1: we will do a female via episode because I think
Speaker 1: that is really needed. But I think that like if
Speaker 1: we demand equal funding to find a female viagra, we
Speaker 1: should also demand equal evidence that what we find is
Speaker 1: therapeutic and not full of side effects and is as
Speaker 1: easy to take as viagra, that it actually does what
Speaker 1: it claims to, rather than just paying lip service to
Speaker 1: equality in medicine capitalism masquerading as feminism, which is I
Speaker 1: think some of the problems that are associated with some
Speaker 1: of these female viagras today, where it's just like, look,
Speaker 1: we did it right, this is what you've been asking for.
Speaker 1: It's the equivalent oh, don't mind those side effects. Oh,
Speaker 1: don't mind this, don't mind that the evidence is kind of,
Speaker 1: you know, a little bit vague and leave something to
Speaker 1: be desired.
Speaker 2: Well, And to do that we would need to do
Speaker 2: a lot more research on sexual health in general.
Speaker 1: Yes, yep, but yeah, sources, sources. I have a bunch
Speaker 1: I didn't really like. I honestly, I feel like a
Speaker 1: lot of these were grain of salt. And again, like
Speaker 1: I mentioned in terms of where they came from, which
Speaker 1: was people who were working with Peiser at the time
Speaker 1: or were kind of one dimensional in other aspects. Anyway,
Speaker 1: there was a book called The Rise of Viagra, How
Speaker 1: the Little Blue Pill Changed Sex in America, And this
Speaker 1: is from like shortly after, just a few years after
Speaker 1: its release, by Micah Lowe. And then if you want
Speaker 1: to read more about like the detailed how Feiser found
Speaker 1: this or how Piser like decided to shift their focus
Speaker 1: to seldeniphil as a treatment for a bactyl dysfunction. There's
Speaker 1: a book titled simply Sildentophil, and there's a chapter about
Speaker 1: the discovery of seldeniphil. Yeah, a whole.
Speaker 2: Book, all right. I have a lot of papers that
Speaker 2: go far more into the detail of the neurobiology, and
Speaker 2: like Bioka, i'mal pathways of erections. There was a paper
Speaker 2: that I found really helpful by Dean and Lou from
Speaker 2: two thousand and five called Physiology of Penal Erection and
Speaker 2: path of Physiology of a rectil Dysfunction. Another by Grotski
Speaker 2: at All from twenty ten Anatomy Physiology and path of
Speaker 2: Physiology of a rectil dysfunction. A few others that are
Speaker 2: specific to stildentophil, and like the pharmacology more of sildentiphil
Speaker 2: and other medications, and at least one on other ways
Speaker 2: that we use it, because again we use this medicine
Speaker 2: for other things too. But you can find the list
Speaker 2: of our sources, all of them from this episode and
Speaker 2: every one of our episodes, on our website, this podcast
Speaker 2: Weekilli dot com and it's under the episode stub that's
Speaker 2: where it is.
Speaker 1: Thank you to Bloodmobile for providing the music for this
Speaker 1: episode and all of our episodes.
Speaker 2: Thank you to Leona Scolacci and Tom Bryfogel for the
Speaker 2: audio mixing. Thank you to everyone at Exactly Right, and
Speaker 2: thank you to you listeners. Hopefully you found this episode enjoyable,
Speaker 2: learn something.
Speaker 1: Yeah. As always, reach out let us know what you think.
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Speaker 1: Until next time, wash your hands
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