Because it's embarrassing?

Ragnhild Ørstavik About the author

After New Year, men will no longer need to talk to their regular GP about impotence problems. Is this a good idea?

Photo: Einar Nilsen

From 2020 onwards, men over the age of 18 will be able to buy Sildenafil, marketed as non-prescription Viagra, at pharmacies (1). The drug will be the first to be sold under the scheme ‘non-prescription medication with guidance’ (2). Pharmacists will use a checklist and must request customers who answer some of the questions in the affirmative to contact their GP for further assessment (3). According to the Norwegian Medicines Agency, the aim of this initiative is to reduce the amount of illegal purchases online (1).

In 2018, more than 6 million doses in the erectile dysfunction drugs’ category were sold in Norway to just over 107 000 users; this came to slightly more than NOK 180 million (4). However, statistics given in the Norwegian Prescription Database provide limited information about the actual use of such drugs. Instead of visiting the doctor, many men choose to buy erectile dysfunction tablets on the illegal market. During an international campaign last year, 37 % of the drugs confiscated in Norway had been sold as erectile dysfunction medication (5). The Netherlands has attempted to chart its use, although this is difficult: analyses of sewage showed that the amount of residue from such drugs was more than twice what could be expected based on the number of prescriptions (6).

Erectile dysfunction tablets are a gift to producers of counterfeit drugs: low production costs give profit margins that are 2 000 higher than for cocaine, while penalty levels are low (7). But the risk to users is substantial: a study, which admittedly was conducted by the pharmaceutical company that produces Viagra, showed that only 18 % of the internet sites that claimed to sell Sildenafil, delivered genuine products (8). Instead of Sildenafil, buyers ran the risk of being fobbed off with medication that contained talc, amphetamine, paracetamol or metronidazole – and maybe a good dose of bacteria as well (7, 8).

Why do men choose to do something illegal to obtain a product that doesn’t contain what they want? The results of a European survey indicate that the main reasons are men’s reluctance to talk to a doctor, and the fact that they want to buy it cheap (9). But will the scheme of non-prescription drugs with guidance feel simpler? It assumes that those who don’t want to talk to their regular GP will think that it’s OK to talk to a pharmacist. And the men concerned must be willing to pay more, not less. The prices of non-prescription drugs aren’t controlled, and it seems clear that non-prescription Viagra will be more expensive than Sildenafil on prescription (1).

There are many good reasons why men should talk to their GP about impotence problems. Erectile dysfunction has a complex etiology with both somatic and psychological components, and even though drug therapy is the first choice, talking therapy or lifestyle changes can also have a good effect (10). Moreover, erectile dysfunction is an independent risk factor for cardiac disease, particularly in men under the age of 60 (10). Men with erectile dysfunction of unknown cause must be assessed for cardiovascular disease (10). A confidential conversation in private may also be a good thing – the pharmacist’s checklist does not include questions about whether the patient has erectile dysfunction or if the young man who wants an erection pill is actually ‘just’ curious or is suffering from sexual performance anxiety.

In 2018, there were altogether 214 245 GP consultations in Norway with the diagnosis ‘gynaecological problems’ (pregnancy, birth and contraception are excluded) (11). None of the 20 diagnostic groups in Statistics Norway’s statistics encompass male genital organs. Women are accustomed from an early age to exposing their private parts to healthcare personnel. Maybe it’s different for men. Nevertheless, it would be useful to find out more about the taboo surrounding a condition that affects 20–40 % of middle-aged men that can often be treated, but which may also be an indicator of other illness (10). Transferring the conversation from the GP’s office to the pharmacy does not appear to be a step in the right direction.

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