Recreational Use of Erectile Dysfunction Medication May Decrease Confidence in Ability to Gain and Hold Erections in Young Males

P. Santtila; N. K. Sandnabba; P. Jern; M. Varjonen; K. Witting; B. von der Pahlen


Int J Impot Res. 2007;19(6):591-596. 

In This Article

Abstract and Introduction

We aimed to estimate the frequency of recreational use of erectile dysfunction medication (EDM) and to identify any adverse effects on confidence in gaining and holding erections resulting from such use. In addition, we explored differences in erectile function and sexual behavior between recreational and medicinal users of EDM to control for the possibility of recreational users having but not admitting erectile dysfunction. A subset from the Genetics of Sex and Aggression population-based sample of 4428 males with a mean age of 29.51 (s.d. = 6.77) years provided information on their use of EDM, erectile function during first intercourse and currently, sexual behavior and confidence in their ability to gain and hold erections. There were 2.6% (n = 115) recreational and 0.9% (n = 39) medicinal users of EDM. Recreational users had currently significantly lower confidence in their erectile ability than non-users even though they had significantly better erectile function and significantly more unrestricted sexual behavior as well as had more confidence when initiating sexual activity. More frequent use of EDM was associated with significantly less confidence in erectile ability among the recreational users. We conclude that recreational users of EDM may be vulnerable for becoming psychologically dependent on pharmacologically induced erection.

Erectile dysfunction (ED) is one of the most common sexual dysfunctions in males.[1] A review article of 67 studies on ED concluded that 5-20% of men suffer from moderate to severe ED, with figures ranging from 5 to 35% in different studies.[2] For mild to moderate ED, prevalence rates range up to around 50%. Although a number of treatment options are available, men prefer oral erectile dysfunction medications (EDMs).[3] In empirical studies, sildanefil (Viagra), taldalafil (Cialis) and vardenafil (Levitra) have all shown to be effective for treatment of organic, mixed and psychogenic ED.[4] All of these also require sexual stimulation to work effectively and their effect is dependent on the mood of the man.[5] The relative high placebo effects reported suggest that EDM partly works by reducing men's performance anxiety.[6,7]

Although intended for treatment of ED, EDM can be used recreationally[8] to enhance sexual performance even though no population-based studies of the prevalence of recreational as opposed to medicinal use of EDM have been conducted so far. A survey of 234 sexually active men between the ages of 18 and 25 found that 13% of the participants reported ED.[9] Six percent of all participants used EDM. About 60% reported using EDM to treat ED whereas about 30% reported using it in order to have more sex. Only 7.7% of those using EDM had obtained it from a physician. Also, of men attending a clinic for sexually transmitted diseases in San Francisco, about 17% reported using EDM in the past year.[10] Gay or bisexual men were significantly more likely to use EDM and among them over half received the drug from a friend (56%) rather than a health-care provider (42%). EDM users had a higher number of sex partners compared with non-users. Similar results have been reported also in a UK sample.[11] Further, an interview study of night club customers reported that 3% of the participants reported using EDM as a recreational drug.[8] A third of these users were women. All said they would take EDM again. According to information from Finnish Customs (, EDM was involved in 300 out of the 703 confiscations of illegally imported medicines during 2005. Even though these results seem to suggest that at least some of the participants were using EDM for recreational purposes and not to treat ED, the possibility remains that they were actually suffering from ED but did not want to acknowledge that. It is well known that sexual dysfunctions are associated with reluctance to acknowledge them with only 25% of men with ED consulting a medical professional.[12] Recreational users, if not really suffering from ED, could be expected to show less ED before the onset of EDM use as well as currently compared to medicinal users. Also, they could be expected to be more unrestricted in their sexual behavior (more sexual partners overall, more expected sexual partners and more 'one-night stands') and, if using EDM to prolong their erections, to report having more than one ejaculation during a single sexual encounter.

Reports regarding adverse effects associated with recreational EDM use have been limited to its role in making the users more likely to engage in unsafe sex, especially when the EDM is used in association with illegal drugs.[10,11] Less attention has been given to the potential role of EDM usage in leading to adverse psychological effects. Confidence in one's ability to gain and hold an erection has been identified as a major psychological factor in ED. The confidence item of the International Index of Erectile Function (IIEF)[13] has been shown to be the second most important variable differentiating between men with and without ED preceded only by the item concerning the ability of the men to maintain erections until the end of the intercourse.[14] Men may believe that erections should be gained automatically whenever an opportunity for sexual activity arises and that the erections should continue until orgasm.[15] With such expectations, occasional difficulties with getting and keeping erections may create performance anxiety that then generates ED.[5] EDM use alleviates such performance anxiety. However, it may lead to decrease in the confidence of users in gaining and holding erections without the medication. Also, as EDM has been reported to enhance the rigidity of erections and prolong them,[16] it may be that recreational use changes the standards for acceptable erection in the minds of the users, thereby making them less content with non-pharmacologically induced erections.

We aimed, first, to estimate the frequency of both medicinal and recreational use of EDM in a population-based sample of Finnish men. Second, we wanted to clarify whether the two groups of EDM users differed from each other and from non-users. We expected recreational users to have experienced less ED during their first intercourse compared to medicinal users and not to differ from non-users. We also expected them to show better current erectile function, to be more unrestricted in their sexual behavior and to be more likely to experience more than one ejaculation in a single sexual encounter. Third, we explored the effects of recreational EDM use on confidence in ability to gain and hold erections. We expected recreational users to show overall less confidence compared to non-users. We also expected more frequent use of EDM to be associated with less confidence in the group of recreational users.


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